A systematic review and meta-analysis of functional outcomes and complications following external fixation or open reduction internal fixation for distal intra-articular tibial fractures: an update

PURPOSE: To conduct a systematic review and meta-analysis comparing physical function and complications following DIATF surgery with external fixation (EF) or open reduction internal fixation (ORIF).

METHOD: A search was conducted using PubMed, Embase, Cochrane CENTRAL, Open Grey and Orthopaedic Proceedings. Studies with a level of evidence of I-III on patients (≥ 18 years) with DIATFs operated on with either EF or ORIF were included. A total of 3814 studies were identified. The Cochrane Risk of Bias Tool for randomised controlled trials and the ROBINS-I tool for nonrandomised studies were used to assess risk of bias.

RESULTS: Nine studies with 478 patients, 271 ORIF and 197 EF met the inclusion criteria. The mean follow-up ranged from 12 to 38 months. The meta-analysis showed a higher incidence of superficial wound infections (RR = 2.94, 95% CI 1.62-5.34, p = 0.0004) and malunions (RR = 2.62, 95% CI 1.27-5.43, p = 0.009) in the EF group compared to the ORIF group. Also worse physical function was associated with the EF group. However, the overall evidence was low.

CONCLUSION: This systematic review is the first to report on physical function following DIATF surgery. In general, decreased physical function was reported. The meta-analysis showed lower incidence of superficial wound infection and malunion rates in the ORIF group. Heterogeneity was low. In conclusion, this review reports lower complication rates following ORIF for DIATF. The overall evidence was limited, and therefore, the authors cannot recommend ORIF to be superior to EF treatment for DIATF. More multi-centre studies with larger sample sizes are needed to assess long-term physical function and complications following DIATF surgery.

LEVEL OF EVIDENCE: Level 1.