Factors Influencing Functional Outcomes After Distal Tibia Shaft Fractures

Department of Orthopaedic Surgery, MetroHealth Medical Center, affiliated with Case Western Reserve University School of Medicine, Cleveland, OH, USA.
Journal of orthopaedic trauma (Impact Factor: 1.8). 12/2011; 26(3):178-83. DOI: 10.1097/BOT.0b013e31823924df
Source: PubMed


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.

47 Reads
  • Source
    • "Until date, the etiology of anterior knee pain after intramedullary nailing of tibia is still unknown. Several studies have proposed that a patellar splitting approach for nail insertion is associated with a higher prevalence of anterior knee pain than a medial paratendinous approach.[67891011] Some other studies have reported technical causes for the chronic anterior knee pain such as nail or screw prominence, traumatization of the fat pad or patellar tendon, iatrogenic intra-articular damage and neuroma of the infra-patellar branch of the saphenous nerve.[412131415] "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background: Intramedullary nailing is the treatment of choice for the majority of tibial shaft fractures and anterior knee pain is the most common complication of this surgery; however, its etiology is still unknown. The purpose of this study was to assess the predicting factors related to anterior knee pain following tibial nailing. Materials and Methods: Patients with isolated, unilateral tibial shaft fracture who had undergone tibial nailing were identified retrospectively. Data including age, sex, type of fracture, technique of surgery and location of the nail were collected and finally the association between the above variables and knee pain were analyzed via SPSS software. Results: A total of 95 patients participated in the study. The mean age of the participants was 33.52 ± 1.62, 87 (91.6%) of whom were male and 74 (77.9%) had close fractures respectively. The method of surgery in 60 (63.2%) patients was paratendinous approach and in 35 (36.8%) was transtendinous. Twenty six (27.4%) of the patients had anterior knee pain. There were no significant differences between the two groups of patients with and without knee pain by age, sex, type of fracture and type of surgery (P = 0.952, 0.502, 0.212 and 0.745, respectively). Patients with protrusion of the nail from the anterior cortex had higher risk of developing knee pain after surgery (odds ratio: 2.76, confidence interval: 1.08, 7.08, P = 0.031). Conclusion: The results revealed a higher risk of developing anterior knee pain after tibial nailing in patients with protrusion of the nail from the anterior cortex.
    Full-text · Article · May 2014
  • Source
    • "The distal introduction portal spares the knee joint and patella tendon. Anterior knee pain, which is the most common complaint of patients treated by antegrade tibial nailing is prevented [10] [11] [12] [13] [14]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Displaced distal tibia fractures require stable fixation while minimizing secondary damage to the soft tissues by the surgical approach and implants. Antegrade intramedullary nailing has become an alternative to plate osteosynthesis for the treatment of distal metaphyseal fractures over the past two decades. While retrograde intramedullary nailing is a standard procedure in other long bone fractures, only few attempts have been made on retrograde nailing of tibial fractures. The main reasons are difficulties of finding an ideal entry portal and the lack of an ideal implant for retrograde insertion.
    Full-text · Article · Oct 2013 · Injury
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objectives: To evaluate the outcome of intramedullary nail and plate fixation for the treatment of extra-articular fractures of the distal tibia and to determine whether there are sufficient objective data in the literature to compare the two methods. Methodology: A comprehensive search of all relevant articles from Jan 1975 to Dec 2011 was conducted. Two reviewers evaluated each study to determine its suitability for inclusion and collected the data of interest. Meta-analytic pooling of group results across studies was performed for the two treatment methods. Results: The systematic review identified 22 primary studies with 880 fractures including 15 groups of intramedullary nail and 15 groups of plate. For extra-articular distal tibia fractures, shorter healing time can be achieved by using the intramedullary nail, but the malformation rate was significantly higher than in the plate group. The average operating time in the intramedullary nail group was longer than in the plate group, but the difference was not statistically significant. No statistically significant difference was found when comparing the rates of infection, rotation, shortening, delayed union and nonunion. The reoperation rate was higher in the intramedullary nail group compared with the plate group, but the difference was also not statistically significant. Conclusions: The functional and efficacy outcomes appear to be similar between the two treatment groups. Thus the patient's general condition and the surgeon's preference dictate the choice of surgical technique.
    No preview · Article · Jul 2012 · Pakistan Journal of Medical Sciences Online
Show more