Percutaneous plate fixation of fractures of the distal tibia

Transcription

1 Act Orthop. Belg., 2004, 70, ORIGINAL STUDY Percutneous plte fixtion of frctures of the distl tii Jens FRANCOIS, Geoffroy VANDEPUTTE, Frnk VERHEYDEN, Guy NELEN Minimlly invsive plte osteosynthesis (MIPO) of the distl tii offers severl theoreticl dvntges compred to clssic open reduction nd internl fixtion. A mechniclly stle frcture-ridging osteosynthesis cn e otined without significnt dissection nd surgicl trum to the one nd surrounding soft tissues. In this retrospective study we looked t the results nd complictions in ten consecutive ptients treted with percutneous plting for frctures of the distl tii nd plfond with minimum follow-up period of one yer. No significnt soft tissue prolems occurred. The need for one grfting should e crefully evluted in every cse s we encountered two delyed unions. All frctures heled within one yer ; there ws no frcture mlunion. The use of indirect reduction techniques nd smll incisions to insert hrdwre is techniclly more demnding nd requires strict rdioscopic control throughout the procedure, ut it considerly decreses surgicl trum to the soft tissues. to the devitlistion of ony frgments nd dditionl dmge to the soft tissues. In order to improve frcture heling, more iologicl methods hve een developed over the lst decdes trying to lessen the surgicl dissection, preserving the lood supply to the ony frgments nd contining t lest prtilly the frcture hemtom. As such, intrmedullry fixtion devices for exmple hve ecome the gold stndrd for the tretment of diphysel frctures in the lower lim. Over the yers however, open reduction nd plte nd screw fixtion hs remined the preferred tretment for peri-rticulr frctures. More nd more, new insights in reduction techniques nd frcture heling re leding to the development of minimlly invsive osteosynthesis promoted y the AO group nd others. The emphsis now lies on indirect reduction, xil lignment nd stle fixtion without disturing the frcture environment nd thus preserving most of the vsculristion nd frcture hemtom, contining ll necessry growth fctors for ony INTRODUCTION The surgicl tretment of frctures hs evolved gret del since the development of the originl open reduction nd internl fixtion technique y the AO group. To otin mximl mechnicl stility in order to chieve primry (endostel) one heling, exct ntomicl reduction nd strict rigid fixtion were emphsized in the eginning. This however cn rrely e otined without significnt dissection of the frcture nd the surrounding soft tissues. Well-known complictions like infection nd delyed or non-union re frequently ttriuted From Heilig Hrt Ziekenhuis, Lier, Belgium. Jens Frncois, MD, Orthopedic Registrr. Geoffroy Vndeputte, MD, Consultnt Orthopedic Surgeon. Frnk Verheyden, MD, Consultnt Orthopedic Surgeon. Guy Nelen, MD, Consultnt Orthopedic Surgeon. Orthopedic nd Trum Deprtment, Heilig Hrt Ziekenhuis, Kolveniersvest 20, 2500 Lier, Belgium. Correspondence : Jens Frnçois, Tervuursesteenweg 552 us 1, 3061 Leefdl, Belgium. E-mil : jensfrncois@hotmil.com. 2004, Act Orthopædic Belgic.

