Fractures of the distal tibia occur commonly, afflicting all ages. On one end of the spectrum, low-energy falls generate torsional spiral fractures of the metaphysis and distal diaphysis, whereas on the other extreme, high-energy blunt impact causes complex comminuted fractures. Even with the least severe fractures, the overlying soft tissue envelope is problematic because the anteromedial cortex of the tibia is subcutaneous.
In skeletally mature patients, displaced distal tibia fractures are treated surgically to provide better fracture alignment, pain relief, support for local soft tissues, and to promote mobility of the adjacent joints. Plates and intramedullary nails are both frequently used in this location, and each performs reliably, with similar restoration of function.1–4 The composite of published literature to date suggests both methods have low rates of primary infection and modest, comparable rates of primary union, with a tendency for more malalignment associated with infrapatellar nails.5–12 Surgeons have personal preferences in implant selection and technique, largely based on their training and experience. However, treatment of distal tibia fractures with both plates and nails should be familiar to all, including an understanding of results and outcomes of large studies, to optimize care of the injured patient.
This article will discuss plate versus intramedullary nail fixation of distal tibia fractures, including technical advances in implant design, instrumentation, and technique. Supporting evidence will be reviewed, and the 2 methods of fixation will be compared in clinical and radiographic results and functional outcomes. The purpose is to provide the treating surgeon with rational indications and expectations for each.
Medial application of standard large fragment plates was historically associated with high rates of wound necrosis and infection.13–16 Modern techniques support medial plating with minimal surgical trauma to the soft tissues.17–20 Tourniquets are avoided. Surgical approaches using smaller wounds with less periosteal stripping are associated with acceptable, low rates of wound complications and infections. Such techniques are facilitated by high-quality intraoperative fluoroscopy and with anatomic implants.21,22 Depending on the fracture pattern and soft tissue injury, anterolateral plates may be favored over medial implants in some cases.6,23 Locking plates with fixed or variable angle trajectories are also widely available, although these introduce more implant prominence and potentially excessive stiffness, as well as much greater implant cost.9,24,25
Many surgeons prefer intramedullary nails for distal tibia fractures. Inherently, a nail implies less surgical trauma to the soft tissues, although it temporarily disrupts the medullary blood supply. If anatomic reduction of the tibia is obtained before instrumenting the canal, and if reduction is maintained during nailing, alignment is likely to be appropriate throughout recovery.10,26–29 Percutaneous clamps, provisional unicortical tibial plates, and Schanz pin(s) are among the methods effective in controlling reduction of the tibia fracture. Reduction and fixation of adjacent fibula fractures may also facilitate tibial reduction.10,28 Recent advances in nailing instrumentation with suprapatellar insertion allow for nailing with the knee semiextended, reducing the tendency for loss of reduction.30–32 If reduction is maintained during canal instrumentation, a nail centered in the distal segment should provide anatomic alignment of the fracture. Two to 3 distal interlocking bolts will support the nail, although initial protected weight bearing and elevation are generally recommended to promote soft tissue healing and to reduce the potential for bolt failure and late malalignment.28,29,33,34
RESULTS OF MODERN PLATING TECHNIQUES
Recent literature has shown minimal soft tissue and infectious complications with modern plating techniques and implants. Meticulous soft tissue handling is imperative with a low threshold for staged definitive surgery.17,35,36 Proponents of minimally invasive plate osteosynthesis, using percutaneous or indirect reduction with small wounds for plate insertion and screw placement, report wound dehiscence or deep infection in less than 9% of cases.17–20,23 However, not all surgery with small skin incisions is minimally invasive—optimal handling of the soft tissue envelope entails limited periosteal stripping and minimal undermining of the soft tissues. Longer, more conventional surgical incisions, when performed with careful handling and sharp dissection, have been shown in some series to have very low rates of infection or other wound complications, even in large groups of open or other high-energy fractures.6,10,11 It has been proposed that underlying patient factors such as diabetes, tobacco use, and obesity are most highly associated with early complications.6,11,36–38
Locking plates have been increasingly popular over the past 15 years, now comprising most plates used in many US hospitals.25 In the distal tibia, the costs of these implants exceed those of standard plates and nonlocking anatomic plates. Some recent series have reported more soft tissue complications, including infections and reoperations for removal of painful implants, both of which are attributed to greater implant thickness, especially over the medial distal tibia and malleolus.24,36 It seems that tendency for delayed fracture healing and greater risk for nonunions is secondary to increased stiffness of locking constructs.9,39,40 However, recent technical modifications, such as far cortical locking, longer plate lengths, and fewer locked screws, may mitigate this risk.8,39,41
RESULTS OF MODERN NAILING TECHNIQUES
Over the past 10 years, relative indications for intramedullary nailing of the distal tibia have extended to more distal fractures, concurrent with modifications in nail design, housing multiplanar locking options, with bolts located more distally within the nail.26–28 Attention to aforementioned surgical techniques has reduced the tendency for nails to be placed within a malaligned fracture. Nailing in the semiextended position, with the knee flexed approximately 30 degrees has improved intraoperative accuracy of reduction, particularly for proximal and distal fractures.31,42 Initially described with a medial parapatellar arthrotomy, more recent studies have demonstrated consistent maintenance of anatomic fracture alignment using a suprapatellar approach. Early data have shown a low incidence of knee pain when compared with infrapatellar nailing, and minimal or no damage to the patellofemoral joint has been identified.31,32 Regardless of the method of insertion, using a nail with optimal nail to canal ratio may enhance the rate of fracture union.43
To date, 5 randomized controlled trials have been published comparing plate versus intramedullary nail fixation of the distal tibia (Table 1).5,6,8,9,11 Two have studied locking plates on the tibia,5,9 1 has used standard anterolateral tibia plates,6 and 2 have reported on standard medial plates on the tibia.8,11 In performing a meta-analysis of these studies, variability in plating type and technique warrants consideration, as implications for soft tissue irritation and wound complications are related.1,2,4 Furthermore, the increased stiffness achieved with locking plates has been associated with more delayed union and nonunion.9,25,40 Mauffrey et al9 reported 17% of their patients to have nonunion after locking plate fixation of the distal tibia.
