Orthopaedics & Traumatology: Surgery & Research (2012) 98, 564—569

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ORIGINAL ARTICLE

Advantage and limitations of a minimally-invasive

approach and early weight bearing in the treatment
of tibial shaft fractures with locking plates
P. Adam ∗, F. Bonnomet , M. Ehlinger

Department of Orthopaedic Surgery and Traumatology, Musculoskeletal Unit, Strasbourg Academic Hospital Group,
Hautepierre Hospital, 1, avenue Molière, 67098 Strasbourg, France

Accepted: 5 April 2012

KEYWORDS
Summary
Tibial shaft fracture;
Objectives: Intramedullary nailing is a common method of treating tibial shaft fractures. How-
Locking plate;
ever, precise control of reduction at the proximal and distal quarters is difficult to achieve. The
Minimally-invasive
purpose of this study was to assess the results of plating using locking screws and the feasibility
surgery;
of a minimally-invasive approach.
Osteosynthesis;
Patients/participants: All patients with tibial shaft fracture treated by means of locking plates
Internal fixation
from January 2004 to October 2006. Thirty-two fractures were treated in 32 patients with a
mean age of 43.8 years.
Intervention: Internal fixation with a locking plate and screw construct, using a minimally-
invasive or standard approach.
Main outcome measurements: Surgical approach, time to weight bearing, complications and
their type, time to bone union, alignment in the frontal and sagittal planes on anteroposterior
and lateral radiographs.
Results: The minimally-invasive approach was performed in 28 cases and immediate full weight
bearing allowed in 25 cases. At a mean follow-up of 27 months, two patients had died and two
patients were lost to follow-up. The mean time to bone union was 9.1 weeks. Four cases had
a complicated course: one infection, one compartment syndrome, one hardware breakage and
one pseudarthrosis. Six cases ended up with valgus malunion exceeding 5◦ in the frontal plane,
already present at the time of surgery.
Conclusion: Where a minimally-invasive approach can be performed, immediate pain-free
weight bearing can be allowed without further displacement at follow-up. The observed rate of

∗ Corresponding author.
E-mail addresses: philippe.adam@chru-strasbourg.fr, phradam@gmail.com (P. Adam).

1877-0568/$ – see front matter © 2012 Published by Elsevier Masson SAS.

doi:10.1016/j.otsr.2012.04.013
Tibial shaft fractures treated with locking plates 565

malunion underlines the need for adequate reduction and shows that the rationale for success
does not solely depend on the plate anatomic design but also on the skills of the operating
surgeon.
Setting: Level I university regional hospital Cohort study.
© 2012 Published by Elsevier Masson SAS.

