|Year : 2023 | Volume
| Issue : 1 | Page : 66-72
Functional outcome of intramedullary interlocking nailing versus minimally invasive percutaneous plate osteosynthesis in distal tibia fracture
R Sahaya Jose1, K Vivek2, N Kattu Bava2, M Syed Moosa2
1 Professor, Department of Orthopaedics, Sree Mookambika Institute of Medical Sciences, Kulasekaram, Tamil Nadu, India
2 Postgraduate, Department of Orthopaedics, Sree Mookambika Institute of Medical Sciences, Kulasekaram, Tamil Nadu, India
|Date of Submission||08-Jul-2022|
|Date of Decision||04-Aug-2022|
|Date of Acceptance||04-Aug-2022|
|Date of Web Publication||27-Dec-2022|
R Sahaya Jose
119, Jose Bhavan, Puthukudieruppu, Nagercoil, Kanyakumari - 629 001, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Aims: The aim of the study was to compare the functional outcome of patients with extra-articular distal one-third tibia fracture, treated with intramedullary interlocking nailing (IMILN) with those treated by minimally invasive percutaneous plate osteosynthesis (MIPPO). Settings and Design: This is a prospective study and nonprobability sampling technique. Subjects and Methods: In this study, 60 patients with distal third tibia fractures of AO classification Type 43 A1, A2, and A3 were selected, in which 30 of them were treated with IMILN and the remaining 30 were managed with MIPPO. The patients were regularly followed up, and functional outcome was measured at 4, 8, 12, and 24 weeks using a modified Klemm and Borner scoring system. Statistical Analysis Used: The data collected were subjected to data entry in MS Excel. The data were analyzed using SPSS version 20.0 using Chi-square test. Results: In our prospective study, the functional outcome of MIPPO has shown excellent outcome in 13 patients (43.3%) and good outcome in 13 patients (43.3%), fair outcome in three patients (10%), and only one patient had poor outcome (3.3%). However, in the IMILN group, excellent outcome was seen in 7 patients (23.3%) and good outcome in 15 patients (50%), fair in five patients (16.7%), and poor outcome in 3 patients (10%). Alignment of fracture was anatomical in 13 patients of MIPPO and 7 patients of IMILN. Complications such as nonunion and malunion were more in the IMILN group than MIPPO, whereas superficial wound infection and delayed union were comparable in both. Conclusions: Distal tibial fractures can be effectively treated by both intramedullary nailing and MIPPO with minimal soft tissue injury providing good-to-excellent results, whereas in our present study, we observed that MIPPO had excellent functional outcome when compared to IMILN. Although interlocking intramedullary nailing allows early weight-bearing in patients, malunion and nonunion were more frequently seen, which affects the functional outcome. Therefore, we recommend that MIPPO is considered a very effective modality of treatment in distal third tibia fractures.
Keywords: AO classification, distal tibia fracture, intramedullary interlocking nailing, minimally invasive percutaneous plate osteosynthesis, modified Klemn and Borner scoring
|How to cite this article:|
Jose R S, Vivek K, Bava N K, Moosa M S. Functional outcome of intramedullary interlocking nailing versus minimally invasive percutaneous plate osteosynthesis in distal tibia fracture. J Orthop Dis Traumatol 2023;6:66-72
|How to cite this URL:|
Jose R S, Vivek K, Bava N K, Moosa M S. Functional outcome of intramedullary interlocking nailing versus minimally invasive percutaneous plate osteosynthesis in distal tibia fracture. J Orthop Dis Traumatol [serial online] 2023 [cited 2023 Jan 30];6:66-72. Available from: https://jodt.org/text.asp?2023/6/1/66/365285
| Introduction|| |
Distal tibial fractures account for <7%, of all tibial fractures and <10%, of all lower extremity fractures. Distal tibial fractures are more commonly seen in males between the age group of 30 and 50 years. Tibial fractures have a bimodal distribution, low-energy spiral patterns being commonly seen in patients over 50 years of age due to rotational forces and high-energy transverse or comminuted fractures seen in patients under 30 years of age due to fall from height and motor vehicle accidents. Low-energy fractures are three times more common in females than males, however, high-energy tibial fractures in young patients are more commonly seen in males. Various other mechanisms of injury to distal tibia include axial loading, compressive force as well as torsional force.,, Due to the proximity to ankle joint, these fractures are difficult to treat than mid-shaft fractures; therefore, distal tibial fractures remain a challenging subject in spite of many advances. The goal in expert care is good fracture reduction, limb length restoration, and quick recovery of function.
