Abstract
Background:
Most cases of tibia and fibula shaft fractures are treated without fixation of the fibula. However, there are some cases where fibula fixation is thought to improve patient outcome. The fibula can be stabilized by surface plating or medullary nailing but literature comparing these 2 fixation techniques is limited. This study evaluates postoperative complications and readmission rates between intramedullary (IM) nailing and surface plating of fibular fractures in patients undergoing concomitant tibial osteosynthesis.
Methods:
Using the Nationwide Readmissions Database (NRD) from 2016 to 2021, we identified patients undergoing tibial open reduction and internal fixation (ORIF) for distal tibial fractures with concurrent fibular fixation using either IM nailing or plate fixation were identified. Propensity score matching was performed to balance demographic and clinical covariates. The prespecified primary endpoint was overall 90-day wound/infectious complications; secondary outcomes included specific complications and 30- and 90-day readmissions.
Results:
After matching, 3497 IM nailing cases and 3381 plating cases were included. Baseline characteristics were similar between groups. IM fixation was associated with significantly lower rates of overall complications (7.5% vs 9.8%, P = .001), wound dehiscence (0.6% vs 1.8%, P < .001), infection (1.3% vs 2.8%, P < .001), malunion (0.4% vs 0.9%, P = .018), and abscess formation (0.1% vs 0.4%, P = .039). Although 30-day and total readmission rates were similar, the plate fixation group had significantly higher rates of infection- and wound-related readmissions.
Conclusion:
In patients undergoing tibial ORIF for distal tibial fractures, adjunctive fibular IM nailing is associated with fewer wound-related complications and infections compared with plate fixation, without compromising union or readmission rates. IM nailing may be a lower-morbidity alternative for selected patients, pending prospective studies that incorporate fracture morphology and functional outcomes.
Level of Evidence:
Level III, prognostic.
Introduction
Distal tibial fractures, which may include injuries involving the distal third of the shaft or periarticular patterns requiring open reduction and internal fixation (ORIF), are frequently accompanied by distal fibular fractures, with co-occurrence reported in up to 85% of cases.9,13,20,21 These injuries often result from high-energy trauma and sometimes may necessitate surgical fixation of both bones to restore limb alignment and stability.11,22 Although most tibial shaft fractures are managed with intramedullary nailing, certain distal tibial or periarticular fractures are treated with ORIF. In this subset of patients undergoing tibial ORIF, the optimal approach for concurrent fibular fixation remains uncertain.3,14,24
Traditionally, fibular fractures that occur alongside tibial shaft or distal metaphyseal tibial fractures have most often been treated with plate fixation. 5 There are 2 common techniques to fix fibular fractures in this setting: open plate fixation and intramedullary fixation. Plate fixation (lateral plating) can restore fibular length and alignment but requires larger incisions and more soft tissue dissection, increasing the risk of wound complications. In contrast, intramedullary methods (nails or pins) offer a more minimally invasive alternative, potentially reducing soft tissue trauma.1,7,22
These fibular fractures are fundamentally different from malleolar fibular fractures of the ankle (which are periarticular and subject to ankle-specific biomechanical and soft tissue constraints), and thus the complications and fixation choices differ. For fibular shaft fractures associated with tibial fixation, 2 common techniques exist, as mentioned above. Our study specifically examines these 2 strategies, as they are the most widely employed and clinically relevant in this setting.
Comparative studies assessing the efficacy of fibular IM nailing have yielded mixed findings. Kim et al 12 found that when fibular fixation was used in mid- and distal tibia extraarticular fractures, the risk of malunion was reduced without a corresponding increase in nonunion. However, Auger et al 2 found no significant difference in infection rates between IM nailing and plating in a medically complex population (5% vs 9%, P = .291), but noted improved functional outcomes with IM fixation. Zhang et al 26 similarly demonstrated lower infection rates with IM nails but reported a slightly higher incidence of hardware failure. In contrast, Attia et al 1 reported a markedly lower complication rate for IM nailing (7.8%) compared with plating (29.1%, P < .001). A meta-analysis by Raj et al 17 further supported the benefits of IM nail fixation, showing a significantly reduced risk of complications across randomized trials (OR 0.26, 95% CI 0.81).
Despite these findings, existing literature focuses on isolated fibular fractures, without considering outcomes in the context of concurrent tibial ORIF—a scenario particularly relevant in patients undergoing tibial ORIF, where a medial or anterior tibial incision combined with a lateral fibular incision may increase cumulative soft tissue morbidity. This represents a critical gap in the literature, as the combined insult from multiple incisions may increase the risk of wound-related complications, particularly in patients with comorbidities or compromised soft tissue envelopes.
