Elsevier

Injury

Volume 36, Issue 12, December 2005, Pages 1467-1475
Injury

Functional outcome of tibial plateau fractures treated with the fine-wire fixator

https://doi.org/10.1016/j.injury.2005.05.008Get rights and content

Summary

Objective

To review the functional outcome of patients with complex tibial plateau fractures treated with fine-wire fixation.

Design

Retrospective review with follow-up of patients in outpatient clinic.

Setting

Tertiary trauma center.

Patients

All patients who had fine-wire fixation for tibial plateau fractures between 1996 and January 2001 were reviewed.

Interventions

Fine-wire fixation with/without limited internal fixation for complex tibial plateau fractures.

Main outcome measures

Knee range of motion, adequacy of articular surface reduction, mechanical axis, Knee Society Clinical Rating Scale and Short-Form 36 Health Questionnaire.

Results

Eighteen of twenty-one eligible patients were available for follow-up. There were 14 Shatzker VI and 4 V fractures. Seven fractures were open. Average follow-up was 28.2 months. All fractures united. There were three cases of delayed union, all progressed to union following additional procedures and bone grafting. There were no cases of osteomyelitis, septic arthritis or deep vein thrombosis. Seven patients had Knee Society Clinical Rating Scores of good/excellent (38.9%), and 11 had fair/poor scores (61.1%). Abnormal mechanical axes and multiple co-morbid injuries were associated with poorer outcomes. Although SF-36 scores were lower in the study group compared to matched population norms, 15 of 18 patients had full or partial return to pre-injury levels of functioning.

Conclusion

Fine-wire fixation with limited internal fixation is a satisfactory method of managing complex high-energy fractures of the tibial plateau where soft tissue injury and bony comminution make traditional techniques of open reduction and internal fixation unsuitable.

Introduction

Tibial plateau fractures are injuries with potentially devastating consequences. Management, especially that of high-energy, complex tibial plateau fractures (Schatzker V and VI), continues to pose a challenge to the orthopaedic surgeon. These injuries are characterised by significant articular depression; severe fracture comminution and displacement; significant associated injury to the soft tissue envelope of the proximal tibia; and in Schatzker VI fractures, dissociation of the tibial metaphysis from the diaphysis.26, 34

The aims of treatment are anatomical reduction and stabilisation of the articular surface, restoration and maintenance of the mechanical axis of the leg, preservation of the soft tissue envelope of the proximal tibia, followed by restoration of a functional range of motion.34, 25 Inadequate treatment of these fractures may result in long term pain, instability, deformity, stiffness and ultimately post-traumatic arthritis.

A universally accepted mode of treatment for complex high-energy tibial plateau fractures remains controversial, with many authors reporting high complication rates and less than satisfactory outcomes.4, 16, 19, 21, 25, 28, 29, 34, 38, 39 Traditional methods of open reduction and internal fixation require the use of single or double buttress plates and this involves extensive stripping of the tenuous soft tissue envelope of the proximal tibia. This compromises the viability of the overlying soft tissue and devitalizes underlying bone, resulting in an unacceptable incidence of soft tissue necrosis, wound dehiscence and deep infection.6, 16, 19, 38, 39 Conventional external fixators are frequently unsuitable for fixation on the proximal side of the fracture and have been reported to have a high incidence of pin site infection and malunion.7 In addition, conventional external fixators often span the knee joint and do not allow for early range of motion in the post-operative period, leading to permanent joint stiffness.25 These concerns have led to the increased use of tensioned fine-wire external fixators which minimises iatrogenic soft tissue damage and its associated risks, provides adequate fixation of the fracture, and permits early range of motion.3, 8, 10, 14, 17, 20, 22, 28, 30, 35, 36, 37

The purpose of this study is to review our experience with the use of tensioned fine-wire fixation for complex (Schatzker V and VI) tibial plateau fractures; and to assess patient satisfaction using generic and disease specific outcome instruments.

Section snippets

Materials and methods

Patient records from 1996 to January 2001 were reviewed. Twenty-one patients with complex tibial plateau fractures were treated with the tensioned fine-wire fixator. In general, the indications for using the fine-wire fixator were severe fracture comminution or significant open injury to the tibia where traditional methods of open reduction and internal fixation were deemed unsuitable. Patients were excluded if the fine-wire fixator was applied more than 14 days after injury.

Patient case

Statistical analysis

All analysis was performed using SAS version 8.2 (SAS Institute Inc., Cary, NC, USA), and Epicalc 2000 version 1.0 (Brixton Books 1997). Statistical analysis was conducted using Wilcoxon rank-sum tests, Spearman correlation coefficients and Student's t-test where appropriate. A two-sided P-value of 0.05 was considered to be statistically significant.

Results

Union was deemed to have occurred when patients had their fine-wire fixators removed and were allowed to fully weight bear without external supports. Fifteen of 18 patients went on to union without additional operative procedures. Average time to union for this group was 14 weeks (range 11–22 weeks). Three required additional procedures for delayed union (Table 1). Patient 2 had a focus of delayed union in the tibial metaphysis, which was treated with autogenous bone graft and internal

Discussion

Fractures of the tibial plateau represent a wide spectrum of injury for which no single treatment modality can apply. Most authors agree that where possible, open reduction and internal fixation is preferred, as this is the best method of restoring anatomy and commencing early range of motion rehabilitation.4, 6, 15, 20, 25, 31 However, the benefits of surgery must be weighed against the risk of compounding injury to the surrounding soft tissues. This is especially relevant in already

Conclusion

This study evaluates our institution's experience with the use of the fine-wire fixator for high energy Schatzker V and VI tibial plateau fractures. There were no cases of deep infection or deep-venous thrombosis. Pin-site infection was common but was easily treated. The follow-up Knee Society Clinical Rating Scores were comparable to other studies. Poorer outcomes were attributed to the presence of multiple co-morbid injuries, abnormal mechanical axes of the lower limb, open fractures and poor

Acknowledgement

We wish to thank Ms. Helen Donaldson for help with the data processing.

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