Hindawi Publishing Corporation

Advances in Orthopedics
Volume 2014, Article ID 806363, 4 pages
http://dx.doi.org/10.1155/2014/806363

Research Article
Hindfoot Valgus following Interlocking Nail Treatment for
Tibial Diaphysis Fractures: Can the Fibula Be Neglected?

Metin Uzun,1 Adnan Kara,2 Müjdat AdaG,3 Bülent KarslioLlu,4

Murat Bülbül,5 and Burak Beksaç6
1
Orthopaedic Department, Acıbadem Maslak Hospital, Darüşşafaka Street, Büyükdere Street No. 40, Maslak, Sarıyer, Istanbul, Turkey
2
Orthopaedic Department, Şişli Etfal Training and Education Hospital, Şişli, Istanbul, Turkey
3
Okmeydani Education and Training Hospital, Okmeydani, Istanbul, Turkey
4
Orthopaedic Department, Kasımpaşa Military Hospital, Istanbul, Turkey
5
Orthopaedic Department, Medipol University, Istanbul, Turkey
6
Orthopaedic Department, Acıbadem University, Darüşşafaka Street, Büyükdere Street No. 40, Maslak, Sarıyer, Istanbul, Turkey

Correspondence should be addressed to Metin Uzun; [email protected]

Received 22 July 2014; Revised 21 November 2014; Accepted 22 November 2014; Published 7 December 2014

Academic Editor: Allen L. Carl

Copyright © 2014 Metin Uzun et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Purpose. We evaluated whether intramedullary nail fixation for tibial diaphysis fractures with concomitant fibula fractures (except
at the distal one-third level) managed conservatively with an associated fibula fracture resulted in ankle deformity and assessed the
impact of the ankle deformity on lower extremity function. Methods. Sixty middle one-third tibial shaft fractures with associated
fibular fractures, except the distal one-third level, were included in this study. All tibial shaft fractures were anatomically reduced
and fixed with interlocking intramedullary nails. Fibular fractures were managed conservatively. Hindfoot alignment was assessed
clinically. Tibia and fibular lengths were compared to contralateral measurements using radiographs. Functional results were
evaluated using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Foot and Ankle Disability Index Score (FADI).
Results. Anatomic union, defined as equal length in operative and contralateral tibias, was achieved in 60 fractures (100%). Fibular
shortening was identified in 42 fractures (68%). Mean fibular shortening was 1.2 cm (range, 0.5–2 cm). Clinical exams showed
increased hindfoot valgus in 42 fractures (68%). The mean KOOS was 88.4, and the mean FADI score was 90. Conclusion. Fibular
fractures in the middle or proximal one-third may need to be stabilized at the time of tibial intramedullary nail fixation to prevent
development of hindfoot valgus due to fibular shortening.

1. Introduction 2. Materials and Methods

Diaphyseal tibial fractures are generally treated surgically and The study included 60 consecutive patients with unilateral
are frequently accompanied by fibular fractures [1–3]. The middle one-third tibial fractures treated by anatomic reduc-
usual treatment for a concomitant fibular fracture in the distal tion and interlocking intramedullary nail fixation and who
one-third is surgical fixation, but if it occurs in the middle had been managed conservatively for a proximal to middle
or proximal one-third, it is typically treated symptomatically one-third (except distal one-third level) fibular fracture.
[1–3]. Ankle alignment and functional results in patients Three surgeons performed the surgeries at three different cen-
symptomatically treated for fibular fractures are unclear [1, ters. All fractures were closed. Patients who had tibial union
2, 4, 5]. complications and/or who had undergone a second surgery
We evaluated whether conservative treatment for these were excluded. The mean follow-up period was 20 months
concomitant-associated fibular fractures leads to ankle defor- (range, 12–36 months) (Figure 1).
mity and assessed the functional results of an ankle deformity, Hindfoot alignment was evaluated clinically with a goni-
if present. ometer at the follow-up assessment, in the manner described
2 Advances in Orthopedics

Figure 3: Clinical images showing the crus heel relationship.

