Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures

Randomized, prospective comparison of plate versus intramedullary nail fixation for distal tibia shaft fractures

OBJECTIVES

Malalignment has been frequently reported after intramedullary stabilization of distal tibia fractures. Nails have also been associated with knee pain in several studies. Historically, plate fixation has resulted in increased risks of infection and nonunion. Our purposes were to compare plate and nail stabilization for distal tibia shaft fractures by assessing complications and secondary procedures. We hypothesized that nails would be associated with more malalignment and nonunion.

DESIGN

Randomized, prospective study.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

One hundred four skeletally mature patients with extra-articular distal tibia shaft fractures with a mean age of 38 years (range, 18-95 years) and mean Injury Severity Score of 13.5 (range, 9-50). The majority had high-energy injuries.

INTERVENTION

Patients were randomized to a reamed intramedullary nail (n = 56) or a large fragment medial plate (n = 48). Forty fractures (39%) were open. Twenty-eight (27%) had concomitant fibula fractures that were stabilized.

MAIN OUTCOME MEASUREMENTS

Malunion, nonunion, infection, and secondary operations.

RESULTS

The two treatment groups were evenly matched with respect to age, gender, Injury Severity Score, fracture pattern, and presence of open fracture. Six patients (5.8%) developed deep infection with equal numbers in the two groups. Eighty-three percent of infections occurred after open fracture (P < 0.001). Four patients (7.1%) developed nonunion after nailing versus two (4.2%) after plating (P = 0.25) with a trend for nonunion in patients who had distal fibula fixation (12% versus 4.1%, P = 0.09). All nonunions occurred after open fracture (P = 0.0007); the primary union rate for closed fractures was 100%. Primary angular malalignment of 5° or greater occurred in 13 patients with nails (23% of all nails) and four with plates (8.3% of all plates; P = 0.02 for plates versus nails). Six additional patients experienced malalignment after immediate weightbearing against medical advice. Valgus was the most common deformity (n = 16). Malunion was more common after open fracture (55%, P = 0.04). Eighty-five percent of patients with malalignment after nailing did not have fibula fixation. Eleven patients underwent 15 secondary procedures after plating, five of which were for prominent implant removal. This was not significantly different from patients treated with nailing: 10 patients had 14 procedures and five for prominent implant removal.

CONCLUSIONS

High primary union rates were noted after surgical treatment of distal tibia shaft fractures with both nonlocked plates and reamed intramedullary nails. Rates of infection, nonunion, and secondary procedures were similar. Open fractures had higher rates of infection, nonunion, and malunion. Intramedullary nailing was associated with more malalignment versus plating. Fibula fixation may facilitate reduction of the tibia at the time of surgery. The effect of fibula fixation on tibia healing deserves further study. Economic assessment and functional outcomes data for this population will help to enhance our treatment decision-making.

Pilon fractures: advances in surgical management

Pilon fractures are challenging to manage because of the complexity of the injury pattern and the risk of significant complications. Variables such as fracture pattern, soft-tissue injury, and preexisting patient factors can lead to unpredictable outcomes. Avoiding complications associated with the soft-tissue envelope is paramount to optimizing outcomes. In persons with soft-tissue compromise, the use of temporary external fixation and staged management is helpful in reducing further injury and complications. Evidence in support of new surgical approaches and minimally invasive techniques is incomplete. Soft-tissue management, such as negative-pressure dressings, may be helpful in preventing complications.

