Surgical Management of Distal Tibia Fracture: Towards An Outcome-based Treatment Algorithm

@#Introduction: Distal tibia fractures are frequently associated with an extensive soft tissue injury which then leads to a higher risk of complications such as infection, non-union and eventually poor overall outcome. The purpose of this study is to measure the outcome of distal tibia fractures treated with internal fixation, external fixator or Ilizarov external fixator(IEF). We aim to propose an algorithm for management of distal tibia fractures by evaluating the treatment options, outcomes and risk factors present. Material and Methods: This study is a cross-sectional study of all distal tibia fractures treated surgically in Tengku Ampuan Rahimah Hospital, Klang from 1st January 2016 till 30th June 2018. Patient records were reviewed to analyse the outcomes of surgical treatment and risk factors associated with it. Results: Ninety-one patients were included with a mean age of 41.5 years (SD = 16.4). Thirty-nine cases (42.9%) were open fractures. Thirty-eight patients (41.8%) were treated with internal fixation, 27 patients (29.7%) were treated with IEF and 26 patients (28.6%) were treated with an external fixator. Among open fractures cases, no significant finding can be concluded when comparing each surgical option and its outcome, although one option was seen better than the other in a particular outcome. Initial skeletal traction or temporary spanning external fixator in close fractures reduced the risk of mal-alignment (p value=0.001). Internal fixation is seen superior to IEF and external fixator in close fractures in term of articular surface reduction (p value = 0.043) and risk of mal-alignment (p value = 0.007). Conclusion: There is no single method of fixation that is ideal for all pilon fractures and suitable for all patients. This proposed algorithm can help surgeons in deciding treatment strategies in the challenging management of distal tibia fractures to reduce associated complications.

The Result of Using an Additional Mini-Locking Plate for Tibial Pilon Fractures

PURPOSE: We evaluated the usefulness of an additional, 2.7 mm mini-locking plate for tibial pilon fractures. MATERIALS AND METHODS: We studied 21 patients (14 males and 7 females), who were treated with a 2.7 mm mini-locking plate via the anterolateral approach for tibial pilon fractures between September 2012 and April 2014. The mean age was 43.85 years, and the mean follow-up period was 16.6 months. The radiologic outcomes were graded by the Burwell and Charnley modified system and clinical outcomes were evaluated by the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hind foot score and visual analogue scale (VAS) score. RESULTS: The mean union period was 14.3 weeks. At the final follow-up, radiologic results showed 16 excellent results, 4 fair results, and 1 poor result. The average VAS was 3.4 points; the average AOFAS score was 81.8 points. During the follow-up period, there were three cases of posttraumatic osteoarthritis and one case of superficial skin infection. CONCLUSION: Additional anterolateral, 2.7 mm mini-locking plate may be a good treatment method to manage tibial pilon fractures.

Analysis of the Result Treated with Locking Compression Plate-Distal Tibia and Zimmer Periarticular Locking Plate in Distal Tibia Fracture

PURPOSE: To evaluate the clinical and radiological results of minimally invasive plate, osteosynthesis, using either a locking compression plate-distal tibia (LCP-DT) or Zimmer periarticular locking plate (ZPLP) for distal tibia fractures. MATERIALS AND METHODS: Fifty one patients (51 cases), who underwent minimally invasive osteosynthesis using locking compression plate for distal tibia fractures between October 2008 and August 2011, were followed for more than six months. Eighteen patients were treated with LCP-DT and 33 patients with ZPLP. Time to bony union and anatomic alignment were evaluated radiologically. Clinically, American Orthopedic Foot & Ankle Society ankle-hindfoot scales (AOFAS score) and range of ankle motion were assessed and compared between two groups. RESULTS: All patients achieved bony union at an average of 18 weeks on LCP-DT group and 16weeks on ZPLP group. The average American Orthopedic Foot & Ankle Society ankle-hindfoot scales was 83.3 points on the LCP-DT group, 84.6 points on the ZPLP group, and range of ankle motion averaged at 45 degrees, 48 degrees, respectively. CONCLUSION: Both types of locking compression plates were effective when performing minimally invasive osteosynthesis for distal tibia fractures.

