الفهرس 
Case Number (1)Only 14 pages are availabe for public view
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Abstract
Summary and Conclusion
Comminuted tibial plateau fractures usually are caused by high-energy trauma that also causes other bony injuries and extensive soft tissue injury. Early problems in the management of this fracture include instability of the fracture fragments and difficulty in adequately stabilizing the fragments when open reduction is attempted. Postoperatively, infection and problems in healing of the soft tissue and incision site are frequent. Late problems include loss of reduction, malunion, and osteoarthritis. When comminution is assossiated with dissociation of the metaphysis from the diaphysis of the tibia, the fracture is unsuitable for treatment by traction, and long-term immobilization is deleterious to joint function in comminuted plateau fractures.
During the last 2 decades, the evolution of new techniques and devices has lead to apply the principles of biological fixation and minimally invasive surgery for treatment of Comminuted tibial plateau fractures.
Circular frames and transfixion wire fixation, although initially used for lengthening, correction of deformities and non unions, gave promising results when their application expanded to fracture care. Circular and hybrid fixator facilitate a better over all fracture reduction and interfragmental compression. The use of olive wires offers a unique adjustability of the fixation system, capable of reducing and maintaining small intraarticular fragments and correcting angular deformities. Ring tensioned wire frames provide mechanical stability of the comminuted tibial plateau fracture comparable with dual plating internal fixation, the excellent stabilization of fracture allows early ambulation of the patient with partial weight bearing, even in comminuted fractures, the beneficial biologic influence of the early weight bearing on osseous healing have been previously mentioned. Circular frames and transfixing wires gives promising results.
The major problem of the skin wound, fracture plasters, subcutaneuos hemorrhage, or extensive bruising are not obstacles for the safe application of the technique. Small pin circular or hybrid fixator can be placed irrespective to the skin condition. Any additional bone necrosis is minimized because the peri-osteal and endo-steal blood supply are not further damaged. The influence of early motion of the knee joint after tibial plateau fracture has been debatable, although the benefits of motion have been clinically and experimentally established, the severe bony comminution and coexistent injuries such as ipsilateral tibial or femoral fractures jeopardize the final results when early motion commences.
In this study fifty cases of comminuted tibial plateau fractures in forty-eight patients were treated by Ilizarov fixator .The fixator permitted for both reduction through ligamento-taxis principle. Ligamentotaxis principle and indirect reduction was through femoral and tibial rings with the tibial metaphyseal ring free as a dead ring before fixing metaphyseal wires through this ring The most common indications in our series of bridging of the joint fixation were a distal femoral fractures ,or instability on stressing the frame due to tibial diaphyseal extension with good clinical results for the knee movement. The present study emphasizes the low morbidity , low rate of postoperative deep infection, and the versatility of the technique , although the technique is technically demanding and needs training, also needs a cooperative patient who can follow the post-operative care instructions. is suitable for the most comminuted and complex plateau fractures .Geriatric patients with comminuted fractures of the tibial plateau are also good candidates for this treatment method .
The excellent stabilization of the fracture with ring fixator allowed early ambulation of the patients with partial weight bearing.The fixator was applied irrespective of the skin condition.
Intra-operative imaging with the aid of image intensifier is a very useful tool in assessing the reduction by ligamentotaxis applied for indirect reduction through the fixator, although sometimes reduction is underestimated.
The degree of initial comminution is a factor in determining the functional outcome(the worse the initial articular comminution, the worse the outcome).
The overall functional outcome of treatment of comminuted tibial plateau fractures treated by indirect reduction and ring fixator in this study were excellent in eighteen cases, good in twenty-two, fair in eight cases, and poor in two cases
According to this study, it is recommended to use ring fixator for treating comminuted tibial plateau fractures with good selection of patients capable of care of the fixator , its wires ,and pins and daily cleaning .At least three wires have to be applied to fix the comminuted plateau taking into consideration to flex the knee to allow for normal muscular function. Diaphyseal screws insertion at near right angles gives good stabilization as thin wires with less thermal necrosis. Weight bearing is better to be postponed for one month in these comminuted fractures, taking into consideration for early knee motion from the first week in frames which are not extended above the knee. This will lead to the best result as regards to knee range of movement.
One limitation of this study is the bias in selection of the patients for treatment with extension of the fixation to the distal femur. The patients included in this group had more severe bony and soft tissue damage compared with the patients treated without tibio-femoral frame. However, although the study presented the final results of both groups, our intent was not to compare the 2 groups, but the necessity of bridging the knee joint in the previously mentioned situations.