2 PERCUTANEOUS PLATING OF THE DISTAL TIBIA 149 heling. Frctures of the distl tii re chllenge for the orthopedic surgeon s they re generlly multifrgmented nd ssocited with severe soft tissue injury nd swelling. Less invsive techniques such s percutneous plting re very ppeling when treting these types of frctures ecuse stle, frcture ridging osteosynthesis cn e chieved without further dmge to the soft tissues. They should llow for etter frcture heling with fewer complictions nd less need for dditionl opertive procedures. The purpose of this retrospective study ws to evlute the functionl nd rdiogrphic results of ten consecutive ptients treted in our deprtment for frctures of the distl tii where we felt locked intrmedullry nil could not e used s the frcture ws too distl or hd distl intr-rticulr extension. In these ptients we opted for n ORIF of the fiul nd percutneous plting of the tii ccording to the technique descried. PATIENTS AND METHODS The medicl chrts of ten consecutive ptients treted for frctures of the distl tii (oth intr- nd extrrticulr) with technique of percutneous plting were retrieved nd reviewed. All ptients were contcted nd interviewed. There were 6 men nd 4 women, ged etween 22 nd 68 yers (verge 42,5 yers). Pre-opertive rdiogrphs were retrieved nd ll frctures were grded ccording to the AO clssifiction. There were 2 type A frctures (extr-rticulr) nd 8 type C frctures (complete intr-rticulr frcture, tiil pilon) ; there were no type B frctures. In the C-type group, there were two C.1 nd six C.2 frctures. No type C.3 frctures were treted. Two of the six C.2 frctures were grde II open ccording to the Gustilo clssifiction. All closed frctures were treted with single-stged procedure of open reduction nd internl fixtion of the distl fiul (if frctured) nd percutneous plting of the distl tii, with or without rticulr reconstruction nd lg-screw fixtion (depending upon the presence nd degree of rticulr displcement). Both open frctures were first stilised with plting of the distl fiul nd n externl fixtor cross the frcture nd nkle joint, followed one week lter y removl of the fixtor nd ppliction of sucutneous plte. The ptient ws positioned supine on the operting tle nd tourniquet ws pplied without exsnguinting the leg. If there ws frcture of the distl fiul (Weer B or C), this ws treted first y clssic open reduction nd internl plte nd screw fixtion through lterl pproch. Specil ttention ws mde to void ny mlrottion of the frgments. Consecutively, if necessry, percutneous reduction nd 3.5 mm lg screw fixtion of the rticulr frgments ws crried out. Finlly, fter closed or percutneous reduction of the distl tii, pre-ent reconstruction plte or lrge-frgment T-plte ws inserted onto the nteromedil surfce in retrogrde wy (distl to proximl). This ws performed through smll 5 cm medil incision y dvncing the plte under the sucutneous ft directly onto the periosteum. The periosteum itself ws not opened. A smll counter-incision ws mde proximlly to optimlly lign the plte on the tii (fig 1). The plte ws then fixed with percutneously plced screws. We mde the smll incisions for screw insertion ccording to the skin lines, which re horizontl nd not longitudinl in the lower leg. This resulted in good wound heling with only little scrring (fig 2). During the whole procedure rdioscopic control ws essentil. Post-opertive tretment consisted of n AFO rce which ws worn fulltime during two weeks. Intermittent non-weight ering moilistion ws therefter strted. Prtil weight ering ws llowed 4 to 6 weeks postsurgery, full weight ering fter rdiologicl consolidtion. Figures 3 to 5 show rdiogrphic exmples of some frctures efore nd fter tretment. RESULTS The men follow-up ws 36 months (rnge : 12 to 58 months). At the moment of our evlution 5 ptients could perform ll sports they wnted ; they did not hve ny pin or restrictions during dily ctivities. Two were unle to run, ut were le to do some other sport ctivities nd ll ctivitities t work nd t home. Three sid they could not prticipte in ny sports, ut did not hve ny restrictions in dily life. These were the ptients with the shortest follow-up period. On physicl exmintion, we noted good heling of ll incisions. Only one ptient ws wlking

3 150 J. FRANCOIS, G. VANDEPUTTE, F. VERHEYDEN, G. NELEN Fig. 1. : Closed reduction of the frcture nd temporry fixtion with K wires ; : A sucutneous tunnel is mde onto the periosteum of the nteromedil tiil surfce. Distl skin incision for plte insertion. Figs. 2 &. Clinicl ppernce of two treted legs one yer postopertively with slight limp. In two ptients minor swelling of the nkle region ws noted. All nkle joints were moile within functionl limits. Some complictions occurred during the tretment. One superficil wound infection on the lterl side ws treted with ntiiotics, without further prolems. There ws one cse in which delyed union ws noted nd utologous cncellous one grfts were dded to the frcture site fter 3 months, no hrdwre ws removed or replced. This frcture lso heled without further complictions. In one cse the screws in the distl tii roke nd the hrdwre ws replced with new plte nd screws. All rdiogrphs one yer fter tretment demonstrted heling of the frcture(s). There were no mlunions (vrus or vlgus of more thn 5 ), loss of reduction, rticulr incongruencies more thn 2 mm or erly signs of rthrosis. All ptients were hppy with the cosmetic results ecuse very little residul swelling ws noted nd the surgicl wounds were rther smll nd heled without much scrring (fig 2). DISCUSSION Minimlly invsive plte osteosynthesis (MIPO) is the logicl next step in the surgicl tretment of frctures. It relies primrily on the indirect reduction of the frcture using vrious techniques, excellently descried in the clssic works of Mst nd Gnz (8). In this wy, the frcture environment is etter preserved, s well s the lood supply to the ony frgments (4, 12). Theoreticl dvntges include less infection nd wound prolems nd etter frcture heling (7). No rndomised prospective

4 PERCUTANEOUS PLATING OF THE DISTAL TIBIA 151 Figs. 3 &. Distl tiil frcture extending into the nkle joint ; the rticulr frgments re fixted percutneously with cncellous screws nd one nteroposterior lg screw. Figs. 4 &. Pilon frcture with metphysel comminution, treted with ORIF of the fiul nd percutneous plting of the distl tii using lrge frgment T plte. studies hve een pulished to dte, ut it is cler tht MIPO results in less surgicl trum to the soft tissues (5). Especilly in the region of the distl tii nd nkle joint the soft tissues re frequently involved in the sustined trum nd ply centrl role in the choice of the surgicl frcture tretment. Very often, it is the initil condition of the surrounding soft tissues tht limits the possiilities for osteosynthesis nd directly reltes to the outcome of distl tiil frctures (6, 9, 11). The importnce of good, mechniclly stle osteosynthesis in the tretment of frctures of the tiil plfond hs een well emphsised. When

