***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objective To describe the extraosseous blood supply of the tibia and how the blood supply of the distal tibia is influenced by different plating techniques . Design Microdissection of cadaveric adult hip disarticulation specimens following sequential arterial injections of india ink and Ward 's Blue Latex was performed . Readily identifiable arterioles measured approximately 0.5 mm in diameter . Their artery of origin was identified , and their position along the medial , lateral , and posterior aspects of the tibia was documented relative to the tibial plafond . Additionally , six matched pairs of limbs were used to assess the effects of different plating techniques on the extraosseous blood supply along the medial aspect of the distal tibia . Setting University anatomy laboratory . Patients / Participants Nine matched pairs ( n = 18 ) of r and omly obtained , adult cadaveric hip disarticulation specimens . Intervention India ink followed by Ward 's Blue Latex was injected into the superficial femoral artery at the level of the inguinal crease after cleansing of the arterial system . The skin , subcutaneous tissue , and muscles were dissected from the leg , exposing the arterial system and the extraosseous vessels of the tibia . Mean Outcome Measurements The extraosseous blood supply of each aspect of the tibial diaphysis was determined . Each extraosseous arteriole was identified , and the locations of each documented relative to the tibial plafond . Changes in the filling of these vessels along the medial aspect of the distal tibia were documented in a separate group of specimens ( n = 12 ) , which had undergone two different plating techniques . Results The proximal metaphysis of the tibia was found to have a rich extraosseous blood supply provided primarily from vessels from the popliteal artery , the anterior tibial artery ( ATA ) laterally , and the posterior tibial artery ( PTA ) medially . In comparison , the tibial diaphysis was found to have relatively few extraosseous vessels and a considerably hypovascular region , posteriorly . Branches of the ATA were found to supply the posterior aspect of the diaphysis with these branches passing through the interosseous membrane . The diaphysis also received a variable contribution from the PTA . The lateral aspect of the diaphysis was supplied by branches of the ATA . An anastomotic network of arteries from the ATA and PTA formed the rich extraosseous blood supply of the medial distal aspect of the tibia . Open plating of the medial aspect of the distal tibia caused a statistically significant ( p < 0.05 ) greater disruption of the extraosseous blood supply of the metaphyseal region than did percutaneously applied plates . In each specimen , open plating prevented filling of each periosteal vessel in the region as opposed to percutaneous plates , which permitted filling of the extraosseous vessels up to the edge of the plate . Conclusions The proximal and distal metaphyseal areas of the tibia have a rich extraosseous blood supply provided primarily by branches of the ATA and the PTA . Open plating of the medial aspect of the distal tibia caused a greater disruption of this extraosseous blood supply than did percutaneously applied plates . Disruption of these extraosseous vessels following fracture and subsequent operative stabilization may slow healing and increase the risk of delayed union and nonunion . These findings support current efforts to develop less invasive methods and implants for operative stabilization of distal tibia fractures Objectives : Surgical treatment of displaced distal tibia fractures yields reliable results with either plate or nail fixation . Comparative studies suggest more malalignment and nonunions with nails . Some studies have reported knee pain after tibial nailing . However , plates may be associated with soft tissue complications , such as infections or wound-healing problems . The purpose of this study was to assess functional outcomes after distal tibia shaft fractures treated with a plate or a nail . We hypothesized that tibial nails would be associated with more knee pain and that plates would be associated with pain from implant prominence , each of which would adversely affect functional outcome scores . Design : R and omized prospect i ve study . Setting : Level 1 trauma center . Patients / Participants : One hundred four patients with extra-articular distal tibia shaft fractures ( OTA 42 ) , mean age of 38 years ( range , 18–95 ) , and mean Injury Severity Score of 14.3 ( range , 9–50 ) . Intervention : Patients were r and omized to