Orthopedics

Feature Articles 

Posteromedial Anatomical Plate for the Treatment of Distal Tibial Fractures with Anterior Soft Tissue Injury

Jiayuan Hong, MD; Rongming Zeng, MD; Dasheng Lin, MD; Linxin Guo, MD; Liangqi Kang, MD; Zhenqi Ding, MD; Jianhua Xiao, MD

Abstract

The treatment of distal tibial fractures with anterior soft tissue injury is relatively difficult. The aim of this study was to explore the efficacy and safety of the posteromedial anatomical plate for such fractures. Between February 2006 and January 2009, twenty-six cases of distal tibial fracture with anterior soft tissue injury were treated with posteromedial anatomical plates designed by our traumatic orthopedic center. Of the 26 cases, 12 were open fractures (4 Gustilo-Anderson type I, 5 type II, 2 type IIIA, and 1 type IIIB), and 14 were closed fractures (3 Tscherne-Oestern type I, 9 type II, 2 type III). Operation time, intraoperative blood loss, fracture healing time, American Orthopaedic Foot and Ankle Society (AOFAS) ankle score, and complications were recorded to evaluate treatment effects.

Mean operation time was 72.5±15.8 minutes (range, 45–105 minutes) with a mean intraoperative blood loss volume of 86.4±17.3 mL (range, 50–150 mL). All 26 patients had good postoperative fracture healing. Mean union time was 19.2±4.4 weeks (range, 13–30 weeks). Average AOFAS ankle score was 87.3±9.2 (range, 68–99). No malunion, nonunion, limb-shortening deformity, or neurovascular injury occurred. Our results suggest that the posteromedial anatomical plate for the treatment of distal tibial fractures with anterior soft tissue injury is effective and results in no severe complications.

Drs Hong, Zeng, Lin, Guo, Kang, Ding, and Xiao are from the Department of Orthopedic Surgery, the Affiliated Southeast Hospital of Xiamen University, Orthopedic Trauma Center of PLA, Zhangzhou, China.

Drs Hong, Zeng, Lin, Guo, Kang, Ding, and Xiao have no relevant financial relationships to disclose.

This study was supported by key projects from Nanjing Military Region during the 11th Five-Year Plan Period (No. 07M068).

Distal tibial fracture is a common traumatic injury often associated with varying degrees of soft tissue injury. It is relatively difficult to treat clinically, especially fractures with anterior soft tissue injury. 1–4 The difficulty is reflected in the contradiction between anterior soft tissue injuries and firm fracture fixation. 5,6 Conventional medial and lateral plates can be fixed firmly, but good anterior soft tissues are needed. 7,8 External fixator fixation will not affect soft tissue repair. 3,9 However, the high prevalence of malunion, nonunion, and pin tract infection makes it difficult for this method to become the ideal one. 6–8,10 Although modified intramedullary nailing can be applied in distal tibial fractures, its effectiveness is controversial. 7,11,12 Therefore, it is often difficult for orthopedic surgeons to choose between treatment options for distal tibial fractures with anterior soft tissue injury.

In this study, we used posteromedial anatomical plates designed by our department for fixation of distal tibial fractures with anterior soft tissue injury. Our aim was to repair fractures by avoiding injured anterior soft tissues and effectively address the contradiction between anterior soft tissue injuries and firm fracture fixation.

From February 2006 to January 2009, twenty-six adults with distal tibial fracture and anterior soft tissue injury of the lower leg were treated with plate fixation (Table ). All operations received ethics committee approval and informed patient consent. Patients with pathologic fractures, autoimmune diseases, blood disorders, severe multiple trauma, and surgical contraindications were excluded. Anteroposterior (AP) and lateral radiographs of the leg, including the ankle joint, were taken in all patients, and computed tomography (CT) was performed if necessary.

