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ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 2  |  Page : 618-623

The use of twin-ring Ilizarov in the treatment of periarticular or intra-articular fractures of the tibia


1 Department of Orthopaedics Surgery, Faculty of Medicine, Menoufiya University, Shebeen El-Kom, Egypt
2 El-Obour Insurance Hospital, El-Obour, Egypt

Date of Submission30-Aug-2017
Date of Acceptance22-Oct-2017
Date of Web Publication25-Jun-2019

Correspondence Address:
Mohammed MM Mohammed
El-Obour Insurance Hospital, El-Obour
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_588_17

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  Abstract 

Objective
The aim of the present study was to report the results of using the twin-ring (TR) module in treatments of juxta-articular fractures of the tibia and the merits of this technique in Menoufia University Hospitals and El-Obour Insurance Hospital over 3 years.
Background
In juxta-articular fractures of the tibia, the presence of short metaphyseal bone fragments may make the application of an Ilizarov external fixator (IEF) challenging. It may be necessary to bridge the adjacent joint to ensure stable fixation. The TR module is proposed as an alternative method that avoids joint bridging, without compromising the stability of fixation.
Patients and methods
This is a descriptive retrospective study with data collected from the analysis of medical records of 20 patients admitted in Menoufia University Hospitals and El-Obour Insurance Hospital with a diagnosis of juxta-articular fractures of the tibia over a 3-year period from May 2013 to July 2016. The patients studied were retrospectively analyzed for sociodemographic data, clinical parameters, duration of hospitalization, the application of TR IEF, and clinical outcome according to the knee society scoring system and the clinical rating system for the ankle and hind foot.
Results
The TR IEF shows more stability, less joint stiffness, and less time needed for both fracture union and physiotherapy.
Conclusion
When treating selected trauma patients, the application of the TR IEF is suggested as a promising surgical alternative, offering satisfactory outcomes and reduced patient morbidity.

Keywords: articular, fracture, juxta, prognosis, tibia, twin-ring Ilizarov


How to cite this article:
Ghoneem HF, Omar AS, Mohammed MM. The use of twin-ring Ilizarov in the treatment of periarticular or intra-articular fractures of the tibia. Menoufia Med J 2019;32:618-23

How to cite this URL:
Ghoneem HF, Omar AS, Mohammed MM. The use of twin-ring Ilizarov in the treatment of periarticular or intra-articular fractures of the tibia. Menoufia Med J [serial online] 2019 [cited 2019 Sep 17];32:618-23. Available from: http://www.mmj.eg.net/text.asp?2019/32/2/618/260902




  Introduction Top


The periarticular or intra-articular fractures of the tibia, which are critical load-bearing surfaces, remain, to date, difficult areas of fracture care for orthopedic surgeon[1].

Often, the associated complications, that is, compartment syndrome cartilage destruction, soft-tissue envelope damage, postsurgery infection, knee and ankle instability/stiffness, and early/late post-traumatic arthritis, are devastating. These fractures can occur with a bimodal distribution in both men and women. In young adults, they are a result of high-energy trauma, whereas in the elderly they usually following accidental low-energy falls[2],[3],[4],[5].

Precise investigations identifying periarticular or intra-articular fractures of the tibia enable an accurate classification of fracture. Different modalities have been used to evaluate these fractures: plain radiographs, computed tomography (CT) scan, and MRI[6],[7],[8].

These fractures are either articular or nonarticular; however, knee and ankle joint functions must be considered in the management of both. The objective of their treatment is to obtain a stable, pain-free joint with a functional range of motion. The optimal treatment of patients with periarticular or intra-articular fractures remains controversial, and a wide variety of treatment modalities have been proposed[9],[10],[11].

There have been many options for the treatment of these fractures in the orthopedic literature, including conservative treatment, external fixation, open reduction-internal fixation, and arthroscopically assisted percutaneous osteosynthesis. The ultimate goal of intra-articular fracture treatment should be precise restoration of the joint surface and stable fixation with good functional outcomes[12],[13].

In recent years, the use of the Ilizarov external fixator (IEF) has increasingly been adopted for the management of complex intra-articular or peri-articular fractures of the knee and ankle joints. Also, the use of external fixation, on the basis of Ilizarov principles, is valuable in the management of difficult open tibia fractures[14].

