Annals of R.S.C.B., ISSN:1583-6258, Vol. 25, Issue 6, 2021, Pages. 13590 – 13600 Received 10 March 2021; Accepted 22 March 2021.
Intramedullary Nailing Versus Plating in the Management of Extra Articular Distal Tibial Fractures
AbdelrahimElmabrouk Muftah Salem1,ElsayedAbdelmoty Mohammed2, Mohamed Elsadik Attia3,and Sameh Mohamed Holyl4
1M.B; B.CH.; Sert University- Libya.
2Professor of Orthopedic Surgery,Faculty of MedicineZagazigUniversity.
3Ass. Professor of Orthopedic Surgery,Faculty of Medicine Zagazig University.
4 Lecturer of Orthopedic Surgery, Faculty of Medicine Zagazig University.
Correspondingauthor:AbdelrahimElmabrouk Muftah Salem
Email:[email protected]
Abstract
Background:Distal tibial fractures are the most common long bonefractures. An incidence of 17 per100 000 person-years, although more recent dataindicate that the incidence may be declining.
Tibial plating using a ‘locking’ plate can achieve accurate reduction, the need for greater soft tissue dissection increases the risk of infection, wound breakdown, and damage to the surrounding structures.
Aim of the study:To find out the best management and improving outcome of extra articular distal tibial fracture.
Patients and methods:This study carried out as a non-randomized controlled clinical trial in which we compared the functional outcome and complication rate between two techniques (nailing versus plating) for the treatment of extra-articular fractures of the distal tibia in an adult population. This study involved 2 groups of patients; each group included 9 patients with tibial fracture. Group I had fracture fixed by intramedullary nail (ILN group); the other was fixed by plate (MIPPO group). Nailing group included 6 males and 3 females and plating group included 9 males. As males are more frequently exposed to outdoor activities and hence more involved in road side accidents and industrial misfortunes.
Results:There was a statistically significant difference between the studied groups regarding classification of tibial fracture. 43A1, 43A2 and 43A3s types occurred in 77.8%, 22.2% and 0%
within nail group versus 22.2%, 66.7% and 11.1% within plate group respectively.But there was statistically significant difference between both groups regarding operative time (88.9 minutes versus 71.11 minutes within nail and plate groups respectively).Regarding union, there was statistically non-significant difference between the studied groups regarding time or score of union. Means time for weaning were 13.13 versus 15.33 weeks within nail and plate groups respectively. Mean union scores were 11.22 and 11.33 within nail and plate groups respectively.
No patient within either group need reoperation.
Conclusion:both medial distal tibial locking plate and closed intramedullary interlocking tibia nailing are appropriate treatments of extra-articular distal tibia fracture (EDTF), with each having its own merits and demerits.
Plate fixation and IM nailing were safe and effective treatment options for EDTF because both of them could provide a similar good function outcome. IM nailing should be taken priority for
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EDTF with serious soft tissue injury. MIPO should be taken priority for EDTF with distal fragment didn't enough for using of distal locking screws of expert nail.
Keywords:Extra Articular Distal Tibial Fractures, Intramedullary Nailing, Plating.
1.Introduction:
Distal tibial fractures are the most common long bonefractures. An incidence of 17 per100 000 person-years, although more recent dataindicate that the incidence may be declining(1).
In mostcases, they are due to a force directed from the foottowards the leg in highenergytraumatic events, as fall down, traffic accident,motorcycle accident or sport injury (2).
Common classifications of distal tibial fractures include distal extra-articular tibial fractures which are located between 4 and 12 cm from the tibial plafond (AO 42A1 and 43A1). Further subdivisions are made on the basis of the morphology and degree of comminution of the fracture:
43-A1 are non-comminuted extra-articular fractures, 43-A2 are wedge fractures, and 43-A3 are comminuted extra-articular fractures. Simple extension of the fracture into the joint without depression of the joint surface are classified as 43-B1 and are often treated in the same way as 43- A fractures (3-4).
These fractures differ from pilon fractures (intra articular distal tibial fractures) also in terms of the mechanism of injury, management, and prognosis of the displaced bones. The proximity of these fractures to the ankle joint leads to more complications than are seen with diaphyseal or middle- third injuries. Thus, the treatment of distal tibia fractures remains problematic(5).
