Distal tibial metaphyseal fractures: the role of fibular fixation

Fibula fixation is not associated with a higher rate of wound complications during pilon fracture open reduction internal fixation

Introduction

There is a lack of consensus regarding indications for fibula fixation in pilon fractures. Reduction of the fibula fracture can assist with restoring lateral column length and reduction of the tibial plafond during pilon ORIF. However, there are theoretical concerns with wound complications and soft tissue insult. The purpose of this study is to compare short-term outcome measures after tibial plafond ORIF with and without supplemental fibula fixation using a validated national database.

Materials and methods

The American College of Surgeons' NSQIP database was utilized to identify all patients undergoing tibial plafond ORIF with and without fibula fixation between January 1, 2015 and December 31, 2020 using Current Procedural Terminology (CPT) codes 27827 and 27828, respectively. Open fractures and cases with concurrent open procedures were excluded from analysis. Demographic data, medical comorbidities, surgical variables, and various 30-day outcome measures were compared between the two groups. Multivariate logistic regression was used to identify independent variables associated with various outcome measure of interest.

Results

A total of 3120 patients were included in the final cohort: 1530 patients underwent tibia fixation alone and 1590 patients underwent both tibia and fibula fixation. The supplemental fibula fixation group had a higher rate of reoperation (2.3 % vs. 1.1 %, p = 0.013) and non-home discharge (14.8 % vs. 11.2 %, p = 0.003). The rate of surgical site infection was comparable between groups. Supplemental fibula fixation was independently associated with unplanned reoperation (RR: 1.939 [1.081-3.477], p = 0.026).

Conclusions

Patients undergoing supplemental fibula fixation during tibial plafond ORIF had a higher rate of 30-day reoperation and non-home discharge. Supplemental fibula fixation during pilon fracture ORIF was independently associated with a higher rate of 30-day reoperation. There was no difference in the rates of surgical site infection or wound dehiscence between the two groups.

Level of evidence

3.

A Dilemma in the Management of Distal Tibia Fractures Solved by Minimally Invasive Percutaneous Plate Osteosynthesis Technique: A Prospective Study

Introduction Managing distal tibia fractures is challenging for trauma surgeons because of their peculiar anatomy with less soft tissue coverage and poor blood supply. There are various treatment options for distal tibia fractures such as open reduction and plating, minimally invasive percutaneous plate osteosynthesis, and intramedullary interlocking nailing. Open reduction and internal fixation can lead to excessive soft tissue dissection and devascularization of fracture fragments. We conducted a study on the functional outcome of distal tibia fractures treated by biological fixation with minimally invasive percutaneous plate osteosynthesis. Methods A total of 23 patients with distal one-third tibia fractures, fulfilling the inclusion criteria, who were treated at St. John's Medical College Hospital with minimally invasive percutaneous plate osteosynthesis between November 2020 and November 2022 were studied using the American Orthopaedic Foot & Ankle Society (AOFAS) score at six weeks, three months, and six months postoperative follow-up. Results This study included 17 males and six females. The mean age of the study participants was 43.78 years, with most of the participants being in the age group between 51 and 60 years (29.2%, n = 7). All the study participants were employed. The mean operative time was two hours and 10 minutes. The mean duration for the radiological union was 22 weeks. The mean AOFAS score at six months was 92.43 + 5.696. There was only one case of superficial infection, which was treated with intravenous antibiotics. There were no cases of malunion/nonunion. Conclusion Minimally invasive percutaneous plate osteosynthesis is an effective treatment for distal tibia fractures avoiding most of the complications such as wound dehiscence and malunion/nonunion involved in conventional open reduction and internal fixation with plating. Therefore, we recommend this technique for all distal tibia fractures.

Simulation-based prediction of bone healing and treatment recommendations for lower leg fractures: Effects of motion, weight-bearing and fibular mechanics

