Treatment Of Distal Fibula Fractures Research Articles

Modern anatomical locking plates are associated with increased postoperative wound complications and unplanned surgical revisions compared to standard tubular plates in the management of unstable ankle fractures: a comparative cohort study in 595 patients

Abstract Background The clinical benefit of locking plates in distal fibula fractures has not yet been proven. In addition, the risk of wound complications appears to be higher than with conventional tubular plates. We hypothesize that the benefits of locking plates in terms of biomechanical properties are outweighed by a higher risk of wound complications. Methods We conducted a retrospective review of fibula fractures treated by osteosynthesis with either a conventional one-third tubular plate or an anatomically shaped locking plate from January 1, 2015 to December 31, 2021. We recorded baseline data and relevant comorbidities and defined the need for revision surgery due to wound-related or mechanical complications as primary endpoints. Results A total of 595 out of 727 patients were eligible for our study. Of these 595 fractures, 526 were fixed with a one-third tubular plate, 69 with a locking plate. Revision surgery was required in 54 patients, in 51 cases due to wound complications. Three patients required revision surgery for mechanical reasons and all of them were younger than 40 years of age, have not been diagnosed with osteoporosis, but experienced complex fracture types. As the third tubular plate and locking plate groups differed in terms of age and comorbidities, we performed a 2:1 matching based on age and gender, leaving data from 138 patients receiving a third tubular plate. While the two groups were comparable in many aspects, the rate of wound complications was significantly higher in the locking plate group. Although the locking plate group had a higher percentage of diabetes mellitus, there was no correlation between this comorbidity and the higher revision rate in this group. Conclusions Our data do not support the general use of locking plates in the treatment of distal fibular fractures. The risk of mechanical complications in osteoporotic ankle fractures seems to be overrated, as there were no mechanical revisions in the osteoporotic subgroup. The rate of wound-related revision surgery was significantly higher after the use of locking plates. This might be attributed to the greater thickness of locking plates.

No difference in early outcomes comparing intramedullary versus extramedullary fibular fixation in operative ankle fractures

IntroductionThe purpose of this study was to compare postoperative complications and outcomes of minimally invasive intramedullary fixation (IMF) versus plate fixation (PF) in the treatment of distal fibular fractures. Materials and methodsA retrospective review was performed from identifying all consecutive ankle fracture patients aged ≥18-years-old surgically managed between August 2017 to September 2022 at a tertiary care center with minimum 6 months clinical follow-up. Patients were grouped into those receiving intramedullary versus extramedullary fibular fixation. The primary outcomes were relevant demographic factors (diabetes, osteoporosis, charlson comorbidity index [CCI]), surgical time, complication rates, reoperation rates. Secondary outcomes included time to definitive fracture fixation, fracture characteristics (AO/OTA and Lauge-Hansen classification), syndesmotic instability requiring fixation and discharge disposition. ResultsForty-one IMF patients (average age 55.3 ± 18.1yrs) and 162 PF patients (47.7 ± 17.4yrs) were identified and included in this study. Within the IMF group, 25 patients received IM nailing and 16 patients received percutaneous screw fixation. A greater proportion of IMF patients had diabetes (39 % vs 22 %, p < 0.001), osteoporosis (22 % vs 3 %, p < 0.001), and moderate or severe CCI (41 % vs 23 %, p = 0.017). Surgical time was significantly reduced when using IMF technique (80.4 ± 43.1 min vs 99.1 ± 43.1 min, p = 0.012). Overall complication rates or time to complication did not differ significantly between groups (p = 0.578 and p = 0.082, respectively); however, when sub-stratified, IMF patients trended towards experiencing fewer wound related complications versus PF patients (5 % vs 9 %, p = 0.291). No IMF patients experienced deep or superficial infections and only 2 (5 %) patients experienced wound dehiscence. Reoperation rates(15 % vs 10 %, p = 0.267) and time to fracture union (2.7 ± 2.2 mos vs 3.1 ± 2.0 mos, p = 0.301) did not differ significantly. At final follow-up (IMF: 15.0 ± 12.2 mos vs PF: 28.5 ± 19.5 mos), Olerud and Molander ankle score was significantly higher in IMF compared to PF (87.1 ± 14.2 vs 76.2 ± 22.6, p = 0.002). ConclusionPatients in the IMF group at baseline had several comorbid medical conditions that put them at high risk for wound related complications, however, postoperatively they demonstrated higher functional scores and similar complication rates compared to the PF group. It is important to note, however, while we expected a higher rate of wound issues with the PF group, there were no significant differences in infection rates. Either IMF and PF is reliable for fixation and outcomes, and thus with proper soft tissue, biologically friendly technique, either IMF or PF is a reliable choice in the fixation of fibula fractures. Level of evidenceIII, retrospective cohort comparison study.

