{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,27]],"date-time":"2025-10-27T10:52:59Z","timestamp":1761562379233,"version":"3.37.3"},"reference-count":52,"publisher":"National Institute for Health and Care Research","issue":"25","license":[{"start":{"date-parts":[[2018,5,1]],"date-time":"2018-05-01T00:00:00Z","timestamp":1525132800000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/www.nationalarchives.gov.uk\/doc\/non-commercial-government-licence\/non-commercial-government-licence.htm"}],"funder":[{"DOI":"10.13039\/501100000664","name":"Health Technology Assessment programme","doi-asserted-by":"publisher","award":["11\/136\/04"],"award-info":[{"award-number":["11\/136\/04"]}],"id":[{"id":"10.13039\/501100000664","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Health Technol Assess"],"abstract":"<jats:sec id=\"abs1-1\"><jats:title>Background<\/jats:title><jats:p>The best treatment for fractures of the distal tibia remains controversial. Most of these fractures require surgical fixation, but the outcomes are unpredictable and complications are common.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-2\"><jats:title>Objectives<\/jats:title><jats:p>To assess disability, quality of life, complications and resource use in patients treated with intramedullary (IM) nail fixation versus locking plate fixation in the 12 months following a fracture of the distal tibia.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-3\"><jats:title>Design<\/jats:title><jats:p>This was a multicentre randomised trial.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-4\"><jats:title>Setting<\/jats:title><jats:p>The trial was conducted in 28 UK acute trauma centres from April 2013 to final follow-up in February 2017.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-5\"><jats:title>Participants<\/jats:title><jats:p>In total, 321 adult patients were recruited. Participants were excluded if they had open fractures, fractures involving the ankle joint, contraindication to nailing or inability to complete questionnaires.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-6\"><jats:title>Interventions<\/jats:title><jats:p>IM nail fixation (<jats:italic>n<\/jats:italic>\u2009=\u2009161), in which a metal rod is inserted into the hollow centre of the tibia, versus locking plate fixation (<jats:italic>n<\/jats:italic>\u2009=\u2009160), in which a plate is attached to the surface of the tibia with fixed-angle screws.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-7\"><jats:title>Main outcome measures<\/jats:title><jats:p>The primary outcome measure was the Disability Rating Index (DRI) score, which ranges from 0 points (no disability) to 100 points (complete disability), at 6 months with a minimum clinically important difference of 8 points. The DRI score was also collected at 3 and 12 months. The secondary outcomes were the Olerud\u2013Molander Ankle Score (OMAS), quality of life as measured using EuroQol-5 Dimensions (EQ-5D), complications such as infection, and further surgery. Resource use was collected to inform the health economic evaluation.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-8\"><jats:title>Results<\/jats:title><jats:p>Participants had a mean age of 45 years (standard deviation 16.2 years), were predominantly male (61%, 197\/321) and had experienced traumatic injury after a fall (69%, 223\/321). There was no statistically significant difference in DRI score at 6 months [IM nail fixation group, mean 29.8 points, 95% confidence interval (CI) 26.1 to 33.7 points; locking plate group, mean 33.8 points, 95% CI 29.7 to 37.9 points; adjusted difference, 4.0 points, 95% CI \u20131.0 to 9.0 points;<jats:italic>p<\/jats:italic>\u2009=\u20090.11]. There was a statistically significant difference in DRI score at 3 months in favour of IM nail fixation (IM nail fixation group, mean 44.2 points, 95% CI 40.8 to 47.6 points; locking plate group, mean 52.6 points, 95% CI 49.3 to 55.9 points; adjusted difference 8.8 points, 95% CI 4.3 to 13.2 points;<jats:italic>p<\/jats:italic>\u2009&lt;\u20090.001), but not at 12 months (IM nail fixation group, mean 23.1 points, 95% CI 18.9 to 27.2 points; locking plate group, 24.0 points, 95% CI 19.7 to 28.3 points; adjusted difference 1.9 points, 95% CI \u20133.2 to 6.9 points;<jats:italic>p<\/jats:italic>\u2009=\u20090.47). Secondary