When is indicated fibular fixation in extra-articular fractures of the distal tibia?

There is no consensus about indications for fibular osteosynthesis in extra-articular fractures of the distal tibia (DTF). This study analyses patients affected by DTF associated to fibular fracture and has the aim to define whether the level of fibular fracture has an influence on bone healing and consequently when its fixation is indicated.Eighty-seven patients were operated from January 2005 to December 2016. Inclusion criteria were: the presence of skeletal maturity, the absence of physical limitations before trauma and a type 43-A AO closed fracture. Clinical outcomes were evaluated using Olerud-Molander Ankle Score (OMAS) and the Disability Rating Index (DRI). Malrotation was also assessed as well as incidence of nonunion and malalignment through x-rays.No differences in clinical scores were reported at follow-up between patients in which fibular fixation was performed (Group 1) in comparison with those in which this procedure was not executed (Group 2).  Nonunions were registered in 8 cases: four in Group 1 and four in Group 2. A statistically significant difference in incidence of external malrotation and valgus malalignment between the groups was documented, with a higher risk in patients of the second group.The level of fibular fracture is important to determine when the fixation of this bone is indicated. In supra-syndesmotic fractures osteosynthesis leads to a higher incidence of nonunions. Fibular osteosynthesis could prevent malrotation and malalignment and is advisable in distal metaphyseal fracture of this bone (trans- or infrasyndesmotic lesion) with syndesmotic injury.