Treating tibial fracture with supra-cutaneous locking plate osteosynthesis: personalized therapy for special patient;A case series study

doi:10.21203/rs.3.rs-1991094/v1

Download PDF

Research Article

Treating tibial fracture with supra-cutaneous locking plate osteosynthesis: personalized therapy for special patient;A case series study

https://doi.org/10.21203/rs.3.rs-1991094/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background The choice of surgical options for open tibial fractures and closed tibial fractures with soft tissue problems has been controversial.Supra-cutaneous locking plate fixation may be able to provide an personalized treatment plan.

Methods After retrospective analysis of the clinical database, we collected data on 19 patients identified as having chronic osteomyelitis after routine surgery for tibial fractures or open tibial fractures.All patients who underwent external fixation with a supra-cutaneous locking plate were followed up for 12.89±3.81 months postoperatively.Further statistical analysis was not performed because the number of cases was too small and the injuries and fracture types were different.

Results The postoperative Fugl-Meyer lower limb motor function score was 32.47±3.34 in 19 operated patients, which was evaluated according to the Mazur ankle scoring system: 11 cases were excellent, 5 cases were good, 2 cases were acceptable, and 1 case was poor, with an excellent rate of 84%. The duration of time that passed between the implantation of the supra-cutaneous locking plate and its subsequent removal ranged from 13.00±1.05 months.

Conclusions In certain tibial patients with specific indications, such as open tibial fractures without significant bone or soft tissue defect, closed tibial fractures with severe blisters or compromised soft tissue condition, and surgical site infections following tibial internal fixation with no significant bone or soft tissue defect, supra-cutaneous locking plate fixation may be used. It offers sufficient biomechanical stability for fracture repair while minimizing the inconveniences associated with bulky circular frames or external fixators.The supra-cutaneous locking plate fixation used as the final treatment may also result in a little shorter hospital stay for these individuals and lower healthcare expenses.

Supra-cutaneous locking plate

Tibial fractures

Chronic osteomyelitis of the tibia

External fixation

Open or closed tibial fractures with soft tissue issues can be problematic for patients and difficult for surgeons to treat. For Gustilo-grade 3 type open fractures,there may be soft tissue contamination or defects, and the infection incidence after first treatment may be high up to 15% [1]. Open fracture reduction and fixation may be comparatively contraindicated for closed tibial fractures if there are significant soft tissue blisters, contusions, or scratches [2].

After initial debridement, the widely recognized approach for treating open tibial fractures is conventional external fixation using Schanz nails and rods [3]. In the treatment of closed tibiofibular fractures, internal fixation with plates and intramedullary nailing is still the mainstay of treatment.The external fixation frame device is heavy and uncomfortable for patients. Long-term use of the external fixation frame may cause the patient's psychological problems and occasionally prevent them from returning to their pre-injury jobs. Even when a typical external fixation treatment is used to treat an open tibial fracture, a chronic osteomyelitis later results. While the chronic osteomyelitis is thoroughly debrided, the presence of the bone defect again makes the external fixation brace seem to be a solution that has to be used again. The patient's physical and financial burdens are increased as a result.

For some particular patients, fixation of an open fracture or a fracture with soft tissue issues using a supra-cutaneous locking compression plate was suggested, and positive therapeutic outcomes were obtained [4–5]. The idea of supra-cutaneous plate oseteosynthesis is not new;it has been utilized for more than ten years [6].

In this paper, we reported our practical experience using supra-cutaneous locking compression plates to repair tibial fractures and tibial chronic osteomyelitis under specific circumstances.

