Expert Tibia Nail: Is a Single Nail Enough to Fix Distal Tibia and Fibula Fractures?

Background  Management of extra-articular distal tibia fractures associated with supra-syndesmotic fibula fractures remains controversial, particularly regarding the need for fibular fixation. With the advent of the Expert Tibial Nail System (ETNS), which provides multidirectional distal locking, adequate stability may be achieved without fibular fixation, potentially reducing surgical morbidity. Objective  To compare clinical, radiological, intra-operative parameters, and complication rates between isolated ETNS fixation and conventional tibial intramedullary (IM) nailing with fibular plating in extra-articular distal tibia and fibula fractures. Materials and methods A hybrid (prospective and retrospective) comparative study was conducted from April 2023 to March 2025, including 120 patients aged 18-60 years with extra-articular distal tibia fractures (4-10 cm from the tibial plafond) and associated supra-syndesmotic fibula fractures. Sixty patients were treated with isolated ETNS fixation, and sixty underwent conventional tibial nailing with fibular plating. Intra-operative parameters (duration of surgery, blood loss, and radiation exposure), time to union, Olerud-Molander ankle score, deformity, and complications were analyzed. Statistical analysis was performed using Student's t-test and the chi-square test, with significance set at p < 0.05. Results  The mean duration of follow-up of 14.2 months. The ETNS group demonstrated significantly shorter operative time (32.9 vs. 63.86 minutes), lower blood loss (15.53 vs. 48.91 mL), and reduced radiation exposure (22.68 vs. 33.55 C-arm shots) (p < 0.05). Mean union time was significantly earlier in the ETNS group (18.1 vs. 22.5 weeks, p < 0.001). Functional outcome assessed by the Olerud-Molander ankle score was superior in the ETNS group (96 vs. 90.66, p < 0.001). Overall complications were fewer with ETNS (23.33%) compared with tibial nailing with fibular plating (43.33%), with higher rates of infection, ankle stiffness, and non-union observed in the fibular fixation group. Conclusion  Isolated ETNS fixation for extra-articular distal tibia fractures with associated supra-syndesmotic fibula fractures provides superior clinical and radiological outcomes, earlier union, reduced operative morbidity, and fewer complications compared with conventional tibial nailing with fibular plating. Routine fixation of the fibula may not be necessary when stable multidirectional tibial fixation is achieved with ETNS.