A meta-analysis of external fixation versus open reduction and internal fixation for complex tibial plateau fractures

Periprosthetic fractures of the tibia in knee arthroplasty have a high risk of treatment failure: A systematic review

PURPOSE

Tibial periprosthetic fractures (PPF) are rare but potentially devastating complications following knee arthroplasty. Despite the increasing number of knee replacements worldwide, there is limited data in the literature regarding these injuries. This systematic review aimed to add up-to-date, evidence-based data on tibial PPF that may lead to a more standardised approach and improved outcomes.

METHODS

A systematic search of PubMed, Virtual Health Library and Cochrane Library databases was performed in accordance with PRISMA guidelines, including studies published from January 2015 to January 2025. Studies were eligible if they reported tibial PPF in knee arthroplasty with at least three patients, describing the treatment approach and follow-up. Data extracted included patient demographics, fracture classification, treatment method, outcomes and methodological quality.

RESULTS

Seventeen studies met the inclusion criteria, including 473 patients with a mean age of 67.6 ± 2.5 years. Felix classification was used for 172 patients, Type 3 being the most common (48%). Overall union rate was 87%. While 29% of fractures were managed conservatively, 71% underwent operative management, with open reduction and internal fixation (ORIF) being the most common at 55%. The complication rate was 38%, with infection being the most common standing at 13%. The secondary intervention rate was 28%, most commonly due to failure of initial management and soft-tissue-related complications.

CONCLUSION

Tibial PPF is a rare but demanding complication of knee arthroplasty, associated with high complication (38%) and reoperation (28%) rates. Optimisation of surgical techniques is crucial to prevent iatrogenic fractures. Provided that the implant is stable, fracture fixation is effective following the appropriate principles depending on the personality of the fracture. Revision TKA may also be effective as a first-line option. Considering the scarce evidence in the literature and the high volume of worldwide knee arthroplasties performed, further high-quality studies are crucial to improve outcomes.

LEVEL OF EVIDENCE

Level IV.

External fixators in austere environments under surge capacity conditions: A systematic review

BACKGROUND

High-energy trauma causing open fractures can take place in low-resource settings ("austere" environment) and mainly affects the lower limbs. In these environments, external fixators often provide definitive surgical treatment. This systematic review identifies those external fixators for use on lower limbs as a definitive treatment that are most clinically effective in the austere environment.

METHODS

Multiple databases were searched to identify studies investigating outcomes of external fixators used in austere environments. Case reports were excluded. Hand searching and expert input identified additional references.

FINDINGS

33 publications met the inclusion criteria. These were used worldwide. Commercially available fixators were used in 18 publications, and non-commercial ones including Balkan-designed devices in 6. The remaining non-commercial devices had 1 or 2 publications each. Union rates, where reported, varied from 47 to 100 % with no discernible difference between devices or location of use. Clinical complications varied from infection (0-79 %) through to nonunion and delayed union (0-22 %), loosening (0-36 %), osteomyelitis (0-19 %), construct stability (27-100 %), and amputation (0-50 %).

INTERPRETATION

The variability in union and complication rates highlights the variability in severity of injuries, type of austere environment, and variability in fixator device efficacy. The non-commercial or "one-off" devices show promise, with comparable or better outcomes to the commercial devices, whereas others did not work well, with poor outcomes. The need for surge capacity availability in these austere environments would enable locally manufactured devices to be quickly made which are fit for purpose, yet regulation and quality control of these remains a challenge in their rollout.

Comparative finite element analysis between three surgical techniques for the treatment of type VI schatzker tibial plateau fractures

