1 Introduction

High-energy tibial plateau fractures are known by extensive bony comminution, substantial soft tissue damage that adversely affects the healing process, and a high incidence of associated adverse effects as compartment syndrome and neurological injuries, particularly involving the common peroneal nerve^1,2

The most frequently employed classification system for categorizing these fractures is the Schatzker classification.³ It categorizes them into low- and high-energy patterns. High-energy fractures, specifically types V and VI, present significant challenges for orthopaedic surgeons due to their complexity. These injuries typically involve articular surface depression, condylar displacement, metaphyseodiaphyseal dissociation (MDD), and associated soft tissue complications as closed degloving injuries (including skin lacerations and ischemia).^4,5

Throughout years, numerous treatment approaches have been suggested for these complex fractures. The most commonly adopted protocol involves application of bridging exfix to allow soft tissue recovery, followed by delayed (ORIF). However, this staged approach still carries significant risk of deep infection.^6,7,8 There is currently no consensus regarding the optimal timing for conversion from exfix to internal fixation. The presence of pin tract infections often precludes safe progression to internal fixation. Additionally, neglected cases such as those complicated by missed compartment syndrome or presence of haemorrhagic bullae pose significant challenges to adhering to this treatment protocol.

Traditional Ilizarov frame with carries the risk of pyoarthrosis. Schanz screws or wires are usually not away from the soft tissue injury zone which might delay better care and healing of these injuries. Associated pin tract infection hinders any possible later internal fixation or total knee replacement.

The aim of this research is to evaluate the findings of limited internal fixation combined with knee-bridging external fixator as a definitive treatment for high-energy tibial plateau fractures, with particular emphasis on the utilization of the spiral Ilizarov frame as an alternative to conventional external fixation systems.

2 Materials and methods

This retrospective case series was performed at OrthopaedicDepartment of Tanta University, a regional Level 1 trauma centre. Between January 2004 and December 2023, a total of 42 tibial plateau fractures Schatzker V and VI were analyzed. All cases were managed using arch-type external fixator, with or without limited ORIF. Inclusion criteria comprised patients aged over 18 years with closed, high-energy Schatzker type V or VI tibial plateau fractures, poor soft tissue conditions, and delayed presentation (i.e., more than two weeks post-injury). Exclusion criteria included patients under 18 years of age, open fractures, concomitant neurovascular injuries, minimal soft tissue damage, compartment syndrome, and prior application of temporary monolateral external fixator. Fractures were defined as high-energy based on the mechanism of injury (e.g., motor vehicle collision, motorcycle accident, or crush injury). Soft tissue status was evaluated according to the Oestern and Tscherne classification.⁹

2.1

2.1 Surgical technique

All procedures were performed under spinal or general anesthesia with the participants positioned on a radiolucent operating table under fluoroscopic imaging. Initial fracture alignment was achieved using manual traction, followed by attempts at closed reduction and compression of the articular surface using percutaneous reduction forceps, with fluoroscopic confirmation (Fig. 1a).

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Fig. 1 Steps of the surgical technique: a) reduction of the articular surface b) reduction of the metaphyseal part c) components of the spiral frame d) intraoperative photos after application of the spiral frame.

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If unsuccessful, open reduction was performed via a lateral parapatellar approach. A bone elevator was utilized to elevate displaced fracture fragments. In some cases, depressed articular fragments required elevation through a limited mini-ORIF technique. Temporary stabilization of the articular surface was achieved using K-wires, followed by definitive fixation with 6.5 mm cannulated screws.

The same technique was utilized for the metaphyseal segment using either closed or open reduction. Open reduction could be done through extension of the lateral parapatellar incision or exposure of the only metaphyseal part. Fixation either by K-wires or screws was done. (Fig. 1b).

Four 120° arches (two for the femoral side, two for the tibial side).Each two arches were connected through threaded sockets(Fig. 1c). The four arches were arranged in stepladder manner from posterolateral side of the femur to the medial side of the tibia (spiral frame).The femoral part was connected to the tibial one through two slots of the arches by two long threaded rods supported by two threaded sockets.(Fig. 1d).

Two femoral Schanz screws—inserted laterally and anterolaterally—were placed parallel to the knee joint and connected to the proximal segment of the external fixator frame. Similarly, two tibial Schanz screws—anteromedial and medial—were inserted parallel to the ankle joint and attached to the distal segment of the frame. To enhance construct stability, two or three additional threaded rods were connected between the proximal and distal portions of the frame, either directly or via oblique support rods (Fig. 1d).

