A randomised pilot trial of "locking plate" fixation versus intramedullary nailing for extra-articular fractures of the distal tibia

Warwick Orthopaedics, University of Warwick, Warwick, United Kingdom.
The Bone & Joint Journal (Impact Factor: 3.31). 05/2012; 94(5):704-8. DOI: 10.1302/0301-620X.94B5.28498
Source: PubMed


The ideal form of fixation for displaced, extra-articular fractures of the distal tibia remains controversial. In the UK, open reduction and internal fixation with locking-plates and intramedullary nailing are the two most common forms of treatment. Both techniques provide reliable fixation but both are associated with specific complications. There is little information regarding the functional recovery following either procedure. We performed a randomised pilot trial to determine the functional outcome of 24 adult patients treated with either a locking-plate (n = 12) or an intramedullary nailing (n = 12). At six months, there was an adjusted difference of 13 points in the Disability Rating Index in favour of the intramedullary nail. However, this was not statistically significant in this pilot trial (p = 0.498). A total of seven patients required further surgery in the locking-plate group and one in the intramedullary nail group. This study suggests that there may be clinically relevant, functional differences in patients treated with nail versus locking-plate fixation for fractures of the distal tibia and differences in related complications. Further trials are required to confirm the findings of this pilot investigation.

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    • "RCT 85 (44 V. 41) 44.2 V. 44.4 35 OTA 43-A1, -A2, -A3 Closed S2 nailing system Percutaneous locking compression plates 12 76.6 Vallier et al. 2012 [35] RCT 104 (56 V. 48) 38.1 V. 38.5 18.3 OTA 42-A, -B, -C Closed, type 1, 2, or 3A Intramedullary nails Nonlocking plates 12–71 96.2 Mauffrey et al. 2012 [2] RCT 24 (12 V. 12) 50 V. 33 33.3 OTA 42-A, -B, -C and OTA43-A Closed, or type 1 Intramedullary nails Percutaneous locking plates 12 100 Li 2014 [38] RCT 82 (40 V. 42) 44 V. 43 15.3 OTA 42-A, -B, -C Closed, type 1, 2 Intramedullary nails Plate 14.8 88.3 Yang et al. 2006 [11] RP 27 (13 V. 14) 54.6 V. 48.2 44.4 OTA 43-A Closed Shortened intramedullary nails Nonlocking plates 33 (16–60) 100 Janssen et al. 2007 [13] RP 24 (12 V. 12) 40.8 V. 43.3 50 OTA 42-A and -B Closed, or type 1 Intramedullary nails Plates 20–112 100 Zhang 2007 [16] RP 51 (27 V. 24) 42.7 V. 39.5 39.2 AO A1-3,C1 Closed, type 1, 2 Intramedullary nails Plates 21.2 (12–27) 100 Vallier et al. 2008 [9] RP 113 (76 V. 37) 38.4 V. 39.8 30 OTA 42-A, -B, and -C Closed, type 1, 2, 3A, or 3B Intramedullary nails Nonlocking plates 24 (12–84) 100 Chen et al. 2008 [17] RP 46 (25 V. 21) 31 17.4 AO A and B Closed Intramedullary nails Plates 12–36 100 Huang 2008 [18] RP 57 (30 V. 27) 42.7 V. 39.5 36.8 "
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    ABSTRACT: The choice between intramedullary (IM) nailing or plating of distal tibia fractures without articular involvement remains controversial. A meta-analysis of randomized controlled trials (RCTs) and observational studies was performed to compare IM nailing with plating for distal tibia fractures without articular involvement and to determine the dominant strategy. The PubMed, Embase, Cochrane Library databases, Chinese Wan-Fang Database, and China National Knowledge Infrastructure were searched. Twenty-eight studies, which included 1863 fractures, met the eligible criteria. The meta-analysis did not identify a statistically significant difference between the two treatments in terms of the rate of deep infection, delayed union, removal of instrumentation, or secondary procedures either in the RCT or retrospective subgroups. IM nailing was associated with significantly more malunion events and a higher incidence of knee pain in the retrospective subgroup and across all the studies, but not significantly in the RCT subgroup, and a lower rate of delayed wound healing and superficial infection both in the RCT and retrospective subgroups relative to plating. A meta-analysis of the functional scores or questionnaires was not possible because of the considerable variation among the included studies, and no significant differences were observed. Evidence suggests that both IM nailing and plating are appropriate treatments as IM nailing shows lower rate of delayed wound healing and superficial infection and plating may avoid malunion and knee pain. These findings should be interpreted with caution, however, because of the heterogeneity of the study designs. Large, rigorous RCTs are required.
    Full-text · Article · Jun 2015 · Journal of Orthopaedic Surgery and Research
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    ABSTRACT: Purpose Unreamed nailing has gained acceptance in the treatment of diaphyseal long bone fractures, especially in cases with polytrauma or high-energy injuries. Its application in distal tibial fractures, however, remains controversial. Methods In this study, 101 distal tibial fractures treated using closed unreamed nailing were reviewed after a mean follow-up of 32 months. There were 59 type A und 42 type B fractures. The most common fracture pattern was the A1 spiral fracture (n = 40) followed by the B2 wedge fracture (n = 18). Intra-articular extension was encountered in 14 cases. One-fourth of the patients (n = 24) had open injuries. Forty-seven patients had additional injuries, and nearly one-third of them were polytraumatised. Results Union occurred after a mean time of 23.9 (range, 11–134) weeks. There were 13 cases of delayed union and seven non-unions; all healed eventually with additional surgery in only six fractures. Malunion was seen in 12 cases (five valgus, two varus and five external torsion), ten of which were associated with unplated fibular fractures. Three fractures (two open) were treated for deep infection. The most common complication seen was fatigue failure of the locking screws (27 cases). Conclusions Unreamed nailing of distal tibial fractures is associated with a rather high rate of bone healing complications and locking screw failure. The decision for its use in the notoriously challenging fractures of this segment should be critically considered.
    No preview · Article · Oct 2013 · International Orthopaedics
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    ABSTRACT: Musculoskeletal injuries are the most common reason for operative procedures in severely injured patients and are major determinants of functional outcomes. In this paper, we summarise advances and future directions for management of multiply injured patients with major musculoskeletal trauma. Improved understanding of fracture healing has created new possibilities for management of particularly challenging problems, such as delayed union and non union of fractures and large bone defects. Optimum timing of major orthopaedic interventions is guided by increased knowledge about the immune response after injury. Individual treatment should be guided by trading off the benefits of early definitive skeletal stabilisation, and the potentially life-threatening risks of systemic complications such as fat embolism, acute lung injury, and multiple organ failure. New methods for measurement of fracture healing and function and quality of life outcomes pave the way for landmark trials that will guide the future management of musculoskeletal injuries.
    Full-text · Article · Sep 2012 · The Lancet
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