Factors influencing functional outcomes after distal tibia shaft fractures.
ABSTRACT Surgical treatment of displaced distal tibia fractures yields reliable results with either plate or nail fixation. Comparative studies suggest more malalignment and nonunions with nails. Some studies have reported knee pain after tibial nailing. However, plates may be associated with soft tissue complications, such as infections or wound-healing problems. The purpose of this study was to assess functional outcomes after distal tibia shaft fractures treated with a plate or a nail. We hypothesized that tibial nails would be associated with more knee pain and that plates would be associated with pain from implant prominence, each of which would adversely affect functional outcome scores.
Randomized prospective study.
Level 1 trauma center.
One hundred four patients with extra-articular distal tibia shaft fractures (OTA 42), mean age of 38 years (range, 18-95), and mean Injury Severity Score of 14.3 (range, 9-50).
Patients were randomized to treatment with a reamed intramedullary nail (n = 56) or standard large fragment medial plate (n = 48).
Ability to work was evaluated after a minimum of 12 months, with mean of 22 months. Foot Function Index (FFI) and Musculoskeletal Function Assessment (MFA) questionnaires were completed.
Mean MFA was 27.5, and mean total FFI was 0.26; P < 0.0001 versus an uninjured reference population. Sixty-one of 64 patients (95%) employed at the time of injury had returned to work, although 31% had modified their work duties because of injury. Three patients were unable to find work. None reported unemployment secondary to their tibial fracture. Forty percent of all patients described some persistent ankle pain, and 31% had knee pain after nailing, versus 32% and 22%, respectively after plating. Both knee and ankle pain were present in 27% with nails and 15% with plates (P = 0.08), and rates of implant removal were similar after nails versus plates. Patients with malunion ≥5 degrees were more likely to report knee or ankle pain (36% vs 20%, P < 0.05). Except 1 patient with knee pain when kneeling, none reported modifying activity because of persistent knee or ankle pain, although knee and ankle pain were more frequent in the unemployed (P = 0.03). Unemployed patients requested implant removal more frequently (24% vs 9.2%, P = 0.07) and continued to report pain afterward. Although FFI and MFA scores were not related to plate or nail fixation, open fracture, fracture pattern, multiple injuries, Injury Severity Score, or age, both MFA and FFI scores were worse when knee pain or ankle pain was present (all Ps < 0.004) and in patients who remained unemployed (P < 0.0001). All 4 patients with work-related injuries had returned to employment but had worse FFI scores (P = 0.01).
Mean MFA and FFI scores suggest substantial residual dysfunction after distal tibia fractures when compared with an uninjured population. Mild ankle or knee pain was reported frequently after plate or nail fixation but was not limiting to activity in most. Angular malunion was associated with both knee and ankle pain, and there was a trend toward more patients with knee and ankle pain after tibial nailing. No patients reported unemployment because of their tibia fracture, but unemployed people described knee and ankle pain more frequently and had the worst functional outcome scores.
SourceAvailable from: Metin Uzun[Show abstract] [Hide abstract]
ABSTRACT: Purpose. We evaluated whether intramedullary nail fixation for tibial diaphysis fractures with concomitant fibula fractures (except at the distal one-third level) managed conservatively with an associated fibula fracture resulted in ankle deformity and assessed the impact of the ankle deformity on lower extremity function. Methods. Sixty middle one-third tibial shaft fractures with associated fibular fractures, except the distal one-third level, were included in this study. All tibial shaft fractures were anatomically reduced and fixed with interlocking intramedullary nails. Fibular fractures were managed conservatively. Hindfoot alignment was assessed clinically. Tibia and fibular lengths were compared to contralateral measurements using radiographs. Functional results were evaluated using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Foot and Ankle Disability Index Score (FADI). Results. Anatomic union, defined as equal length in operative and contralateral tibias, was achieved in 60 fractures (100%). Fibular shortening was identified in 42 fractures (68%). Mean fibular shortening was 1.2 cm (range, 0.5–2 cm). Clinical exams showed increased hindfoot valgus in 42 fractures (68%). The mean KOOS was 88.4, and the mean FADI score was 90. Conclusion. Fibular fractures in the middle or proximal one-third may need to be stabilized at the time of tibial intramedullary nail fixation to prevent development of hindfoot valgus due to fibular shortening.12/2014; DOI:10.1155/2014/806363
[Show abstract] [Hide abstract]
ABSTRACT: Tibial shaft fractures are often treated by intramedullary nailing (IMN) or plate fixation. Our purpose was to compare the 30-day complication rates between IMN and plate fixation of extra-articular tibial fractures.Injury 12/2014; 28(4). DOI:10.1016/j.injury.2014.12.014 · 2.46 Impact Factor
[Show abstract] [Hide abstract]
ABSTRACT: Fractures of the tibial shaft are common injuries, but there are no long-term outcome data in the era of increased surgical management. The aim of this prospective study was to assess the clinical and functional outcome of this injury at 12 to 22 years. Secondary aims were to determine the short- and long-term mortality, and if there were any predictors of clinical or functional outcome or mortality. From a prospective trauma database of 1502 tibial shaft fractures in 1474 consecutive adult patients, we identified a cohort of 1431 tibial diaphyseal fractures in 1403 patients, who fitted our inclusion criteria. There were 1024 men, and mean age at injury was 40.6 years. Fractures were classified according to the AO system, and open fractures graded after Gustilo and Anderson. Requirement of fasciotomy, time to fracture union, complications, incidence of knee and ankle pain at long-term follow-up, changes in employment and the patients' social deprivation status were recorded. Function was assessed at 12 to 22 years post-injury using the Short Musculoskeletal Function Assessment and short form-12 questionnaires. Long-term functional outcome data was available for 568 of the surviving patients, 389 were deceased and 346 were lost to follow-up. Most fractures (90.7%, n = 1363) united without further intervention. Fasciotomies were performed in 11.5% of patients; this did not correlate with poorer functional outcome in the long term. Social deprivation was associated with a higher incidence of injury but had no impact on long-term function. The one-year mortality in those over 75 years of age was 29 (42%). At long-term follow-up, pain and function scores were good. However, 147 (26%) reported ongoing knee pain, 62 (10%) reported ankle pain and 97 (17%) reported both. Such joint pain correlated with poorer functional outcome. Cite this article: Bone Joint J 2014;96-B:1370-7.10/2014; 96-B(10):1370-7. DOI:10.1302/0301-620X.96B10.32914