The locked plates and intramedullary (IM) nails are two viable methods of fixing these fractures, each possesses distinct disadvantages. With intramedullary nailing, the bolts or screws that are inserted across the nail may break, malalignment of the bone may occur, and there is an increased risk of anterior knee pain(6).
While tibial plating using a ‘locking’ plate can achieve accurate reduction, the need for greater soft tissue dissection increases the risk of infection, wound breakdown, and damage to the surrounding structures(7).
Anatomically the medullary cavity of the tibia has a fairly uniform cavity until the junction of the proximal 2/3rd and distal 1/3rd junction. Thereafter, the cavity starts expanding till the subchondral region at the ankle. This explains why nails don't get a good hold in such fractures.
On the other hand, the limited soft tissue envelope at this region continues to be the obstacle to open reduction with internal fixation using plate fixation. This often leads to soft tissue complications and nonunion(8).We aimed in this study to find out the best management and improving outcome of extra articular distal tibial fracture.
2.Patients and Methods:
This study was carried out as a non-randomized controlled clinical trial following approval by our institutional research board (IRB). 18 patients were treated with either plating or intramedullary nailing (where there are 9 cases fixed by IMN 6 males, 3 females and 9 cases fixed by MIPO all them males). This study was conducted in Orthopedic Department, Faculty of Medicine, Zagazig University. It was possible to follow all patients included in the study. The follow-up period
Annals of R.S.C.B., ISSN:1583-6258, Vol. 25, Issue 6, 2021, Pages. 13590 – 13600 Received 10 March 2021; Accepted 22 March 2021.
ranged between 6 and 9 months.
Patients aged between 18 to 70 years with closed extra-articular fractures of distal tibia and simple and Gustilo type I open fractures were included in this study.
We excluded all of the following patients: intra- articular fracture (proximal or distal), fractures associated with neurovascular injury or compartment syndrome, pathological fractures, severe soft tissue injury with fracture blisters, infected fractures, Gustilo type ii and iii open fractures, and patients who refused to participate in the study.
Ethical consent was taken from every patient declaring full data about pre-operative, intra operative procedures and possible post-operative complications.
The patients were randomly (systemic random sampling) divided into two equal groups according to the method of surgical treatment as each odd number subject assigned into group 1 and even- number subject to group 2:
Group I: Patients who underwent fixation by closed reduction and internal fixation with an intra- medullary interlocking tibia nail.
Group II: Patients who underwent fixation by closed reduction and internal fixation with a medial distal tibial locking plate.
All patients underwent full history taking, clinical evaluation with general and local examination, and soft tissue assessment. The fractures were classified according to the AO/OTA classification system.
Routine preoperative lab investigations were requested to all patients including complete blood count (CBC), PT, PTT, INR, random blood sugar (RBS), HbA1c, liver and kidney function tests, HIV, HbSAg and HCV antibodies.
Each patient in the study performed the following radiological investigations: Plain X-Ray: The standard radiographic examination includes AP, mortise and lateral projections and included the entire tibia, fibula, foot and knee joint.
Surgical technique:
Group I:
Preoperative planning:
Preoperative anteroposterior and lateral radiographs of the fractured extremity, including the knee and ankle, are critical to define the fracture and geometry of the tibial injury.
Patient positioning:
Supine positioning on a radiolucent table with removal the end of the table and allow the injured knee to flex over the end of the table. Place the contralateral leg in a support with the hip flexed and abducted and the knee flexed.
Approach and steps:
The incision extends from the tibial tubercle to the inferior aspect of the patella. The medial aspect of the patellar tendon is identified, and the patellar tendon reflected laterally A curved awl is used to open the medullary canal at the junction of the anterior tibia and knee joint. It is important not to enter at the knee joint or at the tibial tubercle. The exact point for the awl is determined on the anteroposterior and lateral fluoroscopic views. In distal tibial fractures, the anteroposterior starting point should be in line with the center of the tibial shaft. On the lateral radiograph, the point of the awl should be just inferior to the joint line (figure 28). A bulb-tip guide wire is inserted down the
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canal. A T handle is used to control the bulb-tip guide, in the midportion of the guide wirethe bulb tip is initially aimed posteriorly to enter the tibia and then immediately turned anteriorly and passed down to the fracture site, the guide wire is advanced to the fracture site, the fracture is reduced, and the guide wire is advanced under image intensification into the distal fragment to reach subchondral bone above the ankle to stabilize the bulb tip. A long ruler is used to determine nail length externally and confirm it with image intensifier.
