Minimally invasive percutaneous plate osteosynthesis versus intramedullary nail fixation for distal tibial fractures: a systematic review and meta-analysis

A novel assisted reduction method in extra-articular fractures of the distal tibia treated with intramedullary nail

Background

To explore the clinical efficacy and safety of Kirschner wires (KWs) as a blocking screw technique for extra-articular fractures of the distal tibia treated with intramedullary nails (IMNs).

Methods

Fifty-three patients were treated with KW-assisted IMN for extra-articular fractures of the distal tibia via the blocking screw technique or Poller screw (PS) technique. The operation time, number of fluoroscopies, number of blocking screws used, blood loss and time to union were compared between the two groups. Additionally, the functional outcomes of the two groups were compared using range of motion (ROM), visual analog scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS), and Lysholm scores.

Results

Compared with those in the PS group, the operation time in the KW group was significantly shorter, and the number of fluoroscopy procedures and amount of blood loss during KW surgery were also significantly lower (p = 0.014, 0.001, and 0.036, respectively). Regarding the functional outcomes, there were no significant differences in the ROM, VAS score, AOFAS score or Lysholm score between the two groups (p > 0.05).

Conclusion

In the treatment of extra-articular fractures of the distal tibia with nails, the use of KW as a blocking screw technique is safe and reliable.

Efficacy comparison between intramedullary nail fixation and plate fixation in distal tibia fractures: a meta-analysis of randomized controlled trials

BACKGROUND

Intramedullary nail (IMN) and plate fixation are the most commonly used surgical modalities for distal tibia fractures. However, the superiority of their efficacy regarding functional outcomes and complications remains controversial. Here, we performed a systematic review and meta-analysis to compare the efficacy of these two modalities.

METHODS

Randomized controlled trials (RCTs) comparing the efficacy of IMN and plate fixation in distal tibia fractures were searched in PubMed, Web of Science, EMBASE, ClinicalTrials.gov, and Cochrane Library up to January 31, 2024. Weighted mean difference (WMD) and odds ratio (OR) with corresponding 95% confidence interval (CI) were estimated using a random-effect model for continuous and categorical outcomes, respectively.

RESULTS

A total of 20 RCTs comprising 1528 patients were included. Compared with plate fixation, IMN significantly shortened surgery time (WMD=-10.73 min, 95%CI: -15.93 to -5.52), union time (WMD=-1.56 weeks, 95%CI: -2.82 to -0.30), and partial (WMD=-1.71 weeks, 95%CI: -1.91 to -0.43) and full (WMD=-2.61 weeks, 95%CI: -3.53 to -1.70) weight-bearing time. IMN was associated with markedly reduced risk of wound infection (OR = 0.44, 95%CI: 0.31-0.63) and secondary procedures (OR = 0.72, 95%CI: 0.55-0.95), but increased the risk of malunion (OR = 1.53, 95%CI: 1.02-2.30) and anterior knee pain (OR = 3.94, 95%CI: 1.68-9.28). The rates of nonunion, delayed union, and functional assessment scores did not significantly differ between the two groups. The percentages of patients obtaining an excellent functional outcome or an excellent and good functional outcome post-operation were comparable.

CONCLUSIONS

Both IMN and plate fixation are effective modalities for the surgical treatment of distal tibia fractures. IMN seems to be preferred since it confers more advantages, but the elevated rates of malunion and knee pain require attention. The decision on fixation modality should be tailored to the specific fracture, considering these pros and cons.

Wound infection and healing in minimally invasive plate osteosynthesis compared with intramedullary nail for distal tibial fractures: A meta-analysis

