Eur J Orthop Surg Traumatol (2008) 18:521–524 DOI 10.1007/s00590-008-0345-2
O R I G I N A L A R T I CL E
Treatment of complex tibial plateau and distal tibial fractures with Taylor spatial frame: experience in a district general hospital Ashok Rampurada · Sanjeev Madan · Tamer Tadross
Received: 7 August 2007 / Accepted: 5 June 2008 / Published online: 29 July 2008 © Springer-Verlag 2008
Abstract Complex tibial fractures especially intraarticular pilon and plateau fractures are diYcult to manage. Literature shows poor results in the treatment of these fractures due to complexity of the fracture and involvement of articular surface. Taylor spatial frame (TSF) is a hybrid, multiplanar, external Wxator, which uses the slow correction principles of Ilizarov system. Specialised centres around the world use these frames to treat various long bone fractures and to correct deformities. Very few district general hospitals and hospitals of similar set-up deal with these injuries. TSF was used to treat 26 complex intraarticular fracture of tibial plateau (Schatzkar type IV–VI) and pilon fractures (Rudi III) in a district general hospital. Seventeen were pilon and nine were plateau fractures. There were 21 male and 5 female patients. Average length of time patients had the frames on was 191 days. The average follow up was 14 months. The average operative time was 2 h 13 min for pilon fractures, 2 h 37 min for tibial plateau fractures. Fourteen patients did not have any complications. Twelve had 1–3 pin-site infection. Four had chronic pain. Two pilon fractures had delayed union and one had nonunion. One patient had foot compartment syndrome and underwent decompression. No cases of osteomyelitis, broken pins or nerve palsy occurred. With proper training, preoperative and postoperative care, TSF can be used in a district general hospital safely. The procedures can be planned well in advance. Referral to specialist centre, possible complications during transfer and a second procedure at the referral centre could be avoided.
A. Rampurada (&) · S. Madan · T. Tadross Department of Trauma and Orthopaedics, Doncaster Royal InWrmary, Doncaster, South Yorkshire DN2 5LT, UK e-mail:
[email protected]
Keywords Taylor spatial frame · Hybrid · External Wxation · Tibial plateau · Pilon
Introduction Complex tibial fractures especially pilon and plateau fractures are diYcult to manage. Literature shows poor outcomes in these types of fracture due to complexity of the fracture and involvement of articular surface. No conventional treatment is feasible and ring external Wxators are the only answer. We have employed Taylor spatial frame (TSF) in the treatment of these complex fractures with good results. TSF is a hybrid, multiplanar, external Wxator. It uses the slow correction principles of Ilizarov system but has advantage of computer accuracy and ease of application. These frames are predominantly being used in specialised centres around the world to treat various orthopaedic problems including major trauma. In a district general hospital setting, we have been able to deal successfully with these fractures and avoid referring them to tertiary centres. Trauma patients particularly long bone fractures might have the circular frame as a second procedure, which could be avoided. We present our experience in a district general hospital using the TSF in 26 patients with complex tibial plateau and pilon fractures. In literature, we have not found a similar paper of experience with TSF in a district general hospital.
Setting District general hospital.
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Design Retrospectively reviewed, consecutive, pilon and tibial plateau fractures.
Material and methods From January 2004 to December 2006, we applied TSF on 30 patients for complex intraarticular fracture of tibial plateau (Schatzkar type IV–VI) and pilon fracture (Rudi III). Conventional orthopaedic management would be extremely diYcult or impossible in these cases. We excluded three patients who still had TSF on from our study and one patient was transferred to other centre. Twenty-six patients met the inclusion criteria. Standard preoperative clinical examination was done on all the patients. Rotational deformity was measured clinically. Standard preoperative anterior-posterior and lateral X rays were taken. Reference fragment and alternate fragment were determined on these X rays. Two consultant orthopaedic surgeons applied all the frames. These consultants had specialist training and previous experience in these procedures. Patients were on prophylactic intravenous antibiotics in open fractures and for closed fractures, perioperative antibiotic was administered. Tourniquet was not used during the procedure in any of these cases. We ensured at least 2-Wnger breadth clearance between the ring and the skin during mounting of these frames. Postoperatively, a trained physiotherapist was responsible for each of these patients. Physiotherapy was started the following day of frame application. A handout was given to each patient that contained information about exercises and frame management. The kurgan method of pin-site care was followed. The patients were gradually mobilised over a period of days and allowed to weight bear as tolerated. Before the patients were discharged, they were trained to take care of the frame including pin-site care and to adjust the screws as necessary. A printout of the schedule provided by the computer software designed for TSF was given to them. The patients were followed up regularly in outpatients department and physiotherapy after interim discharge. During the initial phase, the patients were seen weekly and later once in fortnight. Residual correction was done if a deformity persisted. The frames were removed when both clinical and tricortical radiological union (AP and lateral views) was established. Two weeks prior to complete removal of the frame, it was dynamised.