Introduction. Open reduction internal fixation (ORIF) and external fixation are traditional surgical techniques for treating type VI Schatzker tibial plateau fractures. A newly developed technique integrates the intramedullary tibial nail with condylar bolts. This finite element study investigated the mechanical response of three surgical techniques for fixing type VI Schatzker tibial plateau fractures. We compared the intramedullary nail-bolt (IMNB) technique with the single lateral locking plate (SLLP) and dual plating (DP) techniques.Materials and Methods. A 4th generation Sawbone model of a left tibia with a Type VI tibial plateau fracture was scanned using computed tomography and reconstructed into a 3D model. The plates were digitally reconstructed using 3D scanning technology, while the screws, condylar bolt, and nail were replicated using commercial computer-aided design software. An application engineer guided by a surgeon, virtually positioned the bone-implant construct for the three surgical techniques to align with physical constructs from a previousin-vitrobiomechanical study. A commercial finite element analysis software was used for the computer simulation, with the tibial plateau subjected to uniaxial loads at 500, 1000, and 1500 Newton while the distal tip of the tibia remained fixed. Measurements of vertical subsidence, horizontal diastasis, and passive construct stiffness were recorded and compared to those of the previousin-vitrobiomechanical experiment.Results.DP had the highest stiffness, followed by IMNB and SLLP techniques. DP also resulted in smaller values for measured subsidence and diastasis compared to SLLP and IMNB. The simulation results aligned with those of thein-vitrobiomechanical study.Conclusions.The simulation results may further support the initial suggestion of thein-vitrobiomechanical study that the IMNB technique is a biomechanically suitable method for fixing Type VI Schatzker injuries.

A Biomechanical Comparison Study of Plate-Nail and Dual-Plate Fixation in AO/OTA 41-C2 Tibial Plateau Fractures

BACKGROUND CONTEXT

This study's purpose was to evaluate the biomechanical performance of plate-nail and dual-plate fixation for the treatment of AO/OTA 41-C2 tibial plateau fractures.

METHODS

Twenty synthetic tibias were selected and randomly divided into a plate-nail group (n = 10) and a dual-plate group (n = 10). After the artificial tibias were osteotomized to simulate AO/OTA 41-C2 tibial plateau fractures in both groups, the plate-nail and the dual-plate methods, respectively, were used for fixation, and then axial compression loading, three-point bending, torsion, and axial failure tests were carried out. The data of each group were recorded and statistically analyzed.

RESULTS

In the axial compression test, the average stiffness of the plate-nail group was higher than that of the dual-plate group (p < 0.05). The displacement generated in the plate-nail group was significantly smaller than that in the dual-plate group (p < 0.05). In the resisting varus test, the stress of the plate-nail group was significantly higher than that of the dual-plate group (p < 0.05). In the resisting valgus test, the stress of the plate-nail group was slightly higher than that of the dual-plate group, but the difference was not statistically significant (p > 0.05). In the static torsion test, the load applied to the plate-nail group was smaller than that of the dual-plate group when rotated to 5° (p < 0.05). In the axial compression failure test, the average ultimate load of the plate-nail group was significantly higher than that of the dual-plate group (p < 0.05).

CONCLUSION

The treatment of AO/OTA 41-C2 tibial plateau fractures with plate-nail fixation is superior to that with dual-plate fixation in resisting axial stress and preventing tibial varus deformity, while dual-plate fixation has better resisting torsional ability.

Treatment of complex limb fractures with 3D printing technology combined with personalized plates: a retrospective study of case series and literature review

BACKGROUND

In recent years, 3D printing technology has made significant strides in the medical field. With the advancement of orthopedics, there is an increasing pursuit of high surgical quality and optimal functional recovery. 3D printing enables the creation of precise physical models of fractures, and customized personalized steel plates can better realign and more comprehensively and securely fix fractures. These technologies improve preoperative diagnosis, simulation, and planning for complex limb fractures, providing patients with better treatment options.

PATIENTS AND METHODS

Five typical cases were selected from a pool of numerous patients treated with 3D printing technology combined with personalized custom steel plates at our hospital. These cases were chosen to demonstrate the entire process of printing 3D models and customizing individualized steel plates, including details of the patients' surgeries and treatment procedures. Literature reviews were conducted, with a focus on highlighting the application of 3D printing technology combined with personalized custom steel plates in the treatment of complex limb fractures.

RESULTS

3D printing technology can produce accurate physical models of fractures, and personalized custom plates can achieve better fracture realignment and more comprehensive and robust fixation. These technologies provide patients with better treatment options.

CONCLUSION

The use of 3D printing models and personalized custom steel plates can improve preoperative diagnosis, simulation, and planning for complex limb fractures, realizing personalized medicine. This approach helps reduce surgical time, minimize trauma, enhance treatment outcomes, and improve patient functional recovery.

Acute versus staged fixation of bicondylar tibial plateau fractures: a dual centre international study

BACKGROUND

Bicondylar tibial plateau fractures pose many treatment challenges due to their complex fracture patterns and associated soft tissue compromise. We aim to evaluate outcomes of acute ORIF (aORIF) versus staged ORIF (sORIF) of high energy bicondylar tibial plateau fractures.

