Treatment of distal tibia end fractures by minimally invasive plate osteosynthesis

Abstract

AimDistal tibia fractures are common in daily accidents such as traffic, work, and sports accidents. There are various treatment methods for that injury, such as casting, external fixation, and AO screw and plate fixation. However, in the cases of distal tibia fractures occurred near the ankle joint with damaged soft tissues near the fractures, minimally invasive plate osteosynthesis using the locking compression plate is a suitable fixation method. This study aimed to evalu-ate the bone union, functional rehabilitation, and assessment of complications of treatment of distal tibia fractures by minimally invasive plate osteosynthesis in 7A Military Hospital.MethodsThis prospective cohort study was performed on 38 patients with distal tibia fractures treated from October 2014 to October 2019 in our hospital. Patients were treated with internal fixation using minimally invasive plate osteosynthesis with locking compression plate, and they were moni-tored for bone fusion for functional rehabilitation, and the complications were evaluated.ResultsThe average monitor time was 12.5 months after the operation and the outcomes were assessed based on the American Orthopedic Foot and Ankle Score, as a result of which 24 cases (63.2%) were “very good” 10 cases (26.3%) were “good” and 4 cases (10.5%) were “fair”.DiscussionMinimal invasive plate osteosynthesis provided both postoperative and rehabilitation generally satisfied outcomes. The results were comparable to other authors. Further researches with a larger sample size are needed for better evaluation and optimal protocol conclusion.ConclusionMinimally invasive plate osteosynthesis was a suitable method for the treatment of distal tibia fractures as indirect reduction technique and small incision reduce damages on soft tissues during the operation.

Keywords

Introduction

Distal tibia fractures are common in orthopedics accounting for 1-5% of the lower limb and 7-10% of lower leg fractures.¹² Due to the limit of soft tissues and poor blood supply nature of the area, treating distal tibia fractures is a challenge and quickly poses complications such as open fractures, infections, and slow bone reunion. Careful consideration of various aspects such as fracture patterns, bone quality, and soft tissue injuries is needed when deciding appropriate treatments to ensure optimal results. There is a variety of treatments to be used, such as casting, open reduction with screw-plate fixation, and external fixation.
Minimally invasive plate osteosynthesis (MIPO) was developed to eliminate the extensive surgery to expose the fracture site. Only two small incisions are made near both ends of the fracture site. A plate then inserted through an epi-periosteal tunnel that links the two incisions and is screwed in both ends to stabilize the fracture. MIPO helps significantly reduce operation and hospitalization time comparing to the open surgery approach. It also permits the conservation of soft tissues and feeding blood vessels, reduces infection and non-union risks, and enables quick ankle joint movement after surgery.
MIPO treatment for distal tibia fractures with positive outcomes was reported worldwide.^2-6 For further research of this technique, we carried out the study on the treatment of distal tibia end fractures using minimally invasive plate osteosynthesis in 7A Military Hospital (Ho Chi Minh City, Viet Nam) in order to evaluate bone union, functional rehabilitation, and to assess the complications of treatment using this method.