Clinical Outcomes of Combinations of Locking Compression Plate Fixation through Minimally Invasive Precutaneous Plate Osteosynthesis and Interfragmentary Screw Fixation in Distal Tibia Fracture / 대한족부족관절학회지

PURPOSE: To analyze the outcome of distal tibia fracture treated with the Distal Tibia LCP with combination of interfragmentary screw. MATERIALS AND METHODS: Between January 2008 and March 2012, data of 34 patients with fracture of distal tibia treated with the Distal Tibia LCP with or without combination of interfragmentary screws were reviewed. There were 17 males and 17 females with an average age of 51.8 years (range, 18~77 years). Radiographic union time and time from surgery until ability to full weight bearing were measured and compared. Callus index was measured as quotient of callus thickness and diameter of corticalis both in AP and sagittal direction. RESULTS: 12 fractures were treated with interfragmentary screws and 22 fractures were treated with bridging plate alone. In interfragmentary fixation group, time to full weight bearing was 14 weeks versus 15.75 weeks without screw. Callus index at bearing was not significantly lesser in patients with screw compated with those without, but callus index difference at posterative 4weeks was sigficant. Radiologic union time was 11.3 weeks in interfragmentary fixation group and 12.58 weeks without screw. CONCLUSION: The osteosynthesis with the Distal tibia LCP with combination of interfragmentary screw seems to be more stable in postoperative 4weeks than Distal tibia LCP alone, expecting to earlier ROM exercise and rehabilitation.

Surgical Treatment of Distal Tibia Fractures / 대한족부족관절학회지

Distal tibia fractures were mainly caused by high energy trauma and the lower legs were enveloped in poor soft tissue. Therefore, there are many open fractures and concomitant soft tissue injuries in distal tibia fractures. For the restoration of ankle function, the surgical treatment was performed in distal tibia fractures. However, it is difficult to treat the distal tibia fracture surgically. There are many complications in distal tibia fracture due to highly comminuted fracture and poor soft tissue condition. There are many surgical methods for distal tibia fractures, such as, external fixator, intramedulary nailling, open reduction & internal fixation, and minimally invasive plate osteosynthesis. We reviewed the surgical treatments of distal tibia fractures.

Clinical Outcomes of Locking Compression Plate Fixation through Minimally Invasive Percutaneous Plate Osteosynthesis in the Treatment of Distal Tibia Fracture

PURPOSE: To analyze the clinical results of operative treatment of distal tibia fracture with locking compression plate fixation through a minimally invasive percutaneous plate osteosynthesis technique. MATERIALS AND METHODS: The subjects were 46 patients (conventional open surgery: 22 patients, minimally invasive percutaneous plate osteosynthesis: 24 patients) with fracture of the distal tibia who were treated with plating between November 2006 and June 2010. The time of bony union, complications, range of motion, and clinical functional outcome (according to American Orthopedic Foot and Ankle Society, AOFAS) were investigated. RESULTS: In the minimally invasive percutaneous plate osteosynthesis group, the average union time was 14.3 weeks, postoperative range of motion was an average of 55.2, average AOFAS was 96.9, and incidence of complications was 20.8%. In the open surgery group, the average union time was 18.9 weeks, postoperative range of motion was an average of 49.1, average AOFAS was 83.8, and incidence of complications was 32.6%. There were statistically significant differences (p<0.05). CONCLUSION: Surgical treatment with locking compression plate fixation through the minimally invasive percutaneous plate osteosynthesis technique showed favorable results regarding its union time, postoperative functional outcome, and incidence of complications. The locking compression plate fixation through minimally invasive percutaneous plate osteosynthesis technique can be an effective treatment option.

Minimally Invasive Osteosynthesis with Locking Compression Plate for Distal Tibia Fractures

PURPOSE: To evaluate the outcome of minimally invasive osteosynthesis using locking compression plate for distal tibia fractures. MATERIALS AND METHODS: Forty five patients (45 cases) who underwent minimally invasive osteosynthesis using locking compression plate for distal tibia fractures between January 2006 and June 2008, were followed for more than one year. The average duration of the follow-up was 30.5 months (12~54 months). The fracture types were as followed: 26 cases (58%) of extraarticular fractures, 19 cases (42%) of intraarticular fractures, and 16 cases (36%) of open fractures. RESULTS: All patients achieved bone union at average of 21weeks (12~36 weeks). The average American Orthopedic Foot & Ankle Society ankle-hindfoot scales was 84.6 points (65~100 points) and range of ankle motion averaged at 46.5 degrees (20~60 degrees). Complications included 6 cases of superficial infection, 3 cases of malalignment and 5 cases of skin irritation by plate. There were no cases of deep infection, skin necrosis, shortening and metal breakage. CONCLUSION: Minimally invasive osteosynthesis using locking compression plate for distal tibia fractures is considered to be an effective method with high healing rate, rapid functional recovery and low complication rate due to minimal disruption of bone and soft tissue biology and improved fixation strength.

