International Orthopaedics (SICOT) (2015) 39:2227–2237 DOI 10.1007/s00264-015-2903-7

ORIGINAL PAPER

Locking compression plate as an external fixator in the treatment of closed distal tibial fractures Yu Zhou 1 & Yanbiao Wang 1 & Lifeng Liu 1 & Zhenyu Zhou 1 & Xuecheng Cao 1

Received: 30 May 2015 / Accepted: 22 June 2015 / Published online: 17 July 2015 # SICOT aisbl 2015

Abstract Background Tibial fractures often follow high-energy trauma, and although soft tissue can remain intact, poor blood supply can lead to skin necrosis, infections and potential amputation. We used closed reduction and locking compression plates as external fixators for treating closed distal tibial fractures with soft tissue compromise. The method aims to avoid those potential complications. Methods A retrospective series of 23 closed distal tibial fractures were treated using locking compression plates as external fixators. Protecting the blood supply was an essential intraoperative consideration, and postoperative physical therapy and partial weight bearing were encouraged early. Patients were followed at regular intervals and evaluated radiographically and clinically. Results The average time to radiological bony union was 29.4 weeks (range, 14–52 weeks). No infections were seen. Fractures in 22 cases (95.65 %) united, and most fractures healed in an acceptable position. All patients had good functional

Yu Zhou and Yanbiao Wang contributed equally to this work. * Lifeng Liu [email protected] Yu Zhou [email protected] Yanbiao Wang [email protected] Zhenyu Zhou [email protected] Xuecheng Cao [email protected] 1

Orthopaedic Department, The General Hospital of Jinan Military Command, Jinan 250031, China

results and were fully weight bearing with a well-healed tibia at the final follow-up. Conclusions Locking compression plates can be used as external fixators and provide a high rate of union, comfortable clinical course and excellent ankle-joint motion. Although indications are limited, this method is a suitable surgical approach for treating closed distal tibial fractures with soft tissue compromise. Keywords Closed repair . Locking compression plate . Fracture . Tibia

Introduction The tibia is easily exposed during direct violent trauma because of its unique position. Although the injury itself is not life-threatening, tibial fractures are a concern because union requires an extended recovery period and malunion can lead to permanent dysfunction of the lower extremities, especially when the fracture site is at the distal third of the tibial shaft, near the ankle. Furthermore, open fractures and related skin and muscle damage are common because of the relatively thin, soft tissue coverage of the distal tibia. Although the skin may remain intact following mild trauma, the poor blood supply in this area can result in skin necrosis, infection, bone exposure and post-operative osteomyelitis. Treatment methods vary according to fracture severity and can be challenging in terms of technology and surgeon experience. Choosing the optimal repair method when managing distal tibial fractures has historically been one of the most controversial issues in fracture treatment. Treatment modalities include non-operative management, internal fixation and the use of external fixation devices [1]. Non-operative management of a segmental distal tibial fracture may require a

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long period of immobilisation in a cast, which can lead to fracture redisplacement during healing. When compromised soft tissue occurs with distal tibial fractures, immediate open reduction and internal fixation (ORIF) using plates and screws can result in wound complications, including partial- or fullthickness skin necrosis, wound dehiscence, osteomyelitis and potential amputation [2, 3]. Intramedullary nailing is a common and acceptable method if the fracture is not within 7 cm of the ankle joint, with advantages that include less disability, improved fixation construction and maintenance of anatomical length and alignment [4, 5]. However, when the distal tibial length is <7 cm, rigid interlocking nailing is not possible. Robertson et al. stated that reduction of tibial fractures with unstable intercalary segments is technically demanding and usually requires additional internal fixation to stabilise the free segment while nailing is performed [6]. Also, nailing commonly has a higher incidence of malunion and the need for a second operation to promote union [7]. Standard external fixation is advocated by some orthopaedic surgeons; however, most external frames for the lower leg are bulky and cumbersome for the patient, especially circular frames, leading to problems with sleeping and dressing, and can interfere with the contralateral extremity during walking. The locking compression plate (LCP) has emerged as an external fixator for subcutaneous bone, with satisfactory outcomes when used in the tibia and clavicle [8]. This is because external application of an LCP has many advantages, including angular stability from the locking-head mechanism, reduced irritation because of its low profile compared with traditional external fixators, the possibility of contouring the plate close to the skin [9] and preservation of ankle movement. Since using internal locking plates as external fixators has been described in current literature, we never consider it a novel technique. This study was performed to determine whether such management is suitable for treating closed distal tibial fractures, and we report its successful use in treating closed distal tibial fractures with soft tissue compromise.

