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Year : 2022  |  Volume : 15  |  Issue : 3  |  Page : 145-150

Study of surgical and functional outcome in the management of proximal tibial fracture with circular wire-based external fixation

1 Department of Orthopaedic, Burdwan Medical College, Bardhaman, West Bengal, India
2 Department of Orthopaedics, Rampurhat Government Medical College and Hospital, Rampurhat, West Bengal, India
3 Department of Pathology, Burdwan Medical College, Bardhaman, West Bengal, India

Date of Submission09-Feb-2022
Date of Acceptance09-Mar-2022
Date of Web Publication21-Sep-2022

Correspondence Address:
Soma Ghosh
Bahir Sarbomangala Road, Near IIHT Computer Centre and Carnival Marriage Hall, Burdwan - 713 101, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/hmj.hmj_20_22

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Background: The principle of treatment in proximal tibial fracture includes soft tissue care, restoring articular surface congruity and reduction of anatomical alignment enabling early joint mobility. Aim: Assessing surgical, and functional outcomes by evaluating pain, range of motion (ROM) and muscle power in circular wire-based external fixation procedure in proximal tibial fractures with complications. Objectives: Documenting clinical observations, preoperative, and postoperative symptoms in the study population with time for bony union and complications. Materials and Methods: Thirty patients aged 18–70 years with proximal tibial fractures excluding polytrauma and pathological fracture cases were included in the prospective observational study. Surgery and post-operative follow-up were done at 6, 12, 24 weeks and 6 months. Functional assessment is done by the knee society score system. Removal of fixator followed evidence of clinical and radiological union with advice for full weight bearing. Results: Road traffic accident was a major injury, right laterality more than left. The type of tibial fractures was 41A2, A3 and C3. Eighty per cent of patients had no persistent residual pain after fracture union; 80% showed normal relative to age walking capacity, and 95% showed normal to <10° lack of extension. Fourteen patients had ROM of 125° and 120° in ten. Twenty-six patients showed normal stability in extension and 20° flexion. Twenty-five patients showed excellent knee scores, 24 showed excellent functional scores; four showed good knee scores and five showed good functional scores. Post-operative complications included pin-tract infection in four patients followed by delayed and non-union in one patient each. Conclusion: Circular wire-based external fixation in the proximal tibial fracture is an effective method of treatment even with moderate soft-tissue injury showing excellent to good functional outcome.

Keywords: Fixation, fracture, reduction, soft tissue, tibia

How to cite this article:
Mondal T, Ghosh S, Ghosh S. Study of surgical and functional outcome in the management of proximal tibial fracture with circular wire-based external fixation. Hamdan Med J 2022;15:145-50

How to cite this URL:
Mondal T, Ghosh S, Ghosh S. Study of surgical and functional outcome in the management of proximal tibial fracture with circular wire-based external fixation. Hamdan Med J [serial online] 2022 [cited 2022 Oct 7];15:145-50. Available from: http://www.hamdanjournal.org/text.asp?2022/15/3/145/356437

  Introduction Top

Proximal tibial fracture comprises 1% of all fractures and 8% of fractures encountered in older persons. They can present with either displacement, depressed articular surface or tibial condylar involvement.[1] The treatment focuses on maintaining soft-tissue integrity, restoring conformation of an articular surface, anticipating post-traumatic degenerative joint disease and early mobilisation.[1] Soft tissue is often intolerant to extensive dissection and has significant implications in the surgical management of underlying bony injury. The complications including stiffness of the knee joint with arthritis, infection of deeper tissues, malunion and non-union can be intrinsic in the management of proximal tibial fracture.[1],[2]

Open reduction and internal fixation (ORIF) with plate and screw in tibial fractures focus on the anatomical reduction of articular surface coupled with early mobilisation.[2] However, such modality of internal fixation complicated with soft-tissue envelops injury and application of bulky metallic hardware found to be associated with deep sepsis and chronic osteomyelitis in approximately 10%–20% of cases.[2] Heightened awareness of the importance of soft-tissue management has led to the development of the percutaneous reduction technique which aims in reducing risk. Circular fixation has emerged as a useful treatment option in high energy injury where the injured soft-tissue envelope often precludes ORIF.[3],[4] The studies conducted on comminuted complex proximal tibial fractures emphasising the role of external fixation with ring and wire showed encouraging results. The device used in this procedure is lightweight, inexpensive and simple to use. Even, though the procedure is minimally invasive, taking care of a further soft-tissue injury, thereby averting the need for big incisions and allowing close monitoring with wound nursing.[3],[4]

Assessment of the surgical, functional outcome by evaluating pain, range of motion (ROM) and muscle power in circular wire-based external fixation procedure with complications was the aim of the study. The objectives included documenting clinical observations and pre-operative and post-operative symptoms in the study population of fractures in the proximal tibia. Time for bony union noted with a rate of non-union and complications.

