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

The role of fibula fixation in combined distal-third tibia and fibula fractures: a systematic literature review

OBJECTIVE

The role of concomitant fibula fracture fixation in distal-third tibia fractures regarding alignment, union, and functional outcome is still a topic of debate. In this review, we summarize the available comparative literature regarding fibula fixation in distal third lower leg fractures.

MATERIALS AND METHODS

A systematic literature review of articles published between January 2000 and January 2022 in the PubMed, Cochrane, and EMBASE databases about this topic was performed.

RESULTS

746 unique studies were identified of which four randomized-controlled trials and six retrospective studies were included. Nine studies compared alignment after tibia fixation with or without fibula fixation, six studies reported on tibial union, and three studies reported on functional outcome between groups. Pooling of data was not possible due to varying outcome measures and inclusion criteria. Fibula fixation was associated with less rotational malalignment, while there does not seem to be consensus regarding the effect on sagittal and coronal alignment. Six studies reported on the effect of fibula fixation on tibial union. None of these studies found a significant difference between treatment modalities. Furthermore, one out of three studies reporting functional outcome described a marginal beneficial functional outcome after fibula fixation. Ultimately, no differences in complication rates between treatment modalities were described.

CONCLUSION

Fixation of the fibula in distal-third lower leg fractures does not seem to have a significant effect on coronal and sagittal tibial alignment. Furthermore, fibula fixation is associated with significantly less rotational malalignment, although the clinical importance of this finding is questionable as true differences in rotational alignment between treatment modalities are small. Finally, fibula fixation does not affect union, functional outcome, or complication rate as adjuvant to tibia fixation.

LEVEL OF EVIDENCE

II.

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.

Fibular fixation in mid and distal extra-articular tibia fractures - A systematic review and meta-analysis

BACKGROUND

The surgical management of extra-articular mid and distal tibia fractures has primarily focused on reducing rates of non-union and malunion, preserving hip-knee-ankle alignment and improving functional outcomes. Fibular fractures commonly accompany these injuries and the contributory role of fixation of these fractures has been increasingly studied. A systematic review and meta-analysis were performed to determine whether concurrent fibular fixation (FF) during extra-articular mid and distal tibia fracture fixation (AO/OTA 42 and 43-A) altered the risk of malunion, non-union and post-operative complications when compared to no fibular fixation (NF).

METHODS

A systematic search of literature in the databases of MEDLINE (via OvidSP), PubMed, Embase and Cochrane Central Register of Controlled Trials (CENTRAL) from the dates of inception was performed for randomised and non-randomised controlled trials. All studies published in English were included. Risk of Bias in Non-randomised Studies (ROBINS-I) and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework were utilised. Relative risk (RR) was used for dichotomous outcomes, while mean difference (MD) was used for continuous variables, with 95% confidence intervals. Alpha was set at 0.05.

RESULTS

A total of ten studies with 1174 patients were included for analysis. There was a statistically significant reduced risk of overall malunion in the FF group compared to the NF group (11.8% vs 21.9%, RR 0.63, 95% CI: 0.41-0.98, p = 0.04) and this was supported through a sensitivity analysis of only randomised controlled trials (21.8% vs 40.3%, RR 0.37, 95% CI: 0.18-0.76, p = 0.006). There was no statistically significant difference in rates of non-union between groups (p > 0.05). Overall, there were similar incidences of diabetes, open fractures and smoking history between groups (p > 0.05). Detailed information regarding methods of tibial fixation were not available for subgroup analysis.

CONCLUSION

In conclusion, in extra-articular mid and distal tibia (AO/OTA 42 and 43-A) fracture fixation, additional fibular fixation (FF) appears to significantly reduce the risk of overall malunion (RR, 0.37, 95% CI: 0.18-0.76, p = 0.006) without increasing the risk of non-union. These results should be interpreted with caution given the lack of subgroup analysis for methods of tibial fixation. Future high-quality randomised controlled trials should therefore delineate between types of tibial fixation.

