International Journal of Research in Orthopaedics

Reddy SR et al. Int J Res Orthop. 2019 Sep;5(5):894-898

http://www.ijoro.org

Original Research Article

DOI: http://dx.doi.org/10.18203/issn.2455-4510.IntJResOrthop20193831

Outcome of tibial plateau fractures treated by hybrid and Ilizarov external fixation

Sandeep Raghuram Reddy*, Harshad Mohanlal Shah, Ponugoti Godhasiri

Department of Orthopaedics, M. S. Ramaiah Medical College, Bengaluru, India

Received: 25 May 2019

Revised: 18 June 2019

Accepted: 19 June 2019

*Correspondence:

Dr. Sandeep Raghuram Reddy,

E-mail: drsandeepreddy80@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Tibial plateau fractures pose a challenge to the treating surgeon especially in cases with compromised soft tissue envelope. External fixation achieves good results with minimal complications. The objective of our study was to evaluate the functional outcome of tibial plateau fractures treated by Ilizarov and hybrid external fixation.

Methods: 46 patients with tibial plateau fractures were analysed. 6 were lost to follow-up. 20 patients were treated by Ilizarov method and 20 by hybrid external fixation.

Results: Mean time for union was 24.5 weeks in Ilizarov fixator group and 28 weeks in hybrid fixator group. Mean Lysholm’s score was 86.1 in Ilizarov cases and 83.4 in hybrid fixator cases. The mean knee society score in Ilizarov fixation cases was 78.5 and 77.3 in hybrid fixator cases. At one year by Lysholm score 6 patients had fair, 10 had good and 4 had excellent result in Ilizarov group and 1 had poor, 8 had fair, 8 had good and 3 had excellent results in hybrid group. 15 patients in Ilizarov method had good and excellent knee society scores and 12 patients had good and excellent results and 1 patient had poor score in Hybrid fixator group.

Conclusions: External fixation in complicated tibial plateau fractures gives acceptable outcomes. Ilizarov external fixator has an advantage of earlier mobilization and earlier union but requires longer operation time and a bulky apparatus. Hybrid fixator on the other hand has lesser operating time and simpler construct but has less stability and longer union time.

Keywords: Tibial plateau fracture, Ilizarov fixation, Hybrid fixation

INTRODUCTION

Tibial plateau fractures constitute one of the important fractures due to involvement of weight bearing joint. High impact injuries with associated soft tissue damage further complicates the management. The main goal of treatment of these fractures is to restore the articular surface, joint stability, maintain the normal function of the knee joint, prevent lower limb malalignment, deformity, and to prevent knee osteoarthritis.1-3

The standard approach to these injuries was open reduction of the fragments and internal fixation with plates and screws.4,5 The advantage of anatomic reduction and stable fixation is attainment of early joint motion but surgical trauma on compromised soft tissues leads to wound infection which further leads to increased re-operation rates and poorer outcomes.6-9 Closed reduction or minimal open reduction and application of external fixators helps in addressing these issues.

The aim of our study was to evaluate and compare the outcomes of tibial plateau fractures treated by Ilizarov external fixation and Hybrid external fixation.

METHODS

Study included 46 patients with tibial plateau fractures. 6 patients were lost to follow up. 20 were treated by Ilizarov fixation and 20 with hybrid external fixation. All the cases were operated in MS Ramaiah Teaching Hospital, Bengaluru, between July 2011 to June 2017 by single surgeon.

Inclusion criteria

Patients with age between 21 to 70 years, both the sexes were included. Cases with closed tibia plateau fractures with skin abrasions, open tibial plateau fractures and tibial plateau fractures of type 2 to type 6.

Exclusion criteria

Exclusion criteria were the patients with associated ipsilateral limb fractures, pathological fractures of tibia, patients lost to follow up, who associated organ injuries and those who needed longer immobilization after surgery due to other injuries.

