Abstract
Background
The purpose of this study is to determine differences in outcomes between “extreme” tibial metaphyseal fractures treated with intramedullary nailing (IMN) or plate osteosynthesis.
Methods
545 prospectively collected patients were reviewed by two board-certified orthopedic trauma surgeons to identify extreme tibial shaft fractures (defined as most proximal or distal segments that involved or would have involved the area encompassed by the nail locking bolts). Fifty-one patients were identified. Twenty-five patients treated with an intramedullary nail were compared to 24 patients treated with plate and screws for similar patterns. Data collected included patient demographics, surgical details, and outcomes. Cohorts were compared using fisher's exact test, independent T tests, and multivariable linear regression.
Results
The mean age of all patients was 46.73 years. There were no differences in ASA, CCI, age, male/female composition, or BMI between cohorts. There were no differences in low vs. high-energy mechanism of injury between cohorts, however the IMN cohort had a greater proportion of open fractures (p = 0.018). When controlling for covariates, patients who underwent IMN were allowed earlier weight bearing on the operative extremity. There were no differences in ankle or knee range of motion at latest follow up. There was a greater incidence of total complications among IMN (p = 0.033). Single variable analysis revealed an association between IMN and nonunion (p = 0.050). IMN trended towards greater need for reoperation (p = 0.086).
Conclusion
Intramedullary nailing of “extreme tibia fractures” was associated with higher rates of total complications compared to plate osteosynthesis and trended with greater need for reoperation. However, it should be noted that there was a higher incidence of open fractures in this cohort. There were no differences in the rate of malalignment, range of motion, or time to healing between cohorts.
Keywords: Tibia, Metaphyseal, Trauma, Fracture
1. Introduction
Whether proximal or distal, metaphyseal tibial fractures pose a challenge to clinical decision-making. Complex fracture patterns, limited soft tissue envelope near the joint, and an increasing array of fixation construct options render many considerations for an orthopedic surgeon.1 Similar to diaphyseal fracture fixation, the use of a reamed intramedullary nail has been shown to represent an appropriate option for metaphyseal fracture fixation.2,3 Extreme nailing has been described in the literature as intramedullary nailing (IMN) of peri-articular proximal or distal metaphyseal fractures.2, 3, 4 However, this definition is often open to interpretation. Fixation with a reamed intramedullary nail may allow for earlier weight-bearing.3 Intramedullary nailing, however, has been associated with high rates of patient-reported knee pain.5, 6, 7 Plate osteosynthesis is another surgical option for extreme tibial fractures. Yet, this requires incisions in swollen soft tissues, possible periosteal stripping, and devascularization that can have adverse effects on bone and wound healing.8,9 The purpose of this study is to compare clinical and functional outcomes of extreme tibial fractures fixed with reamed intramedullary nailing and those fixed with plate osteosynthesis.
2. Methods
545 consecutive patients with 555 tibia fractures who presented to a single academic medical center, including an urban level I trauma center and an orthopedic specialty hospital, were reviewed by two board-certified orthopedic trauma surgeons. Cases were categorized as “extreme” based on the location of the tibial fracture involving the most proximal or distal 25 % of the tibia in the area that would encompass the locking bolt section of an IM nail (Fig. 1, Fig. 2). Injuries with and without intra-articular extension were included. Patients who were fixed with intramedullary nail and supplemental peri-articular plating were excluded. A total of 25 tibial fractures treated with reamed intramedullary nail and 24 tibial fractures treated with plate osteosynthesis (Fig. 3, Fig. 4) in a non-randomized manner met this radiographic criterion. These fractures were again reviewed by a fellowship trained trauma surgeon and were noted to be amenable to both plate or nail osteosynthesis. Fractures were classified by a fellowship trained trauma surgeon per the AO/OTA Fracture and Dislocation Compendium.
Fig. 1.
Extreme Nailing of a left proximal distal tibial fracture. Injury (A), immediate post-op (B), and long-term follow-up (C). One locking screw backed out early but no further at final follow up.
Fig. 2.
Extreme Nailing of a right distal tibial fracture. Injury (A), immediate post-op (B), and long-term follow-up (C).
Fig. 3.
Plating of an extreme right distal tibial fracture. Injury (A), immediate post-op (B), and long-term follow-up (C).
Fig. 4.
