- Email: [email protected]
Minimally invasive plate osteosynthesis of distal fractures of the tibia
Injury Vol. 28, Suppl. No. 1, pp. S.A42-S-A48,1997 0 1997 Elsevier Science Ltd. All rights reserved Printed in Great Britain OOZO-1383/97 $17.00 + 0.00
ELSEVIER
PII: SOOZO-1383(97)00077-6
Minimally tibia
invasive plate osteosynthesis
David L. Helfet’, Paul Y. Shonnard:
of distal fractures of the
David Levine’, Joseph Borrelli, Jr.3
lorthopaedic Trauma Service, The Hospital for Special Surgery, New York, NY, 10021 2Reno Orthopaedic Group, Reno, Nevada 3Assistant Professor, DeDartment of Orthopaedic Surgery, Washington University, School of Medicine, St.Louis, MO 63110
Summary1 Minimally invasive plate osteosynthesis of distal tibia1 fractures is technically feasible and may be advantageous in that it minimizes soft tissue compromise and devascularization of the fracture fragments. The technique involves open reduction and internal fixation of the associated fibular fracture when present, followed by temporary external fixation of the tibia until swelling has resolved. Subsequent limited, but open reduction and internal fixation of the articular fragments when displaced followed by minimally invasive plate osteosynthesis of the tibia utilizing precontoured tubular plates and percutaneously placed cortical screws is performed. The semitubular plate was chosen because it adapts more easily to the bone contours than the stiffer small fragment LC-DCP does. Twenty patients (age 25-59 years) with unstable intraarticular or open extraarticular fractures have been treated including 12 A-type, 1 B-type and 7 C-type fractures according to the A0 classification. Two fractures were open (both Gustilo Type I). Closed soft tissue injury was graded according to Tscherne with 3 type CO, 7 type Cl, 7 type C2 and 1 type C3. All fractures healed without the need for a Time to full weight-bearing second operation. averaged 10.7 weeks (range 8-16 weeks). Two fractures healed with >5” varus alignment and 2 fractures healed with >lo” recurvatum. No patient had a deep infection. The average range of motion in the ankle for dorsiflexion was 14” (range O-30”) and plantar flexion averaged 42” (range 20-50’). ‘Abstracts in German, French, Italian, Spanish Japanese are printed at the end of this supplement.
and
With longer follow-up and a larger number of patients, the authors feel confident that the minimally invasive technique for plate osteosynthesis for the treatment of distal tibia1 fractures will prove to be a feasible and worthwhile method of stabilization while avoiding the severe complications associated with the more standard methods of internal or external fixation of those fractures. Keywords: Minimally distal fractures.
invasive
osteosynthesis,
tibia,
Introduction Minimally invasive plate osteosynthesis of distal fractures of the tibia is technically feasible and may be advantageous in that it minimizes soft tissue compromise and devascularization of the fracture fragments. This technique has evolved in response to disappointing results following traditional methods of operative stabilization of these fractures and the complications introduced by the newer methods of limited internal fixation and external fixation (1-14). Indications for minimally invasive plate osteosynthesis of distal, tibia1 fractures include open fractures, displaced fractures involving the tibia1 plafond and those unstable fractures too distal for safe stabilization with intramedullary nails. This technique involves conventional open reduction and internal fixation of the associated fibular fracture when present, followed by temporary external fixation of the tibia until the swelling has subsided. Subsequently, limited but open reduction and internal fixation of displaced articular fragments is performed, followed by minimally invasive plate osteosynthesis
Helfet: Distal fractures of the tibia
A
(’
Fig. 1: A-C Anteroposterior, lateral and mortice radiographs of a 28-year-old female who sustained a distal, tibia1 fracture with an associated comminuted fibular fracture while rollerblading (Al, Tscherne 2).
of the tibia utilizing precontoured semi-tubular plates and percutaneously placed 4.5 mm cortex screws (15,16). Post-operatively early active and passive motion is permitted while weight-bearing gradually progresses. This manuscript describes our operative technique for minimally invasive plate osteosynthesis of distal fractures of the tibia and our initial experience in twenty patients.
