Trans-syndesmotic fibular plating for fractures of the distal tibia and fibula with medial soft tissue injury: report of 6 cases and description of surgical technique.

This report presents a retrospective review of several cases of distal fractures of the tibia and fibula with significant injury to the medial soft tissues treated either primarily or in staged fashion with fixed-angle trans-syndesmotic fixation. This fixation strategy was used in an effort to minimize further surgical trauma and implant load in the zone of soft tissue injury. Ten patients were identified between September 2002 and November 2010 who presented to a level I trauma center with fractures of the distal tibia and fibula associated with open medial wounds (9 patients) or extensive closed medial degloving injury (1 patient). They were all treated with trans-syndesmotic plating of the distal fibula. Two patients were lost to follow-up after initial treatment, and an additional 2 patients had follow-up durations of only 6.5 and 3 months, respectively. This left 6 patients with an average of 23.3 months of follow-up (range: 14-36 months). Radiographs and medical records were reviewed, and clinical and radiographic results were evaluated. All 6 patients had radiographic evidence of bony healing and had resumed weight bearing. Two patients required additional bone graft surgery to encourage healing, 1 of whom also required free-flap coverage as a component of the nonunion repair. One patient resumed weight bearing earlier than instructed and experienced mild but acceptable loss of reduction. No patients developed wound infections of either the medial traumatic or lateral surgical wounds, although, as noted above, 1 of the patients with a nonunion required medial free-flap coverage as a component of the nonunion repair because of incompetent medial soft tissues. Trans-syndesmotic fixation has previously been described as providing enhanced fixation of diabetic and osteoporotic ankle fractures but has not, to our knowledge, been described for the treatment of higher energy traumatic injuries. Specifically, the valgus distal tibial fracture, frequently associated with medial traction wounds, can present challenges to the treating surgeon in terms of obtaining adequate fixation although minimizing wound complications associated with the soft tissue injury. In a select subset of injuries, trans-syndesmotic fixation can provide a viable means of obtaining and maintaining either definitive fixation or enhancing the provisional fixation supplied by spanning external fixation.