DOI: 10.21276/aimdr.2020.6.1.

OR4

Section: Orthopaedics
Original Article ISSN (O):2395-2822; ISSN (P):2395-2814

Intramedullary Interlocking Nailing Versus Plating in distal

Tibial Shaft Fractures in Adults: A Comparative Study
Rabi Narayan Dhar1, Pradeep Kumar Merli2
1
Associate Professor, Department of Orthopedics, VIMSAR, Burla, Odisha, India
2
Assistant Professor, Department of Orthopedics, VIMSAR, Burla, Odisha, India

Received: December 2019

Accepted: December 2019

Copyright: © the author(s), publisher. Annals of International Medical and Dental Research (AIMDR) is an
Official Publication of “Society for Health Care & Research Development”. It is an open-access article distributed
under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-
commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT
Background & Aim: Tibial diaphyseal fractures are the commonest long bone fractures in adults, most commonly
managed by intramedullary interlocking nailing. However, several meta-analysis show that locking plate
osteosynthesis is equally effective in managing tibialdiaphyseal fractures and are associated with less number of
complications. Our aim was to compare the results of fixation of tibial fractures following plating and nailing in
terms of union, patient satisfaction and complications.Methods:100 patients with extra-articular distal tibia shaft
fractures with a mean age of 38 years (range, 18-55 years) and mean Injury Severity Score of 13.5 were included
in this study. Patients were randomized to a reamed intramedullary nail (n =50) or a large fragment medial plate
(n = 50). 80 fractures (80%) were open. 56 had concomitant fibula fractures that were stabilized. Outcomes like
malunion, nonunion, infection, and secondary operations were measured. Results: In intramedullary group,
average union time was 18.68 weeks compared to 21.15 weeks in plating group which was significant (P <
0.0001). Average time required for partial and full weight bearing in the nailing group was 6.65 weeks and 8.79
weeks respectively which was significantly less (P < 0.0001) as compared to 6.70 weeks and 12.22 weeks in the
plating group. Lesser complications in terms of implant irritation, ankle stiffness, and infection, were seen in
interlocking group as compared to plating group. Average functional outcome according to American Orthopedic
Foot and Ankle Society score was measured which came out to be 95.88.Conclusion:Intramedullary group was
associated with lesser duration of surgery, earlier weight bearing and union rate, lesser incidence of infection and
implant irritation which makes it a preferable choice for fixation of extra-articular distal tibial fractures. However,
larger randomized controlled trials are required for confirming the results

Keywords: Intramedullary, nailing, plating, tibia, fibula.

INTRODUCTION injuries including variations of external fixation,

intramedullary nailing (with and without reaming),
Distal tibial fractures continue to be one of the and plate fixation with a recent emphasis on
most controversial fractures that we treat. The type minimally invasive techniques. Studies of treatment
of fractures include extra articular fractures of the outcome for distal tibial fractures of the metaphysis
metaphysis and the more severe intra-articular are uncommon. Locked intramedullary nailing is
tibial plafond or pilon fractures. Fractures of distal the TOC for closed fracture of tibial shaft.
tibia are also distinct from pilon fractures in Minimally invasive percutaneous plate
mechanism of injury and also in the management. osteosynthesis (MIPPO) was one such method in
The mechanism of injury is bending force or which plate was introduced percutaneously and
twisting force that results in transverse, oblique or fixed proximal and distal to the fracture
comminuted fractures resulting from high energy percutaneously.[3] MIPPO had advantage of
road traffic accidents when compared to pilon biological fixation, less vascular damage, indirect
fractures which results from axial loading reduction with less soft tissue stripping, proper
mechanism.[1,2] Several treatment methods have restoration of axial and rotational alignment with
been recommended for the treatment of these sufficient stability to allow early range of motion
(ROM) exercise and ambulation. But delayed
Name & Address of Corresponding Author
healing, infection and hardware problems were
Dr. Pradeep Kumar Merli, some of the major concerns. It was technically
Assistant Professor simple, easier to master, need no additional
Department of Orthopedics expensive instruments, cheaper to the patient and
VIMSAR, Burla, Odisha, India.
facilitate early mobilization of the patients.[4] A