Plating of an extreme right proximal tibial fracture. Injury (A), immediate post-op (B), and long-term follow-up (C). Patient had screw in proximal tibia from previous tibial tubercle surgery prior to injury but was not involved in proximal tibia fracture.
Surgical and post-operative protocol was similar for patients with similar fracture site (proximal vs. distal tibia) and within treatment cohort. Proximal fractures in the plate osteosynthesis cohort were fixed with indirect minimally invasive techniques. An anterolateral incision was made along the proximal anterolateral tibia through the skin and subcutaneous tissue. A large or small fragment locking plates was slid proximally along the lateral aspect of the tibia. Push-pull forces were applied proximally and distally as the fracture was reduced. Once aligned, screws were applied through the targeting jig proximally and distally. Intra-operative fluoroscopy confirmed reduction of the facture. Post-operatively, patients were made non-weight bearing in the immediate post-operative period and were further advanced to full weight bearing on follow up visits depending on clinical progression as well as radiographic findings.
Distal fractures in the plate osteosynthesis were similarly fixed with limited direct visualization. An incision was made below the fracture site and carried down either anterolaterally or anteromedially through the skin and subcutaneous tissue. The fracture was reduced closed with percutaneously applied clamps and a small fragment locking plates were placed in a submuscular or subcutaneous fashion. Lag screws were sometimes used as needed. Locking screws were placed proximally and distally. Intra-operative fluoroscopy confirmed reduction of the facture. Post-operatively, patients were made non-weight bearing and placed in a controlled ankle motion or “CAM” boot as well.
Patients in the IMN cohort who sustained proximal and distal fractures all underwent a similar surgical procedure. Of the 25 patients in the IMN cohort, five patients underwent infrapatellar nailing and twenty underwent suprapatellar nailing. In suprapatellar nailing cases, an incision was made proximal to the patella and carried down through the quadriceps tendon. In infrapatellar cases, an incision was made distal to the patella and carried down through the patellar tendon. In both cases, the tendon was then incised longitudinally and a blunt clamp was applied to the knee. A smooth blunt trochar was inserted at the starting point of the anterior tibia. A guidewire was then placed through the trochar and into the proximal tibia. Once the guidewire position was confirmed radiographically, the tibia was overreamed incrementally. The tibial nail was then inserted across the fracture under fluoroscopic guidance. Locking bolts were inserted proximally through a jig and distally freehand. Lag screws were applied as needed for non-displaced articular splits (Fig. 3, Fig. 4). Intraoperative fluoroscopy was obtained to ensure fracture reduction and alignment. Post-operatively, patients were made non-weight-bearing, placed in either a standard Bledsoe brace or no immobilization and allowed free ankle and knee ROM.
Data collected included age, sex, BMI, patient medical history, surgical details, and length of hospital stay. Injury data collected included open vs. closed fracture and low vs. high energy mechanism of injury. Outcome data collected included readmission within 90 days, radiographic alignment, ability to hold fracture reduction until healing, time to radiographic healing, development of fracture related infection (FRI), patient-reported pain at 6 months post-op, and other major and minor complications including early hardware complications, tibia fibula joint instability, and nonunion. Radiographic union was determined by achievement of a RUST score of at least 910. Five or more degrees of coronal angulation off the anatomic axis was considered malalignment.11 Data on all cause reoperation, pain-related removal of hardware, and subsequent amputation was collected. Radiographic data were reviewed for post-operative alignment and fracture healing. All patients followed a similar post-op protocol: patients were given VTE prophylaxis and progressed to weight-bearing as tolerated at follow-up visits depending on the state of clinical healing, typically with a controlled ankle motion (CAM) boot. Statistics were analyzed using IBM SPSS Version 28 (Armonk, NY: IBM Corporation).
3. Results
There were no differences in patient demographics between groups (Table 1). With regards to in injury characteristics, there were no differences in the mechanism of injury between cohorts. Sixnteen (66.7 %) of fractures treated with plate osteosynthesis were secondary to high-energy injury while eight (33.3 %) were secondary to low-energy injuries. Similarly, 52.0 % of fractures treated with an IMN were secondary to high-energy injury and 48.0 % were secondary to low-energy injury. The IMN cohort had a greater proportion of open fractures than the plate cohort (40.0 % vs. 8.3 %, p = 0.018). There were no differences in the proportion of distal to proximal extreme fractures between plate and IMN cohorts. There were no differences in AO classification of fracture pattern between groupss (Table 1.).
