Review of Functional Outcome in Management of Proximal Tibial Fracture with Ring Fixator vs Hybrid External Fixator

Abstract

Introduction

Tibial plateau fractures are caused by high-energy trauma and are often associated with soft tissue injuries, which complicates the surgical management. ORIF and plating, even though conventionally done for proximal tibia fractures and convenient for the patient, are not free from complications. Ilizarov ring fixators come to the rescue in such cases. However, all centers and all surgeons are not equipped to treat tibial plateau fractures with the Ilizarov fixator, and a hybrid fixator may be a good option. The purpose of this narrative review is to evaluate and compare the outcomes of proximal tibia fractures treated by hybrid and Ilizarov fixators in the existing literature.

Method

Literature search was done using the keywords, one author gathering the studies mentioning the proximal tibia fracture fixation by hybrid fixators and another by the ring fixator. All parameters noted in the studies were compiled and compared.

Results

Eleven studies mention fixation with hybrid fixators and twelve studies with the Ilizarov fixators. Type and duration of study, total patient numbers and average age, gender distribution, fracture classification type mentioned, percentage of open fractures, mechanism of injury, time from injury to surgery, type of construct, post-operative protocol in terms of knee range of motion and weight-bearing total frame time, union time, maximum follow-up, scoring system used, final range of movement at knee and types of complications were noted and compared.

Conclusion

Hybrid and Ilizarov fixators are viable options for the treatment of tibial plateau fractures, especially with bad soft tissue status and open fractures with similar union times and range of motions achieved despite differing post-operative rehabilitation protocols.

Introduction

The goal of operative treatment in proximal tibial fractures is to obtain anatomic realignment of the joint surface while providing enough stability to allow early motion [1]. In proximal tibia high-energy fractures with bad soft tissue, open fractures or severe comminuted fractures often force a surgeon to look for alternative methods of fixation of the fracture like ring fixator or tubular external fixator, as soft tissue stripping in not feasible under such circumstances due to high chances of wound break down and infection [2]. Both methods are being used for these fractures. In hospitals with very limited resources, hybrid fixators are commonly utilized as they are more convenient for the surgeon, more acceptable by the patient, and easy for plastic surgeons to intervene. But ring fixator’s advantages are more stability and effective dynamization of the frame before removal of fixator. A hybrid external fixator with minimal internal fixation is a very good alternative for proximal tibia fractures when open reduction and plating are not feasible. A periarticular proximal tibial ring is connected with the shaft using a monoaxial fixator. This provides a very stable construct and allows an early range of motion, which is critical for cartilage nutrition. Minimal soft tissue damage causes little post-operative pain. Besides, a varus or valgus collapse in the immediate post-operative period can also be addressed [3]. Most Ilizarov surgeons are not much in favor of hybrid fixators, but trauma surgeons usually use hybrid frames because of ease of application, time constraints, and lack of expertise. Hence, in our aims and objectives, we wanted to know if one method is better over other in terms of results, or if both methods give similar results and if any further studies are needed to fill-up the gap or lacunae if any, as most of the proximal tibial fractures are being managed in trauma centers by general orthopedic surgeons.

Methods

This is a narrative review done by two authors. The articles were searched in various search engines: Google Scholar, PubMed, and Scopus with the keywords proximal tibial features, tibial plateau fractures, hybrid external fixator, and Ilizarov ring fixator. There were no articles found on these search engines. Hence, it was decided to search in Google search engine. We could not find articles which had comparison between two methods. Hence, it was decided to find full articles for hybrid fixators and ring fixators separately and calculate the average for each parameter that we were looking for and compare the average of both treatment modalities. A total of 11 (10 where prospective [4–13], and 1 was retrospective [14]) studies with hybrid fixator (Table 1), and 12 (4 were prospective [15–18] and 8 were retrospective [19–26]) with Ilizarov fixator (Table 2) were included in the study.

Table 1.

