Abstract
Purpose
The objective of this study was to compare combined internal and external fixation (CIEF) with minimally invasive percutaneous plate osteosynthesis (MIPPO) in the treatment of distal third tibial fractures, and explore the benefits and defects of these two techniques.
Methods
From April 2004 to February 2012, a total of 44 patients were randomised to operative stabilisation either by two closed titanium elastic nails combined with an external fixator (CIEF, 22) or by minimally invasive percutaneous osteosynthesis with a locking plate (MIPPO, 22). Pre-operative variables included the patients’ age, sex, fracture side, cause of injury, Tscherne classification of soft tissue injury, fracture pattern, presence of open fracture and interval from injury to surgery. Peri-operative variables were the operating time and the radiation time. Postoperative variables were wound problems, bone union time, time of recovery to work, the functional American Orthopaedic Foot and Ankle surgery (AOFAS) score and removal of hardware.
Results
There was no significant difference in the time to union, the time of recovery to work, function, alignment and total AOFAS scores between the two groups (P = 0.704, 0.835, 0.551, 0.716 and 0.212, respectively). The mean operating time and radiation time were longer in the MIPPO group than in the CIEF group (85.3 ± 12.5 vs. 73.2 ± 12.0 minutes, P = 0.002, and 3.1 ± 1.5 vs. 2.1 ± 1.2 minutes, P = 0.019, respectively). Wound complications were more common in the MIPPO group (18.2 % vs. 0 % with CIEF, P = 0.105). There was a trend for patients with MIPPO to have a higher incidence of ankle pain (31.8 % vs. 9.1 % with CIEF, P = 0.135). Painful implants were removed in 31.8 % of patients with MIPPO versus 9.1 % with CIEF (P = 0.135). Of the 165 self-tapping locking screws of the locking plates seven (four patients) were removed with some difficulty because of stripping of the hexagonal recess.
Conclusions
Our results indicated that both CIEF and MIPPO were all efficient methods for treating distal third tibial fractures. However, CIEF had the advantages of a shorter operating and radiation time, less wound complication and ankle pain, less secondary operations for implant removal and easier removal of the implants.
Similar content being viewed by others
References
Newman SDS, Mauffrey CPC, Krikler S (2011) Distal metadiaphyseal tibial fractures. Injury 42(10):975–984
Kritsaneephaiboon A, Vaseenon T, Tangtrakulwanich B (2013) Minimally invasive plate osteosynthesis of distal tibial fracture using a posterolateral approach: a cadaveric study and preliminary report. Int Orthop 37(1):105–111
Braten M, Helland P, Grontvedt T, Aamodt A, Benum P, Molster A (2005) External fixation versus locked intramedullary nailing in tibial shaft fractures: a prospective, randomised study of 78 patients. Arch Orthop Trauma Surg 125:21–26
Li Y, Liu L, Tang X, Pei F, Wang G, Fang Y, Zhang H, Crook N (2012) Comparison of low, multidirectional locked nailing and plating in the treatment of distal tibial metadiaphyseal fractures. Int Orthop 36:1457–1462
Janssen KW, Biert J, Albert van Kampen A (2007) Treatment of distal tibial fractures: plate versus nail a retrospective outcome analysis of matched pairs of patients. Int Orthop 31:709–714
Li YC, Jiang X, Guo QH, Zhu L, Ye TW, Chen AM (2014) Treatment of distal tibial shaft fractures by three different surgical methods: a randomized, prospective study. Int Orthop 38(6):1261–1267
Joveniaux P, Ohl X, Harisboure A, Berrichi A, Labatut L, Simon P, Mainard D, Vix N, Dehoux E (2010) Distal tibia fractures: management and complications of 101 cases. Int Orthop 34(4):583–588
Oh CW, Kyung HS, Park IH, Kim PT, Ihn JC (2003) Distal tibia metaphyseal fractures treated by percutaneous plate osteosynthesis. Clin Orthop Relat Res 408:286–291
Collinge C, Sanders R, DiPasquale T (2000) Treatment of complex tibial periarticular fractures using percutaneous techniques. Clin Orthop Relat Res 375:69–77