Surgical
Technique
Our standard protocol for the management of distal, tibia1 fractures includes the placement of a triangular external fixator on the day of admission extending between the tibia and the calcaneus for temporary stabilization of soft tissue and bone. The external fixator is applied by inserting two 4.5 mm or 5.0 mm Schanz screws into the anterior aspect of the tibia proximal to the fracture and a centrally threaded transfixation pin through the tuberosity of the calcaneus from medial to lateral. Two carbon fibre rods are used to connect the Schanz screws thus completing the triangle. Manual traction is applied before the pin to bar clamps are tightened to approximate the fracture fragments by ligamentotaxis. This temporary external fixator construct provides enough stability to prevent further soft tissue injury, maintain axial alignment and length, and allow pain control and patient mobilization. In addition, open reduction and internal fixation of the fibula, when Injury 1997, Vol. 28, Suppl. 1
fractured, is accomplished with a third tubular or a 3.5 mm dynamic compression plate and screws. The limb is then maintained in a well padded posterior splint and definitive surgery delayed until wrinkling of the skin over the medial and anterior aspects of the leg occurs, typically five to seven days after the injury. Open wounds are treated with serial irrigations and debridements and delayed soft tissue closure or coverage is achieved within five to seven days of the injury. For minimally invasive plate osteosynthesis of distal, tibia1 fractures the patient is placed supine on a radiolucent table, a support cushion is placed beneath the ipsilateral buttock and a pneumatic tourniquet is applied to the proximal thigh. The ipsilateral iliac crest and the entire lower limb are prepared and draped in the usual sterile fashion. After exsanguinating the limb, the tourniquet is inflated to 300 mmHg. Initial attention is directed to the fracture lines which extend into the tibia1 plafond. These articular fragments are anatomically reduced either by percutaneous means, utilizing fluoroscopy and pointed reduction forceps or via a small anterior incision, arthrotomy, and direct open reduction. Once an articular reduction has been achieved, the articular fragments are stabilized with 3.5 mm lag screws. The appropriate length of the semi-tubular plate (Synthes, Paoli, PA, USA) is determined by placing a plate along the anterior aspect of the leg and adjusting it so that under fluoroscopy the distal end
S-A44 of the plate is at the level of the tibia1 plafond and the proximal end extends at least three screw holes beyond the proximal limit of the tibia1 shaft fracture. The plate is then flattened along its entire length and the distal end bent to match the contour of the distal tibia (approx. 25 degrees medial angulation and 20 degrees external rotation). A 2-3 cm incision is made along the anteromedial aspect of the tibia, proximal to the fracture and distally at the level of the medial malleolus. Typically, a subcutaneous tunnel is created between the two incisions and along the medial aspect of the tibia by blunt dissection using a large Kelly clamp. On occasion this is unnecessary and the plate can be advanced directly beneath the soft tissues without making a tunnel. The position of the plate is adjusted under fluoroscopy in both the coronal and sagittal planes so that it lies along the medial aspect of the tibia. 4.5 mm cortex screws are placed at each end of the plate through the two incisions and in the midportion via small percutaneous stab incisions. The distal
metaphyseal articular fragment can be indirectly reduced to the proximal shaft in this way. Lag screws are then placed across the fracture planes to maintain the reduction, to provide interfragmentary compression, and to increase the stability of the construct. Permanent radiographs are taken in the operating room to assess the overall alignment of the limb and ensure proper placement of the implants. The surgical incisions are irrigated and closed. Sterile dressings are applied and the limb is immobilized in a well padded posterior and U-splint with the ankle maintained in the neutral position. Hemovac drains, if in place, can be removed when drainage is less than 20 cc/eight hours, generally within the first 24-48 hours. All patients receive 48 hrs of perioperative prophylactic antibiotics (Kefzol). the limb is maintained in the Post-operatively, elevated position while the patient is in bed and ambulation training is begun on the first post-operative day in the form of toe-touch weight-bearing (TTWB, 20 lbs) with crutches. On post-operative day
Fig. 2: A and B Intra-operative fluoroscopic images. The fibula is fixed in the standard fashion using indirect reduction techniques and third tubular plates that bridge the comminuted section. The precontoured third tubular plate is passed beneath the skin and subcutaneous tissue and secured distally with a single 3.5 mm cortex screw with a washer. Indirect reduction of the tibia1 fracture is achieved by tightening the second screw.
