DOI: 10.7860/JCDR/2016/15367.

7332
Original Article

Minimally Invasive Plate

Orthopaedics Section

Osteosynthesis with Locking

Plates for Distal Tibia Fractures
Ajeet Dhakar1, Rajendra Annappa2, Mahesh Gupta3, Hemeshwar Harshwardhan4, Prem Kotian5, Pooja K. Suresh6

ABSTRACT Results: The fractures united in 48 (96%) patients with 2 (4%) cases
Introduction: Distal tibia fractures are challenging injuries with of delayed union which took 30 weeks of time. Postoperatively, 2
multiple fixation options. Minimal invasive plating for distal tibia patients developed superficial skin infection, 2 patients developed
fracture is becoming more popular with documented good deep infection and 3 patients developed ankle stiffness due to loss
outcomes. of postoperative protocol and 4 patients had implant failure in form
of screw breakage. Good amount of range of mobility of ankle joint
Aim: To evaluate the functional and radiological results of fixation
was present in almost all patients.
of distal tibia fractures with locking plates with Minimally Invasive
Plate Osteosynthesis (MIPO) technique. Conclusion: MIPO with locking plates for distal tibia fractures
is associated with good functional outcomes and is an effective
Materials and Methods: Fifty fractures of distal tibia without
treatment for distal tibia fractures. Although, a larger sample of
Intra-articular extension were operated with locking compression
patients and longer follow up are required to fully evaluate this
plating with MIPO technique. They were followed up at regular
method of treatment, we strongly encourage its consideration in
intervals. Functional and radiological results were evaluated at the
the treatment of such complex fractures.
end on one year.

Keywords: Biological fixation, Distal tibia locking plates, MIPO for extraarticular fractures

INTRODUCTION conventional plate and better protection against loss of reduction

Distal tibia fractures are challenging injuries. They are primarily and minimization of bone contact. Preservation of vascularity of
located within a square based on the width of the distal tibia without fracture fragments, fracture haematoma and minimal soft tissue
intra-articular extension. They are often caused by high energy axial damage favour minimally invasive percutaneous plating for distal
compressive, direct bending or low energy rotation forces. These tibia fractures [6-11].
fractures constitute less than 7% of all the tibial fracture and less This study was planned to assess the union rate, deformity, leg
than 10% of all lower extremity fractures. The aim of treating the length discrepancy, gait and ankle range of motion, return to previous
fracture is to preserve normal mechanical axis, ensure joint stability daily and sports activities, and infections and other complications
and restore a near full range of motion. This is a difficult task to associated with distal tibial plates.
accomplish in each and every case as we face compromised soft
tissue condition, variable bone quality and associated medical MATERIALS AND METHODS
conditions [1,2]. Fifty patients with distal tibia fractures treated with locked com­
Conservative management can be done in selected cases when­ pression plating were included in the study. This was a prospective
ever fractures are stable with minimal shortening. High rate of study done in a tertiary care centre from June 2010 to December
complications like malunion, limb length discrepancy, decreased 2014. All patients with age >18 years, closed fractures without
range of motion and early osteoarthritis of the ankle have been intra-articular extension and Gustillo type 1 fractures were included.
reported following conservative treatment of these fractures [3-5]. Intra-articular fractures, tibial shaft fractures, elderly patients with
Surgical fixation is considered for most distal tibia fractures co-morbid condition, non-weight bearing limb, pathological frac­
which require meticulous preoperative planning. Available tures and Gustillo type II open fractures were excluded. AO/OTA
options for stabilizing fractures are external fixators, interlocking classification system was used to classify fractures [1]. Institutional
nails and locking plates. The factors determining the fixation ethics committee clearance was taken for study. Informed consent
methods are pattern of fracture, quality of bone and condition was obtained from all patients before surgical procedure and for
of soft tissues [5-8]. participation in the study.

