DOI: 10.18410/jebmh/2015/597
ORIGINAL ARTICLE
MANAGEMENT OF FRACTURE DISTAL TIBIA WITH LOCKING
MEDIAL METAPHYSEAL PLATE
Ch. Banikanta Sharma1, Sanjib Waikhom2
HOW TO CITE THIS ARTICLE:
Ch. Banikanta Sharma, Sanjib Waikhom. ”Management of Fracture Distal Tibia with Locking Medial
Metaphyseal Plate”. Journal of Evidence based Medicine and Healthcare; Volume 2, Issue 29, July 20,
2015; Page: 4209-4214, DOI: 10.18410/jebmh/2015/597
ABSTRACT: Distal 1/3rd of tibia being a region with precarious blood supply is known for delayed
union or non-union when a fracture occurs in this part. Conservative treatment with POP cast
after manipulation and reduction, Interlocking nail, Plate osteosynthesis, Ring fixators etc. are the
usual treatment modalities employed for the management of these fractures. Type of fracture,
age of the patient, modality of treatment etc. are some of the factors that determine the outcome
of the fracture. A study was conducted at JNIMS Prompt to evaluate the efficacy of Locking
Medial Metaphyseal plate using Minimally Invasive Plate Osteosynthesis (MIPO) technique in the
management of Fracture Distal Tibia in 21 patients during the period March 2012 to March 2014.
Average injury–surgery interval was 6 days. All fractures got united with an average duration of
15 weeks. 1 patient developed superficial wound infection which resolved spontaneously with 5
days of parenteral 3rd generation cephalosporin. 2 patients complained of hardware prominence
at lower leg. Gentle soft tissue handling and avoiding releasing of tourniquet before the skin
closure, were strictly followed. Pre contoured tibial locking medial metaphyseal plate using MIPO
technique is an effective method in terms of union time and complication rate for treatment of
fracture distal tibia.
KEYWORDS: Locking Medial Metaphyseal plate, MIPO, Ring fixators, Interlocking Nail.
INTRODUCTION: Treatment of distal diametaphyseal tibial fractures with or without intra
articular extension remains a controversy because of anatomical subcutaneous location with
precarious blood supply. Different modalities of treatment for these fractures are closed reduction
and immobilisation in POP cast, closed/open intramedullary nailing, hybrid or ring fixators, open
reduction and internal fixation with LC-DCP etc. All of these techniques have their limitations.(1,2)
Closed reduction and immobilisation in POP cast was associated with high rates of delayed union
and non-union. Intramedullary interlocking nailing was associated with higher rate of malunion
due to difficulty in distal screw fixation.(3) Wound infection, skin breakdown and delayed
union/non-union requiring secondary procedures like bone grafting are some of the complications
associated with conventional osteosynthesis with plates.(4,5,6,7) Similarly cumbersome frames and
pin tract infection are the limitations with hybrid or ring fixators.(8)
Techniques of closed or semi open reduction and minimally invasive plate osteosynthesis
(MIPO) using locking medial metaphyseal plate has emerged as effective and acceptable method
for treatment of distal tibial fractures.(9,10) These implants when applied extraperiosteally do not
disturb the periosteal blood supply, respect fracture haematoma and provides a biomechanically
stable construct. (11) We report a series of patients treated at our institution for closed fracture of
diametaphyseal tibial fractures with or without intra articular extension using locking medial
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DOI: 10.18410/jebmh/2015/597
ORIGINAL ARTICLE
metaphyseal plate and minimally invasive technique. This study was conducted to evaluate the
healing rate, complications and functional outcome of the distal tibial fractures treated with
locking medial metaphyseal plate.
Locking Tibial Medial Metaphyseal Plate: These plates are low profile with increased number
of threaded 3.5 screw holes placed densely in the distal part to increase the purchase in the distal
fragment of the fracture. The plate can be long enough to extend upto the diaphysis. The locking
screw plate interface allows fracture fixation without plate bone adherence thus preserving
fracture haematoma.
MATERIALS AND METHODS: Twenty one patients with closed distal diametaphyseal tibial
fractures with or without intra articular extension treated at our center in between March 2012 to
2014 were prospectively followed. Demographic variables, mode of injury, injury-surgery
intervals, time required for union and complications were recorded.
All the patients were admitted in the ward after application of a posterior below knee slab
with the advice to keep the limb elevated. Baseline investigations are performed before the
surgery. Patients without gross swelling or blisters are operated within 72 hours; and patients
with gross swelling and blisters are delayed till the swelling subside and there is no sign of
secondary infection in the blisters.
Under regional or general anaesthesia, involved leg was prepared and draped. Tourniquet
was applied routinely but inflated only when required. A curvilinear incision was made at the level
of medial malleolus avoiding injury to the great saphenous vein and nerve. A subcutaneous plane
was developed with the help of a periosteal surfer, without stripping the periosteum and
disturbing the fracture haematoma. Reduction of fracture was performed closely under C arm
fluoroscopy. Where ever closed reduction was difficult limited open reduction was performed
using schanz pins as joysticks. Pre contoured locking medial metaphyseal plate was tunnelled in
the subcutaneous plane and its position was confirmed with C arm fluoroscopy before the screws
were fixed. Posterior sagging was checked by keeping a rolled towel underneath the fracture
region. Interfragmentary screw/screws were applied, plate dependent or independent wherever
feasible. With separate stab incisions, at least three locking screws were applied on either sides of
the fracture. Fibula was not routinely fixed unless the fracture was located within syndesmosis.
