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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.
Tibial metaphyseal fractures (TMFs) contain both distal tibial metaphyseal fractures (DTFs, Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type 43 or distal 42) and proximal metaphyseal tibial fractures (PTFs, AO/OTA type 41 or proximal 42) [
]. With the severe damage of soft tissue and the extreme instability, TMFs have a high risk of unsatisfactory function, severe pain, delayed union, malunion and infection [
], which ensures accurate reduction and rigid fixation. Unfortunately, extensive dissection of the host bone and the soft tissue is mandatory. It inevitably raises the risk of infection and nonunion. Furthermore, the complaint about hardware irritation makes it prone to be removed [
]. IMN is the gold standard for tibial diaphyseal fractures. It has a small influence on the blood supply of the host tissue, which would contribute to a low rate of nonunion and infection [
]. Of the two fracture ends, the short part lacked the cortical friction with implants and the adequate purchase of locking screws so that the tibial alignment could be neither obtained nor maintained [
], the interest in applying IMN to TMFs has been renewed. The claimed improvement in the alignment and the stability has been confirmed both in the laboratory and in the clinical follow-up [
]. Meanwhile, the novel technique of minimally invasive plating osteosynthesis (MIPO) has been developed to further alleviate the local damage of plating [
A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia.
Distal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plating and screws fixation.
]. Limited by the sample size, they failed to show a clear superiority of one modality over the other. To address this, the present systematic review and meta-analysis is aimed to cover all the comparative evidence with the purpose of determining: (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 two modalities.
Materials and methods
Three reviewers (XHX, XZC and MMS) searched PubMed (1966 to July 2013), EMBASE (1974 to July 2013), Ovid (1966 to July 2013), Scopus (1966 to July 2013), ISI Web of Science (1945 to July 2013), Cochrane Library, Clinical Trial Grade Center and Google Scholar (1966 to July 2013), Chinese VIP Database (1986 to July 2013) and Chinese Wan-Fang Database (1992 to July 2013) using the search strategy of ‘(‘Fracture Fixation, Intramedullary’ [MeSH]) AND (‘Tibial Fractures’ [MeSH]) AND (plate OR plating)’, plus ‘clinical trial’ AND ‘comparative study’ with no limitation of publication year or language. The reference lists of all the selected articles and the related orthopaedic journals were hand searched for any additional trials. In addition, we searched the Clinical Trial Registry, the Current Controlled Trials, the Trials Central and the Center Watch for grey literature. We defined the criteria of inclusion and exclusion before searching. We only included studies where: (1) DTF (AO/OTA type 43 or distal 42) was involved, (2) the age was ≥18, (3) both IMN and plating were adopted, (4) functional score, pain score or complication rate was assessed and (5) the design was comparative either prospectively or retrospectively. Exclusion criteria included studies where: (1) tibial isthmal fractures or AO type 43-C with serious intra-articular damages were involved, (2) neither of the outcomes was available, (3) the follow-up was <1 year and (4) no control data were provided. All the redundant publications were excluded. The abstracts of the rest of the publications were reviewed for relevance. Excluding the redundant publications and the unsatisfactory publications, the full texts of the rest of the publications were acquired and read in detail. We included the publications that satisfied our inclusion criteria.
We contacted the corresponding authors of the eligible trials if necessary to verify the accuracy of the data abstraction as well as the methodological assessment. We also tried to get any further data or unpublished data which were useful for our data analysis.
Methodological quality
Three reviewers (XHX, SGY and MMS) assessed the methodological quality of the literature according to the 12-item scale [
]. The 12-item scale contained: randomised adequately, allocation concealed, similar baseline, patient blinded, care provider blinded, outcome assessor blinded, avoided selective reporting, similar or avoided cofactor, patient compliance, acceptable drop-out rate, similar timing and intention-to-treat (ITT) analysis. The inconsistent opinions were judged by another author (XZC). The disagreements were evaluated by the means of a kappa (κ) test and resolved by discussion. According to the 12-item standard (Table 1), five studies [
A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia.
Distal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plating and screws fixation.
Distal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plating and screws fixation.
] described ITT analysis. The weighted kappa for the agreement on the trial quality between the reviewers was 0.85 (95% confidence interval (CI), 0.77–0.93).
Table 1Methodological quality of the included studies based on the 12-items scoring system.
Only if the method of sequence generated was explicitly described could get a “Yes”; sequence generated by “Dates of Admission” or “Patients Number” received a “No”.