Reaming is a critical part of the surgical technique and must be done well to avoid complications.
A skin protector should be used to prevent soft tissue damage around the incision, The surgeon starts with a small diameter reamer and increases by 0.5 mm increments until cortical contact is reached. The fracture must be reduced as the reamer passes.
Before nail insertion, a plastic exchange tube is passed over the bulb tip and across the fracture site, the bulb tip is removed, a straight tip guide wire is inserted, and the plastic tube is removed.
The nail is introduced down the tibial canal over this guide wire the nail should be pushed posteriorly on the proximal end of the nail to minimize penetration of the posterior cortex and should be inserted in slight external rotation approximately 10 degrees in relation to the long axis of the tibia.
In stable fracture patterns, traction can be released when the nail tip is 1 cm past the fracture, this allows fracture impaction and avoids distraction. The tibia should be inspected proximally and distally.
After the nail is fully seated, proximal and distal interlocking screws are inserted. Targeting devices that attach to the intramedullary nail are very successful in placing the proximal and distal tibial locking screws.
A free hand technique may be employed for distal locking screw insertion. It requires targeting of the skin incision. The image intensifier is lined up with the nail and tilted and rotated until a perfectly round hole is visualized. The sharp point of the trocar-tipped pin is placed on the skin until it is centered in the hole.
A 1-cm stab wound is made directly over the hole on the medial aspect and the anterior aspect of the tibia to put the whole of distal locking screws of expert nail. The sharp pointed pin is again placed on the bone until it is centered in the hole Fluoroscopy is used to verify that the pin has corrected targeted the nail and the pin drilled through the far cortex. A lateral radiograph should be checked again to be absolutely certain the screw is in the nail and has not moved anteriorly or posteriorly.
Poller (blocking) screws are sited, under image intensifier distal to the fracture site anteroposteriorly, to achieve good control, to correct the deformity in the coronal plane and it enables good reduction and stable fixation. The wounds are then irrigated and closed. Before wound closure, Final radiographs are taken with the patient under anesthesia.
Group II:
A 2-3 cm incision was made along the antero-medial aspect of the tibia at the level of the medial malleolus and proximally about 2-3 cm incision proximal to the end of fracture line.
Introduction of plate:
A subcutaneous extra-periosteal tunnel was created using a dissector, through which a plate was introduced gently to prevent damaging the periosteum. Appropriate plate length was selected
Annals of R.S.C.B., ISSN:1583-6258, Vol. 25, Issue 6, 2021, Pages. 13590 – 13600 Received 10 March 2021; Accepted 22 March 2021.
under the image intensifier. Above the fracture site, a small incision (2-3 cm) was done for plate positioning proximally and centralization over the tibial shaft.
Reduction and Fixation:
Percutaneous reduction of the fracture was done by manual manipulation, reduction forceps or schanz pin. The distal screws were then inserted, two screws were inserted one over the medial malleolus and one right below the fracture site, the later screw helps in bony reduction, taking advantage of the anatomical configuration of the plate.
For spiral and short oblique fractures, compression of the ends was done by inter-fragmentary lag screw either through the plate or percutaneously outside the plate under image intensifier.
For transverse fractures, compression was done by placement of eccentric screws through non locking holes.
Post-operative follow up:
Final evaluation of the clinical results was conducted at nine months using the Teeny and Wissclinical assessment criteria, which are based on a 100-point rating system. The final clinical and symptom scores were graded as excellent (> 92), good (87 - 92), fair (65 - 86), and poor (< 65).
