Functional and radiological outcome of proximal tibia fractures managed with Ilizarov technique with or without minimal internal fixation

Document Type : Original Article

Authors

Dr. Vasantrao Pawar Medical College, Hospital and Research Centre, Nashik, India

Abstract

Background: Proximal tibia fractures are often accompanied by extensive soft tissue injuries, which lead to frequent post-operative complications like wound dehiscence, infection, and non-union. In such injuries, there is a need for anatomical reduction and stable fixation for a good surgical outcome. The surgical procedures involving internal fixation have increased the complication rate of such fractures. Ilizarov ring fixation can provide stable fixation, does not need extensive soft tissue dissection, and encourages early mobilization.
Objectives: This study aimed to assess the functional and radiological outcome of proximal tibia fractures managed with Ilizarov technique with or without minimal internal fixation.
Methods: 35 patients with either intra-articular as well as extra-articular proximal tibia fractures between January 2018 and May 2022 were included in this study. All the included patients were operated on using Ilizarov technique. The functional outcome was assessed using the Modified Rasmussen Criteria for clinical assessment, and the radiological outcome by Modified Rasmussen Criteria for radiological assessment.
Results: All patients achieved radiological union at a mean duration of 16 weeks. Full weight-bearing was also allowed at a mean of 12 weeks. Functional results were excellent in 22 cases, good in 12 cases and poor in one. Most patients achieved functional range of motion at the knee joint (average flexion 128o) except one, who had a flexion of less than 110o. Axial malalignment of less than 10o was seen in 4 cases, and articular step of less than 5 mm was seen in 2 cases.
Conclusion: Ilizarov ring fixation is an excellent method of fixation in proximal tibia fractures, both extra-articular and intra-articular. It gives stable fixation, encourages early mobilization, has a higher union rate, and prevents damage to the soft tissue envelope, which is often compromised in such fractures.

