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Long-Term Outcome After Tibial Shaft Fracture: Is Malunion Important?

Investigation performed at Queen's Medical Centre, Nottingham, United Kingdom

S.A. Milner, FRCS (Tr & Orth)
T.R.C. Davis, FRCS
Department of Orthopaedic and Accident Surgery, Queen's Medical Centre, Nottingham NG7 2UH, United Kingdom. E-mail address for S.A. Milner: stephen.milner{at}clara.net E-mail address for T.R.C. Davis: t.davis@btinternet.com

K.R. Muir, PhD
Department of Public Health Medicine and Epidemiology, Queen's Medical Centre, Nottingham NG7 2UH, United Kingdom. E-mail address: kenneth.muir@nottingham.ac.uk

D.C. Greenwood, MSc
Biostatistics Unit, Academic Unit of Epidemiology and Health Services Research, University of Leeds, 71-75 Clarendon Road, Leeds LS2 9PL, United Kingdom. E-mail address: d.c.greenwood@leeds.ac.uk

M. Doherty, FRCP
Division of Academic Rheumatology, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham NG5 1PB, United Kingdom. E-mail address: michael.doherty@nottingham.ac.uk

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Funds were received in total or partial support of the research or clinical study presented in this article. The funding source was the Arthritis Research Campaign (Grant D0509).

Background: Fractures of the shaft of the tibia often heal with some angulation. Although there is biomechanical evidence that such angulation alters load transmission through the joints of the lower limb, it is not clear whether it can eventually lead to osteoarthritis.

Methods: One hundred and sixty-four individuals who had sustained a tibial shaft fracture were assessed in a research clinic thirty to forty-three years after the injury. The subjects were evaluated with regard to self-reported lower limb joint pain, stiffness, and disability (assessed with the Western Ontario and McMaster Universities [WOMAC] osteoarthritis questionnaire); clinical signs of osteoarthritis; and radiographic evidence of osteophytes and joint-space narrowing in the knees, ankles, and subtalar joints.

Results: Twenty-two (15%) of the 151 subjects who reported no other knee injury reported at least moderate knee pain, and eight (6%) of the 145 subjects who reported no other ankle injury reported at least moderate ankle pain. Seventeen (13%) of the 135 subjects who reported no other knee or ankle injury reported at least moderate disability. The ipsilateral side demonstrated a higher prevalence than the contralateral side in terms of pain with passive ankle movement (nineteen versus nine subjects, p = 0.02), pain with passive subtalar movement (fifteen versus four subjects, p = 0.01), and radiographic signs of ankle joint space narrowing (twelve subjects versus one subject, p = 0.0055). Knee osteoarthritis was frequently bilateral. Forty-seven fractures (29%) healed with coronal angulation of 5°. Apart from an association between shortening of 10 mm and self-reported knee pain (p = 0.016), there were no significant univariate associations between these malunions and the development of osteoarthritis. Seventeen (15%) of 114 eligible subjects had overall malalignment of the lower limb, defined as a hip-knee-ankle angle outside the normal range of 6.25° of varus to 4.75° of valgus. This malalignment was due to the fracture malunion in nine subjects and predated the fracture in eight. In limbs with varus or valgus malalignment, there was an excess of subtalar stiffness (p = 0.04) and a nonsignificant trend toward more frequent knee pain. In limbs with varus malalignment, there was a nonsignificant trend toward more frequent radiographic evidence of osteoarthritis in the medial compartment of the knee joint. Most of the subjects in whom osteoarthritis was observed had normal overall alignment of the lower limb.

Conclusions: The thirty-year outcome after a tibial shaft fracture is usually good, although mild osteoarthritis is common. Fracture malunion is not the cause of the higher prevalence of symptomatic ankle and subtalar osteoarthritis on the side of the fracture. Although varus malalignment of the lower limb occurs occasionally and may cause osteoarthritis in the medial compartment of the knee, other factors are more important in causing osteoarthritis after a tibial shaft fracture.

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