Hybrid external fixation in complex tibial plateau and plafond fractures: an Australian audit of outcomes

Early posterior column internal fixation: A staged treatment of type C3 tibial pilon fracture

Pilon fractures represent a challenging subset of tibial fractures. The management of AO/OTA Type C3 fractures remains complex due to associated complications and lack of clear guidelines for surgical timing and methods. A prospective cohort study was conducted to evaluate two staged treatment strategies for AO/OTA Type C3 tibial pilon fractures. The study focused on assessing surgical difficulty, complications, and patient prognosis. One group of patients received early internal fixation of the fibula and tibial posterior column combined with external fixation, while the other group received external fixation alone in the first stage. Patients who received early internal fixation of the fibula and tibial posterior column combined with external fixation had better outcomes, including lower rate of allogeneic bone grafting (67.74 % versus 94.64 %), reduced incidence of wound delay and skin necrosis (3.23 % versus 21.43 %), shorter surgical time (133.06 ± 23.99 min versus 163.04 ± 26.83 min), shorter hospital stay (13.77 ± 2.53 days versus 18.25 ± 3.67 days), and higher AOFAS (83.05 ± 8.68 versus 79.36 ± 8.92). Additionally, avoiding fibular shortening was shown to be crucial in preventing prolonged surgery and improving patient function. The study demonstrated that the staged treatment approach with early internal fixation led to shorter operative times, improved ankle function, and reduced complications, including a lower risk of infection. The findings support the use of this treatment to optimize outcomes in AO/OTA Type C3 pilon fractures.

Risk factors of hospitalization costs and length of stay for tibial plateau fractures

PURPOSE

This study aimed to analyze the factors influencing the length of stay (LOS) and the cost of hospital stay in patients with tibial plateau fractures (TPFs).

METHODS

We enrolled 233 patients with TPFs in this retrospective study. The general conditions, hematological indicators, and imaging data of hospitalized patients were collected. The factors influencing the cost and LOS were determined by a multivariate logistic regression model controlling confounding factors. Receiver operating characteristic (ROC) curve is used to determine the sensitivity and specificity of risk factors.

RESULTS

The hospitalization cost of hypoproteinemia was significantly higher than that of the standard group (OR 3.07; 95% CI 1.23-7.69; P = 0.017); Low hemoglobin levels in the male will significantly affect patient hospitalization costs (OR 8.32; 95% CI 2.82-24.57; P = 0.015), will also extend the LOS (OR 3.02; 95% CI 1.15-7.89; P = 0.024). Among Schatzker classification of the tibial plateau, hospitalization costs of type V, VI above fractures were significantly higher than those of class I, II, III, and IV fractures (OR 8.78; 95% CI 3.34-23.09; P < 0.001).

CONCLUSION

In this study, hypoproteinemia and the Schatzker classification appeared to be a useful indicator for predicting hospitalization costs for TPFs patients; Male hemoglobin level appears to be an independent risk factor for hospital cost and LOS.

Stress Distributions and Micromovement of Fragment Bone of Pilon Fracture Treated With External Fixator: A Finite Element Analysis

Osteoporosis and osteoarthritis are common pathological problems of the human bone tissue. There are some cases of pilon fractures associated with these 2 pathological conditions. In terms of treatment, for a normal and healthy bone with pilon fracture, the use of the Delta external fixator is a favorable option because it can allow early mobilization for patients and provide stability for the healing process. However, the stability of the external fixator differs when there is low bone stiffness, which has not been previously investigated. Therefore, this study was conducted to determine the stability of the external fixator to treat pilon fracture associated with osteoporosis and osteoarthritis, particularly to differentiate the stress distribution and micromovement of fracture fragment. Three-dimensional finite element models of the ankle and foot bones were reconstructed based on the computed tomography datasets. The bones consisted of 5 metatarsal, 3 cuneiform, and 1 each of cuboid, navicular, calcaneus, talus, fibula, and tibia bones. They were assigned with linear isotropic behavior. The ankle joint consisted of ligament and cartilage, and they were assigned with the use of linear links and the Mooney-Rivlin model, respectively. During simulation of the gait cycle, 70 N and 350 N were applied axially to the tibia bone to represent the swing and stance phases, respectively. The metatarsal and calcaneus bones were fixed to prevent any movement of the rigid body. The study found that the greatest von Mises stress value was observed at the pin-bone interface for the osteoporosis (108 MPa) model, followed by the osteoarthritis (87 MPa) and normal (44 MPa) models, during the stance phase. For micromovement, the osteoporosis model had the largest value at 0.26 mm, followed by the osteoarthritis (0.09 mm) and normal (0.03 mm) models. In conclusion, the greatest magnitudes of stress and micromovement were observed for the osteoporosis bone and extra care should be taken to treat pilon fracture associated with this pathological condition.

