zubin13-ga,
There are quite a number of treatment options for a proximal tibial
fracture. I will attempt to describe a variety of them and provide
scientific papers to back them up so you can make an informed
decision. For your convenience, I have saved these papers to my
personal web server to ensure you can access them.
In general, the biggest problem with these fractures is misalignment,
due to the fracture location. This makes it difficult to stabilize
alignment devices. This is especially a problem with many of the
traditional nail methods.
Primary Treatment Methods
=========================
Poller Blocking Screw Technique
-------------------------------
Reference: http://www.maxlin.ca/tos/ga/zubin13/poller.html
http://www.orthopaedic.ed.ac.uk/poller.htm
Essentially, instead of using nails, a special type of screw called
Poller "blocking" screw is used to secure the fracture (and are very
useful to overcome iatrogenic deformity). X-rays of an example
procedure can be found at http://www.orthopaedic.ed.ac.uk/poller.htm.
Less Invasive Skeletal Stabilization System
-------------------------------------------
Reference: http://www.maxlin.ca/tos/ga/zubin13/LISS.pdf
http://www.maxlin.ca/tos/ga/zubin13/LISSClinic.pdf
A comprehensive 87 patient study on a special stabilization system.
The conclusion to the study was that "the LISS provides stable
fixation (97%), a high rate of union (97%), and a low (4%) rate of
infection for proximal tibial fractures". The procedure is fairly
technical though and requires the successful use of new and
unfamiliar surgical principles to effect an accurate reduction and
acceptable rate of malalignment. A clinical study was also done with a
fairly high success rate
Plate Fixation
--------------
Reference: http://www.maxlin.ca/tos/ga/zubin13/plate.pdf
Four different plate fixation methods were analyzed in this study,
including: a double-plate construct, a locking plate system, a hybrid
external fixator, and a single lateral periarticular plate. The use of
each fixation system depends on the stability of the fracture. The
results are:
"The double-plate construct was significantly stiffer than all other
constructs with regard to resistance to axial displacement, varus
rotation, and posterior rotation for both types of unstable fractures.
With regard to axial stiffness, the double-plate construct was
statistically similar to an intact tibia for moderately stable
fractures. The locking plate and the external fixator were similar for
stabilization of moderately unstable fractures, whereas the locking
plate and the periarticular plate were significantly stiffer than the
external fixator construct for completely unstable fractures."
The discussion portion of the paper should also be read:
"Proximal, metaphyseal tibial fractures remain difficult clinical
challenges fraught with potential complications. Each case must be
treated individually based on the fracture and soft tissue
characteristics, concomitant injuries, and patient compliance.
Availability and surgeon experience also influence the choice of
implant. Although many techniques are used for non-articular proximal
tibia fractures, casting and intramedullary nailing arguably are not
indicated for situations in which the proximal fragment is <6 cm in
height. 18 In these cases, external fixation has been indicated,
particularly in situations with severe concomitant soft tissue
injuries. Double plating and lateral plating with a medial external
fixator seem to offer the best results in cases with
minimal-to-moderate soft tissue involvement. In all of these cases,
progression to varus deformity (ie, tibial plateau tilt into varus) is
always a concern. The LISS LP represents an attempt to deal with these
types of fractures with minimal additional soft tissue insult. 18?25
This study was performed to compare the biomechanical performance of
the new LP and several accepted fixation constructs for nonarticular
unstable proximal tibia fractures." (continues in the paper)
Extras
======
Bone Rivets
-----------
Reference: http://www.maxlin.ca/tos/ga/zubin13/bonerivets.pdf
This is provided as additional information on alternative treatments
for difficult proximal tibia fractures. Unfortunately, they are still
awaiting FDA approval as of June 2004.
For High-Energy Proximal Tibia Fractures
----------------------------------------
Reference: Staged management of high-energy proximal tibia fractures.
Bull Hosp Joint Dis 2004 ; 62(1-2): 62-6
PMID:15517860
High-energy proximal tibia fractures are complicated by soft tissue
compromise and this may result in sub-optimal outcomes. There is a
high association of open injuries, compartment syndromes, and vascular
injuries with these bony disruptions. Surgical treatment of these
injuries has been associated with significant complications such as
infection, knee stiffness, malunion, loss of fixation, soft tissue
failure, and amputations. The loss of fixation is an issue especially
in the elderly, with failure associated with age more than sixty
years, premature weight bearing, preoperative displacement, fracture
fragmentation, and severe osteoporosis. The use of two-stage
reconstruction for the treatment of distal tibia fractures has been
successful in decreasing the complication rates, including wound
compromise. The two stages involve: 1. stabilization of the injured
limb with a bridging external fixator to allow the soft tissues to
improve and recover and 2. definitive fixation for reconstruction of
the articular surface and meta-diaphyseal fractures. The use of such a
protocol has been proposed for high-energy proximal tibia fractures to
decrease the high rate of soft tissue compromise associated with
traditional open methods of treatment. The choice of definitive
fixation may include plates, nails, or non-bridging external fixation.
Suggestions
===========
It seems that the most best method of treatment is the Less Invasive
Stabilization System. From the papers that I have read, it seems that
the success rate for the procedure is quite high, though you need to
find a doctor that can perform the procedure adequately (it is
technically quite difficult). However, you should also read through
the papers yourself and discuss it with your doctor to determine what
is best for you.
Good luck!
tox-ga |