  Materials and Methods Top

The study was conducted in a tertiary health care institute in West Bengal after obtaining clearance from the Institutional Ethics Committee abiding by recommended ethical guidelines and written informed consent from participating patients for a period of 18 months. The study population included thirty patients of ages ranging from 18 to 70 years attending orthopaedic emergency and out-patient departments with clinical, imaging findings of proximal tibial fractures. The inclusion criteria were Gustellio-Anderson type 1, 2, 3A and 3B open fracture of proximal tibia; tibial plateau fracture type 3 onward (Schatzker et al. classification), and AO type 41A, 41C[5] [Figure 1]. Patients excluded were with polytrauma and pathological fractures.
Figure 1: Pre-operative tibia fracture

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The study design was a hospital-based prospective observational one. Documentation of age, gender with comorbidity, type of injury, laterality of fracture, and associated soft-tissue injuries done. The neurovascular status of the affected leg, presence of compartment syndrome, and any blisters or open wounds were also noted. The radiographic images were reviewed to note the type of fracture, location and extent of articular depression with fracture extension to the diaphysis, if present. Surgery was conducted following basic radiological, blood investigations, and anaesthetic fitness reports. Post-surgical follow up done at 6, 12, 24 weeks, and 6 months for the functional assessment using the Knee Society Score System (KSS).[6]

Patients underwent surgery under spinal anaesthesia following pre-operative counselling and informed written consent. They were kept on fast for 6 h and administered systemic antibiotics 30 min prior to the surgical procedure. The abdomen, thigh, knee and leg were prepared and tranquilisers were given as advised by the anaesthetist. Instruments used were dynamic tension wire, olive wire, bayonetting wires, universal clamps, nuts, bolts, tubular rods, Schanz pin, Ilizarov half external fixator ring, and spanners. The measurement of extended articular condylar depression is made from the persisting articular surface or from a line drawn as an extension of the other tibial condyle to point of maximum depression [Figure 2].
Figure 2: Immediate post-operative

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Measurement of widened condyle made with reference to the undamaged femoral condyle. Immediate irrigation with debridement of open fractures is done before fixation. The timing for surgery was not affected by compartment syndrome, abrasion, contusion, crushing or marked swelling of the affected area with skin blister. The position of patient was supine on a radiolucent operating table. Implants and band instruments are kept ready on the table. The close reduction was performed with help of ligamentotaxis under image intensifying television. On achieving adequate reduction, a wire was placed through a safe tissue zone in the proximal tibia. Two or three counter opposed olive wires (eccentric location of 4 mm beads on 1.8 mm Kirschner wires) were placed in the juxta-articular bone in support of soft cancellous bone fragments, parallel to fragment of condyle and perpendicular to the major fracture lines, acting in lag fashion providing maximum intercondylar compression. The ring was attached by the wires which were tensioned up to 30 kg with a dynamic tensioner increasing the stability of the construct. Wires crossing angles were attempted at more than 60° to increase anterior-posterior bending stability.

The juxta-articular pins were placed at a minimum distance of 14 mm from the joint surface preventing synovial contact. The position of each wire was central in the midportion of the ring. In addition, a transverse bayonetting wire or anterior pin was placed to increase varus, valgus, or anterior-posterior bending stability, respectively. The wire ring assembly was connected to the distal tibial fracture fragment using connecting rods, universal clamps, and a schenz pin. The anterior crest of the tibia allowed a clearance of 1.5 cm for fixator rings and of 3–4 cm around the posterior calf accommodating post-operative swelling. The restoration of the mechanical axis is done with utmost care with reference to the condyles [Figure 2].

Accompanying meniscal, cruciate or collateral ligament injuries were ignored at this stage. Patients were kept nil orally for 4–6 h post-operatively. Intravenous (IV) fluids were given with IV antibiotics for 2 days with subsequent administration of oral antibiotics for 3 days. Analgesics with tranquilisers were given accordingly. The wound was dressed on the 2nd–4th postoperative day and the patient was discharged on the 4th day. Patients underwent physiotherapy sessions of passive and active assisted knee mobilization exercises from the first post-operative day.

