Fractures of the Distal Tibia: Minimally Invasive Plate Osteosynthesis

Injury, Int. J. Care Injured (2004) 35, 615620 Fractures of the distal tibia minimally encroaching(a) denture osteosynthesis D. J. Redfern*, S. U. Syed, S. J. M. Davies Department of Orthopaedics, Frimley Park Hospital NHS Trust, Surrey, UK Accepted 9 September 2003 KEYWORDS negligiblely invasive photographic household osteosynthesis Plate ? xation Fracture Tibia Metaphysis Summary Unstable fractures of the distal tibia that are not qualified for intramedullary nailing are comm save treated by open reduction and national ? ation and/or external ? xation, or treated non-operatively. Treatment of these injuries using minimally invasive house osteosynthesis (MIPO) techniques whitethorn minimise velvet create from raw stuff brand and damage to the vascular integrity of the fracture fragments. We report the results of 20 patients treated by MIPO for unopen fractures of the distal tibia. Their mean age was 38. 3 years (range 1771 years). Fractures were classi? ed agree to th e AO system, and intra-articular extensions according to Ruedi and ? alonegower. The mean sequence to full weight-bearing was 12 weeks (range 820 weeks) and to union was 23 weeks (range 1829 weeks), without need for further surgery. at that place was one malunion, no thick infections and no failures of ? xation. MIPO is an effective handling for cockeyedd, crank fractures of the distal tibia, avoiding the complications associated with much traditionalistic methods of internal ? xation and/or external ? xation. ? 2003 Elsevier Ltd. All rights reserved. Introduction Unstable fractures of the distal tibia with or without intra-articular fracture extension can present a management dilemma.Traditionally, at that place obtain been a variety of methods of management described and high rates of associated complications reported. Non-operative manipulation can be technically demanding and may be associated with joint stiffness in up to 40% of cases as well as shortening and rotati onal malunion in over 30% of cases. 14,20 Traditional operative word of such injuries is in like manner *Corresponding author. Present address 16 By? eld Road, Isleworth, Middlesex TW7 7AF, UK. Tel. ? 44-(0)20-8847-1370 fax ? 44-(0)20-8847-1370.E-mail address david. j. emailprotected com (D. J. Redfern). associated with a high incidence of complications. Intramedullary nailing remains the gold standard for treatment of most diaphyseal fractures of the tibia. However, although some authors necessitate described good results with intramedullary nailing in the treatment of distal peri-articular tibial fractures, it is generally considered unsuitable for such injuries, payable to technical dif? culty and design limitations. 17,20 Traditional open reduction and internal ? ation of such injuries results in broad soft tissue dissection and periosteal combat injury and may be associated with high rates of infection, de rangeed union, and non-union. 5,11,13,18,19,22 Similarly, extern al ? xation of distal tibial fractures may excessively be associated with a high incidence of complications, with pin infection and loosening in up to 50% of cases and malunion rates of up to 45%. 20 Minimally invasive dwelling osteosynthesis (MIPO) may offer biological 00201383/$ see front matter ? 2003 Elsevier Ltd. All rights reserved. oi10. 1016/j. injury. 2003. 09. 005 616 D. J. Redfern et al. advpismireages. MIPO involves minimal soft tissue dissection with economy of the vascular integrity of the fracture as well as preserving osteogenic fracture haematoma. 3 MIPO techniques look at been utilise successfully in the treatment of distal femoral fractures. 9,10,23 Experience of the application of these techniques to fractures of the distal tibia is little extensive and opinion regarding optimal technique differs. Some authors advocate temporary external ? xation prior to de? itive MIPO and second ? xation of associated ? bula fractures. 7 otherwises advocate a more sele ctive approach to the role of external ? xation and ? bular ? xation. 2 target We report our experience with minimally invasive plate osteosynthesis in the treatment of unappealing, unstable fractures of the distal tibia that are unsuitable for intramedullary nailing. Patients and methods We undertook a review of patients treated by MIPO for unstable fractures of the distal tibia in our hospital, between 1998 and 2001. Twenty-two patients were identi? d, of whom 20 had followTable 1 Patient Detailed patient data Age (years) 71 46 20 32 27 26 34 23 26 26 50 59 27 39 54 67 25 24 67 46 implement of injury evanesce Fall Football Motorcycle RTA Twisted Motorcycle RTA rugger injury Rugby injury Football injury Motorcycle RTA Fall Fall Fall Fall Fell from wheelchair Fall Motorcycle RTA Motorcycle RTA Fall Fall Fracture classi? cation AO/R&A 42-A2 42-B1 42-A2 42-A2 42-B1 42-C1 42-B1/ grievance 42-A1/grade 42-B1 42-B2 42-A1 43-A3/grade 42-A1 42-A1 42-B1 42-A1 43-B1 42-A1 43-B1/grade 43- B1/grade up available. Their mean age was 38. 