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Arch Orthop Trauma SurgDOI 10.1007/s00402-013-1916-1

TrAumA Surgery

Locking plate as a definitive external fixator for treating tibial fractures with compromised soft tissue envelop

Xu‑sheng Qiu · Han Yuan · Xin Zheng · Jun‑fei Wang · Jin Xiong · Yi‑xin Chen

received: 1 November 2013 © Springer-Verlag Berlin Heidelberg 2013

or good functional results and were fully weight bearing with a well-healed tibia at the final follow-up.Conclusion The locking plate used as a definitive exter-nal fixator provided a high rate of union. The patients experienced a comfortable clinical course, excellent knee and ankle joint motion, satisfactory functional results and an acceptable complication rate. However, the stiffness of external locked plating is not clear, therefore, clinical recommendation on its practical use to reduce the risk of implant failure still need to be determined.

Keywords Locking plate · external fixator · Tibial fractures · Compromised soft tissue envelop

Introduction

Tibial fractures with compromised soft tissue envelop pose a treatment dilemma for the orthopedic surgeon. The lit-erature contains abundant reports of wound complications after immediate open reduction and internal fixation of these fractures, including partial- and full-thickness skin necrosis, wound dehiscence, osteomyelitis, and even ampu-tation [1, 2]. The use of two-stage reconstruction for the treatment of these fractures has been successful in decreas-ing the complication rates [3, 4]. The two stages involve: (1) stabilization of the injured tibia with a bridging external fixator to allow the soft tissues to improve and recover, and (2) definitive fixation for reconstruction of the articular sur-face and meta-diaphyseal fractures.

However, two-stage reconstruction incurs additional cost compared with traditional open methods. Therefore, external fixation used either alone or with limited internal fixation as the definitive treatment for lower extremity frac-tures with compromised soft tissue envelop was advocated

Abstract Introduction Tibial fractures with compromised soft tis-sue envelop may lead to significant complications. The optimal management of these injuries remains controver-sial. recently, locking plate used as a definitive external fixator is attractive because it not only minimizes trauma to the soft tissues, but also overcomes the shortcomings of standard external fixators. The objective of this study was to evaluate the outcome of using locking plate as a defini-tive external fixator for treating tibial fractures with com-promised soft tissue envelop.Patients and methods A prospective series of 12 consecu-tive tibial fractures with compromised soft tissue envelop were treated using locking plate as a definitive external fix-ator. Of these patients, six were gustilo and Anderson type IIIA, three were type II and three were closed fractures (AO/ASIF soft tissue injury classification IC4: 2, IC5: 1). Time to union, nonunion, malunion, leg shortening, range of motion and function for the knee and ankle, deep infec-tion, pin tract infections were evaluated.Results The mean bone healing time was 37.8 weeks (range 20–56 weeks). eventually, all of the fractures united. most of the fractures healed in acceptable positions. There were no cases of deep infection. Pin tract infection was seen in 1 (8.3 %) patient, no loosening or failure of the external fixator was seen. At the most recent follow-up, the mean range of motion at the knee was extension 0° to flexion 135°, and the mean ankle range of motion was dorsi flexion 12° to plantar flexion 32°. All patients had excellent

X. Qiu · H. yuan · X. Zheng · J. Wang · J. Xiong · y. Chen (*) Department of Orthopaedics, Drum Tower Hospital, The Affiliated Hospital of Nanjing university medical School, No. 321 Zhongshan road, Nanjing, Chinae-mail: chenyixin93@126.com

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by some orthopedic surgeons [5, 6]. Standard external fixa-tors are relatively inexpensive and easy to apply. However, frames are often bulky and cumbersome. Patients typically encounter problems with clothing. When used on lower extremities, especially in the knee area, the frames impede the contralateral extremity when walking. most often, when external fixators are used for bridging the fracture across the joint for long periods of time, muscle atrophy and joint stiffness is inevitable.

recently, locking plate as an external fixation without joint spanning has been used as part of staged reconstruc-tion in the management of open tibial fractures [7–9]. The benefits of using the locking plate for temporary external fixation include immediate osseous stabilization with-out crossing the knee, low-profile rigid fixation, access to wounds, better patient comfort, ease of subsequent defini-tive fixation, early range of motion of the joint and shorter hospitalization time [7]. moreover, some studies suggested that the locking plate used as a definitive external fixator provided a high rate of union [10–12]. For instance, ma et al. [12] reported that eight open tibial fractures were healed without major complications by one-stage locking plate treatment (as a definitive external fixator).

