Lateral Plate Versus Isolated Lag Screw Fixation of Unstable Distal Fibula Fractures: A Systematic Review

Background: Lateral plate fixation, the current standard for fixation of unstable distal fibular fractures, can compromise the minimal soft tissue envelope resulting in poorer postoperative outcomes. Isolated lag screw fixation represents a novel method of distal fibula fixation. Methods: Two independent reviewers conducted a literature search of PubMed, EMBASE, Google Scholar and MEDLINE (Ovid) in February 2024. Randomised control trials (RCTs), non-randomised control trials and cohort studies were included. Risk of bias was assessed with the ROBINS-I tool. PRISMA guidelines were followed. This systematic review was prospectively registered in the PROSPERO register (CRD42024521746). Results were synthesised by structured qualitative analysis. Results: Four studies (207 patients) were included. Compared to lateral plate fixation, lag screw-only fixation for distal fibula fractures resulted in reduced operative times, incision lengths, costs, hardware-related issues, ankle symptomatology, and complications, with comparable or improved functional outcomes and similar radiographic healing under equivalent postoperative care. These findings were applicable to patients under 60 years old with noncomminuted, oblique, or spiral unstable distal fibula fractures. Conclusion: Isolated lag screw fixation represents a novel method of distal fibular fracture fixation in select patients. Reducing hardware burden on the soft tissue envelope improved operative and patient outcomes without compromising standard postoperative care. The methodological and clinical differences among the included studies limited this review. Additionally, only four eligible studies were included, all with significant bias.