Comparison of intramedullary nail and plating in treatment of diaphyseal tibial fractures with intact fibulae: A randomized controlled trial.

BACKGROUND: Tibial fracture without concomitant fibular fracture is an injury that has long attracted notice for the fact that it sometimes heals cleanly, other times causes various problems when the bone does not heal, or misaligns. In this randomized clinical trial, we assessed two treatment modalities plating and intramedullary nailing for treatment of closed, noncomminuted tibial fractures with intact fibulae.

MATERIALS AND METHODS: During the three year period, 1470 patients with leg fractures were treated and out of which, 114 were eligible to enter the study. Of the eligible patients, 73 were recruited to enter the trial, and ultimately 69 of these were followed for at least one year. The patients were randomized into two groups, one of which was treated by plating of the fracture, the other group by intramedullary nailing, both of which are standard surgical procedures. The primary variables that influenced the outcome of the procedures in both treatments were the duration of surgery, the amount of bleeding, the time to union, the need to repeat surgery to achieve union, the need to remove a device, and patients' complaints about pain or discomfort in the limb.

RESULTS: One case of nonunion occurred in the group treated with intramedullary nailing and one of the patients in this group developed late, deep infection in the screws location, which was resolved by screw removal (P = 0.285 and P = 0.478, respectively). In both groups the tibial fractures achieved union in about 4 months, though the intramedullary group underwent more operations to achieve union (dynamization was performed in 4 patients, representing 12.1% of the patients in this group, P = 0.047). During the followup period, the incidence of implant removal (after union) was not statistically significant between the two groups: two patients (6.1%) in the intramedullary group and four patients (11.1%) in the plate group (P = 0.675) had implants removed. Of the other studied variables, the difference between the two groups was statistically significant only with regard to patients' complaints of pain in the limb and the number of individuals with knee pain (in both cases, P = 0.001). In the intramedullary group, 18 patients had no complaints (54.4%) and 13 complained of knee pain (39.4%), while in the plate group 29 had no complaints (80.6%).

CONCLUSION: Based upon the findings of the present study, both the methods studied are suitable treatments for closed noncomminuted isolated tibial fractures, but the patients in whom intramedullary nails are used are more likely to require additional surgeries to achieve union, and probably will have more complaints of pain in their limbs or knees.