Effective Kirschner wire fixation for tissue necrosis of open comminuted tibial plateau fracture: A case report and literature review

doi:10.21203/rs.3.rs-3416543/v1

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Case Report

Effective Kirschner wire fixation for tissue necrosis of open comminuted tibial plateau fracture: A case report and literature review

https://doi.org/10.21203/rs.3.rs-3416543/v1

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Background: As a part of the knee joint, the tibial plateau plays a very important role in the weight-bearing function of the knee joint. Tibial plateau fracture is usually caused by severe violent injury. Clinical treatment is mainly to reconstruct the structure of tibial plateau and restore the function of knee joint. The main surgical treatments include traditional open reduction and internal fixation, external fixation, and arthroscopy-assisted minimally invasive techniques, depending on the extent of the tibial plateau fracture and the tissue condition of the wound. For patients with open comminuted tibial plateau fracture with poor tissue condition and not suitable for internal and external fixation, the fixation of Kirschner wires can be used as an option for temporary reconstruction of the tibial plateau structure, which is conducive to the early functional exercise of patients, and is an alternative solution.

Case presentation: We present the case of a 72-year-old female patient with an open comminuted tibial plateau fracture who sufferd a severe violent traffic accident injury with tissue necrosis around the wound. We performed autologous skin flap to transplant necrotic skin and used Kirschner wires to temporarily fix the tibial plateau. One year postoperatively, the patient's knee function recovered well without traumatic osteoarthritis.

Conclusion：Temporary fixation of the Kirschner wires combined with autologous flap transplantation can provide effective support and restore necrotic skin function for open comminuted fractures with poor wound tissue condition that is not suitable for internal and external fixation therapy.

Case report

Effective fixation with Kirschner wires

Open comminuted tibial plateau fracture

Skin necrosis of wound

The knee joint is one of the most complex joints in the human body. The tibial plateau is located at the proximal end of the tibia, and its upper end is enlarged and protrudes to both sides. It is the main bearing part of the knee joint, which is of great importance to the function of the lower limbs. ^1,2 Tibial plateau fracture is one of the most common lower extremity fractures in orthopedics, involving the articular surface and causing irregularity articular surface. Anatomic reduction of the articular surface is an essential prerequisite to ensure the good postoperative effect. If it is not handled properly, it will lead to serious consequences such as poor articular reduction and traumatic osteoarthritis.³

Kirscher wire is one of the most used tools in orthopedic surgery. It can provide elastic fixation and effective support for the fracture site during fracture reduction and fixing, and play an important role in the reconstruction of the articular surface. ⁴ At present, there are no reports about the reconstruction of comminuted tibial plateau by using Kirschner wires alone at home and abroad.

A 72-year-old female patient presented at our clinical with tissue necrosis of open comminuted tibial plateau fracture. The patient complained of left knee swelling, pain, bleeding, and limited movement caused by accidental trauma three days ago. There was no coma, nausea or vomiting at the time of injury, and she was sent to the local hospital for treatment. The left leg was debrided and sutured, and the left knee was fixed with external fixation brace. The wound tissue was not healing well, so she was transferred to the orthopedics department of our hospital for further surgical treatment .CT scan with three-dimensional reconstruction of the left knee indicated that the comminuted fracture of the left tibial plateau (Fig. 1A-C). Admission for physical examination showed that the left knee joint was swollen obviously, and local blister formed. Transverse cracks of about 10 cm and 18 cm were respectively found in the medial part of the left knee and popliteal space (Fig. 1D).which had been debrided and sutured, with red swelling and exudation around. There was a skin bridge about 6 cm long and 0.5 cm wide between the two cracks, and the color was dark. The left knee joint movement was limited, the left dorsal foot artery was palpable, the toes of the left foot could be moved, and the skin sensation and peripheral blood flow of the left lower limb could be felt. One week after admission, a large area of black scab formed inside and behind the knee joint(Fig. 1E-F).

Surgical Procedure

After successful combined epidural anesthesia, the patient was placed in a supine position. Iodophor was used to disinfect surgical field skin and applied a sterile sheet. And Balloon tourniquet on proximal left thigh was set to 250mmHg. Necrotic skin and scab (about 4% area) were removed from the left calf until the underlying muscle and some fresh granulation tissues were visible. Repeatedly rinse the wound surface with a large amount of iodophor water, hydrogen peroxide, and physiological saline. Remove the necrotic tissue until the wound oozed blood, and rinse the wound again until fresh granulation tissue was visible (Fig. 2A-B). For the tissue of wound was to remove the necrotic scab in the first operation and make a skin grafting therapy waiting the new skin arising in the next surgery. Try to manually reduce the fracture end and tibial plateau articular surface under the condition of limited incision of the field skin. The number of six Kirkner wires with a diameter of 2.5 mm were respectively inserted into the inner and outer parts for network fixation after a successful reduction. Confirm that the tibial platform collapsed joint surface was restored to flatten, the posterior camber angle was satisfactory, and the fracture end alignment line was good by the C-arm machine fluoroscopy (Fig. 2C-D). After the wound was washed again, the wound was covered with oil yarn, dressing and VSD suction device successively. After the suction was checked, the suction tube was temporarily clamped, and the patient returned to the ward safely after the operation.

