Study Compares Outcomes, Complications with Plating versus Intramedullary Nailing for Proximal Tibial Fractures

At the AAOS 2024 Annual Meeting, Kevin Monahan, MD, an orthopaedic trauma fellow at Ohio Health Grant Medical Center in Columbus, Ohio, presented findings from a meta-analysis on proximal tibial fractures, comparing locked lateral plating to intramedullary nailing. Key findings included no significant difference in non-union rates between the two treatments, with nailing showing a shorter time to union and less malunion risk. Plating had a lower risk of postoperative compartment syndrome. AAOS Now Editorial Board member Stuart A. Green, MD, FAAOS, sat down with Dr. Monahan to discuss the data.

Dr. Green: Dr. Monahan, what motivated you and your associates to do this study?
Dr. Monahan: Going through the literature on proximal tibia fractures, there wasn’t a lot in terms of creating a surgical treatment algorithm for these fractures.

How did you gather data from the literature?
We adhered to the PRISMA guidelines, which are a set of guidelines to help weed through papers that are relevant and can be analyzed. Through PubMed, we looked for the higher-quality randomized, controlled trials. Our study looked at four randomized, controlled trials that were prospective; two that were retrospective; and one that was a prospective, non-randomized trial. All those papers had the highest level of evidence directly related to proximal tibia fractures that were extra-articular (including simple intra-articular patterns) and compared locked lateral plating to intramedullary nailing, with no dual-plating constructs.

What were some of your initial findings?
All the studies had at least a 1-year follow-up, and there was no difference in the non-union rate. The intramedullary nailing patients had a shorter time to union; the plating groups had significantly less instance of malunion. The deep infection risks between nailing and plating were not different. The risk of postoperative compartment syndrome was lower in the plating group.

Why do you think that would be the case?
The open-reduction plating tended to have larger incisions, with fasciotomies for the approach. The nailing studies tended to be done closed, so you’ve a higher incidence of compartment syndrome postoperatively.

When you describe your conclusions, you say that intramedullary nail fixation demonstrates a significantly shorter time to union and lower risk of infection. Why didn’t you flip it around and say that lateral plating demonstrates a significantly higher time to union and a higher risk of infection? Why did you take the optimized view instead of the risk view of your data?
What’s interesting is that people in trauma are very passionate about plating [and] very passionate about nailing. When you come down to it, there’s not a correct algorithm. Physicians tend to do things that they are a little bit better at. So, it may not be important whether you emphasize plating or nailing being positive, but choosing plates, choosing nails—do the thing that you are best at, in your hands, and you’ll probably get a good result.

Could you tease out a subset of patients who might do better with nailing and another subset who might do better with plating?
Nail technology has improved immensely over the last 10 to 20 years. There are more proximal screw-fixation options, distal screw-fixation options, and the plates have changed. We’re trying to do things [with minimally invasive surgery] and trying to prevent patients from having big incisions. It would be nice if we could say one thing versus another [with regard to nailing versus plating], but … this was a good example that, like a lot of trauma, you can approach [fractures] different ways to get the same outcome.

Stuart A. Green, MD, FAAOS, is cofounder and past president of the Limb Lengthening and Reconstruction Society, past president of the Association of Bone and Joint Surgeons, and an attending surgeon at the Tibor Rubin Long Beach VA Medical Center. He is the son, first cousin, and father of AAOS Fellows. Dr. Green is a member of the AAOS Now Editorial Board.