|
 
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| ORIGINAL ARTICLES |
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| Year : 2023 | Volume
: 38
| Issue : 1 | Page : 39-53 |
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Comparative prospective study between medial and lateral distal tibial locking compression plates for distal third tibial fractures
Johney Juneja1, Mahesh Pradhan1, Mahendra Prakash1, Naresh Saini1, Anurag Talesra1, Ramesh Sen2
1 Department of Orthopaedic, RNT Medical College Hospital, Udaipur, Rajasthan, India
2 Max Super Speciality Hospital, Mohali, Punjab, India
| Date of Submission | 22-Jan-2023 |
| Date of Acceptance | 12-Feb-2023 |
| Date of Web Publication | 20-Apr-2023 |
Correspondence Address:
Johney Juneja
Department of Orthopaedic, RNT Medical College Hospital, Udaipur 313001, Rajasthan
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jbjd.jbjd_6_23
Purpose: The surgical method of repairing distal tibial fractures remains controversial. Open reduction and plating constitute a popular method that can result in good fixation and retention of the achieved position. The usual approach for open plating is anterior. Although it offers good exposure to the tibia, the medial plating is at high risk of wound problems and nonunions. Also, if fixation of the fibula is required, an additional incision must be made on the lateral side of the shin. Lateral plating using a single lateral approach for treating distal tibial and fibular fractures has been reported to have good results; however, most of these studies were small series. Materials and Methods: This prospective clinical study involved 40 patients with distal tibial fractures admitted in Department of Orthopaedics, RNT Medical College and Hospital, Udaipur, Rajasthan, India, from December 2021 to November 2022. Of these, 20 patients were allotted in each group, that is, Group A and Group B. Group A is designated for patients those are operated with distal tibia medial locking compression plate (LCP). Group B is designated for patients those are operated with distal tibia anterolateral LCP. Results: All patients achieved union at the end of study. The mean time for fracture union was 24.6 weeks with medial plating group and 24.2 weeks with anterolateral plating group. In medial plating group, callus appeared at an average of 13 weeks and in anterolateral plating group, callus appeared at 12 weeks. Out of 20 patients in medial plating group, 11 patients had excellent Olerud and Molander ankle (OMAS) score and nine had good OMAS score at final follow-up. Out of 20 patients in anterolateral plating group, 13 patients had excellent OMAS score and seven patients had good OMAS score. The average OMAS score for Group A was 88.5 and for Group B, it was 90. Conclusion: Lateral plating of distal tibia is safe and feasible, which can provide biological fixation and prevent the soft tissue complications associated with medial plating. Keywords: Bone plates, open fracture reduction, tibial fractures
How to cite this article:
Juneja J, Pradhan M, Prakash M, Saini N, Talesra A, Sen R. Comparative prospective study between medial and lateral distal tibial locking compression plates for distal third tibial fractures. J Bone Joint Dis 2023;38:39-53 |
How to cite this URL:
Juneja J, Pradhan M, Prakash M, Saini N, Talesra A, Sen R. Comparative prospective study between medial and lateral distal tibial locking compression plates for distal third tibial fractures. J Bone Joint Dis [serial online] 2023 [cited 2023 Jun 7];38:39-53. Available from: http://www.jbjd.in/text.asp?2023/38/1/39/374436 |
| Introduction | |  |
As the civilization proceeds toward industrialization, more and more accidents have been experienced. In almost all over the world, the incidence of road traffic and industrial accidents are growing up, resulting in fracture of various bones of body. If we scrutinize the statistics of fractures in body parts, leg bones fracture comes at the top because it is the most distal part of the body and actively involves in locomotive system.[1] Out of all the leg bones fracture, a significant number of cases are of pilon which are generally comminuted in nature and are unstable. As these fractures occur in proximity of weight bearing surface of ankle joint, a slight maladjustment in inclination of ankle joint may lead to permanent disability.
