Intramedullary Nailing Versus Plate Fixation for AO/OTA Types 43A and 43B Distal Tibial Fractures: Early Pain Trajectories, 3-Month Ankle Function, and Return to Work in a Retrospective Cohort.

Background/Objectives: Intramedullary nailing (IMN) and plate fixation are established treatments for distal tibial fractures, but differences in early pain, occupational recovery, and short-term function remain uncertain in routine practice. This study examined associations between fixation strategy and early recovery profiles and described union-related complications, fixation failure, and reoperation in AO/OTA 43A-B distal tibial fractures. Methods: This single-center retrospective comparative cohort included 87 adults treated between January 2019 and December 2025 (IMN, n = 35; plate fixation, n = 52). The primary outcome was the 3-month American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score. Secondary outcomes included serial visual analog scale (VAS) pain scores through 2 years, return-to-work time, perioperative outcomes, deep-vein thrombosis, infection, delayed union, nonunion, internal-fixation failure, and reoperation. Multivariable regression, generalized estimating equations, propensity-score overlap weighting, and a sensitivity model additionally accounting for associated fibular fracture and fixation were used. Results: After multivariable adjustment, IMN was associated with a 2.53-point higher 3-month AOFAS score (95% confidence interval [CI], 0.48-4.57; p = 0.015) and return to work 30.8 days earlier (95% CI, 20.0-41.5 days earlier; p < 0.001). Adjusted VAS scores favored IMN on postoperative day 1 (-1.85), week 1 (-1.31), and month 1 (-1.88), with a significant treatment-by-time interaction (p < 0.001). By 6 months, 1 year, and 2 years, mean pain scores were near zero in both groups. Overlap-weighted estimates and analyses additionally accounting for associated fibular fracture and fibular fixation remained directionally consistent. Delayed union, nonunion, fixation failure, and reoperation were uncommon and did not differ statistically between groups, although event counts were small. Conclusions: In appropriately selected AO/OTA 43A-B fractures, IMN was associated with less early postoperative pain, earlier occupational recovery, and a modestly higher 3-month AOFAS score. These observational findings characterize early recovery rather than establish universal implant superiority; low event counts preclude definitive conclusions regarding structural complications.