Hybrid external fixator with or without minimal internal fixation: effective alternative for proximal tibia fractures, review of 25 cases
2 SKIMS Medical College, Bemina, Srinagar, India
Received Date: Oct 11, 2019 / Accepted Date: Nov 25, 2019 / Published Date: Dec 02, 2019
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Background: Open or minimally invasive plating is the most commonly used surgical method to treat proximal tibia fractures. However unhealthy soft tissue or unusual fracture anatomy at times force a surgeon to look for alternative surgical methods.
Materials and Methods: The study was conducted between January 2014 to December 2017. 25 patients were operated for proximal tibia fractures using a hybrid external fixator in a single institute and results evaluated.
Results: By the end of 1 year after surgery Rasmussen score as excellent in 16, good in 6, fair in 3 and poor in 0 patients. The mean range of knee motion at the final follow up was 4 to 120. 2 cases of varus malunion and case of nonunion were observed in our study.
Conclusion: Hybrid external fixator is a viable and effective alternative to conventional locked plates in selected patients.
Tibia, Proximal, External fixator, Fracture
CCS: Cannulated Cancellous Screws; ROM: Range of Motion; HSS: Hospital for Special Surgery; WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index; ORIF: Open Reduction Internal Fixation
Proximal tibia fractures are complex fractures which often pose a challenge to treating surgeon usually due to precarious soft tissue envelope around the proximal tibia. Plating with pre-contoured locking plates using open or minimally invasive techniques are the most commonly used methods of fixation for proximal tibia fractures . However a number of times situation doesn’t allow a surgeon to go for routine method of fixation. In proximal tibia high energy fractures with bad soft tissue, open fractures or severe comminuted fractures often force a surgeon to look for alternative methods of fixation the fracture like ring fixator or tubular external fixator as soft tissue stripping in not feasible under such circumstances due to high chances of wound break down and infection .
A hybrid external fixator with minimal internal fixation is a very good alternative for proximal tibia fractures when open reduction and plating is not feasible. A periarticular ring is connected with the shaft using monoaxial fixator. This provides a very stable construct and allows early range of motion which is critical for cartilage nutrition. Minimal soft tissue damage causes little post-operative pain. Besides a varus or valgus collapse in the immediate post-operative period can also be addressed.
Materials and Methods
This study was conducted between January 2014 to January 2017 at the post-graduate department of Orthopaedics after approval from ethical committee. During this period we got 25 patients, 17 males and 8 females with proximal tibia fractures where standard method of fixation in our institute (single/dual plating) was not possible because of various reasons. 6 patients had open fractures, 19 patients had bad soft tissue like blisters or gross swelling. 19 patients had intra-articular fractures and 6 patients had extra-articular comminuted fractures. All the intra-articular proximal tibia fractures/tibial plateau fractures were classified as of Shatzkar classification . Patients with healthy soft tissue around proximal tibia, patients with neurovascular injury of the involved limb and patients with extensive soft tissue damage who needed flap coverage were excluded from the study.
All the fractures were fixed under C arm control in spinal anesthesia. Fractures were reduced using longitudinal traction and AO clamps. Articular surface reconstruction with bone grafting and Minimal internal fixation with Cannulated Cancellous Screws (CCS) fixation was done through small windows whenever needed. The proximal ring was aligned parallel to articular and fixed with two crossed olive wires. Metaphysio-diaphyseal alignment was corrected under C arm and secured with shanz pins and tubular rods which were connected with the proximal ring. The final reduction was confirmed under C arm.
The patients were regularly followed up in the post-operative period. X rays were taken on first post-operative day, then sequentially at 3 weeks, 6 weeks, 3 months, 6 months and 1 year. Patients were encouraged to start range of motion exercises on first post-operative day. Partial weight-bearing was allowed from 4th to 6th week and full weight was allowed as per the status of fracture union. Patients were explained to take care of pin sites with regular antiseptic dressings and to keep them clean. Signs and symptoms of pin tract infections were explained to the patients.
The patients with compartment syndrome and vascular injuries were excluded from the study due to irregular follow up as patients had to attend plastic surgery and cardiovascular and thoracic surgery follow up regularly.
Patients were assessed clinically and radiologically in the follow up for fracture union, tenderness, knee ROM (Range of Motion), pin site infection, soft tissue status, wound infection, osteomyelitis and neurovascular complications.
