The Role of Fibula Fixation in Preventing Malalignment in Distal Third Tibia Fractures Treated with Intramedullary Nailing

ABSTRACT 

Background: Distal third tibia and fibula fractures treated with intramedullary nailing can fail 

into angular deformity despite appropriate nailing technique. The purpose of this study was to 

examine variables specific to the injury pattern, nail placement, and whether fibula fixation 

assisted in preventing post-operative angular deformity or catastrophic failure. 

Hypothesis: Fibula fixation in distal third tibia fractures treated will intramedullary nailing will assist in preventing post-operative angular deformity or catastrophic failure. 

Methods: We performed a retrospective chart review of all distal third tibia and fibula fractures 

treated with intramedullary tibia nailing at a level 1 trauma center. Immediately post-operative 

and 3-month imaging were examined to determine the distal nail location as well as any angular 

deformity. Other demographic information, injury pattern, hardware failure, and infection 

complications were documented. Regression analysis was performed to identify factors 

associated with malalignment. 

Results: 27 distal tibia-fibula fractures were identified, 3 of which had concurrent fibula fixation. 

Fractures with a more unstable fracture pattern were statistically associated with malalignment. 

Tibia nail endpoint was not associated with malalignment overall, however, among segmental 

and highly comminuted fractures, tibia nail endpoint was statistically associated with 

malalignment postoperatively. The addition of fibula fixation did not prevent malalignment. In 

contrast, tibia nail endpoint did not affect malalignment in simple fractures. 

Conclusions: This study highlights the importance of precise tibia nail endpoint particularly in the 

setting of highly comminuted, unstable distal third tibia-fibula fractures. Furthermore, it suggests 

that fixation of fibula fracture may not compensate for medial endpoint of tibia nail in preventing 

malalignment. Catastrophic hardware failure was observed in a highly comminuted distal third 

tibia fractures with associated simple fibula fracture that was not fixed, despite adequate tibia 

nail endpoint. Although further research is warranted, these findings suggest that distal third 

tibia-fibula fractures with more complex fracture characteristics may likely benefit from stiffer 

constructs to prevent future deformity and catastrophic hardware failure.