Plate vs Nail for Distal Tibia Fxs Frank A. Liporace, MD Associate Professor Dept. of Orthopaedics NYU / HJD Chief Dept. Of Orthopaedics JCMC / RWJBH
??? Controversy??? Nails Minimal invasive Low blood loss Less soft tissue issues Immediate WB ing? Plates More reliable reduction More sustainable reduction Maintain stability better Can be Minimal invasive Low blood loss
??? Controversy??? Nails Distal locking options Fixed angles Should we also fix concomitant distal fibula? Plates Locking vs Non-locking? Fibula fixation?
Favorable Plating Borg T, et al: Injury, June 2004 21 closed fx s 18 anatomic or acceptable 2 re-ops malreduction 2 infections (DM) Helfet DL, et al: Injury, 1997 20 patients closed intra-artic. & open extra-artic 0 re-ops, infections 2 pts > 5 deg varus; 2 pts >10 deg recurvatum
Favorable Nailing Obremskey WT, et al: Orthopedics, Nov 2004 39 pts. Community surgeons 23% with > 5 deg angulation (1 or more planes) 8% with >10 deg angulation 38 pts. Trauma surgeons 5% >5 deg angulation No difference: time to union, nonunion, delayed union, HW failure, infection
Favorable Nailing Tyllianakis M, et al: Orthopedics, Aug 2000 Fixed lateral malleoulus fxs 86.3% satisfactory or excellent results 4.2 mo to union
Favorable Nailing Nork SE, et al: JBJS Am, June 2005 36 fractures 92% <5 degrees malalignment No change in alignment 1 infection Union: ~5 months (3 BG s)
Plate vs Nail Retrospective Janssen KW, et al: Int Orthop, Oct 2007 1993 2001 (Non-locking plates) vs IMN 2 malalignments ORIF 6 malalignments IMN No difference: time to union, nonunion, HW failure, infection
Plate vs Nail Prospective Im GI, et al: J Trauma, Nov 2005 34 IMN : 30 plate Shorter OR time IMN (72m vs 89m) Superficial infection: 3% IMN vs 20% plate Avg. Angulation: 2.8 deg IMN vs 0.9% deg plate Ankle dorsiflexion: 14 deg IMN vs 7 deg plate
Plate vs Nail Prospective Guo JJ, et al: JBJS Br July 2010 44 IMN : 41 plate NO DIFF: time to union Radiation time: Greater w/ plate Operation time: Greater w/ plate IMN: better alignment & better function (not sig) Delayed wound healing: 14.6% plate : 6.8% IMN
Plate vs Nail Prospective Vallier H, et al: JOT Dec 2011 56 IMN : 48 plate Equal deep infection (83% infxn p open fx) Nonunion (100% open fx): 7.1% IMN vs 4.2% plate Increased trend with fibula fixation Malunion (>5 deg): 23% IMN vs 8.3% plate 85% malunion w/ IMN had NO fibula fixation No signif. diff in secondary procedures
Problems w/ Literature Small samples in groups Most studies not prospective randomized Plating is variable Non-locked Large Fragment Hybrid Fixation Locked pre-contoured Small Fragment Fibula Fixation variable
Intramedullary Nailing of AO/OTA Type 43C Distal Tibia Fractures, Matthew S. Marcus, MD, Richard S. Yoon, MD, Joshua Langford, MD, Erik N. Kubiak, MD, What Kenneth J. we Koval, found MD, George J. Haidukewych, MD, Frank A. Liporace, MD; JOT 2014 Retrospective 31 pts w/ distal 1/3 tibia fx s 100% union (14.1 + 4.9 wks) 0% w/ > 5 deg malunion 1 Delayed union / 1 nonunion Infection: 1 superficial / 2 deep ROH: 1
Intramedullary Nailing of AO/OTA Type 43C Distal Tibia Fractures, Matthew S. Marcus, MD, Richard S. Yoon, MD, Joshua Langford, MD, Erik N. Kubiak, MD, What Kenneth J. we Koval, found MD, George J. Haidukewych, MD, Frank A. Liporace, MD; JOT 2014 Fibula fixation was done Poller screws often used Distractor often used All fixed by Traumatologists
Take Home Points 1) Choose technique you are most comfortable with 2) If fixing fibula use flexible but ANATOMIC fixation 3) At least 2 points fixation of IMN distally 4) If IMN be familiar with adjuncts (Poller screws, distractors, etc.) 5) Always consider soft tissues
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