Vol 10 | Issue 2 | July-December 2024 | page: 17-19 | Shrikant Pradeep Savant

https://doi.org/10.13107/jmt.2024.v10.i02.225

Author: Shrikant Pradeep Savant [1]

[1] Department of Orthopaedics and Joint Replacement, Criticare Asia Hospital, Andheri East, Mumbai, Maharashtra , India

Address of Correspondence
Dr. Shrikant Pradeep Savant,
Consultant Orthopaedics and Joint Replacement, Criticare Asia Hospital, Andheri East, Mumbai, Maharashtra ,
India.
E-mail: shrikantsavant11@gmail.com

Abstract

Purpose: The treatment of tibia fractures remains a gray area due to its tendency to have different modalities for different fracture patterns, a high nonunion and malunion rate and its tendency for infection due to its proximity to the skin. We conducted a study to compare the results of tibia fractures in terms of the rate of union, quality of the limb, incidence of complications and patient satisfaction.

Methods: Patients with extra articular tibia fractures, who were admitted in a tertiary care hospital from July 2017 to May 2019 taken for study after obtaining their consent. Follow up of the cases done for a period of 24 months. Exclusion criteria included medically unfit patient for surgery, compound fractures and pathological fractures.

Conclusion: Fracture type or pattern does not influence the eventual functional outcome.Closed reduction with tibia interlocking nail has got lesser early as well as late post operative complications as compared internal fixation with plating. Closed reduction with interlocking nail has got the advantage of early mobilization with full weight bearing as compared to with plating in which weight bearing is delayed.

Keywords: Tibia shaft fracture, Extra articular, Nailing vs plating, LEFS score

Introduction
The tibia, commonly known as the shinbone, is the larger and stronger bone in the lower leg. It bears the full weight of the body and connects the knee joint to the ankle joint. Despite its strength, the tibia is the most commonly fractured long bone, due to its location, orientation, and lack of soft tissue protection. Tibial diaphyseal fractures are particularly common, with an incidence of approximately 26 per 100,000 people per year.

In recent times, closed reduction with intramedullary interlocking nailing has become the preferred method for managing tibial fractures in adults. This technique offers mechanical stability, better alignment, and preserves the biological environment of the fracture, allowing soft tissues to remain intact. Locking plate osteosynthesis is typically used for fractures that extend into the metaphysis, though complications like infection, wound breakdown, malunion, and nonunion are frequently observed.

With both techniques being widely used, the choice of treatment for tibial fractures remains a subject of debate. This study aims to compare the outcomes of these two methods in terms of fracture union, limb quality, complication rates, and patient satisfaction.

Aims and Objective

The primary objective of this study is to compare the clinical outcomes of two surgical methods used to treat tibial fractures: intramedullary interlocking nailing and locking plate osteosynthesis. The study aims to assess the following:

1. Union Rate: Compare the time required for fracture union between the two techniques.
2. Functional Outcome: Evaluate the functional outcome using the Lower Extremity Functional Scale (LEFS).
3. Complication Rate: Identify early and late post-operative complications for both treatment options.
4. Patient Satisfaction: Measure patient satisfaction at follow-ups using clinical and functional parameters.

Materials and Methods

Source of Data
This prospective study was conducted on 46 patients with extra-articular tibia fractures, admitted to a tertiary care hospital from July 2017 to May 2019. Patients were followed for 24 months across six visits (6 weeks, 3 months, 6 months, 12 months, 18 months, and 24 months). The study was conducted after obtaining ethical approval from the institutional review board and informed consent from all patients.

Inclusion Criteria
- Patients with closed extra-articular tibial fractures.
- Patients with a mature skeleton.
- Patients medically fit for surgery.

Exclusion Criteria
- Medically unfit patients.
- Compound fractures.
- Pathological fractures.

Protocol
Upon admission, a detailed examination and routine pre-operative investigations were performed. X-rays (AP and lateral views) of the tibia, knee, and ankle were taken. After obtaining pre-anaesthetic clearance, patients underwent either closed reduction with intramedullary interlocking nailing or open reduction and internal fixation with locking plate osteosynthesis. The choice of surgical technique was based on fracture type and surgeon preference.

