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

Torino, Daniel MD; Mehta, Samir MD

doi: 10.1097/BOT.0000000000000695
Supplement Article

Summary: 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.

*Department of Surgery, Hospital of University of Pennsylvania, Surgery, Philadelphia, PA; and

Department of Orthopaedic Surgery, Penn Orthopaedic Institute, Orthopaedic Trauma and Fracture Service, Penn Presbyterian Medical Center, Philadelphia, PA.

Reprints: Samir Mehta, MD, Department of Orthopaedic Surgery, Penn Orthopaedic Institute, Orthopaedic Trauma and Fracture Service, Penn Presbyterian Medical Center, 3737 Market St, Suite 600, Philadelphia, PA 19104 (e-mail:

The authors report no conflict of interest.

Accepted August 15, 2016

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Distal tibia fractures with associated fibular fractures can result from high-energy trauma such as motor vehicle accidents or low-energy torsional injuries. Treatment of distal tibia fractures is challenging because of the limited soft tissue envelope, subcutaneous location of the bone, poor vascularity, and limited opportunities for surgical incisions.1 Nonsurgical treatment may be recommended for stable minimally displaced fractures or in those not amenable for surgery. Historically, surgical treatment was achieved by casting, external fixation, or open reduction with internal fixation (ORIF) with plates and screws. However, alternative fixation strategies such as intramedullary nailing (IMN) and minimally invasive percutaneous plate osteosynthesis (MIPPO) have been developed to limit complications associated with these previous techniques. Comminution, soft tissue injury, and fracture displacement are often cited as factors best correlated with complications of distal tibia fractures. The most common complications include delayed or nonunion, malunion, infection, reflex sympathetic dystrophy, and posttraumatic arthritis for intraarticular injuries.2 For any fracture, the goals of treatment are obtaining length, proper axial alignment, rotational stability, and restoration of anatomic surfaces for articulation.3 A consensus for the utilization of fibular fracture fixation at the time of distal tibia fracture treatment does not exist and remains a heavily debated topic. The purpose of this article is to review the current literature regarding the role of fibular fixation in the setting of a distal tibia fracture with respect to aiding reduction and providing stability versus increasing postoperative complications, specifically malunion and nonunion.

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A literature search was conducted in June 2016 to identify clinical studies in which patients underwent treatment of distal third tibia fracture with or without fibular fixation. The electronic databases of PubMed/MEDLINE, Cochrane Library, Embase, and Scopus were explored using the combination of the following keywords and variations using wildcard: “distal tibia fracture,” “fibula fixation,” “pilon,” “plafond,” and “fracture fixation.” No restriction in language and publication date was applied. Publications were requested via our biomedical library. All abstracts were reviewed by 2 independent readers (D.T. and S.M.). An article was found eligible when it concerned (1) distal tibia and fibula fractures, (2) fibular fixation versus lack of fibula fixation. Based on title and abstract, a list of full-text articles was created. Exclusion criteria were articles not in English or not amenable for conversion to English. Subsequently, a cross-reference check of all included articles was performed to search for additional relevant studies.

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Concurrent fibular fixation is indicated in distal metaphyseal fractures with syndesmotic injury. No consensus remains for adjunctive fibular fixation in distal metaphyseal fractures without a syndesmotic injury. The current literature is inconclusive on the matter of concurrent fibular fixation for extraarticular distal tibia fractures. Some suggest fixation is possibly unnecessary or even detrimental with emergence of interlocking IMN with standard 2 distal interlocking screws and MIPPO. Others strongly advocate fixation in patients with significant metaphyseal comminution or displacement to facilitate alignment, stability, initial reduction, and maintenance of reduction (Fig. 1).



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The surgical management of distal tibia fractures has significantly evolved over the past several decades. In 1969, precedent for fixation of the fibula associated with distal tibia intraarticular fractures (ie, pilon fractures) was established by Ruedi and Allgower,3 citing the following operative principles:

  1. Restitution of correct length of fibula
  2. Reconstruction of articular surface of tibia
  3. Cancellous bone autograft
  4. Medial support by buttress plate.

The study reported 74% excellent or good results when they reviewed 84 pilon fractures treated with ORIF. Experimental investigations since have demonstrated development of the aforementioned complications after failing to reduce such fibular fractures.4,5 In 1971, Lambert first described the weight-bearing function of the fibula, which assumes approximately 1/6 of the load applied to the knee and in addition assumes more weight-bearing stress with interosseous disruption.6–8

In an effort to avoid well-documented complications associated with open reduction internal fixation procedures and increased utilization of IMN with advanced techniques, the treatment of extraarticular distal tibia fracture and elementary intraarticular fracture patterns has evolved to include IMN. However, utilization of IMN of distal tibia fractures can be technically challenging because of the mismatch between the diameter of the intramedullary canal distally with the diameter of the IMN. Because of the inability to obtain an isthmus fit, fibular fixation was offered to create a more stable construct for reduction and prevention of malunion/nonunion. Malunion of the distal tibia leads to increased tibiotalar contact pressures, which can result in significant hindfoot and ankle stiffness. Disruption of anatomic and biomechanical joint integrity can result in significant articular degeneration and morbidity.