To systematically explore the effects of minimally invasive plate osteosynthesis (MIPO) versus intramedullary nail (IMN) on wound infection and wound healing in patients with distal tibia fractures. A computerised search of PubMed, Web of Science, Cochrane Library, Embase, Wanfang, China Biomedical Literature Database (CBM) and China National Knowledge Infrastructure databases was performed, from their inception to October 2023, to identify relevant studies on the application of MIPO and IMN in patients with distal tibial fractures. The quality of the included literature was evaluated by two researchers based on inclusion and exclusion criteria, and basic information of the literature was collected, with wound infection, postoperative complications and wound healing time as the main indicators for analysis. Stata 17.0 software was applied for analysis. Overall, 23 papers and 2099 patients were included, including 1026 patients in the MIPO group and 1073 patients in the IMN group. The results revealed, when compared with IMN treatment, patients with distal tibia fractures who underwent MIPO treatment had a lower incidence of postoperative complications (OR = 0.33, 95% CI: 0.25-0.42, p < 0.001) and a shorter wound healing time (SMD = -1.00, 95% CI: -1.51 to -0.49, p < 0.001), but the incidence of postoperative wound infection was higher (OR = 2.01, 95% CI: 1.35-3.01, p = 0.001). Both MIPO and IMN are excellent treatments for distal tibia fractures. MIPO is effective in reducing the incidence of complications as well as shortening the time of wound healing time but increases the risk of wound infection. In clinical practice, surgeons can make individual choices based on the patient's wishes and proficiency in both techniques.

Plate-Assisted Intramedullary Nailing of Distal Tibia Fractures

The combination of plate and intramedullary nailing has been established as the treatment of proximal tibial fractures. Nevertheless, at the distal end of the tibia, the application of the plate-assisted intramedullary nailing is rarely applied as a therapeutic technique. This technical note demonstrates the use of the reduction plating technique for nail insertion as the management of distal tibia fractures.

Suprapatellar intramedullary nail combined with screw fixation has comparable surgical outcomes to minimally invasive locking plate fixation in ipsilateral tibial plateau and shaft fractures

PURPOSE

To compare union rate, union time, alignment, and complication rate in ipsilateral tibia plateau and shaft fractures treated via suprapatellar intramedullary nailing with screw fixation and minimally invasive locking plate fixation.

MATERIALS AND METHODS

A retrospective study was conducted on 48 patients who underwent minimally invasive plate fixation (n = 35) or suprapatellar intramedullary nailing with screw fixation (n = 13), for the treatment of ipsilateral tibial plateau and shaft fractures with at least 1-year follow-up. Union rate, union time, radiologic alignment, and complication rate such as malalignment, nonunion, and fracture-related infection (FRI) were investigated.

RESULTS

Demographic data were not different between the two groups. Coronal plane alignment was 0.17 ± 4.23 in the plate group and -0.48 ± 4.17 in the intramedullary nail group (p = 0.637). Sagittal plane alignment was -0.13 ± 5.20 in the plate group and -1.50 ± 4.01 in the suprapatellar intramedullary nail group (p = 0.313). Coronal and sagittal malalignment recorded equal results: (p > 0.99), FRI (p = 0.602), nonunion and union times recorded (p = 0.656) and (p = 0.683, 0.829), respectively, and showed no significant difference between the two groups.

CONCLUSION

Suprapatellar intramedullary nailing with screw fixation had similar surgical outcomes with minimally invasive locking plate fixation in ipsilateral tibial plateau and shaft fractures in terms of union rate, union time, alignment, and complication rate. Thus, frequent use of intramedullary nailing combined with screw fixation is anticipated in patients with ipsilateral tibial plateau and shaft fractures when the soft tissue condition is not desirable.

LEVEL OF EVIDENCE

Level III.

A novel technology integrating robotics and 3D printing for closed reduction of tibia shaft fracture with MIPPO:A proof-of-concept study

Less invasive fixation techniques, such as intramedullary nailing (IMN) and minimally invasive percutaneous plate osteosynthesis (MIPPO), are now the preferred choices for treating tibia shaft fractures (TSFs). However, malreduction and radiation exposure are the main deficiencies associated with less invasive fixation techniques, especially when assessing rotation around the shaft axis intra-operatively. The purpose of this study was to investigate the feasibility and reduction accuracy of an innovative technology that integrates robotics and 3D printing for achieving anatomical reduction of TSFs with MIPPO. The surgical workflow from a standardized CT protocol, via 3D reconstruction, 3D printing tibia model, pre-contouring plate, 3D scanning plate, 3D planning of the trajectories of the robot, and use of a commercial surgical robot, robot-assisted screw hole drilling, to automatic fracture reduction through precise installation of the plate was described. The reduction accuracy was evaluated by an optical tracking system. The mean variations of 1.95 ± 1.36mm in length, 1.63 ± 0.92 mm in apposition, 2.78 ± 1.69° in alignment, and 1.99 ± 1.81° in rotation. The interoperator reliabilities were almost perfect, with values of 0.91, 0.93, 0.92, and 0.90, respectively. The proposed technology achieved anatomic reduction on phantom bones.