All the patients were evaluated for other injuries, haemodynamically stabilized. 3D CT scans were done to know the extent of articular injury. The time period between the trauma and the surgery varied from 8 h to 10 days with an average of 7 day. Bone grafting and minimal internal fixation with cc screws was done in severely comminuted fractures. Patients were followed up at 6 week, 3 months, 6 months and at 1 year. The functional results were measured by Lysholm’s knee score and Knee Society functional Score.10,11

RESULTS

The observations and the results of the study are shown in Table 1 and Figures 1-7 as follows. Our study included 40 cases of tibial plateau of various types as 6 patients were lost to follow-up. 20 patients were treated by Ilizarov fixation and 20 by hybrid external fixator. Union was achieved in all the patients. Figure 1 shows that of the 40 patients, 34 were male and 6 were female. Figure 2 shows that maximum patients were between 31 to 40 years. Right sided injuries were seen in 24 patients (Figure 3). Extensive soft tissue injuries were seen in 14 patients (Figure 4). Mean time for radiological union in patients treated by Ilizarov fixator was 24.5 weeks (range 15 to 32 weeks) and in patients treated by hybrid fixator was 28 weeks. Mean fixator period was 26 weeks (16-34 week) in Ilizarov and 30 week in hybrid fixator. Both the fixators were removed after 2 weeks of union (Figure 7). The functional results were measured by Lysholm’s knee score and knee society score. The mean Lysholm’s score at the end of one year was 86.1 in Ilizarov fixation cases and 83.4 in hybrid fixation cases. The mean knee society score in Ilizarov fixation cases was 78.5 and in hybrid fixator cases it was 77.3. Figure 5 shows that at end of one year by Lysholm score 6 patients had fair, 10 had good and 4 had excellent result in Ilizarov group and 1 had poor, 8 had fair, 8 had good and 3 had excellent results in hybrid fixator group. Figure 6 shows that 15 patients in Ilizarov method had good and excellent knee society scores and 12 patients had good and excellent results and 1 patient had poor score in hybrid fixator group.

Figure 1: Gender distribution. | 6 34 FEMALES MALES
Figure 1: Gender distribution.
Figure 2: Age distribution. | 8 16 7 6 3 0 5 10 15 20 < 30 31-40 41-50 51-60 >60
Figure 2: Age distribution.
Figure 3: Side incidence. | 24 16 RIGHT LEFT
Figure 3: Side incidence.
Figure 4: Associated soft tissue injuries. | 8 4 6 14 8 Abrasions contusions lacerations extensive soft tissue injury Normal
Figure 4: Associated soft tissue injuries.
Figure 5: Lysholm score in both the group patients. | 4 10 6 0 3 8 8 1 0 2 4 6 8 10 12 95-100 84-94 65-83 <64 HYBRID ILIZAROV
Figure 5: Lysholm score in both the group patients.
Figure 6: Follow up knee society functional scores in both groups. | 6 9 5 0 5 4 7 1 0 2 4 6 8 10 80-100 70-79 60-69 <60 1ILIZAROV HYBRID
Figure 6: Follow up knee society functional scores in both groups.

Pin site infection was the most common complication. Twenty patients had pin site infection, 12 in hybrid fixator patients and 8 patients treated by Ilizarov fixator. Only in two cases it required change of pins. The other complications were varus malunion seen in 3 patients treated by hybrid fixator. Knee stiffness in 4 patients treated by Ilizarov fixator (Table 1).

Figure 7: Time for union in weeks in both groups. | 3 12 4 1 8 7 3 2 0 5 10 15 31-35 26-30 21-25 15-20 HYBRID ILIZAROV
Figure 7: Time for union in weeks in both groups.
Table 1: Complications observed in both groups.
Table reproduced from source PDF page 3

DISCUSSION

Tibial plateau fractures both high velocity injury and low velocity injuries due to osteoporosis pose a challenge to the treating surgeon. Over years various treatment options have evolved to manage these complex periarticular fractures.

Various surgical techniques and approaches have been described, all with their own advantages and disadvantages. Likewise, numerous fixation options and devices are available, with their own indications, contraindications, and potential problems.12,13

Though open reduction and internal fixation achieves precise anatomic reduction, complications of wound infection are common in a patient with compromised soft tissue envelope.

