Intramedullary nail fixation versus locking plate fixation for adults with a fracture of the distal tibia: the UK FixDT RCT

A Dilemma in the Management of Distal Tibia Fractures Solved by Minimally Invasive Percutaneous Plate Osteosynthesis Technique: A Prospective Study

Introduction Managing distal tibia fractures is challenging for trauma surgeons because of their peculiar anatomy with less soft tissue coverage and poor blood supply. There are various treatment options for distal tibia fractures such as open reduction and plating, minimally invasive percutaneous plate osteosynthesis, and intramedullary interlocking nailing. Open reduction and internal fixation can lead to excessive soft tissue dissection and devascularization of fracture fragments. We conducted a study on the functional outcome of distal tibia fractures treated by biological fixation with minimally invasive percutaneous plate osteosynthesis. Methods A total of 23 patients with distal one-third tibia fractures, fulfilling the inclusion criteria, who were treated at St. John's Medical College Hospital with minimally invasive percutaneous plate osteosynthesis between November 2020 and November 2022 were studied using the American Orthopaedic Foot & Ankle Society (AOFAS) score at six weeks, three months, and six months postoperative follow-up. Results This study included 17 males and six females. The mean age of the study participants was 43.78 years, with most of the participants being in the age group between 51 and 60 years (29.2%, n = 7). All the study participants were employed. The mean operative time was two hours and 10 minutes. The mean duration for the radiological union was 22 weeks. The mean AOFAS score at six months was 92.43 + 5.696. There was only one case of superficial infection, which was treated with intravenous antibiotics. There were no cases of malunion/nonunion. Conclusion Minimally invasive percutaneous plate osteosynthesis is an effective treatment for distal tibia fractures avoiding most of the complications such as wound dehiscence and malunion/nonunion involved in conventional open reduction and internal fixation with plating. Therefore, we recommend this technique for all distal tibia fractures.

Treatment of complex limb fractures with 3D printing technology combined with personalized plates: a retrospective study of case series and literature review

Background

In recent years, 3D printing technology has made significant strides in the medical field. With the advancement of orthopedics, there is an increasing pursuit of high surgical quality and optimal functional recovery. 3D printing enables the creation of precise physical models of fractures, and customized personalized steel plates can better realign and more comprehensively and securely fix fractures. These technologies improve preoperative diagnosis, simulation, and planning for complex limb fractures, providing patients with better treatment options.

Patients and methods

Five typical cases were selected from a pool of numerous patients treated with 3D printing technology combined with personalized custom steel plates at our hospital. These cases were chosen to demonstrate the entire process of printing 3D models and customizing individualized steel plates, including details of the patients' surgeries and treatment procedures. Literature reviews were conducted, with a focus on highlighting the application of 3D printing technology combined with personalized custom steel plates in the treatment of complex limb fractures.

Results

3D printing technology can produce accurate physical models of fractures, and personalized custom plates can achieve better fracture realignment and more comprehensive and robust fixation. These technologies provide patients with better treatment options.

Conclusion

The use of 3D printing models and personalized custom steel plates can improve preoperative diagnosis, simulation, and planning for complex limb fractures, realizing personalized medicine. This approach helps reduce surgical time, minimize trauma, enhance treatment outcomes, and improve patient functional recovery.

Effects of intramedullary nailing and internal fixation plates on postoperative wound infection and pain in patients with distal tibia fractures: A meta-analysis

A meta-analysis was performed to assess the effects of intramedullary nailing (IMN) and internal fixation plates (IFP) on postoperative wound infection and pain in patients with distal tibia fractures, to provide evidence for the selection of surgical options for this group of patients. Computerised searches were performed on PubMed, Cochrane Library, EMBASE, MEDLINE, CNKI and Wanfang databases from the inception of each library to August 2023. All published randomised controlled trials (RCTs) comparing IMN with IFP for the treatment of patients with distal tibial fractures were selected. Literature screening, data extraction and literature evaluation were independently completed by two researchers. Data analysis was performed using the Review Manager 5.4 software. Overall, 25 RCTs with a total of 2011 patients were finally included, comprised by 1009 patients in the IMN group and 1002 patients in the IFP group. The rate of wound infection was significantly lower in the IMN group than that in the IFP group (5.05% vs. 9.58%, odds ratio [OR]: 0.52, 95% confidence intervals [CIs]: 0.37-0.73, p < 0.001). Meanwhile, the IMN group had a significantly higher rate of joint pain than that of the IFP group (14.57% vs. 2.90%, OR: 4.93, 95% CIs: 3.02-8.03, p < 0.00001), whereas the difference between the two surgical procedures in terms of operative time was not statistically significant (standardised mean differences: 0.08 95% CIs: -0.58-0.74, p = 0.82). Current clinical evidence suggests that both IMN and IFP are excellent treatments for distal tibial fractures. Although IMN is better in reducing postoperative wound infection, the risk of postoperative pain is higher. Thus, an appropriate surgical procedure should be selected in clinical practice in accordance with the actual situation of the patient, and IFP is used to reduce the incidence of postoperative joint pain when the anterior tibial soft tissue of the distal tibial fracture is in good condition, and vice versa. IMN is used to reduce the risk of infection.