Does the distal nail position impact the rates of misalignment and bone union in distal tibial fractures?

PURPOSE

This retrospective study aimed to assess the impact of distal nail placement on misalignment and healing rates in distal tibial fractures.

METHODS

We reviewed all patients with distal tibial fracture treated with intramedullary nailing between 2015 and 2021, and a minimum follow-up of 12 months. Distal nail positioning was determined according to the Triantafillou zones. We related these positioning zones to misalignments (alignment ≥ 3°) and too bony union disorders (delayed union, non-union).

RESULTS

Out of the 62 patients included, 56 (90.3%) show bone union without additional procedure, 3 (4.8%) with dynamization, and 3 (4.8%) showed non-union. Twenty-one (33.8%) presented misalignment, with valgus in the coronal plane being the most frequent (76.19%). In patients with and without misalignment, the most frequent distal nail position was 2-2 in 47.6% and 80.5%, respectively (p = 0.01). In multivariate analysis, distal nail positioning in the 2-2 zone showed a significant protective effect against misalignment (OR 0.18; p = 0.018), while nail positioning in the 3-2 zone generated a significant risk of misalignment (OR 18.55; p = 0.009).

CONCLUSION

In intramedullary nailing of distal tibial fractures, distal positioning of the nail slightly lateral to the center of the talus in the coronal plane and slightly posterior in the sagittal plane (zone 2-2) allows high alignment percentages to be obtained. Positioning medial to this point in the coronal plane (zone 3) is associated with more significant misalignment and should be avoided.

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.

Suprapatellar vs infrapatellar approaches for intramedullary nailing of distal tibial fractures: a systematic review and meta-analysis

BACKGROUND

This review was conducted to compare the efficacy of suprapatellar (SP) and infrapatellar (IP) approaches for treating distal tibial fractures with intramedullary nailing.

METHOD

This systematic review included studies comparing the outcomes of patients receiving nailing for distal tibial fractures using the SP and IP approaches. We searched the Cochrane CENTRAL, MEDLINE and Embase databases for relevant studies till 18th Sep. 2022. We used the Newcastle Ottawa Scale to assess study quality and a random-effects meta-analysis to synthesize the outcomes. We used the mean difference (MD) or standardized mean difference (SMD) with the 95% confidence interval (CI) for continuous data and the odds ratio (OR) with the 95% CI for dichotomous data.

RESULTS

Four studies with 586 patients (302 in the SP group and 284 in the IP group) were included in this systematic review. The SP group may have had little or no difference in pain and slightly better knee function (MD 3.90 points, 95% CI 0.83 to 5.36) and better ankle function (MD: 8.25 points, 95% CI 3.35 to 13.15) than the IP group 12 months after surgery. Furthermore, compared to the IP group, the SP group had a lower risk of malalignment (OR: 0.22, 95% CI 0.06 to 0.75; number needed to treat (NNT): 6), a lower risk for open reduction (OR: 0.58, 95% CI 0.35 to 0.97; NNT: 16) and a shorter surgical time (MD: - 15.14 min, 95% CI - 21.28 to - 9.00).

CONCLUSIONS

With more advantages, the suprapatellar approach may be the preferred nailing technique over the infrapatellar approach when treating distal tibial fractures.

LEVEL OF EVIDENCE

Level III, systematic review of non-randomized studies.

One quick and simple fixation method: posterior malleolus fractures in spiral tibial fractures

OBJECTIVE

Spiral fracture of tibia combined with posterior malleolar fracture (PMF) is a special and regular injury. There is no uniform fixation method for PMF in this kind of injury. Intramedullary nail is the first choice for the treatment of tibial spiral fracture. We proposed a minimally invasive percutaneous screw combined with intramedullary nail technology to fix the PMF in the tibial spiral fracture. This study aims to explore the effectiveness and advantages of this technology.