Annals of International Medical and Dental Research, Vol (6), Issue (1) Page 17
 Dhar & Merli; Distal Tibial Shaft Fractures in Adults

Section: Orthopaedics
recent trend in internal fixation by MIPPO had laterally to expose the insertion site and protect the
been a move towards locking screws which can tendon during insertion. Then the awl is inserted
rigidly stabilize cancellous bone that is normally where the anterior tibia reaches the joint. Utmost
not amenable to screw fixation retaining the care is taken to stay in the extra-articular area
fundamental goal of treatment of distal tibial because back of the nail may impinge on the
fractures as restoration of normal or near normal femoral condyle. Nailing was done using standard
alignment and articular congruity. Locking technique and all fractures were fixed with two
compression plating (LCP) provides an angular proximal and two distal locking screws.
stability for fixation. Locked screws prevent the In MIPO, the leg was prepared circumferentially
plate from pressing the bone, preserving periosteal from the toes to mid-thigh and draped free. A
blood supply. This system stimulates callus longitudinal incision of length 3–4 cm was made
formation due to flexible elastic fixation. The bone deep over the medial malleolus adequate
anatomic shape of the plate prevents malalignment enough to put screws in distal fragment. The
of the fracture and provides a better axial and saphenous nerve and vein were preserved and
angular weight distribution. Our aim was to retracted anteriorly. Then an epiperiosteal space
compare the functional outcomes of distal tibial tunneling toward the diaphysis was made using the
metaphyseal fractures of tibia by anatomical locked blunt tip of the plate. The reduction was achieved
plate by MIPPO technique to that with reamed with manual traction and manipulation.
intramedullary nailing, to alleviate the Anatomically, precontoured plate was used and
controversies regarding the complications arising was positioned on anteromedial aspect of distal
from management of distal tibial metaphyseal tibia by passing it through the subperiosteal tunnel.
fractures by nailing and plating by MIPPO After insertion of plate and achieving the reduction,
technique and to set the indications for both the plate was temporarily fixed to bone with K-
modalities of fixation. wires and fixed proximal fragment with one
locking screw. Distal fragment fixation was done
MATERIALS AND METHODS with a combination of locking and cortical screws.
Depending on fracture pattern and bone quality the
All the patients were admitted to Orthopaedic decision of inserting the lag screw was made.
Department of Veer Surendra Sai institute of Insertion of screws in the proximal fragment was
medical science and research (VIMSAR)from done with small stab incisions.
November 2017 to October 2019.
Postoperative protocol:
The inclusion criteria: Operated limb was immobilised in posterior splint.
1. Adults with age > 18 years and <55 years Mobilization of the knee and ankle was started in
2. Distal tibialextraarticular fracture, minimum of the immediate postoperative period. Early
3cm of distal fragment. nonweight bearing mobilization of the patient was
3. Closed and Gustilo-Anderson grade I fracture started from 5th day onwards after inspection of
4. Patients who were medically fit for surgery suture line. X-ray radiograph of the involved leg
was taken post operatively, at 6 weekly intervals
The exclusion criteria: till union and at 1 year followup.Acceptable
1. Displaced intra articular fractures alignment was defined as less than 10°
2. Gustilo-Anderson grade II and grade III fractures anterior/posterior angulation, less than 5°
3. Fracture with Neuro vascular injury varus/valgus deformity or less than 10° rotation
4. Pathological fractures difference and shortening less than 1 cm.Malunion
5. Fractures associated with compartment Syndrome was measured by the angle created by the
6. Patients who are medically unfit and not willing for intersection of the subchondral line of the plafond
surgery and a line drawn up the centre of the tibial shaft.
Ninety degrees was considered normal and
Operative protocol: deviations of more than 5° were recorded as either
Patients were operated under spinal anesthesia in varus, valgus, more than 10 °anterior or posterior
supine position on a standard radiolucent table. angulation. Rotational malalignment and limb
Prophylactic intravenous antibiotics were length discrepancy was assessed clinically
administered 15 min before skin incision. An image comparing with other limb (block method). Patient
intensifier was used in all the cases to provide was discharged after suture removal with strict
fluoroscopic guidance. The patient was positioned orders of non-weight bearing till next follow up.
supine with the hip flexed 45° and the knees flexed Patient was followed up clinically and
to 90° on radiolucent table. A 5-cm incision along radiologically at 6 weekly interval till union and at
the medial border of the patellar tendon was made, 1 year. A clinical evaluation for the functional
extending from the tibial tubercle in a proximal assessment of the ankle was obtained at one year
direction. The patellar tendon was retracted follow-up byOlerud and Molander Ankle Score

