• Users Online: 623
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 8  |  Issue : 1  |  Page : 16-24

Primary plate osteosynthesis in compound fractures of proximal and distal tibia by locked anatomical plate using minimally invasive technique: Our experience of 94 cases


Department of Orthopaedics, U.P. Rural Institute of Medical Sciences and Research, Etawah, Uttar Pradesh, India

Date of Web Publication13-Jun-2016

Correspondence Address:
Simrat Pal Singh Gill
Department Of orthopaedics, U.P. Rural Institute of Medical Sciences and Research, Saifai, Etawah, Uttar Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-7341.183948

Rights and Permissions
  Abstract 

Introduction: Juxta-articular or intra-articular compound proximal tibia fractures presents a great therapeutic challenge to an orthopaedic surgeon. The treatment of this kind of fractures is often complicated either by the patient's compromised general conditions, or by soft tissue damage. The development of biological techniques in plate fixation and the design of implants which cause the least possible interference with the periosteal blood supply have enhanced the use of plates and screws for stabilisation of open proximal tibia fractures. The primary aim of this study is to assess the role of biological plate fixation in compound proximal and distal tibia fractures. Material and Method: We selected 94 patients of compound proximal and distal tibia fractures including Gustilo and Anderson type 1,2 and 3A. Our protocol included debridement, irrigation, and splint casting in emergency room with definitive stabilization with the biological plate through minimally invasive surgical techniques if the soft tissue injury and wound allowed. Patients were followed up for at least two years. Outcome were measured using knee society clinical rating score for proximal tibia fracture cases and Modified American Orthopaedic Foot and Ankle Society score (AOFAS) for distal tibia fracture cases. Results: Further, final outcome of these patients was assessed after 2 years of follow-up using Knee society score. Excellent results were seen in 35(73%) cases and good result in 10 (20.8%) cases. Three cases show fair to poor score and all these cases were from compound Grade III group. one case required early plate removal and external fixation and showed poor result. Functional outcome of distal tibia fracture cases was assessed with the modified AOFAS ankle-hind foot score at final follow-up. Out of the 40 cases, 20(50%) shown excellent result. Out of the 40 cases, 14 (35%) shown good result. Overall good to excellent result was seen in 34 (85%) cases. Two cases showed fair result and poor result was seen in 4 (10%) cases. Discussion: The biological plate presents another good option in the treatment of open fractures in open proximal and distal tibial fractures. The combination of minimal soft tissue dissection, small surgical approaches, and plates that do not compress the bone, yield an implant that would be expected to yield a lower rate of infection than other alternative methods in treatment of open proximal tibial fracture.

Keywords: Compound tibia fracture, minimally invasive percutaneous plate osteosynthesis, primary plating, tibia metaphyseal fracture


How to cite this article:
Gill SP, Raj M, Kumar D, Singh J, Rastogi P. Primary plate osteosynthesis in compound fractures of proximal and distal tibia by locked anatomical plate using minimally invasive technique: Our experience of 94 cases. J Orthop Traumatol Rehabil 2015;8:16-24

How to cite this URL:
Gill SP, Raj M, Kumar D, Singh J, Rastogi P. Primary plate osteosynthesis in compound fractures of proximal and distal tibia by locked anatomical plate using minimally invasive technique: Our experience of 94 cases. J Orthop Traumatol Rehabil [serial online] 2015 [cited 2017 Mar 27];8:16-24. Available from: http://www.jotr.in/text.asp?2015/8/1/16/183948