3 years (range 1771 years). on that point were 18 males and 4 females. The mechanism of injury was fall (12) motorcycle accident (6) rugby/football injury (4) (see Table 1). Fractures were classi? ed according to the AO system12 and distal intra-articular fracture extension classi? ed according to Ruedi and Allgower18 ? ? (Table 1). All 20 fractures involved the distal onethird of the tibia and in 5 cases the fracture clearly extended distally in to the ankle joint (Ruedi and ? Allgower grade I in 3 cases and grade II in 2 cases). It ? is important to note that although 16/20 of the fractures were classi? d according to the AO system as 42 (diaphyseal), this is somewhat misleading as the essence of these fractures was metaphyseal. Within the strict AO system12 de? nition of a metaphyseal fracture of the distal tibia (43), the kernel of the fracture must lie within a square of sides equal to the widest metaphyseal distance, and the cent re of m any of our fractures lay just outside of the metaphyseal square (Fig. 1a). The fracture pattern was however predominantly long oblique or long spiral and as such extended well into the distal metaphysis ? extension into the joint (Fig. 1).Indications for subprogram of MIPO technique These include distal diaphyseal, or metaphyseal fractures of the tibia that were considered unsuitable Time to callus (weeks) 8 7 8 8 8 8 10 10 8 8 11 8 12 12 8 8 10 8 10 10 Time to FWB (weeks) 12 13 12 14 8 20 12 12 10 17 9 14 13 12 N/A 12 10 13 10 12 Time to union (weeks) 26 24 20 22 20 20 24 18 28 29 24 26 24 20 24 20 20 22 24 20 Complications 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 I I II I II Metalwork discomfort overseer? cial infection Metalwork discomfort Metalwork discomfort Malunion CRPS ( eccentric 1) R&A Ruedi and Allgower. ? Fractures of distal tibia 617 encounter 1 (a) AP and lateral skiagraphs of the distal tibia for case 8 (42-A1, R&A grade 1). (b) AP ra diograph (case 8) at 10 weeks post-operatively showing callus formation (A) AP radiograph (case 8) at 18 weeks showing radiological union (B). for intramedullary nailing due to the distal nature of the fracture and/or intra-articular or peri-articular fracture extensions. gical evidence of callus. All patients were followedup for a minimum of 12 months. Operative technique Management protocol Initially, patients were managed in a plasterwork splint with elevation until de? itive ? xation could be undertaken. Surgery was undertaken on the next available theatre list and only delayed if soft tissue intumescence or anaesthetic concerns dictated that this was necessary. Intravenous antibiotics were given at induction of anaesthesia and two doses following surgery. Post-operatively, patients were not routinely splinted unless deemed unlikely to comply with a partial derivative weight-bearing regime. The mass of patients were encouraged to partial weight-bear on the limb (1015 kg) fro m the ? rst post-operative day. Early active and passive stifle and ankle motion was encouraged.In the majority of cases, patients were discharged from hospital 24 h following surgery. clinical and radiological review took place at 68 weeks to assess for evidence of callus formation. Patients were allowed to maintain to full weight-bearing on the basis of clinical and radiological evaluation but not before there was radioloSurgery was performed with the patient supine on a radiolucent table. Routine preparation and draping of the injured limb was performed. two in submit and direct techniques of fracture reduction were usaged depending upon the nature and pattern of the fracture.Reduction techniques employed included the use of manual traction, the AO femoral distracter, the AO articulated fracture distractor, and direct reduction with fracture reduction forceps across the fracture (via two stab incisions). A 2 cm incision was made proximal and distal to the fracture on the med ial border of the tibia. An extraperiosteal, hypodermic tunnel could then be fashioned between these two incisions using blunt dissection. A pre-measured and pre-contoured narrow 4. 5 mm DCP was then positioned in this extra-periosteal subcutaneous tunnel (Fig. 2). Accurate plate contouring and positioning was con? med by ? uoroscopy. The continuance of plate selected is important and should be as long as is reasonably possible given the particular fracture pattern. As the length of plate is 618 D. J. Redfern et al. Figure 2 Pre-contoured plate insertion with fracture reduction maintained by direct technique. increased, the strength of the ? xation construct is also increased. 21 A cortical rump (4. 5 mm) was then inserted by dint of a screw hole at one end of the plate via the incisions already made for plate insertion. At this stage, axial fracture alignment was con? rmed before inserting any further screws.Subsequent screws were inserted close to either side of the fracture v ia stab incisions. Further screws may be used depending upon the characteristics of the fracture. If possible, a tuck away screw was also inserted across the fracture (via the plate) in order to further reduce the fracture chap and add to the rigidity of the ? xation. However, because the technique employs a bridge plating principle, interfragmentary lag screws were not felt to be obligatory. It is not necessary to place screws through all of the remaining holes in the plate as this does not further increase the strength or rigidity of the ? ation construct4,21 but does require further skin incisions, providing more potential portals of entry for infection (Fig. 1b). The ? bula was not ? xed unless necessary for accurate retraceion of length such as encountered with some severely comminuted fractures. With fractures extending into the ankle joint, careful attention was p support to restoration of the articular surface tenacity and 3. 