Plating technique effective for high-energy tibia fractures

Although patients required an average of 35 weeks to achieve union, 97% achieved acceptable alignment.

BOSTON — Minimally invasive indirect reduction and subcutaneous medial plating can repair high-energy metaphyseal distal tibia fractures with low nonunion rates, a new study shows.

Historically, high-energy distal tibia fractures have high complication rates. Although treatments and technologies have improved, "Outcomes for the bad ones are still not very good in a lot of cases," according to Cory A. Collinge, MD, an orthopedic trauma surgeon at Harris Methodist Hospital in Fort Worth, Texas.

“I think in general these high-energy metaphyseal fractures in the distal tibia present some treatment challenges. You have a wide intramedullary canal, thin cortices, which can be osteoporotic in some patients, you can have eccentric muscle pulls, and the ankle is right there,” Collinge said.

“In the literature, and in teaching at different institutions around the country, I think the personality of these injuries is poorly described and poorly understood. It may be that there is no ideal treatment for these injuries and it may be that each case should be treated individually,” he added.

High-energy fractures

Collinge and colleagues in Fort Worth reviewed their results treating high-energy distal tibia fractures with minimally invasive plating. He presented the results here at the American Orthopaedic Foot and Ankle Society (AOFAS) 21st Annual Summer Meeting.

The study included 30 patients with fractures that meet strict criteria for high-energy injury. All patients had highly comminuted fractures, which had to be classified as Tscherne 2 or Tscherne 3 if they were not open fractures.

The study mainly involved fractures of types A2, A3 or C2, and more than half of the patients had sustained Grade 2 or Grade 3 open fractures. All cases had medial wounds, 90% of which had an accompanying fibular fracture, Collinge said.

A fellowship-trained trauma surgeon performed all procedures once the soft tissue had calmed down. In 18 of the 30 cases, the surgeon used temporary external fixation. Seven patients required bone grafts, and four were revised to intramedullary nailing.

Follow-up ranged from 18 to 45 months.

Delayed healing

“Average time to healing in this series was 35 weeks, which is an awful long time,” Collinge said. “The average time to healing for closed fractures was relatively quick — 25 weeks — relative to the open fractures, which healed after almost a year.”

Six patients healed after six months, four of whom had open fractures.

Nine patients required a second surgery to achieve union. Of these, seven had open fractures and four experienced significant bone loss due to the injury or to subsequent debridements.

Among patients who did not require a second surgery, one-third achieved union after more than six months, Collinge said, adding, “I think most people would call that a delayed union.”

Hardware irritation caused plate removal in three patients after their fractures had healed. Two patients developed late infections at seven and 11 months postop, also after their fractures had healed. “They were treated successfully by debridement, plate removal and antibiotics. No patient had breakdown of the plate,” Collinge noted.

“Motion was quite good. The average dorsiflexion was 9°, the average plantar flexion was 41° and mean AOFAS score was 83,” Collinge said, noting 97% of patients achieved acceptable alignment.

“Only one case lost fixation, but healed ... [and] he had an AOFAS score of 86,” he said.

For more information:
Collinge CA. Results of high-energy metaphyseal distal tibia fractures treated with indirect reduction and subcutaneous medial plating. Presented at the American Orthopaedic Foot and Ankle Society 21st Annual Summer Meeting. July 14-17, 2005. Boston.