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Classic Botter 74 Tibia 26

(1) Evaluate intentional temporary limb deformation for closure of soft-tissue defects as a reconstruction strategy in open tibia fractures and (2) analyze the deformity parameters required for such reconstruction.

Classic Botter 74 Tibia 26

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Management of high energy intra-articular fractures of the proximal tibia, associated with marked soft-tissue trauma, can be challenging, requiring the combination of accurate reduction and minimal invasive techniques. The purpose of this study was to evaluate whether minimal intervention and hybrid external fixation of such fractures using the Orthofix system provide an acceptable treatment outcome with less complications. Between 2002 and 2006, 33 patients with a median ISS of 14.3 were admitted to our hospital, a level I trauma centre, with a bicondylar tibial plateau fracture. Five of them sustained an open fracture. All patients were treated with a hybrid external fixator. In 19 of them, minimal open reduction and stabilization, by means of cannulated screws, was performed. Mean follow-up was 27 months (range 24 to 36 months). Radiographic evidence of union was observed at 3.4 months (range 3 to 7 months). Time for union was different in patients with closed and grade I open fractures compared to patients with grade II and III open fractures. One non-union (septic) was observed (3.0%), requiring revision surgery. Pin track infection was observed in 3 patients (9.1%).

Intra-articular fractures of the proximal end of the tibia, the so-called 'plateau fractures', are serious, complex injuries difficult to treat [1]. The mechanism of injury is based on the presence of an initial axial load, which fractures the tibial articular surface resulting in impaction. In most of the cases the initial load is combined with angular forces, leading to comminution not only of the articular surface, but of the metaphysis as well. The medial compartment is split in a medio-lateral direction with a postero-medial main fragment, combined with various amounts of multifragmental lateral compartment depression [2].

According to Schatzker's classification [3, 4], these fractures are divided into six groups: S-I to S-VI. Of these types, those involving both condyles (S-V) and those separating tibial metaphysis from diaphysis (S-VI) are the most challenging fractures for the Orthopaedic Surgeon to treat not only for the osseous damage but for the restoration of the soft tissue envelope as well.

Standard radiographic imaging includes anteroposterior and lateral views. Suspicion of distal extension of the fracture mandates that full-length tibia and fibula x-rays should be obtained. The CT scan is becoming more and more useful in the evaluation of the size, comminution and orientation of the articular fragments, allowing proper classification and preoperative planning, thus facilitating reduction, especially for the less invasive techniques of treatment [5].

The purpose of the current study was to test the hypothesis whether minimal intervention and hybrid external fixation using the Orthofix system can provide a fair outcome with less complications and to compare our results and complications with previously reported data of internal and external fixation for types V and VI high energy tibial plateau fractures.

After receiving approval from our Institutional Review Board, we retrospectively examined a consecutive series of 33 patients (33 bicondylar tibial plateau fractures (Schatzker type V, VI) admitted at our level I trauma centre between 2002 and 2006. Fractures were identified through our trauma database and were cross-matched with operating room records. Median ISS was 14.3, ranging from 9 to 33. Inclusion criteria were the presence of a bicondylar tibial plateau fracture Schatzker type V-VI, patients' age over 18 years and the ability to walk without assistance before injury. Polytrauma patients with tibial plateau fractures requiring prolonged ICU care (AIS>3 for head and chest) and patients with bilateral plateau fractures, were excluded from the study. All patients were followed according to a protocol. All fractures were treated with either closed reduction and hybrid external fixation (14 fxs/36.6%) or with minimal open reduction and a hybrid system (19 fxs/63.4%). The study group was consisted of 20 males (60.6%) and 13 females (39.4%) with an average age for males of 40.3 years (range 30 - 62 years) and for females 49 years (range 17 - 86 years). In 27 patients (81.8%) the mechanism of injury was high energy trauma (motor vehicle accident or fall from height greater than 3 m). All patients had anteroposterior and lateral radiographs as well as a CT-scan for proper preoperative evaluation of their fracture.