Introduction from titanium alloy. Two types of plates were used: proxi-
mal, lateral tibial plates to treat proximal or middle third
Locked intramedullary nailing is the gold standard for treat- fractures and distal, medial tibial plates to treat middle
ing fractures of the tibial shaft [1]. This technique is known third or distal fractures.
to be difficult when treating fractures that involve either Surgery was performed as an emergency procedure in the
the proximal or the distal quarter of the tibia, although case of open fracture and all the other cases were operated
Nork’s work proved that intramedullary nailing is an effec- within 3 days following trauma (median 1 day).
tive alternative for the treatment of distal tibial fractures Patient positioning for surgery depended on the fracture
[2,3]. In proximal and distal fractures, adequate reduc- type and operating surgeon. Positioning was either per-
tion is difficult to obtain and difficult to maintain with an formed using a traction table, with the reduction obtained
intramedullary nail, due to metaphyseal widening of the using transcalcaneal skeletal traction, or on a standard
tibia associated with a long lever arm. Therefore, some table, with the reduction obtained using a temporary exter-
authors advocate the use of plates in order to treat frac- nal fixator (tibiotibial for proximal or middle third fractures,
tures involving the proximal [4,5] or the distal [6,7] quarters tibiocalcaneal for distal fractures) (Fig. 1A and B) or a trac-
of the tibia. The purpose of this study was to assess the tion manually applied by the attending surgeon. In the cases
results of plating when treating fractures of the tibial where a simple fracture of the distal fibula was associated
shaft. We report the results of a consecutive retrospective with the tibial fracture, osteosynthesis of the fibula was
series of fractures of the tibial shaft treated with locking performed first. The control of length and rotation of the
plates mainly through a minimal-invasive approach, and with fibula provided an indirect partial reduction of the tibia
immediate, full weight bearing allowed in the postoperative with an indication of its appropriate length [8] (Fig. 2A and
course. B). Reduction was obtained using a traction table in seven
cases. A standard table was used in 25 cases and reduc-
tion obtained using an extemporaneous external fixator in 22
Material and methods cases and with the help of manually applied traction in three
cases.
The series The ‘‘minimal-invasive approach’’ performed depended
on the type of plate being used. A proximal anterolate-
This series includes all fractures of the tibial shaft, according ral approach was performed when using proximal tibial
to the AO Classification, and treated with a locking plate in plates and a distal medial paramalleolar approach was per-
a level I academic regional hospital, from March 2004 until formed when using distal tibial plates. Osteosynthesis was
October 2006. performed through a minimal-invasive approach, the plate
We reviewed 32 consecutive fractures retrospectively. being slid subcutaneously and outside of the periosteum.
There were 32 patients, 14 women and 18 men, with a mean The Less Invasive Stabilization System (LISS) instrument was
age of 43.8 years (16—90) at the time of surgery. All were used when inserting a proximal lateral tibial plate, allowing
closed fractures with the exception of one Gustilo I frac- for percutaneous insertion of distal screws. In order to bet-
ture. According to AO Classification, diaphyseal fractures ter distribute and absorb strains, it was advocated to use
involved the proximal third in five cases, the mid-third in one a long construct, with at least five holes beyond the frac-
case and the distal-third in 26 cases. Among the fractures ture and to leave one hole unfilled between two consecutive
located in the distal third, eight had an extension down to screws [9]. All screws were fixed bicortically. According to
the tibial plafond, without articular involvement. They were previously published data, when using this kind of construct,
classified as 43C1, according to AO Classification, because of pain-free weight bearing was allowed postoperatively for
the fracture extending down to the tibial plafond, without patients with a Body Mass Index less than 30 [9].
displacement at articular level, although the main com-
ponent of the fracture was located in the diaphysis. The
remaining fractures were mainly A Type and were comprised
Evaluation criteria
of 21 cases of 42A1, txo cases of 42B1 and one case of
42B3.
At follow-up, clinical and radiographic data were recorded.
To document bony consolidation, bridging callus on three
Surgical technique cortices was sought on anteroposterior and lateral views,
combined with pain-free full weight bearing. Malunion was
The hardware consisted exclusively of anatomical locking defined as a deformation exceeding 5◦ in frontal, sagittal
plates (LCP, Synthes GmbH, Solothurn, Switzerland) made and transversal plans [6].
566 P. Adam et al.

Figure 1 Compound proximal tibial fracture. Reduction using temporary external fixation. A. Standard X-ray, anteroposterior and
lateral view. B. Peroperative X-ray showing quality of reduction.

Figure 2 Spiral fracture of the leg. Reduction and primary osteosynthesis of the fibula. A. Standard X-ray of the fracture,
anteroposterior view. B. Standard X-ray at consolidation. Long construct and spaced screws beyond the fracture line.

Results representing 28 fractures could be assessed with clinical

and radiological data at follow-up. One patient presented
The mean follow-up was 27 months, range from 14 to 45 a hardware breakage, needing reoperation.
months. At follow-up, two patients representing two frac- Among 32 initial cases, a minimal-invasive approach was
tures, died at respectively 4 days and 4 months after surgery performed 28 times. Exposure of the fracture site was per-
from causes unrelated to the fracture itself (acute myocar- formed four times. In one case was on an open fracture. The
dial infarct in the first case and complications following a reduction was performed through the wound. In two cases
cerebral ischemic attack sustained 43 days postoperatively the operating surgeon choose to manage the reduction with
in the second case). The patient who died at 4 months had no further justification. In the last case open reduction was
documented bone healing on X-ray examination, 10 weeks done because of technical difficulties.
after surgery. Two other patients had been lost to follow-up In the postoperative period, weight bearing up to
after bone healing had been documented, and could not be pain threshold was allowed and performed in 25 cases.
assessed clinically at follow-up. The results on 28 patients Weight bearing was forbidden for 6 weeks in four cases,
Tibial shaft fractures treated with locking plates 567

