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Section I: Symposium: Percutaneous Fixation of Fractures

Treatment of Complex Tibial Periarticular Fractures Using Percutaneous Techniques

Collinge, Cory MD; Sanders, Roy MD; DiPasquale, Thomas DO

Editor(s): Herscovici, Dolfi Jr. DO

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Clinical Orthopaedics and Related Research: June 2000 - Volume 375 - Issue - p 69-77
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During the late 1950s and 1960s, the AO/ASIF group advocated the principles of open reduction and internal fixation to overcome the limitations encountered when treating fractures with skeletal traction or other closed methods.10 Their goal was to obtain mechanical stability of the fracture, while allowing the fragments to unite by endosteal bone healing. These techniques allowed axial alignment of the limb and joint, permitted early rehabilitation of the patient, and prevented the complications associated with nonoperative methods.

The surgical treatment of patients with diaphyseal and periarticular fractures using open reduction and plate fixation has become an accepted treatment. Open anatomic reductions, however, may require extensive exposure and can result in the devitalization of surrounding tissues, and the evacuation of osteogenic fracture hematoma.16 Although most fractures heal without complications, these techniques can produce delayed unions or nonunions, necessitating a bone graft.4,9 These dissections also can result in an increase in infections, wound breakdown, and stiffness of adjacent joints. To avoid these problems, methods of indirect reduction and percutaneous or minimally invasive plating have been developed. These techniques are designed to maximize the benefits of biologic fracture healing and minimize complications observed with other plating techniques. Studies have shown that these operative procedures are effective in the treatment of patients with distal femoral, femoral shaft, and tibial pilon injuries.3,5-7,13-15 The authors have applied this approach to selected patients with high-energy tibial shaft fractures who have severe soft tissue injury, in whom healing problems and complications are frequent.2,4 In the current study, the results of percutaneous plating for tibial shaft fractures are reported.


A review of the trauma registry at the authors' institution from January 1, 1992 to September 30, 1998 identified tibial fractures in 17 patients who were treated using a percutaneous plate technique. The indications for use of this method were a tibial shaft fracture with periarticular metaphyseal comminution that precluded the use of a locked intramedullary nail, or a fracture with soft tissue damage of such a magnitude that it prohibited the use of standard incisions.

The mean age of the patients was 32 years (range, 14-56 years). The mechanism of injury included motorcycle collision (six patients), automobile collision (three), pedestrians struck by a motor vehicle (six), fall from a height (one), and airplane crash (one). Eleven of 17 fractures occurred in patients with polytrauma. Twelve patients presented with Gustilo Type III open fractures2 and five presented with closed injuries. These five patients were categorized using the classification of Tscherne and Gotzen13 and all five were rated as having Type III injuries. Shaft fractures were classified according to the system of the AO/Orthopaedic Trauma Association.11 There were three Type B2 fractures, three Type B3 fractures, five Type C1 fractures, four Type C2 fractures, and two Type C3 fractures. Nine fractures were segmental and five extended into adjacent joints. Three fractures extended into the tibial plafond and two extended into the tibial plateau. Four of the patients with open fractures had significant bone loss as a result of their injury and/or after subsequent debridements. Seven patients initially were treated with external fixation before definitive plating (range, 2-10 days) (Table 1).

Patient and Fracture Data

All open fractures were debrided serially until wound closure or coverage was obtained. Range of motion (ROM) was encouraged immediately, but weightbearing was delayed a minimum of 12 weeks or until the fracture showed radiographic and clinical evidence of healing. Patients were followed up for a minimum of 12 months postoperatively and were evaluated with serial radiographs and clinical examinations for fracture and wound healing, pain, axial alignment, limb length, ROM, function (including activities of daily living), and complications.