Eur J Orthop Surg Traumatol (2008) 18:521–524
plateau fractures (Fig. 1). There were 21 male and 5 female patients in our study. The youngest in our study group was 22 years old, oldest was 59 years and the average being 40 years. Ten patients were smokers, 14 were nonsmokers (Fig. 2) and status of two patients was not found in the notes. Average length of time the frames were on was 191 days. Follow up (Post removal of frame) varied between 6 and 24 months with average being 14 months. Five patients had bone grafting at the time of application of frame. Six patients had previous operations (Wxed with other methods or had washout or soft tissue release). The average operative time was 2 h 13 min for pilon fractures, 2 h 37 min (Fig. 3) for tibial plateau fractures.
Fig. 1 Number of pilon and tibial plateau fractures in our study
Fig. 2 Smoking and sex diVerence in our patients
Results We reviewed the notes and serial X rays of these 26 consecutive patients. Seventeen had pilon fractures, nine had tibial
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Fig. 3 Anaesthetic time in tibial plateau and pilon fractures
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Fourteen patients did not have any complications. Twelve patients had 1–3 pin-site infection and were treated with oral antibiotics. Two of them had leg cellulites needing IV antibiotics. One had abscess at the bone graft site, which required debridement and washout under general anaesthesia and intravenous antibiotics. Four patients had chronic pain (two pilon fracture had delayed union and one went for nonunion). One patient had foot compartment syndrome and underwent decompression. We do not know whether this was due to nature of original injury itself or due to application of TSF. No cases of osteomyelitis, broken pins or nerve palsy occurred. Serial preoperative through postoperative X rays of a 50-year-old patient treated with TSF are presented (Figs. 4–9). This patient involved in high-speed road traYc accident was trapped in overturned car and was cut out by Wre services. TSF was applied within 24 h of the injury. Standard
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protocol was followed as described above. The frame was removed 5 months post surgery. Twelve months post surgery patient could full weight bear and mobilise without any pain. Patient had 15° of dorsiXexion and 35° of plantar Xexion after intense physiotherapy. There was some pain beyond 15° of dorsiXexion.
Discussion TSF is a hybrid multiplanar ring external Wxator. It is kinematically equivalent to a Stewart Gough platform. These platforms are routinely used in Parallel Robotics, Flight Simulators and Multiaxial platforms. The TSF consists of two circular bases, 6 telescopic linkage rods (struts) and 12 universal joints [6]. Adjusting the strut lengths can mimic wide-ranging deformities.
Figs. 4–9 Serial X rays of a 50-year-old patient treated with TSF
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TSF has various orthopaedic applications. It is used for acute fracture management [2], correction of congenital, developmental and post-traumatic deformities [4]. Deformities of the lower limb like malunions, tibia vara, genu valgum and limb-length discrepancies can be corrected with ease [4]. Unlike Ilizarov frame, TSF can be used to correct angulation, translation and rotation of a given deformity simultaneously. Adjusting only strut lengths on a single frame does this. The residual deformity can be corrected with TSF in outpatients department. This is diYcult with Ilizarov system and may need to return to theatre for the correction [4]. Multiaxial deformities are corrected with relative ease, with TSF [4]. This is also true with other authors who used computer-assisted six axes correction [9, 10]. Error in preoperative planning is the most important factor resulting in poor results, in cases where Ilizarov frame is used [8]. Computer technology used in TSF reduces planning errors [6]. To authors knowledge there are no papers or data of using TSF in a district general hospital set-up. All the papers in the literature are from university hospitals or tertiary referral centres [1, 5, 7, 12]. Our results are comparable to any published data from the centres of excellence. Disadvantages of using TSF include steep learning curve, TSF frames are more expensive than other traditional frames and patient compliance [3]. Increased surgical experience with system decreases the complication rate and increases the accuracy of correction using these frames. This is in part because it is diYcult to accurately measure the 13 frame parameters and to mount the frame without residual rotational and translational errors [3, 11]. Limitation with this paper is it is a retrospectively reviewed case series. To conduct a prospective randomised controlled trial of diVerent treatment options available in similar cases is extremely diYcult.
Conclusion TSF is a valuable armament in the arsenal of an orthopaedic surgeon where no other conventional technique is feasible. Application of TSF can be well planned ahead of the procedure and gives more Xexibility to the surgeon. It takes less operative time to apply and is easier to manage while on the patient. We have shown with proper training, preoperative and postoperative care, TSF can be used in a district general
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hospital safely. To set up services for managing patients who require TSF in a district general hospital or hospital of similar size and facilities, we recommend a team including of at least two trained orthopaedic surgeons, dedicated nursing staV and specialist physiotherapists. Providing such a service in these hospitals will help reduce pressure on specialist referral centres. It reduces the risks of patients developing complications during transfer and also a possible second procedure in referral centres can be avoided. Acknowledgments The authors wish to thank Mr. K. Nagpal, and K. Guy and Y. Hall, Audit Department, Doncaster Royal InWrmary, Doncaster. ConXict of interest statement this study.
No funds were received in support of
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