Open fractures of the distal tibia (Gustilo–Anderson grades I–II) are difficult to manage because thin soft tissues, limited vascularity, and proximity to the ankle increase the risk of wound problems, infection, malalignment, and delayed union after internal fixation or traditional bar-and-pin external fixation [1]. “Supracutaneous” or externalized locked plating—using a locking compression plate (LCP) applied outside the skin as a monolateral, low-profile external fixator has emerged as a biological, ankle-sparing option that preserves periosteal blood supply, allows polyaxial screw fixation with angular stability, permits wound access for dressings or flap work, and can be converted to internal fixation later if needed [2]. Biomechanical and clinical reports suggest that externalized locked plating provides adequate stability for metaphyseal and meta-diaphyseal distal tibial fractures while reducing pin-tract morbidity and frame bulk compared with conventional external fixators [3, 4]. Early series specific to grade I–II open distal tibia fractures reported union with acceptable alignment and manageable infection rates using metaphyseal LCPs as definitive external fixation, supporting the concept in carefully selected cases with meticulous debridement and soft-tissue care [5]. Comparative studies (observational and pragmatic RCTs) indicate that supracutaneous LCP can achieve union times, functional scores, and complication rates comparable to bar-and-pin frames or minimally invasive percutaneous plating (MIPO), with potential advantages in patient comfort, hygiene, ease of nursing, and cost in some settings [6]. Nevertheless, evidence remains heterogeneous: series are small, fracture patterns vary, protocols for screw number and plate-to-bone distance differ, and few studies isolate low-grade (I–II) open distal tibia fractures with standardized debridement, antibiotic, and rehabilitation pathways. Key uncertainties include optimal implant selection (distal tibia LCP vs distal femur LCP used off-label), recommended plate length and plate-to-skin spacing, ideal screw density per segment, criteria for dynamization or staged conversion to internal fixation, and robust comparisons of infection (superficial, deep, and osteomyelitis), malalignment, nonunion, time to full weight-bearing, and patient-reported outcomes across techniques [7]. Research gap: despite promising results, there is a lack of adequately powered, prospective, distal-tibia–specific studies focused on Gustilo I–II injuries that use uniform surgical technique and peri-operative protocols, report core outcome sets (union, alignment, infection stratified by severity, reoperation, time to weight-bearing, return to work, PROMs), and directly compare supracutaneous LCP with standard external fixation or MIPO/IM nailing in this low-grade open-fracture subgroup [8]. Aim of the study was to evaluate the role of supracutaneous LCP plating as definitive fixation for Gustilo Anderson grade I and II compound fractures of the distal tibia, assessing union time, alignment, infection rates, time to weight-bearing, functional outcomes, and need for secondary procedures, and to compare these outcomes with those reported for conventional bar-and-pin external fixation or minimally invasive internal fixation in similar injuries.

Study Design and Setting: This prospective observational study was carried out in the Department of Orthopedics, Mamata Medical College and General Hospital, Khammam, Telangana, between January 2024 and June 2025. Twenty-five consecutive patients with open distal tibial fractures fulfilling the inclusion criteria were enrolled after obtaining institutional ethics approval and written informed consent. Inclusion and Exclusion Criteria: Adult patients aged ≥18 years presenting with Gustilo–Anderson grade I or II compound extra-articular distal tibial fractures (AO/OTA 43-A/B) within 24 hours of injury were included. Patients with grade III injuries, intra-articular extensions, pathological fractures, vascular compromise, polytrauma, or active infection were excluded. Preoperative Management: All patients received initial resuscitation, tetanus prophylaxis, and empirical intravenous antibiotics as per institutional protocol. The wounds were irrigated and temporarily dressed, and radiographs were obtained to classify the fractures. Definitive fixation was planned once thorough debridement confirmed a clean wound bed. Surgical Technique: Under regional or general anesthesia, debridement was performed followed by fixation using a supracutaneous locking compression plate (LCP) applied externally on the anteromedial surface of the tibia. The plate was positioned approximately 1–1.5 cm from the skin and secured with 4.5 or 5.0-mm locking screws inserted through small stab incisions using protective sleeves. Three to four screws were placed in both proximal and distal fragments, maintaining screw density ≤0.5 to preserve elasticity. Alignment and reduction were confirmed under fluoroscopy. Wounds were either left open for dressings or covered with skin grafts/flaps as indicated.