Evaluation of Functional Outcome Following Hybrid External Fixation in The Management of Schatzkers Type V and VI Tibial Plateau Fractures - A Prospective Study of 30 Patients

Introduction

Fractures of the proximal tibia are high velocity injuries often associated with soft tissue compromise especially in the type V and VI fracture patterns. Dual plating is the preferred treatment option for these injuries but not in a setting where there is extensive soft tissue injury, as this can lead to problems with wound healing. The aim of this study was to evaluate the functional outcome following hybrid external fixation in the management of Schatzkers type V and VI fractures.

Materials and Methods

A total of 30 patients with type V and VI proximal tibial fractures who presented between January 2012 to January 2015 were managed with hybrid external fixation and were followed-up for a period of 3 years.

Results

The mean age of the patients was 42.26 years with the left knee being more commonly affected. Schatzkers type V was the more common fracture type seen. The mean time to union was 12.06 weeks and the average range of motion achieved was 0 to 100°. The mean Rasmussens functional score was 25.4 at last follow-up and we had excellent results in 5 patients and good results in 22 patients.

Conclusion

Through this study, we conclude that the hybrid external fixation is an excellent option in the type V and VI fractures with extensive soft tissue compromise. It is easy to apply, facilitates early mobilisation of the joint and gives good functional results.

Functional outcomes of the failed plate fixation in distal tibial fractures salvaged by hexapod external fixator

PURPOSE

The purpose of this study was to evaluate the clinical and functional outcomes of failed plate fixation in distal tibia fractures salvaged with hexapod circular fixators.

MATERIALS AND METHODS

The database of a specialized limb reconstruction center was searched for all patients with failed plate fixation undergoing limb reconstruction with a circular external fixator between 2008 and 2017. Patients between the ages of 18-65 years, with a symptomatic distal tibia malunion or non-union following plate and screw fixation were included. The SF-12 and Foot Function Index (FFI) scoring systems were used to measure clinical and functional outcomes.

RESULTS

Ten patients with a mean age of 38 ± 13 years met the inclusion criteria. Seven patients had an infected non-union, two hypertrophic non-unions, and one a malunion. The mean follow-up was 41.7 ± 28.3 months. The mean duration of external fixation was 232.9 ± 146.6 days. The SF-12 demonstrated a mean score of 49.4 ± 7.7 for the physical component and a mean score of 55.3 ± 8.1 for the mental component. Five patients (50%) scored above 45 points for the SF12 physical component, and nine patients (90%) scored above 45 points for the mental component, indicating good outcome can be achieved. The mean FFI score was 24.9 ± 19.9, and six patients had a score below 14 points (good outcome). Radiological union was observed in all 10 patients at a mean of 29 ± 14 months.

CONCLUSIONS

The results of this study suggest that hexapod circular external fixation is an attractive surgical alternative for the treatment of failed plate fixation of distal tibial fractures, and can reliably achieve bony union and result in very satisfactory clinical outcomes.

LEVEL OF EVIDENCE

Level IV case series.

Complex Tibial Plateau Fractures Treated by Hybrid External Fixation System: A correlation of followup computed tomography derived quality of reduction with clinical results

BACKGROUND

Tibial plateau fractures are common due to high energy injuries. The principles of treatment include respect for the soft tissues, restoring the congruity of the articular surface and reduction of the anatomic alignment of the lower limb to enable early movement of the knee joint. There are various surgical fixation methods that can achieve these principles of treatment. Recognition of the particular fracture pattern is important, as this guides the surgical approach required in order to adequately stabilize the fracture. This study evaluates the results of the combined treatment of external fixator and limited internal fixation along with the advantages using postoperative computed tomography (CT) scan after implant removal. Materials and.

METHODS

55 patients with a mean age of 42 years (range 17-65 years) with tibial plateau fracture, were managed in our institution between October 2010 and September 2013., Twenty fractures were classified as Schatzker VI and 35 as Schatzker V. There were 8 open fractures (2 Gustilo Anderson 3A and 6 Gustilo Anderson 2). All fractures were treated with closed reduction and hybrid external fixation (n = 21/38.2%) or with minimal open reduction internal fixation and a hybrid system (n = 34/61.8%). After the removal of the fixators, CT-scan was programmed for all the cases, for correlation with the results. At final followup, the American Knee Society Score (AKSS) was administered.

