Hybrid external fixation Orthofix® in complex proximal tibia fractures : a series of 22 cases Laurent GALOIS, Jérome Diligent, Elie Choufani, Didier MAINARD University Hospital of Nancy France L.GALOIS Prof, MD, PhD L.GALOIS Prof, MD, PhD

Introduction Proximal tibia fractures are often high- energy injuries with extensive comminution and metaphyseal—diaphyseal disassociation and soft-tissue problems.Proximal tibia fractures are often high- energy injuries with extensive comminution and metaphyseal—diaphyseal disassociation and soft-tissue problems. Many modalities of treatment are available including traction, external fixation and open internal fixation.Many modalities of treatment are available including traction, external fixation and open internal fixation. We reviewed the outcomes of patients with proximal tibia fractures who were treated with hybrid frames in our department between 2002 and 2005.We reviewed the outcomes of patients with proximal tibia fractures who were treated with hybrid frames in our department between 2002 and 2005.

Material and methods We reviewed twenty-two cases of proximal tibial fractures treated with the hybrid frame Orthofix®.We reviewed twenty-two cases of proximal tibial fractures treated with the hybrid frame Orthofix®. Fractures were classified according the AO system for proximal tibia fractures.Fractures were classified according the AO system for proximal tibia fractures. Two investigators reviewed all X-rays and classified the fractures in this study to minimise intraobserver variability.Two investigators reviewed all X-rays and classified the fractures in this study to minimise intraobserver variability.

Material and methods (2) Initial and recent X-Rays were assessed for fracture alignment and joint congruence.Initial and recent X-Rays were assessed for fracture alignment and joint congruence. Bone union was assessed using clinical and radiological criteria. Bone union was assessed using clinical and radiological criteria. Clinical outcome was assessed using the Lysholm and Hospital for Special Surgery (HSS) scores.Clinical outcome was assessed using the Lysholm and Hospital for Special Surgery (HSS) scores.

Score de Lysholm DouleurDouleur –Aucune 25 –Légère lors d’exercices intenses 20 –Importante lors d’exercices intenses 15 –Importante après marche > 2kms 10 –Importante après marche < 2 Kms 5 –Constante 0 InstabilitéInstabilité –Aucun dérobement 25 –Rarement lors d’exercices intenses 20 –Fréquente lors d’exercices intenses 15 –Occasionnelle lors de la vie quotidienne 10 –Fréquente lors de la vie quotidienne 5 –A chaque pas 0 Blocage ou accrochageBlocage ou accrochage –Aucun 15 –Accrochage 10 –Blocage occasionnel 6 –Blocage fréquent 2 –Blocage permanent 0 GonflementGonflement –Aucun 10 –Lors d’exercices intenses 6 –Lors d’activités ordinaires 2 –Constant 0 Montée d’escaliersMontée d’escaliers –Normale 10 –Légère gêne 6 –Une marche à la fois 2 –Impossible 0 AccroupissementAccroupissement –Pas de gêne 5 –Légère gêne 4 –Pas au-delà de 90° 2 –Impossible 0 BoiterieBoiterie –Aucune 5 –Légère ou occasionnelle 3 –Importante et constante 0 SoutienSoutien –Aucun 5 –Canne ou béquille 2 –Station debout impossible 0

Score HSS Douleur : 30Douleur : 30 –Au repos : aucune (15), légère (10), modérée (5), sévère (0) –À la marche : aucune (15), légère (10), modérée (5), sévère (0). Fonction 22Fonction 22 –Marche et station debout : sans limite (12), PM 1/2h (10), PM de 1 à 5 et debout 1/2h (10), PM de 1 à 5 et debout <1/2h (8), PM< 1 block (4), Marche impossible (0), –Montée d’escaliers : sans limitation (5), avec aide (2) –Transfert : sans limitation (5), avec aide (2). Force du quadriceps 10Force du quadriceps 10 –Excellente contre résistance (10), –Bonne mais diminuée contre résistance (8), –Passable permettant mobilité sans résistance (4), –Médiocre ne permettant pas mobilité complète (0). Flexum 10Flexum 10 –Aucun (10), –Moins de 5° (8), –5 à 10° (5), –Plus de 10° (0). Laxité frontale 10Laxité frontale 10 –Aucune (10), –0 à 5° (8), –5 à 15° (5), –Plus de 15° (0). Amplitude de mobilité 18Amplitude de mobilité 18 –1 point pour 8° d’amplitude. Points négatifs :Points négatifs : –1 canne, déformation frontale par 5° de varus ou valgus : -1 –1 béquille, perte d’extension active de 5° : -2 –2 béquilles, perte d’extension active de 10° :- 3 –perte d’extension active de 15° : -5