Finite element simulation of treatment with locking plate for distal fibula fractures.

An improved Finite Element Model(FEM) is applied to compare the biomechanical stability of plates with three different options in the treatment of distal fibula fractures in this study. The Computed Tomography(CT) scan of the knee to ankle segment of a volunteer was performed. A 3D fibula FEM was reconstructed based on the CT data. Three different loads (uni-pedal standing, torsion, and twisting) were applied, the same as in the experiments in the literature. The stresses and strains of the three options were compared under the same loads, using a 4-hole locking plate (Option A), a 5-hole locking plate (Option B), and a 6-hole locking plate (Option C) in a standard plate for lateral internal fixation. The simulation results show that all three options showed a stress masking effect. Option C had the best overall biomechanical performance and could effectively distribute the transferred weight. This is because option C has greater torsional stiffness and better biomechanical stability than options A and B, and therefore, option C is the recommended internal fixation method for distal fibula fractures. The Finite Element Analysis(FEA) method developed in this work applies to the stress analysis of fracture treatment options in other body parts.

Current Trends in the Surgical Treatment of Fibular Fractures: A National Database Study of Intramedullary vs. Plate Fixation Practice Patterns, Complications, and Cost.

Existing primary evidence comparing fibular intramedullary fixation (IMF) with traditional plate fixation (PF) for the treatment of distal fibular fractures remains limited by modest sample sizes. Using a large national database, this study aims to compare use rates, fracture patterns, patient characteristics, time to surgery, complication rates, and cost between fibular IMF and PF within the United States. Adults treated with fibular IMF or PF between October 2015 and October 2021 were identified within the PearlDiver Database. The ratio of IMF-treated to PF-treated patients was tracked temporally to compare use rates. Fracture patterns were determined using fracture diagnoses within one-month preceding surgery. Further comparisons of IMF- and PF-treated groups only included patients with at least 12 months of follow-up, and patients with upper tibia or tibia shaft fractures were excluded. An analysis of cohorts matched at a 1 : 4 (IMF: PF) ratio to control for risk factors was performed to compare time to surgery, complication rates (infection, nonunion, malunion, revision, hardware removal, pulmonary embolism, and deep vein thrombosis), and cost. 39329 patients (2294 IMF and 37035 PF) were identified. IMF use trended upwards relative to PF use over time. Tibia and fibula shaft fractures were the most common injuries in IMF patients versus bimalleolar and trimalleolar fractures in PF patients. A higher proportion of IMF patients had open fractures. IMF patients were younger, with higher mean ECI, fewer female patients, and higher rates of CKD. Percutaneous approaches were more common among IMF patients. There were no significant differences in time to surgery or complication rates. IMF was less costly. The popularity of IMF trended upwards across the study period. IMF was used more commonly in injuries involving higher energy trauma and soft tissue disruption. Overall, IMF patients were younger with more comorbidities. When used in similar populations, IMF appears to be a cost-effective alternative to PF.

Outcome After Treatment of Distal Fibula Fractures Using One-Third Tubular Plate, Locking Compression Plate or Distal Anatomical Locking Compression Plate

Surgical treatment of lateral distal fibula fractures is associated with high risk of reoperation and complications. The primary aim was to report risks of surgical site infection (SSI) and reoperation ≤1 year after treatment with one-third tubular plate, locking compression plate (LCP) or distal anatomical LCP. Secondary to investigate associations between patient, fracture and operative factors and risk of SSI and reoperation. Retrospectively, we evaluated a consecutive cohort of 588 patients having osteosynthesis of distal fibula with a one-third tubular plate (n=417), LCP (n=115) or distal anatomical LCP plate (n=56) at Bispebjerg Hospital, Denmark from January 2010 to December 2015 with 1-year follow-up. The risk of SSI was 15% (95% confidence interval [CI] 12-18) after treatment with one-third tubular plate, 30% (95% CI 23-39) after LCP and 41% (95% CI 29-54) after distal anatomical LCP. We found a significant association of SSI and LCP (p=.005) and distal anatomical LCP (p < .001). Other factors associated with increased risk of SSI were age>70 years (p < .001), smoking (p=.004), DM (p=.007), surgery time ≥90 minutes (p=.006) and surgery delay of 3-6 days (p=.007). The risk of reoperation ≤1 year was 10% (95% CI 6-11) for one-third tubular plate, 21% (95% CI 14-29) for LCP and 25% (95% CI 16-38) for distal anatomical LCP. We found a significant association between distal anatomical LCP and risk of reoperation (p=.008). The only other risk factor associated with risk of reoperation was surgery delay of more than 7 days (p=.004). We conclude that LCP plate and the distal anatomical LCP plate should only be used after careful considerations.