Helfet: Distal fractures of the tibia number two, gentle exercises for the ankle are begun and the patients are instructed in the use of theraband, and a removable bivalve cast or fracture boot is applied. Our first 20 patients were all capable of walking with the bivalve cast on discharge (TTWB, 20 lbs). The sutures were removed at lo-14 days after surgery. Radiographs, including anteroposterior, lateral and mortice views of the distal tibia and fibula were taken at two weeks, six weeks and three months post-operatively to assess healing and alignment. Progression to partial weight-bearing (PWB) depended upon their clinical and radiographic evaluation, but in general most patients had advanced to PWB by six weeks.
Clinical
Example
A 28-year-old female sustained a fracture of the left distal tibia and an associated comminuted distal fibular fracture in a fall while rollerblading. She was promptly assessed in the emergency department,
S-A45 including anteroposterior, lateral and mortis views of her left ankle (Fig. lA-C). No other injuries were found. The patient was taken to the operating room and underwent open reduction and internal fixation of her fibula via a posterolateral approach. Because of the extensive comminution of the fibular fracture, bridge plating was necessary using two third tubular plates, joined at the last screw holes and combined with several 3.5 mm cortex screws to stabilize the fracture. A ten hole semi-tubular plate was then contoured as previously described and passed subcutaneously down along the medial aspect of the tibia. The plate was fixed distally with a 3.5 mm cortex screw with washer and indirect reduction of the metaphyseal fracture was achieved by insertion of the more proximal 4.5 mm cortex screw (Fig. 2A and B). The fracture was further stabilized by placement of two 4.5 mm interfragmentary lag screws percutaneously (Figs 3A and B) and the final construct (Fig. 4). The patient’s post-operative course was unremarkable with uneventful fracture healing (Fig. 5A-C). Her condition is currently asymptomatic and she has returned to her usual athletic activities, except rollerblading.
Fig. 3: A and B Lag screws are placed across the fracture to obtain interfragmentary Injury 1997, Vol. 28, Suppl. 1
compression.
S-A46
Experience
Fig. 4: The plate is securely fastened to the tibia with percutaneously placed bicortical screws.
to date
Twenty patients with closed, unstable, intra-articular, or open extraarticular fractures of the distal tibia and fibula were treated with minimally invasive plate osteosynthesis by the two senior authors (DLH, JB). There were 13 females and 7 males, ranging in age from 25 to 59 yrs (average 43 yrs). Fourteen patients sustained their fracture as a result of a fall, three in a motor vehicle accident, two skiing, and one was rollerblading. All fractures were classified according to the Comprehensive Classification of Fractures of Long Bones (17): twelve Type A (extra-articular, 7 Al, 2 A2, 3 A3), one Type B (partial articular, 1 Bl) and seven Type C (complete articular, 1 Cl, 1 C2, 5 C3). Those with distal intra-articular extension of the tibia1 fracture were also classified according to Ruedi and Allgower (10); 1 Type I, 1 Type II and 6 Type III fractures. Two fractures were open, both Gustilo and Anderson type I (18). Soft tissue injuries were graded according to Tscherne (19), 3 Type 0, 7 Type I, 7 Type II and 1 Type III. Follow-up on all twenty patients ranged from 6-27 months (average 9 months). All fractures healed without the need for secondary operative procedures. Time to full weight-bearing averaged 10.7 weeks (range 8-16 weeks). There was no loss of fixation or evidence of hardware failure, two fractures healed with greater than 5 degrees of varus alignment and two fractures healed with greater than 10 degrees of recurvatum. The rest of the fractures all healed within acceptable limits of alignment ( <5 degrees varus, < 10 degrees valgus,
A Fig. 5: A-C Follow-up anteroposterior, lateral and mortis radiographs fibula, anatomically reduced ankle without changes in overall alignment
c: demonstrating a well healed tibia and during healing.
