Management of Extra-articular Fractures of the Distal Tibia: Intramedullary Nailing Versus Plate Fixation

The Journal of the American Academy of Orthopaedic Surgeons (Impact Factor: 2.53). 11/2012; 20(11):675-83. DOI: 10.5435/JAAOS-20-11-675
Source: PubMed


Intramedullary nailing and plate fixation represent two viable approaches to internal fixation of extra-articular fractures of the distal tibia. Although both techniques have demonstrated success in maintaining reduction and promoting stable union, they possess distinct advantages and disadvantages that require careful consideration during surgical planning. Differences in soft-tissue health and construct stability must be considered when choosing between intramedullary nailing and plating of the distal tibia. Recent advances in intramedullary nail design and plate-and-screw fixation systems have further increased the options for management of these fractures. Current evidence supports careful consideration of the risk of soft-tissue complications, residual knee pain, and fracture malalignment in the context of patient and injury characteristics in the selection of the optimal method of fixation.

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    • "The union rate in these fractures is still reported as 2.4% and the malunion rate as 14.3% independent of the treatment approach [18]. The current knowledge indicates that is essential to consider the risk of soft-tissue complications and fracture malalignment when selecting the method of fixation [18,19]. "
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    ABSTRACT: Background The management of displaced distal tibial fractures is still controversial. The different internal fixation techniques are often burdened by relatively high complication rates. Minimally invasive techniques with ring fixators have been introduced as an alternative allowing immediate reduction and stabilization, avoiding a staged protocol. The aim of this prospective study was to analyze the clinical and radiographic outcome the Ilizarov technique in patients with distal metaphyseal tibial fractures, with or without intra-articular involvement. Methods Thirty-nine consecutive patients with isolated fractures treated with the Ilizarov technique were followed prospectively for one year. Depending on the type of fracture, 4 or 5 rings were used, in some cases with additional foot extension. Unrestricted weight-bearing was allowed in all cases. Pre- and post-operatively conventional radiographs, post-operative pain assessment and complications were evaluated. The function was evaluated clinically and with self-appraisal protocols: EQ-5D, NHP and FAOS. Results No patient developed compartment syndrome or deep venous thrombosis. Pin infections were frequent, but they were mostly superficial and were treated with antibiotics and/or the removal of isolated pins. Two patients required debridement. One of them had a deep infection and developed a residual deformity which was corrected and healed after re-operation. Another patient had a severe residual deformity. The fixator was removed after a median period of 16 weeks (range 11–30). The radiological results were poor in 5 patients but the overall self-appraisal showed satisfactory results in 36 patients. Conclusions The Ilizarov method allowed early definitive treatment with a low complication rate and a good clinical outcome.
    BMC Musculoskeletal Disorders 01/2013; 14(1):30. DOI:10.1186/1471-2474-14-30 · 1.72 Impact Factor
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    ABSTRACT: Of the biological reconstruction methods for malignant bone and soft tissue tumors, reconstruction with liquid nitrogen has the advantage of maintaining continuity on the distal side of the tumor bone site (pedicle freezing procedure; PFP). This method is expected to result in early blood flow recovery, with early union and low complication rate. The purpose of this study was to compare the outcomes of the PFP and free freezing procedure (FFP) in the lower extremities. The study included 20 patients (12 men and 8 women) with frozen autografts (FFP, 13 cases; PFP, 7 cases). The mean age of the subjects was 36.3 years (range 11-79 years), and the mean follow-up period was 56.4 months (range 12-142 months). Final bone union occurred in 11 patients in the FFP group (84.6 %) and in 7 patients in the PFP group (100 %). The mean union period in patients who did not need additional surgery was 9.8 months (range 4-21 months) in the FFP group and 4.8 months (range 2-7 months) in the PFP group. Postoperative complications occurred in 8 cases: infection in 3 cases, fracture in 3 cases, and joint destruction in 2 cases. Six FFP patients, and 2 PFP patients (two cases of fracture), developed postoperative complications. The union period was shorter and the rate of postoperative complications was lower with the PFP than with the FFP. We considered that early blood flow recovery might have led to the above results in the PFP.
    Journal of Orthopaedic Science 10/2013; 19(1). DOI:10.1007/s00776-013-0487-x · 0.94 Impact Factor
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    ABSTRACT: Using human cadaver specimens, we investigated the role of supplementary fibular plating in the treatment of distal tibial fractures using an intramedullary nail. Fibular plating is thought to improve stability in these situations, but has been reported to have increased soft-tissue complications and to impair union of the fracture. We proposed that multidirectional locking screws provide adequate stability, making additional fibular plating unnecessary. A distal tibiofibular osteotomy model performed on matched fresh-frozen lower limb specimens was stabilised with reamed nails using conventional biplanar distal locking (CDL) or multidirectional distal locking (MDL) options with and without fibular plating. Rotational stiffness was assessed under a constant axial force of 150 N and a superimposed torque of ± 5 Nm. Total movement, and neutral zone and fracture gap movement were analysed. In the CDL group, fibular plating improved stiffness at the tibial fracture site, albeit to a small degree (p = 0.013). In the MDL group additional fibular plating did not increase the stiffness. The MDL nail without fibular plating was significantly more stable than the CDL nail with an additional fibular plate (p = 0.008). These findings suggest that additional fibular plating does not improve stability if a multidirectional distal locking intramedullary nail is used, and is therefore unnecessary if not needed to aid reduction. Cite this article: Bone Joint J 2014;96-B:385-9.
    Bone and Joint Journal 03/2014; 96-B(3):385-9. DOI:10.1302/0301-620X.96B3.32185 · 1.96 Impact Factor
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