Distal tibia fractures are complex injuries with high complication rate. Traditionally, a variety of methods of management have been described with a reportedly high rate of associated complications.[2] Non-operative treatment of these fractures can be technically demanding on account of small size of fragments with poor hold in plaster. There may be associated joint stiffness, shortening, and rotational mal-union.
In addition, there is sizeable incidence of non-union which is difficult to manage at a later stage on the account of disuse osteoporosis.[3]
Many osteosynthesis techniques can be used for these fractures such open reduction and internal fixation with locking plate, external fixation with or without limited internal fixation, and intra-medullary nailing. All of these techniques have their pros and cons, also, there is no consensus concerning the management of these fractures.
External fixation (Ilizarov frames, ankle spanning, and hybrid constructs) have been proposed either as a sole treatment or, more frequently in conjunction with limited internal fixation has an established place in treatment of pilon fractures, particularly when associated with significant soft tissue injury.[4] Complications of external fixation include the development of pin tract infection and malunion or nonunion [Figure 1].
Intramedullary nails have been greatly improved in recent years, and indication for their use has been extended to fractures closer to the ankle joint.[5]
Modern tibia nail designs have interlocking holes that enable distal placement of screws in close proximity to tip of nail. Also, the success of at least two interlocking screws in the distal fragment after removal of the distal tip of the traditional nail has been reported (Dogra et al. 2000).[6] The closed intra-medullary nailing also has been associated with significantly shorter operative time and fewer wound infection but there are concerns regarding nonunion, malunion, and nail migration into the joint.[7]
The surgical treatment of fractures has evolved a great deal since the development of the original “open reduction and internal fixation” technique by the American association (AO) group. To obtain maximal mechanical stability [Figure 2] in order to achieve primary (endosteal) bone healing, exact anatomical reduction and strict rigid fixation were emphasized in the beginning.[8] This however can rarely be obtained without significant dissection of the fracture and the surrounding soft tissues.[7] Well-known complications such as infection and delayed or non-union are frequently attributed to the devitalization of bony fragments and additional damage to the soft tissues [Figure 3] .[10] | Figure 2: (A) A 64-year-old man sustained a right distal tibial fracture (American association/OTA type 43, A3) with medial open wound after traffic accident. (B) First, lateral malleolar fracture was fixed using minimally invasive percutaneous plate osteosynthesis technique, and bridge external fixator was applied. (C) After 3 weeks, lateral plate fixation of distal tibia using minimally invasive percutaneous plate osteosynthesis technique was performed, and postoperative radiograph at 1 year after the injury shows solid bony union and satisfactory alignment
Click here to view |
 | Figure 3: (A) The initial film shows a comminuted fracture of the distal tibia with medial open wound. (B) Lateral plate was inserted anterolaterally through mini skin incision. (C) The location and size of plate were verified by C-arm. (D) Postoperative radiograph shows satisfactory position of plate and screws
Click here to view |
In order to improve fracture healing, more “biological” methods have been developed over the last decades, trying to lessen the surgical dissection, preserving the blood supply to the bony fragments and containing at least partially the fracture hematoma.[11]
More and more new insights in reduction techniques and fracture healing are leading to the development of a “minimally invasive osteosynthesis” [Figure 4] promoted by the AO group and others. The emphasis now lies on indirect reduction, axial alignment, and stable fixation without disturbing the fracture environment and thus preserving most of the vascularization and fracture hematoma,containing all necessary growth factors for bony healing.[12] There has been an increasing trend toward the use of the locking compression plate (LCP) for fracture fixation.[13] The device allows the screws to lock to the plate, therefore creating a stable, fixed angle device.[14] Precise anatomical contour of this plate is no longer necessary because the plate does not need to be pressed on the bone to achieve stability, thus preventing the loss of primary reduction of fracture fragments caused by inadequate contouring of the plate.[15] | Figure 4: (A–C) Preoperative radiographs and 3-dimensional computed tomography of a 39-year-old man shows a distal tibia and fibular fractures classified as the American association/OTA type C2. (D) The operation was delayed for 5 days because of severe soft tissue swelling. (E and F) The distal tibia fracture was stabilized with the LCP metaphyseal plate using a minimally invasive technique. (G and H) Postoperative radiographs show successful union with a good alignment at 14 months after surgery
Click here to view |
Two types of LCP can be used in the management of fractures of distal one third of tibia, that is, medial LCP and the newer anterolateral LCP.[16]
Limited literature exists, comparing method of treatment for pilon fractures. Locking and compression plate are well accepted and effective methods, but are historically related to some complications such as infections, wound complications, and implant prominence particularly with medial plating.[17] The purpose of this study was to compare medial LCP and anterolateral LCP for pilon fracture by assessing the treatment results and complications.
