Comparison of low, multidirectional locked nailing and plating in the treatment of distal tibial metadiaphyseal fractures

Retrograde tibial intramedullary nail versus minimally invasive locking plate for extra-articular distal tibial fractures: a comparative and retrospective study

BACKGROUND

Distal tibial fractures represent common lower limb injuries, frequently accompanied by significant soft tissue damage. The optimal surgical approach for managing these fractures remains a topic of considerable debate. The aim of this study was to perform a comparative analysis of the outcomes associated with retrograde intramedullary tibial nails (RTN) and minimally invasive plate osteosynthesis (MIPO) in the context of treating extra-articular distal tibial fractures.

METHODS

A retrospective review was conducted on a cohort of 48 patients who sustained extra-articular distal tibial fractures between December 2019 and December 2021. Patients underwent either RTN or MIPO procedures. Various parameters, including operative duration, intraoperative fluoroscopy exposure, time to union, duration until full weight-bearing, American Orthopedic Foot and Ankle Society (AOFAS) scores, and complications, were recorded and compared between the two treatment groups.

RESULTS

No statistically significant differences were observed in operative duration, time to union, angulation of the distal tibial coronal plane, or AOFAS scores between the RTN and MIPO groups. However, the RTN group had a higher average number of intraoperative fluoroscopy images (8.2 ± 2.3) compared to the MIPO group (4.1 ± 2.0). The RTN group demonstrated shorter average hospital stays (7.1 ± 1.4 days) and a quicker return to full weight-bearing (9.9 ± 1.3 weeks), which were significantly superior to the MIPO group (9.0 ± 2.0 days and 11.5 ± 1.5 weeks, respectively). In terms of complications, the RTN group had one case of superficial infection, whereas the MIPO group exhibited two cases of delayed union and nonunion, two occurrences of deep infection, and an additional three cases of superficial infection.

CONCLUSIONS

Both RTN and MIPO are effective treatment options for extra-articular distal tibial fractures. However, RTN may offer superior outcomes in terms of decreased inpatient needs, faster return to full weight-bearing capacity, and a lower rate of complications.

Comparative Study of Minimally Invasive Plate Osteosynthesis (MIPO) and Intramedullary Nailing (IMN) for Treating Extraarticular Distal Tibial Fractures: Clinical and Radiological Outcomes

BACKGROUND Treatment of extra-articular distal tibial fractures is problematic owing to limited soft tissue cover, poor vascularity of the location, and adjacency to the ankle, and thus continues to be controversial. This study aimed to compare clinical and radiological outcomes in 69 patients with extra-articular distal tibia fractures treated with minimally invasive plate osteosynthesis (MIPO) and an interlocking intramedullary nail (IMN). MATERIAL AND METHODS Sixty-nine patients, with mean of age 39.8±18.3 years, were retrospectively evaluated. Thirty-five patients were treated with IMN, and 34 patients were treated with MIPO. Clinical and radiological outcomes were evaluated. RESULTS The average follow-up was 13.3±6 months and union time was 16.2±5.4 weeks. Nonunion was observed in only 4.3% of patients treated with MIPO (P=0.114). Non-acceptable malalignment of extremity was observed in 4.3% of patients with IMN and 7.2% of patients with MIPO. There were no significant differences in union time, nonunion, surgical timing, operating time, malalignment, and complications between groups (P>0.05). The mean American Orthopaedic Foot and Ankle Society (AOFAS) surgery score was 95.8±5 in IMN and 91.9±14.3 in MIPO. AOFAS, Tenny-Wiss radiological, and Ovadia-Beals clinical scores were better in IMN than MIPO (P=0.019, P=0.03, P=0.02, respectively). Mean time of full weight-bearing and of return to daily life with IMN was significantly shorter than with MIPO (P.

Similar Clinical Outcome in Locking and Conventional Plate Osteosynthesis for the Treatment of AO 44-B2 Ankle Fractures

INTRODUCTION

Biomechanical studies have proved that locking plates have better primary stability besides versatility regarding fracture pattern while reducing bone contact and bridging the gap, whereas conventional nonlocking plates (plus lag screw) depend on bone-plate compression. The clinical benefit of locking plates over nonlocking plates remains unanswered, however. Therefore, this retrospective cohort study was set up to test the hypothesis that the use of locking plates for unstable ankle fractures will result in fewer re-displacements, superior bony healing, and functional and clinical outcomes better than observed in the nonlocking cohort.