treatment with a reamed intramedullary nail ( n = 56 ) or st and ard large fragment medial plate ( n = 48 ) . Main Outcome Measurements : Ability to work was evaluated after a minimum of 12 months , with mean of 22 months . Foot Function Index ( FFI ) and Musculoskeletal Function Assessment ( MFA ) question naires were completed . Results : Mean MFA was 27.5 , and mean total FFI was 0.26 ; P < 0.0001 versus an uninjured reference population . Sixty-one of 64 patients ( 95 % ) employed at the time of injury had returned to work , although 31 % had modified their work duties because of injury . Three patients were unable to find work . None reported unemployment secondary to their tibial fracture . Forty percent of all patients described some persistent ankle pain , and 31 % had knee pain after nailing , versus 32 % and 22 % , respectively after plating . Both knee and ankle pain were present in 27 % with nails and 15 % with plates ( P = 0.08 ) , and rates of implant removal were similar after nails versus plates . Patients with malunion ≥5 degrees were more likely to report knee or ankle pain ( 36 % vs 20 % , P < 0.05 ) . Except 1 patient with knee pain when kneeling , none reported modifying activity because of persistent knee or ankle pain , although knee and ankle pain were more frequent in the unemployed ( P = 0.03 ) . Unemployed patients requested implant removal more frequently ( 24 % vs 9.2 % , P = 0.07 ) and continued to report pain afterward . Although FFI and MFA scores were not related to plate or nail fixation , open fracture , fracture pattern , multiple injuries , Injury Severity Score , or age , both MFA and FFI scores were worse when knee pain or ankle pain was present ( all Ps < 0.004 ) and in patients who remained unemployed ( P < 0.0001 ) . All 4 patients with work-related injuries had returned to employment but had worse FFI scores ( P = 0.01 ) . Conclusions : Mean MFA and FFI scores suggest substantial residual dysfunction after distal tibia fractures when compared with an uninjured population . Mild ankle or knee pain was reported frequently after plate or nail fixation but was not limiting to activity in most . Angular malunion was associated with both knee and ankle pain , and there was a trend toward more patients with knee and ankle pain  after tibial nailing . No patients reported unemployment because of their tibia fracture , but unemployed people described knee and ankle pain more frequently and had the worst functional outcome scores Purpose The objective of this study was to compare combined internal and external fixation ( CIEF ) with minimally invasive percutaneous plate osteo synthesis ( MIPPO ) in the treatment of distal third tibial fractures , and explore the benefits and defects of these two techniques . Methods From April 2004 to February 2012 , a total of 44 patients were r and omised to operative stabilisation either by  two closed titanium elastic nails combined with an external fixator ( CIEF , 22 ) or by minimally invasive percutaneous osteo synthesis with a locking plate ( MIPPO , 22 ) . Pre-operative variables included the patients ’ age , sex , fracture side , cause of injury , Tscherne classification of soft tissue injury , fracture pattern , presence of open fracture and interval from injury to surgery . Peri-operative variables were the operating time and the radiation time . Postoperative variables were wound problems , bone union time , time of recovery to work , the functional American Orthopaedic Foot and Ankle surgery ( AOFAS ) score and removal of hardware . Results There was no significant difference in the time to union , the time of recovery to work , function , alignment and total AOFAS scores between the two groups ( P = 0.704 , 0.835 , 0.551 , 0.716 and 0.212 , respectively ) . The mean operating time and radiation time were longer in the MIPPO group than in the CIEF group ( 85.3 ± 12.5 vs. 73.2 ± 12.0 minutes , P = 0.002 , and 3.1 ± 1.5 vs. 2.1 ± 1.2 minutes , P = 0.019 , respectively ) . Wound complications were more common in the MIPPO group ( 18.2 % vs. 0 % with CIEF , P = 0.105 ) . There was a trend for patients with MIPPO to have a higher incidence of ankle pain ( 31.8 % vs. 9.1 % with CIEF , P = 0.135 ) . Painful implants were removed in 31.8 % of patients with MIPPO versus 9.1 % with CIEF ( P = 0.135 ) . Of the 165 self-tapping locking screws of the locking plates seven ( four patients ) were removed with some difficulty because of stripping of the hexagonal recess . Conclusions Our results indicated that both CIEF and MIPPO were all efficient methods for treating distal third tibial fractures . However , CIEF had the