Fibular fixation improves ankle functional outcomes and alignment in the intramedullary nailing of distal third tibiofibular diaphyseal fractures

PURPOSE

The study aims to determine the effect of fibular fixation on alignment and fracture healing of tibia, and ankle functional outcomes in the treatment of distal third tibiofibular diaphyseal fractures.

METHODS

Consecutive 111 patients (33 females and 78 males) with distal third tibiofibular diaphyseal fracture who met the inclusion criteria were included in the study. Patients were divided into two groups as those who underwent fibular fixation with tibia intramedullary nailing (study group) and those who did not (control group). Groups were compared in terms of demographic features, trauma and fracture characteristics, functional and radiological outcomes.

RESULTS

No significant difference was observed between the groups in terms of demographic features, trauma characteristics, complications, and follow-up time (p > 0.05). Surgery time was significantly lower in the control group (p = 0.001). Ankle joint range of motion, AOFAS score, OMAS score, and full weight-bearing time were significantly better in the fibular fixation group (p = 0.023, p = 0.001, p = 0.001 and p = 0.039, respectively). Significantly better coronal alignment and sagittal alignment were found in the fibular fixation group (p = 0.001 and p = 0.001, respectively). Patients who underwent fibular fixation had significantly better radiological outcomes in terms of fibular rotation angle and ankle arthrosis (p = 0.000 and p = 0.022, respectively).

CONCLUSION

Fibular fixation not only contributes to fracture union, early full weight-bearing, and alignment but also improves ankle functional outcomes in the distal third tibiofibular fractures treated with intramedullary nailing for tibia.

LEVEL OF EVIDENCE

Level III, retrospective study.

Mathematical Modelling of Destabilization Stress Factors of Stable-Elastic Fixation of Distal Trans- and Suprasyndesmotic Fibular Fractures

Introduction

Specification of possible stress factors destabilizing the fibula stable osteosynthesis by the intramedullary nail with distal blocking and elastic fixation of distal syndesmosis by the thread with endobuttons by mathematical modelling of distal unstable ankle injuries. Material and Methods. We studied the thread tension during the combined stable-elastic fixation of unstable injuries of the ankle joint in cross-syndesmosis fractures of the fibula (B, C Danis–Weber classification), which includes a one-time stable minimally invasive fixation with the intramedullary nail and elastic fixation by the thread with endobuttons. We used a titanium alloy for the intramedullary nail and polyester for the thread. The deformed state was studied using the methods of mechanics.

Results

A model of a fractured fibula blocked with the intramedullary nail and fixed with the elastic thread was developed. A formulation to specify the rational tension forces of the elastic thread depending on the parameters of the fibula and intramedullary blocking nail and on the location of the bone injury was obtained. The effect of foot rotation on the thread tension was investigated. The results of theoretical research should be implemented in medical practice.

Conclusions

A mathematical model of the damaged fibula blocked by the intramedullary nail and fixed with the elastic thread was developed. Dependences for calculation of tension of the fixing thread were obtained. A slight increase in thread tension during foot rotation was found.

Osteosynthesis or non-operative treatment of the fibula for distal lower-leg fractures with tibial nailing: a systematic review and meta-analysis

Fibular fixation to treat distal lower-leg fractures is a controversial intervention. To ensure better stability itself, better rotational stability, and to prevent secondary valgus dislocation – all these are justifications for addressing the fibula via osteosynthesis. High surgical costs followed by increased risks are compelling reasons against it. The purpose of this study was to systematically review the literature for rates of malunion and malrotation, as well as infections and nonunions.

We conducted a systematic review searching the Cochrane, PubMed, and Ovid databases. Inclusion criteria were modified Coleman Methodology Score (mCMS) > 60, a distal lower-leg fracture treated by nailing, and adult patients. Biomechanical and cadaver studies were excluded. Relevant articles were reviewed independently by referring to title and abstract. In a meta-analysis, we compared five studies and 741 patients.

