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

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.

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.

Optimal Design and Biomechanical Analysis of a Biomimetic Lightweight Design Plate for Distal Tibial Fractures: A Finite Element Analysis

The treatment of fractures of the distal tibia can be problematic due to the insubstantial soft-tissue covering this part of the anatomy. This study investigates a novel strategy for minimally invasive plate osteosynthesis of distal tibia fractures called bionic lightweight design plating. Following the structure of the animal trabecular bone, we utilized topological mathematical methods to redesign the material layout of the internal fixation device to fulfill the desired lightweight design within given boundary conditions. The results showed that this method can maintain the same stability of the construct as the original plate after a reduction in the original volume by 30%, and the differences in strain energy of plates and maximum node displacement of constructs between the constructs [RP construct vs. LP construct] were not statistically significant (p > 0.05). In the safety assessment of the constructs, the peak stress of plates between constructs was found to not be statistically significantly different under a doubled physiological load (p > 0.05). The average stress of the plates’ elements exceeding the allowable stress was analyzed, and no statistically significant differences were found between the two constructs under axial compression stress conditions (p > 0.05). The average stress of the plates’ elements in the redesigned plating construct under torsional stress conditions was 3.08% less than that of the locked plating construct (p < 0.05). Under the double physiological load condition, 89% of the elements of the plate in the redesigned plating construct and 85% of the elements of the plate in the locked plating construct were lower than the maximum safe stress of the plate, which was 410 MPa (secondary allowable stresses). That reminds us the topology optimization offer a possible way to improve the capacity of soft tissue protection while ensuring the safety of the RP construct by reducing the volume of the implants.

An Approach to Intraoperatively Identify the Coronal Plane Deformities of the Distal Tibia When Treating Tibial Fractures with Intramedullary Nail Fixation: a Retrospective Study

Objective

To develop a new approach to intraoperatively identify the presence of coronal plane deformities (both valgus and varus) when treating tibial fractures with closed reduction and intramedullary nail fixation.

Methods

A retrospective analysis was conducted by enrolling 33 consecutive patients with tibial fractures who received closed reduction and intramedullary nail fixation from January 2018 to January 2019 at our trauma center. Out of the 33 patients, 23 were males and 10 were females and the average age was 41 years (ranging 22 to 69 years of age). Standard anteroposterior and lateral preoperative radiographs were routinely performed. After intraoperatively inserting the tibial intramedullary nail through the standard entry point, the parallel relationship between the distal horizontal interlocking screw and the tibiotalar joint surface on the anteroposterior fluoroscopy was used to determine the occurrence of valgus or varus deformities of the distal tibial fragment. Radiographic and clinical outcomes were analyzed using the average interval from injury to surgery, the lateral distal tibial angle (LDTA) of the unaffected and affected sides, complications and the Olerud–Molander ankle score.

Results

All 33 patients were postoperatively followed for 13 to 25 months (mean 18.7 months). The fractures achieved bone union at an average of 4.3 months (ranging from 3 to 6 months). The total complication rate was 60.6% (20 cases), including four cases that showed deep vein thrombosis, one case showing an infection and delayed union and 15 cases showing slight to moderate anterior knee pain. The postoperative LDTA of the unaffected side measured 87.3° to 89.6 ° (average 88.7° ± 0.8°), and the LDTA of the affected side was 87.5° to 90.4° (average 88.9° ± 1.1°). There was no significant difference between the unaffected and affected sides (t = −1.865, P = 0.068). The intraoperative measurement indicated six cases of valgus angulation and three cases of varus angulation deformities, and all deformities were corrected during surgery. According to the Olerud–Molander ankle score, clinical outcomes demonstrated 22 excellent cases, eight good cases, two fair cases, and one poor case 12 months after surgery.

Conclusion

The parallel relationship between the distal horizontal interlocking screw and tibiotalar joint surface on intraoperative anteroposterior films were able to determine the onset of valgus or varus angulations of the distal tibial fragment in the fracture zone after the tibial intramedullary nail was inserted through the standard entry point.

