The primary goal in treating tibial plateau fractures is to create a stable, well-aligned, mobile, and pain-free joint while minimizing the risk of post-traumatic osteoarthritis ^[1,2]. In 1979, Schatzker and colleagues classified tibial plateau fractures into six types using anteroposterior radiographs. Fundamental treatment principles include reconstructing the articular surface anatomically, restoring the anatomical axis, achieving fixation that spans the metaphyseal comminution, and minimizing additional damage to the already injured soft tissue ^[3]. For non-osteoporotic proximal metaphyseal tibial fractures classified as Schatzker I-IV, open reduction and internal fixation (ORIF) with screws and plates are recommended. While Schatzker V-VI fractures have traditionally been treated similarly, the Ilizarov circular fixator has emerged as an established alternative treatment method ^[4,5]. Early reduction and internal healing of high-energy tibial plateau fractures are more problematic [6-8]. Initial studies on the Ilizarov method for similar injuries showed promising results with lower infection and soft-tissue complication rates. These studies also highlighted benefits such as immediate weight bearing, improved Knee Society Scores, and better range of motion (ROM) [9-11]. While definitive fracture management with external fixation is now rare in modern orthopedic surgery, current methods have evolved from many years of development in external fixation techniques ^[12,13]. In patients with severe infections or soft-tissue injuries, external joint fixators are recommended to provide adequate stability for the healing tissue. The idea of “spanning” the knee joint was proposed in the 1990s. This approach includes the indirect reduction of fractures with traction and the subsequent maintenance of reduction using internal or external fixation before applying a knee-spanning external fixator. This fixator helps in preserving the reduction of intra-articular fragments. This study aims to evaluate the clinical outcomes of Schatzker type V tibial plateau fractures treated with an Ilizarov spanning fixator across the knee joint.

A 38-year-old male presented to the emergency department with a complaint of acute pain and tenderness in his left knee that had started 12 h earlier. The patient was injured due to a road traffic accident (Fig. 1). Radiographic evaluation by X-ray and CT scan revealed a fracture in the left proximal tibia, Schatzker type V (Fig. 2-5). The time elapsed from the injury to the operation was 12 days.

Operative technique

The patient was placed on the radiolucent operating table in the supine position, and spinal anesthesia was used for induction without a tourniquet. The lower limb was cleansed with 10% betadine scrub solution from hip to groin and draped in the usual sterile fashion. A biplane fluoroscope was used during reduction, pin insertion, and frame assembly. Traction was used to achieve axial reduction, with fragments held by patella-holding forceps. The joint surface was reconstructed through closed pressure using percutaneously inserted elevators, reduction forceps, or wires with olives. Neither arthrotomy nor arthroscopy was employed. After reducing the condyles, interfragmentary compression was achieved using counter-opposed olive wires through the fragments. Stabilization of the condylar and metaphyseal fragments usually requires three wires, each at an angle of at least 60° and placed at least 15 mm from the joint to prevent contact of the synovial and reduce the risk of suppuration in cases of needle arthritis. Initially, 1.8 mm olive wire was placed anterior to the fibula head in the subchondral region of the tibial plateau, from lateral to medial, using an image intensifier to achieve interfragmentary compression. The wires were tensioned to at least 110 kg and were positioned through safe zones. The middle ring is at the level of the fibula head, is fixed to the first wire with two retaining bolts, and is tensioned to ensure compression of the joint parts. Another olive wire from the middle to the side of the distal end of the ring was inserted, and then the drop wire was inserted, as seen in (Fig. 6). This ring is connected to the distal ring with four connection rings and the connection ring of the distal femur to create the knee opening configuration. Particular attention is paid to the alignment of the mechanical axis relative to the condyle. The frame is attached to the distal femur as a retractor and is secured with two half pins between the quadriceps and hamstring muscles. The proximal and distal rings were linked to the middle ring at the level of the fibular head using four connection g rods, as seen in (Fig. 7). Intraoperative images of the knee were taken using an image intensifier, as shown in (Fig. 8). Injection ceftriaxone was used as infection prophylaxis starting preoperatively. The pin sites were dressed in povidone-iodine solution-soaked gauze.