Figure 1: Anteroposterior and lateral X-ray images showing a

middle one-third tibial shaft fracture with an associated fibular
fracture and a healed tibial fracture treated with intramedullary Figure 4: Clinical images showing differences in opposite extremi-
nailing. ties due to weight-bearing.

approved the reporting of this case series and that all investi-
gations conformed with the ethical principles of research.

3. Results
All patients demonstrated radiographic union of both the
tibia and fibula. Anatomic union occurred in 60 cases (100%)
and was defined for tibia with an equal length to the con-
tralateral limb (Figure 1). Fibular shortening was identified
in 42 cases (68%). Mean fibular shortening was 1.2 cm (range,
0.5–2 cm) (Figure 3). The increase in calcaneal valgus on the
clinical hindfoot examination was a mean of 5∘ compared to
that of the other extremity (Figures 3 and 4). The mean KOOS
score was 88.4, and the mean FADI score was 90.

4. Discussion
Figure 2: Stance position. Solid lines were marked on the skin, and Tibial fractures are one of the most frequent orthopedic prob-
dashed lines have been added to the photograph to identify the tibial lems [1, 3]. Treatment remains controversial due to the variety
angle and the calcaneal stance. of fracture patterns and soft tissue problems associated with
these injuries.
Successful results have been reported for tibial intra-
medullary nailing in cases with associated proximal and
by Astrom and Arvidson [6] (Figure 2). Full-length antero- middle one-third fibular fractures, as in the current study
posterior and lateral radiographs of the tibia and fibula were [9–11]. Although associated distal one-third fibular fractures
obtained for both lower extremities at the same distance and are less commonly present with tibial diaphysis fractures,
used to compare tibial and fibular lengths for the injured the accepted treatment for these cases is surgical fixation of
and contralateral limbs [6]. Lengthening was measured with the fibula. Associated distal one-third fibular fractures were
a computer digital system. Functional outcome scores were excluded from our study, but we evaluated outcomes from
determined for each patient using the Knee Injury and nonsurgical management for more proximal fibular frac-
Osteoarthritis Outcome Score (KOOS) and the Foot and tures associated with tibial shaft fractures treated with
Ankle Disability Index Score (FADI) [7, 8]. intramedullary fixation. Complications have been reported
This study was approved by the authors’ Institutional following both surgical and conservative treatment of tibial
Review Board. All authors certify that their institution has fractures, including lower extremity angulation, rotational
Advances in Orthopedics 3

