Session IX - Tibia

The Treatment of Complex Proximal Tibial Fractures (OTA Type C) with Bridging Hybrid Fixation

James J. Hutson, Jr., MD, University of Miami, Miami, FL

Objective: Evaluate the treatment of Type "C" tibial plateau fractures with hybrid fixation incorporating bridging of the knee joint.

Design: Prospective cohort series with retrospective review.

Setting: Level 1 trauma center

Patients: Proximal tibial periarticular fractures with shaft dissociation were treated prospectively over a seven-year interval (1991-1998) with hybrid fixation. One hundred-three patients were treated. Thirty-two fractures were treated with bridging of the knee joint to facilitate and maintain reduction [21 male/11 female; average age 43 (24-68); 30 closed: one GIIIA, one GIIIC, two C1.3, five C2.3, eleven C3.1, one C3.2, thirteen C3.3, five compartment syndrome.]

Intervention: Bridging distraction of the knee joint was applied to the fracture before percutaneous or limited open reduction. The femoral fixation was removed six weeks after fixation to start rehabilitation of the knee joint. Fifteen patients had bridging and limited open reduction. Eight patients had acute bone grafts, three autologous, five allograft. Seventeen fractures had percutaneous reduction and fixation after bridging. Five patients had knee manipulation under anesthesia.

Outcome Measures: Evaluate knee function in comparison to seventy-one proximal tibial fractures not treated with bridging of the knee joint.

Results: Thirty-two fractures healed. Average frame time was sixteen weeks (11-21 wks). Average ROM was 106° flexion (80°-135°). No fracture had loss of reduction or crush down of the joint surface. Complications: ROM <90°, one (80°); septic arthritis, one (MRSA); pintract infection requiring IV antibiotics, three; pulmonary embolus, two. Seventy-one proximal tibial fractures (six A2, thirty-nine A3, seven C1, fifteen C2, four C3) were treated with hybrid fixation not crossing the knee. Ten fractures had compartment syndrome. The average range of motion was 114°. Average frame time was 24 weeks. Complications: nonunion three; deep infection one; septic arthritis one; pintract infection two; necrotizing fasciitis one. The deep infection occurred in a C3.3 fracture which had femoral crush down. Average follow-up was 2 years.

Conclusion: Bridging ligamentotaxis facilitates reduction and augments fixation of C-Type tibial plateau fractures. The average ROM, 106°, is 8° less than the 114° ROM observed in seventy-one proximal tibia fractures treated without bridging of the knee in our series. Bridging was used for fractures with greater joint comminution than non-bridging frames, but the ROM was only slightly less than fractures with lesser degrees of joint involvement. The technique allows treatment of comminuted "C" fractures with hybrid fixation. This technique has become our primary method for treating C3 tibial plateau fractures and provides stable fixation to fractures within 3-cm of the joint surface, which have proved difficult to treat with non-bridging frames.¹ (Mirsky EC, Weiner LS, Ratchis SD. OTA 1996)