METHODS

We retrospectively reviewed 186 patients at two high-volume Level I trauma centers. One hundred one patients underwent aORIF and 85 underwent sORIF between 2011 and 2019. Clinical outcomes of interest included operative time, wound dehiscence, superficial and deep infection, nonunion, flap coverage, arthrodesis, and early conversion to arthroplasty.

RESULTS

Patients had a median follow up of 12 months (6-98 months). The sORIF group had a higher ISS (p = 0.02) and a higher rate of open fractures (24.7% vs 11.9%, p = 0.03). The groups were statistically similar in other demographics and co-morbidities. Operative time was significantly shorter in the aORIF group (157 vs 213 min., p < 0.001). There was no statistical difference in wound dehiscence, deep infection, flap coverage, nonunion, unplanned reoperation, or post-traumatic arthritis between groups. However, aORIF was associated with a significantly lower rate of superficial infection (p = 0.01), arthroplasty (p = 0.003) and unplanned reoperation (p = 0.005). Subgroup analysis of only the 41C3 fractures showed a lower rate of superficial infections in the aORIF group (p = 0.04). No difference in complications was found between the fracture subgroups.

CONCLUSION

We found no increased risk of complications with aORIF compared to sORIF for bicondylar tibial plateau fractures. While not all injuries may be appropriate for aORIF, our results demonstrate the safety of aORIF when patients are properly selected by experienced fracture surgeons.

LEVEL OF EVIDENCE

Level III.

Treatment of Tibial Plateau Fractures with a Circular External Fixator: A Comparative Analysis of Two Assembly Methods

Objective  To compare the functional outcomes of two circular external fixation techniques to treat complex fractures of the proximal end of the tibia. Materials and Methods  The present is a retrospective cohort study with 51 patients who underwent surgical treatment for complex fractures of the tibial plateau with a circular external fixator. There were two groups of patients: 12 subjects underwent treatment with the classic assembly technique, and 39 subjects underwent treatment with the simplified technique. The variables analyzed included age, sex, injury mechanism, trauma energy, associated injuries, fixator type, time of fixator use, and clinical-radiographic outcomes. The classic technique mainly uses transfixing Kirschner wires, while the simplified one replaces the Kirschner wires with Schanz pins in the distal block of the circular external fixator. Result  There were no statistically significant differences ( p  > 0.05) between the two groups concerning the clinical-radiographic outcomes, including fracture consolidation, quality of joint fracture reduction, range of motion, lower limbs residual discrepancy, and postoperative pain. Conclusion  We suggest that the simplified technique, using Schanz pins instead of Kirschner wires, can be a viable and effective alternative to treat complex fractures of the proximal end of the tibia with a circular external fixator. This simplified approach can offer benefits, such as a lower infection rate and greater patient comfort, without compromising clinical and radiographic outcomes, thus justifying its use.

Fixação externa do anel de Ilizarov para fraturas complexas do platô tibial

Objetivo Analisar os resultados clínicos, radiológicos e funcionais da fratura do planalto tibial (Schatzker Tipo V, VI) tratada com fixador externo do anel Illizarov com ou sem abertura mínima.

Métodos Um total de 52 fraturas do planalto tibial dos tipos V e VI foram tratadas com fixador externo do anel Ilizarov com ou sem fixação interna mínima. A avaliação do desfecho funcional foi feita utilizando-se o escore da American Knee Society (AKS, na sigla em inglês) com consolidação clínica, radiológica e complicações encontradas.

Resultados Foram 37 (71,15%) pacientes do sexo masculino e 15 (28,84%) do sexo feminino, com idade média de 39,07 ± 12,58 anos. Acidentes de trânsito (ATs) foram a principal causa das fraturas, contabilizando 32 casos (61,53%), seguidos por lesão por queda, com 16 casos (30,76%), e impacto direto, com 4 casos (7,69%). Foram 21 (40,38%) casos de fraturas tipo V, 31 (59,61%) casos do tipo VI e 24 (46,15%) casos de fratura exposta. Os escores médios da AKS para as fraturas tipo V e VI foram de 82,8 e 80,70, respectivamente, mas não foi estatisticamente significativo em p <0,05. O escore médio da AKS para fraturas fechadas e abertas também não foi estatisticamente significativo em p <0,05.

