Chapter 65 Tibial Diaphyseal Fractures: What Is the Best Treatment?
The management of tibia fractures has evolved over time from nonoperative treatment to operative treatment. Despite their common occurrence, the evidence base to direct the care of tibial shaft fractures is relatively poor. Moreover, there is little evidence to support the commonly recommended parameters of acceptable fracture alignment (less than 5–7 degrees of varus/valgus, less than 10 degrees of flexion/extension, less than 1.5 cm of shortening, and less than 15 degrees of rotational deformity). The characteristics of fractures amenable to nonsurgical management, stable fractures, are not well evidence based. It is generally accepted that nonpathologic, isolated, low-energy fractures, with little displacement, no significant soft-tissue injury, and having an associated fibular fracture can be treated without surgery. For the surgical management of tibial shaft fractures, a variety of implants is available, including external fixators, plates, and intramedullary (IM) nails.
OPERATIVE VERSUS NONOPERATIVE TREATMENT OF DISPLACED TIBIA SHAFT FRACTURES
Minimally displaced, stable tibia shaft fractures are commonly treated without surgery with satisfactory results. Controversies, however, exist in the management of displaced tibial shaft fractures. Six studies have compared nonoperative treatment modalities with surgery for displaced closed tibia fractures.1–7
NONOPERATIVE TREATMENT VERSUS OPEN REDUCTION AND FIXATION WITH PLATES AND SCREWS
In a prospective randomized clinical trial by Abdel-Salam and colleagues,1 45 patients with closed tibial shaft fractures were treated with a long-leg plaster cast and compared with 45 patients managed with open reduction and internal fixation (ORIF).1 Healing time and return to usual activity was significantly shorter in the ORIF group. The complication rate of secondary intervention for bone grafting or deep infection was lower in the ORIF cohort.
In a similar study by van der Linden and Larsson,7 100 patients were randomly assigned to ORIF with plates or closed treatment. Hospital stay seemed to be longer in the group treated by ORIF, and the complication rate was slightly greater. In accordance with Abdel-Salam and colleagues’ study,1 the healing time was significantly shorter in the ORIF group, and malalignment occurred more frequently in the nonoperative group.
A meta-analysis that included these studies reached the conclusion that the quality of the literature was poor. The risk for superficial infection was greater after ORIF versus cast treatment (odds ratio, 0.2; 95% confidence interval [CI], 0.08–0.50); however, there was no difference in the deep infection rate. Fractures treated with ORIF were more likely to be healed by 20 weeks than those treated in a cast (odds ratio, 0.02; 95% CI, 0.06–0.68).8
NONOPERATIVE TREATMENT VERSUS INTRAMEDULLARY NAIL
Hooper and coworkers’4 prospective, randomized study of 62 patients with unstable tibial shaft fractures found that IM nailing reduced time to fracture union by 2 weeks (P < 0.05) compared with long leg casting. IM nailing was also associated with significantly less time off work (13.5 vs. 23 weeks; P < 0.01) and less time in the hospital (8.1 vs. 11.7 days; P < 0.01). Compared with IM nailing, more patients with cast treatment had angular deformity and shortening. One third of casted patients healed with more than 10 degrees of angular deformity, and two thirds with shortening of more than 1 cm. No significant differences were observed in regard to range of motion of the ankle or knee joints. Secondary interventions were necessary in five patients of the nonoperative group compared with only one patient in the ORIF group.
Toivanen and coauthors6 note no delayed union in 33 patients treated with IM nailing compared with 8 of 54 patients treated with cast, representing a delayed union rate of 14.8% (P < 0.05). They did note anterior knee pain in 79% of patients treated with an IM nail compared with only 2% in the casted group (P < 0.001). Mean healing time, hospitalization time, and sick leave duration were significantly longer in the group treated with casting. A significant bias in this study was that patients initially treated without surgery who had a loss of reduction and needed revision surgery were excluded, so that the results in terms of final alignment were not statistically different between the groups. In a prospective, randomized trial, Karladani and researchers5 studied 53 patients, with 27 being treated with IM nails and 26 receiving nonoperative care. The nonoperative group was divided into additional cohorts of 12 and 14 patients because some fractures were not considered stable enough to be treated in cast alone and underwent cerclage wire or screw fixation in addition to casting. In the analysis of the final outcome parameters such as quality of life, weight-bearing time, and union rate, these two groups were analyzed together and compared with the IM nail group. IM nailing resulted in a 6 weeks faster time to union (95% CI, 2.5–12 weeks), and a faster time to full weight bearing by 8 weeks (95% CI, 5–17 weeks). IM nailing was associated with a lower risk for delayed union (odds ratio, 0.36; 95% CI, 0.17–0.78) but an increased risk for anterior knee pain (12/27 vs. 0/26 patients). At 3 months after injury, patients who underwent IM nailing had significantly better mobility, social function, work function, and sexual function as measured on the Nottingham Health Profile (P < 0.05).
