Fibular fixation as an adjuvant to tibial intramedullary nailing in the treatment of combined distal third tibia and fibula fractures: a biomechanical investigation

Objective: Distal third tibia fractures have classically been treated with standard plating, but intramedullary (IM) nailing has gained popularity. Owing to the lack of interference fit of the nail in the metaphyseal bone of the distal tibia, it may be beneficial to add rigid plating of the fibula to augment the overall stability of fracture fixation in this area. This study sought to assess the biomechanical effect of adding a fibular plate to standard IM nailing in the treatment of distal third tibia and fibula fractures. Methods: Eight cadaveric tibia specimens were used. Tibial fixation consisted of a solid titanium nail locked with 3 screws distally and 2 proximally, and fibular fixation consisted of a 3.5 mm low-contact dynamic compression plate. A section of tibia and fibula was removed. Testing was accomplished with an MTS machine. Each leg was tested 3 times; with and without a fibular plate and with a repetition of the initial test condition. Vertical displacements were tested with an axial load up to 500 N, and angular rotation was tested with torques up to 5 N.m. Results: The difference in axial rotation was the only statistically significant finding (p = 0.003), with fibular fixation resulting in 1.1 less rotation through the osteotomy site (17.96 v. 19.10). Over 35% of this rotational displacement occurred at the nail-locking bolt interface with the application of small torsional forces. Conclusion: Fibular plating in addition to tibial IM fixation of distal third tibia and fibula fractures leads to slightly increased resistance to torsional forces. This small improvement may not be clinically relevant.