METHODS

Bimalleolar ankle fractures (AO 44-B2) without syndesmotic injury treated with either a locking or a nonlocking plate were included. Groups were compared for complications, bone healing, secondary dislocation, progressions of osteoarthritis, and clinical outcome using patient-reported outcome measures.

RESULTS

Data revealed no clinical outcome differences (Olerud-Molander Ankle Score: nonlocking 88.2 ± 14.4, locking 88.8 ± 12.3, P = .69, robust two 1-sided test for equality (RTOST): P = .03; American Orthopaedic Foot and Ankle Score: nonlocking 91.2 ± 12.9, locking 91.8 ± 11.3, P = .96, RTOST: P = .04). Nevertheless, a significant postoperative progression of osteoarthritis was detected in both groups (P = .04). This was independent of implant (P = .16). Although difference was not significant, locking plates were preferred in older (P = .78) and sicker patients (P = .63) and in cases with severer osteoarthritis (P = .16), and were associated with a higher complication rate (P = .42) and secondary dislocation (nonlocking 9.4%, locking 18.2%; P = .42). Re-displacement, however, was not a compelling reason for revision.

CONCLUSIONS

The present study shows statistically significant equality of both types of implants. Contrary to our expectation, locking plates seemed to be associated with a higher risk for re-displacement. Overall, the use of either locking or nonlocking plates for unstable AO 44-B2 fractures is safe and successful despite significant progression of osteoarthritis.

LEVEL OF EVIDENCE

III, Retrospective observational cohort study.

Effect of Different Reduction Intramedullary Nails on Spiral Fracture of Middle and Lower Tibia

Objective

To compare the efficacy of different reduction and intramedullary nailing in the treatment of spiral fracture of middle and lower tibia.

Method

A total of 96 patients with spiral fractures of middle and lower tibia treated with intramedullary nails were retrospectively analyzed. The patients were divided into closed functional reduction group, open anatomical reduction group, and closed anatomical reduction group according to different treatment methods. The operation time, intraoperative blood loss, intraoperative fluoroscopy times, fracture healing time, fracture nonunion, wound complications, and healing conditions of the three groups were compared.

Results

The operation time and intraoperative fluoroscopy times of patients in the closed anatomical reduction group were significantly increased compared with those in the closed functional reduction group, while the fracture healing time was significantly reduced. However, patients in the open reduction group had significantly more intraoperative blood loss than those in the closed reduction group. The mean follow-up duration of patients was 15.81 ± 3.25 months. Open anatomical reduction was found to have a higher complication rate during follow-up. Specifically, a total of 3 cases recovered after 2 times of surgical treatment. 6 cases showed a small gap at the fracture end which did not affect the function.

Conclusion

In the treatment of middle and lower spiral fracture of tibia, closed anatomical reduction and intramedullary nail internal fixation have shorter fracture healing time, less blood loss, and fewer complications, which can act as the first surgical choice. However, open reduction and intramedullary nailing have a high complication rate, which is not recommended.

Comparison of Radiological and Clinical Outcomes in Patients Treated with Standard Plating versus Intramedullary Nailing in Distal Tibial Fracture

Objective

To evaluate clinical and radiological outcomes including hindfoot alignment after plate vs intramedullary nailing (IMN) for distal tibia fracture and to define radiologic parameters that influence changes in hindfoot alignment.

Methods

Among 92 patients with distal tibia metaphyseal fractures treated from 2002 to 2015, 39 cases of intramedullary nailing and 53 cases of standard plate osteosynthesis were performed. Union rate and complication rate were compared in both groups. Radiographic measurements including hindfoot angulation, moment arm, calcaneal pitch angle, and Meary angle were evaluated at a minimum of 1‐year follow‐up. Hindfoot alignment changes after surgery were compared between both groups using student t‐test. Correlation and regression were analyzed between fracture alignment parameters and hindfoot alignment.

