|Year : 2014 | Volume
| Issue : 2 | Page : 68-72
Comparison of clinical, radiological, and functional outcome of closed fracture of distal third tibia treated with nailing and plate osteosynthesis
Ganesh Babu Natarajan, Deebak Kumar Srinivasan, PV Vijayaraghavan
Department of Orthopaedics, Sri Ramachandra Medical College, Porur, Chennai, Tamil Nadu, India
|Date of Web Publication||10-Apr-2015|
Dr. Ganesh Babu Natarajan
B2 Private Clinic, Department of Orthopaedics, Sri Ramachandra University, Porur, Chennai - 600 116, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Aim: This is a prospective study of 30 patients with distal tibia fracture (Closed extra - articular distal third tibia fractures - 4 to 11cm from tibial plafond) who underwent surgical fixation were included in this study after excluding compound, pathological and paediatric fractures.
Materials and Methods: 15 underwent closed intramedullary interlocking nail and 15 were treated with plate osteosynthesis (MIPO).
Results: The age distribution ranged from 23 to 68 years with the mean age of 39.4 years. The mode of injury in all patients was due to vehicle accidents. All 30 patients were classified according to AO classification of which 15 belonged to A1, 14 belonged to A2, and 1 belonged to A3. The time of fixation from injury varied from 6 hours to 18 days.
Conclusion: Plate osteosynthesis by minimally invasive technique and Intramedullary interlocking nailing are equally effective method of stabilisation for distal tibia fracture when considering the union rates and final functional outcome. However malunion, nonunion and secondary procedures were more frequent after intramedullary interlocking nail. Randomised prospective evaluation of distal tibia fractures may clarify the efficacy of plate versus nail treatment and optimize the patient care.
Keywords: Distal tibial locking plate, Tibial nailing, MIPPO
|How to cite this article:|
Natarajan GB, Srinivasan DK, Vijayaraghavan P V. Comparison of clinical, radiological, and functional outcome of closed fracture of distal third tibia treated with nailing and plate osteosynthesis. Afr J Trauma 2014;3:68-72
|How to cite this URL:|
Natarajan GB, Srinivasan DK, Vijayaraghavan P V. Comparison of clinical, radiological, and functional outcome of closed fracture of distal third tibia treated with nailing and plate osteosynthesis. Afr J Trauma [serial online] 2014 [cited 2020 Feb 26];3:68-72. Available from: http://www.afrjtrauma.com/text.asp?2014/3/2/68/154924
| Introduction|| |
The mode of treatment of distal third tibial fractures is still controversial. Distal third tibial fractures differ from proximal third fractures by their difference in anatomy and difference in healing potential. ,
Plate osteosynthesis is recognized as the treatment of choice for most articular, many metaphyseal and a few diaphyseal fractures. Plate osteosynthesis using conventional plates is preferred for anatomical fixation, but the complications of infection, wound breakdown, and ankle stiffness creates dilemma to the orthopedic surgeon. ,,,,
Of the available modalities of treatment, intramedullary (IM) interlocking nailing is one of the advocated ways of treating distal third tibial fractures. IM interlocking nailing may sometimes fail to stabilize fractures in the distal metaphysis because of malalignment.
The anatomic reduction of each fracture surface is not critical nor should it be the absolute goal in the fracture except in articular fractures, especially if the trade-off for anatomicity is devitalization of the fracture zone. Hence, the concept of biological plate fixation came into existence.
A comparative study was conducted on the clinical and radiological union in either of the closed IM interlocking nail or plate and screw fixation. The advantages, disadvantages, follow-up, complications if any and overall functional outcome will be evaluated in these patients.
| Materials and Methods|| |
This is a prospective study of 30 patients with distal tibia fracture (closed extra-articular distal third tibia fractures 4-11 cm from tibial plafond) who underwent surgical fixation were included in this study after excluding compound, pathological, and pediatric fractures. Fifteen underwent closed IM interlocking nail and 15 were treated with minimally invasive plate osteosynthesis (MIPO).
The age distribution ranged from 23 to 68 years with the mean age of 39.4 years. The mode of injury in all patients was due to vehicle accidents. All 30 patients were classified according to A0 classification of which 15 belonged to A1, 14 belonged to A2, 1 belonged to A3. The time of fixation from injury varied from 6 h to 18 days.
All the 15 patients who underwent IM interlocking nail were operated under regional anesthesia with patient's supine on standard radiolucent table by patellar splitting approach. Nailing was done using the standard technique and all fractures were fixed with two proximal and two distal locking screws.
All 15 patients who underwent plate osteosynthesis by MIPO technique were operated under regional anesthesia with the patient supine on standard radiolucent table. Through medial approach reduction of the fracture site was achieved and fixed with pre contoured plates and appropriate screws by the minimally invasive technique under the guidance of image intensifier.
