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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 2  |  Issue : 4  |  Page : 260-264

Comparison of therapeutic results of plateau tibia fracture by hybrid method with double-plate classic methods


Orthopedic Research Center, Mazandaran University of Medical Sciences, Sari, Iran

Date of Submission25-Sep-2018
Date of Decision20-Oct-2018
Date of Acceptance29-Oct-2018
Date of Web Publication11-Dec-2018

Correspondence Address:
Dr. Salman Ghaffari
Orthopedic Research Center, Mazandaran University of Medical Sciences, Sari
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bbrj.bbrj_118_18

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  Abstract 


Background: Finding and choice the best treatment for the plateau tibia complex fracture has always been discussed. The present study aimed to compare the therapeutic outcomes of the external hybrid fixation method with a double-plate classic method in the treatment of plateau tibia complex fracture. Methods: Forty patients with plateau tibia complex fracture were treated with either a double plate or an external hybrid fixation. A knee score and clinical-functional table were used to evaluate patients after surgery. Level of evidence for this article is level one. Results: Knee score in the double and hybrid group was good to excellent in 60% and 75% of patients, respectively (P = 0.675). In patients, the union was formed correctly and skin necrosis was not observed in any of the cases. There were no significant differences between the two groups in the complications. In the double group, the risk of deep infection of the surgical site was 2.33 times in the patients. The pin-tract infection was observed in only 8 patients (40%) of the hybrid group. Depression was observed in 5 patients in the double group (25%) and 9 patients in the hybrid group (45%) (P > 0.05). Conclusion: In the treatment of plateau tibia complex fracture, both double plate and external hybrid fixation methods have almost the same therapeutic results and complications. However, the rate of pin-tract infection in the external hybrid surgical technique of fixation and the degree of deep infection is more common in double-plate surgery.

Keywords: Double-plate, hybrid method, therapeutic, tibia


How to cite this article:
Azar MS, Mojrian V, Kariminasab MH, Ghaffari S. Comparison of therapeutic results of plateau tibia fracture by hybrid method with double-plate classic methods. Biomed Biotechnol Res J 2018;2:260-4

How to cite this URL:
Azar MS, Mojrian V, Kariminasab MH, Ghaffari S. Comparison of therapeutic results of plateau tibia fracture by hybrid method with double-plate classic methods. Biomed Biotechnol Res J [serial online] 2018 [cited 2019 Aug 19];2:260-4. Available from: http://www.bmbtrj.org/text.asp?2018/2/4/260/247240




  Introduction Top


The tibia plateau fracture is very common in the third and fifth decades of life, seen in older men and women, especially in the sixth and seventh decades of life.[1],[2] Falling down is the most common cause of this type of fracture in the elderly and is also the most common form of fracture is split depression.[3]

In high-energy traumas, split and rim avulsion fractures are common.[4] The axial force releases more energy than angular, and Valgus's pure force causes fractures, and the pure axial force causes the local depression.[5]

The combination of these two forces leads to a fracture of split depression. The tibia plato is exposed to valgus force because it's in the normal state of 5–7° valgus. These forces in the healthy bone cause split fracture and in the osteoporotic bone, it causes a fracture of the depression.[5],[6]

Nonsurgical treatment is used in the case of a nondeformed fracture, elderly person or in severe medical illness.[7] In the lateral plato, in the case of a small fracture of the joint surface <10 mm thickness, localized results are obtained with a nonsurgical technique used for nonsurgical treatment of the cast brace to unload the damaged side of the joint. Most surgeons prefer early onset movements with a hinged brace that allows for detailed movements. The duration of the intolerance of weight (nonweight bearing) is based on the fracture pattern from 4 to 8 weeks.[6],[8]

Surgical treatment is indicated in cases of transient and unstable fractures, which is not likely to be near normal. Surgical treatment is considered for individuals including almost all cases of shaft dissociation, all condylar medial fractures (with the exception of low displacement) and lateral fractures with valgus alignment without open reduction internal fixation (ORIF).

