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

Document Type : Original Article

Authors

Department of Orthopedics, Kashani Hospital, Isfahan University of Medical Sciences, Isfahan, Iran

Abstract

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.

Keywords

1.
Dombroski D, Scolaro JA, Pulos N, Beingessner DM, Dunbar R, Mehta S. Fibular fracture stabilization with a guidewire as supplementary fixation in tibia fractures. Am J Orthop 2012;41:506-9.  Back to cited text no. 1
    
2.
Bucholz R, Heckman J, Court-Brown C. Rockwood and Green's fractures in adults. 6th ed. Philadelphia: Lippincott Williams and Wilkins; 2006.  Back to cited text no. 2
    
3.
Fan CY, Chiang CC, Chuang TY, Chiu FY, Chen TH. Interlocking nails for displaced metaphyseal fractures of the distal tibia. Injury 2005;36:669-74.  Back to cited text no. 3
    
4.
Ovadia DN, Beals RK. Fractures of the tibial plafond. J Bone Joint Surg Am 1986;68:543-51.  Back to cited text no. 4
    
5.
McKoy BE, Stanitski CL. Acute tibial tubercle avulsion fractures. Orthop Clin North Am 2003;34:397-403.  Back to cited text no. 5
    
6.
Egol KA, Weisz R, Hiebert R, Tejwani NC, Koval KJ, Sanders RW. Does fibular plating improve alignment after intramedullary nailing of distal metaphyseal tibia fractures? J Orthop Trauma 2006;20:94-103.  Back to cited text no. 6
    
7.
Milner SA, Davis TR, Muir KR, Greenwood DC, Doherty M. Long-term outcome after tibial shaft fracture: Is malunion important? J Bone Joint Surg Am 2002;84:971-80.  Back to cited text no. 7
    
8.
Germann CA, Perron AD, Sweeney TW, Miller MD, Brady WJ. Orthopedic pitfalls in the ED: Tibial plafond fractures. Am J Emerg Med 2005;23:357-62.  Back to cited text no. 8
    
9.
Morrison KM, Ebraheim NA, Southworth SR, Sabin JJ, Jackson WT. Plating the fibula. Its potential value as an adjunct to external fixation of the tibia. Clin Orthop 1991;266:209-13.  Back to cited text no. 9
    
10.
Strauss EJ, Alfonso D, Kummer FJ, Egol KA, Tejwani NC. The effect of concurrent fibular fracture on the fixation of distal tibia fractures: A laboratory comparison of intramedullary nails with locked plates. J Orthop Trauma 2007;21:172-7.  Back to cited text no. 10
    
11.
Kumar A, Charlebois SJ, Cain EL, Smith RA, Daniels AU, Crates JM. Effect of fibular plate fixation on rotational stability of simulated distal tibial fractures treated with intramedullary nailing. J Bone Joint Surg Am 2003;85:604-8.  Back to cited text no. 11
    
12.
Weber TG, Harrington RM, Henley MB, Tencer AF. The role of fibular fixation in combined fractures of the tibia and fibula: A biomechanical investigation. J Orthop Trauma 1997;11:206-11.  Back to cited text no. 12
    
13.
Marsh JL, Bonar S, Nepola JV, DeCoster TA, Hurwitz SR. Use of an articulated external fixator for fractures of the tibial plafond. J Bone Joint Surg Am 1995;77:1498-509.  Back to cited text no. 13
    
14.
Morin PM, Reindl R, Harvey EJ, Beckman L, Steffen T. Fibular fixation as an adjuvant to tibial intramedullary nailing in the treatment of combined distal third tibia and fibula fractures: A biomechanical investigation. Can J Surg 2008;51:45-50.  Back to cited text no. 14
    
15.
Khalily C, Behnke S, Seligson D. Treatment of closed tibia shaft fractures: A survey from the 1997 Orthopaedic Trauma Association and Osteosynthesis International-Gerhard Kuntscher Kreis meeting. J Orthop Trauma 2000;14:577-81.  Back to cited text no. 15
    
16.
Rouhani A, Elmi A, Akbari Aghdam H, Panahi F, Dokht Ghafari Y. The role of fibular fixation in the treatment of tibia diaphysis distal third fractures. Orthop Traumatol Surg Res 2012;98:868-72.  Back to cited text no. 16
    
17.
Williams TM, Marsh JL, Nepola JV, DeCoster TA, Hurwitz SR, Bonar SB. External fixation of tibial plafond fractures: Is routine plating of the fibula necessary? J Orthop Trauma 1998;12:16-20.  Back to cited text no. 17
    
18.
Berlusconi M, Busnelli L, Chiodini F, Portinaro N. To fix or not to fix? The role of fibular fixation in distal shaft fractures of the leg. Injury 2014;45:408-11.  Back to cited text no. 18
    
19.
Teitz CC, Carter DR, Frankel VH. Problems associated with tibial fractures with intact fibulae. J Bone Joint Surg Am 1980;62:770-6.  Back to cited text no. 19
    
20.
Varsalona R, Liu GT. Distal tibial metaphyseal fractures: The role of fibular fixation. Strateg Trauma Limb Reconstr 2006;1:42-50.  Back to cited text no. 20
    
21.
DeLee JC, Heckman JD, Lewis AG. Partial fibulectomy for ununited fractures of the tibia. J Bone Joint Surg Am 1981;63:1390-5.  Back to cited text no. 21
    
22.
Obremskey WT, Medina M. Comparison of intramedullary nailing of distal third tibial shaft fractures: Before and after traumatologists. Orthopedics 2004;27:1180-4.  Back to cited text no. 22
    
23.
Nork SE, Schwartz AK, Agel J, Holt SK, Schrick JL, Wniquist RA. Intramedullary nailing of distal metaphyseal tibial fractures. J Bone Joint Surg Am 2005;87:1213-21.  Back to cited text no. 23
    
24.
Duda GN, Mandruzzato F, Heller M, Goldhahn J, Moser R, Hehli M, et al. Mechanical boundary conditions of fracture healing: Borderline indications in the treatment of unreamed tibial nailing. J Biomech 2001;34:639-50.  Back to cited text no. 24
    
25.
Richter D, Hahn MP, Laun RA, Ekkernkamp A, Muhr G, Ostermann PA. Ankle para-articular tibial fracture. Is osteosynthesis with the unreamed intramedullary nail adequate? Chirurg 1998;69:563-70.  Back to cited text no. 25
    
26.
Strecker W, Suger G, Kinzl L. Local complications of intramedullary nailing. Orthopade 1996;25:274-91.  Back to cited text no. 26