Out of 25 patients, 17 were males and 8 females. The mean age of the study group was 37 years with range from 21 to 57 years (Table 1).
|S. no||Soft tissue status||Shatzkar type||Complications||Radiological outcome||Knee ROM||Sports activity|
|2||Open||IV||Pin site infections||Union||0-125||Resumed|
|4||Bad soft tissue||Extra-articular||-||Union||0-120||Not resumed|
|5||Bad soft tissue||V||-||Union||0-110||Resumed|
|6||Bad soft tissue||VI||-||Union||0-100||Resumed|
|7||Bad soft tissue||VI||Pin site infection||Varus mal union||8-130||Not resumed|
|11||Closed||V||Pin site infection||Union||0-115||Resumed|
|12||Bad soft tissue||V||Union||5-110||Resumed|
|13||Bad soft tissue||V||-||Varus mal-union||0-125||Resumed|
|14||Bad soft tissue||Extra-articular||-||Union||0-130||Not resumed|
|15||Bad soft tissue||VI||-||Union||10-120||Resumed|
|16||Bad soft tissue||VI||Pin site infection||Union||5-115||Resumed|
|17||Bad soft tissue||Extra-articular||-||Union||0-130||Resumed|
|18||Bad soft tissue||V||-||Union||6-125||Resumed|
|19||Bad soft tissue||VI||-||Union||0-120||Not resumed|
|20||Bad soft tissue||VI||-||Union||5-130||Resumed|
|22||Bad soft tissue||V||Pin site infection||Union||6-135||Resumed|
|23||Bad soft tissue||V||-||Union||0-115||Not resumed|
|24||Bad soft tissue||Extra-articular||-||Union||0-125||Resumed|
Table 1. Patient and fracture profile, complications and final outcome
Out of 25 patients 6 had extra-articular (Fig. 1a-1c) and 6 had intra-articular fractures (Fig. 2a-2c). Among 19 intra-articular fractures, 2 were Shatzker type IV and 10 were Shatzkar type V and 7 of Shatzkar type VI. 7 were open fractures (Gustilo and Anderson type 1 to 3a) and 18 with bad soft tissue (Fig. 2d) (blisters, gross swelling, small lacerations), knee movements were good (Fig. 2e).
Figure 2: Case 2: Intra-articular proximal tibia fracture with unhealthy soft tissue; a: Anteroposterior and lateral knee x rays showing intra-articular proximal tibia fracture; b: Post-op X-ray showing well reduced fracture; c: Final X-ray after implant removal showing well united fracture; d: unhealthy soft tissue around proximal tibia; e: Good range of knee movements
The mean duration of the application of fixator was 12 weeks (10 to 22 weeks). The average time of fracture union was 15 weeks. In 2 patients time taken for fracture union was more than 20 weeks. Functional outcome after 1 year was observed by Rasmussen Score as excellent in 16, good in 6, fair in 3 and poor in 0 patients (Fig. 3). The mean ROM at final follow up was 4 to 120 (Fig. 2e). No patient had nonunion, 2 patients have varus malunion of 4 and 7 degrees respectively but did well functionally. All the patients achieved pre-injury activity status however only 13 patients resumed sports activities.
No systemic complications were reported in any of the patients during the study. 4 patients developed pin site infections in the follow up which was managed with pin site dressing and oral antibiotics which resolved in all the patients (Table 1). No patients developed deep infection or nonunion. 2 patients had varus malunion but the functional outcome was satisfactory in both the patients. No patient had any neurovascular injury.
High energy proximal tibial fractures are complex bony injuries with unpredictable outcomes. Treatments methods used are conservative or operative depending on the type of fracture . A number of methods of fixation are used for proximal tibia fractures however no method has absolute advantages over other methods . The aim of surgical treatment is articular surface reconstruction for intra-articular fractures, axial and rotational alignment of fracture and stable fixation to allow early knee range of motion . Numerous studies have shown satisfactory results with Open reduction and internal fixation with Single or dual plating for proximal tibia fractures [7,8]. However due respect has to be given to soft tissue envelope as many studies have shown very poor results in cases with bad soft tissue around proximal tibia .
Open reduction allows a better reduction of articular cartilage which is expected to show better functional outcomes. However the drawback of this method is extensive soft tissue stripping which can lead to wound dehiscence, infection, nonunion joint stiffness and risk of septic arthritis. In patients with already compromised soft tissue or open fractures plating can have disastrous consequences. High energy fractures Shatzkar type V and VI usually have compromised soft tissue. Though many studies have shown soft tissue problems even in low energy unicondylar fractures . Various studies have shown significant complications with open plating with respect to infection and soft tissue healing [11-14]. Also many studies have shown that axial and rotational alignment of fragments is more important than absolute articular surface reconstruction [15,16].
With a better understanding of anatomy and importance of posteromedial and posterolateral fragments minimally invasive posteromedial and posterolateral plates are being used with satisfactory results [17-20].Arthroscopy assisted internal fixation has shown better results in intra-articular knee fractures with respect to knee functions and return to sports activity [21-23] Staged management with temporary external fixation with an external fixator and delayed definitive management have shown satisfactory results in various studies . However many studies have shown significantly higher rates of deep infection with staged fixation [25,26].