deformity, and ankle malalignment [12, 13]. Although these patent/licensing arrangement) that would pose a conflict of
complications may compromise lower extremity function interests in connection with the submitted paper.
and result in knee or ankle pain, impaired tibial alignment
was noted, but no complications related to the ankle were Acknowledgments
reported in a study by Pobłocki et al. [14]. In contrast to
those results, a previous study on patients with tibial fractures The English in this document has been checked by at least
found that a delayed diagnosis was associated with a Maison- two professional editors, both native speakers of English. For
neuve, syndesmotic, or posterior or medial malleolar fracture a certificate, please see http://www.textcheck.com/certificate/
at a rate of 20.1% [10]. A tibial alignment disorder may be a 1cVSx3.
rather common complication for distal or proximal fractures,
and functional impairment is expected due to the long-term References
effects of an alignment disorder, but a hindfoot deformity
usually does not occur following a middiaphyseal fracture. [1] J. G. Garrick, R. S. Riggins, R. K. Requa, and P. R. Lipscomb,
Although fibular fractures may lead to fibular shortening, “Fracture of the mid-shaft of the tibia and fibula. A survey of
Hooper et al. [2] reported successful results after conser- treatment,” Clinical Orthopaedics and Related Research, vol. 88,
vatively treating isolated diaphyseal fibular fractures. No pp. 131–137, 1972.
complications related to the ankle occurred but no infor- [2] G. Hooper, R. A. Buxton, and W. J. Gillespie, “Isolated fractures
mation was provided about bone shortening. In the present of the shaft of the tibia,” Injury, vol. 12, no. 4, pp. 283–287, 1981.
study, fibular shortening was common, and a valgus calcaneal [3] J. F. Keating, R. S. Kuo, and C. M. Court-Brown, “Bifocal
deformity was noted after bone healing from a tibial shaft fractures of the tibia and fibula. Incidence, classification and
fracture. Fibular length was measured and compared to a treatment,” Journal of Bone and Joint Surgery, vol. 76, no. 3, pp.
healthy fibula using the same exposure time, position, and 395–400, 1994.
distance on X-rays. Although computed tomography is the [4] K. Weise, H. Hermichen, and S. Weller, “Significance of the
best method for measuring fibular length, it was not available fibula in tibial fractures and pseudarthroses,” Aktuelle Trauma-
to us. A hindfoot assessment must be done in a standing, tologie, vol. 15, no. 5, pp. 195–204, 1985.
weight-bearing position. We used the goniometer method [5] T. C. Merchant and F. R. Dietz, “Long-term follow-up after
described by Astrom and Arvidson [6]. Coronal plane align- fractures of the tibial and fibular shafts,” The Journal of Bone and
ment can be assessed using X-rays as described by Saltzman Joint Surgery—Series A, vol. 71, no. 4, pp. 599–606, 1989.
[15] or on a long axial view under weight-bearing. We did [6] M. Astrom and T. Arvidson, “Alignment and joint motion in the
not use these techniques, as X-ray quality depends on the normal foot,” Journal of Orthopaedic & Sports Physical Therapy,
technician [15, 16]. A hindfoot alignment disorder is dynamic; vol. 22, no. 5, pp. 216–222, 1995.
thus, hindfoot cases must be evaluated in the weight-bearing [7] E. M. Roos, H. P. Roos, L. S. Lohmander, C. Ekdahl, and B.
position both clinically and radiologically. D. Beynnon, “Knee injury and osteoarthritis outcome score
Whorton and Henley [11] showed that fixing the fibula in (KOOS)—development of a self-administered outcome mea-
sure,” Journal of Orthopaedic & Sports Physical Therapy, vol. 28,
patients with open tibial and fibular shaft fractures has no
no. 2, pp. 88–96, 1998.
effect on bone healing or alignment of the tibia. However,
[8] R. L. Martin, R. G. Burdett, and J. J. Irrgang, “Development of
some studies have reported that fixing the fibula in patients
the foot and ankle disability index (FADI),” Journal of Ortho-
with distal tibial or fibular fractures increases fracture stabil- paedic & Sports Physical Therapy, vol. 29, pp. A32–A33, 1999.
ity up to week 12 after surgery [16–18]. Biomechanical results
[9] A. H. Schmidt, C. G. Finkemeier, and P. Tornetta III, “Treatment
have shown that fixing the fibula may help prevent loss of of closed tibial fractures,” Instructional Course Lectures, vol. 52,
alignment in distal tibial fractures repaired with either intra- pp. 607–622, 2003.
medullary nailing or plate fixation methods [16, 19]. [10] E. K. Stuermer and K. M. Stuermer, “Tibial shaft fracture and
ankle joint injury,” Journal of Orthopaedic Trauma, vol. 22, no.
5. Conclusion 2, pp. 107–112, 2008.
[11] A. M. Whorton and M. B. Henley, “The role of fixation of the
Shortening the fibula in patients with upper level fibular fibula in open fractures of the tibial shaft with fractures of the
fractures associated with tibial fractures treated with intra- ipsilateral fibula: Indications and outcomes,” Orthopedics, vol.
medullary nailing may cause a dynamic hindfoot valgus 21, no. 10, pp. 1101–1105, 1998.
deformity. All hindfoot cases must be evaluated in the weight- [12] H. A. Vallier, B. A. Cureton, and B. M. Patterson, “Factors influ-
bearing position both clinically and radiologically. Addi- encing functional outcomes after distal tibia shaft fractures,”
tional study is needed to determine if long-term functional Journal of Orthopaedic Trauma, vol. 26, no. 3, pp. 178–183, 2012.
outcomes in patients treated with tibial nailing can be [13] L. K. Cannada, J. O. Anglen, M. T. Archdeacon, D. Herscovici Jr.,
improved by surgical reduction and fixation of associated and R. F. Ostrum, “Avoiding complications in the care of frac-
suprasyndesmotic fibular fractures. tures of the tibia,” Instructional Course Lectures, vol. 58, pp. 27–
36, 2009.
Conflict of Interests [14] K. Pobłocki, M. Domaradzki, J. Gawdzik, P. Prochacki, and R.
Rajewski, “Complications after intramedullary nailing of the
All authors certify that they have no commercial associa- tibia,” Chirurgia Narządów Ruchu i Ortopedia Polska, vol. 76,
tions (e.g., consultancy, stock ownership, equity interest, or no. 5, pp. 274–277, 2011.
4 Advances in Orthopedics