Ruedi TP et al., advocated open reduction and internal fixation with

Operative Technique
plate as the standard method of treatment of distal tibia fractures
Complete preoperative radiographic assessment was done and
[3]. Results of conventional osteosynthesis with plates have been
preoperative plan was prepared. Broad spectrum intravenous
suboptimal with reported complications of wound infection, skin
antibiotics were given immediate preoperatively. The patient
breakdown and delayed union or non-union, requiring secondary
was positioned supine on a radiolucent operating table under
surgical intervention. Locking compression plating has gained
spinal or epidural anaesthesia. Locking Plate Osteosynthesis is
popularity and is being used frequently for fixation of distal tibia
done with the MIPO technique. Incision is made over the medial
fractures. With the use of minimal invasive techniques excellent
malleolus measuring about 3cms with a gentle curve, sparing
results are obtained in complex fractures. Many studies are
the saphenous vein and nerve. Extraperiosteally a tunnel is
available in literature where encouraging results are reported.
made by blunt dissection in right orientation. Anatomical distal
Locking compression plating is technically feasible and creates a
tibial locking plate is passed through this tunnel by retrograde
stable, fixed angle device when locking screw heads lock itself with
technique. Locking sleeves can be attached to plate and used
the plate. Locking plates provide excellent stability compared to a
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to hold the plate at distal end while insertion. Plate is passed in alignment. Clinically union was defined as painless fracture site
such a way that end of plate is visualized adequately and screws during full weight bearing. Radiographically fracture was considered
can be inserted distally. Using C arm plate is adjusted to meet the united if 3 of 4 cortices in 2 radiographic views were continuous.
contour of the bone. Fracture reduction is achieved under image Patients were followed up for a period of 1 year at 6 weeks, 12
intensifier by assessing length, axial and rotational alignment. weeks, 3 months, 6 months and 1 year [Table/Fig-2]. At the final
Plates can be held temporarily by K wires whenever required. follow up patients were evaluated using American Orthopaedic Foot
Varus-valgus angulation of <50, anterior posterior angulation <100, and Ankle Society (AOFAS) score [16].
and shortening of <15mm were considered acceptable reduction.
Sagging of distal fragment at fracture site-can be prevented by RESULTS
elevating fracture site with a bolster and plantar flexion of foot In this study, 50 fractures of distal fourth fractures of tibia in adults
[Table/Fig-1]. A locking cortical or cancellous screw is inserted. were surgically managed by reduction and internal fixation with
Fracture reduction is confirmed and cortical screw is inserted into minimally invasive plate osteosynthesis (MIPO). The age of the
proximal diaphyseal fragment which helps plate to contact with patients in this study, ranged from 22 years to 62 years average
plate surface [8]. Remaining screws are inserted by stab incisions. being 41 years. There were 34 male and 16 female patients, 26
Associated fibula fractures when present at syndesmotic level patients had fracture of left and 24 patients had fracture of right
was fixed with plates or Rush nail depending on fracture type. tibia. Forty three fractures were closed and 7 were open fractures.
Wound was irrigated with saline and closure done in layers. Sterile
Road traffic accident (high energy trauma) was etiological factor
dressing was done and well padded posterior splint was given
in 33, 17 cases sustained fractures following fall (low energy
with ankle in neutral position [12-15].
trauma). Head injury was present in 5 cases, chest injury in 2
and radius fracture in 1 case. There were 33 cases of associated
fibular fractures. Injury surgery interval was less than 8 hours in
14 cases, < 3 days for 20 cases, 3-7 days for 14 cases and
more than 7 days in 2 cases. Average surgery time was 49mins,
13 cases took 31-40 minutes, 17 (35%) took 41-50 minutes,
12 (24%) took 51-60 minutes, 8 cases took 61-70 minutes.
Average union time was 20.96 weeks. The fractures united in 48
(96%) patients with 2 (4%) case of delayed union which took 30
weeks of time period for the radiological signs of callus formation
Postoperative complications are mentioned in [Table/Fig-3].
Plate removal was done in 5 cases; screw exchange was done
in 3 cases [Table/Fig-4]. Good amount range of mobility of ankle
joint was present in almost all patients. Based on AOFAS scores
excellent results were obtained in 33, good in 14 and fair in 3
cases. The limitations of our study were small sample of patients
[Table/Fig-1]: Sagging at the fracture site and shorter follow-up.

