Single-Stage Externalized Locked Plating for Treatment of Unstable Meta-Diaphyseal Tibial Fractures

Abstract

(1) Background: Unstable meta-diaphyseal tibial fractures represent a heterogeneous group of injuries. Recently, good clinical results have been reported when applying a technique of externalized locked plating in appropriate cases, highlighting its advantage in terms of less additional tissue injury compared with conventional methods of fracture fixation. The aims of this prospective clinical cohort study were, firstly, to investigate the biomechanical and clinical feasibility and, secondly, to evaluate the clinical and functional outcomes of single-stage externalized locked plating for treatment of unstable, proximal (intra- and extra-articular) and distal (extra-articular), meta-diaphyseal tibial fractures. (2) Methods: Patients, who matched the inclusion criteria of sustaining a high-energy unstable meta-diaphyseal tibial fracture, were identified prospectively for single-stage externalized locked plating at a single trauma hospital in the period from April 2013 to December 2022. (3) Results: Eighteen patients were included in the study. Average follow-up was 21.4 ± 12.3 months, with 94% of the fractures healing without complications. The healing time was 21.1 ± 4.6 weeks, being significantly shorter for patients with proximal extra- versus intra-articular meta-diaphyseal tibial fractures, p = 0.04. Good and excellent functional outcomes in terms of HSS and AOFAS scores, and knee and ankle joints range of motion were observed among all patients, with no registered implant breakage, deep infection, and non-union. (4) Conclusions: Single-stage externalized locked plating of unstable meta-diaphyseal tibial fractures provides adequate stability of fixation with promising clinical results and represents an attractive alternative to the conventional methods of external fixation when inclusion criteria and rehabilitation protocol are strictly followed. Further experimental studies and randomized multicentric clinical trials with larger series of patients are necessary to pave the way of its use in clinical practice.

Keywords: externalized locked plating; supercutaneous plating; unstable tibial fractures.

Figure 1

Preoperative radiographs of patients with an AO/OTA 41-C2.2 proximal tibial fracture with simple intra-articular involvement of both tibial condyles without intra-articular comminution and impaction (left), a 41-A3.1 multi-fragmentary proximal tibial extra-articular fracture (middle), or a 43-A2.3 distal tibial multi-fragmentary meta-diaphyseal fracture (right), all accompanied by significant soft tissue injury.

Figure 2

LISS-DF plate with an exemplified sequence of screw insertions into the plate holes.

Figure 3

Postoperative photos of patients with a proximal (left) and a distal (right) meta-diaphyseal fracture fixed via externalized locked plating using either an ipsilateral reversed or a contralateral non-reversed LISS-DF plate, respectively.

Figure 4

Anterior view of bone-plate constructs with an unstable, meta-diaphyseal, either proximal (left images) or distal (right images) tibial fracture, mimicked via osteotomizing a 20 mm gap and fixed with three different plate elevations. While the 2 mm plate elevation represents internal fixation, the 22 mm and 32 mm elevations represent externalized locked plating with soft tissue thicknesses of 20 mm and 30 mm, respectively.

Figure 5

Anterior and medial views of bone-plate constructs with an unstable, meta-diaphyseal, either proximal (left images) or distal (right images) tibial fracture, mimicked via osteotomizing a 20 mm gap and fixed with a plate elevation of 22 mm representing externalized locked plating with 20 mm soft tissue thickness.

Figure 6

Post-operative (A,C,E) and final follow-up (B,D,F) radiographs of patients with an AO/OTA 41-C2.2 proximal tibial fracture with simple intra-articular involvement of both tibial condyles without intra-articular comminution and impaction (radiographs A,B), an AO/OTA 41-A3.1 multi-fragmentary proximal tibial extra-articular fracture (radiographs C,D), and an AO/OTA 43-A2.3 distal tibial multi-fragmentary meta-diaphyseal fracture (radiographs E,F), all accompanied by significant soft tissue injuries and treated via single-stage externalized locked plating with LISS-DF.

Figure 7

Gap strain at the far cortex as predicted by the FE models of the unstable meta-diaphyseal proximal and distal tibial fractures, mimicked via osteotomizing a 20 mm gap and fixed with three different plate elevations of 2 mm, 22 mm, and 32 mm for partial and full weight bearing scenarios of 250 N and 800 N, respectively.