1. Distal Tibia Fractures: Locking or Non-Locking Plate?
EOA Annual Meeting 2013
Miami Beach Florida
Nader Toossi, MD
Amrit S. Khalsa, MD
Loni P. Tabb, PhD
Nirav H. Amin, MD
Douglas L. Cerynik, MD

2. We have nothing to disclose
Disclosure
We have nothing to disclose

3. Background
There has been recent reports in the literature expressing concerns over increased rate of non-union and delayed union after locked plating.1
While some studies report no difference between locked and non-locked plating regarding these complications.2
Henderson et al. Locking plates for distal femur fractures: is there a problem with fracture healing? J Orthop Trauma 2011;25 Suppl 1:S8-14.
Newman et al.Distal metadiaphyseal tibial fractures. Injury 2011;42-10:

4. Background
So the controversies are still there, necessitating a new look into this issue.
Systematic review of the literature may help casting light on the problem.

5. Hypothesis
Treating distal tibia fractures by locked plating leads to less complications than non-locked plating.

6. Purpose
To compare the outcomes of locked plating versus non-locked plating in the fixation of distal tibia fractures.

7. Methods and Materials
Using PubMed, we identified articles up to June 2012 involving minimally invasive locked and non-locked plating of acute distal tibia fractures.

8. “locking plates” OR “locked plating” OR “plate fixation”
“minimally invasive” OR “MIPO” OR “MILPO”
Distal tibia fracture OR “Pilon fracture”

9. Inclusion Criteria
1) English language articles; 2) Studies with at least ten clinical cases involving patients with 18 years of age or older; 3) Open and closed fractures defined as a “distal” AO 42A-C and all AO 43A-C (based on AO classification of fractures).

10. Exclusion Criteria 1)Double plating application;
2) Biomechanical cadaveric or experimental studies;
3) Using a lateral approach for non-invasive plating of the distal tibia rather than a medial approach;
4) Non-specification of minimally-invasive osteosynthesis technique;
5) Non-specification of locked versus non-locked plating.

11. Flow Diagram of Search Process
Titles identified from PubMed search (n=539)
Excluded as irrelevant title (n=472)
Abstracts selected for abstract review ( n=67)
Excluded as not meeting inclusion criteria (n=38)
Articles selected for full-text review (n=29)
Excluded as not reporting enough data (n=2)
Studies included in the final analysis (n=27)

12. Total number of fractures in the pooled data: 764
Total number of fractures treated by locked plating:
499
Total number of fractures treated by non-locked plating:
265
17 Studies
11 Studies
Lau, 2008
Collinge, 2010
Ozkaya, 2009
Hazarika, 2006
Ronga, 2010
Gupta, 2010
Guo, 2010
Bahari, 2007
Ahmad, 2012
Shon, 2012
Leonard, 2009
Aksekili, 2012
Shrestha, 2011
Tong, 2012
Cheng, 2011
Ma, 2010
Salton, 2007
Borg, 2004
Oh, 2003
Helfet, 1997
Ozkaya, 2009
Pai, 2007
Krackhardt, 2005
Redfern, 2004
Maffulli, 2004
Khoury, 2002
Francois, 2004
Borens, 2009

13. Independent Variables

14. ♀ ♂ Studies Characteristics (Locking Studies) Author, Year
Number of cases (n)
Average age (years)
Number of females
Length of follow-up (months)
Number of intra-articular fractures
Number of open fractures
Locking studies
Lau, 2008 48 51 24 19 18 9
Collinge, 2010 38 50 13 32 12 8
Ozkaya, 2009 22 44 25
Hazarika, 2006 20
44.7 4
Ronga, 2010 43 34
Gupta, 2010 80
36.2 16
Guo, 2010 41
44.4 17
Bahari, 2007 42 35 11 27
Ahmad, 2012
43.5 7
Shon, 2012 52
Leonard, 2009 26 31 6 28
Aksekili, 2012 14
Shrestha, 2011 2
Tong, 2012 29
48.3
Cheng, 2011 15
39.8
Ma, 2010 53 21
Salton, 2007
43.3 ♀ ♂