A significantly lower rate of valgus/varus deviation is associated with fixation of the fibula (OR = 0.49; 95% CI: 0.29–0.82; p = .006). A higher risk for pseudarthrosis was revealed when the fibula underwent surgical therapy, but not significantly (OR = 1.46; 95% CI: 0.76–2.79; p = .26). Nevertheless, we noted an increased risk of postoperative wound infection following fibular plating (OR = 1.90; 95% CI: 1.21–2.99; p = .005). There was no statistically significant difference in the rate of nonunions between the two groups.

Overall, the stabilization of the fibula may reduce secondary valgus/varus dislocation in distal lower-leg fractures but is associated with an increased risk of postoperative wound infections. The indication for fibula plating should be made individually.

Cite this article: EFORT Open Rev 2021;6:816-822. DOI: 10.1302/2058-5241.6.210003

Concomitant Distal Tibia-Fibula Fractures Treated with Intramedullary Nailing, With or Without Fibular Fixation: A Meta-Analysis

There is no consensus on whether a fibular fracture should be fixed when a concurrent extra-articular distal tibia fracture is managed with intramedullary nails. We evaluated the use of fibular fixation in a meta-analysis of randomized trials and observational studies. Two researchers independently assessed the quality of eligible studies and extracted the data. We analyzed 4 trials with a pooled sample of 283 patients (mean age, 24 to 43 years; 141 men), 94 who had undergone fibular fixation and 189 who had not. Two randomized trials assessed on the Cochrane risk-assessment criteria were determined to have a moderate risk of bias, and 2 retrospective cohort studies evaluated with the Newcastle-Ottawa Scale were considered to be high quality. Tibia malalignment at follow-up times ranging from 12 to 72 weeks was reported in 20% (19/94) of patients in the fibular-fixation group and 67% (126/189) of patients in the nonfixation group, indicating that fibular fixation was significantly associated with a lower risk of malalignment (risk ratio, 0.34; 95% confidence interval [CI] 0.13 to 0.92; p = .03). The groups did not differ in the proportion of patients with malalignment immediately after surgery, delayed union, nonunion, or infection. When distal extra-articular tibia-fibular fractures are treated with intramedullary nails, fibular fixation may decrease the risk of late malalignment. Further randomized controlled trials with higher quality are required to verify the result.

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.

Prevalence and influencing factors of nonunion in patients with tibial fracture: systematic review and meta-analysis

OBJECTIVE

The aim of this study is to assess the prevalence of nonunion in patients with tibia fracture and the association between influencing factors and tibia fracture nonunion.

METHOD

A database searches of PubMed, the Cochrane Library, EMBASE, China National Knowledge Infrastructure (CNKI), Weipu database, and Wanfang database from inception until June 2019 was conducted. The pooled prevalence, odds ratio (OR), and 95% confidence intervals (CI) were calculated with Stata software.

RESULTS

In this study, 111 studies involving 41,429 subjects were included. In the study of the relationship between influencing factors and tibia fracture nonunion, 15 factors significantly influenced the fracture union, including > 60 years old, male, tobacco smoker, body mass index > 40, diabetes, nonsteroidal anti-inflammatory drugs (NSAIDs) user, opioids user, fracture of middle and distal tibia, high-energy fracture, open fracture, Gustilo-Anderson grade IIIB or IIIC, Müller AO Classification of Fractures C, open reduction, fixation model, and infection.

CONCLUSION

The prevalence of nonunion in patients with tibia fracture was 0.068 and 15 potential factors were associated with the prevalence. Closed reduction and minimally invasive percutaneous plate osteosynthesis (MIPPO) have the low risks of nonunion for the treatment of tibial fractures.

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.

Measuring outcomes following tibial fracture

AIM

The aim of this study was to determine how outcome is measured following adult tibial fracture in the modern era of functional outcome measurement and patient reported outcomes.

METHODS

A systematic review of publications since 2009 was performed, looking specifically at acute, adult tibial shaft fractures. Ovid Medline, Embase, PubMed and PsycINFO databases were searched for relevant titles which were then screened by two authors with adjudication where necessary by a third. Relevant articles were reviewed in full and data was extracted concerning the study participants, study design and any measures that were used to quantify the results following fracture. The results were collated and patient reported outcome measures were assessed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) standards.