Results

All patients ultimately healed, with an average union period of 26 weeks in both groups. The AOFAS and VAS scores were not significantly different between the two groups. Complications were similar between the two groups. Hindfoot alignment angle, calcaneal pitch, and Meary angle showed no significant differences between the groups. The hindfoot moment arm increased with valgus in the IMN group. A low correlation was detected between angulation at the fracture site in the coronal view and hindfoot alignment (angulation and moment arm) changes (R = 0.38). A significantly high correlation was noted only between transverse rotation and hindfoot alignment changes (R = 0.79).

Conclusions

Rotation in the transverse plane notably influenced changes in hindfoot alignment. And this suggests that patients with distal tibia fracture should be closely monitored for hindfoot alignment changes caused by intraoperative transverse rotation regardless of the fixation method.

Does Malrotation After Minimally Invasive Plate Osteosynthesis Treatment of Distal Tibia Metaphyseal Fractures Effect the Functional Results of the Ankle and Knee Joints?

OBJECTIVES

To investigate whether rotational malalignment of tibia, after fracture management with minimally invasive plate osteosynthesis technique (MIPO), leads to impaired results in knee and ankle joint functional scores.

DESIGN

Prospectively collected data were retrospectively analyzed for this study.

SETTING

Level III academic trauma center.

PATIENTS/PARTICIPANTS

Sixty-five consecutive patients who applied between October 2010 and January 2014 with a unilateral distal tibia fracture and had full bone union at their last visit were analyzed. Patients were excluded if they had a pathologic fracture, Gustilo-Anderson type II or III open fracture, additional ligamentous trauma, were pregnant, or had any deformity. A total of 27 patients were accepted into the study.

INTERVENTION

All patients were treated with a MIPO technique after a mean of 2.8 days. The fibular fracture, when present, was fixed first.

MAIN OUTCOME MEASUREMENTS

The main outcome of this study was the relation between tibial malrotation after a MIPO procedure, and Lower Extremity Functional Scale, American Orthopedic Foot and Ankle Society, KOOS scores, and range of motions of adjacent joints.

RESULTS

Fourteen patients (51.8%) had a rotation higher than 10 degrees. The mean malrotation angle was 14.6 degrees. Concomitant fibular fractures were present in 13 patients, which did not seem to have a significant influence on malrotation. There was no significant difference between groups regarding functional scores and range of motions of the knee and ankle joints.

CONCLUSIONS

Despite high rates of malrotation after tibial metaphyseal-diaphyseal fractures treated with MIPO technique, this finding does not seem to have a significantly negative effect on knee and ankle joint functions. Meticulous intraoperative evaluation, through a range of different techniques, should be performed to avoid malrotation.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Minimally invasive plate osteosynthesis or conventional intramedullary nailing for distal tibial fractures: A cohort study protocol

BACKGROUND

Currently, both minimally invasive plate osteosynthesis (MIPO) and intramedullary nailing are the two most commonly used methods of treatment in distal tibial fractures, but controversy still exists regarding the clinical effects of 2 techniques. Our purposes were to compare MIPO and intramedullary nailing for distal tibia shaft fractures by assessing functional outcomes and complications.

METHODS

Data were collected retrospectively from the charts of patients treated for distal tibial extra-articular fractures between May 2012 and July 2018. All cases were performed by a single surgeon. Institutional review board approval in the Second Affiliated Hospital of Army Medical University was obtained prior to conducting chart review and analysis. The criteria for inclusion in the study were being aged at least 18 years at the time of diagnosis and having a closed or type I open fracture of the distal third of the tibial diaphysis. The primary outcome compared between the 2 groups was the American Orthopedic Foot and Ankle surgery score. The secondary outcome measures in this trial included Olerud and Molander Ankle Score, radiographic outcomes, and complications. Statistical analysis was performed using SPSS version. P values < .05 were considered statistically significant.

RESULTS

We hypothesized that MIPO would be associated with better functional outcomes and fewer complications.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry5808).

Treatment of distal tibial fractures: prospective comparative study evaluating two surgical procedures with investigation for predictive factors of unfavourable outcome

PURPOSE

The aim of this study is to compare clinical and radiological outcome of intramedullary nailing (IMN) and locked plate (LP) in patients affected by fracture of the distal tibia (DTF). We performed also an analysis to identify predictive factors of unfavourable outcome.