Table 1.
Patient and injury characteristics. Asterisk denote significance. PD = psychiatric diagnosis, NT = neurotypical. BMI = body mass index, CCI = Charleson Comorbidity Index.
| IMN (N = 25) | Plate (N = 24) | P Value | |
|---|---|---|---|
| Age | 45.84 | 47.67 | 0.709 |
| Sex | |||
| male | 7 | 12 | 0.148 |
| female | 18 | 12 | |
| BMI | 26.57 | 28.09 | 0.427 |
| CCI | 0.20 | 0.38 | 0.459 |
| ASA Score | 2.08 | 2.08 | 0.989 |
| Tobacco Status | |||
| Smoker | 4 (16.0 %) | 15 (37.5 %) | 0.114 |
| Non-smoker | 21 (84.0 %) | 9 (62.5 %) | |
| Injury Mechanism | |||
| high energy | 13 (52.0 %) | 8 (33.3 %) | 0.387 |
| low energy | 12 (48.0 %) | 16 (66.7 %) | |
| Extreme Fracture Site | |||
| Distal | 21 (84.0 %) | 15 (62.5 %) | 0.114 |
| Proximal | 4 (16.0 %) | 9 (37.5 %) | |
| Fracture Pattern | |||
| open | 10 (40.0 %) | 2 (8.3 %) | 0.018∗ |
| closed | 15 (60.0 %) | 24 (91.7 %) | |
| Fracture Classification | |||
| 41A | 4 (16.0 %) | 9 (37.5 %) | 0.224 |
| 43A | 11 (44.0) | 6 (25.0 %) | |
| 43B | 9 (36.0 %) | 9 37.5 %) | |
| 43C | 1 (4.0 %) | 0 (0.0 %) | |
Single variable analysis revealed no difference between cohorts in the rate of fracture related infection (FRI) (p = 0.609). The rate of FRI among the IMN cohort was 12.0 % and among the plate cohort was 4.2 %. Single variable analysis revealed an association between extreme nailing of tibial fractures and nonunion, with 20.0 % of extreme fractures treated with IMN developing nonunion and 0.0 % of extreme fractures treated with plates developing nonunion (p = 0.050). However, this difference may be explained by the greater proportion of open fractures among the IMN cohort. Multivariable analysis of these FRI and nonunion metrics was not possible due to low N (Table 1.).
Multivariable analyses controlled for age, sex, BMI, CCI, ASA score, tobacco use status, open vs. closed fracture, distal vs. proximal fracture, and mechanism of injury. When controlling for these confounders, there was a higher rate of total complications among the IMN cohort than the plate cohort (36.4 % vs. 8.3 %, p = 0.033) (Table 2). Complications included FRI, nonunion, hardware failure, post-traumatic osteoarthritis, and post-operative widening of the syndesmotic space requiring reoperation. There was a trend towards an association of extreme intramedullary nailing and a higher rate of all cause reoperation (p = 0.086). The rate of reoperation was 32.0 % among the IMN cohort and 12.5 % among the plate cohort. All cause reoperation included reoperation due to hardware failure, irrigation and debridement of FRI, nonunion repair, hardware removal due to painful hardware, loss of joint stability, and in one severe FRI case, amputation. There was no significant difference in the time to bone healing, with the IMN cohort averaging 6.07 months until radiographic bone union and the plate cohort averaging 4.88 months until bone union (Table 3).
Table 2.
Multivariable analysis.
| Odds Ratio | Confidence Interval | P Value | |
|---|---|---|---|
| Total Complications | |||
| Plate vs. Nail | 84.48 | 1.422–5018.543 | 0.033∗ |
Table 3.
Outcome data. Single variable analysis for fracture-related infection and nonunion, multivariable analysis for all other outcome measurements.
| IMN (N = 25) | Plate (N = 24) | P Value | |
|---|---|---|---|
| Fracture-Related Infection | 3 (12.0 %) | 1 (4.2 %) | 0.609? |
| Nonunion | 5 (20.0 %) | 0 (0.0 %) | 0.050∗ |
| Complications | 8 (36.4 %) | 2 (8.3 %) | 0.033∗ |
| Malalignment | 2 (8.0 %) | 2 (8.3 %) | 0.643 |
| Reoperation | 8 (32.0 %) | 3 (12.5 %) | 0.086 |
| Time to Bone Healing (months)a | 6.07 | 4.88 | 0.476 |
| Persistent Knee/Ankle Pain | 7 (28.0 %) | 2 (8.3 %) | 0.217 |
| Time to Weight-Bearing Allowance (weeks) | 5.22 | 10.75 | <0.001∗ |
IMN N = 15, Plate N = 14 due to insufficient radiographic follow-up for some patients.
