Tarr et al. and Puno et al. demonstrated that distal tibial malalignment may be more poorly tolerated than more proximal malalignment.
The recommendations in the literature vary widely: 4 to 10 degrees of varus-valgus malalignment, 5 to 20 degrees of anteroposterior malalignment, 5 to 20 degrees of rotatory malalignment, and 10 to 20 mm of shortening. In general, we agree with Trafton's recommendation and strive to achieve less than 5 degrees of varus-valgus angulation, less than 10 degrees of anteroposterior angulation, less than 10 degrees of rotation, and less than 15 mm of shortening.
According to Nicoll, the important factors in prognosis are (1) the amount of initial displacement, (2) the degree of comminution, (3) whether infection has developed, and (4) the severity of the soft-tissue injury excluding infection. Müller, Nazarian, and Koch found that torsional fractures with or without simple comminution have a better prognosis than high-energy patterns, such as short oblique or transverse fractures, with or without comminution. Oni, Stafford, and Gregg showed experimentally that torsional fractures tend to create a longitudinal tear of the periosteum and may not disrupt endosteal vessels, whereas transverse fractures usually tear the periosteum circumferentially and completely disrupt the endosteal circulation. B?stman found, however, that reduction was difficult in displaced spiral fractures of the distal third of the tibia.
Suman found that displacement of more than 50% of the width of the tibia at the fracture site was a significant cause of delayed union or nonunion. B?stman noted that reduction was difficult to maintain in fractures with more than 50% initial displacement, and that comminution delayed fracture healing. Fractures with more than 50% comminution are considered unstable and usually are associated with high-energy trauma and significant open or closed soft-tissue injury. Nicoll found that the presence or absence of a fibular fracture did not influence the prognosis; however, Teitz, Carter, and Frankel reported inhibited fracture healing in 26% of closed tibial fractures associated with intact fibulas treated with cast immobilization.
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