High-energy Proximal Tibia Fractures Research Articles

A hospital based assessment of the clinical and radiological outcome of extra-articular metaphyseal proximal tibia fractures treated with proximal tibia plates using MIPPO technique using Rasmussen’s scoring system

Aim: To assess the clinical and radiological outcome of extra-articular metaphyseal proximal tibia fractures treated with proximal tibia plates using the MIPPO technique using Rasmussen’s scoring system. Materials and Methods: Data related to demographics, mechanism of injury, details of trauma, hospitalization detail, operation description, post-operative rehabilitation, complications, clinical and functional outcomes were collected during the period of hospital stay and follow-up visits in the OPD clinic. Follow-up was conducted regularly at the interval of 4 weeks. The patients were followed up in the outpatient department. At the follow-up, a thorough clinical and radiological evaluation was done for the progress of union, healing of trauma wound, and joint stiffness. Once the fracture had shown early signs of union, partial weight bearing was started on the injured limb. On follow up, the patients were evaluated clinically and radiologically according to the proforma decided (Modified Rasmussen’s criteria for clinical and Radiological evaluation). Results: Majority (83.34%) of the patients in our study were males between the age group of 21-60 years. 90% of the patients had high energy proximal tibia fractures, which were caused by road traffic accidents (RTA) with a peak incidence in the fourth and fifth decade of life. Total 5 patients developed a superficial infection which was resolved by daily dressings and parenteral antibiotics. Rasmussen’s score was applied to assess functional and radiological outcomes. In our study, according to Rasmussen’s clinical scoring, 66.67% of patients had excellent, 12% of patients had well and 10% of patients had fair results. In our study, according to Rasmussen’s radiological scoring, 80% of patients had excellent and 20% of patients had good results. Conclusion: MIPPO is a relatively new concept in fracture management; but with the improved instrumentation and implants, it has the potential to become one of the mainstays of fracture management in the years to come.

Is pin-plate overlap in tibial plateau fractures associated with increased infection rates?

IntroductionDespite advances in the treatment of high energy proximal tibia fractures, including the utilization of staged management with external fixation, the infection rate remains high. Overlap between external fixator pin sites and definitive internal fixation has been proposed as a risk factor for infection. MethodsThis retrospective study reviews 244 patients with staged knee-spanning external fixation followed by delayed definitive internal fixation at two separate level one trauma centers. Presence of pin-plate overlap as well as several other known risk factors for infection were recorded and measured to include open fractures, compartment syndrome, operative time and number of incisions. Development of deep infection was the primary outcome. Both univariate and multivariate statistics were applied to determine differences in rates of infection. Results65 (26.6%) patients had presence of pin-plate overlap while 179 (73.4%) patients had no overlap. There were no differences between overlapping and non-overlapping groups with respect to other infectious risk factors. Deep infection occurred in 34 (13.9%) total patients, 18 (27.7%) were in patients with pin-plate overlap and 16 (8.9%) in those without overlap. (P = 0.003; RR 3.01, 95% CI 1.51–4.76). DiscussionThis large, multicenter study demonstrated a statistically significant association between pin-plate overlap and the development of deep infection in tibial plateau fractures. On multivariate analysis, pin-plate overlap was identified as an independent risk factor for infection. When treating these complex injuries, surgeons should consider the definitive fixation construct when placing external fixation pins.

Result of Ring Fixator in High-energy Schatzker Type VI Fractures of Proximal Tibia

Background: Significant articular depression, separation of both condyles, diaphyseal comminution and dissociation, and loss of soft-tissue envelope integrity are all associated with high-energy proximal tibia fractures (Schatzker VI). Over the past 50 years, there has been a lot of research on plating problems in these complicated fractures. For the care of these complex injuries, Ilizarov devised a new method (ring fixator).
 Aim of the Study: To examine the outcomes of patients who received a ring fixator for the treatment of high-energy proximal tibia fractures (Schatzker VI).
 Materials and Methods: Fourteen patients (mean age 36) were treated with the Ilizarov fixator and transfixion wires for high-energy fractures of the proximal tibia (Schatzker VI). Nine of the patients had open fractures, and five of them had significant soft tissue damage. They were all tracked for an average of 19.4 months. The result was analyzed using the criteria set by Honkonen & Jarvinen (1992).
 Results: Thirteen fractures healed in an average of 14.6 weeks, with one taking six months. Twelve patients recovered complete extension, while eight others regained more than 110 degrees of flexion. All of the patients knees were stable, except one who had a minor varus deformity. Nine patients walked normally, while four had a little limp. Except for one, all of the knees exhibited an articular step-off of less than 4 mm and normal axial alignment. Six knees were found to be outstanding, five to be decent, and three to be fair. There were no instances of postoperative skin infection or septic arthritis, however, three patients did have a pin tract infection that was effectively managed.
 Conclusion: The technique is suitable for the treatment of complex proximal tibia fractures when there is substantial comminution at the fracture site as well as soft tissue damage (Schatzker VI).