MATERIALS AND METHODS

From January 2017 to February 2020, 116 cases of spiral fracture of tibia combined with PMF who were operated in our hospital were divided into Fixation Group (FG) and No Fixation Group (NG) according to whether PMF was fixed. After minimally invasive percutaneous screw fixation of ankle fracture in FG patients, the tibial intramedullary nail was inserted to fix the fracture. Collected the operation and postoperative recovery of the two groups of patients, including the operation time, intraoperative blood loss, AOFAS score, VAS score and dorsiflexion restriction of ankle joint at the last follow-up, and compared whether there is any difference between the two groups of patients.

RESULTS

The fracture of both groups healed.2 patients in NG had secondary displacement of PMF during operation, and the fracture finally healed after fixation. There were statistical differences between the two groups in terms of operation time, AOFAS score and weight bearing time. The operation time of FG was 67.9±11.2 min, and that of NG was 60.8±9.4 min; The weight bearing time of FG was 57.35±34.72 days, and that of NG was 69.17±21.43 days; The AOFAS score of FG was 92.50±3.46, and that of NG was 91.00±4.16. There were no significant difference in blood loss, VAS and dorsiflexion restriction of ankle joint between the two groups. The blood loss of FG was 66.8±12.3 ml, the blood loss of NG was 65.6±11.7 ml, the VAS score of FG was 1.37±0.47, the VAS score of NG was 1.43±0.51, the dorsiflexion restriction of FG was 5.8±4.1; the NG was 6.1±5.7.

CONCLUSION

For the injury of tibial spiral fracture combined with PMF, our fixation technology can achieve minimally invasive fixation of PMF with percutaneous screws on the basis of intramedullary nail fixation of tibial fracture, promoting early functional exercise of ankle joint and early weight bearing of patients. This fixation technology is also characterized by simple and fast operation.

Comparing external fixators and intramedullary nailing for treating open tibia fractures: a meta-analysis of randomized controlled trials

BACKGROUND

External fixators (EFs) and intramedullary nailing (IMN) are two effective methods for open tibial fractures. However, both methods have advantages and disadvantages, and the optimal surgical approach remains controversial. Thus, we performed a meta-analysis of randomized controlled trials (RCTs) to compare EF with IMN to evaluate their efficacy and safety.

METHODS

A systematic study of the literature was conducted in relevant studies published in PubMed, Embase, the Cochrane Library, Web of Science, CNKI, CBM, Wanfang and Weipu from database inception to April 2022. All eligible literature was critically appraised for methodological quality via the Cochrane's collaboration tool. The primary outcome measurements included postoperative superficial infection, postoperative deep infection, union time, delayed union, malunion, nonunion, and hardware failure.

RESULTS

Nine RCTs involving 733 cases were included in the current meta-analysis. The pooled results suggested that cases in the IMN group had a significantly lower postoperative superficial infection rate [risk ratio (RR) = 2.84; 95% confidence interval (CI) = 1.83 to 4.39; P < 0.00001)] and malunion rate (RR = 3.05; 95% CI = 2.06 to 4.52; P < 0.00001) versus EF, but IMN had a significantly higher hardware failure occurrence versus EF (RR = 0.38; 95% CI = 0.17 to 0.83; P = 0.02). There were no significant differences in the postoperative deep infection rate, union time, delayed union rate or nonunion rate between the two groups (p > 0.05).

CONCLUSIONS

Compared to EF, IMN had a significantly lower risk of postoperative superficial infection and malunion in patients with open tibial fractures. Meanwhile, IMN did not prolong the union time and increased the risk of the deep infection rate, delayed union rate and nonunion rate but had a higher hardware failure rate. The reanalysis of union time showed that it was significantly shorter in the IMN group than in the EF group after excluding the study with significant heterogeneity during sensitivity analysis. Therefore, IMN is recommended as a preferred method of fracture fixation for patients with open tibial fractures, but more attention should be given to the problem of hardware failure.

The semi-extended infrapatellar intramedullary nailing of distal tibia fractures: a randomized clinical trial

BACKGROUND

Malalignment is a common event during the intramedullary nailing (IMN) of distal tibia fractures (DTFs). Although it is reported that the semi-extended IMN techniques such as suprapatellar (SP) and parapatellar (PP) approaches may be superior in preventing malalignment, the application of these techniques is concerning owing to the intra-articular involvement. We thus developed an extra-articular semi-extended infrapatellar (SEIP) approach which utilizes the infrapatellar (IP) space while maintaining the knee in a semi-extended position. However, there are no studies on the safety and efficacy of SEIP in treating DTFs. Therefore, in this study, the SEIP technique was examined, particularly in terms of the potential alignment improvement of DTFs, and this technique was compared with the traditional hyperflexed infrapatellar (HFIP) procedure.

