Hybrid External Fixation of Comminuted Tibial Plateau Fractures

Yale University School of Medicine, Orthopaedics and Rehabilitation, Orthopedic Associates of New Haven, CT 06510, USA.
Clinical Orthopaedics and Related Research (Impact Factor: 2.77). 08/1996; 328(328):203-10. DOI: 10.1097/00003086-199607000-00032
Source: PubMed


Comminuted tibial plateau fractures present a surgical challenge to the orthopaedic surgeon. Over the years, treatment has ranged from traction to cast immobilization to open reduction and internal fixation. More recently, indirect reduction techniques with external fixation have been used. At the authors' institution, from 1990 to 1992, 18 Schatzker Types V and VI tibial plateau fractures were treated in 18 patients with indirect reduction and application of a Monticelli-Spinelli hybrid external fixation system. Two patients had additional internal fixation and were excluded from this review. All 16 patients were available for followup evaluation. The mean time to union was 4.5 months. There were no nonunions. Three patients developed a varus deformity. Fifteen had radiographic evidence of early degenerative changes at 1 year followup. There were 11 superficial pin tract infections in 4 patients; all resolved with local pin care and a short course of oral antibiotics. There were no deep infections. With the added advantages of minimal to no soft tissue stripping and early knee range of motion, this technique is recommended for treatment of these difficult fractures.

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    • "Over the past few decades, various Authors have advocated different methods of treatment, but at the present there is no consensus about the best approach in these complex injuries. However, according to literature, ORIF with dual plating [7,16–19] or hybrid [20] [21] [22] [23] [24] and circular external fixation [25] [26], with or without limited internal fixation, represents two of the most common treatment options for tibial plateau fractures. Fig. 4. Difference in post-operative days between the two groups of fracture. "
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    ABSTRACT: 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. 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). 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. 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. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Injury 07/2015; 138(10). DOI:10.1016/j.injury.2015.07.018 · 2.14 Impact Factor
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    • "Complications of wound breakdown, deep tissue infection, compartment syndrome, delayed union, nonunion, secondary loss of reduction, peroneal palsies, hardware failure and arthrofibrosis have been well-documented throughout the literature resulting in great variability in achieving satisfactory outcomes [5–12]. Similarly, while the use of hybrid external fixators obviates the need for extensive surgical dissection, superficial and pin tract infections, osteomyelitis, septic arthritis, varus malalignment and loss of knee motion are among the many complications reported [13–16]. "
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    ABSTRACT: Evolution of periarticular implant technology has led to stiffer, more stable fixation constructs. However, as plate options increase, comparisons between different sized constructs have not been performed. The purpose of this study is to biomechanically assess any significant differences between 3.5- and 4.5-mm locked tibial plateau plates in a simple bicondylar fracture model. A total of 24 synthetic composite bone models (12 Schatzker V and 12 Schatzker VI) specimens were tested. In each group, six specimens were fixed with a 3.5-mm locked proximal tibia plate and six specimens were fixed with a 4.5-mm locking plate. Testing measures included axial ramp loading to 500 N, cyclic loading to 10,000 cycles and axial load to failure. In the Schatzker V comparison model, there were no significant differences in inferior displacement or plastic deformation after 10, 100, 1,000 and 10,000 cycles. In regards to axial load, the 4.5-mm plate exhibited a significantly higher load to failure (P = 0.05). In the Schatzker VI comparison model, there were significant differences in inferior displacement or elastic deformation after 10, 100, 1,000, and 10,000 cycles. In regards to axial load, the 4.5-mm plate again exhibited a higher load to failure, but this was not statistically significant (P = 0.21). In the advent of technological advancement, periarticular locking plate technology has offered an invaluable option in treating bicondylar tibial plateau fractures. Comparing the biomechanical properties of 3.5- and 4.5-mm locking plates yielded no significant differences in cyclic loading, even in regards to elastic and plastic deformation. Not surprisingly, the 4.5-mm plate was more robust in axial load to failure, but only in the Schatzker V model. In our testing construct, overall, without significant differences, the smaller, lower-profile 3.5-mm plate seems to be a biomechanically sound option in the reconstruction of bicondylar plateau fractures.
    Journal of Orthopaedics and Traumatology 11/2013; 15(2). DOI:10.1007/s10195-013-0275-6
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    • "As a result of the problems associated with open reduction and plating described above, recent studies have addressed the use of external fixators,6,14,15) but although the incidence of infection is clearly better than that of plating, it is not always easy to reduce and adequately maintain fractures, especially fractures with articular involvement or comminuted proximal tibial fractures. Furthermore, mal-union, joint motion limitations, and patient inconvenience are main concerns when an external fixator is used, and pin tract infections remain problematic. "
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    ABSTRACT: Relatively few studies have addressed plate osteosynthesis for open proximal tibial fractures by now. The purpose of this study was to assess the results of minimally invasive plate osteosynthesis (MIPO) for open fractures of the proximal tibia. Thirty-four patients with an open proximal tibial fracture were treated by MIPO. Thirty of these, who followed for over 1 year, constituted the subject of this retrospective study. According to the AO Foundation and Orthopaedic Trauma Association (AO-OTA) classification, there were 3 patients of type 41-C, 6 of type 42-A, 8 of type 42-B, and 13 of type 42-C. In terms of the Gustilo and Anderson's open fracture grading system, 11 patients were of grade I, 6 were of grade II, and 13 were of grade III (III-A, 6; III-B, 6; III-C, 1). After thorough debridement and wound cleansing, when necessary, a soft tissue flap was placed. Primary MIPO (simultaneous plate fixation with soft tissue procedures) was performed in 18 patients, and staged MIPO (temporary external fixation followed by soft tissue procedures and subsequent conversion to plate fixation after soft tissue healing) was performed in 12 patients. Results were assessed according to the achievement and time to union, complications (including infections), and function of the knee joint using Knee Society scores. Statistical analysis was performed to identify factors influencing results. Primary union was achieved by 24 of the 30 study subjects. Early bone grafting was performed in 6 cases with a massive initial bone defect expected to result in non-union. No patient had malalignment greater than 10°. The mean Knee Society score was 88.7 at final follow-up visits, 23 patients achieved an excellent result, and 7 a good result. There were 3 superficial and 5 deep infections, but none required early implant removal. Functional results were similar for primary and staged MIPO (p = 0.113). Fracture pattern (p = 0.089) and open fracture grade (p = 0.079) were not found to influence the results. If soft tissue coverage is adequately performed, MIPO could be regarded as an acceptable method for the treatment of open proximal tibial fracture.
    Clinics in orthopedic surgery 12/2012; 4(4):313-20. DOI:10.4055/cios.2012.4.4.313
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