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

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Abstract

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.

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References

  1. Zelle BA, Bhandari M, Espiritu M, Koval KJ, Zlowodzki M (2006) Treatment of distal tibia fractures without articular involvement: a systematic review of 1125 fractures. J Orthop Trauma 20(1):76–79

    Article  PubMed  Google Scholar 

  2. Ovadia DN, Beals RK (1986) Fractures of the tibial plafond. J Bone Joint Surg Am 68(4):543–551

    CAS  PubMed  Google Scholar 

  3. Sarmiento A, Latta LL (2004) 450 closed fractures of the distal third of the tibia treated with a functional brace. Clin Orthop Relat Res 428:261–271

    Article  PubMed  Google Scholar 

  4. Bostman O, Vainionpaa S, Saikku K (1984) Infra-isthmal longitudinal fractures of the tibial diaphysis: results of treatment using closed intramedullary compression nailing. J Trauma 24(11):964–969

    Article  CAS  PubMed  Google Scholar 

  5. Bedi A, Le TT, Karunakar MA (2006) Surgical treatment of nonarticular distal tibia fractures. J Am Acad Orthop Surg 14(7):406–416

    PubMed  Google Scholar 

  6. Gao H, Zhang CQ, Luo CF, Zhou ZB, Zeng BF (2009) Fractures of the distal tibia treated with polyaxial locking plating. Clin Orthop Relat Res 467(3):831–837

    Article  PubMed Central  PubMed  Google Scholar 

  7. Vallier HA, Cureton BA, Patterson BM (2012) Factors influencing functional outcomes after distal tibia shaft fractures. J Orthop Trauma 26(3):178–183

    Article  PubMed  Google Scholar 

  8. Duan X, Al-Qwbani M, Zeng Y, Zhang W, Xiang Z (2012) Intramedullary nailing for tibial shaft fractures in adults. Cochrane Database Syst Rev 1:CD008241

    PubMed  Google Scholar 

  9. Megas P, Zouboulis P, Papadopoulos AX, Karageorgos A, Lambiris E (2003) Distal tibial fractures and non-unions treated with shortened intramedullary nail. Int Orthop 27(6):348–351

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  10. Richmond J, Colleran K, Borens O, Kloen P, Helfet DL (2004) Nonunion of the distal tibia treated by reamed intramedullary nailing. J Orthop Trauma 18(9):603–610

    Article  PubMed  Google Scholar 

  11. Nork SE, Schwartz AK, Agel J, Holt SK, Schrick JL, Winquist RA (2005) Intramedullary nailing of distal metaphyseal tibial fractures. J Bone Joint Surg Am 87(6):1213–1221

    Article  PubMed  Google Scholar 

  12. Rzesacz EH, Konneker W, Reilmann H, Culemann U (1998) Combination of intramedullary nail and covered screw osteosynthesis for managing distal tibial fracture with ankle joint involvement. Unfallchirurg 101(12):907–913

    Article  CAS  PubMed  Google Scholar 

  13. Attal R, Hansen M, Kirjavainen M, Bail H, Hammer TO, Rosenberger R, Hontzsch D, Rommens PM (2012) A multicentre case series of tibia fractures treated with the expert tibia nail (ETN). Arch Orthop Trauma Surg 132(7):975–984

    Article  PubMed  Google Scholar 

  14. El Attal R, Hansen M, Rosenberger R, Smekal V, Rommens PM, Blauth M (2011) Intramedullary nailing of the distal tibia illustrated with the Expert(TM) tibia nail. Oper Orthop Traumatol 23(5):397–410

    Article  PubMed  Google Scholar 

  15. Robinson CM, McLauchlan GJ, McLean IP, Court-Brown CM (1995) Distal metaphyseal fractures of the tibia with minimal involvement of the ankle. Classification and treatment by locked intramedullary nailing. J Bone Joint Surg Br 77(5):781–787

    CAS  PubMed  Google Scholar 

  16. Mosheiff R, Safran O, Segal D, Liebergall M (1999) The undreamed tibial nail in the treatment of distal metaphyseal fractures. Injury 30(2):83–90