Treatment of open and comminuted mid-distal tibial fractures by bilateral external fixation combined with limited-internal fixation

Open and comminuted mid-distal fractures often result from high-energy trauma, and a concomitant poor blood supply often leads to skin necrosis, infection, and bone union. To circumvent such complications, we used limited-reduction and bilateral-external fixators to treat open and comminuted mid-distal tibial fractures with compromised soft tissue. A retrospective series of 34 patients who had open and comminuted mid-distal tibial fractures and treated by bilateral-external fixators with limited-internal fixation were analyzed. Patients were followed for 10-25 months (mean: 12 months) post-treatment and osseous union was achieved in each case. The average union time was 16.3 weeks. Based on the Johner- Wruhs criteria, the retrospective series consisted of 21 'excellent' cases, 8 'good' cases, 4 'fair' cases, and a 'poor' case. The total percentage of 'excellent' and 'good' cases of fracture recovery was 85.29%. Bilateral-external and limited-internal fixators pro- vided high bone union rate and excellent ankle-joint motion. Hence, it is an appropriate surgical approach for treating open and comminuted mid-distal tibial fractures with compromised soft tissue.

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.

A novel low-profile external skeletal fixator for type IIIB open tibial fractures: A biomechanical and clinical pilot study

BACKGROUND

Although external fixator is standard for managing staged treatment of open tibial fracture, the main disadvantage of this device is too bulky to be tolerated by most patients for longtime use. The purposes of this pilot study were to compare the biomechanical properties of a novel low-profile external fixator (LP-ESF) with a traditional ESF and also to evaluate its performance in patients with Gustilo type IIIb tibial open fractures.

METHODS

A prospective clinical pilot study started from January 2015 to December 2017, and 18 patients with Gustilo type IIIb open tibial fractures underwent the fixation with a novel LP-ESF system. The biomechanical properties of the LP-ESF were compared with the Synthes External Fixation System according to the standard ASTM F1541-02. These patients were divided into two groups according to the size of bony defect. The postoperative clinical outcomes were subsequently collected.

RESULTS

The biomechanical properties of the LP-ESF were comparable with those of Synthes External Fixation System and had an improved the axial/torsional stiffness and ultimate strength. In the clinical study, all patients with LP-ESF had fracture union. The duration of application of LP-ESF was 3.5 to 18 months until fracture union. In 10 of 18 patients, their fractures were immobilized with the LP-ESF until bone union, and no pin tract infection and no chronic osteomyelitis were recorded. The 36-Item Short Form Health Survey life quality and health survey were good to excellent in these patients. Notably, the LP-ESF allowed a patient with severe bone and soft-tissue defects to preserve the leg and joints function.

CONCLUSION

In this study, we found that the novel LP-ESFs had improved clinical outcomes. The long-term LP-ESF application seems to be tolerable in our patients. This novel approach permits better controls in deep infection and faster healing of fractures, and thus may provide a viable alternative treatment for Gustilo type IIIb open tibial fractures.

Expert Tibial Nails for Treating Distal Tibial Fractures With Soft Tissue Damage: A Patient Series