Hybrid fixator studies

Author	Aditya K. Aggarwal [4]	George C Babis [5]	Hisam Muhamad Ariffin [6]	S. K. Venkatesh Gupta [7]	MK Aseri [8]
Year of publication	2006	2011	2011	2014	2017
Journal	Acta Orthop. Belg	Journal of Orthopaedic Surgery and Research	Strat Traum Limb Recon	Open Journal of Orthopedics	International Journal of Orthopaedics Sciences
Duration of study	Feb 1997–Oct 2003 = 80 months	2002 and 2006 = 48 months	Jul 2003–Dec 2007. = 53 months	May 2011 and May 2013 = 24 months	Mar 2016 to Dec 2016. = 10 months
Patient numbers	35 patients proximal, 21 patients distal	33 patients	31 patients	23 patients proximal tibia + 25 patients distal tibia	32 patients
Other data		1 patient peroneal nerve injury, 2 patients knee instability	1 patient’s PCL injury, 2 patients supracondylar femur fracture, Tscherene 2/3	1 case had mini-open incision for percutaneous cannulated cancellous screw fixation
Age	(Average age — 39.4 years) of all 56 pts (proximal and distal tibial fractures)	(Average age of both male and female: 44.65 years) Average male age: 40.3 years Average female age: 49 years	(Average age: 44 years) range: 21–68 years	(Average age: 40.2 years)	(Average age: 39.2 years)
Classification	Periarticular NM	Schatzker type 5,6	Schatzker type 5,6	Metaphysis comminution	Schatzker type 3,5,6
Open fractures	27 patients proximal tibia (77.1%)	5 patients (15%)	13 patients (41.9%)	5 patients proximal tibia (21.7%)	25 patients (78.1%)
RTA	49 patients (87.5%)	RTA and FFH together: 81.8%	31 patients (100%)	NM	23 patients (71.8%)
FFH	7 patients (12.5%)		-	NM	8(25%)
Male: Female	38:18 (68:32%)	20:13 (60.6:39.4%)	26:5 (83.87:16.13%)	32:16 (67:33%)	23:9 (71.8:28.2%)
Other information		Mini incision taken for cannulated screw fixation: 19 patients (57%). 17 patients (51%) underwent cortical allografts. Union in open fractures type II/III (14.2 weeks) was more than type I	Surgery for posterior cruciate ligament: 1 patient (3.2%), tension band wiring: 1 patient (3.2%) after union		Inter-fracture comparison Weight-bearing delayed in VI > > V/III p — < 0.05
SSG/Flap	3 patients (5%) flap, 1(1%)SSG	1 patient (3%) SSG
Exclusion		Poly trauma, ppposite limb fractures	Exclusion: vascular injury, non-cooperative Patient	Exclusion: femur fractures, intra-articular fractures	Ipsilateral femur fracture
Duration of surgery	NM	NM	NM	NM	NM
Time to surgery from injury	5–7 days	5 patients open + 18 patients closed—1st day, other c 5 days	NM	NM	NM
Construct	5/8th ring and AO fixator	Full ring and AO fixator	NM	5/8th + AO fixator	½ ring and AO fixator
Early ROM	1–2 weeks/3 weeks	POD1/comminute: 48 h after splint	1 week	NM	3.1–3.4 days
Weight bearing	14–24 weeks – FWB 12.5 PWB	8–12 weeks progressive	Callus	NM	8.9 ± 1.3 weeks. (III/V), 9.5 ± 1.6 weeks (VI)
Frame time	Average of 10.6 weeks Above knee cast applied for all proximal tibial fractures for 4–6 weeks after frame removal	NM	Average: 14 weeks	NM	After union?
Union time	20.5 weeks	3.4 months (12.1 weeks)	14 weeks	13.3 weeks	NM
Follow-up	42.5 months	27 months	12 months	NM	NM
Knee Society Score	G + E: 30(85.7%) F: 2 patients (5.7%) P: 3 patients (8.6%)	E: 18 patients (55%), G: 10 patients (30%), F: 4 patients (12%), P: 1 patient (3%)	-
Rasmussen score			Functional score: E: 15 patients (48%) G: 13 patients (42%) F: 3 patients (10%) (1 patient had posterior cruciate ligament injury, 2 patientspatients had supracondylar fracture of femur)		Functional score: E: 6 patients (50%) G: 13 patients (40.6%) F: 3 patients (9.3%) Radiological score: E: 13 patients (40.6%) G: 6 patients (50%) F: 3 patients (9.3%)
IOWA knee score				E: 5 patients (21.7%) G: 14 patients (60.9%) F: 3 patients (1 due to knee stiffness and 2 due to delayed union) (13%) P: 1 (4.3% due to hardware failure)
Neer’s rating system			-
ROM at knee -	5–103°	115°	120°	NM	Mean ROM in all patients was 107.6 ± 11.4° Mean ROM of 114.3 ± 7.2° in type III Schatzker was better
Pin tract infection	8 patients (22.85%)	3 patients (9.1%)	8 patients (25.8%)	5 patients (21.7%)	4 patients (12.5%)
Malunion	6 patients (17.14%)	2 patients (6.1%)	2 patients (6.5%)	–	2 patients (6.25%)
Non-union	2 patients (5.7%)	2 patients (6.1%) delayed union, 1 non-union (3%)	–	1 patient (4.3%) non-union, 2 (8.6%) delayed union	-
Osteomyelitis	3(8.6%)	1 patient (3%)	–	–	1 patient (3.1%)
Extensor lag	–	2 patients (6.1%)	10–200: 3 patients (1 patient had associated posterior cruciate ligament injury, 2 patients had ipsilateral supra condylar fracture of femur): (9.7%)	-	10 degrees. 2 patients (6.25%) (VI)
Knee stiffness	–	5 patients (15.1%)	-	3 patients (13%)	–
Complications		DVT 1 patient (3%), OA 1 patient (3%)	Septic arthritis 1 patient (3.2%)	Hard ware failure 1 patient (4.3%)	Knee laxity: 2 patients (6.25%)