Multivariable analysis revealed that intramedullary nailing of metaphyseal tibial fractures was associated with earlier weight-bearing allowance (p < 0.001). The average time to weight bearing as tolerated allowance was 5.22 weeks, while patients in the plate cohort were made weight bearing as tolerated in 10.75 weeks on average. It should be noted that this is subjective to surgeon experience as well as the patient's follow up time points which could be earlier or later than expected. There was no difference in the rate of malalignment between cohorts. Two patients (8.0 %) in the IMN cohort were considered mal-aligned: one patient was fixed in valgus while another patient was fixed in appropriate alignment and drifted into valgus by 6 weeks post-op. Two patients (8.3 %) in the plate osteosynthesis cohort were malaligned: one patient healed in varus and one patient healed in valgus. In total, three of the four mal-aligned patients had distal extreme tibial fractures and only one patient who was mal-aligned had a proximal extreme tibial fracture. There were no differences in range of knee or ankle motion between cohorts at any time point (Table 4, Table 5).
Table 4.
Ankle Range of Motion data.
| IMN | Plate | P Value | |
|---|---|---|---|
| 3 Month Range of Motion | 39.17 | 46.92 | 0.367 |
| 6 Month Range of Motion | 40.83 | 45.56 | 0.599 |
| 12 Month Range of Motion | 54.00 | 56.25 | 0.815 |
Table 5.
Knee Range of Motion data.
| IMN | Plate | P Value | |
|---|---|---|---|
| 3 Month Range of Motion | 100.38 | 107.14 | 0.635 |
| 6 Month Range of Motion | 116.82 | 115.00 | 0.867 |
| 12 Month Range of Motion | 123.57 | 133.33 | 0.282 |
4. Discussion
This study found similar outcomes between extreme tibial fractures treated with IMN and those treated with plate osteosynthesis, with respect to knee and ankle range of motion and functional outcome. Multivariable analysis revealed that intramedullary nailing was associated with shorter time to weight bearing allowance. Furthermore, this study indicated an association between intramedullary nailing and increased complications, but found no significant differences in the rate of fracture-related infection, malalignment, time to bone healing, persistent knee or ankle pain, and reoperation. Single variable analysis revealed an association between extreme intramedullary nailing and nonunion, but this did not take into account the higher rate of open fractures among the IMN cohort than the plate cohort, which are typically at higher risk for nonunion.12 Furthermore, there is a possible selection bias that IMN was used for open fractures to mitigate the risks of exposed hardware in the setting of wound breakdown in these injuries.
To our knowledge, this is the first study to compare intramedullary nailing and plate osteosynthesis in a population of both peri-articular distal and peri-articular proximal tibia fractures, referred to as “extreme” tibial fractures. We believe our definition of “extreme” fractures can be more readily described than prior definitions. Studies have similarly reported on surgical options for peri-articular distal tibial fractures. In a study by Vallier et al. reviewing distal tibial fractures between 4 and 11 cm proximal to the tibial plafond, intramedullary nailing was associated with higher rates of malunion. In that study, 29 % of the IMN cohort healed in malunion whereas only 5.4 % of the plate cohort healed in malunion. This study found no difference in malunion rates between IMN cohorts and plate cohorts, although this study included peri-articular proximal tibial fractures.
Vallier et al. also found a trend towards delayed healing and nonunion among patients who had undergone IMN of distal tibial fracture. Single variable analysis in this study similarly found greater rates of nonunion among the IMN cohort. However, nonunion analysis was limited to single variable analysis and could not account for the greater complexity of fractures in the IMN cohort. Although the IMN cohort had a longer time to union, multivariable analysis found no association between fixation type and time to union. Thus, the longer time to union is likely due to confounders like fracture pattern, injury energy, and surgical technique. There are conflicting reports on healing in the literature. A study conducted at a Veterans hospital in Taiwan found greater time to union for plated distal tibial fractures compared to that of distal tibia fractures repaired with limb shortened intramedullary nailing.13 Another study found no difference in the rate of nonunion or the time to union between intramedullary nailing and plate osteosynthesis cohorts.8 Thus, further larger studies are needed to determine if plate osteosynthesis is superior to intramedullary nailing for bone healing of peri-articular distal tibial fractures.
