Vol 31 | Issue 2 | Aug – Dec 2016 | page: 12-16 | Chandra Prakash Pal, Brijesh Sharma, Vipul Aggrawal, Pawan Kumar, Danish Altaf, Ravi Mehrotra
Authors: Chandra Prakash Pal , Brijesh Sharma , Vipul Aggrawal , Pawan Kumar , Danish Altaf , Ravi Mehrotra 
 Department Of Orthopaedics, S.N. Medical College , Agra, India
Address of Correspondence:
Dr. Danish Altaf
Department Of Orthopaedics, S.N. Medical College , Agra, India
Aim: Assessments of result of internal fixation and external fixation in fracture lower third tibia.
Material and Method:-This prospective study was conducted in department of S.N.Medical College, Agra. Patients were divided into two groups of 30 patients each. Group 1 were treated with external fixation (Rail fixator, normal fixator and ilizarov fixator) and Group 2 was treated with internal fixation (distal tibial LCP and distal tibial interlocking nail). Patients were selected on the basis of strict inclusion and exclusion criteria. After fulfilment of clinical as well as radiological criteria fracture were considered healed . Soft tissue outcome was assessed on basis infection and wound dehiscence. Final functional outcome was assessed by Ovadia and Beals criteria and Johner wruhs criteria for fracture distal tibia.
Result: Mean time of union found in group 1(for normal fixator 14 – 52 weeks, for rail fixator 15-48 weeks and for ilizarov fixator 15 – 48 weeks) and in group 2(distal tibial LCP 19- 41 weeks and distal tibial interlocking nail 16- 36 weeks) .Four patient in group 1 reported as non- union and two patients were reported non union in group 2, infection was found in 8 patients in group 1 and 4 patients in group 2. Second procedure required 4 cases of group 1 and 2 cases of group2.According to Johner -Wruhs criteria for fracture distal tibia result were found to be excellent in 40 % case of group 1 and 63.33 % cases of group 2.and according to Ovadia and Beals criteria subjective result assessment in group 1 was 43.33 % and 66.66% in group 2. Objective result assessment 30% in group 1 and 66.66% in group 2.
Conclusion: both external and internal fixation are found to be effective for lower third tibia fracture however lower rate of infection, union time was faster and better functional outcome found in internal fixation than external fixation.
Keywords: – pilon fracture, distal tibia fracture, locking plate, MIPPO.
Lower third metaphyseal fracture of the tibia with or without intra-articular fracture extension in adults is among the most problematic injuries to treat. The most important variables that affect the final clinical result are the type of fracture, associated soft tissue injury, the method of treatment and the quality of the reduction [1, 2]. Conservative treatment of these fractures quite often results in a number of complications including malunion, non-union and ankle stiffness [3, 1, 4]. These fractures are generally not suitable for intramedullary nailing, despite certain reports indicating satisfactory results in some of these fractures [2, 5, and 6]. External fixation can be used as either a temporary or definitive method of treatment, especially in fractures with severe soft tissue injury [7, 8,9,10, 2], but mal-union and delayed union continue to be the main problems with this method of fixation [11, 12]. Conventional plate osteosynthesis with open reduction can further devitalise fragments and lead to higher incidence of non-union, infection and implant failure [13, 14]. Therefore, minimally invasive osteosynthesis, if possible, offers the best possible option as it permits adequate fixation in a biological manner [15, 9, 6].
Treatment of intra-articular fractures of the distal tibia is challenging due to the difficulties they present in achieving anatomical reduction of the articular surface of the ankle joint and the instability that may occur due to ligamentus and soft tissue injury. Numerous methods of treatment for these fractures have been reported, including conservative treatment with cast, open reduction and internal fixation and the combination of different types of external fixators with or without internal fixation . Controversy exists in the literature concerning the way these fractures should be treated .The aim of the present study is to assess the result of internal fixation and external fixation in fracture lower third tibia.
Material and Methods
The proposed study was a hospital based prospective study centred in department of orthopaedics, S.N. Medical College, Agra.
