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TRAUMATOLOGY Table of Contents   
Year : 2005  |  Volume : 39  |  Issue : 3  |  Page : 163-165
Management and follow up of tibial plateau fractures by 'T' clamp external fixator and limited internal fixation


Department of Trauma and Orthopaedics, Manipal Northside Hospital, Bangalore, India

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   Abstract 

Background: Tibial plateau fractures are difficult to treat especially when soft tissue is compromised by open reduction and internal fixation. Many methods have be1en tried in the past to manage these cases of which external fixation were shown to be effective as they limit the soft tissue and wound complications.
Methods: Complex tibial plateau fractures of sixteen patients were treated by closed reduction, fixation of articular fragments by screws and application of unilateral external fixator. The external fixator was kept in place till fracture united clinically and radiologically. The patients were followed up for at least one year to assess the function of the knee joint
Results: The average duration of external fixation was 13 weeks. All the fractures healed. Pin track infection (five patients) and instability (six patients) of the knee were encountered with this procedure. The average duration of follow up was 62 weeks. The mean range of motion was 1250 arc. The IOWA knee score averaged 90.3 points.
Conclusions: External fixation with limited internal fixation may be effective in the management of complex tibial plateau fractures which requires further support from studies with large sample size. 'T' clamp external fixation with limited Internal fixation is the procedure of choice when alignment, stability, early mobilisation is required in a soft tissue compromised tibial plateau fractures.

Keywords: Tibial plateau fracture; ′T′clamp external fixator; IOWA kne1e scores; pin track infection

How to cite this article:
Thimmegowda M, Kurpad S R, Kurpad K, Srinivasan K. Management and follow up of tibial plateau fractures by 'T' clamp external fixator and limited internal fixation. Indian J Orthop 2005;39:163-5

How to cite this URL:
Thimmegowda M, Kurpad S R, Kurpad K, Srinivasan K. Management and follow up of tibial plateau fractures by 'T' clamp external fixator and limited internal fixation. Indian J Orthop [serial online] 2005 [cited 2018 Dec 17];39:163-5. Available from: http://www.ijoonline.com/text.asp?2005/39/3/163/36707

   Introduction Top


Complex fractures of tibial plateau include the condylar fracture with or without metaphyseal extension along with ligamentous injury. These fractures are very difficult to treat as alignment and stability cannot be restored accurately [2] .

Though stable reduction can be achieved and obtained by internal fixation [3] , associated soft tissue injury might lead to wound complications [4] . Therefore external fixation was tried in these fractures to limit the soft tissue and wound complications. The benefits, risks and outcome of external fixation have been reported by very few studies in the literature [5],[6] . The objective of the present study was to analyse the outcome of 'T' clamp external fixation and limited internal fixation for tibial plate fractures.


   Methods and Material Top


Sixteen patients with fractures of tibial plateau were treated by closed reduction, fixation of the articular fragments by screws and 'T' clamp external fixation between 1999 and 2002. Indications were tibial condylar fracture involving medial plateau, bicondylar fracture, intraarticular fracture with dissociation of shaft from condyles and severe soft tissue injury. Local depression fractures and simple split were not treated by this method. The fractures were classified according to the criteria of Schatzker et al [7],[8] as type IV (1 patient), type V (2 patients) and type VI (13 patients) [Figure - 1]a.

The operation was performed with the patient under spinal anaesthesia, on a fracture table under fluoroscopic control. The local complications like abrasion (nine patients) and blisters (seven patients) were noticed in addition to diffuse soft tissue swelling. The limb was elevated over Bohler-Braun splint. The blisters were punctured under sterile condition and fluid let-out with sofratulle dressings. The condyles were reduced and aligned by longitudinal traction tied to the foot (ligamentotaxis). The medial and lateral condyles were compressed with eschmarch bandage, stabilized using patellar reduction clamp, and occasionally fragments were elevated using percutaneous Steinmann pin. One or two 6.5 millimeters cancellous screw was placed close to the articular surface directed latero-medially. Two or three cancellous-bone fixator pins were placed in the proximal condylar fragments, beneath the 6.5 mm cancellous screw in the axial plane. Two to three Schanz screws were placed in the tibial shaft longitudinally. The AO tubular rod was then applied to the pins through universal clamp, transverse 'T' clamp [Figure - 1]b and all the nuts were tightened with the entire construct looking in 'T' shaped manner. The alignment was evaluated by fluoroscopy. Ligaments and menisci were not repaired.

