J Orthop Spine Trauma. 2017 March; 3(1):e14327.

Published online 2017 March 26.

doi: 10.5812/jost.14327.

Research Article

External Fixation by Locking Plate as a Definitive Treatment of Tibial

Distal Metaphyseal Fractures

Arash Arfa,1, * Seyed Mohammad Javad Mortazavi,1 Mohammad Javad Dehghani Firoozabadi,1 and

Mohammad Zarei1

1Department of Orthopedic Surgery, Imam Khomeini Hospital Complex, Tehran, Iran

*Corresponding author: Arash Arfa, Department of Orthopedic Surgery, Imam Khomeini Hospital Complex, Tehran, Iran. Tel: +98-9123076295, Fax: +98-2166192253, E-mail:arash.arfa@dr.com

Received 2017 January 02; Revised 2017 January 31; Accepted 2017 February 20.

Abstract

Background: Traditional external fixation used for open or soft tissue compromised tibial distal metaphyseal fractures is used bothas a temporizing or definitive treatment to minimize more traumas to the soft tissue, but it has its own shortcomings such as jointspanning and bulky construct. Lower profile locked plates used as external fixation may overcome such problems.Methods: A series of 16 open or with soft tissue compromised tibial distal metaphyseal fractures were treated using locking plateas a definitive external fixator. Time to union, nonunion, malunion, device failure, function for the knee and ankle, and deep andpin tract infections were evaluated.Results: All fractures healed without any complications (nonunion, malunion, device failure, or infections including deep and pintracts). The mean time of fracture healing was 18 weeks (ranged 12 to 26). After walking with full weight-bearing for 1 month, thepatients underwent plate removal. The mean hospital for special surgery (HSS) score was 89 (ranged 84 to 100) and 95 (ranged 91 to100), and the mean American orthopaedic foot and ankle society (AOFAS) score was 93 (ranged 89 to 100) and 95 (ranged 92 to 100)at 4 weeks postoperatively and final follow-up (mean period of 16 months).Conclusions: Application of the locking plate as an external fixator for definitive treatment of distal tibial fractures had the advan-tages of traditional external fixators and at the same time overcame its shortcomings due to its low-profile frame; therefore, it wasmore acceptable to patients and Joint-sparing frame gave the opportunity for early range of motion and function exercise. It was asafe and reliable technique with minimal complications and excellent outcomes.

Keywords: Locking Plate, External Fixator, Tibial Distal Metaphyseal Fractures

1. Background

There are no simple set of rules to treat the fractures ofthe tibia due to their nature. Open fractures and compro-mised soft tissue problems are more common here than inany other major long bones; hence, wound complicationsafter immediate open reduction and internal fixation ofsuch fractures are always a major issue in their treatment,particularly in distal metaphyseal part (1-3). Traditional ex-ternal fixation was used for such cases, both as a temporiz-ing and definitive treatment, for many years (4, 5). How-ever, several problems such as joint stiffness and patientacceptance remained. Recently there is a developing trendto use internal locked plates as external fixation construc-tion, either in 2-staged treatment plans or for definitiveones (6-11). These are attractive options due to the benefitsof traditional external fixation in minimizing soft tissuetrauma, and overcoming disadvantages such as joint stiff-ness and muscle atrophy due to bridging across the joint orpatient acceptance of their bulky frames. However, there

is few information available about effectiveness and alsocomplications of this treatment in the literature; hence thecurrent study aimed at evaluating the outcomes of the ex-periences of treating the patients by this method.

2. Methods

From March 2014 to April 2015, a total of 16 patientswith an open or soft tissue compromised tibial distal meta-physeal fracture underwent external fixation by lockingplate as definitive treatment at the under study institute.There were 13 males and 3 females with a mean age of 40years (ranged 23 to 67). Four patients sustained a fractureas a result of falls from height and 12 patients sustained afracture in traffic accidents. There were 11 open fractures,including 3 Gustilo type I, 4 Gustilo type II, and 4 Gustilotype IIIA (Table 1).

