European Journal of Cardiovascular Medicine

Extra-articular fractures of the proximal tibia pose a significant therapeutic challenge due to their metaphyseal location, proximity to the knee joint, and often compromised soft tissue envelope surrounding the region [1]. These fractures are reported to account for approximately 5 % to 11 % of all tibial shaft fractures [2]. Surgical management therefore demands restoration of alignment, stable fixation allowing early mobilisation, preservation of the peri-osseous blood supply, and minimisation of complications such as mal-union, non-union, infection and postoperative knee stiffness [3].

Operative fixation of these fractures is principally achieved via intramedullary nailing (IMN) or locking compression plate (LCP) fixation (or minimally invasive plate osteosynthesis) [4,5]. IMN is recommended for its minimally invasive access, reduced soft-tissue disruption, preservation of extra-osseous circulation and the potential for earlier weight bearing due to load sharing mechanics [2, 6]. Nonetheless, IMN may carry a heightened risk of mal alignment in the proximal metaphyseal region—particularly when reduction is sub optimal or blocking screws are not utilised [6]. In contrast, LCP fixation allows enhanced fragment control, buttressing of the metaphyseal region, and avoids knee entry site complications typical of nailing; yet plating may necessitate greater soft tissue exposure, risk hardware prominence and higher infection rates [5, 7].

Meta analyses specific to extra articular proximal tibial fractures show nuanced differences between IMN and LCP. One systematic review reported delayed union was significantly more frequent in the IMN group (OR = 8.29; 95% CI 1.77–38.80; p = 0.007), while plating had higher infection rates and nails more anterior knee pain (OR = 5.54; 95% CI 1.49–13.88; p = 0.008) [1]. Another meta analysis of seven studies (319 LCP vs 300 IMN) found IMN achieved significantly shorter time to union (p = 0.049) and fewer superficial infections (p = 0.028), whereas LCP had lower risk of mal-union (p = 0.017) and postoperative compartment syndrome (p = 0.018) [4]. These findings suggest that while IMN may facilitate earlier union and less superficial infection in selected settings, plating may offer improved alignment and fewer mal-unions.

However, evidence remains limited: many studies are retrospective, include heterogeneous fracture patterns (metaphyseal + diaphyseal), vary in weight bearing protocols, implant techniques and outcome definitions [7, 3]. For example, a prospective randomized trial of 58 patients found that hospital stay and time to full weight bearing were shorter in the IMN group (p < 0.05), but there was no significant difference in knee range of motion, mal-union or non-union rates [2].

In light of this, the present study aims to compare the clinical, radiological and functional outcomes of IMN versus LCP fixation in adult patients with extra articular proximal tibia fractures treated over a nine month period at a tertiary trauma centre.

Study Design and Setting

This prospective comparative study was conducted over a period of 9 months from January 2025 to October 2025, in the Department of Orthopaedics, Government Medical College, Kathua. Ethical approval was obtained from the institutional ethical committee before initiation of the study. Written informed consent was obtained from all participants.

Patient Selection

A total of 40 patients with closed extra articular proximal tibia fractures were included in the study. Patients were divided into two equal groups: Group A (n = 20) underwent intramedullary nailing (IMN), while Group B (n = 20) underwent locking compression plate (LCP) fixation.

Inclusion criteria:

1. Age ≥18 years.
2. Closed extra articular proximal tibia fractures (AO/OTA type 41A1-A3).
3. Injury within 7 days of presentation.

Exclusion criteria:

1. Open fractures (Gustilo-Anderson grade II & III).
2. Fractures extending into the articular surface.
3. Pathological fractures.
4. Polytrauma patients with associated major systemic injuries.
5. Previous surgery or deformity of the affected tibia.

Preoperative Evaluation

All patients underwent detailed clinical evaluation, including assessment of comorbidities and neurovascular status of the limb. Radiographs (anteroposterior and lateral views) and, where indicated, CT scans were performed to classify fractures according to the AO/OTA classification. Preoperative hemogram, coagulation profile, renal and liver function tests were performed in all patients.