Figure 3 Mechanical failure, due to breakage of the plate at six weeks postop after an open mid-diaphyseal fracture. A. Pre-
operative anteroposterior and lateral view. B. Anteroposterior and lateral view at consolidation, after treatment using anatomical
distal tibial LCP plate.

corresponding to the earliest cases. Partial weight bearing [10], for the proximal part, and by Refdern et al. [6] and
up to 20 kilograms was recommended three times for Helfet et al. [7], for the distal part; but in all these cases,
compound fractures. the fracture line was metaphyseo-epiphyseal or diaphyseo-
Four cases had a complicated evolution. We found: metaphyseal. It is, therefore, difficult to compare their
1 postoperative infection of the operative site, due to results to our series of diaphyseal fractures. Treatment of
meticillin-sensitive Staphylococcus aureus; infection was a few cases of diaphyseal fracture of the tibia using locking
treated with hardware removal, lavage and antibiotherapy. plates combined with a minimal-invasive approach was pre-
One compartment syndrome. One non-union, with no sign viously published by Hasenboehler et al. [11]. These authors
of infection. One hardware breakage 6 weeks after surgery reported a series of 32 cases not exclusively diaphyseal
(Fig. 3). in their location, also comprising distal metaphyseal tibial
Radiologically, the mean time to consolidation was 9 fractures.
weeks (from 6 to 12 weeks). Excluding the patient died Our series is original, when considering the postoperative
4 days after surgery, 31 cases of tibial shaft fracture rehabilitation regimen in use. Weight bearing up to pain
were treated with locking plates. Out of these, 29 frac- threshold was allowed in 27 cases out of 32 (80%). Weight
tures united (93,5%) without any further intervention to bearing was allowed because the locking plate system that
promote bone healing. No malrotation was diagnosed on was used acts as a monobloc construct, ending up in a
clinical examination at follow-up. Radiographic examination true internal fixator with three anchorages per screw (two
at consolidation showed a valgus deviation of more than cortices and the plate), as described by Perren [12]. The
5◦ in six cases out of 29 (5 to 12◦ ). Malunion occurred in long constructs, with well-spaced bicortical locking screws
one proximal tibial shaft fracture and in five distal tibial that were used, allowed for the spreading and absorption
shaft fractures. Deformations observed at consolidation of the strain under application of load (Fig. 2) as stated by
were already present immediately postoperatively and did Ehlinger et al. [9]. These constructs corresponded to the
not increase despite weight bearing. No cases out of these so-called ‘‘bridging effect’’ of the fracture (Fig. 4). True
with minimal-invasive approach, showed postoperative dis- anatomical reduction, as with nailing, was not necessary,
placement, despite immediate weight bearing. All the four only alignment at the length of the whole bony segment
cases united uneventfully. No malunion in the sagittal plan was targeted [12,13].
were found at follow-up. In the whole of the series, there was one mechanical
failure, with breakage of the plate six weeks postopera-
tively, weight bearing having been allowed immediately
Discussion after surgery. This breakage was caused by a fatigue fracture
of the hardware, due to imbalance of the strain applied to
The cases of plating osteosynthesis of the tibial shaft the plate. Indeed, this was a compound, mid-shaft fracture
reported in this series involved mostly particular indications, with a fragmented wedge (42B3). The construct obtained
namely proximal or distal diaphyseal fractures known to be in this case was not mechanically satisfactory: a notable
difficult to treat with the standard nailing technique. Plating gap between the fracture line and the nearest screws on
was used only once as a first choice, when treating mid-shaft each side of the fracture left a weakness zone at the level
fractures: in one open fracture (choice of the operating sur- of the fracture (Fig. 3). Stoffel et al. [14] have recom-
geon). The experience of treating complex tibial fracture mended locking screws to be positioned the nearest possible
has been reported by Phisitkul et al. [4], and Schutz et al. to a compound fracture in order to better stabilize it and
568 P. Adam et al.