Conclusões Para a fratura do planalto tibial complexa dos tipos V e VI de Schatzker, a fixação externa de Ilizarov é um método de tratamento seguro, econômico e eficiente que resulta em resultados satisfatórios.

A Meta-analysis Comparing External Fixation against Open Reduction and Internal Fixation for the Management of Tibial Plateau Fractures

Aim

This article aims to compare the outcomes between open reduction and internal fixation (ORIF) and external fixation (ExFix) in tibial plateau fractures.

Background

Open reduction and internal fixation and external fixation are common methods for managing tibial plateau fractures without a consensus of choice.

Materials and methods

PubMed, Cochrane Library, Ovid, CINAHL®, Scopus, and Embase were searched. Clinical studies in humans comparing ExFix and ORIF for tibial plateau fractures were included. Case reports, pathological, and biomechanical studies were excluded. Two investigators reviewed the studies independently, and any discrepancies were resolved. The quality and heterogeneity of each study were assessed in addition to calculating the odds ratio (OR) of the surgical outcomes and complications at a 95% confidence interval, with p <0.05 as statistical significance.

Results

Of the 14 included studies, one was a randomised trial, one was a prospective study, and 12 were retrospective studies. The 865 fractures identified across the studies constituted 458 (52.9%) in the ExFix group and 407 (47.1%) in the ORIF group. Most studies indicated a better outcome for ORIF as compared to ExFix. Open reduction and internal fixation had a lower incidence of superficial infection and postoperative osteoarthritis, while ExFix revealed a lower proportion with heterotopic ossification (HTO).

Conclusion

ExFix has a higher rate of superficial infections and osteoarthritis, whereas ORIF has a higher incidence of HTO. Larger studies are needed to compare outcomes and investigate the findings of this study further.

Clinical significance

This up-to-date meta-analysis on tibial plateau management will help surgeons make evidence-based decisions regarding the use of ORIF versus ExFix.

How to cite this article

Naja AS, Bouji N, Eddine MN, et al. A Meta-analysis Comparing External Fixation against Open Reduction and Internal Fixation for the Management of Tibial Plateau Fractures. Strategies Trauma Limb Reconstr 2022;17(2):105–116.

Risk of Surgical Site Infections in OTA/AO Type C Tibial Plateau and Tibial Plafond Fractures: A Systematic Review and Meta-Analysis

OBJECTIVES

To analyze the current incidence of postoperative infection for OTA/AO type C fractures of the tibial plateau and tibial plafond.

DATA SOURCES

Three medical databases: PubMed/MEDLINE, ScienceDirect, and the Cochrane Library, were used in our systematic literature search. Search results were restricted to articles transcribed in English/Spanish and publication date after January 1, 2000, to present day.

STUDY SELECTION

Inclusion criteria were studies reporting postoperative infection data for OTA/AO type 41C, 43C, or equivalent fractures of skeletally mature individuals. A minimum of 6 total fractures of interest and a frequency of 75% overall were required. Studies reporting on pathologic fractures, stress fractures, or low-energy fracture types were excluded.

DATA EXTRACTION

Two authors independently screened abstracts, evaluated full-text manuscripts, and extracted relevant data from included studies. Any instances of discrepancy were resolved within the study committee by consensus.

DATA SYNTHESIS

Outcomes were expressed using direct proportions (PR) with a 95% confidence interval. The effects of comorbidities on infection rates were reported using odds ratios with a 95% confidence interval. All analyses used a DerSimonian-Laird estimate with a random-effects model based on heterogeneity. The presence of publication bias was evaluated using funnel plots and Egger's tests.

CONCLUSIONS

Patients with these specific fractures develop infections at a notable frequency. The rates of deep infections were approximately 6% in tibial plateau fractures and 9% in tibial plafond fractures. These results may be useful as a reference for patient counseling and other future studies aimed at minimizing postoperative infection for these injuries.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Post-operative complications of tibial plateau fractures treated with screws or hybrid external fixation

PURPOSE

To assess the complications and second surgeries rates at 1 year follow-up in a group of patients underwent minimally invasive fixation with screws or hybrid external fixation (HEF) for tibial plateau fractures (TPF). The hypothesis was that low Schatzker (I-IV) TPF would have shown a lower complication rate with respect to high Schatzker (V-VI) TPF.