Distal tibial fractures with soft tissue damage are relatively difficult to treat. We assessed the outcomes of patients with these fractures treated with the Expert Tibial Nail^® (DePuy Synthes, Raynham, MA) from March 2012 to December 2014. At 6 months postoperatively, the general health quality of patients was assessed using operative time, interval to return to work, American Orthopaedic Foot and Ankle Society ankle scale score, pain measured using a visual analog scale, and short-form health outcomes 36-item survey physical functioning and mental health dimension scores. Of 11 cases, 7 (63.6%) were open fractures (3 [27.3%] Gustilo-Anderson type II, 3 [27.3%] type IIIA, and 1 [9.1%] type IIIB) and 4 (36.4%) were closed fractures with Tscherne-Oestern type II tissue damage. Their mean age was 52.2 (range 28 to 66) years. The mean operative time was 83 (range 65 to 105) minutes. The mean follow-up period was 16.3 (range 14 to 18) months. The median short-form 36-item survey scores were 79.1 (range 68.9 to 89.0) for the physical function dimension and 77.0 (range 64.3 to 90.0) for the mental health dimension. The mean postoperative ankle score was 88.6 (range 84 to 94). The mean pain score was 1.6 (range 0 to 4) mm. The mean interval to return to work was 14 (range 11 to 17) months. No patient showed evidence of neurovascular damage, malunion, nonunion, or shortening of the tibia. Taken together, we have confirmed that Expert Tibial Nails can effectively treat distal tibial fractures with soft tissue damage.

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.

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.

Comparison of intramedullary nail, plate, and external fixation in the treatment of distal tibia nonunions

PURPOSE

The purpose of this study was to examine time to union of extra-articular distal tibia nonunions based on fracture type and fixation methods: intramedullary nail (IMN), plate osteosynthesis (PO), and external fixation (EF).

METHODS

This retrospective chart review included all patients who presented at a Level I trauma center with AO/OTA 43A & distal third 42A-C fracture nonunions between 2008 and 2014. Fixation methods were recorded and patient course was followed until nonunion had healed clinically.

RESULTS

Thirty-three distal tibia nonunions were included, and 29 reached eventual union (88%). Five AO/OTA fracture types were present. Mean times to union from nonunion diagnosis between original fracture types were compared (p = 0.203). Comminuted fracture types had longer times to union from nonunion diagnosis compared to simple fracture types (78 vs. 46 weeks, p = 0.051) and more revision fixations (1.5 vs. 0.5, p = 0.037). Mean time to union from nonunion diagnosis was shorter when no revision fixation was done compared to revisions (15 vs. 42 weeks, p = 0.102). Times to union from nonunion diagnosis without revision fixation were: IMN (12 weeks), PO (27 weeks), and EF (13 weeks) (p = 0.202). Times to union from definitive revision fixation were: IMN (17 weeks), PO (21 weeks), and EF (66 weeks) (p = 0.009), with EF taking significantly longer than both other methods. 21 patients (64%) underwent revision fixation. Revision fail rates were: IMN (0/6, 0%), PO (2/8, 25%), and EF (15/21, 71%). Time to union was longer in revisions that changed fixation method compared to revisions that used the same method (51 vs. 18 weeks, p = 0.030). Deep infections were also associated with longer union times (81 vs. 47 weeks, p = 0.040).

CONCLUSIONS

In this nonunion population, comminuted fracture types needed more time and revisions to reach union. Time to union was only clinically shorter when revision fixation was not performed, but IMN and PO were both successful fixation options with significantly shorter times to union than EF. Mean time to union increased even more when revision of fixation method was performed vs. exchange revision, as did nonunions with deep infections.

Metaphyseal locking plate as an external fixator for open tibial fracture: Clinical outcomes and biomechanical assessment

OBJECTIVE

This study aimed to evaluate the outcome of using a metaphyseal locking plate as a definitive external fixator for treating open tibial fractures based on biomechanical experiments and analysis of clinical results.

METHODS

A metaphyseal locking plate was used as an external fixator in 54 open tibial fractures in 52 patients. The mean follow-up was 38 months (range, 20-52 months). Moreover, static axial compression and torsional tests were performed to evaluate the strength of the fixation techniques.

RESULTS

The average fracture healing time was 34.5 weeks (range, 12-78 weeks). At 4 weeks postoperatively and at the final follow-up, the average Hospital for Special Surgery knee score was 85 (range, 81-100) and 94 (range, 88-100), respectively, and the American Orthopaedic Foot and Ankle Society score was 88 (range, 80-100) and 96 (range, 90-100), respectively. Based on the static test result, the axial stiffness was significantly different among groups (p=0.002), whereas the torsional stiffness showed no significant difference (p=0.068).