MATERIALS AND METHODS

This randomized clinical trial (RCT) compared IMN malalignment while correcting extraarticular and nondisplaced intra-articular DTFs between April 2018 and June 2021 using the HFIP and SEIP techniques at a level I trauma center in China. The study participants were clinically and radiographically examined for at least 12 months of follow-ups. Intraoperative fluoroscopy time, operation time, blood loss, hospitalization duration, functional ankle score, and complications were assessed as well.

RESULTS

Among the 88 recruited participants, 45 (51%) underwent traditional HFIP IMN and 43 (49%) underwent SEIP IMN. Malalignment occurred in 9 patients (20.0%) from the HFIP cohort and in 2 patients (4.7%) from the SEIP cohort (P value = 0.030). In addition, the SEIP IMN technique significantly reduced the intraoperative fluoroscopy time, operation time, and improved the postoperative ankle function compared to the HFIP IMN technique. However, the intraoperative blood loss, hospitalization duration, infection, delay union, and nonunion remained the same between the two cohorts.

CONCLUSIONS

In summary, we demonstrated that the SEIP IMN provides markedly enhanced alignment of extraarticular and nondisplaced intra-articular DTFs compared to the traditional HFIP IMN procedure. The described technique represents an effective option for IMN of DTFs.

LEVEL OF EVIDENCE

Level 2. Trial registration The Chinese Clinical Trial Registry, ChiCTR2100043673. Registered 26 February 2021, retrospectively registered, http://www.chictr.org.cn/showprojen.aspx?proj=122263.

An old unicondylar tibial plateau fracture (Schatzker type III) with tibial shaft fracture: A case report

Introduction

Case presentation

Clinical discussion

Conclusion

•

Unicondylar tibial plateau fractures with tibial shaft fractures are extremely rare in the elderly.

•

Traditional double plate internal fixation seriously affected soft tissue and bone healing.

•

The use of plates in combination with intramedullary nails can reduce the destruction of soft tissue and fix both the tibial plateau and the tibial shaft.

Is minimally invasive orthopedic surgery safer than open? A systematic review of systematic reviews

BACKGROUND

To assess the safety of minimally invasive surgery (MIS) for orthopedic spinal, upper limb and lower limb procedures, this systematic review of systematic reviews compared their complications with open procedures.

MATERIALS AND METHODS

A literature search was conducted electronically (PubMed, Cochrane library and Web of Science; May 8, 2021) without language restriction in the past five years. Reviews that consulted at least two databases, compared MIS with open orthopedic surgery, and reported the following: intraoperative, post-operative or total complications, function, ambulation, pain, hospital stay, reoperation rate and operation time were included. Article selection, quality assessment using AMSTAR-2, and data extraction were conducted in duplicate on predesigned forms. In each review, a subset analysis focusing on prospective cohort and randomized studies was additionally performed.

PROSPERO

CRD42020178171.

RESULTS

The search yielded 531 articles from which 76 reviews consisting of 1104 primary studies were included. All reviews were assessed as being low quality. Compared to open surgery, MIS had fewer total, postoperative and intraoperative complications in 2/10, 2/11 and 2/5 reviews of spinal procedures respectively, 1/3, 1/4 and 1/2 reviews of upper limb procedures respectively, and 4/6, 2/7 and 0/2 reviews of lower limb procedures respectively.

CONCLUSIONS

MIS had greater overall safety compared to open surgery in spinal procedures. In upper limb and lower limb procedures, MIS was not outright superior to open procedures in terms of safety hence a general preference of MIS is not justified on the premise of a better safety profile compared to open procedures.

MIPO vs. intra-medullary nailing for extra-articular distal tibia fractures and the efficacy of intra-operative alignment control: a retrospective cohort of 135 patients

INTRODUCTION

Definitive treatment of distal extra-articular fractures of the tibia is challenging and both minimal invasive plate osteosynthesis (MIPO) and intramedullary nailing (IMN) are considered to be feasible surgical modalities with their own implant-specific merits and demerits. This retrospective study was designed to compare MIPO versus IMN in terms of fracture healing, complications, functional and radiological outcomes and to assess the efficacy of intra-operative alignment control to reduce the rate of malalignment after definitive fixation of distal extra-articular fractures of the tibia.