RESULTS

A total of 943 titles and articles were reviewed, with 117 included for full analysis. A wide range of clinical and radiological "outcomes" were described, along with named clinician- and patient-reported outcome measures. There was considerable heterogeneity and lack of detail in the description of the simplest outcomes, such as union, infection or reoperation. Reported clinician and patient reported outcome measures are variably used. None of the identified patient reported outcome measures have been validated for use following tibial fracture.

CONCLUSION

We recommend definition of a core outcome set for use following tibial fracture. This will standardise outcome reporting following these injuries. Furthermore, there is need for a validated patient reported outcome measure to better assess patient important outcomes in this patient group.

Treatment of distal tibial fractures: prospective comparative study evaluating two surgical procedures with investigation for predictive factors of unfavourable outcome

PURPOSE

The aim of this study is to compare clinical and radiological outcome of intramedullary nailing (IMN) and locked plate (LP) in patients affected by fracture of the distal tibia (DTF). We performed also an analysis to identify predictive factors of unfavourable outcome.

METHODS

Data about patients with DTF treated at our first level trauma centre between 2008 and 2017 were collected. Patients were divided in group 1 (IMN) and group 2 (LP). The inclusion criteria were age at least 18 years at the time of diagnosis and unilateral DTF (closed or Gustilo 1). Demographic variables and data related to surgical procedure and hospitalization were registered. X-ray at follow-up was reviewed to identify malunions and nonunions. Clinical outcome was evaluated using scores and registering any complication.

RESULTS

One hundred two patients were included in group 1 and 81 in group 2. In group 2 were documented higher operating time and hospitalization. The mean union time was 20.2 weeks for IMN and 24.8 weeks for LP group (p = 0.271). The rate of infections and wound complications was higher in group 2 while malunion and anterior knee pain were more frequent in group 1. No difference in scores for clinical outcome was documented after six months. The full-weight bearing time was significantly longer in the LP group (p = 0.019). At multivariate analysis, no variables showed a predictive power for unfavourable outcome.

CONCLUSIONS

Clinical and radiological results of LP and IMN appear similar. No predictive factors of unfavourable outcome were identified.

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.

The Role of Fibular Fixation in the Treatment of Combined Distal Tibia and Fibula Fracture: A Randomized, Control Trial

Background:

This randomized, parallel-group, non-blinded study was designed to determine the role of fibular fixation in the treatment outcomes of combined distal tibia and fibula fractures.

Materials and Methods:

Sixty patients with distal tibial and fibular fractures were randomly divided in two groups of case and controls. In the case group, fibula was fixed prior to the fixation of tibia. In the control group, tibia was fixed without fibular fixation. Primary outcomes were varus–valgus angulation, anterior–posterior angulation, union and side effects. Follow-up visit and radiographs were taken 2 and 4 weeks as well as 3, 6 and 9 months after surgery.

Results:

During the follow-up, 11 out of 60 patients in case and control groups were excluded. We recruited 24 and 25 patients in the case and control group, respectively. Intramedullary nailing was used in 8 patients of case and 11 patients of control group. Plate and screw were used in 16 patients in the case and 14 patients in the control group. Varus/valgus and anterior–posterior angulation were not statistically significant between two groups (P ≥ 0.05). The frequency of tibial and fibula union after 1, 3, 6 and 9 months in case and controls groups were not statistically significant (P ≥ 0.05). The frequency of nonunion of tibia and fibula, infection and nerve injury in studied groups were not statistically significant (P ≥ 0.05).

Conclusion:

We did not observe any significant improvement using fibular fixation in the treatment outcomes of tibia distal fractures.

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.

Extra-articular distal tibia facture (AO-43A): A retrospective study comparing modified MIPPO with IMN

PURPOSE

We introduce a new MIPPO procedure which is simple and effective for the treatment of extra-articular distal tibia facture (AO-43A). The aim of this retrospective study was to compare our modified MIPPO with IMN.