outcomes showed the same pattern, including a statistically significant difference in mean OMAS and EQ-5D scores at 3 and 6 months in favour of IM nail fixation. There were no statistically significant differences in complications, including the number of postoperative infections (13% in the locking plate group and 9% in the IM nail fixation group). Further surgery was more common in the locking plate group (12% in locking plate group and 8% in IM nail fixation group at 12 months). The economic evaluation showed that IM nail fixation provided a slightly higher quality of life in the 12 months after injury and at lower cost and, therefore, it was cost-effective compared with locking plate fixation. The probability of cost-effectiveness for IM nail fixation exceeded 90%, regardless of the value of the cost-effectiveness threshold.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-9\"><jats:title>Limitations<\/jats:title><jats:p>As wound dressings after surgery are clearly visible, it was not possible to blind the patients to their treatment allocation. This evidence does not apply to intra-articular (pilon) fractures of the distal tibia.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-10\"><jats:title>Conclusions<\/jats:title><jats:p>Among adults with an acute fracture of the distal tibia who were randomised to IM nail fixation or locking plate fixation, there were similar disability ratings at 6 months. However, recovery across all outcomes was faster in the IM nail fixation group and costs were lower.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-11\"><jats:title>Future work<\/jats:title><jats:p>The potential benefit of IM nail fixation in several other fractures requires investigation. Research is also required into the role of adjuvant treatment and different rehabilitation strategies to accelerate recovery following a fracture of the tibia and other long-bone fractures in the lower limb. The patients in this trial will remain in longer-term follow-up.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-12\"><jats:title>Trial registration<\/jats:title><jats:p>Current Controlled Trials ISRCTN99771224 and UKCRN 13761.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-13\"><jats:title>Funding<\/jats:title><jats:p>This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in<jats:italic>Health Technology Assessment<\/jats:italic>; Vol. 22, No. 25. See the NIHR Journals Library website for further project information.<\/jats:p><\/jats:sec>","DOI":"10.3310\/hta22250","type":"journal-article","created":{"date-parts":[[2018,5,22]],"date-time":"2018-05-22T10:03:33Z","timestamp":1526983413000},"page":"1-148","update-policy":"https:\/\/doi.org\/10.3310\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":16,"title":["Intramedullary nail fixation versus locking plate fixation for adults with a fracture of the distal tibia: the UK FixDT RCT"],"prefix":"10.3310","volume":"22","clinical-trial-number":[{"clinical-trial-number":"isrctn99771224","registry":"10.18810\/isrctn","type":"results"}],"author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3644-1388","authenticated-orcid":true,"given":"Matthew L","family":"Costa","sequence":"first","affiliation":[{"name":"Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK"},{"name":"Department of Trauma and Orthopaedics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK"},{"name":"Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8857-5743","authenticated-orcid":true,"given":"Juul","family":"Achten","sequence":"additional","affiliation":[{"name":"Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK"},{"name":"Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8160-6658","authenticated-orcid":true,"given":"Susie","family":"Hennings","sequence":"additional","affiliation":[{"name":"Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3440-0697","authenticated-orcid":true,"given":"Nafisa","family":"Boota","sequence":"additional","affiliation":[{"name":"Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6364-0414","authenticated-orcid":true,"given":"James","family":"Griffin","sequence":"additional","affiliation":[{"name":"Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3121-6050","authenticated-orcid":true,"given":"Stavros","family":"Petrou","sequence":"additional","affiliation":[{"name":"Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2030-3338","authenticated-orcid":true,"given":"Mandy","family":"Maredza","sequence":"additional","affiliation":[{"name":"Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1673-3036","authenticated-orcid":true,"given":"Melina","family":"Dritsaki","sequence":"additional","affiliation":[{"name":"Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3561-1795","authenticated-orcid":true,"given":"Thomas","family":"Wood","sequence":"additional","affiliation":[{"name":"Department