Adam Starr, M.D.
Drew Sanders, M.D.
By Adam Starr, M.D., and Drew Sanders, M.D.
High-energy periarticular or metadiaphyseal tibia fractures almost always involve severe soft-tissue injuries. Open lacerations, poor skin quality, and deep muscle damage can make internal fixation undesirable, or even unsafe. Infection risk is high; in severe cases, fracture-related soft tissue damage can result in amputation.
However, standard ring or hybrid external fixation devices are cumbersome and unfamiliar to many orthopaedic surgeons.
To improve patient outcomes, UT Southwestern has designed a novel external fixation T-bar construct to stabilize these fractures, reduce the risk of soft tissue complication, and promote bone union while allowing flexibility of the knee. Using standard external fixation components and a novel pinning strategy, our technique also increases the odds of achieving full range of motion in the knee.
Together with UT Southwestern orthopedic residents and one medical student, we co-authored a retrospective study of outcomes for 31 patients. Published in Techniques in Orthopaedics, our data cover three types of complex, soft tissue-involved tibial fractures:
- Type 41: Top of the tibia, below the knee (tibial plateau)
- Type 42: Middle of the tibia
- Type 43: Bottom of the tibia, near the ankle
Benefits to patients and surgeons
Study participants all had tibiafractures with extensive soft tissue damage not amenable to standard internal fixation methods. Of the 28 patients for whom we captured follow-up data:
- None needed amputation
- One developed osteomyelitis
- None had infections that needed debridement
- Three had revisional surgery to unite bones near the ankle
- Four had surgery for compartment syndrome
Deep infection rates were similar to or lower than in previous studies, which show 11%-50% infection rates for type 3 injuries and up to 30% infection rates for internal fixation. Malunion is possible but may be preferable to soft tissue complications such as skin or muscle necrosis, vascular or nerve damage, or permanent disability.
Data suggest that our T-bar technique can heal complex, soft tissue-involved tibial fractures when internal fixation is not desirable. With no special equipment needed, most orthopedic surgeons could apply this technique, independently or in combination with limited internal fixation.