Clinical and Radiological Outcome of Complex Proximal Tibia Fractures Managed with Hybrid/Ilizarov Fixator with or without Minimal Internal Fixation.

Complex high grade proximal tibia fractures with associated extensive soft tissue injury pose a management challenge. The timing of surgery and fracture fixation options depend upon the extent of soft tissue damage. Post-operative complications such as wound breakdown, infection and infected non-union are common in such cases managed early with open reduction and internal fixation. Such fractures can be treated with primary closed reduction and Ilizarov/hybrid fixator application. It is a retrospective cross sectional study conducted at two tertiary care multispecialty hospitals to report the mid-term clinical and radiological outcomes of complex high grade proximal tibia fractures. These injuries were managed by closed reduction and external fixation with/without minimal internal fixation as a definitive procedure and outcome measures were checked with serial radiographs and functional scores at a regular interval of follow up. 17 patients with Schatzker's type 5 or 6 proximal tibia fractures with soft tissue compromise were operated on at two tertiary care referral centres from 2017 to 2019. These cases were operated on by two experienced trauma surgeons. Periodic follow-up was done and radiological and functional progression noted from case records. Average time to union was noted to be 12.59 weeks and mean time of fixator removal was 21.4 weeks. At the end of 1 year of follow-up, average range of motion was 121.76 degrees, average WOMAC score was 74.81(63-82) and KOOS score was 78.24(63-85). 1. Hybrid/Ilizarov fixator method is a safe way of fixing high energy proximal tibia fractures. It is associated with a good functional outcome, less soft tissue complications and allows early weight bearing. 2. We recommend this method of treatment for complex high grade proximal tibia fractures.

Strategies to minimize soft tissues and septic complications in staged management of high-energy proximal tibia fractures.

Soft tissues (wound dehiscence, skin necrosis) and septic (wound infection, osteomyelitis) complications have been historically recognized as the most frequent complications in surgical treatment of high-energy proximal tibia fractures (PTFs). Staged management with a temporary external fixator is a commonly accepted strategy to prevent these complications. Nonetheless, there is a lack of evidence about when and how definitive external or internal definitive fixation should be chosen, and which variables are more relevant in determining soft tissues and septic complications risk. The aim of the present study is to retrospectively evaluate at midterm follow-up the results of a staged management protocol applied in a single trauma center for selective PTFs. The study population included 24 cases of high-energy PTFs treated with spanning external fixation followed by delayed internal fixation. Severity of soft tissues damage and fracture type, timing of definitive treatment, clinical (ROM, knee stability, WOMAC and IOWA scores) and radiographic results as well as complications were recorded. Complex fracture patterns were prevalent (AO C3 58.3%, Schatzker V-VI 79.1%), with severe soft tissues damage in 50% of cases. Mean time to definitive internal fixation was 6days, with double-plate fixation mostly chosen. Clinical results were highly satisfying, with mean WOMAC and IOWA scores as 21.3 and 82.5, respectively. Soft tissue complication incidence was very low, with a single case of wound superficial infection (4.3%) and no cases (0%) of deep infection, skin necrosis or osteomyelitis. Staged management of high-energy PTFs leads to satisfying clinical and radiographic results with few complications in selected patients.

Mid term results of staged management of high-energy proximal tibia fractures

Background: Proximal tibial fractures with high energy trauma are extremely complex injuries with significant associated soft-tissue damage. This Retrospective study was used to evaluate the results of staged management of high-energy proximal tibia fractures regards of soft-tissue management, development of complications and functional outcomes. Materials and Methods: This retrospective study includes 50 patients who had sustained high energy Proximal tibial fractures were managed at our institute. In all patients, we placed immediate temporary distraction external fixation with management of soft-tissue injuries with delayed definitive fixation. The mean clinical and radiographic follow-up was 4 year (range 36-72 months) and functional outcome was assessed by knee society score. Results: The mean follow-up is minimum 4 year (range 36-72 months) with KSS was good in 33 cases (66%), fair in 12 cases (24%) and poor in 5 (10%) at latest follow-up. The complications includes 7 patients (14%) suffered superficial infection, deep infection was observed in 5 patients (10%), 2 patients had developed compartment syndrome. 2 patients had deep venous thrombosis. Malalignment included 5 (10%) cases of residual varus and 4 (8%) cases of residual valgus deformity. Conclusion: Mid-term results shows use of staged management protocol, with the initial application of a temporary distraction external fixator followed by delayed internal fixation, is suggested for treatment of high energy tibial plateau fractures. The benefit of this protocol includes bony stabilization, access to soft tissues and prevention of further articular damage and relatively low rates of complications in patients who sustain high-energy proximal tibia fractures.

