Intramedullary Nailing Versus Plating for Proximal Tibia Fractures: A Systematic Review and Meta-analysis

Fixation of Proximal Tibial Fractures with Intramedullary Nail and Immediate Weightbearing: A Beneficial Alternative

Newer intramedullary (IM) nails have become another option in the fixation of proximal tibia fractures. There is limited data on the successful use of these implants in intra-articular and extra-articular fractures of the proximal tibia, and no studies assessing the ability of these implants to maintain alignment with early weight bearing. Our objective was to determine whether immediate weight bearing after IM fixation, with or without supplemental plate or screw fixation, of proximal third tibial fractures (OTA/AO 41A-C) results in a change in alignment prior to union. 35 patients with 39 proximal tibia fractures from 2015 to 2020, all treated with IM nailing with or without supplemental plate or screw fixation, all made weight-bearing as tolerated following surgery, were included. The main outcomes were change in medial proximal tibial angle (MPTA) and posterior proximal tibial angle (PPTA) from initial post-operative films to final follow up. 12 fractures were OTA/AO 41 type A, 14 were type B, and 13 were type C. Mean initial MPTA was 87.0 +/-2.53 degrees, while mean initial PPTA was 79.6 +/- 3.50 degrees. The mean change in MPTA was 0.048 +/- 2.8 degrees (P=0.92), and mean change in PPTA was 0.264 +/- 3.67 degrees. 92.3% of fractures had normal final coronal plane alignment, with MPTA between 85.0 and 90.0 degrees. 89.7% of fractures had normal final sagittal plane alignment, with PPTA between 77.0 and 84.0 degrees. No patients required reoperation for malalignment. In OTA/AO type 41 fractures, immediate weight bearing after IM nail fixation, with or without supplemental plate or screw fixation when indicated, leads to minimal change in final coronal or sagittal alignment, and was well tolerated in most patients. [authors blinded for review].

Assessing the effectiveness of intramedullary nailing for tibial shaft fractures in a low-income setting: a prospective study in Yemen

BACKGROUND

Tibial shaft fractures are common injuries that can be treated with various methods, including interlocked intramedullary nail (IMN). However, there is limited data on the clinical outcomes of IMN for tibial shaft fractures in Yemen.

OBJECTIVE

To evaluate the clinical outcomes of primary IMN for tibial shaft fractures in Yemen.

METHODS

This was a prospective study of 134 patients who underwent primary IMN for tibial shaft fractures et al.-Thawra Modern General Hospital in Sana'a, Yemen, between June 2016 and June 2020. The patients were between 18 and 70 years old, and the fractures were classified according to the AO classification system. The fractures were treated with IMN using a standard technique. The patients were followed up for a minimum of 2 years. The outcome measures included union time, complications, and functional scores.

RESULTS

The mean union time was 17 weeks. The overall complication rate was 18.7%. The most common complications were infection (8.2%), delayed union (6.7%), and nonunion (3.7%). The mean functional scores at the final follow-up were 91.4 for the Knee Society Score and 90.2 for the American Orthopaedic Foot and Ankle Society Score.

CONCLUSION

Primary IMN is an effective and reliable method for treating tibial shaft fractures in Yemen, with acceptable union time, complication rate, and functional outcomes.

Comparison of suprapatellar intramedullary nailing versus minimal invasive locked plating for proximal tibia fractures

PURPOSE

To compare the radiological alignment, union time, union rate, and complication rate between suprapatellar intramedullary nails and minimally invasive locking plate fixation in the treatment of proximal tibial fractures.

MATERIALS AND METHODS

We retrospectively analyzed 103 patients who underwent plate fixation (n = 50) or suprapatellar intramedullary nailing (n = 53) for proximal tibial fractures involving the meta-diaphyseal junction between November 2015 and October 2020 at our institution. The union rate, union time, radiologic alignments, and complications, such as malalignment, nonunion, and deep infection, were investigated.

RESULTS

The demographic data did not differ between the plate and suprapatellar intramedullary nail groups. The alignment of the coronal plane was 0.24 ± 3.19 in the plate group and - 0.49 ± 2.22 in the intramedullary nail group (p = 0.196). Sagittal plane alignment was - 0.29 ± 4.97 in the plate group and 0.24 ± 4.12 in the intramedullary nail group (p = 0.571), and coronal malalignment (p = 0.196), sagittal malalignment (p = 0.57), deep infection (p = 0.264), nonunion (p = 0.695), union time (p = 0.329), and final union rate (p = 0.699) were not significantly different between groups.