Regular cleaning of the pin tract was done with povidone-iodine. Reaching the ground weight-bearing bearing was prohibited until evidence of radiological union. Establishment of fracture union made on radiography images and clinically assessing at post-surgical follow-up visits scheduled at 3, 6, 12, 18 and 24 weeks [Figure 3], [Figure 4], [Figure 5]. The patient was monitored for complications if any and KSS criteria were applied for assessing functional outcomes. The circular external fixator was removed and advice for full weight-bearing was given with the evidence of clinical as well as a radiological union. The ensuing instruction for walking was given with a removable long leg brace for a few days.
Figure 3: Post-operative 3months

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Figure 4: Post-operative 6 months

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Figure 5: Post-operative 12 months

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  Results Analysis Top

Final results were evaluated in terms of severity of fractures, functional recovery, and post-operative complications such as pin-tract infection, malunion, non-union and implant failure. Grading of the results was made as excellent, good, fair and poor. The patients had proximal tibial fractures (AO 41A and C), Schatzker type 5 and 6. Twenty-four (80%) of thirty patients were male and six (20%) were female in the study population. Eleven patients were aged 31–40 years, eight with ages within 41–50 years, six in the range of 21–30 years and five were in between 51 and 55 years. Nineteen patients suffered from right-sided fractures and 11 from the left side. Road traffic accident (RTA) was the principle mechanism of injury in twenty-eight patients and two patients gave a history of falls. Twelve patients presented with fracture type 41 A2; 15 with 41 A3 and three with 41 C3.

A maximum number of patients (80%) presented with no persistent residual pain after fracture union (score 50). Occasional pain was present in 14% of cases (score 45). Walking capacity was normal with respect to age in 80% of patients (score 50) while 20% could walk more than ten blocks (score 40). The lack of an extension was <10° (score-5) in 27 patients, three patients showed 10°–20° lack of extension (score-10). Fourteen patients had ROM of 125° (score 25) while ten patients had ROM of at least 120° (score 24). Twenty-six patients showed normal stability in extension and flexion of 20° (score-15), whereas four patients showed abnormal stability in flexion of 20° (score-12). Twenty-five patients showed an excellent knee score (83.4%); four showed a good score (13.4%) and only one patient showed a poor score (3.2%).

In context to functional scores, 24 patients showed excellent scores (80%); five showed good scores (16.7%) and one patient showed fair scores (3.3%). The postoperative complications comprised pin-tract infection in four cases and delayed union in one case which was managed by bracing and delayed weight-bearing. Unfortunately, non-union was found in one patient with comorbidity of diabetes mellitus Type II. This patient was counselled and columnar plating is done with bone grafting for the management of complications. Pin-tract infection was regularly dressed with normal saline and usage of local antibiotic drops.

  Discussion Top

The challenge of management of proximal tibial fractures is prominent in high-energy trauma cases. The wide variation of methods for treating these complex injuries includes limited open reduction and stabilisation with percutaneous screw, ORIF, indirect reduction and application of hybrid or circular external fixation device.[7] The relevant factors that control the treatment and outcome of intra-articular tibial fractures were assessed in the present study. The study population comprised 30 patients with emphasis on age, sex, mechanism of injury, type of fracture, knee ROM and complications. They were treated with circular wire-based external fixation and functional score on subsequent follow-up was assessed.

Lansinger et al. found a mean age of 55 in their study population of 260 tibial plateau fractures where the ratio of male and female was 1.2:1. They found that 45% of cases were caused by RTA, 33% by falls and 22% by other causes.[8] Dendrinos et al. reported the mean age of 39 years in a study population of 24 cases with a male-to-female ratio of 3:1.[9] Marsh et al. found a male-to-female ratio of 5.6:1 in their study population of 21 complex tibial plateau fractures.[4]

