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    When a Car Met a Motorcycle: Managing a Non-Healing Distal Tibia Fracture

    Callus formation still has not occurred 11 weeks after early definitive fixation of 47-year-old patient’s closed intra-articular distal tibia and fibula fracture. Which course of treatment will help prevent an impending non-union of the tibia?

    Author

    Brandon J. Yuan, MD

    Disclosures

    The author has no disclosures relevant to this article.

    Introduction

    A 47-year-old female patient with a history of nicotine dependence was admitted to the emergency department after sustaining a closed intra-articular distal tibia and fibula fracture in a car versus motorcycle collision (Figure 1). It can be implied that the affected leg received severe energy during the collision based on the degree of comminution and the mechanism of injury. No CT scan was obtained before the patient was taken to the operating room for surgical fixation of this injury.

    Figure 1. Closed intra-articular distal tibia and fibula fracture sustained in a car versus motorcycle collision.

    High-energy injuries about the tibia warrant special consideration with regard to the soft tissue envelope, as they put patients at increased risk of significant swelling, skin and muscle necrosis, and compartment syndrome. For this reason, soft tissue injury should dictate initial surgical treatment, not osseous injury.

    Many high-energy tibia fractures can be managed early with a medullary implant. However, temporary external fixation should be considered in fractures requiring open exposure through the zone of injury to restore stability, length, and alignment. This allows time for resolution of the soft tissue swelling associated with the initial trauma before subjecting the affected limb to additional surgical trauma.

    Initial Treatment

    The surgeon who initially managed this patient opted for early definitive fixation of her fracture on the day of injury. Several aspects of the case can be analyzed.

    The fixation goals for the tibia appear to have been direct reduction of the comminuted fragments and primary bone healing. The majority of the fracture was exposed through a medial incision (presumably to allow for a direct reduction), and there is evidence that the surgeon attempted to compress several of the comminuted segments together with screws or lag screws. One independent lag screw from anterior to posterior was left in place. The plate appears to only partially span the most superior extent of the fracture, reducing the effective working length of the construct and bringing the true stability of the fixation into question (Figure 2). 

    Figure 2. Fixation of the fracture showing that the surgeon attempted to compress several of the comminuted segments together with screws or lag screws. The plate does not span the most superior extent of the fracture.

    Although alignment of the articular segment is in slight recurvatum and valgus, the articular aspect of the fracture appears to be well reduced. There also appears to be a similar malreduction of the fibula.

    The surgeon used skin staples as a closure technique. This is a less-than-optimal choice, given the compromised soft tissue envelope. Previous studies have shown that skin sutures are superior to staples in terms of tissue perfusion. [1-3] As mentioned above, consideration for temporary spanning external fixation would have been wise.

    What Could Have Been Improved?

    Although articular fractures require direct reduction and absolute stability, the metaphyseal and diaphyseal extensions of the same fractures generally do not need to be reduced or stabilized in the same fashion. In cases of extensive extra-articular comminution, a functional reduction is often best achieved via indirect methods, allowing for preservation of periosteal blood supply and anticipation of fracture healing via secondary bone healing (or with callus). This can be accomplished with a plate or a medullary implant; given the relatively small distal segment, a plate would likely be preferable in this case.

    At the time of definitive fixation, it would have been preferable to start with the fibula to allow for direct reduction, provide optimal anatomic alignment of the ankle, and assist in reduction of the tibia. The articular surface of the tibia could have been reduced through a small approach around the joint itself and compressed with lag screws.

    An indirect, functional reduction of the articular segment of the tibia then could have been performed, spanning the area of comminution with an anteriorly or medially based plate extending up the tibia. This would have allowed for a more stable construct with an increased working length.

    Postoperative Concerns and Treatment Options

    The patient was transferred to the author’s institution 5 days after the injury. Significant swelling and fracture blisters were readily apparent (Figure 3), and the wounds were at significant risk of dehiscence or infection. In retrospect, a temporary spanning external fixator likely should have been placed.

    Figure 3. Swelling and blisters apparent 5 days after surgery for fracture fixation.

    Due to concerns regarding her skin and soft tissue, revision surgery was not immediately undertaken. Fortunately, the patient’s incisions healed with minimal complications, although re-epithelization of the epidermis over the anteromedial tibia took 8 weeks to complete.

    Radiographs taken 11 weeks after the injury showed no callus formation around the tibia, but no catastrophic failure of fixation either (Figure 4). The lack of biologic activity around the fracture site was likely secondary to a combination of the initial injury and the degree of soft tissue stripping that occurred at the time of surgery. 

    Figure 4. Eleven weeks after fracture fixation. Radiographs show no biologic activity around the fracture site.