  Introduction Top


Compound fracture of the tibia is one of the most common injuries encountered by any orthopedics center. There was a great evolution in the management of compound fracture of any bone from plaster of Paris (POP) with window, continuous traction, pin and plaster, external fixation, ring fixation, and hybrid fixation to primary locked intramedullary (IM) nailing. The main concern in compound fracture is soft tissue management.[1],[2] Nowadays, with better understanding of soft tissue management, primary fixation of fracture site is advised without further insulting the already damaged soft tissue.[2],[3],[4] However, diaphyseal compound fractures of tibia are well managed by primary locked IM nailing [5],[6],[7],[8],[9] with soft tissue coverage procedure simultaneously depending on the soft tissue defect.[2],[3],[4] Metaphyseal proximal and distal compound fractures of the tibia are still the area of concern for most of the orthopedic surgeons. The known method of management of compound metaphyseal fracture is continuous skeletal traction, which leads to joint stiffness and high dependency of patient on others. Other methods are external fixation either tubular [10],[11],[12],[13] ring fixators [14],[15],[16] or hybrid fixators,[17] external fixator followed by IM nailing in staged procedure,[18],[19],[20],[21] and external fixator followed by minimally invasive percutaneous plate osteosynthesis (MIPPO) plating again in staged manner.[22] These external fixators were used with variable results and have limitations of poor patient compliance, pin loosing, pin tract infection, and also these fixators are now also known as nonunion machines.[20],[21] Early internal fixation of open fracture was also advocated.[10],[23] External fixation of open fracture was also compared with various other methods such as Lottes nail [11] and Enders Nail.[12] Till now, plating in compound fracture is the least preferred method of fixation due to extensive soft tissue stripping and damage during operative procedure of plate application.[24] To overcome these shortcomings of plating, we used minimally invasive technique in compound fracture of metaphyseal tibial fracture for the management of these cases.


  Materials and Methods Top


This study was performed in the Department of Orthopaedics of U.P. Rural Institute of Medical Sciences and Research, Saifai, Etawah, a 1000-bedded tertiary care center situated in a rural setup in North Central India in Uttar Pradesh. Cases were selected from patients attending Emergency Trauma Center and Orthopedics outpatient department of our institute during August 2008 to August 2013.

Inclusion criteria were as follows:

  • All new cases of compound fracture of proximal and distal tibia.
  • Compound proximal and distal tibia fracture up to Grade IIIa.
  • Fracture without severe periosteal stripping.
  • Both intra- and extra-articular compound of proximal tibial fracture included.
  • Healthy wound without any pus discharge/deep infection at the fracture site.
  • Age from skeleton maturity to no upper age limit.


Exclusion criteria were as follows:

  • Compound fracture more than Grade III.
  • Fracture with severe contamination excluded.
  • Compound fracture having not adequate soft tissue coverage.
  • Malnutrition or immunocompromised patients excluded such as HIV.
  • Patients with high risk for infection due to medical conditions such as diabetes.
  • Patients with suspected peripheral vascular diseases such as arthrosclerosis/Berger disease.


During the period of August 2008 to August 2013, 94 patients of compound fracture of proximal and distal tibia were selected for primary locked anatomical plating using MIPPO method. Out of 94 patients, 82 were male and 12 patients were female with age range from 18 years to 58 years and average age was 32.5 years. Out of 94 cases, 52 cases were of proximal tibial compound fracture and 42 were distal tibial compound fracture. The mechanism of injury was road traffic accident in 72 cases, fall from height in 8 cases, agriculture injury in 10 cases, and other causes in 4 cases. Ethical clearance was taken from Institutional Ethical Committee and written informed consent was obtained from each patient.

