A Meta-Analysis of the Outcomes of Extra-Articular Distal Tibia Fractures Treated with Different Surgical Methods

Extra-articular distal tibia fractures are usually treated with intramedullary nailing (IMN), minimally invasive plate osteosynthesis (MIPO), open reduction and internal fixation with a plate (ORIF with plate), or an external locking plate (ELP). However, the outcomes of distal tibia fractures treated with these four methods have not been thoroughly investigated. The aim of this study was to compare the clinical outcomes of patients with distal tibia fractures treated with IMN, MIPO, ORIF with plate, and ELP fixation. Database searches of PubMed, Cochrane, Google Scholar, and Embase were conducted to focus on comparison studies for extra-articular distal tibia fractures. Ultimately, non-comparison studies were included for the ELP fixation group. Outcomes were evaluated by union time, rates of delayed union, nonunion, malunion, superficial infection, and deep infection. Patient-reported outcome measures and rate of revision surgery were considered for inclusion but ultimately excluded because of the heterogeneity of scales used and the absence of these outcome measures in many studies. Portions of the statistical analysis were conducted using Review Manager 5.4. Thirty studies were included in this study, with a total of 2,165 patients. The IMN group had a significantly higher rate of malunion compared with MIPO (odds ratio [OR] = 2.66, 95% confidence interval [CI] 1.65-4.28, p < 0.001) and ORIF with plate (OR = 5.90, 95% CI 1.58-22.07, p = 0.008). There was a significantly lower rate of superficial infection in the IMN group compared with MIPO (OR = 0.53, 95% CI 0.36-0.78, p = 0.001), and the rate of superficial infection was lower in the MIPO group compared with ORIF (OR = 0.30, 95% CI 0.10-0.94, p = 0.04). The IMN group had a significantly shorter union time compared with both the MIPO group (MD = −0.68, 95% CI −1.15 to −0.21, p = 0.004) and the ORIF with plate group (MD = 2.52, 95% CI −3.68 to −1.36, p < 0.001). In comparison with the ELP group, the union time was shorter in the IMN group (MD = 2.10, 95% CI 0.13-4.07, p = 0.04) and shorter in the MIPO group (MD = 2.40, 95% CI 0.49-4.31, p = 0.01). The ELP group had a significantly lower incidence of delayed union when compared with the MIPO group (OR = 0.14, 95% CI 0.02-0.99, p = 0.05) and had a significantly lower incidence of malunion compared with IMN (OR = 0.04, 95% CI 0.00-0.70, p = 0.03). IMN seems to be the preferable method due to its superiority in union time compared with MIPO, ORIF, and ELP groups and its lower rate of superficial infection compared with MIPO. However, the IMN group has a higher malunion rate than MIPO and ORIF with a plate. MIPO showed a lower risk of superficial infection than ORIF and a shorter union time than ELP. ELP showed better outcomes in the incidence of delayed union compared with MIPO and in the incidence of malunion compared with IMN. This shows that MIPO and ELP could be viable alternatives. However, more research must be done to confirm the superior treatment method.