Author	Towseef Ahmad Bhat [9]	Divanshu Goel [10]	Subash Y [11]	E Venkateshulu [12]	Muhammad Anis [13]	Amit Thakur retrospective [14]
Year of publication	2019	2021	2021	2022	2024	2015
Journal	J Orthop Trauma Surg Rel Res	International Journal of Health and Clinical Research	Malaysian Orthopaedic Journal	International Journal of Orthopaedics Sciences	J Pak Med Assoc	IOSR Journal of Dental and Medical Sciences
Duration of study	Jan 2014–Dec 2017 = 47 months	NM	January 2012 to January 2015 = 37 months	Jan 2021–June 2022 = 17 months	July 2019–Dec 31 2021 = 30 months	Sep 2011–September 2014 = 36 months
Patient numbers	25 patients	21 patients	30 patients	18 patients	113 patients	35 patients
Other data					1 surgeon, bone grafting in few, mini-open in few	3 cases of peroneal nerve injury with open fracture type IIIB—recovered in 14 weeks
Age	(Average age: 37 years)	(Average age of both male and female: 48.5 years) Average male age: 43.06 years Average female age: 53.4 years	(Average age −42.26 years)	(Average age: not mentioned) Age > 18 years included	(Average age: 35.56 years) Age range: 20–50 years	(Average age of both male and female: 40 years) Average male age: 37.5 years Average female age: 42.5 years
Classification	19 cases were Schatzker type 4,5, and 6 type 6 cases: extra-articular	Schatzker type 4,5,6	Schatzker type 5/6	Schatzker type 5,6 with Impending Compartment	2/3 column Lou et al	AO/OTA type 41C2 and 41C3
Open fractures	6 patients (24%)	4 patients (19%)	7 patients (23.33%)	NM	00	14 patients (40%)
RTA	NM	20 patients (95.2%)	25 patients (83.3%)	14 patients (77.7)	95 patients (84.1%)	27 patients (60%)
FFH	NM	0	5 patients (26.7%)	2 patients (11.11)	18 patients (15.9%)	08 patients (22.8%)
Male: Female	17:8 (68:32%)	16:5 (76:24%)	20:10 (66.7:33.3%)	NM	91:22 (80.5:19.5%)	23:12 (65.7:34.3%)
Other information		Dynamization: done	8 (25%) ligament injury managed after union Union Clinical criteria: – lack of tenderness/pain on weight-bearing Radiological: 3 cortices union			With or without cannulated cancellous screw 20 cases (26%) minimal open reduction was done Factors affecting poor outcome is mentioned
SSG/Flap			1 patient (3.3%) flap	Delayed closure/SSG in fasciotomy (6 33%) pts		2 patients (5.2%) flap
Exclusion	Exclusion: compartment syndrome, need for flap/vascular injuries				Exclusion: previous injury, ligament injury, open fractures, other bone fractures	Exclusion: pathological fractures, vascular injury, opposite limb fracture
Duration of surgery	NM	NM	51.33 min	NM	NM	NM
Time to surgery from injury	NM	NM	1–3 days	NM	NM	7 days
Construct	Ring? 5/8th ring and AO fixator	5/8th ring and AO fixator	5/8th ring and AO fixator	5/8th ring and AO fixator	NM	5/8th + AO fixator
Early ROM	1 st POD	2nd week	Same day	After 2 weeks above knee slab post op	1 st POD	NM
Weight bearing	PWB: 6 weeks, FWB: after union	PWB: 10 weeks, WB: 14–24 weeks	8 weeks	After callus	PWB: 6th week, WB: 3 month	8th week onwards
Frame time	Average: 12 weeks	Average: 18 weeks (12-24 w)	Average: 12.06 weeks	NM	Average: 16 weeks after callus seen	Average: 16 week
Union time	15 weeks, (2 patients had union time of more than 20 weeks)	18 weeks	12.06 weeks	20 weeks	16th week: 50.4% good union 24th week: 41.6% excellent union	NM
Follow-up	NM	6.42 months	36 months	6 months	12 months	36 months
Knee Society Score
Rasmussen score	E: 16 patients (64%) G: 6 patients (24%) F: 3 patients (12%), P: 0		Functional score: E: 5 patients (16.7%) G: 27 patients (73.3%), F: 3 patients (10%) P: 0 (0%) Radiological score: E: 4 patients (13.3%) G: 23 patients (76.7%) F: 3 patients (10%) P: 0 (0%)		Functional score: E: 59 patients (52.2%) G: 45 patients (39.8%) M: 9 patients (8%) Radiological score: E: 47 patients (41.6%) G: 57 patients (50.4%) F:9 patients (7.9%)	E- 21 patients (60%) G—9 patients (25%) F—5 patients (15%)
IOWA knee score
Neer’s rating system		E: 7 patients (33. 3%) G: 9 patients (42.35%) F: 4 patients (19.04%) F: 1 patient (4.76%)		E: 8 patients (44%) G: 6 patients (33%) F:– 2 patients (11%) P: 2 patients (11%)
ROM at knee -	4–120°	5–105°	0 to 100°	NM	NM	110°
Pin tract infection	5 patients (20%)	2 patients (9.5%)	4 patients (13.3%)	2 patients (11%)	21 patients (18.6%)	14 patients (40%)
Malunion	2 patients (8%)	1 patient (4.76%)		1 patient (5.6%)	–	2 patients (40%) Valgus
Non-union	Nil	1 patient (4.76%) delayed union		NM	2 patients (1.8%) delayed union	Nil
Osteomyelitis	Nil	–		–	–	Nil
Extensor lag	NM	–	10 degree: 1 patient (3.3%)	–	–	NM
Knee stiffness	NM	–		1 patient (5.6%)	NM	NM
Complications	–	Amputation: 1 patient (4.76%) Septic arthritis: 1 patient (4.76%)			–

OA osteoarthritis, DVT deep vein thrombosis, E excellent, G good, F fair, P poor, NA not applicable, NM not mentioned, PWB partial weight-bearing, FWB full weight-bearing, WB weight-bearing, SSG split skin graft

Table 2.