Further difficulty in comparing these studies arises when the management of associated fibula fractures is considered. Patients with an intact fibula or with fibula fixation in combination with intramedullary nailing of the tibia have increased the risk of delayed union or nonunion in some studies.6,10,11,28,34 Three of 5 randomized controlled trials to date have performed fibula fixation at surgeon discretion, accounting for fixation of up to 30% of the associated fibula fractures in those studies.9,11,12 It has also been suggested that reduction and fixation of the fibula will aid in obtaining accurate reduction of the tibia, and that fixation of the fibula will reduce risk for later tibia malalignment, although supporting data are limited.1,10,11,44
Several recent meta-analyses have reviewed comparative studies.1,2,4 In prospective trials, methodological flaws have been noted, including selection bias, small sample sizes, and patient attrition.1,2,7,9,12,45 Another 3 comparative studies are listed in Table 1, all of which are retrospective, and one of which is case matched with 12 patients each treated with plate or nail.7 When analyzing the composite of these studies, several points are noteworthy. Deep infection and wound-healing complications are infrequent, and occur with similar rates after plate or nail fixation, even in patients with high-energy fractures with associated open wounds and severe soft tissue injury. Rates of deep infection range from 0% to 8.3% with either plates or nails, suggesting that thoughtful preoperative assessment and surgical technique are of foremost importance in mitigating risk.5–12 The greatest risks for soft tissue complications and infection may be diabetes, tobacco use, and obesity.6,10,11,36,38,40 Medical optimization and patient counseling are crucial.
Regarding fracture alignment, angular malalignment is more common after infrapatellar nailing of the distal tibia, occurring in up to half of cases.6–12 The majority of these fractures are fixed in a malaligned position, emphasizing the need for attention to accurate fracture reduction and correct technique of instrumentation. Judicious usage of intraoperative reduction aids and of biplanar imaging is essential to achieving anatomic alignment. Angular malalignment after plating is less common, although standard plates are not suitable for early weight bearing on the tibia. Catastrophic failure can result.11
In assessing time to union and ultimate rate of union, current literature suggests that plates and nails are similar, with a tendency for slower healing and more nonunion after locking plates,9,24,25,36,37 and with a trend toward more delayed union and nonunion with nails when compared with standard plates.7,10,11,28 Most comparative studies are underpowered to detect a difference. However, reaming and nailing of the tibia temporarily disrupt the medullary blood supply, which could contribute to slower healing versus standard plates. Several other patient and treatment characteristics have been shown to increase the risk of nonunion of the tibia. These include tobacco use, severe soft tissue damage, and open fractures.10,11,36,40
In recent publications, most patients returned to employment with no limitations once their tibia fracture healed.3,34 Previous comparative work has described similar functional outcome scores after distal tibia fracture, whether treated with plate or intramedullary nail fixation.3,5–12 One study demonstrated a trend for patients with a nail to improve more quickly than those with locking plates; however, these data were not controlled for a high rate of nonunion in the locking plate group.9
Historically, anterior knee pain has been noted commonly after tibia nailing.7,46–48 More recent studies have suggested that nails which are not prominent, and which are placed with meticulous surgical technique, minimizing trauma to the patellar tendon and knee joint, do not have a higher frequency of late knee pain, when compared with plates.3,5,7,9,49 Rather, knee pain is probably related to insufficient quadriceps rehabilitation.47,48,50 Patients who are not employed (unrelated to the tibia injury) are also more likely to report chronic pain, and to have the worst functional outcome scores.3 This is consistent with a growing body of evidence highlighting the need to address underlying social and psychological issues to optimize ability to work, as well as patient satisfaction and outcomes.51–54
In conclusion, plates and nails are both effective in treating distal tibia fractures. High primary union rates are noted with standard implants. Healing of the tibia after nailing may be slowed in patients with fixation of the fibula. Tibia healing may also be delayed with locking versus standard plates. Further study in these areas is needed. With attention to obtaining and maintaining reduction of the tibia intraoperatively, malunion is infrequent with both methods. Rates of infection and secondary operations are also similar. Soft tissue complications and infections appear most related to open fractures and severe soft tissue injuries as well as underlying comorbidities. Long-term function is good in most patients, although baseline social and mental health issues are associated with poor functional outcomes and less patient satisfaction.
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