    Article  CAS  PubMed  Google Scholar 

  17. Zou J, Shi ZM, Zhang W, Zhang CQ (2012) Open reduction and internal fixation better than percutaneous plate osteosynthesis in distal tibial fractures. J Invest Surg

  18. Femino JE, Vaseenon T (2009) The direct lateral approach to the distal tibia and fibula: a single incision technique for distal tibial and pilon fractures. Iowa Orthop J 29:143–148

    PubMed Central  PubMed  Google Scholar 

  19. Manninen MJ, Lindahl J, Kankare J, Hirvensalo E (2007) Lateral approach for fixation of the fractures of the distal tibia. Outcome of 20 patients. Technical note. Arch Orthop Trauma Surg 127(5):349–353

    Article  CAS  PubMed  Google Scholar 

  20. Joveniaux P, Ohl X, Harisboure A, Berrichi A, Labatut L, Simon P, Mainard D, Vix N, Dehoux E (2010) Distal tibia fractures: management and complications of 101 cases. Int Orthop 34(4):583–588

    Article  PubMed Central  PubMed  Google Scholar 

  21. Gupta RK, Rohilla RK, Sangwan K, Singh V, Walia S (2010) Locking plate fixation in distal metaphyseal tibial fractures: series of 79 patients. Int Orthop 34(8):1285–1290

    Article  PubMed Central  PubMed  Google Scholar 

  22. Ehlinger M, Adam P, Bonnomet F (2010) Minimally invasive locking screw plate fixation of non-articular proximal and distal tibia fractures. Orthop Traumatol Surg Res 96(7):800–809

    Article  CAS  PubMed  Google Scholar 

  23. Hess F, Sommer C (2011) Minimally invasive plate osteosynthesis of the distal fibula with the locking compression plate: first experience of 20 cases. J Orthop Trauma 25(2):110–115

    Article  PubMed  Google Scholar 

  24. Ozkaya U, Parmaksizoglu AS, Gul M, Sokucu S, Kabukcuoglu Y (2009) Minimally invasive treatment of distal tibial fractures with locking and non-locking plates. Foot Ankle Int 30(12):1161–1167

    Article  PubMed  Google Scholar 

  25. Pai V, Coulter G (2007) Minimally invasive plate fixation of the tibia. Int Orthop 31(4):491–496

    Article  PubMed Central  PubMed  Google Scholar 

  26. Redfern DJ, Syed SU, Davies SJ (2004) Fractures of the distal tibia: minimally invasive plate osteosynthesis. Injury 35(6):615–620

    Article  CAS  PubMed  Google Scholar 

  27. Dogra AS, Ruiz AL, Thompson NS, Nolan PC (2000) Dia-metaphyseal distal tibial fractures–treatment with a shortened intramedullary nail: a review of 15 cases. Injury 31(10):799–804

    Article  CAS  PubMed  Google Scholar 

  28. Obremskey WT, Medina M (2004) Comparison of intramedullary nailing of distal third tibial shaft fractures: before and after traumatologists. Orthopedics 27(11):1180–1184

    PubMed  Google Scholar 

  29. Guo JJ, Tang N, Yang HL, Tang TS (2010) A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia. J Bone Joint Surg Br 92(7):984–988

    Article  CAS  PubMed  Google Scholar 

  30. Shrestha D, Acharya BM, Shrestha PM (2011) Minimally invasive plate osteosynthesis with locking compression plate for distal diametaphyseal tibia fracture. Kathmandu Univ Med J (KUMJ) 9(34):60–66

    Google Scholar 

  31. Lau TW, Leung F, Chan CF, Chow SP (2008) Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures. Int Orthop 32(5):697–703

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  32. Wijdicks FJ, Van der Meijden OA, Millett PJ, Verleisdonk EJ, Houwert RM (2012) Systematic review of the complications of plate fixation of clavicle fractures. Arch Orthop Trauma Surg 132(5):617–625