Patients were maintained non–weight-bearing and instructed to perform static quadriceps exercises. Regular pin tract care and wound inspections were conducted. Follow-up visits were scheduled at the 3rd week.

(suture removal), at the 8th week (frame removal under general anesthesia followed by the application of an above-knee cast) and at the 12th week for cast removal & hinged knee brace. Physiotherapy and gradual weight-bearing were initiated based on radiological evidence of fracture healing. Fracture union was determined by presence of bridging callus formation, no fracture site mobility, and no pain during full weight-bearing, as evaluated using the single-leg stance test.

Demographic data, clinical and radiological indicators of union, malalignment, malunion, and any complications were recorded and analyzed. Functional outcomes were determined using the method described by Sanders et al.¹⁰

3 Results

A total of 42 participants with high-energy tibial plateau fractures were included in the study, comprising 32 males (76.2 %) and 10 females (23.8 %). All patients were treated with limited internal fixation—either closed or open—augmented by bridging spiral Ilizarov frame. The mean age at time of treatment was 46.6 years (range: 20–70 years). The right lower limb was affected in 22 cases (52.4 %), while the left was involved in 20 cases (47.6 %). The injury mechanism was road traffic accidents in 30 participants (71.4 %) and falls from height in 12 (28.8 %).

According to Schatzker classification, 30 cases (71.4 %) were type VI, while 12 cases (28.8 %) were type V. Based on the Tscherne classification, 18 fractures were grade 2 and 24 were grade 3. Hemorrhagic bullae were observed in 17 patients (40.5 %), while serous bullae were present in 25 cases (59.5 %) (Table 1).

The mean duration of follow-up was 10 years (range: 2–18 years). The average duration between injury and surgical intervention was 8.5 days (range: 2–21 days). Operative time ranged from 2 to 3 h. The external fixator was retained for a mean duration of 8.62 weeks (range: 6–16 weeks). All fractures union was achieved within a mean period of 4.175 months (range: 3–7 months).

No systemic complications related to the surgical procedure were observed, including blood loss, septic arthritis, pulmonary embolism, DVT, soft tissue necrosis, or peroneal nerve palsy.

Functional outcomes, evaluated using the Sanders et al. scoring system, were excellent in 12 patients (28.6 %) (Figs. 2 and 3), good in 19 patients (45.2 %), fair in 8 patients (19 %), and poor in 3 (7.2 %) (Table 2). Certain complications were observed during treatment. Pin tract infections observed in 35 patients (83.3 %), all of which resolved with local care and a short course of systemic antibiotics. Intraarticular screw penetration occurred in two cases (4.76 %), necessitating screw removal. One patient (2.38 %) developed delayed union, successfully treated with onlay bone grafting.

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Fig. 2 Demonstrates case one: 36 years old male after road traffic accident with hemorrhagic bullae a) preoperative images b) postoperative images c)1 year radiological follow up after removal of the frame d)Clinical images after one year.

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Fig. 3 Shows case 5 : 59 years old male after road traffic accident with sever soft tissue contusion a) preoperative images b) immediate postoperative and follow up X rays c) Clinical images after 6 months.

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Five cases (11.9 %) with nonunion and improved soft tissue conditions underwent secondary ORIF using plate, screws, and bone graft. An additional three patients (7.14 %) with nonunion and compromised soft tissues were managed using a classic Ilizarov frame combined with bone grafting (Fig. 4).

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Fig. 4 Shows case presentation 26 : 60 years old male diabetic after falling from height with bad local condition a)preoperative images b)immediate postoperative and follow up after early removal of the spiral frame due to loose infected femoral schanz screws c) conversion to traditional spiral frame with iliac crest bone graft d)Final Follow up with good functional outcome and acceptable range of motion of the knee.

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At one-year follow-up, the average knee flexion was 84.375° (range: 15–130°). All participants regained their former occupational duties within 5 months post-injury.

The relationship between final knee function scores and various clinical parameters is detailed in Tables 3 and 4. Male patients demonstrated better outcomes compared to females, and younger patients achieved significantly superior results compared to older individuals. Smokers and individuals with comorbidities experienced poorer outcomes. A longer interval between trauma and surgery correlated with less favorable results.

Fractures classified as Tscherne type 2 were associated with better functional outcomes than type 3. Prolonged duration of external fixation was negatively correlated with final outcomes (p = 0.001).

