European Journal of Cardiovascular Medicine

Proximal tibial metaphyseal fractures represent a challenging spectrum of injuries in orthopaedic trauma due to their complex fracture morphology, subcutaneous location, and close proximity to the knee joint, which plays a crucial role in weight bearing and functional mobility. These fractures are frequently associated with significant soft-tissue injury, malalignment, and instability, making their management technically demanding. Extra-articular proximal tibial fractures account for approximately 5-11% of all tibial fractures and are increasingly encountered in clinical practice, largely as a consequence of the rising incidence of high-energy trauma, particularly road traffic accidents [1-3]. The primary objectives in the treatment of proximal tibial metaphyseal fractures include restoration of limb alignment, achievement of stable fixation, preservation of fracture biology, promotion of fracture union, and early mobilisation to minimise joint stiffness and long-term disability. Historically, non-operative management was associated with high rates of malunion, joint incongruity, and poor functional outcomes due to difficulties in maintaining reduction and alignment, leading to its declining role in the management of these injuries [9-11]. Consequently, surgical stabilisation has become the preferred treatment approach. Several operative techniques have been described for managing proximal tibial metaphyseal fractures, including intramedullary nailing, plate osteosynthesis, and external fixation. Bridge plating using minimally invasive percutaneous plate osteosynthesis (MIPPO) principles allows indirect fracture reduction while preserving periosteal blood supply and fracture haematoma, thereby facilitating biological healing. This technique has demonstrated good radiological and functional outcomes in extra-articular proximal tibial fractures; however, it requires surgical exposure and may be associated with wound-related complications, particularly in the presence of compromised soft tissues [4,5]. Hybrid external fixation combines the principles of circular and unilateral external fixation and offers an alternative method of stabilisation, especially in fractures associated with severe soft-tissue injury or open wounds. This technique provides stable fixation with minimal additional soft-tissue disruption, facilitates wound care, and allows early joint mobilisation. Nevertheless, hybrid external fixation is associated with specific complications such as pin-tract infections, patient discomfort, and the need for meticulous postoperative care, and its functional outcomes remain variable across studies [12-15]. Despite the widespread use of both bridge plating and hybrid external fixation, there remains ongoing debate regarding the optimal fixation method for extra-articular proximal tibial metaphyseal fractures, particularly in terms of operative parameters, complication profiles, and functional recovery. Comparative data directly evaluating these two techniques in a controlled clinical setting remain limited. Therefore, the present study was designed to compare bridge plating and hybrid external fixation in the management of proximal tibial metaphyseal fractures with respect to operative duration, postoperative mobilisation, complication rates, and functional outcomes assessed using the Knee Society Score. The findings of this study aim to assist surgeons in selecting the most appropriate fixation strategy based on fracture characteristics, soft-tissue condition, and expected functional outcomes.

Study Design and Setting

This prospective randomised study was conducted in the Department of Orthopaedics, Patna Medical College and Hospital (PMCH), Patna, Bihar, India, a tertiary care teaching hospital. The study included adult patients who presented with proximal tibial metaphyseal fractures to the orthopaedic outpatient department or emergency services during the study period.

Sample Size Calculation

The sample size was calculated using G*Power software (Version 3.1.9.7). Based on effect sizes reported in previously published comparative studies evaluating surgical fixation techniques for proximal tibial metaphyseal fractures, a moderate effect size (d = 0.6) was assumed. A statistical power (1−β) of 80% and a two-tailed α error probability of 0.05 were considered for the calculation. The minimum required sample size was estimated to be 44 patients. To compensate for potential exclusions due to loss to follow-up, incomplete clinical or radiological data, or postoperative complications, the sample size was increased, and 46 adult patients were finally enrolled in the study.

Inclusion Criteria

Adult patients aged 18 years and above with radiologically confirmed proximal tibial metaphyseal fractures were included. Both closed fractures and open fractures up to Gustilo–Anderson grade III-B were eligible. Only patients who provided informed written consent and were willing to participate in regular follow-up assessments were included.