The lateral plateau surgical indications include the presence of a split fracture, deeper than 50% of the joint surface, fracture of the fibula, valgus in the radiography, and valgus of the alignment in the clinical examination. The size of the displacement mill is not reliable for indication of operation. The surgical indication is low in elderly, people with low activity and associated illness.[8]

Due to the increased prevalence of high-energy trauma and complications in case of broken bursts and Shatzgar Type V and VI, if surgical procedures are required, two surgical procedures should be used for anterolateral and posterior membranes for placement of 2 plaques, the lateral is plate buttressing and medial side plaque is Antigliding.[9],[10],[11],[12],[13],[14],[15]

In severe soft-tissue injury, some open fractures and fractures associated with compartment syndrome are definitive treatment with external fixator (EF). EF usually lasts 3–4 months and the weight is applied from the second half of this time.[16],[17] Due to the use of two approaches or a wide range for medial and lateral plaques, using the dual plating method in Type-V and VI Schatzker, the probability of an increased infection due to prolonged operation and invasion, increased probability of reoperation, long admission of patients, and the probability of necrosis the skin is present due to two parallel inserts.[18],[19]

Given that the treatment of split fractures of plateau tibia has varied from stretching, plating to ORIF over the years, none of the treatments have achieved the goals of treating these fractures, which result in tight fixation, soft-tissue maintenance, high scaling, and due to the increasing prevalence of plateau tibia fractures, increased traffic trauma, and the importance of restoring the tibia joint and the common complications of routine surgical procedures, the present study was aimed to compare the outcomes of treatments of platelet-tibia fracture with external hybrid and The classic double-plate method was designed and implemented.


  Methods Top


Method of study implementation

All patients with split fractures of plato tibia who were referred to the hospitals between 2014 and 2016 were evaluated. Patients with a history of diabetes, immunocompromised, simultaneous fractures of other bones, history of fracture, or previous surgery in the plato tibia region, multiple trauma patients, or patients with concurrent trauma were excluded from the study. The sample size required for study with 80% strength and 95% confidence interval (CI) (α = 0.05), and according to previous studies, 6 of 40 patients was determined by the statistical formula (each group of 20 patients) and accordingly, 40 patients were enrolled in the study.

Data collection tool

To evaluate patients after surgery, a clinical and functional knee score scale was used to evaluate the return to work and satisfaction of patients. Fill out the knee score table was performed by face-to-face interview and examination by a resident orthopedic. For this purpose, the severity of pain was asked from the patient, which included painless, mild pain, occasional pain, mild pain with movement, mild pain with walking, periodic pain, moderate pain, and severe pain.

Subsequent parts were completed by patient examination, including flexion contraction, extension leg, a total range of flexion, alignment (varus and valgus), and stability. Then, the data were entered into the Knee Society Score online (http://www.orthopaedicscore.com/scorepages/knee_society_score.html) to calculated the knee score. The way to interpret points is that between 80 and 100 excellent, between 70 and 79 good, between 60 and 69 is fair, and <60 is considered to be poor.

Study design and implementation method

After selecting patients based on entry and exit criteria, patients were randomly assigned to either hybrid or double-plate groups. All patients were injected with cefazolin ½ h before surgery.

In both the surgical procedures, the patients were treated with spinal anesthesia and in the position of the supine after the closure of the tourniquet, in a double-plate surgical procedure, two separate openings in the side of the enteric, and anthropometric side of the C-ARM passage through the anatomic plaque. The lateral and medial side was fixed with a T-shape plaque or by a conical screw or a cannula.

In the hybrid method, an anatomical reduction of C-ARM was performed with an anterolateral incision and an anatomical lateral proximal plaque was inserted. Then, the splice was applied to the external medial side of the fixator, which was embedded in the proximal chans in the femur anterolateral and in the distal region of the tibia anteromedial. After washing with normal saline, in both surgical wounds, wicking and nylon wool was restored and sterile dressing and the foot was stained for at least 1 week.

Antibiotic therapy was performed for 3 days and the drain was returned 72 h after surgery. Patients in the hybrid method were removed of the fixator for 30–45 days, depending on the degree of stenosis and radiographic union. The patients were followed up for unions, nonunions, infection, performance, and knee score, and their data were recorded. The proposal was reviewed and approved by Research and Ethical committee of the Orthopedic Research Center, Mazandaran University of Medical Sciences, Sari, Iran before the commencement of the work. (IR. MAZ. Sari. S2018. 123. Dated 2017-2018.

Statistical analysis of data

After collecting data, data were analyzed by SPSS version 20 (Version 20; SPSS Inc., Chicago, IL, USA). To test the qualitative data, Chi-square test and Fisher's exact test was used and for quantitative data, t-test was used. P < 0.05 was considered statistically significant.


  Results Top


In this study, 56 patients were evaluated for inclusion in the study. Of these, 12 patients did not have the required criteria and 4 patients did not want to participate in the study. Finally, 40 patients were enrolled in the study.

