Session IX - Tibia

High-Grade Tibial Plateau Fractures: A Matched Cohort Study Comparing Internal Fixation and Ring Fixator Methods

J.P. Veri; Piotr Blachut, MD; Peter O'Brien, MD; Shafique Pirani, MD; Royal Columbia Hospital, New Westminster, BC, Canada

Displaced bicondylar fractures of the proximal tibia remain a treatment enigma. AO methods emphasize the need for open anatomical reduction and rigid internal fixation. The injury to the soft tissues is, however, usually severe, and extensive dissection for reduction and implant placement may increase the risk of infection. More recently, several authors have supported the treatment of these injuries with ring fixator techniques. No study done to date, however, has directly compared the two methods of the treatment of these complex injuries. The purpose of the present study was to compare the results of ORIF versus ring fixation for high-grade tibial plateau fractures.

The two treatment methods were compared using a matched cohort design. Between January 1988 and January 1998 all (17) patients with traumatic high-grade (Schatzker V, VI) tibial plateau fractures treated at either the Vancouver General Hospital or The Royal Columbian Hospital with ring fixation methods were selected retrospectively and matched 2:1 with a cohort of 34 patients treated over the same period with ORIF. Specific matching criteria for the comparison cohort were sex, age, single or multiple injuries, open vs closed fractures, and the specific fracture pattern. All data for both cohorts was obtained from a standardized trauma patient data base, patient charts, radiographs, and orthopaedic clinic notes.

The median ISS (9) was identical in both cohorts. 35% of fractures were open in each cohort (18% Grade IIIa, 6% IIIb, 6% IIIc). The mean follow-up was 17 months in the ORIF cohort and 15 months in the RF cohort. There was no significant difference in the mean OR time, time to union, or ROM between cohorts. However, 22/34 (64%) ORIF vs 5/17 (29%) RF patients had a wound complication (p=.018) and 15/34 (44%) ORIF vs 2/17 (12%) RF patients had an infection requiring IV antibiotics and/or operative debridement (p=.019). The mean total number of operative procedures was also significantly higher in the ORIF cohort (3.2 vs 2.0, p=.02). The mean time to return to previous level of function (14.6 vs 7.1 months, p=.002) and return to full, unaided weight-bearing (24 vs 10 weeks, p=.001) were also significantly less in the RF cohort.

Results of the present study suggest that external hybrid ring fixation is an effective and safe method for the treatment of complex fractures of the tibial plateau and may be associated with a lower wound complication rate, including infection, and an earlier return to function than open reduction and internal fixation.