Distal tibial fractures: no winner, but plating trades malunion against infection

Design

Systematic review and network meta-analysis, 11 randomised trials and 18 cohorts, INPLASY registered

Population

2145 patients with distal tibial fractures

Primary outcome

Operation time, time to union, malunion, delayed union and nonunion, infection

Effect

Malunion: open reduction vs plating RR 0.30 (95% CI 0.11 to 0.82); plating vs external fixation with limited open reduction RR 3.26 (1.08 to 9.80); plating vs suprapatellar nailing RR 4.03 (1.30 to 12.48)

Eleven randomised controlled trials and 18 cohort studies covering 2145 patients were combined in a network meta-analysis comparing open reduction and internal fixation, minimally invasive plate osteosynthesis, external fixation with limited open reduction, and intramedullary nailing by infrapatellar and suprapatellar routes, with retrograde tibial nailing included.

The union outcomes that matter most did not separate: delayed union and nonunion showed no significant difference across strategies. Malunion did. Open reduction carried a lower malunion risk than minimally invasive plating (RR 0.30, 95 per cent CI 0.11 to 0.82), while plating carried a higher risk than external fixation with limited open reduction (RR 3.26, 1.08 to 9.80) and than suprapatellar nailing (RR 4.03, 1.30 to 12.48). Plating also took longer than infrapatellar nailing, by a mean 8.23 minutes (0.44 to 16.01), and reached union later, by a mean difference of 1.02 (0.10 to 1.93) in units the abstract does not state. Infection risk ran higher with both open reduction and minimally invasive plating than with external fixation or nailing.

So the trade is explicit rather than hidden: the techniques that give the best alignment control here are the ones with the higher infection burden, and the nailing and external fixation strategies buy soft-tissue safety at some cost in malunion. That reads as an argument for choosing by the soft tissues and the fracture pattern in front of you, which is what most surgeons already do, rather than for adopting a house technique. Every confidence interval here is wide and several comparisons are indirect.

• Choose by soft-tissue envelope and fracture pattern; the network gives no strategy a general win.
• Where the skin is compromised, the higher infection signal with open reduction and plating is the finding to weigh.
• Where alignment is the harder problem, plating fared worse than nailing and external fixation on malunion.
• Do not use these estimates to counsel on nonunion risk - that outcome did not separate.
• Note the intervals: a relative risk running from 1.30 to 12.48 tells you the direction, not the magnitude.

The statistics, in plain English

Network meta-analysis borrows strength from indirect comparisons, so a relative risk of 4.03 with an interval from 1.30 to 12.48 rests partly on studies that never compared those two techniques directly. Intervals that wide mean the effect is real in direction but unquantified in size. The null findings for delayed union and nonunion are genuine absences of difference in this dataset, not evidence that the techniques are equivalent - with 2145 patients spread across five strategies, a modest true difference would not have shown.

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