SLR- January 2014- Adam P. Thompson
Reference: Iqbal HJ, Pidikiti P. Treatment of Distal Tibia Metaphyseal Fractures; Plating Versus Intramedullary Nailing: A Systematic Review of Recent Evidence. Foot and Ankle Surgery, 2013 (19) 143–147.
Scientific Literature Review
Reviewed By: Adam P. Thompson, DPM
Residency Program: St. John Hospital and Medical Center
Podiatric Relevance: Fixation techniques for extra-articulardistal tibial fractures varies widely depending on patient demographics, surgeon preference, bone quality and extent of articular involvement. Few studies have illustrated a direct comparison of plating versus intramedullary nailing outcomes in the treatment of these fractures. This study investigates the outcomes of the available literature on this topic and summarizes this data to better illustrate the advantages and disadvantages of each approach.
Methods: A systematic review of recent literature (2005-2010 was implemented utilizing online literature searches of Medline (Ovid), Embase (Ovid) and Cochrane databases. A search for relevant studies comparing plating and intramedullary nailing approaches was conducted using these databases. Quality of the studies was assessed utilizing the 2010 CONSORT 25 point assessment tool regarding methodology, results and overall conduct of the studies. Two prospective randomized controlled trials comparing IM nail with plating were found in the literature. Three retrospective comparative studies comparing intramedullary nailing and plating were available. One retrospective comparative study comparing plating, IM nailing and external fixation was included. Twenty other case series were also found describing outcomes of intramedullary nailing, platingor external fixation. Only studies directly comparing the results of intramedullary nailing and plating of extra articular distal metaphyseal fractures were included in this review. Studies on pediatric fractures, pilon fractures, pathological fractures, stress fractures and experimental laboratory studies were excluded. Two randomized controlled studies and four retrospective comparison studies were used in thedata compilation. Primary fracture fusion rate, malunion, nonunion, infection rate, and hardware removal rates for both groups were analyzed.
Results: Two randomized controlled studies and four retrospective comparison studies were included in the data compilation with 179 intramedullary nail repairs and 134 plating repairs being included and their results analyzed. Primary fusion rate was 95.5 percent for intramedullary nailing and 97.8 percent for plating. Malunion rate was 25.9 percent for nailing and 5.3 percent for plating. Nonunion rate was 4.5 percent for nailing and 2.2 percent for plating. Infection rate was 5 percent for nailing and 11.2 percent for plating. Hardware removal rate was 35.8 percent for nails and 45.2 percent for plates.Conculsions: With regard to repair to extraarticular distal metaphyseal tibial fractures assessed in this review, both intramedullary nailing and plating result in high primary fusion rates (>95 percent) with intramedullary nailing having the slight advantage. Malunion and nonunion rates were higher in the nailing group but the infection rate was higher in the plating group. According to this analysis intramedullary nailing results in a higher incidence of malunion and nonunion that plating but results in lower infection rates. Conversely plating results in lower malunion and nonunion rates but higher incidence of infection that nailing. However, these conclusions should be viewed with caution as they also depend upon various other factors in addition toimplants e.g. severity of the soft tissue injuries, other associated injuries, comorbidities, time interval between injury and surgery, surgeon’s experience,etc. and these confounding factors are not addressed well in any of the studies. It should also be noted that none of these studies had sufficient power to show clinically significant difference between two treatment modalities.