CONCLUSION

Compared with the minimally invasive locking compression plate group, the suprapatellar intramedullary nail group yielded comparable results in terms of radiological alignment and complications. Considering that proximal tibial fractures are associated with high-energy trauma and severe soft tissue damage, we believe that a suprapatellar intramedullary nail may be a good alternative.

LEVEL OF EVIDENCE

Level III.

Intramedullary nail versus minimally invasive plate osteosynthesis for displaced extraarticular proximal tibia fractures: a prospective comparative cohort study

PURPOSE

The treatment of extraarticular proximal tibial fractures is challenging. As the optimal fixation technique is still debated, the purpose of this study was to compare minimally invasive plate osteosynthesis (MIPO) and intramedullary nail (IMN) fixation.

METHODS

A prospective matched comparative study was conducted on patients with displaced extraarticular proximal tibia fractures treated with MIPO (n = 29) versus IMN (n = 30) fixation. Outcomes collected were the Johner-Wruhs grading, range of motion (ROM), union rate, time to union, malunion, coronal and sagittal alignment, and post-operative complications.

RESULTS

Union rates were similar between the MIPO and IMN groups (93% vs. 97%, P = 1.0). The IMN group had an earlier time to union (15 vs. 18 weeks, P < 0.001) and superior functional outcomes at one year (effective Johner-Wruhs score: 80% vs. 55%, P = 0.04). There was a significantly higher incidence of anterior knee pain in the IMN group (23% vs. 0%, P = 0.02) and there was a trend for more infections in the MIPO group (21% vs. 13%, P = 0.73).

CONCLUSION

IMN fixation of extraarticular proximal tibia fractures was associated with a shorter union time and better functional scores compared to MIPO.

Evaluation of effects of small-incision approach treatment on proximal tibia fracture by deep learning algorithm-based magnetic resonance imaging

In this study, magnetic resonance imaging (MRI) based on a deep learning algorithm was used to evaluate the clinical effect of the small-incision approach in treating proximal tibial fractures. Super-resolution reconstruction (SRR) algorithm was used to reconstruct MRI images for analysis and comparison. The research objects were 40 patients with proximal tibial fractures. According to the random number method, patients were divided into a small-incision approach group (22 cases) and an ordinary approach group (18 cases). The peak signal-to-noise ratio (PSNR) and the structural similarity index (SSIM) of the MRI images before and after the reconstruction of the two groups were analyzed. The operative time, intraoperative blood loss, complete weight-bearing time, complete healing time, knee range of motion, and knee function of the two treatments were compared. The results showed that after SRR, the PSNR and SSIM of MRI images were 35.28 and 0.826 dB, respectively, so the MRI image display effect was better. The operation time in the small-incision approach group was 84.93 min, which was significantly shorter than that in the common approach group, and the intraoperative blood loss was 219.95 mL, which was significantly shorter than that in the common approach group (P < 0.05). The complete weight-bearing time and complete healing time in the small-incision approach group were 14.75 and 16.79 weeks, respectively, which were significantly shorter than those in the ordinary approach group (P < 0.05). The half-year knee range of motion and 1-year knee range of motion in the small-incision approach group were 118.27° and 128.72°, respectively, which were significantly higher than those in the conventional approach group (P < 0.05). After 6 months of treatment, the rate of good treatment was 86.36% in the small-incision approach group and 77.78% in the ordinary approach group. After 1 year of treatment, the rate of excellent and good treatment was 90.91% in the small-incision approach group and 83.33% in the ordinary approach group. The rate of good treatment for half a year and 1 year in the small incision group was significantly higher than that in the common approach group (P < 0.05). In conclusion, MRI image based on deep learning algorithm has a high resolution, good display effect, and high application value. The small-incision approach can be applied to the treatment of proximal tibial fractures, which showed good therapeutic effects and a high positive clinical application value.