A Prospective Randomized Study Comparing Functional Outcome in Distal Fibula Fractures between Conventional AO Semitubular Plating and Minimal Invasive Intramedullary “Photodynamic Bone Stabilisation”

(1) Background: As age in western populations is rising, so too are fractures, e.g., of the distal fibula. The aim of this study was to find out whether a novel, minimally invasive intramedullary osteosynthesis technique for the treatment of distal fibula fractures in elderly patients results in not only a reduction of postoperative complications, but also a shorter hospitalization time, an improved clinical outcome, and preserved autonomy in geriatric trauma patients. (2) Methods: In this prospective study, the results following surgical treatment for distal fibula fractures in geriatric patients after using DePuy Synthes® one-third semitubular plate (Group I) or a minimally invasive intramedullary photodynamic Bone StabilizationSystem (IlluminOss®) (Group II) were compared at 6 weeks, 12 weeks, 6 months, and 1 year after initial treatment. (3) Results: Significant improvement regarding clinical outcome was shown in Group II 6 and 12 weeks after surgery. (4) Conclusions: Our study results demonstrate that the use of this new intramedullary stabilization system in combination with an immediate postoperative weight bearing seems to be a safe and stable treatment option for ankle fractures in geriatric patients, especially in the early stages of recovery.

A retrospective assessment of the clinical efficacy of different internal fixation methods in the treatment of distal fibula fractures in the elderly.

An ankle fracture is a fracture of the distal tibia or fibula that forms the ankle joint, usually associated with ligament and soft tissue injury, and is a common type of lower limb fracture and one of the most common types of fracture in the elderly. Although ankle fractures are one of the most common injuries seen by orthopedic trauma surgeons, there is no uniform protocol for the diagnosis and treatment of ankle fractures in the elderly, and there are many controversial indications for surgery. The aim of this study is to assess the clinical efficacy of different internal fixation methods in the treatment of distal fibular fractures in the elderly, in an effort to improve the rational selection and application of clinical acts. A retrospective analysis was performed on 68 cases of patients who suffered an ankle fracture and were treated with different internal fixation methods according to the fracture types and individual differences in distal fibula fractures. The postoperative therapeutic effect assessment was performed in terms of clinical examination, imaging evaluation, and AOFAS ankle-hind foot function scoring. There was no unhealed bone, ankle instability and loose/fractured internal fixation. Fracture healing time was 2.7 to 4.0 months (average 3.2 months). AOFAS score was 88.3 ± 6.2, of which, 34 excellent cases, 30 good cases, and 4 fair cases. Ankle activity dorsiflexion 6º~18º, average 15º; plantar flexion 26º~47º, average 37º. A good clinical efficacy could be achieved from the most appropriate individualized internal fixation for distal fibula fractures of elderly patients.

Distal Fibula Fractures-Intramedullary Fixation Versus Plating: A Systematic Review and Meta-analysis of Randomized Control Trials.

The aim of the present study is to compare the functional scores and complications of intramedullary fixation versus plate osteosynthesis of distal fibular fractures in adults. Study was performed in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses format from MEDLINE, Embase, Ovid, and Cochrane databases. The included articles were assessed according to the risk of bias assessment tool by Cochrane collaboration. A total of 5 randomized control trials were included for quantitative review. Random sequence generation and allocation concealment of the study subjects were the strengths of all the included studies. There was high heterogeneity among the included studies (I2 > 75%). There was no significant difference between the Olerud-Molander scores in both the groups but the trend favored the intramedullary nailing of distal fibula (mean difference of 3.42, 95% confidence interval [CI] of 8.90). Complications were significantly lesser in the intramedullary group across the studies (odds ratio 0.26, 95% CI of 0.81). Intramedullary nailing of fibula with the use of modern locking fibular nails is an alternative to fibular plating for unstable distal fibular fractures in properly selected cases. There remains the need for standardizing the method of operative treatment of distal fibular fractures which can be done by a well-planned large-scale prospective study design. Level 1.

