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ORIGINAL PAPER
Ilizarov external fixation versus plate osteosynthesis
in the management of extra-articular fractures of the distal tibia
Mohamed Fadel &Mohamed Ali Ahmed &
Ahmed Mounir Al-Dars &Mustafa Ahmed Maabed &
Hashem Shawki
Received: 27 September 2014 / Accepted: 14 November 2014 /Published online: 5 December 2014
#SICOT aisbl 2014
Abstract
Purpose The purpose of this study was to evaluate the out-
come of Ilizarov external fixation (IE) versus dynamic com-
pression plate (PO) in the management of extra-articular distal
tibial fractures.
Methods Between 2010 and 2011, extra-articular distal tibial
fractures in 40 consecutive patients met the inclusion criteria.
They were classified according to AO classification fracture type
A (A1, A2, and A3). In a randomized method, two equal groups
were managed using either IE or PO. PO was performed using
open reduction and internal fixation (ORIF) and DCP through
anterolateral approach. IE was done using Ilizarov frame. For the
PO group, non-weight bearing ambulation was permitted on the
second postoperative day but partial weight bearing was permit-
ted according to the progression in union criteria clinically and
radiologically. For the IE group, weight bearing started as toler-
ated from the first postoperative day. Physiotherapy and pin-site
care was performed by the patient themselves.
Results Modified Mazur ankle score was applied to IE (ex-
cellent 10, good 10) and in PO (excellent 2, good 8, poor 6).
Data were statically analysed using (Mann–Whitney test). The
rate of healing in the IE group (average 130) was higher than
the PO (average 196.5); plus, there were no cases of delayed
union or nonunion in the IE group (p value 0.003).
Conclusion It was found that IE compared with PO provides
provision of immediate weight bearing as tolerated following
postoperative recovery, irrespective of radiological or clinical
healing with no infection, deformity or non-union.
Keywords Extra-articular .Distal tibia .Fracture .Ilizarov
external fixation .Plate osteosynthesis
Introduction
Distal tibial fracture remains one of the most common frac-
tures of long bones. This fracture may be caused by bending
and rotational forces. Because of thin skin and less soft tissue
coverage, open fracture and liability to infection with
sloughing of the skin are more common in this type of frac-
ture. When conservative treatment is inappropriate, several
methods of surgical management could be used [1,2]. Open
reduction and internal fixation (ORIF) provides stability, but it
often requires extensive soft-tissue dissection, further
devascularization of the bone fragments with higher
rates of complications and secondary surgery. Minimally
invasive percutaneous plate osteosynthesis (MIPPO) showed
high rates of healing and low rate of soft-tissue complications
[3]. Closed intramedullary nailing (IMN) presents itself as a
treatment option that preserves the extra osseous blood supply,
fracture haematoma and maintains the integrity of the soft
tissue envelope [4]. Some comparative studies have been
published about ORIF, MIPPO, and IMN [2–4].
In our country, generally speaking, ORIF using dynamic
compression plate (DCP) remains preferable for its familiar
experience and low cost management of such fractures com-
pared to Ilizarov external fixation (IE). To our knowledge, there
is no study in the English literature about the use of IE in the
management of extra-articular distal tibial fractures, or a com-
parative study with conventional plate osteosynthesis (PO).
M. Fadel (*):M. A. Ahmed
Department of Orthopaedic Surgery and Traumatology, El-Minia
University Hospital, 53 Mousa Ibn-Nosai, Nasr City,
11471 Cairo, Egypt
e-mail: fadelminia@yahoo.com
A. M. Al-Dars
Arab Institute for continuing professional development (AICPD),
Cairo, Egypt
M. A. Maabed
El-Fayoum General Hospital, El-Fayoum, Egypt
H. Shawki
Manchiet El-Bakry General Hospital, Cairo, Egypt
International Orthopaedics (SICOT) (2015) 39:513–519
DOI 10.1007/s00264-014-2607-4
In this study we prospectively compared the use of PO and
IE as initial and definitive management of post traumatic
extra-articular distal tibia fracture in adults.
