Minimally Invasive Treatment Of Complicated Tibial Plateau Fractures With The Assist Of Bitraction Rapid Reductor

Background:Complicated tibial plateau fractures are mostly a result of either high-energy trauma in young individuals or low-energy trauma in older osteoporotic patients.The goal of treatment have been always to achieve anatomical reduction,stable internal fixation and early mobilization while keeping complications as low as possible.The initial management of complicated tibial plateau fractures is to halt any neurovascular damage and stabilize the patient till the fractured site is operable.The conventional treatment for complicated tibial plateau fracture is open reduction internal fixation.The main goal of this technique was to achieve an excellent anatomical reduction and alignment.The price to achieve such goals was stripping soft tissue extensively thereby jeopardizing bone vascularization.Minimally invasive percutaneous plate osteosynthesis was firstly presented to treat proximal and distal femur fractures,it was extended to treat complex proximal tibial fractures later.The idea behind MIPO technique was to achieve original goals of treatment of articular and periarticular fractures while preserving soft tissue and decreasing periosteum stripping.Objectives:Many surgeons prefer to perform arthrotomy during open reduction internal fixation(ORIF)treatment of complicated types of tibial plateau fractures in order to have a direct visualization of the articular surface and reach good articular reduction.Although there are reports that an incised meniscus with its surrounding soft tissues during submeniscal arthrotomy healed,we questioned ourselves about arthrotomy procedures.How necessary is it or could it be avoided while achieving the same outcome maybe even better.The purpose of this study is to determine if the use of bitraction rapid reductor device will allow us to perform minimum invasive percutaneous plate osteosynthesis(MIPO)technique more often for fixation while restoring stability,alignment and articular fixation without much compromise in soft tissue when it's compared to traditional open reduction internal fixation(ORIF)technique.Methods:During the period from September 2014 to June of 2016,31 patients with tibial plateau fractures were selected for this study.Surgical treatment was indicated for all 31 cases.The cases were divided into two groups,a control group,group A,of17 patients and group B of 14 patients.Group A included 10 females and 7 males while group B were 5 females and 9 males.We used Schatzker system of classification for our study.Group A fracture types are as follow: type II four cases,type III two cases,type IV three cases,type V four cases and another four cases of type six.Group B included three cases of type II,two cases of type III,one case of type IV,five cases of type V and three cases of type VI.We treated group A,the control group,mostly using traditional ORIF technique,in addition we had to perform an arthrotomy for better view of the articular fragment site using a manual distractor with the help of an assistant.The second group,group B,used mostly MIPO technique assisted by bitraction rapid reductor device,which didn't require a human factor to distract the two ends of the fracture into opposite directions while maintaining stability.The bitraction rapid reductor device is primarily composed of a reduction scaffold,traction bow,traction pin,connecting rod,auxiliary reduction pin(Schantz pin or Kirschner wire)and proximal connecting device1.The rapid reductor is connected to distal femur and either to distal tibia or to the calcaneus by two traction bows,each on one side.These traction bows are then connected via connecting rod to form a mechanical closed loop system that is able to generate enormous force to reduce and stabilize fracture sites1.The time spent on fracture reduction,operation and fluoroscopy were recorded as well as the volume of intra-operative blood loss.The necessity for arthrotomy was noted.We also recorded average hospital stay for both groups.The functional and clinical outcome was evaluated using Hospital for Special Surgery Score(HSS).Patients were followed up for an average of 14.06 months for group A and 12.5 months for group B.Results:There were no complications related directly or indirectly to the bitraction rapid reductor device.Both groups had no postoperative infections,skin necrosis or nonunion.The operation time included time spent on exposing,reduction and fixation of fractured tibial plateau and fluoroscopy time.The mean operation time,blood loss volume and follow up for group A was as follow 180.9 minutes,249.4 ml,and 14.06 months respectively,and for group B 135 minutes,121.8,and 12.5 months respectively.Mean postoperative hospital stay in group A was 7 days and 4 days in group B.Average bonny union for group A and group B was 12.2 and 10.5 weeks respectively.There were three cases of delayed healing in bone union in group A,while there was no any delayed healing in group B.The group A and group B had mean HSS score of 89.3 and 94.9 respectively.Conclusion:MIPO technique is superior for preservation of soft tissue of the fractured site.Preservation of soft tissue is becoming a principle in the treatment of tibial plateau fractures.The bitraction rapid reductor is a noble device that offers an effective approach to treat complex tibial plateau fractures using MIPO technique.The rapid reductor allowed us to decrease soft tissue stripping and devascularization of bone.As a result,we were able to decrease operation time,blood loss volume and achieve good clinical outcome.The rapid reductor is a device that stabilizes the fracture site in an anatomical position without the need for a constant human handler to assist and keep it in check.In contrast to other distractors that must be kept in check during the surgery and have to be controlled by an assistant constantly,once the rapid reductor is set up,it can stand alone through the whole surgery.All fractures in group B healed well and achieved good functional recovery compared to the control group.The bitractin rapid reductor device,as easy it is to use,it offers a logical solution for tibial plateau fractures.