Metaphyseal locking compression plate as an external fixator for the distal tibia

Non‑contact locking plate: A useful alternative to external fixation in second‑stage treatment of post‑traumatic tibial osteomyelitis

The treatment of infected tibial bone defects can be challenging for the orthopedic surgeon. Therefore, the aim of the present study was to compare the fixation endurance, bone union time, lower limb joint function and complications associated with different fixation methods in the treatment of bone defects caused by debridement in the treatment of post-traumatic osteomyelitis. The clinical data of 55 patients with infected bone defects of the lower extremities following traumatic injury, who had undergone radical debridement between January 2017 and September 2020, were retrospectively analyzed. The patients were divided into three groups according to the type of fixation during reconstruction, namely the external fixation (EX), internal fixation (IX) and non-contact locking plate (LP) groups. The demographic data, time to bone union, bacterial culture results, complications and Self-Rating Anxiety Scale (SAS) scores of the patients were compared among the three groups. The results indicated that the differences in time to bone union and recurrence rates of osteomyelitis among the three groups were not statistically significant. By contrast, functional status after surgery was significantly higher in the LP group compared with the EX group. In total, 8/22 patients (36.4%) in the EX group, 4/13 patients (30.8%) in the IX group and 4/20 patients (20.0%) in the non-contact LP group had shortened limbs and deformed tibia. The SAS assessment results revealed that patients in the non-contact LP group had the lowest rates of moderate and severe anxiety. In conclusion, the results of the present study demonstrate that the non-contact locking plate technique provided stable fixation without any contact between the implant and bone tissues. Therefore, this technique may be viable for use during the reconstruction stage of post-traumatic tibial osteomyelitis.

Comparative analysis of external locking plate and combined frame external fixator for open distal tibial fractures: a comprehensive assessment of clinical outcomes and financial implications

BACKGROUND

Open distal tibial fractures pose significant challenges regarding treatment options and patient outcomes. This retrospective single-centre study aimed to compare the stability, clinical outcomes, complications, and financial implications of two surgical interventions, namely the external locking plate and the combined frame external fixator, to manage open distal tibial fractures.

METHODS

Forty-four patients with distal open tibial (metaphyseal extraarticular) fractures treated between 2020 and 2022 were selected and formed into two main groups, Group A and Group B. Group A (19 patients) are patients that underwent treatment using the external locking plate technique, while Group B (25 patients) received the combined frame external fixator approach. Age, gender, inpatient stay, re-operation rates, complications, functional recovery (measured by the Johner-Wrush score), pain ratings (measured by the Visual Analogue Scale [VAS]), and cost analyses were evaluated for each group. Statistical analyses using SPSS were conducted to compare the outcomes between the two groups.

RESULTS

The research found significant variations in clinical outcomes, complications, and cost consequences between Group A and Group B. Group A had fewer hospitalisation periods (23.687.74) than Group B (33.5619.47). Re-operation rates were also considerably lower in Group A (26.3%) than in Group B (48%), owing to a greater prevalence of pin-tract infections and subsequent pin loosening in the combination frame external fixator group. The estimated cost of both techniques was recorded and analysed with the locking average of 26,619.69 ± 9,602.352 and the combined frame average of 39,095.64 ± 20,070.077.

CONCLUSION

This study suggests that although the two approaches effectively manage open distal tibia fractures, the locking compression plate approach (Group A) has an advantage in treating open distal tibia fractures. Shorter hospitalisation times, reduced re-operation rates, and fewer complications will benefit patients, healthcare systems, and budget allocation. Group A's functional recovery results demonstrate the locking plate technique's ability to improve recovery and patient quality of life. According to the cost analysis, the locking plate technique's economic viability and cost-effectiveness may optimise healthcare resources for open distal tibia fractures. These findings might improve patient outcomes and inform evidence-based orthopaedic surgery.

Finite element analysis comparison of Type 42A2 fracture fixed with external titanium alloy locking plate and traditional external fixation frame

BACKGROUND

At present, not all Type AO/OTA 42A2 open fractures can be treated by external fixation brackets, not to mention the inconvenience of this technique in clinical practice. External titanium alloy locking plates, which are lightweight and easy-to-operate, can be used as an alternative treatment option for such patients. However, there are few reports of finite element biomechanical analysis on the titanium alloy locking plates and fixation brackets being placed on the medial side of the tibial fracture. In this study, the biomechanical properties of titanium alloy locking plates and fixation brackets for treating Type AO/OTA 42A2 fractures were compared by applying the finite element method, and the results provided data support for the clinical application of the external titanium alloy locking plate technique.

METHODS

Type AO/OTA 42A2 fracture models were constructed using CT data of a male volunteer for two external fixation techniques, namely the external titanium alloy locking plate technique and the external fixation bracket technique, according to commonly-used clinical protocols. Then, the four-point bending, axial compression, clockwise rotation and counterclockwise rotation tests under the maximum load were simulated in finite element analysis software. The stress distribution, peak stress and overall tibial displacement data for the two different external fixation techniques were obtained and compared.

RESULTS

In the four different test conditions (i.e., four-point bending, axial compression, clockwise torsion, counterclockwise torsion) under the maximum load, the two external fixation techniques showed obvious von Mises stress concentration at the contacts between the screw and tibia, between the screw and titanium alloy locking plate, between the self-tapping self-drilling needle and tibia, between the self-tapping self-drilling needle and the external fixation device, as well as around the fracture end and around the cortical bone at the upper and lower ends of the tibia. The peak stress was ranged 26.67-558.77 MPa, all below the yield stress strength of titanium alloy. The peak tibial displacement of the external titanium alloy locking plate model was smaller than that of the fixation bracket model. In terms of structural stability, the external titanium alloy locking plate technique was superior to the external fixation bracket technique.

CONCLUSIONS

When fixing Type AO/OTA 42A2 fractures, external titanium alloy locking plates are not only lightweight and easy-to-operate, but also have better performance in terms of axial compression, bending and torsion resistance. According to the finite element biomechanical analysis, external titanium alloy locking plates are superior to traditional external fixation brackets in treating Type AO/OTA 42A2 fractures and can better meet the needs of clinical application.