Exclusion Criteria

Patients with proximal tibial fractures associated with neurovascular compromise of the affected limb (Gustilo–Anderson grade III-C), pathological fractures, fractures associated with other ipsilateral bony injuries, or patients deemed unfit for surgical intervention were excluded from the study [7].

Preoperative Evaluation

On admission, all patients underwent thorough clinical and radiological evaluation. Patients were screened for associated systemic injuries, particularly in cases of high-energy trauma. The neurovascular status of the injured limb was carefully assessed and documented. Initial fracture stabilisation was achieved by gentle manipulation followed by immobilisation using an above-knee posterior support slab. Standard true anteroposterior and lateral radiographs of the affected limb were obtained. A detailed history regarding the mechanism, mode, and severity of injury was recorded. Fractures were classified according to the Orthopaedic Trauma Association (OTA) classification system [8].

Approval for the study was obtained from the Institutional Ethics Committee. Written informed consent was taken from all participants in their native language after explaining the nature of the study and surgical procedures. Based on the inclusion and exclusion criteria, 46 patients were enrolled and randomly assigned to two equal groups using a single-blind randomisation technique, with 23 patients in each group.

Surgical Technique

Patients in Group A underwent internal fixation using bridge plating with a 3.5-mm locking compression plate (LCP) of the proximal tibia. The procedure was performed through an anterolateral approach using the minimally invasive percutaneous plate osteosynthesis (MIPPO) technique to preserve fracture biology and minimise soft tissue disruption.

Patients in Group B were treated with a hybrid external fixator (HEF). Beaded olive wires were inserted through safe anatomical zones of the proximal tibia and attached to a semi-circular ring, followed by tensioning with a wire tensioner. Two or three Schanz screws were inserted into the tibial diaphysis and connected using tubular rods to each other and to the proximal ring to complete the hybrid construct.

Postoperative Management

Postoperatively, static quadriceps strengthening exercises and ankle pump exercises were initiated on the day of surgery or the first postoperative day. Active and passive knee range-of-motion exercises were started once pain subsided, typically within two to three days following surgery. In the bridge plating group, wound inspection and dressing were performed on the third postoperative day, while in the HEF group, daily pin-tract care was emphasised. Patients were discharged between the fifth and seventh postoperative day with appropriate antibiotics and analgesics. Sutures were removed between the 12th and 14th postoperative days.

Follow-up and Outcome Assessment

Patients were followed up at 2 weeks, 6 weeks, 3 months, and 6 months postoperatively. At each follow-up visit, clinical evaluation and radiographic assessment were performed to assess fracture healing and detect any complications. Functional outcomes were evaluated using the Knee Society Score (KSS), which assesses pain, range of motion, stability, alignment, and extension lag [6].

Statistical Analysis

Data were entered into Microsoft Excel and analysed using the Statistical Package for the Social Sciences (SPSS) software, version 25.0 (IBM Corp., Armonk, NY, USA). Continuous variables were summarised as mean ± standard deviation (SD), while categorical variables were expressed as frequencies and percentages. The normality of continuous data was assessed using the Shapiro–Wilk test. For intergroup comparisons, Student’s independent t-test was used for normally distributed continuous variables, and the Mann–Whitney U test was applied for non-normally distributed data. Categorical variables were analysed using the Chi-square test; Fisher’s exact test was employed when expected cell counts were less than five. Within-group comparisons across follow-up periods were performed using the paired t-test for normally distributed data or the Wilcoxon signed-rank test for non-parametric data, as appropriate. All statistical tests were two-tailed, and a p-value < 0.05 was considered statistically significant.

