Distal tibia and fibula fractures constitute a significant proportion of lower-limb injuries and present considerable therapeutic challenges. Distal one-third tibial fractures account for approximately 37% of all tibial shaft fractures and are associated with increased rates of malunion and delayed healing owing to the metaphyseal anatomy and limited soft tissue coverage.

Intramedullary nailing has become a preferred treatment modality because it minimizes soft tissue disruption, reduces infection risk, and facilitates early mobilization. However, the necessity of concomitant fibular fixation remains debated. Proponents argue that fibular fixation improves rotational and coronal plane stability, restores limb length, and decreases malalignment, while others suggest that it may not significantly influence fracture healing.

The present study was undertaken to compare the functional and radiological outcomes of distal one-third both-bone leg fractures treated with and without fibular fixation.

MATERIALS AND METHODS

Study Design

Prospective comparative study.

Study Setting

Department of Orthopaedics, Gauhati Medical College and Hospital, Guwahati, Assam, India.

Study Duration

One year.

Study Population

Patients presenting to the Orthopaedic Outpatient Department and Emergency Department with distal one-third both-bone leg fractures.

Sample Size

Twenty patients were enrolled and allocated alternately into two groups:

• Group A: Tibial fixation with fibular fixation (n=10)
• Group B: Tibial fixation without fibular fixation (n=10)

Inclusion Criteria

• Age between 18 and 80 years
• Skeletally mature patients
• Closed extra-articular distal one-third tibia-fibula fractures

Exclusion Criteria

• Open fractures
• Intra-articular fractures
• Segmental tibial fractures
• Pathological fractures
• Patients medically unfit for surgery
• Patients unwilling to participate

Preoperative Evaluation

All patients underwent:

• Primary and secondary trauma survey
• Ultrasonography FAST examination where indicated
• NCCT brain where required
• Radiographs of the leg including knee and ankle joints
• Computed tomography with three-dimensional reconstruction
• Routine hematological and biochemical investigations

Outcome Measures

Primary outcomes included:

• Time to radiological union
• Functional outcome using AOFAS score Secondary outcomes included:
• Malalignment
• Delayed union
• Non-union
• Infection
• Implant-related complications

Statistical Analysis

Data were expressed as mean ± standard deviation and analyzed using appropriate comparative statistical methods. A p-value <0.05 was considered statistically significant.

RESULTS

Demographic Characteristics

Baseline demographic characteristics were comparable between the two groups.

Fracture Union

Patients who underwent fibular fixation demonstrated earlier radiological union compared with those treated without fibular fixation.

Functional Outcome

The fibular fixation group demonstrated superior functional outcomes at all follow-up intervals.

Malalignment

Malalignment occurred more frequently in patients who did not undergo fibular fixation.

Complications

The non-fixation group experienced a greater number of healing-related complications.

DISCUSSION

The present study demonstrated superior radiological and functional outcomes among patients treated with fibular fixation. Earlier fracture union, improved AOFAS scores, and lower rates of malalignment were observed in the fixation group.

These findings are consistent with the work of Egol et al., who reported reduced late malalignment following fibular plating in distal tibial fractures managed with intramedullary nailing. Morin et al. demonstrated biomechanically that fibular fixation enhances construct stiffness and resistance to rotational and coronal plane deformities.

Similarly, Varsalona and Liu highlighted the importance of fibular fixation in restoring limb length and maintaining reduction. Prasad et al. observed a significant reduction in malrotation and malalignment with fibular fixation. More recent studies by Sonkusale et al. and Rawal et al. have further supported the role of fibular fixation in improving alignment and fracture stability.

The findings of the current study reinforce the growing body of evidence suggesting that fibular fixation contributes positively to fracture stability and functional recovery without substantially increasing complication rates.

Limitations

• Small sample size
• Single-centre study
• Short follow-up duration
• Alternate allocation instead of randomized allocation

Further multicentric randomized controlled trials with larger sample sizes are recommended.

CONCLUSION

Fibular fixation in closed extra-articular distal one-third tibia-fibula fractures resulted in earlier fracture union, superior maintenance of alignment, and better functional outcomes compared with treatment without fibular fixation. The procedure appears to be a valuable adjunct to tibial fixation and should be considered in suitable cases to optimize patient outcomes.

REFERENCES

1. Egol KA, Weisz R, Hiebert R, Tejwani NC, Koval KJ, Sanders Does fibular plating improve alignment after intramedullary nailing of distal metaphyseal tibia fractures? J Orthop Trauma. 2006;20(2):94–103.
2. Morin P, Reindl R, Harvey E, 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 2008;51(1):45–50.
3. Varsalona R, Liu Distal tibial metaphyseal fractures: the role of fibular fixation. Acta Orthop Belg. 2006;72(1):86–90.
4. Prasad M, Yadav S, Sud A, Arora NC, Kumar N, Singh Assessment of the role of fibular fixation in distal-third tibia-fibula fractures and its significance in decreasing malrotation and malalignment. Injury. 2013;44(12):1885–1891.
5. Li C, Li Z, Wang Q, Shi L, Gao F, Sun The role of fibular fixation in distal tibia-fibula fractures: a meta-analysis. Adv Orthop. 2021;2021:6668467.
6. Sonkusale A, Jagtap S, Khedekar H, Keswani Necessity of fixation of fibula in distal tibia fractures. Int J Res Orthop. 2023;9(2):384–389.
7. Rawal N, et Functional outcome of distal third both bone leg fracture with and without fibula fixation. J Orthop Trauma Surg Relat Res. 2022;17(7).