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

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.

[Effect of three-dimensional printing-assisted minimally invasive plate osteosynthesis on anti-malrotation for different types of tibial fractures]

OBJECTIVE

To compare the postoperative tibial malrotation between traditional minimally invasive plate osteosynthesis (MIPO) and three-dimensional printing-assisted MIPO (3D-MIPO) for different types of tibial fractures, and explore the change of these differences.

METHODS

A prospective randomized controlled trial was conducted. The 120 patients with unilateral tibial fracture who met the selection criteria between January 2016 and October 2018 (40 patients in each of AO types A, B, and C) into the trial group (20 patients, 3D-MIPO) and the control group (20 patients, traditional MIPO) at ratio of 1∶1. There was no significant difference between the two groups (P>0.05) in gender, age, fracture site, and other general information. The bilateral tibial rotation angles were measured on the CT images within 1 week after operation, and the difference of tibial rotation angle between affected and unaffected sides was calculated. The tibial malrotation was defined when the difference exceeded 10°. The degree of tibial rotation and the incidence of malrotation between the two groups in different types of tibial fractures were compared.

RESULTS

Postoperative infection occurred in 1 case, and improved after the dressing change and anti-inflammatory treatment. No complications such as loosening and displacement of internal fixation occurred. There was no significant difference in the difference of bilateral tibial rotation angles between the two groups in type A fractures after operation (t=0.559, P=0.580); while in types B and C fractures, the differences of bilateral tibial rotation angles in control group were significantly higher than those in trial group (P<0.05). There was no significant difference in distribution of internal or external rotation between the two groups in types A, B, and C fractures (P>0.05). No malrotation occurred in type A fractures, and there was no significant difference in the incidence of malrotation between the two groups in type B fractures (P=1.000). The incidence of malrotation in control group was significantly higher than that in trial group in type C fractures (P=0.044).

CONCLUSION

3D-MIPO has the same anti-malrotation effect as traditional MIPO for type A tibial fracture, but for types B and C tibial fractures, the anti-malrotation effect of 3D-MIPO is significantly better than that of traditional MIPO. The more complex the fracture type is, the more significant this advantage is.

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.

Callus Formation and Mineralization after Fracture with Different Fixation Techniques: Minimally Invasive Plate Osteosynthesis versus Open Reduction Internal Fixation

Minimally invasive plate osteosynthesis(MIPO) has been considered as an alternative for fracture treatment. Previous study has demonstrated that MIPO technique has the advantage of less soft tissue injury compared with open reduction internal fixation (ORIF). However, the comparison of callus formation and mineralization between two plate osteosynthesis methods remains unknown. In this experiment, ulna fracture model was established in 42 beagle dogs. The fractures underwent reduction and internal fixation with MIPO or ORIF. Sequential fluorescent labeling and radiographs were applied to determine new callus formation and mineralization in two groups after operation. At 4, 8 and 12 weeks postoperatively, the animals were selected to be sacrificed and the ulna specimens were analyzed by Micro-CT. The sections were also treated with Masson staining for histological evaluation. More callus formation was observed in MIPO group in early stage of fracture healing. The fracture union rate has no significant difference between two groups. The results indicate that excessive soft tissue stripping may impact early callus formation. As MIPO technique can effectively reduce soft tissue injury with little incision, it is considered to be a promising alternative for fracture fixation.