Comparing Minimally Invasive Percutaneous Plate Osteosynthesis With Interlocking Intramedullary Nail Fixation for the Management of Adult Extra-Articular Distal Tibial Fractures: A Comprehensive Systematic Review and Meta-Analysis

Intramedullary nailing (IMN) and minimally invasive percutaneous plate osteosynthesis (MIPPO) fixation are both viable approaches for managing distal tibia fractures. IM nailing offers advantages in terms of shorter operation time, faster union, and reduced infection rates, yet it may lead to alignment issues and residual knee pain. Conversely, MIPPO fixation provides better alignment and minimizes knee discomfort but comes with a higher risk of soft-tissue complications and hardware irritation. Notably, this review reveals that MIPPO is associated with a greater risk of both superficial (15% vs. 7% for IMN) and deep infections (14% vs. 6.3% for IMN). This study aims to comprehensively assess the optimal surgical approaches for distal tibia fractures by comparing clinical and functional outcomes between MIPPO and interlocking IMN techniques in treating extra-articular distal tibial fractures. Key outcome parameters include operation duration, union time, non-union occurrence, malunion cases, infection rates, secondary surgical interventions, and functional results, as indicated by quality of life and ankle scores. Regarding union complications, it is notable that IMN demonstrates a higher incidence of malunion, affecting 14.7% of patients compared to 8.8% in the MIPPO fixation group. Interestingly, both treatment methods exhibit a similar incidence of non-union, occurring in 3.5% of patients in both groups. Furthermore, when assessing the union time, IMN fixation notably achieves significantly shorter union times, especially evident in AO 43A fracture types and closed fractures. The mean time for union is 18 weeks with IMN compared to 20 weeks with MIPPO fixation. In our analysis of nine studies involving 813 patients, the reported operation times revealed an overall weighted mean operation time of 74.1 minutes (ranging from 56.4 to 124 minutes) for IMN and 85.4 minutes (ranging from 51.4 to 124 minutes) for MIPPO fixation. Notably, the operation time for IMN was significantly shorter compared to MIPPO, showing a weighted mean difference (WMD) of -11.24 minutes, with a 95% confidence interval (CI) ranging from -15.44 to -7.05 (P<0.05). This difference exhibited significant moderate heterogeneity (I2 = 68%). In light of this comprehensive study, both MIPPO and IMN emerge as equally effective therapeutic options for addressing functional outcomes in distal tibial extra-articular fractures. While IMN offers several advantages, including lower infection rates, reduced implant irritation, shorter operation time, and earlier weight-bearing and union, it is associated with a heightened risk of malunion and anterior knee pain. Consequently, the choice of implant should be tailored on a case-by-case basis. Patients at elevated infection risk, stemming from factors, such as advanced age, comorbidities, smoking, or severe soft tissue injuries, are better suited for nail treatment. Conversely, MIPPO fixation may present a more advantageous choice for young, active, and healthy patients, given its ability to mitigate the risk of knee pain and malunion.

Five-year outcomes for patients with a displaced fracture of the distal tibia

Aims

To report the outcomes of patients with a fracture of the distal tibia who were treated with intramedullary nail versus locking plate in the five years after participating in the Fixation of Distal Tibia fracture (FixDT) trial.

Methods

The FixDT trial reported the results for 321 patients randomized to nail or locking plate fixation in the first 12 months after their injury. In this follow-up study, we report the results of 170 of the original participants who agreed to be followed up until five years. Participants reported their Disability Rating Index (DRI) and health-related quality of life (EuroQol five-dimension three-level questionnaire) annually by self-reported questionnaire. Further surgical interventions related to the fracture were also recorded.

