Do Not Fix the Fibula in Non-Syndesmotic Distal Both-Bone Leg Fractures Treated with Expert Nail
When treating distal tibia and fibula fractures with an Expert Tibial Nail System (ETNS), routine fixation of non-syndesmotic fibular fractures is not necessary and may cause more harm than benefit. The most recent high-quality evidence demonstrates superior outcomes when the fibula is left unfixed 1.
Primary Recommendation
Isolated ETNS fixation without fibular fixation is the preferred approach for extra-articular distal tibia fractures with associated supra-syndesmotic fibula fractures. This recommendation is based on the most recent 2026 comparative study showing:
- Faster union time: 18.1 weeks vs 22.5 weeks (p < 0.001) 1
- Better functional outcomes: Olerud-Molander score 96 vs 90.66 (p < 0.001) 1
- Fewer complications: 23.33% vs 43.33% 1
- Reduced surgical morbidity: Shorter operative time (32.9 vs 63.86 minutes), less blood loss (15.53 vs 48.91 mL), and lower radiation exposure 1
Supporting Evidence Against Routine Fibular Fixation
Multiple recent studies consistently demonstrate that fibular fixation in non-syndesmotic fractures provides no benefit and increases complications:
Increased Complications with Fibular Fixation
- Higher infection rates: 15% surgical site infections when fibula was fixed, with all infections occurring with plate fixation 2
- More revision surgeries: 40% vs 20% (p = 0.03) in the fibula-fixed group 2
- Greater angular malalignment: 10% vs 1.2% (p = 0.042) when fibula was fixed 2
- Delayed tibial healing: Better tibial union rates when fibula was NOT fixed (p = 0.032), confirmed by RUST scoring (p = 0.047) 3
No Functional Benefit
A 2020 prospective study of 154 patients found no improvement in functional outcome (AOFAS scores) with fibular plating 4. While fibular fixation improved rotational alignment, this did not translate to better clinical outcomes 4.
When to Consider Fibular Fixation (Exceptions)
Fibular fixation should be reserved ONLY for:
- Syndesmotic injuries involving the ankle mortise
- Intra-articular fractures extending to the tibial plafond
- Severe rotational instability despite adequate tibial fixation
Clinical Algorithm
- Confirm fracture location: Ensure fibular fracture is supra-syndesmotic (>4-5 cm from tibial plafond)
- Assess syndesmosis integrity: Clinical and radiographic evaluation for ankle mortise stability
- If syndesmosis intact: Proceed with isolated ETNS fixation
- If syndesmosis disrupted: Consider fibular fixation, but recognize this represents a different injury pattern
Common Pitfalls to Avoid
- Do not routinely fix the fibula based on outdated teaching that "both bones must be fixed"
- Avoid plate fixation of the fibula when fixation is deemed necessary—if you must fix it, intramedullary nailing has lower nerve injury rates 5 and fewer wound complications 6
- Do not assume fibular fixation improves alignment—the evidence shows the opposite, with more angular malalignment when fixed 2
Rationale for This Approach
The multidirectional distal locking capability of the ETNS provides sufficient stability without fibular fixation 1. Additional fibular surgery:
- Creates a second surgical site with infection risk
- Increases operative time and blood loss
- May actually impair tibial healing through unclear mechanisms 3
- Adds hardware-related complications without functional benefit
The evidence overwhelmingly supports leaving non-syndesmotic fibular fractures unfixed when using modern intramedullary nail systems with robust distal locking options.