of Trauma and Orthopaedics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9663-8858","authenticated-orcid":true,"given":"James","family":"Masters","sequence":"additional","affiliation":[{"name":"Department of Trauma and Orthopaedics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK"},{"name":"Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0570-1012","authenticated-orcid":true,"given":"Ian","family":"Pallister","sequence":"additional","affiliation":[{"name":"Medical School, Swansea University, Swansea, Wales"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4349-7195","authenticated-orcid":true,"given":"Sarah E","family":"Lamb","sequence":"additional","affiliation":[{"name":"Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK"},{"name":"Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9975-888X","authenticated-orcid":true,"given":"Nick R","family":"Parsons","sequence":"additional","affiliation":[{"name":"Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"6221","published-online":{"date-parts":[[2018,5]]},"reference":[{"key":"key20180518093205275_ref1-bib1","doi-asserted-by":"crossref","first-page":"e009162","DOI":"10.1136\/bmjopen-2015-009162","article-title":"UK Fixation of Distal Tibia Fractures (UK FixDT): protocol for a randomised controlled trial of \u2018locking\u2019 plate fixation versus intramedullary nail fixation in the treatment of adult patients with a displaced fracture of the distal tibia","volume":"5","author":"Achten","year":"2015","journal-title":"BMJ Open"},{"key":"key20180518093205275_ref1-bib2","doi-asserted-by":"crossref","first-page":"26","DOI":"10.1007\/s00264-002-0405-x","article-title":"Functional bracing in the treatment of delayed union and nonunion of the tibia","volume":"27","author":"Sarmiento","year":"2003","journal-title":"Int Orthop"},{"key":"key20180518093205275_ref1-bib3","doi-asserted-by":"crossref","first-page":"964","DOI":"10.1097\/00005373-198411000-00007","article-title":"Infra-isthmal longitudinal fractures of the tibial diaphysis: results of treatment using closed intramedullary compression nailing","volume":"24","author":"B\u00f6stman","year":"1984","journal-title":"J Trauma"},{"key":"key20180518093205275_ref1-bib4","doi-asserted-by":"crossref","first-page":"432","DOI":"10.1016\/0020-1383(83)90094-3","article-title":"A study of function after tibial cast bracing","volume":"14","author":"Digby","year":"1983","journal-title":"Injury"},{"key":"key20180518093205275_ref1-bib5","doi-asserted-by":"crossref","first-page":"137","DOI":"10.1016\/S0020-1383(00)00157-1","article-title":"Initial rotational stability of distal tibial fractures nailed without proximal locking: the importance of fracture type and degree of cortical contact","volume":"32","author":"Drosos","year":"2001","journal-title":"Injury"},{"key":"key20180518093205275_ref1-bib6","doi-asserted-by":"crossref","first-page":"271","DOI":"10.1016\/0020-1383(95)00116-6","article-title":"A comparison of one versus two distal locking screws in tibial fractures treated with unreamed tibial nails: a prospective randomized clinical trial","volume":"27","author":"Kneifel","year":"1996","journal-title":"Injury"},{"key":"key20180518093205275_ref1-bib7","doi-asserted-by":"crossref","first-page":"1180","DOI":"10.3928\/0147-7447-20041101-15","article-title":"Comparison of intramedullary nailing of distal third tibial shaft fractures: before and after traumatologists","volume":"27","author":"Obremskey","year":"2004","journal-title":"Orthopedics"},{"key":"key20180518093205275_ref1-bib8","doi-asserted-by":"crossref","first-page":"265","DOI":"10.1016\/0020-1383(95)00150-6","article-title":"Unreamed intramedullary tibial nailing \u2013 fatigue of locking