Intramedullary nailing versus plating for extra-articular distal tibial metaphyseal fracture: A systematic review and meta-analysis

Introduction: With development in the techniques of reduction and fixation, there has been a controversy in comparison between intramedullary nailing (IMN) and plating for the treatment of distal tibial metaphyseal fracture (DTF). The study aimed to investigate: (1) which fixation, IMN or plating, was better in the clinical outcomes and in the complications for the treatment of DTF and (2) which modifying variables affected the comparative results between the two modalities. Methods: PubMed, EMBASE, OVID, Scopus, ISI Web of Science, the Cochrane Library, Google Scholar and specific orthopaedic journals were searched from inception to July 2013, using the search strategy of '('Fracture Fixation, Intramedullary' [MeSH]) AND ('Tibial Fractures' [MeSH]) AND (plate OR plating)'. All prospective and retrospective controlled trials comparing function, pain, bone union and complications between IMN and plating for DTF were identified. Our analysis had no limitation of the language or the publication year. The primary outcome measurements were complication rate, union time, operation time and hospital stays, while the secondary outcome measurements were functional score and pain score. Result: Fourteen of 6620 studies with 842 patients were included. IMN was probably preferential to plating for DTF given its higher functional score (p = 0.01), lower risk of infection (p = 0.02) and comparable pain score (p = 0.33), total complication rate (p = 0.53) and time to union (p = 0.86). However, plating had a lower malunion rate than IMN (p < 0.0001). All the results were based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence of moderate quality. Conclusions: With a satisfying alignment obtained, IMN may be preferential to plating for fixation of DTF with better function and lower risk of infection. However, IMN showed higher malunion rate for fixation of DTF. With the biases in our meta-analysis, it will ultimately require a rigorous and adequately powered randomised controlled trial (RCT) to prove. Level of evidence: Level III, therapeutic study (systematic review). (C) 2014 Elsevier Ltd. All rights reserved.