Functional outcomes were assessed using the Lower Extremity Functional Scale (LEFS), with scores ranging from 0 to 80. Higher scores indicate better functional outcomes.

Statistical Analysis
Data was analyzed using SPSS-17. Chi-square and Fischer’s exact tests were used for qualitative data, while Student’s t-test was used for quantitative data. A p-value of <0.05 was considered statistically significant.

Results

1) Demographics: Among the 46 patients, 36 were males (78.26%) and 10 were females (21.74%). The most common age group was 51-60 years (28.26%).
2) Fracture Types: Proximal third tibial fractures were the most common (60.86%), followed by distal and mid-shaft fractures (19.57% each).
3) Mode of Injury: The majority of injuries were caused by road traffic accidents (65%), followed by railway accidents (35%).
4) Associated Injuries: Fibular fractures were the most common associated injury (59.45%).
5) Surgical Intervention: Tibial interlocking nailing was performed in 36.95% of cases, while tibial plating was performed in 45.65% of cases.
6) Complications
Early post-operative complications (e.g., swelling, bleb formation) were more common with plating (27.58%) compared to nailing (11.76%).
Late post-operative complications (e.g., wound dehiscence, infection) were significantly higher in the plating group compared to the nailing group.
7) Functional Outcome: The LEFS score was above 40 in 82.62% of patients, with better results observed in the nailing group.
8) Union Rates: Radiological union occurred within 90 days in 88.23% of nailing cases compared to 44.82% of plating cases. This difference was statistically significant (p=0.0093).

Conclusion

The study suggests that intramedullary interlocking nailing is a more favorable option for treating tibial fractures due to its lower complication rates, faster time to union, and better functional outcomes as measured by the LEFS. Plating, while effective for certain fracture types (e.g., fractures extending into the metaphysis), is associated with higher rates of early and late complications, such as wound infection and implant exposure.

Clinical Message

The results of this study have important implications for clinical practice. Intramedullary interlocking nailing should be the preferred treatment for extra-articular tibial fractures due to its superior outcomes in terms of union time, fewer complications, and better functional recovery. Surgeons should consider patient factors and fracture characteristics, but this study supports the widespread adoption of tibial nailing, especially in cases where early mobilization is desired.