After retrospective analysis of the clinical database,we collected data on 19 patients identified as having chronic osteomyelitis after routine surgery for tibial fractures or open tibial fractures, including 12 males and 7 females; ages ranged from 18 to 74 years,the mean value was 45.53 ± 14.80 years; 5 cases of closed tibial fractures, 5 patients with chronic tibial osteomyelitis, 9 cases of open tibial fractures; Gustilo type II in open tibial fractures 6 cases and 3 cases of Gustilo type III; In 2 cases, the ankle movement was significantly limited, and in 1 cases, the ankle was stiff.Following up with all patients who underwent internal fixation with supra-cutaneous locking plates for tibial fractures and chronic osteomyelitis included calls and outpatient visits.Further statistical analysis was not performed because the number of cases was too small and the injuries and fracture types were different.

Operation Technique

For patients with open tibial fractures, debridement was done first while they were under anesthesia, followed by external fixation using a standard external fixator. If there was no infection or need for soft tissue plastic surgery, the external fixator was then removed, and a supra-cutaneous locking plate was put in place. If the soft tissue damage wasn't too significant, we would conduct a supra-cutaneous locking plate right away following cleaning and suturing the incision.

When there were soft tissue issues or severe blisters in patients with closed tibial fractures, calcaneal bone traction was done initially. The fixation of a supra-cutaneous locking plate was done if the blisters persisted for more than 10 days.

For infection after tibial fracture treatment, thorough debridement was done on patients who developed osteomyelitis. After that, swap out the surgical gown, gloves, and equipment. Additionally, supra-cutaneous locking plate fixation was carried out.

Following fracture reduction, maintain reduction with traction while applying a supra-cutaneous locking plate fixation. Assistant fixes the proximal and distal plate locking holes that were bored with temporary Kirschner nails while holding the plate at a distance of 2 cm from the skin. Anterior-posterior and later X-rays were obtained to assess the location and reduction of the fracture; sometimes, the proper correction was required. When the plate location and fracture reduction were both satisfactory, the proximal and distal locking holes were secured with locking screws.Here are some intraoperative and postoperative photos of the patients(Fig. 1).

Post Operation Treatment

For patients with open fractures and osteomyelitis, the length of the antibiotic treatment regimen after surgery was 4–6 weeks. It took between two and three weeks for individuals with soft tissue blisters. Additionally, the surgical dressing was changed every two to three days, the screw holes were sterilized with 75% alcohol, and the patients were advised not to take a shower. Following surgery, active and passive mobility of the knee and ankle joints was performed.

Every 2–3 months, a routine X-ray was obtained to follow-up the process of fracture healing. Following the procedure, all patients were suggested to quit smoking and consuming alcohol.

All 19 patients in our group who had external fixation with a supra-cutaneous locking plate for various reasons received 12.89 ± 3.81 months postoperative follow-up.Patients with severe blisters with closed tibial fractures, open tibial fractures, and tibial traumatic osteomyelitis were also present.

Patients who had open tibial fractures underwent debridement and external fixation with a supra-cutaneous locking plate. In patients with closed tibial fractures who had extensive blisters, no skin slough, and required cosmetic surgery, there were no infections (Fig. 2). After debridement, all infections in patients with traumatic tibial osteomyelitis were cured, and the fractures healed normally (Fig. 3). The postoperative Fugl-Meyer lower limb motor function score was 32.47 ± 3.34, which was evaluated according to the Mazur ankle scoring system: 11 cases were excellent, 5 cases were good, 2 cases were acceptable, and 1 case was poor, with an excellent rate of 84%. The duration of time that passed between the implantation of the supra-cutaneous locking plate and its subsequent removal ranged from 13.00 ± 1.05 months.Here are the patient's data(Table 1).

After the plates were removed, there was no refracture in any of the patients who had healed fractures. Patients who had a screw tract infection were given oral antibiotic medication, and the illness was cured. After open Pilion fractures, one patient experienced traumatic ankle arthritis without any symptoms as well as ankle joint ankylosis from infection. In the patients in this group, there was no evident misalignment. The outcomes were enjoyed by every patient. In our patients, there was no amputation as a result of infection.