The patients were randomly divided into two groups of 20 (hybrid and double groups) [Figure 1].
Figure 1: Flowchart entry patients to the study

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40 patients remained in the study until the end of the study, with 20 patients in the double group and 20 in the hybrid group. 14 patients (70%) in the double group and 13 patients (65%) in the hybrid group were male. There was no statistically significant difference between the sex of the two groups (P = 0.736).

The mean age of the patients in the double group was 50.0 ± 18.45 years (median 46–27 years old) and in the hybrid group 39.65 ± 11.27 years (25–70 years, median 37.5). The mean age of patients in the double group was significantly more than the hybrid group (P = 0.039).

In examining the mechanism of injury to patients, in the double group, 16 patients (80%) were affected by traffic accidents and 4 patients (20%) had a plateau-tibia fracture. In the hybrid group, 18 patients (90%) were affected by traffic accidents and 2 patients (10%) had falling down with plateau-tibia fractures. There was no statistically significant difference between the two groups (P = 0.376) [Table 1].
Table 1: Primary information of the two groups at the beginning of the study

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Based on Schatzker classification system, 10 patients (50%) in the double group and 9 patients (45%). In the hybrid group had a plateau-tibia fracture type 5 and 10 patients (50%) in the double group and 11 patients (55%). In the hybrid group had a plateau-tibia fracture Type 6. There was no statistically significant difference between the two groups (P = 0.752) [Table 1].

Knee score

In the assessment of patients with knee score in the double Group, 5 patients (25%) were excellent, 7 (35%) were good, 5 (25%) patients were weak, and 3 patients (15%) were very weak. In the hybrid group, 8 (40%) excellent and 7 (35%), 3 (15%), and 2 (10%) patients were very poorly classified. Although the status of patients in the hybrid group was better, this difference was not statistically significant (P = 0.675) [Figure 1].

Complications

Patients were followed up for 30.68 ± 18.63 months (10–60 months, 26.5 median). In the study of the complications of patients, no case was observed with malunion, and in all patients, the union was properly formed. Furthermore, skin necrosis was not seen in any condition.

Deep site infection was seen in 5 patients (25%) in the double group, with no disease from the hybrid group. The prevalence of deep site infection was significantly higher in patients with double so that the risk of this complication in patients undergoing surgery was 2.33 times higher than those treated by hybrid method (relative risk 2.33, 95% CI: 1.59–3.42, P = 0.024). During follow-up, the infection of the pin-tract infection was observed in only 8 patients (40%) of the hybrid group.

Depression was seen in 3 patients, 1 patient in the hybrid group and 2 in the double group. Contraditionally, in this study, we considered depressing more than 3 mm as cutoff of depression. Considering this criterion, depression in 5 patients in the double group (25%) and 9 patients in the hybrid group (45%) were seen, There was no significant difference between the two groups (P = 0.16) [Table 2].
Table 2: Comparison of response to treatment and complications of patients in the two groups

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In the quantitative study, the mean of depression in the hybrid group was 3.84 ± 0.95 mm (range 3–5 mm, 3 = median) and in the double group was 3.44 ± 1.04 mm (between 2 and 5 mm, 3 = median) There were no statistically significant differences between the two groups (P = 0.23) [Table 2].

In total, the complications were observed in 9 patients (45%) in the double group and 13 cases (65%) in the hybrid group. The incidence of complications was not significantly different between the two groups (P = 0.17) [Table 2].


  Discussion Top


The most appropriate treatment for of plateau tibia complex fracture is still under discussion. Over the past few decades, researchers have suggested different therapies but still disagree about the best treatment options for fracture fractures.[20]

The main reason for not finding a proper treatment strategy is the biomechanical complexity and soft-tissue damage that affects the treatment process at the same time.[21] However, according to the available papers, open-field reduction with interfacialization (ORIF) with double platinum[11] or hybrid[12],[13],[14] and external ring fixation with or without internal fixation[22],[23],[24] as two common treatments for fractures of plateau tibia.[20] Overall, the golden goal of treating anatomic knee replacement is a stable flexion for initial improvement and prevention of complications, especially infection and non union.,[21] Although these treatments are commonly used, there is still limited information on the outcome and their complications, and recent studies point to the need for new clinical studies.[25] The aim of this study was to compare the therapeutic results of hybrid method with classic double-plate methods.