RESULTS

All patients were evaluated with a minimum of 12 months (range 12-21 months) followup. Average time to union was 15.5 weeks (range 13-19 weeks). The postoperative joint congruity as evaluated in the postoperative CT-scan was <2 mm of articular step-off in 8 patients (14.5%), between 2 and 4 mm in 18 patients (32.7%) and over 4 mm in 29 (52.7%). The injured limb mechanical axis was restored within 5° compared to the contralateral limb in 36 cases (65%) and with an angulation >5° in 19 cases (35%). Patients with residual joint depression <3.5 mm had a 95% chance of having excellent AKSS knee score results and 80% chance of having excellent AKSS function scores. On the other hand, residual joint depression of >4.5 mm displayed a 100% chance of getting poor-fair scores both in AKSS knee and AKSS function score. The association of a postoperative mechanical axis within 5° of the contralateral limb and improved knee scores was statistically significant for the AKSS function and total scores but not for the AKSS knee score. The AKSS was negatively correlated with postoperative joint depression magnitude which was statistically significant. Only the amount of joint collapse was verified as a prognostic factor in a multivariate logistic regression analysis.

CONCLUSIONS

The postoperative CT-scan shows important information about bone healing, and an exact image of the reduction and the shaft alignment. Postoperative radiographs may have led to an underestimation of the degree of residual displacement. On the contrary, CT-scan demonstrates the exact grade of articular displacement and depending on CT-scan results one can better manage the postoperative rehabilitation.

Clinical efficacy and safety of limited internal fixation combined with external fixation for Pilon fracture: A systematic review and meta-analysis

PURPOSE

To compare the clinical efficacy and complications of limited internal fixation combined with external fixation (LIFEF) and open reduction and internal fixation (ORIF) in the treatment of Pilon fracture.

METHODS

We searched databases including Pubmed, Embase, Web of science, Cochrane Library and China Biology Medicine disc for the studies comparing clinical efficacy and complications of LIFEF and ORIF in the treatment of Pilon fracture. The clinical efficacy was evaluated by the rate of nonunion, malunion/delayed union and the excellent/good rate assessed by Mazur ankle score. The complications including infections and arthritis symptoms after surgery were also investigated.

RESULTS

Nine trials including 498 pilon fractures of 494 patients were identified. The meta-analysis found no significant differences in nonunion rate (RR = 1.60, 95% CI: 0.66 to 3.86, p = 0.30), and the excellent/good rate (RR = 0.95, 95% CI: 0.86 to 1.04, p = 0.28) between LIFEF group and ORIF group. For assessment of infections, there were significant differences in the rate of deep infection (RR = 2.18, 95% CI: 1.34 to 3.55, p = 0.002), and the rate of arthritis (RR = 1.26, 95% CI: 1.03 to 1.53, p = 0.02) between LIFEF group and ORIF group.

CONCLUSION

LIFEF has similar effect as ORIF in the treatment of pilon fractures, however, LIFEF group has significantly higher risk of complications than ORIF group does. So LIFEF is not recommended in the treatment of pilon fracture.

Hybrid external fixation in the treatment of tibial pilon fractures: A retrospective analysis of 162 fractures

OBJECTIVES

To determine the efficacy of hybrid external fixation in the treatment of tibial pilon fractures.

DESIGN

Retrospective, multicentre study.

PATIENTS/PARTICIPANTS

Adult patients with tibial pilon fractures treated with hybrid external fixation.

INTERVENTION

Fracture reduction with ligamentotaxis and fixation with XCaliber hybrid external fixator.

MAIN OUTCOME MEASUREMENTS

Fracture union, complications, functional outcome (Mazur Ankle Score).

RESULTS

Union was obtained in 159 fractures at an average of 125days; there were three delayed unions and three non-unions. The most frequent complication was superficial pin-track infections (48), all of which responded to local wound care and antibiotics. There were no deep infections and no DVT. Only one fracture had loss of reduction that required frame revision. The overall functional scores were 91 (excellent) for AO/OTA type A fractures, 89 (good) for type B fractures, and 75 (satisfactory) for type C fractures.

CONCLUSIONS

Hybrid external fixation is an effective method of stabilising tibial pilon fractures, particularly those with marked comminution. The minimally-invasive technique and stable fixation enable early mobilisation, with good functional results and minimal complications.

LEVEL OF EVIDENCE

Level IV Case series.

Retrospective review of tibial plateau fractures treated by two methods without staging

INTRODUCTION

Management of complex tibial plateau fractures can be challenging for orthopaedic surgeons. Wide disagreement still remains about the best surgical technique to use in these fractures. The purpose of this study was to compare the results of complex tibial plateau fractures treated by an open reduction and internal fixation (ORIF) versus hybrid external fixation (EF) in term of clinical and functional outcomes.

MATERIALS AND METHODS

We retrospectively examined a series of 79 patients affected by tibial plateau fractures admitted at our Department between January 2006 and November 2011. Forty-one patients were treated using a hybrid EF; in 38 cases, ORIF technique was used. Clinical evaluation was performed using the method of Rasmussen; functional assessment was made using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire. Residual pain was detected using a Numeric Rating Scale (NRS).