Patients and methods All patients were treated at the General Hospital of Jinan Military Command, and this retrospective study was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki. Protocols applied and the publishing of patients’ details were approved by the Hospital Ethical Committee. Written informed consent for publication of their medical details was obtained from patients or their relatives. Patients From May 2011 to July 2014, 23 patients with closed fractures in the distal tibia were treated at our hospital using LCPs as

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external fixators. Average patient age was 39.5 years (range, 12–68). The cause of the fracture was 16 traffic accidents, five falls from a height and two machine stretch/contusion injuries. Patients presented with different degrees of skin and soft tissue contusion and acute osteofascial compartment syndrome; four cases were C I, 15 were C II and four were C III according to the AO/ASIF soft tissue injury classification (Table 1). Surgical technique LCPs were applied as external fixators in 20 patients within 24 hours after trauma and in the remaining three patients after noting reduced swelling, reduced diameter of the lower extremity or skin wrinkling. Therapy to reduce swelling involved three to 14 days of elevating the affected limb and promoting blood circulation through fluid administration IV. With the patient under either general or regional anaesthesia, the involved limb is prepared and draped in sterile fashion. The fibula should be reduced and fixed first, if necessary, and reduction of the tibial fracture is achieved with no skin incisions near the bone in order to avoid damaging the tibial blood supply. The following surgical techniques may be used. First, traction is applied to correct shortening and angulation deformity. Second, in some cases, Kirschner wires are inserted into both proximal and distal tibial fragments and used as levers for better reduction and maintaining alignment. A bone retractor is sometimes necessary to help with reduction. Third, the LCP is applied to a suitable position according to the outline of the distal tibia and fracture location. Temporary stabilisation is accomplished by drilling two Kirschner wires into the tibia, penetrating the dipolar holes of the LCP. The most proximal and distal screw holes are drilled first, and one or two screws are inserted to stabilise the segmental fragment of the tibial fracture, taking care to avoid implanting screws at the fracture site. When the fracture is acceptably reduced and confirmed radiologically, the remaining cortical screws are inserted. Usually, three screws (3.5 or 4.5 mm) are placed into both ends of the fracture. An LCP of sufficient length to span fracture fragments is chosen, and screw position and direction are determined before insertion. Mechanical stability of the external fixator increases by placing the plate as close to the bone as possible while allowing for potential swelling. Bicortical locked screw fixation ensures that no screws are drilled into the articular surface. Postoperatively, patients can shower with the external fixator in place. Physical therapy begins on the second to fifth postoperative day and, depending on reconstruction stability, partial weight bearing is encouraged one to two weeks after surgery. All patients were evaluated radiographically and clinically. Radiographic evaluation was performed using anteroposterior (AP) and lateral radiographs at the time of patient admission, immediately postoperatively and after at least one to six months of follow-up. We evaluated time to union, presence

International Orthopaedics (SICOT) (2015) 39:2227–2237 Table 1

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Patient characteristics and fracture types