The presence of short metaphyseal bone fragments may make the application of an IEF challenging. In such cases, it may be necessary to bridge the adjacent joint to ensure stable fixation. The twin-ring (TR) module of circular external fixation is proposed as an alternative method that avoids joint bridging, without compromising the stability of fixation.


  Patients and Methods Top


After obtaining informed consent from the patients and the approval of our Institutional Review Board, all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or the national research committee. Our study included patients who presented with periarticular or intra-articular fractures of the tibia because of falling of heavy objects and motorcycle accidents from May 2013 till July 2016; the inclusion criteria were patients aged from 17 to 58 years with recent periarticular or intra-articular fractures of the tibia less than 1 month from injury with short bone fragments (simple or open fractures type I, II, and IIIa, b). The exclusion criteria were patient presenting late, that is, more than one month after injury, patients with associated injuries, open fracture type IIIc, malunited, and nonunited periarticular or intra-articular fractures of the tibia.

All cases were examined according to personal data (name, age, and sex), history (mechanism of injury, side affected, time since injury, and previous trials of reduction), clinical examination (tenderness, edema, and deformity of the knee or the ankle), radiological examination (radiography and CT), and whether arthroscopy could be used during the operation to enable articular surface reduction and meniscus and cartilage injury and repair.

Operative procedure: According to Grivas and Magnissalis[15]

After complete preoperative investigations and assessment by the preanesthetic clinic, the patients were placed on an operating table. Usually, epidural anesthesia was administered to all patients. After draping, the first transverse wire was passed proximal to the fracture site in cases of the proximal tibia and distal to the fracture in cases of the distal tibia and then the TR was fastened after tensioning the wire either with a wire tensioner or manually with spanners and another wire was passed at least 90° to the first wire on the upper ring, another two wires were applied 45° on the other ring of the TR to the wires on the first ring. We required 1.8 mm plain wires at the diaphysis and an olive tip at the metaphysis. Then, the second construct was created on the other side of the fracture site. The usual distance between the construct proximal and distal to the fracture was 2–3 cm. Then, another construct was made after the second construct and fastened with threaded rods. Then, reduction in all planes was done with rings proximal and distal to fracture site fastened with threaded rods. Most of the time, we used an image intensifier to achieve reduction and near-normal alignment of the fracture.

Sometimes, we used drop wires and attached them with the help of posts to rings. All the rings were larger than two-finger breaths in diameter of the leg over the anterior aspect and three-finger breaths to the posterior aspect of the leg. For each ring, a minimum of three wires were used, except the TR module, which had two wires on each ring. While inserting the wires, they were first gently pushed up to the bone through skin and then drilled with a power drill. As soon as they came out through the other cortex, they were hammered gently to emerge from the other side. Muscles were at their maximum length while inserting the pins and all the wires were passed through safe zones. All the wires were tensionized before they were fastened to rings either with a wire tensioner or manually with spanners at both ends simultaneously on plain wires and only the opposite end on olive tip wires. The wire sites were dressed with hydrogen peroxide and pyodiene solution-soaked gauzes [Figure 1].
Figure 1: A photograph showing Twin-ring lizarov construct for the right leg.

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Follow-up

On return from the operation theater, patients were allowed partial weight-bearing walking with close fractures after 6 h and on the second or the third day with open fracture according to the condition of the wound and the patient. Usually, they were allowed full weight-bearing walking in a week's time if they could tolerate this.

Parenteral antibiotics were administered up to the third or fourth day for closed fractures and up to eradication of infection or wound healing for open and infected fractures. Epidural analgesia was used for 2–3 days usually and then switched to either parenteral or oral analgesics. Weekly alternate compression/distraction at the fracture site was started usually after 10 days of the application of an Ilizarov external fixator. Check radiographs were performed the next day and adjustments were carried out on the second or the third day if required. Patients were trained for daily wash of the fixator, pins, pin care, and mobility of the joints, and quads exercises.

During the follow-up, fixators were checked thoroughly, each and every nut and bolt was tightened, wires were tensionized if needed, and pin sites were cleaned with pyodine solution and washed thoroughly with normal saline. If there was any deep pin-tract infection, or pin loosening, the patients were readmitted for surgical toilets and treated according to the culture and sensitivity report of isolated organisms and readjustments of fixators, respectively.