OPERATIVE TREATMENT OF CLOSED TIBIA FRACTURES
Plate versus Intramedullary Nail
A prospective, randomized trial with a total of 64 patients was conducted by Im and Tae9 to compare IM nailing to plate fixation of distal tibia fractures. Thirty-four patients were treated with an IM nail, and 30 patients underwent open reduction and plate fixation with a follow-up period of 2 years. In the group treated with IM nails, the average angulation was greater (2.8 vs. 0.9 degree; P = 0.01). Locked IM nails seem to be advantageous in regard to the length of operation, restoration of motion, and reduced soft-tissue complications, whereas open reduction and fixation with plate and screws can restore alignment better than IM nails.
A systematic review of the prospective literature by Coles and Gross10 reports more superficial infection with plating (9% vs. <3% with reamed vs. unreamed nailing) but lower rates of malunion (0% vs. 3.2% with reamed and 11.8% with unreamed nailing). No evidence that assesses the utility of minimally invasive plating techniques in comparison with other treatment approaches is currently available.
Intramedullary Nail versus External Fixator
A total of 78 patients with 79 fractures was entered into Braten and coworkers’11 study (41 external fixators, 38 IM nails). Time to radiographic union and full weight bearing did not differ significantly, but unprotected weight bearing was achieved earlier in the IM group (12 vs. 20 weeks; P < 0.001). Reoperation for secondary displacement was more frequent in the external fixator group. No differences were observed in the final alignment or in the amount of shortening. IM nailing was commonly associated with anterior knee pain.
Intramedullary Nail versus Ender Nail
In a study by Chiu and colleagues12 that compares Ender nails with locked IM nails, IM nails were found to be superior for the treatment of comminuted, unstable tibial shaft fractures.
Reamed versus Unreamed Intramedullary Nails
Four Level II studies could be identified in which unreamed nailing was compared with reamed nailing.13–16 Reamed nailing was consistently found to be superior compared with unreamed nailing. The incidence of delayed and nonunion, as well as malunion, was lower, secondary interventions were less frequent, and the overall healing time was shorter in the group treated with reamed IM nails. Implant failure was found to be more frequent with unreamed nailing, whereas no difference in infection rate was encountered.
OPEN FRACTURES
Early versus Late Treatment
Three retrospective cohort studies could be identified to determine the efficiency of early surgical treatment versus delayed treatment in open tibia fractures.17–19 The final outcome measures included infection, secondary procedures, nonunion, and delayed union. Early surgery was defined as surgery less than 6 hours after the injury, whereas delayed surgery was defined as greater than 6 hours. In both groups, antibiotics were administrated. No differences in the overall rate of infection, secondary procedures, nonunion, delayed union, or complications could be determined. Although the present consensus remains that open tibial shaft fractures be treated on an emergent basis (Level V), if unavoidable, delayed management does not seem to jeopardize the final outcome.
Plate Fixation versus External Fixator
In Bach and coauthors’ study,20 published in 1989, a total of 59 patients were randomized to undergo plate fixation or external fixation for grade 2 and 3 open fractures.20 Their study showed a statistically significant greater rate of deep infections in the group treated with ORIF. Time to union and malalignment was not significantly different in both groups. Additional lag screws were used in 12 of 26 patients with external fixation for better alignment. This procedure did not seem to have any adverse effects in regard to the healing time or secondary procedures. This is in contrast with Krettek and colleagues’21
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