Skin was closed with non-absorbable preferably polypropylene suture and limb was splinted in a
posterior POP slab. Limb elevation and active range of motion movements were carried out for
initial two weeks. Stitches were removed on 14th day of surgery in majority of patients except in
those who had significant pre-operative leg swelling in whom stitch removal was delayed for 3-4
days to prevent wound dehiscence.
Non weight bearing ambulation was permitted at approximately three weeks. Patients
were followed up clinically and radiologically at OPD at monthly interval for first six months. Full
weight bearing as permitted only after clinico-radiological evidence of union. Union was defined
as bridging of three of the four cortices and disappearance of fracture line on the plain
radiographs for a patient who was able to bear full weight.
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ORIGINAL ARTICLE
RTA
RTA
Injury
treatment
Interval
(days)
4
4
RTA
5
20
RTA
3
20
RTA
6
16
RTA
4
20
RTA
RTA
3
5
15
18
Fall
4
20
43.A-2
RTA
3
15
M
43.A-1
RTA
4
17
35
M
43.A-1
RTA
2
18
13
14
36
40
M
M
43.A-3
43.A-2
RTA
RTA
5
3
20
18
15
29
M
43.A-3
Assault
5
20
16
40
M
43.A-1
Fall
5
18
17
45
F
43.A-1
Fall
4
20
18
40
M
43.A-2
RTA
5
20
19
42
M
43.A-1
RTA
3
18
20
36
M
43.A-3
RTA
3
16
21
27
M
43.A-2
RTA
4
18
Sl. Age
Sex
No (yrs)
AO
type
1
2
36
24
M
M
43.A-1
43.A-1
3
30
M
43.A-3
4
36
M
43.A-3
5
24
M
43.A-2
6
46
F
43.A-3
7
8
29
26
M
M
43.A-1
43.A-2
9
40
F
43.A-3
10
28
M
11
29
12
Associated
injury
Distal radius
fracture
Fracture
blisters.
Distal radius
fracture
Olecranon
fracture
Fracture blisters
Mode
of
injury
Union
time
(weeks)
Complications
18
16
Superficial
wound infection
Hardware
prominence
Hardware
prominence
Table 1
RESULTS: There were18 male and 3 female patients. According to AO classification 8(38%) of
the fractures were 43.A-1, 6 (28%) were 43.A-2 and 7 (34%) were 4.A-3. More than half of the
patients sustained the fracture in road traffic accidents and others due to fall or assault. One
patient had olecranon fracture which was fixed with TBW in the same sitting. Average duration of
injury treatment was 8 days. Average duration of union was 18 weeks (range 15-20 weeks).
Demographic profiles and outcome of each case are tabulated in Table 1. One patient had
superficial infection of the wound which resolved with antibiotics and 2 patients complained of
hardware prominence at the lower leg. Post-operative stiffness of the ankle was not encountered
in any of the patient in this series.
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DOI: 10.18410/jebmh/2015/597
ORIGINAL ARTICLE
Fig. 1
Fig. 2
Fig. 3
DISCUSSION: Distal diametaphyseal tibial fractures with or without intra articular extension can
be a challenge to the treating surgeon. The key point in management of this injury is to recognise
the importance of soft tissue component. The choice of implant and technique employed also play
important roles in the outcome of the treatment of these injuries. Closed intramedullary nailing or
open reduction and internal fixation using conventional plates for these fractures may be
associate with complications like malunion, non-union, secondary loss of reduction, wound
dehiscence, local septic conditions etc.(2,12,4,13,14) Use of medial metaphyseal locking plate
employing MIPO technique is technically feasible and advantageous in that it minimises the soft
tissue stripping and devascularisation of fracture fragments.(5,6,7) Three main components of this
procedure is closed reduction, minimal soft tissue dissection and extraperiosteally placed long
plate fixed with limited number of widely placed locking screws. Early intervention is
advantageous but delaying the surgery till the appearance of ‘wrinkle sign’ may give better
results.
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ORIGINAL ARTICLE
Reports in the literature on ORIF of distal tibia are plagued by wound infection.(1,4,13,14,15)
In our study there was only 1 case of superficial infection (5.26%). Union rate of fractures in this
study is comparable to other studies of plating of distal tibial fracture incorporating MIPO
technique.
CONCLUSION: Distal diametaphyseal tibia fracture still remains a tricky fracture to treat for the
treating surgeon with all the currently available treatment modalities. Fracture pattern, intra
articular extension, soft tissue condition is important factors that determine the type of fixation
device to be employed and outcome of the treatment. The present case series though small
shows that the use of low profile locking distal metaphyseal tibial plate employing MIPO
technique is an effective and reliable method of treatment for these fractures in terms of union
time and complication rate which is comparable to other studies. Implant prominence in thin
patients due to supramalleolar anatomy remains an issue in some cases.
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AUTHORS:
1. Ch. Banikanta Sharma
2. Sanjib Waikhom
PARTICULARS OF CONTRIBUTORS:
1. Assistant Professor, Department of
Orthopedics, Jawaharlal Nehru
Institute of Medical Sciences, Imphal.
2. Associate Professor, Department of
Orthopedics, Regional Institute of
Medical Sciences, Imphal.
NAME ADDRESS EMAIL ID OF THE
CORRESPONDING AUTHOR:
Dr. Ch. Banikanta Sharma,
Bramhapur Aribam Leikai,
Harinath Road, Imphal East,
Manipur-795001.
E-mail: sharmabanikanta@yahoo.com
Date
Date
Date
Date
of
of
of
of
Submission: 09/07/2015.
Peer Review: 10/07/2015.
Acceptance: 13/07/2015.
Publishing: 17/07/2015.
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Page 4214