A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia.
Distal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plating and screws fixation.
a Only if the method of sequence generated was explicitly described could get a “Yes”; sequence generated by “Dates of Admission” or “Patients Number” received a “No”.
b Intermittent treatment or therapy duration less than 6 months means “Yes”, otherwise “No”.
c Drop-out rate > 20% means “No”, otherwise “Yes”.
d ITT = intention-to-treat, only if all randomised patients are analysed in the group they were allocated to could receive a “Yes”.
e “Yes” items greater than 7 means “High”; greater than 4 but no more than 7 means “Moderate”; no more than 4 means “Low”.
Three reviewers (XHX, TL and MMS) extracted the relevant data and checked the accuracy (Table 2). Study design, sample size, age, gender, loss to follow-up, AO and Gustilo classification of DTFs, reduction technique, implants, fibular fixation, protocol of weight bearing and outcomes were abstracted. We used the ITT data from trials whenever it was possible. If the data were not reported in the original article, we extrapolated them from the accompanying graphs. Most of the studies were small scaled with the sample size ranging from 14 to 160. The total sample size was 443 for IMN and 399 for plating. As for IMN, one study [
A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia.
A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia.
Distal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plating and screws fixation.
A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia.
Distal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plating and screws fixation.
A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia.
A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia.
Distal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plating and screws fixation.
A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia.
Distal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plating and screws fixation.
The primary outcome measurements (Table 3) included the complication rate, the union time, the operation time and the hospital stays. The secondary outcome measurements included the functional score and the pain score. All the studies mentioned the malunion and the nonunion of fractures (13/13). The studies showed a higher malunion rate in the IMN group and three studies showed a higher nonunion rate in the IMN group. All but one literature mentioned the infection rate (12/13) and only three studies showed the inferiority of the IMN group. More than half of the included studies described the secondary surgery rate (7/13) and the union time (8/13). Six studies mentioned the implant removal rate and the operation time (6/13). Few studies mentioned hospital stays (3/13). Functional scores were assessed with three different criteria: Olerud and Molander Ankle Score (OMAS) [
Distal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plating and screws fixation.
A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia.
A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia.
Of the pain score, Janssen adopted anterior knee pain score; Feng adopted VAS pain score; Guo adopted the pain score of AOFAS; Vallier adopted the pain score of MFA.
A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia.
Distal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plating and screws fixation.
IMN, intramedullary nailing; MIPO, minimally invasive plating osteosynthesis; N.A., not applicable; OMAS, olerud and molander functional ankle score; AOFAS, American Orthopaedic Foot and Ankle surgery scores; MFA, Musculoskeletal Function Assessment.
a Of the functional score, Guo adopted AOFAS; Im, Yang, Mauffery, Li and Zhang adopted OMAS; Vallier adopted MFA.
b Of the pain score, Janssen adopted anterior knee pain score; Feng adopted VAS pain score; Guo adopted the pain score of AOFAS; Vallier adopted the pain score of MFA.
Subgroup analysis was done in our meta-analysis, which mainly focuses on the types of internal fixations such as the BS, the locking plate, the DLN and the reamed IMN which would affect the mechanical stability. The degree of injury of different reduction techniques, MIPO or non-MIPO, and fracture type made a difference. The time of weight bearing also influenced the recovery of the fracture. In addition, the quality, the study design and the ITT analysis were included in the subgroup analysis.
Statistical analysis
We converted all outcome measurements using Review Manager 5.1.3 software and Stata 11.0. We used relative risk (RR) for the dichotomous data and weighted mean difference (WMD) or standardised mean difference (SMD) for the continuous data. A chi-squared test on N − 1 degrees of freedom was used to calculate the statistical heterogeneity, with significance at 0.05. I2 (I2 = ((Q − df)/Q) × 100%) was used to calculate the percentage of the variability in effect estimates according to the heterogeneity. Q is the χ2 statistic and df is the degree of freedom. We considered I2 values of 25%, 50% and 75% as low, medium and high heterogeneity, respectively. A fixed-effects model was used if I2 < 50%; otherwise, we used the random-effects model. If substantial heterogeneities across studies (I2 > 50%) were detected in the index five main meta-analyses, we performed post hoc sensitivity analysis by omitting the outlier studies to determine the sources of heterogeneity. The outliers were detected as the studies in which the confidence interval of the estimated effect size did not overlap well with the pooled overall effect size [
]. For skewed distribution, if the sample size was <60, standard deviation (SD) = (upper limit − lower limit)/4. We also calculated SD = standard error (SE) × N1/2 if we could got SE related to Z score. In order to keep the consistent trend in the forest plot, we used the computational method that adjusted mean score = total score − mean score, and the SD did not change for several outcomes in the functional score and the pain score. The funnel plot [
]. When allowed, the subgroup analyses were performed in isolation for DTF. We also used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to evaluate the quality of evidence by each outcome [
Expanding the Grading of Recommendations Assessment, Development, and Evaluation (Ex-GRADE) for Evidence-Based Clinical Recommendations: validation study.
