Fri., 10/15/10 Knee, Tibia & Pediatrics, Paper #57, 3:53 pm OTA-2010
Factors Influencing Functional Outcomes after Distal Tibia Shaft Fractures
Heather A. Vallier, MD; Beth Ann Cureton, BS; Brendan M. Patterson, MD;
MetroHealth Medical Center, Cleveland, Ohio, USA
Purpose: Surgical treatment of displaced distal tibia fractures yields reliable results with either plate or nail fixation. Comparative research in our hospital has shown more malalignment and nonunions with nails. In other studies, knee pain has been associated with tibial nailing. However, plates have been associated with infections and soft-tissue irritation in some reports. We hypothesized that tibial nails would be associated with more knee pain, and that plates would be associated with pain from hardware prominence, each of which would adversely affect functional outcome scores.
Methods: 104 patients with extra-articular distal tibia shaft fractures (OTA 42) were randomized to treatment with a reamed intramedullary nail (n = 56) or standard large-fragment medial plate (n = 48). Mean age was 38 years (range, 18-95) and mean injury severity score (ISS) was 14.3 (range, 9-50). Work ability was evaluated after a minimum of 12 months. Knee pain, Foot Function Index (FFI) and Musculoskeletal Function Assessment (MFA) questionnaires were completed.
Results: After mean follow-up of 22 months, 86 patients were evaluated (45 nails, 41 plates). Mean MFA was 27.1 and mean total FFI was 0.26, which are substantially worse than an uninjured reference population (P < 0.0001). The two treatment groups were evenly matched with respect to age, gender, ISS, fracture pattern, and presence of open fracture and other injuries, and equal numbers had undergone elective removal of prominent hardware. 61 of 64 patients (95%) who were employed at the time of their injury had returned to work, although 31% of these had modified their work duties because of injury. Three patients were unable to find work. None reported unemployment secondary to their tibial fracture. 40% of all patients described some persistent ankle pain and 31% had knee pain after nailing, versus 32% and 22%, respectively, after plating. Both knee and ankle pain were present in 27% of patients with nails and 15% with plates (P = 0.08). Patients with angular malunion ≥5° were more likely to report knee or ankle pain (36% versus 20%, P < 0.05). Excepting one patient with knee pain when kneeling, none reported modifying activity specifically because of persistent knee or ankle pain, although knee pain and ankle pain were present more often in unemployed people (P = 0.03). Patients who were unemployed had requested hardware removal more frequently (24% vs 9.2%), and continued to report pain after hardware removal. While FFI and MFA scores were not related to plate or nail fixation, open fracture, fracture pattern, multiple injuries, ISS, or age, both MFA and FFI scores were worse when knee pain or ankle pain was present (all P < 0.004) and in patients who remained unemployed (P = 0.0001). Only 4 patients had work-related injuries; all of them had returned to employment, but had worse FFI scores (P = 0.01).
Conclusion: Mean MFA and FFI scores suggest substantial residual dysfunction after distal tibia fractures when compared with an uninjured population. Mild ankle or knee pain was reported frequently after plate or nail fixation, but was not limiting to activity in most patients. Angular malunion was associated with both knee and ankle pain, and there was a trend toward more patients with knee and ankle pain after tibial nailing. This is consistent with a larger number of patients with primary angular malalignment after nails versus plates. No patients reported unemployment because of their tibia fracture, but those who were unemployed described knee and ankle pain more frequently and had the worst functional outcome scores.
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• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.