bolts","volume":"27","author":"Boenisch","year":"1996","journal-title":"Injury"},{"key":"key20180518093205275_ref1-bib9","doi-asserted-by":"crossref","first-page":"83","DOI":"10.1016\/S0020-1383(98)00213-7","article-title":"The unreamed tibial nail in the treatment of distal metaphyseal fractures","volume":"30","author":"Mosheiff","year":"1999","journal-title":"Injury"},{"key":"key20180518093205275_ref1-bib10","doi-asserted-by":"crossref","first-page":"108","DOI":"10.1097\/00003086-199307000-00013","article-title":"Open reduction and internal fixation of tibial plafond fractures. Variables contributing to poor results and complications","volume":"292","author":"Teeny","year":"1993","journal-title":"Clin Orthop Relat Res"},{"key":"key20180518093205275_ref1-bib11","doi-asserted-by":"crossref","first-page":"307","DOI":"10.1097\/BOT.0b013e31816ed974","article-title":"Radiographic and clinical comparisons of distal tibia shaft fractures (4 to 11 cm proximal to the plafond): plating versus intramedullary nailing","volume":"22","author":"Vallier","year":"2008","journal-title":"J Orthop Trauma"},{"key":"key20180518093205275_ref1-bib12","doi-asserted-by":"crossref","first-page":"709","DOI":"10.1007\/s00264-006-0237-1","article-title":"Treatment of distal tibial fractures: plate versus nail: a retrospective outcome analysis of matched pairs of patients","volume":"31","author":"Janssen","year":"2007","journal-title":"Int Orthop"},{"key":"key20180518093205275_ref1-bib13","doi-asserted-by":"crossref","first-page":"1219","DOI":"10.1097\/01.ta.0000188936.79798.4e","article-title":"Distal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plate and screws fixation","volume":"59","author":"Im","year":"2005","journal-title":"J Trauma"},{"key":"key20180518093205275_ref1-bib14","doi-asserted-by":"crossref","first-page":"984","DOI":"10.1302\/0301-620X.92B7.22959","article-title":"A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia","volume":"92","author":"Guo","year":"2010","journal-title":"J Bone Joint Surg Br"},{"key":"key20180518093205275_ref1-bib15","doi-asserted-by":"crossref","first-page":"76","DOI":"10.1097\/01.bot.0000202997.45274.a1","article-title":"Treatment of distal tibia fractures without articular involvement: a systematic review of 1125 fractures","volume":"20","author":"Zelle","year":"2006","journal-title":"J Orthop Trauma"},{"key":"key20180518093205275_ref1-bib16","doi-asserted-by":"crossref","first-page":"704","DOI":"10.1302\/0301-620X.94B5.28498","article-title":"A randomised pilot trial of \u2018locking plate\u2019 fixation versus intramedullary nailing for extra-articular fractures of the distal tibia","volume":"94","author":"Mauffrey","year":"2012","journal-title":"J Bone Joint Surg Br"},{"key":"key20180518093205275_ref1-bib17","doi-asserted-by":"crossref","first-page":"1423","DOI":"10.1016\/0895-4356(94)90086-8","article-title":"The Disability Rating Index: an instrument for the assessment of disability in clinical settings","volume":"47","author":"Sal\u00e9n","year":"1994","journal-title":"J Clin Epidemiol"},{"volume-title":"M\u00fcller AO Classification of Fractures \u2013 Long Bones","author":"AO Foundation","key":"key20180518093205275_ref1-bib18"},{"volume-title":"Mental Capacity Act 2005","year":"2005","author":"Great Britain","key":"key20180518093205275_ref1-bib19"},{"key":"key20180518093205275_ref1-bib20","doi-asserted-by":"crossref","first-page":"719","DOI":"10.1080\/10543406.2012.676535","article-title":"Adaptive randomization for clinical trials","volume":"22","author":"Rosenberger","year":"2012","journal-title":"J Biopharm Stat"},{"issue":"12","key":"key20180518093205275_ref1-bib21","doi-asserted-by":"crossref","DOI":"10.3310\/hta5120","article-title":"Statistical assessment of the learning curves of health technologies","volume":"5","author":"Ramsay","year":"2001","journal-title":"Health Technol Assess"},{"key":"key20180518093205275_ref1-bib22","doi-asserted-by":"crossref","first-page":"465","DOI":"10.1093\/aje\/153.5.465","article-title":"Forearm bone mineral density by age in 7620 men and women: the Troms\u00f8 study, a population-based study","volume":"153","author":"Berntsen","year":"2001","journal-title":"Am J Epidemiol"},{"key":"key20180518093205275_ref1-bib23","doi-asserted-by":"crossref","first-page":"529","DOI":"10.1016\/S0020-1383(98)00125-9","article-title":"The epidemiology