The locking plate used as a definitive external fixator is attractive because it not only minimizes trauma to the soft tissues, but also overcomes the shortcomings of standard external fixators. In the present study, all the patients had tibial fractures with compromised soft tissue envelop. They realized the seriousness of immediate open reduction and internal fixation and the pitfalls of standard external fixa-tors. In addition, the total cost of two-stage reconstruction was intolerable for them. Therefore, the locking plate used as a definitive external fixator was the best choice for the

patients. The purpose of this study was to evaluate the out-come of using locking plate as a definitive external fixator for treating tibial fractures with compromised soft tissue envelop in this series of patients.

Patients and methods

Between January 2010 and September 2011, a total of 12 tibial fractures patients (nine men, three women) with com-promised soft tissue envelop were treated at our institution using the described technique (Table 1). The average age was 50 years (range 24–76 years). Of these patients, six were gustilo and Anderson type IIIA, three were type II and three were closed fractures (AO/ASIF soft tissue injury classification IC4: 2, IC5: 1). The fractures were caused by falls from heights of >2 m (n = 4) and traffic accidents (n = 8).

A thorough debridement was initially performed for the patients with open fractures and the wound was closed. Skeletal traction has been used in some patients to prevent further injury to the soft tissues and improve patient com-fort. Locking plates used as definitive external fixators were applied on the patients until loss of swelling, reduced diam-eter, and, most notably, wrinkling of the skin are noted.

All patients were evaluated radiographically and clini-cally. The radiographic evaluation was done using antero-posterior and lateral radiographs at the time of admission, immediately postoperatively, and every 1–3 months at follow-up. Time to union, nonunion, malunion, leg shorten-ing, range of motion for the knee and ankle, deep infection, pin tract infections were evaluated. union was defined as the presence of mature, bridging callus of the four cortices

Table 1 Patient demographics

Case Age gender gustilo grade AO/ASIF soft tissue injury classification

AO/OTA classification

Other fracture

Associated injury

1 34 m II – 42-B3 – –

2 60 m IIIA – 41-B1/43-C3 – –

3 55 F II – 42-C2 – –

4 40 m – IC5 41-C2/44-C3 – elbow dislocation

5 60 m IIIA – 42-C3 – Cervical cord injury

6 24 F IIIA – 41-C3 – –

7 62 m IIIA – 42-B3 – Hemopneumothorax, intracranial hemor-rhage

8 76 m – IC4 42-C3 – –

9 51 m II – 42-C3 Contralateral tibia –

10 47 m IIIA – 42-C3 Pelvis, ribs Hemopneumothorax

11 50 m IIIA – 41-A3 – –

12 43 F – IC4 43-C2 – –

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on both AP and lateral directions and painless, full weight bearing. Time to union was counted from the initial trauma irrespective of intermittent surgery. Nonunion was defined as persistence of the fracture at 9 months from the initial trauma without any tendency to progressive union in the previous 3 months. malunion was defined as malalignment of more than 5° in any plane on full-length tibia radio-graphs, shortening >1 cm and distal fragment rotation >15° or step-off of the articular surface of more than 2 mm on AP/lateral radiographs. Deep wound infection was defined as the presence of local inflammatory symptoms such as redness, erythema, or swelling; presence of purulent dis-charge; and positive bacterial cultures (wound or blood) [13, 14].

Functional results were based on five criteria [9, 12]: the presence of a limp, stiffness of the knee or the ankle, pain, soft tissue sympathetic dysfunction and inability to perform previous activities of daily living. An excellent result was defined as the absence of all of the aforementioned out-comes; a good result was defined as the presence of one of the outcome criteria; a fair result was defined as the presence of two of the outcome criteria; and a poor result was defined as the presence of more than three of the five criteria.

