Description: OTA 2002 - Session 7 Session VII - Tibia Sat., 10/12/02 Tibia, Paper #48, 4:43 PM The Use of Hybrid Fixators in Proximal Tibia Fractures Roberto Varsalona, MD ; Bruce H. Ziran, MD; S. Avondo,
MD; Q. Mollica, MD; University of Catagnia, Sicily, Italy; and University
of Pittsburgh, Department of Orthopaedics, Pittsburgh, Pennsylvania, USA Purpose: Severe proximal tibia fractures, which include intra-
and extraarticular fractures with metaphyseal-diaphyseal dissociation, pose
a difficult treatment problem for the surgeon with significant complication
rates. Use of external or internal fixation remains the main methods of
treatment, with strong advocates for each method. Although there are pros
and cons to both methods, we have found that accurate reduction (closed
or open) with hybrid fixation has provided the best results. The purpose
of this study was to report experience with a series of consecutive severe
proximal tibial fractures. Methods: We treated 118 cases of proximal tibia fracture, of which
52 were treated with hybrid external fixation as part of a protocol that
used a consistent approach and method of hybrid external fixation. Inclusion
criteria for hybrid treatment (as opposed to closed treatment) were severe
soft tissue injury, intraarticular displacement, and unstable fracture pattern
involvement (AO A2, A3, and C patterns). Patients were treated on a fracture
table with calcaneal traction. Reduction was achieved with ligamentotaxis
and percutaneous clamps when possible. If necessary, limited incisions were
used to elevate depressed fragments and place bone grafts. Articular congruity
was assessed with fluoroscopy or arthroscopy or both. Fixation of the condyles
was achieved with cannulated screws or beaded olive wires or both. The distal
frame consisted of a multi-clamp or a single clamp and used three to four
5-mm half pins. The distal frame was connected to the ring with adjustable
components (rods or a monolateral external fixator). A standard postoperative
management protocol was followed involving immediate range of motion, weight-bearing
as tolerated, and pin care. The management of the rigidity of the external
fixations began with three to four rods, and rods were progressively removed
or replaced or both with a dynamic axial monotube assembly. Clinical and
radiographic evaluation was performed at routine intervals. In addition
to routine demographic data, objective data collected included healing,
deformity, complications, and motion. Patients were also evaluated with
an SF-36 questionnaire 12 months after healing. Results: There were 52 patients with an average age of 42 years
(range,17 to 78) with a mean follow-up of 24 months (range, 12 to 30). There
were 40 men and 12 women, who sustained 31 fractures of the right leg and
21 fractures of the left leg. The mechanisms of injury were a motorcycle
accident (18 patients), a pedestrian-motor-vehicle accident (13 patients),
a motor-vehicle accident (9 patients), a fall from a height (9 patients),
being struck by an object (2 patients), and sports activity (1 patient).
There were 13 open fractures and 3 A2, 3 A3, 16 C1, 12 C2, and 18 C3 injuries.
Seven patients had other major fractures of the ipsi- or contralateral limb,
involving the femur, the shaft of the tibia, the ankle, the calcaneus, the
femur, and the distal part of the other tibia. Two patients had upper limb
fractures (one humeral and one wrist fracture). Two patients had a rupture
of the patellar ligament, necessitating repair. All proximal tibia fractures
healed without additional procedures. All patients were radiographically
and clinically healed by 24 weeks. Most patients demonstrated healing by
16 weeks. Full weightbearing was established at a mean of 8.4 weeks (range,
5 to 10). Forty-six patients (88%) achieved full extension, and the remaining
6 (11%) had an extension deficit of less than 10°. Three patients (5%)
had less than 90° of flexion, 27 had flexion beyond 100°, and 22
patients were able to flex beyond 110°. Thigh atrophy of more than 1
cm was noted in only one patient. The SF-36 profiles were health state/rate,
daily activity, work activity, emotional problems, and pain. There were
no intraoperative injuries to nerves or major vessels. Postoperative complications
included superficial pin tract infections in 15 K-wires or pins, all of
which resolved with local pin care and a short course of oral antibiotics.
One patient had a deep venous thrombosis. None required removal of the fixator
before healing of the fracture. No patient developed osteomyelitis or septic
arthritis. Accuracy of reduction was 0 to 1mm in 28 patients, 2 to 3 mm
in 19 patients, 4 to 5 mm in 4 patients, and more than 5 mm in 1 patient.
Only 5 (10%) of the 52 patients had an angular malunion greater than 6°.
One patient had a loss of reduction during treatment with hybrid external
fixation. Four patients developed a mild varus deformity, when compared
with the contralateral uninvolved knee. There were no valgus malunions and
no nonunions. Final malalignment of the tibiofemoral axis did not exceeded
3° on full-length weight-bearing radiographs. Radiographic and clinical
evidence of degenerative arthritis was seen in 12 of 52 patients (23%) 18
months after healing. Ten of these patients had C3 and 2 had C2 fracture
patterns. Six of these patients were those that had angular malunions noted
above. The remaining six patients had reductions to within 3 mm. Discussion: The benefit of restoration of normal anatomic structure
by means of an open procedure must be weighed against the risk of infection,
soft tissue complications, and malunion. Traditional open reduction and
plating carries a significant incidence of wound complications and unsatisfactory
results. Complex proximal tibial fractures sometimes require two plates
for optimal fixation, which can result in an unacceptably high rate of infection.
A hybrid fixator can maintain length and alignment while spanning a zone
of comminution in the metaphyseal-diaphyseal region. It allows for access
to any open wounds or compromised soft tissue. The device allows secondary
correction of angular or rotational deformities when necessary and also
early weightbearing and range of motion of the knee and ankle. We found
that in a fairly large series of patients with medium to long-term follow
up, the hybrid fixator performed very well from a technical standpoint.
The development of radiographic arthrosis seemed to correlate more with
the initial articular injury and alignment than to the nature of treatment.
Intuitively, the quality of reduction will obviously impact the outcome
but we were able to achieve satisfactory reductions in the majority of cases.
We found that patients were allowed to bear weight and regain excellent
knee motion. Our regimen of beginning with absolute construct rigidity in
the first 2 to 6 weeks of healing, followed by gradually decreasing the
stiffness of the frame (rod removal and conversion to monotube dynamic tube),
allowed for progressively increased load-sharing with the developing fracture
callous. In summary, we found that hybrid external fixation is a good alternative
method for treatment of meta- or epiphyseal fractures or both. The technique
and postoperative management we describe respects soft tissue and bone and
allows for early articular mobilization.