Posteromedial anatomical plate for the treatment of distal tibial fractures with anterior soft tissue injury

The treatment of distal tibial fractures with anterior soft tissue injury is relatively difficult. The aim of this study was to explore the efficacy and safety of the posteromedial anatomical plate for such fractures. Between February 2006 and January 2009, twenty-six cases of distal tibial fracture with anterior soft tissue injury were treated with posteromedial anatomical plates designed by our traumatic orthopedic center. Of the 26 cases, 12 were open fractures (4 Gustilo-Anderson type I, 5 type II, 2 type IIIA, and 1 type IIIB), and 14 were closed fractures (3 Tscherne-Oestern type I, 9 type II, 2 type III). Operation time, intraoperative blood loss, fracture healing time, American Orthopaedic Foot and Ankle Society (AOFAS) ankle score, and complications were recorded to evaluate treatment effects.Mean operation time was 72.5 ± 15.8 minutes (range, 45-105 minutes) with a mean intraoperative blood loss volume of 86.4 ± 17.3 mL (range, 50-150 mL). All 26 patients had good postoperative fracture healing. Mean union time was 19.2 ± 4.4 weeks (range, 13-30 weeks). Average AOFAS ankle score was 87.3 ± 9.2 (range, 68-99). No malunion, nonunion, limb-shortening deformity, or neurovascular injury occurred. Our results suggest that the posteromedial anatomical plate for the treatment of distal tibial fractures with anterior soft tissue injury is effective and results in no severe complications.

Single-stage surgical treatment of infected nonunion of the distal tibia

OBJECTIVE

An infected nonunion of the distal tibia after plating is uncommon, and the traditional methods for its treatment have unique disadvantages (time-consuming and patient discomfort being great). A single-stage surgical technique was developed to improve the outcome in this situation.

DESIGN

Retrospective.

SETTING

University hospital.

PATIENTS AND METHODS

We treated 25 consecutive adult patients with 25 infected nonunions of the distal tibia after plating. The inclusion criteria consisted of infected nonunions of the distal tibia with an intact ankle space and a plate in situ. The surgical technique used with all participants called for the removal of all implants, intra-/extramedullary débridement, and placement of cancellous bone graft and antibiotics (vancomycin and gentamicin) followed by the application of an Ilizarov external fixator. Postoperatively, patients ambulated early with protected weightbearing and performed range-of-motion exercises of the ankle.

RESULTS

Twenty-two patients were followed up for at least 2 years (range, 2.0-4.5 years; median, 3.2 years). All infected nonunions healed without recurrence of infection. The median time to union was 4.5 months (range, 3.5-6.0 months). Eighteen cultures had single bacterial flora, whereas five cultures had mixed flora. Two cultures showed no growth of microorganisms. All bacteria were sensitive to vancomycin or gentamicin. Methicillin-resistant Staphylococcus aureus (13 of 25) and methicillin-sensitive S. aureus (seven of 25) were the most commonly detected microorganisms. Patients' ankle function improved with "satisfactory" grades increasing from 0% preoperatively to 86% postoperatively (P < 0.001).

CONCLUSIONS

This single-stage surgical technique had a high success rate with significant reduction in patient discomfort during the course of treatment. However, further revision of the technique may be necessary to ensure high success rates in further series.

Minimally invasive plate osteosynthesis of the distal fibula with the locking compression plate: first experience of 20 cases

OBJECTIVES

The aim of this study was to evaluate the clinical feasibility and the possible complications associated with minimally invasive plate osteosynthesis of the distal fibula.

DESIGN/SETTING

Regional county hospital.

PATIENTS/PARTICIPANTS

All patients with Orthopaedic Trauma Association 42, 43, 44 fractures of the distal tibia requiring plate fixation of the distal fibula were included in this cohort study. A consecutive series of 701 internally fixed fractures of tibia and ankle yielded 20 fibular fractures treated with this technique.

INTERVENTION

Fractures were treated with the minimally invasive plate osteosynthesis technique using an angular stable screw-plate system for the fibula.

MAIN OUTCOME MEASUREMENTS

Clinical and radiologic outcomes at 24 months.

RESULTS

Seventeen fractures healed without complication at an average of 9 weeks. Three aseptic nonunions were recorded: one in a pilon fracture (Orthopaedic Trauma Association 43-C3) and one in a distal lower leg fracture (Orthopaedic Trauma Association 43-A3), both with severe closed soft tissue injury (as a result of a crush mechanism). The third one was in an ankle fracture dislocation (OTA 44-C1) with delayed treatment and inadequate reduction of the simple fibula fracture.