They reported 65% cases by RTA, 15% by fall, 15% from assault and 5% cases of sports injury. Further, right side involvement was found in 70% of cases; left laterality in 25% of cases and 5% had bilateral involvement where surgery was conducted within 1st week in 52% of cases.[10] Hohl and Luck found a male-to-female ratio of 1.58:1 in their study. They found 67% cases from RTA, 26% due to falls and 7% cases from other causes. Left laterality was found in 52% and right side involvement in 48% and surgery was conducted with an average delay of 8 days.[10],[11] Rasmussen found a mean age of 55 years in their study population of 260 tibial plateau fractures.[12] He found RTA in 45% of cases and equal incidence of involvement of left and right tibial plateau. On the contrary, Honkonen and Järvinen found a male-to-female ratio of 0.67:1 in their study and B. B. Porter found a ratio of 0.82:1. Honkonen and Järvinen reported 45% RTA, 17% domestic falls, 8.5% sports injuries, 11% work-related injuries and 18.5% other leisure time injuries.[13]

Fractures of proximal tibia result from strong valgus or varus forces combined with an axial loading. Comminuted fractures happen with axial load in excess of eight thousand pounds which takes place in a fall from a height on an extended knee or due to a high energy motor vehicle accident. RTA was the most frequent cause of fracture (90%) in the present study. High energy fractures (AO 41A2, A3) were associated with RTA including adjoining ligament and meniscus injuries leading to chances of skin and soft-tissue complications. The present study showed a mean age of 39.45 years and commonly affected patients belonged to 31–40 years where the ratio of male and female was 4:1. There were no significant differences in the outcome and appropriate method of fixation with respect to age and gender in the present study. Right-sided fracture cases were more than left with no bilateral involvement. Laterality had no influence on treatment or outcome. Most commonly encountered were 41A3 fractures followed by A2 and C3.

All A2 and A3 fracture cases were caused by high-velocity RTA injury associated with abrasions, superficial white blisters and soft-tissue injuries. The low energy types were associated with less soft-tissue injury. Khatri et al. in their study found the management of fractures being done within 14 days in most patients; however, in five cases, delay exceeded 2 weeks. The ring fixator method is advantageous in operating on all patients without delay.[14] In the present study, all cases were done within 5 days of admission. The duration of surgery was 1 h 15 min (ranging from 50 min to 1 h 30 min) with an average blood loss of <50 ml (ranging from 30 ml–60 ml).

Hutson and Zych found pin site infection in 10% of cases in a meta-analysis of 16 studies of 568 tibial plateau fractures.[15] There was no complication of septic arthritis or deep infection in their study. The ideal distance of the most proximal tibial pin should be 14 mm distal to the joint line caring for the capsule of the knee joint and subsequent septic arthritis.[15] Parameswaran et al. reported ring fixators with the lowest incidence of infection compared to hybrid external and unilateral fixators. This close technique is advantageous in reducing the risk of wound contamination even with extended surgical timing compared to open tibial plateau plating.[16] Four patients had a pin-tract infection, two each from AO type 41A2 and 41C3 in the present study where one patient (41C3) presented with delayed union. A complication of intolerance or pin loosening related to the external fixation device was not observed in the present study.

Formation of soft callus needed a minimum of 6 weeks in the present study and union was evident in an average of 14.6 weeks with resultant early healing. Kumar and Whittle reported evidence of fracture union in an average of 24.71 weeks[17] and 26.57 weeks was reported by Behrens and Searls.[18] Tucker et al. reported healing without bone grafting in all fractures in a mean union time of 25.6 weeks.[19]

The pain was considered as one of the criteria for functional grading of the KSS system with a score ranging from 50 (no pain) to 0 (severe). Kumar et al. reported pain while walking in 20% of cases of type six tibial plateau fracture and 80% of cases of type four and five.[20] Lalić et al. reported moderate pain in 45 of 50 patients.[21] There was no persistent pain following fracture union in the maximum number of patients (80%) in the present study (score 50) and mild to occasional pain in 13.4 cases (score 45).

Eventual impaired ROM in tibial plateau fractures was found where damage to extensor retinaculum was evident and irregular joint surface from inflicted initial trauma or surgical exposure or both. Extension lag was reported in 3 of 33 cases by Ariffin et al.; in 7 of 24 cases by Dendrinos et al. and in 5 of 43 cases by Reddy et al.[9],[22],[23] In the present study, 14 patients (46.7%) had flexion of at least 125° (score 25) and 10 patients (33.3%) had flexion of at least 120° (score 24) at final follow-up with significant improvement of ROM immediately after fixator removal. Post-surgical early motion and programmed physiotherapy are the standard care. This ROM is better than ROM reported by Ali.[24] Immobilising the knee joint for up to 6 weeks does not adversely affect the ultimate knee ROM.