4 Discussion

Management of high-energy tibial plateau fractures remains challenging in orthopaedic practice. Double plating was considered to be the best mechanical stabilization method for these fractures, as it addresses both medial and lateral columns thereby facilitating optimal fracture reduction and stability.³

Traditional double plating has been linked with multiple serious complications including implant failure, malunion, non-union, joint stiffness, secondary osteoarthritis, infection, and significant soft tissue dehiscence.¹¹ Moore et al.¹² reported infection rate of 23 % in association with bicondylar fractures managed by internal fixation. Wound dehiscence occurred in 8 out of 11 knees treated with double plating. Mallik et al.¹³ reported infection complicated 4 out of 5 tibial bicondylar fractures While 216 the use of dual incisions significantly reduced soft tissue complications, 217 deep infections were still observed in 13.8 % of cases, indicating that the 218 risk of serious infection persists despite improved surgical approaches.¹⁴ Jiang et al.¹⁵ documented a deep infection rate of 4.7 % with double plating.

Minimally invasive plate osteosynthesis (MIPO) has been increasingly utilized in management of such fractures due to its less invasive nature. However, despite its advantages, deep infections and soft tissue complications continues to be observed in the literature. Lee et al.¹⁶ documented that, among 36 cases treated with MIPO, two developed deep infections and one experienced severe skin necrosis, underscoring that even less invasive techniques are not without serious soft tissue complications risks. Jiang et al.¹⁵ documented an infection rate of 7.3 % associated with MIPO in tibial plateau fractures treatment, indicating that although less invasive, still carries a notable risk of postoperative infection. MIPO has been linked with a higher incidence of implant-related pain compared to conventional plating techniques, potentially due to the submuscular placement of hardware and limited soft tissue coverage.¹⁷ MIPO also fails to adequately address (MDD), which may lead to secondary collapse beneath the unsupported tibial plateau, compromising long-term alignment and joint function.¹⁸ Single lateral plating is commonly associated with the development of progressive varus collapse over time, due to insufficient support of the medial column and inadequate resistance to axial loading forces.¹⁹

Hybrid fixation, which combines lateral ORIF with unilateral external fixation, often fails to adequately address medial condylar comminution. This limitation is primarily due to larger diameter of half-pins and their limited purchase in the metaphyseal bone, resulting in suboptimal stabilization of the medial column.²⁰

The advancement of circular external fixation systems has introduced new possibilities for managing complex fractures by facilitating biological osteosynthesis through minimally invasive approach, thereby preserving soft tissue integrity and promoting favorable healing conditions.^21,22 The olive wires used in Ilizarov frame offer enhanced reduction and interfragmentary compression of metaphyseal fracture fragments, and allow for optimal correction of rotational deformities, contributing to improved alignment and stability.²³

Ali et al.²⁴ reported that four-wire ring fixator construct applied to proximal tibia provides mechanical stability comparable to that of dual plating, suggesting its viability as an alternative method for stabilizing complex tibial plateau fractures. Watson et al.²⁵ documented that combination of four olive wires with lag screw offered superior stability compared to dual plating in the management of tibial plateau fractures, highlighting the mechanical advantages of circular external fixation in select fracture patterns.

In the current study, the advantages of both internal and external fixation was combined. Spiral frame that spans the knee was used to augment the fixation used. It acts also as neutralization element for screw fixation. Waiting for the improvement of soft tissue might take longer time and hinder easy reduction of the fracture.The mentioned frame was applied away from the injury zone. It also facilitates the care of soft tissue. The sites of pin tract infection didn't preclude the need for conversion to internal fixation by plates if indicated and if there was a need for conversion to total knee replacement in cases with end stage arthritis. Regarding the stability of the frame, it was multiplanar. Therefore, it was more stable than the conventional exfix. Arch constructs with four or five strong connecting rods made the device more rigid that could withstand axial and rotational stresses. The spiral frame was more convenient for the patient with less psychological burden. It doesn't carry risk of pyoarthrosis resulting from reference wire that inserted near the knee joint in the conventional frame. Finally, this capacious frame could withstand the suspected leg swelling more than the ringed frame.

50 % 0f our study cases underwent open reduction (52.4 %). This was much higher than reported by O. Farouk et al.²⁶(23.3 %), El Barbary et al.²⁷ (20 %), but slight lower than Weiner et al.²⁸ (60 %)

In all cases (100 %), minimal internal fixation using percutaneously inserted lag screws was utilized to achieve anatomic reduction and stabilization of the articular surface while minimizing soft tissue disruption. This rate was higher than that reported by O. Farouk et al.²⁶ (20 %, six cases) and El Barbary et al.²⁷ (60 %), and supporting the findings of Weiner et al.²⁸ who also reported 100 % utilization of lag screw fixation.

