Metaphyseal Distal Tibia Fractures: Cohort Study Comparing Outcomes of Patients Treated with Minimally-Invasive Plating vs. Intramedullary Nailing

Purpose: The optimal treatment of non-or minimally articular distal tibia fractures has been debated in the literature. In recent years, minimally invasive plate osteosynthesis (MIPO) and intramedullary nail (IMN) fixation have been commonly used to treat this injury pattern. Both treatment modalities use biology-preserving (indirect) techniques for fracture reduction but the implants’ designs and their application are very different. There are few, limited studies that compare the clinical results and outcomes in patients with metaphyseal distal tibia fractures treated with MIPO vs. IMN. We hypothesized that there would be no difference in clinical or functional outcomes between these treatment modalities in a similar population. Methods: We evaluated all patients with metaphyseal distal fractures (=4cm from the plafond) treated with MIPO or IMN at a busy urban trauma center by a single fellowship trained orthopedic trauma surgeon from 2003 to 2013. The senior surgeon treated this type of injury almost exclusively with MIPO technique until 2009, when technique and design improvements of IMN yielded a potentially superior alternative treatment method. Since then, we have used IMN almost exclusively for this problem. This has created two distinct cohorts of patients treated for a like problem by very different surgical methods. Clinical and radiographic evaluation at a minimum of one year follow up was obtained along with visual analog (VAS) pain scales, limb specific assessments (Olerud and Molander’s ankle score, American Orthopaedic Foot and Ankle Surgeon’s [AOFAS] ankle-hindfoot instrument), and whole-person assessment with the Short Form 36 (SF-36) tool. Results: We studied 86 patients (43 MIPO and 43IMN) with distal tibia fractures within 4 cm of the plafond with minimal or no articular involvement. Thirty-eight of 43 patients in the MIPO group and 26 of 43 patients in the IMN group met inclusion criteria for the study including greater than 1 year follow up. Complications of MIPO included three nonunions, two with malunion [greater than] 5 degrees, no infections, one major wound complication, and four patients who had plates removed. Complications in the IMN group included 2 nonunions (both type 3 open fractures), one delayed union (type 3 open fracture, healed without surgical intervention at 65 weeks), 3 with malunion [greater than] 5 degrees, two deep infections, and three patients undergoing removal of distal locking screws. Pain scores were similar between MIPO and IMN groups. Average AAOS ankle scores were similar between the two groups, but the Olerud and Molander ankle scores were significantly better in the MIPO group (86.6 vs. 77, respectively; P Conclusions: Similar clinical results and functional outcomes were obtained when treating non- or minimally articular metaphyseal distal tibia fractures with MIPO or IMN except for one of two ankle scores that favored MIPO. Complications appeared to correlate with open fracture and high-energy injuries.