The role of external fixators, either Ilizarov or hybrid fixators, has been evaluated in various studies and they reveal good results.14-16 In fractures with severe comminution use of bone graft and percutaneous screw fixation combined with external fixator gives encouraging results.

Study of hybrid fixation of tibial plateau fractures by David et al in 1994 with 22 patients showed excellent results in 13 patients, good in 3, fair in 1 and poor in 6.17 Studies by Mehmet et al in 2007 with 15 patients showed excellent results in 4, good in 5, fair in 3 and poor results in 3 patients.18 Babis et al in 2011 used hybrid fixators for tibial plateau fractures in 33 patients and achieved excellent and good results in 78.8% of patients.19 Mankar et al operated on 78 patients and achieved excellent results in 47 patients, 25 in good, fair in 2 and poor result in 1 patient.20 Aseri et al operated on 32 patients and had excellent results in 16, good in 13 and fair in 3 patients.21 Jahan et al in 2017 had excellent results in 15 patients and fair in 4 patients.22 In our study, 20 patients were operated with Hybrid external fixation. Out of 20, 3 had excellent results, 8 had good, 8 had fair and 1 patient had poor results.

Study of Ilizarov external fixation of tibial plateau fractures by Magby et al in 2005 showed excellent results in 18, good in 7, fair in 1 and poor in 2 patients.23 Study by Ferreira et al in 2011 with 11 patients showed excellent results in 6 patients, good in 2 and fair results in 3 patients.24 Elgafary et al in 2013 operated on 30 patients with Ilizarov external fixation and achieved 76% excellent and good results.25 Ramos et al had 27 patients with excellent results out of 30 operated cases.26 Bari et al in 2014 operated on 40 patients with Ilizarov external fixator and had 28 patients with excellent, 9 patients with good, 2 with fair and 1 patient with poor results.27 Aziz et al in 2016 operated on 20 patients, 18 had excellent and good results, poor in 2 patients.28 In our study, 20 patients were operated with Ilizarov external fixation. Out of 20, 4 patients had excellent results, 10 had good and 6 patients had fair results.

CONCLUSION

When compared to hybrid external fixator, Ilizarov fixator has an advantage of early weight bearing, good fracture stability and earlier union rates. Though hybrid fixator offers an advantage of less hardware, lesser operating time and better patient compliance, delayed weight bearing and delayed union are a disadvantage. Hybrid fixator offers an advantage of good knee range of movements due to unhampered knee movements with proximal half ring.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