We classify the fracture of proximal and distal tibia according to the AO foundation of Orthopaedic Trauma Association (AO-OTA) classification [Figure 1]a. Out of 52 proximal tibial compound fractures, 38 cases were 41A2/3, 6 patients were 41B, and 8 cases were of 41C group. Out of 42 distal compound fractures, 26 were 43A, 10 were 43B, and 6 were 43C types. According to Gustilo and Anderson classification,[25] out of 52 proximal compound fractures, 24 were compound Grade I, 18 cases were of compound Grade II, and 10 cases were of compound Grade IIIa. Out of 42 distal compound fractures, 19 were of compound Grade I, 15 were of compound Grade II, and 8 cases were of compound Grade IIIa group. All patients were managed initially by radical wound debridement, irrigation with low pressure pulse lavage with at least 8 L of normal saline. Limb kept on Bohler-Braun splint and calcaneum traction was applied in all cases. Initially, broad spectrum antibiotics was started including third generation cephalosporin, 1 g ceftriaxone with clavulanic acid plus 500 mg amikacin, both intravenous (IV) 12 hourly and 100 ml metrogyl IV 8 hourly for 3 days followed by antibiotics according to culture and sensitivity. Repeat daily wound inspection was performed daily and repeat debridement was performed if required. Skin and wound condition was assessed daily. The patient posted for primary plating within 5-15 days of injury with average duration of 7.5 days after injury. All cases were done in the supine position in spinal anesthesia. Precountoured anatomical locked plates were used in all cases. For proximal tibia, lateral anatomical locked plate of 4.5 mm was used from 5 to 11 holes length. For distal tibia, medial anatomical hybrid locked plate (3.5 mm metaphyseal screw and 4.5 diaphyseal screws) was used ranging from 5 to 9 holes. All plates were inserted without further damaging the already damaged soft tissue coverage using MIPPO method from proximal to distal insertion in proximal tibial fractures and distal to proximal insertion in distal tibial fractures. Reduction was achieved by indirect method under image intensifier control using K-wires and Steinman's pin as joy stick, where required. Calcaneum traction pin retained till the application of plate and used for perioperative traction if required. Plate length was selected so that at least three good bicortical locked screw purchases were obtained at diaphyseal area. Strength of fixation was assessed perioperatively by gentle movement of knee and ankle joints. Every measure was taken to cover the bone and plate with soft tissue at least without tension. Six of our proximal tibia cases required lateral release incision to cover the bone with soft tissue and skin. These release incision sited were left for secondary healing. Skin incisions giver during operation were closed in layers and compound wound was left open for secondary closure later on either by split thickness skin grafting or left for secondary suturing. Two of our cases required full thickness skin grafting for coverage of exposed bone. At the end of surgery, calcaneum traction pin was removed and well-padded dressing was done with crepe bandage and limb kept on Bohler–Braun splint.
Figure 1: (a) AO classification used for proximal and distal tibia fractures. (b) Scoring system used for proximal tibia fracture case, “Knee society score.” (c) Modified ankle foot score used for distal tibia fracture cases

Click here to view


During postoperative period, all patients were given IV antibiotics injection ceftriaxone 1 g plus clavulanic acid, IV injection amikacin 500 mg 12 hourly for 7 days. For initial 2 days, injection metrogyl 100 ml IV 8 hourly was added. After 7 days, the need of IV antibiotics was again assessed based on any discharge and wound condition. In most of the cases, IV antibiotics were replaced by oral tab cefixime 200 mg BD for the next 21 days. Six of our cases required extended IV antibiotics and repeat culture obtained in these cases and antibiotics were changed accordingly. Routine wound inspection was done daily and condition of skin and any potential plate exposure was looked for the next 5 days. Thereafter, alternative dressing was done till the healing of wound. Gradual knee and ankle mobilization was started over the next 5-7 days depending on recovery from the postoperative pain. Postoperative radiograph was taken on the 2nd or 3rd postoperative day. Nonweight bearing physiotherapy was advised to the patients. Patients were discharged after 7-15 days of operation depending on wound healing. Cases were followed up every 3 weeks for first 2 months, then after every 6 weeks up to 6 months, and thereafter every 12 weeks for at least 2 years. Partial weight bearing was allowed when there were radiological signs of bridging callus seen. Full weight bearing allowed after solid bridging callus was seen on radiograph. During each follow-up, cases were assessed and examined for skin condition, sign of any superficial and deep infection, plate and bone exposure, range of knee and ankle movement, rest and activity pain. Routine follow-up radiograph was obtained every 6 weeks until solid bridging callus formation was observed. On radiographic examination, anteroposterior (AP) and midlateral change in angulations were assessed. Final clinical outcome of proximal tibial fracture cases was evaluated using Knee-Society clinical rating score [26] where excellent result means 85-100 score, 70-84 score means good result, 60-69 score means fair result, and <60 score means poor result [Figure 1]b. For distal tibia fractures, functional outcome was assessed with the modified American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, as described by Mora et al.,[27] at final follow-up. The high score of this survey was 68 points, with 40 points for pain and 28 points for function; a higher score indicated a better outcome [Figure 1]c.{Figure 1}

The Chi-square test and regression analysis were used to determine the nature of relation between fixed clinical outcomes, complication, and possible influencing factors, such as fracture pattern (AO-OTA) and grade of open fracture (Gustilo–Anderson). The analysis was conducted using Statistical Package for the Social Sciences (SPSS) version 17.0, and statistical significance was accepted for P< 0.05.


