Injury, Int. J.

Care Injured 44 (2013) 1885–1891

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Injury
journal homepage: www.elsevier.com/locate/injury

Assessment of the role of fibular fixation in distal-third tibia–fibula

fractures and its significance in decreasing malrotation and
malalignment
Manish Prasad a,1, Sanjay Yadav b,1,*, Ajaydeep Sud a,1, Naresh C. Arora a,1,
Narender Kumar a,1, Shambhu Singh a
a
Base Hospital, New Delhi, India
b
All India Institute of Medical Sciences (AIIMS), New Delhi, India

A R T I C L E I N F O A B S T R A C T

Article history: Background: In the treatment of distal-third tibia/fibula fractures treated by interlocking nailing, the role
Received 21 January 2013 of fibular fixation is not clearly defined. This study aimed to assess the benefits of fibular fixation in such
Received in revised form 14 May 2013 fractures.
Accepted 29 August 2013
Methods: Sixty patients with fractures of the lower third of the leg were enrolled into the study and
divided into two groups based on whether the fibula was fixed (group A) or not (group B). Fracture tibia
Keywords: was treated with interlocked intramedullary nailing and fibular fixation was done using a 3.5-mm
Fibular fixation
Limited Contact Dynamic Compression Plate (LC-DCP). The two groups were compared for differences in
Malalignment
Malrotation
rotation at ankle, angulation at the fracture site, time of union and complications. Clinical and functional
Distal tibia outcomes were assessed regularly. Merchant–Dietz criteria were used to assess ankle function.
Results: The demographics of the two groups were similar. Average valgus angulation was significantly
less in group A (average 58) versus group B (average 98). The degree of rotational malalignment at the
ankle in group A was average 78 versus average 158 in group B. The outcome of two groups for clinical
ankle score, time of union and complications showed no significant differences.
Conclusion: Fixation of the fibula along with interlocking nailing of the tibia decreases the malalignment
of the tibia and malrotation of the ankle in distal-third fractures of the tibia and fibula as compared with
only interlocking nailing.
ß 2013 Elsevier Ltd. All rights reserved.

Aims and objectives
This study aimed to assess the role of fibular fixation in distal-
third tibia and fibula fractures and its significance with respect to
the functional outcomes in decreasing malrotation and malalign-
ment of the limb.
Introduction
With high-speed transport, extensive mechanisation and
increased violence, we are not only encountering a greater number
of fractures but a large number of them are caused by severe
trauma resulting in a higher number of open, segmental and
* Corresponding author at: Flat 247, AIIMS Residential Campus, Ayur Vigyan
Nagar, New Delhi 110049, India. Tel.: +91 9560754591.
E-mail address: drsanjay.pgi@gmail.com (S. Yadav).
1
From the Base Hospital and Army College of Medical Sciences, New Delhi
110010, India.
comminuted fractures of any part of the skeleton. Fractures of
shafts of the tibia and fibula are the most common diaphyseal
fractures among all long bones [1–4]. In the treatment of combined
fractures of the distal-third of the shaft of the tibia and fibula, there
is an ongoing debate over the necessity of fibular stabilisation.
The theories that fixation of the fibula provides a stiffer construct
and aids in achieving a more anatomical reduction of the tibia have
promoted this procedure. However, previous studies have
provided mixed information about the potential role of the fibula
in tibia healing [5–7].
Several cadaveric studies have suggested that the fibula
contributes significantly to lower-leg weight-bearing and could
act as a strut, relieving stress from the tibia and allowing earlier
healing. Others have reported that the intact fibula contributes
little to the support of the lower leg, provides no additional
stability to fixation of a fractured tibia and even creates abnormal
strain and complicates compression and fixation of tibial fractures.
One study concluded that fibular plate fixation increased the initial
rotational stability with distal-third of the shaft tibia–fibula
fractures compared with intramedullary nailing of tibia alone [8].

