Does Concurrent Tibial Intramedullary Nailing and Fibular Fixation Increase Rates of Tibial Nonunion? A Matched Cohort Study

Objectives: To determine if there is a difference in rates of tibial nonunion in patients undergoing tibial intramedullary (IM) nailing and fibular fixation as compared to a matched cohort undergoing tibial IM nailing alone. Design: Retrospective matched cohort study. Setting: Single Level 1 academic trauma center. Patients: Consecutive patients 18 years and older with a tibia and fibula fracture treated with tibial IM nailing and fibular fixation who were determined radiographically and clinically healed or had a minimum 1-year follow-up were included. A matched cohort who underwent tibial IM nailing without fibular fixation was used for comparison. Intervention: Fibular fixation at the time of tibial IM nailing. Main Outcome Measurement: Tibial nonunion, defined as a persistently symptomatic fracture with no radiographic progression toward healing at 9 months on consecutive radiographs over a 2-month period. Results: One hundred sixty six patients met inclusion criteria for the intervention group. Mean follow-up was 21 months. There was a 12% rate of tibial nonunion. In a matched cohort of 174 patients without fibular fixation there was no significant difference in patient demographics, injury characteristics, infection rates, time to union, postoperative complications, or rates of tibial nonunion. The rate of nonunion in both groups was significantly higher in patients with high energy mechanisms, open fractures, and postoperative infections. Conclusion: Fibular fixation did not impact rates of tibial nonunion. The rate of tibial nonunion in both cohorts is comparable with published rates of tibial nonunion after IM nailing without fibular fixation. Open fractures, high energy mechanism, and postoperative infection are significantly associated with tibial nonunion.