A randomised pilot trial of "locking plate" fixation versus intramedullary nailing for extra-articular fractures of the distal tibia
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.
[Show abstract] [Hide abstract] 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.0Comments 0Citations
- "Several functional scores were used in the included studies, including the Olerud and Molander Ankle Score (OMAS) [14, 16, 21, 25], American Orthopaedic Foot and Ankle Surgery scores (AOFAS) [27, 28, 33], EuroQol EQ-5D , Disability Rating Index (DRI) [2, 44] , Musculoskeletal Function Assessment (MFA) [34, 35], and Foot Function Index (FFI) [34, 35]. According to our results, these differences were not statistically significant regarding OMAS and AOFAS (Table 4). "
[Show abstract] [Hide abstract] ABSTRACT: The purpose of this randomized clinical trial is to compare intramedullary nailing (IMN) versus minimally invasive plate osteosynthesis (MIPO) for the treatment of extra-articular distal tibial shaft fractures. Twenty-five consecutive patients with distal extra-articular tibial fractures which were located between 4 and 12 cm from the tibial plafond (AO 42A1 and 43A1) were randomly assigned into IMN (n: 10) or MIPO (n: 15) treatment groups. All patients were followed for at least 1 year. Foot function index, time to weight bearing, union time, duration of operation, length of incision, intra-operative blood loss, intra-operative fluoroscopy time, rotational and angular malalignment, rate of infection, secondary interventions and complications were compared between groups. All patients completed the trial and were followed with a mean of 23.1 ± 9.4 months (range 12-52). Foot function index, weight bearing time, union time, rate of malunion, rate of infection and rate of secondary interventions were all similar between groups (p = 0.807, p = 0.177, p = 0.402, p = 0.358, p = 0.404, p = 0.404, respectively). Intra-operative blood loss, length of surgical incision, radiation time and rotational malalignment were higher in the IMN group (p = 0.012, p = 0.019, p = 0.004 and p = 0.027, respectively). Results of our study showed that both treatment methods have similar therapeutic efficacy regarding functional outcomes and can be used safely for extra-articular distal tibial shaft fractures, and none of the techniques had a major advantage over the other.0Comments 2Citations
- "However, which is the ideal treatment is still controversial . Some authors argue that IMN is superior, while some authors suggest that the MIPO technique provides better functional and clinical results89101112 . In the current literature, there are very few numbers of studies that provide strong evidence to clarify this subject. "
- "However, antegrade intramedullary nailing of far distal tibia fractures is challenging and bears the risk of primary and secondary malalignment. Recent literature shows that the optimal method of treatment in distal tibia fractures remains debat- able91011. Retrograde intramedullary nailing of tibial fractures has not been introduced in routine clinical practice and only a few selected cases have been reported in litera- ture12131415 . This is mainly due to the lack of an adequately designed implant. "