Abstract
Background
Tibial diaphysis fractures, accounting for 17 % of lower extremity fractures, are often associated with fibular fractures. This study compares intramedullary pinning and extramedullary plating for fibular fixation following tibial fracture fixation.
Methods
A retrospective analysis was performed on 215 patients treated between 2012 and 2022. Patients were grouped by fibular fixation: no fixation, intramedullary pin, or extramedullary plate. Logistic regression identified risk factors for postoperative tibial malalignment and soft tissue complications.
Results
Malalignment occurred in 14.9 % of patients, with higher rates in those without fibular fixation (28.6 %) versus pinning (10.8 %) or plating (7.4 %). Logistic regression showed pinning (OR = 0.263, p = 0.029) and plating (OR = 0.162, p < 0.001) reduced malalignment risk without significant differences between methods. Plate fixation increased soft tissue complications (OR = 3.955, p = 0.003), whereas pinning did not (OR = 1.924, p = 0.297).
Conclusion
Intramedullary pinning offers similar alignment benefits to plating without increasing soft tissue complications and may be preferable in comminuted fractures or compromised soft tissue conditions.
Levels of evidence
Level III
1
Introduction
Fractures of the tibial diaphysis constitute 17 % of lower extremity fractures , with up to 78 % having concomitant fibular fractures . Tibial shaft fractures are typically treated with internal fixation to enable early recovery . Conversely, the need for fibular fixation remains debated. While midshaft fibula fractures are often managed conservatively, proximal fractures with ligamentous injuries and distal fractures causing ankle instability require surgical fixation . Concomitant ankle injuries, particularly syndesmotic injuries, occur in approximately 20 % of tibial shaft fractures, especially in distal third spiral or Maisonneuve fractures. Careful assessment of syndesmotic stability is therefore essential during tibial fracture management.
Fibular fixation aids tibial fracture reduction , and prevents postoperative re-displacement , , but it also increases soft tissue complication risks due to additional surgical incisions and high-energy trauma , . Recent systematic reviews have demonstrated that fibular fixation may significantly reduce the risk of malunion without increasing non-union rates in extra-articular mid and distal tibia fractures . Extramedullary plates are the standard for fibular fixation but may exacerbate complications when combined with tibial fixation . Intramedullary pin fixation, performed percutaneously, minimizes soft tissue dissection but raises stability concerns .
Our surgical team used Steinman pins as intramedullary devices for simultaneous fibula fixation to aid tibial reduction. Although intramedullary fixation does not directly restore fibular length or rotational alignment, it can maintain satisfactory fibular alignment and assist in achieving tibial reduction. A preliminary study validated this approach as an alternative to plate fixation, particularly for comminuted fractures with concerns about soft tissue complications . A comparative clinical study examining intramedullary pins and extramedullary plates for low fibula fractures (Weber A and B) suggested intramedullary pins as a viable and effective alternative . To our knowledge, no study has directly compared intramedullary pins and extramedullary plates for simultaneous fibula fixation following tibial fracture fixation. This study aimed to evaluate the benefits of fibula fixation using either an intramedullary Steinmann pin or an extramedullary plate versus no fixation, focusing on postoperative tibial alignment and soft tissue complications to identify the optimal method for managing concomitant fibular fractures.
2
Methods
2.1
Study design and setting
We conducted this retrospective study at a single tertiary-care center, including a consecutive series of patients who underwent internal fixation for tibial shaft and concomitant fibular shaft fractures.
2.2
Patients
Using the hospital’s digital archive and surgical records, we identified patients with diaphyseal tibial fractures (AO/OTA classification type 42 ) and fibular shaft fractures, regardless of fixation, treated from January 2012 to January 2022. Patients with periarticular fractures (AO/OTA type 41 or 43), fractures with suspected major syndesmotic injuries, pediatric patients, and those with incomplete follow-up records were excluded, resulting in a final cohort of 215 patients.
2.3
Surgery protocol
The choice of implants and fixation method for the tibia (plate or nail) and fibula (plate, intramedullary pin, or no fixation) was determined by the operating surgeon without randomization. Cases were categorized into three groups based on the fibula treatment method: no fixation, intramedullary Steinmann pin fixation, or conventional extramedullary plate fixation. When fibular fixation was performed, it was typically carried out prior to tibial fixation to assist with maintaining fibular length and alignment. Intramedullary pin fixation was performed using a Steinmann pin (2.0 mm in diameter), inserted retrogradely from the tip of the lateral malleolus under fluoroscopic guidance.
2.4
Demography, preoperative radiographic characteristics, and postoperative follow-up assessment
We collected demographic data (age, sex, fracture site) and preoperative radiographic characteristics. Fibula fractures were classified as midshaft or based on the Danis-Weber system (types A, B, C) . Tibial comminution was classified according to the AO classification ,and open tibial fractures were classified by the Gustilo–Anderson system . Follow-up occurred at 2, 4, and 6 weeks; 2, 3, and 6 months; and 12 months, with radiographic (anteroposterior and lateral X-rays) and clinical assessments at each visit.