Results

There was no evidence of a difference in patient-reported disability, health-related quality of life, or the need for further surgery between participants treated with either type of fixation at five years. Considering the combined results for all participants, there was no significant change in DRI scores after the first 12 months of follow-up (difference between 12 and 24 months, 3.3 (95% confidence interval -1.8 to 8.5); p = 0.203), with patients reporting around 20% disability at five years.

Conclusion

This study shows that the moderate levels of disability and reduced quality of life reported by participants 12 months after a fracture of the distal tibia persist in the medium term, with little evidence of improvement after the first year.

Nailing distal tibial fractures: does entry technique affect distal alignment?

PURPOSE

In treating distal third tibial fractures, restoration of the axial alignment and therefore accurate reduction of the distal fragment minimise the risk of tibiotalar joint malalignment. The aim of this study is to investigate whether there was a difference in accuracy of reduction and axial alignment, when nailing distal third tibial fractures using either the suprapatellar or the infrapatellar tibial nailing entry technique.

METHODS

This retrospective cohort study compared alignment of intramedullary nails performed for distal third tibial fractures between 2015 and 2018 through the suprapatellar and infrapatellar approach at a UK Level 1 trauma centre. It compared a consecutive series of 74 suprapatellar nails and 51 infrapatellar nails, with radiographic assessment of tibial alignment in the antero-posterior and sagittal planes. It included inter- and intra-observer analyses of radiographic measurements.

RESULTS

In the coronal plane, mean malalignment in the suprapatellar technique group was 2.8 ± 0.7° and 4.7 ± 0.9° in the infrapatellar technique group (P < 0.01). In the sagittal plane, mean malalignment in the suprapatellar technique group was 4.0 ± 0.8° and 3.5 ± 0.9° in the infrapatellar technique group (P = 0.42). Intra- and inter-observer analysis showed strongly positive correlations between observers.

CONCLUSIONS

We suggest that the suprapatellar technique may improve coronal plane alignment when intramedullary nailing distal tibial fractures. There was no significant difference in alignment in the sagittal plane. We conclude that the suprapatellar technique may be superior in preventing malalignment when treating distal third tibial fractures, potentially improving clinical outcome.

Definitive Taylor Spatial Frame management for the treatment of high-energy open tibial fractures: Clinical and patient-reported outcomes

BACKGROUND

High energy open tibial fractures are complex injuries with no consensus on the optimal method of fixation. Treatment outcomes are often reported with union and re-operation rates, often without specific definitions being provided.  We sought to describe union, reoperation rates, and patient reported outcomes, using the validated EQ-VAS and Disability Rating Index (DRI) scores, following stabilisation with a Taylor Spatial Frame (TSF) and a combined orthoplastic approach for the management of soft tissues. A literature review is also provided.

METHOD

A prospective cross-sectional follow up of open tibial fractures, treated at a level 1 major trauma centre, managed with a TSF using a one ring per segment technique between January 2014 and December 2019 were identified. Demographic, injury and operative data were recorded, along with Patient Reported Outcome Measures (PROM) scores, specifically the EQ-VAS and Disability Rating Index (DRI). Union rates, defined by radiographic union scale in tibia (RUST) scores, and re-operation rates were recorded. Appropriate statistical analyses were performed, with a p<0.05 considered statistically significant.

RESULTS

Overall, 51 patients were included. Mean age was 51.2 ± 17.4 years, with a 4:1 male preponderance. Diaphyseal and distal fractures accounted for 76% of cases. Mean time in frame was 206.7 ± 149.4 days. Union was defined and was achieved in 41/51 (80.4%) patients. Deep infection occurred in 6/51 (11.8%) patients. Amputation was performed in 1 case (1.9%). Overall re-operation rate was 33%. Time to union were significantly longer if re-operation was required for any reason (uncomplicated 204±189 vs complicated 304±155 days; p = 0.0017) . EQ-VAS and DRI scores significantly deteriorated at 1 year follow-up (EQVAS 87.5 ± 11.7 vs 66.5 ± 20.4;p<0.0001 and DRI 11.9 ± 17.8 vs 39.3 ± 23.3;p<0.0001). At 1 year post op, 23/51(45.1%) required a walking aid, and 17/29 (58.6%) of those working pre-injury had returned to work.

