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A Retrospective Analysis Of Distal Tibia Aseptic Nonunions: Locking Compression Plate (LCP) Versus Unilateral External Fixator (UEF)


Department of Orthopedic Surgery,SuZhou,China.

Address for Correspondence:
Department of Orthopedic Surgery,
The First Affiliated Hospital of SooChow University,
No. 188 Shizi Street , SuZhou 215006 ,China.

Phone : +86 512 67780111
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+86 512 67780999
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Aseptic nonunions in distal tibia are particularly challenging due to the short distal segment and fragile nature of the local soft-tissue envelope, particularly after type-and type-tibia open fractures. Although many internal-fixation options have been described for the treatment of distal tibia nonunions after open fractures, these were firstly preferred to manage with external fixators. We have attempted to compare a subset of distal tibia nonunions after tibia open fractures treated by Locking Compression Plates or Unilateral External Fixators. From February 2007 to February 2010, we retrospectively reviewed 37 patients (30 men and 7 women) with aseptic nonunions in distal tibia treated by Locking Compression Plates (n=15) and Unilateral External Fixators(n=22). Iliac crest autogenous bone grafting was performed in all patients during the internal or external fixation. The outcome measures included the rates of union, time to union, malunion, lasting nonunion, infection and scores of AOFAS. Although the LCP group had a longer time to union, it got a higher union rate, lower complications and better foot and ankle functions. These differences excepting the scores of AOFAS were showed statistically significant by SAS V8.1 Software (P=0.0107<0.05). Thus, based on our limited study, LCP can be performed as the excellent inter-fixator in distal tibia aseptic nonunions for higher union rates and lower complications. Future larger number of samples and prospective randomized trials are required to analysis the advantages and disadvantages of this inter-fixator in the treatment for these challenging nonunions.

J.Orthopaedics 2010;7(4)e11


Aseptic Nonunion; Distal Tibia; Locking Compression plate; Unilateral External Fixator; Iliac Crest Autogenous Bone Grafting


The incidence of nonunions for tibia is higher than other long bone fractures. Nonunions for type-and type- open tibia fractures was reported as 14% by Edwards and Jaworski1. Presenting factors that have been reported to contribute to nonunions include fracture displacement, bone loss, associated soft-tissue injuries and infection. The nonunion rates for distal tibia fractures were reported as 17%2. Nonunions in distal tibia are particularly challenging due to the short distal segment and fragile nature of the local soft-tissue envelope, particularly after prior surgery. Before the introduction of the inter-fixation for distal tibia open fractues, these nonunions were preferred to manage with external fixation. This technique gained widespread acceptance because of the ease appliance and minimal obstruction to soft tissue. However, several studies have demonstrated this preferable management with high rates of pin loosening, malunion and lasting nonunion3,4,5. Although Locking Compression Plates with minimal invasion and stable internal fixation have been widely used in clinic for long bone fractures and nonunions, few paper reported their efficacy for distal tibia nonunions. We made a small sample study to compare the treatment of Locking Compression Plate with Unilateral External Fixator for distal tibia nonunions in our orthopedic center from February 2007 to February 2010.

Materials and Methods:

We retrospectively reviewed 37patients with distal tibia aseptic nonunions treated in our orthopedic center over a 3-year period. Nonunion has been defined by the United States Food and Drug Administration as a fracture that occurred a minimum of nine months previously and has not shown radiographic signs of progression toward healing for three consecutive months6. Diagnosis for nonunion was made based on clinical examination that included local tenderness or false motion, and plain radiographs in all patients. The infection nonunions and bone defect more than 2cm were not included in this series. There were 30 men and 7 women, with an average age of 43.02years (range19-74years). All initial fractures were open. These were classified according to Gustilo and Anderson as type , type , type A, type B and typeC .The nonunion time was 9 to 27.5 months, with a mean time of 18.07 months. 4 patients had hypertrophic, and 33 patients had atrophic nonunions according to the criteria of Weber and Cech7 . 15 nonunions were treated with Locking Compression Plates and the others were treated with Unilateral External Fixators. These two groups were eventually matched in terms of age, nonunion time, nonunion types, open fracture types, fracture classifications and soft-tissue treatments.  (Details in Table 1) .

External fixators were removed 2weeks before and internal fixations were removed by small incision during the nonunion operation in the LCP group. Iliac crest autogenous bone grafting was performed in two groups during the fixation. Postoperatively, patients were allowed to move the ankles with no weight bearing. All patients remained non-weight bearing for the first 4 to 6 weeks. Partial weight bearing in two groups then started, provided that radiographs showed some evidence of callus formation. Full weight bearing was allowed when adequate bridging callus was visible on radiographs. Clinic and radiographic examinations were scheduled regularly at 4 weeks, and 3, 6, 9and 12 months after surgery till to bony union. Union was defined as bridging callus crossing three of four cortices on orthogonal radiographs with no pain on palpation over the fracture site or when weight bearing. Time to bony union union ratescomplications and sores of AOFAS were recorded.