Postoperative Care

Postoperatively, the patients were treated with prevention of infection, anticoagulation, detumescence and analgesia, promoting blood circulation and fluid replenishing support treatment. The left knee was immobilized with an external cast for four weeks. On the first day after surgery, patient was instructed to perform active quadriceps muscle relaxation and contraction exercises and the wound healing was observed. Two weeks after surgery, the VSD suction device was removed, the wound healed well, and fresh granulation tissue was formed. The surgery with left thigh skin removal combined calf debridement and free skin graft was performed under the epidural anesthesia.

Outcomes

Three weeks after surgery, the donor area of the left thigh healed well, the skin flap was fixed in the grafted area of the left calf with bright red color, local growth of fresh granulation was visible, and no redness, swelling or fluid leakage was observed (Fig. 3A-B). One month after operation, anterior-lateral radiographs of the left knee joint indicated that Kirschner wires of internal fixation were in place and primitive callus formed at the fracture(Fig. 3C-D). The plaster external fixation was removed, and the patient was instructed to perform active and appropriate resistance flexion and extension exercises of the knee joint. Two months after the operation, a Kirschner wire located in the lateral plateau of the knee joint appeared loose and withdrew, and local symptoms of swelling, pain and discomfort appeared. The symptoms disappeared after the Kirschner wire was removed. Three months after operation, the CT scan and three-dimensional reconstruction of the left knee joint showed that the fracture line alignment was good, the fracture end space was reduced, and the positions of Kirschner wires left were not loosened (Fig. 3E-F). The patient was instructed to perform knee flexion exercises and partial weight-bearing exercises. Six months after operation, the CT scan and three-dimensional reconstruction of the left knee joint showed that the fracture end was osseous union, and the Kirschner wires were fixed securely (Fig. 3G-J). The patient was instructed to perform full weight bearing exercises on the knee joint. Twelve months after operation, anterior-lateral radiographs of the left knee joint indicated that the fracture end healed well and there was no ectopic ossification to form surrounding (Fig. 3K-L). The range of motion and function of knee joint recovered well. The patient was hospitalized, and the Kirschner wires internal fixation device was removed. Intraoperative fluoroscopy showed that the fracture healed well and there was no obvious manifestation of traumatic arthritis (Fig. 3M).

Tibial plateau fracture is complex injuries caused by high or low energy trauma and one of the most common intra-articular fractures, accounting for about 1.66% of total body fractures. ⁵ Tibial plateau fractures are often associated with complications such as soft tissue injury, infection, the development of traumatic arthritis, and long-term persistent knee instability. ⁶ Complex tibial plateau fractures are usually accompanied by serious damage to meniscus, articular cartilage, and ligaments. If not treated in time, it will have a serious impact on knee joint function, resulting in knee joint deformity, joint stability, and lower limb force line changes, which will seriously affect the future quality of life of patients. ⁷ Open tibial plateau fracture is often associated with nerve, vascular, and soft tissue injuries, coupled with poor tibial blood supply and less soft tissue coverage, resulting in slow healing after injury. ⁸ The main objective of clinical treatment for patients with open tibial plateau fracture is to restore joint surface flatness, ligament integrity and knee joint function. ^9,10 At present, staging treatment is usually used in clinical practice. External fixation of knee joint is fixed in stage I, and external fixation is converted into internal fixation in stage II. ¹¹ When the local soft tissue conditions were poor, limited internal fixation with Kirschner wires combined with external fixation stent was performed. Early functional exercise after tibial plateau fracture can effectively prevent joint capsular adhesion, contracture, and traumatic arthritis. However, premature weight bearing can easily lead to trabecular compression and joint surface collapse. Therefore, the principle of early activity and late weight bearing should be followed for functional exercise after tibial plateau fracture. ¹² Schatzker classification and three-column theoretical classification are currently the most common theoretical references to guide the treatment of tibial plateau fractures in clinical practice, and the final treatment plan is determined according to the specific injury conditions.^13,14