Table 1. Patient Information

Seventeen men and 9 women had a mean age of 43.1±8.6 years (range, 22–63 years). Ten patients had left-side fracture and 16 had right-side fracture. Mechanism of injury included motor vehicle accident (n=12), fall from a height (n=5), fall of heavy objects (n=5), simple fall (n=3), and sport activities (n=1). Of the 26 cases, 12 were open…

Abstract

The treatment of distal tibial fractures with anterior soft tissue injury is relatively difficult. The aim of this study was to explore the efficacy and safety of the posteromedial anatomical plate for such fractures. Between February 2006 and January 2009, twenty-six cases of distal tibial fracture with anterior soft tissue injury were treated with posteromedial anatomical plates designed by our traumatic orthopedic center. Of the 26 cases, 12 were open fractures (4 Gustilo-Anderson type I, 5 type II, 2 type IIIA, and 1 type IIIB), and 14 were closed fractures (3 Tscherne-Oestern type I, 9 type II, 2 type III). Operation time, intraoperative blood loss, fracture healing time, American Orthopaedic Foot and Ankle Society (AOFAS) ankle score, and complications were recorded to evaluate treatment effects.

Mean operation time was 72.5±15.8 minutes (range, 45–105 minutes) with a mean intraoperative blood loss volume of 86.4±17.3 mL (range, 50–150 mL). All 26 patients had good postoperative fracture healing. Mean union time was 19.2±4.4 weeks (range, 13–30 weeks). Average AOFAS ankle score was 87.3±9.2 (range, 68–99). No malunion, nonunion, limb-shortening deformity, or neurovascular injury occurred. Our results suggest that the posteromedial anatomical plate for the treatment of distal tibial fractures with anterior soft tissue injury is effective and results in no severe complications.

Drs Hong, Zeng, Lin, Guo, Kang, Ding, and Xiao are from the Department of Orthopedic Surgery, the Affiliated Southeast Hospital of Xiamen University, Orthopedic Trauma Center of PLA, Zhangzhou, China.

Drs Hong, Zeng, Lin, Guo, Kang, Ding, and Xiao have no relevant financial relationships to disclose.

This study was supported by key projects from Nanjing Military Region during the 11th Five-Year Plan Period (No. 07M068).

Correspondence should be addressed to: Jiayuan Hong, MD, Department of Orthopedic Surgery, the Affiliated Southeast Hospital of Xiamen University, Orthopedic Trauma Center of PLA, Zhangzhou 363000, China (hongjy175@yahoo.com.cn).
Posted Online: June 14, 2011

Distal tibial fracture is a common traumatic injury often associated with varying degrees of soft tissue injury. It is relatively difficult to treat clinically, especially fractures with anterior soft tissue injury. 1–4 The difficulty is reflected in the contradiction between anterior soft tissue injuries and firm fracture fixation. 5,6 Conventional medial and lateral plates can be fixed firmly, but good anterior soft tissues are needed. 7,8 External fixator fixation will not affect soft tissue repair. 3,9 However, the high prevalence of malunion, nonunion, and pin tract infection makes it difficult for this method to become the ideal one. 6–8,10 Although modified intramedullary nailing can be applied in distal tibial fractures, its effectiveness is controversial. 7,11,12 Therefore, it is often difficult for orthopedic surgeons to choose between treatment options for distal tibial fractures with anterior soft tissue injury.

In this study, we used posteromedial anatomical plates designed by our department for fixation of distal tibial fractures with anterior soft tissue injury. Our aim was to repair fractures by avoiding injured anterior soft tissues and effectively address the contradiction between anterior soft tissue injuries and firm fracture fixation.

Materials and Methods

From February 2006 to January 2009, twenty-six adults with distal tibial fracture and anterior soft tissue injury of the lower leg were treated with plate fixation (Table ). All operations received ethics committee approval and informed patient consent. Patients with pathologic fractures, autoimmune diseases, blood disorders, severe multiple trauma, and surgical contraindications were excluded. Anteroposterior (AP) and lateral radiographs of the leg, including the ankle joint, were taken in all patients, and computed tomography (CT) was performed if necessary.

Patient Information

Table 1. Patient Information

Seventeen men and 9 women had a mean age of 43.1±8.6 years (range, 22–63 years). Ten patients had left-side fracture and 16 had right-side fracture. Mechanism of injury included motor vehicle accident (n=12), fall from a height (n=5), fall of heavy objects (n=5), simple fall (n=3), and sport activities (n=1). Of the 26 cases, 12 were open fracture, including 4 cases of Gustilo-Anderson 13 type I, 5 type II, 2 type IIIA, and 1 type IIIB. Fourteen cases were closed fracture, including 3 cases of Tscherne-Oestern 14 type I, 9 II, and 2 type III. According to AO fracture classification, 15 all cases were AO types 43A (n=21) and 43C1 (n=5). The average distance from the fracture line to the ankle was 3.1±1.7 cm (range, 0–5.2 cm). Eighteen cases were accompanied by fibular fractures (69.2%).