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 Dhar & Merli; Distal Tibial Shaft Fractures in Adults

Section: Orthopaedics
(OMAS) and The American Orthopaedic Foot and sinus carefully followed-up every 2weeks with
Ankle surgery (AOFAS) scoring. The OMAS is a proper antibiotic cover, finally they united at 27wks
patient reported score but is more specifically .In the immediate postoperative period radiographic
related to injuries around the ankle and includes evaluation of reduction and alignment was done, in
assessment of: pain, stiffness, swelling, stair which 36 fractures showed acceptable alignment, 4
climbing, running, jumping, squatting, supports and fractures of nail group had valgus angulation of 8
work and activities of daily living. It is transformed and 2 fracture of mippo group had varus
to a 100 point scale, where 100 represents normal angulation of 10 . [Figure 1]
function and 0 the worst possible function. The
American Orthopaedic Foot and Ankle Society
(AOFAS) Ankle-Hindfoot Scale is a clinical rating
system developed by Kitaoka et al. It combines
subjective scores of pain and function provided by
the patient with objective scores based on the
surgeon's physical examination of the patient. The
AOFAS clinical rating systems do not incorporate
any radiographic criteria into the assessment. The
patients rate his or her pain and function levels on a
written questionnaire. Then we do the physical
examination of the patient to assess the sagittal
motion, the hind foot motion, the ankle-hind foot
stability, and the alignment of the ankle-hind foot.
The AOFAS Ankle-Hind foot Scale is scored with
Figure 1: Allignment of Limb on Post op and Follow
a possible 100 points. There are no defined limits
up Period
of what scores constitute excellent, good or poor
outcome. The final results at the end of 2 year
When followed up for one year the degree of
follow up were evaluated using the “Johner &
alignment in all cases did not differ significantly
Wruhs’ Criteria” as excellent, good, fair and poor.
and cases which were malaligned in immediate
postoperative period went on to unite in that
RESULTS position except two cases in nail group which had
good post-operative alignment developed recurvate
In our study, 100cases of extra articular distal tibia deformity on subsequent follow-up and finally
fractures were treated. All cases were fresh, 76 united with 15 ° anterior mlalignment. None of the
patients were male and 24 female. The mean age of cases had rotational malunion and shortening.
patients was 37.6 years.Out of 100 fractures, 82 Infection occurred in eight cases all of which
were caused by road traffic accident, 8 from fall belong to the mippo group out of which 4 were
and 10 had history of assault. 68 patients had superficial that controlled with dressing and
fracture on left side and 32 on right side.All antibiotic and caused no hinderance to bone
fractures were classified according to AO/OTA union.[4] other cases which developed deep
classification of which 26 fractures were 43A1, 58 infection,two of them were gone into delayed union
fractures were 43A2 and 16 fractures were 43A3. but two other cases ended up with infected non-
72 fractures were closed and28 were compound. union. 4 cases of MIPPO had impingement and
The soft tissue injury was graded according to implant irritation for which symptomatic treatment
Tscherne classification of which 8 fractures were was given. None of the cases which were treated
type 0, 16 were type 1 and another 20 were of type with intramedullary nailing had infection as
2 injury,8 were type 3.All compound fractures were complication though 10 cases of our series were
Gustilo-Anderson grade I type.All fractures in nail gustilo-anderson grade I. Two of the cases had
group united in this study and most of them united implant failure in the form of breakage of distal
between 16-20 weeks. The mean union time was locking screw in nail group, but it had no
18.68 weeks (95% confidence interval 18.712- interference with fracture union. There were two
20.817).All fractures in plate group except two cases of delayed union. Four of the cases of nail
united and most of them united between 16-24 group had anterior knee pain that improved after
weeks (95% confidence interval 18.987-22.551). 28 nail removal. 8 cases required secondary
fractures in the nail group united between 21- procedures to achieve union. 6 cases were of
24wks including 6 cases of dynamisation. Out of intramedullary nailing group and all 6 were
four fractures in mippo group which got dynamised. The rest two cases were of mippo
deepinfection, two cases finally turned to infected group that got infected and ring fixation was done
nonunion and treated with ring fixator after implant to unite the fracture. [Figure 2]
removal and infection control, which finally united
at 46 weeks. The other two cases with discharging

