Surgical interventions for treating distal tibial metaphyseal fractures in adults

Background The distal tibial metaphysis is located in the lower (distal) part of the tibia (shin bone). Fractures of this part of the tibia are most commonly due to a high energy injury in youngmen and to osteoporosis in older women. The optimal methods of surgical intervention for a distal tibial metaphyseal fracture remain uncertain. Objectives To assess the effects (benefits and harms) of surgical interventions for distal tibial metaphyseal fractures in adults. We planned to compare surgical versus non-surgical (conservative) treatment, and different methods of surgical intervention. Search methods We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (9 December 2014), the Cochrane Central Register of Controlled Trials (2014, Issue 12), MEDLINE (1946 to November Week 3 2014), EMBASE (1980 to 2014 Week 48), the Airiti Library (1967 to 2014 Week 8), China Knowledge Resource Integrated Database (1915 to 2014 Week 8), ClinicalTrials.gov (February 2014) and reference lists of included studies. Selection criteria We included randomised and quasi-randomised controlled clinical studies comparing surgical versus non-surgical (conservative) treatment or different surgical interventions for treating distal tibial metaphyseal fractures in adults. Our primary outcomes were patientreported function and the need for secondary or revision surgery or substantive physiotherapy because of adverse outcomes. Data collection and analysis Two authors independently selected studies, assessed the risk of bias in each study and extracted data. We resolved disagreement by discussion and, where necessary, in consultation with a third author. Where appropriate we pooled data using the fixed-effect model. Main results We included three randomised trials that evaluated intramedullary nailing versus plating in 213 participants, with useable data from 173 participants of whom 112 were male. The mean age of participants in individual studies ranged from 41 to 44 years. There were no trials comparing surgery with non-surgical treatment. The three included trials were at high risk of performance bias, with one trial also being at high risk of selection, detection and attrition bias. Overall, the quality of available evidence was rated as very low for all outcomes, meaning that we are very unsure about the estimates for all outcomes. The results of two large ongoing trials of nailing versus plating are likely to provide sufficient evidence to address this issue in a future update. Authors' conclusions Overall, there is either no or insufficient evidence to draw definitive conclusions on the use of surgery or the best surgical intervention for distal tibial metaphyseal fractures in adults. The available evidence, which is of very low quality, found no clinically important differences in function or pain, and did not confirm a difference in the need for re-operation or risk of complications between nailing and plating. The addition of evidence from two ongoing trials of nailing versus plating should inform this question in future updates. Further randomised trials are warranted on other issues, but should be preceded by research to identify priority questions.