All patients gave informed consent for inclusion in the study. The study was authorized by the local ethical com-mittee and was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki.

Surgical technique

The patient was under either general or regional anesthe-sia; the involved limb was prepared and draped. A thorough debridement was then performed if needed; and further devitalization of the soft tissue and bone was avoided. The tibia was reduced and aligned using indirect or direct meth-ods. good reduction was achieved using the direct method through the open wound or through short incisions extend-ing from the wound. If necessary, reduction was achieved by making small incisions with limited soft tissue stripping around the fracture site. When the fracture is acceptably reduced, provisional stabilization, usually with Kirschner wires or screws is necessary. Then, soft tissues are gener-ally closed prior to placement of the locking plate as the plate might limit easy access for wound closure.

After reduction and limited fixation of the fragments, locking plate was applied as an external fixator. gener-ally, proximal lateral tibia locking compression plate (LCP) (Synthes, Paoli, PA) or proximal lateral tibia LCP (SAN-yOu, Shanghai, China) was used for proximal tibial frac-ture; anterolateral distal tibia LCP (Synthes, Paoli, PA) or anterolateral distal tibia LCP (SANyOu, Shanghai, China)

was used for distal tibial fracture; distal femur LCP (Syn-thes, Paoli, PA) or distal femur LCP (SANyOu, Shanghai, China) was used for segmental tibial fracture. Then a LCP of appropriate length is chosen. We recommend relatively long plates to increase the options for screw fixation. The plate was placed as close to the bone as possible because mechanical stability decreased as the distance between the plate and bone increased. To ensure secure fixation, 3–5 screws were placed into both ends of the fractures, and two screws were inserted to stabilize the segmental fragment in the patients with segmental tibial fracture. Two LCPs fixation may be needed in some patients. Bicortical locked screw fixation was used for the patients.

Screw tracks were cleaned with 75 % alcohol daily. Once the wound is closed, the patient can shower with the external fixator in place. Physical therapy began on the second to the fifth postoperative day using a continuous passive-motion apparatus (Fig. 1). Depending on the stabil-ity of the reconstruction, toe-touch or partially weight bear was encouraged for the patients 4–6 weeks after surgery.

Results

The time between injury (admission) and definitive surgery was 10 days (range 5–18 days). The mean follow-up was 33 months (range 24–44 months). The mean bone healing time was 37.8 weeks (range 20–56 weeks); it was 21.2, 23.5, 48.1 weeks for the proximal, distal, and shaft fracture lines, respectively. eventually, all of the fractures united (Figs. 1, 2). most of the fractures healed in an acceptable position. No clinically relevant malrotation or limb-length discrepancies were observed. There were no cases of deep infection. Pin tract infection was seen in 1 (8.3 %) patient, and the infection was resolved by removing the plate and screws, a thorough debridement and oral antibiotic therapy (Fig. 2). No loosening or failure of the external fixator was seen. The skin tolerates the titanium screws well and seems to “adhere” to the screw. At the most recent follow-up, the mean range of motion at the knee was extension 0° to flexion 135° and the mean ankle range of motion was dorsi flexion 12° to plantar flexion 32° (Figs. 1, 2). All patients had excellent or good functional results and were fully weight bearing with a well-healed tibia at the final follow-up.