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 Dhar & Merli; Distal Tibial Shaft Fractures in Adults

Section: Orthopaedics
Orthopaedic Foot and Ankle surgery (AOFAS)
scoring. [Table2]
The mean OMAS for mippogoup were
97.143(range from 95 to 100),the 95% confidence
interval being 94.685-99.601.The mean OMAS for
nailing group were 99.333(range from 95 to
100),the 95% confidence interval being 98.385-
99.316).The American Orthopaedic Foot and Ankle
Society (AOFAS) Ankle-Hindfoot Scale is a
clinical rating system developed by Kitaoka et al. It
combines subjective scores of pain and function
Figure 2: Complications Following the Procedures
provided by the patient with objective scores based
on the surgeon's physical examination of the
The minimum period of follow up in our study was
patient.The mean AOFAS score for mippo group
1 year ranging from 12 months to 18 months,
were 83.571(range from 78-89),95% confidence
except 4 cases which lost to followup after union of
interval being 81.881-85.262 .The mean AOFAS
fracture.A clinical assessment of ankle function
score for nail group were 84.867 (range from 82-
was done according to the criteria ofOlerud and
90),the 95% confidence interval being 83.579-
Molander Ankle Score (OMAS) and The American
86.155.
Table 1: Clinical assessment of ankle function.
Ankle Score NAIL (n=50) MIPPO(n=50)
OLERAUD No of cases Percentage No of cases Percentage
SCORE 100 46 92% 30 60%
95 4 4% 10 20%
90 0 0% 5 10%
85 0 0% 5 10%
<85 0 0% 0 0%
AOFAS 75-80 0 0% 15 30%
SCORE 81-85 40 80.00% 25 50%
85-90 10 20.00% 10 20%
>90 0 0% 0 0%