2.5
Study outcomes
Postoperative alignment was evaluated using the Freedman and Johnson technique, with malalignment defined as a deviation exceeding 5° in coronal angulation or 10° in sagittal angulation . Rotational malalignment was not evaluated; only coronal and sagittal plane alignment was assessed based on plain radiographs. Soft tissue complications were categorized as superficial wound infection (including cases of cellulitis or skin bullae) or wound infections requiring surgical intervention, which were further classified as wound infection requiring surgical debridement, wound infection requiring skin grafting, or wound infection requiring flap coverage.
2.6
Descriptive data
This study included 215 patients (mean age: 51.77 ± 16.71 years) with a nearly equal gender distribution (108 males, 50.2 %; 107 females, 49.8 %). Fractures affected 119 left tibias (55.3 %) and 96 right tibias (44.7 %). Most patients (68.8 %) had closed fractures, while open fractures were classified as type I (10.2 %), type II (13 %), type IIIA (6.5 %), and type IIIB (1.4 %). Tibia comminution was categorized as type A (45.1 %), type B (38.6 %), and type C (16.3 %). Tibial fixation methods included nails (56.7 %) and plates (43.3 %). For fibular fixation, 32.6 % had no fixation, 50.2 % had extramedullary plate fixation, and 17.2 % had intramedullary pin fixation. Postoperative malalignment occurred in 14.9 %, and soft tissue complications were noted in 21.4 %, including superficial wound infection (11.2 %), wound infection requiring surgical debridement (6.5 %), wound infection requiring skin grafting (1.9 %), and wound infection requiring flap coverage. (1.9 %). ( Table 1 ) In addition, soft tissue complications were further categorized according to the type of fibular fixation (no fixation, intramedullary pin fixation, and plate fixation) as detailed in Table 2 . In this retrospective cohort, approximately 20 % of the patients underwent tibial fracture fixation with intramedullary nails. This relatively low proportion may be attributed to the fracture characteristics, such as proximal or distal third locations and long oblique or spiral patterns, which are less suitable for nailing.
Table 1
Subject demographic data (N = 215).
| Variable | |
|---|---|
| Age (years) | 51.77 ± 16.71 |
| Gender | |
| Male | 108 (50.2 %) |
| Female | 107 (49.8 %) |
| Fracture Site | |
| Left | 119(55.3 %) |
| Right | 96(44.7 %) |
| Tibia open fracture | |
| Closed | 148(68.8 %) |
| I | 22(10.2 %) |
| II | 28(13 %) |
| IIIA | 14(6.5 %) |
| IIIB | 3(1.4 %) |
| Tibia comminution | |
| A | 97(45.1 %) |
| B | 35(16.3 %) |
| C | 83(38.6 %) |
| Fibular fracture level (Weber classification) | |
| A | 2(0.9 %) |
| B | 91(42.3 %) |
| C | 122(56.7 %) |
| Tibial fixation | |
| Nail | 40(18.6 %) |
| Plate | 175(81.4 %) |
| Fibular fixation | |
| None | 70(32.6 %) |
| Plate | 108(50.2 %) |
| Pin | 37(17.2 %) |
| Postoperative alignment | |
| Normal alignment | 183(85.1 %) |
| Malalignment | 32(14.9 %) |
| Soft tissue complication | |
| No soft tissue complication | 169(78.6 %) |
| Superficial wound infection | 24(11.2 %) |
| Wound infection requiring surgical debridement | 14(6.5 %) |
| Wound infection requiring skin grafting | 4(1.9 %) |
| Wound infection requiring flap coverage | 4(1.9 %) |
Data are expressed as mean±SD or number (%).
Table 2
Distribution of soft tissue complications according to the fibular fixation method.
| Soft tissue complication | ||||
|---|---|---|---|---|
| Superficial wound infection (n = 24) | Wound infection requiring surgical debridement (n = 14) | Wound infection requiring skin grafting (n = 4) | Wound infection requiring flap coverage (n = 4) | |
| No fixation (n = 8) | 3 | 4 | 0 | 1 |
| Pin (n = 6) | 2 | 3 | 1 | 0 |
| Plate (n = 32) | 19 | 7 | 3 | 3 |
2.7
Statistical analyses
Statistical analyses were conducted using SPSS 20.0(SPSS Inc., Chicago, IL, USA) to assess demographics, fracture patterns, and postoperative outcomes. Radiological measurements by two authors demonstrated good reliability for continuous variables (intraclass correlation coefficient scores: 0.75–0.9) and near-perfect agreement reliability for categorical variables (Cohen’s kappa: >0.9). Chi-squared and Student’s t -tests were used for categorical and continuous variables, respectively. Univariate logistic regression identified significant factors (p < 0.05) for malalignment and soft tissue complications, which were further analyzed using multivariate logistic regression. A p-value < 0.05 was considered statistically significant.