RESULTS

The average time to union in the plate group was 17.2 weeks (9.1-45 weeks), while in the EF one 15.9 (7.5-32). The mean overall hospital stay was 14.2 days for the ORIF group and 7.8 for the EF group. At the last follow-up, the mean Rasmussen score was 24.9 (good) in the patients treated with ORIF and 25 (good) in those who received EF. The WOMAC index disclosed a relatively higher score in the EF group (80.5 ORIF-84.2 EF). Pain evaluation revealed no differences between the groups. In terms of complications, deep infection occurred in four (10.5%) patients belonging to the ORIF group and 2 (4.9%) to EF one. Signs of osteoarthritis (OA) were observed in 4 (10.5%) knees that had open reduction and in 11 (26.9%) that had a hybrid external fixator.

CONCLUSIONS

Either ORIF or hybrid EF represents a valid treatment option in complex tibial plateau fractures. However, hybrid external fixation has shown relative better functional outcome results, relative lower rate of infection and decreased hospital stays. These aspects make of EF our best choice in case of high-energy complex tibial fractures.

Surgical fixation methods for tibial plateau fractures

BACKGROUND

Fractures of the tibial plateau, which are intra-articular injuries of the knee joint, are often difficult to treat and have a high complication rate, including early-onset osteoarthritis. Surgical fixation is usually used for more complex tibial plateau fractures. Additionally, bone void fillers are often used to address bone defects caused by the injury. Currently there is no consensus on either the best method of fixation or bone void filler.

OBJECTIVES

To assess the effects (benefits and harms) of different surgical interventions, and the use of bone void fillers, for treating tibial plateau fractures.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (12 September 2014), the Cochrane Central Register of Controlled Trials (2014 Issue 8), MEDLINE (1946 to September Week 1 2014), EMBASE (1974 to 2014 Week 36), trial registries (4 July 2014), conference proceedings and grey literature (4 July 2014).

SELECTION CRITERIA

We included randomised and quasi-randomised controlled clinical trials comparing surgical interventions for treating tibial plateau fractures and the different types of filler for filling bone defects.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, selected studies, extracted data and assessed risk of bias. We calculated risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CIs). Only very limited pooling, using the fixed-effect model, was possible. Our primary outcomes were quality of life measures, patient-reported outcome measures of lower limb function and serious adverse events.

MAIN RESULTS

We included six trials in the review, with a total of 429 adult participants, the majority of whom were male (63%). Three trials evaluated different types of fixation and three analysed different types of bone graft substitutes. All six trials were small and at substantial risk of bias. We judged the quality of most of the available evidence to be very low, meaning that we are very uncertain about these results.One trial compared the use of a circular fixator combined with insertion of percutaneous screws (hybrid fixation) versus standard open reduction and internal fixation (ORIF) in people with open or closed Schatzker types V or VI tibial plateau fractures. Results (66 participants) for quality of life scores using the 36-item Short Form Health Survey (SF-36)), Hospital for Special Surgery (HSS) scores and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function scores tended to favour hybrid fixation, but a benefit of ORIF could not be ruled out. Participants in the hybrid fixation group had a lower risk for an unplanned reoperation (351 per 1000 people compared with 450 in the ORIF group; 95% CI 197 fewer to 144 more) and were more likely to have returned to their pre-injury activity level (303 per 1000 people, compared with 121 in the ORIF group; 95% CI 15 fewer to 748 more). Results of the two groups were comparable for the WOMAC pain subscale and stiffness scores, but mean knee range of motion values were higher in the hybrid group.Another trial compared the use of a minimally invasive plate (LISS system) versus double-plating ORIF in 84 people who had open or closed bicondylar tibial plateau fractures. Nearly twice as many participants (22 versus 12) in the ORIF group had a bone graft. Quality of life, pain, knee range of motion and return to pre-injury activity were not reported. The trial provided no evidence of differences in HSS knee scores, complications or reoperation entailing implant removal or revision fixation. A quasi-randomised trial comparing arthroscopically-assisted percutaneous reduction and internal fixation versus standard ORIF reported results at 14 months in 58 people with closed Schatzker types II or III tibial plateau fracture. Quality of life, pain and return to pre-injury activity were not reported. There was very low quality evidence of higher HSS knee scores and higher knee range of motion values in the arthroscopically assisted group. No reoperations were reported.Three trials compared different types of bone substitute versus autologous bone graft (autograft) for managing bone defects. Quality of life, pain and return to pre-injury activity were not reported. Only one trial (25 participants) reported on lower limb function, finding good or excellent results in both groups for walking, climbing stairs, squatting and jumping at 12 months. The incidences of individual complications were similar between groups in all three trials. One trial found no cases of inflammatory response in the 20 participants receiving bone substitute, and two found no complications associated with the donor site in the autograft group (58 participants). However, all 38 participants in the autologous iliac bone graft group of one trial reported prolonged pain from the harvest site. Two trials reported similar range of motion results in the two groups, whereas the third trial favoured the bone substitute group.

