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

Abstract

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.

Management of Pilon Fractures—Current Concepts

“…In the acute trauma setting, ankle spanning external fixators should be applied to restore the tibial length and help to preserve the soft tissue. When the two –staged treatment protocol was first introduced, some authors suggested internal fixation of simple, non-comminuted fibula fractures simultaneously to mounting the temporary ankle spanning external fixator ( 28 , 52 , 53 ). They suggested that restoring the length of the fibula helps with the later realignment and reconstruction of the tibia especially in valgus deformation.…”

“…The benefits derived were lower rates of infection and fewer soft tissue problems and also a lower rate of non-union cases. Furthermore, fibula implants tend to cause irritation requiring implant removals and another surgery later on ( 53 , 55 ). Modern therapeutical strategies, like intramedullary nailing or retrograde intramedullary screw fixation, may be beneficial in reducing the soft tissue problems, but problems of malrotation have to be considered and further discussed in the current literature ( 56 , 57 ).…”

“…In a retrospective study Rouhani et al found no difference in outcomes of tibial pilon fractures with or without fibula fixation at 2 years follow-up ( 51 ). Nevertheless, it is commonly agreed that fibula fixation is mandatory in metaphyseal fractures with syndesmotic injury ( 53 ).…”

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

“…Till now it is still a big challenge to treat it because of the wound contamination, limited soft tissue envelope and poor vascularity. The role of bular xation in the treatment of distal tibio bular syndesmosis injury and pilon fractures has been well de ned [1,2], however, it is still controversial whether the fracture of bular needs xation and which method is selected in extra-articular fractures of the lower leg [3][4][5].…”

“…Javdan [10] reported that dynamic compression bone plate (DCP) or tubular plate xation of bula had no signi cant difference in tibial fracture healing, reduction of postoperative complications and recovery of affected limb function. In addition, a few studies have shown that bular plate internal xation can increase the rate of delayed healing and nonhealing of tibial fractures [1]. In summary, previous studies on the xation of bula fractures was platescrew internal xation, elastic intramedullary nail or non-xation, no attempt has been made to x the bula with kirschner wire(K-wire).…”