Different effect of percutaneous plate insertion via anteromedial vs anterolateral approach on intracompartmental pressure of the leg: A cadaveric study.

Currently Minimally Invasive Plate Osteosynthesis (MIPO) technique for tibial shaft fracture management has gained wide attention. However, an increased intracompartmental pressure after the plate insertion may result in postoperative acute compartment syndrome. We reported the difference of immediate effect of percutaneous plate insertion using 2 approaches of MIPO technique on anterior compartment pressure of the legs. Eight soft cadaveric legs (one female and three males) without previous history of skeletal trauma or surgery were infused with normal saline to create the sustained intracompartmental pressure of 20mm Hg in all four compartments. The Synthes® 4.5mm 11-hole Narrow Locking Compression Plate was inserted via anteromedial and anterolateral approach. Anterior compartment pressure was measured by portable digital monitoring device through side-port needle (Stryker® Intracompartmental Monitoring Device) before and after plate insertion for each approach. By using anteromedial approach, a mean of anterior compartment pressure was increased by 0.375mm Hg after plate insertion (5 of 8 legs had no change in pressure and the remaining 3 resulted in 1mm Hg pressure elevation). For anterolateral plate insertion, all of the 8 legs had an elevation of anterior compartment pressure with a mean of 3.5mmHg (ranged from 2 to 6mm Hg). When both approaches were compared to each other, the anterolateral plate insertion resulted in higher intracompartmental pressure elevation of the anterior compartment than the anteromedial approach. Surgeon should be more aware of acute compartment syndrome when considering the anterolateral approach in treating close tibial fracture. However, in patients with suspected acute compartment syndrome, close observation and continuous monitoring of the intracompartmental pressure is still imperative for all healthcare provider.

Amarase C ，Thimasarn W ，Tantavisut S ，Huanmanop T ，Wangroongsub Y ，Limthongkul W ... -  《-》

Intracompartmental pressure changes after anterolateral bridge plating of tibial fractures.

Dağlar B ，Delialioğlu ÖM ，Bayrakcı K ，Tezel K ，Günel U ，Ceyhan E ... -  《-》

The risk of neurovascular injury in minimally invasive plate osteosynthesis (MIPO) when using a distal tibia anterolateral plate: a cadaver study.

Lidder S ，Masterson S ，Grechenig C ，Clement H ，Gänsslen A ，Grechenig S ... -  《-》

Staged minimally invasive plate osteosynthesis of proximal tibial fractures with acute compartment syndrome.

High-energy proximal tibial fractures often accompany compartment syndrome and are usually treated by fasciotomy with external fixation followed by secondary plating. However, the initial soft tissue injury may affect bony union, the fasciotomy incision or external fixator pin sites may lead to postoperative wound infections, and the staged procedure itself may adversely affect lower limb function. We assess the results of staged minimally invasive plate osteosynthesis (MIPO) for proximal tibial fractures with acute compartment syndrome. Twenty-eight patients with proximal tibial fractures accompanied by acute compartment syndrome who underwent staged MIPO and had a minimum of 12 months follow-up were enrolled. According to the AO/OTA classification, 6 were 41-A, 15 were 41-C, 2 were 42-A and 5 were 42-C fractures; this included 6 cases of open fractures. Immediate fasciotomy was performed once compartment syndrome was diagnosed and stabilization of the fracture followed using external fixation. After the soft tissue condition normalized, internal conversion with MIPO was done on an average of 37 days (range, 9-158) after index trauma. At the time of internal conversion, the external fixator pin site grades were 0 in 3 cases, 1 in 12 cases, 2 in 10 cases and 3 in 3 cases, as described by Dahl. Radiographic assessment of bony union and alignment and a functional assessment using the Knee Society Score and American Orthopedic Foot and Ankle Society (AOFAS) score were carried out. Twenty-six cases achieved primary bony union at an average of 18.5 weeks. Two cases of nonunion healed after autogenous bone grafting. The mean Knee Society Score and the AOFAS score were 95 and 95.3 respectively, at last follow-up. Complications included 1 case of osteomyelitis in a patient with a grade IIIC open fracture and 1 case of malunion caused by delayed MIPO due to poor wound conditions. Duration of external fixation and the external fixator pin site grade were not related to the occurrence of infection. Staged MIPO for proximal tibial fractures with acute compartment syndrome may achieve satisfactory bony union and functional results, while decreasing deep infections and soft tissue complications.

Kim JW ，Oh CW ，Oh JK ，Kyung HS ，Park KH ，Kim HJ ，Jung JW ，Jung YS ... -  《-》

Ability of modern distal tibia plates to stabilize comminuted pilon fracture fragments: Is dual plate fixation necessary?

The purpose of this study was to examine the screw trajectory of ten commercially available distal tibia plates and compare them to common fracture patterns seen in OTA C type pilon fractures to determine their ability to stabilize the three most common fracture fragments while buttressing anterolateral zones of comminution. We hypothesized that a single plate for the distal tibia would fail to adequately stabilize all three main fracture fragments and zones of comminution in complex pilon fractures. Ten synthetic distal tibia sawbones models were used in conjunction with ten different locking distal tibia plate designs from three manufacturers (Depuy Synthes, J&J Co, Paoli, PA; Smith & Nephew, Memphis, TN; and Stryker, Mawa, NJ). Both medial and anterolateral plates from each company were utilized and separately applied to an individual sawbone model. Three implants allowing variable angle screw placement were used. The location of the locking screws and buttress effect 1cm above the articular surface was noted for each implant using axial computed tomography (CT). The images were then compared to a recently published "pilon fracture map" using an overlay technique to establish the relationship between screw location and known common fracture lines and areas of comminution. Each of the three main fragments was considered "captured" by a screw if it was purchased by at least two screws thereby controlling rotational forces on each fragment. Three of four anterolateral plates lacked stable fixation in the medial fragment. Of the 4 anterolateral plates used, only the variable angle anterolateral plate by Depuy Synthes captured the medial fragment with two screws. All four anterolateral plates buttressed the area of highest comminution and had an average of 1.25 screws in the medial fragment and an average of 3 screws in the posterolateral fragment. All five direct medial plates had variable fixation within anterolateral and posterolateral fragments with an average of 1.8 screws in the anterolateral fragment and an average of 1.3 screws in the posterolateral fragment. The Depuy Synthes variable angle anterolateral plate allowed for fixation of the medial fragment with two screws while simultaneously buttressing the zone of highest comminution and capturing both the anterolateral and posterolateral fragments with five and three screws respectively. The variable angle anteromedial plate by Depuy Synthes captured all three main fracture fragments but it did not buttress the anterolateral zone of comminution. In OTA 43C type pilon fractures, 8 out of 10 studied commercially available implants precontoured for the distal tibia, do not adequately stabilize the three primary fracture fragments typically seen in these injuries. Anterolateral plates were superior in addressing the coronal primary fracture line across the apex of the plafond, and buttressing the zone of comminution. None of the available plates can substitute for an understanding of the fracture planes and fragments typically seen in complex intra-articular tibia fractures and the addition of a second plate is necessary for adequate stability. Level IV.

Penny P ，Swords M ，Heisler J ，Cien A ，Sands A ，Cole P ... -  《-》