  Results Top


During the period of August 2008 to August 2013, a total of 94 cases of compound fracture of tibia were treated by primary plating using MIPPO technique. In proximal compound tibial fracture, out of 52 cases, 48 cases completed the follow-up of at least 2 years. The average follow-up was 30.4 months. Out of 48 cases, 45 cases (93.8%) showed complete bony union in follow-up radiographs. The average radiological union time in proximal compound fracture cases was from 12 weeks to 18 weeks with average 14.2 weeks. Out of 48 cases, one case (2%) showed loss of reduction and marked varus angulation due to deep infection at fracture site, this case was managed by removal of plate and external fixator application. This case of early plate removal belonged to compound Grade IIIa group to start with. Plate screw back out and breakage were seen in none of these cases. Two of these cases (4%) required delayed removal of plate after attaining bony union as they complain of continuous sinus discharge due to low-grade infection [Figure 2]. These two cases of delayed plate removal were also from compound Grade IIIa group to start with. Out of 48 cases, 43 cases (90%) in this series have full range of knee movement. Five cases (10%) show some terminal restriction of movement with extension lag of 5-10°. Forty-five cases (95%) show no sign of infection in follow-up. There was 100% union rate in compound Grade II and compound Grade I group fracture case in this series without any sign of early or delayed infection. Further, final outcome of these patients was assessed after 2 years of follow-up using Knee society score. Excellent results were seen in 35 (73%) cases and good result in 10 (20.8%) cases. A total of 45 cases (93.8%) show good to excellent results according to this score [Figure 3], [Figure 4], [Figure 5], [Figure 6]. Three cases show fair to poor score and all these cases were from compound Grade III group. Out of the total 10 compound Grade III proximal tibia cases, 8 cases completed the follow-up and out of these 8 cases, 5 cases showed good to excellent results (62.5%), two cases (25%) were in fair group, which required delayed plate removal. A total of seven cases (87.5%) gave good to fair results and one case required early plate removal and external fixation and showed poor result. In distal tibial compound fracture group, out of 42 cases, 40 cases completed their follow-up of at least 24 months with average follow-up of 34 months. Out of these 40 cases, 35 cases (87.5%) showed complete bony union of follow-up radiograph with average union time of 15.4 weeks with range from 14 to 20 weeks. Out of those 40 cases, 4 cases showed sign of infection (10%) and skin problem over plate, so removal of implant was done in these cases and further managed by triangular fixator. All these four cases were from compound Grade IIIa group cases to start with. Out of the 40 cases, 3 cases showed some delayed loss of alignment in AP and lateral view, but not more than 10°. Functional outcome of all these cases was assessed with the modified AOFAS ankle-hindfoot score, as described by Mora et al.,[6] at final follow-up. The high score of this survey was 68 points, with 40 points for pain and 28 points for function; a higher score indicated a better outcome. Out of the 40 cases, 20 (50%) cases scored more than 58 points showing excellent result. Out of the 40 cases, 14 (35%) cases scored between 48 and 58 giving good result. Overall good to excellent result was seen in 34 (85%) cases [Figure 7] and [Figure 8]. Two cases showed fair result and poor result was seen in 4 (10%) cases. Other complications recorded in distal tibia fracture group were superficial skin infection, plate prominence, and skin itching in four cases [Figure 9]. All these four cases were giving poor results due to infection and again belonged to compound Grade IIIa group. Two cases required revision surgery of removal of plate and other two cases were managed by retaining of locking plate and delayed removal of implant, once union achieved.
Figure 2: Superficial skin infection, postfaciotomy minimally invasive plate osteosynthesis plating case

Click here to view
Figure 3: (a) Case 1 preoperative clinical condition of leg. (b) Case 1 preoperative radiograph. (c) Case 1 postoperative radiograph. (d) Case 1 follow-up radiograph at 6 weeks. (e) Case 1 follow-up radiograph at 14 weeks. (f) Case 1 follow-up radiograph at 22 weeks. (g) Case 1 clinical follow-up