CONCLUSION

Open tibial fracture have significant morbidity and long recovery periods as determined by EQVAS and DRI outcome measures.  We report the largest series of open tibial feature treated primarily with a TSF construct, which has similar outcomes to other techniques, and should therefore be considered as a useful technique for managing these injuries.

A Scoping Review of Item-Level Missing Data in Within-Trial Cost-Effectiveness Analysis

OBJECTIVES

Cost-effectiveness analysis (CEA) alongside randomized controlled trials often relies on self-reported multi-item questionnaires that are invariably prone to missing item-level data. The purpose of this study is to review how missing multi-item questionnaire data are handled in trial-based CEAs.

METHODS

We searched the National Institute for Health Research journals to identify within-trial CEAs published between January 2016 and April 2021 using multi-item instruments to collect costs and quality of life (QOL) data. Information on missing data handling and methods, with a focus on the level and type of imputation, was extracted.

RESULTS

A total of 87 trial-based CEAs were included in the review. Complete case analysis or available case analysis and multiple imputation (MI) were the most popular methods, selected by similar numbers of studies, to handle missing costs and QOL in base-case analysis. Nevertheless, complete case analysis or available case analysis dominated sensitivity analysis. Once imputation was chosen, missing costs were widely imputed at item-level via MI, whereas missing QOL was usually imputed at the more aggregated time point level during the follow-up via MI.

CONCLUSIONS

Missing costs and QOL tend to be imputed at different levels of missingness in current CEAs alongside randomized controlled trials. Given the limited information provided by included studies, the impact of applying different imputation methods at different levels of aggregation on CEA decision making remains unclear.

Beyond the pedicle screw-a patent review

PURPOSE

This review provides an overview of the patent literature on posteriorly placed intrapedicular bone anchors. Conventional pedicle screws are the gold standard to create a fixation in the vertebra for spinal fusion surgery but may lack fixation strength, especially in osteoporotic bone. The ageing population demands new bone anchors that have an increased fixation strength, that can be placed safely, and, if necessary, can be removed without damaging the surrounding tissue.

METHODS

The patent search was conducted using a classification search in the Espacenet patent database. Only patents with a Cooperative Patent Classification of A61B17/70 or A61B17/7001 concerning spinal positioners and stabilizers were eligible for inclusion. The search query resulted in the identification of 731 patents. Based on preset inclusion criteria, a total of 56 unique patents on different anchoring methods were included, reviewed and categorized in this study.

RESULTS

Five unique fixation methods were identified; (1) anchors that use threading, (2) anchors that utilize a curved path through the vertebra, (3) anchors that (partly) expand, (4) anchors that use cement and (5) anchors that are designed to initiate bone ingrowth. Of the anchor designs included in this study, eight had a corresponding commercial product, six of which were evaluated in clinical trials.

CONCLUSION

This review provides insights into worldwide patented intrapedicular bone anchors that aim to increase the fixation strength compared to the conventional pedicle screw. The identified anchoring methods and their working principles can be used for clinical decision-making and as a source of inspiration when designing novel bone anchors.

Current practice in the measurement and interpretation of intervention adherence in randomised controlled trials: A systematic review

BACKGROUND

Ideally all participants in a randomised controlled trial (RCT) should fully receive their allocated intervention; however, this rarely occurs in practice. Intervention adherence affects Type II error so influences the interpretation of trial results and subsequent implementation. We aimed to describe current practice in the definition, measurement, and reporting of intervention adherence in non-pharmacological RCTs, and how this data is incorporated into a trial's interpretation and conclusions.

METHODS

We conducted a systematic review of phase III RCTs published between January 2018 and June 2020 in the National Institute for Health Research Journals Library for the Health Technology Assessment, Programme Grants for Applied Research, and Public Health Research funding streams.

RESULTS

Of 237 reports published, 76 met the eligibility criteria and were included. Most RCTs (n = 68, 89.5%) reported adherence, though use of terminology varied widely; nearly three quarters of these (n = 49, 72.1%) conducted a sensitivity analysis. Adherence measures varied between intervention types: behavioural change (n = 10, 43.5%), psychological therapy (n = 5, 83.3%) and physiotherapy/rehabilitation (n = 8, 66.7%) interventions predominately measured adherence based on session attendance. Whereas medical device and surgical interventions (n = 17, 73.9%) primarily record the number of participants receiving the allocated intervention, a third (n = 33, 67.3%) of studies reported a difference in findings between primary and sensitivity analyses.