AUTHORS' CONCLUSIONS

Currently, there is insufficient evidence to ascertain the best method of fixation or the best method of addressing bone defects during surgery. However, the evidence does not contradict approaches aiming to limit soft-tissue dissection and damage or to avoid autograft donor site complications through using bone substitutes. Further well-designed, larger randomised trials are warranted.

Hybrid External Fixation for Arbeitsgemeinschaft für Osteosynthesefragen (AO) 43-C Tibial Plafond Fractures

Arbeitsgemeinschaft für Osteosynthesefragen (AO) type 43-C tibial plafond/pilon fractures represent a challenge for the treating orthopedic surgeon. We assessed the outcomes of using hybrid external fixation for this fracture type. The present prospective cohort study was started in August 2009 and ended by July 2012. Thirty consecutive patients (mean age 37.4 ± 10.7 years) with a type C tibial plafond fracture who had presented to our tertiary care orthopedic hospital were included. Motor vehicle accidents and fall from height were the cause of the fracture in 14 (46.7%) and 13 (43.3%) patients, respectively. A type C3 fracture was present in 25 patients (83.3%), and type C1 and C2 fractures were present in 2 (6.7%) and 3 (10.0%) patients, respectively. Nine fractures (30.0%) were open. Hybrid external fixation was used for all fractures. All fractures were united; clinical healing was achieved by a mean of 18.1 ± 2.2 weeks postoperatively and radiologic healing at a mean of 18.9 ± 1.9 weeks. The fixator was removed at a mean of 20.4 ± 2.0 weeks postoperatively. At a mean follow-up point of 13.4 ± 2.6 months, the mean modified Mazur ankle score was 84.6 ± 10.4. It was not associated with wound classification (p = .256). The most commonly seen complication was ankle osteoarthritis (17 patients; 56.7%); however, it was mild in >50.0% of the affected patients. In conclusion, using hybrid external fixation for type C tibial plafond fractures resulted in good outcomes. However, this should be investigated further in studies with a higher level of evidence.

External Fixation combined with Limited Internal Fixation versus Open Reduction Internal Fixation for Treating Ruedi-Allgower Type III Pilon Fractures

Background

The optimal treatment of type III pilon fractures remains controversial. Hence, we performed this study to investigate whether open reduction and internal fixation (ORIF) is superior to external fixations combined with limited internal fixations (EFLIF).

Material/Methods

From January 2012 to October 2013, a total of 78 patients were included. Twenty-six patients underwent EFLIF and 52 patients underwent ORIF. All subjects were followed up at 1, 3, 6, and 12 months postoperatively. All outcomes and complications were recorded.

Results

No statistical differences were observed in Mazur score or ROM between the 2 groups. There were significant differences between the 2 groups in hospital stay (P<0.001), reduction results (P=0.019), screw loosening (P=0.025), and traumatic arthritis (P=0.037).

Conclusions

Similar functional outcomes were achieved in EFLIF and ORIF groups. Due to several limitations of this study, a well-designed randomized controlled trial involving more patients and long-term follow-up is needed to find an optimal treatment protocol.

Finite element analysis of three commonly used external fixation devices for treating Type III pilon fractures

Pilon fractures are commonly caused by high energy trauma and can result in long-term immobilization of patients. The use of an external fixator i.e. the (1) Delta, (2) Mitkovic or (3) Unilateral frame for treating type III pilon fractures is generally recommended by many experts owing to the stability provided by these constructs. This allows this type of fracture to heal quickly whilst permitting early mobilization. However, the stability of one fixator over the other has not been previously demonstrated. This study was conducted to determine the biomechanical stability of these external fixators in type III pilon fractures using finite element modelling. Three-dimensional models of the tibia, fibula, talus, calcaneus, navicular, cuboid, three cuneiforms and five metatarsal bones were reconstructed from previously obtained CT datasets. Bones were assigned with isotropic material properties, while the cartilage was assigned as hyperelastic springs with Mooney-Rivlin properties. Axial loads of 350 N and 70 N were applied at the tibia to simulate the stance and the swing phase of a gait cycle. To prevent rigid body motion, the calcaneus and metatarsals were fixed distally in all degrees of freedom. The results indicate that the model with the Delta frame produced the lowest relative micromovement (0.03 mm) compared to the Mitkovic (0.05 mm) and Unilateral (0.42 mm) fixators during the stance phase. The highest stress concentrations were found at the pin of the Unilateral external fixator (509.2 MPa) compared to the Mitkovic (286.0 MPa) and the Delta (266.7 MPa) frames. In conclusion, the Delta external fixator was found to be the most stable external fixator for treating type III pilon fractures.

The reconstruction of tibial metaphyseal comminution using hybrid frames in severe tibial plafond fractures

OBJECTIVES

To evaluate the treatment alternatives for the management of the metaphyseal tibial comminution in severe plafond fractures, and to investigate the role of the fibula fracture fixation.