Sample size: 60 patients divided into two group 30 each. Group 1 for external fixation and group 2 for internal fixation. Patient selected according to inclusion and exclusion criteria
All cases presenting to outpatient and emergency department of orthopaedic S.N. Medical College, Agra and fulfilling the below mentioned criteria will be taken up for the study.
1. Compound lower third tibia fracture.
2. Compound fracture lower third tibia with bone loss.
3. Closed lower third tibia fracture.
4. Age 20 to 70 years.
1. Pathological fractures.
2. Medically unfit patient.
3. Noncompliant patients.
4. Distal third tibia fracture with intra-articular extension.
Criteria For Internal Fixation:
1. Healthy skin condition at fracture site.
2. Fracture with compound grade I wound.
3. Fracture without massive swelling.
4. Comminuted fracture without compounding.
Criteria For External Fixation:
1. Fracture with compound grade II and III / with bone loss.
2. Infected skin condition at fracture site.
3. Fracture site massive swelling.
4. Comminuted fracture with compounding
In external fixation group
·18 cases done by normal fixator.
·6 cases done by rail fixator.
·6 cases done by ilizarov fixator.
In internal fixation group
· 18 cases done by distal tibial interlocking nail.
·12 cases done by distal tibial LCP plating.
Follow Up: Follow up the patients done at 3 week, 6 weeks then monthly for 6 month then at interval of 3month up to 15 month. Patients are observed clinically and radiologically and final result outcome was calculated by using Criteria for assessments of results (ovadia and beals, 1986) (table no.1) and Johner-wruhs’ criteria for evaluation of final results (table no.2).
In this study 38(63.33%) patient were male and 22 female (36.66%) with mean age of patients 31 – 40 years (38.33%), most of the patients were lower socio economic status. In our study 39 fracture were right and 21 fractures were of left side with most common mode of injury was road traffic accident 28 patient (46.66%). Of all the fractures 24 were extra-articular type, 20 were partial-articular type and 16 intra-articular types. There were 28 compound fractures of which 5 fractures were grade I, 7 fractures were grade II and 16 fractures were grade III According to Gustilo-Anderson classification. The mean time of partial weight bearing in fractures of distal tibia treated by normal fixator (12-14 weeks), rail fixator (3-4 weeks), ilizarov fixator (3-4 weeks) ,distal tibial interlocking nail(7.6 weeks) and distal tibial LCP(9.5 weeks).
The mean time of full weight bearing in fractures of distal tibia treated by normal fixator (16-18 weeks), rail fixator (5-6 weeks), ilizarov fixator (5-6 weeks) ,distal tibial interlocking nail (14.25 weeks) and distal tibial LCP(17.32 weeks).
Mean time of union in fracture distal tibia treated by distal tibial interlocking nail (23.45 weeks), treated by rail fixator was 32.5 weeks, and treated by ilizarov fixator was 30.5 weeks and treated by normal fixator was 34 weeks.
According to Ovadia and Beal criteria 1986,
In subjective result assessment in internal fixation 66.66% excellent results and in external fixation 43.33% excellent results and In objective result assessment in internal fixation 66.66% excellent results and in external fixation 30.00% excellent results. According Johner-Wruhs criteria in internal fixation 63.33% excellent results and in external fixation 40.00% excellent results. Second procedure was required in 6 case of non union in which two case of normal fixator non union with implant breakage were treated by distal tibial nailing, two cases of normal fixator with non union without implant breakage were treated by distal tibial interlocking nailing and early dynamization. One case of distal tibial interlocking nail implant breakage with non-union were treated by exchange nailing and one case distal tibial LCP implant breakage with non union was treated by plating with bone grafting.
There were total 38 male patients (63.33%) and 22 female patients (36.66%) in this study showing male preponderance because of travelling and Working (Court-Brown CM et al, 1995) .The mean age of Fracture was Commonest in age group of 31 – 40 year (38.33%) as most active group of society. The most common mode of injury was road traffic Accident 28 patient (46.66%) followed by 15 (25.00%) fractures were fall from Height. This is similar to previous study Conducted by Siddhartha et al 2014 , Aso Mohammed et al 2008 , Janssen et al 2007 , Vallier et al 2008 , Im GI et al 2005  and Guo JJ et al 2010) .
