Study of complications and functional outcome of fixation of distal tibial fractures with anatomical locking plate using mipo technique.
Fractures of distal tibia are critical because the tibial bone in lower end is subcutaneous with minimal muscle cover and with precarious blood supply, which makes fracture in this part of tibia prone for many complications like wound dehiscence, infections, delayed union, malunion and ankle stiffness following surgery or conservative management. [1,7] The ideal treatment for unstable distal tibial fractures remains controversial. Conservative management with pop cast application and immobilisation leads to ankle stiffness (Upto 30% of cases) as well as shortening and angulation at fracture site in significant number of cases.  Open Reduction and Internal Fixation (ORIF) with conventional plate is associated with high risk of infection, delayed union and non-union because ORIF needs extensive soft tissue dissection. 
Nail osteosynthesis is the preferred treatment in middle 3rd region shaft fractures, but is not always possible for distal third fractures with small metaphyseal fragment, spiral fractures and comminuted fractures. 
Minimally Invasive Plate Osteosynthesis (MIPO) using anatomically contoured locking plate reduces iatrogenic soft tissue injury and preserves bone vascularity,  and aims to achieve correct limb length and both axial and rotational alignment of the bone fragments [5,4,6] with minimal damage at bone fracture site, while preserving fracture haematoma.  Results of closed reduction and percutaneous plating for distal tibial fractures are encouraging. We studied prospectively 24 number of cases who underwent MIPO for distal tibial fractures and evaluated them for functional and radiological outcome in these cases.
MATERIALS AND METHODS
We prospectively analysed patients with distal tibial fractures came to Gandhi Medical Hospital/Gandhi Medical College between Sept. 2013 to Sept. 2014. During this period, a total number of 24 patients were operated as aged between 25-80 years with mean age of 39 years. There were 20 males and 4 female patients. All fractures are classified according to Ruedi-Allgower classification  and Gustilo-Anderson classification. All closed fractures and Gustilo-Anderson type I and type II compound fractures of distal tibia with or without intraarticular extension upto 10 days old fracture are included in the study. Pathological fractures, compound fractures, Gustilo-Anderson type III and fractures more than 2 weeks old are excluded from this study. In all the patients at the time of admission, a careful history was taken to identify the mechanism of injury, severity of trauma. All the patients were submitted to routine AP and lateral view x-ray of leg and ankle were taken. All the patients were evaluated to these general conditions and below knee pop slab were applied till the surgery was taken up. Surgical profile, consent for surgery and appropriate prophylactic antibiotics were given before surgery.
Patients were operated under regional anaesthesia under tourniquet control. Patients were placed on C-arm compatible table in supine position, a vertical incision about 3 cms was placed over medial malleolus. The anatomical pre-shaped 4.5 mm locking plate (Sharma surgical) was inserted extra periosteally under C-arm control. Closed reduction of fracture was obtained by manual traction/calcaneal pin/Schanz pin in distal tibia. Then the plate was implanted with at least 3 locking screws in proximal tibia and distal fragment (5.0 mm and 4.5 mm screws respectively) when there was comminution of fracture; fibula was also fixed with 3.5 mm reconstruction plate or semi-tubular plate depends on the need for accurate limb length and to maintain stability at fracture site in tibia.
Post-operatively, an above knee pop slab was applied for one week to get the limb oedema to be reduced. Sutures were removed at the end of 2 weeks; early active and passive knee and ankle movements were encouraged on next day of surgery. Touch down weight bearing with help of walker and partial weight bearing started the movement with callus seen on x-ray. Patients were regularly followed up at 3 weeks, 6 weeks and months 3, 6, 9 and 12. Bone union was defined as presence of callus bridging on radiograph and the ability to full weight bearing without pain.
The age of the patients ranged from 25-80 years with mean age of 39 years; there were 20 male and 4 female patients. The mode of injury in majority of patients was road traffic accidents. The majority of the fractures included in our series were extra-articular and associated with fibula fracture at about the same level.
The mean duration between trauma and surgery was 7 days with a range of 5-12 days. The average surgery time was 90 minutes with average time of 70-140 minutes. The mean fracture healing time was 20 weeks (14-24 weeks), mean hospital stay was 16 days (8-20 days). Partial weight bearing with crutches started at 10 days and the mean time of callus formation was 10 weeks. The mean time for full weight bearing was 15 weeks (Between 8-22 weeks). On average 60% of patients had Oleaur and Mollander et al score of 80 points out of 100 points with average of 90 points. We encountered superficial skin infection and dehiscence in about 4 patients (16.6%) who responded well to regular dressing and extended dose of oral antibiotics for few more days. All the patients sustained direct injury to leg leading to associated soft tissue damage at site of fracture.
Two patients were treated for delayed union as a result of high comminution at the site of fracture in one case and grade 2 compound fracture in other case; both these cases united at the end of 24 weeks. Two patients (8.5%) developed ankle stiffness with ROM of 50% of contralateral side due to lack of regular followup, who were advised active movements at guidance of physiotherapist. No patient in our series had plate bending, vascular injury or tourniquet palsy.