Minimally invasive plate osteosynthesis (MIPO) versus open reduction and internal fixation (ORIF) in the treatment of distal fibula Danis-Weber types B and C fractures

BackgroundMinimally invasive plate osteosynthesis (MIPO) has been reported to be superior to open reduction and internal fixation (ORIF) in the treatment of different long bone fractures. Nevertheless, in distal fibula fractures, the evidence of MIPO remains scarce. The aim of this retrospective study was to compare the clinical and radiological outcomes of the minimally invasive techniques applied to the distal fibula with open reduction and internal fixation within a 12 months follow-up.MethodsA consecutive series of patients who underwent surgery using either ORIF or MIPO for the treatment of distal fibula fractures between 2010 and 2014 were retrospectively analyzed. All distal fibular fractures requiring an operative treatment (Danis-Weber type B ≙ AO type 44 B1, 2, 3 and Danis-Weber type C ≙ AO type 44 C1, 2) were included (ORIF n = 35, MIPO n = 35). Patients were assessed for postoperative pain using a visual analog scale (VAS) for pain (ranging from 0 to 10) and classified into 4 groups: “no pain” for VAS = 0, “low” for VAS = 1–3, “moderate” for VAS = 3–5, and “severe” for VAS = 5–10. In addition, complications of postoperative fracture-related infection, wound healing disorders, vascular and nerve injury and development of nonunion were evaluated and analyzed. Radiologic outcome measures assessing the talocrural angle, lateral and medial clear space, tibiofibular overlap, and talar tilt angle were evaluated postoperatively.ResultsThe overall complication rate showed to be lower in the MIPO group compared to the ORIF group (14% vs. 37%, p = 0.029). Even though not statistically significant, specific surgery-related complications such as skin necrosis (3% vs. 9%, p = 0.275), nonunion (0% vs. 6%, p = 0.139), infections and wound healing disorders (9% vs. 20%, p = 0.141), as well as postoperative pain (17% vs. 26%, p = 0.5) were found more frequently in the ORIF group. The tibiofibular overlap demonstrated to be significantly lower in the ORIF group (3.3 mm vs. 2.7 mm, p = 0.033). The talocrural angle, talar tilt angle, and lateral and medial clear space showed to be equivalent in both groups.ConclusionIn this retrospective single-center consecutive series, MIPO was superior to ORIF in the surgical treatment of distal fibula fractures with respect to the overall complication rate.Trial registrationEKNZ Project-ID: 2019-02310, registered on the 20th of December 2019 with swissethics

Percutaneous bridge plating of extra-articular distal fibular fracture for the management of distal tibia type III open fracture

PurposeThe aim of this study is to conduct clinical and radiographic evaluations of the use of percutaneous bridge plating for distal fibular fractures combined with distal tibia type III open fractures. MethodsThirty-four patients with acute distal third fibular shaft fractures (4F2A(c) and 4F2B(c) according to the AO/OTA classification) combined with distal tibia type III open fractures were enrolled. Concurrent fibular fractures were fixed with the percutaneous bridge plating simultaneously, while distal tibia open fractures were temporally stabilized with a spanning external fixator. Clinical and radiographic outcomes were evaluated using the Lower Extremity Functional Scale (LEFS), the proportional length difference of the fibula, the talocrural angle, the union rate of the fibula and tibia, the operation time, and complications at the final follow-up. ResultsAll fibular fractures healed with an average bone healing time of 20.7 ± 6.3 weeks (range, 16–35). The mean proportional length difference was 0.492 ± 0.732% compared with that in the uninjured fibula. The functional assessment result according to the LEFS was 74.0 ± 3.70 points (range, 57–80). No cases of fibula fracture infection developed throughout the follow-up period in any of the patients. Iatrogenic postoperative superficial peroneal nerve injury was not found in any of the patients. ConclusionWith the perspective of minimizing soft tissue problems due to high-energy trauma, the application of percutaneous bridge plating for the treatment of distal fibular fractures can be an alternative to conventional treatment methods.

Does Intramedullary Nailing for Distal Fibular Fractures Restore Anatomic Parameters and Syndesmotic Relationship?

