Increase in wound complication rates found with use of locking compression plates in distal fibular fractures

Schepers T. Injury. 2011. doi:10.1016/j.injury.2011.01.009.

Issue: October 2011

Researchers in the Netherlands have identified a significant increase in wound complications inherent in treating distal fibular fractures with a locking compression plate, according to the study.

The team performed a 6-year study in which they retrospectively analyzed all consecutive, closed distal fibular fractures that had been treated with either a non-locking or locking plate. Complications related to the fibula were identified.

In all, 165 patients received a one-third tubular plate and 40 received a locking plate. Patient, injury and operation characteristics were comparable, the authors wrote, but the complication rate in the locking plate group was 17.5% compared with the 5.5% complication rate in the conventional plating group. The difference, the team reported, was primarily in an increase in major complication rates that necessitated removal of the plate.

“In light of the current study, we would caution against the application of the currently used locking compression plates in the treatment of distal fibular fractures,” the authors wrote.

This is an interesting retrospective study written by an author well published in the field. The clinical outcomes of consecutive patients treated over a five year period with a closed fracture of the fibula, internally fixed with either a conventional non-locking third tubular plate (n=165) or locking plate (n=40) were reviewed. Fracture classification and patient demographics were similar in both groups. The non-locking cohort had a higher percentage of smokers and diabetics.

The main strengths of this paper include the previously unreported difference in complications between the devices, thorough follow-up and overall cohort size. I agree with the study conclusions. The thicker profile of locking plates, subsequent difficulty in contouring the implant and less satisfactory reduction achieved, could all predispose to increased soft tissue complications and hardware irritation.

Weaknesses include the retrospective nature of the study and underlying selection bias. The authors make no attempt to explain the surgeons’ justification in opting for a locking construct. Was this personal preference or a reflection that the fracture was more serve necessitating its use? Clearly such cases would more likely to have a poorer outcome.

Overall, I commend the authors for highlighting the increased complication rate and poorer reduction associated with locking plates, but do not share their high level of caution based on this paper’s methodology. A randomised study would be useful. Locking plate fixation of the fibula may be appropriate in selected circumstances, namely osteoporotic, comminuted fractures, as a bridging device. Clearly surgeons need to exercise caution, and select the most appropriate implant based on clinical indication.

— Graeme S. Carlile, MBChB, MRCS
Trauma and Orthopaedics Department
Plymouth Hospitals NHS Trust
United Kindgom.

Disclosure: Carlile has no relevant financial disclosures.

The authors present a retrospective study that found a higher rate of wound complications and hardware removal among patients undergoing fixation with locking versus non-locking plates for distal fibular fractures. This study highlights the caution that should be used when interpreting the results of retrospective studies. Specifically, the use of locking plates in an uncontrolled, retrospective study may well be non-random and linked to confounding factors including measures of severity not captured by simple classification such as the number of malleoli involved. A randomized, controlled trial is necessary before drawing definitive conclusions regarding the relative risks of non-locking and locking plate for fibula fracture.

— Nelson F. SooHoo, MD
Department of Orthopedic Surgery
University of California Los Angeles