Metaphyseal locking compression plate as an external fixator for the distal tibia

Abstract

Purpose: Recently we coined the term supercutaneous plating using a locking compression plate (LCP) as an external fixator. The use of this technique in peri-articular areas is facilitated by the development of anatomical plates with various screw sizes. The purpose of this report is to describe our results using the metaphyseal locking plate (LCP) as an external fixator in the treatment of infected post-traumatic problems of the distal tibia.

Methods: Between August 2008 and January 2012 a total of seven patients underwent external plating ("supercutaneous plating") of the distal tibia using a metaphyseal locking plate. Average age was 43 years (range 20-79). Six out of seven patients had a documented infection at the time of external plate application. All patients in this cohort were followed prospectively at regular intervals by the senior author (PK).

Results: The plate was in situ for an average of 17.5 weeks (range 6-60). There were no clinically significant pin site infections. In four patients the plate was kept in place until there was complete consolidation. In three patients the external plate was exchanged for formal internal fixation once the infection had subsided. At the latest follow-up (average 12.8 months, range 4-31), all patients were fully weight bearing with a fully healed tibia. All patients were infection-free with well-healed wounds.

Conclusion: Infection of the distal tibia after treatment of traumatic and post-traumatic problems is a challenging problem. It is common practice that after initial debridement and hardware removal, temporary bony stabilisation is provided by external fixation. Most external frames for the lower leg are bulky and cumbersome, causing significant problems for the patient. To circumvent these issues, we have successfully used an anatomically-contoured metaphyseal locking compression plate as external fixator in a series of seven patients for acute or post-traumatic problems of the tibia.

Fig. 1

A 19-year-old man presented with a pilon fracture of his right leg (a), which was treated by osteosynthesis via an anterolateral approach and a percutaneous medial approach leading to an anatomically reduced joint surface. Four months later, the medial wound showed evidence of infection and delayed union with failure of the medial hardware; notice the broken screw (b). The medial plate was removed followed debridement of nonvital bone fragments leaving a large metaphyseal defect stabilised by metaphyseal external LCP fixation (c, d). After eight weeks of external fixation, the wound healed and his infectious parameters normalised and revision osteosynthesis with bone grafting was performed. Six months later, radiological union was achieved (e). His ankle showed a good function and there were no residual signs of infection

Fig. 2

A 41-year-old male presented two years after a distal tibial fracture and failed attempt at a lengthening osteotomy of the tibia. He presented with post-traumatic osteomyelitis (MRSA and Pseudomonas aeruginosa) to our hospital for further treatment (a, b). The patient underwent re-operation with removal of the medial plate followed by thorough debridement and implantation of gentamycin beads followed by stabilisation of the defect by external plate fixation using a metaphyseal LCP (c). Five months after placement of the LCP external fixator and three further debridements, a free vascularised fibula transplant was applied in the debrided area by the plastic surgeon. The LCP external plate can easily be concealed under the regular clothing of the patient. Nine months after the free vascularised fibula transfer the tibia had healed (d) and there were no residual signs of infection. The plate was removed in the outpatient clinic. The patient was full weightbearing without complaints at the latest follow-up