Hevet: Distal fractures of the tibia < 10 degrees procurvatumrecurvatum). No patient had evidence of delayed wound healing, wound dehiscence, or deep infection. There were isolated occurrences of delayed union, superficial cellulitis in the immediate post-operative period, a stitch abscess treated with local wound care, and a pin site infection around an external fixator pin. In the latter case, the patient returned to the operating room for treatment of the pin site infection. Although our follow-up of these twenty patients is short, the early clinical results are encouraging. The time to full unprotected weight-bearing averaged 10.7 weeks (range 8-16), range of motion at the ankle on average was 14 degrees of dorsiflexion (range O-30) and plantar flexion averaged 42 degrees (range 20-50 degrees). With longer follow-up and a larger number of patients the authors feel confident that the minimally invasive technique of plate osteosynthesis for the treatment of distal fractures of the tibia will prove to be a feasible and worthwhile method of stabilization while avoiding the severe complications associated with the more standard methods of internal or external fixation of these fractures.
References 1. McFerran
MA, Smith SW, Boulas HJ, Schwartz HS. Complications encountered in the treatment of pilon fractures. J. Orthop. Trauma, 1992;6(2):195-200.
2. Brumback RJ and McGarvey WC. Fractures of the tibia1 plafond. Orthop. Clin. North Am. 1995;26(2):273-285. 3. Teeny SM, Wiss DA. fixation of tibia1 plafond to poor results and 1993;292:108-117.
Open reduction and internal fractures;Variable contributing complications. Clin. Orthop.
4. Tornetta P III, Weiner L, Bergman M, et al. Pilon fractures: Treatment with combined internal and external fixation. J. Orthop. Trauma, 1993;7:489-496. 5. Trumble TE, Benirschke SK, Vedder NB. Use of radial forearm flaps to treat complications of closed pilon fractures. J. Orthop. Trauma, 1992;6:358-365. 6. Wyrsch B, McFerran M, Johnson K, et al. A randomized, prospective study comparing the complications encountered in the management of pilon fractures. Presented at the Annual Meeting of the Orthopaedic Trauma Association, New Orleans, Louisiana, September 23,1993. 7. Kellam JG, Waddell JP. Fractures of the distal tibia metyaphysis with intra-articular extension: the distal tibia explosion fracture. J. Trauma, 1979;19(8):593.
Injury 1997, Vol. 28, Suppl. 1
S-A47 8. Ovadia DN, Beals RK. Fractures of the tibia1 plafond. Bone Joint Surg. Am. 1986;68:543-551.
J.
9. Ruedi T, Allgbwer M. The operative treatment of intraarticular fractures of the lower end of the tibia. Clin. Orthop. 1979;138:105-110. 10. Ruedi T, Allgower M. Fractures of the lower end of the tibia into the ankle joint. Injury;1969;1:92. 11. Bone LB. Fractures of the tibia1 plafond. The pilon fracture. Orthop. Clin. North Am. 1987:18:95-104. 12. Bourne RB, Rorabeck CH, Macnab J. Intra-articular fractures of the distal tibia: the pilon fracture. J. Trauma, 1983;23(7):591-596. 13. Mast JW, Spiegel PC, Pappas NJ. Fractures pilon. Clin. Orthop. 1988;230:68-82.
of the tibia1
14. Helfet DL, Koval K, Pappas J, Sanders RW, DiPasquale T. Intraarticular “Pilon” fracture of the tibia. Clin. Orthop. 1994;298:221-228. 15. Gerber C, Mast JW, Ganz R. Biological of fractures. Arch. Orthop. 1990;109:295-303.
internal Trauma
fixation Surg.
16. Mast JW. Reduction techniques in fractures of the distal tibia1 articular surface. Techniques Orthop. Surg. 1987;2/3:29-36. 17. Miiller M, Nazarian S, Koch P, Schatzker J. The comprehensive classification for fractures of long bones. Berlin Heidelberg New York Springer, 1990. of infection in the 18. Gustilo RB, Anderson JT. Prevention treatment of one thousand and twenty-five open fractures of long bones. Retrospective and prospective analyses. J. Bone Joint Surg. Am. 1976;58:453-458. 19. Tscherne H, Gotzen L. Fractures with soft tissue injuries. Berlin Heidelberg New York: Springer, 1984.