0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.injury.2013.08.028
1886 M. Prasad et al. / Injury, Int. J. Care Injured 44 (2013) 1885–1891
Clinical reports of significance of an intact fibula are also
conflicting. While some studies have found that an intact fibula is a
source of distraction and partial fibulectomy facilitates compres-
sion of tibial fractures, others have promoted primary fixation of
the fibula to prevent fibular nonunion, which can interfere with
tibial healing. Reported effects of fibula integrity on tibial
nonunion are mixed [4,5].
Considerable concern exists that malalignment of a healed
distal-third tibial-shaft fracture may result in posttraumatic
arthritis of the ankle. As the location of the deformity approaches
the ankle, malalignment results in maldistribution of articular
surface pressures that may predispose a patient to premature
osteoarthritis [9–11].
This study was undertaken to examine the effects of fibular
fixation on healing of the ipsilateral tibia in combined fractures of
distal-third shafts of the tibia and fibula and to outline the
advantages and benefits of fixation of the fibula in such fractures, if
any.
Materials and methods
A total of 60 patients who had fractures of the lower-third
shafts of the tibia and fibula were included in the present study
from July 2009 to December 2011. The purpose of the study was to
compare the effects of fixation of the fibula in fractures of the lower
third of the leg (group A) with those in which fixation of the fibula
was not done (group B), the fractured tibia being treated with an
interlocking intramedullary tibial nail (EXPERT nail, AO Synthes,
Paoli, IN, USA) in all the cases and fixation of fibular fracture done
using a 3.5-mm dynamic compression plate (DCP).
Inclusion criteria
1. Patients with fracture of both bones of the leg distal to the
isthmus and 4–5 cm proximal to the ankle joint so that at least
two distal locking bolts can be put in an AO Synthes EXPERT
tibial nail,
2. fresh cases of lower one-third leg fractures,
3. patients who attained skeletal maturity and were active (20–45
years) and
4. closed as well as Gustilo–Anderson type I and type II open lower
one-third diaphyseal fractures of the leg.
Exclusion criteria
1. Patients with intra-articular fractures of the distal third of the
tibia and fibula,
2. paediatric and elderly patients with a non-active lifestyle and
minimum functional requirement,
3. segmental fractures of the tibia and
4. Gustilo–Anderson type III fractures.
In all the cases included in the study, the tibial fracture was
fixed with interlocking intramedullary nails. Two well-trained
senior surgeons with vast experience in trauma management were
involved and at least one of them was part of the surgical team in
each case in the study. The decision to fix the fibular fracture was
by randomisation of cases as described in Statistical Methods. All
patients underwent a primary survey and haemodynamic stabi-
lisation in the Emergency Department. Evaluation of the presence
of other fractures and systemic evaluation was done subsequently
on secondary survey.
Appropriate antero-posterior and lateral radiographs were
taken and the limb was immobilised and elevated on a Bohler–
Braun splint. The fracture patterns were classified according to the
Orthopaedic Trauma Association classification. Open fractures
were classified according to the criteria of Gustilo and Anderson.
Surgical tactic
The fibula was addressed first in all cases as it was presumed to
help in achieving the length and rotation and aiding the tibial
reduction.
Technique of fibular fixation
Open reduction and 3.5-mm DCP fixation
All cases were managed under regional anaesthesia. Spinal/
epidural anaesthesia provided sufficient muscle relaxation for
lower-limb surgeries [12,13]. Preoperatively, calcaneal pin traction
was applied for all the patients. An image intensifier with a C-arm
was used in all cases to provide fluoroscopic guidance. The patient
was positioned supine on the fracture table. A well-padded bar was
put beneath the proximal thigh avoiding any pressure in the
popliteal area. The hip was flexed to 70–908 and the knee flexed at
60–908.
Longitudinal traction was applied along the calcaneal skeletal
pin. Rotational alignment was achieved by aligning the anterior
superior iliac spine, patella and second ray of the foot. The affected
leg was cleaned and draped from mid-thigh to the foot.
The image intensifier was draped with sterile isolation drapes.
After painting and draping the leg, a straight incision that parallels
the shaft of the lower third of the fibula was made. The
subcutaneous tissue was not undermined. The fracture site was
opened and reduction held with bone-holding clamps. The fracture
was fixed with a 3.5-mm DCP and cortical screws.
Technique of interlocking nailing of the tibia
A 5-cm incision was made medial to the patellar ligament.
Using a curved awl, the medullary canal was opened proximal to
the tibial tuberosity at the level corresponding to the proximal tip
of the fibular head. The bone awl was centred in the medullary
canal in orthogonal views.
A curved 3.2-mm ball-tipped guide wire was inserted up to the
level of the fracture. The proximal fragment was reduced with the
distal fragment. Under C-arm guidance, the guide wire was
advanced in the distal fragment, centring in both antero-posterior
(AP) and lateral views. The guide wire was introduced 0.5–1 cm
proximal to the ankle joint.
The tibia was reamed using cannulated reamers over the guide
wire in 0.5-mm increments until the desired diameter was
achieved. A nail 1–1.5 mm smaller than the final reamer was
selected. The 3.2-mm guide wire was exchanged for a 3.0-mm non-
ball-tipped guide wire; a medullary exchange tube was used to
avoid loss of fracture reduction.
The selected nail was attached to the proximal drill guide with
the hexagonal bolt. The nail was driven over the guide rod until it
entered the metaphysis of the distal fragment. The guide wire was
