Staged management of high-energy proximal tibia fractures (OTA types 41): The results of a prospective, standardized protocol

Kenneth A. Egol, Nirmal C. Tejwani, Edward L. Capla, Philip R Wolinsky, Kenneth J. Koval

Research output: Contribution to journalArticle

173 Citations (Scopus)

Abstract

Objectives: This study evaluated the use of a staged protocol involving temporary spanning external fixation and delayed formal definitive fixation in the management of high-energy proximal tibia fractures (OTA types 41) with regard to soft-tissue management, development of complications, and functional outcomes. Setting: Two level-one trauma centers and a tertiary care orthopaedic center. Patients: Fifty-three patients with 57 high-energy tibial plateau fractures. Methods: The authors instituted a protocol of immediate placement of knee spanning external fixation with management of soft-tissue injuries for all high-energy proximal tibia fractures. Between August 1999 and May 2002, 62 consecutive patients with 67 high-energy proximal tibia fractures (OTA types 41A, B, C) underwent temporary knee spanning external fixation on the day of admission. Nine patients with 10 fractures who transferred care after initial stabilization or sustained an extraarticular fracture were excluded. The remaining 53 patients with 57 fractures underwent repair of articular fractures and meta-diaphyseal fracture repair with plates and screw constructs or conversion to a ring fixator. These patients had a mean age of 47 years (standard deviation (SD), 14). Of these 53 patients, 42 (79%) were men and 11 (21%) were women. Characteristics of the 57 fractures were: 42 Schatzker VI (74%), 12 Schatzker V (21%), 2 Schatzker IV (4%), and 1 Schatzker II (2%). There were 41 closed fractures and 16 open fractures. (One patient had bilateral fractures with 1 extremity open and 1 closed). Orthopaedic evaluation at latest follow-up included a clinical and radiographic examination and functional outcome measurement with the Western Ontario McMaster functional knee score (WOMAC). Eight patients with 8 fractures were lost to follow-up. This left 45 patients with 49 fractures with a mean follow-up of 15.7 (SD, 5.7; range, 8-40) months. Results: Complications included 3 (5%) deep wound infections, 2 (4%) nonunions, and 2 patients (4%) with significant knee stiffness (<90°). Nine patients (16%) underwent additional surgery after definitive skeletal stabilization related to their injury. Range of knee motion at final follow-up was 1° (SD, 4) to 106° (SD, 15). The mean WOMAC was 91 (SD, 55). Poor results did not correlate with demographic or injury characteristics. Discussion: We had a relatively low rate of wound infection in these complex injuries (5% overall). There was only 1 wound problem in our subset of patients with closed fractures and 2 infections in those with open fractures. One downside of this technique may be residual knee stiffness. The benefits of temporizing spanning external fixation include osseous stabilization, access to soft tissues, and prevention of further articular damage. Our relatively low rates of complications in patients who sustain high-energy proximal tibia 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-articular and extra-articular fractures of the proximal tibia. Clinical Relevance: This study supports the practice of delayed internal fixation until the soft-tissue envelope allows for definitive fixation.

Original languageEnglish (US)
JournalJournal of Orthopaedic Trauma
Volume19
Issue number7
DOIs
StatePublished - Aug 2005

Fingerprint

Tibia
Knee
Open Fractures
Joints
Closed Fractures
Wounds and Injuries
Wound Infection
Orthopedics
Compartment Syndromes
Soft Tissue Injuries
Tibial Fractures
Trauma Centers
Lost to Follow-Up
Ontario
Articular Range of Motion
Tertiary Care Centers
Extremities
Demography

Keywords

  • Complications
  • External fixator
  • Spanning
  • Staged management
  • Tibial plateau fracture

ASJC Scopus subject areas

  • Surgery
  • Orthopedics and Sports Medicine
  • Physical Therapy, Sports Therapy and Rehabilitation

Cite this

Staged management of high-energy proximal tibia fractures (OTA types 41) : The results of a prospective, standardized protocol. / Egol, Kenneth A.; Tejwani, Nirmal C.; Capla, Edward L.; Wolinsky, Philip R; Koval, Kenneth J.

In: Journal of Orthopaedic Trauma, Vol. 19, No. 7, 08.2005.

Research output: Contribution to journalArticle

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T2 - The results of a prospective, standardized protocol

AU - Egol, Kenneth A.

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AU - Capla, Edward L.

AU - Wolinsky, Philip R

AU - Koval, Kenneth J.

