Letter to the editor to comment on “Intramedullary pinning of concomitant fibular shaft fractures prevents postoperative tibial shaft malalignment without increasing soft tissue complications”

To the editor:

We read with interest the study by Lee et al. , which focuses on the clinical value of fibular fixation strategies and provides a reference for the management of tibial shaft fractures complicated by fibular fractures. While its conclusions hold certain clinical significance, we wish to share several unaddressed supplementary insights.

First, the study evaluated only coronal and sagittal angular deformities via radiography, without incorporating an assessment of rotational deformity . Tibial rotational malalignment represents a critical contributor to postoperative gait abnormalities and ankle joint degeneration; the omission of this assessment may underestimate the actual incidence of malalignment, thereby rendering the evaluation of the stability of the two fixation methods less comprehensive.

Second, the study did not employ patient-reported outcome measures patient-reported outcome measures (PROMs), it relied solely on radiographic and objective complication data，without patient-centered instruments such as the Visual Analog Scale (VAS) for pain, the Foot and Ankle Outcome Score (FAOS), or the Foot Function Index (FFI), it becomes challenging to reflect patients’ subjective functional recovery and quality of life—factors that constitute one of the core references for clinical treatment decision-making .

Third, the study failed to conduct subgroup analyses stratified by Weber subtypes or the degree of tibial comminution, potentially obscuring subgroup-specific treatment effects . Additionally, the study did not clarify whether radiographic measurements were performed using blinded assessments, leaving open the possibility of observer bias influencing alignment evaluations . Critical perioperative data, such as surgical duration and intraoperative blood loss—which are strongly correlated with soft tissue morbidity—were also omitted, limiting mechanistic insights into complication pathways.

Finally, the 12-month follow-up period insufficiently captured long-term outcomes (e.g., delayed union, hardware failure, or degenerative changes), precluding definitive conclusions regarding the sustained efficacy and safety of the two fixation strategies. These methodological gaps weaken the robustness of comparative effectiveness claims and hinder comprehensive evaluation of clinical trade-offs.

In summary, this letter highlights several critical methodological gaps in Lee et al.’s study. These limitations weaken the validity of conclusions comparing fibular fixation strategies. Addressing these limitations would not only strengthen the comparative effectiveness claims of the present study but also provide a more solid foundation for future research.

The authors (Dr. Lee et al.) of the aforementioned published paper (Intramedullary pinning of concomitant fibular shaft fractures prevents postoperative tibial shaft malalignment without increasing soft tissue complications), Foot and Ankle Surgery, Volume 32, Issue 3, April 2026, Pages 296-301, that this Letter to the editor pertains to were contacted by the journal but they declined the invitation to submit a reply letter