MATERIALS AND METHODS

All consecutive adult patients with extra-articular distal meta- or diaphyseal tibia fractures that were treated between January 2012 and September 2019 either with MIPO or IMN were included. Outcome measures included fracture healing, complications (infection, malalignment, subsequent surgeries), functional and radiological outcomes. Intra-operative alignment control encompassed bilateral draping of the lower extremities.

RESULTS

A total of 135 patients were included out of which 72 patients (53%) were treated with MIPO and 63 patients (47%) underwent IMN. There was a significantly higher incidence of non-union for fractures treated with IMN (13 (22%) vs. 4 (6%), p = 0.04). There was no significant difference between both groups in terms of rotational malalignment (3% vs. 10%) and angular malalignment (4% vs. 5%). A significantly higher rate of infection was found after MIPO after correction of significant differences in baseline characteristics. No differences were found in subsequent surgeries or functional outcomes.

CONCLUSION

Both MIPO and IMN are reliable surgical techniques. IMN is associated with higher rates of non-union, whereas MIPO results in a higher risk for infection. The incidence of malalignment was surprisingly low endorsing the utility of the intra-operative alignment control.

Plate vs. nail for extra-articular distal tibia fractures: How should we personalize surgical treatment? A meta-analysis of 1332 patients

BACKGROUND

Treatment for distal diaphyseal or metaphyseal tibia fractures is challenging and the optimal surgical strategy remains a matter of debate. The purpose of this study was to compare plate fixation with nailing in terms of operation time, non-union, time-to-union, mal-union, infection, subsequent re-interventions and functional outcomes (quality of life scores, knee- and ankle scores).

METHODS

A search was performed in PubMed/Embase/CINAHL/CENTRAL for all study designs comparing plate fixation with intramedullary nailing (IMN). Data were pooled using RevMan and presented as odds ratios (OR), risk difference (RD), weighted mean difference (WMD) or weighted standardized mean difference (WSMD) with a 95% confidence interval (95%CI). All analyzes were stratified for study design.

RESULTS

A total of 15 studies with 1332 patients were analyzed, including ten RCTs (n = 873) and five observational studies (n = 459). IMN leads to a shorter time-to-union (WMD: 0.4 months, 95%CI 0.1 - 0.7), shorter time-to-full-weightbearing (WMD: 0.6 months, 95%CI 0.4 - 0.8) and shorter operation duration (WMD: 15.5 min, 95%CI 9.3 - 21.7). Plating leads to a lower risk for mal-union (RD: -10%, OR: 0.4, 95%CI 0.3 - 0.6), but higher risk for infection (RD: 8%, OR: 2.4, 95%CI 1.5 - 3.8). No differences were detected with regard to non-union (RD: 1%, OR: 0.7, 95%CI 0.3 - 1.7), subsequent re-interventions (RD: 4%, OR: 1.3, 95%CI 0.8 - 1.9) and functional outcomes (WSMD: -0.4, 95%CI -0.9 - 0.1). The effect estimates of RCTs and observational studies were equal for all outcomes except for time to union and mal-union.

CONCLUSION

Satisfactory results can be obtained with both plate fixation and nailing for distal extra-articular tibia fractures. However, nailing is associated with higher rates of mal-union and anterior knee pain while plate fixation results in an increased risk of infection. This study provides a guideline towards a personalized approach and facilitates shared decision-making in surgical treatment of distal extra-articular tibia fractures. The definitive treatment should be case-based and aligned to patient-specific needs in order to minimize the risk of complications.

[Treatment of tibial shaft fracture with intramedullary nailing fixation in semi-extended position via extraarticular parapatellar approach]

Objective

To investigate the effectiveness of intramedullary nailing fixation in semi-extended position via extraarticular parapatellar approach for tibial shaft fracture.