The distal tibial fractures remain a challenge to orthopaedic surgeons even today, because of dilemma of method of fracture fixation either open plate/locked ILN or conservative management with pop casing. [1,7] Minimally invasive percutaneous osteosynthesis with anatomical pre-contoured distal tibial plate was now an established technique of management of distal tibial fractures. [11,12] Conservative management with pop immobilisation was associated with prolonged period of rest and ankle stiffness. Open reduction and DCP plate fixation and locked IM nails were associated with more number of infections, delayed union, non-union of fracture and soft tissue healing problems from dissection of soft tissue while doing surgery. [10,9] Damage to distal tibial extraosseous blood supply provided by branches at anterior and posterior tibial arteries was least with MIPO technique. Hence, chances of complications are less and rate of bone union was high.  We evaluated our results and compared with those obtained by various other studies utilising different modalities of treatment and MIPO technique for distal tibial fractures as our analysis follows. Our study revealed the average age of patients was 39 years (25-80 years), was comparable with study on similar fractures conducted by other authors. In our study more number of male patients are involved over females, i.e. 85% compared to the study conducted by Collinge C et al,  which was 77% possible due to the fact that males travel a lot and these are occupational injuries. Our study had 25% compound fractures, was compatible to studies conducted by Heather and Vallier  et al who had 30% open fractures. The average operation time was 60 minutes (55-85 minutes) comparable with the average of 77 minutes by J. J. Guo et al in their study. The average time taken for fracture to unite was 24 weeks comparable to 16-28 weeks in various studies [11,12] conducted using MIPO technique, which was comparable to our study.
The MIPO technique for fracture of distal tibial fracture was an established procedure with less incidence of delayed union, non-union, skin complications and infections because of less disturbance to bone vascularity and soft tissue damage around fracture site during surgery. MIPO technique can be used even in distal tibial fractures with small distal fragment, comminuted fractures and fracture with intra-articular extension.
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G. Ramesh (1), N. Ravinder Kumar (2)
(1) Associate Professor, Department of Orthopaedics, Gandhi Medical College, Hyderabad.
(2) Associate Professor, Department of Orthopaedics, Gandhi Medical College, Hyderabad.
Financial or Other, Competing Interest: None.
Submission 16-08-2016, Peer Review 27-08-2016, Acceptance 30-08-2016, Published 14-04-2017.
Dr. G. Ramesh, #2/3RT. Opp. Post Office, Vijayanagar Colony, Hyderbad-500057.
Table 1: Oleaur and Mollander Scoring System was used in this Study to Assess Parameter Degree Score 1. Pain None 25 While Walking on Uneven 20 Surface While Walking on Even Surface 10 Outdoors While Walking Indoors Constant 5 and Severe 2. Stiffness None 10 Stiffness 0 3. Swelling None 10 Only in Evenings 5 Constant 0 4. Stair- No Problems 10 Climbing Impaired 5 Impossible 0 5. Running Possible 5 Impossible 0 6. Jumping Possible 5 Impossible 0 7. Squatting No problems 5 Impossible 0 8. Supports None 10 Taping, Wrapping 5 Stick or Crutch 0 9. Work, Same as Before Injury 20 Activities Loss of Tempo 15 of Daily Change to Simpler Job 15 Life Severely Impaired 0 Work Capacity Table 2: Showing Age Distribution Age (In years) No. of Patients Percentage 21-30 4 17 31-40 8 33 41-50 4 17 51-60 4 17 61-70 2 8 71-80 2 8 Total 24 100 Sex Male 20 83 Female 4 17 Total 24 100 Table 3: Side and Mode of Injury No. of Patients Percentage Side of Injury Right 16 67 Left 8 33 Mode of Injury RTA (High energy) 20 83 Fall (Low energy) 4 17 Type Closed 18 75 Open 6 25 Table 4: Showing Duration of Surgery and Fracture Union No. of Patients Percentage Type of Open Fracture Type I 4 75 Type II 2 25 Type III A -- -- Type III B -- -- Type III C -- -- Fracture Pattern A1 6 25 A2 2 8 A3 12 51 B1 -- 0 B2 -- 0 B3 -- 0 C1 2 8 C2 2 8 C3 -- 0 Table 5: Duration of Surgery and Fracture Union No. of Cases Percentage Duration of Surgery (In minutes) 51-60 16 68 61-70 2 8 71-80 2 8 81-90 4 16 Duration of Fracture Union (In weeks) 14 12 48 16 8 36 18 2 8 20 2 8 Table 6: Rating According to Oleaur and Mollander Scoring System Score Results 100-80 Excellent 50-79 Good 25-49 Fair < 25 Poor Table 7: Showing Complications Complications No. of Patients Percentage Superficial Skin Infection 2 16 Ankle Movement Restriction > 75% 0 0 50-75% 0 0 25-50% 0 0 < 25% 2 16 Anterior angulation 5[degrees] 0 0 Table 8: Showing Objective Criteria (American Ankle & Foot Score) Rating Ankle/Subtalar Tibiotalar Tibial Chronic Motion Alignment Shortening Swelling Excellent > 75% Normal Normal None None Good 50-75% Normal None Minimal Fair 25-50% < 5U < 1 cm Moderate Angulation Poor < 25% > 5U > 1 cm Severe Angulation Rating Pronation/ Equinus Supination Deformity Excellent Normal None Good Normal None Fair Moderate None Decrease Poor Marked Present Decrease
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|Title Annotation:||Original Research Article|
|Author:||Ramesh, G.; Kumar, N. Ravinder|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Apr 17, 2017|
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