METHODS

Data about patients with DTF treated at our first level trauma centre between 2008 and 2017 were collected. Patients were divided in group 1 (IMN) and group 2 (LP). The inclusion criteria were age at least 18 years at the time of diagnosis and unilateral DTF (closed or Gustilo 1). Demographic variables and data related to surgical procedure and hospitalization were registered. X-ray at follow-up was reviewed to identify malunions and nonunions. Clinical outcome was evaluated using scores and registering any complication.

RESULTS

One hundred two patients were included in group 1 and 81 in group 2. In group 2 were documented higher operating time and hospitalization. The mean union time was 20.2 weeks for IMN and 24.8 weeks for LP group (p = 0.271). The rate of infections and wound complications was higher in group 2 while malunion and anterior knee pain were more frequent in group 1. No difference in scores for clinical outcome was documented after six months. The full-weight bearing time was significantly longer in the LP group (p = 0.019). At multivariate analysis, no variables showed a predictive power for unfavourable outcome.

CONCLUSIONS

Clinical and radiological results of LP and IMN appear similar. No predictive factors of unfavourable outcome were identified.

A comparison of the cost-effectiveness of intramedullary nail fixation and locking plate fixation in the treatment of adult patients with an extra-articular fracture of the distal tibia: economic evaluation based on the FixDT trial

Aims

The aim of this study was to compare the cost-effectiveness of intramedullary nail fixation and 'locking' plate fixation in the treatment of extra-articular fractures of the distal tibia.

Patients and Methods

An economic evaluation was conducted from the perspective of the United Kingdom National Health Service (NHS) and personal social services (PSS), based on evidence from the Fixation of Distal Tibia Fractures (UK FixDT) multicentre parallel trial. Data from 321 patients were available for analysis. Costs were collected prospectively over the 12-month follow-up period using trial case report forms and participant-completed questionnaires. Cost-effectiveness was reported in terms of incremental cost per quality adjusted life year (QALY) gained, and net monetary benefit. Sensitivity analyses were conducted to test the robustness of cost-effectiveness estimates.

Results

Mean NHS and PSS costs were significantly lower for patients treated with an intramedullary nail than for those treated with a locking plate (-£970, 95% confidence interval (CI) -1685 to -256; p = 0.05). There was a small increase in QALYs gained in the nail fixation group (0.01, 95% CI -0.03 to 0.06; p = 0.52). The probability of cost-effectiveness for nail fixation exceeded 90% at cost-effectiveness thresholds as low as £15 000 per additional QALY. The cost-effectiveness results remained robust to several sensitivity analyses.

Conclusion

This trial-based economic evaluation suggests that nail fixation is a cost-effective alternative to locking plate fixation. Cite this article: Bone Joint J 2018;100-B:624-33.

Nail or plate in the management of distal extra-articular tibial fracture, what is better? Valutation of outcomes

INTRODUCTION

Distal tibial fractures are the most common long bone fractures. Several studies focusing on the methods of treatment of displaced distal tibial fractures have been published. To date, locked plates, intramedullary nails and external fixation are the three most used techniques. The aim of our study was to compare intramedullary nail (IMN) and locked plate (LP) for treatment of this kind of fracture.

MATERIALS AND METHODS

We collected data on 81 patients with distal tibial fractures (distance from the joint between 40 and 100 mm) and we divided into two groups: IMN and LP. We compared in the 2 groups the mean operation time, the mean union time, the infection rate the rate of malunion and nonunion, the full weight bearing time.

RESULTS

No patient in the two groups developed a nonunion. None of the patients obtained a fair or poor outcome. Overall 52 patients obtained an excellent result (69.3%) and 23 obtained a good result (30.6%).

DISCUSSION

Our study results indicate a superiority of IMN over LP in terms of lower rates of infections and statistically significant shorter time to full weight bearing. Whereas LP appeared to be advantageous over IMN in terms of leading to a better anatomical and fixed reductions of the fracture and a lower rate of union complications. The two treatments achieved comparable results in terms of operation time, hospital stay, union time and functional outcomes.