The metaphyseal flare involved in the fracture of distal third of tibia usually causes disturbance in implant contact leading to instability and malalignment during fixation. Any slight malalignment in the distal third tibia grossly alters the mechanism of the ankle joint that greatly affects the function of the joint and also produces increased pain in later stages. Preoperative planning of distal third tibial fractures is of much importance since operative management is challenging in this injury. Fracture pattern, soft tissue injury, and bone quality critically influence the selection of fixation technique. Numerous techniques have been developed for management of distal third tibial fractures which include conservative management, hybrid external fixation, minimally invasive percutaneous plate osteosynthesis (MIPPO), and intramedullary nailing.
Most of the distal tibial fractures are usually associated with fracture fibula also. The need for fixation of fibula fractures in patients with distal tibia fracture is inconclusive according to many literature. The fibular fractures are not necessarily fixed while using the intramedullary multidirectional interlocking nailing for fixation of tibia. However, fixation of fibula fracture provides improved reduction of fracture. Comorbid conditions such as diabetes mellitus, peripheral vascular diseases, smoking, and alcoholism complicate this delicate situation. Conservative management,, such as traction and application of plaster of Paris have a limited role in patients medically unfit. However, there are more complications in conservative management such as shortening, decreased ankle movements, malalignment, secondary osteoarthritis of the ankle joint, risks of pneumonia, deep vein thrombosis, and pressure sores.
In the MIPPO technique, the rate of fracture union is high, ranging from 80% to 100%. In this procedure, trauma to the soft tissue is reduced and it provides the apt environment for fracture healing. The intramedullary interlocking nailing (IMILN) of distal tibial fractures acts as load sharing device and it does not damage the soft tissue attachments, thereby it preserves periosteal blood supply without disturbing the fracture hematoma. IMILN allows early mobilization and returns to function in most of the individuals, which is the need for the hour. However, IMILN cases with short distal tibial fracture fragment has complications such as instability of fracture, coronal plane malalignment, and nonunion due to muscle forces producing displacement at the fracture site. Hence few cases require secondary procedures such as dynamization for union.
The malalignment in intramedullary nailing of distal tibial fracture is a consequence of disparity among the diameter of the medullary canal of distal end of tibia and the diameter of nail. This variation results in loss of contact between nail and the cortex, allowing the nail to sway laterally along coronally placed locking screws, and stress is increased on the locking holes to maintain alignment of the fracture after surgery resulting in failure. Furthermore, in MIPPO technique, complications such as implant failure, nonunion, and malunion have been reported and weight-bearing is delayed in case of MIPPO whereas immediate weight-bearing is possible in IMILN. Therefore, various techniques have evolved to improve fixation of distal both-bone fractures of leg including fibular plating (distal third fractures), different nail designs with different proximal bends (proximal third fractures), blocking screws (poller screws), and locking plates. All methods have some merits and demerits of their own; therefore, gold standard treatment option for distal one-third tibia fracture is still controversial. Hence, we conducted this study to compare the functional outcome using a modified Klemn and Borner score of these two methods, MIPPO and IMILN, in treatment of distal tibia fracture.