To address this gap, we used the Nationwide Readmissions Database (NRD) from 2016 to 2021 to evaluate postoperative complications and readmissions in patients undergoing tibial ORIF with concurrent fibular fixation using either IM nailing or plating. We hypothesized that IM nailing would be associated with fewer wound-related complications and comparable readmission rates, supporting its role as a lower-risk alternative to traditional plating in patients who are at increased risk of sustaining wound complications following operative fixation.
Methods
Data Source
This retrospective cohort study used the NRD for the years 2016 through 2021. Maintained by the Healthcare Cost and Utilization Project (HCUP), the NRD is a large, publicly available data set designed to support readmissions research across the United States. The NRD includes discharge data from a wide range of hospitals and captures readmissions both within the same hospital and across different hospitals, providing a wide view of inpatient care that has been used extensively in the orthopaedic literature. The database covers roughly 60% of all US hospitalizations and is weighted to generate nationally representative estimates.4,8,25 The database covers roughly 60% of all US hospitalizations and is weighted to generate nationally representative estimates. Discharge weights provided by the NRD were applied to produce national estimates that adjust for sampling design to approximate outcomes in the entire US hospitalized population. These weights account for hospital-level characteristics such as bed size, teaching status, location, ownership, and geographic region. Finally, the NRD tracks readmissions within the same calendar year. To ensure at least 90 days of follow-up for all patients, we limited inclusion to cases with an index admission during the first three quarters of each year. This approach enabled consistent assessment of both early (≤30 days) and later (31-90 days) postoperative readmissions.
Study Population
Patients who underwent surgical treatment for concurrent tibial and fibular fractures between 2016 and 2021 were identified using International Classification of Diseases, Tenth Revision (ICD-10), procedure and diagnosis codes. Patients included in the analysis had an ICD-10 diagnosis code for distal tibia/fibular fracture and ICD-10 procedure codes for tibial ORIF and either fibula IM fixation or plate fixation. All International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), diagnostic codes and International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS), procedural codes used in this study are in the appendix. The ICD-10 procedure codes used to classify surgical treatment were reviewed to minimize overlap and confirm differentiation between IM fixation and plating techniques. Although these codes have not been formally validated for this specific clinical application, they have been extensively used in the literature for this application. For clarity, our use of the term distal tibial shaft fracture reflects ICD-10 coding and does not correspond directly to OTA classification. We included codes most consistent with tibial shaft fractures. However, we acknowledge that ICD-10 does not perfectly distinguish distal third tibial shaft fractures from distal tibial periarticular/pilon patterns, and some overlap may have occurred.
Two surgical procedures were evaluated: intramedullary (IM) fixation and traditional plate fixation. Patients were excluded if they had missing demographic information (age, sex, or income quartile), missing a fibula fracture diagnosis, missing a tibial ORIF procedural record, or underwent fibula fixation via other surgical techniques. Furthermore, because the NRD does not include surgical exposure details, we could not distinguish open, minimally invasive, or percutaneous techniques.
Propensity Score Matching
Propensity score matching was performed to account for potential confounders and balance baseline characteristics between treatment groups. Patients receiving IM fixation were matched 1:1 with those undergoing plating using greedy nearest-neighbor matching without replacement and a caliper of 0.1 pooled SDs. Propensity scores were calculated using logistic regression based on demographic and clinical covariates, including age, sex, and comorbidities. Matching quality was evaluated using Pearson χ2 analysis, with P > .05 indicating balance between groups. This process resulted in 1799 matched pairs (n = 3598). After applying the NRD discharge weights, the weighted sample included 3497 patients in the IM nail group and 3381 in the plate group.
Outcome Measures
The primary outcome of interest was the occurrence of postoperative complications following fibula fixation. Complications were identified using ICD-10 diagnosis codes and included infection, hardware failure, deep vein thrombosis, pulmonary embolism, wound complications, and other procedure-related adverse events. Secondary outcomes included hospital readmission within 30 days, between 31 and 90 days, and cumulatively within 90 days postoperatively. The NRD tracks readmissions within the same calendar year, enabling assessment of both early and later postoperative periods.