Click here to view
Figure 4: (a) Case 2 preoperative radiograph. (b) Case 2 postoperative radiograph. (c) Case 2 follow-up radiograph at 6 weeks. (d) Case 2 follow-up radiograph at 12 weeks. (e) Case 2 clinical follow-up

Click here to view
Figure 5: (a) Case 3 preoperative clinical. (b) Case 3 preoperative radiograph. (c) Case 3 postoperative radiograph. (d) Case 3 follow-up radiograph at 6 weeks. (e) Case 3 follow-up radiograph 12 weeks

Click here to view
Figure 6: (a) Case 4 preoperative radiograph. (b) Case 4 postoperative radiograph. (c) Case 4 follow-up radiograph 6 weeks. (d) Case 4 follow-up radiograph 12 weeks

Click here to view
Figure 7: (a) Case 5 clinical preoperative distal tibial fracture. (b) Case 5 preoperative radiograph. (c) Case 5 postoperative radiograph. (d) Case 5 final follow-up at 12 weeks

Click here to view
Figure 8: (a) Case 6 preoperative radiograph. (b) Case 6 postoperative radiograph. (c) Case 6 follow-up radiograph at 6 weeks. (d) Case 6 follow-up radiograph at 12 weeks. (e) Case 6 clinical follow-up

Click here to view
Figure 9 : (a) Perioperative minimally invasive plate osteosynthesis plating of compound distal tibia fracture. (b) Superficial skin infection with minimal serous discharge seen during follow-up in one case without any other serious consequences, fracture was united uneventfully and infection was controlled conservatively

Click here to view



  Discussion Top


Compound fracture of tibia is one of the most common injuries encountered nowadays. Most of these patients are young male adults. The prime concern in these cases is soft tissue management. Soft tissue takes weeks to month to settle. Various methods were used to manage the underlying fracture with compound fracture ranging from POP immobilization with window, continuous skeletal traction with regular dressing and left the fracture to unite conservatively, Ilizarov fixation, tubular external fixation, hybrid external fixator, and locked IM nailing for diaphyseal fracture.

Plaster immobilization of compound fracture is nowadays the least preferred method as it has poor patient compliance, high rate of joint stiffness, high rate of malunion, and prolonged morbidity. External fixation is also known as nonunion machine and again has complications such as pin loosening, pin tract infection, and secondary loss of reduction. Ilizarov ring fixation is a well known method for management of compound fracture with bone loss. Without bone loss and metaphyseal fracture, Ilizarov ring fixation have limitations such as pin loosing and loss of reduction. Ilizarov ring fixation also has poor patient compliance due to bulky ring around limb and also difficulty in dressing through ring fixator.

Recent trends go toward the use of primary locked IM nail for the management of compound fractures. Closed interlocked nailing is the best biological fixation method done without any further damage to surrounding tissue with good to excellent results. The main limitation was that this cannot be used in juxtra- and intra-articular fractures.

Bhandari et al.[28] fixed compound diaphyseal fracture of tibia with IM nail with good results. He concluded that the risk of re-operation was as high as 18%, implying that one re-operation would be avoided for every five patients treated with IM nailing instead of external fixator. He also reported that external fixator group has the higher revision surgery rate then IM nail.

Sarmiento et al.[29] reported that external fixation in compound fracture suffers from up to 33% malunion and angulation rate.

Bach and Hansen [30] showed up to 50% revision surgery required when compound tibial fracture treated with conventional plating. He compared conventional open plating to external fixator for compound tibial fracture. He noted that 50% of patients treated with tibial conventional plate required further operation as opposed to 6.7% in the external fixator group.

Whittle et al.[31] reported cases of compound fractures of tibia managed by IM nailing up to compound Grade IIIb with infection rate of 3-8% with a rate of 12% for compound Grade IIIa and 25% for IIIb fractures. However, the metaphyseal and intra-articular fractures of tibia cannot be managed by IM nails due to the high incidence of mal-reduction and instability. Furthermore, nailing is contraindicated in intra-articular fractures.