then withdrawn. The nail was driven further until its proximal tip
was countersunk into the tibial entry portal and distally the nail
reached the tip of the guide wire. Two distal locking screws were
inserted using a freehand technique with the help of an image
intensifier. Gentle back hammering was done to close any
remaining fracture gap. Proximal locking was done with two
locking bolts with the help of a proximal tibial locking jig.
Postoperative regime
Postoperatively, all the patients were mobilised non-weight-
bearing with crutches or walkers from the first postoperative day.
Mobilisation of the knee and ankle was started in the immediate
 M. Prasad et al. / Injury, Int. J. Care Injured 44 (2013) 1885–1891
postoperative period. Sutures were removed on the 14th
postoperative day. An X-ray of the involved leg was taken
postoperatively, including both knee and ankle joints in the same
film. Patients were followed up clinically and radiographically at 2,
4, 6, 9, 12 and 18 months. Data were collected by verbal
communication, clinical examination and radiographs. In the
postoperative radiographs, tibial malalignment was measured. The
degree of the tibial angulation (varus or valgus) was measured on
the AP radiographs by determining the angle formed by the
intersection between the perpendicular lines drawn from the tibial
plateau and the tibial plafond [14].
At the end of 6 months, evaluation of the range of movement
(dorsiflexion and plantar flexion) at the ankle and clinical
assessment of rotational malalignment was done. The functional
assessment of the ankle was done at regular follow-up using the
Ankle-Evaluation Rating System of Merchant and Dietz [4]. The
final results were evaluated at the end of 18 months using the
Johner and Wruhs’ criteria as ‘excellent’, ‘good’, ‘fair’ and ‘poor’
[15].
Statistical methods
Randomisation: Cases were randomised by the block method of
randomisation using sealed envelopes with a block size of four and
six. Thirty envelopes of each group were prepared. Two envelopes
from each group were taken for a block of four and three envelopes
from each group for a block of six. In this manner, six blocks each of
size four and six were produced. Envelopes were shuffled within a
block but ‘not’ among the blocks. Then, these blocks of four and six
were piled up by flipping a coin. For heads, a block of four was
taken and for tails, a block of six was taken and piled up. This pile
was ‘not’ mixed. The envelopes were then sequentially numbered
from 1 to 60 and were ready to be used for the study [16].
Analysis: The two groups, A and B, were analysed for significant
differences for different variables. The chi-squared test was used to
test the significant percentage of side distribution, mode of injury,
rotational alignment and valgus angulation, range of motion at the
ankle, complications and the final results in two groups. The
Student t-test was used to test the significance of rotational
alignment, valgus score, ankle evaluation scoring system and the
time of union in months between the two groups.
Statistical software
The statistical software, namely SPSS 11.0 and Systat 8.0, were
used for the analysis of the data and Microsoft Word and Excel,
2007 edition, were used to generate graphs and tables.
Table 1
Demographic data.
Parameters Group A (fibula fixed)
Side Left 10
right 20
Mode of injury RTA 28
Others 02
OTA classification A1 02
A2 16
A3 10
B1 02
Open vs closed wound Open 14
Closed 16
Type of open fracture (Gustilo Anderson) I 12
II 02
1887
Study design
A prospective clinical study consisting of 60 patients, who
presented to the Department of Orthopaedics of our hospital with
fractures of the lower third of the tibia and fibula, was undertaken
to assess the functional difference in patients in whom fibular
fixation was done (group A) compared to those in whom fibular
fixation was not done (group B).
Results and analysis
Sixty patients who had fractures of the lower third of the tibia
and fibula and who were treated in the Department of Orthopae-
dics of our hospital were followed up for 18 months in this study.
Demographics
Age and sex distribution: Age ranged from 20 to 45 years with the
average age for males (52/60) being 30.26 years and the average
age for females (08/60) being 38 years. The mean age was 31.3
years (Table 1).
Side of the fracture: The right side was more commonly involved
(34/60) than the left side (26/60).
Nature of the injury: Most cases were due to road traffic
accidents (90%). Other causes were simple fall or injury during
military training, which constituted 10% of the cases.
Pattern of the fracture: About 6.6% were spiral type fractures and
46.67% were simple oblique type. The spiral transverse fracture
type accounted for 40% and the spiral wedge type accounted for
6.6% of total fractures.
Type of fracture (open or closed): In the study, 60% of cases were
closed fractures and 40% were open fractures of the tibia. In group
A 16/30 (75.55%) and in group B 20/30 (66.66%) were closed
fractures. In group A, 10 patients had type I and four had type II
open fractures. In group B, four patients had type I and eight
patients had type II open fractures.
Assessment of rotational alignment
Normally, the ankle is in 12–158 of external rotation. Any
deviation from the same is taken as external/internal rotation
deformity at the ankle. In our study, however, the normal limb of
the subject was taken as control for comparison of rotational
alignment. The subjects were made to lie down supine. By standing
at the foot end of the patient, the rotation of the ankle was
determined by measuring the angle subtended by a plumb line
with a line passing through the mid-point of the knee, the line
joining the mid-point of the ankle (intermalleolar distance) and the
second toe.
Group B (fibula not fixed) P value
14 0.713
16
26 0.595
04
02 0.892
12
14
02
12 0.456
18
04 –
08
1888 M. Prasad et al. / Injury, Int. J. Care Injured 44 (2013) 1885–1891

