Plate vs. nail for extra-articular distal tibia fractures: How should we personalize surgical treatment? A meta-analysis of 1332 patients

Abstract

Background: Treatment for distal diaphyseal or metaphyseal tibia fractures is challenging and the optimal surgical strategy remains a matter of debate. The purpose of this study was to compare plate fixation with nailing in terms of operation time, non-union, time-to-union, mal-union, infection, subsequent reinterventions and functional outcomes (quality of life scores, knee-and ankle scores).Methods: A search was performed in PubMed/Embase/CINAHL/CENTRAL for all study designs comparing plate fixation with intramedullary nailing (IMN). Data were pooled using RevMan and presented as odds ratios (OR), risk difference (RD), weighted mean difference (WMD) or weighted standardized mean difference (WSMD) with a 95% confidence interval (95%CI). All analyzes were stratified for study design.Results: A total of 15 studies with 1332 patients were analyzed, including ten RCTs ( n = 873) and five observational studies ( n = 459). IMN leads to a shorter time-to-union (WMD: 0.4 months, 95%CI 0.1 -0.7), shorter time-to-full-weightbearing (WMD: 0.6 months, 95%CI 0.4 -0.8) and shorter operation duration (WMD: 15.5 min, 95%CI 9.3 -21.7). Plating leads to a lower risk for mal-union (RD: -10%, OR: 0.4, 95%CI 0.3 -0.6), but higher risk for infection (RD: 8%, OR: 2.4, 95%CI 1.5 -3.8). No differences were detected with regard to non-union (RD: 1%, OR: 0.7, 95%CI 0.3 -1.7), subsequent re-interventions (RD: 4%, OR: 1.3, 95%CI 0.8 -1.9) and functional outcomes (WSMD: -0.4, 95%CI -0.9 -0.1). The effect estimates of RCTs and observational studies were equal for all outcomes except for time to union and mal-union. Conclusion:Satisfactory results can be obtained with both plate fixation and nailing for distal extraarticular tibia fractures. However, nailing is associated with higher rates of mal-union and anterior knee pain while plate fixation results in an increased risk of infection. This study provides a guideline towards a personalized approach and facilitates shared decision-making in surgical treatment of distal extraarticular tibia fractures. The definitive treatment should be case-based and aligned to patient-specific needs in order to minimize the risk of complications.

Plating Versus Intramedullary Nailing of OTA/AO 43C1 and C2 Intra-articular Distal Tibia Fractures: A Propensity Score and Multivariate Analysis

“…The definition of nonunion used in Haller et al 24,25 is similar to the definition used in the current study and incidence of nonunion is consistent with existing literature. 13,23–25 Open fractures and injuries requiring soft-tissue coverage were also associated with nonunion in bivariate analysis. This is corroborated by existing literature, which supports an increase in nonunion rate with more severe soft-tissue injury.…”

Suprapatellar vs infrapatellar approaches for intramedullary nailing of distal tibial fractures: a systematic review and meta-analysis

“…At the same time, the width of the distal tibia metaphysis is much greater in the coronal plane than in the sagittal plane; therefore, coronal malreduction could occur more easily through the nailing procedure. This is why plate fixation for distal tibia fracture was preferred over IP intramedullary nail in the previous meta-analysis [26]. However, plate fixation has the disadvantage of higher soft-tissue complications and wound infections than IP nailing [25,27,28].…”

Imaging risk factors for predicting postoperative complications of intramedullary nailing for tibial fracture

“…Kim et al reported that complications were more likely in subisthmic fractures with shorter working lengths and wider medullary ducts at the distal end [21]. A su cient working length is helpful for preoperative planning and intraoperative judgment [22]. A long lever arm, short distal locking and a relatively wide metaphysis, greater distal lever force, and automatic fracture alignment due to lack of contact with the cortex and considerable intramedullary nail mobility can lead to higher rates of misalignment and an increased risk of screw failure with locking screws [23.24].…”