There were patients with delayed fracture healing, but at the time of the most recent follow-up, the fracture had already healed, necessitating no further surgical intervention. One patient, who had severe rheumatoid arthritis and often used oral steroids, had a fracture that had not healed after a year. Before the accident, she was unable to walk or stand. She was happy with the outcome since she experienced no pain other than little discomfort from the supra-cutaneous locking plate fixation.

Treatment for tibial fractures may occasionally be simple, but it may also be difficult. Whether the fracture is closed or open, soft tissue issues and infection associated to the fracture account for the majority of the challenges [7]. The infection incidence for open Gustilo type III tibial fractures might reach 25% [8]. The overall infection incidence for closed tibial fractures treated with open reduction and internal fixation with plate and screws was between 2.3 percent and 2.5 percent [9–10]

Debridement was the initial step in the traditional way of treating open tibial fractures, followed by the placement of a large external fixator or, where soft tissue injury and contamination were not severe, one stage debridement and internal fixation [11–12]. However, due to instability or inconveniency brought on by bulky external fixators, internal fixation with a plate or intramedullary locking nail may occasionally be required [13]. The risk of infection was considerable with one stage debridement and internal fixation for an open tibial fracture [14].

According to prior studies, the internal design of the locking plate osteosynthesis's biomechanical stability was superior to that of the standard dynamic compression plate [15]. Internal stability is provided by the locking mechanism between the screw head and the locking holes, which is independent of friction between the bone and the plate [16]. In published articles as an external fixator, locking plate might offer high bio-mechanical stability in axial compression and torsion tests [17–19]. Under tibial fracture osteosynthesis owing to open fracture or tibial infection for particular circumstances, the authors of various articles that have been published employed supra-cutaneous locking plates [20]. And positive clinical outcomes were obtained, the fracture healed, or the infection was under control. After debridement, supra-cutaneous locking plate fixation for open tibial fractures without substantial soft tissue open damage or soft tissue defect offers good stability and lowers the risk of infection from internal fixation [21–22]. External fixation with a supra-cutaneous locking plate as a definitive treatment for these particular patients with open tibial fractures without substantial soft tissue open damage or soft tissue defect and some closed tibial fractures with tension blisters not only shortens their hospital stay but also lessens the pain and expense of multiple surgeries.Supra-cutaneous locking plate fixation also eliminates the drawback of the bulky external fixator, which causes patients a great deal of inconvenience [23–24].

The use of supra-cutaneous locking plate fixation to treat closed tibial fractures, however, is controversial and was done in certain reports [21]. Even if there weren't many issues in the prior study, most physicians didn't agree since they were worried about an infection from a screw hole during personal hygiene. Nonetheless, internal fixation in such a state has a higher risk of infection since the soft tissue barrier was compromised in closed tibial fractures with extensive blisters. Accordingly, in our practice, the use of supra-cutaneous locking plate fixation appears reasonable. When internal fixation was used on patients who had significant blisters or soft tissue contusions, the risk of infection was high. The fractures healed with no infection after supra-cutaneous locking plate fixation. Supra-cutaneous locking plate fixation has the same risk of screw tract infection as an external fixator, but in our patients, the incidence is minimal, thus the screws didn't need to be taken out; instead, the patients only required to get oral antibiotic medication. However, having a shower for personal hygiene was forbidden for our patients even after the incision had healed, which may have contributed to the low occurrence of screw tract infections.

After surgical treatment of patients with closed tibial fractures, the infection rate was 1 percent [25]. In this sort of circumstance, debridement should remove any prior internal fixation devices, such as plates and screws or intramedullary nails [26]. An external fixator was used in a prior study following debridement to maintain fracture stability. But if a circular frame wasn't used, stability could not be as robust. If there was no significant bone defect, supra-cutaneous locking plate fixation might be utilized to maintain fracture stability following debridement until fracture healed, eliminating the discomfort of a large external frame [27–29]. After internal fracture treatment, we had instances of surgical site infection, but no significant bone defects. Before the supra-cutaneous locking plate was removed after the fracture healed, the infection was under control and the fracture had healed.The limitation of this study is that the patients with a supra-cutaneous locking plate were so specific that the sample size was too small.And this study can only explore the advantages of using a supra-cutaneous locking plate, and no valid inferences can be made.