The literature search initially yielded 6620 relevant studies, from which 2391 redundant publications were excluded. According to our criteria of inclusion and exclusion, 4213 studies were excluded. In the remaining full texts, three studies had data duplication and only the newest one was included [
A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia.
Distal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plating and screws fixation.
] with 842 participants were included (Fig. 1). The weighted kappa for the agreement on eligibility between reviewers was 0.84 (95% CI: 0.71–0.93). No publication bias was found in the funnel plot (Fig. 2).
Fig. 1A QUOROM flowchart illustrated the selection of studies included in our meta-analysis.
Fig. 2Funnel plot for total complication rate between IMN and plating showed no publication bias in visual. IMN, intramedullary nailing; RR, risk ratio.
IMN decreased the infection rate by 48% (N = 695, RR: 0.52 (0.30, 0.89); p = 0.02), but increased the malunion rate by 147% (N = 842, RR: 2.47 (1.58, 3.85); p < 0.0001) compared with plating. There was no significant difference in the total complication rate (N = 842, RR: 1.14 (0.75, 1.72); p = 0.53), the nonunion rate (N = 842, RR: 1.16 (0.51, 2.67); p = 0.72), the secondary surgery rate (N = 457, RR = 0.87 (0.52, 1.43); p = 0.57) and the implant removal rate (N = 411, RR = 0.82 (0.51, 1.31)) (Table 4). All the outcomes did not change if the studies with moderate to low quality were omitted.
Table 4The statistical comparison in outcomes between IMN and plating.
Outcomes
Fracture type
Event (IMN/plating)
Sample size (IMN/plating)
Mean [CI]
I2
p
1. RR
Total complication rate
DTF
118/89
443/399
1.14 [0.75, 1.72]
57%
0.53
Malunion rate
DTF
68/22
443/399
2.47 [1.58, 3.85]
29%
<0.0001
Nonunion rate
DTF
13/9
443/399
1.16 [0.51, 2.67]
0%
0.72
Infection rate
DTF
19/35
369/326
0.52 [0.30, 0.89]
15%
0.02
Secondary surgery rate
DTF
73/75
250/207
0.87 [0.52, 1.43]
67%
0.57
Implant removal rate
DTF
48/58
225/186
0.82 [0.51, 1.31]
53%
0.42
2. WMD
Time to union
DTF
N.A.
200/208
−0.21 [−2.46, 2.05]
88%
0.86
Operation time
DTF
N.A.
162/158
−10.66 [−16.64, −4.68]
65%
0.0005
Hospital stays
DTF
N.A.
48/49
−1.08 [−3.33, 1.17]
79%
0.35
3. SMD
Functional score
DTF
N.A.
198/185
−0.26 [−0.47, −0.06]
0%
0.01
Pain score
DTF
N.A.
123/122
0.23 [−0.23, 0.70]
67%
0.33
DTF, distal tibial fracture; IMN, intramedullary nailing; RR, relative risk; WMD, weighted mean difference; SMD, standardised mean difference; N.A., not applicable; RR > 1 or WMD > 0 or SMD > 0 means the results favouring plating, vice versa.
We found medium heterogeneity (I2 = 57%) in the total complication rate. We conducted the subgroup analysis and found the origin of the heterogeneity. After the separation in the subgroup analysis of locking plate, the heterogeneity was significantly reduced (p = 0.04). We also found medium heterogeneity in the secondary surgery rate (I2 = 67%) and the implant removal rate (I2 = 52%). When excluding the data of Seyhan et al. [
], which included two different IMNs, the heterogeneity reduced to 37% (p = 0.007) and 16% (p = 0.04), respectively.
