title: Surgical interventions for treating distal tibial metaphyseal fractures in adults.
abstract: 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 young men and to osteoporosis in older women. The optimal methods of surgical intervention for a distal tibial metaphyseal fracture remain uncertain.
  
  
  OBJECTIVE
  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.
  
  
  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.
  
  
  METHODS
  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 patient-reported function and the need for secondary or revision surgery or substantive physiotherapy because of adverse outcomes.
  
  
  METHODS
  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.
  
  
  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.
  
  
  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.
authors.affiliation: Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, No. 6, West Sec. Chia-Pu Road Putz, Chiayi, Taiwan, 613.
authors.forename: Liang Tseng
authors.initials: LT
authors.lastname: Kuo
authors.forename: Ching-Chi
authors.initials: CC
authors.lastname: Chi
authors.forename: Ching-Hui
authors.initials: CH
authors.lastname: Chuang
mesh_terms: D000328:Adult; D001860:Bone Plates; D004838:Epiphyses / Q000293:injuries / Q000601:surgery; D005260:Female; D005594:Fracture Fixation, Intramedullary / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D008297:Male; D016032:Randomized Controlled Trials as Topic; D012086:Reoperation / Q000706:statistics & numerical data; D013978:Tibial Fractures / Q000601:surgery*
references.citation: J Orthop Trauma. 1997 Feb-Mar;11(2):103-5
references.pmid: 9057144
references.citation: J Trauma. 2005 Nov;59(5):1219-23; discussion 1223
references.pmid: 16385303
references.citation: BMJ. 1997 Sep 13;315(7109):629-34
references.pmid: 9310563
references.citation: J Orthop Trauma. 2006 Jan;20(1):76-9
references.pmid: 16424818
references.citation: J Orthop Trauma. 2011 Feb;25(2):101-5
references.pmid: 21245713
references.citation: Injury. 2014 Apr;45(4):667-76
references.pmid: 24275358
references.citation: J Orthop Trauma. 2002 Nov-Dec;16(10):691-5
references.pmid: 12439191
references.citation: Clin Orthop Relat Res. 1988 May;(230):68-82
references.pmid: 3284685
references.citation: Injury. 2006 Jun;37(6):531-5
references.pmid: 16413025
references.citation: J Bone Joint Surg Br. 2012 May;94(5):704-8
references.pmid: 22529095
references.citation: J Am Acad Orthop Surg. 2006 Jul;14(7):406-16
references.pmid: 16822888
references.citation: J Trauma Acute Care Surg. 2012 Feb;72(2):E81-7
references.pmid: 22439240
references.citation: Clin Orthop Relat Res. 1997 Aug;(341):99-105
references.pmid: 9269161
references.citation: Zhongguo Gu Shang. 2009 May;22(5):361-3
references.pmid: 19522397
references.citation: Injury. 1983 Mar;14(5):432-9
references.pmid: 6874051
references.citation: Int Orthop. 2014 Nov;38(11):2349-55
references.pmid: 25086821
references.citation: Arch Orthop Trauma Surg. 1984;103(3):190-4
references.pmid: 6437370
references.citation: Injury. 2004 Jun;35(6):615-20
references.pmid: 15135282
references.citation: Injury. 2006 Aug;37(8):691-7
references.pmid: 16814787
references.citation: J Bone Joint Surg Am. 1986 Apr;68(4):543-51
references.pmid: 3957978
references.citation: J Invest Surg. 2012 Oct;25(5):326-9
references.pmid: 22612244
references.citation: Injury. 1999 Mar;30(2):83-90
references.pmid: 10476275
references.citation: J Bone Joint Surg Br. 1995 May;77(3):417-21
references.pmid: 7744927
references.citation: J Bone Joint Surg Am. 2014 Nov 19;96(22):1889-97
references.pmid: 25410507
references.citation: J Bone Joint Surg Br. 1984 Jan;66(1):84-8
references.pmid: 6363421
references.citation: J Orthop Sci. 2012 Sep;17(5):562-6
references.pmid: 22570013
references.citation: J Orthop Trauma. 2014 Sep;28(9):542-8
references.pmid: 24464094
references.citation: J Orthop Trauma. 2010 Jan;24(1):24-9
references.pmid: 20035174
references.citation: J Orthop Trauma. 2012 Mar;26(3):178-83
references.pmid: 22198653
references.citation: Int Orthop. 2011 May;35(5):737-42
references.pmid: 20517695
references.citation: Orthopedics. 2004 Nov;27(11):1180-4
references.pmid: 15566130
references.citation: J Bone Joint Surg Br. 1990 Jul;72(4):605-11
references.pmid: 2380211
references.citation: Int Orthop. 2014 Jun;38(6):1261-7
references.pmid: 24549966
references.citation: Injury. 2007 Mar;38(3):365-70
references.pmid: 17241634
references.citation: Injury. 2013 Aug;44(8):1102-6
references.pmid: 23473266
references.citation: J Orthop Trauma. 2001 Mar-Apr;15(3):153-60
references.pmid: 11265004
references.citation: Foot Ankle Int. 1994 Jul;15(7):349-53
references.pmid: 7951968
references.citation: Stat Med. 2004 Jun 15;23(11):1663-82
references.pmid: 15160401
references.citation: J Orthop Trauma. 2011 Dec;25(12):736-41
references.pmid: 21904230
references.citation: J Orthop Trauma. 1996;10 Suppl 1:v-ix, 1-154
references.pmid: 8814583
references.citation: J Bone Joint Surg Br. 1995 Sep;77(5):781-7
references.pmid: 7559711
references.citation: J Bone Joint Surg Am. 2002 Apr;84(4):580-5
references.pmid: 11940618
references.citation: J Bone Joint Surg Br. 2010 Jul;92(7):984-8
references.pmid: 20595119
references.citation: Injury. 2003 Nov;34 Suppl 2:B31-42
references.pmid: 14580984
references.citation: BMJ. 2003 Sep 6;327(7414):557-60
references.pmid: 12958120