Our study comprised of 68 patients with

extrarticular distal tibia fracture out of which 34
were treated with intramedullary nailing and 28
with plate fixation using minimally invasive
techniques based on soft tissue condition and
fracture pattern. Decision of fixing the associated
fibula fracture was done depending on
initialdisplacement, intraoperative alignment of
tibia fracture and whether it caused any disturbance
to ankle mortise and syndesmotic stability.
In our study, we allowed weight bearing only after
Figure 3: Final Outcome Based On Johner and
Wruhs Criteria signs of union in form of bridging callus on at least
3 cortices on radiograph, absence of tenderness at
fracture site and patient ability to bear weight is
The final outcome was assessed based on Johner
present usually by 12-14 weeks. We had 28 cases
and Wruhs criteria, 16 had excellent outcome,10
(82%) out of 34 in nail group and 20 cases
had good outcome, 4 had fair outcome and 4 are
(78%)out of 28 case in mippogruop, having
lost to follow- up in nail group. Out of 28 of
fulfilling above criteria around 12-14 weeks and
mippogroup 12 had excellent outcomes,10 had
were allowed to bear weight. In study by Oh W, et
good outcome,4 had fair outcomes and 2 had poor
al,[5] on mippo the mean time for complete weight
outcome. [Figure 3]
bearing was 13.2 weeks and it was 14 weeks in
study by Mehmet et al.[22]In study by M Aslam
DISCUSSION Siddiqui et al,[21] on intramedullary nail the mean
time for complete wt bearing was 13 wks and in
Careful preoperative planning is needed in similar study by Kasper W. Janssen et al, it was
consideration with above mentioned factors in 14.2 weeks. Our findings are similar to these
selecting the correct implant for given fracture results.
pattern and associated soft tissue injury and All fractures in nail group united in our study and
minimizing the postoperative mal alignment and most of them (24 fractures) united between 16-20
soft tissue complication. weeks. The mean union time was 19.8 weeks (95%

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 Dhar & Merli; Distal Tibial Shaft Fractures in Adults

Section: Orthopaedics
confidence interval 18.712-20.817). 8 fractures in In study by RongaM et al,[16] 4 cases (21%) out of
the nail group united between 21-24 weeks 21cases who were treated with MIPPO had
including 6 cases of dynamisation. In similar study unacceptable malunion with varus deformity and 2
by NorkS, et al,[9] 80% of the fractures united had anterior angulation. None of the patients had
before 30 weeks and the mean time for union was rotational deformity and shortening. In study by
23.5 weeks. Ehlinger M, et al,[18] achieved union CollingeCet al,[12] 93% fractures united without
before 30 weeks in all cases, the mean time being significant malalignment..
16 weeks. In study by Fan C, et al,[8] had mean In study by Ehlinger M, et al,[18] on these fractures
union time of 17.2 weeks. Robinson C,et al,[3] 12 with IMIL nail, they had 27.5% of cases having
achived union in all cases by 22.2 weeks when malunion the most common being valgus or
treated with IMIL nail. combination of valgus with other deformity in AP
In MIPPO group,most fractures (18 fractures, 65%) or rotational plane. In the study by NorkSet al,[9] 3
united between 18-22wks,the mean being 20.8 out of 30 cases had malunion with one case in
weeks (95% confidence interval 18.987-22.551).2 valgus and 2 cases recurcvatum.JGuo et al in their
cases in MIPPO group with delayed infection study did not detect any case on mal-
showed delayed union at 27 weeks.OhW,et al,[5] in alignment.Study by A.Krishanet al,[15] had
their study, similar to ours found the mean union malunion rate of 8% both in coronal and saggital
time for these fractures treated with MIPPO was axis. In above mentioned studies they did not had