Despite recent experimental and clinical progress in the treatment of tibial and fibular fractures, in clinical practice rates of delayed bone healing and non-union remain high. The aim of this study was to simulate and compare different mechanical conditions after lower leg fractures to assess the effects of postoperative motion, weight-bearing restrictions and fibular mechanics on the strain distribution and the clinical course. Based on the computed tomography (CT) data set of a real clinical case with a distal diaphyseal tibial fracture, a proximal and a distal fibular fracture, finite element simulations were run. Early postoperative motion data, recorded via an inertial measuring unit system and pressure insoles were recorded and processed to study strain. The simulations were used to compute interfragmentary strain and the von Mises stress distribution of the intramedullary nail for different treatments of the fibula, as well as several walking velocities (1.0 km/h; 1.5 km/h; 2.0 km/h) and levels of weight-bearing restriction. The simulation of the real treatment was compared to the clinical course. The results show that a high postoperative walking speed was associated with higher loads in the fracture zone. In addition, a larger number of areas in the fracture gap with forces that exceeded beneficial mechanical properties longer was observed. Moreover, the simulations showed that surgical treatment of the distal fibular fracture had an impact on the healing course, whereas the proximal fibular fracture barely mattered. Weight-bearing restrictions were beneficial in reducing excessive mechanical conditions, while it is known that it is difficult for patients to adhere to partial weight-bearing recommendations. In conclusion, it is likely that motion, weight bearing and fibular mechanics influence the biomechanical milieu in the fracture gap. Simulations may improve decisions on the choice and location of surgical implants, as well as give recommendations for loading in the postoperative course of the individual patient.

Fibula fixation in the treatment of tibial pilon fractures - Is it really necessary?

BACKGROUND

There is a lack of consensus about the role of fibula fixation in these complex fractures, with only two clinical studies in the literature. We hypothesize that the fibula fracture need not be fixed in the tibial pilon fractures if primary stability can be achieved with tibial fixation alone.

METHODS

We reviewed 79 patients with operatively treated tibial pilon with associated fibula fractures from 2007 to 2017 and divided them into two groups; patients with fibula fracture fixation and those without fixation. The primary outcome measure was any mechanical complications. Secondary outcomes were wound complications and other morbidities.

RESULTS

There were 54 (68.4%) patients with fibula fixation and 25 (31.6%) patients without fixation. There were no statistically significant differences in mechanical complications between the two groups. However, patients without fibula fixation were noted to have more wound complications (44% vs 25.9%, p = 0.108) although this was not statistically significant. In terms of removal of implant (ROI), there were no differences noted in patients with or without fibula fixation (33.3% vs 28%, p = 0.796). There were also no significant differences in ROI for those fixed with plate and screws when compared to those fixed with Rush rod and K wire within the group with fibula fixation.

CONCLUSION

Fibula fixation in the treatment of tibial pilon fractures is not routinely necessary and does not result in decreased mechanical complications such as malunion, delayed union, nonunion and implant failure. Fibula fracture fixation should be reserved for cases where it may aid reduction or provide additional stability.

The value of fibular fixation in patients with stabilized distal tibia fractures

PURPOSE

There is currently no consensus regarding the need for fixation of concomitant fibula fractures in patients with surgically treated distal tibia fracture. Although studies have shown it to be beneficial for fractures involving the syndesmosis, it remains unclear for suprasyndesmotic fractures. This study evaluates what effect the fixation of such suprasyndesmotic fibula fractures had on patients who underwent fixation of distal tibia fractures.

METHODS

This retrospective cohort study included all consecutive adult patients who received surgical treatment for an extra-articular or simple intraarticular distal tibia fracture between 2012 and 2020 and had a concomitant fibula fracture proximal to the syndesmosis. Two groups were formed depending on whether the fibula was stabilized. The need for revision surgery, the occurrence of complications, fracture healing, rotational and angular malalignment were evaluated for both groups.

RESULTS

This study included 120 patients, of which 40 (33.3%) had operative treatment of the fibula fracture. Of those with stabilized fibula fractures, 28 (70%) were treated with a plate and 12 (30%) with a titanium elastic nail. The group of patients with surgically treated fibula fractures had significantly more angular malalignments (10% vs 1.2%, p = 0.042), while there was no difference regarding rotational malalignment or fracture healing. Further, infections of the fibular surgical site occurred in 15% of surgically treated patients leading to significantly more revision surgeries in this group (40% vs 20%, p = 0.03). All infections occurred when a plate was used.

CONCLUSION

This study was unable to show any benefit from stabilizing concomitant, suprasyndesmotic fibula fractures in surgically treated distal tibia fractures. On the contrary, infection, revision surgery and angular malalignment were more frequent when the fibula was fixed. Therefore, such concomitant fibula fractures should not routinely be fixed and if stabilization is deemed necessary, the implant should be chosen carefully.

