A series of 30 patients (22 men and 8 women) with concurrent distal tibia and fibula fractures underwent minimally plate osteosynthesis utilizing precontoured dital tibial medial locking plates without fibular fracture fixation. The outcome of the surgery was assessed and the patients were followed up clinically and radiographically during the post-operative period. 14 fractures were type A1, 6 type A2, and 4 type A3. Open Grade II fracture were 4 and Open Grade IIIA fracture were 2.

Extra-articular distal tibial metaphyseal fractures with concomitant fibular fracture at or above the level of the distal tibio-fibular syndesmosis.

For minimally invasive plate osteosynthesis of distal tibial fractures, the patient was placed supine on radiolucent table. The plate position was medial, the length of the plate was determined by fracture geometry and the locking plate principles. Distal 3cm incision over medial malleolus was taken, the plate passed over the medial aspect of tibia proximally under fluoroscopic guidance. A 4mm and 5mm locking screws were placed at each end of the plate through the two incisions and in the mid position via small percutaneous stab incisions. The distal metaphyseal articular fragment was indirectly reduced to the proximal shaft. Post-operatively the limb was positioned with strict elevation, cryo application, gentle ankle-toes movements. Absolute non- weight bearing walking in the first post-operative month was mandatory, later partial to full weight bearing was started as the fracture healing progressed [3,7,8] and radiological bony union appeared.

The evaluation was done based on Teeny and Wiss clinical assessment criteria [Table/Fig-1] [10].

Most of the patients were in age group of 20-50 years (70%) with mean age of 36 years. Road traffic accidents were found to be the most common mode of trauma (90%). Right limb was involved more often (70%) than the left. The time taken for partial weight bearing, mean time for starting partial weight bearing, time taken for full weight bearing, time for starting full weight bearing & time interval for complete union are shown in [Table/Fig-2]. The mean interval for radiological union was 20 weeks. The range of motion at the ankle & degrees of dorsi & plantar flexion is shown in [Table/Fig-2].

The need for fibular fixation in such fractures is somehow not clear. Many researchers agree, but there is no consensus over the role of fibular fixation in extra-articular fractures of the distal tibia.

It was seen in a study by Lambert [11] that the fibula carries a total of 1/6 of the load applied to the knee joint also the load distribution is around 6% and 7% of the total load transmitted through both the tibia and fibula [12,13].

From plantar flexion to dorsi flexion of the ankle, Close [14] reported an increase in intermalleolar distance of 1.5 mm and lateral rotation of the fibular by 2.5°. This is usually seen due to the trochlear shape of the talar dome being wide anteriorly and narrow posteriorly. It was demonstrated that the fibula usually descends approx 2.4 mm during stance phase of gait [15].

The interosseous membrane between the tibia and fibula has been shown to function as a conduit for stress transmission, creating a load sharing function of the fibula. In a holographic investigation of cadaveric limbs, complete sectioning of the interosseous membrane revealed that there was an reduction in fibular load transference by 30% [16]. In another study, complete transection of the interosseous membrane revealed that the fibular strains to almost zero [17]. These findings suggest that the tibia bears most of the weight bearing stress during the disruption of interosseous membrane.

The historic reasons for fibular fixation in distal tibial fractures are based on the findings by Ruedi and Allgower [1], in 1969. They have described the principles and classic technique for open reduction with internal fixation of the distal tibial intra-articular fracture as:

- fibular length maintainance;

- reconstruct the articular surface of the distal tibia;

- use of autogenous cancellous bone to fill the tibial metaphyseal gap

- stabilising tibia with a medial plate.

These principles still form the standard of care. The importance of fibular reconstruction and accurate restoration of the articular surface of the distal tibia was considered as an important criteria for good functional outcome in these fractures [1,4,5]. These ideas were used in experimental studies and they showed that malreduction of fibular fractures at the level of ankle joint have often lead to increased focal pressure on the joint surface, which then can lead to early degenerative arthritis [18,19]. It has been shown that the distal metaphyseal fractures with syndesmotic injury and fibula fracture need fibula fixation [2,3,10]. The clinical outcome also depends on other factors - whether syndesmotic injury is present or not [20].

Few studies confirmed that fibula fixation improves mechanical stability of middle third tibia fractures also [21].

Increased soft tissue envelope morbidity: High-energy fractures of the distal tibia are often associated with a high incidence of soft tissue trauma along with a high incidence of wound infections and necrosis [1,22]. This high incidence of complications suggests that a more open approach should be utilized. Correspondingly, open reduction internal fixation of the fibula are often accompanied by an increased rate of wound complications [23].

Effects of an intact fibula: There are no studies that demonstrate the effect of fibular fixation on union rates of tibial fractures. However, several clinical reports have demonstrated that fracture stability of the distal tibia with an intact or stabilised fibula does not ensure successful healing. Teitz et al., [24] examined the effects of an intact fibula associated with a tibial fracture. They found that distal tibial fractures in patients aged 20 years or older with an intact fibula had a 61% complication rate including 22% delayed union, 4% nonunion and 26% varus malunion. Other reports of delayed tibial fracture healing with an intact or healed fibula have suggested that an intact fibula may prevent cyclic compression of the fractured tibia necessary for physiologic bone healing. Minimally invasive techniques are based on principles of limited exposure, indirect reduction methods and limited contact between bone and implant. As a result, in the present study, we could avoid major soft tissue complications and shorten the length of the patient’s stay in the hospital [3,6]. The bone healing was excellent with this type of fixation because the stresses were distributed over a longer segment of bone [25].

Hence, it can be concluded that minimally invasive percutaneous plate osteosynthesis for distal tibia fractures without fibula fixation is more feasible and has less complications.

The concept is not clear about the fibula fracture fixation in distal metaphyseal extra articular tibia fracture with non syndesmotic fibula fracture. In such situations fixing fibula fracture may invite more local soft tissue morbidity. Hence in such distal tibia and fibula fractures, stabilisation of tibial fracture alone with distal medial locking plate using minimally invasive technique is proved to be a feasible and worthwhile method of stabilization.