[Osteosynthesis of extra-articular proximal tibial fractures]

The treatment of extra-articular proximal tibial fractures is a therapeutic challenge due to the frequently significant soft tissue injury, the effect of the deforming forces and the need for an exact restoration of the bony alignment. Various methods of osteosynthesis are available for surgical stabilization. The locking plate osteosynthesis is the most frequently used procedure because of its good biomechanical stability, especially in osteoporotic bones, and the protection of the periosteal blood flow. Depending on the extent and stability of the defect zone, especially in the case of a medial comminuted zone and the bone quality, bilateral plate osteosynthesis can be necessary. If the proximal fragment is big enough, closed reduction and intramedullary nailing are possible. In the case of severely compromised soft tissue or very short epiphyseal fragments, the construction of an external fixator, e.g. hybrid external fixator, is recommended, which also allows definitive treatment under early full weight bearing. The most important complications are axial and torsional malalignments.

Comparable outcomes with intramedullary nail and plate constructs for Schatzker VI tibial plateau fractures

BACKGROUND

Outcomes data of intramedullary nail fixation (IMN) constructs for complex Schatzker VI tibial plateau fractures are scant in the literature. This study compares the clinical and radiographic outcomes of IMN, dual plate, and single plate constructs for Schatzker IV tibial plateau fractures.

METHODS

Retrospective cohort study of sixty-two patients at a University-based Level 1 trauma center who underwent open reduction internal fixation for Schatzker VI tibial plateau fracture. Constructs evaluated were IMN (with or without raft screws), dual plating, and single plating. Demographic, clinical, and radiographic outcomes were recorded. All fractures were additionally classified based on the OTA classification for sub analyses. Mean follow-up was 13.2 (SD 13.3) months. Predictors of construct selection and outcomes were evaluated with bivariate logistic regression. Outcomes were compared between groups with independent samples t-tests and Chi Square tests.

RESULTS

No significant demographic differences were found between IMN, dual plate or single plate construct cohorts. There was a higher proportion of open fractures within the IMN construct group versus the dual plate cohort (21.1% vs 3.6%). No statistically significant differences in radiographic outcomes were observed between cohort groups except for small but statistically significant differences in condylar width (CW) ratio change and tibial slope; when fracture cohorts were sub analyzed by specific OTA classification, there were no significant differences in any radiographic outcomes. There was a significant difference between the ratio of OTA 41C1, C2 and C3 fractures regarding treatment allocation (p = 0.004), favoring dual plate fixation for OTA 41C3 fractures. There were no significant differences found between treatment cohorts in terms of all cause complications (p > 0.05). IMN and single plate constructs were utilized when posteromedial condyle fractures were nondisplaced or minimally displaced.

CONCLUSION

Intramedullary nail fixation with or without supplemental raft screws produced similar short-term clinical and radiographic results compared to dual and single plate constructs among patients with Schatzker VI fracture types, regardless of OTA classification. Level of Evidence Level III retrospective cohort.

Combined Medial Plate and Intramedullary Nailing for the Fixation of Extra-Articular Proximal Tibial Fractures: a Biomechanics Study

Purpose: The extra-articular proximal tibial fractures continue to have high malunion rates despite development in intramedullary nailing (IMN) technology. Combined plate and IMN fixation can increase mechanical stability. The purpose of this study was to investigate combined plate and IMN for the treatment of extra-articular proximal tibial fracture using a biomechanical model.

Methods: A 10-mm defective osteotomy was created in the fourth-generation composite tibia to simulate extra-articular proximal tibial fractures (AO/OTA 41A2). The fractures were stabilized with IMN alone (IMN group), IMN with supplementary medial plate (M-IMN group), and IMN with supplementary lateral plate (L-IMN group). The biomechanical properties of each specimen were tested under axial compression loading, bending stress, and cyclic loading. The maximum displacement of the fragments and implant-bone construct failure was recorded.

Results: The maximum displacement of the M-IMN group was significantly less than either the L-IMN or IMN group in both axial compression loading and bending stress (p < 0.05 for both comparisons). All specimens in the three groups survived in 10,000 cyclic loading without hardware deformation. The maximum stiffness of failure was similar between the M-IMN and L-IMN groups, but the IMN group was statistically lower than either the L-IMN or the IMN group (p < 0.05).

Conclusion: The results indicated that combined medial plate and IMN fixation could effectively increase the mechanical stability of proximal tibial fractures.