The Role of Fibular Fixation in Distal Tibia-Fibula Fractures: A Meta-Analysis

OBJECTIVES

The necessity of fibular fixation in distal tibia-fibula fractures remains controversial. This study aimed to assess its impact on radiographic outcomes as well as rates of nonunion and infection.

METHODS

A systematic search of the electronic databases of PubMed, Embase, and Cochrane library was performed to identify studies comparing the outcomes of reduction and internal fixation of the tibia with or without fibular fixation. Radiographic outcomes included malalignment and malrotation of the tibial shaft. Data regarding varus/valgus angulation, anterior/posterior angulation, internal/external rotation deformity, and the rates of nonunion and infection were extracted and then polled. A meta-analysis was performed using the random-effects model for heterogeneity.

RESULTS

Additional fibular fixation was statistically associated with a decreased rate of rotation deformity (OR = 0.13; 95% CI 0.02-0.82, p=0.03). However, there was no difference in the rate of malreduction between the trial group and the control group (OR = 0.86; 95% CI 0.27-2.74, p=0.80). There was also no difference in radiographic outcomes of varus-valgus deformity rate (OR = 0.17; 95% CI 0.03-1.00, p=0.05) or anterior-posterior deformity rate (OR = 0.76; 95% CI 0.02-36.91, p=0.89) between the two groups. Meanwhile, statistical analysis showed no significant difference in the nonunion rate (OR = 0.62; 95% CI 0.37-1.02, p=0.06) or the infection rate (OR = 0.81; 95% CI 0.18-3.67, p=0.78) between the two groups.

CONCLUSIONS

Additional fibular fixation does not appear to reduce the rate of varus-valgus deformity, anterior-posterior deformity, or malreduction. Meanwhile, it does not appear to impair the union process or increase the odds of infection. However, additional fibular fixation was associated with decreased odds of rotation deformity compared to controls.

External fixator combined with three different fixation methods of fibula for treatment of extra-articular open fractures of distal tibia and fibula: a retrospective study

Background

To compare the efficacy of three different fixation methods of fibula combined with external fixation of tibia for the treatment of extra-articular open fractures of distal tibia and fibula.

Methods

From January 2017 to July 2019, 91 cases of open fractures of distal tibia and fibula were treated with external fixator, and the fibula was fixed with non-fixation (group A, n = 35), plate-screw (group B, n = 30) and Kirschner wire (group C, n = 26). The operation time, intraoperative blood loss, surgical and implants costs, fracture healing time, postoperative complications, and American Orthopaedic Foot and Ankle surgery (AOFAS) scores were compared among the groups.

Results

Four patients were lost to follow-up, and 87 patients were followed up for 5–35 months (average, 14.2 months). The operation time of group C (114.92 ± 36.09 min) was shorter than that of group A (142.27 ± 47.05 min) and group B (184.00 ± 48.56 min) (P < 0.05). There was no difference in intraoperative blood loss among the three groups (P > 0.05). The surgical and implants costs in group C (5.24 ± 1.21, thousand dollars) is lower than that in group A (6.48 ± 1.11, thousand dollars) and group B (9.37 ± 2.16, thousand dollars) (P < 0.05). The fracture healing time of group C (5.67 ± 1.42 months) was significantly less than that of group A (6.90 ± 1.33 months) and group B (6.70 ± 1.12 months) (P < 0.05). The postoperative complications such as fractures delayed union and nonunion in group C (2 cases, 8.00%) is less than that in group A (13 cases, 39.39%) and group B (11cases, 37.93%) (P < 0.05). The wound infection and needle-tract infection did not differ among the three groups (P > 0.05). The excellent or good rate of ankle function was 69.70% in group A, 72.41% in group B and 84.00% in group C, with no statistical difference among the three groups (P > 0.05).

Conclusion

Compared with simple external fixator fixation and external fixator combined with plate-screw osteosynthesis, external fixator combined with K-wire intramedullary fixation shortens the operative time and fracture healing time, reduced costs and complications of fracture healing, while the blood loss, infection complications and ankle function recovery showed no difference with the other two groups. External fixator combined with plate-screw osteosynthesis had no advantage in treating extra-articular open fractures of distal tibia and fibula when compared with simple external fixation.

