Management of Extra-articular Fractures of the Distal Tibia: Intramedullary Nailing Versus Plate Fixation

Casstevens, Chris; Le, Toan; Archdeacon, Michael T.; Wyrick, John D.

doi:10.5435/jaaos-20-11-675

Cited by 45 publications

(39 citation statements)

References 31 publications

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“…The proximity of these fractures to the ankle joint leads to more complications than are seen with diaphyseal or middle-third injuries [ 2 ]. Thus, the treatment of distal tibia fractures remains problematic [ 3 ].…”

Section: Introductionmentioning

confidence: 99%

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Intramedullary nailing versus plating for distal tibia fractures without articular involvement: a meta-analysis

et al. 2015

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BackgroundThe 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.Materials and methodsThe PubMed, Embase, Cochrane Library databases, Chinese Wan-Fang Database, and China National Knowledge Infrastructure were searched.ResultsTwenty-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.ConclusionsEvidence 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.

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Section: Introductionmentioning

confidence: 99%

“…Plating is indicated for fractures with risk of malalignment, fractures with simple articular involvement, and fractures in which IM nailing is not amenable [ 4 ]. The two approaches have some theoretical disadvantages [ 3 , 5 ]. IM nailing frequently results in malalignment, malunion, and knee pain [ 1 , 6 – 9 ].…”

Section: Introductionmentioning

confidence: 99%

Intramedullary nailing versus plating for distal tibia fractures without articular involvement: a meta-analysis

et al. 2015

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“…The finding that medial plating was biomechanically optimal in a simulated varus fracture pattern was consistent with the authors' hypothesis and corroborated expert opinion that the initial deformity should help to guide plate location. 8 This combination of fracture pattern and plate location allowed the plate to function in anti-glide mode, with an axilla created according to AO technique. 24 However, anterolateral plating did not seem to confer a biomechanical advantage in a simulated valgus fracture pattern.…”

Section: Discussionmentioning

confidence: 99%

“…[1][2][3][4][5][6][7] In an effort to perform an appropriate osseous reconstruction and preserve the soft tissue envelope, multiple surgical approaches and fixation strategies have been proposed. 8 Options for plate osteosynthesis include medial plating and anterolateral plating via a variety of surgical approaches. 3,9,10 Proponents of medial plating cite the technical ease of the approach, the ability to perform a minimally invasive procedure, and decreased local soft tissue disruption at the fracture site as the primary advantages.…”

mentioning

confidence: 99%

Anterolateral Versus Medial Plating of Distal Extra-articular Tibia Fractures: A Biomechanical Model

Pirolo¹,

Behn²,

Abrams³

et al. 2015

Orthopedics

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Both medial and anterolateral plate applications have been described for the treatment of distal tibia fractures, each with distinct advantages and disadvantages. The objective of this study was to compare the biomechanical properties of medial and anterolateral plating constructs used to stabilize simulated varus and valgus fracture patterns of the distal tibia. In 16 synthetic tibia models, a 45° oblique cut was made to model an Orthopedic Trauma Association type 43-A1.2 distal tibia fracture in either a varus or valgus injury pattern. Each fracture was then reduced and plated with a precontoured medial or anterolateral distal tibia plate. The specimens were biomechanically tested in axial and torsional loading, cyclic axial loading, and load to failure. For the varus fracture pattern, medial plating showed less fracture site displacement and rotation and was stiffer in both axial and torsional loading (P<.05). For the valgus fracture pattern, there was no statistically significant difference between medial and anterolateral plating. There were no significant differences between the 2 constructs for either fracture pattern with respect to ultimate load, displacement, or energy absorption in load to failure testing. When used to stabilize varus fracture patterns, medial plates showed superior biomechanical performance compared with anterolateral plates. In this application, the medial plates functioned in anti-glide mode. For valgus fracture patterns, no biomechanical differences between anterolateral and medial plating were observed. In clinical practice, surgeons should take this biomechanical evidence into account when devising a treatment strategy for fixation of distal tibia fractures.

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“…Although both techniques have demonstrated success in maintaining reduction and promoting stable union, they possess distinct advantages and disadvantages that require careful consideration during surgical planning. Differences in soft-tissue health and construct stability must be considered when choosing between intramedullary nailing and plating of the distal tibia [15] [16].…”

Section: Resultsmentioning

confidence: 99%

Results of Dynamic Interlock Nailing in Distal Tibial Fractures

Gadegone¹,

Salphale²,

Lokhande³

2015

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A study was performed in adults to determine the efficacy of closed reduction and intramedullary nailing in dynamic mode on union, implant failure and incidence of malalignment in patients who sustained an extra-articular fracture of the distal tibia. Methods: Between January 2007 and December 2013, one hundred and twelve patients of distal tibia that involved the distal 6 cm of the tibia were treated at our hospital with reamed intramedullary nailing with use of two distal interlocking screws and one proximal screw in dynamic mode. The augmentation was done with poller screws whenever it was necessary. The nailing of fibular fractures was done in 27 cases. There were 85 males and 27 females with a mean age of 30.9 (range: 20 to 72). Eighty fractures were closed whereas 32 were grade 1 open fractures. Results: The average time to union of the closed fracture was 15.4 weeks (range: 12 -28 weeks). The healing times for the primarily nailed compound Grade I averaged 17.8 (range: 15 -34 weeks). After minimum follow-up of one year, rate of primary union was in 97.32%. One case of broken nail required revision surgery. There were three cases of delayed union and two cases of non union. In one case there was deep infection which required exchange nailing with antibiotic impregnated nail. There was breakage of interlocking screws in three cases but fracture had united. In twenty two cases acceptable malalignment of the tibia was observed after union. The outcome was determined at a minimum of one year in our study based on the criteria of Johner and Wruhs. Out of 112 patients, 79 patients had excellent results, 29 had good results and 4 had fair results. Conclusions: The dynamic osteosynthesis of distal tibia by interlocking nail and judicious use of poller screws is an effective alternative for the treatment of distal metaphyseal tibial fractures.

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Management of Extra-articular Fractures of the Distal Tibia: Intramedullary Nailing Versus Plate Fixation

Cited by 45 publications

References 31 publications

Intramedullary nailing versus plating for distal tibia fractures without articular involvement: a meta-analysis

Intramedullary nailing versus plating for distal tibia fractures without articular involvement: a meta-analysis

Anterolateral Versus Medial Plating of Distal Extra-articular Tibia Fractures: A Biomechanical Model

Results of Dynamic Interlock Nailing in Distal Tibial Fractures

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