| Aims and Objectives | | |
- To evaluate functional outcome between medial locking compression plate and anterolateral locking compression plate in the management of tibial pilon fracture.
- To assess and compare the end results of the above procedures in terms of benefits and complications.
| Materials and Methods | | |
Source of data
- Type of study: Prospective analytic study.
- Study place: Department of Orthopaedics, Maharana Bhupal Government hospital attached with RNT Medical College, Udaipur, Rajasthan, India.
- Duration of study: December 2021 to November 2022.
- Patient population: All patients with tibial pilon fracture required treatment
Inclusion criteria
- Adults (18–60 years old) men and women.
- Simple fractures unfavorable for interlocking nailing.
- All closed extra articular distal tibia fractures as per AO classification 43A1, 43A2, 43A3 with Tsherene and Ostern grade 0 and grade 1.
- Distal tibia intra-articular fractures as per AO classification 43B1–43B3, 43C1–43C3.
- Distal tibia fractures extending into diaphysis.
- Gustilo and Anderson Type 1 fracture.
Exclusion criteria
- Gustilo and Anderson Type 2 and Type 3 fractures.
- All pathological fractures.
- Patient not willing for surgery.
- Patient medically unfit for surgery.
- Patient does not give surgical consent.
The management of injury was based on the following protocol.
Methodology
Patient fulfilling inclusion and exclusion criteria was recruited for study and approached by investigator her/himself, and detailed history and thorough general and systemic examination were done.
Patients were randomized into two groups. Group A who were treated by medial LCP and Group B who were treated by anterolateral LCP.
Operative technique
Medial LCP: The patient was positioned supine on operation table, with at high tourniquet. Intravenous antibiotics were given, before inflating tourniquet. Before proceeding to percutaneous plating,[18] the fibular fracture was fixed first using a one-third tubular or recon plate, which helped in maintaining the length, alignment, and indirect reduction of the tibial fracture. In all cases, fibular fixation was done. Following lateral malleolar fixation, the integrity of syndesmosis was checked by pulling the distal fibula. After conventional plating of lateral malleolus, distal tibial LCP was tunneled sub-cutaneously,[19] through limited skin incisions avoiding injury to the saphenous nerve and vein [Figure 5]. Plate was temporarily fixed using K-wires through the especially designed holes on the distal and proximal ends of the plate. Preliminary reduction and position of plate were checked under image intensifier. Interfragmentary compression was accomplished in selected cases with cortical screws placed through the plate. Following inter fragmentary compression, a mechanically stable construct was made by use of locking screws.[20] All through the fixation care was taken to prevent posterior sagging of the tibia at the fracture site. Wound closure was done in layers without a suction drain. Following operation compression bandage was given, and limb was elevated. No splintage was used postoperatively.