Operative Technique

Patients were placed supine on the radiolucent table and axial alignment of the fracture was achieved through manual traction, by using the femoral distractor, or an articulated tensioning device (Synthes U.S.A.®, Paoli, PA).8 A 2- to 3-cm incision was made in the metaphyseal region proximal or distal to the fracture, and a subcutaneous tunnel was created along the medial border of the tibia. A premeasured and prebent narrow 4.5-mm dynamic compression plate (Synthes, U.S.A.®) then was inserted into the subcutaneous tunnel. The plate was manipulated until properly positioned, which was verified using intraoperative fluoroscopy. In open fractures, the open wounds were used for plate placement if coincident with planned incisions. One end of the plate then was secured with a screw placed through a stab incision. Axial alignment of the fracture then was performed using indirect reduction techniques.8 After the quality of reduction was verified by fluoroscopy, stab incisions were used to place the remaining screws. These were placed as needed with the addition of lag screws, also placed in a percutaneous manner, usually through the plate (Fig 1). For those fractures with intraarticular extension, a direct open reduction of the articular fragments was performed initially, followed by percutaneous plating as described above.

Fig 1A
Fig 1A:
B. (A) Anteroposterior radiograph of comminuted distal diaphyseal-metaphyseal closed tibia fracture in an 18-year-old woman as a result of a motor vehicle accident. (B) Lateral view of the fracture (continues).
Fig 1C
Fig 1C:
E. (continued) (C) The correct size plate is chosen, measured against the leg under fluoroscopy and then prebent, similar to what would be performed using an open technique. (D) Two incisions, one proximal and one distal, are used to insert the plate through a subcutaneous tunnel. For patients with open fractures, the open wound may be used for plate insertion after thorough irrigation and debridement (E) The plate then is inserted until the correct position is verified under fluoroscopy. The most distal screw is placed first and reduction maneuvers then are performed to allow axial alignment of the tibia (continues).
Fig 1F
Fig 1F:
H. (continued) (F) Clinical view of the leg at the completion of the procedure. Stab incisions were used to place the screws, preserving the osteogenic potential of the hematoma. (G) Anteroposterior and (H) lateral radiographs obtained at the completion of the procedure.

Postoperatively, patient mobilization depended on the associated injuries. To control edema, the extremities of all patients were placed in a bulky splint for the first 7 to 10 days. After 7 to 10 days, the patients' began wearing removable boots and ROM exercises to the ankle and foot were begun. At approximately 12 weeks postoperatively if clinical and radiographic signs of healing were present, and their concurrent injuries allowed, weightbearing was initiated.


Fourteen of 17 patients (nine of 11 patients with open fractures and five of six patients with closed fractures) were available for followup at an average of 23 months after injury (range, 12-50 months). There were no amputations, and in eight patients (57%), the fractures healed after the index procedure. The remaining six fractures healed after a secondary procedure. All five patients who presented with closed fractures had complete union after the index procedure. There were no malalignments and all patients obtained a range of knee and ankle motion within 5° of motion of the contralateral knee and ankle. Additionally, there were no infections or skin problems. These patients had minimal complaints of pain and all returned to work.

In the nine patients with open fractures, only three patients' fractures healed after the index procedure. In the remaining six patients, there were three delayed unions and three nonunions. Four of these patients presented with significant bone loss as a result of their injury or from subsequent debridements. The fractures in six patients healed after bone grafting (four patients) or an exchange nailing after percutaneous removal of the plate and screws (two patients). Four of these six patients had infections develop; three were superficial infections and one was a deep infection. Two infections were in areas unrelated to the index procedure (fixator pin sites) and resolved after a short course of oral antibiotics. The third patient had a superficial wound infection that resolved after irrigation and debridement and a short course of intravenous antibiotics. The fourth patient had osteomyelitis develop and required serial debridements and long-term use of antibiotics. This patient's fracture healed completely and the patient had no additional infectious episodes.