CONCLUSIONS

Although most trials report elements of adherence, terminology was inconsistent, and there was no systematic approach to its measurement, analyses, interpretation, or reporting. Given the importance of adherence within clinical trials, there is a pressing need for a standardised approach or framework.

Rates and timing of short-term complications following operative treatment of tibial shaft fractures

Introduction

Tibial shaft fractures are a relatively common injury in orthopaedic surgery, with management options including intramedullary nail (IMN) fixation or open reduction internal fixation (ORIF) with plate osteosynthesis. Using a large national database, we sought to compare the prevalence and timing of short-term complications following either IMN or ORIF for tibial shaft fractures.

Methods

The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients undergoing IMN or ORIF for the treatment of tibial shaft fracture between 2012 and 2018. Multivariate Poisson hurdle regression models were utilized to determine predictors of postoperative complications as well as the timing of postoperative complications.

Results

A total of 4963 tibial shaft fracture were identified, with 3601 patients undergoing IMN (72.6%) and 1362 undergoing ORIF (27.4%). Patients undergoing IMN had a lower mean age of 48.8 compared with 53.9 for plate osteosynthesis (P < .001). IMN patients were also more likely to be male (53.5%) compared with ORIF patients (44.2%, P < .001). In multivariate analysis, ORIF patients were significantly more likely to experience surgical site complications, including dehiscence, superficial, and deep infections (OR 2.04, P = .003). There was no difference in probability of VTE between constructs; however, patients who underwent ORIF were diagnosed with VTE earlier than those who underwent IMN (relative rate 0.50, P < .001). There was no difference between ORIF and IMN with regard to probability or timing of subsequent blood transfusion, major complications, or return to the operating room. Many patient factors, such as higher American Society of Anesthesiologists score, congestive heart failure, and hypertension, were independently associated with an increased risk of postoperative complications.

Conclusions

Postoperative complications within 30 days are common after the surgical treatment of tibial shaft fractures. The risk of developing specific complications and the timing of these complications vary depending on numerous factors, including potentially modifiable risk factors such as the method of fixation or operative time, as well as nonmodifiable risk factors such as medical comorbidities.

Retrograde intramedullary nail fixation compared with fixed-angle plate fixation for fracture of the distal femur: the TrAFFix feasibility RCT

BACKGROUND

Fractures of the distal femur are an increasingly common injury; the optimal management of these injuries remains controversial. The two interventions used in UK practice are intramedullary fixation, with a locked retrograde nail, and extramedullary fixation, with a fixed angle plate.

OBJECTIVES

This study assessed the feasibility of a definitive trial and included a process evaluation to understand the generalisability and likely success of a future trial.

DESIGN

A multicentre, parallel, two-arm, randomised controlled feasibility trial with an embedded process evaluation. Treatment with a plate or nail was allocated in a 1 : 1 ratio, stratified by centre and chronic cognitive impairment. Surgeons were not blinded, but participants were not told their allocation.

SETTING

Seven NHS hospitals.

PARTICIPANTS

Patients aged ≥ 18 years with a fracture of the distal femur who the attending surgeon believed would benefit from internal fixation were potentially eligible. Patients were excluded if they had a loose arthroplasty requiring revision or a femoral deformity or arthroplasty that precluded nail fixation. The sample was recruited between 29 September 2016 and 31 August 2017. Consent was obtained from the patient or appropriate consultee before enrolment.

INTERVENTIONS

Patients were randomised to receive fixation of their distal femur fracture with either a proximally and distally locked retrograde nail that spanned the diaphysis of the femur or an anatomical distal femoral locking plate with at least one locked screw distal to the fracture. Reduction and supplemental fixation were at the surgeon's discretion.

OUTCOMES

The primary outcome measures for this study were the recruitment rate and the completion rate of the EuroQol-5 Dimensions, five-level version (EQ-5D-5L), at 6 weeks and 4 months. Additional measurements included baseline characteristics, measures of social support and self-efficacy, disability rating index, dementia quality-of-life measures and a radiographical assessment of any malunion. Participants' and staff views were obtained, at interview, for the process evaluation.