All patients were evaluated clinically and radiograph-ically at the time of admission, immediately postopera-tively, and every 1 to 3 months at follow-up for: time to

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union (counted from the initial trauma) defined as pain-less full weight bearing and 4 cortices bridging callusin radiographs; complications defined by fixation failure,nonunion, malunion, deep and pin tract infections andalso functional outcomes of the joint using the hospital forspecial surgery (HSS) knee scoring system and Americanorthopaedic foot and ankle society (AOFAS) ankle scoringsystem.

2.1. Surgical Technique

Under general or spinal anesthesia, in the supine posi-tion the affected lower limb was prepared and draped in astandard sterile fashion, without tourniquet.

For open fractures, after initial debridement, externalplating was performed primarily during the emergencyoperation.

By indirect or direct methods, tibia was reduced andaligned; it was achieved through the open wound or shortincisions extending from the wound, or if necessary, bymaking small incisions around the fracture site; followedby using a clamp or K-wires for provisional stabilization.Then, before definitive external fixation, soft tissue wasclosed.

Anatomical locking plate of distal of tibia was placedon the anteromedial aspect of the tibia as close as possibleto the skin and 4 - 5 bicortical locking screws on each endof the fracture were applied through stab incisions in theintact overlying soft tissue, and then, the position and ori-entation of them were checked by fluoroscopy.

Screw tracks were cleaned with 75% alcohol daily, pa-tients were allowed partial weight-bearing from the sec-ond postoperative day and taking shower with the externalfixator in place from 5 days after wound closure. Once cor-tical bridging was observed on radiographs, the patientswere allowed to walk with full weight-bearing for 1 monthbefore removing the plate in the clinic.

3. Results

All patients were followed up for a mean period of 16months (ranged 13 to 21).

All fractures healed without any complications(nonunion, malunion, device failure, or infections in-cluding deep and pin tracts). The mean time for fracturehealing was 18 weeks (ranged 12 to 26). After walking withfull weight-bearing for 1 month, the patients underwentplate removal.

The mean HSS scores was 89 (ranged 84 to 100) and95 (ranged 91 to 100), and the mean AOFAS scores was 93(ranged 89 to 100) and 95 (ranged 92 to 100) at 4 weeks post-operatively and final follow-up.

Table 1. Patients’ Demographics

Case Age Gender Soft Tissue

1 44 F Gustilo I

2 23 M Gustilo II

3 67 M Gustilo IIIA

4 45 M Closed

5 32 M Gustilo IIIA

6 54 M Closed

7 55 M Closed

8 27 M Closed

9 30 F Gustilo II

10 51 M Closed

11 43 M Gustilo II

12 23 M Gustilo I

13 35 M Gustilo IIIA

14 62 F Gustilo IIIA

15 57 M Gustilo I

16 42 M Gustilo II

4. Discussion

External fixation is an accepted and useful tool to treattibial fractures. These devices are commonly used to treatopen or closed fractures with compromised soft tissuethroughout the length of the tibia, because they providefixation and at the same time preserve soft tissue andbone vascularity and access to the wound. There are sev-eral indications to use them instead of internal fixation,both as a temporizing and definitive treatment, such as se-vere open fractures, open fractures receiving delayed treat-ment (> 24 hours), severely contaminated fractures, man-agement of fractures with bone loss, patients with verysmall medullary canals, fractures associated with burnsor wounds over the tibial nail entry portal, fractures withvascular injury, war injuries, and in some patients withmultiple-system trauma; also, in patients with unstableclosed fractures, fractures with compartment syndrome,segmental fractures with a periarticular component, andhead injury or impaired sensation. However, they are as-sociated with problems such as joint stiffness and muscleatrophy due to bribing over joints for a long time and thereis a patient acceptance issue because of their bulky instruc-tions.