Extra-articular distal tibia fractures-controversies regarding treatment options. A single-centre prospective comparative study

Distal tibia fractures are reported to have a high complication rate pre-operatively as well as post-operatively, which can include open fractures, soft tissue damage, infection, malalignment, pseudarthrosis and ankle arthrosis. The operative treatment for the extra-articular distal tibia fractures is a controversial topic in the orthopaedic literature. Some of these fractures are proximal enough to be treated with an intramedullary nail while others are too distal for that. The aim of our study was to compare the results we have had with intramedullary nail (IMN) and minimally invasive plate osteosynthesis (MIPO) in distal metaphyseal (extra-articular) tibia fractures. The study was designed prospectively between January 2013 and March 2016 and took place on the Orthopaedics and Traumatology ward of a Clinical Emergency County Hospital in western Romania. The follow-up visits were scheduled one month, three months and six months post-operatively. For evaluating the ankle function, we used the Olerud-Molander ankle score (OMAS) and union was evaluated at six months on ankle X-rays. At the six-month follow-up visit the average scores were 75.55 (20-100) for the IMN lot and 74.23 (20-90) for the MIPO lot, without finding any statistical difference between the two groups (p >0.1). At the six-month follow-up, X-ray union was objected in 48 (90.5%) of our patients, the IMN lot having worse results (85.18%) than the MIPO lot (96.15%). The results we encountered showed little to no statistical difference when it comes to the functional score we used (OMAS score), leading us to believe that you can achieve comparable results with both implants.

A comparative study of intramedullary interlocking nailing and minimally invasive plate osteosynthesis in extra articular distal tibial fractures

BACKGROUND

Extraarticular distal tibial fractures are among the most challenging fractures encountered by an orthopedician for treatment because of its subcutaneous location, poor blood supply and decreased muscular cover anteriorly, complications such as delayed union, nonunion, wound infection, and wound dehiscence are often seen as a great challenge to the surgeon. Minimally invasive plate osteosynthesis (MIPO) and intramedullary interlocking nail (IMLN) are two well-accepted and effective methods, but each has been historically related to complications. This study compares clinical and radiological outcome in extraarticular distal tibia fractures treated by intramedullary interlocking nail (IMLN) and minimally invasive plate osteosynthesis (MIPO).

MATERIALS AND METHODS

42 patients included in this study, 21 underwent IMLN and 21 were treated with MIPO who met the inclusion criteria and operated between June 2014 and May 2015. Patients were followed up for clinical and radiological evaluation.

RESULTS

In IMLN group, average union time was 18.26 weeks compared to 21.70 weeks in plating group which was significant (P < 0.0001). Average time required for partial and full weight bearing in the nailing group was 4.95 weeks and 10.09 weeks respectively which was significantly less (P < 0.0001) as compared to 6.90 weeks and 13.38 weeks in the plating group. Lesser complications in terms of implant irritation, ankle stiffness, and infection, were seen in interlocking group as compared to plating group. Average functional outcome according to American Orthopedic Foot and Ankle Society score was measured which came out to be 96.67.

CONCLUSION

IMLN group was associated with lesser duration of surgery, earlier weight bearing and union rate, lesser incidence of infection and implant irritation which makes it a preferable choice for fixation of extra-articular distal tibial fractures. However, larger randomized controlled trials are required for confirming the results.

Minimally invasive percutaneous plates versus conventional fixation techniques for distal tibial fractures: A meta-analysis

OBJECTIVE

This meta-analysis was performed to determine the effects of minimally invasive percutaneous plate osteosynthesis (MIPO) versus conventional fixation techniques (CFT) for treating distal tibial fractures.

METHODS

A literature search was performed in EMBASE, Medline, the Cochrane Library, and Web of Science. The trials searched were evaluated for eligibility. The Cochrane Collaboration's Review Manager software was used to perform meta-analyses.

RESULTS

Eight studies were enrolled, including five randomized controlled trials, one control-matched trial and two retrospective cohort trials. The meta-analysis revealed that MIPO has a longer operating time, longer radiation time and higher incidence rate of soft tissue irritation symptoms than those of CFT. There was no significant difference between the two techniques with regard to union time, the American Orthopedic Foot and Ankle Society (AOFAS), infection rate and various other complications.

CONCLUSIONS

The present meta-analysis showed that MIPO did not have obvious advantages over CFT in the treatment of distal tibia fracture. However, more rigorous randomized controlled trials are required in the future.