RESULTS

The process evaluation showed that surgeon-related factors, principally confidence with both technologies and a lack of individual equipoise, were key barriers to recruitment. A total of 23 participants were randomised and analysed (nail, n = 11; plate, n = 12). The recruitment rate was estimated as 0.42 [95% confidence interval (CI) 0.27 to 0.62] participants per centre per month, lower than the prespecified feasibility threshold of 1.0 participants per centre per month. Data completeness of the EQ-5D-5L was estimated at 65% (95% CI 43% to 83%).

CONCLUSIONS

This feasibility study has challenged many of the assumptions that underpinned the development of proposed definitive trial protocol. A modified protocol is proposed that would be feasible given the recruitment rate observed here, which is equal to that reported in the similar FixDT trial [Health Technology Assessment (HTA) 11/136/04: Costa ML, Achten J, Hennings S, Boota N, Griffin J, Petrou S, et al. Intramedullary nail fixation versus locking plate fixation for adults with a fracture of the distal tibia: the UK FixDT RCT. Health Technol Assess 2018;22(25)], which delivered to target and budget.

FUTURE WORK

A definitive trial with a modified design is recommended, including an internal pilot to confirm initial recruitment rate assumptions.

REGISTRATION

Current Controlled Trials ISRCTN92089567.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 51. See the NIHR Journals Library website for further project information. Funding was also supported by the NIHR Oxford Biomedical Research Centre.

Comparison Between Nailing and Plating in the Treatment of Distal Tibial Fractures: A Meta-Analysis

BACKGROUND AND AIMS

To evaluate evidence on the superiority of plate fixation over intramedullary nail fixation in the treatment of distal tibial fractures regarding functional outcomes and complication rates.

MATERIAL AND METHODS

Cochrane Controlled Trials Register, Medline, Embase, CINAHL, Scopus, and Web of Science databases were searched in December 2019. The risk of systematic bias was assessed according to the Cochrane Collaboration's domain-based evaluation framework.

RESULTS

The search resulted in 514 records, the final sample included 10 randomized controlled trials (782 patients). There were statistically significant differences in operating time (-11.2, 95% confidence interval: -16.3 to -6.1 min), time to partial weight bearing (-0.96, 95% confidence interval: -1.8 to -0.1 weeks), time to full weight bearing (-2.2, 95% confidence interval: -4.32 to -0.01 weeks), the rates of deep infections (risk ratio = 0.37, 95% confidence interval: 0.19 to 0.69), and the rates of soft-tissue complications (risk ratio = 0.52, 95% confidence interval: 0.33 to 0.82) favoring intramedullary nail. Intraoperative blood loss (127.2, 95% confidence interval: 34.7 to 219.7 mL) and postoperative knee pain and stiffness (relative risk = 5.6, 95% confidence interval: 1.4-22.6) showed significant differences favoring plate fixation. When combining all complication rates, the difference was risk ratio = 0.77 (95% confidence interval: 0.63 to 0.95) favoring intramedullary nail. No significant differences in radiation time, length of incision, length of hospital stay, time to return to work, time to union, the rates of healing complications or secondary procedures, ankle pain or stiffness, or functional scores were found.

CONCLUSION

This meta-analysis suggests that intramedullary nail might be slightly superior in reducing postoperative complications and result in slightly faster healing when compared to plate fixation.

Prevalence and influencing factors of nonunion in patients with tibial fracture: systematic review and meta-analysis

OBJECTIVE

The aim of this study is to assess the prevalence of nonunion in patients with tibia fracture and the association between influencing factors and tibia fracture nonunion.

METHOD

A database searches of PubMed, the Cochrane Library, EMBASE, China National Knowledge Infrastructure (CNKI), Weipu database, and Wanfang database from inception until June 2019 was conducted. The pooled prevalence, odds ratio (OR), and 95% confidence intervals (CI) were calculated with Stata software.

RESULTS

In this study, 111 studies involving 41,429 subjects were included. In the study of the relationship between influencing factors and tibia fracture nonunion, 15 factors significantly influenced the fracture union, including > 60 years old, male, tobacco smoker, body mass index > 40, diabetes, nonsteroidal anti-inflammatory drugs (NSAIDs) user, opioids user, fracture of middle and distal tibia, high-energy fracture, open fracture, Gustilo-Anderson grade IIIB or IIIC, Müller AO Classification of Fractures C, open reduction, fixation model, and infection.