Complications No. of Patients Percentage (%)

Postoperative Management
Static quadriceps exercises & toe movements, as tolerated were Superficial skin infection 2 4
begun from 1st postoperative day. Ankle mobilization was started Deep Infection 2 4
from 3rd postoperative day. Intra-venous antibiotics were given Ankle movement restriction
for 3 days followed by a course of oral antibiotics for 5 days. >75% 0 0
50-75% 0 0
Analgesics were given as per need. Suture removal was done on 25-50% 2 4
10th Postoperative day. Protected weight bearing was allowed only <25% 1 2
once signs of progress toward union were evident, usually at 6 Varus angulation 2 4
weeks postoperatively. Full weight bearing was allowed after 10 to
Implant Failure 4 8
12 weeks, depending on the radiographic signs of fracture healing.
[Table/Fig-3]: Complications
X-rays would be taken at regular intervals and evaluated for fracture
healing, alignment at fracture site & look for any evidence of mal-

[Table/Fig-2]: (a) Fracture of distal tibia; (b) Plate osteosynthesis with MIPO technique; (c) Uncomplicated union.

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www.jcdr.net Ajeet Dhakar et al., Minimally Invasive Plate Osteosynthesis with Locking Plates for Distal Tibia Fractures

[Table/Fig-4]: (a)Fracture of distal tibia-Preoperative; (b)Postoperative radiograph; (c) Implant failure-Multiple screw breakage; (d) Screw breakage managed with replacement
with new screws; (e) Union.