Postoperatively all the patients were managed with a third-generation cephalosporin for forty-eight hours and heparin till discharge. The limbs were elevated until swelling of the soft tissue resolved. Tight wraps were left on both the proximal and distal pin clusters for about 10 days. Assisted active movement of knee was initiated after 48 hours once the check X-ray was satisfactory. The patients were ambulated with non-weight bearing initially. They were followed up for 6 weeks, 12 weeks, 16 weeks and 20 weeks with radiographs, thereafter if necessary. The fixator remained in place until the fracture united clinically and radiologically. All the patients were provided with knee brace and allowed weight bearing about a month from fixator removal.

At the latest follow up visits, the IOWA knee score [9] questionnaire was given to the patients to asses the function of the knee. A score of 100 points being assigned to a normal knee, 90 to 100 points was considered excellent; 80 to 89 points as good; and 70 to 79 points as fair.


   Results Top


All the patients in the study group were men, with an average age of 43 years (22 -64 years). Left sided fracture and right sided fracture were equal in number. All the patients met with motorcycle accident with skid and fall (nine cases) or hit and fall (seven cases). All the fractures were of closed type. Nine patients got admitted within 24 hours (range 1-9 days) of injury. Twelve patients underwent external fixation in less than 48 hours (range1-7 days). The mean duration of surgery was 1 hour 25 minutes. Nine patients received primary treatment in the form of above-knee slab with calcaneal pin traction. Four patients had associated diabetes mellitus and two patients had hypertension. One patient had associated radial styloid and 4th metacarpal fracture and other had clavicle fracture.

The average hospital stay of patients was 10 days (7-21 days). All the fractures healed without additional procedures. The average duration of follow up was 62 weeks (range 14 - 189 weeks). The time to union judged both clinically and radiologically [Figure - 1]c averaged 17 weeks (range 13-22 weeks). Most of them had external fixator on for about 13 weeks (range 9-18 weeks). Five patients had pin track infection of which, one patient underwent debridement along with antibiotics and in other four patients infection resolved with antibiotics after fixator removal. There was no compartment syndrome in any of our patients.

Two patients had varus instability and one of them in addition had antero-posterior instability. Valgus instability was seen in four patients. One patient had mild recurvatum and another with 10 0 fixed flexion deformity of knee. Early changes of osteoarthritis were evident in seven patients. The knee range of movements averaged 125 0 (110 - 135 0 ).

The average IOWA knee score was 90.3 points (70 to 100 points) of which, eight patients had above 90 points. Out of sixteen patients, two patients got their external fixator removed recently; hence IOWA knee score was inapplicable in them. In remaining fourteen patients, nine patients had excellent results, one had qood result and rest of the three performed fairly. The patient, who had least score, was mainly due to recurvatum and varus fixation. Those patients with less than 90 points reported some difficulties with functional activities such as kneeling, squatting and stair-climbing.


   Discussion Top


Alignment and stability are very difficult to achieve in complex fractures of tibial plateau. Simple fractures can be treated by cast-brace, skeletal tractions, arthroscopically assisted fixation" and closed reduction and percutaneous screw [12] and fixation. Most of the Schatzker type IV to VI tibial plateau fracture can be managed by open reduction and internal fixation [3],[13] ,external fixator [6] , ring fixator [14] or medial external fixator with lateral plate fixation's. External fixation and limited internal fixation was reported to be effective in the treatment of complex tibial fractures [6] . Lasinger et al [16] have reported that long-term outcome depends more on the stability of the knee and less extensive operations may lead to satisfactory results. Though internal fixation can achieve more accurate alignment and' stability, the risk of wound complications are higher. The technique used in the present study, use of cancellous screw and a 'T' clamp design biplanar fixator applied to half-pins is technically very simple.

The 'T' clamp biplanar external fixation method is far superior than uniplanar external fixation is proved earlier by many studies. Accurate reduction of the articular surface may not be obtained by indirect reduction and external fixation compared with that obtained with open reduction. Koval et al [18] have also reported about difficulties encountered with indirect reduction. The articular surface in some of our patients was imperfectly reduced was reflected by low IOWA knee score and developed post-traumatic osteoarthritis later.

The instability of the knee could be due to primary ligamentous injury, imperfectly reduced articular surface or residual osseous depression. Since we did not open the joint, menisci and cruciate ligaments were neither visualized nor treated surgically. In the present study, we encountered antero-posterior instability in one patient because of incorrect fixation. Varus and valgus instability was primarily due to tear in the ligaments with potential disadvantage on external fixation. No patient had displacement of fracture fragments at latest follow up.