    Article  PubMed Central  PubMed  Google Scholar 

  33. Vallier HA, Cureton BA, Patterson BM (2011) Randomized, prospective comparison of plate versus intramedullary nail fixation for distal tibia shaft fractures. J Orthop Trauma 25(12):736–741

    Article  PubMed  Google Scholar 

  34. Vaisto O, Toivanen J, Kannus P, Jarvinen M (2004) Anterior knee pain and thigh muscle strength after intramedullary nailing of tibial shaft fractures: a report of 40 consecutive cases. J Orthop Trauma 18(1):18–23

    Article  PubMed  Google Scholar 

  35. Court-Brown CM, Gustilo T, Shaw AD (1997) Knee pain after intramedullary tibial nailing: its incidence, etiology, and outcome. J Orthop Trauma 11(2):103–105

    Article  CAS  PubMed  Google Scholar 

  36. Higgins JP, Thompson SG (2002) Quantifying heterogeneity in a meta-analysis. Stat Med 21(11):1539–1558

    Article  PubMed  Google Scholar 

  37. Im GI, Tae SK (2005) Distal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plate and screws fixation. J Trauma 59(5):1219–1223

    Article  PubMed  Google Scholar 

  38. Mauffrey C, McGuinness K, Parsons N, Achten J, Costa ML (2012) A randomised pilot trial of “locking plate” fixation versus intramedullary nailing for extra-articular fractures of the distal tibia. J Bone Joint Surg Br 94(5):704–708

    Article  CAS  PubMed  Google Scholar 

  39. Yang SW, Tzeng HM, Chou YJ, Teng HP, Liu HH, Wong CY (2006) Treatment of distal tibial metaphyseal fractures: plating versus shortened intramedullary nailing. Injury 37(6):531–535

    Article  PubMed  Google Scholar 

  40. Vallier HA, Le TT, Bedi A (2008) Radiographic and clinical comparisons of distal tibia shaft fractures (4 to 11 cm proximal to the plafond): plating versus intramedullary nailing. J Orthop Trauma 22(5):307–311

    Article  PubMed  Google Scholar 

  41. Li Y, Liu L, Tang X, Pei F, Wang G, Fang Y, Zhang H, Crook N (2012) Comparison of low, multidirectional locked nailing and plating in the treatment of distal tibial metadiaphyseal fractures. Int Orthop

  42. Janssen KW, Biert J, van Kampen A (2007) Treatment of distal tibial fractures: plate versus nail: a retrospective outcome analysis of matched pairs of patients. Int Orthop 31(5):709–714

    Article  PubMed Central  PubMed  Google Scholar 

  43. Khoury A, Liebergall M, London E, Mosheiff R (2002) Percutaneous plating of distal tibial fractures. Foot Ankle Int 23(9):818–824

    PubMed  Google Scholar 

  44. Krackhardt T, Dilger J, Flesch I, Hontzsch D, Eingartner C, Weise K (2005) Fractures of the distal tibia treated with closed reduction and minimally invasive plating. Arch Orthop Trauma Surg 125(2):87–94

    Article  CAS  PubMed  Google Scholar 

  45. Borg T, Larsson S, Lindsjo U (2004) Percutaneous plating of distal tibial fractures. Preliminary results in 21 patients. Injury 35(6):608–614

    Article  PubMed  Google Scholar 

  46. Helfet DL, Suk M (2004) Minimally invasive percutaneous plate osteosynthesis of fractures of the distal tibia. Instr Course Lect 53:471–475

    PubMed  Google Scholar 

  47. Maffulli N, Toms AD, McMurtie A, Oliva F (2004) Percutaneous plating of distal tibial fractures. Int Orthop 28(3):159–162

    Article  PubMed Central  PubMed  Google Scholar 

  48. Gao D, Jia B, Zheng J (2012) Case-control study on minimally invasive percutaneous anatomic plate osteosynthesis for the treatment of distal tibia fracture. Zhongguo Gu Shang 25(3):194–197