DESIGN

Retrospective clinical study.

SETTING

Level-2 trauma hospital.

PARTICIPANTS

Patients with highly comminuted tibial plafond fractures.

INTERVENTION

All patients were treated with open reduction and internal fixation of the articular surface and external fixation of the metaphyseal fracture. If metaphyseal comminution was minimal, bone graft was applied and the fibular was plated (group 1); if comminution was between 1 and 3 cm, acute shortening and distraction osteogenesis was performed (group 2); and if comminution was >3 cm, distraction osteogenesis without acute shortening was performed (group 3).

MAIN OUTCOME MEASUREMENTS

Radiographic union, AOFAS ankle score.

RESULTS

Of 30 fractures, 15 fractures (50%) had an anatomic reduction of the joint. Union occurred in all but 2 fractures. Group 1 fractures healed at an average of 19 weeks (16-22). Four fractures had associated malalignment problems. The mean AOFAS score was 72.5 (range 45-100). Group 2 fractures healed at an average of 18.3 weeks (16-21). One fracture healed with 5-degrees of angulation. Group 3 fractures healed at an average of 17.5 weeks (14-24). Two fractures healed with malalignment. When groups 2 and 3 were combined to evaluate the AOFAS outcome for fractures treated with distraction osteogenesis, a score of 75.83 was obtained (45-90). There was no difference between the Group 1 versus combined Groups 2/3 with regard to this latter score (P = 0.372). Additionally, when fibula fixation (Group 1) was compared with those fractures where it was not performed (groups 2/3), no difference was seen (P = 0.276).

CONCLUSIONS

The reconstruction of severe tibial plafond fractures treated with small wire hybrid fixation may be achieved by different techniques leading to a satisfactory result. The fixation of the fibula fracture is dependent mainly on the treatment chosen for the management of the metaphyseal lesion.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgical treatment of open pilon fractures

OBJECTIVE

To discuss the methods, timing and clinical outcomes of surgical treatment for open pilon fractures.

METHODS

From April 2003 to July 2008, 28 patients with open pilon fractures were treated. All had type C fractures according to the Arbeitsgemeinschaft für osteosynthesefragen-Association for the Study of Internal Fixation (AO/ASIF) classification. Three operative methods were applied, the methods being determined by the types of fracture, soft tissue damage and time interval after injury. Seven cases were treated by debridement and internal fixation with plate; 19 by limited internal fixation combined with external fixation; and 2 by delayed surgery. The clinical outcomes were evaluated by the Burwell-Charnley score.

RESULTS

All cases were followed up for from 6 to 48 months (average 24 months). The Burwell-Charnley score of clinical outcomes: anatomic reduction achieved in 12 cases, functional reduction in 15, and unsatisfactory reduction in 1. The healing time was from 2.5 to 11 months (average 4.7 months). Two cases had delayed union. According to the American Orthopaedic Foot and Ankle Society (AOFAS) scale for the ankle joint, there were excellent results in 8 cases, good in 14, fair in 5 and poor in 1. Complications included four cases of skin superficial sloughing, two of superficial infection, one of deep infection, two of delayed fracture union and ten of post-traumatic arthritis.

CONCLUSION

It is important to perform appropriate surgeries for open pilon fracture according to fracture classification, different damage to skin and tissue and time interval after injury. Thorough debridement, proper use of anti-infective medication, appropriate bone grafting, and postoperative ankle function exercise can reduce the occurrence of complications.

Modified hybrid fixator for high-energy Schatzker V and VI tibial plateau fractures

High-energy tibial plateau fractures associated with severe soft tissue injury are difficult to manage. The risk of wound complications following open reduction and internal fixation is notably high owing to extensive soft tissue dissection. Alternatively, application of hybrid external fixator minimizes soft tissue dissection and provides adequate fracture stabilization to allow early range of motion and correction of any mal-alignment. With this technique, soft tissue complications particularly surgical site infections are expected to be significantly reduced. This prospective study aims to determine the effectiveness of a modified hybrid external fixator in the management of high-energy tibial plateau fractures. Thirty-three patients with high-energy Schatzker V and VI tibial plateau fracture with severe soft tissue injury precluding formal open reduction were enrolled into the study. The fixator was a construct combining the Ilizarov ring with a monolateral external fixator. The results—bony union, range of motion, and associated complications of the treatment—were assessed. All fractures united within an average time of 14 weeks. Neither loss of reduction nor surgical site wound breakdown/osteomyelitis was noted. Eight patients developed superficial pin track infection and one septic arthritis of the knee joint. Hybrid external fixation is a safe option for complex high-energy tibial plateau fractures by simultaneously providing adequate fracture stabilization and protection of soft tissue healing to achieve bony union. The complication is mainly related to pin tract infection.

Tibial pilon fractures: which method of treatment?

