Abstract
Purpose
External fixator pin site overlap with definitive fixation implants (pin-plate overlap) has been identified as a risk factor for surgical site infection in tibial plateau fractures. Despite this, pin-plate overlap occurs in 24–38% of patients. This study sought to identify radiographic characteristics associated with pin-plate overlap to help minimize occurrences.
Methods
283 patients at two Level I trauma centers were retrospectively reviewed. Radiographic measurements were recorded including fracture length, distance from fracture to proximal tibial pin site, and pin site distance-to-fracture (PSF) ratio.
Results
70 (24.7%) cases of pin-plate overlap were identified. Pin-plate overlap was associated with increased fracture length (81.5 ± 32.1 mm vs 56.9 ± 26.1 mm, p < 0.001) and decreased distance from fracture to proximal tibial pin site (84.5 ± 37.1 mm vs 126.9 ± 35.8 mm). Pins placed greater than 100 mm and 150 mm from the fracture eliminated 36/70 (51%) and 67/70 (96%) pin-plate overlaps, respectively. Pins placed with a PSF ratio greater than 1.5 and 2.0 eliminated 47/70 (67%), and 57/70 (81%) of pin-plate overlaps, respectively.
Conclusions
Longer fractures, pins closer to the fracture, and decreased PSF ratio were associated with overlap. Placing proximal tibial pins more than 100 mm from the fracture eliminated most pin-plate overlaps.
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References
Berkson EM, Virkus WW (2006) High-energy tibial plateau fractures. J Am Acad Orthop Surg 14:20–31. https://doi.org/10.5435/00124635-200601000-00005
Henry P, Wasserstein D, Paterson M, Kreder H, Jenkinson R (2015) Risk factors for reoperation and mortality after the operative treatment of tibial plateau fractures in Ontario, 1996–2009. J Orthop Trauma 29:182–188. https://doi.org/10.1097/bot.0000000000000237
Ruffolo MR, Gettys FK, Montijo HE, Seymour RB, Karunakar MA (2015) Complications of high-energy bicondylar tibial plateau fractures treated with dual plating through 2 incisions. J Orthop Trauma 29:85–90. https://doi.org/10.1097/bot.0000000000000203
Thabet AM, Simson JE, Gerzina C, Dabash S, Adler A, Abdelgawad AA (2018) The impact of acute compartment syndrome on the outcome of tibia plateau fracture. Eur J Orthop Surg Traumatol 28:85–93. https://doi.org/10.1007/s00590-017-2017-6
Lin S, Mauffrey C, Hammerberg EM, Stahel PF, Hak DJ (2014) Surgical site infection after open reduction and internal fixation of tibial plateau fractures. Eur J Orthop Surg Traumatol 24:797–803. https://doi.org/10.1007/s00590-013-1252-8
Hansen L, Larsen P, Elsoe R (2022) Characteristics of patients requiring early total knee replacement after surgically treated lateral tibial plateau fractures-A comparative cohort study. Eur J Orthop Surg Traumatol 32:1097–1103. https://doi.org/10.1007/s00590-021-03083-0
Watson JT (1994) High-energy fractures of the tibial plateau. Orthop Clin N Am 25:723–752
Canton G, Santolini F, Stella M, Moretti A, Surace MF, Murena L (2020) Strategies to minimize soft tissues and septic complications in staged management of high-energy proximal tibia fractures. Eur J Orthop Surg Traumatol 30:671–680. https://doi.org/10.1007/s00590-019-02619-9
Egol KA, Tejwani NC, Capla EL, Wolinsky PL, Koval KJ (2005) Staged management of high-energy proximal tibia fractures (OTA types 41): the results of a prospective, standardized protocol. J Orthop Trauma 19:448–455; discussion 456. https://doi.org/10.1097/01.bot.0000171881.11205.80
Haidukewych GJ (2002) Temporary external fixation for the management of complex intra- and periarticular fractures of the lower extremity. J Orthop Trauma 16:678–685. https://doi.org/10.1097/00005131-200210000-00012
Henkelmann R, Glaab R, Mende M et al (2021) Impact of surgical site infection on patients’ outcome after fixation of tibial plateau fractures: a retrospective multicenter study. BMC Musculoskelet Disord 22:531. https://doi.org/10.1186/s12891-021-04402-6