Statistical analysis:
Data collected throughout history, basic clinical examination, laboratory investigations and outcome measures coded, entered and analyzed using Microsoft Excel software. Data were then imported into Statistical Package for the Social Sciences (SPSS version 20.0) (Statistical Package for the Social Sciences) software for analysis. According to the type of data qualitative represent as number and percentage, quantitative group represent by mean ± SD, the following tests were used to test differences for significance; difference and association of qualitative variable by Chi square test (X2). Differences between quantitative independent groups by t test or Mann Whitney, multiple by ANOVA or Kruskal Wallis, correlation by Pearson's correlation or Spearman's. P value was set at <0.05 for significant results &<0.001 for high significant result.
3.Results:
This study involved 2 groups of patients; each group included 9 patients with tibial fracture. Group I had fracture fixed by intramedullary nail (ILN group); the other was fixed by plate (MIPPO group).
There was statistically non-significant difference between the studied groups regarding age, gender or associated comorbidities. All patients within plate group were males versus 66.7% within intramedullary nail group. Mean age of patients within intramedullary nail and plate groups were 48.89 versus 44.89 years. Comorbid hypertension within nail and plate groups prevailed in 22.2% and 22.2%
groups respectively. Comorbid diabetes within nail and plate groups prevailed in 22.2% and 22.2%
groups respectively. About 56% and 33% within nail and plate groups respectively were smokers (Table 1).
There was statistically non-significant difference between the studied groups regarding side, or associated fibula fracture. About 78% and 22% of patients within nail and pate groups had right side fractures respectively. Regarding associated fibula fracture, 88.9% and 77.8% within nail and plate groups had fracture. Both groups with fracture had webber C; lower one third suprasyndesmotic type.
All patients within plate group were males versus 66.7% within intramedullary nail group. Mean age of patients within intramedullary nail and plate groups were 48.89 versus 44.89 years (Table 2).
There was statistically significant difference between both groups regarding operative time (88.9 minutes versus 71.11 minutes within nail and plate groups respectively). There was statistically non- significant difference between the studied groups regarding method of fixation of fibula fracture. Two thirds versus 44.4% of patients within nail and plate groups had their fracture not fixed (Table 3).
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There was statistically significant difference between both groups regarding length of hospital stay (mean LOS were 1.11 days versus 1.78 days within nail and plate groups respectively) (Table 4).
There is statistically non-significant difference between both groups regarding presence or severity of pain, distance, swelling, stair climbing, running, toe rising, hill climbing, plantar, dorsal range of movement or support (Table 5).
Table (1): Comparison between the studied groups regarding demographic data:
Groups
Parameter Intramedullary nail (ILN) Plate (MIPPO) Test
group group p
N=9 (%) N=9 (%) χ2/t
Gender:
Male 6 (66.7) 9 (100) Fisher 0.206
Female 3 (33.3) 0 (0)
Age (year):
Mean ± SD 48.89 ± 11.297 44.89±15.744 0.619 0.544
Min – Max 29–63 20–65
Associated comorbidities:
No 2 (22.2) 4 (44.4) Fisher 0.62
Hypertension 2 (22.2) 2 (22.2) Fisher >0.999
DM 2 (22.2) 2 (22.2) Fisher >0.999
Smokers 5 (55.6) 3 (33.3) Fisher 0.637
Table (2): Comparison between the studied groups regarding fracture related data:
Groups
Intramedullary nail Plate
Fracture (MIPPO Test p
(ILN) group
) group
N=9 (%) N=9 (%) χ2/t
Side:
Left 2(22.2) 7 (77.8)
Fisher 0.057
Right 7(77.8) 2 (22.2)
Classification of tibial fracture:
43A1 7(77.8) 2 (22.2)
43A2 2(22.2) 6 (66.7)
5.276 0.022*
43A3 0(0) 1 (11.1)
Mode of trauma
RTA 6(66.7) 5(55.7)
Hit by car 1(11.1) 3(33.3)
Fisher <0.999
FFH 2(22.2) 1(11,1)
Associated fibula fracture:
No 1(11.1) 2 (22.2)
Yes (Webber C;1/3 suprasyndesmotic) 8(88.9) 7 (77.8) Fisher >0.999
Tab
le (3):Comparison between the studied groups regarding operative data:Groups
Fracture Intramedullary Plate (MIPPO) Test
nail (ILN) group group p
N=9 (%) N=9 (%) t/χ2
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Annals of R.S.C.B., ISSN:1583-6258, Vol. 25, Issue 6, 2021, Pages. 13590 – 13600 Received 10 March 2021; Accepted 22 March 2021.