In the early stage of splint, cast and brace fixation, joint braking is required for a long time, which affects the functional exercise of the knee joint, and is easy to cause the adhesion of the knee joint and affect the mobility of the knee joint. Traditional open reduction and internal fixation is a common method for the treatment of tibial plateau fractures. ¹⁵ It can provide good fracture reduction and stability, promote the healing of the fracture end, and is conducive to the early postoperative functional exercise of patients. However, the surgical trauma is large, which will affect the local blood flow, and postoperative complications such as infection, deformity union and knee stiffness occur. ¹⁶ External fixator is a circular external fixator used for fracture reduction with less trauma, which can provide corrective reduction for fracture and avoid soft tissue destruction. ¹⁷ However, due to insufficient fixation strength and micro-movement between fracture surfaces, articular surface malunion is more likely to occur, and the operation is more difficult, the operation time is longer, and the postoperative infection of nail and wound is easy to occur. ¹⁸ Arthroscopy-assisted minimally invasive treatment is to evaluate and deal with the degree of fracture and soft tissue injury with the assistance of arthroscopy. The operation and reduction are accurate, which can overcome the blind area of open surgery, locate collapsed bone mass, guide screw insertion, accurately anatomical reduction of the articular surface, and achieve good internal fixation and reduction effect. ^18,19 However, it is necessary to conduct joint cavity exploration and repair of damaged ligaments and meniscus, which has small operable space, high technical requirements for operators and long learning curve. ²⁰

In this case, the patient had an open comminuted fracture of the left tibial plateau caused by violent car crushing, obvious collapse of the joint surface, and serious soft tissue damage. Due to the poor tissue condition of the patient, it is not appropriate to immediately perform internal and external fixation treatment. Local doctors considered to make debridement and suture in the first treatment and internal fixation in the next surgery. A large area of black scab and subcutaneous soft tissue necrosis appeared on the patient's skin around the wound after debridement and suture, and infection was easily complicated after internal and external fixation, which led to the failure of the fixation. If the tibial plateau fracture fragment is not fixed in time, the subsequent treatment will become difficult, and the impact on the knee joint function is also immeasurable. Therefore, after discussion, our treatment group decided to completely debride intraoperatively and try to reduce the tibial plateau fracture at the same time. And if the reduction is satisfactory, it can be temporarily fixed with Kirschner wires firstly. To observe the fixation effect of the internal fixator on the fracture end and the healing of the wound and determine the further treatment measures for the patient. It is hoped that Kirschner wires can provide effective support for fracture end, which is conducive to the early postoperative functional exercise of patients. Observation of the postoperative effect, only one Kirschner wire on the lateral side appeared loose and withdrew at two months after operation. The left Kirschner wires showed good fixation effect, and the fracture end healed well. At the last follow-up, the patient's knee motion and function basically returned to be normal. All in all, for clinically encountered patients with open comminuted tibial plateau fracture whose wound tissue condition is poor and not suitable for internal and external fixation treatment, the fixation of Kirschner wires can be considered as a temporary fixation option. If the fixation effect is satisfactory, there is no need to perform secondary internal fixation surgery, which avoids the harm of secondary surgery trauma, reduces the occurrence of postoperative complications. It is conducive to the postoperative knee function recovery of patients, and greatly improves the treatment satisfaction of patients. The report of this case is expected to provide some reference for the treatment choice of patients with this type of injury.

Our case shows successful reconstruction of an open comminuted tibial plateau fracture with wound tissue conditions inhospitable to internal and external fixation. When the risk of infection is very high in internal and external fixation, Kirschner wires fixation can be chosen to reconstruct the tibial plateau structure and provide effective support for the fracture end. And autologous flap transplantation can safely restore necrotic skin function. Finally, the structure and function of the knee joint are restored.

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Sir Run Run Hospital, Nanjing Medical University (approval number: 2023-SR-042), and all methods were performed in accordance with the Declaration of Helsinki and other relevant guidelines and regulations. Informed consent was obtained from all individual participants included in the study.

Consent for publication

Not applicable.

Availability of data and materials

All data generated or analyzed during this study are included in this published article.

Competing interests

The authors declare no competing financial interests.

Funding

This study was supported by 2022 Nanjing Health Science and Technology Development Special Fund Project (No. YKK22207).

Authors' contributions

Tangbo Yuan and Jian Qin designed the study. Tangbo Yuan operated on the patients and performed the postoperative follow-up. Zeyong Wang prepared the manuscript. Fei Yang and Yiran Zhu collected and analyzed the data. All authors read and approved the final manuscript.

Informed consent

Informed consent has been obtained from the patient and her family for the information and images of articles published in an online open-access publication.

Publication Statement

All authors and patient agree that the article will be published in an open access publication.

Acknowledgements

The authors would like to thank the study participants.

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No competing interests reported.

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Effective Kirschner wire fixation for tissue necrosis of open comminuted tibial plateau fracture: A case report and literature review

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Abstract

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Introduction

Case Presentation

Surgical Procedure

Postoperative Care

Outcomes

Discussion

Conclusions

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