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Surgical outcomes and complications of fixation strategies for distal tibial fractures: a systematic review and network meta-analysis.

Lei Zhang·Zhihui Fang·Wei Yu·Yue Xi
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Abstract

BACKGROUND: Multiple fixation options exist for distal tibial fractures, but the optimal approach remains controversial. Common techniques includeopen reduction and internal fixation(ORIF), minimally invasive plate osteosynthesis (MIPO), external fixation combined with limited open reduction and internal fixation (EF + LORIF), intramedullary nailing (IMN), and retrograde tibial nailing (RTN). METHODS: PubMed, Embase, Web of Science, and the Cochrane Library were searched through March 19, 2026. Network meta-analysis (R v4.5.1) assessed operation time, fracture healing time, malunion, delayed union/nonunion, and infection, reporting MDs or RRs with 95% CIs. RESULTS: Eleven randomized controlled trials and 18 cohort studies (2145 patients) were included. MIPO was associated with a longer operative time and a longer time to union than IMN-IP (MD = 8.23, 95% CI 0.44-16.01; and MD = 1.02, 95% CI 0.10-1.93, respectively). For malunion, ORIF had a lower risk than MIPO (RR = 0.30, 95% CI 0.11-0.82), whereas MIPO had a higher risk than EF + LORIF (RR = 3.26, 95% CI 1.08-9.80) and IMN-SP (RR = 4.03, 95% CI 1.30-12.48). ORIF, EF + LORIF, and IMN-SP also showed lower malunion risk than IMN-IP. No significant differences were observed for delayed union and nonunion. Infection risk was generally higher with ORIF and MIPO than with several comparators, particularly EF + LORIF and intramedullary nailing-based strategies. CONCLUSIONS: No single strategy was consistently superior. Operation time and impaired union ( delayed union and nonunion) did not differ significantly among techniques. MIPO may be associated with longer time to union than IMN-IP and higher malunion risk than EF + LORIF and IMN-SP. Infection risk appeared higher with ORIF and MIPO in network estimates, although several comparisons remained uncertain. Findings should be interpreted in light of imprecision and study-level heterogeneity. PROTOCOL REGISTRATION: INPLASY2025120055.

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HumansTibial FracturesPostoperative ComplicationsFracture Fixation, InternalFracture FixationTreatment OutcomeFracture HealingOpen Fracture ReductionOperative TimeFracture Fixation, IntramedullaryBone PlatesRandomized Controlled Trials as TopicComplicationDistal tibial fractureFracture fixationMeta-analysisJournal ArticleSystematic ReviewNetwork Meta-AnalysisReview

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Lei Zhang, Zhihui Fang, Wei Yu, Yue Xi. 2026-09-08. Surgical outcomes and complications of fixation strategies for distal tibial fractures: a systematic review and network meta-analysis.. https://doi.org/10.1007/s00590-026-04776-0

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Fracture Fixation, Internal subjectFracture Healing subjectHumans subjectJournal Article subjectJournal Article; Systematic Review; Network Meta-Analysis; Review resourceMeta-Analysis subjectNetwork Meta-Analysis subjectOperative Time subjectPostoperative Complications subjectSystematic reviews study

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