Operative procedure 1st step : closed fracture reduction on orthopaedic table, image intensification1st step : closed fracture reduction on orthopaedic table, image intensification 2nd step : limited percutaneous approaches and complementary percutanous osteosynthesis (if necessary) : cannulated screws2nd step : limited percutaneous approaches and complementary percutanous osteosynthesis (if necessary) : cannulated screws 3rd step : K wire and ring insertion3rd step : K wire and ring insertion 4th step : diaphyseal screw insertion, fracture reduction and fixator body assembling4th step : diaphyseal screw insertion, fracture reduction and fixator body assembling

1st step : closed fracture reduction on orthopaedic table, image intensification

2nd step : limited percutaneous approaches and complementary percutanous osteosynthesis (if necessary) : cannulated screws

3rd step : K wire and ring insertion

4th step : diaphyseal screw insertion, fracture reduction and fixator body assembling

Results 12 M and 10 F12 M and 10 F mean age of the patients : 49 years.mean age of the patients : 49 years. mean follow-up : 2 yearsmean follow-up : 2 years Fractures were classified according the AO system as followed: 41 A (1 case), 41 B (1 case) and 41 C (20 cases).Fractures were classified according the AO system as followed: 41 A (1 case), 41 B (1 case) and 41 C (20 cases). Nine patients had open injuries.Nine patients had open injuries. A complementary internal fixation was performed in 7 cases.A complementary internal fixation was performed in 7 cases.

Results Bone union was obtained after 13 weeksBone union was obtained after 13 weeks The average duration of external fixation was 20 weeksThe average duration of external fixation was 20 weeks A partial weight bearing was allowed for 10 weeks as an average and full weight bearing at mean 14 weeksA partial weight bearing was allowed for 10 weeks as an average and full weight bearing at mean 14 weeks The mean HSS score was 82.9The mean HSS score was 82.9 The mean Lysholm score was 81.2.The mean Lysholm score was Knee ROM averaged 115°.Knee ROM averaged 115°.

Results Four patients had 5-10° of valgus malalignment at analysis of films of fracture union.Four patients had 5-10° of valgus malalignment at analysis of films of fracture union. All fractures had joint congruence of 2mm).All fractures had joint congruence of 2mm).

Results 2 cases of superficial pin site infection (without extension to the bone)2 cases of superficial pin site infection (without extension to the bone) No cases of wound infectionNo cases of wound infection One case of deep venous thrombosisOne case of deep venous thrombosis One case of peroneal nerve palsy (resolved spontaneously at 5 months)One case of peroneal nerve palsy (resolved spontaneously at 5 months)

F 78 yF 78 y C2 closed fractureC2 closed fracture Bone union after 12 weeksBone union after 12 weeks

F de 57 yF de 57 y C3 open fracture C3 open fracture

Percutaneous screw + external fixatorPercutaneous screw + external fixator Bone union 14 weeks Flexion 120°Flexion 120° –HSS = 83 –Lysholm = 91

Discussion The treatment of high-energy fractures of the proximal tibia is fraught with complications because – of metaphyseal and articular comminution, – the frequent occurrence of associated open wounds, compartment syndrome, and severe soft-tissue injury The advantages of external fixation : –minimize the risks of wound complications and infection –Can be used even in case of poor bone quality

Discussion External fixation = similar results than classical internal plating (AO device) in term of bone union and functionExternal fixation = similar results than classical internal plating (AO device) in term of bone union and function 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

Alternative technic :Alternative technic : fixed-angle locking plates using percutaneous procedures –Hernanz Gonzalez Y, Early results with the new internal fixator systems LCP and LISS: a prospective study. Acta Orthop Belg Hernanz Gonzalez Y, Hernanz Gonzalez Y, –Initial reports in the literature have shown excellent results, with low complication rates,

The combination of fracture comminution and the injured soft-tissue envelope presents risks for treatment that are not avoided by fixed-angle screws or smaller operative approache : -infection and malalignment

Conclusion Orthofix hybrid fixator appear to be a good solution for comminuted fractures.Orthofix hybrid fixator appear to be a good solution for comminuted fractures. The technique has a short learning curve but must be very strictThe technique has a short learning curve but must be very strict External fixator must be placed meticulously after closed fracture reduction.External fixator must be placed meticulously after closed fracture reduction. The use of a 2/3 ring is suitable rather than a full circumference ringThe use of a 2/3 ring is suitable rather than a full circumference ring The use of the orthopaedic table is suitable to improve the quality of fracture reductionThe use of the orthopaedic table is suitable to improve the quality of fracture reduction