A comprehensive review of the existing literature, related to treatment options and management principles of pilon fractures was performed, and its results are presented. The identified series advocate in favour of a number of different treatment strategies and fixation methods. Decision making was mostly dependent on the severity of the local injury, the fracture pattern, the condition of the soft tissues, patient's profile and surgical expertise. External fixation and conservative treatment did not provide sufficient articular congruence in many cases. Internal fixation allowed excellent restoration of joint congruity in Rüedi type I and II fractures. A staged approach, consisting of fibular plating and temporary bridging external fixation, later substituted by an internal minimal invasive osteosynthesis or by a definitive external fixation, was favourable for Rüedi type III fractures. Closed pilon fractures with bad soft tissue conditions (Tscherne ≥ 3) or open pilon fractures are regarded as contraindication of open reduction plate fixation. Anatomic reduction of the fracture, restoration of joint's congruence, reconstruction of the posterior column, with minimal soft tissue insult, were all highlighted as of paramount importance.

Distal tibial fractures treated with hybrid external fixation

Management of distal tibia fractures remains challenging. The purpose of this study was to evaluate whether hybrid external fixation, as definite treatment, was associated with satisfactory results and low rate of complications. Between November 1999 and October 2006, 48 patients (33 men and 15 women) with a mean age of 45.6 years and a median ISS of 14.3 were admitted to our department with a distal tibia fracture and treated with the use of a hybrid external fixator. Eight patients had an open fracture. Mean follow-up was 14 months (range, 9-36 months). In 40 patients, radiographic evidence of union was observed at 3.6 months (range, 3-6 months). Delayed union was observed in three patients. There were five non-unions (10.4%) with three of them were septic. When compared to previously reported series, with conventional open reduction and internal fixation, the use of hybrid external fixation with or without open reduction and internal fixation of the fibula, was associated with satisfactory clinical and radiographic results and limited complications.

Combination of fine wire fixation and limited internal fixation for high-energy tibial plateau fractures: functional results at minimum 5-year follow-up

OBJECTIVES

To assess knee function and the development of knee arthrosis, at 3 and 5 years postoperatively, in high-energy tibial plateau fractures that were treated with minimal internal fixation augmented by small wire circular frames.

SETTING

Level II trauma hospital.

DESIGN

: Retrospective study.

PATIENTS AND METHODS

Between October 1988 and December 1999, 145 consecutive high-energy tibial plateau fractures were treated with hybrid fixation including small wire circular or hybrid frames, minimal internal fixation, and occasionally provisional extension of the external fixation to the distal femur. One hundred twenty-seven patients with 129 fractures (89%) were included in the study. There were 68 (53%) C1, 20 (15%) C2, and 41 (32%) C3 fractures. Forty-seven (36.5%) of the total were open fractures. Clinical, subjective, objective, and radiographic results were evaluated at the time of union, at a minimum 3 years postoperatively, and at final minimum follow-up of 5 years.

RESULTS

Results were assessed according to the Honkonen-Jarvinen criteria. An excellent or good subjective result was noted in 106 fractures (82%) at a minimum 3-year follow-up, whereas an excellent or good score was achieved in 101 fractures (78%) at a minimum 5 years. A statistically significant deterioration (P = 0.001) of the post-traumatic radiographic arthritis was recorded at 5 years postoperatively.

CONCLUSIONS

High-energy tibial plateau fractures treated with minimal internal fixation augmented by small wire external fixation frames yielded a high percentage of cases exhibiting radiographic post-traumatic arthritis. However, because all the objectives of fracture treatment seemed to be obtained, the functional results remain satisfactory over time.

Functional and radiological evaluations of high-energy tibial plateau fractures treated with double-buttress plate fixation

OBJECTIVE

This study was designed to evaluate the functional and radiological outcomes of patients with complex tibial plateau fractures treated with double-buttress plate fixation.

METHODS

Sixty five cases of complex (Schatzker type V and VI) tibial plateau fractures were treated with double-buttress plate fixation in our centre from September 2001 to September 2006 through two separate plate incisions. Fifty four patients were followed up for a period ranging from 12 to 48 months and evaluated for the functional and radiological outcomes by a series of standard questionnaire and measurement.

RESULTS

Due to the good exposure without any extensive soft-tissue dissection of the double-buttress plate fixation, the fractures in all 54 patients were healed and the treatment achieved greater than 90% of satisfactory-to-excellent rates of reduction. The mean time of bone union was 15.4 weeks (range, 12-30 weeks), and the mean time of full weight-bearing was 18.7 weeks (range, 14-26 weeks). At the final follow-up visit, no patients showed knee instability; the mean range of motion was 107.6 degrees (range, 85 degrees -130 degrees ). For all patients, no statistically significant difference in the functional outcomes was observed between their 6-months and final follow-up visits; or in the radiological findings between their immediate postoperative and final follow-up examinations.