In certain tibial patients with specific indications, such as open tibial fractures without significant bone or soft tissue defect, closed tibial fractures with severe blisters or compromised soft tissue condition, and surgical site infections following tibial internal fixation with no significant bone or soft tissue defect, supra-cutaneous locking plate fixation may be used. Only certain patients may it be used, and there are restrictions. It offers sufficient biomechanical stability for fracture repair while minimizing the inconveniences associated with bulky circular frames or external fixators.The supra-cutaneous locking plate fixation used as the final treatment may also result in a little shorter hospital stay for these individuals and lower healthcare expenses.

Ethics approval and consent to participate

The need for ethics approval was waived Institutional Review Board of The First People's Hospital of Yunnan Province.

Consent for publication

Written informed consent was obtained from the patient for the publication

of this report and any accompanying images.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Competing interest

The authors of this work have nothing to disclose.

Funding

This work is supported by the National Natural Science Foundation of China (62063034). The funding bodies played no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Authors’ contributions

LHJ conceived the idea of the case report. ZC and ZJY wrote the manuscript. ZC treated the patients and participated in the conception of the study. ZJY interpreted the data and prepare the figures to draft the manuscript. ZC and LHJ revised the manuscript. All authors read and approved the final

manuscript. ZC and ZJY are first authors.

Acknowledgements

We thank the patient for providing consent for this case report.