| Subjects and Methods|| |
After getting institutional human ethical committee and research committee approval, this prospective study was conducted among 60 patients in Sree Mookambika Institute of Medical Sciences, Kulasekharam, who were diagnosed to have extra-articular distal tibia fractures. Patients were grouped into two groups with each group having 30 patients based on nonprobability sampling technique. We included patients with age >18 years, extra-articular we included patients with age >18 years, extraarticular fractures (AO Type 43 A1, A2, A3), closed and open fractures (Gustilo and Anderson Type 1 and 2) and fractures < 2 weeks. We have excluded patients with age <18 years, intra-articular fractures (AO type B1-3, C1-3), open fractures (Gustilo and Anderson Type 3 and 4), pathological fractures, and fractures >2 weeks. In our study, most of the patients were in the age group of 31–45 years, with 25 patients of this age. However, 23 patients were in the age group of 46–60 years in the study population. In our study of 60 patients with distal tibia fractures, there were 34 males and 26 females with slight male predominance owing to the more incidence of road traffic accidents (RTAs) among males.
All the patients involved in the study were explained in detail, and informed consent forms were obtained. All required investigations were done including X-ray, computed tomography scan, and blood investigations. Out of which 30 patients were treated with IMILN and the remaining 30 patients were treated with MIPPO The patients were regularly followed up for a period of 6 months in regular intervals at 4, 8, 12, and 24 weeks. Functional outcome was measured using a modified Klemn and Borner scoring system. Patients were evaluated for complications such as infection, malalignment, and pain on weight-bearing, muscle atrophy, and ankle range of motion. The data collected were subjected to data entry in MS Excel. The data were analyzed using SPSS (SPSS inc IBM Chicago city, Illinois state, USA) version 20.0 using Chisquare test.
| Results|| |
A total of 60 patients were diagnosed to have extra-articular distal tibial fracture. Out of 60 cases, 49 (81%) cases were closed fractures and 11 (19%) cases were Grade I open fractures according to the compound Gustilo-Anderson classification. Based on fracture pattern by AO classification, A1 type were 44 (73%) cases, in which 20 (46%) A1 type cases underwent Minimally Invasive Percutaneous Plate Osteosynthesis (MIPPO) and remaining 24 (54%) A1 type cases underwent Intra Medullary Interlocking Nailing (IMLIN). A2 type were 14 (23%) cases, in which 9 (64%) A2 type cases underwent MIPPO and remaining 5 (36%) A2 type cases underwent IMLIN. A3 type were 2 (4%) cases, in which 1(50%) A3 type case underwent MIPPO and 1 (50%) A3 type case underwent IMLIN [Figure 1].
In our study, the most common mode of injury was found to be RTA in about 33 patients (55%). Fall from height caused distal tibia fracture in 5 patients, fall of object led to fracture in 10 patients, and self-fall was the mode of injury in 12 patients. The duration between injury and operation was noted that <10 days was among 26 (43%) cases, 11–15 days among 10 (17%) cases, and >15 days among 24 (40%) cases.
The functional outcome of 60 patients in our study was evaluated using a modified Klemn and Borner score. Based on the score, the patients were graded as excellent, good, fair, and poor. According to this score in MIPPO, excellent was observed in 13 (44%) patients, good outcome in 13 (44%), fair in 3 (10%), and poor outcome in only 1 (3%) patient. However, in IMILN, excellent was observed in 7 (23%) patients, good outcome in 15 (50%), fair in 5 (17%), and poor outcome in 3 (10%) patients. In our study, MIPPO has 26 patients of excellent-to-good results (86.7%), whereas IMILN has 22 patients of excellent-to-good results (73.3%), P = 0.328 not significant [Figure 2].
In our study, the range of movements of ankle joint was assessed at each follow-up. There was no restriction of movements seen in about 13 patients of MIPPO and 7 patients of IMILN and minimal (<25%) restriction was observed in 13 MIPPO and 15 IMILN patients. Moderate restriction (>25%) was seen in 3 MIPPO and 5 IMILN patients. Severe restriction was seen in only 1 MIPPO and 3 IMILN patients. Among 30 IMILN patients, 22 patients (73%) had full range of movements to minimal restriction only. In MIPPO among 30 patients, 26 patients (86%) had full movements to minimal restriction only [Figure 3].
|Figure 3: Comparison of ankle ROM in the study case. ROM: Range of motion|
Click here to view
In our study on 60 patients, atrophy of calf muscle was observed in 39 patients (65%), of which 17 (28%) were treated with MIPPO and 22 patients (37%) underwent IMILN. There was no muscle atrophy seen in 21 patients, of which 13 patients were treated by MIPPO and 8 were IMILN.