CONCLUSION

Although this technique is comparable to minimally invasive plate osteosynthesis in the tibia or femur, it appears to be more difficult as a result of small bone size. As a result, we reserve this technique for selected complex fractures of the distal fibula with critical soft tissue conditions.

Tibial pilon fractures: which method of treatment?

A comprehensive review of the existing literature, related to treatment options and management principles of pilon fractures was performed, and its results are presented. The identified series advocate in favour of a number of different treatment strategies and fixation methods. Decision making was mostly dependent on the severity of the local injury, the fracture pattern, the condition of the soft tissues, patient's profile and surgical expertise. External fixation and conservative treatment did not provide sufficient articular congruence in many cases. Internal fixation allowed excellent restoration of joint congruity in Rüedi type I and II fractures. A staged approach, consisting of fibular plating and temporary bridging external fixation, later substituted by an internal minimal invasive osteosynthesis or by a definitive external fixation, was favourable for Rüedi type III fractures. Closed pilon fractures with bad soft tissue conditions (Tscherne ≥ 3) or open pilon fractures are regarded as contraindication of open reduction plate fixation. Anatomic reduction of the fracture, restoration of joint's congruence, reconstruction of the posterior column, with minimal soft tissue insult, were all highlighted as of paramount importance.

A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia

We compared the outcome of closed intramedullary nailing with minimally invasive plate osteosynthesis using a percutaneous locked compression plate in patients with a distal metaphyseal fracture in a prospective study. A total of 85 patients were randomised to operative stabilisation either by a closed intramedullary nail (44) or by minimally invasive osteosynthesis with a compression plate (41). Pre-operative variables included the patients' age and the side and pattern of the fracture. Peri-operative variables were the operating time and the radiation time. Postoperative variables were wound problems, the time to union of the fracture, the functional American Orthopaedic Foot and Ankle surgery score and removal of hardware. We found no significant difference in the pre-operative variables or in the time to union in the two groups. However, the mean radiation time and operating time were significantly longer in the locked compression plate group (3.0 vs 2.12 minutes, p < 0.001, and 97.9 vs 81.2 minutes, p < 0.001, respectively).After one year, all the fractures had united. Patients who had intramedullary nailing had a higher mean pain score (40 = no pain, 0 = severe pain), [corrected] but better function, alignment and total American Orthopaedic Foot and Ankle surgery scores, although the differences were not statistically significant (p = 0.234, p = 0.157, p = 0.897, p = 0.177 respectively). Three (6.8%) patients in the intramedullary nailing group and six (14.6%) in the locked compression plate group showed delayed wound healing, and 37 (84.1%) in the former group and 38 (92.7%) in the latter group expressed a wish to have the implant removed. We conclude that both closed intramedullary nailing and a percutaneous locked compression plate can be used safely to treat Orthopaedic Trauma Association type-43A distal metaphyseal fractures of the tibia. However, closed intramedullary nailing has the advantage of a shorter operating and radiation time and easier removal of the implant. We therefore prefer closed intramedullary nailing for patients with these fractures.

Comparison study of two surgical options for distal tibia fracture-minimally invasive plate osteosynthesis vs. open reduction and internal fixation

The aim of this study was to compare the results between two surgical options for distal tibia fracture, i.e. minimally invasive plate osteosynthesis (MIPO) vs. open reduction and internal fixation (ORIF), and explore the benefits and defects of these two techniques. Thirty cases of distal tibia fracture (15 pairs of ORIF and MIPO) were submitted for pair comparison with consistence of gender, age and AO fracture classification. Indexes for evaluation included operative time, blood loss, healing time, time of recovery to work, implant irritation symptoms, and union status. Mazur grading standard was introduced for functional evaluation. Statistical Package for Social Sciences (SPSS) 13.0 was used for analysis. No malunion occurred and one case of osteomyelitis developed in the ORIF group. In the ORIF group, ten cases were evaluated as excellent, three as good, one as fair and one as poor. In the MIPO group, ten cases were excellent and five good. Paired t-test found no significant differences between groups on the indexes for analysis. In conclusion, the MIPO technique is not distinctively superior to ORIF in treatment of distal tibia fracture.

