Costa, Matthew L., Achten, Juul, Hennings, Susie, Boota, Nafisa, Griffin, James M., Petrou, Stavros, Maredza, Mandy, Dritsaki, Melina, Wood, Thomas, Masters, James P. M., Pallister, Ian, Lamb, S. E. (Sallie E.) and Parsons, Nicholas R. (2018) Intramedullary nail fixation versus locking plate fixation for adults with a fracture of the distal tibia : the UK FixDT RCT. Health Technology Assessment, 22 (25). pp. 1-148. doi:10.3310/hta22250

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Abstract

Background

The best treatment for fractures of the distal tibia remains controversial. Most of these fractures require surgical fixation, but the outcomes are unpredictable and complications are common.

Objectives

To assess disability, quality of life, complications and resource use in patients treated with intramedullary (IM) nail fixation versus locking plate fixation in the 12 months following a fracture of the distal tibia.

Design

This was a multicentre randomised trial.

Setting

The trial was conducted in 28 UK acute trauma centres from April 2013 to final follow-up in February 2017.

Participants

In total, 321 adult patients were recruited. Participants were excluded if they had open fractures, fractures involving the ankle joint, contraindication to nailing or inability to complete questionnaires.

Interventions

IM nail fixation (n = 161), in which a metal rod is inserted into the hollow centre of the tibia, versus locking plate fixation (n = 160), in which a plate is attached to the surface of the tibia with fixed-angle screws.

Main outcome measures

The primary outcome measure was the Disability Rating Index (DRI) score, which ranges from 0 points (no disability) to 100 points (complete disability), at 6 months with a minimum clinically important difference of 8 points. The DRI score was also collected at 3 and 12 months. The secondary outcomes were the Olerud–Molander Ankle Score (OMAS), quality of life as measured using EuroQol-5 Dimensions (EQ-5D), complications such as infection, and further surgery. Resource use was collected to inform the health economic evaluation.

Results

Participants had a mean age of 45 years (standard deviation 16.2 years), were predominantly male (61%, 197/321) and had experienced traumatic injury after a fall (69%, 223/321). There was no statistically significant difference in DRI score at 6 months [IM nail fixation group, mean 29.8 points, 95% confidence interval (CI) 26.1 to 33.7 points; locking plate group, mean 33.8 points, 95% CI 29.7 to 37.9 points; adjusted difference, 4.0 points, 95% CI –1.0 to 9.0 points; p = 0.11]. There was a statistically significant difference in DRI score at 3 months in favour of IM nail fixation (IM nail fixation group, mean 44.2 points, 95% CI 40.8 to 47.6 points; locking plate group, mean 52.6 points, 95% CI 49.3 to 55.9 points; adjusted difference 8.8 points, 95% CI 4.3 to 13.2 points; p < 0.001), but not at 12 months (IM nail fixation group, mean 23.1 points, 95% CI 18.9 to 27.2 points; locking plate group, 24.0 points, 95% CI 19.7 to 28.3 points; adjusted difference 1.9 points, 95% CI –3.2 to 6.9 points; p = 0.47). Secondary outcomes showed the same pattern, including a statistically significant difference in mean OMAS and EQ-5D scores at 3 and 6 months in favour of IM nail fixation. There were no statistically significant differences in complications, including the number of postoperative infections (13% in the locking plate group and 9% in the IM nail fixation group). Further surgery was more common in the locking plate group (12% in locking plate group and 8% in IM nail fixation group at 12 months). The economic evaluation showed that IM nail fixation provided a slightly higher quality of life in the 12 months after injury and at lower cost and, therefore, it was cost-effective compared with locking plate fixation. The probability of cost-effectiveness for IM nail fixation exceeded 90%, regardless of the value of the cost-effectiveness threshold.

Limitations

As wound dressings after surgery are clearly visible, it was not possible to blind the patients to their treatment allocation. This evidence does not apply to intra-articular (pilon) fractures of the distal tibia.

Conclusions

Among adults with an acute fracture of the distal tibia who were randomised to IM nail fixation or locking plate fixation, there were similar disability ratings at 6 months. However, recovery across all outcomes was faster in the IM nail fixation group and costs were lower.

Item Type:	Journal Article
Subjects:	R Medicine > RD Surgery
Divisions:	Faculty of Medicine > Warwick Medical School > Health Sciences Faculty of Medicine > Warwick Medical School
Library of Congress Subject Headings (LCSH):	Intramedullary fracture fixation, Leg -- Fracture -- Treatment
Journal or Publication Title:	Health Technology Assessment
Publisher:	NIHR Health Technology Assessment programme
ISSN:	1366-5278
Official Date:	1 May 2018
Dates:	Date Event 1 May 2018 Published 1 March 2018 Accepted
Date of first compliant deposit:	23 May 2018
Date of first compliant Open Access:	23 May 2018
Volume:	22
Number:	25
Page Range:	pp. 1-148
DOI:	10.3310/hta22250
Status:	Peer Reviewed
Publication Status:	Published
Access rights to Published version:	Open Access
RIOXX Funder/Project Grant:	Project/Grant ID RIOXX Funder Name Funder ID UNSPECIFIED National Institute for Health Research http://dx.doi.org/10.13039/501100000272 UNSPECIFIED Stryker http://dx.doi.org/10.13039/100008894 UNSPECIFIED X-Bolt Orthopaedics (Firm) UNSPECIFIED UNSPECIFIED Onbone (Firm) UNSPECIFIED UNSPECIFIED Smith and Nephew Orthopaedics http://dx.doi.org/10.13039/100009027 UNSPECIFIED Leybold-Heraeus (Firm) UNSPECIFIED UNSPECIFIED DePuy Synthes Spine (Firm) UNSPECIFIED UNSPECIFIED AO Foundation http://dx.doi.org/10.13039/501100001702

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