Two Staged Management Of Proximal Tibial Fractures With Impending Compartment Syndrome By Temporary External Stabilisation And Fasciotomy And Delayed Definative Fixation

Introduction: High energy proximal tibia fractures with soft tissue involvement presenting with dicolored patches over the leg and severe swelling, compound wounds, blisters with tight compartments and absent or feeble dorsalis pedis or posterior tibial arteries warrant to go in for a staged procedure. In patients with multiple injuries, an external fixator can be applied quickly with minimal blood loss for unstable periarticular fractures around the knee. Two-stage procedures involve (1) early joint spanning external fixators with fasciotomy for the medial and posterior compartments, (2) and late definitive fixation with plates or nails and with skin grafting. Materials and Methods: In our study, we present a short series of 15 proximal tibial fractures with impending compartment syndrome. Patients selected for this study were (1) closed proximal tibia fracture intra- and peri-articular and metaphysis diaphysis junction communited and noncommunited fractures (2) impending compartment syndrome evaluated based on excessive swelling, tight compartments, blisters over skin, feeble or absent dorsalis pedis or posterior tibial pulsations, color Doppler suggestive of severe subcutaneous edema associated with monophasic or absent flow over distal arteries. Exclusion criteria: (1) Low energy proximal tibia fracture without soft tissue insult and compound wounds over the proximal tibia fractures, (2) associated popliteal artery injuries. Conclusion: With the initial application of a bridging external fixator followed by delayed internal fixation protocol for pilon fractures has been successful in reducing the historically high rates of wound complications associated with these high-energy injuries. As well this protocol allows the use of minimally invasive plate osteosynthesis technique which is based on a combination of the principles of stability, restoration of anatomy and early motion while eliminating the need for excessive soft tissue dissection. Keywords: Proximal Tibial fractures, External fixators, Fasciotomy, Definitive fixation.

English

BACKGROUND : Proximal tibial fractures with high energy trauma are extremely complex injuries with significant associated soft-tissue damage. This Retrospective study was used to evaluate advantage of two stage reconstructions as a protocol in management of high- energy proximal tibia fractures regards of soft-tissue management, development of complications, and functional outcomes. MATERIALS AND METHODS : This retrospective study includes 40 patients who had sustained high energy Proximal tibial fractures were managed at our institute. In all patients, we placed immediate temporary distraction external fixation with management of soft-tissue injuries with delayed definitive fixation. The mean clinical and radiographic follow-up was 1year (range 12-18 months), and functional outcome was assessed by knee society score. RESULTS : The mean follow-up is minimum 1 year (range 12-18 months) with KSS was good in 26 cases (65%), fair in 10 cases (25.0%) and poor in 4(10.0%) at latest follow-up. The complications includes 6 patients (15%) suffered superficial infection, deep infection was observed in 4 patients (10%), 2 patients had developed compartment syndrome. 2 patients had deep venous thrombosis. Malalignment included 4 (10%) cases of residual varus and 3 (7.5%) cases of residual valgus deformity. CONCLUSION : The use of this protocol, with the initial application of a temporary distraction external fixator followed by delayed internal fixation, is suggested for treatment of high energy tibial plateau fractures. The benefit of this protocol includes access to soft tissues, and prevention of further articular damage and relatively low rates of complications in patients who sustain high-energy proximal tibia fractures. In addition, this protocol allows use of MIPO technique which is based on combination of the principles of stability, restoration of anatomy and early motion, while eliminating the need for excessive soft tissue dissection.

Staged Management of High Energy Proximal Tibia Fractures with Severe Soft Tissue Damage

통신저자:김 영 모 대전시 중구 대사동 640번지 충남대학교 의과대학 정형외과학교실 Tel:042-280-7352ᆞFax:042-252-7098 E-mail:osdr69@cnu.ac.kr 접수: 2008. 11. 2 심사 (수정): 2008. 12. 12 게재확정: 2009. 5. 3 Address reprint requests to:Young-Mo Kim, M.D. Department of Orthopaedic Surgery, Chungnam National University School of Medicine, 640, Daesa-dong, Jung-gu, Daejeon 301-721, Korea Tel:82-42-280-7352ᆞFax:82-42-252-7098 E-mail:osdr69@cnu.ac.kr 심한 연부 조직 손상을 동반한 고 에너지 경골 근위부 골절에서의 단계적 치료

Late Recognized Vascular Injury after High-energy Fracture of the Proximal Tibia: a Pitfall to Know in Current Practice.