15.2 weeks( range, 10-24weeks). In study by rotational deformity and shortening. It is evident
Ronga M, et al,[16] union was achieved in all that these fractures tend to malalign in valgus/varus
fractures by 24 weeks. In study by Borg T et al,[7] or in anterior /posterior direction. Our results are
they achieved union in 90% of fractures within 24 comparable to above studies.
weeks. The mean time for union in CollingeC et None of the fractures treated with nailing in our
al,[12] study was 35 weeks but all fractures which study had infection (superficial and deep) as
were closed healed within 25 weeks. complication though we had nailed 10 cases of
Based on these findings we can conclude that Gustilo-Anderson grade I injuries.A.Krishan et
dynamisation is an effective procedure and should al,[15] in their study got only 2 cases of superficial
be done in cases with slow progress to union before infection though they had done nailing in 11 case
deciding on to more invasive procedure.In MIPPO including Gustilo-Anderson Grade I ,II and IIIA.
group all fractures united without need of any In study by Ehlinger M, et al,[18] they had 2 deep
secondary procedure except 2 cases that ended as infections (5%) requiring lavage and in study by
infected nonunion and needed ring fixator for Nork S, et al,[9] one case had deep infection. Guo J,
union. CollingeC et al,[12] in their study had 8% et al,[19] in their comparative study of IMIL nail
cases requiring secondary procedures for union.In with MIPPO concluded that wound complication
their study by J Guo, et al,[19] all fractures in are more with MIPPO than nailing (3% vs 6%).Our
MIPPO group had united without any secondary study also showed the same trend as above
procedure. Secondary procedure rate varies in mentioned trend.
different studies, 5% S.Hazarica, et al,[10]2% (T W Four of our cases in nail group experienced knee
Lau et al)and 2.5 % in study by R K Gupta et al.All pain, The cause for knee pain might be Proximal
cases in our study treated with MIPPO healed end of nail prominence above the cortex,that was
without secondary procedures, this may be because subsided after nail removal.
of small number of cases in our study, all cases None of the cases had implant failure as
being closed and correct intraoperative techniques. complication in our study except two where the
In our study, we had acceptable alignment in 28 distal locking bolt was broken. In these cases
cases out of 34 (82.4%) in nail group and 26 cases fracture united in due course but patient was lost to
out of 28(93%) in MIPPO group. Of 8 cases 6 follow-up .In study by EhlingerM,et al,[18] and in
cases which had malailgnment evident on study by NorkS et al9 no complications related
immediate postoperative period healed in same implant failure occurred. Oh W,et al,[5] and
position at follow up of 1 year and no significant A.Krishan et al,[15] in their study had no implant
change was noted.2 cases in nail group failure cases. Where as M AslamSiddiqui,et al,[21]
developedrecurvatum deformity on weight bearing had 2 cases of distal screw breakage. In MIPPO
and united with 15° anterior angulation. This groupCollinge C et al,[12] 38 had 7% cases having
finding suggests intraoperative error could the loss of fixation and S.Bahariet al,[25] had implant
prime cause for malunion and it also throws light failure fixation in 1 case. Where as Mehmet et
on difficulty in reducing the distal fragment al,[22]D.Shrestha, et al,[20] and Mohamed Sukeik,et
accurately. 4 cases had valgus malunion and 2 al,[17] found no implant failure in their studies on
cases had recurvatum deformity which were MIPPO.We had implant impingement and irritation
primarily fixed with IMIL nail and 2 had in 4 of 28(14%) cases of MIPPO for which
varusmalallignment which belonged to MIPPO. symptomatic treatment was given and patients are
doing well. Oh W,et al,[5] in their study had 40%