Is intramedullary nailing superior to plating in patients with extraarticular fracture of the distal tibia?

Distal tibial metaphyseal fractures are generally produced by high-energy trauma such as car accidents and can cause severe disability due to pain and deformity. In the management of these fractures, there are multiple surgical alternatives, but it is uncertain which the best option is. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified six systematic reviews including three randomized trials. We combined the evidence using meta-analysis and generated a summary of findings table following the GRADE approach. We concluded it is not clear whether one surgical option is better than the other, because the certainty of the evidence is very low. Two ongoing randomized trials might help solving this uncertainty.

Outcomes After Intramedullary Nailing of Distal Tibial Fractures

OBJECTIVES

To determine outcomes in the treatment of distal tibial fractures treated with intramedullary nails.

DESIGN

Retrospective analysis.

SETTING

Level I trauma center with follow-up in a private orthopaedic practice.

MAIN OUTCOME MEASUREMENTS

Radiographic determination of alignment, nonunion, and malunion, clinical outcome (range of motion, and implant-associated complaints), wound complications, and fibular fixation.

PATIENTS

A total of 105 patients with OTA/AO type A and C tibial fractures (<11 cm from the joint line) treated with intramedullary nailing.

RESULTS

Distance of the fracture from the joint line averaged 6.1 cm (range, 0-11). Mean follow-up was 25.6 months (range, 12-74). Nonunion occurred in 20 (19%) fractures and were significantly associated with open fractures (P = 0.012), wound complications (P < 0.001), and the need for fibular fixation (P = 0.007). Sagittal plane alignment averaged 2.5 degrees (±4.4) valgus. Malunion occurred in 25 (23.8%) fractures and again were significantly associated with open fractures (P = 0.045). Fifty (47.6%) patients had implant-related pain, which resolved in 27 (54.0%) after removal.

CONCLUSIONS

Intramedullary nailing of distal tibial fractures is a suitable treatment option. Acceptable alignment and range of motion can be achieved. Both nonunions and malunions were significantly associated with open fractures, wound complications, and fibular fixation. Implant removal was needed in 25% of cases.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Intramedullary nailing versus plating for distal tibia fractures without articular involvement: a meta-analysis

Background

The choice between intramedullary (IM) nailing or plating of distal tibia fractures without articular involvement remains controversial. A meta-analysis of randomized controlled trials (RCTs) and observational studies was performed to compare IM nailing with plating for distal tibia fractures without articular involvement and to determine the dominant strategy.

Materials and methods

The PubMed, Embase, Cochrane Library databases, Chinese Wan-Fang Database, and China National Knowledge Infrastructure were searched.

Results

Twenty-eight studies, which included 1863 fractures, met the eligible criteria. The meta-analysis did not identify a statistically significant difference between the two treatments in terms of the rate of deep infection, delayed union, removal of instrumentation, or secondary procedures either in the RCT or retrospective subgroups. IM nailing was associated with significantly more malunion events and a higher incidence of knee pain in the retrospective subgroup and across all the studies, but not significantly in the RCT subgroup, and a lower rate of delayed wound healing and superficial infection both in the RCT and retrospective subgroups relative to plating. A meta-analysis of the functional scores or questionnaires was not possible because of the considerable variation among the included studies, and no significant differences were observed.

Conclusions

Evidence suggests that both IM nailing and plating are appropriate treatments as IM nailing shows lower rate of delayed wound healing and superficial infection and plating may avoid malunion and knee pain. These findings should be interpreted with caution, however, because of the heterogeneity of the study designs. Large, rigorous RCTs are required.

Expert tibia nail for subtrochanteric femoral fracture to prevent thermal injury

INTRODUCTION

Subtrochanteric femoral fractures are relatively uncommon, accounting for 7-15% of all hip fractures and treatment of these fractures are considered challenge for orthopaedic surgeons. Although several treatment options are reported with up to 90% of satisfactory results, the choice of the appropriate implant is still a matter of debate. Some authors reported thermal injury after reaming for intramedullary nail fixation in patients with narrow medullary canal.

PRESENTATION OF CASE

A 21-year-old female patient was admitted to our hospital because of right subtrochanteric femoral fracture. The narrowest diameter of medullary canal of her femur was about 7mm but she refused open reduction and internal fixation with plate due to large scar formation. We used expert tibia nail instead of femoral intramedullary nail to prevent thermal injury.