Materials and methods
The cohort consisted of 40 consecutive patients treated by the
authors at Manchiet El-Bakry and El-Fayoum General Hos-
pitals between 2010 and 2011. Their data were collected
prospectively and the study was approved by the ethical
committee. There were 26 men and 14 women, with a mean
age of 28.6 years (range 20–40). Patients were immobilized in
an above knee back slab before surgery. The right leg was
affected in 28 patients and the left in 12. The injuries were
caused by a motor car accident in 20 patients, a motorcycle
accident in four, an automobile–pedestrian accident in 11 and
fall from a height in five. All patients were prepared pre-
operatively as poly-trauma patients to be sure that they were
vitally stable. Examination for abrasion, bruises, contusion,
laceration, neurovascular injury and radiological investigation
was done and classified according to AO classification frac-
ture type A (A1, A2, and A3). All patients were manual
Tabl e 1 Demographic data of the patients
Operative technique PO IE
Number of patients 20 20
Gender (M/F) 12/8 14/6
Mean age in years 32.6 32.8
Side (Rt/Lt) 14/6 16/4
Fracture type: number of patients A1: 8 (40 %) A1: 8 (40 %)
A2: 6 (30 %) A2: 6 (30 %)
A3: 6 (30 %) A3: 6 (30 %)
Time interval between trauma
and surgery in hours
Mean 58.6±13 Mean 72.4± 18
Follow-up duration in months 26± 10
a
b
c
d
e
Fig. 1 A 28-year-old male,
presented with A1 extra-articular
fracture left tibia and fibula
treated with Ilizarov external
fixation (IE). AAP and lateral
radiographs of post traumatic
fracture left leg bones. BAP and
lateral radiographs of
postoperative Ilizarov application
C. AP radiograph after Ilizarov
removal D. Lateral radiograph
after Ilizarov removal E.Clinical
photo during last follow up
514 International Orthopaedics (SICOT) (2015) 39:513–519
workers from El-Fayoum governorate (103 km south-east of
Cairo). PO cases were done in El-Fayoum General Hospital
while IE was done in Manchiet El-Bakry General Hospital in
Cairo (non-paid). The inclusion criteria were patients between
20 and 40 years old, with extra articular distal tibial fracture
which was: closed or open grade I (GI) according to Gustilo
and Anderson classification (GAC), and type “A”fracture
according to AO classification (Table 1).
All patients had pre-operative explanation of full details
about their condition, operative details and postoperative in-
structions. They had been consented to be included in this
study and to undergo either PO or IE in a randomized method.
Surgical technique
All surgeries were done under spinal anaesthesia. Pre-operative
parental antibiotics (first generation cephalosporin) were admin-
istrated one hour pre-operatively, and tourniquet used for the
group of PO. PO was performed using ORIF and DCP through
an anterolateral approach. We used Ilizarov frames of stainless
steel material, consisting of three rings only for all patients, with
1.8-mm k-wire and 3.5-mm Schanz. In six cases we added
calcaneal 5/8-ring. Reduction was possible in PO using ORIF.
In the IE group, we used manual traction or distraction techniques
or olive wires of IE itself or aided by percutaneous mobilization
using Steinmann pins, assisted by an image intensifier.
Postoperative instructions
For the PO group, non-weight bearing ambulation was permit-
ted on the second postoperative day, with hospital discharge in
a below knee back slab, removed temporarily in the first
two weeks to check the wound and forsuture removal, then
once daily for free mobilisation during the next two weeks,
finally it was removed completely if pain subsided with active
knee and ankle ROM. Because of low socioeconomics, post-
operative physiotherapy was done by patients themselves in the
form of active range of motion for knee and ankle joints. This
was done immediately in the IE group, and gradually after
suture removal in the PO group. Partial weight bearing was
permitted according to the progression in union criteria clini-
cally and radiologically. For the IE group, weight bearing
started as tolerated from the first postoperative day (Fig. 1).
