Intramedullary nail fixation for tibial plateau fractures: a systematic review of techniques and outcomes.

Objectives: To evaluate the surgical techniques, outcomes, and complications of intramedullary nail (IMN) fixation for tibial plateau fractures (TPFs). Methods: Data Sources: The MEDLINE, Embase, Google Scholar, and Cochrane databases were systematically searched up to January 2025, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Study Selection: Studies reporting outcomes of IMN fixation in adult TPF patients were included. Biomechanical analyses, animal studies, and non-English articles were excluded. Data Extraction: Study quality was assessed using the Methodological Index for Nonrandomized Studies (MINORS) criteria. Data on surgical technique, radiographic outcomes, functional outcomes, and complications were extracted. Studies were categorized by whether they used supplemental plate fixation. Data Synthesis: Descriptive statistics summarized outcomes. Results: Ten studies met inclusion criteria, including 2 comparative studies, 7 case series, and one case report. Fifty-two TPFs were treated with IMN with or without percutaneous screws (group 1), 45 with IMN with supplemental plate fixation (group 2), 30 with IMN plus condylar bolt support (group 3), and 78 with open reduction and internal fixation alone (group 4). Groups 1 and 3 had a combined infection rate of 2.4%, a mean bony union time of ≤4 months, and good-to-excellent knee scores. Three cases of malalignment and knee pain in 11% were reported. Group 2 had a 2.2% infection rate, no malalignment, and knee pain in 15.6%. No cases of nonunion or malunion were observed in TPFs treated with a IMN construct. Conclusions: In the TPF patterns represented in the available literature, predominantly bicondylar Schatzker V/VI (OTA/AO 41-C) fractures, IMN with or without supplemental plating or condylar bolt fixation demonstrated clinical and radiographic outcomes comparable to open reduction and internal fixation. These findings should not be extrapolated to isolated unicondylar TPFs or to fractures with relative contraindications to IMN, such as severe articular impaction requiring bone grafting, medial plateau fracture-dislocations, or tibial tubercle involvement. Additional controlled trials are required to further define the role of IMN in TPFs. Level of Evidence: Therapeutic Level IV.