Table 2 Table 3
Comparison of rotational alignment. Comparison of radiological valgus angulation.

Rotation in degrees (difference in Group A Group B Valgus in degrees Group A Group B

external rotation from normal limb) n = 30 n = 30 n = 30 n = 30

Excellent (0–5) Nil Nil Excellent (0–1) Nil Nil

Good (5–10) 30 (100%) 20 (66.67%) Good (2–5) 24 (80%) Nil
Fair (10–15) Nil 10 (33.33%) Fair (6–10) 06 (20%) 30 (100%)
Poor (>15) Nil Nil Poor (>10) Nil Nil
Mean  SD 7.73 (1.03) 10.60 (2.75) Mean  SD 7.73 (1.03) 10.60 (2.75)
Inference Average external rotation score is Inference Average valgus score is less when the fibula
slightly better when fibula is fixed is fixed with p = 0.001
(p = 0.01)

assess the range of movements at the ankle, the patients were

Malrotation was defined as an internal/external rotation divided into four groups:
deformity >108 as compared to the normal contralateral limb.
All the cases were assessed for external rotation deformity 1. excellent: 100% motion of ankle,
whether the fibula was fixed or not. The average external rotation 2. good: >75% motion of ankle,
deformity of the ankle in patients of group A was 7.738 and that for 3. fair: 50–75% motion of ankle and
patients of group B was 10.608. To assess the effect of rotation, the 4. poor: <50% motion of ankle.
patients were divided into four groups:
In group A, 73.33% of the patients had good results and 26.66%
1. excellent: 0–58 external rotation, had fair results. In group B, 66.67% of the patients had good results
2. good: 5–108 external rotation, and 33.33% had fair results (Table 4).
3. fair: 10–158 external rotation and
4. poor: >158 external rotation. Ankle evaluation rating system

