A Comparative Study Of Treatment Of Tibial Diaphyseal Fractures With Intramedullary Nailing And Minimally Invasive Percutaneous Plate Osteosynthesis Techniques

Title:A Comparative Study of Treatment of Tibial Diaphyseal Fractures with Intramedullary Nailing and Minimally Invasive Percutaneous Plate Osteosynthesis Techniques.Objective:The purpose of this study was to compare the tibial diaphyseal fractures treated with Interlocked Intramedullary Nailing (IM nail) and Minimally Invasive Percutaneous Plate Osteosynthesis (MIPPO) techniques in order to assess the outcomes in the two groups and establish the indications for each technique.Design:Retrospective Clinical StudySetting:Level1Trauma CenterPatients and Methods:Between September2010and March2013, skeletally mature patients who had sustained tibial diaphyseal fractures and undergone either IM nail or MIPPO at our institution were identified. A total of68patients comprising of36patients treated with IM nail and32patients treated with MIPPO were enrolled in the study with a minimum of1year follow-up. The patient and fracture characteristics were compared between the two groups. Outcomes in the IM nail and MIPPO groups were compared under the headings of time to initiation of full weight bearing, time to clinical bone healing, superficial and deep infections, malunion, nonunion and functional outcomes in terms of long term pain, ability to climb stairs without support, return to previous work and knee, ankle and subtalar range of motion deficits.Results:Patient characteristics including age and gender demographics, smoking status and associated medical conditions were similar in the IM nail and MIPPO groups. However, fracture characteristics had some significant differences in the two groups with more fall injuries (χ2=4.168, p=0.041) and middle third fractures (χ2=8.027, p=0.005) in IM nail group and more of lower third fractures (χ2=4.632, p=0.031) in the MIPPO group. The mean follow up period was25.67±7.21weeks in IM nail group and23.12±7.16weeks in the MIPPO group. The duration of time required for surgery was90.75±25.46(range58to151) minutes in IM nail group and85.86±17.51(range61to126) minutes in the MIPPO group. The mean time to clinical bone healing was20.72±8.67(range11to48) weeks in the IM nail group whereas it was19.87±10.6(range9to53) weeks in the MIPPO group.Similarly, the mean time to full weight bearing was23.67±9.33weeks (range13to53) in the IM nail group and22.41±11.2weeks (range10to46) in the MIPPO group respectively. Time to bone union and weight bearing time had no significant difference between the two treatment groups. A significantly higher number of patients in the MIPPO group had superficial wound infections (18.75%,6/32) compared to the IM nail group (2.7%,1/36, Fisher’s exact test, p=0.031). Majority of patients (87.50%,7/8) who had developed infections, superficial and deep, were open fracture cases and two were smokers with diabetes mellitus in one. Four patients had malunion and two had nonunion in IM nail group whereas one had malunion and one had nonunion in the MIPPO group. One patient in IM nail group and two patients in MIPPO group had implant failure. IM nail group had significantly higher number of patients with long term pain. Knee range of motion deficits were observed more in IM nail group and ankle and subtalar range of motion deficits were observed more in MIPPO group although no statistically significant difference was noted between the two groups.Conclusion:Both the techniques are equally effective in terms of fracture stabilization. Intramedullary nailing is a better option in the management of fractures with greater degree of soft tissue damage. Otherwise, MIPPO is a promising alternative to Intramedullary nailing in the management of tibial diaphyseal fractures.