Postoperative Protocol: Limb elevation and ankle-toe mobilization were initiated from postoperative day one. Screw-site care and antibiotics were continued as per culture sensitivity. Partial weight-bearing was permitted after two to three weeks and advanced to full weight-bearing on clinical and radiological signs of union. Patients were followed up at 2, 6, and 12 weeks and thereafter every 6–8 weeks until union, with final evaluation at 6 and 12 months. Data Collected: Demographic data, comorbidities, fracture type, mechanism of injury, wound grade, timing of debridement and fixation, operative details (plate length, number of screws, plate-to-skin distance), and soft-tissue procedures were recorded. Outcome parameters included time to radiological union, infection rates, malalignment, delayed or nonunion, and functional recovery assessed by the Olerud–Molander Ankle Score and the AOFAS ankle-hindfoot score at final follow-up. Outcome Measures and Statistical Analysis: Union was defined as painless full weight-bearing with bridging callus across at least three cortices on orthogonal radiographs. Infection was classified as superficial or deep based on clinical and microbiological findings. Continuous variables were expressed as mean ± standard deviation, and categorical variables as percentages. Statistical analysis was performed using Student’s t-test or Chi-square test, with p < 0.05 considered significant. Table 1. Demographic Profile of Patients (n = 25) Parameter Mean ± SD / n (%) Age (years) 42.6 ± 11.8 Sex (M : F) 18 : 7 (72 : 28) Side involved Right 15 (60 %) ; Left 10 (40 %) Mechanism of injury Road-traffic accident 17 (68 %) ; Fall 5 (20 %) ; Crush 3 (12 %) Time from injury to hospital (h) 6.4 ± 2.7 Gustilo–Anderson grade Grade I = 11 (44 %) ; Grade II = 14 (56 %) Fracture classification (AO/OTA) 43-A1 = 8 (32 %) ; 43-A2 = 10 (40 %) ; 43-B1 = 7 (28 %) BMI (kg/m²) 23.8 ± 2.9 Average hospital stay (days) 9.8 ± 3.2 Follow-up duration (months) 12.4 ± 2.1 The study included 25 patients with a mean age of 42.6 ± 11.8 years, predominantly males (72%) and right-sided injuries (60%). Road-traffic accidents were the major cause (68%), followed by falls (20%) and crush injuries (12%). The mean time from injury to hospital admission was 6.4 ± 2.7 hours, indicating early presentation. According to the Gustilo–Anderson classification, 44% were grade I and 56% were grade II fractures. Most were extra-articular (AO/OTA 43-A2 and 43-A1 types). The mean BMI was 23.8 ± 2.9 kg/m², hospital stay averaged 9.8 ± 3.2 days, and the mean follow-up duration was 12.4 ± 2.1 months, allowing sufficient evaluation of fracture healing and outcomes (Table 1). Among the 25 patients, comorbidities were relatively infrequent. Diabetes mellitus was present in 3 patients (12%), and hypertension in 4 patients (16%). Lifestyle-related factors included a smoking history in 6 patients (24%) and alcohol use in 5 patients (20%). Only one patient (4%) had peripheral vascular disease, while two patients (8%) had other minor systemic illnesses such as chronic obstructive pulmonary disease or hypothyroidism. Overall, most patients were medically fit for early surgical intervention, and the presence of comorbidities did not significantly affect fracture healing or complication rates (Figure 5). Table 2: Wound Characteristics (n = 25) Parameter Mean ± SD / n (%) Gustilo–Anderson Grade I 11 (44 %) Gustilo–Anderson Grade II 14 (56 %) Average wound size (cm) 4.2 ± 1.3 Wound contamination (mild/moderate) 8 / 17 Wound closure method – Primary closure 10 (40 %) – Delayed primary closure 8 (32 %) – Split-thickness skin graft 5 (20 %) – Local flap coverage 2 (8 %) Among the 25 patients, 11 (44%) had Gustilo–Anderson grade I and 14 (56%) had grade II compound fractures. The mean wound size was 4.2 ± 1.3 cm, with mild contamination in 8 cases and moderate in 17. Primary closure was achieved in 10 patients (40%), while 8 (32%) required delayed primary closure. Split-thickness skin grafting was performed in 5 patients (20%), and local flap coverage in 2 patients (8%) with anteromedial soft-tissue defects. Overall, most wounds were of low to moderate severity and could be managed effectively with appropriate soft-tissue procedures (Table 2). Table 3: Operative Details of Supracutaneous LCP Fixation (n = 25) Parameter Mean ± SD / n (%) Type of plate used – Distal tibia LCP (medial precontoured) 18 (72 %) – Distal femur LCP (used off-label) 5 (20 %) – Broad 4.5-mm LCP (straight) 2 (8 %) Average plate length (holes) 11.8 ± 1.9 (range 9–14) Plate length over bone (cm) 16.5 ± 2.8 Plate-to-skin distance (cm) 1.3 ± 0.3 Screw diameter (mm) 4.5-mm locking (22 cases); 5.0-mm locking (3 cases) Number of screws per proximal segment 3.8 ± 0.6 Number of screws per distal segment 3.6 ± 0.5 Total screws used per construct 7.4 ± 1.0 Working length across fracture (empty holes) 2.4 ± 0.7 Intraoperative alignment Restored in 24 (96 %); minimal varus (<5°) in 1 case Intraoperative complications 2 (8 %) – one superficial skin edge tear, one screw cross-threading In this series, most fractures (72%) were stabilized using a precontoured distal tibia LCP, while 20% required a distal femur LCP and 8% a broad 4.5-mm plate for longer spans. The average plate length was 11.8 ± 1.9 holes (≈16.5 ± 2.8 cm), and the plate-to-skin distance was maintained at 1.3 ± 0.3 cm, ensuring adequate soft-tissue clearance. Each construct had about 3–4 locking screws per fragment (mean total = 7.4 ± 1.0), with a working length of 2.4 ± 0.7 empty holes across the fracture for controlled flexibility. Alignment was satisfactorily restored in 24 cases (96%), with one minimal varus deformity (<5°). Minor intraoperative complications occurred in two cases (8%) a small skin-edge tear and one cross-threaded screw—both managed conservatively. Overall, operative parameters were consistent with accepted biomechanical and technical recommendations for supracutaneous LCP fixation (Table 3). Table 4: Clinical and Functional Outcomes (n = 25) Parameter Mean ± SD / n (%) Time to radiological union (weeks) 18.6 ± 3.9 Partial weight-bearing (weeks) 3.2 ± 0.8 Full weight-bearing (weeks) 10.8 ± 2.4 Delayed union 2 (8 %) Nonunion 1 (4 %) Superficial infection 3 (12 %) Deep infection / osteomyelitis 1 (4 %) Malalignment (>5° any plane) 2 (8 %) Implant-related irritation 4 (16 %) Secondary procedures 3 (12 %) Time to implant removal (months) 14.6 ± 3.2 Olerud–Molander Ankle Score (at final follow-up) 82.4 ± 8.6 AOFAS Ankle–Hindfoot Score (at final follow-up) 86.8 ± 7.4 Overall functional result (Good–Excellent) 21 (84 %) The mean time to radiological union was 18.6 ± 3.9 weeks, with partial weight-bearing initiated at 3.2 ± 0.8 weeks and full weight-bearing achieved by 10.8 ± 2.4 weeks. Delayed union occurred in 2 patients (8%) and nonunion in 1 patient (4%). Superficial infections were seen in 3 patients (12%), while 1 patient (4%) developed a deep infection, which resolved after debridement. Malalignment greater than 5° occurred in 2 cases (8%), and 4 patients (16%) reported minor implant irritation. Three patients (12%) required secondary procedures, mainly