A total of 46 patients were included in the study, with 23 patients in each treatment group. The mean age of patients in the bridge plating group was 46.2 ± 15.4 years, while that of the hybrid external fixator group was 42.8 ± 16.1 years. The difference in age between the two groups was not statistically significant (p = 0.42). The sex distribution was comparable between the two groups, with 19 males and 4 females in the bridge plating group and 20 males and 3 females in the hybrid external fixator group. No statistically significant difference was observed in sex distribution between the groups (p = 0.68). Regarding side involvement, the right limb was affected in 13 patients and the left in 10 patients in the bridge plating group, while in the hybrid external fixator group, 14 patients had right-sided and 9 had left-sided fractures. The distribution of side involvement was similar between the two groups, with no statistically significant difference (p = 0.77). Overall, the baseline demographic and clinical characteristics were comparable between the two groups, indicating that the study populations were well matched for subsequent outcome analysis (Table 1).

Table 1: Comparison of baseline demographic and clinical characteristics of the study population

The mechanism of injury was comparable between the two groups. Road traffic accidents were the most common cause of injury in both the bridge plating group (82.61%) and the hybrid external fixator group (86.95%). Other mechanisms, including being hit by an animal, a fall of a heavy object, and a fall from height, were infrequently observed and similarly distributed between the groups. The difference in the mechanism of injury between the two groups was not statistically significant (p = 0.95). With respect to fracture classification based on the Orthopaedic Trauma Association (OTA) system, type 41A2 fractures were more common in both groups, accounting for 65.22% of cases in the bridge plating group and 52.17% in the hybrid external fixator group. Type 41A3 fractures constituted 34.78% and 47.83% of cases in the bridge plating and hybrid external fixator groups, respectively. The distribution of OTA fracture types did not differ significantly between the two groups (p = 0.55). Regarding the type of fracture, closed fractures predominated in both groups, observed in 95.65% of patients in the bridge plating group and 82.61% in the hybrid external fixator group. Open fractures were relatively fewer, accounting for 4.35% and 17.39% of cases in the respective groups. The difference in fracture type distribution between the two groups was not statistically significant (p = 0.34). Overall, the two groups were comparable with respect to mechanism of injury, fracture classification, and fracture type, indicating a well-matched study population for subsequent outcome analysis (Table 2).

Table 2: Showing the comparison of the mechanism of injury and fracture-related variables

The mean duration of surgery was significantly longer in the bridge plating group (72.4 ± 8.2 minutes) compared to the hybrid external fixator group (59.1 ± 7.9 minutes), and this difference was statistically significant (p < 0.001). The mean length of hospital stay was comparable between the two groups, with patients in the bridge plating group staying for 5.1 ± 1.6 days and those in the hybrid external fixator group for 5.4 ± 1.4 days. The difference in hospital stay was not statistically significant (p = 0.48). Patients treated with hybrid external fixation achieved earlier mobilisation compared to those managed with bridge plating. The mean time to partial weight bearing was 7.2 ± 1.7 weeks in the bridge plating group and 5.4 ± 2.9 weeks in the hybrid external fixator group, with the difference being statistically significant (p < 0.01). Similarly, the mean time to full weight bearing was significantly shorter in the hybrid external fixator group (9.8 ± 3.1 weeks) compared to the bridge plating group (12.4 ± 2.1 weeks) (p < 0.01). Extension lag was observed in 2 patients (8.7%) in the bridge plating group and in 4 patients (17.4%) in the hybrid external fixator group. However, this difference was not statistically significant (p = 0.38).

Overall, hybrid external fixation was associated with shorter operative time and earlier weight-bearing mobilisation, while hospital stay and incidence of extension lag were comparable between the two groups (Table 3).

Table 3: Comparison of intraoperative and postoperative variables

Figure 1: Bar diagram showing comparison of intraoperative and postoperative variables between the bridge plating group and the hybrid external fixator group.