Lua J. Tan VH, Sivasubramanian H. Kwek E. Complications of Open Tibial Fracture Management: Risk Factors and Treatment. Malays Orthop J. 2017 Mar;11(1):18–22. doi: 10.5704/MOJ.1703.006.
Lavini F. Dall'Oca C, Mezzari S. Maluta T, Luminari E. Perusi F, Vecchini E. Magnan B. Temporary bridging external fixation in distal tibial fracture. Injury. 2014 Dec;45 Suppl 6:58–63. doi: 10.1016/j.injury.2014.10.025. Epub 2014 Oct 31.
Khatod M. Botte MJ, Hoyt DB. Meyer RS, Smith JM. Akeson WH. Outcomes in open tibia fractures: relationship between delay in treatment and infection. J Trauma. 2003 Nov;55(5):949–54. doi: 10.1097/01.TA.0000092685.80435.63.
Hidayat L. Triangga AFR, Cein CR. Irfantian A, Rahayu BFP. Resubun AP, Magetsari R. Low profile external fixation using locking compression plate as treatment option for management of soft tissue problem in open tibia fracture grade IIIA: A case series. Int J Surg Case Rep. 2022 Apr;93:106882. doi: 10.1016/j.ijscr.2022.106882. Epub 2022 Feb 26.
Kenyon RM. Morrissey DI, Molony DC. Quinlan JF. Locking plate external fixation and negative pressure wound therapy for treatment of a primary infection in a closed clavicle fracture. BMJ Case Rep. 2016 Nov 28;2016:bcr2016218241. doi: 10.1136/bcr-2016-218241.
Kloen P. Supercutaneous plating: use of a locking compression plate as an external fixator. J Orthop Trauma. 2009 Jan;;23(1):72–5. 10.1097/BOT.0b013e31818f8de4. doi.
Albright PD. MacKechnie MC, Roberts HJ. Shearer DW, Padilla Rojas LG. Segovia J, Quintero JE. Amadei R, Baldy Dos Reis F. Miclau T 3rd; and the ACTUAR Open Tibia Study Group. Open Tibial Shaft Fractures: Treatment Patterns in Latin America. J Bone Joint Surg Am. 2020 Nov 18;102(22):e126. doi: 10.2106/JBJS.20.00292.
Li J. Wang Q, Lu Y. Feng Q, He X. Li Md Z, Zhang K. Relationship Between Time to Surgical Debridement and the Incidence of Infection in Patients with Open Tibial Fractures. Orthop Surg. 2020 Apr;12(2):524–32. doi: 10.1111/os.12653. Epub 2020 Mar 22.
Ma Q. Aierxiding A, Wang G. Wang C, Yu L. Shen Z. Incidence and risk factors for deep surgical site infection after open reduction and internal fixation of closed tibial plateau fractures in adults. Int Wound J. 2018 Apr;15(2):237–242. doi: 10.1111/iwj.12856. Epub 2017 Nov 29.
Li J. Zhu Y, Zhao K. Zhang J, Meng H. Jin Z, Ma J. Zhang Y. Incidence and risks for surgical site infection after closed tibial plateau fractures in adults treated by open reduction and internal fixation: a prospective study. J Orthop Surg Res. 2020 Aug 24;15(1):349. doi: 10.1186/s13018-020-01885-2.
Prodromidis AD. Charalambous CP. The 6-Hour Rule for Surgical Debridement of Open Tibial Fractures: A Systematic Review and Meta-Analysis of Infection and Nonunion Rates. J Orthop Trauma. 2016 Jul;30(7):397–402. doi: 10.1097/BOT.0000000000000573.
Nicolaides M. Pafitanis G, Vris A. Open tibial fractures: An overview. J Clin Orthop Trauma. 2021 Jun 24;20:101483. doi: 10.1016/j.jcot.2021.101483.
Liu Y. Liu K, Cai F. Zhang X, Li H. Zhang T, Ma C. Yusufu A. Retrospective clinical outcomes in the definitive treatment of high-energy tibial diaphyseal fractures using hexapod external fixator versus monolateral external fixator. BMC Musculoskelet Disord. 2022 Apr 8;23(1):330. doi: 10.1186/s12891-022-05257-1.
Pari C. Raggini F, Paderni S. Bettinelli G, Salini V. Vicenti G, Belluati A. One-stage procedure for open tibial fractures: feasible without orthoplastic surgery? Acta Biomed. 2021 Jul 26;92(S3):e2021018. doi: 10.23750/abm.v92iS3.11736.
Gautier E. Sommer C. Guidelines for the clinical application of the LCP. Injury. 2003 Nov;34 Suppl 2:B63-76. doi: 10.1016/j.injury.2003.09.026.
Stoffel K. Dieter U, Stachowiak G. Gächter A, Kuster MS. Biomechanical testing of the LCP–how can stability in locked internal fixators be controlled? Injury. 2003 Nov;34Suppl 2:B11-9. doi: 10.1016/j.injury.2003.09.021.