Various external fixation modalities that have been used when internal fixation is not feasible are ring fixator, joint spanning or joint sparing tubular external fixator. However, with joint spanning fixator knee ROM is not possible and is not considered a good option. Many studies have shown good results in proximal tibia fractures with joint sparing external fixator and ring fixator [27-29].
A hybrid external fixator combines the advantages of ring fixator and tubular fixator. Ring fixator with k wires makes the construct very stable proximally and prevents fracture collapse or displacement. The monoaxial tubular part makes it less bulky and lighter which makes early knee ROM and early patient mobility easier for the patient. Besides adjustments can be made is the post-operative period if needed which is not possible in plating.
Mahadeva et al. in their study reported significant advantages regarding soft tissue related complications with hybrid external fixation over open reduction and no advantage over accurate fracture reduction [30,31]. In our study we had a satisfactory reduction in all the cases however one case ended up in collapse and varus malunion.
In our study, we had 5 patients (18%) with superficial pin site infection which was managed with pin site dressing with H2O2 and oral antibiotics, no deep infection and septic arthritis. Hutson et al. in their meta-analysis on external fixation in proximal tibia fractures observed pin site infection of 10%, deep infection of 4% and septic arthritis in 1% patients [22,32]. Hall et al. in their study observed better results regarding soft tissue related complications and comparable results regarding fracture reduction and in Knee ROM (Range of Motion), HSS (Hospital for Special Surgery) scores, WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) and SF-36 between ORIF (Open Reduction Internal Fixation) and external fixation [33,34].
There are very few studies are in the literature on the results of plating on high energy (Shatzkar type V and VI) fractures. Nikolaou et al. in their study on complex proximal tibia fractures treated with locking plates had 94.5% union rate, 3.7% cases of superficial infection [35-37], 3.7% cases of deep infection and 3.7% cases of nonunion. In our study we had 100% union rate and no case of nonunion. The number of cases with superficial infection was more (16%) in our study but infection resolved well in all the cases and no patient ended up with deep infection.
Under certain circumstances when ORIF with plating fox proximal tibia fractures is not feasible like open fractures or unhealthy soft tissue hybrid external fixator with minimal internal fixation is an effective alternative method of fixation with distinct advantages regarding soft tissue complications.
Conflict of Interest
Towseef Ahmad Bhat designed the study and drafted the manuscript. Towseef Ahmad and Zameer Ali participated in the design of the study. Mudasir Rasool and participated in design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript.
- Van Dreumel R.L., Van Wunnik B.P., Janssen L., et al.: Mid to long-term functional outcome after open reduction and internal fixation of tibial plateau fractures. Injury. 2015;46:1608-1612.
- Borrelli J Jr.: Management of soft tissue injuries associated with tibial plateau fractures. J Knee Surg. 2014;27:5-9.
- Schatzker J., McBroom R., Bruce D.: The tibial plateau fracture: the Toronto experience 1968-1975. Clin Orthop. 1979;138:94-104.
- Tscherne H., Lobenhoffer P.: Tibial plateau fractures. Management and expected results. Clin Orthop. 1993;292:87-100.
- McNamara I.R.1., Smith T.O., Shepherd K.L., et al.: Surgical fixation methods for tibial plateau fractures. Cochrane Database Syst Rev. 2015;15:CD009679.
- Lowe J.A., Tejwani N., Yoo B., et al.: Surgical techniques for complex proximal tibial fractures. J Bone Joint Surg. 2011;93:1548-1559.
- Timmers T.K., Van der Ven D.J., de Vries L.S., et al.: Functional outcome after tibial plateau fracture osteosynthesis: a mean follow-up of 6 years. Knee. 2014;21:1210-1215.
- Benirschke S.K., Agnew S.G., Mayo K.A., et al.: Open reduction internal fixation of complex proximal tibial fractures. J Orthop Trauma. 1991;5:236.
- Young M.J., Barrack R.L.: Complications of internal fixation of tibial plateau fractures. Orthop Review. 1994;23:149-154.
- Metcalfe D., Hickson C.J., McKee L., et al.: External V internal fixation for bicondylar tibial plateau fractures; systemic review and metaanalysis. J Orthop Traumatol. 2015;16:275-285.
- Egol K.A., Tejwani N.C., Capla E.L., et al.: Staged management of high-energy proximal tibia fractures (OTA types 41): the results of a prospective, standardized protocol. J Orthop Trauma. 2005;19:448-455.
- Laible C., Earl-Royal E., Davidovitch R., et al.: Infection after spanning external fixation for high-energy tibial plateau fractures: is pin site-plate overlap a problem? J Orthop Trauma. 2012;26:92-97.