We used the Orhtofix hybrid external fixation system. Surgery was performed under general or spinal anesthesia with the patient positioned on the operating table with the knee flexed at 30. A tourniquet is not a significant advantage in closed reduction, but if used, should be deflated as soon as possible. The fracture reduction was visualized with an image intensifier. Through a small incision over the antero-medial aspect of the tibial metaphysis, a small "window" was made in the tibial cortex. A blunt tipped curved 3 mm k-wire or a simple pusher was inserted through the hole, up to the articular fragments, which were elevated under image intensifier control. In most of the cases, more than one k-wire was required to reduce the articular fracture. Bone grafts were applied to feel osseous gaps. Through a small lateral incision, a Kirschner wire was inserted across the tibial plateau to stabilize the reduced fragments and a cannulated screw was introduced over it. After closed or minimal open reduction of fracture fragments, an Orthofix hybrid external fixator was applied. A ring of appropriate size was positioned at the level of the fibular head. All wires were applied in the transverse plane, 2 from lateral to medial and the remaining 2 from antero-lateral to postero-medial. Each wire was tensioned to 1,400 N and locked to the frame. The metaphyseal fracture was reduced accurately and the body of the external fixator was applied on the ring on the antero-medial aspect of the tibia. Two pin guides were inserted down to the skin which was then incised. Pin holes were pre-drilled with a 4.8 mm drill bit and three 5/6 mm tapered self-tapping cortical pins were inserted. The fixator was clamped to the screws. It was of crucial importance that the fracture was reduced before the permanent fixation of the hybrid system. After achieving adequate reduction, the system was locked and secured. The reduction was then confirmed by C-arm. If alignment was not satisfactory, a minimal exposure of the fracture site was performed to enable the desirable reduction (Figure 1, 2).

Internal fixation, despite the advantages of direct visualization, proper and stable reduction of the articular surface as well as the acute repair of soft tissue injuries, presents also serious disadvantages, including skin or soft-tissue necrosis caused by surgical manipulations on an already damaged soft-tissue envelope and the high rate of infection, which may compromise the final result. Tscherne et al, comparing the results of surgical versus conservative treatment for tibial plateau fractures, reported improved range of motion, decreased percentage of malunion and 5% reoperation rate for the surgical group [29]. Stevens et al, presented several transoperative - postoperative complications [30], while Young and Barrack, in their series of dual plating for complex bicondylar tibial plateau fractures reported an 88% deep infection rate [31, 32]. Certain authors have treated bicondylar tibial fractures by means of a lateral fixed angular plate (FAP) through a single lateral approach, thus avoiding medial periosteal striping [33, 34]. Jiang R et al, in their prospective study comparing locked plates, to classic double plates (DP), for the repair of bicondylar tibial plateau fractures reported similar results for the two groups [35]. Nevertheless, as presented by Higgins et al., bicondylar fractures stabilized by means of a FAP present a higher rate of subsidence compared to dual plating stabilized fractures [36].

The external fixation as a definite treatment for the polytrauma patient with multiple osseous and soft tissue injuries has been described in the literature [37, 38]. Certain authors believe that external fixation should be limited to bicondylar tibial fractures with a compromised soft-tissue envelope, as a temporary stabilizing technique, prior to definite treatment [39]. In the last 2 decades, the evolution of devices and techniques of external fixation has led many surgeons to apply the principles of biologic osteosynthesis and minimally invasive surgery for the treatment of comminuted tibial plateau fractures [4, 28, 32, 39]. The development of circular and hybrid frames, the capability of axial, lateral compression and dynamization, the development of olive wires have offered new possibilities to the external fixators for the treatment of complex fractures [40]. Mahadena et al, comparing external to internal fixation, concluded that hybrid external fixation possesses theoretical advantages in terms of the soft tissues protection; however the benefit over internal fixation is modest as far as accuracy of reduction is concerned [41]. Chin et al presented 38.9% good/excellent, and 61.1% fair/poor results in his type V and VI fracture series [42]. Catagni et al, in their series of high-energy Schatzker V and VI tibial plateau fractures treated with circular external fixator, reported excellent and good results in 30 (50.85%) and 27 (45.76%) patients respectively [23]. In a similar study on type V and VI tibial plateau fractures, Katsenis et al recorded excellent or good final clinical results in 36 patients (76%) [24]. In 2009, the Canadian Orthopaedic Trauma Association, in a multicenter, prospective, randomized clinical trial of 83 S-V, VI tibial plateau fractures treated with internal or external fixation, reported similar quality of osseous reduction and ROM for both groups but lower rate of early postoperative complications and improved HSS scores for the external fixation group at the six months' follow up. However, at the two years' follow up, no significant difference in ROM, HSS scores, WOMAC and SF-36 was observed between the two groups [43]. 350c69d7ab




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