Single-Stage Externalized Locked Plating for Treatment of Unstable Meta-Diaphyseal Tibial Fractures

(1) Background: Unstable meta-diaphyseal tibial fractures represent a heterogeneous group of injuries. Recently, good clinical results have been reported when applying a technique of externalized locked plating in appropriate cases, highlighting its advantage in terms of less additional tissue injury compared with conventional methods of fracture fixation. The aims of this prospective clinical cohort study were, firstly, to investigate the biomechanical and clinical feasibility and, secondly, to evaluate the clinical and functional outcomes of single-stage externalized locked plating for treatment of unstable, proximal (intra- and extra-articular) and distal (extra-articular), meta-diaphyseal tibial fractures. (2) Methods: Patients, who matched the inclusion criteria of sustaining a high-energy unstable meta-diaphyseal tibial fracture, were identified prospectively for single-stage externalized locked plating at a single trauma hospital in the period from April 2013 to December 2022. (3) Results: Eighteen patients were included in the study. Average follow-up was 21.4 ± 12.3 months, with 94% of the fractures healing without complications. The healing time was 21.1 ± 4.6 weeks, being significantly shorter for patients with proximal extra- versus intra-articular meta-diaphyseal tibial fractures, p = 0.04. Good and excellent functional outcomes in terms of HSS and AOFAS scores, and knee and ankle joints range of motion were observed among all patients, with no registered implant breakage, deep infection, and non-union. (4) Conclusions: Single-stage externalized locked plating of unstable meta-diaphyseal tibial fractures provides adequate stability of fixation with promising clinical results and represents an attractive alternative to the conventional methods of external fixation when inclusion criteria and rehabilitation protocol are strictly followed. Further experimental studies and randomized multicentric clinical trials with larger series of patients are necessary to pave the way of its use in clinical practice.

Biomechanical study of the stiffness of the femoral locking compression plate of an external fixator for lower tibial fractures

BACKGROUND

A locking compression plate (LCP) of the distal femur is used as an external fixator for lower tibial fractures. However, in clinical practice, the technique lacks a standardized approach and a strong biomechanical basis for its stability.

METHODS

In this paper, internal tibial LCP fixator (Group IT-44), external tibial LCP fixator (Group ET-44), external distal femoral LCP fixator (Group EF-44, group EF-33, group EF-22), and conventional external fixator (Group CEF-22) frames were used to fix unstable fracture models of the lower tibial segment, and anatomical studies were performed to standardize the operation as well as to assess the biomechanical stability and adjustability of the distal femoral LCP external fixator by biomechanical experiments.

RESULTS

It was found that the torsional and flexural stiffnesses of group EF-44 and group EF-33 were higher than those of group IT-44 and group ET-44 (p < 0.05); the flexural stiffness of group EF-22 was similar to that of group IT-44 (p > 0.05); and the compressive stiffness of all three EF groups was higher than that of group ET-44 (p < 0.05). In addition, the flexural and compressive stiffnesses of the three EF groups decreased with the decrease in the number of screws (p < 0.05), while the torsional stiffness of the three groups did not differ significantly between the two adjacent groups (p > 0.05). Group CEF-22 showed the highest stiffnesses, while group ET-44 had the lowest stiffnesses (P < 0.05).

CONCLUSIONS

The study shows that the distal femoral LCP has good biomechanical stability and adjustability and is superior to the tibial LCP as an external fixator for distal tibial fractures, as long as the technique is used in a standardized manner according to the anatomical studies in this article.

Low profile external fixation using locking compression plate as treatment option for management of soft tissue problem in open tibia fracture grade IIIA: A case series

INTRODUCTION

External fixators are the most common fixation method for fractures with substantial soft tissue compromise. Nonetheless, the frames used are bulky, uncomfortable, and cumbersome to patients. Using locking compression plate (LCP) as an external fixator (low profile external fixation/LPEF) owns the same properties as standard external fixators but may overcome disadvantages because of its low-profile frame. This case series aims to evaluate the results of LPEF for the management of tibia fracture with soft tissue compromise.

PRESENTATION OF CASES

We reviewed five patients at our centers who underwent surgery in 2020 with the application of LPEF. These patients had grade IIIA open tibia fracture with respective complications. The follow-up duration was 6 months post-operative in which we assessed Southampton Wound Assessment Scale (SWAS), laboratory infection markers, radiographic evaluation, and the Lower Extremity Functional Scale (LEFS). The results showed all wounds healed and cases with infection showed tendency of resolving, alongside varying degree of bone healing. The implant was well tolerated for patients and the functional outcome was overall good (mean LEFS: 71.26%).

DISCUSSION

The LPEF is fortuitously lightweight and more convenient for patients to ambulate, thus the compliance of early functional exercise is more likely to happen.

CONCLUSION

Application of LPEF can be considered as an option for treating soft tissue compromised tibia fracture. In our experience, it is low profile, more acceptable to the patients, and displayed favorable outcomes especially in terms of soft tissue or skin healing and infection resolution.

Comparison between external locking plate fixation and conventional external fixation for extraarticular proximal tibial fractures: a finite element analysis

Background

Good clinical outcomes for locking plates as an external fixator to treat tibial fractures have been reported. However, external locking plate fixation is still generally rarely performed. This study aimed to compare the stability of an external locking plate fixator with that of a conventional external fixator for extraarticular proximal tibial fractures using finite element analysis.

Methods

Three models were constructed: (1) external locking plate fixation of proximal tibial fracture with lateral proximal tibial locking plate and 5-mm screws (ELP), (2) conventional external fixation of proximal tibial fracture with an 11-mm rod and 5-mm Schanz screws (EF-11), and (3) conventional external fixation of a proximal tibial fracture with a 7-mm rod and 5-mm Schanz screws (EF-7). The stress distribution, displacement at the fracture gap, and stiffness of the three finite element models at 30-, 40-, 50-, and 60-mm plate–rod offsets from the lateral surface of the lateral condyle of the tibia were determined.

Results

The conventional external fixator showed higher stiffness than the external locking plate fixator. In all models, the stiffness decreased as the distance of the plate–rod from the bone surface increased. The maximum stiffness was 121.06 N/mm in the EF-11 model with 30-mm tibia–rod offset. In the EF-7 model group, the maximum stiffness was 40.00 N/mm in the model with 30-mm tibia–rod offset. In the ELP model group, the maximum stiffness was 35.79 N/mm in the model with 30-mm tibia–plate offset.