advantages of a shorter operating and radiation time , less wound complication and ankle pain , less secondary operations for implant removal and easier removal of the implants Purpose A few studies focused on the methods of treatment for displaced distal tibial shaft fractures have been published , all of which compared two different methods . In this r and omized , prospect i ve study , we aim ed to compare minimally invasive plate osteo synthesis , locking intramedullary nail stabilization and external fixation combined with limited open reduction and absorbable internal fixation for distal tibial shaft fractures by assessing complications and secondary procedures . Methods From November 2002 to June 2012 , 137 skeletally mature patients with displaced distal tibial shaft fractures with or without fibula fracture were r and omized to be treated by minimally invasive plate osteo synthesis ( group A , n = 46 ) , locking intramedullary nail ( group B , n = 46 ) or external fixation combined with limited open reduction and absorbable internal fixation ( group C , n = 45 ) . Age , gender , mechanism of injury , fracture pattern and presence of open fracture were equally distributed among the three groups . Indexes for evaluation included hospital stay , operative time , time to radiographic union , union status , infection and the incidence of re-operation . Mazur ankle score was introduced for functional evaluation . Statistics Analysis System ( SAS ) 9.2 was used for analysis . Results A total of 121 patients were included in the final analysis ( group A 42 , group B 40 and group C 39 ) and evaluated after a mean of 14.8 months follow-up . There was no significant difference ( P > 0.05 ) in hospital stay , time to radiographic union and the incidence of union status among the three groups . Although group C was associated with less secondary procedures versus groups A and B , it was related with more pin tract infections ( 15.4 % ) . Anterior knee pain occurred frequently after locking intramedullary nailing ( 37.5 % ) and the irritation symptoms were more frequently encountered in group A ( 59.5 % ) . There was no difference in ankle function between the three methods after operation ( P > 0.05 ) . Conclusions We consider that the minimally invasive plate osteo synthesis , locking intramedullary nail stabilization and external fixation combined with limited open reduction and absorbable internal fixation techniques are all efficient methods for treating distal tibia fractures . With its wide indications , external fixation combined with limited open reduction and absorbable internal fixation leads to minimal soft tissue complication , good functional result and no local soft tissue irritation or implant removal All tibial shaft fractures treated at one hospital during a five-year period were studied in a prospect i ve trial . Ninety-one displaced fractures in adults were treated using a conservative policy that included early bone grafting when indicated . Sound bony union was obtained in all cases . Those that healed primarily took on average 16.3 weeks whereas the 24 per cent that required bone grafts took 35.1 weeks . The number of complications , most of which were minor , was considered acceptable . It is concluded that provided early bone grafting is performed when necessary , a basically conservative policy of treatment is satisfactory ; bony union of all displaced tibial fractures is achieved in a reasonable period of time ABSTRACT Minimally invasive percutaneous plate osteo synthesis ( MIPPO ) was compared with traditional open reduction and internal fixation ( ORIF ) in treating distal tibial fractures . Patients diagnosed with displaced extraarticular distal tibial fractures during October 2005–June 2007 were r and omly assigned to a closed ( treated using MIPPO ) and an open ( treated using ORIF ) group . Ninety-four patients with fractures were treated and followed up , of which 42 and 52 patients were enrolled in the open and closed groups , respectively . The 94 fracture cases were classified into three types : Type A , 52 ( 55.3 % ) ; Type B , 24 ( 25.5 % ) ; and Type C , 18 ( 19.1 % ) . The average follow-up time was 15.6 and 16.2 
    Output:
    
Overall , there is either no or insufficient evidence to draw definitive conclusions on the use of surgery or the best surgical intervention for distal tibial metaphyseal fractures in adults .
The available evidence , which is of very low quality , found no clinical ly important differences in function or pain , and did not confirm a difference in the need for re-operation or risk of complications between nailing and plating .