Statistical Analysis
Descriptive statistics were used to summarize patient demographics and clinical characteristics. Categorical variables were compared using Pearson χ2 test (or Fisher exact test when expected frequencies were <5). Continuous variables were compared using the Mann-Whitney U test. Propensity score matching effectiveness was evaluated by examining standardized mean differences between groups. All analyses were conducted using IBM SPSS Statistics, version 29 (IBM Corp, Armonk, NY). Statistical significance was defined as P <.05.
Results
Following 1:1 propensity score matching, a total of 6878 patients were included in the final analysis, comprising 3497 patients in the IM fibular nailing group and 3381 patients in the fibular plate fixation group (Table 1). Baseline demographic characteristics were well balanced between cohorts. The mean age was 49.27 ± 20.82 years in the IM nail group and 49.02 ± 20.89 years in the plating group (P = .639). The distribution of sex was similar, with females comprising 47.5% of the IM nail group and 46.4% of the plate group (P = .393). Insurance status, income quartile, and rural-urban classification also did not differ significantly between groups. Comorbidity profiles after matching were comparable across all major conditions assessed, including hypertension, diabetes, nicotine use, obesity, and chronic kidney disease (all P > .05) (Table 2).
Demographics of Cohorts After Propensity Score Matching.
Mann-Whitney U test.
Pearson χ2 test.
Comorbidity Distribution Before and After Propensity Score Matching (PSM).
Abbreviations: IM, intramedullary; SMD, standardized mean difference.
Complication rates were significantly lower in the IM nail group compared with the plating group (7.5% vs 9.8%, P = .001). Wound dehiscence (0.6% vs 1.8%, P < .001) and postoperative infection (1.3% vs 2.8%, P < .001) were both significantly less frequent in the IM nail group. Rates of malunion (0.4% vs 0.9%, P = .018) and abscess formation (0.1% vs 0.4%, P = .039) were also significantly lower among IM patients; however, the absolute event rates were extremely low in both groups, suggesting these findings have limited clinical significance. The rate of surgical debridement was numerically lower in the IM nail group although not statistically significant (1.3% vs 2.0%, P = .051) (Table 3).
Complications and Readmissions by Cohort.
Abbreviations: DVT, deep vein thrombosis; IM, intramedullary.
Total readmission rates were similar between cohorts (17.4% IM vs 18.0% plate fixation, P = .561), as were 30-day readmission rates (10.9% vs 10.3%, P = .451). Readmission between 31 and 90 days was numerically higher in the plating group (6.5% vs 7.7%), but this difference did not reach statistical significance (P = .069). Notably, several postdischarge complications were significantly more frequent in the plate fixation group. Wound dehiscence leading to readmission occurred in 1.8% of plating patients vs only 0.5% of IM patients (P < .001), and the rate of patients being readmitted with operative-site infection were more than twice as high in the plate fixation group (2.4% vs 1.0%, P < .001). Cellulitis was also significantly more common among readmitted plate fixation patients (2.3% vs 1.4%, P = .006).
Discussion
The purpose of this study was to compare postoperative complication rates between intramedullary (IM) fibular nailing and fibular surface plating in patients undergoing concurrent tibial ORIF for distal tibial fractures. Our analysis revealed that IM fibular fixation is associated with significantly lower rates of overall short-term complications, wound dehiscence, and postoperative infections (absolute differences generally ≤2% to 3%) compared with plating. These are observational associations within an NRD cohort that likely includes distal shaft and periarticular patterns; results should not be extrapolated to isolated ankle fractures. These findings align with a growing body of literature suggesting that IM fixation offers clinical advantages, particularly in cases requiring dual surgical approaches where soft tissue preservation is paramount. 5
Our data demonstrated a lower overall complication rate in the IM nailing group compared with the surface plate fixation group (7.5% vs 9.8%, P = .001). Although this represents a 23.5% relative reduction, the absolute difference of 2.3% is modest and should be interpreted in that context. Notably, wound dehiscence (0.6% vs 1.8%) and infections (1.3% vs 2.8%) were significantly less frequent with IM fixation. These results are consistent with the findings of Samuel et al, 19 who conducted a systematic review of 29 studies and reported a significantly lower risk of complications in IM-treated patients (relative risk = 0.49, 95% CI: 0.29-0.82), with equivalent union rates (99% vs 97%) and slightly improved patient-reported outcomes. Similarly, Raj et al 17 and Zhang et al 26 found that IM nailing led to a substantial reduction in complications, including infections and wound issues, without compromising union rates.