Conclusions

Finite element analysis indicated that external locking plate fixation is more flexible than conventional external fixation and can influence secondary bone healing. External locking plate fixation requires the placement of the plate as close as possible to the skin, which allows for a low-profile design because the increased distance from the plate to the bone can be too flexible for bone healing. Further experimental mechanical model tests are necessary to validate these finite element models, and further biological analysis is necessary to evaluate the effect of external locking plate fixation on fracture healing.

Supercutaneous locking compression plate in the treatment of infected non-union and open fracture of the leg

INTRODUCTION

Salvage of infected tibia and fibula non-union and severe open fractures is challenging and often requires staged treatment. We describe all cases that underwent supercutaneous plating of the leg as external fixation technique and assessed union rate, time to union, rate of infection clearance, and patient-reported outcome measures.

METHODS

This is a retrospective cohort study from a single level 1 trauma center. We included 19 patients that underwent supercutaneous plating-locking compression plate applied as external fixator-of the leg. Indications were: infected non-union of a pilon, cruris, or ankle fracture (n = 13); post-traumatic fistula draining osteomyelitis of the tibia (n = 3); infected mal-reduced subacute cruris fracture (n = 1); acute open pilon fracture (n = 1); and acute open cruris fracture (n = 1). Outcome measures were: union, time to union, infection clearance, the 36-item Short Form (SF-36) physical component summary scale (PCS) and mental component summary scale (MCS), and NRS pain scores.

RESULTS

Union was achieved in 88% of the patients after a median of 279 days [interquartile range (IQR) 154-440]. Infection clearance was achieved in 94% of the patients. The PCS (median 51, IQR 46-56, p = 0.903) and MCS (median 57, IQR 50-60, p = 0.241) do not differ from normative population values. NRS Pain score at rest was 0 on average (IQR 0-1), 2 on average when walking (IQR 0-4), and 1 on average when climbing stairs (IQR 0-2).

CONCLUSION

Supercutaneous plating is a simple and reliable technical trick to bridge and stabilize a nonunion or fracture site while clearing an infection and have soft-tissues heal before subsequent definitive (internal)fixation and/or cancellous bone grafting. Reasonable union and infection clearance rates are achieved, and good functional outcome can generally be expected.

LEVEL OF EVIDENCE

Therapeutic level III.

Locking Compression Plate as an External Fixator for the Treatment of Tibia Infected Bone Defects

PURPOSE

This study was designed to observe the medium-term efficacy of an induced membrane technique combined with a locking compression plate as an external fixator for the treatment of tibia infected bone defects.

METHODS

Patients with a tibial infection were admitted to our department between January 2013 and November 2014. All patients were treated with the induced membrane technique. In the first stage, polymethyl methacrylate (PMMA) cement was implanted in the defects after debridement and then fixed with a locking compression plate (LCP) as an external fixator. In the second stage, bone grafts were implanted to rebuild the defects. The external plates were replaced with nails in 57 patients (internal group), and the remaining 30 patients were not exchanged with fixation (external group). The infection control rate, bone union rate, and complications of the two groups were compared.

RESULTS

Eighty-seven patients were enrolled in this study, and all patients had a minimum follow-up of 5 years (average 62.8 months) after grafting. Eighty-three patients (95.4%) achieved bone union, and the average union time was 6.77 months. Five patients (5.7%) experienced recurrence of infection. Complications included pin tract infection, fixation loosening, deformity connection, and limitation of joint range of motion (ROM). No significant differences in the infection control rate or bone defect union rate were noted between the two groups. The overall rate of complications in the external group was 50%, which was greater than that noted in the internal group (21.1%).

CONCLUSIONS

Locking compression plates are external fixators with smaller sizes that are easier to operate than conventional annular fixators or assembled external fixators. The use of locking compression plates in combination with the induced membrane technique in the treatment of tibia infected bone defects can achieve good clinical efficacy after medium-term follow-up.

Recalcitrant Septic Nonunion of the Ulna

An infected diaphyseal forearm nonunion can be a challenge. After several failed salvage procedures, the patient can be left with residual pain, shortening, bone loss, and poor soft tissue envelope. Keystones for infected nonunion treatment are debridement, cultures, antibiotics, stability, and restore alignment. This report describes the current literature on the treatment of forearm nonunion, and we present a case of a recalcitrant infected ulna nonunion that ultimately healed after 12 surgeries.

Investigating the biomechanical function of the plate-type external fixator in the treatment of tibial fractures: a biomechanical study

Background

The design of an external fixator with the optimal biomechanical function and the lowest profile has been highly pursued, as fracture healing is dependent on the stability and durability of fixation, and a low profile is more desired by patients. The plate-type external fixator, a novel prototype of an external tibial fixation device, is a low profile construct. However, its biomechanical properties remain unclear. The objective of this study was to investigate the stiffness and strength of the plate-type external fixator and the unilateral external fixator. We hypothesized that the plate-type external fixator could provide higher stiffness while retaining sufficient strength.

Methods

Fifty-four cadaver tibias underwent a standardized midshaft osteotomy to create a fracture gap model to simulate a comminuted diaphyseal fracture. All specimens were randomly divided into three groups of eighteen specimens each and stabilized with either a unilateral external fixator or two configurations of the plate-type external fixator. Six specimens of each configuration were tested to determine fixation stiffness in axial compression, four-point bending, and torsion, respectively. Afterwards, dynamic loading until failure was performed in each loading mode to determine the construct strength and failure mode.

Results

The plate-type external fixator provided higher stiffness and strength than the traditional unilateral external fixator. The highest biomechanics were observed for the classical plate-type external fixator, closely followed by the extended plate-type external fixator.

Conclusions

The plate-type external fixator is stiffer and stronger than the traditional unilateral external fixator under axial compression, four-point bending and torsion loading conditions.