5 152 J. FRANCOIS, G. VANDEPUTTE, F. VERHEYDEN, G. NELEN c Fig. 5,, c, d & e. Grde 2 open frcture of the distl tii, treted with ORIF of the distl fiul nd temporry externl fixtion of the tii (), followed y percutneous plting of the distl tii one week lter (). Three months lter the hrdwre filed (c) nd ws replced y lrger plte nd the lrge metphysel defect ws filled with utologous cncellous one grfts. The frcture then successfully heled without further prolems (d nd e). d e fixing the often comminuted metphysel frgment to the diphysis in n ttempt to restore proper xil lignment, very often considerle hrdwre nd thus surgicl dissection is required. Percutneous plting of the distl tii offers similr stility s clssic ORIF, however without the need for extensive dissection. Therefore fewer soft tissue complictions cn e expected, thus llowing the use of this technique even in the presence of moderte to severe soft tissue contusion or grde I

6 PERCUTANEOUS PLATING OF THE DISTAL TIBIA 153 or II open frctures. As such, it promises to e vlid lterntive to externl (hyrid) fixtion, lthough two-stge procedures my e performed (1, 5, 9). We prefer single-stge osteosynthesis for closed frctures of the distl tii. Open frctures re first stilized y mens of n nkle-spnning externl fixtor, followed y percutneous plting of the tii one week lter. The tretment of frcture of the distl fiul is quite strightforwrd nd well estlished in the literture (5). We elieve it is very importnt to restore the originl length nd rottion of the lterl column of the nkle joint, lthough there is no generl greement in the literture (13). Limited open or percutneous reduction nd lgscrew fixtion of the distl tiil rticulr frgments is overll well ccepted s the preferred tretment (5). This is not lwys possile in complex, very comminuted pilon frctures where smll nteromedil incision needs to e performed to ccess the nkle joint in order to reconstruct the rticulr surfce of the distl tii. This sme incision cn e used to insert the medil plte. It is sfe s long s the lterl incision is posterior enough to hve good skin ridge etween oth incisions. Although this technique of MIPO offers the possiility of chieving good mechnicl fixtion of the distl tii even in the presence of metphysel defect (s it cts s n internl fixtor (2)), the need for one grfting should still e considered in every cse (3, 6). This cn either e done primrily or in lter, second opertion when union is delyed. Recently we hve strted to use lockingcompression pltes s they llow for the plcement of locking hed screws in the epiphysis nd metphysel region, definitely contriuting to the mechnicl stility of the construct. Moreover these pltes do not hve to e perfectly contoured to the one to chieve optimum stility, which mkes their use more simple. However, these lst cses were not included in this study ecuse of too short follow-up period. Our study ws performed retrospectively, ut includes ll ptients treted in our deprtment for tiil plfond frcture or very distl tiil frcture tht ws too low for n intrmedullry nil. No ptients were excluded nd ll were ville for follow-up t t lest one yer post-opertively. Erlier pulished studies remin rther smll like our presented series nd no true rndomised prospective studies hve een presented compring MIPO with clssic ORIF nd/or the vrious methods of externl fixtion. CONCLUSION The finl outcome of pilon frctures is lrgely dependent upon the residul rticulr displcement nd chondrl dmge. It is ovious tht these re not directly influenced y this technique of MIPO. Insted we elieve the rel dvntges lie in the prevention of soft tissue prolems nd the possiilities for erlier nd even single-stge opertive procedures, contriuting to fvourle outcome. Our presented study supports the few other pulished studies concerning percutneous plting of the tii nd these should inspire more trum surgeons treting distl tii frctures to use minimlly invsive techniques, in n effort to decrese moridity nd ssocited complictions, especilly of the soft tissues. REFERENCES 1. Bluth M, Bstin L, Krettek C, Knop C, Evns S. Surgicl options for the tretment of severe tiil pilon frctures : study of three techniques. J Orthop Trum 2001 ; 15 : Collinge CA, Snders R. Percutneous plting in the lower extremity. J Am Acd Orthop Surg 2000 ; 8 : Collinge CA, Snders R, Dipsqule T. Tretment of complex perirticulr frctures using percutneous techniques. Clin Orthop 2000 ; 375 : Frouk O, Krettek C, Miclu T, Schndelmier P, Guy P, Tscherne H. Minimlly invsive plte osetosynthesis : does percutneous plting disrupt femorl lood supply less thn the trditionl technique? J Orthop Trum 1999 ; 13 : Helfet DL, Shonnrd PY, Levine D, Borelli J. Minimlly invsive plte osteosynthesis of distl frctures of the tii. Injury 1997 ; 28 (suppl) : A42-A Kilin O, Bundner MS, Hors U, Heiss C, Schnettler R. Long-term results in the surgicl mngement of pilon

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