The decision for adjunctive fibular stabilization as well as the number of orientation of distal locking bolts was made at the surgeon's discretion. Duration of surgery and blood loss intra-operatively was estimated for all 30 patients. None of the patients were operated under tourniquet control.
Radiographic evaluation was done with standard antero-posterior and lateral view of the tibia with knee and ankle joint. Active range of movements of knee and ankle joint along with quadriceps strengthening exercises was started on the next day of surgery. All patients were given 3-5 days of broad spectrum intravenous antibiotics. Wound inspection was done on 2 nd , 5 th , 7 th postoperative day. Suture removal was done on 11 th postoperative day. Patients were maintained non- or toe-touch followed by partial weight bearing until clinical and radiographic signs of healing were seen after which full weight bearing was allowed. Secondary surgeries like bone grafting, dynamization, implant exchange were performed as determined by the surgeon for failure of progression of healing, loss of fracture fixation or infection.
Radiographic and clinical evaluation
All 30 patients were followed-up for clinical and radiological evaluation using modified Klemn and Borner scoring system at 6 weeks, 3 months, 6 months, 1 year, and 2 years [Table 1].
| Results|| |
Fracture union was defined as healing of at least 3 of 4 cortices on biplanar plain radiograph. Delayed union was defined as a lack of any healing on plain radiograph within 3 months. Nonunion was defined as a lack of any healing on plain radiograph within 6 months. Malunion was defined as more than 5° of angular deformity or shortening of more than 1 cm. ,
All the fractures united solidly with mean union time of 24.5 weeks ranging from 18 to 38 weeks. The patient who underwent nailing showed mean healing time of 24.9 weeks which has not shown any significant advantage over the healing time of patients treated with plate osteosynthesis by MIPO technique which is 24.2 weeks [Table 2].
All patients who underwent nailing shows a good regain of range of movements in both knee and ankle. Two of the patients in the plating group had ankle stiffness which compromised the overall functional outcome. In our series, none of the patients had significant limb length discrepancy and no note of limping gait was made.
Of 30 patients with distal tibia fractures, 25 patients were associated with distal fibula fractures. There were 13 and 12 patients in the plating and nailing group, respectively. Fixation of fibula fractures usually results in better alignment. In our series, there were 12 out of 13, and 5 out of 12 patients underwent fibula fixation in plate and nailing group, respectively [Table 3].
In the plating group, 90% of patients underwent fibula fixation. In this group, malalignment was resulted in two patients (antero-posterior deformity). In the nailing group, only 40% of patients were treated with simultaneous fibula plating but the fractures were united in valgus/varus malalignment in six cases. Even though fibula plating in the nailing group will prevent malalignment sometimes, it affects the fracture union rate and results in nonunion.  In our series two patients in the nailing group who had fibula fixation resulted in nonunion. These two patients had secondary procedures like implant exchange and bone grafting.
In the nailing group, the infection rate was 20% which is significantly higher when compared to patients who were treated with plate osteosynthesis (6.6%) [Table 4].
The final clinical and radiological outcome using modified Klemn and Borner scoring system in our study majority of patients had ended in excellent and good results [Table 5].
| Discussion|| |
Distal tibial fractures which were treated with plate osteosynthesis especially after high energy injuries had encountered higher complication rates, because of which many surgeons preferred IM interlocking nailing technique to minimize surgical insult to the fracture and adjacent soft tissue. However, proximal and distal tibia fractures can be difficult to control with IM device leading to malunion rates of 5-58%.  Minimally invasive plating technique reduces surgical trauma and maintains more biological environment for fracture healing. 
Despite recently reported success of locking plates using MIPO for distal tibia fracture the optimal treatment for these remain controversial. ,,,
In our study, to analyze these two techniques various parameters like union rate, incidence of malalignment, rate of complications, and functional outcome using Klemn and Borner scoring system were used. 
In our study, there were 11 male and 4 female patients among the nailing group and 10 male and 5 female patients among the plating group. The mean average age incidence was 39 years. The youngest individual was 23 years, and oldest was 68 years. In the nailing group, eight cases were of A0 type A2 comprising the majority. In plating group, there were eight cases of A0 type A1 comprising the majority.
In the present study, the average period of radiological union was found to be 24.2 weeks for the plating group and 24.9 weeks among the nailing group. In Tzeng et al. study, the mean union times were 22.6 weeks in the nailing group and 27.8 weeks in the plating group. It has been found that preservation of soft tissue envelope and blood supply surrounding the fractures by using indirect reduction techniques would promote fracture healing regardless of the type of fixation  [Table 6].
