Comparative study between Medial & Lateral distal tibial locking compression plate for treatment of distal third tibia fractures. A thesis presentation by Dr Amrut Uddhavrao Borade. Under supervision & guidance of Dr M.P.Goyal sir, Associate professor , Department of Orthopaedics, SMS Hospital.

What makes distal third tibia special? Proximity to ankle joint. Peculiar Blood supply. Thin soft tissue covering. Myriad options for individualized treatment of its fractures.

How is blood supply of distal third tibia different than rest of it? Paucity of muscle attachments makes this region relatively avascular & principally dependent on periosteal & intramedullary blood supply for nutrition. On the medial aspect of the distal tibia, branches of ATA & PTA anastomose with each other forming a complex vascular network. Additionally, the posterior tibial artery provides numerous extraosseous branches to the medial malleolar area and the posterior aspect of the distal metaphysis just proximal to the tibial plafond. This extraosseous blood supply is at risk for disruption during the injurious process & during plate applications to the distal tibia.

What do we mean by Distal Tibia Fractures & Pilon Fractures? Distal tibia fractures are primarily located within a square based on the width of the distal tibia. Pilon fractures are the intra-articular distal tibia fractures. First described by the French radiologist Destot in 1911, ankle fractures that involve the weight-bearing distal tibial articular surface are known as pilon fractures. The term pilon in French refers to a pestle, specifically a club-shaped tool for grinding substances in a mortar, or a large bar moved vertically to stamp or pound.

What is the MOI in distal tibia fractures? Axial compression Rotational injury.

How are distal third tibia fractures classified? 1.1.2Muller AO classification

Variable fracture patterns. Variable severity of the soft tissue injury. Peculiar soft tissue envelope which necessitates instrumentation to be selective & ingenious. Bias due to variable expertise of surgeon.

What are pros & cons of plating in management of these cases? Anatomical Reduction & Rigid fixation. Earliest possible rehabilitation. Expensive, Demanding surgical expertise. Carries risk of infection which can be devastating. Disadvantages of surgical procedure like anaesthesia risk, scar mark.

Why are precontoured LCPs preferred in metaphyseal periarticular region? Angular Stability provided by an fixed angle device. Potential to be applied in MIPO technique as they need not to be anatomically contoured. Locking head screws allow stable fixation in metaphyseal area. Specific designs allow maximum possible purchase when bone block near joint is small.

Medial distal tibial LCP Lateral distal tibial LCP

The strongest cancellous bone in the region of distal tibia is located near subchondral bone plate & may provide an optimal area for fixation devices. Aitken GK, Bourne RB, Finlay JB, et al. Indentation stiffness of the cancellous bone in the distal human tibia. Clin Orthop Relat Res 1985(201):264-270.

What are the complications being encountered by surgeons following application of Medial distal tibial LCP? Medial plating increases skin tension of the anteromedial aspect of the tibia. Also it disrupts the extra-osseous vascular anastomosis previously mentioned. In addition, medial plating often requires a separate incision for treating the accompanied distal fibular fracture. A double incision around the ankle may disturb the skin circulation. These conditions can result in poor blood supply to the region and produce wound necrosis. 

What is the main concern in considering lateral distal tibial LCP as definitive alternative ? Lateral distal tibial LCP being newer & unfamiliar to many orthopaedicians. The lack of studies of biomechanical differences between the two. The orthodox concept of lateral pillar-medial pillar fixation implying medial plate to be more biomechanically sound.

What are the biomechanical differences in Medial & Lateral distal tibial LCP? Distal tibia extra-articular fractures stabilized with anterolateral or medial locking plate constructs demonstrated no statistically significant difference in biomechanical stiffness in compression and torsion testing. Anterolateral and medial locking plate stiffness in distal tibial fracture model. Yenna ZC, Bhadra AK, Ojike NI, ShahulHameed A, Burden RL, Voor MJ, Roberts CS. Foot Ankle Int. 2011 Jun;32(6):630-7

 What`s single lateral approach for the fixation of both the fibula and the tibia? It was described with the intent of avoiding severe soft tissue complications by minimizing the operative trauma and by offering good soft tissue covering for the tibia plate. Banks SW, Laufman H (1953, 1981) Exposure of the anterior and the lateral surface of the distal end of the tibia through a lateral incision. In: An atlas of surgical exposures of the extremities. W.B. Saunders Company, Philadelphia

The technique of lateral approach The technique of lateral approach. a Right shin from antero-lateral aspect. Skin incision is made laterally along the anterior margin of fibula and the anterior compartment muscles are retracted anteriorly thus revealing the lateral aspect of tibia and fibula. b Cross-section. c Both plates at their places without screws

What was the research question which embarked the study? Does Lateral distal tibial LCP provide a more biological option than Medial distal tibial LCP in terms of decreased incidence of soft tissue complications at the same time without any significant difference in biomechanical result?