ILizarov Fixator

Author	Telmo Ramos [15]	Keightley A [16]	Ujjwal Debnath [17]	Shahzaib R Baloch [18]	Dendrinos [19]	Katsenis [20]
Year of publication	2013	2015	2018	2020	1996	2005
Journal	BMC Musculoskeletal disorders	The Bone & Joint Journal	Journal of Clinical Orthopedics and Trauma	Cureus	Journal of Bone and Joint Surgery, British	Journal of Orthopedic Trauma
Study type	Prospective	Prospective	Prospective	Prospective	Retrospective	Retrospective
Duration of study	Jan 2005–Dec 2009	Jan 1994 to June 2013	2011–2014	2015–2018	Oct 1989 July 1993	Oct 1996—Nov 2000
Patient numbers	30	105	15	72	24	48 fractures in 46 patients
Average age/range	(Range- 18–75 years)	49 years (range: 15—87 years)	36 years (range: 18–65 years)	(Range: 39 ± 25 years)	39 years (range: 18–69 years)	43.5 years (range: 17–78 years)
Schatzker type	All	IV–VI	VI	III–VI	V–VI	V–VI
Schatzker type and number of patients	Type I–IV: 11 patients (36.6%) Type V–VI: 19 patients (63.3%)	Type IV: 18 patients (17.1%) Type V: 10 patients (9.5%) Type VI: 77 patients (73.3%)	Type VI: 15 patients (100%)	Type V: 19 patients (26.4%) Type V: 5 patients (6.9%)	Type V: 5 patients (20.8%) Type VI: 19 patients (79.2%)	Type V: 8 patients (16.6%) Type VI: 40 patients (83.4%)
OTA	Mentioned	Type C1: 12 patients (11.4%) Type C2: 21 patients (20%) Type C3: 72 patients (8.5%)	NM	NM	NM	Type C1:25 patients (52.1%) Type C2: 12 patients (25%) Type C3: 11 patients (45.8%)
RTA	10 patients—33.3%	NM	15 patients—100%	66 patients—91.6%	19 patients −79.1%	42 patients (87.5%)
FFH	13 patients—43.3%	NM	0 patients	4 patients—5.55%	4 patients—16.6%	11 patients – (22.9%)
Open fractures	0 open fractures	NM	9 open fractures (60%)	11 open fractures (15.2%)	11 open fractures (45.8%)	18 open fractures (37.5%)
Male(M):female (F)	18 M:12 F-60:40%	62 M:43 F - 59:41%	13 M:02 F - 86.6:13.4%	52 M:20 F 72.2:27.7%	18 M:F 75%:25%	36 M:8 F 75:25%
Duration of surgery	Schatzker type I–IV: average—130 min (range: 92 min–117 min) Schatzker type V–VI: average—223 min (range: 97 min–275 min)
Time from injury to surgery	16 patients were operated within 2 days In 14 patients, the time taken ranged from 3 to 11 days	Average time to surgery: 4 days (range 0–16 days)	Average 5.6 days (3.5–10 days)	NM	Less than 48 h	NM
Frame type	2–3 rings for I-IV Schatzker type and 3–4 rings for V-VI Schatzker type			2 rings + 5/8th ring		Minimum invasive internal fixation plus external fixator in all cases. 33.4% cases open reduction
Spanning fixator	16 patients (53.5%)	Number not specified	13 patients (86.6%)		12 patients (50%)	30 patients (62.5%)
Internal fixation
Bone grafting/calcium phosphate	In 18 patients (60%), calcium phosphate was used	In 58 patients (55.23%) calcium phosphate was used			Bone grafting used in 5 patients (20.8%)	Bone grafting used in 21 patients (43.75%)
Early ROM		NM	After femoral frame is removed—1 month	Post-operative day1	Encouraged	As soon as pain decreased, in cases without knee spanning After removal of the knee spanning fixator, if present—4 weeks (3–6 weeks)
Weight-bearing	FWB Post-op day 1	FWB Post-op Day 1	PWB week 1 (average 5.5 days) FWB average 17.4 weeks (range 15–25)	PWB Post-op Day 1	FWB 2–4 weeks	Toe touch for 6 weeks and in knee spanning PWB up to 50% FWB 18 week (11–18)
Frame time	Schatzker type I-IV: 11 weeks (6–16 weeks), Schatzker type V-VI: 12 weeks (8–20 weeks)		Femoral frame for average 4.4 weeks		Femoral frame kept for an average of 6 weeks (range 4–7 weeks); tibial frame kept for an average of 13 weeks (12–20 weeks)	Femoral frame kept for an average of 6 weeks (range 4–8 weeks) tibial frame kept for average of 14.5 weeks (range 11–29 weeks)
Union time		Average- 20.1 weeks range- (10.6- 42.3 weeks)	Average 14.6 weeks	NM	Average 14.4 weeks: 1 delayed union	Average 13.5 weeks (range 11-18 weeks)
Post frame removal			In 11 patients, cast applied for 3 to 4 weeks
Knee Society Score	NM			Not mentioned
ASAMI Italy Score
Rasmussen criteria	G: 27 patients (90%)			NM
Honkonen Jarvinen score			E: 7 patients (46.6%) G: 7 patients (46.6%) F: 1 patient (6.66%)		E: 5 patients (20.8%) G: 12 patients (50%) F: 6 patients (25%) P: 1 patient (4.1%)	E: 24 patients (50%) G: 14 patients (29.16%) F: 6 patients (12.5%) P: 4 patients (8.3%)
Iowa score		Average score: 85
Knee ROM	Schatzker type I–IV: average ROM—140 degrees (range: 86−156 degrees) Schatzker type V–VI: average ROM—120 degrees (range: 83−148 degrees) 3 patients, range: 10—90 degrees	Median value: 110 degrees	Average ROM 110 degrees (70–130 degrees) In 8 patients, ROM > 110 degrees	Average ROM: 67 degrees: (range—0–100 degrees)	In 12 (49.2%) patients, ROM was > 110 degrees In 5 (20.5%) patients, ROM was > 130 degrees	In 34 (70.55%) patients with non-spanning fixators, immediate ROM was > 110 degrees
Superficial infection		1 patient (0.9%)
Deep/intra-articular infection		0 patients
Pin tract infection	In 16 patients, 25 pin infections noted, 83.3%	77 patients (73.33%)	3 patients (20%)	7 patients (9.7%)	0 patients	10 patients (20.8%)
Osteomyelitis	0 cases	0 cases	0 cases	NM	0 cases	NM
Malunion	13 patients (83.3%)	No	1 patient (6.66%)		2 patients (8.25%)	1 patients (2.08%)
Non-union		0 cases				1 patient with infected non-union (2.08%)
Compartment syndrome	2 patients (6.66%)			3 patients (4.2%)	3 patients (12.5%)	4 patients (8.33%)
DVT	1 Patient (3.33%)	7 patients (6.66%)			8 patients (33%) -	6 patients
Lateral popliteal nerve palsy	1 Patient (3.33%)	1 patient (0.9%)				1 patient (2.08%)
Repeat surgery for non-union/mal-union/infection	Debridement in 2 patients (6.66%) Fasciotomy in 1 patient (3.33%)			Debridement in 2 patients (2.7%)
Knee stiffness		1 oatient (0.9%): FFD of 10 degrees	3 patients (20%)—FFD of 5 degrees
Mean follow-up	Not mentioned	10 years	8 years	9 years	6 years	5 years