Outcome and complications of distal tibia fractures treated with intramedullary nails versus minimally invasive plate osteosynthesis and the role of fibula fixation

INTRODUCTION

Distal tibia fractures have been managed conservatively as well surgically. A large number of implants have been used for surgical management of these fractures. No treatment method or implant has been proven to be superior to others. In this prospective comparative study, the complications and outcome of distal tibia fractures managed with intramedullary nails and minimally invasive plate osteosynthesis has been compared. Further, the role of fibula fixation in these fractures has been evaluated.

MATERIALS AND METHOD

One hundred and fifty-four patients of distal tibia fractures with concomitant fibula fractures were randomized into 4 treatment groups based on predetermined inclusion criteria. Functional outcome in these groups was compared based on AOFAS score at 1 year. Intra-operative, post-operative parameters as well as radiological alignment, complications and the need for reoperation were also compared in these groups.

RESULT

The functional outcome in all four treatment groups was similar. The duration of surgery and radiation exposure was higher with minimally invasive plate osteosynthesis. There was no improvement in outcome with plating of fibula. However, fixation of fibula improved the rotational alignment in distal tibia fractures.

CONCLUSION

Although there is no difference in outcome of distal tibia fractures with either nailing or minimally invasive plating, nailing is recommended for closed displaced extraarticular fractures. Fixation of fibula should not be done routinely but should be reserved only for a few specific fracture patterns.

Efficacy of Pie-Crusting Technique on Soft Tissues in Distal Tibia and Fibula Fractures

Distal tibia and fibula fractures are challenging injuries to treat as evidenced by the high rates of wound complications because of vulnerable soft tissue coverage. The aim of this study was to examine the effect on soft tissue complications of the pie-crusting technique when applied between 2 incisions in distal tibia and fibula fractures treated with open reduction and internal fixation. We reviewed 34 patients with distal tibia and fibula fractures treated between September 2014 and March 2017. The pie-crusting technique was performed during wound closure in 16 (47.06%) fractures (group 1) and classic wound closure was done in 18 (52.94%) fractures (group 2). The primary outcome was evaluated as the presence or absence of soft tissue complications such as superficial skin necrosis, deep skin necrosis, and deep infection. The mean age was 50.44 ± 13.51 (range 23 to 65) years in group 1 and 51.67 ± 14.49 (range 18 to 68) years in group 2. The mean follow-up time was 27.35 ± 9.02 (range 16 to 46) months. The mean surgery time after injury was 5.88 ± 3.5 (range 1 to 14) days in group 1 and 7.32 ± 4.25 (range 1 to 16) days in group 2. No soft tissue complications were seen in any patient in group 1. Five (27.77%) occurrences of superficial skin necrosis were observed in group 2. In 2 (11.11%) patients in group 2, deep necrosis and wound dehiscence occurred, and subsequent deep infection developed in 1 (5.55%) of these patients. The overall complication rate was higher in group 2 (p = .005). We believe that the pie-crusting technique is beneficial for wound closure in distal tibia and fibula fractures, because it reduces the tension of the skin and allows leakage of subcutaneous fluids.

Foot Loading and Gait Analysis Evaluation of Nonarticular Tibial Pilon Fracture: A Comparison of Three Surgical Techniques

The aim of our study was to investigate which technique among hybrid external fixation, plate and screws, and intramedullary nailing produces better outcomes in foot loading when treating type 43.A1, 43.A2, and 43.A3 fractures, according to the AO classification. From November 2011 to December 2014, 34 patients, including 25 (73.5%) males and 9 (26.5%) females with an average age of 32.3 (range 16 to 67) years, with a type A tibia fracture were treated with intramedullary nailing, plate and screws, or hybrid external fixation. The patients were divided into 3 groups: 16 (47%) received hybrid external fixation, 10 (29.4%) received plate and screw fixation, and 8 (23.5%) received intramedullary nailing fixation. The follow-up protocol included clinical and radiologic evaluations performed at 15 days, 1 month, 3 months, 6 months, and 12 months after surgery. The selected outcome parameters for the 3 groups were as follows: visual analog scale for pain of the traumatized tibia, interval from surgery to weightbearing, average time required for fracture recovery, subjective and objective Ovadia-Beals scores, baropodometric examination at 12 months, walking recovery at 12 months, outcomes, and surgical complications. The endpoint assessment was set at 12 months. The results showed that incorrect reduction of a type A tibia fracture can lead to changes in the sagittal balance line for foot loading and pace training. In conclusion, these findings have shown that the experience of the surgeon in the reduction of the fracture and knowledge of the method of synthesis is essential.