- Shah C.M., Babb P.E., McAndrew C.M., et al.: Definitive plates overlapping provisional external fixator pin sites: is the infection risk increased? J Orthop Trauma. 2014;28:518-522.
- Sirkin M., Sanders R., Di-Pasquale T., et al.: A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma. 1999;13:78-84.
- Garner M.R., Warner S.J., Lorich D.G. Surgical approaches to posterolateral tibial plateau fractures. J Knee Surg. 2016;29:12-20.
- Solomon L.B., Stevenson A.W., Lee Y.C., et al. Posterolateral and anterolateral approaches to unicondylar posterolateral tibial plateau fractures: a comparative study. Injury. 2013;44:1561-1568.
- Carlson D.A.: Posterior bicondylar tibial plateau fractures. J Orthop Trauma. 2005;19:73-78.
- Kandemir U., Maclean J.: Surgical approaches for tibial plateau fractures. J Knee Surg. 2014;27:21-29.
- Helfet D.L., Lorich D.G.: Posteromedial supine approach for reduction and fixation of medial and bicondylar tibial plateau fractures. J Orthop Trauma. 2008;22:357-362.
- Weaver M.J., Harris M.B., Strom A.C., et al. Fracture pattern and fixation type related to loss of reduction in bicondylar tibial plateau fractures. Injury. 2012;43:864-869.
- Ricci W.M., Rudzki J.R., Borrelli J.Jr.: Treatment of complex proximal tibia fractures with the less invasive skeletal stabilization system. J Orthop Trauma. 2004;18:521-527.
- Hutson J.J.Jr, Zych G.A.: Infections in periarticular fractures of the lower extremity treated with tension wires hybrid fixators. J Orthop Trauma. 1998;12:214-218.
- Veri J.P., Blachut P., O’Brien P., et al.: High-grade tibial plateau fractures: a matched cohort study comparing internal fixation and ring fixator methods. J Orthop Trauma. 2000;14:153.
- McLaurin T.M.: Hybrid ring external fixation in the treatment of complex tibial plateau fractures. Tech Knee Surg. 2005;4:226-236.
- Kumar A., Paige W.A.: Treatment of complex (Schatzker type VI) fractures of the tibial plateau with circular wire external fixation: retrospective case review. J Orthop Trauma. 2000;14:339-344.
- Watson T.J., Ripple S., Hoshaw S.J., et al.: Hybrid external fixation for tibial plateau fractures: clinical and biomechanical correlation. Orthop Clin North Am. 2002;33:199-209.
- Watson T.J.: High energy fractures of the tibial plateau. Orthop Clin North Am. 1994;25:723-752.
- Burri C., Bartzke G., Coldeway J., et al. Fractures of the tibial plateau. Clin Orthop. 1979;138:84-93.
- Reid J., Van Slyke M., Moulton M., et al.: Safe placement of proximal tibial transfixation wires with respect to intracapsular penetration. J Orthop Trauma. 2001;15:10-17.
- Mahadeva D., Costa M.L., Gafrey A.: Open reduction and internal fixation versus hybrid fixation for bicondylar/severe tibial plateau fractures: a systematic review of the literature. Arch Orthop Trauma Surg. 2008;128:1169-1175.
- Piper K.J., Won H.Y., Ellis A.M.: Hybrid external fixation in complex tibial plateau and Plafond fractures: an Australian audit of outcomes. Injury. 2005;36:176-184.
- Ali A.M., Lang Y., Hashimi M., et al.: Bicondylar tibial plateau fractures managed with Sheffield hybrid fixator: biomechanical study and operative technique. Injury. 2001;32:86-89.
- Hall J.A., Beuerlein M.J., McKee M.D.: Open reduction and internal fixation compared with circular fixator application for bicondylar tibial plateau fractures: Surgical Technique. J Bone Joint Surg Am. 2009;91:74-88.
- Gaudinez R.F., Mallik A.R., Szporn M.: Hybrid external fixation of comminuted tibial plateau fractures. Clin Orthop. 1996;328:203-210.
- Nikolaou V.S., Tan H.B., Haidukewych G., et al.: Proximal tibial fractures: early experience using polyaxial locking-plate technology. Int Orthop. 2011;35:1215-1221.
- Stamer D.T., Schenk R, Staggers B., et al.: Bicondylar tibial plateau fractures treated with a hybrid ring external fixator: a preliminary study. J Orthop Trauma. 1994;8:455-461.
- Chin T.Y.P, Bardana D., Bailey M., et al.: Functional outcome of tibial plateau fractures treated with the fine-wire fixator. Injury. 2005;36:1467-1475.