Anterolateral LCP: This incision is centered at the ankle joint, parallel to the fourth metatarsal distally, and parallel to and between the tibia and fibula proximally.[21] Dissection through the skin and subcutaneous tissues should proceed sharply with maintenance of full thickness skin flaps. As the anterior compartment muscles arise from the anterior fibula, the incision is usually not extended more than 7 cm above the ankle joint. Distally, the incision can extend as far as the talonavicular joint.[22]
Due care must be given not to damage the superficial peroneal nerve which lies directly beneath the skin. This nerve invariably crosses the surgical incision proximal to the ankle joint. It should be identified, mobilized, and protected throughout the surgical procedure.[23]
Surgical dissection: The fascia over the anterior compartment of the distal tibia is incised sharply, beneath the superficial peroneal nerve. Distally, the extensor retinaculum is incised, and the anterior compartment tendons are all retracted medially.[24] Proximally, the entire anterior compartment musculature, including the peroneus tertius, can then be mobilized and retracted medially. These muscles and tendons are usually easy to mobilize from the underlying anterior tibiofibular ligament, the periosteum of the distal tibia, and the joint capsule.[25]
The fascia of the extensor digitorum brevis can be incised, with the muscle carefully dissected and retracted medially.[26] This allows exposure of the talar neck for pin placement and distractor application. Proper location of the arthrotomy, preplanned to lie over the fracture, is critical to avoid unnecessary and damaging devascularization of fracture fragments.[27] Proximally, the dissection is limited by the origin of the anterior compartment muscles from the fibula and from the interosseous membrane.[28]
| Observations | | |
The present study was aimed at assessing the outcomes of fracture of distal tibia treated by either medial LCP or with anterolateral LCP.
The study was performed on a total of 40 patients in Department of Orthopaedic, RNT Medical College, Udaipur, India from December 2021 to November 2022. Of these, 20 patients were allotted in each group, that is, Group A and Group B.
Group A is designated for patients those are operated with distal tibia medial LCP.
Group B is designated for patients those are operated with distal tibia anterolateral LCP.
Following are the observations of the study.
In this study in Group A 75% men patients and 25% women patients and in group B 90% men and 10% women participated.
Most of patients, 80% in Group A and 95% in Group B in our study were between 18 and 60 years, probably because this age group is involved in outdoor activities. Mean age for Group A was 38.4 years and for Group B was 39.8 years.
Maximum cases were caused by road traffic accidents indicating this fracture is high velocity type trauma associated with significant soft tissue injury. Other causative factors were fall on ground and slip from vehicle.
Right side was involved more common in both groups accounting for 70% cases in Group A and 60% cases in Group B.
Most of the patients were from AO classification 43A (75% in Group A and 70% in Group B).
We included both close and open type of injuries in our study. Close injuries were classified with Tscherne classification and open injuries were classified according to Gustilo Anderson classification. Open injuries involved in our study were grade type I only.
In our study, most of the patients, that is, 60% in Group A and 70% in Group B were operated between 5 and 10 days after the injury allowing some time for swelling to subside.
Most of the patients, that is, 75% in Group A and 70% in Group B were operated by minimally invasive percutaneous plate osteosynthesis (MIPPO) compared to only 25% in Group A and 30% in Group B for open reduction and internal fixation [Figure 5].[29]
The average duration required for surgery was 58.25 min in medial LCP group and it was 59.25 min in anterolateral LCP group.
On taking X-rays during follow-up of included patients starting of radiological union was observed carefully by looking for bridging callus, haziness of fracture line. Appearance of callus took average time of around 12 weeks in both groups.
Average time taken by patients for full weight bearing in Group A was 17.6 weeks as compared to 17.3 weeks in Group B. All patients were able to bear weight before complete union of fracture. By the process of weight bearing, we believed that it would promote secondary bone healing.[30]
Average time taken for union of fracture in our study groups was 24.6 weeks in Group A and 24.2 weeks in Group B. Union was defined clinically as the ability to walk without aid or pain and radiologically as a solid callus bridging of the fragments.[31]
Most of cases of the study maintained initial reduction and showed minimal angulation in any plane (0°–5°) in both medial LCP group and anterolateral LCP group.
Complications
Intraoperative complications: There were no cases with intraoperative complications in both the groups.