METHODS

148 patients who underwent minimally invasive surgery with screws or HEF for TPF were included and pooled in two groups: mono-condylar (Schatzker I-IV) and bi-condylar (Schatzker V-VI). The rate of second surgeries and complications, such as stiffness, infection, wound dehiscence and malunion occurred within 1 year, were reported.

RESULTS

Statistically significant difference between mono-condylar and bi-condylar groups was found in terms of stiffness (18% vs. 37%, p = 0.01), malunion (4% vs 21%, p = 0.004) and second surgeries (32% vs. 48%, p = 0.049). Associated procedures performed during TPF fixation increased risk of second surgeries (OR 2.1, p < 0.001). No differences in terms of second surgeries and complications were found in bi-condylar group treated with screws and HEF.

CONCLUSION

Bi-condylar TPF treated with minimally invasive surgery developed a significantly higher rates of stiffness, malunion and second surgeries within 1 year compared to mono-condylar fractures. Moreover, when an associated procedure was performed, the risk of a reoperation was nearly doubled. Trial registration number PG 0012506 CE AVEC 620/2018/Oss/IOR.

A comparison of clinical, radiological, and quality-of-life outcomes of double-plate internal and Ilizarov external fixations for Schatzker type 5 and 6 tibia plateau fractures

PURPOSE

To compare clinical, functional, and radiological outcomes in patients with bicondylar tibial fractures treated with either double-plate or Ilizarov external fixation.

METHODS

Patients with Schatzker type 5 and 6 tibial plateau fractures who were treated with double-plate (Group O) and Ilizarov external fixations (Group E) between March 2012 and April 2018 were selected. Demographic data and preoperative, intraoperative, and postoperative variables were analyzed and compared. In the last follow-up, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford Knee Score (OKS), Knee Society Score-Knee (KSS-Knee), KSS-Function (KSS-F), and Short-Form Health Survey (SF-36) were used to measure clinical and functional outcomes. Treatment costs and complication rates were also recorded and compared.

RESULTS

A total of 64 patients (43 men and 21 women) were included in the study (group O: 36, group E: 28). WOMAC, KSS-F, KSS-Knee, and OKS scores were similar between the two groups (P > 0.05). The role limitations due to emotional problems, emotional well-being, and social functioning domains of SF-36 were higher in group O (P < 0.001). Three (8.3%) deep infections occurred in group O, whereas no deep infection was observed in group E (P = 0.035). The treatment cost was higher in group O (P < 0.001).

CONCLUSION

In bicondylar tibial plateau fractures, functional outcomes of ORIF and Ilizarov method milar were sibut, role limitations due to emotional problems, emotional well-being and social functioning domains of SF-36 score were higher in ORIF group. However, Ilizarov method is more cost-effective and related with lesser complications.

Ilizarov Fixation Method of Tibia Plateau Fractures: A Prospective Observational Study

BACKGROUND

 Tibia plateau fractures are most commonly managed with open reduction and internal fixation (ORIF) technique, external fixation via minimally invasive technique are an excellent alternative. The aim of this study was to assess the results of tibia plateau fractures by using the Ilizarov external fixator. The analysis was done both clinically and radiologically.

METHODOLOGY

 Some 72 patients with isolated tibia plateau fractures were brought to ED and clinics and assessed. The fractures were classified according to Schatzker Tibia Plateau Fracture classification, only Schatzker type III to VI were included using conventional X-rays. All patients for their tibia plateau fractures underwent surgical correction using Ilizarov technique with full weight bearing and knee range of motion allowed the next day. Patient follow-up up to one year was done. KOOS and self-appraisal were used to evaluate the knee pain and function.

RESULTS

 All the fractures healed with 67 patients achieving a range of motion better than 0-100º. KOOS score shows that patients who had worse fracture patterns (Schatzker-V and VI) have worse global scores (p=0.002); still when managed with an Ilizarov it has been seen that these patients are able to maintain a moderately pain free knee (p=0.013) other aspects of the KOOS. Patients with higher BMI showed to have worsening fracture patterns with 20 out of the 30 overweight patients suffering Schatzker-V (66.67%). We experienced an extremely low rate of pin tract infections with only two debridements required.

CONCLUSION

 Ilizarov external fixation method is a valuable alternative treatment with excellent clinical outcomes and early mobilization.