Category:Trauma; AnkleIntroduction/Purpose:Fibular nailing (FN) is a method of fixation that has proven to be useful for the treatment of distal fibular fractures (DF). FN minimizes soft tissue complications, provides similar stability compared to plating with less hardware related symptoms. Nevertheless, FN has been associated with syndesmotic malreduction and incapacity of restoring length and rotation of the fibula. We aimed to evaluate the fibular and syndesmotic reduction after fixation with FN compared to the uninjured ankle.Methods:Prospective cohort, cross-sectional study with a paired control group. Patients with DF fractures treated with FN between January 2017 and July 2019 were included. Immediate postoperative bilateral Ankle CT was obtained in all cases. Two independent radiologists performed all the measurements on both ankles (fibular rotation, length, translation, and syndesmotic diastasis. Statistical analysis was made using the Wilcoxon Test and Intraclass correlation coefficient (ICC). Considering a medium size sample effect, 95% confidence with .05 alpha error, a total sample of 26 subjects were needed to achieve a .80 of statistical power (G-Power 3.1). All analyses were performed using SPSS V20.Results:Twenty-six patients were included (14 Women). The mean age was 47 years (18-91). No statistically significant differences were identified considering fibular rotation (p:0,694), fibular length (p:0,585) and syndesmotic diastasis (p:0,078) between the injured and uninjured ankle. Fibular translation has statistical differences (p:0,043). The ICC shows an excellent concordance between radiologists except for Fibular translation (ICC 0,47)Conclusion:In this cohort, fixation of DF fractures with FN allows restoration of anatomical parameters of the ankle in terms of fibular rotation, length, and syndesmotic diastasis. However, Fibular translation had significant differences compared with the uninjured ankle.

Does the Use of Locking Screws Decrease the Rate of Hardware Removal in Ankle Fractures?

Background. While biomechanical characteristics of locking screw fixation versus traditional plating has been studied extensively in orthopaedic literature, clinical outcome studies are lacking. The goal of this study was to evaluate the efficacy and complications rate of locking versus traditional nonlocking screws in complex ankle fractures employing distal fibula internal fixation with 1/3 semitubular small fragment plates. Methods. A retrospective review was performed between January 2010 and June 2013 of all patients in whom internal fixation of the fibula in an ankle fracture (open or closed) was performed using only 1/3 semitubular small fragment fibular plates. Patient characteristics, fracture patterns, specific screw choice that were placed in the most distal 2 fibular plate holes (either locking or nonlocking), infectious wound complications, and concomitant syndesmotic injury and the need and corresponding purpose for hardware removal were recorded. Results. A total of 135 patients were found to meet inclusion criteria and were analyzed for this study. Of the patients with locking screws, 25 of 98 (25%) elected to have hardware removed, while 13 of 37 (35%) of those with nonlocking screws elected hardware removal. This did not reach statistical significance (P = .30). There was no statistically significant difference between the groups with regards to age, smoking status, body mass index, diabetes, or use of syndesmotic screw fixation. There was no significant difference in loss of fixation, infection, or other surgical complications in between the groups. Conclusions. There was no significant decrease in the rate of hardware removal with the use of 1/3 tubular locking versus nonlocking plates in the treatment of distal fibula fractures. Despite these screws locking flush to the plate, the hardware is equally symptomatic in both groups. There was no significant difference in the rate of complications between the 2 groups and our data suggest that the added expense of using locking screws routinely when fixing lateral malleolar fractures should be carefully considered, especially if the fracture pattern does not warrant locking technology. Levels of Evidence: Prognostic, Level III.

Minimally invasive plate osteosynthesis in type B fibular fractures versus open surgery

In traumatology, the search for better surgical access points has led to the increased use of the minimally invasive plate osteosynthesis (MIPO) technique. There are few studies on the treatment of distal fibular fractures with MIPO. Locking compression plates (LCP) for distal fibular fractures is generally applied after open reduction, but may involve complications to the surgical wound. In this study, we compared two groups of patients receiving either ORIF or MIPO, in order to analyse the advantages and disadvantages of the two techniques. Two homogeneous groups of patients (18+18) received LCP for distal fractures of the fibula, type B, according to AO. Group A patients underwent open surgery, whereas Group B patients received plates applied with the MIPO technique. Both groups were examined physically and radiographically 1 and 3months after the two types of procedure and then 1year later, with functional assessment according to Olerud and Molander. ROM Group A: 5° reduction in tibiotarsal extension in 8 patients and 5° in supination in 1 patient; Group B: 5° reduction in extension in 7 cases. Mean healing time: 3months (range 2-4) in Group A and 2.9 (range 2-4) in Group B. Dehiscence of the surgical wound was observed in five Group A patients, but none in Group B. Functional assessment according to Olerud and Molander was 87.4 points in Group A (range 80-100) and 95.6 in Group B (range 82-100). We believe that the MIPO technique for distal fractures of the fibula should be used more often, especially if soft tissue is in a critical condition. Healing times should be reduced in the more complex cases. It is important that the learning curve should be improved, to minimize exposure to radioscopy and possible damage to the superficial fibular nerve.