Case

Sex

Age

Mechanism of Injury

AO/ASIF soft tissue injury classification

AO/OTA classification

Other fracture

1

M

37

Traffic

C III

42-C2

Calcaneal

2 3

M M

45 55

Traffic Traffic

C IIl C II

42-A3 43-A2

None None

4

F

19

Traffic

CI

42-B1

Fibular

5

M

17

Traffic

C ll

42-C1

Fibular

6 7

M M

35 47

Fall from height Traffic

C ll Cl

43-B2 43-C1

Fibular None

8 9

M F

53 68

Traffic Traffic

C ll C ll

42-B1 42-A1

Fibular None

10

F

12

Fall from height

C ll

43-A2

Fibular

11 12

M F

61 35

Traffic Fall f rom height

C ll C ll

43-A3 43-A1

Pelvis

13 14

M M

42 25

Machine stretch/contusion Traffic

C lll C lll

42-C2 42-B3

None None

15 16 17

F M M

36 56 27

Traffic Traffic Traffic

Cl C ll C ll

42-B1 42-B3 43-A1

None None Skull

18 19 20 21 22

M F M M M

18 38 65 31 46

Fall from height Traffic Machine stretch/contusion Traffic Fall from height

C ll Cl C ll C ll C ll

42-A1 43-C1 42-B1 42-C1 43-C2

Fibular and calcaneal None Metatarsal Ipsilateral proximal tibial Fibular

23

F

41

Traffic

C ll

43-A2

None

of malunion, leg shortening, deep infection and pin-tract infections. We defined union as >50 % visible bridging callus across the fracture on conventional radiographs. The length of the affected extremity was compared with the other by measuring the distance of the anterior superior spine and prominence of the medial malleolus, respectively; >2 cm difference was defined as shortening.

Results Follow-up in the 23 patients ranged from five to 38 months (average, 19.6 months). Average time to radiological bony union was 29.4 weeks, ranging from 14–52 weeks. Fractures in 22 cases (95.65 %) united, and most of them healed in an acceptable position. In one patient (case 21 in Table 1), delayed union occurred in the distal tibia because of both proximal and distal severe comminuted fracture on admission. Due to poor skin and soft tissue conditions, two LCPs were used as external fixators on the medial aspect of the tibia to fix the fractures. At eight months’ follow-up, the proximal fracture united but the distal one did not. Then, the external fixator was removed and replaced with an internal plate with iliac bone graft. The fracture eventually united without complications.

Post-operatively there were late infections, including superficial screw-track infections in two patients, which resolved with antibiotic treatment orally and care of screw sites. We defined deep infections as subcutaneous soft tissue and bone infections, which must be managed by incision or debridement; no deep infections or flap failures occurred. No clinically relevant malrotation or limb-length discrepancies were observed, and no fixator loosening or failure was seen. The skin tolerated the titanium screws and plate well and even adhered to the screws. All patients had good functional results and were fully weight bearing with a well-healed tibia at the final follow-up.

Case report Case 1 A 25-year-old man (No. 14 in Table 1) suffered automobile accident trauma and was admitted to a local hospital with a right distal tibial fracture (Fig. 1). Non-operative management, including primary plaster fixation, was applied because of the degree of lower-extremity swelling and severe skin and soft tissue injury, with several ulcers. Thirteen

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Fig. 3 Appearance of the transferred pedicle flap

Case 2

Fig. 1 X-ray of an AO/OTA 42-B3 fracture of the right tibia

days later, he presented to our institution with a chief complaint of skin necrosis (1 cm×2 cm) and unstable fracture fixation. Pre-operatively, an anteromedial local pedicle flap was designed to cover the wound (Fig. 2). When the flap was transferred, the LCP was applied as an external fixator to repair the fracture (Figs. 3 and 4). Intra-operative X-ray showed acceptable alignment post-operatively. Antibiotics IV were used for 48 hours post-operation, and non-weightbearing exercise was encouraged thereafter. At follow-up ∼ten days later, the flap had survived and the wound had healed well. At the one month follow-up, no infection or loosening of the fixation was seen, and at the nine month follow-up, complete bony union had occurred and the external fixator was removed (Figs. 5 and 6).

