Comparison of intramedullary nailing and plate fixation in treatment of distal extra-articular tibial fractures: a systematic review and meta-analysis

Background/Aims: Intramedullary nailing (IMN) and plate fixation were widely accepted to treat distal extra-articular tibial fractures. However, the ideal treatment for extra-articular tibial fractures remained controversial. We conducted a systematic review and meta-analysis to compare the efficacy and safety of intramedullary nailing versus plate fixation in patients with distal extra-articular tibial fractures. Methods: PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched. Randomized controlled trials (RCTs) assessing the effect of intramedullary nailing and plate fixation on distal extra-articular tibial fractures were included. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. The primary outcome were malunion and nonunion. Meta-analysis was performed using random-effect model. Results: Seven RCTs involving 480 patients were included in the meta-analysis. Overall, compared with plate fixation, IMN resulted in low and comparable incidence of malunion (RR=1.14; 95% CI=0.60 to 2.18; P=0.69), nonunion (RR=1.57; 95% CI=0.46 to 5.34; P=0.47), deep infection (RR=0.83; 95% CI=0.34 to 2.01; P=0.68), and infection (RR=0.59; 95% CI=0.25 to 1.40; P=0.23) in patients with distal extra-articular tibial fractures. And no significant difference of secondary operations (RR=0.90; 95% CI=0.67 to 1.21; P=0.48), hospital stay (Std. MD=0.10; 95% CI=-0.48 to 0.29; P=0.62), delayed wound healing (RR=0.87; 95% CI=0.26 to 2.99; P=0.83), knee pain (RR=5.26; 95% CI=0.30 to 92.31; P=0.26) was found after the treatment of plate fixation and IMN. Conclusions: Compared to plate fixation, IMN showed low and comparable incidence of malunion, nonunion, deep infection and infection in patients with distal extra-articular tibial fractures. And there was no significant difference of secondary operations, hospital stay, delayed wound healing, and knee pain after the treatment of plate fixation and IMN.