Complications were observed in a small proportion of patients in both groups. In the hybrid external fixator group, delayed union was noted in one patient (4.3%), and pin-tract infection occurred in three patients (13.0%). In the bridge plating group, one patient (4.3%) developed screw backout, two patients (8.7%) had superficial wound infection, and one patient (4.3%) experienced wound gaping. The overall incidence of complications was identical in both groups, with four patients (17.4%) in each group experiencing at least one complication, while the majority of patients had an uncomplicated postoperative course (82.6% in both groups). Statistical analysis revealed no significant difference in the overall complication rates between the hybrid external fixator group and the bridge plating group (p = 1.00). These findings indicate that both treatment modalities were associated with comparable safety profiles, with differences observed only in the pattern of complications rather than their overall frequency (Table 4, Figure 2 and 3).

Table 4: Comparison of complications between the two groups

Figure 2: Bar diagram showing comparison of overall postoperative complications between the hybrid external fixator group and the bridge plating group.

Figure 3: Bar diagram showing the number of patients without postoperative complications in the hybrid external fixator and bridge plating groups.

Functional Outcome (Knee Society Score)

Functional outcomes were assessed at the final follow-up using the Knee Society Score (KSS). The mean KSS was slightly higher in the bridge plating group compared to the hybrid external fixator group; however, the difference was not statistically significant (Table 5). Both groups demonstrated satisfactory functional recovery, indicating comparable knee function following fracture management.

Table 5: Comparison of Knee Society Scores (KSS) between the two groups

Operational Definition of Extension Lag: Extension lag was defined as the inability to achieve full active knee extension compared to passive extension, with a deficit of ≥5 degrees measured using a goniometer during clinical examination at follow-up. Extension lag was recorded as present or absent for each patient and analysed as a categorical variable.

