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

Abstract

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.The mechanism of injury and the prognosis of displaced, extra-articular fractures of the distal tibia is different to that for pilon fractures. Their proximity to the ankle, however, makes the surgical treatment more complicated than the treatment of diaphyseal fractures of the tibia.

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).…”

Intramedullary nail versus plate treatments for distal tibial fractures: A meta-analysis

“…Though more preference is given to IMN, locked IMN is found closely associated with instability of the fixation and high risk of infection in the ankle joint. Besides, it could not well-aligned in the metaphysis of the tibia fracture [15]. Overall, there is not a consistent conclusion about which method is more advantageous.…”

“…Among the selected 16 studies, (11 in English [7,10,12,15,19e25] and 5 in Chinese [26e30]) there were 6 RCTs [10,12,15,19,23,24] and 10 CCTs [7,20e22,25e30], which were published from 2005 to 2014. The studies were consisted of 1140 patients, in which 599 were distributed in case group and 541 were in control group ( Table 1).…”

Retrospective analysis of AO 42A-B type tibia fractures treated with percutaneus locked plating and intramedullary nailing

“…[17,21,23] Bu eksikliği gidermeye yönelik yapılan konvansiyonel plak yerine kilitli plağın kullanıldığı güncel bir çalışmada kırık fragmanlarındaki dizilimin İMÇ ile daha iyi sağlandığı bildirilmiştir. [18,30] Bu çalışmada kırık fragmanlarının dizilimi her iki grup arasında benzerdi. Dizilimin sağlanması, kullanılan implanttan çok yapan kişinin tecrübesiyle ilişkili olduğu görüşündeyiz.…”