of open long bone fractures","volume":"29","author":"Court-Brown","year":"1998","journal-title":"Injury"},{"key":"key20180518093205275_ref1-bib24","doi-asserted-by":"crossref","first-page":"64","DOI":"10.1093\/rheumatology\/keu293","article-title":"Measurement properties of the Disability Rating Index in patients undergoing hip replacement","volume":"54","author":"Parsons","year":"2015","journal-title":"Rheumatology"},{"issue":"75","key":"key20180518093205275_ref1-bib25","doi-asserted-by":"crossref","DOI":"10.3310\/hta20750","article-title":"The Ankle Injury Management (AIM) trial: a pragmatic, multicentre, equivalence randomised controlled trial and economic evaluation comparing close contact casting with open surgical reduction and internal fixation in the treatment of unstable ankle fractures in patients aged over 60 years","volume":"20","author":"Keene","year":"2016","journal-title":"Health Technol Assess"},{"key":"key20180518093205275_ref1-bib26","doi-asserted-by":"crossref","first-page":"53","DOI":"10.1016\/0168-8510(96)00822-6","article-title":"EuroQol: the current state of play","volume":"37","author":"Brooks","year":"1996","journal-title":"Health Policy"},{"volume-title":"Stata 14 Base Reference Manual","year":"2015","author":"StataCorp","key":"key20180518093205275_ref1-bib27"},{"key":"key20180518093205275_ref1-bib28","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1177\/2158244014534858","article-title":"Bias in area under the curve for longitudinal clinical trials with missing patient reported outcome data: summary measures versus summary statistics","volume":"4","author":"Bell","year":"2014","journal-title":"SAGE Open"},{"key":"key20180518093205275_ref1-bib29","doi-asserted-by":"crossref","first-page":"1095","DOI":"10.1097\/00005650-199711000-00002","article-title":"Modeling valuations for EuroQol health states","volume":"35","author":"Dolan","year":"1997","journal-title":"Med Care"},{"key":"key20180518093205275_ref1-bib30","doi-asserted-by":"crossref","first-page":"e1","DOI":"10.1016\/j.jval.2013.02.010","article-title":"Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement","volume":"16","author":"Husereau","year":"2013","journal-title":"Value Health"},{"volume-title":"Guide to the Methods of Technology Appraisal 2013","year":"2013","author":"National Institute for Health and Care Excellence (NICE)","key":"key20180518093205275_ref1-bib31"},{"volume-title":"Hospital and Community Health Services (HCHS) Pay and Price Inflation","author":"Department of Health and Social Care","key":"key20180518093205275_ref1-bib32"},{"volume-title":"Reference Costs 2014\u201315","year":"2015","author":"Department of Health and Social Care (DHSC)","key":"key20180518093205275_ref1-bib33"},{"volume-title":"Unit Costs of Health and Social Care 2015","year":"2015","author":"Curtis","key":"key20180518093205275_ref1-bib34"},{"key":"key20180518093205275_ref1-bib35","volume-title":"British National Formulary","author":"Joint Formulary Committee","year":"2015","edition":"69 ed."},{"volume-title":"Annual Survey of Hours and Earnings: 2015","year":"2015","author":"Office for National Statistics (ONS)","key":"key20180518093205275_ref1-bib36"},{"volume-title":"EQ-5D-3L User Guide EUROQOL","year":"2015","author":"van Reenen","key":"key20180518093205275_ref1-bib37"},{"key":"key20180518093205275_ref1-bib38","doi-asserted-by":"crossref","DOI":"10.1093\/med\/9780199685028.001.0001","volume-title":"Economic Evaluation in Clinical Trials","author":"Glick","year":"2014"},{"key":"key20180518093205275_ref1-bib39","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1002\/sim.4067","article-title":"Multiple imputation using chained equations: issues and guidance for practice","volume":"30","author":"White","year":"2011","journal-title":"Stat Med"},{"key":"key20180518093205275_ref1-bib40","doi-asserted-by":"crossref","first-page":"1157","DOI":"10.1007\/s40273-014-0193-3","article-title":"A guide to handling missing data in cost-effectiveness analysis conducted within randomised controlled trials","volume":"32","author":"Faria","year":"2014","journal-title":"PharmacoEconomics"},{"key":"key20180518093205275_ref1-bib41","doi-asserted-by":"crossref","first-page":"1261","DOI":"10.1007\/s00264-014-2294-1","article-title":"Treatment of distal tibial shaft fractures by three different