DISCUSSION

Subtrochanteric femoral fractures are difficult to treat because of their biomechanical and anatomical characteristics. Although several implants are reported for the surgical treatment of these fractures, intramedullary nails have been advocated due to their biological and biomechanical advantages. However, under certain circumstances with associated injury or anatomic difference we might consider another treatment options.

CONCLUSION

Expert tibia nail may be considered one of the treatment options for subtrochanteric femoral fracture with narrow medullary canal. We also emphasize the importance of preoperative evaluation of the medullary canal size for these risky fractures.

Intramedullary nailing versus plating for extra-articular distal tibial metaphyseal fracture: a systematic review and meta-analysis

INTRODUCTION

With development in the techniques of reduction and fixation, there has been a controversy in comparison between intramedullary nailing (IMN) and plating for the treatment of distal tibial metaphyseal fracture (DTF). The study aimed to investigate: (1) which fixation, IMN or plating, was better in the clinical outcomes and in the complications for the treatment of DTF and (2) which modifying variables affected the comparative results between the two modalities.

METHODS

PubMed, EMBASE, OVID, Scopus, ISI Web of Science, the Cochrane Library, Google Scholar and specific orthopaedic journals were searched from inception to July 2013, using the search strategy of '('Fracture Fixation, Intramedullary' [MeSH]) AND ('Tibial Fractures' [MeSH]) AND (plate OR plating)'. All prospective and retrospective controlled trials comparing function, pain, bone union and complications between IMN and plating for DTF were identified. Our analysis had no limitation of the language or the publication year. The primary outcome measurements were complication rate, union time, operation time and hospital stays, while the secondary outcome measurements were functional score and pain score.

RESULT

Fourteen of 6620 studies with 842 patients were included. IMN was probably preferential to plating for DTF given its higher functional score (p=0.01), lower risk of infection (p=0.02) and comparable pain score (p=0.33), total complication rate (p=0.53) and time to union (p=0.86). However, plating had a lower malunion rate than IMN (p<0.0001). All the results were based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence of moderate quality.

CONCLUSIONS

With a satisfying alignment obtained, IMN may be preferential to plating for fixation of DTF with better function and lower risk of infection. However, IMN showed higher malunion rate for fixation of DTF. With the biases in our meta-analysis, it will ultimately require a rigorous and adequately powered randomised controlled trial (RCT) to prove.

LEVEL OF EVIDENCE

Level III, therapeutic study (systematic review).

Treatment of distal tibial shaft fractures by three different surgical methods: a randomized, prospective study

PURPOSE

A few studies focused on the methods of treatment for displaced distal tibial shaft fractures have been published, all of which compared two different methods. In this randomized, prospective study, we aimed to compare minimally invasive plate osteosynthesis, locking intramedullary nail stabilization and external fixation combined with limited open reduction and absorbable internal fixation for distal tibial shaft fractures by assessing complications and secondary procedures.

METHODS

From November 2002 to June 2012, 137 skeletally mature patients with displaced distal tibial shaft fractures with or without fibula fracture were randomized to be treated by minimally invasive plate osteosynthesis (group A, n = 46), locking intramedullary nail (group B, n = 46) or external fixation combined with limited open reduction and absorbable internal fixation (group C, n = 45). Age, gender, mechanism of injury, fracture pattern and presence of open fracture were equally distributed among the three groups. Indexes for evaluation included hospital stay, operative time, time to radiographic union, union status, infection and the incidence of re-operation. Mazur ankle score was introduced for functional evaluation. Statistics Analysis System (SAS) 9.2 was used for analysis.

RESULTS

A total of 121 patients were included in the final analysis (group A 42, group B 40 and group C 39) and evaluated after a mean of 14.8 months follow-up. There was no significant difference (P > 0.05) in hospital stay, time to radiographic union and the incidence of union status among the three groups. Although group C was associated with less secondary procedures versus groups A and B, it was related with more pin tract infections (15.4 %). Anterior knee pain occurred frequently after locking intramedullary nailing (37.5 %) and the irritation symptoms were more frequently encountered in group A (59.5 %). There was no difference in ankle function between the three methods after operation (P > 0.05).