3
Results
3.1
Risks of postoperative malalignment
Our study evaluated 215 patients, with 32 (14.9 %) experiencing postoperative malalignment. The incidence was significantly higher without fibular fixation (28.6 %, 20/70) compared to pin fixation (10.8 %, 4/37) and plate fixation (7.4 %, 8/108) (p = 0.000), underscoring the role of fibular stabilization in malalignment prevention. ( Table 3 ) Logistic regression showed that both pin fixation (OR = 0.263, p = 0.029) and plate fixation (OR = 0.162, p < 0.001) significantly lowered malalignment risk compared to no fixation. However, plate fixation did not significantly outperform pin fixation (OR = 0.615, p = 0.464) when pin fixation was the reference. Furthermore, comminuted tibial fractures (type C) were strongly associated with malalignment risk (OR = 4.084, p = 0.004), identifying fracture complexity as a key predictive factor. ( Table 4 )
Table 3
Patient demographic and clinical characteristics.
| Variable |
Normal alignment
( n = 183) |
Malalignment
( n = 32) |
p value |
|---|---|---|---|
| Demography | |||
| Age (years) | 51.2 ± 16.8 | 54.9 ± 16.3 | 0.255 |
| Gender | |||
| Male | 92 (85.2) | 16 (14.8) | 0.977 |
| Female | 91 (85) | 16 (15) | |
| Fracture side | |||
| Right | 85 (88.5) | 11 (11.5) | 0.205 |
| Left | 98 (82.4) | 21 (17.6) | |
| Preoperative radiographic analyses | |||
| Fibular fracture type | |||
| Weber A and B | 76 (81.7) | 17 (18.3) | 0.222 |
| Weber C | 107 (87.7) | 15 (12.3) | |
| Tibia fracture comminution | |||
| A | 89 (91.8) | 8 (8.2) | 0.038 |
| B | 29 (82.9) | 6 (17.1) | |
| C | 65 (78.3) | 18 (21.7) | |
| Tibia open fracture | |||
| Close | 127 (85.8) | 21 (14.2) | 0.949 |
| I | 18 (81.8) | 4 (18.2) | |
| II | 24 (85.7) | 4 (14.3) | |
| III | 14 (82.4) | 3 (17.6) | |
| Operative treatment | |||
| Fibular fixation | |||
| No fixation | 50 (71.4) | 20 (28.6) | 0.000 |
| Pin | 33 (89.2) | 4 (10.8) | |
| Plate | 100 (92.6) | 8 (7.4) | |
| Tibial fracture fixation | |||
| Nail | 32 (80) | 8 (20) | 0.314 |
| Plate | 151 (86.3) | 24 (13.7) | |
p values are based on
Data are presented as mean ± standard deviation or number and percentage in parentheses.
Table 4
Logistic regression analyses of the influence of variables on the likelihood of postoperative malalignment (N = 215).
| Univariate | Multivariate | |||
|---|---|---|---|---|
| Variables | OR (95 % CI) | p value | OR (95 % CI) | p value |
| Demography | ||||
| Age (years) | 1.013 (0.990, 1.037) | 0.255 | ||
| Gender | ||||
| Male | Reference | |||
| Female | 1.011 (0.477, 2.143) | 0.977 | ||
| Fracture Site | ||||
| Right | Reference | |||
| Left | 1.656 (0.755, 3.631) | 0.208 | ||
| Preoperative radiographic analyses | ||||
| Fibular fracture type | ||||
| Weber C | Reference | |||
| Weber A and B | 1.596 (0.751, 3.391) | 0.225 | ||
| Tibia fracture comminution | ||||
| A | Reference | Reference | ||
| B | 2.302 (0.737, 7.186) | 0.151 | 2.775 (0.833, 9.242) | 0.096 |
| C | 3.081 (1.262, 7.518) | 0.013 | 4.084(1.581,10.549) | 0.004 |
| Tibia open fracture | ||||
| Close | Reference | |||
| I | 1.344 (0.414, 4.364) | 0.623 | ||
| II | 1.008 (0.318,3.199) | 0.989 | ||
| III | 1.296 (0.343, 4.898) | 0.702 | ||
| Operative treatment | ||||
| Fibular fixation | ||||
| No fixation | Reference 1 | Reference 1 | ||
| Pin | 0.303 (0.095, 0.967) | 0.044 | 0.263(0.079,0.875) | 0.029 |
| Plate | 0.200 (0.082, 0.486) | 0.000 | 0.162(0.064, 0.409) | 0.000 |
| No fixation | 3.300(1.034,10.527) | 0.044 | 3.803(1.143,12.650) | 0.029 |
| Pin | Reference 2 | Reference 2 | ||
| Plate | 0.660 (0.187, 2.334) | 0.519 | 0.615 (0.168, 2.258) | 0.464 |
| Tibial fracture fixation | ||||
| Plate | Reference | |||
| Nail | 1.573 (0.648, 3.817) | 0.317 | ||
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