High energy plafond fractures treated by a spanning external fixator initially and followed by a second stage open reduction internal fixation of the articular surface—preliminary report

Abstract

Early open reduction and internal fixation (ORIF) with plates and screws for plafond injuries caused by skiing initially reported by Ruedi and Allgower proved inadequate for the treatment of high-energy motor vehicle accident type injuries. The purpose of our study was to review our treatment protocol using a spanning external fixator placed semi-emergently medially across the joint and a later staged ORIF of just the articular surface to achieve and maintain anatomic reduction. Methods: We preformed a retrospective study of 35 patients with 37 highly comminuted severe (OTA 43-B3 and -C3 or Ruedi type II or III) tibial plafond fractures treated by a single surgeon. All patients were treated with an initial spanning unilateral external fixator and subsequent ORIF. Radiographs were examined for: classification, number of pieces of the tibial dome, evidence of ground-glass comminution (more than three pieces <2 mm in size on CT), anatomic reduction, alignment, and presence/absence of arthritis. Results: Evidence of ground glass comminution existed in 26/37 patients (70%). Following ORIF, articular reduction was perfect (0–1 mm displacement) in 29/36 (81%), imperfect (1–3 mm) in 6/36 (17%) and poor (>3 mm) in 1/36 (3%) cases. Joint alignment was anatomical in 35/37 (96%), with 15° anterior angulation in one patient and 5° valgus angulation in another patient. Radiographic arthritis was present in 10/36 patients (28%) at latest follow-up. Joint distraction at time of reduction was present in 27/37 patients (73%). A total of 25/37 patients (65%) had no post-operative complications, while 3/37 (8%) had a joint infection requiring one patient to have hardware removed. A total of 4/37 (11%) showed loss of reduction at latest follow-up. A total of 3/37 (8%) had a secondary arthrodesis; A total of 1 (3%) had a primary arthrodesis; 1 (3%) diabetic man had a below-knee amputation after a failed arthrodesis. Discussion and conclusion: We treat severe tibial plafond fractures with a spanning external fixator at the time of injury, wait between 10 and 21 days to allow for soft tissue healing, and then perform a limited ORIF of the articular surface with canulated screws. In a group of high-energy plafond fractures, we achieved 81% good to excellent results with this protocol. We conclude that use of a spanning external fixator with delayed ORIF compares favorably with the literature.