External fixation of the lower extremities: Biomechanical perspective and recent innovations

The concept of supporting fractured long bones externally with mechanical fixation has been evidentially applied for over 2000 years, and since been expanded on in the mid-19th century by percutaneous bone fixation. Surgical techniques, external fixator systems, and materials have made continued progress since. The benefits of traditional external fixation have been enhanced in recent years with the introduction of hexapod-style fixators, innovative configurations, and pin modifications, among other things. It is generally agreed upon that biomechanical testing of advancements in external fixation must be inclusive of transverse or torsional loading to simulate construct behaviour in realistic scenarios. Biomechanical studies indicate that hexapod-style fixators show comparable axial stiffness to Ilizarov-style systems and improved performance under torsional and transverse forces. The addition of configuration elements to fixators, inclusion of certain carbon fibre chemical compositions, and techniques intended to augment ring thickness have also been investigated, in hopes of increasing construct stiffness under loading. Novel external fixators attempt to broaden their applications by rethinking bone mounting mechanisms and either expanding on or simplifying the implementation of 3D bone segment transport for corrective osteotomy. Older and seemingly unconventional fixation techniques are being rediscovered and evolved further in order to increase patient comfort by improving everyday usability. The development of new pin coatings can potentially enhance the pin-bone interface while lowering infection rates typically expected at thicker soft tissue envelopes. Although complication, malunion, and nonunion rates have decreased over the past 50 years, the clinical results of external fixation today can still be optimized. Unsatisfactory healing in the lower extremities has especially been reported at locations such as the distal tibia; however, advancements such as osteoinductive growth hormone treatment may provide improved results. With the current progression of technology and digitization, it is only a matter of time before 'smart', partly-autonomous external fixation systems enter the market. This review article will provide a versatile overview of biomechanically proven fixator configurations and some carefully selected innovative systems and techniques that have emerged or been established in the past two decades.

Lateral Subcutaneous Locking Compression Plate and Small Incision Reduction for Distal-third Diaphyseal Humerus Fractures

Objective

Iatrogenic radial nerve injury is a great challenge for orthopaedic surgeons who deal with distal‐third diaphyseal humerus fractures. Conventional open reduction and internal fixation (ORIF) remains the gold standard, but complications such as nonunion and iatrogenic radial nerve injury still occur. We fixed the fractures with a lateral locking compression plate (LCP) subcutaneously after small incision reduction to protect the radial nerve. This study reports the clinical and radiographic outcomes of our modified method.

Methods

Thirty‐eight patients with distal‐third diaphyseal humerus fractures were treated with lateral subcutaneous LCP and small incision reduction at our department between September 2013 and August 2016. There were 33 males and 5 females, with an average age of 30.3 years (range, 17 to 49 years). All the cases were types A or B (AO/OTA classification, type A, 24 cases; type B, 14 cases). Among them, 6 cases were combined with preoperative radial nerve palsy. All patients were diagnosed with closed humeral fractures after X‐ray examination, and had typical upper limb pain, swelling, and movement disorders. The operations were performed by a single surgeons’ team. Union time, range of motion (ROM), University of California, Los Angeles (UCLA) shoulder rating scale, and Mayo Elbow Performance Index (MEPI) scores were assessed to evaluate the postoperative results.

Results

All patients were followed up for an average of 11.4 months (range, 3 to 36 months). The average operation time was 75.5 min (range, 60 to 150 min) and average intraoperative radiation exposure was 10.5 s (range, 8 to 18 s). Bony union was achieved in all cases after an average of 16.2 weeks (range, 12 to 25 weeks). No complications such as infection or screw and plate fracture occurred, and no iatrogenic radial nerve injury was observed. According to the UCLA shoulder rating scale, the average score was 33.7 (range, 31 to 35), with 33 excellent (86.8%) and 5 good cases (13.2%). They were all excellent according to their MEPI scores (ranging, 94 to 100, with an average of 97.4). The average operation time for secondary removal of the plate was 15.2 min (range, 10 to 20 min), and no complications such as infection or secondary radial nerve injury occurred.

Conclusions

Lateral subcutaneous LCP and small incision reduction may reduce the risk of iatrogenic radial nerve injury significantly in the treatment of distal‐third diaphyseal humerus fractures. It also leads to solid fixation, good postoperative function, and convenient removal of the plate without injuring the radial nerve.

[Treatment of femur re-fracture with occult infection by using non-contact locking plate under deep fascia]

Objective

To investigate the effectiveness on the re-fracture of the femur with occult infection by using non-contact locking plate which was placed under the deep fascia.

Methods

Clinical data of 12 cases of occult infective re-fracture after femoral fracture operation were retrospectively analysed between January 2010 and December 2014. There were 8 males and 4 females with an age of 28-69 years (mean, 42.8 years). Femur re-fractured in 5 cases after 3 days to 4 weeks (mean, 10.6 days) of removal of internal fixation, including 4 cases of plate fixation and 1 case of intramedullary nail fixation; femur in 7 cases re-fractured because of breakage of internal fixator after 7-16 months (mean, 9.3 months) of internal fixation, including 5 cases of plate fixation and 2 cases of intramedullary nail fixation. The tissues near the fracture were collected for bacteria culturing and pathological examining. All the patients were treated by debriding the site of the fracture, bridging with the non-contact locking plate, and transplanting with granulated cancellous bone autograft. Intravenous infusion of antibiotics were used for 2-3 weeks after operation and oral administration for 4 weeks. The X-ray films were taken regularly and the function of the knees were evaluated by the Hospital for Special Surgery (HSS) score system.

Results

The results of bacteria culturing were positive in 8 patients and negative in 4 patients, and the pathological results of all the patients were confirmed to be chronic bone infection. All the fractures healed with no signs of exudation and ulceration of the incisions. The 12 patients were followed up 18-36 months (mean, 29.6 months). The fracture healed well and no re-fracture occurred. The fracture healing time was 14-22 weeks (mean, 18 weeks). At last follow-up, the function of the knee joint was excellent in 9 cases and good in 3 cases according to HSS score system.

Conclusion

The treatment of re-fractures after femur fracture operation needs to determine whether there is an occult infection, and non-contact locking plate placed under the deep fascia is an effective way for the re-fracture.

Management of pediatric open tibia fractures with supracutaneous locked plates

We evaluated the novel application of supracutaneous locked plates in pediatric open tibia fractures. Pediatric open tibia fractures stabilized with a locked supracutaneous plate from January 2011 to December 2014 were reviewed. Twenty-eight children, mean age 8.9 years, with 29 open tibia fractures were included. Nine of these children who had metaphyseal or metadiaphyseal fractures did not require joint spanning. The mean follow-up duration was 13.5 months. The mean time to uneventful union was 11.46 weeks, with no unacceptable malunion. Supracutaneous locked plates showed early union and no refractures. They could favorably replace tubular external fixators in stabilizing pediatric open tibia fractures.