Staged Protocol in Treatment of Open Distal Tibia Fracture: Using Lateral MIPO

BACKGROUND: To evaluate the radiological, clinical results in patients with open distal tibia factures, who were treated with a staged treatment protocol using the lateral minimally invasive plate osteosynthesis (MIPO) technique. METHODS: From January 2007 to June 2009, 10 patients with open distal tibia fractures (Gustilo-Anderson classification II, 3; IIIA, 1; IIIB, 6) were treated using a staged treatment protocol. The initial debridement and application of an external fixator were performed within 24 hours and the mean interval from injury to definitive surgical treatment was 15 days (range, 6 to 52 days). Eight weeks later, an additional bone graft was performed in 3 patients. The follow-up duration was more than 1 year. RESULTS: The mean fracture healing time was 21 weeks (range, 17 to 28 weeks), and the average Iowa ankle rating score was 84.5 points. At the last follow-up, there was no non-union, angular deformity > 5degrees, shortening > 10 mm or infection. In 10 patients, 2 patients had a superficial wound infection, and another 2 patients showed limitation of ankle joint motion. CONCLUSIONS: This staged treatment protocol using a lateral MIPO technique is a useful alternative method for achieving high functional recovery with good healing and low complication rates in patients with an open distal tibia fracture.

Comparative Study Using of Treatment with Minimally Invasive Plate Osteosynthesis Using Periarticular Plate and Interlocking Intramedullary Nailing in Distal Tibia Fractures

PURPOSE: To compare the result of treatment between minimally invasive plate osteosynthesis (MIPO) using periarticular plate and intramedullary nailing in treatment of distal tibia fractures. MATERIALS AND METHODS: 28 cases of distal tibia fractures form Jan. 2006 to Mar. 2008 were divided into two group. Minimum follow-up was for 12 month. Group 1 consisted of 14 patients who were treated by MIPO technique and group 2 consisted of 14 patients who were treated by interlocking intramedullary nailing. The results were compared by assessing radiologic and clinical result. RESULTS: The mean bony union time was 14 weeks (8~17) in group 1 and 15 weeks (11~20) in group 2. Operation time was 58 minutes (55~65) in group 1 and 82.7 minutes (70~100) in group 2. The average angulation in AP view was 1.5 degrees (0~2) in group 1 and 2 degrees (0~5) in group 2, in lateral view was 1.8 degrees (0~4) in group 1 and 2.3 degrees (0~12) in group 2. The average range of motion for dorsi flextion was 17.5 degrees (15~20) in group 1 and 18 degrees (16~20) in group 2, for plantar flextion was 45 degrees (42~50) in group 1 and 44 degrees (42~50) in group 2, which means that there were no severe limitation of motion in all patients, resulting in satisfactory ambulation. There was no post operative complications such as skin irritation problem caused by internal device and no implant failure and superficial wound infection. CONCLUSION: There were no difference in bony union time, clinical result and anatomical reduction between Group 1 and Group 2 in distal tibia fractures, but operation time was shorter in MIPO than nailing.

The Function and Symptoms of Ankle Joint in the Distal Tibial Fractures Treated by Nailing / 대한족부족관절학회지

PURPOSE: To evaluate the safety and prognostic factors of intramedullary nailing of distal tibia fractures in terms of function and symptoms of the ankle joint. MATERIALS AND METHODS: We retrospectively analyzed 22 distal tibial fractures with intramedullary nailing. The mean duration of follow-up was 43 months. We reviewed medical records to describe each case. We measured radiographic parameters such as fracture configuration, arthritic change of the ankle joint and status of reduction. We also assessed clinical results by AOFAS ankle hind foot scoring system, degree of pain by VAS and range of motion to find out prognostic factors for functional result of the ankle joint. RESULTS: Bone healing was obtained in all cases without any wound complications. Mean AOFAS ankle score was 94. There were 4 cases with mild (VAS<3/10) ankle pain and 2 cases with mild limitation of ankle motion. The comminution of fracture had a significant relationship with delayed angular deformity of ankle joint (p=0.032). There was no other significant parameter affecting ankle joint function except the location of nail-end. CONCLUSION: Intramedullary nailing in distal tibia fracture is a safe and effective procedure. But further study may need to evaluate the relationship between the position of nail-end and the function of ankle joint.

