treatment of tibial plateau schatzker type vi fractures with the

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ABSTRACT

This is a retrospective review of 18 patients with tibialplateau fractures Schatzker type VI. These cases wereperformed in our medical centre from January 2003 toDecember 2004. The Ilizarov technique (Russian technique)using the ring external fixator was the technique performed.Articular reconstruction and joint alignment were achievedwith traction and olive wires with washers. One caserequired percutaneous elevation of the articular surface andbone grafting through a cortical window. Average clinicalunion was achieved within 4 months of trauma. Mean finalknee flexion was 85°, which is compatible with walking. Allpatients successfully returned to their previous occupations.In conclusion, the Ilizarov technique has been shown to be agood option and a viable tool in the management of thesecomplex and unstable injuries.

Key Words: Knee Spanning External Fixator

INTRODUCTION

Schatzker et al. 1 described a systematic classification of sixtypes of tibial plateau fractures that was based onanteroposterior tibial plateau radiographs. These six typesinclude pure cleavage fractures with depression, pure centraldepression, fractures of the medial condyle, bicondylarfractures and fractures with dissociation of the tibialmetaphysis and diaphysis. Schatzker type VI tibial plateaufracture truly encompassed transverse or oblique fractures ofthe proximal third of the tibia with a fracture of one or bothtibial condyles and articular surfaces and a dissociation ofthe metaphysis and diaphysis regions. Agnew et al. 2 reportedin his study that out of 2440 reported tibial plateau fracturesthere were only reported 41 cases of Schatzker type VIfractures. The rarity of this type of fracture has caused verylimited documentation of the treatment. Most of the paperspublished have advocated operative intervention 3.

Schatzker type VI tibial plateau fractures are caused byconsiderable high energy trauma. This traumatic force notonly causes severe bony comminution but also considerablesoft tissue injury. Watson et al. 4. described these high energyinjuries as those which cause significant articular depression,condylar displacement, metadiaphyseal fracture extensionwith open wounds or extensive closed degloving injuries ofthe proximal tibia. Complications include severe soft tissuecompromise requiring coverage procedures, lower limbcompartment syndrome, peroneal nerve injury, vascularinjury and eventual knee arthrosis 5. If the soft tissue injuriesare not adequately treated, amputation may be necessary inthe end. Associated injuries include ipsilateral femoral andtibial diaphyseal fractures, cruciate and collateral ligamentinjuries and meniscal tears 6. All these complications directlyimpact surgical treatment and finally long term outcomes.

The goals of treatment are anatomical reconstruction of thearticular surface, restoration of the limb axis, fixationspanning the metaphyseal comminution and furtherminimization of morbidity to an already traumatized softtissue envelope 7. These objectives can be achieved withinternal fixation, bridge plating, percutaneous screws withcasting, external fixators with or without limited open andbone grafting or a combination of these methods.

In the 1990s, the concept of ‘spanning’ the knee joint wasintroduced. This concept evolved as proponents of indirectfracture reduction and biological fixation reported increasedrates of fracture healing with decreasing infection rates inthis type of fracture 8. With this method, the fractures areindirectly reduced with traction, and then maintained witheither internal or external fixation before a knee spanningexternal fixator is finally applied. Watson et al introduced theknee spanning external fixator to rest the knee joint. With theknee spanning external fixator, reduction of the intraarticularfragments is maintained.

The aim of this study was to assess the clinical outcomes oftreating tibial plateau fracture type VI with Ilizarov spanningfixator across the knee joint.