Continuous pin-site care was performed by the patient himself
and checked regularly at every visit.
a
b
c
Fig. 2 A 30-year-old male presented with A1 extra-articular
fracture of the right tibia and fibula treated with conventional
plate osteosynthesis (PO). AAP and lateral radiograph of post
traumatic fracture of lower leg bones. BAP, oblique and lateral
radiographs of postoperative fracture fixation using conventional plating.
CAP, oblique and lateral radiographs at last follow up after 213 days and
results were good
Tabl e 2 Different
grades in Modified
Mazur Ankle Score
Result Score
Excellent 92
Good 87–92
Fair 65–87
Poor 65
International Orthopaedics (SICOT) (2015) 39:513–519 515
Post hospital discharge, the follow-up visit for both groups
was weekly in the first month, bimonthly in the second month,
monthly up to the sixth month and every three months till the
end of the follow-up period. Urgent calls and visits were
available if needed. In each visit, the patients were assessed
clinically, functionally, and radiographically for union, infec-
tion, deformity, leg-length discrepancy, knee and ankle ROM,
return to previous job, return to previous activity, sports prac-
tice, complications, and need for secondary procedures.
By the end of follow up, all clinical, functional and radio-
logical outcomes were compared between the immediate post-
operative and final visit. Radiographic union was considered
if mature callus bridging of at least three of four cortices on
two orthogonal [5] views and clinically if the patient had
painless full weight bearing.
Results
The time from trauma to surgery ranged from 45 to 71 hours
(mean 58.6 hours) for PO and from 54 to 90 hours (mean
72.4 hours) for IE. The main cause for the extended period before
surgery was financial support. The longer period for the IE group
was related to logistics for budget and transportation from El-
Fayoum to Cairo. Operative time ranged from 90 to 110 minutes
(average 85 minutes) for the PO group and from 120 to 180
minutes (average 140 minutes) for the IE group. No major intra-
operative complications were encountered. Hospital stay ranged
from one to three days (mean 1.3 days) in IE and from two to
five days (mean 3.4) in PO. The mean follow up was 26 months
(18–36 months). In the PO group, two cases developed superfi-
cial infection and two hardware failures. In both groups all
wounds healed smoothly without deep infection. Pin-site inflam-
mation was recorded in all cases of the IE group. Pin-site infection
was also common. It occurred in more than four sites in six
patients. All cases had been controlled via oral or parental first
generation cephalosporin with no deep infection. All fractures
united without any secondary procedures to achieve union, ex-
cept two metal failures in the PO group. Postoperative X-ray
revealed acceptable reduction, and the last follow-up X-rays
showed no indication for deformity correction. All patient had
PO progressed union in an average healing time of 196.5 days
(161–273) (Fig. 2) and 130 days for the IE (110–150) group. The
clinical evaluation was performed using the modified Mazur
ankle score [6], based on clinical examination of the injured
extremity and rated as excellent, good, poor and fair (Table 2).
Results were excellent in two cases, good in eight cases, fair in
four cases and poor in six cases of the PO group, while in the IE
group it was excellent in ten cases and good in ten cases (Table 3).
Statistical analysis
Data were statically analysed, whereby comparison of vari-
ables between the study groups was done using Mann–Whit-
ney test. For comparing the two groups, a probability value (p
value) less than 0.05 was considered statically significant. The
rate of healing in the IE group (average 130) was higher than
the PO (average 196.5) (Fig. 3.); plus, there were no cases of
delayed union or nonunion in the IE group (p value 0.003).
