Radiographic Assessment of Fibular Length Variance: The Case for "Fibula Minus"

Given the high prevalence of ankle fractures and morbidity of malalignment after fixation, an appropriate anatomic relationship between the distal fibula and adjacent tibia and talus is important. The tip of the lateral malleolus of the fibula has often been described to be at the level of the lateral talar process. However, no studies to date have examined the relationship of the distal fibular tip to the lateral process of the talus. We assessed 66 weightbearing mortise radiographs for variability of the distal fibular tip in relation to the lateral process of the talus. The subjects were all skeletally mature, with a mean age of 45.3 ± 14.6 years. We used a paired t test with a null hypothesis that the true mean difference in the distance from the distal fibula to the lateral process was equal to 0. The mean distance of the distal tip of the fibula was 0.257 ± 0.127 cm proximal to the tip of the lateral process of the talus. The 95% confidence interval was 0.226 to 0.288. Of the 66 subjects, 65 had the distal tip of the fibula proximal to the lateral process of the talus, corresponding to a negative fibular variance. In the remaining subject, the distal tip of the fibula was at the same level of the tip as the lateral process of the talus. The distal tip of the fibula is most commonly not at the level of the talus lateral process, as often described in published reports. Instead, it has a variance analogous to the relationship between the lengths of the ulna compared with the radius. The distal tip of the fibula in our study was more often proximal to the tip of the lateral process of the talus and can be described as a negative fibular variance, or "fibula minus."

Two-Stage Surgical Procedure in Intra-articular Distal Tibiofibular Fractures with Soft Tissue Injury: in Which Stage Should the Fibular Plate be Applied at Initial Surgery?

Introduction:

The selection of the stage where fibular plate was performed in two-stage surgery of the intra-articular distal tibiofibular fractures with soft tissue injury is still controversial. The aim of the study was to compare the complications, radiological and functional outcomes between the patients who had fibular plate at initial or second phase during surgical management of such fractures.

Materials and Methods:

In this study, medical records of 47 patients who underwent a two-stage surgical procedure for intra-articular distal tibia fractures accompanying soft tissue injury were retrospectively examined. Delta frame was applied in all cases within 24 hours following admission to the emergency department in accordance with AO principles. Those cases where fibular plate was applied during the initial stage and the second stage were classified as Group 1 and Group 2 in order to compare recorded data between the two groups.

Results:

According to the results of the study, there were 25 cases in Group 1 and 22 cases in Group 2 in which fibular plate was applied at the first stage and the second stage, respectively. The mean follow-up was found as 27.7±7.0 months in Group 1 and 28.2±6.2 months in Group 2 (p=0.778). No difference was found between the two groups in terms of the age, sex, hospital stay, the time between two surgical procedures, tibiofibular angle and AOFAS scoring (p>0.05).These two groups were also similar in mechanism of injury, Denise-Weber or AO classification, rates of tibiofibular malalignment on post-operative CT, fibular rotation, intra-articular tibial step-off, tibial varus-valgus duration of union, rate of infection, fibular angulation and the presence of the flap/graft/debridement (p>0.05).

Conclusion:

In conclusion, two-stage surgical procedure in intra-articular distal tibiofibular fractures may be an effective method decreasing soft tissue complications. The timing of the open reduction and internal fixation of the fibula at different stages may not necessarily have an impact on the success of the post-operative tibial reduction, the total duration of surgery, syndesmosis malalignment or soft tissue complications.

Distal Fibula Fractures-Intramedullary Fixation Versus Plating: A Systematic Review and Meta-analysis of Randomized Control Trials

PURPOSE

The aim of the present study is to compare the functional scores and complications of intramedullary fixation versus plate osteosynthesis of distal fibular fractures in adults.

METHODS

Study was performed in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses format from MEDLINE, Embase, Ovid, and Cochrane databases. The included articles were assessed according to the risk of bias assessment tool by Cochrane collaboration.

RESULTS

A total of 5 randomized control trials were included for quantitative review. Random sequence generation and allocation concealment of the study subjects were the strengths of all the included studies. There was high heterogeneity among the included studies (I2 > 75%). There was no significant difference between the Olerud-Molander scores in both the groups but the trend favored the intramedullary nailing of distal fibula (mean difference of 3.42, 95% confidence interval [CI] of 8.90). Complications were significantly lesser in the intramedullary group across the studies (odds ratio 0.26, 95% CI of 0.81).

CONCLUSION

Intramedullary nailing of fibula with the use of modern locking fibular nails is an alternative to fibular plating for unstable distal fibular fractures in properly selected cases. There remains the need for standardizing the method of operative treatment of distal fibular fractures which can be done by a well-planned large-scale prospective study design.

LEVEL OF EVIDENCE

Level 1.