Liu W. Yang L, Kong X. An L, Hong G. Guo Z, Zang L. Stiffness of the locking compression plate as an external fixator for treating distal tibial fractures: a biomechanics study. BMC Musculoskelet Disord. 2017 Jan 19;18(1):26. doi: 10.1186/s12891-016-1384-1.
Ma CH. Wu CH, Jiang JR. Tu YK, Lin TS. Metaphyseal locking plate as an external fixator for open tibial fracture: Clinical outcomes and biomechanical assessment. Injury. 2017 Feb;48(2):501–505. doi: 10.1016/j.injury.2016.11.031. Epub 2016 Nov 29. Erratum in: Injury. 2017 Aug;48(8):1861..
Blažević D. Kodvanj J, Adamović P. Vidović D, Trobonjača Z. Sabalić S. Comparison between external locking plate fixation and conventional external fixation for extraarticular proximal tibial fractures: a finite element analysis. J Orthop Surg Res. 2022 Jan 11;17(1):16. doi: 10.1186/s13018-021-02907-3.
Ma CH. Wu CH, Tu YK. Lin TS. Metaphyseal locking plate as a definitive external fixator for treating open tibial fractures–clinical outcome and a finite element study. Injury 2013 Aug;44(8):1097–101. doi: 10.1016/j.injury.2013.04.023. Epub 2013 May 22.
Luo P. Xu D, Wu J. Chen YH. Locked plating as an external fixator in treating tibial fractures: A PRISMA-compliant systematic review. Med (Baltim). 2017 Dec;96(49):e9083. doi: 10.1097/MD.0000000000009083.
Zhang JW. Ebraheim NA, Li M. He XF, Schwind J. Zhu LM, Yu YH. Distal tibial fracture: An ideal indication for external fixation using locking plate. Chin J Traumatol. 2016 Apr 1;19(2):104-8. doi: 10.1016/j.cjtee.2015.05.006.
Qiu XS. Yuan H, Zheng X. Wang JF, Xiong J. Chen YX. Locking plate as a definitive external fixator for treating tibial fractures with compromised soft tissue envelop. Arch Orthop Trauma Surg 2014 Mar;134(3):383–8. doi: 10.1007/s00402-013-1916-1. Epub 2013 Dec 22.
Haonga BT. Areu MMM, Challa ST. Liu MB, Elieza E. Morshed S, Shearer D. Early treatment of open diaphyseal tibia fracture with intramedullary nail versus external fixator in Tanzania: Cost effectiveness analysis using preliminary data from Muhimbili Orthopaedic Institute. SICOT J. 2019;5:20. doi: 10.1051/sicotj/2019022. Epub 2019 Jun 17.
Zhu Y. Qin S, Jia Y. Li J, Chen W. Zhang Q, Zhang Y. Surgeon volume and the risk of deep surgical site infection following open reduction and internal fixation of closed tibial plateau fracture. Int Orthop. 2022 Mar;46(3):605–614. doi: 10.1007/s00264-021-05221-z. Epub 2021 Sep 22.
Oliveira PR. Leonhardt MC, Carvalho VC. Kojima KE, Silva JS. Rossi F, Lima ALL. Incidence and risk factors associated with infection after intramedullary nailing of femoral and tibial diaphyseal fractures: Prospective study. Injury. 2018 Oct;49(10):1905–11. doi: 10.1016/j.injury.2018.07.024. Epub 2018 Jul 27.
Zhou SQ. Zhang Q, Ding XD. Qin YY, Cai S [Locking plate external fixation combined with membrane induction technology for the treatment of open and comminuted tibial fractures with bone defects]. Zhongguo Gu Shang. 2021 May 25;34(5):400-5. Chinese. doi: 10.12200/j.issn.1003-0034.2021.05.003.
Xiao H. Wang S, Wang F. Dong S, Shen J. Xie Z. Locking Compression Plate as an External Fixator for the Treatment of Tibia Infected Bone Defects. Z Orthop Unfall. 2021 Sep 8. English. doi: 10.1055/a-1545-5363. Epub ahead of print..
Zhang J. Ebraheim N, Li M. He X, Liu J. Zhu L, Yu Y. External fixation using femoral less invasive stabilization system plate in tibial proximal metaphyseal fracture. Clin Orthop Surg. 2015 Mar;7(1):8–14. doi: 10.4055/cios.2015.7.1.8. Epub 2015 Feb 10.

Download PDF

Editorial decision: Reject before sending to peer reviewers
23 Mar, 2023
Reviewers invited by journal
12 Dec, 2022
Editor invited by journal
19 Sep, 2022
Editor assigned by journal
24 Aug, 2022
First submitted to journal
23 Aug, 2022

You are reading this latest preprint version

Treating tibial fracture with supra-cutaneous locking plate osteosynthesis: personalized therapy for special patient;A case series study

Status:

Version 1

Abstract

Figures

Introduction

Method

Operation Technique

Post Operation Treatment

Results

Discussion

Conclusion

Declarations

References

Status:

Version 1