Radiographs were taken at every third week [Figure 2]. Fixators were dynamized on callus formation and removed after 3–4 weeks of dynamization. Before removal, fixators were dismantled first without anesthesia and the fracture site was examined for movement and tenderness. If there was any tenderness and mobility at the fracture site, fixators remained in situ for more 3–4 weeks. All the fixators were removed without anesthesia as an OPD procedure. All the pin-site wounds were washed with saline and pyodine-soaked gauzes and an above-knee or a below-knee walking cast was applied according to the fracture site for 2 weeks; then, radiographs were taken without the cast and full weight-bearing walking was allowed, and advised first monthly and then thrice a year for follow-up.
Figure 2: Plain X-ray postroanterior and lateral views showing United proximal tibia fracture treated with twin-ring Ilizarov external fixator.

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Statistical analysis

Data were fed into a computer and analyzed using IBM SPSS software package, version 20.0 (IBM Corporation, Armonk, New York, USA). The end results were assessed according to the knee society score and the clinical rating system for the ankle and the hind foot.

Each grading system had 100 points and the scoring was as follows: 80–100 = excellent; 70–79 = good; 60–69 = fair; <60 = poor.


  Results Top


Twenty cases were treated by TR IEF; in 14 cases, the proximal tibia was involved and in six cases, the distal tibia was involved.

According to functional end results, one patient achieved union with a fair score, four patients achieved union with a good score, and 15 patients achieved union with an excellent score.

According to infection, four patients achieved union with pin-tract infection, two patients achieved union with the wound at the time of injury being minimally infected, which was cleaned by repeated dressing, and 15 patients achieved union with no signs of infection.

Factors affecting the overall results

In terms of the effect of etiology [Table 1], the correlation between the etiology and results was found to be statistically significant. In terms of the effect of etiology [Table 1], the correlation between the etiology and results was found to be statistically significant with a significantly more satisfaction with falling of heavy object cases than motorcycle accidents cases (P < 0.05).
Table 1: Effect of etiology on the results

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In terms of the effect of soft-tissue problems and the presence of wounds [Table 2], the correlation between the fracture type and results was found to be statistically significant. In terms of the effect of soft-tissue problems and the presence of wounds [Table 2], the correlation between the fracture type and results was found to be statistically significant with a significantly more statisfaction in cases not associated with soft-tissue problems than those associated with soft-tissue problems (P < 0.05).
Table 2: Effect of soft-tissue problems on the results

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In terms of the effect of intra-articular extension of the fracture [Table 3], the correlation between the intra-articular extension and the results was found to be statistically significant. In terms of the effect of intra-articular extension of the fracture [Table 3], the correlation between the intra-articular extension and the results was found to be statistically significant with a significantly more satisfaction in cases with no extension to articular surface (P value < 0.05).
Table 3: Effect of intra-articular extension of the fracture on the results

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Age and duration of treatment

There is a direct relationship between age and the duration of treatment, that is the older the age, the longer the duration of treatment and the younger the age, the shorter the duration of treatment [Figure 3].
Figure 3: Receiver operating characteristic (ROC) curve showing Correlation between age and duration of treatment.

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  Discussion Top


When treating trauma patients with an IEF, the surgeon is not infrequently faced with the challenge of fractures involving relatively short-length bone fragments (for instance, in the proximal or distal tibial metaphysis). Under these circumstances, it may be necessary to extend the frame beyond the involved joint to maximize the mechanical stability of the construct. In doing so, however, this joint is unnecessarily 'locked' in place together with the fractured bone fragments. The resultant immobilization of the articular surfaces may have detrimental implications for the final outcome as it is classically known that immobilization of the articular surfaces is associated with adverse sequelae, including stiffness or even arthritis.

As an alternative, it was considered that a TR module could be used for the ring located adjacent to the short bone fragment. It was found that patients were satisfied clinically and functionally when the TR module was used. It remains to be proven, however, that this configuration has adequate mechanical features. As a proof-of-principle procedure, biomechanical tests were carried out to comparatively characterize the behavior of single-ring and TR IEF modules[15].