Annotation
by I-‘. Warlock: The authors have drawn attention to the difficulties of management of distal fractures of the tibia, particularly when they enter the ankle joint. Conventional open reduction/internal fixation and external fixation are not always associated with good results. The technique of minimally invasive plate osteosynthesis is an attractive option. Restoring length by fibula fixation and external fixation is a key element in this process and these
S-A48 techniques also allow rapid resolution of soft tissue swelling. The time taken for the operation can be speeded up somewhat by contouring the plate before surgery. In an average adult, the plate can be pre-bent to the shape of an artificial tibia. Final adjustment can then be carried out in the operating theatre. The advantage of using the semi-tubular plate is that it has relatively little bulk when sitting on the medial surface of the fibula. However, the plate is relatively flexible compared with other types of plate. For this
reason, if the soft tissue is suitable, it is always worthwhile considering whether a 4.5 mm reconstruction plate or a 4.5 mm narrow DCP can be placed safely in position. This decision depends entirely on the soft tissue coverage available for the distal tibia. The authors emphasise the importance of a specific rehabilitation programme with toe-touch weightbearing. Patient cooperation is essential if this technique of minimally invasive plate osteosynthesis is to succeed; this means that care must be taken in patient selection.
ELSEVIER
PII: SOOZO-1383(97)00077-6
Minimally tibia
invasive plate osteosynthesis
David L. Helfet’, Paul Y. Shonnard:
of distal fractures of the
David Levine’, Joseph Borrelli, Jr.3
lorthopaedic Trauma Service, The Hospital for Special Surgery, New York, NY, 10021 2Reno Orthopaedic Group, Reno, Nevada 3Assistant Professor, DeDartment of Orthopaedic Surgery, Washington University, School of Medicine, St.Louis, MO 63110
Summary1 Minimally invasive plate osteosynthesis of distal tibia1 fractures is technically feasible and may be advantageous in that it minimizes soft tissue compromise and devascularization of the fracture fragments. The technique involves open reduction and internal fixation of the associated fibular fracture when present, followed by temporary external fixation of the tibia until swelling has resolved. Subsequent limited, but open reduction and internal fixation of the articular fragments when displaced followed by minimally invasive plate osteosynthesis of the tibia utilizing precontoured tubular plates and percutaneously placed cortical screws is performed. The semitubular plate was chosen because it adapts more easily to the bone contours than the stiffer small fragment LC-DCP does. Twenty patients (age 25-59 years) with unstable intraarticular or open extraarticular fractures have been treated including 12 A-type, 1 B-type and 7 C-type fractures according to the A0 classification. Two fractures were open (both Gustilo Type I). Closed soft tissue injury was graded according to Tscherne with 3 type CO, 7 type Cl, 7 type C2 and 1 type C3. All fractures healed without the need for a Time to full weight-bearing second operation. averaged 10.7 weeks (range 8-16 weeks). Two fractures healed with >5” varus alignment and 2 fractures healed with >lo” recurvatum. No patient had a deep infection. The average range of motion in the ankle for dorsiflexion was 14” (range O-30”) and plantar flexion averaged 42” (range 20-50’). ‘Abstracts in German, French, Italian, Spanish Japanese are printed at the end of this supplement.
and
With longer follow-up and a larger number of patients, the authors feel confident that the minimally invasive technique for plate osteosynthesis for the treatment of distal tibia1 fractures will prove to be a feasible and worthwhile method of stabilization while avoiding the severe complications associated with the more standard methods of internal or external fixation of those fractures. Keywords: Minimally distal fractures.
invasive
osteosynthesis,
tibia,
Introduction Minimally invasive plate osteosynthesis of distal fractures of the tibia is technically feasible and may be advantageous in that it minimizes soft tissue compromise and devascularization of the fracture fragments. This technique has evolved in response to disappointing results following traditional methods of operative stabilization of these fractures and the complications introduced by the newer methods of limited internal fixation and external fixation (1-14). Indications for minimally invasive plate osteosynthesis of distal, tibia1 fractures include open fractures, displaced fractures involving the tibia1 plafond and those unstable fractures too distal for safe stabilization with intramedullary nails. This technique involves conventional open reduction and internal fixation of the associated fibular fracture when present, followed by temporary external fixation of the tibia until the swelling has subsided. Subsequently, limited but open reduction and internal fixation of displaced articular fragments is performed, followed by minimally invasive plate osteosynthesis
Helfet: Distal fractures of the tibia
A
(’
Fig. 1: A-C Anteroposterior, lateral and mortice radiographs of a 28-year-old female who sustained a distal, tibia1 fracture with an associated comminuted fibular fracture while rollerblading (Al, Tscherne 2).
of the tibia utilizing precontoured semi-tubular plates and percutaneously placed 4.5 mm cortex screws (15,16). Post-operatively early active and passive motion is permitted while weight-bearing gradually progresses. This manuscript describes our operative technique for minimally invasive plate osteosynthesis of distal fractures of the tibia and our initial experience in twenty patients.