In our study on 60 patients, all fractures united except one patient irrespective of the method of fixation with an overall, average union time of 23.18 weeks. In which the union time for MIPPO was 23.03 weeks and for IMILN it was 23.34 weeks. There was one case of nonunion among the IMILN group [Figure 4].
In our study on 60 patients, the fracture alignment was normal in 20 patients, of which 13 patients (65%) underwent MIPPO and 7 patients (35%) underwent IMILN, and angular deformity of varying degrees was noted in the rest. The MIPPO group had 13 (43%) normal alignment, 13 (43%) patients had minimal angular deformity (<5), 3 (1%) patients had 10° malalignment. The IMILN group had 7 (23%) normal alignment, 15 (50%) patients had minimal angular deformity (10° malalignment. Normal alignment was highest in MIPPO than IMILN [Figure 5].
Among 60 patients, In MIPPO group pain complaints were noted on, prolonged activity in 13 (43%) patients, weight bearing in 4 (13%) patients, and no pain in 13 (43%) patients. Whereas in IMILN group pain complaints were noted on, prolonged activity in 15 (50%) patients, weight bearing in 8 (26%) patients, and no pain in 7 (23%) patients [Figure 6].
In our study, the time for full weight-bearing was ranging from 14 to 24 weeks. Among the MIPPO group, full weight-bearing was tolerated by 22 patients by the end of 16 weeks and about 27 patients in the IMILN group.
In this study, there were complications such as malunion, delayed union, nonunion, and superficial wound infection. In MIPPO, there were 4 cases (13.3%) of malunion and 1 case (3.3%) of delayed union and 2 cases(6.6%) of superficial infection and no case of nonunion were seen. In IMILN, there were 8 cases of malunion (26.6%), 2 cases (6.6%) of superficial wound infection, and 1 case of nonunion (3.3%) [Figure 7].
| Discussion|| |
Distal third tibia fractures had encountered higher complication rates when treated with plate fixation specifically after high-energy trauma. Therefore, many surgeons chose IMILN to reduce damage to fracture hematoma and surrounding soft tissue. Using intramedullary device, it is highly challenging to control proximal and distal third tibia fractures. Therefore, there is a variable rate of malunion from 5% to 58%.
In our study, we used Gustilo-Anderson classification for open fractures and the Tscherne classification for closed fractures with soft tissue injury to assess and grade the severity of soft tissue injury. Definitive surgical fixation is desirable and posted for surgery only when there is soft tissue healing. This is indicated by the skin wrinkle sign, once limb edema subsides.
In our study MIPPO versus IMILN techniques were analysed using various factors such as rate of fracture union, rate of malalignment, muscle atrophy, range of ankle movements, pain during rehabilitation and incidence of complications. The overall functional outcome were analyzed and graded using a modified Klemm and Borner scoring system were used. No patients in our study required secondary procedures in MIPPO and seven patients in IMILN underwent dynamization. All patients were given spinal anesthesia.
In our study population, the age group of patients who sustained distal third tibia fracture ranges from 24 to 60 years. The majority of patients were between the age group of 31 and 45 years for both the IMILN (41.967) and MIPPO groups (41.133). The P valve is about 0.769, and it is statistically not significant. This is comparable to the study conducted by Vallier HA et al., in which the age group was between 16 years and 77 years with an average of 39.1 years. In addition, Collinge and Protzman also had the age group of 17–62 years with a mean age of 43 years in their study population.