In the present study, the mechanism of trauma and type of injury were the same according to the Schatzker classification. The knee score of 15 patients (75%) in the hybrid group and 12 patients (60%) in the double group were good to excellent, but there was no significant difference between the two groups.

In a study by Kasturi et al., 23 patients (92%) in the internal fixation group and 19 patients (76%) in the external fixation group achieved anatomical reduction.[25] In the study by Malakasi et al., who compared the methods of internal surgical and hybrid fixation in the condylar tibial fracture, the same performance was similar in both studies, and there was no statistically significant difference.[14]

Furthermore, Lee et al., in their study of the therapeutic results, evaluated the three surgical methods of unilateral locking plate, classic dual plates, and hybrid dual plates for the treatment of bicondylar fractures of plateau tibia, similar to the present study, the difference was not statistically significant.[21]

In this study, in all patients, the union was properly formed and skin necrosis was not observed in any cases. There were no significant differences in the complications between the two groups (45% in the double group and 65% in the hybrid group). Deep infection of the surgical site was observed only in patients with double surgery (25%), with a risk of incidence of it being 2.33% higher than that of the hybrid group. However, pin-tract infection was detected in 40% of the patients in the hybrid group. Depression was observed in 5 patients in the double group (25%) and 9 patients in the hybrid group (45%), which was not significantly different between the two groups.

In a study by Ruffolo et al., the complications of dual plating in the treatment of fractures were 27.9%, including 23.6% deep infection and 10% nonunion. Open fractures had higher infection rates (43.8% versus 21%, odds ratios: 2.96, P = 0.05).[26]

Kasturi et al. reviewed the treatment regimen of external fixation and internal fixation in treating fractures of bicondylar fractures of plateau tibia. The rate of pin-path infection was 24% in the external fixation group, which was more prevalent than the internal fixation. In the internal fixation group, there was not a profound infection.[25]

The incidence of infection in Conserva et al., which retrospectively evaluated the two methods of open and internal reduction (ORIF) and external hybridization fixation in fractures without fracture classification, was 7.6%, which included deep infection in 4 patients (10.5%) of the ORIF group and 2 patients (4.9%) of the hybrid group.[20]

Overall, in the present study, the incidence of complications from the reported studies was higher, one of the reasons was considering of more than 3 mm as a complication that was not studied in other studies. Previous studies have suggested that double-plate classical surgery can be associated with potentially complications such as fracture of fixation, malunion, nonunion, joint dryness, secondary posttraumatic osteoarthritis, infection, and most importantly, severe soft-tissue complications. The incidence of these complications varies between 23% and 87.5%.[2],[22],[23],[24],[27],[28] It has also been shown that pin-tract infection is one of the major complications of hybrid fixation surgery that has been reported in various studies ranging from 10% to 43%.[23],[29],[30] the incidence of this complication in the present study was 40%.

In this study, two methods of double-plate and external hybrid-fixation surgery had therapeutic results and almost the same complications. However, the rate of pin-path infection in the hybrid group and the rate of deep infection were higher in patients with double plate.

According to the previous studies, deep infection is due to soft-tissue manipulation during surgery, and because of less soft tissue manipulation in the hybrid extraction technique, the incidence of infection will be less.[20]

In the end, the results of our study showed that for the treatment of plateau tibia complex fracture, two methods of double plate and external hybrid fixation therapy have the same therapeutic results and almost the same complications. The rate of pin-path infection in patients with external hybrid surgical fixation and the degree of deep infection is more common in double-plate surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Babis GC, Evangelopoulos DS, Kontovazenitis P, Nikolopoulos K, Soucacos PN. High energy tibial plateau fractures treated with hybrid external fixation. J Orthop Surg Res 2011;6:35.  Back to cited text no. 11
    
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Yao Y, Lv H, Zan J, Li J, Zhu N, Jing J, et al. Functional outcomes of bicondylar tibial plateau fractures treated with dual buttress plates and risk factors: A case series. Injury 2014;45:1980-4.  Back to cited text no. 13
    
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Malakasi A, Lallos SN, Chronopoulos E, Korres DS, Efstathopoulos NE. Comparative study of internal and hybrid external fixation in tibial condylar fractures. Eur J Orthop Surg Traumatol 2013;23:97-103.  Back to cited text no. 14
    
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Zura RD, Browne JA, Black MD, Olson SA. Current management of high-energy tibial plateau fractures. Curr Orthop 2007;21:229-35.  Back to cited text no. 15
    
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