Elsevier

Injury

Volume 42, Issue 10, October 2011, Pages 1066-1072
Injury

The management of complex fractures of the proximal tibia with minimal intra-articular impaction in fragility patients using intramedullary nailing and compression bolts

https://doi.org/10.1016/j.injury.2011.03.024Get rights and content

Abstract

Background

Intra-articular fractures of the proximal tibia that extend to the meta-diaphyseal part of the bone represent a severe injury, especially if they occur in osteoporotic patients. Current treatment modalities include either internal fixation with traditional or modern plating techniques or external fixation with circular frames or hybrid systems. However, problems and complications related with these techniques are increasing with age and future reconstructive operations, such as arthroplasty, may be jeopardised.

Method

This is a prospective pilot study about a novel type of osteosynthesis for complex intra-articular proximal tibial fractures without significant articular impaction in patients over 60 years of age. Within a period of 54 months, eight patients underwent fixation of such fractures with condylar compression bolts and intramedullary nailing.

Results

The follow-up period was from 12 to 50 months (mean 24.7 months). There were no neurovascular complications, wound infections, delayed unions or nonunions. All patients had their fractures healed without secondary displacement or malalignment. At the final follow-up, all patients had full extension of the knee joint whilst the flexion ranged from 125 to 140°. The mean new Oxford Knee score was calculated to be 43.75 points.

Conclusions

The management of selected osteoporotic complex intra-articular fractures of the proximal tibia with compression bolts and intramedullary nailing offers specific advantages and, in the present pilot study, provided promising results. These results should be validated and confirmed with larger case series and comparison studies in the future.

Introduction

Bicondylar fractures of the tibial plateau and segmental fractures of the tibia that involve the plateau are not frequent in osteoporotic patients. Their treatment should aim towards early mobilisation and rehabilitation with a low complication rate. Conservative management has been abandoned as it cannot allow prompt mobilisation of the patient and the knee joint with severe and irreversible consequences. Surgical techniques used nowadays include plating – open or minimally invasive – or external fixation with circular frames or hybrid constructs.3, 5, 24, 29, 2, 33 However, there does not seem to be a consensus about the optimal treatment regime regarding the management of the specific fractures in osteoporotic patients.

The purpose of the current pilot study is to evaluate the hypothesis that intramedullary nailing and compression bolts could offer an optimal treatment option in the management of complex intra-articular fractures of the proximal tibia without significant impaction that occur in fragile patients. To the best of our knowledge, such a technique has not been described before in the English literature.

Section snippets

Patients and fractures’ characteristics (Table 1)

From June 2005 to December 2009, eight patients (five male and three female), aged between 61 and 78 years were treated at our level I Trauma centre for complex intra-articular proximal tibia fracture (CIPTF) following road traffic accident. According to Schatzker classification for tibial plateau fractures, five fractures were classified as type VI (Fig. 1) and one as type V (Fig. 2),27 whereas there were two cases of segmental fractures (proximal intra-articular and a separate diaphyseal

Results (Table 1)

The mean operating time was 94.6 min. All fractures united clinically (no pain during motion and/or weight bearing) and radiologically (dullness or disappearance of fracture lines from three cortices on AP and lateral radiographs) between 12 and 18 weeks (mean: 15.5 weeks). There have been no neurovascular complications or wound infections. All fractures united without secondary displacement. There was no case of hardware failure or loosening. Passive and active exercises of the knee joint

Discussion

It is generally accepted that the treatment of complex intra-articular proximal tibial fractures should be operative to minimise the risks for stiffness, deformity and arthritis of the knee joint.5, 7, 27, 32 However, there is no consensus regarding the method of surgical treatment, especially in osteoporotic patients. Conventional open reduction and internal fixation with two plates has produced contradictory results, as the extensive soft-tissue stripping can create problems and high

Conflict of interest statement

The authors of this manuscript would like to declare that they have no financial or personal relationships with other people or organisations that could inappropriately influence (bias) their work.

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      The purpose of this study was to introduce the retropatellar approach for the management of complex fractures of the tibial plateau with intramedullary nailing and condylar compression bolts. The retropatellar approach accommodates problems related to intra-operative visualisation and maintenance of fracture reduction that are encountered when the leg is in the free hanging position, as described in a previous article [14]. These problems include the inability to obtain reproducible antero-posterior views of the knee joint with the image intensifier during the operation (unless the leg is elevated by an assistant), increased risk for fracture displacement (due to impingement of the nail and its handle on the patella during nail insertion) and the need for additional leg support during distal interlocking.

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      A novel minimal invasive technique (introduced by the second author of the present study CG), utilizing intramedullary nailing and compression bolts (IMNB) was compared biomechanically to two currently used plate fixation techniques: single lateral locking plating (SLLP) and dual buttress plating (DBP), in a non-osteoporotic bone environment. Preliminary clinical results of this new technique have been described recently, in a cohort study of osteoporotic patients.17 Our hypothesis was that the proposed new technique combines biomechanical characteristics of both rigid fixation (for the intra-articular fracture) and biologic fixation (for the metaphyseal–diaphyseal fracture) incorporating the advantages of both compatible plating techniques (SLLP and DBP).

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      The ‘independent’ bolt is introduced posterior to the nail under fluoroscopic control and converts, the intra-articular fracture to extra-articular. The use of such ‘independent’ compression bolts for the stabilisation of intra-articular fractures has already been described by our author group for intra-articular fractures of the proximal tibial metaphysis20 with similarly good results. The ‘independent’ bolt engages two cortexes (medial–lateral) in the condylar area and its tightening applies optimum compression to the inter-condylar fracture in contrast to inter-fragmentary, partially threaded lag screws that exhaust their tightening potential on the cancellous bone and thus the stability that they provide depends mostly on cancellous bone quality.

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