Injury Vol. 29, Suppl. No. 3, pp.
S-C22-S-C28,1998
ELSEVIER
Combined internal and external osteosynthesis
A biological approach to the treatment of complex fractures of the
proximal tibia
A. Gerber, R. Ganz
Department of Orthopaedic Surgery, University of Berne, Inselspital, CH-3010 Bern
Summary 1
Lateral plating was combined with external fixation to
treat 18 complex, proximal, tibial fractures with severe
soft tissue injury. All patients were followed up until
functional restoration of the limb had been achieved. In
15 cases, bone healing was uneventful. One deep infec-
tion without knee joint arthritis, one delayed union and
one malunion necessitated revision. Pin track compli-
cations were negligible and soft tissue breakdown was
not observed. The short-term results regarding the func-
tional outcome showed a painless condition and good
function in all patients. The method of fixation described
is more invasive than the currently proposed minimally
invasive combined fixation techniques, but can be
regarded as an optimization of the mechanical and bio-
logical advantages of the implants..
Keywords: complex proximal tibial fracture, biologi-
cal osteosynthesis, combined fixation technique
Injury 1998, Vol. 29, Suppl. 3
Introduction
Treatment of complex meta-epiphyseal fractures is
characterized by the difficulty of achieving accurate
joint reconstruction and sufficient stabilization without
jeopardizing the usually severely traumatized soft tis-
sue envelope. On the proximal tibia, non-operative
treatment using casts, braces or traction is complicated
1 Abstracts in German, French, Italian, Spanish, Japanese and
Russian are printed at the end of this supplement.
© 1998 Elsevier Science Ltd. All rights reserved
Printed in Great Britain
0020-1383/98 $19.00+0.00
by prolonged hospital stays and poor functional results
(1,2) and the incidence of infection and soft tissue prob-
lems associated with double plate fixation (3) has been
reported to be high (4,5).
Mast applied the technique of combined internal and
external osteosynthesis for the first time when treating
a difficult distal intra-articular humeral fracture where,
instead of posterior and medial plating, a posterior plate
was used in combination with a lateral external fixator
to neutralize the bending moments on the plate (6). He
applied these techniques successfully in the treatment
of complex ankle joint fractures (7). The field of appli-
cation extended to other locations, including the proxi-
mal tibia (8). Only one series of six patients has ever been
reported (9) using a similar configuration to the one
described here. Good results for proximal tibial frac-
tures treated with minimally invasive techniques, such
as the'Ilizarov system (10,11) or the hybrid fixation sys-
tems, have been presented (12-14). In the current study,
we describe the mechanical testing of combined inter-
nal plate and external fixator techniques, emphasize
some technical aspects of this method, and present our
own clinical results for this technique.
Theoretical and technical considerations
According to Mast (8) the term substitution describes
the function of the external fixator when used to com-
pensate for the broken cortex until it is healed. Near the
proximal end of the tibia, one can theoretically use two
fixator systems, one medial and one lateral for neutral-
ization of the adverse forces which become manifest
Gerber: Treating the proximal tibia
during the fun4tional rehabilitation of complex frac-
tures. Circular, ring type systems such as the Ilizarov or
hybrid fixation systems represent a mechanical opti-
mization. However, the lateral pins penetrate through
a rather mobile soft tissue layer compared with the
medial side with an increased risk of pin track infections
and increased difficulty in preserving alignment in frac-
tures extending into the diaphysis.
The combination of a lateral plate with a medial fix-
ator is more invasive but allows a more individual fix-
ation of the given fracture type (Fig. 1). The long level
arm of the external fixator ensures good stability
although assembled in a simple manner (one Schanz
screw in each fragment). The external fixator may be
used as a distractor and maintained in combination with
internal fixation.
When combined with an external fixator the dimen-
sion of the plate can be smaller and a limited number of
screws is necessary to fix the fracture. In this way a more
elastic system is created allowing a modification of the
mechanical properties (tension, compression) a n d / o r
the correction of an axial deviation (varus/valgus) in
the postoperative phase. The implants needed are avail-
able in most of the hospitals and are not terribly expen-
sive.
Mechanical testing
Testing conditions
The mechanical properties of several fixation configu-
rations of the proximal tibia were tested using an artifi-
cial bone model (Synthes educational kit). A medial,
Fig. 1: This example shows the versatility of the external fixator. In the proximal comminuted segment the fixator is placed in
buttress mode with distraction between the first two pins. In the distal part of the fracture where stability through interfrag-
mentary compression was possible, the fixator was placed in tension against the plate, changing its mechanical property to a
tension band.
Injury 1998, Vol. 29, Suppl. 3
S-C23
wedge-shaped defect with lateral bone contact was cre-
ated in the proximal tibial metaphysis. The material
used for fixation consisted of 9-hole steel T-plates for the
tibia, the corresponding cortical screws, and a half-
frame AO external fixator.
The mechanical tests were performed on an Instron
4302 machine, applying an axial 0.1 kN force in a stan-
dardized way on the model (Fig. 2) and measuring the
corresponding deformation (Fig. 3). The values were
recorded as a graph on an x / y plotter. The test was
repeated several times for each sample. The stiffness
(N/mm) was defined as the mean slope of three com-
parable curves.
Sample 1
Having adjusted the T-plate to the lateral cortex, it
was fixed with three cortical screws in the proximal frag-
ment and three cortical screws in the distal fragment
such that bone contact of the fragments was achieved
beneath the plate. The external fixator was applied per-
pendicularly to the facies medialis of the tibia and to the
plate using one Schanz screw in each fragment respec-
tively. In sample 1 neither distraction nor compression
forces were applied to the external fixator.
Sample 2
The medial fixator was removed and placed laterally
through the free holes of the plate without distraction
or compression between the pins.
Sample 3
The external fixator was removed and a second 9-hole
T-plate was fixed medially using the same screw con-
figuration as laterally.
 S-C24