Materials and Methods

Experimental ParticipantsThis study was performed on 38 patients with distal tibia fractures (based on A/O classification) treated with MIPO using locking compression plate from October 2014 to October 2019. The criteria for selection were patients aged over 18 with closed distal tibia fractures based on A/O classification, having no contra-indication against surgery or anesthesia, and monitored for at least six months. The criteria for rejection include patients with pathologic fractures or multiple injuries.Research MethodsThis study was a prospective cohort study with longitudinal description. The patients were given explanations about the surgery and underwent pre-operative examinations and tests. C-Arm machine, orthopedics operative table, and tools were prepared. Spinal anesthesia or endotracheal anesthesia was applied to the patients. A surgical tourniquet was employed at the thigh base for a maximum of 90 minutes and should exert a pressure of 350 - 400 mmHg.
The surgical procedure was performed in the following way:^3,6
1. The patients lied in supine posture on the operation table.
2. If the patients had accompanied fistula fracture, the fistula had to be treated first with screw-plate or K-wire fixation.
3. The compressive locking plate must fit the size of the distal tibia fracture and had to be prepared beforehand.
4. The skin-projected position of the plate was located and the positions of the proximal and distal ends of the plate were identified for the convenience of screw installation.
5. Skin incisions were made at the distal and proximal ends of the plate following the anterior-medial line of the tibia; the incisions were 2- 3 cm apart each other and dissected all subcutaneous layers.
6. An internal dissection of the subcutaneous tissues was made and the plate was inserted below the skin layer.
7. The bone axis and the large fragment were manually reduced (with the assistance of towel clips) by the sagittal plane.
8. Sagittal and coronal planes of the fractures were monitored using C-Arm machine to ensure a proper reduction of the bone fragments.
9. One distal screw was inserted and the distal deviation was micro-adjusted.
10. One proximal screw was inserted.
11. The sagittal and coronal deviations were micro-adjusted and the remaining screws were inserted.
12. The skin was sutured.
Post-operative care was as follows: antibiotics, analgesics, and anti-inflammatory agents were administered to the patients. The leg was put in a high position to prevent swelling and to take care of the surgical wound. The patients then had early post-operative ankle joint exercise. The patients could be discharged 3 – 5 days after the operation when the surgical wound became clean and dry, swelling reduced and active ankle and knee joints movements were possible.
Post-operative physical therapy was as follows: the patients had light angular exercise of the ankle joints 24 hours after surgery. After two weeks as swelling reduced, the plate could be removed and back and ankle angular exercises and ankle rotational exercises were started. After one month, the patients started ankle exercise with a gradual increase of resistance. After three months, the patients began walking and allowed weight bearing on the treated limb. After six months, the patients could walk normally. Treatment outcomes assessment was based on post-operative radiography, bone union and rehabilitation, and complications.
Ethics Committee Approval: Medicine Scientific Research Ethics Committee of the 7A Military Hospital approved this study (Number: 134/QĐ-HĐYĐ-BV7A, date: 18.05.2014)

Results

Patient General ınformationThe patients were from 18 to 58 years of age; the average age was 36.4 years. There were more males (28 patients, accounting for 73.7%) than females (10 patients, 26.3%), and male/female ratio was 2.8/1. The leading cause for fractures was traffic accidents, 20 cases accounted for 52.6%, then workplace accident (15 cases, 39.5%), and sport accident (3 cases, 7.9%).
The average hospital stay-in was 4.9 days, and post-operative monitor time was 12.5 months.
Types of distal tibia fractures based on A/O classification The distal tibia fracture types of studied patients were based on A/O classification.^7-8 A1 type was the most frequent fracture types with 14 cases and accounted for 36.8%; A2, A3, and C1 types were in 11 cases (28.9%), 10 cases (26.4%), and 3 cases (7.9%), respectively.Fibula Accompanying FracturesIn this study, 20/38 cases (52.6%) had accompanying fibula fractures. Amongst them, 16 cases (80%, n=20) had fibula fractures with significant deviation and unstable ankle joints; these cases were treated with the screw-plate fixations for the fibula. Four remaining cases (20%, n=20) only had small deviation and needed no fibula fusion, only required additional foot casting.Post-Operative Radiography ResultsIn the post-operative radiography results,⁹ the majority was “Very good” in 22 cases, accounting for 57.9%; “Good” and “Fair” results were 11 cases (28.9%) and 5 cases (13.2%), respectively. There was no case with the “Poor” result.
Bone union results based on A/O classification
In our study, all 38 patients had bone union in minimum of 16 weeks and maximum of 23 weeks.
The time for bone union by fracture type was listed in Table 1. A1 fractures had significantly faster union than A2, A3, and C1 (p < 0.001, ANOVA test).Functional Rehabilitation OutcomesRehabilitation based on patients’ subjective remarks: 34 cases had no ankle pain, and 4 had slight ankle pain within an acceptable level. For daily activities, 37 cases reported no difficulties in regular walking, 1 case reported challenges in moving up and down the stairs.Rehabilitation Based on Objective CriteriaThe dorsiflexion, plantarflexion, eversion, inversion ankle range of motion were 18.4o, 47.8o. 16.9o and 17.4o, respectively. Angular motion usually recovered faster than other kinds of motion. Based on American Orthopedic Foot and Ankle Score,^2-3,9 “Very good” and “good” outcomes took place in 89.5% cases and “fair” in 10.5% cases.ComplicationsInfections took place in one patient and slow union in one patient. No patient had joint stiffness or non-union.