Treament of Tibial Plateau Schatzker Type VI Fractures withthe Ilizarov Technique Using Ring External Fixators Acrossthe Knee: A Retrospective Review

IR Ranatunga, MS Ortho (UM), M Thirumal, FRCS (Edin)

Department of Orthopaedics, Tengku Ampuan Rahimah Hospital Kelang, Malaysia

Corresponding Author: Dr Ivan R Ranatunga, 38, Jalan Amanputra 2/4, Taman Amanputra, 47310 Puchong, Selangor, MalaysiaEmail: [email protected]

Malaysian Orthopaedic Journal 2010 Vol 4 No 2 IR Ranatunga, et al

Treament of Tibial Plateau Schatzker Type VI Fractures with the Ilizarov Technique Using Ring External Fixators Across the Knee

MATERIALS AND METHODS

Study Sample

This is a retrospective study of 18 patients seen at ourhospital from January 2003 to December 2004. The datasource was Orthopaedic operative registry book. All patientsfrom this time period with the diagnosis of tibial plateaufractures were enrolled into study. Medical records andradiographs were studied by the authors. The patients werealso seen on follow up with the Ilizarov Clinic. Fourpolytrauma patients were excluded. In the Ilizarov clinic thepatients’ outcomes were recorded including range of flexionof the knee joint and level of activity at their presentoccupation. The follow up period was one year post trauma.These 18 patients underwent Ilizarov technique with ringfixators spanning the knee joint. All operative procedureswere performed by the senior consultant. One patientneeded percutaneous elevation of the articular fragment andbone grafting. None had open reduction or screw fixation.

Operative Technique

The patient was positioned supine on a normal radiolucenttable. No tourniquet was applied. The affected limb was heldon two ‘U’ wooden supports (Figure 1), which were placedposteriorly at the thigh region and at the heel. These areuseful in creating the necessary space for the application ofthe ring fixators. A calcaneal Steinmann pin is then insertedwith weights 20 to 25 kg weights across a Mayo table(Figure 1) to achieve ligamentotaxis.

The first 1.8 mm olive wire with a 3.5 mm washer wasinserted using image intensifier in a lateral to medialdirection just anterior to the head of the fibula at the tibialplateau subchondral region to provide interfragmentarycompression (Figure 2). The size of the ring needs to have atleast 2 fingerbreadths clearance from the patient’s skincircumferentially and is fixed to the first wire with twocentre fixation bolts and tensioned to 110 Newton to createcompression in between the articular fragments thusreconstructing the articular surface. Another olive wire isapplied from medial to lateral on the distal side of the ring(Figure 3) and then a drop wire is inserted.

This ring with three tensioned wires is then connected to twomore completed rings distally with three interconnectingrods (Figure 3) at the midshaft of the tibia with the mostdistal ring at the distal metaphysic of the tibial bone. Bothrings are attached to the tibia with one Schanz pin and onetensioned K-wire. The construct is then completed with ahalf ring attached to the femur on the lateral side with twoSchanz pins attaching it to the femoral condyle. This femoralhalf ring is attached to the proximal first complete ring withtwo interconnecting rods spanning the knee joint inextension thus maintaining ligamentotaxis. The weights onthe traction are then released.

There was no screw fixation, nor was there wasarthroscopically assisted reduction. One patient neededpercutaneous elevation of the articular fragments and bonegrafting through a cortical bone window.

Postoperative

All patients were allowed to weight-bear as tolerated. Somefound it difficult to weight-bear because of the kneespanning ring fixator. The femoral half ring was removed sixweeks postoperatively. After the removal of the femoral halfring, patients were encouraged to fully weight-bear. Attwelve weeks, the interconnecting threaded rods at thefracture site were removed to test clinical union. If there wasany abnormal motion at the fracture site the fixator was notremoved and the threaded rods were reconnected again. Ifthe fracture was clinically united then the fixator wascompletely removed. Follow-ups were done at 2, 4, 6, 8, 12,16, 20 weeks, 6 months and the final follow up visit was atone year post trauma.

Radiographic examination (Figure 4) and knee range ofmovements were recorded. The time of radiographic unionwas recorded. Radiographic union was achieved when threeout of four cortices on anteroposterior and lateralradiographs showed bony continuity. There were nosecondary surgeries performed. Local pin site care wasinstituted with water and soap. The patients were encouragedto wash the pin sites and the frame at least three times a day.