Functional score and pain score
IMN increased the functional score (N = 383, SMD: −0.26 (−0.47 to −0.06); p = 0.01) compared with plating. However, no difference was found in the pain score (N = 245, SMD: 0.23 (−0.23 to −0.70); p = 0.33). All the outcomes did not change if the studies with moderate-to-low quality were omitted. We found medium heterogeneity (I2 = 67%) in the pain score. We noted three studies [
A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia.
] that assessed knee pain. The heterogeneity reduced to 22% after excluding the study by Janssen et al. (p = 0.01). All the outcomes did not change if the studies with moderate to low quality were omitted.
Other data
IMN decreased the operation time (N = 320, WMD = −10.66 (−16.64, −4.68); p = 0.0005) but had no influence on the time to union (N = 408, WMD: −0.21 (−2.46 to −2.05); p = 0.86) or the hospital stays (N = 97, WMD = −1.08 (−3.33, 1.17); p = 0.35). All the outcomes did not change if the studies with moderate to low quality were omitted. The high heterogeneity in the time to union (I2 = 88%) reduced to 42% (p < 0.00001) after excluding the study by Feng et al. [
IMN conferred more than twice the risk of malunion than plating. However, if the technique of either the BS or the DLN was adopted, the inferiority of IMN disappeared (RR of BS: 3.00 (0.34–26.76), RR of non-BS: 2.45 (1.55–3.85); RR of DLN: 3.00 (0.34–26.76) and RR of non-DLN: 2.33 (1.46, 3.71)) (Table 5). For DTF (Table 5), there was a reduced trend of PRT in the malunion rate for IMN (p = 0.13). MIPO also showed no statistical significance in the infection rate compared with IMN (RR: 0.61 (0.30–1.23)). However, no benefit of MIPO was found in the nonunion rate (p = 0.70).
Table 5Subgroup analysis of the included studies between IMN and plating based on influential factors.
All the prospective studies were with high quality according to 12-items, while retrospective studies were all with moderate or low quality, yes=high quality according to 12-items scoring system; no=moderate and low quality.
All the prospective studies were with high quality according to 12-items, while retrospective studies were all with moderate or low quality, yes=high quality according to 12-items scoring system; no=moderate and low quality.
a All the prospective studies were with high quality according to 12-items, while retrospective studies were all with moderate or low quality, yes = high quality according to 12-items scoring system; no = moderate and low quality.
b Yes = cases with intact fibula or fibular fixation/total cases >50%, no = cases with intact fibula or fibular fixation/total cases <50%.
Our GRADE analysis showed the comprehensively moderate quality in all the outcomes (Table 6). The most important reasons for the reduced level of evidence were inadequate blinding and lack of concealed allocation. Small sample size also decreased the evidence grade of the pain score, the union time and the functional score. Furthermore, the heterogeneity in the pain score and the union time had a negative effect on the quality.
Table 6GRADE evidence of comparison between IMN and plating in efficacy and safety for treatment of TMF.
Plating was always accepted as the first choice for DTF until the late 20th century when IMN gained satisfactory results and wide popularity with improvement in techniques [
]. In this systematic review and meta-analysis, we asked: (1) which fixation is better with regard to the clinical function and the complications and (2) which modifying factors affect the comparative effect between both techniques.
To the best of our knowledge, the present meta-analysis is the first to comprise all the available comparative controlled evidence and comprehensively investigate the difference in function, pain and complications between IMN and plating for DTF. As the previous systematic reviews only included retrospective observational studies, their validity was limited by imbalances between groups, lack of independent assessment, failure for blinding of outcome measurements and inadequate follow-up [
A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia.
Distal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plating and screws fixation.
]. All the studies were also included in our analysis except for one study, which did not meet our inclusion criteria, involved serious intra-articular fractures and lacked concrete data of complication rate or functional score in the IMN group [
]. This systematic review gave exactly the same results in complication rate, but the lack of adequate sample size limited the level of evidence. The present sample size in our analysis is larger with elevated quality of GRADE evidence compared with the previous reviews. Furthermore, our analysis has no language restriction so that the publication bias is reduced as much as possible.
