Research Article| Volume 42, ISSUE 10, P1066-1072, October 2011

The management of complex fractures of the proximal tibia with minimal intra-articular impaction in fragility patients using intramedullary nailing and compression bolts



      Intra-articular fractures of the proximal tibia that extend to the meta-diaphyseal part of the bone represent a severe injury, especially if they occur in osteoporotic patients. Current treatment modalities include either internal fixation with traditional or modern plating techniques or external fixation with circular frames or hybrid systems. However, problems and complications related with these techniques are increasing with age and future reconstructive operations, such as arthroplasty, may be jeopardised.


      This is a prospective pilot study about a novel type of osteosynthesis for complex intra-articular proximal tibial fractures without significant articular impaction in patients over 60 years of age. Within a period of 54 months, eight patients underwent fixation of such fractures with condylar compression bolts and intramedullary nailing.


      The follow-up period was from 12 to 50 months (mean 24.7 months). There were no neurovascular complications, wound infections, delayed unions or nonunions. All patients had their fractures healed without secondary displacement or malalignment. At the final follow-up, all patients had full extension of the knee joint whilst the flexion ranged from 125 to 140°. The mean new Oxford Knee score was calculated to be 43.75 points.


      The management of selected osteoporotic complex intra-articular fractures of the proximal tibia with compression bolts and intramedullary nailing offers specific advantages and, in the present pilot study, provided promising results. These results should be validated and confirmed with larger case series and comparison studies in the future.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. Open reduction and internal fixation compared with circular fixator application for bicondylar tibial plateau fractures. Results of a multicenter, prospective, randomised clinical trial.
        J Bone Joint Surg Am. 2006; 88: 2613-2623
        • Ali A.M.
        • Burton M.
        • Hashmi M.
        • Saleh M.
        Treatment of displaced bicondylar tibial plateau fractures (OTA-41C2&3) in patients older than 60 years of age.
        J Orthop Trauma. 2003; 17: 346-352
        • Benirschke S.K.
        • Agnew S.G.
        • Mayo K.A.
        • et al.
        Immediate internal fixation of open, complex tibial plateau fractures: treatment by a standard protocol.
        J Orthop Trauma. 1992; 6: 78-86
        • Bhandari M.
        • Audige L.
        • Ellis T.
        • Hanson B.
        Operative treatment of extra-articular proximal tibial fractures.
        J Orthop Trauma. 2003; 17: 591-595
        • Blokker C.P.
        • Rorabeck C.H.
        • Bourne R.B.
        Tibial plateau fractures. An analysis of the results of treatment in 60 patients.
        Clin Orthop Relat Res. 1984; : 193-199
        • Cole P.A.
        • Zlowodzki M.
        • Kregor P.J.
        Less Invasive Stabilization System (LISS) for fractures of the proximal tibia: indications, surgical technique and preliminary results of the UMC Clinical Trial.
        Injury. 2003; 34: 16-29
        • DeCoster T.A.
        • Nepola J.V.
        • el-Khoury G.Y.
        Cast brace treatment of proximal tibia fractures. A ten-year follow-up study.
        Clin Orthop Relat Res. 1988; : 196-204
        • Egol K.A.
        • Su E.
        • Tejwani N.C.
        • et al.
        Treatment of complex tibial plateau fractures using the less invasive stabilization system plate: clinical experience and a laboratory comparison with double plating.
        J Trauma. 2004; 57: 340-346
        • Egol K.A.
        • Tejwani N.C.
        • Capla E.L.
        • et al.
        Staged management of high-energy proximal tibia fractures (OTA types 41): the results of a prospective, standardized protocol.
        J Orthop Trauma. 2005; 19 (discussion 56): 448-455
        • Gaudinez R.F.
        • Mallik A.R.
        • Szporn M.
        Hybrid external fixation of comminuted tibial plateau fractures.
        Clin Orthop Relat Res. 1996; : 203-210
        • Goesling T.
        • Frenk A.
        • Appenzeller A.
        • et al.
        LISS PLT: design, mechanical and biomechanical characteristics.
        Injury. 2003; 34: 11-15
        • Gosling T.
        • Schandelmaier P.
        • Muller M.
        • et al.
        Single lateral locked screw plating of bicondylar tibial plateau fractures.