The posteromedial anatomical plate used in this study (Xiamen Double Engine Medical Material Co, Xiamen, China) included a head and body (Figure ). The head was shaped as a trapezoid and had 4 nail holes, with a maximal width of 16 mm. The body was shaped as a long board with a width of 13 mm. The length varied according to the fracture. The plate was designed according to the anatomical features of the posteromedial surface of the distal tibia of healthy adults. The good fit of the plate and its bony surface was proven during surgery.

Front (A) and Back (B) Sides of the Plate, Designed According to Anatomical Features of the Posteromedial Plane of the Distal Tibia of Healthy Adults, Including the Head and Body.

Figure 1:. Front (A) and Back (B) Sides of the Plate, Designed According to Anatomical Features of the Posteromedial Plane of the Distal Tibia of Healthy Adults, Including the Head and Body.

Closed fractures underwent conventional sustained calcaneal traction or routine plaster support external fixation (Figure ). After dehydration and detumescence treatment, the swelling was resolved and tense blisters were dried. Then, plate internal fixation was performed. All open wounds underwent thorough debridement. Routine tetanus anti-virus serum and appropriate broad-spectrum antibiotics (cefuroxime, 1.5 g intravenously) were given. Within 6 hours of injury, if the patient’s physiological condition allowed, first-stage plate internal fixation was performed for Gustilo type I and II fractures without obvious swelling and contamination. 16 For the other Gustilo type II and Gustilo type IIIA/B fractures, angle-spanning external fixation was performed first. After the initial management, skin flap/grafts were performed, and antibiotic-impregnated dressing was applied as needed. After the soft tissue appeared stable, the external fixator was removed and definitive plate internal fixation was conducted. The average interval of fracture and internal fixation was 3.4±0.6 days (range, 3 hours to 18 days).

Closed Fracture of the Distal Tibia with Large Areas of Anterior Soft Tissue Injury. Conventional Medial and Lateral Approach Surgery Was Difficult to Perform.

Figure 2:. Closed Fracture of the Distal Tibia with Large Areas of Anterior Soft Tissue Injury. Conventional Medial and Lateral Approach Surgery Was Difficult to Perform.

Surgical Technique

After the onset of continuous epidural or general anesthesia, the patient was placed on a radiolucent operating table. In 18 cases of fracture of the lower fibula, 16 were treated by plate fixation, and 2 with poor skin condition were fixed with thick Kirschner needles. Fracture end alignment and fibula length were recovered as much as possible. 17,18 The incision for the posteromedial approach was made according to the ligature of the point 1.5 cm backward to the medial tibial spine and the midpoint of the Achilles tendon and medial malleolus. Posterior tibial muscle and flexor digitorum longus were dissected bluntly along the medial spine longitudinally. The posterior tibial muscle, flexor digitorum longus, posterior tibial artery and vein, and tibial nerve were retracted back to expose the fracture. Finally, the posteromedial bone surface was reached, and the periosteum was stripped as minima as possible. Fracture reduction was performed. The anatomical plate was placed at the posterior side of tibia. After adjustment of the plate, fixation was performed (Figure ). If the fracture end had defects, the bone was grafted with iliac bone or bone substitutes. 19

Internal Fixation by Posteromedial Anatomical Plate. Tibial Neurovascular Bundles Were Pulled Back and Well Protected.

Figure 3:. Internal Fixation by Posteromedial Anatomical Plate. Tibial Neurovascular Bundles Were Pulled Back and Well Protected.

Antibiotic treatment was given postoperatively. Peripheral circulation and skin sensation were closely observed. Ankle and knee joint exercises were started immediately postoperatively. Weight-bearing walking time was related to the type of fracture, fixation strength, age, and growth of the callus. In general, partial weight-bearing walking was allowed 6 to 8 weeks postoperatively and full weight-bearing walking was allowed at 10 to 12 weeks.