surgical methods: a randomized, prospective study","volume":"38","author":"Li","year":"2014","journal-title":"Int Orthop"},{"key":"key20180518093205275_ref1-bib42","doi-asserted-by":"crossref","first-page":"531","DOI":"10.1016\/j.injury.2005.09.013","article-title":"Treatment of distal tibial metaphyseal fractures: Plating versus shortened intramedullary nailing","volume":"37","author":"Yang","year":"2006","journal-title":"Injury"},{"key":"key20180518093205275_ref1-bib43","doi-asserted-by":"crossref","first-page":"189","DOI":"10.5505\/tjtes.2014.92972","article-title":"Comparison of intramedullary nail and plate fixation in distal tibia diaphyseal fractures close to the mortise","volume":"20","author":"Yavuz","year":"2014","journal-title":"Ulus Travma Acil Cerrahi Derg"},{"key":"key20180518093205275_ref1-bib44","doi-asserted-by":"crossref","first-page":"736","DOI":"10.1097\/BOT.0b013e318213f709","article-title":"Randomized, prospective comparison of plate versus intramedullary nail fixation for distal tibia shaft fractures","volume":"25","author":"Vallier","year":"2011","journal-title":"J Orthop Trauma"},{"key":"key20180518093205275_ref1-bib45","doi-asserted-by":"crossref","first-page":"178","DOI":"10.1097\/BOT.0b013e31823924df","article-title":"Factors influencing functional outcomes after distal tibia shaft fractures","volume":"26","author":"Vallier","year":"2012","journal-title":"J Orthop Trauma"},{"key":"key20180518093205275_ref1-bib46","doi-asserted-by":"crossref","first-page":"e627","DOI":"10.3928\/01477447-20160606-01","article-title":"Comparison of 3 minimally invasive methods for distal tibia fractures","volume":"39","author":"Fang","year":"2016","journal-title":"Orthopedics"},{"key":"key20180518093205275_ref1-bib47","doi-asserted-by":"crossref","first-page":"695","DOI":"10.1007\/s00776-015-0713-9","article-title":"Intramedullary nailing versus minimally invasive plate osteosynthesis for distal extra-articular tibial fractures: a prospective randomized clinical trial","volume":"20","author":"Polat","year":"2015","journal-title":"J Orthop Sci"},{"key":"key20180518093205275_ref1-bib48","doi-asserted-by":"crossref","first-page":"513","DOI":"10.1007\/s00264-014-2607-4","article-title":"Ilizarov external fixation versus plate osteosynthesis in the management of extra-articular fractures of the distal tibia","volume":"39","author":"Fadel","year":"2015","journal-title":"Int Orthop"},{"volume-title":"Reference Costs 2013\u201314","year":"2014","author":"Department of Health and Social Care (DHSC)","key":"key20180518093205275_ref1-bib49"},{"volume-title":"Unit Costs of Health and Social Care 2010","year":"2010","author":"Curtis","key":"key20180518093205275_ref1-bib50"},{"volume-title":"Unit Costs of Health and Social Care 2014","year":"2014","author":"Curtis","key":"key20180518093205275_ref1-bib51"},{"volume-title":"The Income of the Self-Employed","year":"2016","author":"Department for Business Innovation & Skills","key":"key20180518093205275_ref1-bib52"}],"container-title":["Health Technology Assessment"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.journalslibrary.nihr.ac.uk\/publications\/hta22250\/hta22250.xml","content-type":"unspecified","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/njl-admin.nihr.ac.uk\/document\/download\/2003392","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.journalslibrary.nihr.ac.uk\/publications\/hta22250\/hta22250.xml","content-type":"text\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/njl-admin.nihr.ac.uk\/document\/download\/2014449","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,8,15]],"date-time":"2023-08-15T15:50:35Z","timestamp":1692114635000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.journalslibrary.nihr.ac.uk\/hta\/hta22250"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2018,5]]},"references-count":52,"journal-issue":{"issue":"25","published-online":{"date-parts":[[2018,5]]}},"alternative-id":["10.3310\/hta22250"],"URL":"https:\/\/doi.org\/10.3310\/hta22250","relation":{},"ISSN":["1366-5278","2046-4924"],"issn-type":[{"type":"print","value":"1366-5278"},{"type":"electronic","value":"2046-4924"}],"subject":[],"published":{"date-parts":[[2018,5]]},"assertion":[{"value":"This content has been made freely available to all.","name":"free","label":"Free to read"}]}}