The current study revealed a trend towards greater need for reoperation among extreme tibial fractures treated with IMN. Similarly, Vallier et al. found that reoperation rates were higher for patients who underwent intramedullary nailing of distal tibia fractures than those who underwent plate fixation of distal tibial fracture. Another study conducted at a Level II trauma center also found there was a greater need for reoperation among patients who had undergone intramedullary nailing of distal tibia fracture.14
The correlation of fixation type and wound complications or infection is less clear as results in the current literature do not provide a resounding answer. One study reviewing distal tibial fracture found an association between IMN with more wound complications. In contrast, a systematic review found there was a significantly greater incidence of infection following plate fixation of distal tibia fracture.15 In agreement with the results of our study, there are a few studies that reported no differences in rates of infection with respect to fixation type5,14,16 A systematic review found that IMN of distal tibial fracture was associated with heightened rate of overall complications, similar to this study.17
Few studies comparing plate osteosynthesis and intramedullary nailing of proximal metaphyseal tibia fractures exist within the literature. Historically, intramedullary nailing of comminuted proximal tibia fractures was avoided due to unfavorable biomechanics associated with infrapatellar nail insertion that exacerbated fracture deformity.18 However, semi-extended intramedullary nail insertion offers positioning that is more conducive to reducing proximal tibial fracture.19 Thus, semi-extended nailing of proximal metaphyseal tibia fractures has been explored and has shown to render satisfactory clinical outcomes. A multicenter study found no differences in the rate of complications, nonunion, malalignment, pain or function between proximal tibial fractures treated with locked lateral plating and those treated with suprapatellar intramedullary nailing.20 Other studies have noted post-operative anterior knee pain following IMN fixation of proximal tibial fracture but not at any increased rate compared to diaphyseal fractures fixed with IMN.21
This study is subject to several limitations. First, due to small sample size, multivariable analysis of fracture-related infection and nonunion were not possible. Thus, these analyses were limited to single variable analysis, and correlations are subject to possible confounders that were controlled for in other analyses. The significantly higher incidence of open fractures in the IMN cohort should be considered when reviewing these results. Additionally, the N limits the power of other analyses conducted in this study. Second, certain data were collected and reviewed retrospectively. Thus, this study is subject to information and data bias, as the results are contingent on the accuracy and completeness of the medical record. Third, not all patients had complete range of motion data for each time point. Thus, the N for the range of motion data varies per time point. Similarly, not all patients had reliable radiographic data available to determine time to bone union. Patients without appropriate radiographic intervals were excluded from the time to union analysis. It should also be noted that the choice of nail vs plate can be subjective based on surgeon expertise and comfort. Due to the retrospective nature, selection bias, and small cohort of patients there are significant limitations. However, this paper does highlight the need for further research in this topic and only a randomized multicenter trial would be able to address these issues.
5. Conclusion
Intramedullary nailing and plate osteosynthesis of “extreme” tibia fractures offer similar clinical outcomes. These results demonstrate no differences in time to healing, knee or ankle range of motion, or malalignment between fixation types. Intramedullary nailing, however, may be associated with higher rates of total complications and trends with increased need for all-cause reoperation. This study can help serve as initial pilot data with regards to implant choice for these injuries rather as guidance for definitive treatment.
CRediT authorship contribution statement
Abhishek Ganta: Conceptualization, Methodology, Formal analysis, Investigation, Resources, Writing – original draft, Writing – review & editing. Fiona K. Cherry: Methodology, Software, Validation, Formal analysis, Investigation, Writing – original draft, Visualization. Nirmal C. Tejwani: Investigation, Resources. Sanjit R. Konda: Investigation, Resources. Kenneth A. Egol: Conceptualization, Investigation, Resources, Writing – review & editing, Project administration.
Informed consent IRB approval
NYU IRB approval was obtained for the included research (i06-581). Informed, written consent was obtained from all included subjects in accordance with IRB-mandated protocols.
Ethical statement
The included research was granted NYU IRB approval (i06-581).
Funding sources
There were no sources of funding to report for the included work.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
There are no acknowledgements for the included work.
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