Masquelet technique with external locking plate for recalcitrant distal tibial nonunion

OBJECTIVE

In the present retrospective study, we aimed to analyze the results of treatment for recalcitrant distal tibial nonunion using Masquelet technique with locking plate as a definitive external fixator.

MATERIALS

We included 15 consecutive cases of distal tibial nonunion treated at our hospital between January 2012 and December 2015. The reconstructive procedure comprised debridement of the nonunion site, deformity correction, stabilization with an external locked plate, defect filling with cement spacer for inducing membrane formation, and bone reconstruction using a cancellous bone autograft (Masquelet technique). All patients were followed-up for at least one year.

RESULTS

Fracture union occurred in all cases after a median of 6.5 months (range, 5-12 months). Mean ankle motion ranged from 12.3 (range, 5-20) degrees of dorsiflexion to 35 (range, 5-55) degrees of plantar flexion. At the final follow-up, the median Iowa ankle score was 83 (range, 68-91). Eight patients had excellent scores, six had good scores, and one had fail score.

CONCLUSION

Although the current study involved only a small number of patients and the intervention comprised two stages, we consider that the used protocol is a simple and valuable alternative for the treatment of recalcitrant distal tibial nonunion.

Locked plating as an external fixator in treating tibial fractures: A PRISMA-compliant systematic review

OBJECTIVES

This article is a systematic review of the published literature about the biomechanics, functional outcomes, and complications of a locked plate as an external fixator in treating tibial fractures.

METHODS

We searched the PubMed, Ovid Medline, Embase, ScienceDirect, and Cochrane Library databases to retrieve the relevant studies. Studies published in English and Chinese which assessed adult patients and more than 4 cases who had sustained any type of fresh tibial fracture treated with the external locking plate, provided that they reported functional outcomes, range of motion (ROM), union or complication rates, and the biomechanical studies of external locked plating are also included.

RESULTS

The electronic search strategy revealed 248 studies, and 2 studies were identified as relevant through manual search of references. Finally, 12 studies were included in this systematic review. These consist of 3 pure biomechanical studies, 8 case series, and 1 study including both of biomechanics and case series. Due to the heterogeneity of biomechanical studies, we can only conclude that external locked plate shows inferior structural stiffness than internal locked plate. The clinical studies reported that external locked plating gave a satisfactory ROM of the knee and ankle, functional outcomes, union rate, and low complication rate.

CONCLUSIONS

We can only conclude that external locked plate shows inferior structural stiffness than internal locked plate because of the heterogeneity of biomechanical studies. The clinical studies showed locked plating as an external fixator in treating tibial fractures can be considered as a safe and successful procedure. However, as yet, there is unconvincing evidence that it is superior to standard techniques with regards to clinical and functional outcomes. More and well-designed studies about this technique should be carried out.

Induced membrane technique combined with two-stage internal fixation for the treatment of tibial osteomyelitis defects

INTRODUCTION

The purpose of this study was to observe the effects of induced membrane technique combined with two-stage internal fixation in the treatment of tibial osteomyelitis defects.

METHODS

A retrospective analyses for 67 cases of tibialosteomyelitis defects were admitted to our department between September 2012 to February 2015, which were treated with induced membrane technique. At the first stage, implanted with a PMMA cement spacer in the defects after radical debridement and fixed with reconstructive locked plate. Bone grafting and exchanged the plate with intramedullary nail at the second stage.

RESULTS

In current study, all patients were followed up for 18-35 months. Sixty-six patients achieved bone union with the average radiographic and clinical healing times of 5.55±2.19 and 7.45±1.69months, respectively. Seven patients required a second debridement before grafting, while four patients experienced a recurrence of infection or a relapse following second stage treatment. Twelve patients experienced either knee or ankle dysfunctions and 2 patients faced delayed wound healing. Donor site complications includes pain and infection were found in 7 and 3 patients, respectively with delayed stress fracture in 1 patient only.

CONCLUSIONS

Induced membrane technique for the treatment of tibial osteomyelitis defects, seems a reliable method. The use of reconstructive locked plate as a temporary internal fixation at the first stage and exchanged with intramedullary nail at the second stage, potentially achieves good clinical efficacy. Care should be taken to restore the joint function especially in distal tibia.

Supracutaneous plating using a locking plate for the treatment of a tibial fracture in a cat

Radiographs revealed a slightly displaced long oblique diaphyseal tibial fracture with bone fissures running distally in a 2-year-old, 4.5 kg cat that had been hit by a car. An angle stable implant was applied in a supracutaneous fashion. The patient tolerated the external implant and had a satisfactory functional recovery. Radiographic follow-up after 60 days revealed sign of osseous union; therefore, the plate was removed.

Externalised locking compression plate as an alternative to the unilateral external fixator: a biomechanical comparative study of axial and torsional stiffness

Objectives

External fixators are the traditional fixation method of choice for contaminated open fractures. However, patient acceptance is low due to the high profile and therefore physical burden of the constructs. An externalised locking compression plate is a low profile alternative. However, the biomechanical differences have not been assessed. The objective of this study was to evaluate the axial and torsional stiffness of the externalised titanium locking compression plate (ET-LCP), the externalised stainless steel locking compression plate (ESS-LCP) and the unilateral external fixator (UEF).

Methods

A fracture gap model was created to simulate comminuted mid-shaft tibia fractures using synthetic composite bones. Fifteen constructs were stabilised with ET-LCP, ESS-LCP or UEF (five constructs each). The constructs were loaded under both axial and torsional directions to determine construct stiffness.

Results

The mean axial stiffness was very similar for UEF (528 N/mm) and ESS-LCP (525 N/mm), while it was slightly lower for ET-LCP (469 N/mm). One-way analysis of variance (ANOVA) testing in all three groups demonstrated no significant difference (F(2,12) = 2.057, p = 0.171).

There was a significant difference in mean torsional stiffness between the UEF (0.512 Nm/degree), the ESS-LCP (0.686 Nm/degree) and the ET-LCP (0.639 Nm/degree), as determined by one-way ANOVA (F(2,12) = 6.204, p = 0.014). A Tukey post hoc test revealed that the torsional stiffness of the ESS-LCP was statistically higher than that of the UEF by 0.174 Nm/degree (p = 0.013). No catastrophic failures were observed.