References

1. He GC, Wang HS, Wang QF, Chen ZH, Cai XH. Effect of minimally invasive percutaneous plates versus interlocking intramedullary nailing in tibial shaft treatment for fractures in adults: a meta-analysis. Clinics. 2014;69(4):234-40.
2. Lindvall E, Sanders R, DiPasquale T, Herscovici D, Haidukewych G, Sagi C. Intramedullary nailing versus percutaneous locked plating of extra-articular proximal tibial fractures: comparison of 56 cases. Journal of orthopaedic trauma. 2009 Aug 1;23(7):485-92.
3. Vallier HA, Cureton BA, Patterson BM. Randomized, prospective comparison of plate versus intramedullary nail fixation for distal tibia shaft fractures. Journal of orthopaedic trauma. 2011 Dec 1;25(12):736-41.
4. Kwok CS, Crossman PT, Loizou CL. Plate versus nail for distal tibial fractures: a systematic review and meta-analysis. Journal of orthopaedic trauma. 2014 Sep 1;28(9):542-8.
5. Mao Z, Wang G, Zhang L, Zhang L, Chen S, Du H, Zhao Y, Tang P. Intramedullary nailing versus plating for distal tibia fractures without articular involvement: a meta-analysis. Journal of orthopaedic surgery and research. 2015 Dec;10(1):95.
6. Meena RC, Meena UK, Gupta GL, Gahlot N, Gaba S. Intramedullary nailing versus proximal plating in the management of closed extra-articular proximal tibial fracture: a randomized controlled trial. Journal of Orthopaedics and Traumatology. 2015 Sep;16(3):203.
7. Saied A, Ostovar M, Mousavi AA, Arabnejhad F. Comparison of intramedullary nail and plating in treatment of diaphyseal tibial fractures with intact fibulae: A randomized controlled trial. Indian journal of orthopaedics. 2016 May;50(3):277.
8. Mukherjee S, Arambam MS, WaikhOM S. Interlocking Nailing Versus Plating in Tibial Shaft Fractures in Adults: A Comparative Study. Journal of Clinical and Diagnostic Research: JCDR. 2017 Apr;11(4):RC08.
9. Daolagupu AK, Mudgal A, Agarwala V, Dutta KK. A comparative study of intramedullary interlocking nailing and minimally invasive plate osteosynthesis in extra articular distal tibial fractures. Indian journal of orthopaedics. 2017 May;51(3):292.
10. Mohindra M, Jain JK. Fundamentals of orthopedics. JP Medical Ltd; 2017 Dec 31.
11. Prasad PN, Nemade A, Anjum R, Joshi N. Extra-articular distal tibial fractures, is interlocking nailing an option? A prospective study of 147 cases. Chinese Journal of Traumatology. 2019 Apr 1;22(2):103-7.
12. Yao Q, Ni J, Peng LB, Yu DX, Yuan XM. Locked plating with minimally invasive percutaneous plate osteosynthesis versus intramedullary nailing of distal extra-articular tibial fracture: a retrospective study. Zhonghua yi xue za zhi. 2013 Dec;93(47):3748-
13. Huang P, Tang PF, Yao Q, Liang YT, Tao S, Zhang Q, Guo YZ, Liang XD, Wang Y. A comparisive study between intramedullary interlocking nail and plate-screw fixation in the treatment of tibial shaft fractures. Zhongguo gu shang= China journal of orthopaedics and traumatology. 2008 Apr;21(4):261-3.
14. Guo JJ, Tang N, Yang HL, Tang TS. A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia. The Journal of bone and joint surgery. British volume. 2010 Jul;92(7):984-8.
15. Gao WQ, Hu JH, Gu ZC, Zhang HX, Min P, Zhang LJ, Yu WW, Wang GL. Comparison of effect between early and delayed in primary intramedullary nailing combined with locked plate fixation for the treatment of multi-segments tibial fractures of type. Zhongguo gu shang= China journal of orthopaedics and traumatology. 2015 Feb;28(2):122-5.
16. Li Y, Jiang X, Guo Q, Zhu L, Ye T, Chen A. Treatment of distal tibial shaft fractures by three different surgical methods: a randomized, prospective study. International orthopaedics. 2014 Jun 1;38(6):1261-7.
17. Kuhn S, Appelmann P, Pairon P, Mehler D, Rommens PM. The Retrograde Tibial Nail: presentation and biomechanical evaluation of a new concept in the treatment of distal tibia fractures. Injury. 2014 Jan 1;45:S81-6.
18. Kiel J, Kaiser K. Stress reaction and fractures. InStatPearls [Internet] 2019 Jun 4. StatPearls Publishing.
19. Nelson Jr GE, Kelly PJ, Peterson LF, Janes JM. Blood supply of the human tibia. JBJS. 1960 Jun 1;42(4):625-36.
20. Jastifer JR, Gustafson PA, Labomascus A, Snoap T. Ball and socket ankle: mechanism and computational evidence of concept. The Journal of Foot and Ankle Surgery. 2017 Jul 1;56(4):773-5.
21. Zeltser DW, Leopold SS. Classifications in brief: Schatzker classification of tibial plateau fractures.
22. Galbraith RM, Lavallee ME. Curr Rev Musculoskelet Med. 2009 Oct 7; 2 (3): 127-33. doi: 10.1007/s12178-009-9055-6. Medial tibial stress syndrome: conservative treatment options.
23. Thakur AJ. Elements of Fracture Fixation-E-book. Elsevier Health Sciences; 2015 Jul 30.
24. Grecco MA, Prado Junior ID, Rocha MA, Barros JW. Epidemiology of tibial shaft fractures. Acta Ortopédica Brasileira. 2002 Dec;10(4):10-7.

Full Text PDF |  Full Text HTML