CONCLUSIONS

Clinical outcomes show that the use of locking plate as a definitive external fixator is an alternative choice for tibial fractures after obtaining appropriate fracture reduction. However, external locked plating constructs were not as strong as standard locked plating constructs. Therefore, the use of external locked plating constructs as a definitive treatment warrants further biomechanical study for construct strength improvement.

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.

The treatment options for posterior malleolar fractures in tibial spiral fractures

PURPOSE

The posterior malleolar fracture (PMF) in tibial spiral fractures are a common type of complication that occurs in tibial fractures. However, the indication of fixation for posterior fractures is still under debate and varies between different surgeons'. It is not unusual to find the smaller PMF (<25%), which could be treated conservatively within guidelines, treated with internal fixation in clinic. The aim of this study is to evaluate the clinical outcomes of tibial spiral fractures with PMF and provide proper guidance for the treatment of this special fracture.

METHODS

A total of 284 cases of spiral fractures combined with PMF were collected and analyzed. Demographic data, fragment size (classified by 25% involvement of ankle joint), time to weight-bearing and functional scores post-operatively were recorded. The ankle-hindfoot scale of the American Orthopaedic Foot and Ankle Society (AOFAS), a visual analogue scale (VAS) pain score, assessment of dorsiflexion restriction and arthritis scale were used as the main evaluations.

RESULTS

Forty patients with a larger PMF (≥25%) and 72 with smaller ones (<25%) were fixed and categorized as the fixation group (FG). In the nonfixation group (NG), the corresponding numbers were four and 168 patients respectively. A total of 279 PMF were classified as large posterolateral triangular fragment carrying the posterior half of the fibular notch and intra-incisural posterolateral fragment involving one-fourth to one-third of the fibular notch. However, no obvious differences were observed in terms of the clinical outcomes in PMF involving one-fourth to one-third of the fibular notch. In the treatment of smaller PMF (<25%) of this type, there were no obvious differences in the functional outcomes between fixed (SF) and nonfixed PMF (SN).

CONCLUSIONS

Many patients with smaller PMFs were fixated, but functional outcomes of SF were not better than those of SN. There is no need to emphasize other factors guiding the treatment of PMF involving one-fourth to one-third of the fibular notch in spiral fractures. The traditional size of PMF may be only enough to guide the treatment of spiral fracture with PMF. But other types of PMF should still be treated considering morphology and fragment simultaneously.

History of internal fixation with plates (part 2): new developments after World War II; compressing plates and locked plates

The first techniques of operative fracture with plates were developed in the 19th century. In fact, at the beginning these methods consisted of an open reduction of the fracture usually followed by a very unstable fixation. As a consequence, the fracture had to be opened with a real risk of (sometimes lethal) infection, and due to unstable fixation, protection with a cast was often necessary. During the period between World Wars I and II, plates for fracture fixation developed with great variety. It became increasingly recognised that, because a fracture of a long bone normally heals with minimal resorption at the bone ends, this may result in slight shortening and collapse, so a very rigid plate might prevent such collapse. However, as a consequence, delayed healing was observed unless the patient was lucky enough to have the plate break. One way of dealing with this was to use a slotted plate in which the screws could move axially, but the really important advance was recognition of the role of compression. After the first description of compression by Danis with a "coapteur", Bagby and Müller with the AO improved the technique of compression. The classic dynamic compression plates from the 1970s were the key to a very rigid fixation, leading to primary bone healing. Nevertheless, the use of strong plates resulted in delayed union and the osteoporosis, cancellous bone, comminution, and/or pathological bone resulted in some failures due to insufficient stability. Finally, new devices represented by locking plates increased the stability, contributing to the principles of a more biological osteosynthesis while giving enough stability to allow immediate full weight bearing in some patients.

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.