Minimally invasive locked plating of distal tibia fractures is safe and effective

Distal tibial fractures are difficult to manage. Limited soft tissue and poor vascularity impose limitations for traditional plating techniques that require large exposures. The nature of the limitations for traditional plating techniques is intrinsic to the large exposure required to approach distal tibia, a bone characterized by limited soft tissue coverage and poor vascularity. The locking plate (LP) is a new device for treatment of fractures. We assessed the bone union rate, deformity, leg-length discrepancy, ankle range of motion, return to preinjury activities, infection, and complication rate in 21 selected patients who underwent minimally invasive osteosynthesis of closed distal tibia fractures with an LP. According to the AO classification, there were 12 Type A, 5 Type B, and 4 Type C fractures. The minimum followup was 2 years (average, 2.8 years; range, 2-4 years). Two patients were lost to followup. Union was achieved in all but one patient by the 24th postoperative week. Four patients had angular deformity less than 7 degrees . No patient had a leg-length discrepancy more than 1.1 cm. Five patients had ankle range of motion less than 20 degrees compared with the contralateral side. Sixteen patients had not returned to their preinjury sporting or leisure activities. Three patients developed a delayed infection. We judge the LP a reasonable device for treating distal tibia fractures. The level of physical activities appears permanently reduced in most patients.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Complications of definitive open reduction and internal fixation of pilon fractures of the distal tibia

A series of 49 pilon fractures in a tertiary referral centre treated definitively by open reduction and internal fixation have been assessed and the complications of such injuries examined. A retrospective analysis of case notes, radiographs and computerised tomographs over a seven-year period from 1999-2006 was performed. Infection was the most common postoperative problem. There were seven cases of superficial infection. There was a single case of deep infection requiring intravenous antibiotics and removal of metalwork. Other notable complications were those of secondary osteoarthritis (three cases) and malunion (one case). The key finding of this paper is the 2% incidence of deep infection following the direct operative approach to these fractures. The traditional operative approach to such injuries (initially advocated by Rüedi and Allgöwer in Injury 2:92-99, 1969) consisted of extensive soft tissue dissection to gain access to the distal tibia. Our preferred method is to access the tibia via the "direct approach" which involves direct access to the fracture site with minimal disturbance of the soft tissue envelope. We therefore believe that open reduction and internal fixation of pilon fractures via the direct approach to be a safe technique in the treatment of such devastating injuries.

Treatment of Distal Lower Leg Fractures: Results with Fixed-Angle Plate Osteosynthesis

Twenty-five patients with closed distal tibial fractures were treated with a fixed-angle (locked) plate osteosynthesis. The study period was from 1.1.06 to 31.12.07. According to AO classification, there were three A1, eight A2, nine A3, one B2, two C1, and two C3 fractures. All patients had a follow up examination after an average of 16.6 months. Complications included a technical mistake (fixation in slight malangulation), two infections, and one non union that showed consolidation after 15 months. All other patients reached bone consolidation and full weight bearing after an average of 3.5 months. The ankle range of motion for all patients was, on average, flexion/extension 18°/35°, without restrictions on the walking distance. No loss of reduction occurred. Fixed-angle plate osteosynthesis is a good alternative to intramedullary nailing when treating closed distal lower leg fractures. It is a demanding surgical method with good clinical and functional results.