Postoperative complications: Superficial skin infection was more common in medial plating group accounting for 25% infection rate. It was only 5% in anterolateral plating group [Figure 5].[32]
Symptomatic hardware was much more common in medial LCP group, that is, 40% cases as compared to anterolateral LCP group, that is, only 10% cases.
Skin necrosis with subsequent exposure of the implant was much more common in medial LCP group, that is, 25% cases and accounted for only 5% cases in anterolateral LCP group.
Ankle stiffness: None of the patients in medial LCP group and only 1 patient in anterolateral LCP group had ankle stiffness.[33] It was probably due to the incompliance of the patient to the advised physiotherapy regimen. Ankle stiffness ranged from restriction of ankle movement by 20–40°. [34]
Olerud and Molander ankle (OMAS) score at the final follow-up showed that excellent results [34] were achieved in 55% cases in Group A and 65% cases in Group B. Good results were obtained in 45% cases in Group A and 35% cases in Group B. Mean OMAS score at final follow-up for Group A was 88.5 and for Group B it was 90.
| Results | | |
We included total 40 patients in this prospective study who sustained distal tibia fracture. Half of the patients were treated with medial locking and compression metaphyseal plating using open reduction/MIPPO technique and half were treated with anterolateral locking and compression plate using open reduction/MIPPO technique.[35]
All patients achieved union at the end of study. The mean time for fracture union was 24.6 weeks with medial plating group and 24.2 weeks with anterolateral plating group.[36]
The average time for appearance of callus formation on X-ray was comparable in both the groups. In medial plating group, callus appeared at an average of 13 weeks and in anterolateral plating group, callus appeared at 12 weeks.[37]
The average time for full weight bearing was comparable in both the groups. In medial plating group, it was 17.6 weeks and in anterolateral plating group, average time for full weight bearing was 17.3 weeks.[38]
Out of 20 patients in medial plating group, five patients showed superficial skin infection, eight patients complained of hardware prominence and pain at medial malleolus, five patients had skin necrosis with subsequent exposure of implant and no patient had ankle stiffness [Table 1].[39]
Out of 20 patients with anterolateral plating group, one patient had superficial skin infection, two patients complained of hardware prominence, one patient had skin necrosis with implant exposure, and one patient had ankle stiffness.[38]
None of the patients in both the groups had nonunion.
Out of the 20 patients in medial plating group, 11 patients had excellent OMAS score and nine had good OMAS score at final follow-up. Of 20 patients in anterolateral plating group, 13 patients had excellent OMAS score and seven patients had good OMAS score. The average OMAS score for Group A was 88.5 and for Group B, it was 90 [Figure 5].
By the analysis of the data collected in our study, we conclude that most of the cases of pilon fractures can be treated by either medial locking and compression plate or anterolateral locking and compression plate [Table 2]. Both had similar outcome in terms of fracture union,[40] time for weight bearing, and functional outcome. However anterolateral locking and compression plate are associated with much lower complication rates.
| Discussion | | |
Fractures of distal tibia are among the most difficult fractures to treat effectively. Muller et al.[41] defined the distal tibial metaphysis as the area included within a square the sides of which are the same length as the widest part of the distal articular surface [Table 3]. The status of the soft tissues, the degree of comminution sustained at the time of injury affect the long-term clinical results [Table 4]. The goal of operative treatment is to obtain anatomic realignment of the joint surface while providing enough stability to allow early motion. This should be accomplished using techniques that minimize osseous and soft tissue devascularization with the hope of decreasing the complications resulting from treatment.[42]
The present study was under taken to determine the role of medial and anterolateral locking and compression plates in the management of the fractures of distal tibia and to compare the end results of above procedures in term of benefit and complications.[43]
We evaluated our results and compared them with those obtained by various other studies utilizing different modalities of treatment, our analysis is as follows [Table 5].
Age distribution
Our study revealed the mean age of such fractures to be 38.75 years in Group A and 39.75 years in Group B. It is comparable to some other studies conducted on similar fractures by other authors [Table 6].