Author	El Babary [21]	Catagni [22]	Kataria H [23]	IR Ranatunga [24]	Ferreira [25]	Koushik Narayan Subramanyam [26]
Year of publication	2005	2007	2007	2010	2011	2019
Journal	International Orthopedics	Journal of Trauma, Injury, infection and critical care	J Orthop Surg (Hong Kong)	Malaysian Orthopedic Journal	Strategies in Trauma and Limb Reconstruction	Chin J Traumatol
Study type	Retrospective	Retrospective	Retrospective	Retrospective	Retrospective	Retrospective
Duration of study		1992—2002	April 2002—May 2004	Jan 2003 to Dec 2004	July 2008—Jan 2012	July 2006—Dec 2015
Patient numbers	30 fractures in 29 patients	59	38	18	46	30
Average age/range	41.4 years (range: 20–76 years)	43 years (range: 23–63 years	32 years (range: 21- 60 years)	(Range- 20–50 years)	43 years (range- 19–68 years)	43.3 years (range- 25–58 years)
Schatzker type	VI	V-VI	V-VI	VI	V-VI	V-VI
Schatzker type and number of patients	Type VI: 30 patients (100%)	Type V: 20 patients (33.9%) Type VI: 39 patients (66.1%)	V: 16 patients (42.1%) Type VI: 22 patients (57.9%)	Type V—18 patients (100%)	Type V—10 patients (21.7%) Type VI—36 patients (78.3%)	Type V—15 patients (50%) Type VI—15 patients (50%)
OTA	NM	Type C1: 41 patients (69.5%) Type C2: 3 patients (5.1%) Type C3: 3 patients (5.1%)	NM	NM	NM	Type C1:11 patients (36.6%) Type C2: 12 patients (40%) Type C3: 7 patients (23.3%)
RTA	29 patients (96.6%)	41 patients (69.50%)	36 patients (94.7%)	NM	29 patients: 63%	15 patients: 50%
FFH	0 patients	16 patients: 27.10%	2 patients: 5.3%	NM	16 patients: 34.8%	12 patients: 40%
Open fractures	9 open fractures (30%)	5 open fractures (8.5%)	4 open fractures (10.5%)	3 open fractures (16.6%)	5 open fractures (10.9%)	3 open fractures (10%)
Male (M):female (F)	26 M: 3 F 90:10%	40 M:19 F 67.8: 32.2%F	32 M:6 F 84.2:15.8%	15 M:3 F 83.3:16.7%	29 M:17F 63:37%F	24 M:6 F 80:20%
Duration of surgery						2.5 h (2—3.5 h)
Time from injury to surgery	NM	NM	Average 5 days (ranges 0–22 days)	Average: 7.34 days	Within 48 h for open, otherwise 8.5 days	Average 4 days range (1–7 days)
Frame type					30 Ilizarov and 16 Truelok fixator with lag screw
Spanning fixator	7 patients—(23.3%)	40 patients (67.7%)	Not mentioned	Not mentioned	Not confirmed	Not mentioned
Internal fixation	18 patients (60%)			18 patients (100%)		7 patients (23.3%)
Bone grafting/calcium phosphate	Bone grafting used in 5 patients (16.6%)					Bone grafting used in 4 patients (13.3%)
Early ROM	The next day post-operative	Early	After spanning was removed: 3 weeks		Post-operative day 1
Weight-bearing	In comminuted fractures—WBAT then FWB at 6 weeks	PWB of 20–25 kg post 1 month	Toe touch then PWB:FWB 3.7 months	As tolerated, FWB after femoral ring removal, average week 6	Immediate PWB with crutches progressed to FWB in 2–3 weeks	In patients with knee spanning fixators -FWB with crutches: In other patients, PWB: FWB started at an average of 5.3 weeks (0–20)
Frame time	Frame kept for average 16.3 weeks (range 14–24 weeks)	Frame kept for an average of 115 days (range 65—153 days)				Frame kept for average 11.8 weeks (range 7–16 weeks)
Union time				All within 4 months of surgery. Average: 3.72 months	Average 18.3 weeks (range 9-54 weeks): 2 delayed unions united at 24 weeks and 54 weeks
Post frame removal				NM		Braced for 3–5 weeks
Knee Society Score	E: 18 patients (60%) G: 7 patients (23.3%) F: 1 patient (3.33%) P: 2 patients (6.66%)			NM	E-22 patients (47.8%) G-16 patients (34.8%) F—4 patients (8.7%) P—4 patients (8.7%)
ASAMI Italy Score		E: 30 patients (50.8%) G: 27 patients (45.8%) F: 1 patient (1.7%) P: 1 patient (1.7%)
Rasmussen criteria	E: 17 patients (56.6%) G: 11 patients (36.6%)		E: 6 patients(15.7%) G: 26 patients (68.4%) F: 6 patients(15.7%)	NM		Not clearly mentioned
Honkonen Jarvinen score
Iowa score
Knee ROM		Average ROM—119 degrees (range: 60–135 degrees) In 46 patients (78.2%), 135 degrees were achieved	Average ROM 132 degrees (90-140 degrees)	Average ROM: 85 degrees	Average ROM: 100.5 degrees (35 −125 degrees)	Average RO: 114.7 degrees (100–150 degrees)
Superficial infection			2 patients (5.8%)	0 patients	0 patients
Deep/intra-articular infection		0 patients	0 patients	0 patients	0 patients
Pin tract infection	NM	0 patients	3 patients (7.8%)	4 patients (22.22%)	11 patients (23.9%)	7 patients (23.3%)
Osteomyelitis	NM	0 cases	NM	0 cases	0 cases	NM
Malunion	1 patient (3.33%)					2 Patient (6.66%)
Non-union
Compartment syndrome					2 patients (4.3%)
DVT		2 patients (3.4%)
Lateral popliteal nerve palsy		2 patients (3.4%)	4 patients (10.5%)			2 patients (6.66%)
Repeat surgery for non-union/mal-union/infection
Knee stiffness	3 patients (10%) ROM < 60 degrees			3 patients (16.6%): FFD 5 degrees 9 patients (50%): ROM < 80 degrees 5 patients (27.7%): ROM < 60 degrees	3 patients (6.5%): 5 degrees FFD 3 patients (6.5%): 10 degrees FFD 1 patient (2.1%): 20 degrees FFD
Mean follow-up	4 years	2 years	3 years	1 year	1 year	7 years

Average Average, OA Osteo arthritis, DVT deep vein thrombosis, E excellent, G good, F fair, P poor, NA not applicable, NM not mentioned, week week, PWB partial weight bearing, FWB full weight bearing, WBAT weight bearing as tolerated, FFD fixed flexion deformity, ROM range of movement, RTA Road traffic Accident, FFH Fall from Height