Failure to recognize associated soft-tissue injuries after high-energy proximal tibia fractures is not uncommon. Despite the progress in managing these complex injuries, a prompt diagnosis of associated arterial injuries still remains difficult. A high index of suspicion for arterial damages is nevertheless mandatory in these severe fractures. Treatment protocols have been developed to reduce the previously reported high rates of amputation and permit an optimal management of soft-tissue and an acceptable functional outcome. We report here a well-documented case of a severely displaced proximal tibia fracture that illustrates the problem of diagnosing and managing the associated vascular injuries.

Less invasive stabilization system for high-energy fractures of proximal tibia

目的 总结应用微创内固定系统( LISS)治疗胫骨近端骨折的临床经验,讨论应用指征及手术技巧.方法分析 2003年 11月～ 2004年 6月间应用 LISS 治疗的 22例高能量胫骨近端骨折,其中男 16例,女 6例,平均年龄 41.8岁( 22～ 69岁).按 AO分型: 41- A型 7例 ,41- C型 15例.其中 9例合并其它骨折, 5例为开放性骨折( Gustilo Ⅲ A 3例,Ⅲ B 2例).结果平均随访 15个月( 12～ 17个月). 22例完全愈合; 2例发生浅表感染,经保守治疗痊愈;患者完全负重时间 15.2周( 12～ 18周); X线愈合时间 14.5周( 11～ 17周). 1例术后 6个月随访出现关节面复位丢失,无固定失效及力线不正;关节活动度平均为 2°( 0°～ 15°)～ 98.6°( 60°～ 120°);按照 Johner- Wruhs胫骨骨折临床疗效评价法,术后 6个月功能优 13例,良 7例,中 2例,差 0例,优良率为 90.9%.结论 LISS治疗胫骨近端骨折,特别是干骺端粉碎的骨折具有较好的力学稳定性,骨折愈合率高,软组织损伤小,并发症发生率低,是一种有效的 治疗手段.但作为新型的固定系统其有特殊的手术技巧及指征,临床应用时应充分理解。

Staged Management of High-Energy Proximal Tibia Fractures (OTA Types 41)

This study evaluated the use of a staged protocol involving temporary spanning external fixation and delayed formal definitive fixation in the management of high-energy proximal tibia fractures (OTA types 41) with regard to soft-tissue management, development of complications, and functional outcomes. Two level-one trauma centers and a tertiary care orthopaedic center. Fifty-three patients with 57 high-energy tibial plateau fractures. The authors instituted a protocol of immediate placement of knee spanning external fixation with management of soft-tissue injuries for all high-energy proximal tibia fractures. Between August 1999 and May 2002, 62 consecutive patients with 67 high-energy proximal tibia fractures (OTA types 41A, B, C) underwent temporary knee spanning external fixation on the day of admission. Nine patients with 10 fractures who transferred care after initial stabilization or sustained an extraarticular fracture were excluded. The remaining 53 patients with 57 fractures underwent repair of articular fractures and meta-diaphyseal fracture repair with plates and screw constructs or conversion to a ring fixator. These patients had a mean age of 47 years (standard deviation (SD), 14). Of these 53 patients, 42 (79%) were men and 11 (21%) were women. Characteristics of the 57 fractures were: 42 Schatzker VI (74%), 12 Schatzker V (21%), 2 Schatzker IV (4%), and 1 Schatzker II (2%). There were 41 closed fractures and 16 open fractures. (One patient had bilateral fractures with 1 extremity open and 1 closed). Orthopaedic evaluation at latest follow-up included a clinical and radiographic examination and functional outcome measurement with the Western Ontario McMaster functional knee score (WOMAC). Eight patients with 8 fractures were lost to follow-up. This left 45 patients with 49 fractures with a mean follow-up of 15.7 (SD, 5.7; range, 8-40) months. Complications included 3 (5%) deep wound infections, 2 (4%) nonunions, and 2 patients (4%) with significant knee stiffness (<90 degrees). Nine patients (16%) underwent additional surgery after definitive skeletal stabilization related to their injury. Range of knee motion at final follow-up was 1 degrees (SD, 4) to 106 degrees (SD, 15). The mean WOMAC was 91 (SD, 55). Poor results did not correlate with demographic or injury characteristics. We had a relatively low rate of wound infection in these complex injuries (5% overall). There was only 1 wound problem in our subset of patients with closed fractures and 2 infections in those with open fractures. One downside of this technique may be residual knee stiffness. The benefits of temporizing spanning external fixation include osseous stabilization, access to soft tissues, and prevention of further articular damage. Our relatively low rates of complications in patients who sustain high-energy proximal tibia fractures and the access this technique affords in open fractures and those with compartment syndrome lead us to recommend this technique in all high-energy intra-articular and extra-articular fractures of the proximal tibia. This study supports the practice of delayed internal fixation until the soft-tissue envelope allows for definitive fixation.