MATERIALS AND METHODS

This retrospective study included 64 patients treated with our modified MIPPO and 61 patients with IMN. The data of sex, age, operation time, blood loss, wound complications, mal-reduction, shortening and fracture healing was analyzed.

RESULTS

The operation time was significantly shorter in the MIPPO group than in the IMN group (56.0min vs. 85.0min, P<0.001). There were 5 patients (8.2%) in the IMN group and 2 patients (3.1%) in the MIPPO group who had wound complications (P=0.399). Mal-reduction occurred in 17 patients (27.9%) managed with IMN and in 3 patients (4.7%) who had MIPPO (P<0.001). Furthermore, no patients had a left/right difference in the length of the tibia of >1cm and nonunion in both groups.

CONCLUSIONS

Our results have shown that our modified MIPPO has enormous advantages over IMN for extra-articular distal tibia fracture (AO-43A).

Minimally invasive surgical technique: Percutaneous external fixation combined with titanium elastic nails for selective treatment of tibial fractures

INTRODUCTION

Several techniques have been described to treat tibial fractures, which respectively remains defects. This article presents a novel intra- and extramedullary fixation technique: percutaneous external fixator combined with titanium elastic nails (EF-TENs system). The purpose of this study is to introduce this new minimally invasive surgical technique and selective treatment of tibial fractures, particularly in segmental fractures, diaphysis fractures accompanied with distal or proximal bone subfissure, or fractures with poor soft-tissue problems.

METHODS

Following ethical approval, thirty-two patients with tibial fractures were treated by the EF-TENs system between January 2010 and December 2012. The follow-up studies included clinical and radiographic examinations. All relevant outcomes were recorded during follow-up.

RESULTS

All thirty-two patients were achieved follow-ups. According to the AO classification, 3 Type A, 9 Type B and 20 Type C fractures were included respectively. According to the Anderson-Gustilo classification, there were 5 Type Grade II, 3 Type Grade IIIA and 2 Type Grade IIIB. Among 32 patients, 8 of them were segmental fractures. 12 fractures accompanied with bone subfissure. Results showed no nonunion case, with an average time of 23.7 weeks (range, 14-32 weeks). Among them, there were 3/32 delayed union patients and 0/32 malunion case. 4/32 patients developed a pin track infection and no patient suffered deep infection. The external fixator was removed with a mean time of 16.7 weeks (range, 10-26 weeks). Moreover, only 1/32 patient suffered with the restricted ROM of ankle, none with the restricted ROM of knee.

CONCLUSION

This preliminary study indicated that the EF-TENs system, as a novel intra- and extramedullary fixation technique, had substantial effects on selective treatment of tibial fractures.

Treatment of distal intraarticular tibial fractures: A biomechanical evaluation of intramedullary nailing vs. angle-stable plate osteosynthesis

In factures of the distal tibia with simple articular extension, the optimal surgical treatment remains debatable. In clinical practice, minimally invasive plate osteosynthesis and intramedullary nailing are both routinely performed. Comparative biomechanical studies of different types of osteosynthesis of intraarticular distal tibial fractures are missing due to the lack of an established model. The goal of this study was first to establish a biomechanical model and second to investigate, which are the biomechanical advantages of angle-stable plate osteosynthesis and intramedullary nailing of distal intraarticular tibial fractures. Seven 4(th) generation biomechanical composite tibiae featuring an AO 43-C2 type fracture were implanted with either osteosynthesis technique. After primary lag screw fixation, 4-hole Medial Distal Tibial Plate (MDTP) with triple proximal and quadruple distal screws or intramedullary nailing with double proximal and triple 4.0mm distal interlocking were implanted. The stiffness of the implant-bone constructs and interfragmentary movement were measured under non-destructive axial compression (350 and 600 N) and torsion (1.5 and 3Nm). Destructive axial compression testing was conducted with a maximal load of up to 1,200 N. No overall superior biomechanical results can be proclaimed for either implant type. Intramedullary nailing displays statistically superior results for axial loading in comparison to the MDTP. Torsional loading resulted in non-statistically significant differences for the two-implant types with higher stability in the MDTP group. From a biomechanical view, the load sharing intramedullary nail might be more forgiving and allow for earlier weight bearing in patients with limited compliance.

