n tips & techniques
Section Editor: Steven F. Harwin, MD
One-Stage External Fixation Using a Locking
Plate: Experience in 116 Tibial Fractures
Jingwei Zhang, MD; Nabil A. Ebraheim, MD; Ming Li, MD; Xianfeng He, MD; Jiayong Liu, MD
Abstract: The authors report the results of 1-stage external
fixation using a locking plate in 116 tibial fractures (85 closed
and 31 open). The patients were followed for an average of
22 months. The mean duration of surgery was 42 minutes.
The mean fracture healing time was 12 weeks for proximal,
20 weeks for shaft, 14 weeks for distal, and 24 weeks for
multisegmental tibial fractures. Nonunion, deep infection,
and breakage of screws did not occur. External plate fixation
is effective for tibial fractures and especially for metaphyseal
fractures. It has the advantages of being easy to perform and
less invasive, and the plate is conveniently located for removal. [Orthopedics. 2015; 38(8):494-497.]
T
he early design of the external plate was part of the
Zespol system.1 It involved
multiple nuts and washers,
which may have dissuaded
surgeons receptive to this
technique. Since the advent of
the locking plate with fewer
moving parts, there has been
a resurgence of interest in this
technique.2 This external plate
fixation has been described
in the management of open
fractures and septic arthritis,
and has even been called the
“supercutaneous plating technique.”3-5
However, most of the published studies on this topic
have involved small numbers
of patients. Furthermore, external plate fixation has of-
The authors are from the Department of Orthopaedic Surgery (JZ, ML,
XH), Ningbo No. 6 Hospital, Ningbo, China; and the Department of Orthopaedic Surgery (NAE, JL), University of Toledo, Toledo, Ohio.
The authors have no relevant financial relationships to disclose.
Correspondence should be addressed to: Nabil A. Ebraheim, MD, Department of Orthopaedic Surgery, University of Toledo, 3000 Arlington Ave,
Mail Stop 1094, Toledo, OH 43614 ([email protected]).
Received: June 30, 2014; Accepted: July 28, 2014.
doi: 10.3928/01477447-20150804-05
494
ten been described in staged
surgeries for open fractures.6
Therefore, the use of external
plate fixation remains controversial.
The current authors describe their early experience
with 1-stage external fixation
using a locking plate in 116
tibial fractures including both
closed and open fractures.
and 25 women, with a mean
age of 43 years (range, 19-63
years). There were 20 proximal, 39 shaft, 52 distal, and 5
multisegmental tibial fractures. Fractures were due to a
fall (n=16), a motor vehicle accident (n=42), and a motor vehicle accident when the patient
was a pedestrian (n=58).
Materials and Methods
Femoral LISS (Less Invasive Stabilization System;
Synthes, West Chester, Pennsylvania) plates were positioned over the anteromedial
aspect of the tibia as an external fixator intended for definitive fixation of tibial fractures.
For proximal tibial fractures,
ipsilateral femoral LISS plates
were used (ie, the left proximal
tibial fracture was fixed with
the left femoral LISS plate).
For distal tibial fractures,
contralateral femoral LISS
plates were used (ie, the left
distal tibial fracture was fixed
with the right femoral LISS
plate). For tibial shaft and
multisegmental fractures, the
type of plate depended on
whether the fracture line was
To be included in this
study, patients had to be skeletally mature and have a fracture involving the tibia with
or without a fibular fracture.
Patients were excluded if they
had pathological fractures,
Gustilo type IIIB or IIIC open
fractures, comminuted fractures with substantial articular displacement, lower limbs
with preexisting neurological
deficit, or vascular disease.
Between July 2011 and
January 2013, 116 successive
patients with tibial fractures,
including 85 closed and 31
open fractures (18 Gustilo
type I and 13 Gustilo type
II), underwent external plate
fixation. There were 91 men
Surgical Technique
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n tips & techniques
close to the proximal or distal
tibia. After that, it was fixed
as a proximal or distal tibial
fracture. This peculiarity was
incorporated into the authors’
surgical technique because
they found that the plate could
be placed close to the anteromedial aspect of the tibia in
this way.