Intramedullary tibial nailing of distal tibiofibular fractures: additional fibular fixation or not?

INTRODUCTION

The anatomy of the distal tibia accounts for reduced biomechanical stability and higher complication rates when treating distal tibiofibular fractures with an intramedullary tibia nail (IMTN). The goal of this study was to identify variables that affect the stability of IMTN. We assessed the value of additional fibular fixation, angular stable interlocking screws (ASLS) and multiplanar screw configuration in IMTN.

PATIENTS AND METHODS

A retrospective cohort study was performed including 184 distal tibial fractures and associated fibula fracture treated with IMTN. Relevant demographic, fracture-related (type and level of the tibia and fibula fracture) and operative variables (depth of the nail, screw type and configuration, use of polar screws, fibular fixation) were studied. Coronal and sagittal alignment was assessed directly and 3-6 months after IMTN. Loss of reduction (LOR) was classified as 5-9° or ≥10°.

RESULTS

48.4% of the patients showed ≥5° LOR in one or both planes. Coronal LOR 5°-9° significantly correlated with low tibial fractures (p = 0.034), AO/OTA type 43 distal tibial fractures (p = 0.049), and sagittal LOR 5°-9° (p = 0.015). Although sagittal LOR 5°-9° was associated with fibular fractures (non-fixated suprasyndesmotic, p = 0.011), conversely we could not demonstrate the added value of (suprasyndesmotic) fibula fixation in IMTN. Coronal LOR ≥10° significantly correlated with AO/OTA type 43 distal tibial fractures (p = 0.009). In contrast to multiplanar configuration, we found a clear benefit of ASLS in distal IMTN locking.

CONCLUSIONS

The level of the tibial fracture (AO/OTA type) and (suprasyndesmotic) fibular fractures were the main determinants of LOR after IMTN. ASLS was found to increase the stability of IMTN. Due to heterogeneity, however, we could not demonstrate the value of fibular fixation in IMTN. Therefore, a future prospective study with uniform treatment strategy for IMTN of distal tibiofibular fractures, with or without fixation of the fibula, is mandatory.

Fibular Fixation in Distal Tibia Fractures: Reduction Aid or Nonunion Generator?

The role of fibular fixation in patients with distal tibia fractures is controversial. Although the stability of the fibula is critical in patients with syndesmotic instability or highly comminuted pilon fractures, fibular fixation in extraarticular distal tibia fractures or elementary intraarticular distal tibia fractures is more controversial. Biomechanical studies, as performed in sawbones or cadaveric models, denote advantages to fibular fixation with respect to specific uniplanar motion. However, the increased stability is susceptible to the fracture pattern of the tibia, fixation strategy for the tibia, fixation strategy for the fibula, and loading pattern of the entire construct. Clinical studies examining fibular fixation in patients with concomitant distal third tibia fractures have also not been definitive in their conclusions. Fibular fixation may improve the ability to obtain and maintain reduction in complex fractures of the distal tibia, but as a result of the increased stability of the construct, may also increase rates of nonunion in this challenging patient population.

Role of the fibula in the stability of diaphyseal tibial fractures fixed by intramedullary nailing

BACKGROUND

For tibial fractures, the decision to fix a concomitant fibular fracture is undertaken on a case-by-case basis. To aid in this clinical decision-making process, we investigated whether loss of integrity of the fibula significantly destabilises midshaft tibial fractures, whether fixation of the fibula restores stability to the tibia, and whether removal of the fibula and interosseous membrane for expediency in biomechanical testing significantly influences tibial interfragmentary mechanics.

METHODS

Tibia/fibula pairs were harvested from six cadaveric donors with the interosseous membrane intact. A tibial osteotomy fracture was fixed by reamed intramedullary (IM) nailing. Axial, torsion, bending, and shear tests were completed for four models of fibular involvement: intact fibula, osteotomy fracture, fibular plating, and resected fibula and interosseous membrane.

FINDINGS

Overall construct stiffness decreased slightly with fibular osteotomy compared to intact bone, but this change was not statistically significant. Under low loads, the influence of the fibula on construct stability was only statistically significant in torsion (large effect size). Fibular plating stiffened the construct slightly, but this change was not statistically significant compared to the fibular osteotomy case. Complete resection of the fibula and interosseous membrane significantly decreased construct torsional stiffness only (large effect size).