The role of concomitant fibular fixation during treatment of closed extraarticular distal tibia fractures and simple intraarticular distal tibia fractures remains unclear. Cadaveric biomechanical investigations designed to define the role adjunctive fibular fixation with tibial fixation have vastly contributed to this subject. In comparing intramedullary nail fixation to locked plating in the treatment of 43-A tibia fractures with concurrent same level fibula fractures, Strauss et al8 established that locked plates produced greater stability than intramedullary nails in vertical loading but less effective stabilization in cantilever bending. Furthermore, construct displacements significantly increased with cyclical loading after simulated fibular fracture was achieved through osteotomy. Therefore, the authors concluded that a distal tibia fracture with intact fibula improved fracture fixation stability in both fixation constructs. Lastly, the locked plate fixation specimens demonstrated increased stiffness in torsion after fibular osteotomy, lending to the conclusion that when the fibula cannot be adequately stabilized, locked plates confer greater mechanical stability than that of locked intramedullary nails.

When testing cadaveric tibia fractures with diaphyseal defects treated with external fixation, Morrison et al9 found significant resistance to deformation in axial loading without effect on torsional stiffness with fibular fixation, Weber et al10 demonstrated increased stability of the tibia fractures treated with external fixation with fibular plate fixation; however, the effect of fibular plate fixation on stability was mitigated if the tibia was fixed with an intramedullary device. Kumar et al11 performed a cadaveric study investigating the effect of fibular plate fixation on same level simulated distal fractures of the tibia and fibula, demonstrating that fibular plate fixation increased the initial rotational stability by decreasing axial rotation of distal metaphyseal fractures treated with IMN compared with that of tibia fractures treated with IMN alone when torque was applied to the tibial tubercle. There was no difference found in rotational stiffness between the treatment groups as the applied tibial torque increased. It was concluded that fibular plate fixation increased rotational stability in patients with distal tibia fractures with ipsilateral fibula fracture and may reduce the risk of valgus malunion. Comparable findings of increased rotational stability without improved stability with axial or angular loading were reported by Morin et al.12 These cadaveric studies infer fibular fixation improved construct stability and may aid in the reduction of 43-A fractures treated with IMN.

Teitz et al13 was one the first published series identifying this clinical dilemma, observing 23 patients greater than 20 years of age treated for lower tibial fractures with intact fibula. There was a 61% complication rate reported, including 22% delayed union, 4% nonunion, and 26% varus malunion of the fractured tibia. It was concluded that the intact fibula led to tibiofibular length discrepancy causing altered tibia/fibula strain patterns suggesting that inherent mechanics of intact fibula or anatomic fibular fixation may increase malunion, the latter of which has been described by Bhandari et al.14,15

The indication for fibular fixation has since been clearly elucidated in distal metaphyseal fractures with syndesmotic injury and pilon fractures.1,16,17 These findings were corroborated later by Varsalona et al and Lui et al.18–20 Similarly, Liu et al18 demonstrated the beneficial effect of fibular fracture ORIF in pilon fractures associated with ipsilateral fibular fractures. Of note, patients with syndesmotic instability were excluded. The fixation rate of fibula fractures with open reduction and plate fixation was higher than open reduction and pin fixation or closed reduction (P < 0.05). Adequate reduction was seen in 89 of the 98 (90.1%) patients. The adequate reduction rate showed no significant difference among the three treatment groups (92% vs. 91.3% vs. 88%, all P values > 0.05). The 3 groups were similar with respect to nonunions. However, closed reduction (n = 4, 16%) showed a trend of higher rate of distal tibia malunion than open reduction and plate fixation (n = 2, 4%) (P = 0.091). These data suggest that stable fibular fixation with open reduction and plate fixation may improve distal tibial alignment and may decrease pilon fracture malunion.

Previous series have determined that fibular fixation in the treatment of acute 43-A fractures facilitated reduction of tibial displacement and promoted mechanical stability, especially in high-risk patients, including fractures with abundant comminution, bone loss, or open fractures.22–28 As mentioned previously, biomechanical studies have substantiated these data.9–12 Discernibly, many researchers suggest supplementary fibular fixation, yet still concede that further investigation is mandated given the lack of prospective, randomized, clinical trials in the literature. To evaluate the effect of fibular fixation on incidence of axial malalignment, Egol et al23 performed a retrospective chart and radiographic review of 71 patients representing 72 distal metaphyseal tibia–fibula shaft fractures that underwent distal interlocking IMN with or without ORIF of the fibula fracture with a primary outcome of maintenance of reduction at 12 weeks, as previously defined.28,29 One of the 25 (4%) cases in which the fibula was plated lost reduction compared with 6 of the 47 (13%) cases that lost reduction when the fibula was not plated. The use of 2 medial-to-lateral distal locking bolts showed a trend against late malalignment. In all, 10 patients developed a delayed or nonunion, a rate substantially less than other reports14,30 and similar to those determined by Zelle et al's31 systematic review. It was concluded that fibular fixation significantly facilitated maintenance of distal tibia fracture reduction, leading the authors to strongly recommend this adjunctive treatment modality in conjunction with IMN.

