Intramedullary tibial nailing of distal tibiofibular fractures: additional fibular fixation or not?
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°.
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.
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.
KeywordsDistal tibial fractures Fibular fixation Outcome
Loss of reduction
American Society of Anesthesiologists physical status score
Intramedullary tibia nailing
Angular stable locking system
Compliance with ethical standards
Conflict of interest
Margaux Van Maele, Ben Molenaers, Eric Geusens, Stefaan Nijs, and Harm Hoekstra declare that they have no conflict of interest.
- 2.Mao Z, Wang G, Zhang L, Zhang L, Chen S, Du H, et al. Intramedullary nailing versus plating for distal tibia fractures without articular involvement: a meta-analysis. J Orthop Surg Res [Internet]. 2015 [cited 2016 Aug 3];10:95. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26078031.
- 3.Wähnert D, Stolarczyk Y, Hoffmeier KL, Raschke MJ, Hofmann GO, Mückley T. Long-term stability of angle-stable versus conventional locked intramedullary nails in distal tibia fractures. BMC Musculoskelet Disord [Internet]. BioMed Central; 2013 Dec 20 [cited 2016 Aug 3];14(1):66. Available from: http://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/1471-2474-14-66.
- 4.Tejwani NC. Intramedullary nail fracture compression techniques: when and how to do it? J Orthop Trauma [Internet]. 2009;23(5):S18–21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19390370.
- 7.Kuhn S, Hansen M, Rommens PM. Extending the indications of intramedullary nailing with the Expert Tibial Nail? Acta Chirurgiae Orthopaedicae et Traumatologiae Cechoslovaca. 2008;77–87.Google Scholar
- 9.Augat P, Bühren V. Intramedullary nailing of the distal tibia. Does angular stable locking make a difference?. Unfallchirurg [Internet]. 2015;118(4):311–7. http://www.ncbi.nlm.nih.gov/pubmed/25835206.
- 10.Teeny SM, Wiss DA. Open reduction and internal fixation of tibial plafond fractures. Variables contributing to poor results and complications. Clin Orthop Relat Res [Internet]. 1993;(292):108–17. http://www.ncbi.nlm.nih.gov/pubmed/8519097.
- 15.Kumar A, Charlebois SJ, Cain EL, Smith RA, Daniels AU, Crates JM, et al. Effect of fibular plate fixation on rotational stability of simulated distal tibial fractures treated with intramedullary nailing. J Bone Joint Surg Am [Internet]. The American Orthopedic Association. 2003;85–A(4):604–8. http://www.ncbi.nlm.nih.gov/pubmed/12672833.
- 16.Reindl R, Morin PM, 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(1).Google Scholar
- 18.Krettek C, Miclau T, Schandelmaier P, Stephan C, Möhlmann U, Tscherne H. The mechanical effect of blocking screws ("Poller screws") in stabilizing tibia fractures with short proximal or distal fragments after insertion of small-diameter intramedullary nails. J Orthop Trauma [Internet]. 1999;13(8):550–3. http://www.ncbi.nlm.nih.gov/pubmed/10714781.
- 19.Xavier F, Goldwyn E, Hayes W, Carrer A, Elkhechen R, Berdichevsky M, et al. A comparison of the compressive strength of various distal locking screw options in the treatment of tibia fractures with intramedullary nails. J Long Term Eff Med Implants [Internet]. 2011;21(3):185–92. http://www.ncbi.nlm.nih.gov/pubmed/22150350.
- 20.Chen AL, Tejwani NC, Joseph TN, Kummer FJ, Koval KJ. The effect of distal screw orientation on the intrinsic stability of a tibial intramedullary nail. Bull Hosp Jt Dis [Internet]. 2016;60(2):80–3. http://www.ncbi.nlm.nih.gov/pubmed/12003359.