Sample 4 C l i n i c a l report
The medial plate was removed leaving the lateral
plate as the only fixation. Materials and Methods
Between 1984 and 1995, 18 patients with complex prox-
imal tibial fractures (6 women, 12 men) were treated
Testing results
with a combined internal and external osteosynthesis.
The mean age of the patients was 50 years (range 22 - 81
As expected the double plate fixation (sample 3) showed
years). The mechanisms of injury were a traffic accident
the highest mechanical properties. The stiffness of the
(16 patients), a fall from a ladder (1 patient), a sports
model decreased 5.4 times when the medial plate was
injury (1 patient), and a military accident (1 patient). 14
removed (sample 4). The application of the medial exter-
multiply injured patients suffered from at least one other
nal fixator increased the stiffness 4 times in a neutral
fracture and an additional injury (head, thorax or
loading mode (sample 1). The application of a lateral
abdomen). Two patients had another minimal injury of
external fixator increased the stiffness 1.7 times in neu-
the musculoskeletal system. Two patients had sustained
tral loading. Table 1 and Figure 3 show a summary of
a leg injury only. All fractures were classified as com ~
the results.
plex (type c) according to the AO classification. Soft tis-
sue injury was severe in all fractures. The Tscherne grad-
Table 1: Protocol of the mechanical tests describing the ing scale (15) was used for closed fractures; the Gustilo
devices and loading modes used for each sample and classification for open injuries (16). In Table 2 the dis-
showing the calculated stiffness values (N/mm). tribution of fracture type is presented together with the
soft tissue injurY. In 10 patients, a one stage treatment
device stiffness ( N / m m ) was possible within 24 hours of injury. In 8 patients, the
sample 1 lateral plate 249. 0 condition of the soft tissue did not allow definitive man-
agement of the fracture. Articular reconstruction was
medial external fixator
achieved by a minimally aggressive approach using
sample 2 lateral plate 159, 6 screws and K-wires only and the meta-diaphyseal frac-
lateral external fixator ture was stabilized with a knee-bridging anterior uni-
lateral external fixator. Soft tissue management
sample 3 lateral plate 334, 1
(d6bridement, opening of compartments, soft tissue
medial plate reconstruction) was performed at the same time and
sample 4 lateral plate 62, 3 repeated a n d / o r completed as required. The definitive
stabilization of the fracture was performed within 35
days (range 2-120 days).