Figure 4 Least displaced tibial fracture with distal articular irradiation. A. Standard X-ray, anteroposterior view. B. Standard
X-ray, anteroposterior and lateral view after breakage of the plate.

to leave one to two holes unfilled on each side of the formation was 9 weeks (7 to 12 weeks), according to Red-
fracture, in the case of a simple fracture, to allow the fern et al. [6], in a series of 22l fractures of the distal
elasticity of the titanium to come into play, made possible tibia treated using a minimal-invasive approach, 15 weeks
with weight bearing. Hasenboehler et al. [11], in a series (8 to 24 weeks), according to Phisitkul et al. [4], in a
of 32 leg fractures, observed one mechanical complication series of 21 distal metaphyseal fractures treated percuta-
with bending of the plate following early weight bearing, neously, and 12 weeks (6 to 20 weeks), according to Phisitkul
in the case of a 42C3 fracture according to AO Classifica- et al. [4] in a series of 37 complex proximal epiphysiometa-
tion. physal fractures. Comparison with other series was difficult,
The minimal-invasive approach allowed in theory to com- because they consider consolidation as the time of pain-free
bine the principles of a stable construct to a closed reduction full weight bearing. Hasenboehler et al. [11] reported 27
with conservation of the haematoma. However, we report patients out of 30 (two lost to follow-up) healed at 9 months
1 nonunion in our series (3,6%). Hasenboehler et al. [11] (walking with pain free full weight bearing and bony callus).
also reported two non-unions out of a series of 32 frac- The association we recommend, between weight bearing
tures. Zelle et al. [15] found similar figures in a systematic and a minimal-invasive approach conserving the haematoma
review of 1125 extra-articular fractures of the distal tibia might explain the shortening time before the appearance of
treated with plating or nailing: a 5,2% nonunion rate when good quality endosteal callus. In no other series reported
using plates and 5,5% when using nails. The CECOP study was free weight bearing allowed. This might have been of
[16] that gathers the largest series of intramedullary nai- benefit—stimulation of the fracture site owing to the elasti-
ling of the tibia reports 3,2% rate of nonunion. The time to city of the plate. The minimal-invasive approach might play
consolidation reported in our series was slightly reduced, a protective part by preserving the local biology of bone and
when compared to the data known from the literature con- soft tissues as stated by Helfet et al. [7], Hasenboehler et al.
cerning plating osteosynthesis. The mean time for callus [11], Perren [12], Oh et al. [17].
Tibial shaft fractures treated with locking plates 569