Discussion

Minimally invasive surgery is a surgical method commonly applied in many sectors.¹⁰¹¹ Including treatment of bone injuries as, for example, it minimizes damages on soft tissue, improves healing time, reduces decubitus complications, and enables weight bearing when possible.¹²¹³
In this study, the minimally invasive plate osteosynthesis was employed to treat the distal tibia fragment of 38 patients in the 7A Military Hospital, and the observed results were promising.
Bone union was achieved in all the cases; radiographs showed positive outcomes generally. Post-operative complications were very few with one infection and one slow union in thirty cases; few or no complication was also reported in other literature.^113-15 And the complications were treated successfully.
The average time for bone union in this study within an average time of 18.7 weeks is comparable with Sanjay and Sanjay (2018) study (about 18 weeks). This result is faster than in the reports by Chandrakant and Martand (2018)¹⁶ and Daolagupu et al.(2017)¹⁷ (about 19 weeks and 21.7 weeks, respectively), and slower than in the study by Serban et al.(1997)¹ (about 17 weeks). Our result can be considered as comparable with the mentioned authors, but further researches with larger samples are necessary.
Postoperative rehabilitation outcomes were generally positive in this study. Pain level was mostly nonexistence or very little and there was no interference on postoperative daily activities. Ankle range of motion in dorsiflexion and plantarflexion were 18.4° and 47.8°, respectively, which was better than the study of Helfet et al.(1997) (14° and 42°, respectively).¹³ Based on American Orthopedic Foot and Ankle Score, the “good” and “very good” outcome in this study (89.5%, 34/38 patients) was similar to results report by Supe et al.(2016)² (93.8% of the total 32 patients) and Hegazy et al.(2015)³ (86.7% of the total 30 patients). The study by Chandrakant and Martand (2018) reported an average score of 89.9 in 32 investigated patients.¹⁶ The results were also compatible with our research.
In general, our study result was satisfactory; still, further researches are needed to evaluate the treatment outcomes better and devise a more accurate treatment protocol for these kinds of injuries.¹⁸

Conclusion

Thirty patients with distal tibia fractures were treated using minimally invasive plate osteosynthesis with locking compressive plate from October 2014 to October 2019 at the 7A Military Hospital, Ho Chi Minh City, Vietnam. Based on this study, it can be concluded that this method only required small incisions, reduced infection risks, promote bone union rate, enabled early post-operative ankle joint exercises. The treatment outcomes of this method were very encouraging. Further researches with larger samples are necessary to evaluate the treatment outcomes better and devise a more accurate treatment protocol for this kind of injuries.