Keywords

References

  1. Buckle R, Blake R, Watson JT, Morandi M, Browner BD. Treatment of complex tibial plateau fractures with the Ilizarov external fixator. J Orthop Trauma. 1993;7:167 doi:10.1097/00005131-199304000-00044
  2. Patel T, Brod B, Ahmed SS, Khoja MZ, Sainvil F, Rizvi SA. Chronic Thromboembolic Pulmonary Hypertension (CTEPH) presenting as a right atrial myxoma-A case report and review of the literature. Novel Clin Med 2023;2(4):209-18. doi: 10.22034/ncm.2023.407925.1100
  3. Watson JT, Coufal C. Treatment of complex lateral plateau fractures using Ilizarov techniques. Clin Orthop Relat Res. 1998; 353:97-106. doi:10.1097/00003086-199808000-00012 PMid:9728164
  4. El Barbary H, Abdel Ghani H, Misbah H, Salem K. Complex tibial plateau fractures treated with Ilizarov external fixator with or without minimal internal fixation. Int Orthop. 2005;29(3): 182-5. doi:10.1007/s00264-005-0638-6 PMid:15756605 PMCid:PMC3456886
  5. Dendrinos GK, Kontos S, Katsenis D, Dalas A. Treatment of high-energy tibial plateau fractures by the Ilizarov circular fixator. J Bone Joint Surg Br. 1996;78(5):710-7. doi:10.1302/0301-620X.78B5.0780710 PMid:8836055
  6. Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto experience 1968-1975. Clin Orthop Relat Res. 1979; (138): 94-104.
  7. AO/OTA Fracture and Dislocation Classification Compendium-2018. www.aofoundation.org
  8. Tscherne H and Gotzen L. Fractures with soft tissue injuries. Berlin: Springer; 1984. doi:10.1007/978-3-642-69499-8
  9. Oestern H-J, Tscherne H. Pathophysiology and Classification of Soft Tissue Injuries Associated with Fractures. Fract with Soft Tissue Inj. 1984;3:1-9. doi:10.1007/978-3-642-69499-8_1
  10. Scotland T, Wardlaw D. The use of cast-bracing as treatment for fractures of the tibial plateau. J Bone Joint Surg Br. 1981; 63B(4): 575-8. doi:10.1302/0301-620X.63B4.7298688 PMid:7298688
  11. Ambroziak M, Durka M, Maciąg B, Hadamus A, Strzelczyk P. Intraoperative Complications in an Open Intra-articular Fracture of the Proximal Tibia. A Case Study. Ortop Traumatol Rehabil 2017;19(3):301-9. doi:10.5604/15093492.1241410
  12. Henkelmann R, Frosch KH, Glaab R, Lill H, Schoepp C, Seybold D, Josten C, Hepp P; Committee TRAUMA of the AGA-Society for Arthroscopy and Joint Surgery. Infection following fractures of the proximal tibia - a systematic review of incidence and outcome. BMC Musculoskelet Disord. 2017;18(1):481. doi:10.1186/s12891-017-1847-z PMid:29162084 PMCid:PMC5699108
  13. Arnold JB, Tu CG, Phan TM, Rickman M, Varghese VD, Thewlis D, Solomon LB. Characteristics of postoperative weight bearing and management protocols for tibial plateau fractures: Findings from a scoping review. Injury. 2017;48(12):2634-42. doi:10.1016/j.injury.2017.10.040 PMid:29102370
  14. Pandey S, Bidary S. Functional and Radiological Outcome of Schatzker Type V and VI Tibial Plateau Fracture Treated with Closed Reduction and Ilizarov Fixation with or without Minimally Invasive Screw Supplementation. J Coll Med Sci Nepal 2022;18(3):244-53 doi:10.3126/jcmsn.v18i3.47475
  15. Kumar J, Siddiqui AA, Katto MS, Jamil M, Wasim MA, Yaqoob U. Treatment of high-energy intra-articular fractures of tibia with Ilizarov external fixator in adults: A tertiary centre experience. Int J Clin Pract. 2021;75(9):e14488. doi:10.1111/ijcp.14488
  16. Naude JJ, Manjra MA, Birkholtz F, Barnard AC, Tetsworth K, Glatt V, Hohmann E. Functional Outcomes and Quality of Life Following Complex Tibial Fractures Treated with Circular External Fixation: A Comparison between Proximal, Midshaft, and Distal Tibial Fractures. Strategies Trauma Limb Reconstr. 2021;16(1):32-40. doi:10.5005/jp-journals-10080-1506 PMid:34326900 PMCid:PMC8311744
  17. Bove F, Sala F, Capitani P, Thabet AM, Scita V, Spagnolo R. Treatment of fractures of the tibial plateau (Schatzker VI) with external fixators versus plate osteosynthesis. Injury. 2018 Nov;49 Suppl 3:S12-8. doi:10.1016/j.injury.2018.09.059 PMid:30415663
  18. Kawoosa AA, Mantoo SA, Ali N, Dar GN. Clinico - Radiological Results of Tibial Bicondylar Fractures Managed with Ilizarov Technique with or without Minimal Internal Fixation. Malays Orthop J. 2022;16(1):18-27. doi:10.5704/MOJ.2203.004 PMid:35519521 PMCid:PMC9017920
  19. Subramanyam KN, Tammanaiah M, Mundargi AV, Bhoskar RN, Reddy PS. Outcome of complex tibial plateau fractures with Ilizarov external fixation with or without minimal internal fixation. Chin J Traumatol. 2019;22(3):166-71. doi:10.1016/j.cjtee.2018.11.003 PMid:31072699 PMCid:PMC6543267
  20. Hegde AS, Madegowda A, Khanna V, Rao S. Clinical and Radiological Outcome of Complex Proximal Tibia Fractures Managed with Hybrid/Ilizarov Fixator with or without Minimal Internal Fixation. Ortop Traumatol Rehabil. 2021;23(4):279-85. doi:10.5604/01.3001.0015.2365 PMid:34511431
  21. Bhowmick K, Boopalan PRJVC, Gunasekeran C, Livingston A, Jepegnanam TS. Management of Chronic Infected Intra-Articular Fractures of the Proximal Tibia with Ilizarov Ring Fixation. J Knee Surg. 2020;33(2):213-22. doi:10.1055/s-0038-1677512 PMid:30650438
  22. Debnath UK, Jha DK, Pujari PK. Results of ring (Ilizarov) fixator in high energy Schatzker type VI fractures of proximal tibia. J Clin Orthop Trauma. 2018;9(2):186-91. doi:10.1016/j.jcot.2017.08.005 PMid:29896026 PMCid:PMC5995004