Gao H, Zhang CQ, Luo CF, Zhou ZB, Zeng BF (2009) Fractures of the distal tibia treated with polyaxial locking plating. Clin Orthop 467:831–837
Collinge C, Kuper M, Larson K, Protzman R (2007) Minimally invasive plating of high energy metaphyseal distal tibia fractures. J Orthop Trauma 21:355–361
Ronga M, Longo UG, Maffulli N (2010) Minimally invasive locked plating of distal tibia fractures is safe and effective. Clin Orthop Relat Res 468(4):975–982
Guo JJ, Yang H, Qian H, Huang L, Guo Z, Tang T (2010) The effects of different nutritional measurements on delayed wound healing after hip fracture in the elderly. J Surg Res 159(1):503–508
Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myserson MS, Sanders M (1994) Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 15:349–353
Farouk O, Krettek C, Miclau T, Schandelmaier P, Guy P, Tscherne H (1997) Minimally invasive plate osteosynthesis and vascularity: preliminary results of a cadaver injection study. Injury 28(Suppl 1):A7–A12
Farouk O, Krettek C, Miclau T, Schandelmaier P, Guy P, Tscherne H (1999) Minimally invasive plate osteosynthesis: does percutaneous plating disrupt femoral blood supply less than the traditional technique? J Orthop Trauma 13:401–406
Hazarika S, Chakravarthy J, Cooper J (2006) Minimally invasive locking plate osteosynthesis for fractures of the distal tibia-results in 20 patients. Injury 37:877–887
Magyar G, Toksvig-Larsen S, Moroni A (1997) Hydroxyapatite coating of threaded pins enhances fixation. J Bone Joint Surg (Br) 79-B(3):487–489
Moroni A, Toksvig-Larsen S, Maltarello MC, Orienti L, Stea S, Giannini SA (1998) Comparison of hydroxyapatite-coated, titanium-coated and uncoated tapered external fixation pins. J Bone Joint Surg Am 80(4):547–554
Babis GC, Kontovazenitis P, Evangelopoulos DS, Tsailas P, Nikolopoulos K, Soucacos PN (2010) Distal tibial fractures treated with hybrid external fixation. Injury 41(3):253–258
Dall’Oca C, Christodoulidis A, Bortolazzi R, Bartolozzi P, Lavini F (2010) Treatment of 103 displaced tibial diaphyseal fractures with a radiolucent unilateral external fixator. Arch Orthop Trauma Surg 130(11):1377–1382
Lau TW, Leung F, Chan CF, Chow SP (2008) Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures. Int Orthop 32:697–703
Bae JH, Oh JK, Oh CW, Hur CR (2009) Technical difficulties of removal of locking screw after locking compression plating. Arch Orthop Trauma Surg 129:91–95
Maffulli N, Toms AD, McMurtie A, Oliva F (2004) Percutaneous plating of distal tibial fractures. Int Orthop 28:159–162
Francois J, Vandeputte G, Verheyden F, Nelen G (2004) Percutaneous plate fixation of fractures of the distal tibia. Acta Orthop Belg 70:148–154
Toms AD, McMurtie A, Maffulli N (2004) Percutaneous plating of the distal tibia. J Foot Ankle Surg 43:199–203
Richardson JB, Gardner TN, Evans M, Kuiper JH, Kenwright J (1995) Dynamisation of tibial fractures. J Bone Joint Surg (Br) 77(3):412–416
Egger EL, Gottsauner-Wolf F, Palmer J, Aro HT, Chao EY (1993) Effects of axial dynamization on bone healing. J Trauma 34(2):185–192
Christopher J, Cunnigham JL, Kenwright J (1993) Tibial external fixation, weight bearing, and fracture movement. Clin Orthop Relat Res 293:28–36
Kenwright J, Richardson JB, Cunningham JL, White S, Goodship AE, Adams MA, Newman JH (1991) Axial movement and tibial fractures: a controlled randomised trial of treatment. J Bone Joint Surg (Br) 73:654–659
Conflict of interest
None of the authors received financial support for this study. The authors have no conflicts of interest to declare.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Sun, LJ., Wu, ZP., Guo, XS. et al. Management of distal third tibial fractures: comparison of combined internal and external fixation with minimally invasive percutaneous plate osteosynthesis. International Orthopaedics (SICOT) 38, 2349–2355 (2014). https://doi.org/10.1007/s00264-014-2467-y
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00264-014-2467-y