Distal tibial metaphyseal malunion: current concepts

Distal tibial metaphyseal malunion is a challenging complication of lower-extremity trauma due to its effects on alignment, ankle mechanics, and long-term function. This narrative literature review synthesizes current evidence regarding the pathophysiology, evaluation, and management of distal tibial metaphyseal malunion. Since the ankle is a highly congruent joint, even small degrees of angular or rotational deformity can alter tibiotalar contact patterns, producing pain, instability, and progressive post-traumatic arthritis. Malunion typically arises from the interaction of fracture morphology, fixation challenges in the metaphyseal region, soft-tissue compromise, and associated fibular or syndesmotic injury. Accurate evaluation requires systematic assessment with weight-bearing radiographs and computed tomography to characterize deformity and joint congruity. Management is guided primarily by cartilage preservation and symptom severity, with treatment options ranging from corrective osteotomy to circular external fixation, intramedullary techniques, ankle arthrodesis, or total ankle replacement following deformity correction. Early recognition and individualized treatment are essential to optimize outcomes.