The hybrid fixator construct (Fig. 1: Paper diagram and saw bone model showing lateral condyle (fragment in green) and medial condyle (fragment in brown). Blue represents metaphysis (comminution). A: Showing the proximal ring with olive wire for each fragment. B: Entire hybrid fixator from front. C: Entire hybrid fixator from side) meant wires with a ring fixator (half ring/full ring/5/8th ring) for proximal tibia and distally AO fixator with Schanz pins. We have included minimal incision and cannulated cancellous screw application into consideration in both categories. The studies with knee spanning Ilizarov frame also were included. Hence, the Ilizarov frame was a three- or four-ring construct (Fig. 2: Paper diagram and saw bone model showing lateral condyle (fragment in green) and medial condyle (fragment in brown). Blue represents metaphysis (comminution). A: Showing the proximal ring with olive wire for each fragment. B: Entire Ilizarov frame from front. C: Entire Ilizarov frame from side). The parameters were author, year of publication, journal name, duration of study, patient numbers, age of patients, fracture classification type, percentage of open fractures, mechanism of injury, male: female ratio, duration of surgery, time to surgery from injury, construct type, day of early movement of knee, day of weight-bearing, total frame time, union time, maximum follow-up, scoring system used, final range of movement at knee, percentage of complications like pin tract infection, malunion, delayed or non-union, osteomyelitis, extensor lag, knee stiffness, deep vein thrombosis, compartment syndrome, osteoarthritis, knee laxity, plastic surgery intervention, peroneal nerve injury septic arthritis, and amputation. Only the matched values shall be compared (Table 3), and the rest of the values shall be described for each modality of treatment. No statistical analysis shall be made in this review. One author analyzed the above parameters for the hybrid fixator and another author for the Ilizarov fixator. The analysis table was then exchanged for comparison by each author. The summary was then compared, and the final discussion was written.

Fig. 1.

Hybrid fixator construct

Fig. 2.

Ilizarov fixator construct

Table 3.

Comparing hybrid fixator studies and Ilizarov fixator studies

	Hybrid fixator studies	Ilizarov fixator studies
Total studies	11	12
Prospective	10	4
Retrospective	01	8
Total duration of all studies	384 m (except one)
Average duration of study	38.4 m(except one)
Patient numbers	396	512
Average numbers	36
Average age	41.1	40.9
Fracture number	396	515
Type – Schatzker	7 studies(3,4,5,6)	12 studies
AO/OTA	1 studies	5 studies
Lou Et al Column	1 studies	None
Not mentioned	2 studies	None
Open fractures included	09 studies: average – 37.8% Not included: 01 study, not mentioned: 01 study	11 studies: 19.02%
RTA	84.6%	78.3%
FFH	13%	18.6%
Male:female	70.84%: 29.16%	70.8%: 20.2%
Duration of surgery, time injury to surgery	The duration of surgery one study: 51.33 min Time from injury to the surgery four studies < 3 days/< 7 days	2 studies mention average 167 min the time to surgery 8 studies: average 2.7 days 2 studies: after 1 wk
Construct	5/8th and AO: 6 studies ½ ring and AO: 1 study Full ring and AO: 1 study Both: 1 study Not mentioned: 1stuy
Knee spanning fixator	None	8 studies mention
Use of bone graft	1 study cortical allografts in 51% 1 study bone grafting in few	6 studies mention used in 21.5% 2 studies mention use of Calcium phosphate
Early ROM	Not mentioned in 2 studies  < 1 wk: 7 studies (slab applied 2 days in one study)  > 1 wk: 3 studies (slab applied 2 weeks in one study)	< 1 wk. = 6 studies  > 1 wk. (after femoral frame) = 3 studies Not clear = 3 studies
Weight-bearing	After callus: 3 studies, not mentioned: 1 study Partial or full: 1 day—1 study, 8 wk—1 study, 9.2 wk—1 study Partial: 6 wk—2 studies, 10 wk—2 studies, 12.5 wk—1 study Full: 18.5 wk—2 studies, 12 wk—2 studies	Not mentioned: 2 studies Partial: early—9 studies Full: first post-operative day—3 studies, < 4 weeks—4 studies, > 4 weeks—3 studies
Frame time	14.09 wks in seven studies	Femoral frame removed average 5.6 wks—3 studies Tibial frame average 14 wks—6 studies
Union time	NM: 2 studies, not clear: 2 studies Average value in 7 studies: 16 wks	Average value in 6 studies—16.05 wks
Casting/bracing after fixator removal		3 studies mention
Follow-up	Average: 7 studies—20.7 months Not mentioned: 3 studies, not clear: 1 study	9 studies: 34.2 months average 3 studies: NM
Knee society score	Two studies: E—48.9%,G—36.45%,F—8.85%,P—5.8%	2 studies: E—53.9%, G—29.0%, F—5.9%, F—7.6%
Rasmussen score	6 studies functional score: E—48.5%, G—36.7%, F—7.38%, P—00% 3 studies radiological score: E—31.8%, G—59%, F—5.7%, P—00%	3 studies functional score: – E—53.3%, G—40.9%, F—5.2%
Neer’s rating system	2 studies:– E—38.7%, G—37.7%, F—15%, P—7.9%	NA
IOWA score	1 study:– E—21.7%, G—60.9%, F—13%, P—4.3%	NA
Honkonen Jarvinen criteria		3 studies: E—39.2%, G—41.9%, F—14.7%, P—4.2%
ASAMI Italy		1 study: E—50.8%, G—45.7%, F—1.8%, P—1.8%
ROM at knee	Not mentioned in 3 studies Average in 8 studies: 97 degrees	9 studies mention: 104.0 degrees Maximum achieved Avg: 130.6°
Pin tract infection	17.8%	28.5%
Malunion	5.5%	2.3%
Non-union	NM in 1 Average 1.5% in 10 studies	1 case: 0.2% 1 case delayed union 0.2%
Complications	OA: one study 3%, DVT (3% one study), septic arthritis (3.2% and 4.76% two studies), hard ware failure (4.3% one study), amputation (4.76% one study), septic arthritis (4.76% one study)	Knee stiffness: 12.2% FFD < 5 degrees, 1.2% FFD 5–10 degrees, 0.9% FFD > 10 degrees, DVT 5%, compartment syndrome 2.7%, peroneal palsy 2.1%, osteomyelitis: 0

Avg average, OA osteoarthritis, DVT deep vein thrombosis, E excellent, G good, F fair, P poor, NA not applicable, NM not mentioned, wk. week

Observations and Results

Average scores of particular parameter were calculated from summation of the values mentioned for particular number of studies. Studies which did not mention the values of the parameters were not considered to calculate the values. Very few parameters were mentioned in all studies (Tables 1 and 2 give values of parameters in particular study and Table 3 gives comparison of average values).