Fig. 2 Design of the anteromedial local pedicle flap (2 cm×4 cm)

A 46-year-old man (No. 22 in Table 1) sustained an AO/ASIF C I, AO/OTA 43-C2 fracture of the right tibia and a fibular fracture after falling from a height (Fig. 7). On admission, he had slight swelling and several skin and soft tissue contusions in the lower extremity (Fig. 8). Because he was admitted within two hours of the trauma, there was no extreme swelling; therefore, ORIF was performed on the fibula, and an LCP was used as an external fixator for the tibia to allow for further postoperative swelling. To gain anatomic reduction of the Bpilon^ surface and better stability, a Kirschner wire and a standard compression screw were placed, with reduction of the distal infra-articular fracture using bone tenacula (Fig. 9). One week later, the degree of active motion in the right ankle was similar to the contralateral joint. At the six month follow-up, after bone union, the external fixator was removed easily (Fig. 10) and the patient was walking normally without a brace. Case 3 A 17-year-old man (No. 5 in Table 1) presented with an AO/ AISF C II and AO/OTA 42-C1 distal tibial fracture (Fig. 11). On admission, swelling was apparent in the distal limb, with skin damage, ankle deformity and a dramatic purple skin color, especially in the toes (Fig. 12). Immediate reduction and

Fig. 4 Appearance of the external plate

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Fig. 5 X-ray showing complete bone union at the 9-month followup

fixation was performed to relieve the venous compression symptoms and promote reperfusion, taking care to avoid incisions that would damage the vascular system. Based on preoperative radiographs, we determined that the distal tibial

segment was too small to insert two large Schanz screws, so an LCP was applied. Skin color returned to normal on the second postoperative day (Fig. 13). Radiological union was confirmed at the three month follow-up (Fig. 14), and at nearly five months of follow-up, the external fixator was removed, and excellent functional outcome was obtained (Fig. 15).

Discussion

Fig. 6 X-ray at the 9-month follow-up after external fixator removal

Treating distal tibial fractures remains controversial and challenging for orthopaedic surgeons. Vascularity of the soft tissue sleeve surrounding the distal tibia is tenuous, and aggressive handling with extensive periosteal stripping disturbs nutrition to the myocutaneous tissue and underlying bone [10]. Although Ruedi and Allgower demonstrated good outcomes in their cases by reduction and rigid internal fixation, their results were biased in that the majority of fractures were low-energy injuries [11]. Similar treatment in injuries resulting from highenergy trauma with severe soft tissue compromise or extensive bony communication does not yield good results. Kellam and Waddell reported that 53 % of patients with high-energy compressive fractures had good function compared with 84 % in low-energy injuries [12]. Dillin and Slabaugh also advocated rigid internal fixation only for lower-energy injuries when they had an alarming 55 % infection rate in their series of 11 high-energy trauma patients [13]. Since these reports, reducing devitalisation of soft tissue or bone and minimally

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Fig. 7 X-ray of an AO/OTA 43C2 fracture of the right tibia

invasive operations have become popular, with many authors choosing to use external fixation [14–16]. This management technique is acceptable in tibial fractures complicated with severe soft tissue injury because of the advantages of less secondary iatrogenic injury, ease of application and the ability to dynamise the fixator to promote union [17]. However, stability created by the external fixator cannot be compared with that provided by an LCP. Also, it is impossible to insert Schanz screws when distal tibial length is insufficient or the

Fig. 8 Appearance of the injured leg

fracture line reaches the distal tibial surface. In these cases, ankle-spanning systems can be considered if the surgeon insists on using standard external fixators. However, patients treated with spanning frames have loss of reduction more often than those treated with sparing frames [18]. Also, large pins are associated with a higher risk of soft tissue complications, and ankle-joint articulation affects post-operative mobilisation. Alternatively, many authors have used the Ilizarov circular external fixator for treating such injuries. These frames have smaller pins and do not cross the ankle joint, and it is possible to stabilise the fracture soon after injury. The main disadvantages of the Ilizarov method are the lengthy treatment time and long-term obstruction to walk properly with the frame on. The fixator is also more awkward and bulky than standard external fixators and may cause more discomfort. The minimally invasive plate osteosynthesis technique causes less damage to the blood supply of the injured tibia but would still have caused a skin problem on the medial side of the tibia, particularly distally [5]. When the affected limb is swollen, insertion of a less invasive stabilisation system (LISS) plate more often results in osteofascial compartment syndrome. Reynder et al. [19] reported 23 type 42-C2 fractures treated with LISS plates using the minimally invasive plate osteosynthesis technique. In that series, three patients developed compartment syndrome after immediate plate