INTERPRETATION

These results suggest that fixation of the fibula may not contribute significantly to the stability of diaphyseal tibial fractures and should not be undertaken unless otherwise clinically indicated. For testing purposes, load-sharing through the interosseous membrane contributes significantly to overall construct mechanics, especially in torsion, and we recommend preservation of these structures when possible.

Outcomes After Intramedullary Nailing of Distal Tibial Fractures

OBJECTIVES

To determine outcomes in the treatment of distal tibial fractures treated with intramedullary nails.

DESIGN

Retrospective analysis.

SETTING

Level I trauma center with follow-up in a private orthopaedic practice.

MAIN OUTCOME MEASUREMENTS

Radiographic determination of alignment, nonunion, and malunion, clinical outcome (range of motion, and implant-associated complaints), wound complications, and fibular fixation.

PATIENTS

A total of 105 patients with OTA/AO type A and C tibial fractures (<11 cm from the joint line) treated with intramedullary nailing.

RESULTS

Distance of the fracture from the joint line averaged 6.1 cm (range, 0-11). Mean follow-up was 25.6 months (range, 12-74). Nonunion occurred in 20 (19%) fractures and were significantly associated with open fractures (P = 0.012), wound complications (P < 0.001), and the need for fibular fixation (P = 0.007). Sagittal plane alignment averaged 2.5 degrees (±4.4) valgus. Malunion occurred in 25 (23.8%) fractures and again were significantly associated with open fractures (P = 0.045). Fifty (47.6%) patients had implant-related pain, which resolved in 27 (54.0%) after removal.

CONCLUSIONS

Intramedullary nailing of distal tibial fractures is a suitable treatment option. Acceptable alignment and range of motion can be achieved. Both nonunions and malunions were significantly associated with open fractures, wound complications, and fibular fixation. Implant removal was needed in 25% of cases.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Management of fractures of the distal third tibia by minimally invasive plate osteosynthesis - A prospective series of 50 patients

BACKGROUND

Minimally invasive plate osteosynthesis (MIPO) is an established technique for fixation of fractures of the distal third tibia. Our study aimed to manage intra articular and extraarticular fractures of the distal third tibia by the minimally invasive plate osteosynthesis technique and follow them prospectively. Clinical and radiological outcomes were studied and clinical indications & efficacy of the procedure reviewed. Though many studies on the subject have been done previously, these have been retrospective reviews or small series.

METHODS

From May 2010 to May 2013, 50 patients of closed distal tibial fractures were operated by MIPO technique with a distal tibial anatomical locking plate having 4.5/5 proximal and 3.5/4 distal screw holes. The follow up duration was for 3 years.

RESULTS

The mean fracture healing time was 21.4 weeks (range 16-32 weeks) and average AOFAS score 95.06 was out of a total possible 100 points. At last follow up, superficial infection occurred in 5 patients (10%); deep infection, implant failure and malunion in 1-patient each (2%).

CONCLUSION

MIPO technique provides good, though slightly delayed bone healing and decreases incidence of nonunion and need for bone grafting. This technique should be used in distal tibia fractures where locked nailing cannot be done like fractures with small distal metaphyseal fragments, vertical splits, markedly comminuted fractures and in fractures with intra-articular extension.

The influence of distal locking on the need for fibular plating in intramedullary nailing of distal metaphyseal tibiofibular fractures

Using human cadaver specimens, we investigated the role of supplementary fibular plating in the treatment of distal tibial fractures using an intramedullary nail. Fibular plating is thought to improve stability in these situations, but has been reported to have increased soft-tissue complications and to impair union of the fracture. We proposed that multidirectional locking screws provide adequate stability, making additional fibular plating unnecessary. A distal tibiofibular osteotomy model performed on matched fresh-frozen lower limb specimens was stabilised with reamed nails using conventional biplanar distal locking (CDL) or multidirectional distal locking (MDL) options with and without fibular plating. Rotational stiffness was assessed under a constant axial force of 150 N and a superimposed torque of ± 5 Nm. Total movement, and neutral zone and fracture gap movement were analysed.

In the CDL group, fibular plating improved stiffness at the tibial fracture site, albeit to a small degree (p = 0.013). In the MDL group additional fibular plating did not increase the stiffness. The MDL nail without fibular plating was significantly more stable than the CDL nail with an additional fibular plate (p = 0.008).