Conclusion

Using the LCP as an external fixator may provide a viable and attractive alternative to the traditional UEF as its lower profile makes it more acceptable to patients, while not compromising on axial and torsional stiffness.

Cite this article: B. F. H. Ang, J. Y. Chen, A. K. S. Yew, S. K. Chua, S. M. Chou, S. L. Chia, J. S. B. Koh, T. S. Howe. Externalised locking compression plate as an alternative to the unilateral external fixator: a biomechanical comparative study of axial and torsional stiffness. Bone Joint Res 2017;6:216–223. DOI: 10.1302/2046-3758.64.2000470.

The outcome of super-cutaneous locked plate fixation with percutaneous reduction of displaced intra-articular calcaneal fractures

INTRODUCTION

Supercutaneous (external) fixation with locking plate is utilized for fixation of long bone fractures. One retrospective study for open reduction and supercutaneous fixation of the calcaneus is reported. We prospectively evaluated the use of this method of fixation combined with percutaneous reduction.

MATERIALS AND METHODS

Between January 2014 and June 2015, 32 displaced calcaneus fractures in 30 patients were stabilized with percutaneous reduction and super-cutaneous fixation. They were 24 males and six females. The mean age was 37.9±5.7 years (21-55). All cases were closed. The time to surgery, complications, radiographic alignment, and time to radiographic union were recorded. Clinical results at the final follow-up were assessed by evaluating Bohler's angles for the radiographic alignment, and the system of the American Orthopedic Foot and Ankle Society (AOFAS) for the functional outcome.

RESULTS

According to the Sanders' classification, two cases were type II, 17 cases were type III and 13 cases were type IV. The preoperative average Bohler's angle was 10.57°±4.8. The postoperative X-ray films demonstrated that the average Bohler's angle improved to 29.07°±5.9 (p<0.001). At the time of radiologic healing (about 3 months), the plates and screws were removed under general anesthesia. The average follow-up was 13.2 months (11-18). Four cases (type IV) showed mal-union and heel pain. According to (AOFAS) rating, the fine score was 87.1±17.1 points.

CONCLUSION

Super-cutaneous fixation with percutaneous reduction of calcaneal fracture is an effective method in type II and III and can be effective with type IV but with less favorable results.

Stiffness of the locking compression plate as an external fixator for treating distal tibial fractures: a biomechanics study

BACKGROUND

Locking compress plate, as external fixator, is an attractive technique for distal tibial fracture treatment. But it still remains unclear whether the external LCP has sufficient stiffness. Thus, the present study aims to make a comprehensive evaluation of the stiffness of external locking compress plate when it is used as an external fixator in distal tibial fractures treatment.

METHODS

Composite tibia was used to simulate distal tibia fracture (Orthopedic Trauma Association type 43 A3 fracture). The fractures were stabilized with medial distal tibial locking compress plates (LCP group), medial distal tibial locking compress plates with 30-mm plate-bone distances (EF-tibia group), and medial distal femur locking compress plates with 30-mm plate-bone distances (EF-femur group). Stiffness of each configuration was measured under axial compression loading and in axial torsion loading directions. Compression stiffness and torsional rigidity were compared across different groups.

RESULTS

Compared with LCP group, (1) EF-tibia group showed significantly lower (p < 0.001) compression stiffness and torsional rigidity; (2) EF-femur group showed significantly lower (p < 0.001) compression stiffness, but significantly higher (p < 0.001) torsional rigidity.

CONCLUSIONS

The results indicated that locking compress plate as an external fixator was flexible, and the distal femur locking compress plate was preferred over the distal tibial locking compress plate to be an external fixator in distal tibia fracture treatment.

A locking compression plate as an external fixator for treating infected nonunion of the humeral diaphysis

Background

Infected nonunion of the humeral diaphysis is a challenging problem for orthopedic surgeons. This study aimed to evaluate the outcome of using a locking compression plate (LCP) as a definitive external fixator in the management of infected nonunion of the humeral diaphysis after failure of internal fixation.

Methods

We retrospectively reviewed a series of seven patients with infected nonunion of the humeral diaphysis treated with an LCP as an external fixator between June 2010 and August 2014. There were five males and two females, with an average age of 40.9 years. Six out of seven patients had been definitively diagnosed with infection due to known bacteria by germiculture. The clinical and radiographic outcomes were retrospectively evaluated.

Results

All patients were followed-up for a mean period of 26.3 months (range 12–48 months). All fractures obtained complete bone union, and the average time to bone union was 7.9 months (range 3.5–15 months). All infections were eventually resolved without any recurrence of deep infection. Pin tract infection was only seen in one case. Only one patient had transient radial nerve palsy after surgery for traction. The average shortening length of the affected upper limb was 3 cm (range 2–4 cm) compared with the contralateral limb. At the last follow-up, the average Disabilities of the Arm, Shoulder and Hand score of the involved limbs was 3.2 (range 0–13.4). All patients obtained excellent or good functional results, and returned to their original work.

Conclusions

The novel use of an LCP as a definitive external fixator was an effective method for treating infected nonunion of the humeral diaphysis. However, a large-scale prospective clinical study is still needed to verify these findings.

Distal tibial fracture: An ideal indication for external fixation using locking plate

OBJECTIVE

To evaluate the feasibility and efficiency of one-stage external fixation by using locking plate in distal tibial fractures.

METHODS

In this non-control prospective study, 28 patients with distal tibial fractures were included and underwent one-stage external fixation by using locking plate. There were 21 males and 7 females, with a mean age of 43 years (19-63). According to AO/OTA fracture classification, there were 9 cases of Type A1, 9 of Type A2, 10 of Type A3 fractures. There were 21 close and 7 open fractures. The locking plate was placed on the anteromedial aspect of the tibia with 4-5 bicortical screws inserted in both distal met- aphysis and diaphysis. The radiographic and clinic results were evaluated.

RESULTS

All patients were followed up for the average of 16 months (ranging from 12 to 21 months). The average surgery duration was 38 (25-60) minutes. The mean time to fracture healing were 14.6 ± 2.67, 17.5 ± 3.66, and 18.4 ± 3.37 (p < 0.05) weeks in type A1, A2, and A3 fractures respectively. By the end of the follow-ups, the mean AOFAS score were 96.11 ± 2.32, 92.67 ± 1.80 and 92.00 ± 2.06 (p > 0.05) in type A1, A2, and A3 fractures respectively. None of nonunion, deep infection, or breakage of screw or plate were observed.