Comparison between open reduction with internal fixation to circular external fixation for tibial plateau fractures: A systematic review and meta-analysis

Peer-reviewed published studies on tibial plateau fractures treated with either open reduction with internal fixation (ORIF) or circular external fixation were reviewed to compare functional, radiological outcomes, postoperative complications, and reoperation rates between the two methods. A systematic search of various databases including Medline, Cochrane Controlled Register of Trials (CENTRAL), ScienceDirect, and Google Scholar from inception until June 2019 was performed. 17 studies with 1168 participants were included in the review. Most of the studies (76%) were retrospective in nature and had low or unclear bias risks. Incidence of total infection (Odds ratio [OR], 2.58; 95% CI, 1.33–5.02) and malunions (OR, 2.56; 95% CI, 1.12–5.84) were higher and length of hospital stay was shorter in patients treated with circular external fixator (Mean difference [MD], -6.1; 95% CI, -11.1–-1.19). There were no differences in the incidence of secondary osteoarthritis (OR, 1.49; 95% CI, 0.92–2.42), range of motion (MD, 2.28; 95% CI, -11.27–15.82) non-union (OR, 1.44; 95% CI, 0.14–14.27) and reoperation rates (OR, 1.84; 95% CI, 0.90–3.78) between the two groups. Results from this investigation suggest that circular fixation may offer some advantages over ORIF such as a shortened length of hospital stay and early return to preinjury activities. Definitive clinical recommendations cannot be made as it also presents higher rates of postoperative complications than ORIF.

[External fixator for temporary stabilization of complex periarticular knee fractures]

OBJECTIVE

Temporary stabilization of the knee joint in order to minimize soft tissue strain until definitive surgery is possible.

INDICATIONS

Bicondylar distal femoral and tibial plateau fractures, additional vascular injury, open fractures (second or third degree), severe soft tissue damage, unicondylar fracture with contralateral ligament tear, (open) knee dislocation, polytrauma.

CONTRAINDICATIONS

Unsafe pin placement, severe osteoporosis.

SURGICAL TECHNIQUE

Two femoral and tibial pins are connected by two rods and are spanned over the knee with two additional longitudinal rods via a tube-to-tube clamp. Alternatively, this can be facilitated by a direct connection of two rods in case of anteriorly placed femoral pins. A reasonable distance should be kept to open wounds, the fracture, and later operative approaches. The knee is fixed in 5-15° of flexion.

POSTOPERATIVE MANAGEMENT

Definitive treatment depending on patient well-being and amenable soft tissue.

Seltene Gefahr eines Kompartmentsyndroms bei arthroskopischer Versorgung der Tibiaplateaufraktur

Frakturen des Tibiaplateaus gehen häufig mit Begleitverletzungen (z. B. vorderes Kreuzband, Seitenbänder, Meniskus) sowie einer komplexen Beteiligung der Gelenkflächen einher. Die Therapie erfolgt in der Regel durch eine operative Versorgung mittels winkelstabiler Platten. In diesem Beitrag wird der Fall einer 61-jährigen Patientin nach Sturz in der häuslichen Umgebung beschrieben, bei dem sie sich eine Fraktur des vorderen Tibiakopfes und der medialen Femurkondyle mit einer multiligamentären Ruptur sowie eine Lappenruptur des lateralen Meniskus zuzog, sodass die Indikation für eine arthroskopische Operation bestand. Aufgrund der Gefahr eines Kompartmentsyndroms musste der Eingriff jedoch vorzeitig abgebrochen werden. Im Anschluss wurde die Patientin erfolgreich mit einer Knietotalendoprothese versorgt. Das Kompartmentsyndrom stellt eine sehr seltene, aber ernsthafte Komplikation der Arthroskopie dar. Eine gute invasive Therapieoption ist die Fasziotomie, wobei deren Indikation u. a. vom Druck des Kompartiments abhängt. Genaue Richtlinien bezüglich der Behandlung des Kompartmentsyndroms liegen noch nicht vor. Die Therapie sollte in erster Linie patientenorientiert erfolgen.

Preoperative Plan with 3D Printing in Internal and External Fixation for Complex Tibial Plateau Fractures

OBJECTIVE

To compare short-term treatment effects of internal and external fixation in the treatment of complicated tibial plateau fractures by preoperative planning with 3D printing.