Methods

Between July 2018 and September 2019, 22 patients with tibial shaft fracture treated with intramedullary nailing fixation in semi-extended position via extraarticular parapatellar approach. There were 15 males and 7 females, with an average age of 46.4 years (range, 25-68 years). The fractures were caused by falling in 7 cases, by traffic accident in 14 cases, and by a heavy object in 1 case. Sixteen patients were closed fractures and 6 were open fractures. According to the AO classification, there were 4 cases of 42-A1 type, 2 cases of 42-A2 type, 3 cases of 42-A3 type, 3 cases of 42-B2 type, 4 cases of 42-B3 type, 2 cases of 42-C1 type, 3 cases of 42-C2 type, and 1 case of 42-C3 type. Twenty cases complicated with fibular fractures. The time from injury to operation was 2-15 days (mean, 7.5 days). The fracture healing time, complications, the incidence of anterior knee pain during the follow-up were observed; and knee joint functions were evaluated by Lysholm score at last follow-up.

Results

The operation time was 50-140 minutes (mean, 85 minutes). Two cases experienced incision exudation which healed after symptomatic treatment. The incisions of other patients healed by first intention. All patients were followed up 8-23 months (mean, 14.9 months). X-ray films reexamination showed that all fractures healed with the healing time of 12-20 weeks (mean, 14.4 weeks). Four patients (18.18%) experienced the anterior knee pain. No patellofemoral instability was observed during the follow-up period. Lysholm score of knee function was 85-100 (mean, 94.3) at last follow-up.

Conclusion

Application of the intramedullary nailing fixation in semi-extended position via extraarticular parapatellar approach is effective for tibial shaft fractures, which can not only realize the effective fixation of the fracture, but also avoid the adverse factors including re-displacement and anterior knee pain in the application of the intramedullary nailing fixation via the sub-patellar approach.

Comparison of suprapatellar versus infrapatellar approaches of intramedullary nailing for distal tibia fractures

Background

This study aimed to analyze and compare the clinical and functional outcomes of distal tibia fractures treated with intramedullary nailing (IMN) using the suprapatellar (SP) and infrapatellar (IP) surgical approaches.

Methods

A retrospective analysis was performed in 63 patients with distal fractures that were treated with IMN between August 2014 and August 2018. A total of 27 and 36 patients underwent IMN using the SP and IP techniques, respectively. The surgical time, blood loss, closed reduction rate, rate of adjuvant reduction technique, fracture healing time, and complications were reviewed in this study. Anterior knee pain was assessed using the visual analog scale. The Lysholm Knee Scoring Scale and American Orthopaedic Foot and Ankle Society (AOFAS) scale were used as clinical measurements.

Results

A total of 63 patients, with a minimum follow-up of 12 months, were evaluated. The average surgical time, blood loss, rate of adjuvant reduction technique, closed reduction rate, fracture healing time, and Lysholm Knee Scoring Scale score were insignificantly different (P > 0.05) between the two groups. However, the SP approach was superior to the IP approach in terms of pain score, AOFAS score, and fracture deformity rate (P < 0.05).

Conclusions

In the treatment of distal tibia fractures, the SP IMN technique is associated with a significantly higher functional outcome, lower knee pain, and lower rate of fracture deformity than the IP IMN technique.

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).

Tibial shaft fractures treated with intramedullary nailing and reduction device assistance

PURPOSE

This study aimed to assess the outcomes of a newly invented reduction device on assisting reduction of intramedullary nailing (IMN) in the treatment of tibial shaft fractures.

METHODS

From January 2015 to December 2018, data of patients with tibial shaft fractures treated with IMN were reviewed. In total, 42 patients underwent treatment with the new reduction device (group A) and 56 underwent treatment using a traditional reduction technique (group B). Data related to the closed reduction rate, surgical time, blood loss, number of fluoroscopies, number of surgeons, and number of complications were also reviewed. Fracture healing was assessed using radiographs at each follow-up, and the functional outcome (AOFAS score) was evaluated at the final follow-up.

RESULTS

The two treatment groups were evenly matched with respect to age, sex, fracture grade, and time to surgery. The average surgical time, blood loss, number of fluoroscopies, and number of surgeons in group A were all lesser than those in group B (P < 0.05). The closed reduction rate in group A was higher than those in group B (P < 0.05). The fracture healing time, AOFAS score, and complication rate were not significantly different (P > 0.05) between the two groups.

CONCLUSION

The new reduction device could effectively achieve and maintain the reduction of tibia shaft fractures in a minimally invasive fashion.