    This patient warranted close observation: Although not enough time had passed to call this a non-union, the lack of any radiographic healing over the course of 3 months was worrisome for impending non-union. Options considered at this point included:

    • Continued observation.The patient was unlikely to go on to develop sufficient healing callus to unite this fracture prior to catastrophic implant failure, given the less-than-ideal alignment of the fracture, the poor quality of the fixation, and the degree of soft tissue stripping that occurred at the time of surgery. 
    • Revision internal fixation with bone grafting. This option has the advantage of removing the previous implants, allowing for correction of deformity, and providing biologic augmentation. However, it would also mean the patient would have to undergo the same larger surgery that would have been required if catastrophic fixation failure had occurred, as well as reopening of the recently healed medial incision.
    • Bone grafting and additional fixation.Bone graft can be placed on the tibia posterolaterally, where the soft tissue envelope is the most robust. Through this same approach, a posterolateral plate may be applied to the tibia to act as additional fixation without disturbing the medial wound.

    Prior to any revision procedure, the surgeon must rule out underlying infection or endocrine abnormalities that may contribute to delayed bone healing. Preoperatively, this patient’s C-reactive protein (CRP) level, erythrocyte sedimentation rate (ESR), white blood cell (WBC) count, and endocrine labs (vitamin D, thyroid-stimulating hormone, parathyroid hormone, alkaline phosphatase, calcium, and phosphorus levels) were all within normal limits.

    Revision Procedure

    The author chose the third option above: bone grafting and additional fixation. Goals of the revision procedure were to enhance the biologically compromised fracture with autograft bone and to augment the questionably stable fixation with another implant.

    Through a posterolateral approach, the posterior tibia and fracture site was exposed and decorticated with a high-speed burr. Autograft cancellous bone from the posterior iliac crest was then placed on top of the posterior tibia, over the fracture site and the area of decorticated bone. Finally, a posterolateral plate was applied, spanning the fractured area by several cortical diameters (Figure 5).

    Figure 5. Postoperative radiographs following bone grafting and additional fixation of the fracture.

    Three months after the bone grafting procedure, the fracture demonstrates excellent callus formation and progression toward union (Figure 6). At 1 year from the original date of injury, the medial plate was removed due to prominence. The tibia demonstrated complete remodeling and osseous union, with a mild malunion in valgus and recurvatum that was not clinically detectable (Figure 7).

    Figure 6. Radiographs taken 3 months after revision surgery show callus formation and progression toward union.

     

    Figure 7. Radiographs taken 1 year after the original injury show complete remodeling and osseous union.

    Key Points

    • High-energy fractures around the tibia warrant special consideration, with management of soft tissue injury prioritized over management of osseous injury. This patient avoided major infectious complications, but her overall management could have been improved if an external fixator had been used for the initial treatment.
    • Articular fractures with metaphyseal or diaphyseal extension must be approached systematically. Although the articular segment requires direct reduction and compression, extra-articular comminution may be managed with functional, indirect reduction and relative stability constructs.
    • When faced with an impending non-union, several factors must be considered:
      • How stable is the current fixation? Patients with fixation showing signs of early failure or less-than-ideal stability may benefit from earlier intervention.
      • What is the biologic potential of the fracture? Closed fractures with a healthy soft tissue envelope may be monitored, as their potential for continued osseous healing is greater than in fractures that have been previously devitalized or that have a compromised soft tissue structure.
      • Has infection been ruled out? Although the diagnostic yield of laboratory studies such as CRP level, ESR, and WBC count are not perfect, they offer more information if infection is suspected. Advanced imaging studies can also be utilized as needed (MRI, Indium scan).
    • Adding biologic supplementation to selected non-unions is an important consideration. Options include bone grafts from the iliac crest, proximal tibia, or calcaneus. Bone graft may also be harvested from the medullary canal of long bones with the use of the Reamer Irrigator Aspirator (RIA).

    Author Information

    Brandon J. Yuan, MD, is an Assistant Professor in the Division of Orthopedic Trauma, Mayo Clinic, Rochester, Minnesota.

    References

    1. Sagi HC, Papp S, Dipasquale T. The effect of suture pattern and tension on cutaneous blood flow as assessed by laser Doppler flowmetry in a pig model. J Orthop Trauma. 2008;22:171–175.
    2. Wyles CC, Jacobson SR, Houdek MT, et al. The Chitranjan Ranawat Award: running subcuticular closure enables the most robust perfusion after TKA: a randomized clinical trial. Clin Orthop Relat Res. 2016;474:47–56
    3. Shannon SF, Houdek MT, Wyles CC, et al. Allgower–Donati Versus Vertical Mattress Suture Technique Impact on Perfusion in Ankle Fracture Surgery: A Randomized Clinical Trial Using Intraoperative Angiography. J Orthop Trauma, 2017; 31:97-102