To overcome these limitations of IM nails, proximal and distal compound fracture of the tibia can be managed with plating, but using minimally invasive technique without further jeopardizing the vascular damage to the underlying bone. Anatomical locked plate can be applied to metaphyseal area with minimal exposure and percutaneous under image intensifier control. This gives advantages of both IM nail and plate.

Giannoudis et al.[24] in their systemic review of 11 studies used conventional plating for the management of severe open tibial fractures. The overall union rate raged from 62% to 95% with time to union ranging from 13 to 41 weeks. The re-operation rate ranged from 8% to 69% and deep infection rate was 11%.

Stannard et al.[32] in their study reported that less invasive stabilization system can be used as an alternative for the management of compound proximal tibia fracture with 5-8% deep infection rate. The incidence of deep infection as per Gustilo and Anderson classification was Type I and II −0%; Type II −2.7%; Type IIIA −7.7%; and Type IIIB −7.1%.

Kim et al.[33] used minimally invasive plate osteosynthesis for open fracture of proximal tibia. He reported deep infection rate up to 16.7%, but no severe complication requiring procedure such as implant removal or amputation. They also noted that lower grade open fracture had significantly lower infection rate.

Sohn et al.[34] used staged protocol in the treatment of open distal tibial fracture using lateral MIPPO with good results. The average union time in their study was 21 weeks. In their study, average delay for plating was 15 days after injury.

Young and Barrack [35] also reported satisfactory results of compound fractures treated by staged protocol using MIPPO on open distal tibia fracture patients.

Collinge et al.[36] and Boren et al. also reported good result using staged protocol using MIPPO in open distal fracture of tibia.

Pal et al.[37] also conducted primary plating osteosynthesis in open fracture in a small series of 12 cases with satisfactory result. They reported good to fair result in 90% cases and deep infection in 6.5% cases. Overall union rate was good with one case requiring bone grafting.

In our series, we carefully selected patients up to compound Grade IIIa for primary definitive plate fixation of metaphyseal fractures by minimally invasive plating using percutaneous anatomical locked plate system. Care was taken to cover the plate and bone by soft tissue and plating is followed by regular wound dressing. Wound closure attained by 15 days in most of the cases either by secondary suturing or split thickness skin grafting. Two of our cases required full thickness rotation flap due to skin necrosis and bone exposure.

One case of compound Grade IIIa fracture of proximal tibia and two cases of compound Grade IIIa of distal tibia required removal of plate after 5 days of plating due to uncontrolled deep infection and the patient was further managed by ring fixator. Average duration of soft tissue feeling in distal tibial fracture cases were 23 days whereas in proximal tibial fracture, cases were 15 days. Average union time was lower in proximal tibial fracture, that is, 14.2 weeks and of distal tibial were 15.6 weeks.

Skin problems related to plate were more in distal tibial compound fracture; again patients of distal compound fracture complained more of plate prominence and pain compared to proximal plating group.

Plating of proximal compound fracture is better tolerated than distal tibial compound fracture.


  Conclusion Top


Primary plating of compound fracture is a good alternative method of management for proximal and distal metaphyseal and intra-articular fracture of tibia with lesser complication rate in proximal compound tibial fracture than distal compound fracture of tibia. Up to compound Grade II, primary platting can be used with excellent to good result without any risk of increased infection and delayed union. In compound Grade IIIa, most of the cases can be managed with primary plating with proper selection of the patients and wound condition without any severe complications such as amputation. Locked plating used by MIPPO technique in metaphyseal compound tibia fracture is a very good alternative method of management of these cases without any risk of any severe complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Sinclair JS, McNally MA, Small JO, Yeates HA. Primary free-flap cover of open tibial fractures. Injury 1997;28:581-7.  Back to cited text no. 1
    
2.
Caudle RJ, Stern PJ. Severe open fractures of the tibia. J Bone Joint Surg Am 1987;69:801-7.  Back to cited text no. 2
    
3.
Starman JS, Castillo RC, Bosse MJ, MacKenzie EJ; LEAP Study Group. Proximal tibial metaphyseal fractures with severe soft tissue injury: Clinical and functional results at 2 years. Clin Orthop Relat Res 2010;468:1669-75.  Back to cited text no. 3
    
