Intramedullary nailing versus plate osteosynthesis for extra-articular distal tibial fractures: a systematic review and meta-analysis

To compare intramedullary nailing (IMN) and plate osteosynthesis for extra-articular distal tibial fractures in terms of operative variables, fracture healing, functional outcomes, and complications. PubMed, Web of Science, and Scopus were searched through February 2026 (PROSPERO CRD420261527390, registered retrospectively). Randomised controlled trials (RCTs) and non-randomised comparative studies of skeletally mature patients with extra-articular distal tibial fractures (AO/OTA 43 A and distal-third 42 A–C) were eligible. Risk of bias was assessed with RoB 2, NOS and AXIS. Outcomes were pooled with random-effects models as odds ratios (ORs), mean differences (MDs) or, for functional scores, standardized mean differences (SMDs). Robustness was tested by restriction to RCTs, exclusion of studies at high risk of bias and other sensitivity analyses; certainty of evidence was rated with GRADE. Thirty studies (19 RCTs; 2,428 patients) were included. Infection was more frequent after plate fixation (OR = 2.35; 95% CI: 1.69 to 3.28; I 2 = 0%), including among RCTs (OR = 2.33; 95% CI: 1.60–3.39), and anterior knee pain after IMN (OR = 0.29; 95% CI: 0.15–0.59), both with moderate certainty. Secondary procedures were more frequent after plate fixation (OR = 1.37; 95% CI: 1.06–1.77) and IMN allowed earlier full weight-bearing (MD = 2.30 weeks; 95% CI: 1.47–3.14), both with low certainty. Plate fixation was associated with less malunion or malalignment (OR = 0.61; 95% CI: 0.41–0.90), but not among RCTs. Time to union was longer after plating (MD = 1.44 weeks; 95% CI: 0.34–2.55) with extreme heterogeneity (I 2 = 94%; very low certainty). Functional outcomes were equivalent (SMD = − 0.15; 95% CI: −0.26 to − 0.05; about one point on 100-point scales). Nonunion, delayed union, total complications, operative time and length of stay did not differ. Plate fixation carries a higher risk of infection and IMN a higher risk of anterior knee pain; plating may also lead to more secondary procedures, and IMN permits earlier weight-bearing. Differences in alignment and union time are uncertain, and function is equivalent. Implant choice should be individualised to fracture morphology and distal extent, soft-tissue condition and surgeon experience. Level II.