CONCLUSIONS

Distal tibial fracture was the ideal indication for external fixation using locking plate. The external plating is characterized by ease of performance, less invasive, fewer soft tissue impingement, improved cosmesis, and convenient for removal.

Induced membrane technique for the treatment of bone defects due to post-traumatic osteomyelitis

Objectives

Induced membrane technique is a relatively new technique in the reconstruction of large bone defects. It involves the implantation of polymethylmethacrylate (PMMA) cement in the bone defects to induce the formation of membranes after radical debridement and reconstruction of bone defects using an autologous cancellous bone graft in a span of four to eight weeks. The purpose of this study was to explore the clinical outcomes of the induced membrane technique for the treatment of post-traumatic osteomyelitis in 32 patients.

Methods

A total of 32 cases of post-traumatic osteomyelitis were admitted to our department between August 2011 and October 2012. This retrospective study included 22 men and ten women, with a mean age of 40 years (19 to 70). Within this group there were 20 tibias and 12 femurs with a mean defect of 5 cm (1.5 to 12.5). Antibiotic-loaded PMMA cement was inserted into the defects after radical debridement. After approximately eight weeks, the defects were implanted with bone graft.

Results

The patients were followed for 27.5 months (24 to 32). Radiographic bone union occurred at six months for 26 cases (81%) and clinical healing occurred in 29 cases (90%) at ten months. A total of six cases had a second debridement before bone grafting because of recurrence of infection and one patient required a third debridement. No cases of osteomyelitis had recurred at the time of the last follow-up visit.

Conclusion

The induced membrane technique for the treatment of post-traumatic osteomyelitis is a simple, reliable method, with good early results. However, there are many challenges in determining the scope of the debridement, type of limb fixation and source of bone graft to be used.

Cite this article: Dr Z. Xie. Induced membrane technique for the treatment of bone defects due to post-traumatic osteomyelitis. Bone Joint Res 2016;5:101–105. DOI: 10.1302/2046-3758.53.2000487.

One-Stage External Fixation Using a Locking Plate: Experience in 116 Tibial Fractures

The authors report the results of 1-stage external fixation using a locking plate in 116 tibial fractures (85 closed and 31 open). The patients were followed for an average of 22 months. The mean duration of surgery was 42 minutes. The mean fracture healing time was 12 weeks for proximal, 20 weeks for shaft, 14 weeks for distal, and 24 weeks for multisegmental tibial fractures. Nonunion, deep infection, and breakage of screws did not occur. External plate fixation is effective for tibial fractures and especially for metaphyseal fractures. It has the advantages of being easy to perform and less invasive, and the plate is conveniently located for removal.

Locking compression plate as an external fixator in the treatment of closed distal tibial fractures

BACKGROUND

Tibial fractures often follow high-energy trauma, and although soft tissue can remain intact, poor blood supply can lead to skin necrosis, infections and potential amputation. We used closed reduction and locking compression plates as external fixators for treating closed distal tibial fractures with soft tissue compromise. The method aims to avoid those potential complications.

METHODS

A retrospective series of 23 closed distal tibial fractures were treated using locking compression plates as external fixators. Protecting the blood supply was an essential intra-operative consideration, and postoperative physical therapy and partial weight bearing were encouraged early. Patients were followed at regular intervals and evaluated radiographically and clinically.

RESULTS

The average time to radiological bony union was 29.4 weeks (range, 14-52 weeks). No infections were seen. Fractures in 22 cases (95.65 %) united, and most fractures healed in an acceptable position. All patients had good functional results and were fully weight bearing with a well-healed tibia at the final follow-up.

CONCLUSIONS

Locking compression plates can be used as external fixators and provide a high rate of union, comfortable clinical course and excellent ankle-joint motion. Although indications are limited, this method is a suitable surgical approach for treating closed distal tibial fractures with soft tissue compromise.

External fixation using femoral less invasive stabilization system plate in tibial proximal metaphyseal fracture

BACKGROUND

The locking plates are often used for internal fixation of closed tibial fractures. The use of a locking plate as an external fixator is still controversial, particularly for closed fractures. The purpose of this study is to evaluate the results of external fixation using the femoral less invasive stabilization system (LISS) plate in proximal metaphyseal fractures of the tibia.

METHODS

We prospectively evaluated 35 patients (26 males and 9 females) with a mean age of 42 years (range, 21 to 62 years) who presented with fresh tibial proximal metaphyseal fractures. According to the AO Foundation and Orthopaedic Trauma Association (AO/OTA) classification, the fractures were identified as type 41-A2 in 18 cases and type 41-A3 in 17 cases, including 25 closed fractures and 10 open fractures. The femoral LISS plate was used to fix these fractures, which was placed on the anteromedial aspect of the tibia as an external fixator. The mean follow-up period was 18 months (range, 13 to 22 months).

RESULTS

All fractures healed in a mean time of 14 weeks (range, 10 to 20 weeks). There was no case of nonunion, deep infection, and loosening of screws and plates. One month after the appearance of cortical bridging on biplanar radiographs, the locking plate was removed within 3 minutes in the clinic without any difficulty. According to the Hospital for Special Surgery (HSS) knee scoring system and American Orthopaedic Foot & Ankle Society (AOFAS) ankle scoring system, the mean HSS score was 91 (range, 85 to 100) and 98 (range, 93 to 100), and the mean AOFAS score was 94 (range, 90 to 100) and 98 (range, 95 to 100) at 4 weeks postoperatively and final follow-up, respectively.

CONCLUSIONS

For proximal metaphyseal fracture of the tibia, external fixation using the femoral LISS plate is a safe and reliable technique with minimal complications and excellent outcomes. Its advantages include ease of performing the surgery, use of a less invasive technique, and convenience of plate removal after fracture healing.

Staged treatment of proximal tibial fracture using external locking compression plate

OBJECTIVE

To share our preliminary clinical success and failure with using an external locking compression plate (LCP) for proximal tibial fractures, further refine the indications for this procedure and review relevant published reports.

METHODS

The current study reports two cases of proximal tibial fracture treated with external LCP as the second stage of a two-stage treatment. One patient was a 59-year-old man with a closed proximal tibial/fibular fracture caused by falling on ice while getting out of his car, and another patient was a 42-year-old male smoker with right comminuted proximal tibia, tibial plateau and proximal fibular fractures. The outcomes were evaluated by radiographs and weight bearing status.