0.12 , ,

0.10

0.08 31 2 4

Z 0.06-

o 0.04

0.02

0.00 ', '," ,

).0 0.5 1 .'0 1 '.5 2'.0

Displacement mm

Fig. 3: Graph showing the mean load/displacement curve

Fig. 2: Sample 1 (2a) and sainple 3 (2b) during measurement obtained for each sample. The slope of each curve was defined
in the Instron testing device. as stiffness (N/mm).
Gerber: Treating the proximal tibia
Plate osteosynthesis was performed through a lateral
approach in all patients. In 17 patients the external fix-
ation was applied medially, in one patient laterally to
preserve the reconstructed medial soft tissues, whereby
the Schanz screws placed in each main fragment passed
through a plate hole. For intraarticular fractures treated
in one stage, additional screws and even K-wires were
used for articular reconstruction. In two patients, an
autogenous bone graft was inserted in the same proce-
dure. After definitive surgery the following supple-
mentary surgical procedures were required: autoge-
nous bone graft, a gastrocnemius flap, four split thick-
ness skin grafts.
After surgery all operated legs were elevated until
swelling of the soft tissues had resolved. Motion of the
knee was achieved with a CPM apparatus. Range of
motion was limited to varying extents in the early weeks
and all patients were allowed to bear partial weight, i.e.
5 and 15 Kp, depending on the fracture type.
Instructions were given regarding pin care and
w o u n d dressing. All patients were seen weekly in the
out-patient clinic as long as the fixator was in place.
After a mean time of 11 weeks (range 6-20 weeks) for
radiological evidence of progressive fracture consoli-
dation to appear, the external fixation was removed in
16 patients.fin two patients the external fixator had to
be removed earlier due to a complication (see below).
Soft tissue injury
Closed fractures O p e n fractures
Fx-Typ Fx-Numbel G2 G3 TI Til TIIIA
41-C11 1
41-C12 1
41=C22 5 1 2 1
41-C23 6 3 1 1 1
41-C31 3 2 1 allow accurate joint reconstruction and provide stable
41-C32 1 1
41 -C33 1 1
Table 2: Distribution of soft tissue injury in relation to fracture
type. The Tscherne and Gustilo classifications were used for
closed and open fractures respectively.
Results
15 of 18 fractures healed without complications. In an
alcohol dependent patient, a deep infection necessitated
the removal of all fixation devices and thorough
d6bridement 8 weeks after the operation. However, the
fracture healed with plaster fixation within a year of the
accident without additional surgery. In another patient,
there were no signs of fracture healing four months post-
operatively. Limited decortication, cancellous bone
grafting and lateral repeat plating were performed after
Injury 1998, Vol. 29, Suppl. 3
S-C25
removal of the external fixator. 14 months after the
accident, the fracture had healed. In one patient with a
varus deformity after removal of the fixator, a high tibial
valgus osteotomy had to be performed two years later.
In one patient, an arthroscopy with medial partial
meniscectomy was performed after fracture healing due
to persistent knee pain.
At the most recent physical examination, the mean
range of motion of all knees was flexion/extension 129 °
(range 110-145 °) -2 ° (range (-10)-(+5°)) -0 ° (4 patients
with flexion contracture)
Discussion
The mechanical testing presented here shows a com-
parison of the bending properties of several types of fix-
ation on the proximal tibia. The test is a considerable
simplification of the reality since bone quality and frac-
ture type have not been considered and torsion tests
have not been performed. However, it was of interest to
measure the mechanical effect of the external fixator on
the system and to note the nearly comparable bending
stiffness of double plate fixation and combined lateral
plate and medial external fixation.
Anatomical joint reconstruction, axial alignment, and
relative stability of the meta-diaphysis allowing imme-
diate passive motion while keeping complications to a
minimum are major goals in the treatment of complex
TIIIB TIIIC
proximal tibial fractures. Long hospital stays and com-
plications due to bed rest made other treatment modal-
ities superior to traction (1).
Cast immobilization or cast bracing as proposed by
some authors do not provide enough stability and lead
to a loss of reduction and malunion respectively (2).
Open reduction and internal fixation w o u l d seem to
fracture fixation. The extensive bone exposure required
for double plate fixation however increases the risk of
soft tissue complications and infection. Moore et al. (17)
reported wound dehiscence a n d / o r infection in 8 of 11
bicondylar fractures treated with double plate fixation.
Young and Barrack report that 7 of 8 knees became
infected after open reduction and internal fixation (5).
Jakob and Wagner showed a rate of 38% w o u n d heal-
ing problems and 15% deep infections in bicondylar tib-
ial plateau fractures treated by double plating with the
soft tissue problems being mainly on the antero-medial
side (4).
In this context, the use of an external fixator as a sub-
stitute is an attractive concept. Several variations of this
principle have been proposed. Marsh (13) presented 21
complex fractures of the tibial plateau treated with
closed reduction, interfragmentary screw fixation and
application of a medial unilateral half pin external fix-
ator. Although all fractures healed a high incidence of
pin track problems (7 cases) and 2 cases of septic arthri-

