SLR - July 2011 - Edward Au
Reference: Oog Jin Sohn, MD, Dong Hwa Kang, MD. (2011). Staged Protocol in Treatment of Open Distal Tibia Fracture: Using Lateral MIPO. Clinics in Orthopedic Surgery, 3:69-76.
Scientific Literature Review
Reviewed by: Edward Au, DPM
Residency Program: Roxborough Memorial Hospital
Podiatric Relevance:
Traumatic open fractures of the distal tibia are a relatively common occurrence in the podiatric field and are commonly treated with lateral plate fixation after an open reduction. However, it may lead to many complications, including skin/soft tissue necrosis, core infection, osteomyelitis, and amputation. Therefore, it is important to explore other surgical options in the treatment of open distal tibial fractures with minimal complications – in this case, using lateral MIPO (minimally invasive plate osteosynthesis).
Methods:
Over the course of 18 months, 10 patients (mean age of 52.4 years) with open distal tibia fractures were treating using a staged protocol described by the authors. Ages ranged between 29 and 82 and consisted of 6 men and 4 women. Average follow-up period was 14.8 months with a range of 12 to 23 months. Causes of injuries were all from traffic accidents with the exception of one, which was from a fall. Six of these cases were classified as Gustilo-Anderson IIIB, one case as IIIA, and three cases as II. The staged treatment occurred as follows: The first stage involved a thorough debridement of all dead soft tissue and bone with wound lavage. A temporizing ankle-spanning external fixator (mono or delta frame) was then used. To address soft tissue injury, delayed primary closure was utilized in four cases and for patients in whom a delayed primary suture could not be performed, a NPWT device was used within 24 hours. Intramedullary nailing using a rush pin was performed in three cases with accompanied lateral malleolar fracture and severe lateral soft tissue injury. After stage 1 treatment and a delay for a mean period of 15 days (range of 6 to 52 days), when the status of soft tissue was properly stabilized enough for soft tissue reconstruction and no sign of infection, closed reduction through traction was then achieved under C-arm fluoroscopy. A plate (periarticular lateral distal tibial plate; Zimmer, Cowpens SC, USA) was then inserted anterolaterally through a 2-3 cm incision at the level of the tibial plafond. This plate was then pushed proximally and was fixated with a cancellous screw at the distal aspect and a cortical screw at the proximal aspect through a 3-4 cm proximal skin incision. In the third stage, a bone graft was used to achieve bony union in three cases with a severe metaphyseal bone defect and after limited progression of bone healing for > 8 weeks in the distal tibia. A posterior splint was applied for 2 days after surgery and after 3 days, full range of motion at the ankle joint was allowed. The majority of the patients were allowed to partially bear weight 5-7 weeks after surgery and went on to subsequent full weight bearing when there was radiological evidence of complete bony union with no pain.
Results:
Radiographic evidence of bony union was exhibited in all cases, with a mean union time of 21 weeks (range of 16 to 28 weeks). There were no signs of angular deformity over 5°. The average varus/valgus angulation was 2° and 1.7° respectively. In addition, there was no sign of tibial shortening more than 10 mm (average of 3.5 mm). Ankle joint function was then evaluated during the final follow-up using the Iowa Ankle Rating System. Eight out of the ten cases showed satisfactory results (either excellent or good) and two cases were fair. The latter two cases had additional sequelae; one was accompanied with a foot fracture and the other had a flap due to the severity of the open fracture. These two cases also exhibited a limitation in ankle motion after final treatment. None of the cases had signs of serious complications, such as nonunion, malunion, deep infection, osteomyelitis, breakage of hardware, or neurovascular injury.
Conclusions:
A staged protocol using MIPO showed good clinical results, with minimal complications that one may see using a traditional lateral plate after an open reduction. Therefore, staged treatment using MIPO has been shown to be a very effective treatment method for open distal tibia fractures. However, it is difficult to compare the results of this study with those of other studies because the methods are not exactly identical. A larger cohort study will be needed to more accurately assess this particular treatment method.