Open Reduction and Internal Fixation Compared with Circular Fixator Application for Bicondylar Tibial Plateau Fractures: Surgical Technique

• Published in: Journal of bone and joint surgery. American volume 2009-03, Vol.91 (Supplement_2_Part_1 Suppl 2), p.74-88
• Main Authors: Hall, Jeremy A, Beuerlein, Murray J, McKee, Michael D
• Format: Article
• Language: English
• Subjects: Biological and medical sciences; Bone Plates; Diseases of the osteoarticular system; External Fixators; Fracture Fixation, Internal - adverse effects; Fracture Fixation, Internal - methods; Humans; Injuries of the limb. Injuries of the spine; Knee Injuries - rehabilitation; Knee Injuries - surgery; Medical sciences; Minimally Invasive Surgical Procedures - methods; Patient Selection; Postoperative Complications - prevention & control; Prospective Studies; Range of Motion, Articular; Tibial Fractures - rehabilitation; Tibial Fractures - surgery; Traumas. Diseases due to physical agents
• ISSN: 0021-9355; 1535-1386
• DOI: 10.2106/JBJS.G.01165

BACKGROUNDStandard open reduction and internal fixation techniques have been successful in restoring osseous alignment for bicondylar tibial plateau fractures; however, surgical morbidity, especially soft-tissue infection and wound necrosis, has been reported frequently. For this reason, several investigators have proposed minimally invasive methods of fracture reduction followed by circular external fixation as an alternative approach. To our knowledge, there has been no direct comparison of the two operative approaches.METHODSWe performed a multicenter, prospective, randomized clinical trial in which standard open reduction and internal fixation with medial and lateral plates was compared with percutaneous and/or limited open fixation and application of a circular fixator for displaced bicondylar tibial plateau fractures (Schatzker types V and VI and Orthopaedic Trauma Association types C1, C2, and C3). Eighty-three fractures in eighty-two patients were randomized to operative treatment (forty-three fractures were randomized to circular external fixation and forty to open reduction and internal fixation). Follow-up consisted of obtaining a history, physical examination, and radiographs; completion of the Hospital for Special Surgery (HSS) knee score, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Short Form-36 (SF-36) General Health Survey; and recording of complication and reoperation rates.RESULTSThere were no significant differences between the groups in terms of demographic variables, mechanism of injury, or fracture severity and/or displacement. However, patients in the circular fixator group had less intraoperative blood loss than those in the open reduction and internal fixation group (213 mL and 544 mL, respectively; p = 0.006) and spent less time in the hospital (9.9 days and 23.4 days, respectively; p = 0.024). The quality of osseous reduction was similar in the groups. There was a trend for patients in the circular fixator group to have superior early outcome in terms of HSS scores at six months (p = 0.064) and the ability to return to preinjury activities at six months (p = 0.031) and twelve months (p = 0.024). These outcomes were not significantly different at two years. There was no difference in total arc of knee motion, and the WOMAC scores at two years after the injury were not significantly different between the groups with regard to the pain (p = 0.923), stiffness (p = 0.604), or function (p = 0.827