RESULTS

In the first case, the fracture healed uneventfully whereas the second case required further open-reduction with internal fixation because correct alignment could not be achieved with an external LCP.

CONCLUSION

Correct alignment of proximal tibial fractures followed by use of an external LCP can achieve favorable outcomes.

Surgical treatment of extra-articular or simple intra-articular distal tibial fractures: MIPO versus supercutaneous plating

Minimally invasive plate osteosynthesis (MIPO) has become a widely accepted technique to treat distal tibial fractures. Recently, the novel application of a locking plate used as an external fixator (supercutaneous plating) was introduced for the management of open fractures and infected nonunions and even as an adjunct in distraction osteogenesis, which is considered another less invasive method. The aim of this study was to compare the results of supercutaneous plating with closed reduction and minimally invasive plating in the treatment of distal tibial fractures. Forty-eight matched patients were divided according to age, sex, Injury Severity Score, and fracture pattern into the MIPO group and the supercutaneous plating group. Minimum follow-up was 12 months (mean, 18.5 months; range, 12-26 months). No patient had nonunion, hardware breakdown, or deep infection. Patients in the supercutaneous plating group had a significantly shorter mean operative time (65.6±13.2 vs 85.9±14.0 minutes; P=.000), hospital stay (7.5±2.0 vs 13.0±4.4 days; P=.000), and union time (15.2±2.4 vs 17.0±2.8 weeks; P=.000). In the MIPO group, 15 (62.5%) patients reported implant impingement or discomfort and there was 1 incidence of stripping of 15.6% at the time of locking screw removal, whereas in the supercutaneous plating group, no patient reported skin irritation, and removal of the supercutaneous plate was easily performed in clinic without anesthesia. Distal tibial fractures may be treated successfully with MIPO or supercutaneous plating. However, the supercutaneous plating technique may represent a superior surgical option because it offers advantages in terms of mean operative time, hospital stay, and union time; skin irritation; and implant removal.

Treatment of segmental tibial fractures with supercutaneous plating

Segmental tibial fractures usually follow a high-energy trauma and are often associated with many complications. The purpose of this report is to describe the authors' results in the treatment of segmental tibial fractures with supercutaneous locking plates used as external fixators. Between January 2009 and March 2012, a total of 20 patients underwent external plating (supercutaneous plating) of the segmental tibial fractures using a less-invasive stabilization system locking plate (Synthes, Paoli, Pennsylvania). Six fractures were closed and 14 were open (6 grade IIIa, 2 grade IIIb, 4 grade II, and 2 grade I, according to the Gustilo classification). When imaging studies confirmed bone union, the plates and screws were removed in the outpatient clinic. Average time of follow-up was 23 months (range, 12-47 months). All fractures achieved union. Median time to union was 19 weeks (range, 12-40 weeks) for the proximal fractures and 22 weeks (range, 12-42 weeks) for the distal fractures. Functional results were excellent in 17 patients and good in 3. Delayed union of the fracture occurred in 2 patients. All patients' radiographs showed normal alignment. No rotational deformities and leg shortening were seen. No incidences of deep infection or implant failures occurred. Minor screw tract infection occurred in 2 patients. A new 1-stage protocol using supercutaneous plating as a definitive fixator for segmental tibial fractures is less invasive, has a lower cost, and has a shorter hospitalization time. Surgeons can achieve good reduction, soft tissue reconstruction, stable fixation, and high union rates using supercutaneous plating. The current patients obtained excellent knee and ankle joint motion and good functional outcomes and had a comfortable clinical course.

Locking plate as a definitive external fixator for treating tibial fractures with compromised soft tissue envelop

INTRODUCTION

Tibial fractures with compromised soft tissue envelop may lead to significant complications. The optimal management of these injuries remains controversial. Recently, locking plate used as a definitive external fixator is attractive because it not only minimizes trauma to the soft tissues, but also overcomes the shortcomings of standard external fixators. The objective of this study was to evaluate the outcome of using locking plate as a definitive external fixator for treating tibial fractures with compromised soft tissue envelop.

PATIENTS AND METHODS

A prospective series of 12 consecutive tibial fractures with compromised soft tissue envelop were treated using locking plate as a definitive external fixator. Of these patients, six were Gustilo and Anderson type IIIA, three were type II and three were closed fractures (AO/ASIF soft tissue injury classification IC4: 2, IC5: 1). Time to union, nonunion, malunion, leg shortening, range of motion and function for the knee and ankle, deep infection, pin tract infections were evaluated.

RESULTS

The mean bone healing time was 37.8 weeks (range 20-56 weeks). Eventually, all of the fractures united. Most of the fractures healed in acceptable positions. There were no cases of deep infection. Pin tract infection was seen in 1 (8.3 %) patient, no loosening or failure of the external fixator was seen. At the most recent follow-up, the mean range of motion at the knee was extension 0° to flexion 135°, and the mean ankle range of motion was dorsi flexion 12° to plantar flexion 32°. All patients had excellent or good functional results and were fully weight bearing with a well-healed tibia at the final follow-up.

CONCLUSION

The locking plate used as a definitive external fixator provided a high rate of union. The patients experienced a comfortable clinical course, excellent knee and ankle joint motion, satisfactory functional results and an acceptable complication rate. However, the stiffness of external locked plating is not clear, therefore, clinical recommendation on its practical use to reduce the risk of implant failure still need to be determined.

Using a reconstruction locking compression plate as external fixator in infected open clavicle fracture

Open clavicle fracture is an uncommon injury mostly caused by severe direct trauma. It is often associated with multiple organ injuries. Generally, surgical intervention with debridement and fracture repair is always indicated in order to prevent infection, non-union, and malalignment. In situations of bony exposure and significant contamination concomitant with severe soft tissue damage, the external fixation is the treatment of choice because of the possibility it offers of providing stable fixation with minimal local tissue damage resulting in excellent union rates and better soft tissue outcome. Nevertheless, traditional external fixation encountered some potential problems as its bulkiness and sharp edges caused discomfort to the patient. In this study, we present an interesting case of a polytraumatized patient with a gunshot injury with complex open clavicle fracture that was successfully treated with external fixation using reconstruction with a locking compression plate as definitive treatment.