SICOT-J 2018, 4, 2

© The Authors, published by EDP Sciences, 2018

https://doi.org/10.1051/sicotj/2017058
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ORIGINAL ARTICLE

Nail or plate in the management of distal extra-articular tibial

fracture, what is better? Valutation of outcomes
Michele Bisaccia1, Andrea Cappiello1, Luigi Meccariello2,*, Giuseppe Rinonapoli1, Gabriele Falzarano3,
Antonio Medici3, Cristina Ibáñez Vicente1, Luigi Piscitelli1, Verdiana Stano4, Olga Bisaccia5, and Auro Caraffa1
1
Department of Orthopaedics and Traumatology, “S.M. Misericordia Hospital”, University of Perugia, Perugia, Italy
2
Department of Orthopedics and Traumatology, Vito Fazzi Hospital, Lecce, Italy
3
Department of Medical and Surgical Sciences and Neuroscience, Section of Orthopedics and Traumatology, University of
Siena, University Hospital “Santa Maria alle Scotte”, Siena, Italy
4
Department of Civil Engineering and Computer Engineering, Faculty of Medical Engineering, University of Rome Tor
Vergata, Rome, Italy
5
Department of Radiology, “San Donato Hospital” University of Milano, Milano, Italy
Received 22 June 2016, Accepted 14 November 2017, Published online 21 February 2018

Abstract -- Introduction: Distal tibial fractures are the most common long bone fractures. Several studies
focusing on the methods of treatment of displaced distal tibial fractures have been published. To date, locked
plates, intramedullary nails and external fixation are the three most used techniques. The aim of our study was
to compare intramedullary nail (IMN) and locked plate (LP) for treatment of this kind of fracture.
Materials and methods: We collected data on 81 patients with distal tibial fractures (distance from the joint
between 40 and 100 mm) and we divided into two groups: IMN and LP. We compared in the 2 groups the mean
operation time, the mean union time, the infection rate the rate of malunion and nonunion, the full weight
bearing time.
Results: No patient in the two groups developed a nonunion. None of the patients obtained a fair or poor
outcome. Overall 52 patients obtained an excellent result (69.3%) and 23 obtained a good result (30.6%).
Discussion: Our study results indicate 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. The two treatments achieved comparable results in terms of operation time, hospital stay, union
time and functional outcomes.

Key words: Plate, Nail, Extra-articular distal tibia, Outcome, Surgical management distal tibia

Introduction fractures are even more at risk of exposure because of their

proximity to the ankle and the lack of arterial supply in the
Distal tibial fractures are the most common long bone distal tibia [4,5]. In a rate of 80% of this kind of traumas,
fractures. Published data suggest an incidence of 17 per fibula is involved. Furthermore, fibula tends to heal more
100 000 person-years [1], although more recent data rapidly than tibia [1].
indicate that the incidence may be declining [2]. In most Several studies focusing on the methods of treatment of
cases, they are due to a force directed from the foot displaced distal tibial fractures have been published [5–
towards the leg in the environment of outstanding high- 11]. To date, locked plates, intramedullary nails and
energy traumatic events, as fall down, traffic accident, external fixation are the three most used techniques, but
motorcycle accident or sport injury [3,4]. each has been historically related to complications: mal-
Their management presents a series of problems alignment and knee pain have been associated with
because this kind of fractures could determine the damage nailing; infections, wound complications and implant
of the surrounding soft tissues; indeed, soft tissues are very prominence are frequently reported after tibial plating;
thin in this region of the leg; furthermore, tibial distal prolonged fracture healing, frequent need of secondary
operations and infections of the pin tract are inherent
*Corresponding author: [email protected] problems in external fixation [6,7,12].

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
2 M. Bisaccia et al.: SICOT-J 2018, 4, 2

Figure 1. Tibial distal fracture AO 42-B1 with irradiation of

the fracture line up to the joint.

Figure 3. The same fracture of Figure 1 after surgery. IMN and

K wire to stabilize the fibua. Use of Poller’s screws in the distal
tibia because the fracture was very close to joint line.

Figure 2. (a,b) AO: 42-A1 fracture of right tibia.

The aim of our study was to compare intramedullary The distance from the joint was in all the cases between
nail (IMN) and locked plate (LP) for: operation time, 40 and 100 mm. All the tibial fractures were associated
hospital stay, union time, rate of infections and union with fibular fractures. In 54 patients we performed a
complications (nonunion and malunion). stabilization with intramedullary K wire because they
presented a lower fracture. Overall 6/81 patients were lost
Materials and methods
at follow up.
We collected our data retrospectively between Janu- Exclusion criteria were: associated proximal intra-
ary 2009 and January 2015, on 81 patients with distal articular or distal intra-articular fractures of the tibia, tibial
tibial fractures (Figures 1, 2a and b). plafond fractures, vascular injury requiring repair, patho-
Patients were divided into two groups: the IMN group logic fractures, previous fractures of the same limb, open
included 41 patients who underwent IMN (Figure 3), fractures along with past or present corticosteroid use.
whereas LP group included 34 patients who underwent LP All of the fractures: 75 were classified with AO system
(Figures 4a and b). and the obtained results are described in Graph 1.
 M. Bisaccia et al.: SICOT-J 2018, 4, 2 3

Figure 4. (a,b) The same case of Figure 2 after surgery. We use a LCP plate for distal tibia and 3 lag screws.