CONCLUSION

Double-buttress plate fixation is a feasible treatment option for bilcondylar and complex tibial plateau fractures. Although technically demanding, it offers reliable stability without additional postoperative adjuvant external fixation, and at the same time avoids extensive soft tissue dissection, allowing the early painless range of motion.

The classification systems for tibial plateau fractures: how reliable are they?

OBJECTIVE

The aim of the study was to assess the inter-observer reliability and intraobserver reproducibility of three different classification systems for tibial plateau fractures.

MATERIALS AND METHODS

Four observers of various levels of experience classified 50 tibial plateau fractures. The same observers repeated the classification of the same fractures after an interval of 8 weeks. Inter- and intra-observer variability was assessed using the mean kappa co-efficient and the mean percentage of agreement.

RESULTS

For inter-observer reliability, the mean kappa co-efficient values for Arbeitsgemeinschaft für Osteosynthesefragen (AO), Schatzker and Hohl and Moore classifications were 0.36, 0.47 and 0.14, respectively. The mean percentage of agreement was 0.52, 0.59 and 0.34, respectively. For intra-observer reliability kappa-values were 0.80, 0.91 and 0.76 and the mean percentage of agreement was 0.88, 0.93 and 0.85 in the same order.

CONCLUSIONS

Our results show that none of the classification systems were ideal. The Schatzker classification system was superior to the AO and the Hohl and Moore systems both in terms of inter-observer reliability and intra-observer reproducibility. However, there is a need for developing a more comprehensive approach to judge the classification systems.

Small wire external fixation for high-energy tibial plateau fractures

PURPOSE

To assess results of small wire external fixation using a ligamentotaxis technique for high-energy tibial plateau fractures.

METHODS

Between April 2002 and May 2004, 38 consecutive patients aged 21 to 60 (mean, 32) years underwent small wire external fixation for high-energy tibial plateau fractures. 15 involved the right and 23 the left knee. 34 were closed and 4 were open injuries. Fractures were classified according to Schatzker's staging system. After a minimal of 2 years' follow-up (range, 24-42 months), each affected knee was evaluated using Rasmussen's (1) 30-point clinical grading system and (2) radiological evaluation.

RESULTS

There were 22 type-VI and 16 type-V Schatzker tibial plateau fractures. Complications consisted of: 2 superficial infections, 3 pin site infections, and 4 peroneal nerve palsies. No soft tissue necrosis or devitalisation occurred. The mean range of knee movement was 132 degrees. The mean Rasmussen radiological score was 14 (range, 10-18): excellent in 6, good in 26, and fair in 6. The mean Rasmusssen functional score was 26 (range, 17-30): excellent in 19 patients, good in 17, and fair in 2. Clinical results did not parallel the radiological results.

CONCLUSION

Small wire external fixation allows anatomical reconstruction of the articular surface, stable fixation of fracture fragments, early movement of the joint, and care of associated soft tissue injuries, without a high rate of complications.

Operative treatment of 109 tibial plateau fractures: five- to 27-year follow-up results

OBJECTIVE

To analyze the long-term (5-27 years) functional and radiologic results of surgically treated fractures of the tibial plateau.

DESIGN

Retrospective study.

SETTING

University hospital.

PATIENTS AND METHODS

Two hundred two consecutive tibial plateau fractures were included in this study. All fractures were classified according to both the AO and the Schatzker classification. There were 112 men and 90 women. The mean age at injury was 46 years (16 to 88). One hundred sixty-three patients had isolated fractures and 39 had multiple fractures. A 1 year follow-up was done in all 202 patients. One hundred nine of these patients also had an additional long-term follow-up visit. Functional results of these 109 patients were graded with the Neer- and HSS-knee scores. Radiologic results were graded with the Ahlbäck score. Statistical analysis was performed by means of the SPSS data analysis program.

RESULTS

An uneventful union was present at the 1 year follow-up in 95% of the patients, along with a mean knee ROM of 130 degrees (range, 10-145 degrees). One hundred nine patients had a long-term follow-up visit after a mean period of 14 years (range, 5-27 years). The mean ROM at this time was 135 degrees (range, 0-145 degrees). Functional results showed a mean Neer score of 88.6 points (range, 56-100 points) and a mean HSS score of 84.8 points (range, 19-100 points). Monocondylar fractures showed statistically significant better functional results compared to bicondylar fractures. In 31% of the patients, secondary osteoarthritis had developed but was well tolerated in most (64% of the patients). Patients with a malalignment of more then 5 degrees developed a moderate to severe grade of osteoarthritis statistically significant more often (27% of the patients) compared to patients with an anatomic knee axis (9.2%; MWU, P = 0.02). Age did not appear to have any influence on the results.

CONCLUSION

Long-term results after open reduction and internal fixation for tibial plateau fractures are excellent, independent of the patient's age.