The following measures were evaluated in all patients postoperatively:

  • Fracture healing time: radiological fracture healing and no pain at fracture end when weight bearing.
  • Ankle joint function: evaluated by interviewing patients on ankle joint pain, movement function, and mechanical stability using the American Orthopedic Foot and Ankle Society (AOFAS) ankle function scoring system (90–100 points=excellent; 75–89 points=good; 50–74 points=general; <50 points=poor). 20
  • Complication rates:
    • Malunion of fracture evaluation: Johnson angle of ankle joint measured on latest AP and lateral radiographs of full-length lower leg. 6,21,22 If varus and valgus or AP angle was >5°, malunion was confirmed
    • Limb-shortening deformity: >1 cm shortening of the limbs. 5–8
    • Fracture nonunion, delayed union, infection of anterior skin wound and surgical incisions infection, skin necrosis, failed internal fixation, and neurovascular injury.

Results

All patients were followed for a mean 21.4±5.1 months (range, 12–43 months) (Table ). Average operation time was 72.5±15.8 minutes (range, 45–105 minutes), with a mean blood loss volume of 86.4±17.3 mL (range, 50–150 mL). All fractures healed in an average time of 19.2±4.4 weeks (range, 13–30 weeks). Average healing time for closed fractures was 17.5±3.7 weeks (range, 13–23 weeks), while average healing time for open fractures was 21.8±4.1 weeks (range, 16–30 weeks). The 2 healing times were significantly different ( P<.05). Radiographs taken at final follow-up showed 1 case with 4° valgus and 1 with 3° varus. No limb-shortening deformity occurred. At final follow-up, the average AOFAS score of all patients was 87.3±9.2 points (range, 68–99 points), with 10 excellent cases, 13 good, 3 general, and 0 poor. The fine rate was 88.5%. The average score for open fractures was 86.3±8.8 points (range, 70–95 points), while the average score for closed fractures was 88.1±8.5 points (range, 68–99 points), with no significant difference between the 2 groups ( P>.05).

Follow-Up Data

Table 2. Follow-Up Data

Wound necrosis of the anterior lower leg occurred in 1 case, which was a Tscherne-Oestern type 3 fracture. After applying wound dressing and a skin graft, contusion and skin necrosis were healed. A case of anterior superficial wound infection occurred in a Gustilo type II fracture of the distal lower leg. After thorough debridement, suture, and internal fixation, the anterior wounded skin showed redness, swelling, and purulent secretion. After applying a dressing and starting antibiotic treatment, second-stage wound healing was achieved. No deep infection, plate exposure, failed internal fixation, neurovascular injury, or discomfort due to friction of the plate occurred. A typical case is shown in Figure .

Preoperative AP (left) and Lateral (right) Radiographs of a 55-Year-Old Man with a Distal Tibia and Fibula Fracture (A). The Tibia Was Fixed by External Fixator and the Fibula Was Fixed by Kirschner Needle Emergently Because of the Bad Condition of the Anterior Soft Tissues. AP (left) and Lateral (right) Radiographs 2 Days Postoperatively (B). AP (left) and Lateral (right) Radiographs 23 Weeks Postoperatively Displaying a Completely Healed Fracture (C). Photographs Taken at 1-Year Follow-Up Demonstrating Healing of the Surgical Incision and Anterior Wounds with Normal Ankle Joint Function (D).

Figure 4:. Preoperative AP (left) and Lateral (right) Radiographs of a 55-Year-Old Man with a Distal Tibia and Fibula Fracture (A). The Tibia Was Fixed by External Fixator and the Fibula Was Fixed by Kirschner Needle Emergently Because of the Bad Condition of the Anterior Soft Tissues. AP (left) and Lateral (right) Radiographs 2 Days Postoperatively (B). AP (left) and Lateral (right) Radiographs 23 Weeks Postoperatively Displaying a Completely Healed Fracture (C). Photographs Taken at 1-Year Follow-Up Demonstrating Healing of the Surgical Incision and Anterior Wounds with Normal Ankle Joint Function (D).