Operative time (minute):
Mean ± SD 88.89 ± 9.28 71.11± 9.93 3.924 0.001**
Min - max 65–95 60–90
Fibula fixation:
No 6 (66.7) 4 (44.4)
1.543 0.631
Intramedullary K wire 0 (0) 1 (11.1)
ORIF by 1/3 plate 3 (33.3) 4 (44.4)
Table (4): Comparison between the studied groups regarding hospital stay:
Groups
Fracture Intramedullary nail Plate (MIPPO) Test (ILN) group group p
N=9 (%) N=9 (%) χ2/t
Hospital stay (day):
1.11 ± 0.333 1.78 ± 0.441
Mean ± SD -3.168 0.002*
1 – 2 1 – 2
Min - max
Table (5): Comparison between the studied groups regarding tenny&wiss criteria:
Groups
Intramedullary Plate
Fracture (MIPPO) Test p
nail (ILN) group
group
N=9 (%) N=9 (%) χ2/t
Pain:
No 4 (44.4) 5 (55.6)
Mild pain 4 (44.4) 3 (22.2) 0.038 0.846
Mild to moderatepain 0 (0) 2 (22.2)
Continuous 1 (11.1) 0 (0)
Distance:
Unlimited 4 (44.4) 5 (55.6)
Unlimited but >6 blocks 2 (22.2) 2 (22.2)
0.038 0.846
Limited but>6 blocks 2 (22.2) 1 (11.1)
4-6 blocks 1 (11.1) 0 (0)
Indoor only 0 (0) 1 (11.1)
Swelling:
No 3 (33.3) 2 (22.2)
0.106 0.745
Only evening 4 (44.4) 5 (55.6)
Constant 2 (22.2) 2 (22.2)
Stair climbing:
Climb and descend normally 4 (44.4) 6 (66.7)
0.447 0.504
Need banister 4 (44.4) 2 (22.2)
Impossible 1 (11.1) 1 (11.1)
Running:
Unlimited 7 (77.8) 7 (77.8)
Limited but able 1 (11.1) 1 (11.1)
Unable 1 (11.1) 1 (11.1)
Toe rising:
10 repetitions 8 (88.9) 7 (77.8) Fisher >0.999
5 repetitions 1 (11.1) 2 (22.2)
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Groups
Intramedullary Plate
Fracture (MIPPO) Test p
nail (ILN) group
group
N=9 (%) N=9 (%) χ2/t
Hill:
4 (44.4) 5 (55.6)
Up and downnormally
5 (55.6) 2 (22.2) 0.114 0.736
Climbs with foot externally rotated Unable
0 (0) 2 (22.2)
Support:
4 (44.4) 6 (66.7)
None 4 (44.4) 1 (11.1)
Orthosis only for long walks 0 >0.999
1 (11.1) 1 (11.1)
Single crutch fulltime
0 (0) 1 (11.1)
Two crutches
Plantar range:
>300 8 (88.9) 7 (77.8) Fisher >0.999
>100 1 (11.1) 2 (22.2)
Dorsal range: N=8)
>150 7 (87.5) 7 (77.8)
<150 1 (12.5) 0 (0)
<100 0 (0) 2 (22.2)
4.Discussion:
Extra-articular distal tibial shaft fractures are common fractures requiring operative treatment.
Although several treatment methods exist, none of the fixation techniques are ideally suited for all combinations of bony and soft tissue injuries. The decision to proceed with either plate fixation or IMN is further complicated by evolving implant designs and surgical approaches (9).
Although open reduction with internal fixation can achieve optimal reduction and maintain anatomical fixation and distal tibia reconstruction, wound complications and deep infection have resulted from this form of treatment due to increased soft tissue and vascular disruption. So, surgical advances have been developed to improve plate fixation and to limit iatrogenic soft tissue trauma and preserve blood supply to the fracture site by less invasive technique (MIPO) (10).