In our study, six cases in the nailing group showed higher than acceptable range of angulation, malalignment or loss of reduction may occur after nailing mostly due to improper reduction, poor nail position (e.g., not centering the nail in the distal fragment), or loose fixation. Nonetheless, correct nail position, good contact of the nail to the end plate, and rigid fixation of the nail-screw-bone construct should certainly be established  [Table 7].
Among the plating group, only two cases had significant rotational deformity. It has been found that indirect fracture reduction and fixation with medial plate were effective at restoring and maintaining alignment in high energy, mechanically unstable fractures of the distal tibia. Malalignment has been recognized previously as a potential pitfall when using minimally invasive plating techniques because the bone is not directly visualized. Reports of 7-35% of distal tibia fractures treated with MIPO have had problems with malalignment [Table 8]. 
There were three cases of superficial infection in the nailing group, which healed on oral antibiotics. There was one case of infection among the plating group which required debridement, closure, and antibiotics. In both cases, spontaneous union occurred without any chronic osteomyelitis. The mechanism resulting in distal tibial metaphyseal fractures usually consists of a high energy trauma that not only creates complicated fracture but also extends the injuries to the soft tissues. This extended soft tissue injury could be further compromised by open reduction and internal fixation.  Teeny et al., reported as many as 50 patients with at least one major complications such as skin slough, wound dehiscence, infection, nonunion, and malunion or implant failure [Table 7]. Furthermore, in case of recurrent osteomyelitis or soft tissue dehiscence, 16.6% of these patients eventually go on to amputation. ,,,,, Recently, minimally invasive plating of injuries in this area has demonstrated less soft tissue problems and reasonably lessens the risk of infection. 
It has been noted that concurrent fibula fixation among the patients treated by IM interlocking nail will prevent malalignment but sometimes, it affects the fracture union rate and results in nonunion.  In our series, two patients who were treated by IM interlocking nail, and concurrent fibula fixation resulted in nonunion. Mosheiff et al. and Schmidt et al. recommended routine fixation of the concomitant fibular fractures to lessen the risk of malalignment. However, the essential benefit of IM nailing in avoiding soft tissue dissection might be compromised in this way. No patient suffered from the loss of reduction in the series conducted by them demonstrating that it is not necessary to fix the fibula in the fractures of distal tibial metaphysis. 
It is possible that fibula fixation improves tibia alignment in some cases, but that an increased potential for delayed healing of the tibia may be seen when the fibula is stabilized concurrently. ,, It has been noted angular malalignment of 5° or more after nailing in 29% of patients, although malunion was not associated with the presence of fibula fracture or fixation of the fibula. , Recent comparative study has also described more malalignment after nailing (50% vs. 17% after plating), suggesting that plating of complex fractures may result in less malalignment. 
Percutaneous plating has had rates of secondary surgery between 0% and 20% for delayed fracture healing, compared with rates up to 42% after nailing suggesting that plating may be more efficacious in achieving timely fracture union without any secondary procedures.  Our study consisted of four patients among the nailing group who had undergone secondary procedures such as dynamization, bone grafting, and implant exchange. None of the patients in the plating group had undergone any secondary surgery.
Recently, minimally invasive plating of injuries in this area has demonstrated excellent healing rates and only a few required bone grafts. Zelle et al., recently reviewed the literature and found 115 cases of minimally invasive plating for distal tibia fractures, and only 3% of these resulted in nonunion.
After reviewing various articles, our study shows that plating by MIPO technique has given an equally good result when comparing with the patients who had undergone IM interlocking nail. In recent times, plate fixations by MIPO technique for distal tibia fractures show minimal incidence of wound gaping and implant failure. These may be due to evolution of minimally invasive surgical technique and better anatomical profile plates (thin profile plates) and locking plate technique.
| Conclusion|| |
- Plate osteosynthesis by minimally invasive technique and IM interlocking nailing are equally effective method of stabilization for distal tibia fracture when considering the union rates and final functional outcome
- However, malunion, nonunion, and secondary procedures were more frequent after IM interlocking nail
- Concurrent fibula fixation will minimize the incidence of malunion after stabilization with IM interlocking nail for distal tibia fracture
- Randomized prospective evaluation of distal tibia fractures may clarify the efficacy of plate versus nail treatment and optimize the patient care.
| References|| |
Boos N, Bugyi I. Results of locking intramedullary nailing in distal tibial shaft fractures. Unfallchirurg 1989;92:453-8.
Lau TW, Leung F, Chan CF, Campbell's Opertive Orthopaedics. 9 th
ed.2001, Chapter 34, p. 2675-8.
Fan CY, Chiang CC, Chuang TY, Chiu FY, Chen TH. Interlocking nails for displaced metaphyseal fractures of the distal tibia. Injury 2005;36:669-74.