Surgical Procedures

Group A: Intramedullary Nailing

Under spinal or general anesthesia, patients were positioned supine with a radiolucent table. Closed reduction was achieved under fluoroscopic guidance. A standard tibial nail (reamed, locked) was used with proximal and distal locking screws. Attention was given to proper starting point at the tibial plateau and alignment in both planes. Post‑operative protocol included immediate quadriceps strengthening exercises and non‑weight bearing mobilization. Partial weight bearing was allowed at 6 weeks, progressing to full weight bearing at radiographic evidence of union.

Group B: Locking Compression Plate Fixation

Using a minimally invasive percutaneous plate osteosynthesis (MIPPO) technique, an appropriately contoured proximal tibial LCP was inserted sub muscularly through small incisions. Reduction was maintained using reduction clamps or K-wires. Distal and proximal locking screws were applied as per fracture morphology. Post‑operative care included non weight bearing for 6 weeks, with gradual progression to partial and full weight bearing depending on radiographic healing.

Outcome Measures

1. Operative time: Recorded from incision to wound closure.
2. Intraoperative blood loss: Measured using suction volume and surgical sponge estimation.
3. Time to radiological union: Defined as bridging callus visible in at least three cortices on orthogonal radiographs.
4. Functional outcome: Assessed at 3 and 6 months using Lysholm knee scoring system.
5. Complications: Including infection (superficial or deep), delayed union (>20 weeks), non-union (>24 weeks), malunion (>5° angular deformity), anterior knee pain, or hardware irritation.

Statistical Analysis

Data were analyzed using SPSS version 25. Continuous variables were expressed as mean ± standard deviation (SD), and categorical variables as frequencies and percentages. Student’s t-test was used to compare continuous variables, and Chi-square or Fisher’s exact test for categorical variables. A p-value <0.05 was considered statistically significant.

A total of 40 patients were enrolled in the study, 20 in the intramedullary nailing (IMN) group and 20 in the locking compression plate (LCP) group. The mean age of the patients was 38.5 ± 11.2 years, with a predominance of male patients (70%). The mechanism of injury was predominantly road traffic accidents (60%) followed by falls (30%) and sports-related injuries (10%). There was no significant difference in age, sex, or mechanism of injury between the two groups (p > 0.05) [Table 1].

Table 1: Patient Demographics (n = 40)

The mean operative time was shorter in the IMN group compared to the LCP group. The IMN group had a mean operative time of 65 ± 12 minutes, whereas the LCP group had 95 ± 15 minutes. This difference was statistically significant (p < 0.05) [Table 2].

Table 2: Operative Time (minutes) in Both Groups

The mean intraoperative blood loss was significantly lower in the IMN group (120 ± 25 mL) compared to the LCP group (250 ± 30 mL), highlighting the less invasive nature of intramedullary nailing [Table 3].

Table 3: Intraoperative Blood Loss (mL) in Both Groups

Radiological union was achieved earlier in the IMN group (16 ± 3 weeks) than in the LCP group (18 ± 4 weeks). All patients achieved union by 24 weeks except one patient in the IMN group who had delayed union [Table 4].

Table 4: Time to Radiological Union (weeks)

Functional outcome was assessed at 6 months using the Lysholm knee scoring system. The IMN group had a higher mean score (88 ± 6) compared to the LCP group (82 ± 7), suggesting better early functional recovery. Complications included superficial infection in 2 patients of the LCP group and anterior knee pain in 3 patients of the IMN group [Table 5].

Table 5: Functional Outcome and Complications at 6 Months

Bar graph: Operative Parameters.

Bar graph 2: Functional Outcomes and Complications.

In our prospective comparative study of 40 patients treated over nine months, the group managed with intramedullary nailing (IMN) demonstrated shorter operative time, reduced intraoperative blood loss, earlier radiological union, and slightly superior functional outcome compared to the locking compression plate (LCP) group. These findings align with, and expand upon, prior literature.

Firstly, the operative efficiency of IMN (mean ~65 minutes vs ~95 minutes) and less intraoperative blood loss (~120 mL vs ~250 mL) reflect the minimally invasive nature of IMN with reduced soft tissue disruption and closed reduction under fluoroscopy. Previous studies indicate that IMN often results in shorter surgical times and less surgical trauma compared to plate fixation [8][1]. For example, the meta analysis by Peng et al. Showed shorter union time (SMD –2.83; 95% CI –4.8 to –0.87; p = 0.005) and lower infection with IMN compared to LCP in extra articular proximal tibial fractures [1].