tis were observed. These complications were attributed
clearly to the external fixator which was left until the
fractures consolidated, 13.5 weeks on average. Soft tis-
sue breakdown did not occur.
The use of ring type systems, such as the Ilizarov or
hybrid fixator systems, combined with minimal inter-
nal osteosynthesis for joint reconstruction offers high
mechanical properties but pin track problems are not to
be underestimated since the device has to be left in situ
more or less until the fracture has healed. Ilizarov him-
self described the technique on the proximal tibia show-
ing amazing results without mentioning any complica-
tions (10). Watson et al. (11) reported on 50 complex frac-
tures treated with the Ilizarov external fixator. All frac-
tures healed on average within 15 weeks and the aver-
age time of external fixation was 17 weeks. Complica-
tions were not mentioned. In Murphy's series of 5 severe
fractures of the proximal tibia treated with limited open
reduction and a small circular external fixation device,
union was achieved within 4-5 months and the exter-
nal fixator was removed after 3 months. One pin track
infection with septic arthritis was reported. Weiner et
al. (18) treated 25 proximal tibial fractures with com-
bined minimal internal and external fixation. The fixa-
tor consisted of tensioned wires and half pins attached
to a semicircular frame. Pin track problems were
reported to be common and septic arthritis occurred
twice. One malunion and one delayed union were
observed.
All except two fractures healed in our series. A deep
infection without knee joint contamination occurred in
an older alcohol dependent patient and was treated by
removal of the fracture fixation material and subsequent
d6bridement. In the patient with delayed union, poor
Fig. 4: High-energy injUrywith fracture of the distal humeral meta-epiphysis, avulsion of the volar-radial musculature, including
a laceration of the radial nerve and a gaping volar skin defect of the elbow region. The case demonstrates the use of a combined
internal-external fixation. The external fixator is applied as a substitute for a second plate on the distal humerus.
S-C26
circulatory conditions related to extreme nicotine abuse
were observed preoperatively. Delayed union necessi-
tated reoperation; soft tissue problems were not
observed when they might have been expected for a
more aggressive primary surgical procedure.
Pin track infection and pin loosening are known to be
quite frequent problems in fracture treatment with
external fixation and represent a limiting factor in com-
bined internal and external fixation. The incidence of
such complications is known to be low at the beginning
of the treatment and to increase with time (19). In our
cases, the high mechanical properties of the plate in com-
parison to simple screw fixation allowed an earlier
removal of the external device compared with the times
mentioned in the literature. Because the external fixator
was used to stabilize the meta-diaphyseal fracture, the
proximal pin could be placed at least 2 cm away from
the joint surface which explains the absence of septic
arthritis in our series. Another factor explaining the
absence of pin track problems may be the meticulous
pin care instructions given to each patient.
All in all, including our report, cases of soft tissue
breakdown were not observed for combined osteosyn-
thesis which represents a significant advantage of this
technique when compared with the high rate of com-
plications in patients treated with double plating. Con-
solidation in correct alignment does not seem to be a
problem in combined osteosynthesis. Considering the
severity of trauma, the rates of delayed union and mal-
union are low.
The short-term results regarding the functional out-
come of the various series are difficult to compare
because a standardized comparable evaluation is lack-
ing. In our patients, a painless condition and a good
Gerber: Treating the proximal tibia S-C27

Fig. 5: Example of combined internal and external osteosyn-

thesis as one surgical instrument respecting the philosophy of
biological fracture treatment. This fracture healed without
complications. The cosmetic and functional results are
optimal.

functional outcome were observed at the last follow-up

in all patients. The principle of substitution described
above can be applied in the same way and for the same
reason in other locations. The method was successfully
applied in the treatment of complex fractures of the dis-
tal humerus (Fig. 4) and the distal tibia (7), (20).