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Fig. 9 Immediately post-operative X-ray of the fracture fixation

fixation, and five patients developed post-operative neural palsy of the extensor hallucis longus muscle. Therefore, the authors stressed that long LISS plates cannot be used to stabilise the distal segment in patients with short distal segmental fracture of the tibia and that immediate fixation should be avoided. Although Ma et al. [1] inserted an LCP in a retrograde fashion on the medial aspect of the tibia to prevent nerve and tendon injury, the procedure was performed after the soft tissue had healed or the flap had incorporated well. Two issues in treating distal tibial fractures remain: (1) minimal invasion and (2) developing a repair method that decreases the negative effects of compromised soft tissue that delays timely operation. Sven et al. were the first to describe the use of an LCP as external fixation [20], with Kloen stating that when an LCP is used as an internal fixator, stable connection of the locking screws to the plate does not rely on friction between plate and bone [8]. The principle is similar to the external fixator, which has angle-stabilising properties. Therefore, LCPs are being used as external fixators with increasing frequency. Recently, a number of surgeons demonstrated excellent outcomes in the treatment of infected nonunion, open fractures and bone defects and concluded that the subcutaneous plate osteosynthesis technique combined with an LCP provides adequate stability and is associated with decreased rates of infection and soft tissue complications [5, 8, 9, 20, 21].

In this study, we described closed reduction using LCPs as external fixators for treating closed distal tibial fractures with compromised soft tissue. Clinical outcomes were satisfactory, and we gained experience using this technique. The plate device with locking screws in our series is a minimally invasive approach that maximises tissue preservation. In all cases, we made no incisions (except for fibular fixation, fascial compartment syndrome decompression and flap elevation) near the tibia to achieve tibial reduction, thus preventing damage to the periosteal blood supply. Promising results were shown by Leonard et al., who found that early intervention (<36 hours posttrauma), prior to the initiation of swelling and using the minimally invasive technique, can reduce the rate of soft tissue complications [22]. Most of our patients (86.96 %) were operated on within 24 hours after trauma. The remaining three (13.04 %) were transferred to our hospital several days later, which delayed operation. The benefit to patients from using this technique is that the low-profile external fixator plate is easily concealed under regular clothing, and there is much less tendency for the frame to strike the contralateral lower leg in the swing-through phase of either leg during ambulation [20]. Also, the frame has no sharp edges or points that can injure a patient’s caretaker, which contrasts with standard external fixators. Another beneficial finding is that skin and subcutaneous tissue adhere

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Fig. 10 X-ray showing complete bone union at the 6-month followup

easily to locking screws without pin-site infection. Kloen et al. [8] reported that this could be because the largest screw diameter available in titanium LCPs is 4.5 mm with a threaded

surface, whereas stainless steel Schanz screws are 6.5 mm in diameter with a smooth surface. Once bone union occurs, hardware can be removed in an outpatient setting without anaesthesia or with pain relievers orally, if necessary. From a surgical perspective, the expanded Bscallop^ outline of the distal part of the LCP is similar to that of the distal tibia. This structural feature is beneficial when applied to the distal tibia, and the plate provides multiple locking holes distally, which allows the surgeon to choose the screw holes for distal fixation depending on the fracture pattern, as opposed to