These findings suggest that additional fibular plating does not improve stability if a multidirectional distal locking intramedullary nail is used, and is therefore unnecessary if not needed to aid reduction.

Cite this article: Bone Joint J 2014;96-B:385–9.

To fix or not to fix? The role of fibular fixation in distal shaft fractures of the leg

BACKGROUND

The role of stabilisation of the fibula in distal two-bone fractures of the leg is controversial. Some studies indicate the need for fibular stabilisation in 43 AO fractures, but few studies consider the role of the fibula in 42 AO fractures. The aim of the current paper is to explain the role of stabilisation of the fibula in 42 AO fractures, correlating the rates of healing and non-union between patients with and without fibula fixation.

MATERIALS AND METHODS

A total of 60 patients with 42 AO (distal) shaft fracture of the tibia with associated fracture of the fibula were selected. Patients were divided into two groups according to whether or not the fibula was fixed: Group I (n=26) comprised patients who had their fibula fixed while Group II (n=34) comprised patients who did not. The fibular fracture was classified according to the AO and related to the level of the tibial fracture. Other parameters examined were the union rate of the two groups correlated to the fracture pattern and position of the fibular fracture; the demographic data, such as age and gender; the presence of an open fracture, and the type of tibial fixation device used (nail or plate).

RESULTS

None of the parameters considered (open injury, AO classification, device used and level of the fibular fracture relative to the tibial) were shown to have an influence on the development of a non-union.

CONCLUSION

This study showed a higher non-union rate when the fracture of the tibia and fibula were at the same level, the tibia was fixed with a bridging plate and the fibula left untouched. For this reason, we recommend fibular fixation in all 42 distal fractures when both fractures lie on the same plane and the tibial fracture is relatively stabilised.

The role of fibular fixation in the treatment of tibia diaphysis distal third fractures

INTRODUCTION

Combined fractures of the distal third of tibia diaphysis and fibula diaphysis are a common orthopedic injury. There is an ongoing debate about the necessity of fibular fixation when associated to distal third tibial fracture. This study aims at evaluating the role of fibular fixation in the treatment of distal third tibial fractures.

HYPOTHESIS

We hypothesized that fixation of the fibula increases the stability of fixation in distal third tibial and fibular fractures.

MATERIALS AND METHODS

In a randomized clinical trial, 53 patients with concomitant fractures of tibia and ipsilateral fibula at distal third level were recruited in this study during a 23-month period. Patients were randomized in two groups: patients with fibular fixation (case group) and without fibular fixation (control group). The patients were followed up for at least 6 months postoperatively.

RESULTS

There were seven cases exhibiting malalignment on immediate postoperative radiographs. Six of them were in group II (control group) and one was in group I (case group) (P=0.084). We didn't find nonunion in group I and we found three patients in group II (P=0.141). Infection was one in group I and two in group II on gustillo II injuries (P=0.516).

CONCLUSION

Despite its low count of patients, our study didn't show any advantage to fix the fibula fracture associated to distal third of tibia diaphysis fracture. It didn't show either an increase of complication after fibula open reduction and internal fixation.

LEVEL OF EVIDENCE

Level III. Randomized prospective study.

Surgical treatment of open pilon fractures

OBJECTIVE

To discuss the methods, timing and clinical outcomes of surgical treatment for open pilon fractures.

METHODS

From April 2003 to July 2008, 28 patients with open pilon fractures were treated. All had type C fractures according to the Arbeitsgemeinschaft für osteosynthesefragen-Association for the Study of Internal Fixation (AO/ASIF) classification. Three operative methods were applied, the methods being determined by the types of fracture, soft tissue damage and time interval after injury. Seven cases were treated by debridement and internal fixation with plate; 19 by limited internal fixation combined with external fixation; and 2 by delayed surgery. The clinical outcomes were evaluated by the Burwell-Charnley score.

RESULTS

All cases were followed up for from 6 to 48 months (average 24 months). The Burwell-Charnley score of clinical outcomes: anatomic reduction achieved in 12 cases, functional reduction in 15, and unsatisfactory reduction in 1. The healing time was from 2.5 to 11 months (average 4.7 months). Two cases had delayed union. According to the American Orthopaedic Foot and Ankle Society (AOFAS) scale for the ankle joint, there were excellent results in 8 cases, good in 14, fair in 5 and poor in 1. Complications included four cases of skin superficial sloughing, two of superficial infection, one of deep infection, two of delayed fracture union and ten of post-traumatic arthritis.