RESULTS

The study sample was comprised of three females and fifteenmales patients. There were twelve Malays and six Indians.Sixteen patients between 20 to 50 years old and two patientswere above 50 years. There were three open fractures; onecase was a Grade 1 open fracture and two cases were Grade2 open fractures. The rest were closed fractures. The meaninterval between the injury and application of the Ilizarovring external fixator was 7.34 days in our hospital.

Fractures were considered united once radiographic unionwas achieved and there was no abnormal motion, whichoccurs with stressing of the fracture site after loosening ofthe frame.

Mean union time was recorded at 3.72 months. All fractureswere united within four months. Ten patients requiredadditional casting and eight patients did not require any otherform of supports.

Mean flexion of the affected knee joint was 85° at finalfollow up at one year post trauma. Three patients had flexionknee contracture of 5°. Nine out of 18 cases (50%) had rangeof motion 80° or less, and 5 out of 18 cases (27.8%) hadflexion 60° or less.

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Four patients had pin site infection. These infections weretreated with a one-week course of antibiotics and dailydressings. There were no other recorded complications ofseptic arthritis, osteomyelitis, amputation or knee laxity. Allthe patients were allowed to go back to work within 5months of their injury and were able to carry out therequirements of their job level occupation as before theinjury.

DISCUSSION

Tibial plateau Schatzker type VI energy fractures, caused byhigh energy trauma, inflict extensive damage to the bone andmore injury to the soft tissue. Early problems in managementof this high energy complex fracture include fractureinstability and inability to internally fixate to address thestability when open reduction is attempted. Postoperativecomplications include infection, wound dehiscence andwound healing problems 9. Long term complication includesecondary knee osteoarthritis, loss of reduction, collapse ofarticular fragments, malunion and nonunion 10. Dissociationof the metaphysis from the diaphysis does not allow forconservative treatment with traction. It has been shown thatlong term immobilization can cause decreased function ofthe knee joint 11.

We have shown in the present study, that despite extensivearticular comminution and spanning of the fixator across theknee joint, satisfactory functional results can be achievedwith the Ilizarov frame. Reduction of intraarticularfragments is confirmed indirectly by the image intensifier.Opponents of this technique may argue that congruous

reduction can only be confirmed by open reduction, but evenwith open reduction one requires imaging to confirmcongruous reduction.

Internal fixation of these highly complex injuries had lead tosome disastrous results. Moore and Harvey 12 reported 23%of cases treated with open reduction with internal fixation(ORIF) became infected. The rate of infection with ORIFreported by Malik et al. was four out of five 13, Young andBarrack report seven out of eight 14 and Yang et al. 15 reportedfive out of sixteen for type VI fracture.

Morandi et al. reported an advantage of external fixation ofcomplex tibial plateau fractures was decreasing rates ofcomplications 16. Marsh et al. in his paper advocated the‘spanning’ concept across the knee joint to allow the kneejoint to rest and further immobilize the articular fragments 17.In our series, we saw that the optimal fixation time was sixweeks to give enough time for the intra-articular fractures toform soft callus. Spanning the knee with the external fixatorsalso prevents wire migration into the knee joint and theassociated risk of septic arthritis.

The six-week period of keeping the knee in extension causedsome stiffness, but the mean flexion of the affected kneejoint was satisfactory was 85° at final follow up at one yearpost trauma. There were three patients who had flexion kneecontracture of 5°. Nine out of eighteen cases (50%) had anaverage flexion of 80° or less, and five out of eighteen cases(27.8%) had an average flexion of 60° or less. According toAli et al., flexion of less than 60° is incompatible withnormal gait 18.

