Session II - Tibia

*Spanning External Fixation for the Initial Management of High- Energy Proximal Tibia Fractures: A Standardized Protocol

Kenneth A. Egol, MD¹; Nirmal C. Tejwani, MD¹; Edward Capla, MD¹; Philip R. Wolinsky, MD²; Kenneth J. Koval, MD¹ (e-EBI);

¹NYU-Hospital for Joint Diseases, New York, New York, USA;

²University of California at Davis, Davis, California, USA (a-New York University Hospital)

Purpose: In this institutional review board-approved prospective study, we evaluated the use of temporary spanning external fixation in the management of high-energy proximal tibial fractures with regard to soft tissue management, development of complications, and functional outcomes.

Methods: We instituted a protocol of immediate placement of knee-spanning external fixation with management of soft tissue injuries for all high-energy proximal tibial fractures. Between August 1999 and May 2002, 65 consecutive patients with 71 high-energy proximal tibial fractures (OTA types 41A, B, and C) underwent temporary knee-spanning external fixation on the day of admission. This was followed by repair of articular fractures and meta-diaphyseal fracture repair with either plate-and-screw constructs or conversion to a ring fixator when the condition of soft tissues allowed.

Orthopaedic evaluation at the latest follow-up included a clinical and radiographic examination and functional outcome measurement with the WOMAC score. Standard statistical methods were employed, with a P value of less than 0.05 considered significant.

Results: Sixty-three patients with 68 fractures were available for follow-up examination. For the purpose of this analysis, we divided the study population into two groups: those with closed fractures (group I) and those with either open fractures and or compartment syndrome on admission (group II). Group I consisted of 38 patients with 40 closed fractures. The mean time to follow-up was 19 months (range, 6 to 40). The mean range of knee motion at the latest follow up was 10° to 110°. The mean WOMAC score was 66.3 (range, 0 to 177). There were six complications in four patients, including one (3%) deep wound infection. Group II consisted of 25 patients with 28 open fractures or closed fractures with compartment syndrome. The mean time to follow-up was 16.9 months (range, 6 to 36).

The mean range of knee motion at the latest follow-up was 1° to 103°. The mean WOMAC score was 79 (range, 7 to 203). There were 11 complications in 11 patients, including five (19%) deep wound infections.

Discussion: Compared with historical controls, we had a low rate of wound infection (10% overall). There was only one wound problem in our subset of patients with closed fractures. The benefits of temporizing spanning external fixation include: osseous stabilization, access to wounds, and prevention of further articular damage. Our relatively low rates of complications in patients who sustained high-energy proximal tibial fractures and the access this technique affords in open fractures and those with compartment syndrome lead us to recommend this technique in all high-energy intra- and extraarticular fractures of the proximal tibia.

Conclusion: We recommend the use of knee-spanning external fixation for the initial management of high-energy proximal tibial fractures. Furthermore, the results of this study support the practice of delayed internal fixation until the soft tissue envelope allows for definitive fixation.

* If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options and e-consultant or employee.