Intramedullary Nailing Versus Minimally Invasive Plate Osteosynthesis for Distal Tibial Fractures: A Systematic Review and Meta-Analysis

To evaluate the application, safety and efficacy of the patients treated with intramedullary nailing (IMN) and minimally invasive plate osteosynthesis (MIPO) in distal tibia fractures. Following the Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA) guidelines, we searched databases PubMed, Cochrane library, EMBASE and Web of Science from inception of the database up to 10 October 2018, using the keywords "distal tibia fractures", "plate", "intramedullary nailing" and "RCT" to identify randomized clinical trials about distal tibia fractures. The included studies were assessed by two researchers according to the Cochrane risk-of-bias criteria. The primary outcome of measurement included operation time, malunion rate, nonunion/delayed union rate, and wound complication. Data analysis was conducted with Review Manager 5.3 software. A total of 10 RCTs involving 911 patients fulfilled the inclusion criteria with 455 patients in the IMN group and 456 patients in the MIPO group. There were no significant differences in radiation time, nonunion or delayed union rate, union time and operation time between the two groups. Patients treated with MIPO had lower incidence of malunion compared with IMN (RR = 1.85, 95%CI: 1.21 to 2.83, P = 1.00), while IMN seemed to have lower surgical incision complications whether in closed or opening fractures (RR = 0.49, 95%CI 0.33 to 0.73, P = 0.43). But in patients classified as 43A, the result of subgroup analysis suggested that there was no significant inwound complication between the two groups. MIPO was superior in preventing malunion compared with IMN, and intramedullary nailing appeared to have lower wound complications. However, in patients with 43A distal tibial fractures, MIPO was more recommended for its prevention of malunion. No matter which method we choose, we should notice and prevent the associated complications.