An unexpected finding in our analysis was the lower rate of fibular malunion in the IM nail group compared with the plate fixation group (0.4% vs 0.9%). Although the differences in malunion rates reached statistical significance, the absolute differences were small (<1% in both groups) and unlikely to influence clinical decision making on their own. Nevertheless, this outcome warrants discussion, as fibular nails have historically been criticized for offering less precise alignment control than plates, with concerns about higher malunion rates. Several factors may explain our findings. Contemporary intramedullary devices incorporate interlocking and targeting mechanisms that enhance stability and improve control of length and rotation, mitigating earlier limitations. In addition, because all patients in our cohort underwent concurrent tibial ORIF, the tibial fixation itself may have contributed to maintaining fibular alignment and reducing malunion risk. Finally, the possibility of misclassification inherent to administrative coding cannot be excluded and may partly account for this difference. Although not clinically significant in isolation, the finding suggests that contemporary IM fixation provides alignment outcomes at least equivalent to plating, which is noteworthy given its minimally invasive approach and potential to reduce soft tissue morbidity without increasing union-related complications.
Further supporting these findings, Attia et al 1 reported that IM nailing was associated with no postoperative infections and significantly fewer complications overall (7.8% vs 29.1%, P < .001). Auger et al 2 specifically studied a medically complex population and found improved outcomes in IM-treated patients, including significantly higher Olerud-Molander scores (87.1 vs 76.2, P = .002), despite more comorbidities in the IM nail group. Although our data set did not include functional scores, our analysis mirrored these trends, suggesting that the benefits of a minimally invasive approach may be particularly impactful in medically complex patients or those with compromised soft tissue envelopes.
The improved short-term outcomes associated with IM fixation may be attributable to the minimally invasive nature of the technique, which preserves the lateral soft tissue envelope and reduces the risk of hardware prominence or wound breakdown. 18 This finding is especially relevant in patients undergoing concurrent tibial ORIF, where anterior or medial surgical approaches already compromise soft tissue.10,23 By avoiding a second extensive incision for fibular plating, IM fixation may reduce cumulative tissue trauma and the likelihood of infection or wound breakdown. 15 However, although IM fixation is frequently performed in a minimally invasive manner and may reduce soft tissue compromise, our data cannot confirm the surgical approach or wound type. Therefore, these potential mechanisms should be interpreted with caution.
Similarly, from a clinical standpoint, although our data set did not capture wound type, mechanism of injury, or soft tissue quality, prior literature suggests that IM fibular fixation may be particularly advantageous in reducing short-term complications in cases involving dual-bone injuries, high-energy trauma, or patients with compromised soft tissue quality.6,7 Our findings add to this body of evidence by demonstrating, even without stratification by these specific clinical variables, that the benefits of a minimally invasive approach may extend broadly across diverse patient populations. Moreover, given the comparable union and reoperation rates, the reduction in soft tissue complications may justify the routine use of IM implants in patients with poor soft tissue quality, multiple comorbidities, or those at high risk for infection. 16 As device design improves and familiarity increases, IM fixation may become the preferred strategy in select patient populations. However, our data do not capture long-term outcomes such as post-traumatic arthritis, hardware failure, or late complications beyond the early postoperative period. As such, any inferences made about long-term durability from this study should be interpreted with caution.
This study has several strengths. The study represents one of the largest analyses to date comparing fibular IM nailing to fibular plate fixation in the setting of concurrent tibial fixation and uses data from a national readmissions database. The large sample size enhances the generalizability of our findings.
However, limitations of this study include the retrospective design, reliance on administrative coding in the NRD (which may underreport or overreport minor complications or lack surgical nuance), and absence of functional outcome measures.
First, ICD-10 diagnosis codes do not reliably distinguish distal tibial shaft fractures from distal tibial periarticular or pilon fractures. Although we excluded codes explicitly describing pilon injuries, misclassification remains possible. This limits the precision of our cohort definition. As such, the relatively high number of patients undergoing fibular fixation in our cohort compared with rates reported in isolated tibial shaft fracture series may reflect inclusion of distal tibial periarticular patterns, in which fibular fixation is more commonly performed. Similarly, the relatively high readmission rates observed (~17%-18%) may reflect the inclusion of periarticular injuries and the broader capture of readmissions across hospitals in the NRD, rather than rates expected in isolated tibial fracture populations. These discrepancies underscore the limitations of administrative coding and suggests that our findings are most applicable to the broader group of distal tibial fractures managed with ORIF, rather than to isolated shaft fractures alone. These results should therefore be interpreted in the broader context of patients undergoing tibial ORIF with concurrent fibular fixation.