CONCLUSION

The prevalence of nonunion in patients with tibia fracture was 0.068 and 15 potential factors were associated with the prevalence. Closed reduction and minimally invasive percutaneous plate osteosynthesis (MIPPO) have the low risks of nonunion for the treatment of tibial fractures.

Intramedullary Nailing Versus Minimally Invasive Plate Osteosynthesis for Distal Tibial Fractures: A Systematic Review and Meta-Analysis

To evaluate the application, safety and efficacy of the patients treated with intramedullary nailing (IMN) and minimally invasive plate osteosynthesis (MIPO) in distal tibia fractures. Following the Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA) guidelines, we searched databases PubMed, Cochrane library, EMBASE and Web of Science from inception of the database up to 10 October 2018, using the keywords "distal tibia fractures", "plate", "intramedullary nailing" and "RCT" to identify randomized clinical trials about distal tibia fractures. The included studies were assessed by two researchers according to the Cochrane risk-of-bias criteria. The primary outcome of measurement included operation time, malunion rate, nonunion/delayed union rate, and wound complication. Data analysis was conducted with Review Manager 5.3 software. A total of 10 RCTs involving 911 patients fulfilled the inclusion criteria with 455 patients in the IMN group and 456 patients in the MIPO group. There were no significant differences in radiation time, nonunion or delayed union rate, union time and operation time between the two groups. Patients treated with MIPO had lower incidence of malunion compared with IMN (RR = 1.85, 95%CI: 1.21 to 2.83, P = 1.00), while IMN seemed to have lower surgical incision complications whether in closed or opening fractures (RR = 0.49, 95%CI 0.33 to 0.73, P = 0.43). But in patients classified as 43A, the result of subgroup analysis suggested that there was no significant inwound complication between the two groups. MIPO was superior in preventing malunion compared with IMN, and intramedullary nailing appeared to have lower wound complications. However, in patients with 43A distal tibial fractures, MIPO was more recommended for its prevention of malunion. No matter which method we choose, we should notice and prevent the associated complications.

Intramedullary nails versus distal locking plates for fracture of the distal femur: results from the Trial of Acute Femoral Fracture Fixation (TrAFFix) randomised feasibility study and process evaluation

OBJECTIVES

This feasibility study and process evaluation assessed the likely success of a definitive trial of intramedullary fixation with locked retrograde nails versus extramedullary fixation with fixed angle plates for fractures of the distal femur.

DESIGN & SETTING

A multicentre, parallel, two-arm, randomised controlled feasibility study with an embedded process evaluation was conducted at seven NHS hospitals in England. Treatment was randomly allocated in 1:1 ratio, stratified by centre and chronic cognitive impairment. Participants, but not surgeons or research staff, were blinded to the allocation.

PARTICIPANTS

Patients 18 years and older with a fracture of the distal femur, who their surgeon believed would benefit from internal fixation, were eligible to take part.Participants were allocated to receive either a retrograde intramedullary nail or an anatomical locking plate.

OUTCOMES

The primary outcomes for this feasibility study were the recruitment rate and completion rate of the EQ-5D-5L at 4 months post-randomisation. Baseline characteristics, disability rating index, quality of life scores, measurements of social support and self-efficacy, resource use and radiographic assessments were also collected. The views of patients and staff were collected during interviews.

RESULTS

Recruitment and data completion were lower than expected. 23 of 82 eligible patients were recruited (nail, 11; plate, 12). The recruitment rate was estimated as 0.42 (95% CI 0.27 to 0.62) participants per centre-month. Data completeness of the EQ-5D-5L at 4 months was 61 per cent (95% CI 43% to 83%). The process evaluation demonstrated that the main barriers to recruitment were variation in treatment pathways across centres, lack of surgeon equipoise and confidence in using both interventions and newly formed research cultures that lacked cohesion.

CONCLUSIONS

A modified trial design, with embedded recruitment support intervention, comparing functional outcome in cognitively intact adults who have sustained a fragility fracture of the distal femur is feasible.

ETHICS APPROVAL

The Wales Research Ethics Committee 5 approved the study (ref: 16/WA/0225).

TRIAL REGISTRATION NUMBER

ISRCTN92089567; Pre-results.