5 mm cortical screws inserted through stab in cisions or formal open exposure as required. In only one case was it deemed necessary to ? x the ? ula in order to accurately reconstruct length before proceeding to minimally invasive plating of the tibia. The mean hospital stay was 6 days (range 231 days). The mean meter to radiological evidence of callus formation was 9 weeks (range 712 weeks). Sixty percent of patients achieved radiological callus by 8 weeks and all by 3 months (Table 1 and Fig. 2). The mean time to full weight-bearing was 12 weeks (range 820 weeks) and the mean time to union was 23 weeks (range 1829 weeks). There were no non-unions and one malunion in whom there was 58 of varus angulation.There were no cases of failure of ? xation. Three soldiers have subsequently had their metalwork removed due to discomfort during training, and have reported no further symptoms. One patient required exchange of a distal screw that was too long and was impinging upon the distal tibia? bula joint. A further patient developed t ype I complex regional pain syndrome (CRPS). He required guanethidine blocks to control his pain. There were no deep infections (one super? cial infection which resolved on oral antibiotics). Sixteen of the 20 patients were employed at the time of their injury.Six patients were soldiers. All patients in this study have subsequently returned to their pre-injury occupations/level of activity. Discussion Results Of the 20 patients presented, 12 were operated upon within 24 h of the injury, and 16 within 72 h of the injury. Surgery was delayed in the remaining four patients due to transfer from another hospital (1) swelling at the site of injury (1) medical problems (1) and for further imaging (1). The surgery was performed by, or supervised by, one of six consultant orthopedic surgeons in the department.Favourable results have been described using minimally invasive plate osteosynthesis techniques for ? xation of distal femoral fractures. 9,10,23 Cadaveric and animal studies have empha sised the importance of minimising the degree of soft tissue damage in the region of long bone fractures. 3,16,24 Recently, Borrelli et al. 1 have demonstrated that the distal metaphyseal region of the tibia has a relatively rich extraosseous kin proviso, provided primarily by Fractures of distal tibia 619 branches of the anterior tibial and tooshie tibial arteries.They also demonstrated that open plating in this region produces signi? cantly greater disruption of this extraosseous blood supply than minimally invasive plate application. Helfet et al. 7 described their experience with MIPO in 20 closed pilon fractures and advocated routine use of external ? xation acutely, followed by de? nitive ? xation 57 days later once the swelling has subsided. They also advocated the routine ? xation of associated ? bula fractures. They splinted the limb post-operatively but allowed toe-touch weight-bearing (20 lb) from the ? rst post-operative day.Their patients achieved full weight-bearing at an average of 10. 7 weeks (range 816 weeks). Malunion occurred in 20% of cases although all patients had a good functional outcome and none required any further surgery. Collinge et al. 2 have reported their experience using MIPO in 17 tibial bonk fractures. Twelve cases had open injuries and ? ve of these required bone grafting at a later stage such that they suggested that this should be considered at an early stage in such injuries. The ? ve patients with closed injuries had complete union subsequently the index procedure with no cases of malunion or infection.These closed injuries all achieved a good functional outcome. They routinely splinted the limb post-operatively with weightbearing commenced at approximately 12 weeks. In this series, we con? rm that good results can be obtained with this technique in the treatment of closed tibial fractures with intra-articular or periarticular fracture extensions, which are not suitable for intramedullary nailing. However, intramedu llary nailing shut away remains the treatment of choice for most dim-witted diaphyseal fractures of the tibia. We would not advocate the routine use of external ? ation in the acute management of such injuries, except in some open injuries with extensive soft tissue damage. Early de? nitive surgery negates the need for any form of temporary ? xation other than a POP back-slab for closed fractures. This avoids the added risk of complications arising from the use of such devices. It is our experience that ? xation of the ? bula is not necessary except to aid in reconstructive memory of length when there is extensive comminution of the tibial fracture. In the current series (and those of Collinge et al. 2 and Koury et al. ), a 4. 5 mm DCP has been used with satisfactory results. However, this is a relatively bulky implant and disdain pro? le plate designs might be expected to result in a move incidence of postoperative metalwork discomfort along this subcutaneous medial aspect of t he tibia, especially in the region of the medial malleolus. This in turn may reduce the need for subsequent implant removal. Other recent developments in plate design include pre-contoured and fasten plates (e. g. LCP system, Synthes), which may offer signi? cant advantages. The internal ? ator design of locking plates has the advantage that screw insertion does not draw the bony fragments to the plate (as occurs with traditional non-locking plates) and hence, the precise contouring of the plate is less important in achieving accurate fracture reduction. 6,15 For the same reason, the footprint of the locking plates should also be signi? cantly smaller than traditional non-locking plates, hence preserving periosteal blood supply to the fracture. 6 In the majority of cases, we have found it possible to safely mobilise patients, partial weightbearing (1015 kg), from the ? st post-operative day without external splintage of the limb. This also allows early mobilisation of the knee, ank le and subtalar joints. 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