Proximal tibial metaphyseal fractures represent complex injuries involving both osseous and soft-tissue components and are frequently associated with significant functional impairment if not managed appropriately. High-energy trauma, particularly road traffic accidents, remains the predominant mechanism of injury, a trend that continues to rise with increasing motorisation. Prompt and appropriate management of these fractures is crucial, as delayed or inadequate treatment may result in malalignment, joint stiffness, prolonged disability, and compromised quality of life [1]. Non-operative treatment has largely fallen out of favour for these injuries due to the high incidence of unsatisfactory outcomes resulting from inadequate reduction and loss of alignment [9-11]. Operative stabilisation using internal or external fixation techniques has therefore become the mainstay of treatment. Bridge plating offers the advantages of indirect fracture reduction, restoration of limb alignment, and preservation of fracture biology when performed using minimally invasive techniques. However, in fractures associated with significant soft-tissue compromise or open wounds, extensive surgical exposure may increase the risk of wound complications, making external fixation a preferred alternative in selected cases. Hybrid external fixation, performed under fluoroscopic guidance, allows adequate fracture reduction and stable fixation while minimising additional soft-tissue insult, thereby addressing many of the limitations of open reduction and internal fixation [12,13]. Previous studies have reported favourable clinical and radiological outcomes with hybrid external fixation, particularly in fractures with compromised soft-tissue envelopes [13,14]. Despite its advantages, external fixation is not without drawbacks. Pin-tract infection, patient discomfort, and the need for meticulous pin-site care remain well-recognised concerns. Nevertheless, hybrid constructs reduce soft-tissue dissection and have demonstrated acceptable union rates when appropriately applied [15]. Regardless of the fixation method, achieving anatomical alignment and stable fixation remains the fundamental principle in the management of proximal tibial metaphyseal fractures [16]. In the present study, both treatment groups were comparable with respect to age, sex distribution, side involvement, fracture pattern, and mechanism of injury, ensuring a balanced comparison. The study population predominantly comprised young to middle-aged adults, with a mean age of 42.8 ± 16.1 years in the hybrid external fixator group and 46.2 ± 15.4 years in the bridge plating group. These findings are consistent with those reported by Duwelius and Connolly [17] and Porter [18], who observed mean ages of 48 and 47 years, respectively, in similar fracture cohorts. A marked male predominance was observed in both groups, reflecting greater exposure of males to high-energy trauma, a trend also reported by Albuquerque et al. [19], Manidakis et al. [20], and Mehin et al. [21]. Road traffic accidents accounted for the majority of injuries in both groups (82.61% in the bridge plating group and 86.95% in the hybrid external fixator group), consistent with previous studies highlighting RTA as the leading cause of proximal tibial fractures [22]. The distribution of fracture types and OTA classifications was similar between groups, further supporting the comparability of the study population. The mean duration of surgery was significantly shorter in the hybrid external fixator group (59.1 ± 7.9 minutes) compared to the bridge plating group (72.4 ± 8.2 minutes), a finding that is clinically relevant and consistent with earlier reports. Shorter operative time may reduce anaesthetic exposure and perioperative morbidity, particularly in polytrauma patients. The duration of hospital stay was comparable between groups, with no statistically significant difference, a finding similar to that reported by the Canadian Orthopaedic Trauma Society [23]. Early mobilisation is a key determinant of functional recovery following proximal tibial fractures. In the present study, patients treated with hybrid external fixation achieved significantly earlier partial and full weight bearing compared to those managed with bridge plating. This advantage may be attributed to the stable construct provided by the hybrid fixator and the avoidance of extensive soft-tissue dissection. Extension lag was observed more frequently in the hybrid external fixator group; however, this difference was not statistically significant. The overall complication rate was identical in both groups (17.4%), although the pattern of complications differed. Pin-tract infection was the most common complication in the hybrid external fixator group (13.0%), which is slightly higher than the rate reported by Babis et al. [24]. In contrast, the bridge plating group demonstrated complications related to surgical exposure, including superficial wound infection, screw backout, and wound gaping. These complication rates were lower than those reported by Barei et al. [25] and the Canadian Orthopaedic Trauma Society [23]. Importantly, no statistically significant difference was observed in the overall complication rates between the two treatment modalities, indicating comparable safety profiles. Functional outcomes, assessed using the Knee Society Score, were satisfactory in both groups, with the bridge plating group demonstrating marginally better scores. This finding aligns with previous reports suggesting superior knee function following internal fixation in selected cases. The Canadian Orthopaedic Trauma Society reported better knee range of motion following external fixation; however, functional outcomes remain influenced by multiple factors, including fracture severity, rehabilitation protocols, and patient compliance [23]. Chaix et al. similarly reported excellent to good outcomes in a majority of surgically treated patients, supporting the effectiveness of operative management in these fractures [22]. Overall, the findings of the present study reinforce that both bridge plating and hybrid external fixation are effective treatment modalities for proximal tibial metaphyseal fractures. Each technique offers distinct advantages, and the choice of fixation should be individualised based on fracture morphology, soft-tissue condition, and surgeon expertise to optimise clinical and functional outcomes.

Limitations of the Study: This study was conducted at a single centre with a relatively small sample size and a follow-up period limited to six months, which may restrict the generalisability of the findings and preclude assessment of long-term outcomes. Blinding of surgeons and patients was not feasible due to the nature of the interventions. Additionally, functional assessment was limited to the Knee Society Score, and patient-reported outcome measures were not included. Future multicentric studies with larger cohorts, longer follow-up, and inclusion of patient-reported outcomes are recommended to further validate these results.

Both bridge plating and hybrid external fixation are effective and safe treatment modalities for proximal tibial metaphyseal fractures, yielding satisfactory clinical and functional outcomes. Hybrid external fixation offers the advantages of shorter operative time and earlier weight-bearing mobilisation, while bridge plating provides stable internal fixation with comparable complication rates and functional recovery. As overall outcomes and complication rates were similar between the two groups, the choice of fixation method should be individualised based on fracture characteristics, soft-tissue condition, and surgeon expertise to optimise patient outcomes.

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