Outcomes following the treatment of bicondylar tibial plateau fractures with fine wire circular frame external fixation compared to open reduction and internal fixation: A systematic review

Bicondylar tibial plateau fracture osteosynthesis with double-plate fixation: Similar complication rates and clinical results but improved radiographic outcomes with dual compared to single approach

INTRODUCTION

Associating posteromedial and anterolateral approaches should improve fracture line visualization and optimize bicondylar tibial plateau fracture reduction compared to a single midline approach. The present study aimed to compare postoperative complications rates and functional and radiographic results after double-plate fixation via either a single or a dual approach. The study hypothesis was that double-plate fixation using a dual approach provides equivalent complications rates with improved radiographic results compared to a single approach.

MATERIAL AND METHODS

A retrospective 2-center study compared bicondylar tibial plateau fractures treated by double-plate fixation on a single versus a dual approach between January 2016 and December 2020. Comparison focused on major complications requiring surgical revision, radiographic measurements of medial proximal tibial angle (MPTA) and posterior proximal tibial angle (PPTA); change from their respective baseline values of 87° and 83° (deltaMPTA and deltaPPTA), and functional results on KOOS, SF12 and EQ5D-3L self-reported questionnaires.

RESULTS

Major complications occurred in 2 of the 20 single approach group patients (10%) [1 surgical site infection (SSI) (5%), and 1 skin complication (5%)], and in 3 of the 39 dual approach group patients (7.69%) (p=0.763), at an average 29 months' follow-up. In the sagittal plane, deltaPPTA was significantly lower with dual than single approach (respectively, 4.67° versus 7.43°; p=0.0104). There were no significant intergroup differences in deltaMPTA or functional results at last follow-up.

CONCLUSION

The present study suggests an absence of significant difference in major complications, between single and dual approach for double-plate osteosynthesis of bicondylar tibial plateau fractures. Using a dual approach enabled improved anatomic restoration in the sagittal plane, without significant differences observed in the frontal plane or functional scores at an average 29months' follow-up.

LEVEL OF EVIDENCE

III; case-control study.

[Finite element study of three novel internal fixation modes for bicondylar four-quadrant fractures of tibial plateau]

Objective

To compare the biomechanical differences among the three novel internal fixation modes in treatment of bicondylar four-quadrant fractures of the tibial plateau through finite-element technique, and find an internal fixation modes which was the most consistent with mechanical principles.

Methods

Based on the CT image data of the tibial plateau of a healthy male volunteer, a bicondylar four-quadrant fracture model of the tibial plateau and three experimental internal fixation modes were established by using finite element analysis software. The anterolateral tibial plateaus of groups A, B, and C were fixed with inverted L-shaped anatomic locking plates. In group A, the anteromedial and posteromedial plateaus were longitudinally fixed with reconstruction plates, and the posterolateral plateau was obliquely fixed with reconstruction plate. In groups B and C, the medial proximal tibia was fixed with T-shaped plate, and the posteromedial plateau was longitudinally fixed with the reconstruction plate or posterolateral plateau was obliquely fixed with the reconstruction plate, respectively. An axial load of 1 200 N was applied to the tibial plateau (a simulation of a 60 kg adult walking with physiological gait), and the maximum displacement of fracture and maximum Von-Mises stress of the tibia, implants, and fracture line were calculated in 3 groups.

Results

Finite element analysis showed that the stress concentration area of tibia in each group was distributed at the intersection between the fracture line and screw thread, and the stress concentration area of the implant was distributed at the joint of screws and the fracture fragments. When axial load of 1 200 N was applied, the maximum displacement of fracture fragments in the 3 groups was similar, and group A had the largest displacement (0.74 mm) and group B had the smallest displacement (0.65 mm). The maximum Von-Mises stress of implant in group C was the smallest (95.49 MPa), while that in group B was the largest (177.96 MPa). The maximum Von-Mises stress of tibia in group C was the smallest (43.35 MPa), and that in group B was the largest (120.50 MPa). The maximum Von-Mises stress of fracture line in group A was the smallest (42.60 MPa), and that in group B was the largest (120.50 MPa).

Conclusion

For the bicondylar four-quadrant fracture of the tibial plateau, a T-shaped plate fixed in medial tibial plateau has a stronger supporting effect than the use of two reconstruction plates fixed in the anteromedial and posteromedial plateaus, which should be served as the main plate. The reconstruction plate, which plays an auxiliary role, is easier to achieve anti-glide effect when it is longitudinally fixed in posteromedial plateau than obliquely fixed in posterolateral plateau, which contributes to the establishment of a more stable biomechanical structure.

