Does maintaining external fixators during definitive fixation of bicondylar tibial plateau fractures influence fracture alignment and deep infection rates?

Abstract

External fixators are utilized to temporarily stabilize bicondylar tibial plateau fractures. They can be prepped during definitive surgery to help maintain fracture length and alignment. However, there is a potential for increased infection by leaving the external fixator on during the surgery. We hypothesize that maintaining the external fixator during surgery will result in no difference in rates of deep infection but improve reduction quality. We performed a retrospective cohort study of all bicondylar tibial plateau fractures treated at an academic, level one trauma center over a 10-year period. The primary outcome analyzed was the rate of deep infection. Secondary outcomes analyzed included reduction quality by comparing the medial proximal tibia angle (MPTA) and posterior proximal tibia angle (PPTA), complication rate, and reoperation rate. One hundred and thirty-nine fractures in 133 patients met the inclusion criteria. There was no difference between the external fixator removed and prepped groups in terms of baseline patient characteristics except for more motor vehicle collisions in the removed group (42 % vs 22.99 %, p = 0.0193) and more open fractures in the prepped group (6 % vs 18.39 %). Operative characteristics were also not statistically different except for more patients in the prepped group underwent preoperative skin shaving (22 % vs 48.28 %, p = 0.0023) and more patients in the removed group had fixation constructs with plate and pin site overlap (46 % vs 24.14 %, p = 0.0083). There was no difference in deep infection between the groups (16.00 % vs 8.05 %, p = 0.1511). There was no difference in reduction quality when comparing the MPTA (87.64° vs 87.40°, p = 0.6607) and PPTA (83.18° vs 83.97°, p = 0.3592). The rates of superficial infection (20 % vs 29.89 %, p = 0.2056), unplanned reoperation (30 % vs 18.39 %, p = 0.1179), complications (58 % vs 44.83 %, p = 0.1376), and nonunion (8 % vs 6.89 %, p = 0.8111) were also similar. Bicondylar tibial plateau fractures are challenging injuries with a high complication profile. Our findings suggest that maintaining the external fixator is not associated with increased rates of deep infection or complications. However, maintaining the external fixator during surgery did not lead to differences in final coronal or sagittal alignment reduction quality.