Discussion
A wide range of treatment modalities are indicated for man-
agement of extra-articular distal tibial fractures either by IMN,
PO or external fixation. Janssen et al. [7] compared the use of
PO and IMN in extra-articular distal tibial fractures. The
Tabl e 3 Results in IE
and PO groups Results IE PO
Excellent 10 2
Good 10 8
Fair –4
Poor –6
0
50
100
150
200
250
PO IE
time of union
fixation method
A1
A2
A3
Fig. 3 Healing time in both
conventional plate osteosynthesis
(PO) and Ilizarov external
fixation (IE) groups
516 International Orthopaedics (SICOT) (2015) 39:513–519
Tab l e 4 Literature table
Author /Year Region Journal Type of
fixation
Mean time of
union in weeks
Union rate % Mean
follow-up
in months
Outcome parameter
“scoring system”
Results of
scoring
systems
Site of fracture
PO IMN IE PO IMN IE PO IMN IE
Janssen et al.
[7],
2007
Netherlands Int Orthop 12 12 –19 21 83.3 75 –PO 54 IMN
69
Knee society score PO 146
IMN 139
Extra articular
distal tibia
Lee et al. [8],
2008
Taiwan Int Orthop –– 82 –– 17.25 ––96.3 12 Functional score of
Karlstrom and
Olerud
IE 33.65 Middle and distal
1/3 tibia
Brown et al.
[10],
1997
Scotland J Orthop
Trauma
–– 169 –– – – – –– Knee pain NA Tibial diaphysis
Keeting et al.
[11],
1997
Scotland J Orthop
Trauma
–– 11 –– – – – –31.2 Knee pain NA Tibial diaphysis
Vallier et al.
[14],
2008
USA J Orthop
Trauma
37 76 –– – – – 97.3 –24 –NA Extra articular
distal tibia
BACH
et al.[15],
1989
USA CORR 29 –30 –– – 82 –97 12 –NA Tibial diaphysis
Ristiniem et al.
[16], 2011
Finland J Orthop
Trauma
34 –33 21 23 –––36 Olerud-Molander
ankle score
PO 75 IE 74 Extra articular
distal tibia
Phisitkul et al.
[19], 2007
USA J Orthop
Trauma
37 ––12.8 –94.5 ––14 Knee society score PO 91 Complex proximal
tibia
Hosney &
Fadel
[20], 2003
Egypt Int Orthop –– 30 19 –––40.5 Grading system NA Tibial diaphysis
Current study Egypt Int Orthop 20 –20 28 –18.5 2 metal failure 100 26 Modified Mazur Ankle
Score
PO E 2,G 8 F 4, P 6 IE
E10,G10
Extra articular
distal tibia
NA not available, PO plate osteosythesis, IMN intra medullary nailing and IE ilizarov external fixator, EExcellent, GGood, FFair and PPoor
International Orthopaedics (SICOT) (2015) 39:513–519 517
average hospital stay was 9.5 days for PO and 9.8 days for
IMN, while in our study it was 3.5 days in PO and 1.3 days in
the IE group. Janssen reported that the average time for
radiological union was 133 days for PO and 147 days for
IMN. In our study, it was 196.5 days in PO and 130 days in IE.
Regarding time to weight bearing, it was after 3.8 and
3.3 months in PO and IMN, respectively. While in our IE
group weight bearing was as tolerated from the first day
postoperative, in the PO group it was after bone union
(6.5 months). Patients with IE were permitted to return to
work as early as possible, while those who underwent PO or
IMN had to wait for six months as reported by Janssen et al.
Lee et al. [8] reported a comparative study between locked and
unlocked IMN and had 6.1 % mal-union and recommended
that distal third fracture tibia treated with IMN showed a trend
of increased mal-union rate when compared to middle third
fractures (P=0.06). He also reported four cases on nail migra-
tion in the unlocked group and two cases had broken distal
locking screws in the locked group. At last follow-up there
was no indication for mal-union correction in both groups but
two cases of metal failure in the PO group that had been
treated by IE.