In contrast, recent studies involving IMN and MIPPO32–34 have demonstrated good functional outcomes without significant malalignment irrespective of fibular fixation, suggesting that adequate stabilization of tibia fractures is possible while avoiding morbidity of soft tissue disruption and infection risk innate with standard ORIF approaches.22 Avilucea et al34 in the largest retrospective cohort study comparing suprapatellar and infrapatellar IMN technique with a minimum of 2 distal interlocking bolts determined that suprapatellar IMN technique improved alignment of extraarticular and elementary intraarticular distal fractures in both the coronal and sagittal planes, notwithstanding adjunctive fibular fixation. Primary angular malalignment of 26.1% was reported in the infrapatellar IMN insertion and 3.8% with the suprapatellar IMN insertion (P < 0.0001), whereas fibular fixation was decided on at the discretion of the surgeon. Within the suprapatellar group, the fibula was intact, fixed, and remained fractured in 6 (4.5%), 22 (16.7%), and 104 (78.8%) cases, respectively. The fibula was treated similarly in the infrapatellar group in 9 (6.7%), 32 (23.9%), and 93 (69.4%) cases. Overall, there was not a significant difference in the rate of fibular fixation between treatment groups (P = 0.2). Most recently, these findings were supported by De Giacomo et al35 in a retrospective case review of 132 distal tibia and fibula fractures treated with interlocking IMN and 2 medial-to-lateral distal screws which reported decreased complication rates comparatively. They reported a malalignment rate of 2% and malunion rate of 3%. It was determined that adequate 43-A fracture reduction is possible with interlocking IMN alone, without need for fibular fixation, and lack of fibular fixation does not assume any additional risk of malalignment or malunion. Vasanad et al32 published a case series of 30 patients with extraarticular distal tibia metaphyseal and concomitant fibula fractures at or above the level of the distal tibiafibular syndesmosis (14 43-A1, 6 43-A2, 4 43-A3, 4 open type II, and 2 open type IIIA) who underwent MIPPO with precontoured medial locking plate without fibular fixation. Of the 30 patients, 24 had excellent results and 6 had good results using Tenny Wess Criteria.

A few series established fibular fixation as possibly detrimental to tibial fracture reduction demonstrating significantly higher rates of delayed union and nonunion.26,31,36 Kruppa et al30 reported increased rates of nonunion associated with fibular ORIF in distal tibia fractures treated with IMN (P = 0.007). Twenty nonunions were recorded and of them, 13 (65%) had undergone fibular fixation. This nonunion rate is similar to that of Teitz et al,13 as previously discussed. Similarly, Attal et al's33 multicenter case series reported a negative effect of fibular plating on tibial fractures treated with an IMN, citing an 8-fold increase risk of delayed union. Vallier et al's36 prospective study of 104 43-A fractures, of which 28 had associated fibular fractures (27%), were randomized to IMN versus medial plate fixation, subsequently found 4 patients (7.1%) to have developed nonunion after nailing versus 2 (4.2%) after plating (P = 0.25) with a trend for nonunion in patients who had distal fibula fixation (12% vs. 4.1%, P = 0.09). Eighty-five percent of patients with malalignment after nailing did not have fibula fixation. Based on their data, it was concluded that fibular fixation aids in tibial fracture reduction at the time of surgery, but ultimately may contribute to nonunion.

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Based on the current published data, concurrent fibular fixation is indicated in distal metaphyseal fractures with syndesmotic injury. No consensus remains for adjunctive fibular fixation in distal metaphysical fractures with nonsyndesmotic fracture. Reports vary widely on the matter. Some suggest fixation is unnecessary with emergence of interlocking IMN with standard 2 distal interlocking screws and MIPPO or even detrimental given possible increase in nonunion rates. Others strongly advocate for routine fixation in patients with significant metaphyseal comminution or displacement in order to facilitate alignment, stability, initial reduction, and maintenance of reduction. The predominance of reviewed literature was retrospective in design or alternatively prospective case series, demonstrating a paucity of prospective, randomized, clinical trials, which hinders ability to guide standard therapy patterns. Ultimately, orthopaedic surgeons should recognize the role of fibular fixation as a tool in achieving adequate reduction and stability in fractures of the distal tibia, with the added need for close observation in patients who are not healing as anticipated.

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distal tibia fracture; fibular fixation; pilon/plafond fracture; fracture reduction; malunion; nonunion

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