A Comparison between Minimally Invasive Plate Osteosynthesis & Interlocking Intramedullary Nailing in Distal Tibia Fractures

PURPOSE: To compare the effectiveness between minimally invasive plate osteosynthesis (MIPO) and interlocking IM nailing in the treatment of distal tibia fracture without involvement of ankle joint retrospectively. MATERIALS AND METHODS: 38 patients with distal tibia fracture from Jan. 2004 to Oct. 2005 were divided into two groups. Minimum follow-up was for 12 months. Group MIPO consisted of 18 patients were treated with MIPO and group Nail consisted of 20 patients were treated with interlocking intramedullary nail. The results were compared between two groups by assessing bony union time and operation time. Clinical evaluation was evaluated by Olerud score. RESULTS: The mean bony union time was 14.4 weeks (12~17 weeks) in group MIPO and 16.7 weeks (13~19 weeks) in group Nail (p=0.011). The mean operation time was 1.05 hours (0.6~1.6 hours) in group MIPO and 0.74 hours (0.4~1.1 hours) in group Nail (p=0.044). The Olerud score was 83.8 (75~100) in group MIPO and was 89.6 (70~100) in group Nail (p=0.075). In Complication, group MIPO showed one metal failure and two skin irritations, group Nail showed three superficial wound infections. CONCLUSION: MIPO was the shorter bony union time and the longer operation time than the interlocking intramedullary nailing. There were no significant differences between the two groups in clinical results.

Comparative Study of Intramedullary Nailing and Plate for Metaphyseal Fractures of the Distal Tibia

PURPOSE: To compare the radiological and clinical results between intramedullary nailing and plate fixation in the treatment of distal tibial fractures. MATERIALS AND METHODS: 19 cases of distal tibial metaphyseal fractures within 4 cm of the ankle joint line were enrolled. Ten patients were treated with interlocking intramedullary nail and the others with plate and screws. RESULTS: The mean union time was 14 weeks in nailing group and 16 weeks in plate group. The average angulation in AP view was 4.1 degrees in nailing group and 3.1 degrees in plate group. The average angulation in lateral view was 1.7 degrees in nailing group and 2.7 degrees in plate group. The rotational deformity was 2.8 degrees in nailing group and 1.7 degrees in plate group in average. There was no implant failure and soft tissue problem. CONCLUSION: There was no difference in clinical and radiological results between intramedullary nailing and plate in the treatment of the distal tibial fractures and, considering the preservation of the soft tissue, the intramedullary nails are a reliable method for managing distal metaphyseal fractures of the tibia.

The Comparison of MIPPO vs Open Plate Fixation in the Treatment of the Distal Tibia Fracture

PURPOSE: To evaluate the efficacy of the surgical treatment through the comparison of MIPPO vs open plate fixation in the treatment of the distal tibia fracture retrospectively. MATERIALS AND METHODS: 30 patients with distal tibia fracture from Jun. 2001 to Jun. 2004 were divided into two groups depending on the surgical method. Minimum follow up was 12 months. Group A consisted of 15 patients treated with MIPPO, Group B was 15 patients treated with open plate fixation. The clinical outcomes were evaluated retrospectively from operation time, rehabilitation, ROM, interval change of postoperative CRP to assess postoperative inflammatory reaction, postoperative complications and clinical result with the use of McLennan and Ungersma criteria. RESULTS: There were no significant differences in clinical result by McLennan and Ungersma criteria in both groups. The postoperative 3 days and 7 days CRP were 4.0mg% (0.9~7.2)/0.5 mg% (0.1~1.5) in group A and 7.97mg% (2.8~14.6)/1.0mg% (0.3~1.6) in group B, shows more minimal tissue injury and early recovery in group A. Operation time in group A was shorter than group B. Normal recovery of ROM was quicker in Group A. In complications, group A showed one superficial infection and one angular deformity and group B showed one superficial infection, one infected nonunion and two ankle stiffness. CONCLUSION: There were no significant differences in clinical result and bony union. MIPPO technique is superior to group B in view of the minimal tissue injury, complications, operation time and postoperative rehabilitation.

Percutaneous Fixation of Distal Tibia Comminuted Fracture by Using Normal Anatomical Plate / 中国微创外科杂志

Objective To explore efficacy of minimally invasive percutaneous plate osteosynthesis (MIPPO) for the treatment of distal tibia comminuted fracture by using normal anatomical plate. Methods Between January 2007 and July 2008,18 cases of distal tibia facture were treated by MIPPO using anatomical plate. The clinical data of the patients were reviewed. Results A mean of 6.5 cm incision (5.0-8.5 cm) was made in the patients; the intraoperative blood loss ranged from 60 to 300 ml (mean,145 ml);and the operation time ranged from 30 to 120 min with a mean of 63 min. After the surgery,2 patients developed mild skin necrosis,and was then cured by conventional therapy; no patient had nonunion of the fracture,failure of internal fixation,or delayed wound healing. The 18 cases were followed up for a mean of 8 months (range,4 to 10 months); all of them were healed clinically and could walk without crutch in 4 months postoperatively. According to Johner-Wruhs score system,11 were excellent and 7 were good; the excellent-good rate was 100%. Conclusions MIPPO with anatomical plate is an optimal treatment for distal tibia comminuted fracture with advantages in protecting the soft issues and bony blood supply,promoting the wound-healing process,and reducing the rate of complications.