We acknowledge limitations such as: (1) some might argue against the inclusion of the retrospective studies because of their inherent risk of bias. However, most of the patient data were obtained from these studies and, despite methodological limitations, ignoring this source of data might underpower the analysis, raise the risk of false negative error and influence the accuracy of our findings. Most of them balanced the demographic parameters between two groups, which limited the opportunity of selection bias. Furthermore, the results of the subgroup analysis remained unchanged after excluding these retrospective studies. (2) The unavailable raw data of the early studies, such as weight bearing and fibular fixation, made part of our subgroup analyses impossible. In addition, the different scoring criteria for function and pain across the studies might lead to the heterogeneity. These drawbacks necessitated a uniform and standardised format of follow-up in future. (3) The heterogeneity was significant in the outcomes of the total complication rate, the pain score and the time to union. The sensitivity analysis and the subgroup analysis were done to find the origins. (4) The small sample size in the subgroup analysis reduced the precision of the pooled estimates and the ability to detect the statistical significance of some variables, that is, the BS, the DLN and the PRTs in the evaluation of the malunion rate and MIPO in the evaluation of the infection rate. More RCTs would be warranted to clarify them.
One of the most significant results of our analysis is that IMN had higher functional score and comparable pain score of DTF compared with plating. However, we were unable to explain the clinical implications of the statistical difference because SMD was merely an absolute value without a unit or a cut-off reference. Of the included four studies in the pain comparison, three assessed the ankle [
A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia.
]. The present data, indicating the similar rates of hardware removal and the ankle pain of both modalities, might confirm the possible relationship between ankle pain and hardware irritation [
A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia.
] found a trend of more knee pain with IMN, whereas 95% of the patients returned to work without activity limitation. Further, the more severe knee pain with IMN reported by Janssen et al. [
] mainly occurred during kneeling or squatting, which did not influence the excellent knee function.
Our data showed that the malunion rate of IMN was considerably higher than in the case of plating, which was in agreement with the biomechanical data [
Biomechanical evaluation of the less invasive stabilization system, angled blade plate, and retrograde intramedullary nail for the internal fixation of distal femur fractures.
]. Interestingly, when the studies with combination of IMN and either the BS or the DLN were analysed separately in the subgroup analysis, the inferiority of IMN disappeared. In addition, there was a trend of reduced malunion rate of IMN when the PRTs were adopted. In a multicentre case series of TMFs treated with the DLN, Attal et al. [
] treated TMFs using reamed IMN combined with the percutaneous locking techniques, which showed acceptable alignment in 92% of the patients. All the clinical and biomechanical evidence supported the potential advantages of the BS, the DLN and the PRTs.
With regard to DTF, our results demonstrated the excellence of IMN over plating in the infection rate, which one previous systematic review failed [
]. It turned out that the previous result was potentially biased by the higher percentage of the open fractures in the IMN group. Besides, MIPO had an infection rate similar to IMN in the subgroup analysis, which was consistent with the cadaveric data [
] both suggested a similar nonunion rate between IMN and plating, which might be attributed to the minimal exposure, the precise reduction and the rigid fixation. Despite its theoretical advantage in local vascularity [
], we did not detect the statistical significance of MIPO in lowering the nonunion risk. More comparative data would be needed to address this hypothesis.
Conclusion
IMN and plating appear to share a similar nonunion rate, secondary surgery rate and implant removal rate for DTF. Specifically for DTF, IMN may be preferential, given its higher function score, lower risk of infection and comparable pain score and time to union. Plating could be an alternative when BS, DLN and PRT are unavailable. However, with the biases in our meta-analysis, all these viewpoints will ultimately require a rigorous and adequately powered RCT to prove.
Conflict of interest
Xun-Zi Cai is currently receiving grants from Zhejiang Provincial Natural Science Foundation of China (Y2110239), National Natural Science Foundation of China (81101345) and Zhejiang Key Programme Science and Technology (2011C13033). For the remaining authors none were declared.
Acknowledgements
We thank the corresponding authors of included studies, especially Vallier HA, for their sincere assistance in obtaining and verifying data. The project was funded by Zhejiang Provincial Natural Science Foundation of China (Y2110239), National Natural Science Foundation of China (81101345), and Zhejiang Key Programme Science and Technology (2011C13033).
Appendix A. Supplementary data
The following are the supplementary data to this article:
A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia.
Distal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plating and screws fixation.
Expanding the Grading of Recommendations Assessment, Development, and Evaluation (Ex-GRADE) for Evidence-Based Clinical Recommendations: validation study.
Biomechanical evaluation of the less invasive stabilization system, angled blade plate, and retrograde intramedullary nail for the internal fixation of distal femur fractures.
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