title: Intramedullary nailing versus plating for extra-articular distal tibial metaphyseal fracture: a systematic review and meta-analysis.
abstract: BACKGROUND
  With development in the techniques of reduction and fixation, there has been a controversy in comparison between intramedullary nailing (IMN) and plating for the treatment of distal tibial metaphyseal fracture (DTF). The study aimed to investigate: (1) which fixation, IMN or plating, was better in the clinical outcomes and in the complications for the treatment of DTF and (2) which modifying variables affected the comparative results between the two modalities.
  
  
  METHODS
  PubMed, EMBASE, OVID, Scopus, ISI Web of Science, the Cochrane Library, Google Scholar and specific orthopaedic journals were searched from inception to July 2013, using the search strategy of '('Fracture Fixation, Intramedullary' [MeSH]) AND ('Tibial Fractures' [MeSH]) AND (plate OR plating)'. All prospective and retrospective controlled trials comparing function, pain, bone union and complications between IMN and plating for DTF were identified. Our analysis had no limitation of the language or the publication year. The primary outcome measurements were complication rate, union time, operation time and hospital stays, while the secondary outcome measurements were functional score and pain score.
  
  
  RESULTS
  Fourteen of 6620 studies with 842 patients were included. IMN was probably preferential to plating for DTF given its higher functional score (p=0.01), lower risk of infection (p=0.02) and comparable pain score (p=0.33), total complication rate (p=0.53) and time to union (p=0.86). However, plating had a lower malunion rate than IMN (p<0.0001). All the results were based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence of moderate quality.
  
  
  CONCLUSIONS
  With a satisfying alignment obtained, IMN may be preferential to plating for fixation of DTF with better function and lower risk of infection. However, IMN showed higher malunion rate for fixation of DTF. With the biases in our meta-analysis, it will ultimately require a rigorous and adequately powered randomised controlled trial (RCT) to prove.
  
  
  METHODS
  Level III, therapeutic study (systematic review).
authors.affiliation: Department of Orthopaedic Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88 Jiefang Road, Hangzhou 310009, PR China. Electronic address: qq524689473@163.com.
authors.forename: Xing-He
authors.initials: XH
authors.lastname: Xue
authors.affiliation: Department of Orthopaedic Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88 Jiefang Road, Hangzhou 310009, PR China.
authors.forename: Shi-Gui
authors.initials: SG
authors.lastname: Yan
authors.affiliation: Department of Orthopaedic Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88 Jiefang Road, Hangzhou 310009, PR China. Electronic address: emilcai@hotmail.com.
authors.forename: Xun-Zi
authors.initials: XZ
authors.lastname: Cai
authors.affiliation: Department of Orthopaedic Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88 Jiefang Road, Hangzhou 310009, PR China.
authors.forename: Ming-Min
authors.initials: MM
authors.lastname: Shi
authors.affiliation: Department of Orthopaedic Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88 Jiefang Road, Hangzhou 310009, PR China.
authors.forename: Tiao
authors.initials: T
authors.lastname: Lin
mesh_terms: D001858:Bone Nails; D001860:Bone Plates; D005260:Female; D005594:Fracture Fixation, Intramedullary / Q000379:methods*; D017102:Fracture Healing; D005599:Fractures, Ununited / Q000473:pathology / Q000601:surgery*; D006801:Humans; D007902:Length of Stay; D008297:Male; D010147:Pain Measurement; D013978:Tibial Fractures / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome
keywords: Distal tibial fracture; Internal fixation; Intramedullary nailing; Plating