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Section: Orthopaedics
patients and D.Shrestha, et al,[20] had 38% patients 4. Dogra A, Ruiz A, Thompson N, Nolan P “Dia-metaphyseal
experiencing implant impingement. Lau T et al,[14] distal tibial fractures treatment with a shortened
intramedullary nail: a review of 15 cases”. Injury2000;
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discomfort. Only 14% had their implant removed 5. OhCW, Kyung HS, Park IH, et al. Distal tibia metaphyseal
for this reason and opined that decision on implant fractures treated by percutaneous plate osteosynthesis.
removal for this complication should be ClinOrthop. 2003;408:286–291.
justified.We opine that implant irritation and 6. Schmidt A, Finkemeier C, TornettaIII P “Treatment of
impingement is related to thickness of implant and Closed TibialFractures”.J Bone Joint Surg 2003; 85(2):
1582-85.
designs,the better result in our study is due to use 7. Borg T, Larsson S, Lindsjö U “Percutaneous plating of distal
of low profile 3.5mm plate and better designed tibial fractures. Preliminary results in 21 patients”. Injury.
plate in our case series. 2004 Jun; 35(6): 608-14.
Oh Wet al,[5] in their study on MIPPO had excellent 8. Fan C, Chiang C, Chuang T, Chiu F, Chen T “Interlocking
to satisfactory results in all cases using olerud score nails for displaced metaphyseal fractures of the distal tibia”.
at the end of mean followup of 20 months. Guo J et Injury 2005; 36(5): 669-674.
9. Nork S, Schwartz A, Agel J, Holt S, Schrick J, Winquist R
al,[19] in their comparative study of IMIL nail with “Intramedullary nailing of distal metaphysealtibial
MIPPO had mean score of 83 for IMIL and 81 for fractures”. J Bone Joint Surg Am. 2005; 87 (6):1213-21.
MIPPO using AOFAS (American orthopaedic foot 10. Hazarika S, Chakravarthy J, Cooper J “Minimally invasive
and ankle surgery) as scoring system for ankle locking plate osteosynthesis for fractures of distal Tibia—
function. According to this system, results will be Results in 20 patients”. Injury 2006; 37(9): 877-887.
11. Kenneth A. Egol, Russell Weisz, Rudi Hiebert, Nirmal C.
graded as good if score is between 80-90. Collinge Tejwani,Kenneth J. Koval, and Roy W. Sanders “Does
Cet al,[12] in their study used both AOFAS Fibular Plating Improve Alignment After Intramedullary
(American orthopaedic foot and ankle surgery) and Nailing of Distal Metaphyseal Tibia Fractures?”;J Orthop
olerud score to evaluate functional outcome and Trauma 2006;20:94–10310.AO Manual :Distal Tibia
had good results in most of their cases. So our Fibula,2008.
study conclude that functional outcomes at one 12. Collinge C, Kuper M, Larson K, Protzman R “Minimally
Invasive Plating of High-Energy Metaphyseal Distal Tibia
year follow-up does vary significantly between Fractures”. J OrthopTrauma;july 2007: 21(6): 355-360.
MIPPO or interlocking nail treated patients and it 13. Kasper W. Janssen & Jan Biert& Albert van Kampen
was in accordance with above mentioned studies. “Treatment of distal tibial fractures: plate versus nail A
The final outcome was assessed based on Johner retrospective outcome analysis of matched pairs of
and Wruhs 24 criteria, 16 had excellent outcome,10 patients”;International Orthopaedics (SICOT) (2007)
had good outcome, 4 had fair outcome and 4 are 31:709–714
14. Lau T, Leung F, Chan F, Chow S, “Wound complication of
lost to follow- up in nail group. Out of 28 of minimally invasive plate osteosynthesis in distal tibia
mippogroup 12 had excellent outcomes,10 had fractures”. IntOrthop. 2008; 32(5): 697–703.
good outcome,4 had fair outcomes and 2 had poor 15. Krishan A, Peshin C, Singh D “Intramedullary nailing and
outcome. plate osteosynthesis for fractures of the distal metaphyseal
tibia and fibula”. J OrthopSurg 2009; 17(3): 317-320.
16. Ronga M, Longo U, Maffulli N “Minimally Invasive Locked
CONCLUSION Plating of Distal Tibia Fractures is Safe and Effective”.
ClinOrthopRelat Res. 2010; 468(4): 975–982.
Both operative procedures have shown a reliable 17. Mohamed Sukeik, Michael Maru, Cathy Lennox“Minimally
method of fixation and preserving most of the Invasive Plate Osteosynthesis Of Distal Tibial Fractures: A
osseous vascularity, fracture hematoma which Multicentred Review”;J.Orthopaedics 2010;7(1)e7
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infection and implant irritation and failure which
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makes it a preferable choice for fixation of extra- 2010; 92-B (7):984-988.
articular distal tibial fractures. 20. Shrestha D, Acharya BM, Shrestha PM “ Minimally
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 Dhar & Merli; Distal Tibial Shaft Fractures in Adults

Section: Orthopaedics
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How to cite this article: Dhar RN, Merli PK.

Intramedullary Interlocking Nailing Versus Plating in
distal Tibial Shaft Fractures in Adults: A Comparative
Study. Ann. Int. Med. Den. Res. 2020; 6(1):OR17-OR23.

Source of Support: Nil, Conflict of Interest: None declared

Annals of International Medical and Dental Research, Vol (6), Issue (1) Page 23