All procedures were performed by 3 physicians (J.Z.,
M.L., X.H.). Each of them
had 15 years of orthopedic
surgery experience. The mean
time between trauma and surgery was 3 days (range, 2-5
days) for closed fractures. For
open fractures, fracture fixation was achieved after debridement in the emergency
setting.
The associated distal fibular fractures were internally
plated first to restore the correct length. The proximal and
middle fibular fractures were
not fixed.
For tibial fractures with
spiral and oblique morphology, a small incision was made
to expose and anatomically reduce the fracture. A clamp or 2
K-wires were used to temporarily fix and maintain the
anatomic reduction. The broad
end of the plate was placed
close to the joint; this can provide more screws to stabilize
the short metaphyseal segment. A stack of evenly folded
towels (1 to 2 cm thick) was
provisionally used to keep
the plate apart from the skin.
Successive holes were drilled
over locking drill-guides
through stab incisions, where
the overlying soft tissue envelope was intact. Once the
depth had been determined,
locking screws of corresponding length were inserted. All
screws achieved bicortical
purchase. In both proximal
and distal fragments, 4 to 5
bicortical locking screws were
inserted, respectively. The position and the orientation of
the screws were checked with
fluoroscopy. The skin was
sutured and a drainage tube,
which was discontinued after
24 hours, was embedded.
For comminuted tibial
fractures, reduction of length
and alignment were achieved
via manual traction and percutaneous manipulation using
Schanz pins under live C-arm
fluoroscopy. The K-wires were
used to percutaneously fix and
maintain the reduction. The
subsequent steps for placement
of the screws and plate were
the same as those mentioned
above.
Patients were allowed to
walk with partial weight bearing starting on postoperative
day 2. The screw sites were
cleaned twice a day with a
Betadine solution (Aidplus
Medical Appliance Co, Ltd,
Shenzhen, China). Patients
were seen in the clinic every
4 weeks for radiographic and
functional evaluation.
Results
The patients were followed
for a mean of 22 months (range,
18-30 months). The mean duration of surgery was 42 minutes
(range, 30-71 minutes). All
traumatic wounds healed without further problems.
The mean fracture healing
time was 12 weeks (range,
10-20 weeks) for proximal
tibial, 20 weeks (range, 12-
A
B
C
Figure 1: Anteroposterior radiographs showing a proximal tibial fracture preoperatively (A), postoperatively (B), and after plate removal (C).
Figure 2: Postoperative medial side photograph showing a proximal tibial fracture with an external plate in situ.
28 weeks) for tibial shaft, 14
weeks (range, 12-20 weeks)
for distal tibial, and 24 weeks
(range, 16-36 weeks) for tibial multisegmental fractures.
Once cortical bridging was
observed on biplanar radiographs, patients were allowed
to walk with full weight bearing for 1 month before the
plate was removed in an outpatient setting. All plates and
screws were removed without
difficulty within 3 minutes.
Eight patients had transient
pin site infections without
compromise of clinical outcome. Five infections occurred
4 weeks postoperatively and
were controlled after continual
cleansing with Betadine solution for 1 week. Three infec-
tions occurred 12 weeks postoperatively and were resolved
by removing the involved
screws.
All of the patients were
satisfied with their outcomes
and returned to their previous activity levels. Nonunion,
deep infection, and breakage
of screws and plates did not
occur.
Representative cases of
proximal tibial (Figures 1-2),
tibial shaft (Figures 3-4), distal tibial (Figures 5-6), and
tibial multisegmental (Figures
7-8) fractures are presented in
this article.