In our study, we had overall male preponderance with 34 males (56.7%) and 26 females (43.3%), in which 16 males and 14 female patients among the MIPPO group and 18 male and 12 female patients among the IMILN group. However, there was more male predominance in the study by Collinge and Protzman with 77 males and 23 females, and in Vallier HA et al. study, there were 69 males and 31 females. In this present study, left side was most commonly fractured. There were 28 (47%) patients with right distal tibia fracture and 32 (53%) patients with left distal tibia fractures.
In our study population of 60 patients with distal tibia fracture, the most common mode of injury was found to be high-energy RTA with 33 patients, which accounts for 55% of total study population. Followed by low-energy injuries such as fall from height, fall of object, and self-fall, five patients were observed in the rest with 45%. This was similar to the study by Grose et al. where there were 58% of high-energy injuries and 42% of low-energy injuries; similarly, Vallier HA et al. also had 51% of high- and 49% of low-energy injuries; in addition, Shrestha et al. had an equal amount of high- and low-energy injuries.
In our study population, there were 49(81%) patients with closed distal tibial fractures and 11(19%) patients with Grade I of Gustilo-Anderson type. This was comparable to the other studies conducted by Vallier HA et al. who had 70% of closed and 30% of open fractures and also Hazarika et al. who had 60% of closed and 40% of open fractures. According to AO fracture classification, there were 44 patients (73.3%) who sustained AO type A1 fracture and 14 (23.3%) with AO type A2 and 2 patients (3.3%) with A3 type of fracture tibia. Whereas in Shrestha et al. study there were 60% of A1 type and 20% of A2 type and 10% of A3 and B1 type each.
In our study on 60 patients, all fractures united except one patient irrespective of the method of fixation with an overall, average union time of 23.18 weeks. In which the union time for MIPPO was 23.03 weeks and for IMILN it was 23.34 weeks. There was one case of nonunion among the IMILN group that may be attributed to fibular plate fixation and in addition poor bone quality with osteoporosis in that patient. These findings in our study are similar to the Fang et al., 2016, study, which has a mean union time of 22.6 weeks in the IMILN group and 21.8 weeks in the plating group. It has been established that safeguarding the soft tissue environment and the blood supply of surroundings, the fractures by using indirect reduction techniques would promote fracture healing. Furthermore, Cheng et al., in their study, also had an average union time of 21.3 weeks in the IMILN group and 23.1 weeks in the percutaneous plating group; this is also similar to our study [Table 1].
In this present study among 60 patients of distal third tibia fracture, patients were allowed for weight-bearing as tolerated. The average time required for full weight-bearing was 14.56 weeks among the study group. In the MIPPO group, the average time for full weight-bearing was 16.06 weeks, and in the IMILN group, it was 13.06 weeks. This outcome is similar to the study conducted by Daolagupu et al., which had an average time for full weight-bearing of 13.38 weeks in minimally invasive plating and 10.09 weeks in the IMILN group. There was delayed weight-bearing among 8 patients of the MIPPO group that is attributed to fracture comminution, unstable fracture pattern, comorbidity of the patients, and osteoporosis causing prolonged time for bony union. In IMILN, only three patients had delay in weightbearing that is also due to fracture comminution, unstable fracture pattern, and associated comorbidities of the patients [Table 2].
In our study on 60 patients, the fracture alignment was normal in 20 patients, of which 13 patients (65%) underwent MIPPO and 7 patients (35%) underwent IMILN, and angular deformity of varying degrees was noted in the rest. In the MIPPO group, four patients (13.3%), and in the IMILN group, eight patients (26.6%) had developed malalignment. In Li et al. study, there were 4 cases (10%) of malalignment noted in IMILN and 3 cases (7.14%) in the MIPPO group. This shows that IMILN has more mal alignment compared to the MIPPO.