Major complications following IMN include infection,
compartment syndrome, venous thrombo-embolic events, fat
embolism syndrome, neurovascular damage and non-union
[9]. Brown et al. [10], in their study about knee pain after
IMN, showed that functional impairment was in 91.8 % of
patients experiencing pain on kneeling and 33.7 % having
pain even at rest. Keeting et al. [11] reported in his study about
IMN in tibial fracture that 80 % of patients required nail
removal. Chronic knee pain after IMN remains a troublesome
complication regardless of the surgical approach used, ranging
from 5 to 86 %. Removal of the nail failed to eliminate the
pain, which according to some persisted in as many as 69 % at
an average of 1.5 years [12]. We had no case with anterior
knee pain. Another operation is required for metal removal
either in the IM nailing or PO groups, while in IE removal of
theframehadbeendoneasanoutpatientprocedure.Plate
fixation is effective in stabilizing distal tibia fractures but
conventional techniques involve extensive dissection and
periosteal stripping, which increase the risk of soft tissue
complications [13]. No study has specifically evaluated the
clinical outcomes of conventional plating techniques in the
management of nonarticular distal tibia fractures [13], but
Va l l i e r e t al . [ 14] launched a retrospective comparative study
between PO and IMN for 111 patients with extra-articular
distal tibia fractures (76 were treated with IMN and 37 were
treated with PO). Osteomyelitis developed in 5.3 % treated by
IMN and 2.7 % after PO, 12 % had delayed union ornonunion
after IMN and 2.7 % had a nonunion after plating (P=0.10).
Bach et al. [15] compared the use of external fixator and plate
in 59 patients with distal tibia open fracture types II and III,
and there were 19 % of patients complicated by severe
osteomyelitis, and 11.5 % had plate fixation failure which
required an external fixator, while only one case of the exter-
nal fixator group reported osteomyelitis. We reported no deep
infection or osteomyelitis in both groups. Pin-site infection in
IE and two cases of superficial infection in the PO group was
successfully treated with local dressing, oral or parental first
generation cephalosporin. Ristiniemi et al. [16] reported a
retrospective comparative study between IMN and external
fixator in the distal tibial fracture. The healing time was 21 and
23 weeks in the IMN and external fixator groups, respectively
(P=0.53), while in our study the mean healing time was 18.5
and 28 weeks in IE and PO groups, respectively (P=
0.003). Conventional plating of distal tibial fractures has
been associated with high rates of infection and soft-
tissue complications requiring revision surgery [17,18];
however these outcomes have been attributed to the
extensile exposure and soft-tissue dissection required
with conventional AO plating techniques [13].
Some authors reported that the fracture closed to the
plafond is difficult to stabilize using IMN or PO. PO has
a higher complication rate, particularly infection, hardware
prominence, malalignment, and loss of alignment. Some of
the complications may reflect the techniques that were
used and should decrease with more experience; however,
some may be inherent in the treatment of high-energy
fractures using PO [19]. Bach et al. [15] recommended
that external fixators should be the primary method of
stabilization for Grades II and III open tibial shaft frac-
tures. Hosny and Fadel [20] treated 34 open tibial fracture
(GI, II & III) using IE. Twenty-eight patients graded as
excellent and good results, one fair, and one poor. They
recommended use of IE as initial and definitive treatment
for such fractures (Table 4).
We found that IE provides provisions of immediate weight-
bearing as tolerated following postoperative recovery, irre-
spective of radiological or clinical signs of healing with no
need for secondary surgical interference for management of
non-union, mal-union or infection. Consequently, the present
study as well as that of Phisitkul [19], Bach et al. [15], Hosny
and Fadel [20], we recommend further research in using IE in
different grade II and III open fracture tibia. According to the
results of this prospective randomized comparative study, we
found that use of IE is recommended over PO in management
of extra-articular distal tibial fracture.
Acknowledgments We would like to acknowledge the LRS.PD pro-
gram. Professional Diploma in Limb Reconstructive Surgery and Cor-
rection of Deformity (LRS.PD) is organized by the Arab Institute for
continuing professional development (AICPD) in association with the
Pan Arab Orthopaedic Association (PAOA) and scientific support of the
International Orthopedic Association (SICOT).
Conflict of interest There are no conflicts of interest associated with
this work.
518 International Orthopaedics (SICOT) (2015) 39:513–519
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