METHODS

Sixty-nine patients with tibial plateau fractures were examined. 3D printing was used to establish the model in all patients before the operation. Thirty-four patients were treated with an external fixator (9-Schatzker Type V, 25-Schatzker Type VI) and 35 patients were treated with internal fixation (12-Schatzker Type V, 23-Schatzker Type VI). The time span of the study was 2 years after the operation. All patients were followed up in the clinic of the attending physician who recorded patient follow-up information at the same time. Finally, the Rasmussen functional score, radiographic parameters, complication rates, hospital days and operative parameters of the two groups were analyzed.

RESULTS

The short-term (within 2 years) Rasmussen score in the external fixation group was close to that of the internal fixation group; the differences were not significant (P > 0.05). The fractures were reduced adequately using both forms of surgical treatment. There is no significant difference between internal and external fixation in terms of radiographic parameters after 2 years (Mann-Whitney U-tests, P > 0.05). Thrombosis was detected in 7 cases (2 external fixation, 5 internal fixation). Superficial infection was detected in 3 cases (1 external fixation, 2 internal fixation). Deep infection was detected in 3 cases (0 external fixation, 3 internal fixation). Knee stiffness was detected in 4 cases (2 external fixation, 2 internal fixation); 1 (2.7%) case of screw pullout occurred in the internal fixation group. The external fixation group had shorter operation times (172.94 ± 50.00 min vs 253.86 ± 64.59 min), less bleeding volume (395.88 ± 121.10 mL vs 864.29 ± 238.12 mL), and fewer days (17.03 ± 5.03 days vs 30.17 ± 8.64 days) of hospitalization compared to the internal fixation (t-test, P = 0.00); subgroup analysis of all patients with complex tibial plateau fractures revealed that for patients with tibial plateau fracture type VI, the functional score of external fixation (26.79 ± 2.04) is better than that (25.54 ± 1.69) of internal fixation (t- test, P = 0.026) and the overall infection rate of external fixation is lower than that of internal fixation (χ² - test, P = 0.047).

CONCLUSION

Using 3D printed models in combination with external fixation has more advantages for short-term treatment of complex tibial plateau fractures. In particular, relatively better functional recovery and lower rates of infection can be achieved for Schatzker type VI fractures. The external fixation treatment was preferred in cases of Schatzker VI tibial plateau fractures.

Comparison of Postoperative Outcomes Between Open Reduction and Internal Fixation and Ilizarov for Schatzker Type V and Type VI Fractures

Introduction

Open reduction and internal fixation (ORIF), hybrid fixation, and external fixation are available treatment options for bicondylar fractures of the proximal tibia but which one is superior to the others is not yet established. Therefore, the study aimed to establish a gold standard treatment option for bicondylar fractures by comparing the clinical, functional, and radiological outcomes managed by Ilizarov and ORIF at 24 months.

Methods

This was a retrospective study conducted from 2009 to 2014 at a public sector, tertiary care, level I trauma center. Patients with Schatzker type V and type VI open and closed fractures were included. Floating knee, pathological fractures of the tibia, and patients having medical conditions were excluded from the study. Honkonen and Jarvinen (HJ) criteria for subjective, clinical, radiological, and functional outcomes were used to compare between the two groups at 24 months. Demographic data included age, gender, Schatzker type, mechanism of injury, and range of knee flexion. Chi-square was used to find the level of significance, which was 0.05.

Results

A total of 137 patients were included in this study, with 68 patients in the ORIF group and 69 in the Ilizarov group during the study period. The mean age of the patients was 45.08 ± 10.52, respectively. The male to female distribution was 107/30 (78.1% and 21.89%). According to the mechanism of injury, road traffic accidents (RTA) were the primary cause of injury: 96 (70.07%), falls were 21 (15.32%), and gunshots were 18 (13.13%). Seventy-four were Schatzker type VI (54.01%) whereas 63 (45.98) were Shcatzker V. The average knee flexion at 24 months was 115.51 ± 16.82. There were no differences in the clinical, functional, and radiological outcomes at 24 months between the two treatment groups.

Conclusion

No single treatment option can be applied in all cases, and the decision depends on the complexity of the injury, the surgeon’s expertise, and host factors.