Statistical analysis was performed by SAS V8.1 Software. The normality test, T test or Wilcoxon Two-Sample test were used where appropriate. A P value of less than 0.05(0.1 for normality) was considered statistically significant. We made statistical analysis of the two sample distributions in terms of agenonunion typesnonunion timeopen fracture types and fracture classifications. No statistical significant differences were found in the constitution of the two groups (p>0.05 Table1).

Results :

Average time of follow-up was 10months (range 6-32 months).There were significant differences in the treatment outcomes of union rates time to union and complications including malunioninfection and lasting nonunion in two groups. The LCP group had a higher union rate and lower complications (p=0.0107<0.05) but a longer time to bony union(P=0.0235<0.05). Though the mean scores of AOFAS in LCP group were better than that in UEF group, there was no statistically significance between the two groups (p =0.2620>0.05). (Table2)

Discussion :

Many factors have been associated with nonunions. Most are related to the initial injury. There is a direct correlation between the nature of the injury and the likelihood of nonunions. The prevalence of distal tibia nonunions increases with the severity of open fractures. The endosteal and periosteal blood supply is often extensively destroyed when the open fracture occurs in the distal one-third of the tibia, which are regarded as the most important to the healing of a tibia fracture8.

Nonunions are classified according to their radiographic appearance as hypertrophic, oligotrophic, or atrophic as defined by LaVelle6. Hypertrophic nonunions have abundant callus. This indicates an adequate blood supply but a lack of sufficient mechanical stability for completion of fracture-healing. Oligotrophic nonunions have little callus but still have an adequate blood supply. These nonunions are typically due to inadequate reduction with little or no contact between the fracture surfaces. Atrophic nonunions have no or little callus and have resorption of the bone. Most distal tibia nonunions after open fractures are inclined to be atrophic nonunions due to deficient biologic processes with sever soft tissue injuries.

Failure to inadequately mobilize the fractures are also known to increase the prevalence of nonunion and delay the time to union9.Successful management of a nonunion often depends on appropriate reduction and realignment of the fracture, bone grafting, and stabilization. Three main methods of fixation are used for the distal tibia nonunions: intra-medullary nailing, plate fixation or external fixation. The literatures supporting the successful using of each method have been published. External fixation was considered for definitive fixation of type-II and type-III open fractures or for patients with compromised soft tissue10. Experimental and clinical studies have shown unilateral external fixators some advantages, which provides free wound access and allows stabilization of bone fragments at a distance from the lesion. However, there is a significant risk of complications from pin tract infection, pin loosening, malunion and lasting nonunion. Locked intramedullary nailing also has been used in this type of reconstruction. This may be technically difficult when the intramedullary canal was closed in a atrophic nonunion. It is also difficult to obtain adequate segment in the distal fragment with the interlocking screws due to its small size and osteopenia 11. Use of compression plates for the treatment of closed tibia nonunions has been advocated by Muller and Thomas12,13. Success rates with compression plates alone have been reported to be high in the treatment of hypertrophic nonunions, and supplementary bone-grafting was suggested for atrophic nonunions.

Since the introduction of the LCP in 2001, various papers have dealt with clinical results obtained with this osteosynthesis system. In Martyn Snow’s14 study, the LCP was more stable than the DCP. Many researches have reported the successful treatment of distal tibia fracture using LCP with MIPPO technology. In 2004, Ring D15 reported the good results of LCP for the treatment of the humerus osteoporotic nonunons.

All above support the possibility of using LCP for distal tibia nonunions. We made a comparative study between LCP and UEF with iliac crest autogenous bone grafting for distal tibia nonunions and we found some statistical significance in terms of union rates, time to union and complications between two groups. There has been some controversy concerning the role of internal fixation following previous external fixation. Because of the risk of infection, we also do not recommend insertion of plates regardless of the condition of the soft tissue. After removal of external fixation with no infection and good soft tissue covering, LCP can be performed with a low risk. The limitation of this study is that this is a comparative study with relatively small number of study groups. A large number of samples and prospective randomized trials are required for further confirming the advantages of LCP in the treatment of distal tibia nonunion.


We recommend LCP with iliac crest autogenous bone grafting for the high union rates and lower complications for distal tibia nonunions in which there was no any infection.


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This is a peer reviewed paper 

Please cite as: HuiLin-Yang: A Retrospective Analysis Of Distal Tibia Aseptic Nonunions: Locking Compression Plate (LCP) Versus Unilateral External Fixator (UEF).

J.Orthopaedics 2010;7(4)e11





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