Declarations

References

1. Serban AI, Obadă B, Turcu R, Anderlik ST, Botnaru V. Distal tibial fracture treated by minimally invasive plate osteosynthesis after external fixation: retrospective clinical and radiographic assessment. ARS Med Tomitana. 2014;1(76):44-49.
   PubMed · Google Scholar
2. Supe AC, Kinge KV, Badole CM. Minimally invasive percutaneous plate osteosynthesis in distal tibial fracture: a series of 32 cases. Int J Orthop. 2016;2(1):6-9.
   PubMed · Google Scholar
3. Hegazy G, Rashed RE, Al-Shal EAE, Hassan MAE. Biological fixation of distal tibial fractures by locking compression plate. J Am Sci. 2015;11(5):179-184.
   PubMed · Google Scholar
4. Kundu AK, Phuljhele S, Jain M, Sahare KK. Outcome of minimally invasive plate osteosynthesis technique with locking compression plate in distal tibial fracture management. Indian J Orthop. 2015;1(3):138-145. doi:10.5958/2395-1362.2015.00015.8
   Article · PubMed · Google Scholar
5. Paluvadi SL, Lal H, Mittal D, Vidryathi MS. Management of fractures of the distal third tibia by minimally invasive plate osteosynthesis: a prospective series of 50 patients. J Clin Orthop Trauma. 2014;5(3):129-136. doi:10.1016/j.jcot.2014.07.010
   Article · PubMed · Google Scholar
6. Senna ASA. Minimally invasive plate osteosynthesis for distal tibial fractures. J Am Sci. 2013;9(10):562-566.
   PubMed · Google Scholar
7. Canale ST, Beaty J, eds. Campbell’s Operative Orthopaedics. 12th ed. Mosby; 2013.
   PubMed · Google Scholar
8. Bucholz RW, ed. Rockwood and Green’s Fractures in Adults. 6th ed. Lippincott Williams & Wilkins; 2006:117-1204.
   PubMed · Google Scholar
9. Morshed S, Corrales L, Genant H. Outcome assessment in clinical trials of fracture-healing. J Bone Joint Surg Am. 2008;90(suppl 1):62-67. doi:10.2106/jbjs.g.01556
   Article · PubMed · Google Scholar
10. Karabulut İ, Yılmaz AH, Yılmazel FK, Özkaya F. Outcomes of robot-assisted transperitoneal pyeloplasty: case series. J Surg Med. 2019;3(12):870-872. doi:10.28982/josam.638664
    Article · PubMed · Google Scholar
11. Katrancıoğlu Ö, Akkaş Y, Şahin E, et al. Is it easy to remove the bar fitted with Nuss procedure? J Surg Med. 2018;2(2):87-90. doi:10.28982/josam.399825
    Article · PubMed · Google Scholar
12. Ehlinger M, Adam P, Bonnomet F. Minimally invasive locking screw plate fixation of nonarticular proximal and distal tibia fractures. Orthop Traumatol Surg Res. 2010;96(7):800-809. doi:10.1016/j.otsr.2010.03.025
    Article · PubMed · Google Scholar
13. Helfet DL, Shonnard PY, Levine D, Borrelli J Jr. Minimally invasive plate osteosynthesis of distal fractures of the tibia. Injury. 1997;28(suppl 1). doi:10.1016/s0020-1383(97)90114-5
    Article · PubMed · Google Scholar
14. Aksekili MA, Celik I, Arslan AK, Kalkan T, Uğurlu M. The results of minimally invasive percutaneous plate osteosynthesis in distal and diaphyseal tibial fractures. Acta Orthop Traumatol Turc. 2012;46(3):161-167.
    PubMed · Google Scholar
15. Sanjay B, Sanjay M. Minimally invasive plate osteosynthesis of periarticular fractures of distal tibia: a clinical study. Nat J Clin Orthop. 2018;2(2):1-3. doi:10.33545/orthor.2018.v2.i2a.37
    Article · PubMed · Google Scholar
16. Chandrakant KA, Martand BC. Distal tibia metaphyseal fractures: which is better, intramedullary nailing or minimally invasive plate osteosynthesis? J Orthop Trauma Rehab. 2014;24:66-71.
    PubMed · Google Scholar
17. Daolagupu AK, Mudgal A, Agarwala V, Dutta KK. A comparative study of intramedullary interlocking nailing and minimally invasive plate osteosynthesis in extra-articular distal tibial fractures. Indian J Orthop. 2017;51(3):292. doi:10.4103/0019-5413.205674
    Article · PubMed · Google Scholar
18. Gulabi D, Bekler Hİ, Sağlam F, Taşdemir Z, Çeçen GS, Elmalı N. Surgical treatment of distal tibia fractures: open versus minimally invasive plate osteosynthesis? Ulus Travma Acil Cerrahi Derg. 2016;22(1):52-57. doi:10.5505/tjtes.2015.82026
    Article · PubMed · Google Scholar

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