Size matters: The influence of the posterior fragment on patient outcomes in trimalleolar ankle fractures

INTRODUCTION

Ankle fractures are increasing in incidence. The more complicated the lesion is, the higher the risk of developing posttraumatic arthrosis. Severe posttraumatic arthrosis results in a reduced quality of life. Therefore, the treatment of a trimalleolar fractures is crucial. However, the treatment guidelines for posterior malleolar fractures (PMF) are still based on recommendations from 1940. Only a few retrospective studies have been conducted, which analysed patient outcomes based on lateral X-rays of the ankle. The purpose of this retrospective analysis was to survey patient outcomes in relation to the size of the PMF on the basis of CT-scans.

METHODS

We retrospectively examined 42 patients with trimalleolar fractures with an average follow-up of 2.5 years. Twenty-four patients (57%) received a CT scan of the ankle joint. The radiologic images were analysed for the size of the PMF and the involvement of the joint surface using lateral X-rays and available CT images. We examined all 42 patients clinically and radiologically, and estimated the grade of arthrosis of the ankle in accordance with the Bargon Score and assigned AOFAS Scores for each patient. We divided our patients into different groups according to the size of their PMF and evaluated patient outcomes in accordance with the compiled data first on the basis of X-ray data and then on the basis of CT data.

RESULTS

Comparing the measurement results by two different radiologic methods revealed that CT results in a more precise determination of PMF size in contrast to lateral X-rays, by which measurements were generally overrated. The statistical evaluation of our data demonstrated that patients with an osteosynthesis of the PMF and a PMF size of >25% showed signs of posttraumatic arthrosis but had better outcomes in accordance to the AOFAS score. All results were not significant.

CONCLUSION

An exact evaluation of CT images of posterior malleolar fractures in patients with trimalleolar ankle fractures is crucial for the decision to perform an osteosynthesis of the PMF and, therefore, an analysis of patient outcomes. The results of previous studies should be evaluated cautiously due to missing CT data. To date, this is the largest retrospective patient series of patient outcomes based on CT data.

Analysis of 213 currently used rehabilitation protocols in foot and ankle fractures

INTRODUCTION

Fractures of the ankle, hind- and midfoot are amongst the five most common fractures. Besides initial operative or non-operative treatment, rehabilitation of the patients plays a crucial role for fracture union and long term functional outcome. Limited evidence is available with regard to what a rehabilitation regimen should include and what guidelines should be in place for the initial clinical course of these patients. This study therefore investigated the current rehabilitation concepts after fractures of the ankle, hind- and midfoot.

METHODS

Written rehabilitation protocols provided by orthopedic and trauma surgery institutions in terms of recommendations for weight bearing, range of motion (ROM), physiotherapy and choice of orthosis were screened and analysed. All protocols for lateral ankle fractures type AO 44A1, AO 44B1 and AO 44C1, for calcaneal fractures and fractures of the metatarsal as well as other not specific were included. Descriptive analysis was carried out and statistical analysis applied where appropriate.

RESULTS

209 rehabilitation protocols for ankle fractures type AO 44B1 and AO 44C1, 98 for AO 44A1, 193 for metatarsal fractures, 142 for calcaneal fractures, 107 for 5(th) metatarsal base fractures and 70 for 5(th) metatarsal Jones fractures were evaluated. The mean time recommended for orthosis treatment was 6.04 (SD 0.04) weeks. While the majority of protocols showed a trend towards increased weight bearing and increased ROM over time, the best consensus was noted for weight bearing recommendations.

CONCLUSION

Our study shows that there exists a huge variability in rehabilitation of fractures of the ankle-, hind- and midfoot. This may be contributed to a lack of consensus (e.g. missing publication of guidelines), individualized patient care (e.g. in fragility fractures) or lack of specialization. This study might serve as basis for prospective randomized controlled trials in order to optimize rehabilitation for these common fractures.