It seems that the idea to use locked plating for angu-lar stability principle was described for internal fixation(12) even before that of external fixation. A group of Pol-ish surgeons in the 80s developed a system with conven-

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Figure 1. A, a 23-year-old patient with an open distal tibial fracture; B, fracture healing and plate removal after 20 weeks.

tional plates and screws, which was applied to the medialaspect of the tibia, but outside the skin and were lockedwith some sort of washers in the screw holes (13). They were

attractive options because of having benefits of traditionalexternal fixation in minimizing soft tissue trauma and pre-serving soft tissue vascularity; due to their lower profile,

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they can overcome traditional external fixation disadvan-tages such as patient acceptance issues of the bulky frames,and can also provide stable fixation without bridging overjoints, and therefore, prevent joint stiffness and muscle at-rophy, which is a major problem with the traditional fixa-tions. Recently, using locked plates as external fixation findits way back to management of several conditions such asinfected nonunion and open fractures.

Kloen et al., used locking compression plate as an ex-ternal fixator and called it supercutaneous plating (9, 10).The LCPs were used as temporary or definitive externalfixators to manage infected nonunion fractures and con-cluded that this technique was versatile, low profile, andwell tolerated by their patients. Although its indicationsare relatively limited, it can be a useful adjunct to treatcomplex reconstructive cases.

Ma et al., (6-8) designed a 2-stage protocol to treat opentibial injury using locking plates as external fixation; theyfirst used low profile locking plates for temporary externalfixation after debridement and anatomic reduction, fol-lowed by soft tissue reconstruction. Then, they used lock-ing plates for definitive internal fixation. Also, 8 open tibialfractures healed without major complications by only thefirst-stage treatment due to patients’ refusing the second-stage treatment. These patients also experienced a com-fortable clinical course, excellent knee and ankle joint mo-tion, satisfactory functional results and an acceptable com-plication rate (11).

In the current study, anatomical distal tibia lockingplates were used as an external fixator for definitive treat-ment of a series of 16 open and closed plates with compro-mised soft tissue distal tibial metaphyseal fractures, andthe clinical outcomes and complications were evaluated.

Application of lower profile locking plates as joint-sparing frame of external fixation provided the advantageof early range of motion of joints and avoiding stiffness,which is a major issue in spanning frames of traditionalexternal fixation. Koulouvaris et al., found that patientswith external fixation and the ankle spanning experiencereduced activity, compared with the ones with external fix-ation and the ankle sparing to treat severe pilon fractures(14). In the current study, the functional recovery of ad-jacent joint was evaluated using HSS knee scoring systemand the AOFAS ankle scoring system.

The mean HSS scores was 89 (ranged 84 to 100) and95 (ranged 91 to 100), and the mean AOFAS scores was 93(ranged 89 to 100) and 95 (ranged 92 to 100) at 4 weeks post-operatively and final follow-up that was satisfactory.

Infection is always a major problem in the treatmentprocedure of open or closed compromised soft tissue dis-tal tibial fractures. Dillin and Slabaugh (15) reported 36%rate of skin slough and a 55% rate of deep infection on

a total of 11 patients with severe tibial plafond fracturestreated with early ORIF (the open reduction internal fixa-tion). However, the employment of the 2-stage treatmentdecreased the high complication rates. Sirkin et al., (4) re-ported the results of pilon fractures treated with stagedmanagement. The deep infection rates were 3.4% and 10.5 %for closed and open pilon fractures, respectively. The ratesof partial thickness skin necrosis were 17% in patients withclosed pilon fractures and 10.5% in patients with open pi-lon fractures. In the current study, all of fractures in the pa-tients healed completely without any signs of deep or pintract infections.

In conclusion, using the locking plate as an external fix-ator for definitive treatment of distal tibial fractures hadthe advantages of the traditional external fixator includingminimized trauma to the soft tissue and complications af-ter immediate open reduction and internal fixation of tib-ial fractures with compromised soft tissue, and at the sametime overcame the shortcomings of standard external fix-ators due to its low-profile frame; therefore, it is more ac-ceptable to patients and Joint-sparing frames give the op-portunity for early range of motion and function exercise.

It is a safe and reliable technique with minimal com-plications and excellent outcomes. However, more stud-ies are needed to definitely confirm the results of this tech-nique.

Footnote

Conflict of Interest: Authors declared no conflict of inter-est.

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