Hybrid fixator observations and results: A total of 11 studies were included in this review article. Articles comparing internal fixation were not included. The articles with periarticular fractures of tibia were included only when results were mentioned separately for proximal and distal tibial fractures. Ten studies were prospective [4–13], and one was retrospective [14]. Only one study did not mention the duration of the study [10]. The total duration of all studies was 384 months. The average duration was 38.4 months per study. Total patient numbers in all studies were 396. The average age of the patients was 41.1 years. Only one article mentions a narrow age range of inclusion criteria [13]. Three types of classification systems were used to classify proximal tibial fractures among the studies: Schatzker’s classification in seven studies [5, 6, 8–12] (type III, IV, V, VI), AO/OTA in one study [14], Loue et al. column [13] classification in one study, and two studies [4, 7] did not mention any classification system. Open fractures are included in nine studies [4–11, 14] with an average incidence of 37.8%. Open fractures were not included in one [13] and not mentioned in one study [12]. Road traffic accidents were found to be the most common mode of injury, accounting for an average of 84.6%, followed by falls from height at 13%. The male to female ratio was 70.8:29.2%. Time from injury to the surgery was mentioned in four studies as less than 3 days [5, 11] or 7 days [4, 14]. The duration of surgery was mentioned in one study [11], which was 51.33 min. The construct used was either 5/8 ring with AO fixator in 6 [4, 7, 10–12, 14] studies, half ring with AO fixator in 1 study [8], full ring with AO fixator in 1 study [5] and not mentioned in 2 studies [6, 13]. Early range of movement was not mentioned in two studies [7, 14], less than 1 week in six studies [5, 6, 8, 9, 11, 13], and it was more than 1 week in three studies [4, 10, 12]. Weight-bearing was mentioned after callus formation in two [6, 12] studies, not mentioned in one study [7]. Partial or full weight-bearing was done in 8 weeks in three studies [5, 8, 14], 9.2 weeks in one study [8]. Partial weight-bearing was done in 6 weeks in two studies [9, 13], 10 weeks in one study [10], 12.5 weeks in one study [4]. Full weight-bearing was done in 12 weeks in one study [13], after callus formation in one study [9], and 19 weeks in two studies [4, 10]. Frame time was not mentioned in three studies [5, 7, 12], not clear in one study [8], and the rest of the seven studies [4, 6, 9–11, 13, 14] had an average frame time of 14.09 weeks. The union time was not mentioned in two studies [8, 14], not clear in one study [13], and in the rest of eight studies [4–7, 9–12], average time was 16 weeks.

Follow-up was not mentioned in three studies [7–9], it was not clear in one study [12], and the average maximum follow-up was 20.7 months in seven studies [4–6, 10, 11, 13, 14]. The outcome scores used were Knee Society score in two studies [4, 5] (with functional scores of excellent, good, fair, and poor in 48.5%, 36.7%, 7.38%, 00% and radiological results of excellent, good, fair, and poor in 48.9%, 36.45%, 8.85%, and 5.8% cases), Rasmussen score in six studies [6, 8, 9, 11, 13, 14] (with functional scores of Excellent, good, Fair and poor in 31.8%, 59%, 5.7% 00% cases respectively), Neer rating system in two studies [10, 12], and FOWA in one study [7]. The range of movement at the knee was not mentioned in three studies [7, 12, 13] and in the rest of the studies [4–6, 8–11, 14], it was 97 degrees. Pin tract infection was reported at an average of 7.8% in all studies. Malunion was reported at an average of 5.5%. Non-union was not mentioned in one study [12] and the remaining ten studies [4–11, 13, 14] reported an average of 1.5%.

There was significant variability in the analysis of different parameters across all these studies. Consequently, we included only the important parameters where clarity was evident in our review article. Knee spanning was not performed in any of the studies; however, in one study [12], above knee slab was applied for 2 weeks, while one study [5] did so for just 2 days. Only one study [10] involved dynamization. Most of the studies did not utilize any internal fixation, although a few [5, 14] employed minimal open reduction with the application of cannulated cancellous screws. In addition, only one study [5] made use of a cortical allograft. Several studies included patients who underwent skin grafting [4, 5, 12], or flap surgeries [4, 11, 14], and one study [12] focused on all cases with impending compartment syndrome in contrast to one study [9] that excluded the cases with compartment syndrome or which need flap surgery. Radiological and clinical criteria for union were mentioned only in one study [11]. Radiological outcome by Rasmussen score was mentioned in three studies [8, 11, 13]. Factors affecting poor outcome were mentioned in one study [14]. Inter-fracture comparison was done in one study [8] where weight-bearing was delayed in type VI >  > V/III (p value—< 0.05). One study [5] observed delayed union in open fracture type II/III as compared to type I.

Ilizarov fixator observation and results: There were 12 studies that were included in the group of proximal tibia fractures fixed with the Ilizarov circular fixator. Of these, four were prospective [15–18] and eight were retrospective [19–26]. Five hundred fifteen proximal tibia fractures were described in five hundred twelve patients across these studies. The average number of patients per study was 42.6. All studies included Schatzker’s type VI fractures with six studies including Type V–VI [19, 20, 22, 23, 25, 26], and one each including Schatzker’s type III–VI [18] and Schatzker’s type IV–VI [16]. One study included all Schatzker-type fractures [15]. Five out of the twelve studies also described the fractures based on AO/OTA classification [15, 16, 20, 22, 26]. All but two studies [15, 16] included open fractures, which constituted 19.02% of the fractures treated. The duration of studies varied and ranged from a minimum of 23 months [24] to a maximum of 233 months [16]. The average age of the patients included in the studies was 40.9 years. In the studies, 70.8% of the patients who sustained these proximal tibia fractures were males, and 20.2% were females. High-energy trauma caused by road traffic accidents amounted to 78.3% of the proximal tibia fractures, followed by 18.6% of the fractures caused by a fall from height and the remainder from either a fall of an object onto the limb or assault, as calculated from ten studies that mention the etiology. Two studies do not include the etiology of the proximal tibia fratures [16, 24].

