Comparison of intramedullary nailing and plate fixation in distal tibial fractures with metaphyseal damage: a meta-analysis of randomized controlled trials

Abstract

Background: Distal metadiaphyseal tibial fractures are commonly seen lower limb fractures. Intramedullary nail fixation (IMN) and plate internal fixation (PL) are the two mainstay treatments for tibial fractures, but agreement on the best internal fixation for distal tibial fractures is still controversial. This meta-analysis was designed to compare the success of IMN and PL fixations in the treatment of distal metadiaphyseal tibial fractures, in terms of complications and functional recovery.

Methods: A systematic research of the literature was conducted to identify relevant articles that were published in PubMed, MEDLINE, Embase, the Cochrane Library, SpringerLink, Clinical Trials.gov, and OVID from the database inception to August 2018. All studies comparing the complication rate and functional improvement of I2MN and PL were included. Data on the 12 main outcomes were collected and analyzed using the Review Manager 5.3.

Results: Eleven studies were included in the current meta-analysis. A significant difference in malunion (RR = 1.76, 95%CI 1.21-2.57, P = 0.003), superficial infection (RR = 0.29, 95%CI 0.13-0.63, P = 0.002), FFI (MD = 0.09, 95%CI 0.01-0.17, P = 0.02), and knee pain (RR = 3.85, 95%CI 2.07-7.16, P < 0.0001) was noted between the IMN group and PL group. No significant difference was seen in the operation time (MD = - 10.46, 95%CI - 21.69-0.77, P = 0.07), radiation time (MD = 7.95, 95%CI - 6.65-22.55, P = 0.29), union time (MD = - 0.21, 95%Cl - 0.82-0.40, P = 0.49.), nonunion (RR = 2.17,95%CI 0.79-5.99, P = 0.15), deep infection (RR = 0.85, 95%CI 0.35-2.06, P = 0.72), delay union (RR = 0.92, 95%CI 0.45-1.87, P = 0.82), AOFAS (MD 1.26, 95%Cl - 1.19-3.70, P = 0.31), and Disability Rating Index in 6 or 12 months (MD = - 3.75, 95%CI - 9.32-1.81, P = 0.19, MD = - 17.11, 95%CI - 59.37-25.16, P = 0.43, respectively).

Conclusions: Although no significant difference was seen between IMN and PL fixation with regards to the operation time, radiation time, nonunion, deep infection delay union, union time, AOFAS, and Disability Rating Index, significant differences were seen in occurrence of malunion, superficial infection, FFI, and knee pain. Based on this evidence, IMN appears to be a superior choice for functional improvement of the ankle and reduction of postoperative wound superficial infection. PL internal fixation seems to be more advantageous in achieving anatomical reduction and decreasing knee pain.

Keywords: Distal metaphyseal fractures; Distal tibial fracture; Intramedullary nail; Plate.

Fig. 1

Flow chart showing study identification, inclusion, and exclusion

Fig. 2

Risk of bias summary

Fig. 3

Forest plot of operation time in the IMN group compared with the PL group

Fig. 4

Forest plot of radiation time in the IMN group compared with the PL group

Fig. 5

Forest plot of union time in the IMN group compared with the PL group

Fig. 6

Forest plot of nonunion in the IMN group compared with the PL group

Fig. 7

Forest plot of deep infection in the IMN group compared with the PL group

Fig. 8

Forest plot of malunion in the IMN group compared with the PL group

Fig. 9

Forest plot of knee pain in the IMN group compared with the PL group

Fig. 10

Forest plot of superficial infection in the IMN group compared with the PL group

Fig. 11

Forest plot of delay union in the IMN group compared with the PL group

Fig. 12

Forest plot of AOFAS score in the IMN group compared with the PL group

Fig. 13

Forest plot of Foot Function Index in the IMN group compared with the PL group

Fig. 14

Forest plot of Disability Rating Index in the IMN group compared with the PL group