All the patients in group A had good results. In group B, 66.66% A clinical assessment of ankle function according to the criteria
of the patients had good results, 33.33% had fair results and no of Merchant and Dietz was determined for each ankle at the end of
patient had poor results (Table 2). 2, 4, 6, 9, 12 and 18 months’ follow-up. The final results were
considered for the follow-up scores at 18 months. The rating
Assessment of radiological valgus/varus angulation system is a 100-point scale allotting 40 points each for function
and pain and 10 points each for gait and ankle range of motion. The
All the cases were assessed for valgus angulation, irrespective of mean clinical score in group A was 93.86 points and in group B, it
whether the fibula was fixed or not. The average valgus deformity was 90.53 points (Table 4).
of the tibia in group A was 5.068 and in group B was 7.868. To assess Time of union: The mean time of union in patients in group A
the effect of angulation, the patients were divided into four groups: was 4.93 months and in group B it was 5 months.
Complications: Six out of the 30 patients in group A developed
1. excellent: 0–18 valgus/varus, superficial wound infections at the fibular wound site.
2. good: 2–58 valgus/varus,
3. fair: 6–108 valgus/varus and According to Johner and Wruh’s criteria
4. poor: >108 valgus/varus
At the end of 18 months, patients were divided into four groups,
Eighty percent of patients of group A had fair results, 20% of the those with excellent, good, fair and poor results. In group A, 24
patients had fair results and none had poor results. Among patients patients (80%) had good results and six (20%) had fair results.
of group B, all had fair results (Table 3). Among the 30 patients in group B, 20 patients (66.66%) had good
results and 10 (33.33%) had fair results (Tables 5 and 6).
Association of range of movements at the ankle (expressed as a %) with
fixation of fibula Discussion

The mean range of movements in patients with fibula fixation The role of fibula fixation in distal-third fractures of the shaft of
was 78.338 and in those without fibula fixation, it was 74.668. To tibia and fibula has not been clearly defined [5–7]. This study was

Table 4
Ankle range of motion and ankle evaluation rating (AER).

Ankle ROM Group A Group B Inference

n = 30 n = 30

Excellent (100.0%) Nil Nil Ankle ROM is similar in the two groups (p = 0.121)
Good (75–100%) 22 (73.33%) 20 (66.67%)
Fair (50–75%) 08 (26.67%) 10 (33.33%)
Poor (<50%) Nil Nil
Mean  SD 78.33 (3.09) 74.66 (8.34)
Ankle evaluation score (max-100)
Range 93–94 84–98 Ankle evaluation rating is more in patients with fibula fixation (p = 0.01)
Mean  SD 93.87 (0.35) 90.53 (4.67)
Time of union (months)
Range 4–7 4–7 Time of union is similar between two groups (p = 0.863)
Mean  SD 4.93 (0.96) 5.00 (1.13)
 M. Prasad et al. / Injury, Int. J. Care Injured 44 (2013) 1885–1891 1889

Table 5 Table 6
Final results according to Johner and Wruhs’ criteria at 18 months follow up. Johner and Wruhs’ criteria for evaluation of final results.

Results Group A Group B Parameters Excellent Good Fair Poor

(n = 30) (n = 30)
Non-union None None None Yes
Excellent Nil Nil Deformity: varus/valgus None 2–58 6–108 >108
Good 24 (80%) 20 (66.67%) Mobility at ankle (%) Normal >75% >50% <50%
Fair 06 (20%) 10 (33.33%) Gait Normal Normal Insignificant limp Significant
Poor Nil Nil hip
Inference Distribution of results are similar between
the two groups (p = 0.409)