Evidence Based Development of a Novel Lateral Fibula Plate (VariAx Fibula) Using a Real CT Bone Data Based Optimization Process During Device Development

Development of novel implants in orthopaedic trauma surgery is based on limited datasets of cadaver trials or artificial bone models. A method has been developed whereby implants can be constructed in an evidence based method founded on a large anatomic database consisting of more than 2.000 datasets of bones extracted from CT scans. The aim of this study was the development and clinical application of an anatomically pre-contoured plate for the treatment of distal fibular fractures based on the anatomical database.48 Caucasian and Asian bone models (left and right) from the database were used for the preliminary optimization process and validation of the fibula plate. The implant was constructed to fit bilaterally in a lateral position of the fibula. Then a biomechanical comparison of the designed implant to the current gold standard in the treatment of distal fibular fractures (locking 1/3 tubular plate) was conducted. Finally, a clinical surveillance study to evaluate the grade of implant fit achieved was performed. The results showed that with a virtual anatomic database it was possible to design a fibula plate with an optimized fit for a large proportion of the population. Biomechanical testing showed the novel fibula plate to be superior to 1/3 tubular plates in 4-point bending tests. The clinical application showed a very high degree of primary implant fit. Only in a small minority of cases further intra-operative implant bending was necessary. Therefore, the goal to develop an implant for the treatment of distal fibular fractures based on the evidence of a large anatomical database could be attained. Biomechanical testing showed good results regarding the stability and the clinical application confirmed the high grade of anatomical fit.

Increased rates of wound complications with locking plates in distal fibular fractures

There is a growing use of locking compression plates in fracture surgery. The current study was undertaken to investigate the wound complication rates of locking versus non-locking plates in distal fibular fractures. During a 6-year study period all consecutive, closed distal fibular fractures treated with either a locking or a non-locking plate were included and retrospectively analysed for complication related to the fibula. A total of 165 patients received a one-third tubular plate and 40 patients were treated with a locking plate. The two groups were comparable with respect to patient characteristics (age, gender, smokers and diabetics), injury characteristics (affected side, fracture dislocations, number of fractured malleoli and classification) and operation characteristics (surgical delay and duration, use of a tourniquet and plate length). The wound complication rate was 5.5% in the conventional plating group, and 17.5% in the locking plate group (p=0.019). This difference was largely due to an increase in major complications, for which removal of the plate was necessary (p=0.008). There is a significant increase in wound complications in distal fibular fractures treated with a locking compression plate. In light of the current study, we would caution against the application of the currently used locking compression plates in the treatment of distal fibular fractures.

Diagnosis and Treatment of Combined Intra-articular Disorders in Acute Distal Fibular Fractures

Some patients have residual ankle pain and disability after the treatment of an ankle fracture, despite the fracture site being well aligned. We identified intra-articular disorders in distal fibular fractures and sought to clarify the results of their operative treatment. This is a prospective, randomized study. Seventy-two patients with Weber type B distal fibular fractures were randomly treated with arthroscopy-assisted open reduction and internal fixation (AORIF) or with open reduction and internal fixation without arthroscopy (ORIF). In the AORIF group, the patients were followed for a mean duration of 3 years 4 months (range, 2 years 4 months-4 years 5 months). There were 27 male patients and 14 female patients. The mean age of the patients at the time of surgery was 36 years (range, 20-64 years). In the ORIF group, the patients were followed for a mean duration of 3 years 5 months (range, 2 years 7 months-4 years 5 months). There were 21 male patients and 10 female patients. The mean age of the patients at the time of surgery was 38 years (range, 20-58 years). We described intra-articular disorders in the AORIF group using ankle arthroscopy and compared their operative results with those of the ORIF group. Including duplication, the arthroscopic findings showed 30 cases with osteochondral lesions of the talar dome (73.2%) and 33 cases with tibiofibular syndesmosis disruptions (80.5%). Six cases (14.6%) had no combined disorders. The mean AOFAS score was 91.0 +/- 3.5 (range, 85-100) in the AORIF group, in contrast to 87.6 +/- 5.5 (range, 77-97) in the ORIF group (p = 0.0106). In the treatment of distal fibular fractures, precisely diagnosing and treating the combined intra-articular disorders is important for gaining satisfactory clinical results.