Failure analysis of primary surgery and therapeutic strategy of revision surgery for complex tibial plateau fractures

PURPOSE

To analyze the cause of failure of the primary surgery for complex tibial plateau fractures and to define the therapeutic strategy of the revision surgery for the same.

METHODS

Twenty-one cases with failure of primary surgery for complex tibial plateau fractures were treated in our hospital from January 2012 to September 2016. There were 13 males and 8 females with an average age of 39.4 years (ranged between 27 and 58 years). Patients presented with different types of complex tibial plateau fractures like Schatzker type V (n=9), VI (n=12), type 41.C1 (n=9), type 41.C2 (n=6), and type 41.C3 (n=6). The therapeutic strategy for revision surgery in individual patients was decided following careful analysis and accurate assessment of the causes of failure of the primary surgery. All the patients were followed-up with Rasmussen radiographic scores and Hospital for Special Surgery (HSS) knee scores.

RESULTS

All 21 patients underwent clinical and radiological examination after a mean follow-up time of 32.6 months. The average time of fracture healing was 4.5 months (ranged between 3 and 6 months). During the last follow-up, the mean range of motion of knee extension was 2.3° and knee flexion was 123.8°. The mean radiological Rasmussen score was 15.6 points, with an overall success rate of 85.7%. The average HSS knee score was 84.3 points, with an overall success rate of 80.9%.

CONCLUSION

The common reasons for the failure of primary surgery of complex tibial plateau fractures were inadequate experience of the surgeon, inaccurate diagnosis and management, improper selection of implants, and poor surgical techniques. The key factors to succeed revision surgery were adequate preoperative evaluation, accurate intraoperative procedures, and proper postoperative rehabilitation.

LEVEL OF EVIDENCE

Level IV, case series, treatment study.

Disseminating technology in global surgery

Background

Effective dissemination of technology in global surgery is vital to realize universal health coverage by 2030. Challenges include a lack of human resource, infrastructure and finance. Understanding these challenges, and exploring opportunities and solutions to overcome them, are essential to improve global surgical care.

Methods

This review focuses on technologies and medical devices aimed at improving surgical care and training in low- and middle-income countries. The key considerations in the development of new technologies are described, along with strategies for evaluation and wider dissemination. Notable examples of where the dissemination of a new surgical technology has achieved impact are included.

Results

Employing the principles of frugal and responsible innovation, and aligning evaluation and development to high scientific standards help overcome some of the challenges in disseminating technology in global surgery. Exemplars of effective dissemination include low-cost laparoscopes, gasless laparoscopic techniques and innovative training programmes for laparoscopic surgery; low-cost and versatile external fixation devices for fractures; the LifeBox pulse oximeter project; and the use of immersive technologies in simulation, training and surgical care delivery.

Conclusion

Core strategies to facilitate technology dissemination in global surgery include leveraging international funding, interdisciplinary collaboration involving all key stakeholders, and frugal scientific design, development and evaluation.

The impacts of internal versus external fixation for tibial fractures with simultaneous acute compartment syndrome

PURPOSE

High-energy tibial fractures may cause compartment syndrome, which needs fasciotomy. However, in this procedure, close fractures become an open wound and choosing the best type of fixation for this situation has been a problem. We assumed early open reduction and internal fixation (ORIF) instead of late internal fixation or external fixation, or stage-based approach is a better method.

METHODS

We collected fifty-seven medical records from 2012 to 2017 stored in Alzahra and Kashani University Hospital databases. We selected important information of their medical files, called the submitted phone numbers, and asked them to come to our clinic and examined their leg for any malunion and/or movement restriction postoperatively. We asked about pain and paresthesia in their leg. Twelve cases were excluded.

RESULTS

Demographic variables were not significantly different between these two groups. Deep infection, malunion, decreased range of motion in both knee and ankle joints, pain and paresthesia mainly occurred in external fixation group, except malunion (p value = 0.032), other variables were not statistically significant between two groups. More surgeries were performed predominantly for external fixation group (p value < 0.001). External fixation stayed 4.7 days longer at hospital although it was not statistically significant (p value = 0.108).

CONCLUSION

It is better to perform fasciotomy and ORIF simultaneously in one surgery to lower the number of surgeries, days of hospitalization, decrease the risk of deep infection, malunion and movement restriction although its postoperative outcomes were not considerably different from external fixation. We indicate that stage-based approach is accompanied by poor outcomes and lesser satisfaction.