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.
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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)