Rehabilitation following locked intramedullary fibular nail fixation: a systematic review

This systematic review aims to assess locked intramedullary fibula fixation by (1) identifying and reporting current rehabilitation protocols, and (2) determining if there is an evidence-based rehabilitation protocol supported by consensus. We hypothesize that no current consensus exists and there is significant heterogeneity in reported rehabilitation protocols.

A systematic review of the current literature was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The certainty of evidence was reported using GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Primary outcomes included rehabilitation protocols, specifically addressing weightbearing, range of motion, and physical therapy, following locked intramedullary fibular nail. Secondary outcomes included patient-reported outcome scores.

Ten studies were reviewed, including seven retrospective case series and three randomized control trials. Three studies had varied weight-bearing protocols based on fracture pattern, intraoperative assessment, or surgeon preference, while others used standardized protocols. Only four studies reported postoperative Physical Therapy (PT) and Range of Motion (ROM) protocols; two initiated PT after cast removal at six weeks. Immobilization protocols varied across studies in terms of duration and method. Two studies used a postoperative splint followed by a cast after swelling reduced or 24 h post-surgery.

There is significant heterogeneity in reported rehabilitation protocols, and proposed benefits of locked IMN procedures like early weightbearing are seldom included. No evidence-based rehab protocol has been established. We propose developing an evidence-informed rehabilitation protocol that utilizes unique characteristics of locked IMN procedures.