Figure 5. Subdivision of the 75 fractures according A.O.

Trauma classification.
Figure 6. Description of the population.

– 14 with a 43-A1 fracture in the IMN group and 12 in the All patients received 4000 international units of
LP group;
enoxaparin sodium to prevent thromboembolism and 2 g
– 20 with a 43-A2 fracture in the IMN group and 16 in the
LP group; of intravenous cefazolin as preventive antibiotic therapy
– 7 with a 43-A3 fracture in the IMN group and 6 in the LP before the operation. All surgical procedures were
group. performed using bi-block anesthesia on a radiolucent
operating table.
The overall mean distance of the fracture from the joint Clinical and radiological follow-ups were done at 1, 3, 6
was 80.1 mm (range 40–96.5 mm): IMN group: 73.2 (range
50.5–96.5 mm); LP group: 59.2 (range 40–53.8). and 12 months after the operation (Figures 7 and 8).
In the IMN group we used Trigen Smit and Nephew Nonunion was defined as the absence of any sign of
nails with parapatellar medial access. While in the LP callus formation after 6 months. Moreover, malunion was
group, we used and antero-medial access. defined as angulation of more than 5° on any plane. Union
There were 27 female and 48 male patients. In 38 cases, was clinically defined as the ability to walk without pain
the right limb was involved while in the remaining 37 cases and when a radiograph showed a solid bridging callus of
the left limb was involved. Mean age was 31 years (range obliteration of the fracture line. Radiological assessment
18–71 years). was performed in antero-posterior and lateral views.
Age, sex, time between fracture and surgery along with Our patients were encouraged to perform ankle flexion
side of the fracture are described in Figure 6. and extension exercises after the operation; partial-weight
In 72 patients, we performed a close reduction of the bearing was allowed after three weeks in both groups.
fracture and temporarily applied a open plaster. A skeletal Clinical results were assessed using the Olerud–
traction was applied in 9 cases. Molander Ankle Score [11,13–15].
4 M. Bisaccia et al.: SICOT-J 2018, 4, 2

Figure 7. (a,b,c) Post-operative radiography at 3 months follow-up of IMN.

Figure 8. (a,b,c) Post-operative radiography at 6 months follow-up of LP patient with good formation of bone callus.

Statistical analysis The mean operation time was 78 min for the IMN
group (range 75’–83’) and 92 min for the LP group (range
We used Student’s t test to compare the inter-group 88’–97’). This difference did not result being statistically
parameters with quantitative data and descriptive significant (p > 0.05).
statistical methods (mean, standard, frequency). We used The mean union time was 21.8 weeks for the IMN
the chi-square test and Fischer’s exact chi-square test to group (17.4–23.3) and 24.2 weeks for the LP group (range
compare qualitative data. The significance level was set at 17.6–28.3). This difference did not result being statisti-
p < 0.05. cally significant (p > 0.05).
The infection rate for the IMN was 0; while the same
rate was 5.88% for the LP group (2 patients developed
Results infection). This rate difference was not statistically
significant (p > 0.05). The two infected patients were
Overall, the complete case series included 75 patients.
treated by removing the synthesis means, implanting a
The mean time between the trauma and the operation
temporary external fixation and adequate antibiotic
was 2.7 days for the IMN group (range: 1–6) and 3.1 for the
therapy was prescribed. After the infection was healed,
LP (range 1–7); without being statistically significant.
we performed a new surgical procedure to implant a
The mean hospital time after surgery was 4.5 days for
second locked plate.
the IMN group (range 3–7 days) versus 5 days for the LP In the IMN group, 9 patients developed a malunion
group (range 3–8 days); without resulting statistically (rate 21.9%): 6 varus and 3 valgus deformities. Thus, we
significant (p < 0.05). did not obtain a malunion greater than 11°. In the LP
 M. Bisaccia et al.: SICOT-J 2018, 4, 2 5