Fig. 11 X-ray of an AO/OTA 42-C1 fracture of the right tibia

Fig. 12 Appearance and skin colour of the injured leg

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Fig. 13 Appearance of the injured leg on the second post-operative day

when using the standard two large external fixator pins. In our experience, to avoid drilling screws across the distal tibial surface, sometimes it is not necessary to lock every screw strictly according to the designed direction of the locking holes in the plate. Because the locking plate provides enough stability and does not cross the ankle joint, rehabilitation can be started early [23]. Several reports have described the use of a two-stage protocol for treating open, severe high-energy tibial fractures [1, 23–25]. We did not apply this method because the fractures in Fig. 14 X-ray showing complete bone union at the 3-month followup

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our series were closed. Initial reduction and one-stage LCP treatment as an external fixator is sufficient and can dramatically decrease the cost and duration of hospitalisation. We agree with other authors that LCPs have the disadvantage that, in contrast to standard external fixators, the plate as external fixator can be harder to manipulate and adjust [8]. The purpose of the standard external fixator is to provide a certain amount of stability and acceptable fracture reduction by inserting several Schanz screws. However, when using LCPs, highly accurate anatomical reduction of the ankle joint and fracture site should be achieved. This can be accomplished easily using the reduction methods we report, including the use of Kirschner wires, then locking screws are drilled into the bone individually to firmly approximate the fragments and plates. However, this procedure requires considerable patience and skill by the surgeon, and it cannot be used in severely communicated fractures. Therefore, in our series, the most serious fracture type was 42-C2 (three cases). Another concern when using an LCP as external fixator is adequate stability of the locking screws in the distal tibia for early weight bearing, and few authors have described exact fixation stability. Apivatthakakul et al. presented one case with only two locking screws in the distal tibia. Weight bearing was resumed early, and no cast or brace was required after final removal of the external fixator [5]. Sven et al. reported that seven cases in which three or four 3.5-mm screws were used for the distal tibia were instructed to toe touch or partially

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Fig. 15 X-ray after removal of the external fixator at the 5-month follow-up

weight bear once the wound was closed [20]. In our study, we encouraged patients to perform non-weight-bearing functional exercises and permit partial weight bearing with a brace or crutch one week post-operatively. We saw no reduction loosening during follow-up. Apivatthakakul et al. inferred that an uninjured fibula or fibular fixation supported the lateral column, affording stability sufficient for partial weight bearing and ankle-joint movement during the distraction/ consolidation phase [5]. All fractures in our study achieved union, although delayed union occurred in one patient with significant proximal and distal tibial fractures. We consider the possible reason is that the LCP cannot sustain compression to the same degree as standard external fixators. Although our patient numbers were limited, our results indicated that LCPs as external fixators did not adversely affect bone union. We attribute our high union rate to the following: (1) LCPs provide good stability for distal tibial fractures; (2) as much anatomic reduction as possible provides sufficient contact surface between fragments; (3) little blood supply to the tibia is destroyed; (4) no bone defects are present. The drawback to our study is lack of a control group. Creating a control group seems difficult, since using the methods

mentioned previously in treating these injuries would obviously result in complications. Further experience with the described technique helps to corroborate its potential advantages or to detect possible drawbacks.

Conclusions In conclusion, high-energy segmental distal tibial fractures are severe injuries with a high risk of complications and poor outcome. For closed fractures with intact skin, soft tissues may be severely affected. Immediate ORIF may result in skin necrosis, infection and nonunion. In our study, LCPs as external fixators proved to be versatile, provided a high rate of union and were easily accepted by the patient. Patients experienced a comfortable clinical course, good ankle-joint motion and satisfactory functional results. All of our cases had mild to moderate comminuted fractures of the distal tibia. Although the fracture line may have reached the distal tibial surface, it was not obvious for displaced intra-articular fractures. We concede that the indications for this technique are limited but believe it is an alternative operative approach for treating closed distal tibial fractures.

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Conflicts of interest The authors declare that they have no conflict of interest.

12.

Funding The authors declare that no funding support was received for this study.

13.

14.

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