Mean time of partial weight bearing and full weight bearing in distal tibial LCP was 9.5 weeks and 17.30 weeks. Which was longer than previous study by N Mahajan  (2011) shows partial weight bearing and full weight bearing at an mean time period of 6 and 12 weeks respectively.
Mean time of partial weight bearing and full weight bearing in Distal tibial interlocking nail was 7.6 weeks and 14.25 weeks respectively which was similar to previous study by Obulapathy D and Suresh Reddy .S 2015  in which partial weight bearing was 6.8weeks and full weight bearing was 13.6 weeks. Mean time of partial weight bearing and full weight bearing in rail fixator was 3.5 weeks and 5.5 weeks respectively Mea.n time of partial weight bearing and full weight bearing in ilizarov fixator was 3.5and 5.5 weeks. Mean time of partial weight bearing and full weight bearing in normal fixator was 13.5weeks and 17.5weeks.
Mean time of union in fracture distal tibia treated by distal tibial interlocking nail (23.45 weeks, range 16-36weeks ) which was similar result as done in previous study by Wasudeo Gadegone, Yogesh Salphale , Vijayanand Lokhande 2015  treated by rail fixator was 32.5 weeks(range 15-48 weeks) ,treated by ilizarov fixator was 30.5 weeks(range 15-48weeks) , treated by normal fixator was 34 weeks (range 14-52 weeks) and treated by distal tibial LCP plating 26weeks(range 19-41weeks).
According to Ovadia and Beal criteria 1986:In subjective result assessment in internal fixation 66.66% excellent results and in external fixation 43.33% excellent results and In objective result assessment in internal fixation 66.66% excellent results and in external fixation 30.00% excellent results. This result was similar to previous study by Ovadia and Beals 1986 found 55/80 (69%) excellent result in internal fixation and 28/54(43%) excellent result in external fixation.
According Johner-wruhs criteria in internal fixation 63.33% excellent results and in external fixation 40.00% excellent results. Similar results were found in previous study Internal fixation by Obulapathy D and Suresh Reddy .S 2015 Results were excellent in 66.6% and 41.6%, Good in 25% and 33.3%, fair in 8.3% and16.6% of ILN and plating groups respectively and 8.3% Show poor results in plating group.
In the management of fracture distal one third tibia as both internal Fixation and external fixation procedures were found to have merits and demerits, the choice of surgical procedure should be based on individual patient requirements, availability of equipment and Expertise. In this study internal fixation showed favourable Outcome and less complication when compared to external fixation Procedure. Similar results were also found in previous study done by many surgeons and institutes. Hence it may be concluded that from my study and previous held studies that internal fixation is the better Method for treating fracture distal lower third tibia.
1. Ovadia DN, Beals RK. Fractures of the tibial plafond. J Bone Joint Surg Am.1986;68(4):543–551.
2. Streicher G, Reilmann H. Distal tibial fractures (in German) Unfallchirug.2008;111(11):905–918.
3 . Digby JM, Holloway GM, Webb JK. A study of function after tibial cast bracing. Injury.1983;14(5):432–439.
4 . Rüedi TP, Allgöwer M. The operative treatment of intra-articular fractures of the lower end of the tibia. Clin Orthop Relat Res. 1979;138:105–110.
5. Fisher WD, Hamblen DL. Problems and pitfalls of compression fixation of long bone fractures: a review of results and complications. Injury. 1978;10(2):99–107.
6. Redfern DJ, Syed SU, Davies SJ. Fractures of the distal tibia: minimally invasive plate osteosynthesis. Injury. 2004;35(6):615–620.
7. Blauth M, Bastian L, Krettek C, Knop C, Evans S. Surgical options for the treatment of severe tibial pilon fractures: a study of three techniques. J Orthop Trauma.2001;15(3):153–160.