group, no patient developed a malunion (rate 0%). This In our study, we did not find a statistically significant
rate difference resulted being statistically significant difference in terms of operation time, hospital stay,
(p > 0.05). infection rate, union time and functional outcomes
No patient in the two groups developed a nonunion. between the two groups but we did observe at least 3
In the IMN group 8 patients developed anterior knee points of interest. First, regarding the rate difference in
pain (19.5%). This rate was higher than those reported in terms of malunion, 9 patients developed a malunion in the
previously published clinical studies; probably depending IMN group (rate 21.9%) while no patient developed a
on the nailing approach. Indeed, with the trans-patellar malunion in the LP group (rate 0%). This event could
access, pain could be due to patellar tendon and retro- occur because locked plating advances a more anatomical
patellar fat pad damage [5]. We used only the para-patellar and fixed reduction of the fracture, while intramedullary
approach. nailing treatment mainly permits minimal movements of
The full weight bearing time was significantly longer in the bone fragments.
the LP group compared to the IMN group (15.3 ± 2.9 Second, regarding the time of permission to apply full
weeks versus 12.8 ± 3 weeks, respectively). This difference weight bearing, it was 12.8 ± 3 weeks for the IMN group,
was statistically significant (p < 0.05). and 15.3 ± 2.9 weeks for the LP group. We allowed full
Olerud–Molander Ankle Score: 30 patients in the IMN weight bearing depending on the operator surgeon
group and 22 patients in the LP group obtained an indications, based on clinical and radiographic signs. This
excellent outcome (rate 62.2% and 64.7%, respectively), suggests that intramedullary nailing guarantees a signifi-
11 patients in the IMN group and 12 in the LP group cantly shorter full weight bearing time than locked
obtained a good outcome (rate 26.8% and 35.3%, plating.
respectively). None of the patients obtained a fair or poor Finally, with regards to functional outcome patients in
outcome. Overall 52 patients obtained an excellent result the two groups had similar Olerud–Molander Ankle
(69.3%) and 23 obtained a good result (30.6%). Scores: 30 in the IMN group and 22 in the LP group
obtained excellent outcomes, 11 in the IMN group and 12
Discussion in the LP group obtained good outcomes; none of the 75
patients obtained a fair or poor outcome.
In the context of distal tibial fractures, surrounding We did not obtained significant results in terms of
soft tissues are often damaged; therefore, a treatment that union time. Probably in the LP group union was advanced
respects these tissues is very important. A complete by a more anatomical reduction, in the IMN group it was
reduction of the fracture could be obtained with an advanced by a shorter bearing time.
anatomical plating, that require large incisions and, These results strongly suggests that intramedullary
subsequently, a risk of high rate of infections and tissue nailing and locked plating treatment are comparable
suffering, while minimal invasive methods minimize the treatments when considering functional outcome for
damage of the soft tissues [13,14]. At present, the main distal tibial fractures. Our study results indicate a
surgical procedures for the treatment of tibial distal superiority of IMN over LP in terms of lower rates of
fractures are intramedullary nails, locked plates and infections and statistically significant shorter time to full
external fixation. The latter procedure is particularly weight bearing. Whereas LP appeared to be advanta-
indicated when the cutaneous suffering determined by the geous over IMN in terms of leading to a better
high-energy traumatic event does not allow any other anatomical and fixed reductions of the fracture and a
surgical procedure [7,8–10,15]. lower rate of union complications. The two treatments
Several studies were carried out [16,17] to compare achieved comparable results in terms of operation time,
intramedullary nailing to plating, plating to external hospital stay, union time and functional outcomes. A
fixation and intramedullary nailing to external fixation. future clinical study will need to include at least 300
The aim of our study was to compare IMN to LP [18,19]. patients in order to better characterize any differences or
Actually, at present, their indications are still discussed. similarities between IMN and LP in patients with distal
Various clinical studies have compared IMN and LP tibial fractures.
[13,20–22]: the former leads to a lower rate of soft tissue
complications and infections and has been associated with
a significantly shorter full weight bearing and a shorter Conflict of interest
union time. On the other hand, IMN appears has been
The authors declare no conflict of interest.
reported to lead to a higher rate of malunion and nonunion
because it may involve reduction issues [16,19,20,23].
Locked plate is advantageous given that it generally Acknowledgments. G. Rollo revised the data, the text and
leads to a better and a greater reduction of the fracture. contributed in discussion update according to his experience and
Additionally it allows for a better stabilization of distal scientific background. Human and animal right: For this type of
tibial fractures and it advances the bone healing more than study is not required any statement relating to studies on
intramedullary nails [23–28]. humans and animals.
6 M. Bisaccia et al.: SICOT-J 2018, 4, 2

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Cite this article as: Bisaccia M, Cappiello A, Meccariello L, Rinonapoli G, Falzarano G, Medici A, Vicente CI, Piscitelli L, Stano
V, Bisaccia O, Caraffa A (2018) Nail or plate in the management of distal extra-articular tibial fracture, what is better? Valutation
of outcomes. SICOT-J, 4, 2.