Fibular fixation in mid and distal extra-articular tibia fractures - A systematic review and meta-analysis

The surgical management of extra-articular mid and distal tibia fractures has primarily focused on reducing rates of non-union and malunion, preserving hip-knee-ankle alignment and improving functional outcomes. Fibular fractures commonly accompany these injuries and the contributory role of fixation of these fractures has been increasingly studied. A systematic review and meta-analysis were performed to determine whether concurrent fibular fixation (FF) during extra-articular mid and distal tibia fracture fixation (AO/OTA 42 and 43-A) altered the risk of malunion, non-union and post-operative complications when compared to no fibular fixation (NF).

A systematic search of literature in the databases of MEDLINE (via OvidSP), PubMed, Embase and Cochrane Central Register of Controlled Trials (CENTRAL) from the dates of inception was performed for randomised and non-randomised controlled trials. All studies published in English were included. Risk of Bias in Non-randomised Studies (ROBINS-I) and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework were utilised. Relative risk (RR) was used for dichotomous outcomes, while mean difference (MD) was used for continuous variables, with 95% confidence intervals. Alpha was set at 0.05.

A total of ten studies with 1174 patients were included for analysis. There was a statistically significant reduced risk of overall malunion in the FF group compared to the NF group (11.8% vs 21.9%, RR 0.63, 95% CI: 0.41-0.98, p = 0.04) and this was supported through a sensitivity analysis of only randomised controlled trials (21.8% vs 40.3%, RR 0.37, 95% CI: 0.18-0.76, p = 0.006). There was no statistically significant difference in rates of non-union between groups (p > 0.05). Overall, there were similar incidences of diabetes, open fractures and smoking history between groups (p > 0.05). Detailed information regarding methods of tibial fixation were not available for subgroup analysis.

In conclusion, in extra-articular mid and distal tibia (AO/OTA 42 and 43-A) fracture fixation, additional fibular fixation (FF) appears to significantly reduce the risk of overall malunion (RR, 0.37, 95% CI: 0.18-0.76, p = 0.006) without increasing the risk of non-union. These results should be interpreted with caution given the lack of subgroup analysis for methods of tibial fixation. Future high-quality randomised controlled trials should therefore delineate between types of tibial fixation.