Distal tibia fractures: management and complications of 101 cases

Distal tibia fractures are complex injuries with a high complication rate. In this retrospective and multicentre study we attempted to detail complications and outcomes of this type of injury in order to determine predictive factors of poor results. Between 2002 and 2004, 104 patients were admitted for 105 distal tibia fractures. One hundred patients (101 fractures) were reviewed with an average follow-up of 19 months (range, 12-46). Internal fixation, external fixation, limited internal fixation (K-wires or screws), intramedullary nailing and conservative treatment were used. Outcome parameters included occurrence of complications, radiographic analysis, evaluation of the American Orthopaedic Foot and Ankle Society (AOFAS) ankle score and measures of the ankle range of motion. The average functional score was 76 points (range, 30-100 points), and complications occurred in 30 patients. Predictive factors of poor results were fracture severity, complications, malunion and the use of external fixation. We believe that external fixation must be reserved for trauma with severe skin injury, as a temporary solution in a two-staged protocol. For other cases, we recommend ORIF with early mobilisation.

Fractures of the distal tibia treated with polyaxial locking plating

We evaluated the healing rate, complications, and functional outcomes in 32 adult patients with very short metaphyseal fragments in fractures of the distal tibia treated with a polyaxial locking system. The average distance from the distal extent of the fracture to the tibial plafond was 11 mm. All fractures healed and the average time to union was 14 weeks. Six patients (19%) reported occasional local disturbance over the medial malleolus. There were two cases of postoperative superficial infections and evidence of delayed wound healing. Using the American Orthopaedic Foot and Ankle Society ankle score, the average functional score was 87.3 points (of 100 total possible points). Our results show the polyaxial locking plates, which offer more fixation versatility, may be a reasonable treatment option for distal tibia fractures with very short metaphyseal segments.

Minimally invasive plating of the distal tibia: do we really sacrifice saphenous vein and nerve? A cadaver study

OBJECTIVE

To investigate the risk of saphenous nerve (SN) and great saphenous vein (GSV) injury during percutaneous screw placement of the 3.5/4.5 LCP Distal Tibial Metaphyseal Plate and the 3.5-mm LCP Medial Distal Tibia Plate with tab in distal tibias of cadaver extremities.

METHODS

Thirty-one unpaired (1 fresh and 30 formalin fixed) adult cadaveric lower extremity specimens were dissected. Using the principles of minimally invasive plating, a 3.5/4.5 LCP Distal Tibial Metaphyseal Plate was implanted in 16 extremities and a 3.5-mm LCP Medial Distal Tibia Plate with tab in the remaining 15 extremities. Injuries to or any evidences of direct contact with the SN or GSV were recorded. Additionally, the shortest distances of each hole to the main branches of these anatomic structures were measured.

RESULTS

The risk of injury to the SN and GSV was higher in holes 4, 5, and 6 when using the 3.5/4.5 LCP Distal Tibial Metaphyseal Plate and in holes 3, 5, and 8 when using the 3.5-mm LCP Medial Distal Tibia Plate.

CONCLUSIONS

The SN and GSV are at high risk for injury during percutaneous screw placement of the 3.5/4.5 LCP Distal Tibial Metaphyseal Plate and the 3.5-mm LCP Medial Distal Tibia Plate at the distal tibia. Careful dissection in the stab incisions down the plate, atraumatic placement of the drill sleeves, and protection of the soft tissues during screw insertion might decrease the risk of injury to the SN and GSV.

Minimally-invasive treatment of high velocity intra-articular fractures of the distal tibia

The pilon fracture is a complex injury. The purpose of this study was to evaluate the outcome of minimally invasive techniques in management of these injuries. This was a prospective study of closed AO type C2 and C3 fractures managed by early (<36 hours) minimally invasive surgical intervention and physiotherapist led rehabilitation. Thirty patients with 32 intra-articular distal tibial fractures were treated by the senior surgeon (GK). Our aim was to record the outcome and all complications with a minimum two year follow-up. There were two superficial wound infections. One patient developed a non-union which required a formal open procedure. Another patient was symptomatic from a palpable plate inferiorly. An excellent AOFAS result was obtained in 83% (20/24) of the patients. Early minimally invasive reduction and fixation of complex high velocity pilon fractures gave very satisfactory results at a minimum of two years follow-up.