SLR - July 2012 - Shweta Raina
Reference: Vallier HA, Cureton BA, Patterson BM. J Orthop Trauma. Mar;26(3):178-83. 2012
Scientific Literature Review
Reviewed by: Shweta Raina, DPM
Residency Program: New York Hospital Queens
Podiatric Relevance:
Functional outcome of displaced distal tibia fractures (OTA 42) is dependent on proper surgical management. Both IM nailing and plate fixation have unique associated complications. In this article, the authors attempt to determine, via a randomized prospective study (Therapeutic Level 2 Evidence), whether IM nailing or plate fixation is the superior treatment choice based on long-term pain levels as well as ability to return to work. The authors state that there are no previous studies comparing functional outcomes of plate versus nail fixation in distal tibia fractures.
Methods:
The study design consisted of a randomized prospective study of 104 patients with extra-articular distal tibial shaft fractures. They were treated at a single Level 1 Trauma Center between November 2002 and June 2008. The researchers hypothesized that tibial nails would be associated with more knee pain whereas plates would be associated with pain from implant prominence. The surgical treatment was randomized, with patients assigned to either reamed anterograde IM nail (n=56) or standard large fragment medial plate (n=48). The main outcome measure was the patient’s ability to work 12 months postoperatively, which was evaluated based on Foot Function Index (FFI) and Musculoskeletal Function Assessment (MFA) questionnaires. FFI values range from zero to 1.0; with higher FFI scores indicating greater impairment. MFA values range from zero to 100, with low scores indicating better function.
Results:
There was an 83 percent response rate to the questionnaires (45 nails and 41 plates). The mean time for returning to work was 22 months (range 12-71). The mean MFA score was 27.5 (28 for nails versus 27 for plates; uninjured reference value 9.3), and mean total FFI was 0.26 (0.29 for nails versus 0.23 for plates; uninjured reference value 0.15). The most common adverse outcomes consisted of mild ankle or knee pain, which was reported after both plate and IM nail fixation; however, the pain was reported more frequently after tibial nailing (27 percent, vs. 15 percent with plates, P=0.08). Knee and ankle pain were not related to age, fracture pattern or presence of open fracture. Rates of implant removal were similar after both nail and plate fixation.
Conclusions:
Mean outcome scores suggested substantial residual dysfunction after distal tibia fractures when compared with an uninjured population. Angular malunion of 35 degrees was associated with both knee and ankle pain, and there was a trend toward more patients with knee and ankle pain after tibial nailing. Unemployed people described knee and ankle pain more frequently, and had higher incidence of implant removal as well as the worst functional outcome scores.