Conclusion

Combined internal and external osteosynthesis for com-

plex fractures of the proximal tibia is the treatment of
choice in our institution. Compared with those tech-
niques using an external fixator and minimally invasive
internal fixation, our method is more invasive. Despite
the more extensive lateral approach, soft tissue prob-
lems were not observed and the relatively short time of
external fixation meant that any pin track complications
were negligible. More than minimally invasive, the tech-
nique carl be considered as optimally invasive combin-
References
ing the mechanical and biological advantages of the 1. Hohl M, Johnson E, Wyss D. Fractures of the knee. In: Rock-
implants (Fig. 5). Submuscular lateral tunnelling for wood C, Green D, eds Fractures in adults. Philadelphia:
plate fixation may represent a further improvement of JP Lippincott, 1991:1725-1752.
the technique. 2. Apley A. Fractures of the tibial plateau. Orthop. Clin.
North Am. 1979;10:61-74.
3. Miiller M, Allg6wer M, Schneider R, Willenegger H, eds
Acknowledgement Manual of Internal Fixation. 3rd Ed. Berlin, Heidelberg:
Springer Verlag, 1991.
The authors express their gratitude to Jacques Cordey 4. Jakob R, Wagner H. Zur Problematik der Platten-
and Dieter Wahl at the AO ASIF Research Institute in osteosynthese bei den bicondyl~ren Tibiakopffrakturen.
Davos, for their assistance during mechanical testing. Unfallchirurg 1986;89:304-311.

Injury 1998, Vol. 29, Suppl. 3

 S-C28

5. Young M, Barrack R. Complications of internal fixation of

tibial plateau fractures. Orthop. Rev. 1994:149-154.
6. Mast J. pers. comm. 1980.
7. Mast J, Spiegel P. Complex ankle fractures. In: Meyers M,
ed. The multiply injured patient with complex fractures.
Philadelphia: Lea and Febiger, 1984.
8. Mast J, Jakob R, Ganz R, eds Planning and reduction tech-
nique in fracture surgery. 1st Ed. Berlin Heidelberg:
Springer-Verlag, 1989.
9. Ries M, Meinhard B. Medial external fixation with lateral
plate internal fixation in metaphyseal tibia fractures. Clin.
Orthop. 1990;256:215-223.
10. Ilizarov G. Treatment of fractures. In: Ilizarov G, ed. Trans-
osseous Osteosynthesis. 1st Ed. Berlin, Heidelberg:
Springer, 1992:406-444.
11. Watson J, Morandi M, Pearse M. Treatment of complex tib-
ial plateau fractures with the Ilizarov external technique.
SICOT. Amsterdam, 1996:336.
12. Murphy C, D'Ambrosia R, Dabezies E. The small pin cir-
cular fixator for proximal tibial fractures with soft tissue
compromise. Orthopedics 1991;14:273-280.
13. Marsh J, Smith S, Do T. External and limited internal fixa-
tion for complex fractures of the tibia plateau. J. Bone Joint
Surg. 1995;77A(5):661-672.
14. Raschke M, Khodadyan C, Windhagen H, Hoffmann R.
Tibial plateau fractures with severe soft tissue damage -
Percutaneous screw fixation and supportive composite
hybrid fixation - A minimal invasive alternative? SICOT.
Amsterdam, 1996:337.
15. Tscherne H, Gotzen L, eds Fractures with soft tissue
injuries. Berlin: Springer, 1984.
16. Gustilo R. Current concepts in the managment of open
fractures. Instr. Course Lect. 1987;36:359-366.
17. Moore T, Patzakis M, Harvey J. Tibial plateau fractures:
definition, demographics, treatment rationale, and long-
term results of closed traction managment or operative
reduction. J. Orthop. Trauma 1987;1:97-119.
18. Weiner S, Kelly M, Yang E et al. Treatment of severe prox-
imal tibia fractures with minimal internal and external fix-
ation. J. Orthop. Trauma 1991;5(2):236.
19. Korkala O, Antti-Poika I, Karaharju E. La fixation externe
darts les fractures ouvertes de la jambe. Rev. Chir. Orthop.
1987(73):637-642.
20. Tornetta P, Weiner L, Bergman M e t al. Pilon fractures:
treatment with combined internal and external fixation.
J. Orthop. Trauma 1993;7:489-496.