Moreover, readmissions for wound or infectious complications could not be definitively attributed to the index surgery or the side of injury, given limitations in coding specificity within the NRD. Therefore, we were unable to specify whether the infection was related to the tibial or fibular incision, and therefore we were unable to report fibula-specific infection rates. Similarly, because NRD coding does not allow for confirmation that all readmission diagnoses were directly related to the index fracture fixation, complications such as thromboembolism, nerve injury, or cellulitis may have been unrelated events. This introduces potential misclassification that should be considered when interpreting readmission-related outcomes.
Another key limitation of this study is the inability to stratify outcomes based on fracture type, as certain fracture patterns—such as severely comminuted fibular fractures—may not be suitable candidates for intramedullary nailing. This limitation arises because the NRD does not differentiate fractures by specific pattern, nor does it capture whether fractures were open, closed, the result of crush injuries, or a part of a polytrauma event. Furthermore, we could not stratify by implant type, and surgeon selection bias may have influenced the choice of fixation method. IM nailing may have been chosen by early adopters with specific indications or greater technical familiarity, or concentrated at centers with different perioperative protocols. Because surgeon identifiers and detailed operative variables are unavailable in the NRD, we could not account for learning-curve or surgeon-/institution-level effects. These limitations are critical to acknowledge when interpreting the observed associations. Thus, although our use of propensity score matching attempts to control for observable confounders, unmeasured factors such as fracture pattern, mechanism of injury, and institutional or surgeon preference likely influenced the selection of fixation technique, and therefore the outcomes reported in this study. These sources of residual confounding should be acknowledged when interpreting the results.
In addition, the NRD lacks patient-reported outcomes and intermediate or long-term functional measures such as ankle range of motion or arthritis progression—key domains in distal tibia fracture recovery that cannot be captured in administrative data. As such, although our analysis demonstrates reduced soft tissue complications with IM fixation, it cannot determine whether nailing or plating better achieves the ultimate functional goals of fibular fixation. This represents a gap in the current analysis.
Finally, although our analysis included nonunion and pseudoarthrosis as coded complications, these diagnoses are typically established after 6-9 months. Their appearance within a 30-90-day window likely reflects early coding practices, suspicion of impaired healing, or revision procedures rather than true biologic diagnoses, and should therefore be interpreted with caution.
Fibular intramedullary nailing appears to be a reasonable alternative to plating when fibular fixation is added during tibial ORIF for distal tibial fractures, with fewer short-term wound/infectious complications and small absolute risk reductions. Because fracture pattern, openness, and side-specificity are not available in NRD, these findings are hypothesis-generating and best applied to patients similar to this administrative cohort. Prospective work that stratifies by fracture morphology, reports patient-centered outcomes, and analyzes direct and indirect resultant costs is needed to define indications.
Supplemental Material
sj-pdf-1-fao-10.1177_24730114251388097 – Supplemental material for Intramedullary Nailing vs Plate Fixation of the Fibula in the Setting of Distal Tibial Fractures Requiring ORIF: National Readmissions Database Propensity Score–Matched Analysis
Supplemental material, sj-pdf-1-fao-10.1177_24730114251388097 for Intramedullary Nailing vs Plate Fixation of the Fibula in the Setting of Distal Tibial Fractures Requiring ORIF: National Readmissions Database Propensity Score–Matched Analysis by Gnaneswar Chundi, Abhiram Dawar, Ian Briggs, David B. Ahn, Avani A. Chopra, Zachary Fuller, Sheldon S. Lin and Tuckerman Jones in Foot & Ankle Orthopaedics
Footnotes
Appendix
International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), Codes for Comorbidities.
| Comorbidity | Codes Used |
|---|---|
| Hypertension | I10 |
| Nicotine dependence (history) | Z87891 |
| Nicotine dependence (current) | F17210 |
| Diabetes | E119 |
| Hypothyroidism | E039 |
| Psychiatric diagnosis | F329, F419 |
| Heart disease | I2510 |
| Obesity | E669 |
| Morbid obesity | E6601 |
| Osteoporosis | M810 |
| Chronic kidney disease | I129, N183 |
| Anemia | D649 |
| Fibromyalgia | M797 |
| Anticoagulant therapy | Z7901 |
ORCID iDs
Ethical Considerations
Ethical approval was not sought for the present study because the research involved analysis of preexisting, anonymized data.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.
Data Availability Statement
Data used in this study is publicly available through the Healthcare Cost and Utilization Project, Nationwide Readmissions Database.
References
Supplementary Material
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