Discussion

Treatment of distal tibial fractures varies, but anterior soft tissue injury makes choosing between fracture fixation methods difficult. For open distal tibia fractures with serious anterior soft tissue injury, an external fixator is the preferred option. 3,9 It can stabilize the fracture temporarily without affecting soft tissue repair. However, complications such as pin tract infection, malunion, nonunion, and inconvenience resulting from long-term cross-joint fixation are common. 6–8,10 Therefore, external fixation is often used emergently, and second-stage fixation is often necessary. 5,6,23

Intramedullary nails and plate fixation are 2 widely reported methods of fixation. The unique anatomy of the distal tibia is unfit for intramedullary nailing, although in recent years, modified intramedullary nails have expanded indications for nailing. The effect of this technology remains controversial, with common problems being malunion, nonunion, infection, nail breakage, and knee pain, 7,11,12,24 particularly for open or comminuted fractures due to high-energy injuries. 12,25

Currently, medial and lateral anatomical plates of the distal tibia are generally considered the ideal internal fixation materials for treatment of distal tibia fractures. 7,8,10 However, it is unwise to make an incision on the anterior skin of a lower leg with soft tissue injury, severe scarring, and skin grafting. The studies in Table reflect different infection rates in the treatment of distal tibia fractures through varied approaches (0%–31.3%). 5,10,21,24,26–30 Therefore, poor anterior soft tissue plays a central role on the fracture fixation program and choice of the fixation method. Krackhardt et al 6 treated 71 cases of distal tibia fracture with anteromedial minimally invasive plate osteosynthesis technology. Sixteen cases (22.5%) took >6 weeks (range, 6 weeks to 8 months) from fracture to determine internal fixation, and the main reason was poor anterior soft tissue. Thus, although minimally invasive plate osteosynthesis technology through an anterior approach may reduce damage to the blood supply of injured tissues, it cannot remove its reliability on anterior skin conditions.

Different Approaches of Plate Internal Fixation for Treating Distal Tibial Fractures

Table 3. Different Approaches of Plate Internal Fixation for Treating Distal Tibial Fractures

Therefore, the purpose of this study was to find a better solution for this problem. This study also involved staged treatment, but we used a unique and more appropriate posteromedial method without impacting anterior injured soft tissues. Final fixation was performed when stable conditions of anterior skin were achieved rather than complete healing. Skin or flap grafts can be performed with internal fixation under the same anesthesia if needed, which significantly reduces time from fracture to ultimate treatment and patient suffering. Although 1 case of skin necrosis (3.8%) and 1 case of superficial infection (3.8%) occurred on anterior wounds postoperatively, they were healed 1 week later after treatment with wound dressing and skin grafting.

The core concept of posteromedial approach fixation is to avoid the anterior damaged soft tissue to fix the fracture. Clinically, the posterolateral approach to fixation of distal tibia fractures had a common philosophy with our program. Sheerin et al 5 reported that 15 cases of distal tibia fractures treated by the posterolateral approach had satisfied results, with an average healing time of 20 weeks and an average AOFAS ankle score of 81 points. They proposed that fibulas can be fixed with this approach, realizing the convenience of fixation of the tibia and fibula by a single incision. However, in the posterolateral approach for fixation of the distal tibia fracture, the fibula and Achilles tendon will be blocking factors in surgery, increasing the difficulty of distal fracture end exposure and fixation.

Few reports exist on the posteromedial approach to treatment of distal tibial fractures. One reason is the relatively complex posteromedial anatomical structure of the distal tibia. The tibial nerve and posterior tibial artery and vein reside in the tarsal tunnel. The question of whether it is convenient to expose these structures intraoperatively or whether it will damage important nerves and blood vessels concerns many surgeons. Oznur et al 31 confirmed in a cadaver study that posteromedial approach exposure is simple. It is safe to place the plate posterior to the tibia because the tibial vessels and tibial nerve are protected by the posterior tibial muscles, which is consistent with our clinical findings.