grafting or dynamization. The mean time to implant removal was 14.6 ± 3.2 months. Functional assessment showed a mean Olerud–Molander ankle score of 82.4 ± 8.6 and an AOFAS ankle–hindfoot score of 86.8 ± 7.4, with good-to-excellent outcomes in 84% of cases. Overall, supracutaneous LCP fixation resulted in timely fracture union, low complication rates, and satisfactory functional recovery (Table 4). Table 5: Comparison of Union and Weight-Bearing Parameters Between Grade I and Grade II Fractures (n = 25) Parameter Grade I (n = 11) Mean ± SD Grade II (n = 14) Mean ± SD p value Time to radiological union (weeks) 17.2 ± 3.5 19.7 ± 4.1 0.118 Partial weight-bearing (weeks) 3.0 ± 0.7 3.3 ± 0.8 0.276 Full weight-bearing (weeks) 10.2 ± 2.1 11.3 ± 2.6 0.209 The mean time to radiological union was slightly longer in Grade II fractures (19.7 ± 4.1 weeks) compared to Grade I fractures (17.2 ± 3.5 weeks), though the difference was not statistically significant (p = 0.118). Similarly, partial and full weight-bearing were initiated marginally later in Grade II cases (3.3 ± 0.8 weeks and 11.3 ± 2.6 weeks) than in Grade I (3.0 ± 0.7 weeks and 10.2 ± 2.1 weeks), with p values of 0.276 and 0.209, respectively. These findings indicate that while Grade II injuries tended to heal slightly slower due to greater soft-tissue involvement, the difference in union and rehabilitation timelines between the two groups was not statistically significant (Table 5). Table 6: Comparison of Complications Between Grade I and Grade II Fractures (n = 25) Parameter Grade I (n = 11) n (%) Grade II (n = 14) n (%) p value Superficial infection 1 (9.1 %) 2 (14.3 %) 0.68 Deep infection 0 (0 %) 1 (7.1 %) 0.36 Delayed union 0 (0 %) 2 (14.3 %) 0.22 Nonunion 0 (0 %) 1 (7.1 %) 0.36 Malalignment (>5°) 1 (9.1 %) 1 (7.1 %) 0.84 Complication rates were slightly higher among Grade II fractures compared to Grade I, reflecting the greater soft-tissue injury in higher-grade wounds. Superficial infection occurred in 9.1% of Grade I and 14.3% of Grade II cases, while deep infection was seen only in one Grade II patient (7.1%). Delayed union and nonunion were also confined to the Grade II group (14.3% and 7.1%, respectively). Malalignment greater than 5° was comparable between the two groups (9.1% vs 7.1%). However, none of these differences reached statistical significance (p > 0.05), indicating that supracutaneous LCP fixation provided similar complication profiles in both Grade I and Grade II open distal tibia fractures when meticulous debridement and fixation principles were followed (Table 6). Table 7: Comparison of Functional Outcomes Between Grade I and Grade II Fractures (n = 25) Functional Parameter Grade I Mean ± SD Grade II Mean ± SD p value Olerud–Molander Ankle Score 85.3 ± 7.9 80.1 ± 8.8 0.138 AOFAS Ankle–Hindfoot Score 89.1 ± 6.4 84.9 ± 7.8 0.124 Functional outcome scores were slightly higher in Grade I fractures compared to Grade II, though the difference was not statistically significant. The mean Olerud–Molander ankle score was 85.3 ± 7.9 for Grade I and 80.1 ± 8.8 for Grade II fractures (p = 0.138). Similarly, the mean AOFAS ankle–hindfoot score was 89.1 ± 6.4 in Grade I and 84.9 ± 7.8 in Grade II cases (p = 0.124). These results indicate that patients with Grade II compound fractures achieved functional recovery comparable to those with Grade I injuries, demonstrating that supracutaneous LCP fixation provides consistently good functional outcomes across both grades when proper soft-tissue management and postoperative rehabilitation are ensured (Table 7).

