Is fibular fixation necessary for tibia malunion (tibial bone improper healing) repair?

Fibular Fixation in Tibial Malunion Repair

Fibular fixation is generally not necessary for tibial malunion correction and may actually increase complications, including infection and angular malalignment, without improving outcomes.

Evidence-Based Recommendation

The decision to fix the fibula during tibial malunion repair should be based on whether fibular fixation aids in achieving or maintaining tibial reduction and stability, not as a routine practice.

When Fibular Fixation Should Be Avoided

• Routine fibular fixation is not recommended when adequate tibial stability can be achieved through tibial fixation alone 1
• Fibular fixation in distal tibia fractures leads to significantly more angular malalignments (10% vs 1.2%, p = 0.042) compared to no fibular fixation 2
• Infection risk is substantially elevated with fibular fixation, occurring in 15% of surgically treated fibulas, leading to significantly more revision surgeries (40% vs 20%, p = 0.03) 2
• When plates are used for fibular fixation, all infections in one study occurred in this group 2
• There is no statistical difference in mechanical complications (malunion, delayed union, nonunion, implant failure) between patients with and without fibular fixation 1

When Fibular Fixation May Be Considered

• Fibular fixation should be reserved for specific cases where it aids in tibial reduction or provides additional stability that cannot be achieved through tibial fixation alone 1
• Fibular fixation plays a positive role when it directly improves mechanical stability of the tibiofibular complex 3
• In cases where the fibula fracture pattern suggests instability of the tibial construct, fixation may be warranted 3

Critical Pitfall to Avoid

• Primary fibular fixation can cause or worsen tibial malunion - in 4 of 11 cases of axial tibial malunion in one series, the primary fibular fixation either caused or worsened the malalignment 3
• Fibular fixation that locks in a reduction abnormality of the tibia perpetuates the deformity 3

Clinical Algorithm for Decision-Making

Step 1: Assess Tibial Stability

• Achieve optimal tibial reduction and fixation first using appropriate techniques (intramedullary nailing, plating, or external fixation depending on the malunion pattern)
• Confirm tibial stability under fluoroscopy with stress testing 4

Step 2: Evaluate Need for Fibular Intervention

• If tibial construct is stable with <5 degrees angulation in all planes: Do not fix the fibula 4
• If tibial reduction cannot be achieved or maintained without fibular support: Consider selective fibular fixation 1

Step 3: Monitor Fibular Healing

• Fibular nonunion may indicate occult tibial instability - the fibula characteristically heals before the tibia, so delayed fibular healing warrants intensive investigation of the tibial construct 5
• Fibular pseudarthrosis rate is 4.7% at 1 year when treated conservatively, but this does not correlate with poor tibial outcomes if the tibia is stable 3

Modern Technique Considerations

• Modern intramedullary nailing techniques with proper reduction aids (nailing in relative extension, transfixion external fixation, clamps) achieve low rates of malalignment (2%) and malunion (3%) without fibular fixation 4
• Standard distal interlocking with 2 medial-to-lateral screws provides adequate stability with only 0.9-degree difference between initial postoperative and final united alignment 4
• The presence or level of fibula fracture does not influence malalignment (p = 0.86) or malunion (p = 0.81) rates when modern techniques are used 4