REFERENCES

  1. 1. Bhandari M, Audige L, Ellis T, Hanson B, Evidence-Based Orthopaedic Trauma Working Group. Operative treatment of extra-articular proximal tibial fractures. J Orthop Trauma. 2003;17:591–5.
  2. 2. Agnew SG, Tibial plateau fractures. Oper Tech Orthop. 1999;9:197–205.
  3. 3. Maripuri SN, Rao P, Manoj-Thomas A, Mohanty K. The classification systems for tibial plateau fractures: how reliable are they? Injury. 2008;39(10):1216–21.
  4. 4. Schatzker J. Fractures of the tibial plateau. In: Schatzker J, Tile M (eds). Rationale of Operative Fracture Care. New York: Springer; 1987: 279-295.
  5. 5. Tscherne H, Lobenhoffer P. Tibial plateau fractures. Management and expected results. Clin Orthop Relat Res. 1993;292:87-100.
  6. 6. Moore TM, Patzakis MJ, Harvey JP. Tibial plateau fractures: Definition, demographics, treatment rationale, and long term results of closed traction management or operative reduction. J Orthop Trauma. 1987;1:97-119.
  7. 7. Mallik AR, Covall DJ, Whitelaw GP. Internal versus external fixation of bicondylar tibial plateau fractures. Orthop Rev. 1992;21:1433-6.
  8. 8. 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;18:649-57.
  9. 9. Young MJ, Barrack RL. Complications of internal fixation of tibial plateau fractures. Orthop Rev 1994;23:149-54.
  10. 10. Peccin MS, Ciconelli R, Cohen M. Specific questionnaire for knee symptoms- the Lysholm knee scoring scale. Acta Ortop. 2006;14:5.
  11. 11. Insall JN, Dorr LD, Scottt RD, Scott WN. Rationale of the knee society clinical rating system. Clin Orthop Relat Res. 1989;248:13-4.
  12. 12. Kateros K, Galanakos SP, Kyriakopoulos G, Papadakis SA, Macheras GA. Complex tibial plateau fractures treated by hybrid external fixation system: A correlation of followup computed tomography derived quality of reduction with clinical results. Int J Orthop. 2018;52(2):161-9.
  13. 13. Kokkalis ZT, Iliopoulos ID, Pantazis C, Panagiotopoulos E. What's new in the management of complex tibial plateau fractures? Injury. 2016;47:1162-9.
  14. 14. Singh H, Misra RK, Kaur M. Management of proximal tibia fractures using wire based circular external fixator. J Clin Diagn Res. 2015;9:1-4.
  15. 15. Piper KJ, Won HY, Ellis AM. Hybrid external fixation in complex tibial plateau and plafond fractures: An Australian audit of outcomes. Injury. 2005;36:178-84.
  16. 16. Watson JT, Ripple S, Hoshaw SJ, Fhyrie D. Hybrid external fixation for tibial plateau fractures: Clinical and biomechanical correlation. Orthop Clin North Am. 2002;33:199-209.
  17. 17. Stamer DT, Schenk R, Staggers B, Aurori K, Aurori B, Behrens FF. Bicondylar tibial plateau fractures treated with a hybrid ring external fixator: a preliminary study. J Orthop Trauma. 1994;8:455–61.
  18. 18. Subasi M, Kapukaya A, Arslan H, Ozkul E, Cebesoy O. Outcome of open comminuted tibial plateau fractures treated using an external fixator. J Orthop Sci. 2007;12(4):347-53.
  19. 19. Babis GC, Evangelopoulos DS, Kontovazenitis P, Nikolopoulos K, Soucacos PN. High energy tibial plateau fractures treated with hybrid external fixation. J Orthop Surg Res. 2011;6:35.
  20. 20. Mankar SH, Golhar AV, Shukla M, Badwaik PS, Faizan M, Kalkotwar S. Outcome of complex tibial plateau fractures treated with external fixator. Indian J Orthop. 2012;46(5):570–4.
  21. 21. Aseri MK, Gupta A, Khilji U. Role of hybrid external fixator in proximal tibial fractures: A prospective analysis. Int J Orthop Sci. 2017;3(1):810-3.
  22. 22. Jahan A, Haseeb M, Wazir F. Treatment of high energy tibial plateau fractures with hybrid external fixator: intermediate term outcome. Int J Res Med Sci. 2017;5(10):4582-7.
  23. 23. Hassan EB, Hisham G, Misbah H, Khaled S. Complex tibial plateau fractures treated with Ilizarov external fixator with or without minimal internal fixation. Int J Orthop. 2005;29:182-5.
  24. 24. Ferreira N, Senoge ME. Functional outcome of bicondylar tibial plateau fractures treated with the Ilizarov circular external fixator. SA Orthop J. 2011;10(3):80-4.
  25. 25. Kamal E, Wael EA, Osama F, Mohamed H, Marwa MA. Management of high-energy tibial plateau fractures by Ilizarov external fixator. Eur Orthop Traumatol. 2013;5.
  26. 26. Elsoe R, Larsen P, Petruskevicius J, Kold S. Complex tibial fractures are associated with lower social classes and predict early exit from employment and worse patient-reported QOL: a prospective observational study of 46 complex tibial fractures treated with a ring fixator. Strategies in Trauma and Limb Recons. 2018;13(1):25–33.
  27. 27. Bari MM, Shahidul I, Shetu NH, Mahfuzer RM. Complex Tibial Plateau Fractures Treated with Ilizarov Ring Fixator. MOJ Orthop Rheumatol. 2014;1(2):9.
  28. 28. Aziz MA, Fawzy S. Treatment of complex tibial plateau fractures using Ilizarov external fixator with or without minimal internal fixation. Egypt Orthop J. 2016;51:60-4.