No difference in early outcomes comparing intramedullary versus extramedullary fibular fixation in operative ankle fractures

•Although IMF of fibular fractures significantly reduced operative time, there were no significant differences in complication rates, unplanned reoperation rates, or time to fracture union.•IMF group exhibited higher functional scores and no surgical site infections compared to PF group.•IMF group maintained stable radiographic reduction over time, with no significant loss of fracture reduction observed when compared to PF group.•Both IMF and PF are reliable modes of fibular fixation and with appropriate patient selection, excellent clinical outcomes can be achieved in either fixation techniques. The purpose of this study was to compare postoperative complications and outcomes of minimally invasive intramedullary fixation (IMF) versus plate fixation (PF) in the treatment of distal fibular fractures. A retrospective review was performed from identifying all consecutive ankle fracture patients aged ≥18-years-old surgically managed between August 2017 to September 2022 at a tertiary care center with minimum 6 months clinical follow-up. Patients were grouped into those receiving intramedullary versus extramedullary fibular fixation. The primary outcomes were relevant demographic factors (diabetes, osteoporosis, charlson comorbidity index [CCI]), surgical time, complication rates, reoperation rates. Secondary outcomes included time to definitive fracture fixation, fracture characteristics (AO/OTA and Lauge-Hansen classification), syndesmotic instability requiring fixation and discharge disposition. Forty-one IMF patients (average age 55.3 ± 18.1yrs) and 162 PF patients (47.7 ± 17.4yrs) were identified and included in this study. Within the IMF group, 25 patients received IM nailing and 16 patients received percutaneous screw fixation. A greater proportion of IMF patients had diabetes (39 % vs 22 %, p < 0.001), osteoporosis (22 % vs 3 %, p < 0.001), and moderate or severe CCI (41 % vs 23 %, p = 0.017). Surgical time was significantly reduced when using IMF technique (80.4 ± 43.1 min vs 99.1 ± 43.1 min, p = 0.012). Overall complication rates or time to complication did not differ significantly between groups (p = 0.578 and p = 0.082, respectively); however, when sub-stratified, IMF patients trended towards experiencing fewer wound related complications versus PF patients (5 % vs 9 %, p = 0.291). No IMF patients experienced deep or superficial infections and only 2 (5 %) patients experienced wound dehiscence. Reoperation rates(15 % vs 10 %, p = 0.267) and time to