High energy tibial plateau fractures treated with hybrid external fixation

Journal of Orthopaedic Surgery and Research, Jul 2011

Management of high energy intra-articular fractures of the proximal tibia, associated with marked soft-tissue trauma, can be challenging, requiring the combination of accurate reduction and minimal invasive techniques. The purpose of this study was to evaluate whether minimal intervention and hybrid external fixation of such fractures using the Orthofix system provide an acceptable treatment outcome with less complications. Between 2002 and 2006, 33 patients with a median ISS of 14.3 were admitted to our hospital, a level I trauma centre, with a bicondylar tibial plateau fracture. Five of them sustained an open fracture. All patients were treated with a hybrid external fixator. In 19 of them, minimal open reduction and stabilization, by means of cannulated screws, was performed. Mean follow-up was 27 months (range 24 to 36 months). Radiographic evidence of union was observed at 3.4 months (range 3 to 7 months). Time for union was different in patients with closed and grade I open fractures compared to patients with grade II and III open fractures. One non-union (septic) was observed (3.0%), requiring revision surgery. Pin track infection was observed in 3 patients (9.1%). Compared to previously reported series of conventional open reduction and internal fixation, hybrid external fixation with or without open reduction and minimal internal fixation with the Orthofix system, was associated with satisfactory clinical and radiographic results and limited complications.

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High energy tibial plateau fractures treated with hybrid external fixation

Journal of Orthopaedic Surgery and Research High energy tibial plateau fractures treated with hybrid external fixation George C Babis 3 Dimitrios S Evangelopoulos 0 2 Panagiotis Kontovazenitis 3 Konstantinos Nikolopoulos 1 Panagiotis N Soucacos 3 0 C' Orthopaedic Department, University of Athens, KAT Accidents' Hospital , Athens , Greece 1 Associate Professor, C' Orthopaedic Department, University of Athens, KAT Accidents' Hospital , Athens , Greece 2 C' Orthopaedic Department, University of Athens, KAT Accidents' Hospital , Athens , Greece 3 A' Orthopaedic Department University of Athens, Attikon University Hospital , Athens , Greece Management of high energy intra-articular fractures of the proximal tibia, associated with marked soft-tissue trauma, can be challenging, requiring the combination of accurate reduction and minimal invasive techniques. The purpose of this study was to evaluate whether minimal intervention and hybrid external fixation of such fractures using the Orthofix system provide an acceptable treatment outcome with less complications. Between 2002 and 2006, 33 patients with a median ISS of 14.3 were admitted to our hospital, a level I trauma centre, with a bicondylar tibial plateau fracture. Five of them sustained an open fracture. All patients were treated with a hybrid external fixator. In 19 of them, minimal open reduction and stabilization, by means of cannulated screws, was performed. Mean follow-up was 27 months (range 24 to 36 months). Radiographic evidence of union was observed at 3.4 months (range 3 to 7 months). Time for union was different in patients with closed and grade I open fractures compared to patients with grade II and III open fractures. One non-union (septic) was observed (3.0%), requiring revision surgery. Pin track infection was observed in 3 patients (9.1%). Compared to previously reported series of conventional open reduction and internal fixation, hybrid external fixation with or without open reduction and minimal internal fixation with the Orthofix system, was associated with satisfactory clinical and radiographic results and limited complications. - Introduction Intra-articular fractures of the proximal end of the tibia, the so-called plateau fractures, are serious, complex injuries difficult to treat [1]. The mechanism of injury is based on the presence of an initial axial load, which fractures the tibial articular surface resulting in impaction. In most of the cases the initial load is combined with angular forces, leading to comminution not only of the articular surface, but of the metaphysis as well. The medial compartment is split in a medio-lateral direction with a postero-medial main fragment, combined with various amounts of multifragmental lateral compartment depression [2]. According to Schatzkers classification [3,4], these fractures are divided into six groups: S-I to S-VI. Of these types, those involving both condyles (S-V) and those separating tibial metaphysis from diaphysis (S-VI) are the most challenging fractures for the Orthopaedic Surgeon to treat not only for the osseous damage but for the restoration of the soft tissue envelope as well. Standard radiographic imaging includes anteroposterior and lateral views. Suspicion of distal extension of the fracture mandates that full-length tibia and fibula x-rays should be obtained. The CT scan is becoming more and more useful in the evaluation of the size, comminution and orientation of the articular fragments, allowing proper classification and preoperative planning, thus facilitating reduction, especially for the less invasive techniques of treatment [5]. Over the years, many treatment modalities have been proposed for these complex fractures. All of them, from simple traction to demanding surgery, presented fair results but also serious complications. Traction, in terms of ligamentotaxis and casting, do not properly reduce the articular surface and lack the necessary stability, leading to unacceptable rate of varus/ valgus deformity, collapsed articular surface and postimmobilization stiffness [6-9]. On the other hand, open surgical procedures, despite their good reduction results, do not protect the already damaged soft-tissue envelope, leading to skin or muscle necrosis and to high rates of infection [10,11]. The use of a minimal invasive technique, an external fixator, in the treatment of S-V and S-VI fractures may provide fair reduction results without endangering the soft-tissue elements. Moreover, it facilitates the access to any endangered soft tissue elements requiring interventions along the treatment period. The addition of minimal internal fixation with cannulated screws and kwires prior to an external fixator application provides minimum soft tissue striping and greater fixation stability, allowing for early mobilization and greater range of motion [12-17]. The purpose of the current study was to test the hypothesis whether minimal intervention and hybrid external fixati (...truncated)


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George C Babis, Dimitrios S Evangelopoulos, Panagiotis Kontovazenitis, Konstantinos Nikolopoulos, Panagiotis N Soucacos. High energy tibial plateau fractures treated with hybrid external fixation, Journal of Orthopaedic Surgery and Research, 2011, pp. 35, 6, DOI: 10.1186/1749-799X-6-35