Percutaneous screw fixation of unicondylar tibial plateau fractures

Tibial plateau fractures are common injuries which often produce major disability. Open reduction and internal fixation of these fractures has a significant complication rate and numerous recent reports have a tendency to avoid open plating in favour of a variety of limited surgical approaches and percutaneous techniques usually in association with external fixation. The technique of closed manipulation, indirect reduction and percutaneous screw fixation was attempted in 29 displaced tibial plateau fractures [Schatzker types I - IV] in 29 patients. Closed, indirect reduction was successful in only 25 fractures [86.2%]; and the remaining four cases were excluded from the study. Patients' age ranged from 19 - 62 years [average 41 y.]. Of the 25 fractures, 4 [16%] were open; type I or II Gustilo Anderson classification. Additional mini incision to raise a depressed articular fragment and to apply a bone graft was needed in 12 fractures [48%]. Post operative cast or brace was applied for 3-5 weeks. Full weight bearing was started 8-12 weeks postoperatively. Anatomical reduction was achieved in 20 fractures [80%], and the remaining 5 [20%] were showing grade I residual step or gap formation. Bone healing was achieved in all cases [100%]; and occurred in 8-12 weeks [average 9.4 w.]. Patients were followed for 24-37 months with an average of 30 months. According to the HSS knee score; there were 9 excellent [36%], 13 good [52%], and 3 fair [12%] final end results. According to the Iowa Knee Score there were 14 excellent [56%], 9 good [36%], and 2 fair [8%] final end results. Of these 25 patients, 76% [19 patients] were satisfied; and 24% [6 patients] were not satisfied by the final end result. There were no cases of loss of reduction, wound infection, or cases with poor final clinical outcome. Indirect technique of reduction combined with percutaneous screw fixation could effectively reduce most displaced unicondylar tibial plateau fractures [Schatzker types I - IV] and is associated with good final outcome, with few reported complications

Tibial pilon fracture, results of limited internal fixation

Intra-articular fractures of the tibial plafond [pilon fractures] are a combination of an ankle and distal tibial metaphyseal fracture; usually with intra-articular comminution. They are considered among the most challenging of orthopaedic problems. The optimum treatment of these fractures remains controversial. Eighteen patients [19 - 54 y.] with 18 tibial pilon fractures were operated upon. There were 4 fractures [22.2%] type II; and 7 fractures [38.9%] type III Ruedi and Allgower classification. Another four fractures [22.2%] were type IV and the remaining three fractures [16.7%] were type V; Ovadia and Beals added other types. Eleven fractures [61.1%] were open type I, II or IIIA Gustilo and Anderson classification. Treatment was: limited open reduction with small direct incisions over the main fractures fragments and with the least needed dissection and with minimal internal fixation of both the tibia and the fibula. Only two patients [11.1%], who had an intact fibula, had fixation of their tibiae only. Only inter fragmentary screws [ +/- K. wires] were used for fixation. Bone-grafting of structurally deficient metaphyseal areas was done in seven [38.9%] cases. Post-operative below knee bracing was used for 4 - 6 weeks. Early mobilization and early weight bearing were always aimed. Bone healing was achieved in all cases [in 6 - 18 weeks; average 10.3 w]. At a minimum of two years of follow-up postoperatively, [range: 24 to 33 months with an average of 28 m.], the range of motion was excellent in 6 patients [33.3%], good in nine [50%], fair in two [11.1%], and poor in one [5.6%]. The final clinical score was: excellent in 7 patients [38.9%], good in another 7 patients [38.9%], fair in 3 patients [16.6%] and poor in one patient [5.6%]. Limited open reduction with minimal internal fixation is a satisfactory method for treatment of pilon fractures. It is associated with good final outcome, significant reduction in bone healing time, delayed union incidence and reoperation rate; with few reported complications

One stage intervention for infected, non-united, short tibia

Post-traumatic tibial non-union in association with infection is a real surgical problem. When tibial shortening occurs and soft tissue [especially skin] complications are added to this problem due to multiple surgical procedures to solve the first problem, this is one of the heaviest complications in bone-joint surgery. Twenty five tibial non-united fractures; [8-65y],complicated with infection shortening [4-9 cm.] and skin or other soft tissue complications; following repeated surgeries [2-5 previous operations] were subjected to debridement of the soft tissues at the non-union site with excision of bone ends till healthy bone [adding more shortening]. Mono-planer external fixators were applied to all cases; compression was applied to fracture site, and distraction-callotasis principle was performed at a proximal [or distal] corticotomy. Bone healing was achieved in 24 cases [96%] in 12 - 28 weeks [mean of 18.2 weeks]. Infection was eradicated in 22 cases [88%]; all were united. The mean length gained was 7.7 cm [6 to 12.5 cm]. Satisfactory results were obtained in 22 patients [88%] and unsatisfactory results in 3 patients [12%].No major complications were encountered; There have been no refractures or loss of length, after a follow-up of 2.3 years [range 2 - 4 y] mono-planer devices when applied properly and combined with proper debridement can give a high success rate in achieving bone healing, eradication of infection and correction of shortening in tibial non-union associated with infection and shortening