A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia

Abstract

We compared the outcome of closed intramedullary nailing with minimally invasive plate osteosynthesis using a percutaneous locked compression plate in patients with a distal metaphyseal fracture in a prospective study. A total of 85 patients were randomised to operative stabilisation either by a closed intramedullary nail (44) or by minimally invasive osteosynthesis with a compression plate (41). Pre-operative variables included the patients' age and the side and pattern of the fracture. Peri-operative variables were the operating time and the radiation time. Postoperative variables were wound problems, the time to union of the fracture, the functional American Orthopaedic Foot and Ankle surgery score and removal of hardware. We found no significant difference in the pre-operative variables or in the time to union in the two groups. However, the mean radiation time and operating time were significantly longer in the locked compression plate group (3.0 vs 2.12 minutes, p < 0.001, and 97.9 vs 81.2 minutes, p < 0.001, respectively).After one year, all the fractures had united. Patients who had intramedullary nailing had a higher mean pain score (40 = no pain, 0 = severe pain), [corrected] but better function, alignment and total American Orthopaedic Foot and Ankle surgery scores, although the differences were not statistically significant (p = 0.234, p = 0.157, p = 0.897, p = 0.177 respectively). Three (6.8%) patients in the intramedullary nailing group and six (14.6%) in the locked compression plate group showed delayed wound healing, and 37 (84.1%) in the former group and 38 (92.7%) in the latter group expressed a wish to have the implant removed. We conclude that both closed intramedullary nailing and a percutaneous locked compression plate can be used safely to treat Orthopaedic Trauma Association type-43A distal metaphyseal fractures of the tibia. However, closed intramedullary nailing has the advantage of a shorter operating and radiation time and easier removal of the implant. We therefore prefer closed intramedullary nailing for patients with these fractures.

Unreamed intramedullary nailing in distal tibial fractures

“…Nonunion occurred in 8 % of the fractures in this study. This compares favourably to the reports by Im and Tae [6] and Vallier et al [32] nailing groups, whereby the rate of delayed and non-union after nailing distal tibial fractures vary between 0 and 23 % in the literature [3,6,8,13,14,[22][23][24][25][26][27][28][29][30][31][32][33][34][35][36]. Screw failure remains a common problem with small diameter nails [2,15,16].…”

“…This may support early dynamisation in axially stable fractures to avoid delayed union and fatigue failure of the locking screws. Multiple prospective [6,[32][33][34] and retrospective [7,8,31] studies comparing open plating and locked intramedullary nailing for distal tibial fractures have described similar results as regards infection, secondary procedures, time to union (17-27 weeks) and rate of non-union (0-9 %) for both techniques. Whereas nailing has the advantage of shorter operative duration and reduced wound problems, ORIF can restore alignment better than nailing that was associated with more malunion (Table 2).…”

Surgical treatment of distal tibia fractures: Open versus MIPO?

“…Li et al [1] have reported no delayed union or nonunion in their retrospective study involving twenty-threepatients treated with MIPO. Guo et al [16] reported no delayed union or nonunion in their prospective randomised study involving forty-one patients treated with MIPO. Seyhan et al [5] have reported two (5.6%) nonunion with MIPO in their retrospective study.…”

“…Successful radiological and clinical outcomes were recommended with this technique. [15][16][17] Traditional open surgical technique is based on absolute stability achieved by full contact at the fracture side, and rigid internal fixation; however, open surgery has some limitations, such as infection, and long hospital stay. [5] Delayed union, and nonunions are important morbidities in the treatment of distal tibia fractures and common findings.…”

Are clinical and functional results of MIPPO and IMN for treatment of extraarticular distal tibia fractures similar?

“…IMN, which is a minimally invasive and biological method, provides symmetrical and dynamic fracture fixation (3,4). However, for fractures very close to the joint, the distal type of nail and the locking mechanism cannot provide adequate stability, especially when the distal fragment is very short.…”