Surgical
Technique
Our standard protocol for the management of distal, tibia1 fractures includes the placement of a triangular external fixator on the day of admission extending between the tibia and the calcaneus for temporary stabilization of soft tissue and bone. The external fixator is applied by inserting two 4.5 mm or 5.0 mm Schanz screws into the anterior aspect of the tibia proximal to the fracture and a centrally threaded transfixation pin through the tuberosity of the calcaneus from medial to lateral. Two carbon fibre rods are used to connect the Schanz screws thus completing the triangle. Manual traction is applied before the pin to bar clamps are tightened to approximate the fracture fragments by ligamentotaxis. This temporary external fixator construct provides enough stability to prevent further soft tissue injury, maintain axial alignment and length, and allow pain control and patient mobilization. In addition, open reduction and internal fixation of the fibula, when Injury 1997, Vol. 28, Suppl. 1
fractured, is accomplished with a third tubular or a 3.5 mm dynamic compression plate and screws. The limb is then maintained in a well padded posterior splint and definitive surgery delayed until wrinkling of the skin over the medial and anterior aspects of the leg occurs, typically five to seven days after the injury. Open wounds are treated with serial irrigations and debridements and delayed soft tissue closure or coverage is achieved within five to seven days of the injury. For minimally invasive plate osteosynthesis of distal, tibia1 fractures the patient is placed supine on a radiolucent table, a support cushion is placed beneath the ipsilateral buttock and a pneumatic tourniquet is applied to the proximal thigh. The ipsilateral iliac crest and the entire lower limb are prepared and draped in the usual sterile fashion. After exsanguinating the limb, the tourniquet is inflated to 300 mmHg. Initial attention is directed to the fracture lines which extend into the tibia1 plafond. These articular fragments are anatomically reduced either by percutaneous means, utilizing fluoroscopy and pointed reduction forceps or via a small anterior incision, arthrotomy, and direct open reduction. Once an articular reduction has been achieved, the articular fragments are stabilized with 3.5 mm lag screws. The appropriate length of the semi-tubular plate (Synthes, Paoli, PA, USA) is determined by placing a plate along the anterior aspect of the leg and adjusting it so that under fluoroscopy the distal end
S-A44 of the plate is at the level of the tibia1 plafond and the proximal end extends at least three screw holes beyond the proximal limit of the tibia1 shaft fracture. The plate is then flattened along its entire length and the distal end bent to match the contour of the distal tibia (approx. 25 degrees medial angulation and 20 degrees external rotation). A 2-3 cm incision is made along the anteromedial aspect of the tibia, proximal to the fracture and distally at the level of the medial malleolus. Typically, a subcutaneous tunnel is created between the two incisions and along the medial aspect of the tibia by blunt dissection using a large Kelly clamp. On occasion this is unnecessary and the plate can be advanced directly beneath the soft tissues without making a tunnel. The position of the plate is adjusted under fluoroscopy in both the coronal and sagittal planes so that it lies along the medial aspect of the tibia. 4.5 mm cortex screws are placed at each end of the plate through the two incisions and in the midportion via small percutaneous stab incisions. The distal
metaphyseal articular fragment can be indirectly reduced to the proximal shaft in this way. Lag screws are then placed across the fracture planes to maintain the reduction, to provide interfragmentary compression, and to increase the stability of the construct. Permanent radiographs are taken in the operating room to assess the overall alignment of the limb and ensure proper placement of the implants. The surgical incisions are irrigated and closed. Sterile dressings are applied and the limb is immobilized in a well padded posterior and U-splint with the ankle maintained in the neutral position. Hemovac drains, if in place, can be removed when drainage is less than 20 cc/eight hours, generally within the first 24-48 hours. All patients receive 48 hrs of perioperative prophylactic antibiotics (Kefzol). the limb is maintained in the Post-operatively, elevated position while the patient is in bed and ambulation training is begun on the first post-operative day in the form of toe-touch weight-bearing (TTWB, 20 lbs) with crutches. On post-operative day
Fig. 2: A and B Intra-operative fluoroscopic images. The fibula is fixed in the standard fashion using indirect reduction techniques and third tubular plates that bridge the comminuted section. The precontoured third tubular plate is passed beneath the skin and subcutaneous tissue and secured distally with a single 3.5 mm cortex screw with a washer. Indirect reduction of the tibia1 fracture is achieved by tightening the second screw.
