Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures

Abstract

Nowadays, the use of minimally invasive plate osteosynthesis (MIPO) in the management of fracture of the distal tibia is common. The various advantages of the MIPO technique, namely, preserving blood supply and better bone healing, have been described extensively in the literature. However, this technique is not without complication. Among all the complications, infection is one of the commonest. In the last 3 years, we have performed 48 cases of MIPO in treating distal tibia fractures. Our study was to evaluate the clinical outcome of these cases, with special attention to the infection rate and our experience in managing these infection cases. Our results showed that the average time until the patient started to bear full weight was 9.4 weeks. The average time for bony union was 18.7 weeks. There were 7 cases of late infection among these 48 cases. The rate was 15%. The presence of late infection had no obvious effect on the time to bony union. Twenty-five patients (52%) had the implants removed and the most common reason was skin impingement by the implant. The clinical presentation and management of these late infections are discussed. In conclusion, MIPO fixation of distal tibia fractures using a metaphyseal locking plate is safe and efficient. However, complications such as late wound infection and impingement are relatively common. The overall clinical outcome is still good despite the presence of these complications.

Treatment of distal tibial shaft fractures by three different surgical methods: a randomized, prospective study

“…Although we found the irritation symptoms were more frequently encountered in the MIPO group, the symptoms had no effect on their daily life. Similar results were reported by Lau et al whereby 52 % (25/48) of distal tibia fracture cases treated by MIPO had the implants removed due to skin impingement [33]. This could be related to the thin subcutaneous tissue and suboptimal premoulding of plates.…”

Fractures of the Distal Tibia Treated with Polyaxial Locking Plating

“…Two major local problems have been observed in patients with monoaxial locking plates for distal tibial fractures: skin irritation from wearing tall boots and pain over the medial malleolus, both attributed to the monoaxial locking compression plate [10,17,18,25]. For the polyaxial locking plate, it is not necessary to adjust the subcutaneous location of the plate to gain adequate fixation of very distal fractures or to avoid impingement between these locking screws and those inserted for articular reconstruction; therefore, a perfect match between the plate and the distal part of the tibia can be achieved, which in turn may further reduce tension in the soft tissue.…”

“…For the polyaxial locking plate, it is not necessary to adjust the subcutaneous location of the plate to gain adequate fixation of very distal fractures or to avoid impingement between these locking screws and those inserted for articular reconstruction; therefore, a perfect match between the plate and the distal part of the tibia can be achieved, which in turn may further reduce tension in the soft tissue. With MIPO (nonlocking or monoaxial locking plate) of the distal fractures of the tibia, 8% to 100% of patients reported discomfort around the medial tibia shin region, whereas 8% to 66% of patients needed hardware removal [5,10,17,25]. Although the Numelock II 1 polyaxial locking plate is a little thicker than the monoaxial locking compression plate, soft tissue irritation and the need for removal of hardware were less frequent in our series, which may be attributed to this good match between the plate and the distal part of the tibia.…”

“…With monoaxial locking plate osteosynthesis for metaphyseal fractures of the distal tibia using a long conventional incision, 23.5% of the patients had severe soft tissue damage with exposed plates and all needed flap coverage owing to the choice of an inappropriate surgical exposure technique rather than to the features of the locking compression plate system [27]. Using the MIPO technique for management of fractures of the distal tibia, some studies had infection rates of 5% to 18% and a rate of delayed wound healing of 10% [10,18,25]. Our study, using the same technique with polyaxial locking plating, showed similar or better results.…”

“…The treatment of fractures of the distal tibia with or without intraarticular involvement is associated with high complication rates and provides a management challenge to orthopaedists [5,23,25]. The fixation options for a distal tibial fracture include hybrid external fixation, limited internal fixation with external fixation, traditional open reduction internal fixation (ORIF), minimally invasive plate osteosynthesis (MIPO), fine-wire fixation, or possibly intramedullary nailing [2,4,11,28,33].…”