of the ankle is done while observing the anterior aspect of the

DISCUSSION ankle for skin creases; the absence of a skin crease or wrinkle
Distal diametaphyseal tibia fractures are one of the most
suggests severe swelling [17,20]. In our study 8 cases were
problematic injuries to manage. Results of operative treatment
operated after 3 days due to poor skin condition. There was
are dependent on the severity of the initial injury, the quality and
no difference in union rates and complications in those who
stability of the reduction. The mechanism of injury, status of soft
were operated before 3 days or after. Wound dehiscence and
tissues, the degree of comminution and articular damage affect
the long term clinical outcome. A variety of treatment options infection are of concerns when operated with locking plates. Guo
are available. But there is no consensus on the best treatment JJ et al., reported more wound complications in LCP group (14.6%)
modality [1-3]. Options for surgical fixation include external fixation, compared to nailing group (6.8%) [15]. Lau et al., reported late
intramedullary nailing and plate fixation. External fixators are used infection rate of 15% in fixation with locking plates [19]. Average
in open fractures with soft tissue injury where nail or plate fixation rate of infection in various literature available was 5-15%. In our
is contraindicated. Many complications are reported when external study infection was seen in 5 cases (10%). Delaying surgery if limb
fixators are used for definitive management of distal tibia fractures. is swollen and bruised, gentle soft tissue handling and reducing
Review of literature report high rate of malunion (5-25%), nonunion operative time helps in reducing infection rates [13-15,18,19].
(2-17%), loss of reduction and pin tract infection (10-100%) which Malunion is an uncommon complication after LCP. Rate of malunion
makes it less preferred technique [3-5]. in literature varies from 0-5%. Delayed union and nonunion has been
Many authors have advocated intramedullary fixation with inter­ reported to be 5-16% in various studies. Collinge et al., reported a
locking nails in distal tibia fractures with good outcomes. reoperation rate of 5% which included secondary procedure like
Intramedullary nailing has advantages of closed stabilization with bone grafting for delayed union [11]. Rate of secondary procedures
preservation of fracture haematoma and no damage to overlying for delayed union or non union or change of hardware has been
soft tissues [10]. However, due to the widening of medullary canal reported 3.8% to as high as up to 35%. Implant failure has been
at metaphysis, angular and rotational stability is not achieved. reported to be 2-6%. Plate bending or breakage is often associated
Inadequate reduction, intraoperative loss of reduction after nail with malalignment, delayed or nonunion [15,18,19].
insertion, implant failure and malunion are reported complications
[13,17]. Guo JJ et al., in their study concluded nailing to be better Pain over medial malleolus, hardware prominence and pain due to
option for treating distal tibial fractures with atleast 3cm distal impingement of the implant on the skin was common. Gao et al.,
fragment and no articular incongruity. They found no difference suggested polyaxial locking plates to gain adequate fixation and to
in union rate but mean radiation time and operating time were achieve a perfect match between the plate and the distal part of the
significantly longer in LCP group and no statistical difference was tibia [12], which in turn may further reduce tension in the soft tissue
noted in alignment [15,18,19]. [13,19].
Open reduction and internal fixation leads to increased risk of The great saphenous vein and nerve injury can occur rarely. Careful
infection and nonunion [6,7]. Minimally invasive plating techniques identification during surgery and adequate drill sleeve placement
reduce iatrogenic soft tissue trauma and damage to vascularity usually suffice. We did not have any case of saphenous nerve or
of bone fragments, as well as preserve the fracture haematoma vein injury. Removal of LCP can be difficult and includes all general
resulting in uncomplicated union. Anatomical reduction of fractures risks associated with surgical procedures. Complication rates
should be done under image intensifier before fixation. Different of 20% have been reported. Stripping of screw head or threads
methods for fracture reduction include calcaneal traction, external occurs frequently. Screw extraction devices cannot be engaged to
fixators or distractors, reduction clamps and interfragmentary screws remove locking screws which makes the procedure cumbersome
through stab incision [3-5]. Fibula fractures when present also affect [12-15,19].
fracture reduction. We preferred fixation of fibular fractures before
tibia for better alignment. No clear guidelines exist in literature for Conclusion
fibular fixation but when syndesmosis is involved it should be fixed Effective stabilization of distal tibia fractures can be achieved by
[13,18-20]. distal tibia locking plating through MIPO technique which not only
Distal tibia fractures are associated with gross swelling, skin helps in achieving reduction in difficult situations, but also in rapid
injury and blisters because of subcutaneous location. Skin union, because it facilitates preservation of the blood supply to the
condition determines the timing of surgery. Wound dehiscence fragment and anatomical reduction of the fracture. It is a simple,
and infection are complications when surgery is done with poor rapid and straight forward procedure which has good results.
soft tissue conditions. Immobilization by splinting, icepacks and
delaying surgery help in limiting further soft tissue injury and better Acknowledgments
preoperative soft tissue condition. Surgery was done when the We are grateful to Dr. Nand Lal Jhamaria and Dr. Devkant for their
swelling subsided, and the wrinkle sign was seen. Dorsiflexion help in conducting the study and preparation of the manuscript.
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PARTICULARS OF CONTRIBUTORS:
1. Consultant, Department of Orthopaedics, JLN Medical College, Ajmer, Rajasthan, India.
2. Assistant Professor, Department of Orthopaedics, Kasturba Medical College, Mangalore, Manipal University, Karnataka, India.
3. Ex Professor and Head, Department of Orthopaedics, JLN Medical College, Ajmer, India.
4. Associate Professor, Department of Orthopaedics, JLN Medical College, Ajmer, Rajasthan, India.
5. Professor, Department of Orthopaedics, Kasturba Medical College, Mangalore, Manipal University, Karnataka, India.
6. Assistant Professor, Department of Pathology, Kasturba Medical College, Mangalore, Manipal University, Karnataka, India.
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Rajendra Annappa,
Assistant Professor, Department of Orthopaedics, Kasturba Medical College, Date of Submission: Jun 26, 2015
Mangalore-575001, Manipal University Karnataka, India. Date of Peer Review: Aug 28, 2015
E-mail: rajendra.orthopaedics@gmail.com Date of Acceptance: Nov 18, 2015
Financial OR OTHER COMPETING INTERESTS: None. Date of Publishing: Mar 01, 2016

4 Journal of Clinical and Diagnostic Research. 2016 Mar, Vol-10(3): RC01-RC04