Helfet: Distal fractures of the tibia number two, gentle exercises for the ankle are begun and the patients are instructed in the use of theraband, and a removable bivalve cast or fracture boot is applied. Our first 20 patients were all capable of walking with the bivalve cast on discharge (TTWB, 20 lbs). The sutures were removed at lo-14 days after surgery. Radiographs, including anteroposterior, lateral and mortice views of the distal tibia and fibula were taken at two weeks, six weeks and three months post-operatively to assess healing and alignment. Progression to partial weight-bearing (PWB) depended upon their clinical and radiographic evaluation, but in general most patients had advanced to PWB by six weeks.
Clinical
Example
A 28-year-old female sustained a fracture of the left distal tibia and an associated comminuted distal fibular fracture in a fall while rollerblading. She was promptly assessed in the emergency department,
S-A45 including anteroposterior, lateral and mortis views of her left ankle (Fig. lA-C). No other injuries were found. The patient was taken to the operating room and underwent open reduction and internal fixation of her fibula via a posterolateral approach. Because of the extensive comminution of the fibular fracture, bridge plating was necessary using two third tubular plates, joined at the last screw holes and combined with several 3.5 mm cortex screws to stabilize the fracture. A ten hole semi-tubular plate was then contoured as previously described and passed subcutaneously down along the medial aspect of the tibia. The plate was fixed distally with a 3.5 mm cortex screw with washer and indirect reduction of the metaphyseal fracture was achieved by insertion of the more proximal 4.5 mm cortex screw (Fig. 2A and B). The fracture was further stabilized by placement of two 4.5 mm interfragmentary lag screws percutaneously (Figs 3A and B) and the final construct (Fig. 4). The patient’s post-operative course was unremarkable with uneventful fracture healing (Fig. 5A-C). Her condition is currently asymptomatic and she has returned to her usual athletic activities, except rollerblading.
Fig. 3: A and B Lag screws are placed across the fracture to obtain interfragmentary Injury 1997, Vol. 28, Suppl. 1
compression.
S-A46
Experience
Fig. 4: The plate is securely fastened to the tibia with percutaneously placed bicortical screws.
to date
Twenty patients with closed, unstable, intra-articular, or open extraarticular fractures of the distal tibia and fibula were treated with minimally invasive plate osteosynthesis by the two senior authors (DLH, JB). There were 13 females and 7 males, ranging in age from 25 to 59 yrs (average 43 yrs). Fourteen patients sustained their fracture as a result of a fall, three in a motor vehicle accident, two skiing, and one was rollerblading. All fractures were classified according to the Comprehensive Classification of Fractures of Long Bones (17): twelve Type A (extra-articular, 7 Al, 2 A2, 3 A3), one Type B (partial articular, 1 Bl) and seven Type C (complete articular, 1 Cl, 1 C2, 5 C3). Those with distal intra-articular extension of the tibia1 fracture were also classified according to Ruedi and Allgower (10); 1 Type I, 1 Type II and 6 Type III fractures. Two fractures were open, both Gustilo and Anderson type I (18). Soft tissue injuries were graded according to Tscherne (19), 3 Type 0, 7 Type I, 7 Type II and 1 Type III. Follow-up on all twenty patients ranged from 6-27 months (average 9 months). All fractures healed without the need for secondary operative procedures. Time to full weight-bearing averaged 10.7 weeks (range 8-16 weeks). There was no loss of fixation or evidence of hardware failure, two fractures healed with greater than 5 degrees of varus alignment and two fractures healed with greater than 10 degrees of recurvatum. The rest of the fractures all healed within acceptable limits of alignment ( <5 degrees varus, < 10 degrees valgus,
A Fig. 5: A-C Follow-up anteroposterior, lateral and mortis radiographs fibula, anatomically reduced ankle without changes in overall alignment
c: demonstrating a well healed tibia and during healing.