    PubMed  Google Scholar 

  49. Horn C, Dobele S, Vester H, Schaffler A, Lucke M, Stockle U (2011) Combination of inter fragmentary screws and locking plates in distal meta-diaphyseal fractures of the tibia: a retrospective, single-centre pilot study. Injury 42(10):1031–1037

    Article  CAS  PubMed  Google Scholar 

  50. Ahmad MA, Sivaraman A, Zia A, Rai A, Patel AD (2012) Percutaneous locking plates for fractures of the distal tibia: our experience and a review of the literature. J Trauma Acute Care Surg 72(2):E81–E87

    PubMed  Google Scholar 

  51. Leung FK, Law TW (2009) Application of minimally invasive locking compression plate in treatment of distal tibia fractures. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 23(11):1323–1325

    PubMed  Google Scholar 

  52. Sommer C, Gautier E (2003) Relevance and advantages of new angular stable screw-plate systems for diaphyseal fractures (locking compression plate versus intramedullary nail. Ther Umsch 60(12):751–756

    Article  PubMed  Google Scholar 

  53. Perren SM (2002) Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br 84(8):1093–1110

    Article  PubMed  Google Scholar 

  54. Hasenboehler E, Rikli D, Babst R (2007) Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture: a retrospective study of 32 patients. Injury 38(3):365–370

    Article  CAS  PubMed  Google Scholar 

  55. Bone LB, Johnson KD (1986) Treatment of tibial fractures by reaming and intramedullary nailing. J Bone Joint Surg Am 68(6):877–887

    CAS  PubMed  Google Scholar 

  56. Gorczyca JT, McKale J, Pugh K, Pienkowski D (2002) Modified tibial nails for treating distal tibia fractures. J Orthop Trauma 16(1):18–22

    Article  PubMed  Google Scholar 

  57. Gomez-Benito MJ, Fornells P, Garcia-Aznar JM, Seral B, Seral-Innigo F, Doblare M (2007) Computational comparison of reamed versus unreamed intramedullary tibial nails. J Orthop Res 25(2):191–200

    Article  PubMed  Google Scholar 

  58. Toivanen JA, Vaisto O, Kannus P, Latvala K, Honkonen SE, Jarvinen MJ (2002) Anterior knee pain after intramedullary nailing of fractures of the tibial shaft. A prospective, randomized study comparing two different nail-insertion techniques. J Bone Joint Surg Am 84-A(4):580–585

    PubMed  Google Scholar 

  59. Keating JF, Orfaly R, O’Brien PJ (1997) Knee pain after tibial nailing. J Orthop Trauma 11(1):10–13

    Article  CAS  PubMed  Google Scholar 

  60. Song SY, Chang HG, Byun JC, Kim TY (2012) Anterior knee pain after tibial intramedullary nailing using a medial para tendinous approach. J Orthop Trauma 26(3):172–177

    Article  PubMed  Google Scholar 

  61. Demirtas A, Azboy I, Durakbasa MO, Ucar BY, Mercan AS, Cakir IA (2011) The relationship between the quadriceps muscle strength and the anterior knee pain occurring after locked intramedullary nailing for tibial diaphysis fractures. Eklem Hastalik Cerrahisi 22(2):81–84

    PubMed  Google Scholar 

  62. Vaisto O, Toivanen J, Kannus P, Jarvinen M (2008) Anterior knee pain after intramedullary nailing of fractures of the tibial shaft: an eight-year follow-up of a prospective, randomized study comparing two different nail-insertion techniques. J Trauma 64:1511–1516

    Article  PubMed  Google Scholar 

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  1. Department of Orthopaedic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China

    Bo Li, Yuehua Yang & Lei-Sheng Jiang

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  1. Bo Li
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  2. Yuehua Yang
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Correspondence to Yuehua Yang.

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Bo Li and Yuehua Yang have contributed equally to this work.

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Li, B., Yang, Y. & Jiang, LS. Plate fixation versus intramedullary nailing for displaced extra-articular distal tibia fractures: a system review. Eur J Orthop Surg Traumatol 25, 53–63 (2015). https://doi.org/10.1007/s00590-013-1362-3

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