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Excerpt
I would like to comment on the article by Egol KA et al. “Does fibular plating improve alignment after intramedullary nailing of distal metaphyseal tibia fractures?” (J Orthop Trauma. 2006;20:94–103).1
In the authors study, they advocate fibular stabilization for the maintanance of reduction when intramedullary nailing of a distal tibial fracture is contemplated.
However, a laboratory study has shown that plating the fibula can decrease motion across a tibial defect only when less rigid (ie, external) fixation is used, but there was no effect on defect site motion when the tibia was fixed with an intramedullary nail.2 This finding is also supported by an additional study that found that fixation of the fibula in open fractures of the tibia and fibula has no effect on fracture healing or alignment.3
The critical question is: Why is there loss of reduction after intramedullary nailing of a distal tibial fracture? Is the loss of reduction solely the result of an unfixed fibular fracture? I believe the answer is no. If the authors had used blocking screws, they might have normalized alignment without fixing the fibula as blocking screws have been shown to improve alignment.4
Furthermore, malalignment can result from technical failures. A study by Obremskey et al5 showed that patients treated by community orthopedic surgeons had a higher incidence of malalignment, as compared with those treated by orthopedic trauma specialists.
Additonally, intramedullary nailing is an effective method for treating distal metaphyseal tibial fractures.6
Finally, open reduction and internal fixation of the fibular fracture may result in complications including nonunion, infection, loss of fracture hematoma, blood loss, and additional operative time with additional costs.7
In conclusion, on the basis of our experiences and other authors, intramedullary fixation of distal tibial fractures without the addition of fibular plating is a very effective and valuable option.