Post-operative rehabilitation

Post-operative care included daily pin tract dressing following the “Kurgan protocol.” Pin site infections were classified using the Checketts–Otterburns classification system ^[14,15]. Radiographs were taken  postoperatively; they were made accordingly. Intravenous antibiotics were continued until day 5 and shifted to oral medications after 5 days. On the 2^nd day after surgery, active and passive dorsiflankle exercises ankle were initiated. A splint was used to maintain the foot in a neutral position to prevent equine deformity. Isometric quadriceps exercises and hip-raising exercises were also encouraged. By the end of the 1^st week, patients were allowed to bear partial weight as tolerated, depending on their pain levels. Follow-up check-ups, including radiographs, were conducted every 4 weeks. The patient was initially motivated for partial weight bearing. Upon radiographic union, the frame was dynamized accordingly to reduce pin bone stress and was advised for total weight-bearing walking. The external fixator was tightened further to promote consolidation. It was removed once X-rays confirmed union and clinical examination indicated healed fractures. Radiological healing was determined by bridging the callus across three or four cortices on anteroposterior and lateral radiographs and stability under manual stress, without pain during weight-bearing. Clinically, healing progress was assessed based on the patient’s ability to bear total weight and undergo valgus and varus stress tests on the operated tibia. Fixator removal was conducted as an outpatient procedure without anesthesia. Physiotherapy continued after the cast was removed to enhance knee motion range. Follow-up appointments were scheduled at 6 weeks, 3 months, 6 months, and 12 months.

Assessment

The functional outcome of the knee was determined by measuring knee stability and ROM, assessing the presence of post-traumatic osteoarthritis, and calculating the Hospital for Special Surgery Score (HHS) knee score ^[16]. Rasmussen’s radiographic score was used to evaluate the radiographs ^[17]. Ilizarov removal was done after 6 months, and an X-ray of the knee was done, as shown in Fig. 9. Pain and patient satisfaction were assessed using a Visual Analog Scale (VAS) at 6 weeks, 6 months, and 12 months follow-up ^[18]. Clinical evaluation included measurement of extension lag of knee (in degrees), flexion range (in degrees), atrophy of thigh (in cm), ROM, and manual testing for stability in varus and valgus compared to the contralateral limb at 6 weeks, 6 months and 12 months postoperatively as mentioned in Table 1.

Severe or complex tibial plateau fractures can be challenging to treat. Reducing and opening the repair plate needs to be expanded, which can cause more soft tissue and bone fractures, leading to infection. Knee stiffness is a common complication after tibial plateau bone surgery ^[19]. The report by Gaston et al. ^[20] stated that after 1 year, patients with a high tibial plateau still faced a 20% increased risk of knee stiffness, meaning <100° of flexion and <5° of extension. However, good results were achieved with a hybrid or ring retainer ^[21,22]. However, in our study, findings show that fractures of the tibia plateau (specifically Schatzker V) operated with an external fixator allowed an early ROM up to 120°, allowing for early weight-bearing and full extension without compromising fracture stability or hindering the healing process. These results are consistent with those reported by Ramos et al. ^[23], supporting the effectiveness of this treatment approach for such injuries. In addition, the VAS score at 12 months was 1, indicating minimal pain reported by patients. The mean HHS knee score was 87 points, achieving an excellent result. The mean Rasmussen radiological score was 16, achieving a good result. The clinical and radiological outcomes were satisfactory, and there were no complications, signifying one of the superiority of external fixators over ORIF; a low infection rate. However, Colman et al. their study stated that ring fixators had the lowest infection rate compared to various external devices ^[24]. Besides its minimally invasive nature, the Illizarov technique for managing tibial plateau fractures offers the advantage of reduced surgical time compared to the more time-consuming ORIF procedures. The main advantage of the Ilizarov procedure is the importance of the closed method, which leads to a lower risk of contamination compared to open plating in the event of a long surgery. Due to high-energy trauma, there was soft tissue contusion, and plating would have hampered wound closure and would have led to further soft-tissue complications such as necrosis of the wound. Ilizarov fixation is one of the established methods to treat fractures without disturbing the hematoma. Fracture can be healed with this less invasive technique. This is the rationale for using Ilizarov fixation in this particular case.

The Ilizarov technique is considered a safe and effective approach for proximal tibia fractures, characterized by low morbidity. It allows for early and stable fixation without disturbing the hematoma, enabling early partial weight bearing, which enhances patient compliance. Attempt at closed reduction under anesthesia failed due to the irreducible nature of the condylar fracture. It was observed that femoral ring removal, especially after 6 weeks, does not interfere with the function of the knee, and it promotes bone healing. In most patients, bone healing is completed within 4 months after the Ilizarov application, so this method can also be used. This was a novel approach to dislodge the condyle and can be considered as a viable option.

The Ilizarov external fixator provides stable fixation with minimal soft-tissue disruption, making it a valuable option for treating complex Schatzker type V tibial plateau fractures while reducing the risk of complications.