Sex distribution
In our study, the men preponderance for such fractures was higher in both the groups which is comparable to some other studies on similar type of fractures. It is possibly due to the men dominance in travelling and occupation [Table 7].
Mode of injury
Collinge et al.[44] observed 100% high energy fractures in his study. Grose et al.[44] could attribute only 58% of such injuries to be of high energy [Table 8].
Our study correlates well with the study conducted by Grose et al.[46] and Vallier et al.[45]
Nature of the fracture
Our study had 25% open fractures of Gustilo Anderson type 1 in Group A and 35% in Group B [Table 9]. This was comparable to other studies conducted by Vallier et al.[45] who had 30% open fractures and Hazarika et al.[47] who had 40% open fractures.
Fracture patterns
However, study by Collinge et al.[44] showed 16% CI, 32% C2 and 24% C3. Grose et al.[46] also had fractures types 2% B1, 4% B2, 12% B3, 6% C1, 12% C2, 64% C3. We had a higher percentage of type A fracture [Table 10]. | Table 10: American association classification of fractures involved in study
Click here to view |
Duration of surgery
The average duration of surgery in our study was 58.25 min in Group A as compared to 59.25 min [Table 11] in anterolateral plating group. Guo et al.[48] in their study took an average of 97 min for the surgery.[49]
The length of the operating time reflects a learning curve. The first few locking and compression plates in both the group required 70–80 min which decreased to 40–50 min over a period of time [Table 12].[50] Time taken for surgery was higher in the cases of open reduction as compared to the MIPPO group.
Time taken for union
The average time taken by fracture to unite in various studies conducted using different techniques was around 16–28 weeks [Table 13]. In our study the average time taken by the patient for fracture union was 24.6 weeks in Group A and 24.2 weeks in Group B [Table 14]. The results of our study were comparable with other studies.
OMAS score
OMAS score at the final follow-up showed that excellent results were achieved in 55% cases in Group A and 65% cases in Group B. Good results were obtained in 45% cases in Group A and 35% cases in Group B. Mean OMAS score at final follow-up for Group A was 88.5 and Group B was 90. Statistically calculated P value for the OMAS score is 0.564 which is statistically insignificant indicating that the function outcome was similar in both the groups. This is comparable to some other studies conducted by other authors [Table 15].
Lee et al.[51] in their study found non-significant difference in the function outcome of medial plating and lateral plating of distal tibia [Table 16].
Shon and Park[52] compared and evaluated the results of medial and lateral plating of distal tibia fractures by MIPO. Between June 2005 and February 2009, 24 patients with a distal tibia fracture were treated using MIPO. Patients were divided into two groups according to the MIPO methods used; 12 patients were fixated by medial MIPO (group M), and the other 12 patients by lateral MIPO (group L). These two groups were compared with regard to time to union. Clinical results were assessed by use of the IOWA ankle-rating system and the range of ankle motion at last follow-up [Table 17]. Mean operation time and postoperative complications were evaluated by chart review. Radiographic results were assessed on the basis of tibial angulation and shortening at last follow-up. Radiological evidence of bony union was observed for all study subjects.[53] Mean union time was not significantly different between the two groups. Mean IOWA score, range of ankle motion, and operation time were no different between the two groups.[57]
Ethical approval
This article does not contain any studies with human participants or animals performed by any of the authors.
Financial support and sponsorship
Nil.
Conflicts of interest
On behalf of all authors, the corresponding author states that there is no conflict of interest.
Consent to participate
Informed consent was taken from all the patient undergoing this procedure were included in this study. They were informed & documented with their signature regarding their participation in this study.
Consent for publication
all consent taken from patients & other respective authors.
Availability of supporting data
Available but not included.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22], [Figure 23], [Figure 24], [Figure 25], [Figure 26]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15], [Table 16], [Table 17], [Table 18], [Table 19], [Table 20], [Table 21], [Table 22], [Table 23]
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