4.
Clancey GJ, Hansen ST Jr. Open fractures of the tibia: A review of one hundred and two cases. J Bone Joint Surg Am 1978;60:118-22.  Back to cited text no. 4
    
5.
Finkemeier CG, Schmidt AH, Kyle RF, Templeman DC, Varecka TF. A prospective, randomized study of intramedullary nails inserted with and without reaming for the treatment of open and closed fractures of the tibial shaft. J Orthop Trauma 2000;14:187-93.  Back to cited text no. 5
    
6.
Mora S, Thordarson DB, Zionts LE, Reynolds RA. Pediatric calcaneal fractures. Foot Ankle Int 2001; 22:471-7.  Back to cited text no. 6
    
7.
Xue D, Zheng Q, Li H, Qian S, Zhang B, Pan Z. Reamed and unreamed intramedullary nailing for the treatment of open and closed tibial fractures: A subgroup analysis of randomised trials. Int Orthop 2010;34:1307-13.  Back to cited text no. 7
    
8.
Henley MB, Chapman JR, Agel J, Harvey EJ, Whorton AM, Swiontkowski MF. Treatment of type II, IIIA, and IIIB open fractures of the tibial shaft: A prospective comparison of unreamed interlocking intramedullary nails and half-pin external fixators. J Orthop Trauma 1998;12:1-7.  Back to cited text no. 8
    
9.
Bone LB, Kassman S, Stegemann P, France J. Prospective study of union rate of open tibial fractures treated with locked, unreamed intramedullary nails. J Orthop Trauma 1994;8:45-9.  Back to cited text no. 9
    
10.
Haidukewych GJ. Temporary external fixation for the management of complex intra- and periarticular fractures of the lower extremity. J Orthop Trauma 2002;16:678-85.  Back to cited text no. 10
    
11.
Swanson TV, Spiegel JD, Sutherland TB, Bray TJ, Chapman MW. A prospective, comparative study of the Lottes nail versus external fixation in 100 open tibia fractures. Orthop Trans 1990;14:716-7.  Back to cited text no. 11
    
12.
Holbrook JL, Swiontkowski MF, Sanders R. Treatment of open fractures of the tibial shaft: Ender nailing versus external fixation. A randomized, prospective comparison. J Bone Joint Surg Am 1989;71:1231-8.  Back to cited text no. 12
    
13.
Giotakis N, Narayan B. Stability with unilateral external fixation in the tibia. Strategies Trauma Limb Reconstr 2007;2:13-20.  Back to cited text no. 13
    
14.
Dendrinos GK, Kontos S, Katsenis D, Dalas A. Treatment of high-energy tibial plateau fractures by the Ilizarov circular fixator. J Bone Joint Surg Br 1996;78:710-7.  Back to cited text no. 14
    
15.
Inan M, Halici M, Ayan I, Tuncel M, Karaoglu S. Treatment of type IIIA open fractures of tibial shaft with Ilizarov external fixator versus unreamed tibial nailing. Arch Orthop Trauma Surg 2007;127:617-23.  Back to cited text no. 15
    
16.
Kumar A, Whittle AP. Treatment of complex (Schatzker Type VI) fractures of the tibial plateau with circular wire external fixation: Retrospective case review. J Orthop Trauma 2000;14:339-44.  Back to cited text no. 16
    
17.
Gaudinez RF, Mallik AR, Szporn M. Hybrid external fixation of comminuted tibial plateau fractures. Clin Orthop Relat Res 1996;328:203-10.  Back to cited text no. 17
    
18.
McGraw JM, Lim EV. Treatment of open tibial-shaft fractures. External fixation and secondary intramedullary nailing. J Bone Joint Surg Am 1988;70:900-11.  Back to cited text no. 18
    
19.
Antich-Adrover P, Martí-Garin D, Murias-Alvarez J, Puente-Alonso C. External fixation and secondary intramedullary nailing of open tibial fractures. A randomised, prospective trial. J Bone Joint Surg Br 1997;79:433-7.  Back to cited text no. 19
    