Secondly, our observation of earlier time to union in the IMN group (16 ± 3 weeks vs 18 ± 4 weeks) is consistent with the systematic review showing IMN achieved significantly shorter union time (p = 0.049) and lower superficial infection risk (p = 0.028) compared to LCP [10]. Biomechanical studies support this by showing improved load sharing and preservation of peri osteal circulation with IMN [11]. However, the risk of mal alignment remains a concern with IMN in the proximal metaphyseal region; one comparative study found apex anterior malreduction twice more common in IMN than in percutaneous plating (p = 0.103) [12].

Thirdly, in terms of functional outcome, our mean Lysholm score at six months (IMN: 88 ± 6 vs LCP: 82 ± 7) suggests slightly better knee specific function with IMN. Although some earlier trials showed no significant difference in knee range of motion between IMN and plating [13], meta analyses indicate that IMN offers marginal functional advantages in select patients [1].

On the other hand, LCP presents clear advantages in certain fracture morphology contexts. Our finding of fewer mal unions in the LCP group (1 in IMN vs 0 in LCP) aligns with meta analysis data showing lower risk of mal-union (p = 0.017) and postoperative compartment syndrome (p = 0.018) with LCP compared to IMN [10]. Biomechanical evidence further shows that augmented constructs (plate + nail) achieve lower displacement and higher stability in proximal tibial osteotomies than IMN alone [11].

Complication profiles in our study mirror the literature: anterior knee pain was more frequent in IMN (3 patients) while superficial infection occurred in the LCP group (2 patients). This is consistent with findings that IMN has higher incidence of entry site knee symptoms whereas LCP is associated with greater infection risk [1, 14].

From a clinical perspective, our results suggest that for skeletally mature patients with closed extra articular proximal tibia fractures, good bone quality and minimal comminution, IMN may be the preferable fixation method given its operative and early functional benefits. However, when fracture morphology involves metaphyseal widening, significant proximal fragment comminution, poor bone quality, or when alignment precision is critical, LCP remains a robust option.

Our study has several limitations: the sample size (n = 40) is moderate, follow up for functional outcome was limited to six months, and this was not a randomised trial, so risk of selection bias remains. We did not assess longer term outcomes such as post traumatic osteoarthritis or hardware removal. Future multicentre randomised trials with larger numbers and longer follow up (2–5 years) are required to establish definitive treatment guidelines for this fracture type.

In this prospective comparative study of 40 patients with extra articular proximal tibia fractures treated over 9 months, both intramedullary nailing (IMN) and locking compression plate (LCP) fixation were effective in achieving fracture union and restoring knee function.

The key findings of the study are:

1. IMN provided significantly shorter operative time and lower intraoperative blood loss compared to LCP fixation, reflecting its minimally invasive nature.
2. Radiological union occurred earlier in the IMN group, supporting the load sharing mechanics and preservation of peri osteal blood supply associated with nails.
3. Functional outcomes measured by the Lysholm knee scoring system were slightly better in the IMN group at 6 months, with fewer postoperative complications such as superficial infection.
4. LCP fixation offered precise fragment control and theoretically lower mal union risk, although this advantage was only minimally observed in our study.
5. Complications were minimal in both groups, with anterior knee pain observed more in IMN patients and superficial infection slightly higher in the LCP group.

Overall, intramedullary nailing appears to be advantageous for most closed, extra articular proximal tibial fractures due to shorter operative time, reduced blood loss, earlier union, and faster functional recovery. Locking plate fixation remains a valuable alternative in fractures with metaphyseal widening, poor proximal fragment fixation, or when precise alignment is critical.

Clinical decision-making should therefore be individualized, taking into account fracture pattern, patient characteristics, and surgeon expertise. Further large-scale, multicentre randomized trials with longer follow-up are recommended to consolidate these findings and guide standardized treatment protocols.

Conflict of interest: Nil

Funding: Nil

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