RESULTS
On average, patients were hospitalized for 5 days (range, 3-7 days). There were no postoperative complications. None of the patients developed a clinically significant pin site infection. There were no re-operations during follow-up. All patients achieved union at a mean of 5.2 months (range, 5-5.5 months) (Figure 1).
Deformity correction was achieved in all 3 patients. The average range of motion (ROM) arc was 100° (range, 100°-115°). None of the patients had an extension deficit. TUG test was <8 seconds in all patients. The IKDC knee score averaged 52 (range, 41-66). Of note is that 2 patients already had compromised knee function before the fracture because of rheumatoid arthritis. The Ahlbäck classification of osteoarthritis showed grade 1 in cases 1 and 3, and grade 2 in case 2.14 Postoperative ROM of the knee returned to pre-injury levels in all patients (Figure 2). The 2-pin external fixator was removed at 9 weeks on average (range, 6-12 weeks) postoperatively in the outpatient clinic. At the last follow-up appointment at an average of 10.3 months (range, 9-12 months), all wounds had healed without infection. All patients had a normal neurovascular examination.
DISCUSSION
Nonunion after a proximal tibial fracture is rare.4 In cases when nonunions do develop, they most often pertain to the extra-articular component with the plateau component healed. Surgical exposure for débridements, hardware removal, bone grafting, and revision of fixation carries the risk of wound breakdown, necrosis, and infection. The alternative strategy of composite fixation (a plate combined with a contralateral 2-pin external fixator) to limit additional soft tissue compromise was already described in proximal tibial fractures by Bolhofner.9 He treated 41 extra-articular proximal tibial fractures using this composite fixation technique and attained successful results with an average time to union of 12.1 weeks. There was only 1 malunion, 2 wound infections, and 3 delayed unions.
In our practice, we have extrapolated this idea to an extra-articular nonunion that developed after a tibial plateau fracture. With the use of an external fixator, we provided sufficient mechanical stability of the nonunion without unnecessarily compromising previously infected or tenuous soft tissues, a muscle flap, or further devascularizing poor bone. Limitations of this study include the retrospective data and small sample size prone to bias. However, all patients received the same treatment protocol from 1 orthopedic trauma surgeon, follow-up intervals were similar, and data were acquired consistently.
Meanwhile, we have used this technique in a fourth patient with a septic nonunion of a tibial plateau fracture. All 4 patients in whom we have used this method so far have healed successfully.
CONCLUSION
This technique respects both the demand for minimal soft tissue damage and a maximal stable environment without notable perioperative and postoperative complications. It also offers an alternative option for the treatment of a proximal tibial nonunion that is not amenable to invasive revision dual plate fixation. As such, it can be a useful addition to the existing armamentarium of the treating surgeon.