The distal third is the least common segment of the tibia to be fractured, with an incidence of only 0.7 % in all adult fractures, but it presents a particular problem owing the generally high energy nature of these injuries, and associated soft tissue damage, metaphyseal comminution and articular involvement [1]. These challenges have been extensively described in the literature, with it being acknowledged that these characteristics served historically as a deterrent to surgeons providing operative management. Rüedi and Allgöwer published several series of their patients undergoing open reduction and internal fixation (ORIF) for these injuries, with encouraging results, along with their often referenced classification system for injury severity based on the nature of articular involvement [[2], [3], [4]].

Other methods of fixation exist, and there is continued debate regarding the optimum approach for operative care. Intramedullary tibial nailing (IMN) is one such option, having previously been compared to ORIF in the UK FixDT randomised clinical trial, demonstrating equivalent outcome scores at 1 year; however this study included only patients with extra-articular fractures, which represent only a portion of the spectrum of distal tibial fractures [5]. Retrograde tibial nailing is a more novel alternative that may offer benefits over both, but again most patients in included studies have extra-articular fracture patterns [6]. Circular frame fixation (CFF) is the other commonly cited management option, affording the ability to reduce and stabilise both extra- and intra-articular components of these fractures, whilst minimising the secondary soft tissue insult from surgical intervention, and also permitting immediate unrestricted weight bearing.

There is a small selection of level 1 evidence available that makes comparisons between these options for operative management, and thus the results of the ACTIVE multi-centre randomised controlled trial should be useful at guiding the continued management of this patient cohort [7]. The National Institute for Health and Care Excellence had previously published statements based on their evidence review, highlighting benefits to external fixation compared to ORIF, including rates of unplanned surgery, surgical site infection (SSI), osteomyelitis and amputation [8]. Unfortunately, even in the most robust observational studies, the number of patients included undergoing CFF remains reasonably small, and of relatively short follow-up duration [9,10].

The aim of the present study was to assess the mid-to-long term outcomes of circular frame fixation of distal third tibia fractures performed acutely in adults in a centre with a resourced limb reconstruction service over the last 15 years, with a focus on return to theatre and post-operative complications over that period. All data analysed was collected as part of routine clinical practice and thus ethical approval was not required.