The main factor that led us to use locking plates to References

treat fractures of the tibial shaft was the difficulty in con-
trolling the reduction of the proximal or distal fractures [1] Kempf I, Grosse A, Lafforgue D. Combined Kuntscher nailing
with intramedullary nailing. Radiographic results that we and screw fixation. Rev Chir Orthop 1978;64: 635—51.
report did not meet our expectations. Our series included six [2] Nork SE, Schwartz AK, Agel J, Holt SK, Schrick JL, Winquist RA.
cases (18,8%) with valgus mal-alignment exceeding 5◦ . In the Intramedullary nailing of distal metaphyseal tibial fractures. J
CECOP study [16], there were 15,1% mal-alignment in the Bone Joint Surg 2005;87A:1213—21.
whole series, mostly in valgus, and up to 26,5% at the proxi- [3] Nork SE, Barei DP, Schildhauer TA, Agel J, Holt SK, Schrick JL,
mal third and 17,6% at the distal third, the difference being et al. Intramedullary nailing of proximal quarter tibial frac-
tures. J Orthop Trauma 2006;20:523—8.
statistically significant. In the proximal third, we found one
[4] Phisitkul P, McKinley TO, Nepola JV, Marsh JL. Complications
mal-alignment out of five fractures, and in the distal third, of locking plate fixation in complex proximal tibia injuries. J
five mal-alignments out of 26 fractures. The essential fac- Orthop Trauma 2007;21:83—91.
tors that could be elicited were: lack of experience of the [5] Lang GJ, Cohen BE, Bosse MJ, Kellam JF. Proximal third tibial
operating surgeon, failure to use the anatomical characte- shaft fractures. Should they be nailed? Clin Orthop Relat Res
ristics of the LCP plates (most epiphyseal screws parallel to 1995:64—74.
the joint line), lack of osteosynthesis of the fibula. Accor- [6] Redfern DJ, Syed SU, Davies SJ. Fractures of the dis-
ding to Egol et al. [6] osteosynthesis of distal fractures of the tal tibia: minimally invasive plate osteosynthesis. Injury
fibula, when they are simple and associated with a fracture 2004;35:615—20.
of the distal tibia, should be performed first; because this [7] Helfet DL, Shonnard PY, Levine D, Borrelli Jr J. Minimally inva-
sive plate osteosynthesis of distal fractures of the tibia. Injury
allows control of the length and the rotation. Osteosynthe-
1997;28S1:A42—7.
sis of the fibula also maintains the reduction in the future. [8] Egol KA, Weisz R, Hiebert R, Tejwani NC, Koval KJ, Sanders RW.
The CECOP study [16] also proved statistically the protective Does fibular plating improve alignment after intramedullary
effect of the use of a traction table against the occurrence nailing of distal metaphyseal tibia fractures? J Orthop Trauma
of malunions and the unfavourable effect of fracture com- 2006;20:94—103.
minution. In our series, although not statistically significant, [9] Ehlinger M, Cognet JM, Simon P. Treatment of femoral fracture
four malunions had been preceded by a temporary reduction on previous implants with minimally-invasive surgery and total
using a temporary external fixator. weight-bearing: benefit of locking plate. Preliminary report.
Osteosynthesis by means of locking plates and a minimal- Rev Chir Orthop 2008;94:26—36.
invasive approach is demanding and requires the mastering [10] Schütz M, Kääb MJ, Haas N. Stabilization of proximal tibial frac-
tures with the LIS-System: early clinical experience in Berlin.
of the implant and its biomechanics. Conversely to what was
Injury 2003;34S1:A30—5.
noted by Hasenboehler et al. [11], the bridging effect was [11] Hasenboehler E, Rikli D, Babst R. Locking compression plate
a real advantage of this hardware, allowing the treatment with minimally invasive plate osteosynthesis in diaphyseal and
of almost all types of fractures. We advocate early weight distal tibial fracture: a retrospective study of 32 patients.
bearing within the pain-free range, as long as the construct Injury 2007;38:365—70.
is mechanically sufficient: the use of titanium alloy, with a [12] Perren SM. Evolution of the internal fixation of long bone
long construct and spaced locked screws, and screw place- fractures. The scientific basis of biological internal fixation:
ment at a distance from stable fracture lines. This kind of choosing a new balance between stability and biology. J Bone
surgery requires preoperative planning. Joint Surg (Br) 2002;84:1093—110.
[13] Wagner M. General principles for the clinical use of the LCP.
Injury 2003;34:31—42.
Conclusion [14] Stoffel K, Dieter U, Stachowiak G, Gachter A, Kuster
MS. Biomechanical testing of the LCP–How can stability
Radiological results we report led us to be cautious in locked internal fixators be controlled? Injury 2003;34S2:
and proved the necessity of rigorous technique. Plating B11—9.
osteosynthesis did not prove superior to nailing in the treat- [15] Zelle BA, Bhandari M, Espiritu M, Koval KJ, Zlowodzki M.
Treatment of distal tibia fractures without articular involve-
ment of tibial shaft fractures, when considering the quality
ment: a systematic review of 1125 fractures. J Orthop Trauma
of reduction obtained radiographically with comparable
2006;20:76—9.
results. However, using this system can allow early weight- [16] Terver S, Miazzolo N, Hery JY. Prospective and retrospec-
bearing within a pain-free range; and in association with tive study of complications after centromedullary nailing
minimal-invasive approach, this might be beneficial related of weight-bearing bones (CECOP study). Rev Chir Orthop
to the time to consolidation. 2005;91S5:S155—82.
[17] Oh CW, Kyung HS, Park IH, Kim PT, Ihn JC. Distal tibia metaphy-
seal fractures treated by percutaneous plate osteosynthesis.
Disclosure of interest
Clin Orthop Relat Res 2003;408:286—91.

P. Adam and M. Ehlinger: consulting for Synthes.

F. Bonnomet: none.