Discussion
Compared with traditional
external fixators, which are of-
AUGUST 2015 | Volume 38 • Number 8495
n tips & techniques
Figure 4: Postoperative medial side photograph showing a tibial shaft fracture
with an external plate in situ.
A
B
C
Figure 3: Anteroposterior radiographs showing a tibial shaft fracture preoperatively (A), postoperatively (B), and after plate removal (C).
Figure 6: Postoperative medial side photograph showing a distal tibial fracture
with an external plate in situ.
A
B
C
Figure 5: Anteroposterior radiographs showing a distal tibial fracture
preoperatively (A), postoperatively (B), and after plate removal (C).
ten bulky, locking plates have
a low profile and thus are less
likely to strike the contralateral
lower leg in the swing-through
phase of either leg during ambulation.7
The current authors used
femoral LISS plates instead
of tibial locking plates for
3 reasons. First, they have
found that the contour of the
femoral LISS plate matches
496
the anteromedial aspect of the
tibia. The plate can be placed
very close to the skin and
can be well concealed under
stockings, enabling patients
to walk while wearing trousers. Second, the anteromedial aspect of the tibia can be
clearly palpated, facilitating
fast and accurate insertion of
screws with less risk of neurovascular injuries. Third,
the broad end of the femoral
LISS plate has 7 holes, allowing more precise modulation
to obtain the greatest bone
purchase. The diameter of the
screws in the femoral LISS
plate is greater than that of
the screws in the tibial plate.
Bicortical screws were used
in this study. All of these features increase the stability of
the construct.
All of the patients eventually achieved fracture healing.
The fracture healing time was
shorter for tibial metaphyseal
than for tibial shaft and multisegmental fractures.
Conventional treatment for
tibial fractures includes plating or nailing.8 Internal plating
with large exposure increases
the risks of nonunion and infection. Percutaneous plating
reduces these risks. Nevertheless, the submuscle or subcutaneous plates may be prominent under the skin or muscles
and may cause soft tissue
problems.9-11 Intramedullary
nailing can provide rigid stability in tibial shaft fractures.
However, for tibial metaphyseal fractures that have an
hourglass-shaped medullary
canal, nailing is a technically challenging procedure
with risk of malalignment.
Complementary devices such
as blocking screws and an additional locking plate, both of
which will increase surgical
duration and costs, are recommended to augment the stabil-
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n tips & techniques
Figure 8: Postoperative medial side photograph showing a tibial multisegmental
fracture with an external plate in situ.
References
A
B
C
Figure 7: Anteroposterior radiographs showing a tibial multisegmental fracture preoperatively (A), postoperatively (B), and after plate removal (C).
ity of nailing. Additionally, anterior knee pain is commonly
reported after antegrade tibial
nailing.12-14
One-stage external plate
fixation decreases both costs
and surgical injuries. Fractures are anatomically reduced via a small incision
without massive dissection.
The medially placed screws
and plate have less influence
on muscle activity. Because
stab incisions were used for
screw insertion, and therefore
digging and tunneling around
the bone was not necessary,
the risk of infection could be
decreased. With external plating, deep infection is less of a
concern due to maintenance of
the integrity of the soft tissue
envelope.
In this study, 31 open fractures underwent external plating and none developed an infection. All of the screws and
plates were removed within
3 minutes in an outpatient
setting. The authors did not
encounter difficulty removing these external screws and
plates. No recurrent fracture
occurred after plate removal.
In contrast, surgery to remove
an intramedullary nail or an internal locking plate can lead to
complications in some cases.
Raja et al15 reported a complication rate as high as 47% for
plate removal.
Conclusion
The authors found that
external plate fixation is effective for tibial fractures and
especially for metaphyseal
fractures. The femoral LISS
plate is effective as an external fixator for tibial fractures
because the contour of the
plate matches the anteromedial aspect of the tibia. This
technique has the advantages
of being easy to perform and
less invasive, and the plate is
conveniently located for removal. Additional studies are
needed to confirm these findings.
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