Document Type: RESEARCH PAPER

Authors

1 Head of Department Orthopedics & spinal injury Govt Medical college. Jammu

2 Government medical college Jammu. Jammu & kashmir

3 Govt Medical college Jammu

4 Government Medical college Jammu

Abstract

Background: 
 Fractures of the distal third of the tibia are mostly associated with a fibular fracture that often requires fixation. The preferred treatment of distal tibial fracture is the minimally invasive percutaneous plate osteosynthesis  (MIPPO) procedure. However, there are no clear cut guidelines on fixation of the fibular fracture and currently most orthopedic surgeons use a plate osteosynthesis for the fibula as well. A common complication associated with dual plating is an increased chance of soft tissue necrosis, infection, and in some cases resulting in an exposed implant. We conducted a prospective study to analyze the results of fractures of the distal in both leg bones managed by the MIPPO procedure for tibial fractures and a rush nail for fibular fractures. 
 Methods: 
 The study was conducted in a tertiary care hospital from November 2012 to May 2014, a total of 30 fractures in 30 patients (18 males, 12 females) with a mean age of 42.4 years (26-60 years) were treated in our institution in the aforesaid time period with MIPPO for tibia and rush nail for fibular fractures. All the cases were operated on by a single surgeon in emergency within 24 hours. The patients with skin blistering and compound fractures were excluded from this study. Rehabilitative measures were proceeded as per patient’s pain profile, isometric and isotonic exercises were started on the first post-operative day, with full weight bearing at 10-12 weeks after assessing clinical and radiological union. Regular follow up of patients was done, radiographs were taken at the immediate post-operative period and at 3, 6, 12 and 24 weeks. 
 Results: 
 All the patients were available for regular follow up. Radiological and clinical union proceeded normally in all the patients, no patients had signs of any deep infection, delayed union or nonunion, three patients had a superficial infection of the tibial incision that healed with a change in antibiotic. 
 Conclusions: 
 The use of dual plating for fixation of the lower tibia and fibula fractures is often associated with soft tissue complications, exposed implant, and increased risk of infection. We conclude that in fractures of the distal tibia and fibula it is better to use a rush nail for the fibula with a concurrent MIPPO for the tibia for the reasons cited above. Moreover, with the use of rush nail the cost of implant is also reduced, which is a very important factor in developing  countries. 
 

Keywords

  1. Court‑Brown CM, McBirnie J, Wilson G. Adult ankle fractures: An increasing problem? Acta Orthop. 1998;69(1):43‑7.
  2. Koval KJ, Lurie J, Zhou W, Sparks MB, Cantu RV, Sporer SM, et al. Ankle fractures in the elderly: What you get depends on where you live and who you see. J Orthop Trauma. 2005;19(9):635‑9.
  3. Kannus P, Palvanen M, Niemi S, Parkkari J, Järvinen M. Increasing number and incidence of low‑trauma ankle fractures in elderly people: Finnish statistics during 1970‑2000 and projections for the future. Bone. 2002;31(3):430‑3.
  4. Canale ST, Beaty JH. Campbell operative orthopedics. 12th ed. Maryland Heights, Missouri: Mosby; 2013.
  5. Höiness P, Engebretsen L, Strömsöe K. The influence of perioperative soft tissue complications on the clinical outcome in surgically treated ankle fractures. Foot Ankle Int. 2001;22(8):642‑8.
  6. McKenna PB, O›Shea K, Burke T. Less is more: Lag screw only fixation of lateral malleolar fractures. Int Orthop. 2007;31(4):497‑502.
  7. Beauchamp CG, Clay NR, Thexton PW. Displaced ankle fractures in patients over 50 years of age. J Bone Joint Surg Br. 1983;65(3):329‑32.
  8. Appleton P, McQueen M, Court‑Brown C. The fibula nail for treatment of ankle fractures in elderly and high risk patients. Tech Foot Ankle. 2006;5(3):204‑8.
  9. Lee YS, Huang HL, Lo TY, Huang CR. Lateral fixation of AO type‑B2 ankle fractures in the elderly: The Knowles pin versus the plate. Int Orthop. 2007;31(6):817‑21.
  10. Smith G, Wallace R, Findlater G, White T. The fibular nail: A biomechanical study. Procs Seventh SICOT/SIROT Anuual International Conference, Gothenburg; 2010.
  11. Ramasamy PR, Sherry P. The role of a fibular nail in the management of Weber type B ankle fractures in elderly patients with osteoporotic bone: A preliminary report. Injury. 2001;32(6):477‑85.
  12. Rajeev A, Senevirathna S, Radha S, Kashayap NS. Functional outcomes after fibula locking nail for fragility fractures of the ankle. J Foot Ankle Surg. 2011;50(5):547‑50.
  13. Rüedi T. Fractures of the lower end of the tibia into the ankle joint: results 9 years after open reduction and internal fixation. Injury. 1973;5(2):130-4.
  14. Borens O, Kloen P, Richmond J, Roederer G, Levine DS, Helfet DL. Borens O, Kloen P, Richmond J, et al: Minimally invasive treatment of pilon fractures with a low profile plate: preliminary results in 17 cases. Arch Orthop Trauma Surg. 2009;129(5):649-59.
  15. Anderson SA, Li X, Franklin P, Wixted JJ. Ankle fractures in the elderly: Initial and long‑term outcomes. Foot Ankle Int. 2008;29(12):1184‑8.
  16. Nåsell H, Ottosson C, Törnqvist H, Lindé J, Ponzer S. The impact of smoking on complications after operatively treated ankle fractures: A follow‑up study of 906 patients. J Orthop Trauma. 2011;25(12):748‑55.
  17. Wukich DK, Joseph A, Ryan M, Ramirez C, Irrgang JJ. Outcomes of ankle fractures in patients with uncomplicated versus complicated diabetes. Foot Ankle Int. 2011;32(2):120‑30.
  18. Borg T, Larsson S, Lindsjo U. Percutanous plating of distal tibial fractures- preliminary results in 21 patients. Injury. 2004;35(6):608–14.
  19. Bahari S, Lenehan B, Khan H, McElwain JP. Minimally invasive percutaneous plate fixation of distal tibia fractures. Acta Orthop Belg. 2007;73(5):635-40.
  20. Redfern DJ, Syed SU, Davies SJ. Fractures of the distal tibia: minimal invasive plate osteosynthesis. Injury. 2004;35(6):615-20.
  21. Lau TW, Leung F, Chan CF, Chow SP. Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures. Int Orthop. 2008;32(5):697-703.
  22. Teeny SM, Wiss DA. Open reduction and internal fixation of tibial plafond fractures. Variables contributing to poor results and complications. Clin Orthop Relat Res. 1993;292:108-17.