        Clin Orthop Relat Res. 2005; 439: 207-214
        • Hansen M.
        • El Attal R.
        • Blum J.
        • et al.
        Intramedullary nailing of the tibia with the expert tibia nail.
        Oper Orthop Traumatol. 2009; 21: 620-635
        • Higgins T.F.
        • Klatt J.
        • Bachus K.N.
        Biomechanical analysis of bicondylar tibial plateau fixation: how does lateral locking plate fixation compare to dual plate fixation?.
        J Orthop Trauma. 2007; 21: 301-306
        • Horwitz D.S.
        • Bachus K.N.
        • Craig M.A.
        • Peters C.L.
        A biomechanical analysis of internal fixation of complex tibial plateau fractures.
        J Orthop Trauma. 1999; 13: 545-549
        • Hutson Jr., J.J.
        • Zych G.A.
        Infections in periarticular fractures of the lower extremity treated with tensioned wire hybrid fixators.
        J Orthop Trauma. 1998; 12: 214-218
        • Jiang R.
        • Luo C.F.
        • Wang M.C.
        • et al.
        A comparative study of Less Invasive Stabilization System (LISS) fixation and two-incision double plating for the treatment of bicondylar tibial plateau fractures.
        Knee. 2008; 15: 139-143
        • Kubiak E.N.
        • Camuso M.R.
        • Barei D.P.
        • Nork S.E.
        Operative treatment of ipsilateral noncontiguous unicondylar tibial plateau and shaft fractures: combining plates and nails.
        J Orthop Trauma. 2008; 22: 560-565
        • Mallik A.R.
        • Covall D.J.
        • Whitelaw G.P.
        Internal versus external fixation of bicondylar tibial plateau fractures.
        Orthop Rev. 1992; 21: 1433-1436
        • Marsh J.L.
        • Slongo T.F.
        • Agel J.
        • et al.
        Fracture and dislocation classification compendium—2007 Orthopaedic Trauma Association classification, database and outcomes committee.
        J Orthop Trauma. 2007; 21: S1-S133
        • Murray D.W.
        • Fitzpatrick R.
        • Rogers K.
        • et al.
        The use of the Oxford hip and knee scores.
        J Bone Joint Surg Br. 2007; 89: 1010-1014
        • Nork S.E.
        • Barei D.P.
        • Schildhauer T.A.
        • et al.
        Intramedullary nailing of proximal quarter tibial fractures.
        J Orthop Trauma. 2006; 20: 523-528
        • Parekh A.A.
        • Smith W.R.
        • Silva S.
        • et al.
        Treatment of distal femur and proximal tibia fractures with external fixation followed by planned conversion to internal fixation.
        J Trauma. 2008; 64: 736-739
        • Parker P.J.
        • Tepper K.B.
        • Brumback R.J.
        • et al.
        Biomechanical comparison of fixation of type-I fractures of the lateral tibial plateau. Is the antiglide screw effective?.
        J Bone Joint Surg Br. 1999; 81: 478-480
        • Partenheimer A.
        • Gosling T.
        • Muller M.
        • et al.
        Management of bicondylar fractures of the tibial plateau with unilateral fixed-angle plate fixation.
        Unfallchirurg. 2007; 110: 675-683
        • Phisitkul P.
        • McKinley T.O.
        • Nepola J.V.
        • Marsh J.L.
        Complications of locking plate fixation in complex proximal tibia injuries.
        J Orthop Trauma. 2007; 21: 83-91
        • Schatzker J.
        • McBroom R.
        • Bruce D.
        The tibial plateau fracture. The Toronto experience 1968–1975.
        Clin Orthop Relat Res. 1979; : 94-104
        • Schutz M.
        • Kaab M.J.
        • Haas N.
        Stabilization of proximal tibial fractures with the LIS-System: early clinical experience in Berlin.
        Injury. 2003; 34: 30-35
        • Stamer D.T.
        • Schenk R.
        • Staggers B.
        • et al.
        Bicondylar tibial plateau fractures treated with a hybrid ring external fixator: a preliminary study.
        J Orthop Trauma. 1994; 8: 455-461
        • Stokel E.A.
        • Sadasivan K.K.
        Tibial plateau fractures: standardized evaluation of operative results.
        Orthopedics. 1991; 14: 263-270
        • Su E.P.
        • Westrich G.H.
        • Rana A.J.
        • et al.
        Operative treatment of tibial plateau fractures in patients older than 55 years.
        Clin Orthop Relat Res. 2004; : 240-248
        • Waddell J.P.
        • Johnston D.W.
        • Neidre A.
        Fractures of the tibial plateau: a review of ninety-five patients and comparison of treatment methods.
        J Trauma. 1981; 21: 376-381
        • Young M.J.
        • Barrack R.L.
        Complications of internal fixation of tibial plateau fractures.
        Orthop Rev. 1994; 23: 149-154