  23. Markhardt BK, Gross JM, Monu JU. Schatzker classification of tibial plateau fractures: use of CT and MR imaging improves assessment. Radiographics. 2009;29(2):585-97. doi:10.1148/rg.292085078 PMid:19325067
  24. AO/OTA Fracture and Dislocation Classification Compendium-2018. https://www.aofoundation.org/trauma/clinical-library-and-tools/journals-and-publications/classification.
  25. Ibrahim DA, Swenson A, Sassoon A, Fernando ND. Classifications In Brief: The Tscherne Classification of Soft Tissue Injury. Clin Orthop Relat Res. 2017;475(2):560-564. doi:10.1007/s11999-016-4980-3 PMid:27417853 PMCid:PMC5213932
  26. Court-Brown, C. M., Paul Tornetta, I., McQueen, M. M., Ricci, W. Rockwood and Green's Fractures in Adults. (2019). United States: Wolters Kluwer Health.
  27. Solomin L. The Basic Principles of External Skeletal Fixation Using the Ilizarov and Other Devices. (2013). Italy: Springer Milan. doi:10.1007/978-88-470-2619-3
  28. Rasmussen PS. Tibial condylar fractures. Impairment of knee joint stability as an indication for surgical treatment. J Bone Joint Surg Am. 1973;55:1331-50. doi:10.2106/00004623-197355070-00001
  29. Reátiga Aguilar J, Rios X, González Edery E, De La Rosa A, Arzuza Ortega L. Epidemiological characterization of tibial plateau fractures. J Orthop Surg Res. 2022;17(1):106. doi:10.1186/s13018-022-02988-8 PMid:35183211 PMCid:PMC8858541
  30. Ranatunga IR, Thirumal M. Treament of Tibial Plateau Schatzker Type VI Fractures with the Ilizarov Technique Using Ring External Fixators Across the Knee: A Retrospective Review. Malays Orthop J. 2010;4(2). doi:10.5704/MOJ.1007.006
  31. DeCoster TA, Nepola JV, el-Khoury GY. Cast brace treatment of proximal tibia fractures. A ten-year follow-up study. Clin Orthop Relat Res. 1988;(231):196-204. doi:10.1097/00003086-198806000-00026
  32. Ruffolo MR, Gettys FK, Montijo HE, Seymour RB, Karunakar MA. Complications of high-energy bicondylar tibial plateau fractures treated with dual plating through 2 incisions. J Orthop Trauma. 2015; 29(2): 85-90. doi:10.1097/BOT.0000000000000203 PMid:25050747
  33. Khatri K, Sharma V, Goyal D, Farooque K. Complications in the management of closed high-energy proximal tibial plateau fractures. Chin J Traumatol. 2016;19(6):342-7. doi:10.1016/j.cjtee.2016.08.002 PMid:28088939 PMCid:PMC5198935
  34. Yu Z, Zheng L, Zhang Y, Li J, Ma B. Functional and radiological evaluations of high-energy tibial plateau fractures treated with double-buttress late fixation. Eur J Med Res. 2009;14(5): 200-5. doi:10.1186/2047-783X-14-5-200 PMid:19541576 PMCid:PMC3351978
  35. Unno F, Lefaivre KA, Osterhoff G, Guy P, Broekhuyse HM, Blachut PA, et al. Is early definitive fixation of bicondylar tibial plateau fractures safe? An observational cohort study. J Orthop Trauma. 2017;31:151e157. doi:10.1097/BOT.0000000000000779 PMid:28072649
  36. Barei DP, Nork SE, Mills WJ, Henley MB, Benirschke SK.. Complications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision technique. J Orthop Trauma. 2004; 18:649e657. doi:10.1097/00005131-200411000-00001 PMid:15507817
  37. Li Z, Wang P, Li L, Li C, Lu H, Ou C. Comparison between open reduction with internal fixation to circular external fixation for tibial plateau fractures: A systematic review and meta-analysis. PLoS One. 2020; 15(9): e0232911. doi:10.1371/journal.pone.0232911 PMid:32941429 PMCid:PMC7498044
  38. Hall JA, Beuerlein MJ, McKee MD; Canadian Orthopaedic Trauma Society. Open reduction and internal fixation compared with circular fixator application for bicondylar tibial plateau fractures. Surgical technique. J Bone Joint Surg Am. 2009; 91(2):74-88. doi:10.2106/JBJS.G.01165 PMid:19255201
  39. Ali AM, Burton M, Hashmi M, Saleh M. Outcome of complex fractures of the tibial plateau treated with a beam-loading ring fixation system. J Bone Joint Surg Br. 2003;85(5):691-9. doi:10.1302/0301-620X.85B5.13855 PMid:12892192
  40. Ramos T, Ekholm C, Eriksson BI, Karlsson J, Nistor L. The Ilizarov external fixator-a useful alternative for the treatment of proximal tibial fractures. A prospective observational study of 30 consecutive patients. BMC Musculoskelet Disord. 2013;14:11. doi:10.1186/1471-2474-14-11 doi:10.1186/1471-2474-14-30
  41. Catagni MA, Ottaviani G, Maggioni M. Treatment strategies for complex fractures of the tibial plateau with external circular fixation and limited internal fixation. J Trauma. 2007; 63(5): 1043-53. doi:10.1097/TA.0b013e3181238d88 PMid:17993949
  42. Ferreira N, Marais LC. Bicondylar tibial plateau fractures treated with fine-wire circular external fixation. Strategies Trauma Limb Reconstr. 2014;9(1): 25-32. doi:10.1007/s11751-014-0185-z PMid:24510395 PMCid:PMC3951617
  43. Katsenis D, Athanasiou V, Megas P, Tyllianakis M, Lambiris E. Minimal internal fixation augmented by small wire transfixion frames for high-energy tibial plateau fractures. J Orthop Trauma. 2005;19(4):241-8. doi:10.1097/01.bot.0000155309.27757.4c PMid:15795572
Archives of Trauma Research
Volume 13, Issue 1
March 2024
Pages 27-35

Files

History

  • Receive Date: 08 November 2023
  • Revise Date: 16 December 2023
  • Accept Date: 25 March 2024

Share

How to cite

Statistics