Henkelmann R, Frosch KH, Glaab R et al (2017) Infection following fractures of the proximal tibia—a systematic review of incidence and outcome. BMC Musculoskelet Disord 18:481. https://doi.org/10.1186/s12891-017-1847-z
Behrens F, Searls K (1986) External fixation of the tibia. Basic concepts and prospective evaluation. J Bone Joint Surg Br 68:246–254. https://doi.org/10.1302/0301-620x.68b2.3514629
Hodel S, Link BC, Babst R, Mallee WH, Posso P, Beeres FJP (2018) Perioperative management of external fixation in staged protocols: an international survey. Eur J Orthop Surg Traumatol 28:565–572. https://doi.org/10.1007/s00590-018-2135-9
Laible C, Earl-Royal E, Davidovitch R, Walsh M, Egol KA (2012) Infection after spanning external fixation for high-energy tibial plateau fractures: is pin site-plate overlap a problem? J Orthop Trauma 26:92–97. https://doi.org/10.1097/BOT.0b013e31821cfb7a
Shah CM, Babb PE, McAndrew CM et al (2014) Definitive plates overlapping provisional external fixator pin sites: is the infection risk increased? J Orthop Trauma 28:518–522. https://doi.org/10.1097/bot.0000000000000077
Potter JM, van der Vliet QMJ, Esposito JG, McTague MF, Weaver M, Heng M (2019) Is the proximity of external fixator pins to eventual definitive fixation implants related to the risk of deep infection in the staged management of tibial pilon fractures? Injury 50:2103–2107. https://doi.org/10.1016/j.injury.2019.09.016
Hadeed MM, Evans CL, Werner BC, Novicoff WM, Weiss DB (2019) Does external fixator pin site distance from definitive implant affect infection rate in pilon fractures? Injury 50:503–507. https://doi.org/10.1016/j.injury.2018.10.041
Dombrowsky A, Abyar E, McGwin G, Johnson M (2021) Is definitive plate fixation overlap with external fixator pin sites a risk factor for infection in Pilon fractures? J Orthop Trauma 35:e7–e12. https://doi.org/10.1097/bot.0000000000001884
Haase LR, Haase DR, Moon TJ et al (2022) Is pin-plate overlap in tibial plateau fractures associated with increased infection rates? Injury. https://doi.org/10.1016/j.injury.2022.01.017
Seitz WH Jr, Froimson AI, Brooks DB, Postak P, Polando G, Greenwald AS (1991) External fixator pin insertion techniques: biomechanical analysis and clinical relevance. J Hand Surg Am 16:560–563. https://doi.org/10.1016/0363-5023(91)90033-8
Placzek R, Ruffer M, Deuretzbacher G, Heijens E, Meiss AL (2006) The fixation strength of hydroxyapatite-coated Schanz screws and standard stainless steel Schanz screws in lower extremity lengthening: a comparison based on a new torque value index: the fixation index. Arch Orthop Trauma Surg 126:369–373. https://doi.org/10.1007/s00402-006-0142-5
Oliphant BW, Kim H, Osgood GM et al (2013) Predrilling does not improve the pullout strength of external fixator pins: a biomechanical study. J Orthop Trauma 27:e25-30. https://doi.org/10.1097/BOT.0b013e3182511ed7
Berdis G, Singh V, Day JB (2020) Iatrogenic tibia fracture from an “errant” traction pin placement resulting in a cortical defect: a case study. JBJS Case Connect 10:e0251. https://doi.org/10.2106/jbjs.Cc.19.00251
Reipond L, Trompeter A, Szarko M (2019) Neurovascular anatomy around the knee: Relevance of the dangers of self-drilling external fixator pin tips. Sicot j 5:9. https://doi.org/10.1051/sicotj/2019006
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Haase, D.R., Haase, L.R., Moon, T.J. et al. External fixator pin placement during initial management of tibial plateau fractures: are there parameters to minimize pin-plate overlap?. Eur J Orthop Surg Traumatol 33, 1827–1833 (2023). https://doi.org/10.1007/s00590-022-03363-3
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DOI: https://doi.org/10.1007/s00590-022-03363-3