Intramedullary tibial nailing of distal tibiofibular fractures: additional fibular fixation or not?

  • M. Van Maele
  • B. Molenaers
  • E. Geusens
  • S. Nijs
  • H. HoekstraEmail author
Original Article



The anatomy of the distal tibia accounts for reduced biomechanical stability and higher complication rates when treating distal tibiofibular fractures with an intramedullary tibia nail (IMTN). The goal of this study was to identify variables that affect the stability of IMTN. We assessed the value of additional fibular fixation, angular stable interlocking screws (ASLS) and multiplanar screw configuration in IMTN.

Patients and methods

A retrospective cohort study was performed including 184 distal tibial fractures and associated fibula fracture treated with IMTN. Relevant demographic, fracture-related (type and level of the tibia and fibula fracture) and operative variables (depth of the nail, screw type and configuration, use of polar screws, fibular fixation) were studied. Coronal and sagittal alignment was assessed directly and 3–6 months after IMTN. Loss of reduction (LOR) was classified as 5–9° or ≥10°.


48.4% of the patients showed ≥5° LOR in one or both planes. Coronal LOR 5°–9° significantly correlated with low tibial fractures (p = 0.034), AO/OTA type 43 distal tibial fractures (p = 0.049), and sagittal LOR 5°–9° (p = 0.015). Although sagittal LOR 5°–9° was associated with fibular fractures (non-fixated suprasyndesmotic, p = 0.011), conversely we could not demonstrate the added value of (suprasyndesmotic) fibula fixation in IMTN. Coronal LOR ≥10° significantly correlated with AO/OTA type 43 distal tibial fractures (p = 0.009). In contrast to multiplanar configuration, we found a clear benefit of ASLS in distal IMTN locking.


The level of the tibial fracture (AO/OTA type) and (suprasyndesmotic) fibular fractures were the main determinants of LOR after IMTN. ASLS was found to increase the stability of IMTN. Due to heterogeneity, however, we could not demonstrate the value of fibular fixation in IMTN. Therefore, a future prospective study with uniform treatment strategy for IMTN of distal tibiofibular fractures, with or without fixation of the fibula, is mandatory.


Distal tibial fractures Fibular fixation Outcome 



Loss of reduction


American Society of Anesthesiologists physical status score


Intramedullary tibia nailing


Angular stable locking system






Compliance with ethical standards

Conflict of interest

Margaux Van Maele, Ben Molenaers, Eric Geusens, Stefaan Nijs, and Harm Hoekstra declare that they have no conflict of interest.


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Copyright information

© Springer-Verlag Berlin Heidelberg 2017

Authors and Affiliations

  • M. Van Maele
    • 1
  • B. Molenaers
    • 2
  • E. Geusens
    • 3
  • S. Nijs
    • 4
    • 5
  • H. Hoekstra
    • 4
    • 5
    Email author
  1. 1.Faculty of MedicineKU Leuven, University of LeuvenLeuvenBelgium
  2. 2.Department of Orthopaedic SurgeryUniversity Hospitals LeuvenLeuvenBelgium
  3. 3.Department of RadiologyUniversity Hospitals LeuvenLeuvenBelgium
  4. 4.Department of Trauma SurgeryUniversity Hospitals LeuvenLeuvenBelgium
  5. 5.Department of Development and RegenerationKU Leuven, University of LeuvenLeuvenBelgium

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