Hybrid fixation allows for earlier weight-bearing compared to dual plating, due to its enhanced stability and reduced soft tissue disruption, thereby facilitating earlier functional rehabilitation, although our case series didn't weight bear earlier than those treated with ring fixators This may be attributed to the relatively lower biomechanical stability of the spiral frame compared to the conventional full-ring Ilizarov construct. Nonetheless, Ilizarov frame promotes fracture healing through controlled axial micromotion while minimizing detrimental shear forces. Additionally, the condition of soft tissue envelope plays a critical role in the healing of tibial plateau fractures, and well-established correlation exists between poor outcomes and the presence of severe soft tissue damage.²⁹

In our case series, meniscal or ligamentous injuries were not addressed with primary repair, as this would have necessitated arthrotomy which in context of compromised soft tissue conditions could have increased risk of wound complications and intra-articular infection. We concur with Kataria et al.³⁰ that most cruciate and meniscal injuries are best managed as second-stage procedure, following fracture consolidation and restoration of adequate knee motion range. This staged approach helps to minimize soft tissue complications and allows for more effective assessment and treatment of intra-articular pathology. Moreover, most meniscal lesions linked with tibial plateau fractures have been documented to be located peripherally within the vascularized "red zone," where spontaneous healing is possible without surgical intervention.¹⁸ In cases where meniscal or ligamentous injuries were identified, the postoperative rehabilitation protocol was initiated promptly following removal of the frame. This included immediate passive knee motion exercises, along with strengthening of the quadriceps, hamstring, calf, and gluteal muscles to facilitate functional recovery and joint stability.

Multiple published studies have demonstrated reduction in complication rates when bicondylar tibial plateau fractures are managed using fine-wire external fixators, particularly in terms of soft tissue preservation, infection control, and fracture stability.^26,30–32 The findings of the current study are consistent with them, as no systemic complications related to the surgical intervention were observed. Pin tract infection, a commonly encountered but often unavoidable complication with external fixation, occurred in 35 cases. However, all instances were successfully managed with local care and a short course of systemic antibiotics. Additionally, the mean operative time in our series was shorter than that documented by kataria et al.³⁰ and O.Farouk et al.²⁶ reflecting the relative efficiency of the applied technique.

Smokers and those with medical morbidities had poorer outcome than their counterparts. This could be explained that nicotine decrease the blood flow to the fracture sites.

Regarding the spanning of the frame across the knee joint, Marsh et al.³³ advocated for spanning exfix across the knee joint to allow joint rest and provide additional immobilization of the articular fragments. For unstable fractures or insufficient tibial plateau fixation John et al.³⁴ recommended maintaining an external fixation bridge across the knee joint for up to six weeks, as premature knee movement may lead to fracture displacement and further soft tissue damage. Ligamentous injuries related to tibial plateau fractures may also benefit from delayed knee mobilization, with bridging fixation promoting more effective healing. Hutson³⁵ found that removing the bridging frame at six weeks doesn't markedly compromise long-term knee mobility in complex plateau fractures. Meanwhile, Catagni et al.³⁶ suggested extending the frame onto distal femur in cases of knee joint instability to improve stability.

In our series, the frame maintained for eight weeks to allow sufficient time for the intra-articular fractures to develop soft callus. Although this immobilization period may contribute to some degree of knee stiffness, all patients achieved an acceptable functional range of motion by one year post-injury. Nearly all participants were able to ambulate and regain knee function adequate to resume their pre-injury occupational activities. The functional outcomes observed in this cohort compare favourably with those reported in the existing literature.^26,33,36 These findings suggest that limited internal fixation combined with a bridging spiral arch frame provides an effective and stable fixation method for managing these complex injuries without significant complications. However, the study is limited by a relatively small sample size, the lack of a control group, short follow-up duration, and its retrospective design.

5 Conclusion

Spanning bridging spiral frame fixation is a safe and effective approach for managing high-energy Schatzker type V and VI tibial plateau fractures complicated by severe soft tissue injury. This technique facilitates anatomical restoration of the articular surface, provides stable fixation of fracture fragments, and allows for appropriate management of associated soft tissue conditions, all while maintaining a low complication rate.

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Patient consent

None.

Author contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by [Hosam Mohamed Ghaly], [Mahmoud A. El-Rosasy] [Ahmed Farid Mekky ]and [Mohamed Rohayem]. The first draft of the manuscript was written by [Hosam Mohamed Ghaly],[Mohamed Rohayem ] prepared the figures and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Human ethical approval

The study fulfilled the Institutional Ethics Code of Research (Approval code 36264PR500/1/24).

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.