Discussion

recently, the locking plates used as external fixation have been reported by several surgeons [7–12, 15, 16]. It has been described in the management of infected nonunion [10, 11], open fracture [7–9, 12, 16] and even as an adjunct

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in distraction osteogenesis [15]. Kloen et al. [10] were the first to describe the use of a locked compression plate as external fixation. They used the LCP as an external fixa-tor in the management of infected nonunions [10, 11]. The LCPs were used as temporary or definitive external fixator. The authors concluded that this technique was versatile, low profile, and well tolerated by their patients. Although its indications are relatively limited, it can be a useful adjunct in the stage of treatment of complex reconstruc-tive cases. ma et al. [7–9] used locking plate as external fixation and designed a two-stage protocol for the treatment of open tibial injury: The first stage used low profile, lock-ing plates for temporary external fixation after debridement and anatomic reduction, followed by soft tissue reconstruc-tion. The second stage then consisted of locking plates for definitive internal fixation, using minimally invasive percu-taneous osteosynthesis. During ma’s practice, eight open tibial fractures were healed without major complications by only the first-stage treatment due to patients’ refusing the second-stage treatment. These patients also experienced a comfortable clinical course, excellent knee and ankle joint motion, satisfactory functional results and an accept-able complication rate [12]. In the present study, a series of 12 tibial fractures patients with compromised soft tissue envelop were planned to be treated with locking plate used as definitive external fixator; and the clinical outcome was also tempting.

Locking plate used as external fixator was a joint-spar-ing frame. Joint-sparing frame is superior to spanning frame in some aspects. Koulouvaris et al. [17] compared different fixation methods in the treatment of severe pilon fractures. They found that patients in external fixation with

the ankle spanning have reduced their activities compared with patients in external fixation with the ankle sparing. In the present study, the locking plate used as external fixa-tor was a joint-sparing frame, physical therapy could begin early postoperatively (on the second to the fifth postop-erative day). Therefore, all patients had excellent or good functional results. At the most recent follow-up, the mean range of motion at the knee was extension 0° to flexion 135° and the mean ankle range of motion was dorsi flex-ion 12° to plantar flexion 32°. Furthermore, most of the fractures healed in an acceptable position. No clinically relevant malrotation or limb-length discrepancies were observed. On the other hand, Papadokostakis et al. [18] reported that patients treated with spanning frames had significantly greater incidence of malunion compared with patients treated with sparing frames.

Nonunion of the tibial shaft is a common problem that can be disabling. Although the definitions of nonunion have varied from author to author, the prevalence of nonunion can be estimated from the literature. In a review article, Phieffer and goulet [19] reported the combined prevalence of nonunion was 2.5 %, which calculated from 5,517 frac-tures. Open fractures with gross contamination and exten-sive soft tissue damage have a higher prevalence of nonun-ion. In series of open tibial fractures, edwards and Jaworski [20] reported that 41 % of grade III fractures required bone grafting before union was achieved. Velazco et al. [21] reported that the rate of nonunion for type II and type III open tibial fractures was 14 %. In the present study, a total of 12 tibial fractures patients with compromised soft tis-sue envelop were united at finally follow-up. recently, ma et al. [12] also reported using LCPs as a definitive external

Fig. 1 a A 60-year-old male sustained gustilo type IIIA fracture. b X-ray films showed left proximal and distal tibial fractures (AO/OTA classifica-tion 41-B1/43-C3). c The frac-tures were stabilized with two metaphyseal locking plates used as definitive external fixator, and limited internal fixations. d, e Antero-posterior and lateral X-ray images after surgery. f Physical therapy began on the fifth postoperative day using a continuous passive-motion apparatus. g–j The fractures united and external fixators removed at the 5-month follow-up visit. k, l good functional result was noted

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fixator in the treatment of eight open tibial fracture patients. Similarly, all the fractures united and the mean bone heal-ing time was 37.5 weeks (range 20–52 weeks). Although both studies have limited patients, it is indicated that using locking plate as a definitive external fixator in the treatment of tibial fracture patients seems does not have bad effects in bone healing process.