CONCLUSIONS

We consider that the minimally invasive plate osteosynthesis, locking intramedullary nail stabilization and external fixation combined with limited open reduction and absorbable internal fixation techniques are all efficient methods for treating distal tibia fractures. With its wide indications, external fixation combined with limited open reduction and absorbable internal fixation leads to minimal soft tissue complication, good functional result and no local soft tissue irritation or implant removal.

Plate fixation versus intramedullary nailing for displaced extra-articular distal tibia fractures: a system review

PURPOSE

The optimal surgical procedure for displaced extra-articular distal tibia fractures remains debated at present. The objective of this systematic review is to compare the complications and functional outcomes of this type of fracture after plate fixation and intramedullary nailing .

METHODS

A computer-aided search of PubMed, Embase and Cochrane was carried out on July, 2012. Two independent reviewers screened and assessed abstracts. Every study published in English about the comparison between plate fixation and intramedullary nailing for displaced extra-articular distal tibia fractures was included. The outcomes were pooled or summarized separately per study according to heterogeneity between studies. Pooled risk ratios (RR) with 95 % confidence intervals (95 % CIs) were calculated by Mantel-Haenszel method using either the fixed effects model or random effects model.

RESULTS

Eight studies, with 270 patients in the intramedullary nailing and 217 patients in the plates fixation group, met the inclusion criteria. Functional outcome, days of hospital stay and time for bone union were comparable between intramedullary fixation and plate fixation. Total complication rate was significant higher for intramedullary nailing compared with plate fixation (44.5 vs. 25.8 %, P < 0.001). Similarly, the rate of minor complications was higher for intramedullary nailing than that for plate fixation (35.9 vs. 21.2 % P < 0.001). Major complication rate was 8.52 % for intramedullary nailing and 4.6 % for plate fixation, but the difference had no statistical significance (P = 0.06). Our pooled estimates showed a decreased risk of total complication in plate fixation (RR, 2.38; 95 % CI, 1.13-5.03; P = 0.02). Among these complications, malunion and anterior knee pain were more common in intramedullary nailing than in plate fixation (20.1 vs. 4.5 %, P < 0.001; 4.2 vs. 0.45 %, P = 0.02, respectively). Meanwhile, significantly less wound problems happened in intramedullary nailing than in plate fixation (2.9 vs. 7.5 %, P = 0.03). In addition, locking plate fixation with mini-invasive technique tended to have a lower complication rate than conventional plate fixation, although the difference was not significant (21 vs. 28.4 %, P = 0.26).

CONCLUSIONS

The results of this systematic review suggested that plate fixation, especially minimally invasive percutaneous plating osteosynthesis technique would be preferred for extra-articular distal tibia fractures because of its low complication rate. Nevertheless, intramedullary fixation should be taken priority for distal tibia fractures with serious soft tissue injuries.

Unreamed intramedullary nailing in distal tibial fractures

PURPOSE

Unreamed nailing has gained acceptance in the treatment of diaphyseal long bone fractures, especially in cases with polytrauma or high-energy injuries. Its application in distal tibial fractures, however, remains controversial.

METHODS

In this study, 101 distal tibial fractures treated using closed unreamed nailing were reviewed after a mean follow-up of 32 months. There were 59 type A und 42 type B fractures. The most common fracture pattern was the A1 spiral fracture (n = 40) followed by the B2 wedge fracture (n = 18). Intra-articular extension was encountered in 14 cases. One-fourth of the patients (n = 24) had open injuries. Forty-seven patients had additional injuries, and nearly one-third of them were polytraumatised.

RESULTS

Union occurred after a mean time of 23.9 (range, 11-134) weeks. There were 13 cases of delayed union and seven non-unions; all healed eventually with additional surgery in only six fractures. Malunion was seen in 12 cases (five valgus, two varus and five external torsion), ten of which were associated with unplated fibular fractures. Three fractures (two open) were treated for deep infection. The most common complication seen was fatigue failure of the locking screws (27 cases).

CONCLUSIONS

Unreamed nailing of distal tibial fractures is associated with a rather high rate of bone healing complications and locking screw failure. The decision for its use in the notoriously challenging fractures of this segment should be critically considered.