What were the Aims & Objectives of the study? 1. To compare results & complications of Medial distal tibial LCP with Lateral distal tibial LCP in ORIF of Distal Tibia fractures. 2. To evaluate use of single incision technique for ORIF of both tibia & fibula during application of lateral distal tibial LCP.

What was the study design? Criteria : This prospective clinical study was being carried out from May 2011 to July 2012 in patients admitted in SMS hospital , Orthopaedics department in accordance with the following criteria- Inclusion Criteria: 1. Patients willing to participate & give consent for the study. 2. Patients who are skeletally mature. 3. Patients with Distal tibia fractures with or without concomitant fibula fractures: Closed fractures or Open fractures in which soft tissue injury and skin condition is good allowing for definitive treatment. Exclusion Criteria: 1. Patients with open fractures in which soft tissue injury is not healed or skin condition is poor. 2. Patients with concomitant vascular injury. I

Treatment Protocol Temporary treatment. Patients included in study open fractures upto Gustilo Anderson class IIIa closed fractures Open fractures IIIb Debridement, irrigation, Closure CR GT slab application iv antibiotics Debridement, irrigation, Spanning external fixator /calcaneal pin traction application iv antibiotics. CR & GT slab application

3.2.2 Pre operative evaluation this includes optimum condition of skin & soft tissues for definitive step, CT scan if required & ensuring administration of pre op antibiotic dose. Definitive treatment with ORIF with LCP. Medial Distal Tibial LCP Lateral Distal Tibial LCP Approach: Medial or Anteromedial. Approach:Lateral.

FINAL OUTCOME ANALYSIS POST OP day 0 : iv antibiotics,limb elevation and active toe movements, static & active quadriceps exercises. Post op day 2: check dressing Post op day 14: Removal sutures and splint. Active mobilisation of ankle. Post op 6 weeks: Radiological assessment, partial wt bearing & knee-ankle ROM. Post op 3 MONTHS: radiological assessment, full wt bearing & knee-ankle ROM Post op 6 MONTHS : radiological assessment, full wt bearing & knee-ankle ROM. return to full activities after clinical & radiological union. FINAL OUTCOME ANALYSIS CLINICAL OUTCOME Clinical evidence of union. Occurrence of complications Ankle and Knee ROM Tenny and Wiss Scoring RADIOLOGICAL OUTCOME Fracture union Implant failure Any secondary collapse

What was the surgical technique used …? 1.Medial distal tibial LCP group…Hukumchand.

2.Lateral distal tibial LCP group…Mangusingh

What is the preoperative patient demographics? Medial Plating group Lateral Plating group p value Sex(F/M) 3/22 4/21 0.67 Average age, years 36.27 ± 7.1 41.61 ± 8.2 0.61 Average follow up, months 6.7 ± 1.1 6.2 ± 1.4 0.15 Mechanism of Injury RTA 20 (80%) 18 (72%) 0.87 Fracture type ( Open/Closed) 2/23 0.75 Fracture location Average distance from fracture site to tibial plafond, cm 5.1 ± 1.1 5.6 ± 1.2 0.68 Intra-articular / Extra-articular fracture 5/20 Concomitant Fibula Fracture 22/25 21/25 0.85

Muller AO Fracture Class

Results Medial Plating Lateral Plating p value Operative time(min) 95.6±13.3 86.4±12.7 0.22 Union rate 23/25 Healing time(weeks) 19.2 ± 4.2 18.6 ± 5.1 0.32 Symptomatic Hardware 13/25 4/25 <0.01 Implant Failure 1/25 Hardware removal 11/25 2/25 Superficial infection 7/25 <0.05 Wound Dehiscence 0/25 Result Grading Excellent/Good/Fair/Poor 1/8/13/3 2/11/10/2 Ankle Dorsiflexion 17.2 ± 7.8 19.3 ± 8.5 0.28 Ankle Plantar flexion 30.7 ± 8.6 34.2 ± 9.1 0.19

Clinical Results (Tenny & Wiss criteria)

Comparison of occurrence of complications Medial Plating Group Lateral Plating Group

Jagdish 25 yr student

Babulal 45 yr teacher

Kantadevi 50 yr old Housewife :I/A fracture

Ramphool 40 yr Serviceman :I/A fracture

Complications Medial distal tibial LCP group… Mohanlal

Complications Lateral Distal tibial LCP group .. Mahendra

Symptomatic Hardware problem Medial distal tibial LCP group…

How can we conclude ? Lateral distal tibial LCP seems to provide biological advantage than medial distal tibial LCP without difference in biomechanical properties of the implants. Single lateral incision technique is an ingenious, biologically sound, cosmetically superior for fixation of both lower third tibia & fibula fractures together.

Take Home Message… Thank you Distal third tibia fractures are challenging injuries to treat in view of thin soft tissue cover over it. Medial surface of distal tibia is not preferable from biological point of view. Lateral distal tibial LCP is a biomechanically equivalent & biologically superior option. Thank you