8 . Dickson KF, Montgomery S, Field J. High energy plafond fractures treated by a spanning external fixator initially and followed by a second stage open reduction internal fixation of the articular surface—preliminary report. Injury. 2001;32(Suppl 4):SD92–SD98
9 . Hazarika S, Chakravarthy J, Cooper J. Minimally invasive locking plate osteosynthesis for fractures of the distal tibia—results in 20 patients. Injury. 2006;37(9):877–887. 10. Krackhardt T, Dilger J, Flesch I, Höntzsch D, Eingartner C, Weise K. Fractures of the distal tibia treated with closed reduction and minimally invasive plating. Arch Orthop Trauma Surg. 2005;125(2):87–94.
11. Pugh KJ, Wolinsky PR, McAndrew MP, Johnson KD. Tibial pilon fractures: a comparison of treatment methods. J Trauma. 1999;47(5):937–941.
12. Ristiniemi J, Flinkkilä T, Hyvönen P, Lakovaara M, Pakarinen H, Biancari F, Jalovaara P. Two-ring hybrid external fixation of distal tibial fractures: a
13. Borrelli J, Jr, Prickett W, Song E, Becker D, Ricci W. Extraosseous blood supply of the tibia and the effects of different plating techniques: a human cadaveric study. J Orthop Trauma. 2002;16(10):691–695.
14. Fisher WD, Hamblen DL. Problems and pitfalls of compression fixation of long bone fractures: a review of results and complications. Injury. 1978;10(2):99–107.
15. Borg T, Larsson S, Lindsjö U. Percutaneous plating of distal tibial fractures. Preliminary results in 21 patients. Injury. 2004;35(6):608–614.
16. Adams CI, Keating JF, Court-Brown CM. Cigarette smoking and open tibial fractures.Injury. 2001;32(1):61–65.
17.Court-Brown CM, Mc Birnie J 1995.The epidemiology of tibial fractures. J Bone Joint Surg Br. May;77(3):417-21
18.Siddhartha Venkata Paluvadi’ Hitesh Lal. Deepak Mittal and Kandarp Vidyarthi,2014. Management of fractures of the distal third tibia by minimally invasive plate osteosynthesis – A prospective series of 50 patients. J Clin Orthop Trauma. sep; 5(3):129-136.
19.Aso Mohammed, Ramaswamy Saravanan, Jason Zammit and Richard King 2008 . Intramedullary tibial nailing in distal third fractures: distal locking screws and fracture
non-union. I nt Orthop. Aug; 32(4):547549
20.Janssen KW, Biert J, Van KA,2007. Treatment of distal tibia fractures: a retrospective outcome analysis of match pairs of patients. Int Orthop;31(5):709-71Johner
21. Vallier HA, Le TT, Bedi A,2008. Radiographic and clinical comparisons of distal tibia fracture (4 to 11 cm proximal to the plafond): plating versus intramedullary nailing. J Orthop Trauma; 22(5):307-11
22.Im GI, Tae SK, 2005. Distal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plate and screws fixation. J Trauma; 59(5):1219-23
23.Guo JJ, Tang N, Yang HL, Tang TS. A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia. J Bone Joint Surg Br. 2010
24. Neeraj Mahajan. Minimally Invasive Techniques in Distal Tibial Fractures JK SCIENCE Vol. 10 No. 2, April-June 2008
25. Obulapathy D and Suresh Reddy.S 2015International Journal of Recent Scientific Research Vol. 6, Issue, 6, pp.4918-4920, June, 2015
26. Wasudeo Gadegone, Yogesh Salphale, Vijayanand Lokhande 2015 Surgical Science, 2015; (6) 317-326.
|How to Cite this Article: Pal CP, Sharma B, Aggrawal V, Kumar P, Altaf D, Mehrotra R. Assessment of Results of Internal Fixation and External Fixation in Fracture Lower Third Tibia. Journal of Bone and Joint Diseases Aug-Dec 2016;31(2):12-16 . .|