Comparative Effectiveness of Circular Frames, Plate Fixation, and Intramedullary Nailing in Distal-Third Tibial Fractures: A Systematic Review and Meta-Analysis

Distal-third tibial fractures are surgically challenging due to limited soft-tissue coverage and a high risk of complications. The optimal fixation method remains uncertain. This systematic review and meta-analysis compared intramedullary nailing, plate fixation, and circular external fixation for distal-third tibial fractures. A comprehensive search identified 54 studies, including 15 randomised controlled trials. Meta-analyses of randomised evidence demonstrated that intramedullary nailing was associated with a modest but statistically significant reduction in time to fracture union and a lower rate of superficial infections compared with plating, without significant differences in deep infection rates, functional outcomes, or overall complications. Functional scores were broadly comparable between techniques. Evidence for circular external fixation was limited and largely derived from non-randomised studies, which suggested longer union times and higher complication rates compared with internal fixation. Overall, intramedullary nailing offers a favourable balance between fracture healing and infection risk for distal-third tibial fractures, particularly extra-articular patterns, while achieving similar functional outcomes to plating. Plate fixation remains an appropriate alternative when nailing is contraindicated. The role of circular external fixation appears more selective and warrants further high-quality comparative trials.