Infection is sometimes an inevitable complication for treating tibial fractures with compromised soft tissue envelop. In a meta-analysis, Fang et al. [22] reported that the combined deep infection rate of gustilo grade III tibial fractures was 8.9 % (19/214) for the patients treated with external fixator, 10.4 % (22/212) for the patients treated with unreamed intramedullary nailing. Immediate open reduction and internal fixation (OrIF) of closed tibial frac-tures with severe soft tissue injuries often results in high rates of soft tissue complications. Dillin and Slabaugh [23] reported on a total of 11 patients with severe tibial plafond fractures treated with early OrIF. In this patient popula-tion, they realized a 36 % (4/11) rate of skin slough and a 55 % (6/11) rate of deep infection. The use of two-stage reconstruction has been successful in decreasing the com-plication rates. For example, Sirkin et al. [3] reported the results of pilon fractures treated with staged management. The deep infection rates were 3.4 and 10.5 % for closed and open pilon fractures, respectively. The rates of partial thickness skin necrosis were 17 % in closed pilon fractures

patients and 10.5 % in open pilon fractures patients. In the present study, no deep infection occurred. Pin tract infec-tion was seen in 1 (8.3 %) patients and resolved after removing the plate and screws and a thorough debridement. Therefore, the locking plate used as a definitive external fixator maybe a useful treatment option for treating tibial fractures with compromised soft tissue envelop.

In conclusion, the locking plate used as a definitive external fixator has the following advantages: (1) It func-tions as external fixator could minimize trauma to the soft tissues, eliminate the complications after immediate open reduction and internal fixation of tibial fractures with com-promised soft tissue envelop; hardware removal can be per-formed in an outpatient setting under local anesthesia. (2) It overcomes the shortcomings of standard external fixators. The locking plate is able to construct a low-profile frame close to the skin and can be concealed under clothing, mak-ing it more acceptable to patients. The locking plate used as a definitive external fixator does not need to across the joint, early function exercise is possible. (3) It used as one-stage reconstruction decreases the cost compared with two-stage reconstruction.

Although there are several advantages when using lock-ing plate as a definitive external fixator, surgeons should keep certain points in mind. First, optimal alignment of the bone is difficult before placing the screws. In contrast to the standard external fixator with clamps and tubes, the

Fig. 2 a A 40-year-old male sustained closed proximal tibial fracture (AO/ASIF soft tissue injury classification IC5). b, c X-ray films showed right proximal tibial fractures (AO/OTA classification 41-C2). d The fractures were stabilized with two metaphyseal locking plates used as definitive external fixator. e, f Antero-posterior and lateral X-ray images after surgery. g Pin tract infection occurred 2 months after surgery. h, i The lateral plate and screws were removed and a thorough debridement was performed to resolve the pin tract infection. j–l The fractures united and external fixators removed at the 5-month follow-up visit; good functional result with knee range of motion 0°–145° was noted

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plate as external fixator can be harder to manipulate and adjust. Therefore, traditional external fixators were still used for the patients with severe open fractures (gustilo and Anderson type IIIB or IIIC) in the acute setting at our institution. Second, although the locking plate used as a definitive external fixator provided a high rate of union, concern arose about insufficient stiffness in external lock-ing plate. Therefore, in our practice, most of the patients with compromised soft tissue envelop were still treated with two-stage reconstruction; and the traditional external fixators were used. The locking plate used as a definitive external fixator was only applied in the patients who were intolerable of the total cost of two-stage reconstruction; and the patients were informed with the risk of implant failure preoperatively. There is little literature describing fixation stability using this new external locking plate technique. ma et al. [12] used finite element models of internal (IPF) as well as two different external plate fixations (ePFs) for proximal tibial fractures and revealed that axial stiffness and angular stiffness decreased as the offset distance from the bone surface increased. Compared to the IPF models, in the two ePF models, axial stiffness decreased by 84–94 %, whereas the angular stiffness decreased by 12–21 %. Hence, large-scale clinical study is still needed.

Acknowledgments This study has received financial support from the Peak Talents Foundation in Jiangsu Province (#2012-WS-092), Key Project of Department of Health, Nanjing, China (JQX12005), and the Key Program of Science and Technique Development Founda-tion in Jiangsu Province (Be20116004). We acknowledge Dr. Hong-fei Shi, Dr. Jun Jiang, Dr. Xiao-xiao Xie, and Dr. Chang-jun Wang for their assistance during the data collection. The authors would also like to thank ms. Xiao-xia Zhong for her help in patient follow-up.

Conflict of interest None.

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