The lack of suitable internal fixation material is the most important reason why so few reports exist on the posteromedial approach for treatment of distal tibial fractures. Therefore, the strict anatomical plate is particularly important for the relatively complex anatomy of the posteromedial distal tibia because it may not only help fixation, but also reduce complication rates, such as discomfort caused by friction of the plate and skin and neurovascular symptoms. The anatomical plate designed by our institution met the anatomical criteria of the posteromedial distal tibia. Therefore, it fit well with cortical bone and maintained anatomical reduction without shaping intraoperatively, which saves operation time, decreases blood loss, and reduces malunion rate. Average operation time was 72.5±15.8 minutes (range, 45–105 minutes), with a mean intraoperative blood loss volume of 86.4±17.3 mL (range, 50–150 mL). All 26 patients had good postoperative fracture healing. Average healing time was 19.2±4.4 weeks (range, 13–30 weeks), and average AOFAS ankle score was 87.3±9.2 (range, 68–99), with a fine rate of 88.5%. No discomfort caused by friction of the plate with skin or by foot paresthesias was encountered.

This study has limitations. Although the posteromedial approach to the distal tibia was confirmed to be safe, the operation is more complex than anterior medial or anterior lateral approaches due to the adjacent posterior tibial artery and vein and tibial nerve. 31 The surgeon should be proficient in the anatomy of the lower leg and operate in the correct anatomical spaces to avoid serious damage to nerves and blood vessels. Furthermore, the use of this program has some limitations. Exposure of the ankle articular surface is difficult. Therefore, this technique applies only to AO type 43A and 43C1 fractures at the present stage. In patients with serious posteromedial skin injury, this program is also inapplicable. In addition, minimally invasive treatment of fractures is the general trend 2,7,10 ; however, we used open reduction and internal fixation in this study. Despite minimal periosteal stripping in surgery and postoperative fracture healing, the minimally invasive efforts in this technique should be improved.

Conclusion

A posteromedial anatomical plate for treatment of distal tibial fractures with anterior soft tissue injury was effective and resulted in no serious complications. This regimen can fix fractures well while protecting local blood supply and is the preferred treatment for such injuries.

References

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Patient Information

No. (%)
Sex
M:F 17:9
Side of injury
Left:right 10:16
Mechanism of injury
Motor vehicle accident 12 (46.2)
Fall from height 5 (19.2)
Fall of heavy object 5 (19.2)
Simple fall 3 (11.5)
Sports activities 1 (3.9)
AO fracture type 15
43A1 4 (15.4)
43A2 8 (30.8)
43A3 9 (34.6)
43C1 5 (19.2)
Gustilo-Anderson type 13 open fracture 12 (46.2)
I 4 (15.4)
II 5 (19.2)
IIIA 2 (7.7)
IIIB 1 (3.9)
Tscherne-Oestern type 14 closed fracture 14 (53.8)
1 3 (11.5)
2 9 (34.6)
3 2 (7.7)
Distal fibula fracture 18 (69.2)

Follow-Up Data

Assessment No. (%)
Time to heal, wk
13–18 8 (30.8)
19–24 11 (42.3)
25–30 7 (26.9)
AOFAS score 20
90–100 (excellent) 10 (38.5)
75–89 (good) 13 (50.0)
50–74 (fair) 3 (11.5)
<50 (poor) 0 (0)
Complications
Malunion 21,22
Varus
<5° 1 (3.8)
=5° 0 (0)
Valgus
<5° 1 (3.8)
=5° 0 (0)
Delayed union 0 (0)
Nonunion 0 (0)
Infection 1 (3.8)
Neurovascular injury 0 (0)

Different Approaches of Plate Internal Fixation for Treating Distal Tibial Fractures

Author Year No. of Patients Treatment Open Fracture, % Mean Union Time, wk Infection, % Malunion, % Nonunion, % Delayed Union, %
Sheerin et al 5 2006 15 PL/ORIF 86.7 20 0 3.15
Collinge & Protzman 10 2010 38 AM/MIPO 21 21 0 3 0 10
Gupta et al 26 2010 79 AM/MIPO 24.1 19 1.3 2.5 3.8 8.9
Vallier et al 24 2008 37 AM/ORIF 30 20.1 2.7 5.4 2.7 0
Manninen et al 27 2007 20 AL/ORIF 20 20 10 0 0
Im & Tae 30 2005 30 AL/ORIF 16.7 20 23.3 0 6.7 0
Lau et al 28 2008 48 AM/MIPO 19 18.7 17
Collinge et al 29 2007 26 AM/MIPO 35 31.3 3.8 34.6
Hong et al a 2011 26 PM/ORIF 46.2 19.2 3.8 0 0 0

10.3928/01477447-20110427-15

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