CONCLUSION

It is important to perform appropriate surgeries for open pilon fracture according to fracture classification, different damage to skin and tissue and time interval after injury. Thorough debridement, proper use of anti-infective medication, appropriate bone grafting, and postoperative ankle function exercise can reduce the occurrence of complications.

Posteromedial anatomical plate for the treatment of distal tibial fractures with anterior soft tissue injury

The treatment of distal tibial fractures with anterior soft tissue injury is relatively difficult. The aim of this study was to explore the efficacy and safety of the posteromedial anatomical plate for such fractures. Between February 2006 and January 2009, twenty-six cases of distal tibial fracture with anterior soft tissue injury were treated with posteromedial anatomical plates designed by our traumatic orthopedic center. Of the 26 cases, 12 were open fractures (4 Gustilo-Anderson type I, 5 type II, 2 type IIIA, and 1 type IIIB), and 14 were closed fractures (3 Tscherne-Oestern type I, 9 type II, 2 type III). Operation time, intraoperative blood loss, fracture healing time, American Orthopaedic Foot and Ankle Society (AOFAS) ankle score, and complications were recorded to evaluate treatment effects.Mean operation time was 72.5 ± 15.8 minutes (range, 45-105 minutes) with a mean intraoperative blood loss volume of 86.4 ± 17.3 mL (range, 50-150 mL). All 26 patients had good postoperative fracture healing. Mean union time was 19.2 ± 4.4 weeks (range, 13-30 weeks). Average AOFAS ankle score was 87.3 ± 9.2 (range, 68-99). No malunion, nonunion, limb-shortening deformity, or neurovascular injury occurred. Our results suggest that the posteromedial anatomical plate for the treatment of distal tibial fractures with anterior soft tissue injury is effective and results in no severe complications.

Distal quarter leg fractures fixation: The intramedullary nailing alone option

INTRODUCTION

Intramedullary (IM) nailing is the classical treatment for diaphyseal fractures of the tibia. Stabilizing fractures of the distal quarter is recognized as being delicate. We report a continuous, multicenter prospective study of distal tibia-fibula fractures treated with anterograde intramedullary nailing.

HYPOTHESIS

The working hypothesis was to identify the problems encountered with IM nailing alone of distal leg fractures.

PATIENTS AND METHODS

From May 2007 to November 2008, 51 fractures in 51 patients (19 females and 32 males; mean age, 46.2 years [range, 17-93 years]) were treated with IM nailing. The fractures were classified according to the association pour l'ostéosynthèse (AO) classification, with most type A1 (29/51). Thirteen fractures presented a distal articular extension treated with screws in five cases. Fixation consisted in intramedullary nailing, reamed in all cases, performed on a standard or orthopaedic surgery table. Nailing was static and distally locked (50/51). The patients were evaluated clinically and radiologically, with AP and lateral images of both legs and the Olerud score.

RESULTS

We report one death and eight patients lost to follow-up, providing 42 cases to reviewing at 1 year. The bone union rate was 97.6% in a mean 15.7 weeks. Immediately after surgery, 14 axial deviations greater than 5° were observed, mainly valgus, with only one greater than 10°. The absence of fibular fixation was the only identifiable risk factor for appearance of an initial axial deviation as well as fracture instability over time. Two infections were observed and at 6 months four secondary displacements, one of which can be explained by changing the distal locking due to infection. Four dynamizations were performed. No other risk factor was found. The mean Olerud functional score at 12 months was 83.5 points.

DISCUSSION

The clinical results are comparable to those reported in the literature. From a radiological point of view, the rates and times to bone union were identical. However, the rates of malunion were clearly higher. The risk factors for malunion found in the literature are metaphyseal enlargement, fracture comminution, a too distal location of fracture site, young patient age, patient installation on a standard operating table, and technical errors. The absence of supplementary fibular fixation, the subject of debate in the literature, was the only statistically significant point found in the present study. Nailing distal fractures of the leg provides good clinical results. However, with regard to the malunion rates, the technique must be precise and rigorous. We recommend systematic fibular fixation and use of an orthopaedic table.

LEVEL OF EVIDENCE

Level IV; cohort type prospective study.