[15] C. L. Saltzman and G. Y. El-Khoury, “The hindfoot alignment

view,” Foot & Ankle International, vol. 16, no. 9, pp. 572–576,
1995.
[16] E. J. Strauss, D. Alfonso, F. J. Kummer, K. A. Egol, and N. C.
Tejwani, “The effect of concurrent fibular fracture on the fixa-
tion of distal tibia fractures: a laboratory comparison of intra-
medullary nails with locked plates,” Journal of Orthopaedic
Trauma, vol. 21, no. 3, pp. 172–177, 2007.
[17] A. Kumar, S. J. Charlebois, E. L. Cain, R. A. Smith, A. U. Daniels,
and J. M. Crates, “Effect of fibular plate fixation on rotational
stability of simulated distal tibiae fractures treated with intra-
medullary nailing,” Journal of Bone and Joint Surgery—Series A,
vol. 85, no. 4, pp. 604–608, 2003.
[18] K. A. Egol, R. Weisz, R. Hiebert, N. C. Tejwani, K. J. Koval, and
R. W. Sanders, “Does fibular plating improve alignment after
intramedullary nailing of distal metaphyseal tibia fractures?”
Journal of Orthopaedic Trauma, vol. 20, no. 2, pp. 94–103, 2006.
[19] S. A. Stufkens, C. J. van Bergen, L. Blankevoort, C. N. van Dijk,
B. Hintermann, and M. Knupp, “The role of the fibula in varus
and valgus deformity of the tibia: a biomechanical study,” Jour-
nal of Bone and Joint Surgery, vol. 93, no. 9, pp. 1232–1239, 2011.
 MEDIATORS of

INFLAMMATION

The Scientific Gastroenterology Journal of

World Journal
Hindawi Publishing Corporation
Research and Practice
Hindawi Publishing Corporation
Hindawi Publishing Corporation
Diabetes Research
Hindawi Publishing Corporation
Disease Markers
Hindawi Publishing Corporation
http://www.hindawi.com Volume 2014
http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Journal of International Journal of

Immunology Research
Hindawi Publishing Corporation
Endocrinology
Hindawi Publishing Corporation
http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Submit your manuscripts at

http://www.hindawi.com

BioMed
PPAR Research
Hindawi Publishing Corporation
Research International
Hindawi Publishing Corporation
http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Journal of
Obesity

Evidence-Based
Journal of Stem Cells Complementary and Journal of
Ophthalmology
Hindawi Publishing Corporation
International
Hindawi Publishing Corporation
Alternative Medicine
Hindawi Publishing Corporation Hindawi Publishing Corporation
Oncology
Hindawi Publishing Corporation
http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Parkinson’s
Disease

Computational and
Mathematical Methods
in Medicine
Behavioural
Neurology
AIDS
Research and Treatment
Oxidative Medicine and
Cellular Longevity
Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation
http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014