The mode of treatment of distal third tibial fractures is still controversial. Distal third tibial fractures differ from proximal third fractures by their difference in anatomy and difference in healing potential [1]. In current orthopedic practice, minimally invasive plating osteosynthesis (MIPO) and interlocking nailing are the preferred techniques for fractures of the distal third tibia. The intramedullary nail spares the extraosseous blood supply, allows load sharing, and avoids extensive soft tissue dissection [2-3]. However, proximal and distal shaft fractures can be difficult to control with an intramedullary device, increasing the frequency of malalignment [4]. Concerns regarding difficulties with reduction/loss of reduction, inappropriate fixation in fractures with articular extension, anterior knee pain [5], and hardware failure have slowed the acceptance of intramedullary nailing as a treatment of fractures of the distal tibia. The recent innovation of nails with tip locking is a testimony that earlier nails were insufficient fixation tools for the distal tibia; however, tip locking is technically difficult and fractures that require it are essentially difficult to fix with nails [2-6].

A comparative study was conducted on the clinical and radiological union in either of the closed IM interlocking nail or plate and screw fixation. The advantages, disadvantages, follow‑up, complications if any and overall functional outcome will be evaluated in these patients.

This is a prospective study of 30 patients with distal tibia fracture (closed extra-articular distal third tibia fractures 4–11 cm from tibial plafond) who underwent surgical fixation were included in this study after excluding compound, pathological, and pediatric fractures. Fifteen underwent closed IM interlocking nail and 15 were treated with minimally invasive plate osteosynthesis (MIPO).

The age distribution ranged from 23 to 68 years with the mean age of 39.4 years. The mode of injury in all patients was due to vehicle accidents. All 30 patients were classified according to A0 classification of which 15 belonged to A1, 14 belonged to A2, 1 belonged to A3. The time of fixation from injury varied from 6 hours to 18 days.

Patients were maintained non- or toe-touch followed by partial weight bearing until clinical and radiographic signs of healing were seen after which full weight-bearing was allowed. Secondary surgeries like bone grafting, dynamization, implant removal, implant exchange were performed as determined by the surgeon for the failure of progression of healing, loss of fracture fixation, or infection.

Radiographic and clinical evaluation:

All 30 patients were followed-up for clinical and radiological evaluation using modified Klemn and Borner scoring system at 6 weeks, 3 months, 6 months, 1 year [Table 1].

Table-1: Modified Klemm and Borner scoring system.

Excellent: 15-19, Fair: 5-9

Good: 10-14, Poor: 4-8

Fig-1: Pre-Operative.

Fracture union was defined as the healing of at least 3 of 4 cortices on a biplanar plain radiograph. Delayed union was defined as a lack of any healing on plain radiograph within 3 months. Nonunion was defined as a lack of any healing on plain radiograph within 6 months. Malunion was defined as more than 5° of angular deformity or shortening of more than 1 cm.

All the fractures united solidly with a mean union time of 24.5 weeks ranging from 18 to 38 weeks. The patient who underwent nailing showed a mean healing time of 24.9 weeks which has not shown any significant advantage over the healing time of patients treated with plate osteosynthesis by MIPO technique which is 24.2 weeks [Table 2].

All patients who underwent nailing shows a good regain of a range of movements in both knee and ankle. Two of the patients in the plating group had ankle stiffness which compromised the overall functional outcome. In our series, none of the patients had significant limb length discrepancy and no note of limping gait was made.

Of 30 patients with distal tibia fractures, 25 patients were associated with distal fibula fractures. There were 13 and 12 patients in the plating and nailing group, respectively. Fixation of fibula fractures usually results in better alignment. In our series, there were 11 out of 13, and 6 out of 12 patients underwent fibula fixation in the plate and nailing group, respectively.

Table 4: Rate of infection

Table 5: Final outcome.

[7-9].

Minimally invasive plating technique reduces surgical trauma and maintains a more biological environment for fracture healing. Despite the recently reported success of locking plates using MIPO for distal tibia fracture the optimal treatment for these remain controversial [10-13].

In the present study, to analyze these two techniques various parameters like union rate, the incidence of malalignment, rate of complications, and functional outcome using Klemn and Borner scoring system were used [14-16].

In the present study, there were 11 male and 4 female patients among the nailing group and 10 male and 5 female patients among the plating group. The mean average age incidence was 39 years. The youngest individual was 23 years, and the oldest was 68 years. In the nailing group, eight cases were of A0 type A2 comprising the majority.

In the plating group, there were eight cases of A0 type A1 comprising the majority. In the present study, the average period of the radiological union was found to be 24.2 weeks for the plating group and 24.9 weeks among the nailing group.

In Tzeng et al. study, the mean union times were 22.6 weeks in the nailing group and 27.8 weeks in the plating group. It has been found that the preservation of soft tissue envelope and blood supply surrounding the fractures by using indirect reduction techniques would promote fracture healing regardless of the type of fixation [15] [Table 6].

Table 6: Comparison with other studies.

In the present study, six cases in the nailing group showed higher than acceptable range of angulation, malalignment or loss of reduction may occur after nailing mostly due to improper reduction, poor nail position (e.g., not centering the nail in the distal fragment), or loose fixation.

Nonetheless, the correct nail position, good contact of the nail to the endplate, and rigid fixation of the nail‑screw‑bone construct should certainly be established [14] [Table 7].

In our series, two patients who were treated by IM interlocking nail, and concurrent fibula fixation resulted in nonunion. Mosheiff et al. and Schmidt et al. recommended routine fixation of the concomitant fibular fractures to lessen the risk of malalignment.

However, the essential benefit of IM nailing in avoiding soft tissue dissection might be compromised in this way. No patient suffered from the loss of reduction in the series conducted by them demonstrating that it is not necessary to fix the fibula in the fractures of distal tibial metaphysis [14].

Fibula fixation may improve tibia alignment in some cases, but that increased potential for delayed healing of the tibia may be seen when the fibula is stabilized concurrently [12]. It has been noted angular malalignment of 5° or more after nailing in 33.3% of patients, although malunion was not associated with the presence of fibula fracture or fixation of the fibula [17].

A recent comparative study has also described more malalignment after nailing (33.3% vs. 13.3% after plating), suggesting that the plating of complex fractures may result in less malalignment [15].

Percutaneous plating has had rates of secondary surgery between 0% and 20% for delayed fracture healing, compared with rates up to 42% after nailing suggesting that plating may be more efficacious in achieving timely fracture union without any secondary procedures [15].

The present study consisted of four patients among the nailing group who had undergone secondary procedures such as dynamization, bone grafting, and implant exchange.1 patient in the plating group had undergone any secondary surgery.

Recently, minimally invasive plating of injuries in this area has demonstrated excellent healing rates, and only a few required bone grafts. Recently reviewed literature founded 115 cases of minimally invasive plating for distal tibia fractures, and only 3% of these resulted in nonunion.

After reviewing various articles, the present study shows that plating by the MIPO technique has given an equally good result when comparing with the patients who had undergone IM interlocking nail.

In recent times, plate fixations by the MIPO technique for distal tibia fractures show the minimal incidence of wound gaping and implant failure.