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N2 - Objectives: This study evaluated the use of a staged protocol involving temporary spanning external fixation and delayed formal definitive fixation in the management of high-energy proximal tibia fractures (OTA types 41) with regard to soft-tissue management, development of complications, and functional outcomes. Setting: Two level-one trauma centers and a tertiary care orthopaedic center. Patients: Fifty-three patients with 57 high-energy tibial plateau fractures. Methods: The authors instituted a protocol of immediate placement of knee spanning external fixation with management of soft-tissue injuries for all high-energy proximal tibia fractures. Between August 1999 and May 2002, 62 consecutive patients with 67 high-energy proximal tibia fractures (OTA types 41A, B, C) underwent temporary knee spanning external fixation on the day of admission. Nine patients with 10 fractures who transferred care after initial stabilization or sustained an extraarticular fracture were excluded. The remaining 53 patients with 57 fractures underwent repair of articular fractures and meta-diaphyseal fracture repair with plates and screw constructs or conversion to a ring fixator. These patients had a mean age of 47 years (standard deviation (SD), 14). Of these 53 patients, 42 (79%) were men and 11 (21%) were women. Characteristics of the 57 fractures were: 42 Schatzker VI (74%), 12 Schatzker V (21%), 2 Schatzker IV (4%), and 1 Schatzker II (2%). There were 41 closed fractures and 16 open fractures. (One patient had bilateral fractures with 1 extremity open and 1 closed). Orthopaedic evaluation at latest follow-up included a clinical and radiographic examination and functional outcome measurement with the Western Ontario McMaster functional knee score (WOMAC). Eight patients with 8 fractures were lost to follow-up. This left 45 patients with 49 fractures with a mean follow-up of 15.7 (SD, 5.7; range, 8-40) months. Results: Complications included 3 (5%) deep wound infections, 2 (4%) nonunions, and 2 patients (4%) with significant knee stiffness (<90°). Nine patients (16%) underwent additional surgery after definitive skeletal stabilization related to their injury. Range of knee motion at final follow-up was 1° (SD, 4) to 106° (SD, 15). The mean WOMAC was 91 (SD, 55). Poor results did not correlate with demographic or injury characteristics. Discussion: We had a relatively low rate of wound infection in these complex injuries (5% overall). There was only 1 wound problem in our subset of patients with closed fractures and 2 infections in those with open fractures. One downside of this technique may be residual knee stiffness. The benefits of temporizing spanning external fixation include osseous stabilization, access to soft tissues, and prevention of further articular damage. Our relatively low rates of complications in patients who sustain high-energy proximal tibia 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-articular and extra-articular fractures of the proximal tibia. Clinical Relevance: This study supports the practice of delayed internal fixation until the soft-tissue envelope allows for definitive fixation.

AB - Objectives: This study evaluated the use of a staged protocol involving temporary spanning external fixation and delayed formal definitive fixation in the management of high-energy proximal tibia fractures (OTA types 41) with regard to soft-tissue management, development of complications, and functional outcomes. Setting: Two level-one trauma centers and a tertiary care orthopaedic center. Patients: Fifty-three patients with 57 high-energy tibial plateau fractures. Methods: The authors instituted a protocol of immediate placement of knee spanning external fixation with management of soft-tissue injuries for all high-energy proximal tibia fractures. Between August 1999 and May 2002, 62 consecutive patients with 67 high-energy proximal tibia fractures (OTA types 41A, B, C) underwent temporary knee spanning external fixation on the day of admission. Nine patients with 10 fractures who transferred care after initial stabilization or sustained an extraarticular fracture were excluded. The remaining 53 patients with 57 fractures underwent repair of articular fractures and meta-diaphyseal fracture repair with plates and screw constructs or conversion to a ring fixator. These patients had a mean age of 47 years (standard deviation (SD), 14). Of these 53 patients, 42 (79%) were men and 11 (21%) were women. Characteristics of the 57 fractures were: 42 Schatzker VI (74%), 12 Schatzker V (21%), 2 Schatzker IV (4%), and 1 Schatzker II (2%). There were 41 closed fractures and 16 open fractures. (One patient had bilateral fractures with 1 extremity open and 1 closed). Orthopaedic evaluation at latest follow-up included a clinical and radiographic examination and functional outcome measurement with the Western Ontario McMaster functional knee score (WOMAC). Eight patients with 8 fractures were lost to follow-up. This left 45 patients with 49 fractures with a mean follow-up of 15.7 (SD, 5.7; range, 8-40) months. Results: Complications included 3 (5%) deep wound infections, 2 (4%) nonunions, and 2 patients (4%) with significant knee stiffness (<90°). Nine patients (16%) underwent additional surgery after definitive skeletal stabilization related to their injury. Range of knee motion at final follow-up was 1° (SD, 4) to 106° (SD, 15). The mean WOMAC was 91 (SD, 55). Poor results did not correlate with demographic or injury characteristics. Discussion: We had a relatively low rate of wound infection in these complex injuries (5% overall). There was only 1 wound problem in our subset of patients with closed fractures and 2 infections in those with open fractures. One downside of this technique may be residual knee stiffness. The benefits of temporizing spanning external fixation include osseous stabilization, access to soft tissues, and prevention of further articular damage. Our relatively low rates of complications in patients who sustain high-energy proximal tibia 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-articular and extra-articular fractures of the proximal tibia. Clinical Relevance: This study supports the practice of delayed internal fixation until the soft-tissue envelope allows for definitive fixation.

KW - Complications

KW - External fixator

KW - Spanning

KW - Staged management

KW - Tibial plateau fracture

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