In presenting his study on the value of damage-control plating, Manish K. Sethi, MD, first framed the economic impetus for evaluating an alternative to external fixation in temporizing open tibia fractures prior to intramedullary (IM) nailing. Noting that Medicare is bundling payments for selected services such as major joint arthroscopy, he said the federal government “intends to expand this system across all of orthopaedics.”
This payment trend, he told his colleagues during the 2014 annual meeting of the Orthopaedic Trauma Association, “puts the onus on us to find cheaper and equally effective solutions in the management of orthopaedic trauma.” Dr. Sethi and his colleagues at Vanderbilt University wanted to see if “in temporizing open tibia fractures with plating, can we reduce cost and maintain quality?”
Their retrospective case series of 31 patients with open tibia fractures who were treated first with either damage-control plating (n = 12) or external fixation (n = 19) prior to IM nailing found no significant difference in the complication rates for delayed union, nonunion, infection, reoperation, bone grafting, and amputation. The median implant cost of damage-control plating was $1,448 versus $4,062 for external fixation.
“We concluded that damage-control plating is a viable and less costly alternative to external fixation,” Dr. Sethi said.
External fixation evolves
Historically, external fixators were the definitive treatment for tibial shaft fractures. Studies then revealed a number of problems associated with prolonged external fixation while demonstrating the reliability of IM nailing in the treatment of these injuries. As surgeons transitioned from external fixators to IM nailing for definitive treatment of tibial shaft fractures, they began to use external fixators as a temporizing treatment in severe open tibial shaft fractures that were contaminated or had large soft-tissue defects.
“As damage-control orthopaedics was proving to be a useful surgical strategy in the management of the polytrauma patient, the use of temporizing external fixators increased as well,” Dr. Sethi said.
The advantages of an external fixator in this setting include the allowance of soft-tissue recovery, maintenance of stability in an unstable fracture pattern, and reliable and rapid application. Dr. Sethi noted, however, that these devices are not without flaws. “Significant cost, complications surrounding pin sites and their care, and difficulty in accommodating the device for patients and care providers are all drawbacks to this treatment,” he said.
He explained that in provisional plating of open tibia fractures, the surgeon uses a cortical plate to reduce and stabilize the fracture while the wound is still open (Fig. 1). “Following this reduction and fixation, you proceed to implant an IM nail as definitive treatment and remove the adjunctive plate once interlocking screws have been placed, thus setting the length and rotation of the bone,” said Dr. Sethi.
The study identified 445 patients who underwent surgical management of an open tibial shaft fracture from 2008 to 2012. A review of charts and radiographs identified the 31 patients who met the inclusion criteria by having received staged management with either a plate or external fixator prior to definitive treatment. Minimum length of follow-up for inclusion was 3 months. In all patients, the initial implant was removed at the time of definitive fixation. The time in place prior to definitive fixation was an average of 4.4 days for plating (range 1 to 13 days) and 6.5 days for external fixation (range 2 to 16 days).
Operative reports, clinical notes, and the patient’s charts were reviewed to identify complications such as additional soft-tissue or osseous procedures following definitive fixation, including the incidence of bone grafting. Radiographs were assessed for nonunion or delayed union.
The direct plating group had a total of three complications (25.0 percent)—one infection, one malunion/nonunion, and one hardware removal. The external fixation group had a total of five complications (26.3 percent)—two infections, two malunions, and one hardware removal. The difference was not significant (P > 0.99). However, the striking difference in cost between the two approaches was significant (P < 0.01).
Other advantages of plating?
The authors noted that plating “held a number of advantages over external fixation not highlighted in the data of this study.” Among these was the speed and ease of application of the damage-control plate in delayed fixation situations.
“Although the application of an external fixator is often used as a damage-control orthopaedic procedure, we found that the application of a plate through the traumatic open fracture proved to be an equally rapid and facile procedure,” they wrote. Finally, “having damage-control plating as an option in open fracture of the tibia becomes increasingly important in polytrauma patients who are, or become, unstable in the operating room and would benefit from a stabilizing procedure to their fracture.”
The damage-control plates were removed prior to definitive nailing in the study group, but it may be possible to leave them in place until definitive fixation is achieved.
Relating their experience, the authors responded: “Provided the surgeon attains a good quality reduction when performing the initial damage-control procedure, we have found that the plate can be left in place during the IM nailing of the tibia, aiding in the accurate reduction of the tibia and decreasing operative times associated with achieving adequate length and rotation. Following the definitive fixation of the tibia, the provisional plate can be removed and the traumatic open wound closed or left open for future soft-tissue procedures, depending on the condition of the soft tissues and size of the defect. Finally, it is our experience that some fractures of the tibia are not readily amenable to external fixation due to the severity of the injury (ie, segmental shaft fractures involving both the proximal and distal aspects of the tibia), and damage-control plating is an important adjunct to have available in situations where external fixation may prove to be challenging.”
Limitations of the study include its retrospective nature and small sample size. Dr. Sethi said a larger prospective study is warranted. In the meantime, the authors concluded, “Our study demonstrated equivalent damage-control plating clinical results and decreased implant-associated costs associated with plating when compared with external fixation. Additionally, our clinical experience has demonstrated a number of unique advantages to damage-control plating that makes it a valuable tool in the armamentarium of an orthopaedic trauma surgeon treating open tibial shaft fractures in the isolated or polytrauma population.”
Co-authors with Dr. Sethi are Aaron M. Perdue, MD; Arnold J. Silverberg, BS; Rachel V. Thakore, BS; Vasanth Sathiyakumer, BA; Daniel J. Stinner, MD; Hassan R. Mir, MD, MBA; David J. Polga, MD; and William T. Obremskey, MD, MPH.
Disclosure information: Dr. Stinner—OTA; Dr. Mir—Smith & Nephew, Journal of Orthopaedic Trauma, OTA/ OTA Newsletter, AAOS; Dr. Polga—Synthes; Dr. Obremskey—OTA, Southeastern Fracture Consortium. The other authors reported no conflicts.
Terry Stanton is a senior science writer for AAOS Now. He can be reached at firstname.lastname@example.org