However, Ali et al. found patients with cross knee flexion showed poor results.[25] The lack of extension in the present study was mainly due to inadequate exercise and prolonged immobilisation. Physiotherapy including knee mobilising exercises has immense importance for an excellent ROM of the knee. An efficient and well-trained physiotherapy department helped a lot for early functional recovery in the present study. The functional outcome was excellent to good in high-energy proximal tibial fractures with minimal soft-tissue complications.

This procedure is attributed to rigid fixation which is considered essential for early aggressive rehabilitation. Full ROM retrieval depends on early and aggressive knee mobilisation, in ensuring optimal functional recovery and ultimate patient satisfaction. The study conducted on circular fixator treated high energy tibial fractures by Babis et al. found excellent and good results in 85% of cases.[26] Catagni et al. reported a progressive increase in patients' ROM at consecutive clinical evaluations in their study. Their study comprised of circular external fixator treated grade five and six tibial plateau fractures where they reported excellent results in 50.85% cases and good in 45.76%.[27] Kataria et al. used a small wire external fixator with beaded 'olive' wires in their study where they reported 94.7% excellent and good functional results.[28] However, on using a ring fixator and beaded olive wires 81.8% excellent and good functional scores were reported by Khan et al.[29] In the present study, excellent results were found in 25 (83.4%) patients and good in four (13.4%). The study is, however, limited by its small size, short follow-up period and not including radiological outcomes.

  Conclusion Top

Circular wire-based external fixation in closed tibial plateau fractures (AO 41 C) is an effective method of treatment even with a moderate soft-tissue injury. Articular reduction is possible while restoring maximum joint stability and congruity. This technique proved to give excellent to good functional outcomes with comparative better outcomes in AO 41 C1 and C2 fractures. Proper handling of soft tissue can minimise commonly encountered postoperative superficial infection.

Ethical clearance

The study was approved by the institutional ethics committee of Burdwan Medical College with approval number : BMC/563 dated 13/02/2019.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Azar Frederick M, Beauty James H, Terry Canale S. Fractures of the lower extremity. In: Campbell's Operative Orthopaedics. 13th ed., Vol. 3. Ch. 54.Philadelphia: Elsevier; 2017. p. 770-2774.  Back to cited text no. 1
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. 2
Kateros K, Galanakos SP, Kyriakopoulos G, Papadakis SA, Macheras GA. Complex tibial plateau fractures treated by hybrid external fixation system: A correlation of followup computed tomography derived quality of reduction with clinical results. Indian J Orthop 2018;52:161-9.  Back to cited text no. 3
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Marsh JL, Theddy FS, Agel J, Broderick S, Creevey W. Fracture and dislocation classification compendium-2007: Orthopaedic trauma association classification, data-base and outcome committee. J Orthop Trauma 2007;21 Suppl 10:S1-133.  Back to cited text no. 4
Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto experience 1968--1975. Clin Orthop Relat Res 1979;138:94-104.  Back to cited text no. 5
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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;77:661-73.  Back to cited text no. 7
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Dendrinos GK, Kontos S, Katsenis D, Dalas A. Treatment of high-energy tibial plateau fractures by the Ilizarov circular fixator. J Bone Joint Surg Br 1996;78:710-7.  Back to cited text no. 9
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Khatri K, Lakhotia D, Sharma V, Kiran Kumar GN, Sharma G, Farooque K. Functional evaluation in high energy (Schatzker Type V and Type VI) tibial plateau fractures treated by open reduction and internal fixation. Int Sch Res Notices 2014;2014:589538.  Back to cited text no. 14
Hutson JJ Jr., Zych GA. Infections in periarticular fractures of the lower extremity treated with tensioned wire hybrid fixators. J Orthop Trauma 1998;12:214-8.  Back to cited text no. 15
Parameswaran AD, Roberts CS, Seligson D, Voor M. Pin tract infection with contemporary external fixation: How much of a problem? J Orthop Trauma 2003;17:503-7.  Back to cited text no. 16
Kumar A, Whittle AP. Treatment of complex (Schatzker Type VI) fractures of the tibial plateau with circular wire external fixation: Retrospective case review. J Orthop Trauma 2000;14:339-44.  Back to cited text no. 17
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Ali AM, Burton M, Hashmi M, Saleh M. Outcome of complex fractures of the tibial plateau treated with a beam-loading ring fixation system. J Bone Joint Surg Br 2003;85:691-9.  Back to cited text no. 25
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