NO. DIAGNOSIS INTERVAL UNION RANGE OF COMPLICATIONS REMARKS(days) (months) MOTIONS(°)

1 Closed Fractures 5 3 0-30 Pin site infection Infection treated with 1 week ofantibiotics & dressings

2 Closed Fractures 5 4 0-1103 Closed Fractures 10 4 5-60 Medical co-morbidities4 Closed Fractures 11 3 0-60 Medical co-morbidities5 Closed Fractures 7 4 0-1006 Closed Fractures 13 4 0-1007 Closed Fractures 4 5 5-808 Closed Fractures 7 3 0-1009 Closed Fractures 14 4 0-100 Medical co-morbidities10 Open Fractures Same day 4 0-80 Pin site infection Infection treated with 1 week of

antibiotics & dressings11 Open Fractures Same day 4 0-11012 Open Fractures Same day 3 0-11013 Closed Fractures 15 2 0-110 Medical co-morbidities14 Closed Fractures 15 4 0-60 Pin site infection Infection treated with 1 week of

antibiotics & dressingsMedical co-morbidities

15 Closed Fractures 4 5 0-6016 Closed Fractures 6 3 5-11017 Closed Fractures 5 5 0-80 Pin site infection Infection treated with 1 week of

antibiotics & dressings18 Closed Fractures 12 3 0-80 Medical co-morbidities

Table I: Physical outcome of surgery and complications


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Fig. 1: Patient is in supine position with the affected limb onthe draped ‘U’ supports with traction across the Mayotable.

Fig. 3: Insertion of two more wires to stabilize the proximal ring.

Fig. 2: A parallel K-wire to the joint line is inserted (a) under guidance of the image intensifier (b).

A B


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In the current study, most patients were able to walk andachieved functional knee flexion which allowed them to goback to their original occupation.

The open fractures were fixated immediately as anemergency procedure, but closed fractures were treatedelectively after the comorbidities were optimized. Thedifferences in when the operative procedure was performeddid not reflect the final knee range of movement. There werepatients on whom the operative procedures were performed10 days after the trauma range of motion of 110° at the oneyear follow up. In these cases, the ring fixator was extendedup to the femoral shaft for six weeks. The femoral half ringwas then removed and the patient was encouraged to weight-bear to encourage more healing. We did not have anycomplications of deep infection, osteomyelitis or knee laxity,since our technique was performed percutaneously.

Among the drawbacks of the Ilizarov technique are the riskof losing full range of movement of the knee joint and thevisually less appealing and cumbersome ring externalfixator. In addition, it is also a very demanding techniquewith a steep learning curve, requiring specialized trainingand experience. Hence it has not gained popularity to dateeven though it has been practiced for more than 15 years inthis country with promising results.

The limited size of the study sample was a limiting factor ofthis study. It is our aim to increase the awareness that kneespanning ring fixation is a safe and viable technique fortreatment of these highly unstable injuries. In addition, thisstudy also did not explore the joint surface thoroughly with acomputerized tomography study or arthroscopic examinationof the joint to look for joint incongruity. Therefore, a longterm outcome study should be undertaken to examine thedevelopment of secondary onset of posttraumatic kneeosteoarthritis in this group of patients.

CONCLUSION

We believe that ring fixation with small K-wires and olivewires with a temporary spanning knee half ring is efficaciousfor treating both the bony articular comminution and softtissue damage. Intraoperative traction and the insertion ofsmall K-wires to stabilize the articular fragments areessential to reestablishing the alignment and the length of thetibial bone. The external circular rings attach these K-wiresand Schanz pins to a rigid 360° frame which neutralizes allshear and rotational forces. Early weight bearing astolerated after removal of the femoral ring especially aftersix weeks does not disturb knee function and also encouragesfracture healing by axial micromotion without shear force 19.Subsequently, all patients had bony union within fourmonths and all returned to their work within six months.Therefore, we have adopted the Ilizarov method for all openor closed Schatzker type VI tibial plateau fractures.

Fig. 4: Example of a patient with tibial plateau fracture type VI after treatment (A). Her knee extension (B) and flexion (C) are shown.

A B C


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treatment of tibial plateau schatzker type vi fractures with the

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