middle of the medullary canal and that it is perpendicular to the

conducted to analyse the results of plating the fibula fracture in
cases of fractures of the lower-third of the shaft of tibia and fibula
when compared with cases in which the fibula is not fixed. In all of
the cases, the fractured tibia was treated with interlocking
intramedullary nailing (AO Synthes EXPERT nail). The demo-
graphics of the two groups, with and without fibular fixation,
were similar with respect to age, sex, side of the fracture, fracture
classification, nature of the injury and open fractures. In all the
patients, irrespective of whether fibula was fixed or not, there was
valgus angulation at the fracture site. The probable reasons are
discussed:
1. The relatively wider diameter of the medullary canal of the
distal fragment decreases the amount of fixation with less
contact surface between the nail and the bone; this in turn can
result in the distal fragment going for valgus/varus angulation.
2. The short distal tibial segment could be a factor.
3. The most important factor in avoiding malreduction of the distal
fragment is ensuring that the guide wire is placed in the exact
tibial plafond. Any variation from this can result in the distal
segment being assessed for valgus/varus angulation [17,18].
Figs. 1 and 2 illustrate the point.
4. Comminution at the fracture site could also be involved.
The average valgus angulation was less, (i.e., 5.668) when the
fibula was fixed (group A) when compared to 88 in cases where the
fibula was not fixed (group B). The fixation of the fibula establishes
the length of the lateral column. When the fixation of the fibula is
done prior to nailing of the tibia, it helps to restore the alignment of
proximal and distal tibial fragments [17,18]. This may be the
reason for less valgus angulation in cases where the fibula was
fixed (p = 0.01).
The average rotation at ankle was less (i.e., 7.678 of external
rotation in group A) as compared to 10.68 of external rotation in
group B (p = 0.01). Range of motion at the ankle was statistically
similar in the two groups (p = 0.121).
Merchant and Dietz [4], in their clinical study of 37 patients
followed up for 29 years, had a mean ankle evaluation score of 88.4

Fig. 1. (a) Pre-operative AP and lateral views, (b) immediate post-operative AP and lateral views, (c) six months follow up and (d) eighteen months follow up.
1890 M. Prasad et al. / Injury, Int. J. Care Injured 44 (2013) 1885–1891

Fig. 2. (a) Pre-operative AP and lateral views, (b) immediate post-operative AP and lateral views, (c) six months follow up and (d) eighteen months follow up.

points for patients with distal-third fracture of the shaft of tibia. All 2. The duration of the follow-up period has to be longer to assess
of the patients in their series were treated non-operatively with a the rates of complication such as osteoarthritis at the ankle and
cast. In this study, the mean ankle evaluation score for patients in functional disability.
whom the fibula was fixed was 93.86 points and it was 90.53
points for patients without fibular fixation; that is, the ankle
Conclusions
evaluation score was statistically similar in patients with and
without fixation of fibula (p = 0.01) [4].
Based on the results of the study, the following conclusions
Patients treated with fixation of fibula had comparatively
were drawn:
higher complications than those without. Three out of 30 patients
treated with fixation of fibula developed superficial wound
1. Rotational malalignment was less in patients with lower-third
infections over the fibular wound site. All of them were controlled
tibia and fibula fractures in whom the fibula was fixed (group A)
by appropriate dressing and antibiotics.
compared to those in whom the fibula was not fixed (group B).
Assessment of results according to Johner and Wruh’s criteria
2. Tibial malalignment (valgus angulation) was less in patients in
showed that the distribution of results were statistically similar
group A as compared to group B.
between patients with and without fibula fixation (p = 0.341).
3. The functional score after 12 months’ follow-up between the
two groups was statistically similar.
Limitations of the study
4. There was no significant difference in the time of union of the
tibial fracture between the two groups.
1. The two groups were small, which decreases the power to detect
5. There was no significant difference in the rate of complications
the possible real differences that might exist between the two
between the two groups.
groups.
2. The follow-up period was short.
3. The results may also be influenced by the experience and Intellectual contributions of authors
personal bias of senior surgeons and they may be less reflective
of the procedure or sequence itself. Study concept: Col. Ajaydeep Sud and Maj. Gen NC Arora.
Drafting and manuscript revision: Col. Ajaydeep Sud, Maj.
Suggestions Manish Prasad, Dr. Sanjay Yadav, Col. Narender Kumar and Maj.
Shambhu Singh.
1. The number of cases in the two groups can be increased so as to Statistical analysis: Maj. Manish Prasad, Dr. Sanjay Yadav, Col.
detect the real differences that might exist between the two Narender Kumar and Maj. Shambhu Singh.
groups. Study supervision: Maj. Gen NC Arora and Col. Ajaydeep Sud.
 M. Prasad et al. / Injury, Int. J. Care Injured 44 (2013) 1885–1891
Conflicts of interest
We report no conflicts of interest whatsoever.
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