External fixation limits soft tissue and wound complications seen with internal fixation. In the present study there were no early wound breakdowns or early infection of the fracture site. About five patients developed pin track infection, which settled with antibiotics. Contrary to a study by Marsh Et al [6] , we did not encounter any cases of septic arthritis.

To conclude, complex tibial plateau fractures can be successfully treated by closed reduction, fixation of articular fragments by screws and application of 'T' clamp biplanar external fixator as evident by our study. The reduction was done by longitudinal traction using fracture table. Healing occurred in all the patients. Pin track infection and instability were the two main complications encountered with this procedure. Most of the patients had satisfactory results at the time of follow-up as indicated by IOWA knee score. Studies with larger sample size should be conducted to strengthen our results.

 
   References Top

1.Gaudinez RF, Mallik AR, Szporn M. Hybrid external fixatior of com­ minuted tibial plateau fractures. Clin Orthop. 1996; 328:203-10.  Back to cited text no. 1    
2. Delamarter R, Hohl M. The cast brace and tibial plateau fractures. Clin Orthop. 1989; 242: 26-31.  Back to cited text no. 2    
3. Mills WJ, Nork SE. Open reduction and internal fixation of high-energy tibial plateau fractures. Orthop Clin North Am. 2002; 33:177-98.  Back to cited text no. 3    
4. Mallik AR, Covall DJ, Whitelaw GP. Internal versus external fixation of bicondylar tibial plateau fractures. Orthop Rev. 1992;21(12):1433-6  Back to cited text no. 4    
5. Murphy CP, D'Ambrosia R, Dabezies EJ. The small pin circular fixator for proximal tibial fractures with soft tissue compromise. Ortho­pedics. 1991; 14:273-80.  Back to cited text no. 5    
6. Marsh JL, Smith ST, Do TT. External fixation and limited internal fixation for complex fractures of the tibial plateau. J Bone Joint Surg (Am). 1995; 77:661-673.  Back to cited text no. 6    
7. Muller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classification of fractures. New York; Springer, 1990.  Back to cited text no. 7    
8. Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto experience 1968-1975. Clin Orthop. 1979; 138: 94-104.  Back to cited text no. 8    
9. Merchant TC, Dietz FR. Long-term follow-up after fractures of the tibial and fibular shafts. J Bone Joint Surg (Am). 1989; 71:599-606.  Back to cited text no. 9    
10. Apley AG. Fractures of the lateral tibial condyle treated by skeletal traction and early mobilisation; a review of sixty cases with special reference to the long-term results. J Bone Joint Surg (Br). 1956; 38:699­708.  Back to cited text no. 10    
11. O'Dwyer KJ, Bobic VR. Arthroscopic management of tibia[ plateau fractures. Injury. 1992; 23:261-4.  Back to cited text no. 11    
12. Keogh P, Kelly C, Cashman WF, McGuinness AJ, O'Rourke SK. Percutaneous screw fixation of tibial plateau fractures. Injury. 1992; 23(6):3879  Back to cited text no. 12    
13. Tscherne H, Lobenhoffer P. Tibial plateau fractures. Management and expected results. Clin Orthop. 1993; 292:87-1 00.  Back to cited text no. 13    
14. Buckle R, Blake R, Watson JT, Morandi M, Browner BD. Treat­ment of complex tibial plateau fractures witfi the ilizarov external fixator. J Orthop Trauma. 1993; 7: 167-168.  Back to cited text no. 14    
15. Ries MD, Meinhard BP. Medial external fixation with lateral plate internal fixation in metaphyseal tibia fractures. A report of eight casee associated with severe soft-tissue injury. Clin Orthop. 1990; 256:215­23.  Back to cited text no. 15    
16. Lansinger 0, Bergman B, Korner L, Andersson GB. Tibial ccndylar fractures. A twenty-year follow-up. J Bone Joint Surg (Am). 1986; 68:13-19.  Back to cited text no. 16    
17. 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.  Back to cited text no. 17    
18. Koval KJ, Sanders R, Borrelli J, Helfet D, DiPasquale T, Mast JW. Indirect reduction and percutaneous screw fixation of displaced tibial plateau fractures. J Orthop Trauma. 1992; 6:340-6  Back to cited text no. 18    

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Correspondence Address:
M Thimmegowda
Dr K Srinivasan clinic, No.57, 17 th 'A' cross, 8th main, Malleswaram, Bangalore - 560055, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5413.36707

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This article has been cited by
1 Proximal tibial fractures with impending compartment syndrome managed by fasciotomy and internal fixation A retrospective analysis of 15 cases
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[Pubmed] | [DOI]



 

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    Abstract
    Introduction
    Methods and Material
    Discussion
    Results
    References
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