Radiographic and Clinical Comparisons of Distal Tibia Shaft Fractures (4 to 11 cm Proximal to the Plafond): Plating Versus Intramedullary Nailing

Abstract

Objective: The purposes of this study were to review distal tibia shaft fractures treated with a plate or a nail and to assess the clinical and radiographic results, complication rates, and the need for secondary procedures.Design: Retrospective review.Setting: Two Level I trauma centers. Patient/Participants: We retrospectively reviewed 111 patientswith 113 extra-articular distal tibia fractures between 4 and 11 cm proximal to the plafond. Seventy-six were treated with an intramedullary nail and 37 were treated with a medial plate. Twenty-nine (27%) of the concomitant fibula fractures were fixed. Main Outcome Measurements: Complications and secondaryprocedures were evaluated in 111 patients after a mean of 24 months (range, 12-84 months).Results: A total of 111 patients with 113 fractures of the distal tibia were reviewed. Their mean age was 39.1 years, 69% were men, and 30% had open fractures. Four patients underwent additional procedures for soft tissue coverage. None of these had infection. Five patients (4.4%) developed osteomyelitis: four after intramedullary nailing (5.3%) and one after plating (2.7%). Nine patients (12%) had delayed union or nonunion after nailing. One patient (2.7%) had a nonunion after plating (P = 0.10). Nonunion was more common after concurrent fixation of the fibula (14% versus 2.6%, P = 0.04). Angular malalignment of $5 degrees occurred in 22 patients with nails (29%) and 2 with plates (5.4%, P = 0.003). Eight patients had malunions of $10 degrees. Valgus was the most common deformity (n = 16). Malunion was more common after open fracture (38%, P = 0.006) but was not related to fibula fixation. Painful hardware was removed in six patients (7.9%) with nails and in two patients (5.4%) with plates.Conclusions: Distal tibia fractures may be treated successfully with plates or nails. Delayed union, malunion, and secondary procedures were more frequent after nailing. Randomized prospective assessment may further clarify these issues and provide information about costs associated with these fractures.

The primary stability of angle-stable versus conventional locked intramedullary nails

“…Following this change in the spectrum of indications, the numbers of complications such as secondary loss of reduction, mal/non-union and delayed union increased [2,4,6,7,13,14]. Various modifications and implant developments have been investigated to exploit the benefits of intramedullary nailing [6,15]. With respect to the local anatomic characteristics of the distal tibia (wide intramedullary canal, thin cortex), the distal locking options (number and sites) have been adapted.…”

“…The standard treatment option includes open reduction and internal fixation using angular stable plate osteosynthesis. One major disadvantage of this procedure is the considerable soft tissue damage with the increased risk of wound healing problems and infection [2,5,6]. Intramedullary nailing of distal tibia fractures can decrease these risks but is attended by other problems such as decreased biomechanical stability due to the anatomical conditions of the distal tibia [1,7].…”

Treatment of distal tibial shaft fractures by three different surgical methods: a randomized, prospective study

“…Nonoperative treatment can be applied to stable extra-articular fractures with minimal shortening which may be complicated by loss of reduction, subsequent malunion, motion restriction and osteoarthritis [23,24]. Open reduction and internal fixation results in extensive soft tissue dissection and large periosteal elevation, which may be associated with wound complications and infections [3,25,26]. There is some concern about the use of intramedullary nails in distal tibia fractures because of technical difficulties with distal nail fixation, the risk of nail propagation into the ankle joint and the discrepancy between the diaphyseal and metaphyseal diameter of the intramedullary canal.…”

“…Although previous studies have compared plates with intramedullary nails [1][2][3][4][5]10], plates with external fixation [7] and intramedullary nails with external fixation [6], few data are available on the three methods above. The minimally invasive plate osteosynthesis (MIPO) technique has gained prevalence in recent years.…”

“…In the past few years, several studies focussing on the methods of treatment for displaced distal tibial shaft fractures have been published [1][2][3][4][5][6][7]. Plates, intramedullary nails and external fixations are three well-accepted and effective methods, but each has been historically related to complications.…”