Range of motion in patients with open fractures averaged 5° full extension to 122° flexion (range, 0°-130°). Ankle ROM averaged 20° plantar flexion (range, 15°-40°) and 10° dorsiflexion (range, 0°-20°). Eight patients reported no or minimal pain, for which occasional analgesic medication was required and one patient required long-term oral analgesic and chronic pain management therapy. Six of nine patients reported that they could walk farther than 0.5 miles; however, only two patients with open fractures have returned to work.


The vascular supply of the tibia is supplied by intramedullary vessels, which provide nourishment to all of the intramedullary contents and to 2/3 of the cortical bone.12 The outer 1/3 of the cortex receives its blood supply from the overlying soft tissues.12 In patients with displaced long bone fractures, the intramedullary vascularity frequently is disrupted and the traumatized bone and soft tissues must rely solely on the remaining periosteum and other soft tissues for nutrition. Therefore, any extensive surgical dissections of the bone fragments may devitalize the remaining vascular pedicles, resulting in delayed union or nonunion of the fracture.

Farouk et al1 performed studies in femurs from cadavers to compare the injury to the vascular system from conventional open lateral plating with percutaneous plate insertion. They found that open plating interrupted 80% of perforating arteries in the thigh, although no perforating arteries or nutrient vessels were damaged in femurs that receive percutaneous plates. Additionally, all femurs undergoing the minimally invasive technique had superior periosteal and medullary perfusion as compared with femurs treated with the open technique. Other clinical studies in which minimally invasive plating techniques of the femur were used also have shown good early results with minimal complications.5-7,15 Although these studies have concluded that percutaneous plating was safe, they acknowledged that the technique was challenging and careful attention given to detail was required to prevent rotational malalignment of the limb.

The concern when evaluating the tibia is the precarious blood supply and eccentric nature of the tibia just below the skin, compared with concentric bones such as the femur, which have abundant blood supplies. When Whiteside and Lesker16 evaluated the effects of extensive soft tissue dissection in a traumatized tibia model, they reported significant healing problems. The experimental groups experiencing the least mechanical strength included those animals that had significant muscle trauma and had undergone surgical dissection around the osteotomy site. Helfet et al3 reported the results of 20 patients with closed pilon fractures who were treated with delayed percutaneous plate fixation using semitubular plates and screws. They reported no hardware failures or major wound complications. All patients had good functional results and, although four patients had some malalignment, none required a second surgical procedure. Other authors also have proposed percutaneous plate techniques as an alternative to intramedullary nailing, but have presented few objective data.7,14

In the current series, good results were obtained in patients with closed fractures, and in patients with open fractures, the rate of complications is thought to be similar to that reported for other techniques.2-4 Although bone grafting was required in six patients, four patients had significant bone loss, which most likely would have delayed healing regardless of the implant or technique used. Although intramedullary nailing remains the treatment of choice for most patients with long bone fractures, percutaneous plating is though to be a viable treatment for patients with complex diaphyseal tibia fractures with severe soft tissue compromise or for patients with articular fractures with retrophyseal-diaphyseal extension. Because fracture sites are not visualized, length, rotation, and angular alignment must be determined indirectly. Therefore, it must be understood that these methods are challenging technically and that special attention must be given to prevent malalignment. Surgeons experienced in these techniques have emphasized that vigilance regarding alignment during the operation is critical.3,16 Additionally, although these techniques tend to spare the osteogenic hematoma, delayed unions or nonunions can occur, especially in patients with open fractures and bone loss.

Percutaneous plating techniques offer surgeons a good method of bone stabilization in patients with complex tibial shaft fractures, fractures with severely compromised soft tissues, and injuries with intraarticular or periarticular extension. Percutaneous plating minimizes soft tissue stripping, preserves vascular pedicles, and allows the osteogenic fracture hematoma to remain essentially undisturbed. This technique seems to cause no increase in the risk of infection or soft tissue damage, and allows for rapid mobilization of the limb and patient. When using this method of treatment in patients with open injuries, particularly those with bone loss, early bone grafting should be considered.


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