Hevet: Distal fractures of the tibia < 10 degrees procurvatumrecurvatum). No patient had evidence of delayed wound healing, wound dehiscence, or deep infection. There were isolated occurrences of delayed union, superficial cellulitis in the immediate post-operative period, a stitch abscess treated with local wound care, and a pin site infection around an external fixator pin. In the latter case, the patient returned to the operating room for treatment of the pin site infection. Although our follow-up of these twenty patients is short, the early clinical results are encouraging. The time to full unprotected weight-bearing averaged 10.7 weeks (range 8-16), range of motion at the ankle on average was 14 degrees of dorsiflexion (range O-30) and plantar flexion averaged 42 degrees (range 20-50 degrees). With longer follow-up and a larger number of patients the authors feel confident that the minimally invasive technique of plate osteosynthesis for the treatment of distal fractures of the tibia will prove to be a feasible and worthwhile method of stabilization while avoiding the severe complications associated with the more standard methods of internal or external fixation of these fractures.
References 1. McFerran
MA, Smith SW, Boulas HJ, Schwartz HS. Complications encountered in the treatment of pilon fractures. J. Orthop. Trauma, 1992;6(2):195-200.
2. Brumback RJ and McGarvey WC. Fractures of the tibia1 plafond. Orthop. Clin. North Am. 1995;26(2):273-285. 3. Teeny SM, Wiss DA. fixation of tibia1 plafond to poor results and 1993;292:108-117.
Open reduction and internal fractures;Variable contributing complications. Clin. Orthop.
4. Tornetta P III, Weiner L, Bergman M, et al. Pilon fractures: Treatment with combined internal and external fixation. J. Orthop. Trauma, 1993;7:489-496. 5. Trumble TE, Benirschke SK, Vedder NB. Use of radial forearm flaps to treat complications of closed pilon fractures. J. Orthop. Trauma, 1992;6:358-365. 6. Wyrsch B, McFerran M, Johnson K, et al. A randomized, prospective study comparing the complications encountered in the management of pilon fractures. Presented at the Annual Meeting of the Orthopaedic Trauma Association, New Orleans, Louisiana, September 23,1993. 7. Kellam JG, Waddell JP. Fractures of the distal tibia metyaphysis with intra-articular extension: the distal tibia explosion fracture. J. Trauma, 1979;19(8):593.
Injury 1997, Vol. 28, Suppl. 1
S-A47 8. Ovadia DN, Beals RK. Fractures of the tibia1 plafond. Bone Joint Surg. Am. 1986;68:543-551.
J.
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Annotation
by I-‘. Warlock: The authors have drawn attention to the difficulties of management of distal fractures of the tibia, particularly when they enter the ankle joint. Conventional open reduction/internal fixation and external fixation are not always associated with good results. The technique of minimally invasive plate osteosynthesis is an attractive option. Restoring length by fibula fixation and external fixation is a key element in this process and these
S-A48 techniques also allow rapid resolution of soft tissue swelling. The time taken for the operation can be speeded up somewhat by contouring the plate before surgery. In an average adult, the plate can be pre-bent to the shape of an artificial tibia. Final adjustment can then be carried out in the operating theatre. The advantage of using the semi-tubular plate is that it has relatively little bulk when sitting on the medial surface of the fibula. However, the plate is relatively flexible compared with other types of plate. For this
reason, if the soft tissue is suitable, it is always worthwhile considering whether a 4.5 mm reconstruction plate or a 4.5 mm narrow DCP can be placed safely in position. This decision depends entirely on the soft tissue coverage available for the distal tibia. The authors emphasise the importance of a specific rehabilitation programme with toe-touch weightbearing. Patient cooperation is essential if this technique of minimally invasive plate osteosynthesis is to succeed; this means that care must be taken in patient selection.