The functional outcome of 60 patients in our study was evaluated using a modified Klemn and Borner score. Based on the score, the patients were graded as excellent, good, fair, and poor. According to this score in MIPPO, excellent was observed in 13 (44%) patients, good outcome in 13 (44%), fair in 3 (10%), and poor outcome in only 1 (3%) patient [Figure 9]. However, in IMILN, excellent was observed in 7 patients (23.3%) [Figure 8], good outcome in 15 (50%), fair in 5 (16.6%), and poor outcome in 3 patients (10%). In MIPPO, there were 86.6% of excellent-to-good results, and in the IMILN group, there were 73.3% of excellent-to-good results. In MIPPO, the poor outcome in one patient is attributed to comminution of fracture and poor general health condition of the patient with comorbidity. In IMILN, there were three patients who had poor outcome that is due to inability to maintain fracture reduction of distal fragment in nailing. Li et al.  in their study had 90% of excellenttogood results in MIPPO and 87% of excellenttogood results following IMILN [Table 3].
|Figure 8: Case 1: IMILN excellent result: (a) Preoperative X-Ray, (b) Immediate postoperative X-ray, (c) 12-week follow-up X-ray, (d) 24-week follow-up X-ray, (e) Postoperative knee extension, (f) Postoperative knee flexion, (g) Postoperative standing (h) Postoperative ankle ROM. IMILN: Intramedullary interlocking nailing, ROM: Range of motion|
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|Figure 9: Case 2: MIPPO excellent result: (a) Preoperative X-ray, (b) Immediate postoperative X-ray, (c) 12-week follow-up X-ray, (d) 24-week follow-up X-ray, (e) Postoperative knee flexion, (f) Postoperative knee extension, (g) Postoperative plantar flexion, (h) Postoperative dorsiflexion. MIPPO: Minimally invasive percutaneous plate osteosynthesis|
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In our study, there were 4 cases of malunion among MIPPO which is 13% of the study population, and in the IMILN group, malunion was seen among 8 patients which is 27%. This is similar to the study conducted by Cheng et al., in which there were 3 cases (13.4%) of malunion in IMILN method of treatment and 1 case (4.3%) in minimally invasive percutaneous plating. This shows that IMILN has more malunion rate than MIPPO. This complication is greatly reduced by concurrent fibular fixation in both the groups; however, fibula fixation in IMILN causes nonunion in few cases.
In our study, there was one case of nonunion (3.3%) observed in the IMILN group; this may be attributed to fibular fixation in that patient, and in the MIPPO group, all fractures united. Delayed union of fracture was seen in one patient (3.3%) of the MIPPO group. This was probably due to the age and bone quality of the patients. Guo et al., in their study, reported no cases of nonunion in both the nailing and percutaneous plating groups. Li et al., in their study, there was 1 case of nonunion in both the MIPPO and IMILN groups and delayed union was seen in 4 cases (9.5%) of the MIPPO group and 5 cases (12.5%) of the IMILN group.
In our study, there was superficial infection seen in two patients of the MIPPO group and two patients of the IMILN group. These infections were settled with routine dressing and regular antibiotic course. All the patients who developed infections were diabetic. However, no deep surgical site infection was seen in our study. Furthermore, the chance of infection was highly reduced due to shorter duration of operative procedure and very minimal exposure of the soft tissue in both the techniques of fixation under study. Guo et al., in their study, reported that 15% of percutaneous plating cases had superficial infection including other wound complications and it was only 6.8% in the intramedullary nailing group. Similarly, Cheng et al., in their study, found one case (4.3%) of superficial infection in IMILN and three cases (13%) in MIPPO and there was no deep infection in both the groups observed in their study.
| Conclusions|| |
Distal tibial fractures can be effectively treated by both intramedullary nailing and MIPPO with minimal soft tissue injury providing good-to-excellent results, whereas in our present study, we observed that MIPPO had excellent functional outcome when compared to IMILN. Although interlocking intramedullary nailing allows early weight-bearing in patients, malunion and nonunion were more frequently seen, which affects the functional outcome. Therefore, we recommend that MIPPO is considered a very effective modality of treatment in distal third tibia fractures. However, more number of cases are needed to determine the complications.
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Conflicts of interest
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
[Table 1], [Table 2], [Table 3]