The Treatmen Of Distal Tibial Fractures With Posteromedial Plate And Bone-setting Manipulation: An Anatomical Research And Clinical Applied Study

Objective This anatomical research and clinical applied study explored the efficacy and safety of minimally invasive application of the posteromedial anatomical plate (PmAP) and bone-setting manipulation for distal tibial fractures with anterior soft tissue injury.Methods1. The simulated operation of minimally invasive plate osteosynthesis using PmAP was performed on six pairs frozen adult lower extremity specimens through posteromedial approach. The relationship between plate and posterior neurovascular structures was studied. And the degree of difficulty on operational field exposing was also evoluted. Postoperatively, the crura were dissected on there regions. Firstly, the posterior superficial zone of lower legs was anatomied to find out the relationship between the surgical incision and the GSV, SN. And the compression of postormedial skin created by PmAP was also observed. Secondly, for the posterior deep zone, the integrality and intensity of tibial nerve, posterior tibial vessels and the contact relation between the palte and neurovascular bundle were the important points we facoued on. Finally, the safe zone of anterior distal tibia was defined after the distance between the screws and anterior neurovascular bundle was measured.2. From September 2009 to May 2010, distal tibial fractures meeting the inclusion criteria were treated with PmAP and traditional chinese medicine bone-setting manipulation. After this operation, traditional chinese medicine dirigation was introduced to patients. The average postoperative follow-up was 15.4±2.7 (12-18) months. The operation time, intraoperative blood loss, fracture healing time, American Orthopedic Foot and Ankle Society (AOFAS) ankle score and complications such as infection, cutaneous necrosis, neurovascular damage were recorded for treatment effects evaluating.Results1. A simulated operation and cadaver study was performed on six pairs intact adult lower extremities. The operation was simple. And the operational field exposing was sufficient. There was no contact friction between the plate and neurovascular structures when the posterior tissues were drawn back. On the posterior superficial zone of crus, the dissection study found that the GSV, SN and surgical incision intersected at the point 7.37±1.65 (5.02-8.16) cm above the medial malleolus. And there was no posteromedial skin compression from the PmAP. The anatomy of posterior deep zone showed that no neurovascular damage, compression or entrapment by the plate was found. And there was even no direct contact between the inplant and neurovascular bundle. However, the interval in the area that below the plane 3.65±0.76 (2.84-4.48) cm above the angle surface was only consist of thin soft tissues. There was no anterior neurovascular damage caused by screws. And the average distance between the screw d and anterior neurovascular bundle was 4.92±1.97 (3.36-6.14) mm, which was the closest one.2. The average operation time was 72.5±10.8 (55-105) minutes with mean intraoperative blood loss volume of 86.4±17.3 (50-150) ml. All 26 patients had good postoperative fracture healing. The average healing time was 17.2±4.4 (13-30) weeks. No malunion, nonunion, limb shortening deformity or neurovascular injury occurred. Average AOFAS ankle score was 91.3±9.2 (68-99) points. Two cases had superficial wound infection and skin necrosis of the anterior portion of the distal leg. After wound care, antibiotic treatment and skin grafting, the wound healed by second intention. All the remaining incisions healed by first intention without infection, skin flap necrosis or plate exposure.Conclusion1. The anatomical study indicates that the MIPO application of PmAP for treatment of distal tibial fractures using a posteromedial approach is simple and safe. Both anterior and posterior neurovascular structures are no injured by this operation.2. The MIPO application of PmAP, traditional chinese medicine bone-setting manipulation and dirigation for the treatment of distal tibial fractures with anterior soft tissue injury are effective and have no severe complications.