Session VII - Tibia

Minimally Invasive Plating of High Proximal Tibial Fractures Unsuitable for Nailing

Tadeusz F. Wisniewski, MD, PhD; Marek J. Radziejowski, MD, FCS (SA); Johannesburg Hospital, University of the Witwatersrand, Department of Orthopaedic Surgery, Johannesburg, South Africa

Purpose: Many studies have demonstrated numerous complications in treatment of unstable proximal metaphyseal and high diaphyseal tibial fractures. The purpose of the study was to determine the accuracy of fracture reduction, stability of fixation, time of fracture healing, and complications with use of a minimally invasive method of fracture reduction with percutaneous plating.

Method: In a prospective study, we reviewed 56 extra-articular high proximal tibial fractures treated by minimally invasive percutaneous plating between January 1996 and July 2001. All fractures were located in the zone of 10 cm below the knee joint. Five fractures were open, 10 were comminuted with an extension into the diaphysis, and 5 were segmental. Fracture reduction was achieved by using an image intensifier either by hand manipulation and traction or by use of a femoral distractor and reduction clamp. The plates were inserted percutaneously through a short incision proximal to the fracture site and, in most cases, placed on the medial aspect of the tibia. In the majority of the fractures, the tibial head buttress plates were used. On average, three proximal and three distal screws were inserted through short additional incisions. Postoperatively, a knee brace was applied for an average of 6 to 12 weeks, and gradual weight bearing was permitted between 3 and 6 weeks.

Results: Accurate reduction in the anteroposterior plane was achieved in all fractures, but in the sagittal plane, tilting of the proximal fragment was observed in five cases. Soft tissue healing was uneventful. Weight bearing was permitted when radiological signs of healing were present between 6 and 8 weeks. On average, fracture healing was observed within 12 weeks (range, 8 to 18). Delayed union occurred in two cases. Secondary fracture fragment displacement or failure of fixation was not observed. None of the patients had functional limb restrictions and all were satisfied. No neurovascular complications were encountered. Late sepsis developed in six patients at the pronounced distal screw heads under the skin. In four fractures, proximal screws have backed out, but this had no influence on the functional outcome.

Discussion: High proximal tibial fractures unsuitable for intramedullary nailing that are treated by percutaneous plating may result in satisfactory fracture reduction, stable fixation, fracture healing within 12 weeks, and good functional outcome without failure of fixation or neurovascular or soft tissue healing complications. The late sepsis at bulky distal screws may be eliminated by development of a thin and flat locking plate device.

Conclusions: Percutaneous plating may be safely and successfully used as an alternative method of management for high proximal tibial fractures. Medial plate application is technically easy with a minimal soft stripping procedure.