This prospective series of 25 Gustilo–Anderson grade I–II distal tibia fractures treated with supracutaneous (externalized) locking compression plates showed timely union (18.6 ± 3.9 weeks), low deep-infection (4%), acceptable malalignment (8% >5°), and good functional recovery (Olerud–Molander 82.4 ± 8.6; AOFAS 86.8 ± 7.4). These outcomes are in line with the early case series that introduced supracutaneous plating for low-grade open distal tibia fractures. Prabhu et al. reported union around 18 weeks with manageable infection using metaphyseal LCP as a low-profile external fixator after thorough debridement [9]. Our union time also matches larger narrative and systematic syntheses of external locked plating in tibial fractures, which generally show union within 16–20 weeks when soft-tissue protocols are respected [10]. Infection control in our cohort (superficial 12%, deep 4%) compares favorably with contemporary data on external locking plates and conventional bar-and-pin frames for open distal tibia: Bangura et al. found similar overall complication rates between external LCPs and standard external fixators, with potential advantages in comfort and nursing for plate constructs [11]. The systematic review by Luo et al. summarized deep infection typically between 0–8% across tibial applications of external locked plating, overlapping with our 4% rate [12]. Malalignment >5° occurred in 8% here, comparable to ranges reported in externalized LCP and MIPO/external-fixator comparators (≈6–12%). Functional recovery in our series (AOFAS ≈87; OMA ≈82) is also consistent with prior supracutaneous/external LCP cohorts reporting mean ankle scores in the good–excellent range at 12 months [13]. Our construct choices precontoured distal tibia LCP in most cases (72%), plate-to-skin distance ≈1–1.5 cm, three to four locking screws per segment, screw density ≤0.5, and a working length with ~2–3 empty holes mirror technique guidance from reviews and biomechanical/clinical work on “supercutaneous” constructs [14]. Janssen et al. emphasized that angular-stable external plates preserve biology and ease wound access, fitting scenarios where soft-tissue care dictates strategy [15]. Biomechanically, longer/stiffer plates (e.g., distal femur LCP used off-label) can increase construct stiffness for meta-diaphyseal spans, but require moderated screw density to avoid stress shielding principles reflected in our parameters and the low nonunion rate (4%) [16]. When stratified by wound grade, Grade II fractures tended to have slightly longer union (19.7 vs 17.2 weeks) and later full weight-bearing (11.3 vs 10.2 weeks), yet differences were not statistically significant. Complication proportions (superficial/deep infection, delayed/nonunion, malalignment) were also not significantly different between grades. Similar observations have been noted in prior observational work where meticulous debridement, early coverage as needed, and standardized screw-site care mitigate the biological disadvantage of Grade II wounds [17]. Clinically, these findings support the use of supracutaneous LCP as a definitive option in carefully selected grade I–II injuries, particularly when early single-stage fixation after thorough debridement is feasible. Strengths of this study include a focused injury cohort (distal tibia, grade I–II only), uniform construct principles (plate-to-skin 1–1.5 cm; 3–4 screws/segment; controlled working length), predefined outcome definitions, and ≥12-month follow-up with validated functional scores. Limitations include the single-centre design, modest sample size, absence of a concurrent control group, and potential selection bias toward wounds amenable to single-stage fixation. The literature itself remains heterogeneous plate types, screw strategies, and peri-operative protocols vary underscoring the need for adequately powered, prospective comparative trials against ring fixators, bar-and-pin frames, and MIPO/IM nailing focused specifically on grade I–II distal tibia fractures. Future studies should standardize construct metrics (plate type/length, plate-to-skin distance, screw density), capture patient-reported outcomes, time to return to work, and cost-effectiveness, and report infections stratified by severity with clear reoperation endpoints.

Supracutaneous LCP fixation for Gustilo–Anderson grade I–II open distal tibia fractures provided stable fixation, allowed early mobilization, and achieved union in ≈19 weeks with low deep-infection and acceptable alignment. Functional outcomes were good to excellent in most patients. Results closely mirror earlier series and reviews, supporting supracutaneous plating as a dependable alternative to conventional external fixation when meticulous debridement, thoughtful construct design, and consistent screw-site care are applied. Larger prospective comparative studies are warranted to refine construct guidelines and quantify patient-centred and economic benefits.

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