15. Major Outcomes

16. Studies Characteristics (Locking Studies)
Author, Year
Non-unions
Delayed unions
Superficial infections
Deep infections
Implant failures
Re-operations
Bone graft applications
Wound healing difficulties
Mal-alignments
Implant removals
Locking studies
Lau, 2008 5 2 6 1 23
Collinge, 2010
Ozkaya, 2009
Hazarika, 2006 3
Ronga, 2010
Gupta, 2010 7 27
Guo, 2010 24
Bahari, 2007 4
Ahmad, 2012
Shon, 2012
Leonard, 2009
Aksekili, 2012
Shrestha, 2011 8
Tong, 2012 29
Cheng, 2011
Ma, 2010
Salton, 2007

17. Study-level quasibinomial regression was used on the pooled data across the included studies

18. Results

19. Average Age Distribution in Non-locked Group
Number of Fractures
Average Age Interval in Years

21. Non-locking Studies Fracture Types

22. Locking Studies Fracture Types

23. Implant removal 7% Infection 12% Malunion 2 % Delayed union 4%
Incidence
Implant removal 7%
Infection 12%
Malunion 2 %
Delayed union 4%
Non union 3%

24. Major Outcomes In Locking Plate Studies
Implant removal 21 %
Infection 6%
Malunion 2 %
Delayed union 6%
Non union 2%

25. Table 1. Quasibinomial Regression Results for the Effect of Locking Status on Various Outcomes (i.e. Model 1)
Outcome
Estimate
SE1
p-value2
OR3
LB4
UB6
Non-Union
-0.906
0.352
0.016
0.404
0.203
0.805
Delayed Union
0.437
0.476
0.367
1.548
0.610
3.933
Bone Grafting
-0.100
0.971
0.919
0.905
0.135
6.066
Superficial Infection
0.528
0.601
0.387
1.696
0.522
5.505
Deep Infection
0.023
0.575
0.968
1.023
0.332
3.156
Wound Healing Difficulty
0.811
0.842
0.345
2.249
0.432
11.716
Implant Failure
-0.320
0.621
0.611
0.726
0.215
2.454
Re-operation
-1.981
0.743
0.013
0.138
0.032
0.591
Malalignment
-2.390
0.409
0.000
0.092
0.041
0.204
Implant Removal
1.773
0.608
0.007
5.889
1.789
19.390
1SE = Standard Error; 2Estimates with p -values < 0.05 are in bold font; 3OR = Odds Ratio; 3LB = 95% Confidence Interval Lower Bound; 5UB = 95% Confidence Interval Upper Bound.

26. Table 2. Quasibinomial Regression Results for the Effect of Locking Status on Various Outcomes Adjusted for All of the Independent Variables (i.e. Model 2)
Outcome
Estimate
SE1
p-value2
OR3
LB4
UB6
Non-Union
-0.824
0.600
0.185
0.439
0.135
1.421
Delayed Union
0.384
0.581
0.516
1.468
0.470
4.589
Bone Graft
1.386
1.763
0.441
4.000
0.126
Superficial Infection
0.559
0.472
0.250
1.749
0.694
4.408
Deep Infection
1.080
1.156
0.361
2.946
0.306
28.401
Wound Healing Difficulty
0.627
0.842
0.465
1.872
0.359
9.759
Implant Failure
-0.031
0.601
0.959
0.969
0.299
3.147
Re-operation
-2.016
0.739
0.013
0.133
0.031
0.567
Malalignment
-2.287
0.727
0.005
0.102
0.024
0.422
Implant Removal
1.149
0.586
0.064
3.155
1.001
9.941
1SE = Standard Error; 2Estimates with p -values < 0.05 are in bold font; 3OR = Odds Ratio; 3LB = 95% Confidence Interval Lower Bound; 5UB = 95% Confidence Interval Upper Bound.

27. Limitations
Lack of standardization of complications and independent variables in the studies.
Comorbidities were not adjusted for either because they were not reported or underreported in the studies.

28. Conclusion
This study demonstrated that locked plating significantly reduced the odds of reoperation and malalignment after acute distal tibia fracture treatment compared to non-locked plating. Future studies are needed to determine the cost-benefit of such devices in light of reported outcomes in this era of budget-focused health care systems.

29. Thank you
Thank you
Hahnemann
University Hospital