Bono CM, Sirkin M, Sabatino CT, Reilly MC, Tarkin I, Behrens FF. Neurovascular and tendinous damage with placement of anteroposterior distal locking bolts in the tibia. J Orthop Trauma 2003;17:677-82.
Collinge C, Kuper M, Larson K, Protzman R. Minimally invasive plating of high-energy metaphyseal distal tibia fractures. J Orthop Trauma 2007;21:355-61.
Collinge C, Protzman R. Outcomes of minimally invasive plate osteosynthesis for metaphyseal distal tibia fractures. J Orthop Trauma 2010;24:24-9.
Dogra AS, Ruiz AL, Thompson NS, Nolan PC. Dia-metaphyseal distal tibial fractures - treatment with a shortened intramedullary nail: A review of 15 cases. Injury 2000;31:799-804.
Egol KA, Weisz R, Hiebert R, Tejwani NC, Koval KJ, Sanders RW. Does fibular plating improve alignment after intramedullary nailing of distal metaphyseal tibia fractures? J Orthop Trauma 2006;20:94-103.
Freedman EL, Johnson EE. Radiographic analysis of tibial fracture malalignment following intramedullary nailing. Clin Orthop Relat Res 1995;315:25-33.
Francois J, Vandeputte G, Verheyden F, Nelen G. Percutaneous plate fixation of fractures of the distal tibia. Acta Orthop Belg 2004;70:148-54.
Netter FH. Atlas of Human Anatomy. 2 nd
6 edition, 2014. p. 575-9.
Gorczyca JT, McKale J, Pugh K, Pienkowski D. Modified tibial nails for treating distal tibia fractures. J Orthop Trauma 2002;16:18-22.
Drake R, Vogl AW, Gray's Anatomy for Students Churchill Livingstone; 3 edition, chapter 9. 2014. p. 342-4.
Im GI, Tae SK. Distal metaphyseal fractures of tibia: A prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plate and screws fixation. J Trauma 2005;59:1219-23.
Vallier HA, Le TT, Bedi A. Radiographic and clinical comparisons of distal tibia shaft fractures (4 to 11 cm proximal to the plafond): Plating versus intramedullary nailing. J Orthop Trauma 2008;22:307-11.
Helfet DL, Shonnard PY, Levine D, Borrelli J Jr. Minimally invasive plate osteosynthesis of distal fractures of the tibia. Injury 1997;28 Suppl 1:A42-7.
Gregory P, Sanders R. The treatment of closed, unstable tibial shaft fractures with unreamed interlocking nails. Clin Orthop Relat Res 1995;315:48-55.
Puno RM, Teynor JT, Nagano J, Gustilo RB. Critical analysis of results of treatment of 201 tibial shaft fractures. Clin Orthop Relat Res 1986; 212:113-21.
Redfern DJ, Syed SU, Davies SJ. Fractures of the distal tibia: Minimally invasive plate osteosynthesis. Injury 2004;35:615-20.
Resch H, Pechlaner S, Benedetto KP. Long-term results after conservative and surgical treatment of fractures of the distal end of the tibia. Aktuelle Traumatol 1986;16:117-23.
Reudi T, Weber TK, Allgower M. Experience with DCP in 418 recent fracture of distal tibia. Injury 1976;7:252.
Richter D, Ostermann PA, Ekkernkamp A, Hahn MP, Muhr G. Distal tibial fracture - An indication for osteosynthesis with the unreamed intramedullary nail?. Langenbecks Arch Chir Suppl Kongressbd 1997;114:1259-61.
Robinson CM, McLauchlan GJ, McLean IP, Court-Brown CM. Distal metaphyseal fractures of the tibia with minimal involvement of the ankle. Classification and treatment by locked intramedullary nailing. J Bone Joint Surg Br 1995;77:781-7.
Russel TA. Fractures of the tibia and fibula. Rockwood and Green fractures in Adults. Vol. 1; 1928-54.
Tyllianakis M, Megas P, Giannikas D, Lambiris E. Interlocking intramedullary nailing in distal tibial fractures. Orthopedics 2000;23:805-8.
Yang SW, Tzeng HM, Chou YJ, Teng HP, Liu HH, Wong CY. Treatment of distal tibial metaphyseal fractures: Plating versus shortened intramedullary nailing. Injury 2006;37:531-5.
Copin G, Nérot C. Recent fractures of the tibial pilon in adult (Symposium du 66ème Congrès de la SOFCOT) Rev Chir Orthop 1992;78(Suppl-1):3-83.
Pugh KJ, Wolinsky PR, McAndrew MP, Johnson KD. Tibial pilon fractures: A comparison of treatment methods. J Trauma 1999;47:937-41.
McFerran MA, Smith SW, Boulas HJ, Schwartz HS. Complications encountered in the treatment of pilon fractures. J Orthop Trauma 1992;6:195-200.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]