Although intramedullary nailing can limit wound complication and deep infection, delayed fracture healing and mal union have been the most debated complication. Achieving and maintaining good reduction with IM nailing is notably difficult because of the anatomic characteristics of distal tibial fractures. So, surgical advances have been developed to improve IM nailing durability and to aid fracture reduction including blocking screws and multiple plane locking screws (11).
Ali et al. (12) compared the outcome of installing a medial distal tibial locking plate through minimally invasive percutaneous plate osteosynthesis (MIPPO) with closed intramedullary interlocking nailing in the treatment of extra-articular distal tibial fractures. Both groups were similar with respect to sex (p > 0.05).
In our study, the mean age for the nailing group was 48.89 years while in plating group was 44.89
Annals of R.S.C.B., ISSN:1583-6258, Vol. 25, Issue 6, 2021, Pages. 13590 – 13600 Received 10 March 2021; Accepted 22 March 2021.
years. This can be explained because of active engagement and exposure to outdoor life and road traffic accidents in this active age group. Statistically, there is non-significant difference between the studied groups regarding age. Similarly, Ali et al. (12) found that both groups were similar with respect to age (p > 0.05).
Kruppaet al. (13) reported that no significant association between fracture type, severity and malunions could be demonstrated. Ali et al. (12) found that both groups were similar with respect to side involved, mode of trauma, clinical type of fracture and radiological type of fracture (p >
0.05).
Li et al. (14) showed significant decrease in operative time in ILN group. This can be attributed to many factors such as presence of fibular fracture, difficulties in reduction, presence of good assistance and the expert of surgeon. ButBisaccia et al. (15) did not find a statistically significant difference in terms of operation time between the two groups.
In our study, there is statistically significant difference between both groups regarding length of hospital stay (mean LOS were 1.11 days versus 1.78 days within nail and plate groups respectively). ButBisaccia et al. (15) did not find a statistically significant difference in terms of hospital stay between the two groups.
Regarding union, there is statistically non-significant difference between the studied groups regarding time or score of union. Means time for union were 13.13 versus 15.33 weeks within nail and plate groups respectively. Mean union scores were 11.22 and 11.33 within nail and plate groups respectively. No patient within either group need reoperation. Bisaccia et al (15) compared between intramedullary nail (IMN) and locked plate (LP) and found that the mean union time was 21.8 weeks for the IMN group (17.4–23.3) and 24.2 weeks for the LP group (range 17.6–28.3).
This difference did not result being statistically significant (p>0.05).
Ali et al. (12) concluded that both treatment via medial distal tibial locking plate by MIPPO and closed intramedullary interlocking tibia nailing are viable options for management of extra- articular distal tibia fractures. The final choice between the two depends on the surgeon’s experience.
Bisaccia et al. (15) suggested that intramedullary nailing and locked plating treatment are comparable treatments when considering functional outcome for distal tibial fractures. They indicated a superiority of IMN over LP in terms of lower rates of infections and statistically significant shorter time to full weight bearing. Whereas LP appeared to be advantageous over IMN in terms of leading to a better anatomical and fixed reductions of the fracture and a lower rate of union complications.
5.Conclusion:
Distal tibial fractures often present a challenge to the orthopaedic surgeon. The treatment of this type of fracture is of current research interest, since there is no universally agreed treatment method. The choice of treatment must take into account not only the stabilization of the fracture, but also the management of the soft tissue injury which is a frequent cause of subsequent
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complications.
This study suggests that both medial distal tibial locking plate and closed intramedullary interlocking tibia nailing are appropriate treatments of extra-articular distal tibia fracture (EDTF), with each having its own merits and demerits. Plate fixation and IM nailing were safe and effective treatment options for EDTF because both of them could provided a similar good function outcomes. IM nailing should be taken priority for EDTF with serious soft tissue injury. MIPO should be taken priority for EDTF with distal fragment didn't enough for using of distal locking screws of expert nail.
6.ConflictofInterest:
Noconflictofinterest.7.References
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