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.

Malreduction of tibial articular width in bicondylar tibial plateau fractures treated with circular external fixation is associated with post-traumatic osteoarthritis

Objectives

We aimed to report outcomes of Bicondylar Tibial Plateau (BTP) fractures treated using Ilizarov fixation, and identify risk factors for developing post-traumatic radiographic osteoarthritis (ROA).

Methods

Retrospective study of 80 BTP fractures managed with Ilizarov fixation.

Results

All fractures united, with only 3 cases of deep infection. ROA was evident in 12.5% at average 13 months post-injury. Increased tibial articular-widening associated with risk of developing ROA (p = 0.02).

Conclusion

Ilizarov fixation is safe and reliable in the management of BTP fractures. Restoration of tibial articular-width at fixation associated with reduced risk of developing radiographic OA.

Costs and Complications of Single-Stage Fixation Versus 2-Stage Treatment of Select Bicondylar Tibial Plateau Fractures

OBJECTIVES

To determine the differences in costs and complications in patients with bicondylar tibial plateau (BTP) fractures treated with 1-stage definitive fixation compared with 2-stage fixation after initial spanning external fixation.

DESIGN

Retrospective cohort study.

SETTING

Level 1 Trauma Center.

PATIENTS/PARTICIPANTS

Patients with OTA/AO 41-C (Schatzker 6) BTP fractures treated with open reduction internal fixation.

INTERVENTION

Definitive treatment with open reduction internal fixation either acutely (1 stage) or delayed after initial spanning external fixation (2 stage).

MAIN OUTCOME MEASURES

Wound healing complications, implant costs, hospital charges, Patient-Reported Outcomes Measurement Information System (PROMIS), reoperation, nonunion and infection.

RESULTS

One hundred five patients were identified over a three-year period, of whom 52 met the inclusion criteria. There were 28 patients in the 1-stage group and 24 patients in the 2-stage group. Mean follow-up was 21.8 months, and 87% of patients had at least 12 months of follow-up. The mean number of days to definitive fixation was 1.2 in the 1-stage group and 7.8 in the 2-stage group. There were no differences between groups with respect to wound healing or any other surgery-related complications. Functional outcomes PROMIS were similar between groups. Mean implant cost in the 2-stage group was $10,821 greater than the 1-stage group, mostly because of the costs of external fixation. Median hospital inpatient charges in the 2-stage group exceeded the 1-stage group by more than $68,000 for all BTP fractures and by $61,000 for isolated BTP fractures.

CONCLUSIONS

Early single-stage treatment of BTP fractures is cost-effective and is not associated with a higher complication rate than 2-stage treatment in appropriately selected patients.

LEVEL OF EVIDENCE

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

Advantages of external hybrid fixators for treating Schatzker V-VI tibial plateau fractures: A retrospective study of 40 cases

INTRODUCTION

Proximal tibia fractures make up 1% of all fractures in adults. The fractures classified as Schatzker V and VI fractures can compromise knee structure and function. They are challenging to treat and often have complications. While plate fixation is the gold standard, the resulting infection rate has led us to favor external hybrid fixation. The aims of this study were to assess the radiographic and functional outcomes along with the complication rate when using this method and to compare them to historical plate fixation data.

MATERIAL AND METHODS

This was a retrospective study of 40 patients. The complications, quality of reduction, IKS, Lysholm and Rasmussen functional scores at the latest follow-up and factors affecting the functional outcome were evaluated. These parameters were compared to published results from plate fixation studies.

RESULTS

The deep infection rate was 2.5%. The union rate was 80%. Satisfactory reduction was obtained in 70% of cases; however, 52% of patients had malunion. The mean IKS score was 73.74, the mean Rasmussen score was 22.85 and the mean Lysholm score was 75.53. Age, reduction at latest follow-up, mechanical axis and anteroposterior laxity had a significant effect on the functional outcome.

DISCUSSION

Despite the malunion rate being higher than other studies, the functional outcomes were nearly identical based on the variables measured. There are several advantages associated with using a hybrid external fixator: shorter operative time, less bleeding, shorter hospital stays and lower infection rate.

CONCLUSION

Hybrid external fixation is a reliable fracture fixation method that leads to satisfactory functional outcomes, while reducing the infection rate and allowing arthroplasty to be performed in the future if needed.