20.
Blachut PA, Meek RN, O'Brien PJ. External fixation and delayed intramedullary nailing of open fractures of the tibial shaft. A sequential protocol. J Bone Joint Surg Am 1990;72:729-35.  Back to cited text no. 20
    
21.
Maurer DJ, Merkow RL, Gustilo RB. Infection after intramedullary nailing of severe open tibial fractures initially treated with external fixation. J Bone Joint Surg Am 1989;71:835-8.  Back to cited text no. 21
    
22.
Ma CH, Wu CH, Yu SW, Yen CY, Tu YK. Staged external and internal less-invasive stabilisation system plating for open proximal tibial fractures. Injury 2010;41:190-6.  Back to cited text no. 22
    
23.
Chapman MW, Mahoney M. The role of early internal fixation in the management of open fractures. Clin Orthop Relat Res 1979;138:120-31.  Back to cited text no. 23
    
24.
Giannoudis PV, Papakostidis C, Kouvidis G, Kanakaris NK. The role of plating in the operative treatment of severe open tibial fractures: A systematic review. Int Orthop 2009;33:19-26.  Back to cited text no. 24
    
25.
Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: A new classification of type III open fractures. J Trauma 1984;24:742-6.  Back to cited text no. 25
    
26.
Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the knee society clinical rating system. Clin Orthop Relat Res 1989;248:13-4.  Back to cited text no. 26
    
27.
Mora S, Thordarson DB, Zionts LE, Reynolds RA. Pediatric calcaneal fractures. Foot Ankle Int 2001;22:471-7.  Back to cited text no. 27
    
28.
Bhandari M, Guyatt GH, Swiontkowski MF, Schemitsch EH. Treatment of open fractures of the shaft of the tibia: A systematic overview and meta-analysis. J Bone Joint Surg 2001;83-B:62-8.  Back to cited text no. 28
    
29.
Sarmiento A, Gersten LM, Sobol PA, Shankwiler JA, Vangsness CT. Tibial shaft fractures treated with functional braces. Experience with 780 fractures. J Bone Joint Surg Br 1989;71:602-9.  Back to cited text no. 29
    
30.
Bach AW, Hansen ST Jr. Plates versus external fixation in severe open tibial shaft fractures. A randomized trial. Clin Orthop Relat Res 1989;241:89-94.  Back to cited text no. 30
    
31.
Whittle AP, Russell TA, Taylor JC, Lavelle DG. Treatment of open fractures of the tibial shaft with the use of interlocking nailing without reaming. J Bone Joint Surg Am 1992;74:1162-71.  Back to cited text no. 31
    
32.
Stannard JP, Finkemeier CG, Lee J, Kregor PJ. Utilization of the less-invasive stabilization system internal fixator for open fractures of the proximal tibia: A multi-center evaluation. Indian J Orthop 2008;42:426-30.  Back to cited text no. 32
[PUBMED]  Medknow Journal  
33.
Kim JW, Oh CW, Jung WJ, Kim JS. Minimally invasive plate osteosynthesis for open fractures of the proximal tibia. Clin Orthop Surg 2012;4:313-20.  Back to cited text no. 33
    
34.
Sohn OJ, Kang DH. Staged Protocol in Treatment of Open Distal Tibia Fracture: Using Lateral MIPO. Clin Orthop Surg 2011;3:69-76.  Back to cited text no. 34
    
35.
Young MJ, Barrack RL. Complications of internal fixation of tibial plateau fractures. Orthop Rev 1994;23:149-54.  Back to cited text no. 35
    
36.
Collinge C, Sanders R, DiPasquale T. Treatment of complex tibial periarticular fractures using percutaneous techniques. Clin Orthop Relat Res 2000;375:69-77.  Back to cited text no. 36
    
37.
Pal CP, Mishra N, Dinkar KS, Kumar H, Singh P, Goyal RK. Primary plating osteosynthesis in open fractures. J Orthop Traumatol Rehabil 2014;7:64-8.  Back to cited text no. 37
  Medknow Journal  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed716    
    Printed30    
    Emailed0    
    PDF Downloaded221    
    Comments [Add]    

Recommend this journal