In axial loading, curves of load versus displacement showed a trend that was close to linear at low amplitudes (±3 mm) and less so at higher (±5 and ± 7 mm) amplitudes. In all cases, however, trends were continuous and quite regular, enabling us to quantify values of passive stiffness as the linear slopes between the zero and maximum displacement points. In all instances, the TR module showed clearly lower values of passive stiffness than the SR module. The phenomenon of wire pretension-loss during axial loading (long recognized and still investigated for IEF), although not detrimental in any case, is expected to be more clearly manifested in TR rather SR modules as the increased vertical distance of TR wire levels induces successive rather than simultaneous loading of wire levels and therefore less stiff behavior. In the current context of TR modules, a lower stiffness in axial loading is considered to be beneficial as it allows for the necessary axial micromotion and consequent compression between bone fragments [Figure 4]. In shear loading, curves of load versus displacement showed a trend consisting of distinct loops. The loops had a longer dimension along the x-axis (displacement) than along the y-axis (load) [Figure 5]. This pattern can be explained by the fact that, upon application of shear load, the plastic model simulating bone first slides against the wire aligned to the direction of load and then transfers the load to the construct. Our analysis deliberately ignored intermediate sliding events and was focused on the overall effective behavior of constructs instead[15]. Therefore, it was conducted between zero and maximum displacement points. In all instances, the TR module showed clearly higher values of passive stiffness than the SR module. A higher stiffness in shear loading is considered to be beneficial because it resists motion along the axial (transverse) plane of bone segments, potentially jeopardizing, or even disorganizing, callus formation[15].
Figure 4: For all axial loading tests, a comparative graph of load versus displacement.

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Figure 5: For all shear loading tests, a comparative graph of load versus displacement.

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The present biomechanical study was conceived, designed, and carried out to comparatively provide an insight into the mechanical performance of single-ring and double-ring modules of Ilizarov constructs. By eliminating potential confounding factors, the experimental setup and methodology ensured a comparative demonstration of biomechanical events, leading to satisfactory clinical and functional outcomes[15].

This work may be expanded (and further research is currently under way) to encompass more elaborate mechanical testing, with different wire configurations and loading conditions (e.g., torsion). Furthermore, in an effort to create a permanent numerical model of Ilizarov constructs, computational studies involving finite element modeling and analysis on both module configurations can be carried out[15].

The results of the present study have implications in the clinical setting. In cases of knee and ankle intra-articular or periarticular fractures, it is often considered necessary to extend the IEF so as to span the involved joint for the purposes of increased stability in bending loads. By being stiffer in shear loading, the use of the TR configuration may achieve an equally stable fixation without the need to bridge a joint. If a surgeon still decides to span a joint, the TR module enables earlier removal of the frame. In either case, an optimal clinical outcome is more likely. Furthermore, and possibly more importantly, in the immediate postoperative period, when the limb is immobilized for a 2–3-week period, neovessel formation occurs at the fracture region[16]. After the initiation of weight bearing, the TR system is more flexible in axial loading. This increased flexibility exploits those neovessels and promotes fracture healing, whereas the increased shear stiffness prevents horizontal micromotion and development of a nonunion or a malunion. It is accepted that pin loosening and subsequent pin-tract infection[17] is a problem of rather mechanical etiology, and usually occurs at the proximal or distalmost ends of the external fixator.

Pin-tract infection also appeared in some of our cases and was treated with meticulous local cleaning and dressing, antibiotics, and rarely with pin exchange. In this report, this IEF treatment complication is not mentioned in detail as we principally focus on the technical aspects of the TR configuration. This complication has been attributed to local bending effects, particularly those in the vicinity of joints, and can be addressed effectively either by extending the construct across the joint or by locally increasing the number of wires. Both options aim at increasing mechanical stability and enhancing bony union. The latter, however, is preferable and can be implemented more easily in a TR IEF configuration.

The TR Ilizarov construct has favorable biomechanical properties, which enhance fracture union and at the same time reduce complications arising from joint immobilization and pin/wire tract infections. Our clinical outcomes, corroborated by the biomechanical proof-of-principle, are encouraging enough for us to recommend its continued use in patients with the appropriate clinical indications.


  Conclusion Top


When treating selected trauma patients, the application of the TR module in Ilizarov circular external fixators is suggested as a promising surgical alternative, offering satisfactory outcomes and reduced patient morbidity.

Acknowledgements

This study was supported by Menoufia University Hospitals and El-Obour Insurance Hospital.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Grivas A, Magnissalis A. The use of twin-ring Ilizarov external fixator constructs: application and biomechanical proof-of principle with possible clinical indications. J Orthop Surg Res 2011; 6:41.  Back to cited text no. 15
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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