Only two studies mention the duration of the surgeries [15, 26], which was 167 min on average. Eight studies mention the time taken from injury to surgery, which averages 2.7 days [15–17, 19, 23–26]. Two studies also mention cases operated a week after injury [15, 25]. Four studies did not mention the duration from the time of injury to when the surgery was done [18, 20–22].In all 12 studies, circular Ilizarov fixators were used. One study mentions the use of Ilizarov and also TrueLok fixators [25]. Four studies mention minimal internal fixation with lag screws along with Ilizarov fixators [20, 21, 25, 26]. Eight studies describe the spanning of fixators across the knee proximally to the distal femur [15–17, 19–22, 24]. Six studies [15, 16, 19–21, 26] mention the use of bone grafting/substitutes with two studies mentioning the use of calcium phosphate [15, 16].

Rehabilitation protocols varied greatly in the studies regarding when the weight-bearing and the knee range of motion were initiated. Knee range of motion as a part of the post-operative rehabilitation protocol was mentioned in eight studies [17–23, 25]. Immediate post-surgery day or early knee range of motion is mentioned in six studies [18–22, 25]. Three studies [17, 20, 23] mention knee range of motion initiated after the femoral component of fixator was removed around 4–6 weeks. Weight-bearing protocols followed by studies varied greatly. Full weight-bearing started on post-operative day one was mentioned in three studies [15, 16, 18]. Partial weight-bearing was followed in the remaining nine studies [17, 19–26]. Of these studies, partial weight-bearing progressed to full weight-bearing within 4 weeks in four studies [19, 22, 23, 26] and beyond 1 month in three studies [17, 20, 25], whereas two studies did not specify full weight-bearing status [21, 24].

Three studies mention the removal of femoral frame at an average of 5.3 weeks [17, 19, 20] and the tibial frames were removed at an average of 14 weeks as mentioned in six studies [15, 19–22, 26]. Studies that did not mention the exact frame removal protocol were four in numbers [16, 18, 24, 25]. The union time was mentioned in six studies which amounted to an average of 16.05 weeks [16, 17, 19, 20, 24, 25], whereas six other studies did not mention the union time clearly [15, 18, 21–23, 26]. After the removal of the frame, additional casting and bracing were mentioned in three studies [17, 24, 26]. The range of motion achieved in the proximal tibia fractures treated with the Ilizarov fixator averaged 104.0 degrees of flexion. The maximum flexion achieved on average was 130.6 degrees as mentioned in nine studies [15, 17–20, 22, 23, 25, 26] except three where it was not clearly noted [16, 21, 24].

Knee Society Score [21, 25], Rasmussen criteria [15, 21, 23, 26], Honkonen Jarvinen criteria, ASAMI Italy score [22], KOOS score [15, 18], IOWA score [16] were used by studies that assessed fractures treated with the Ilizarov fixator. One study did not make the use of any score or criteria [24]. The average Knee Society Score was 85.9 with 53.9% excellent, 29% good, 5.9% fair, and 7.6% poor outcomes as noted in two studies [21, 25]. Rasmussen functional score on an average was 53.3% excellent, 40.9% good, and 5.2% poor as noted in three studies [15, 21, 23] One study mentions Rasmussen radiological score as 16.7 [26]. Three studies used the Honkonen Jarvinen criteria which noted 39.2% excellent, 41.9% good, 14.7% fair, and 4.2% poor outcomes [17, 19, 20]. One study also used the ASAMI Italy scoring system and noted a 50.8% excellent, 45.7% good, and 1.7% each of fair and poor outcomes [22].

Pin tract infections were noted in 28.5% of all fractures in ten studies [15–18, 20, 21, 23–26]. One study noted no pin tract infections [19], and one study did not clearly mention the incidence [22]. Malunions were noted in 2.3% of the proximal tibia fractures treated with the Ilizarov fixators. There was only one case of delayed union [19] and a case of infected non-union [20] reported that amounted to 0.2% each of the total fractures. Knee stiffness was categorized into fixed flexion deformity (FFD) less than 6 degrees, 6 to 10 degrees and more than 10 degrees.12.2% patients had fixed flexion deformity (FFD) less than 5 degrees as noted in five studies [17, 19, 20, 24, 25], 1.2% patients had fixed flexion deformity (FFD) ranging from 6–10 degrees noted in two studies [19, 25], and 0.9% patients had an fixed flexion deformity (FFD) more than 10 degrees as mentioned in two studies [19, 25]. One study mentioned no reported fixed flexion deformity [18]. 1.5% incidence of patients with post-operative range of motion less than 60⁰ was noted in two studies [21, 24]. Deep vein thrombosis amounted to 5% of the complications in the fractures mentioned in five studies [15, 16, 19, 20, 22]. 2.7% patients had a compartment syndrome mentioned in five studies that was treated with fasciotomies [15, 16, 19, 20, 25]. The incidence of lateral popliteal nerve palsy was noted to be 2.1% in six studies [15, 16, 20, 22, 23, 26]. All of the results and complication were noted during follow-up with nine studies mentioning the follow-up time with the average amounting to 34.2 months [16–20, 22–24, 26].

Discussion/summary: We compared the similar parameters in both treatment modalities after calculating the average values. There was a total of 11 (10 prospective [4–13] and 1 retrospective [14]) studies with a hybrid fixator, and 12 (4 were prospective [15–18] and 8 retrospective [19–26]) with an Ilizarov fixator. The hybrid fixator study involved 396 patients, with an average age of 41.1 years, while the Ilizarov fixator study had 512 patients, averaging 40 years old. It is clear that the Ilizarov group had a larger patient population, yet their average ages were remarkably comparable. The average duration of study was not comparable as one study in Ilizarov management had a longer duration of 233 months [16]. Schatzker’s and AO/OTA were most common classification used.

Average percentage of open fractures were 37.8% (nine studies [4–12]) in hybrid fixator and 19.02% (10 [17–26] studies) in Ilizarov fixator. Road traffic accident was the most common mode of injury in 84.6% of cases in hybrid fixator and 78.3% in Ilizarov fixator. The fall from height was 13% in the hybrid fixator and 18.6% in the Ilizarov fixator. The male to female ratio was almost similar with values of 70.84%:29.16% in hybrid fixator and 70.8%:20.2% in Ilizarov fixator. Time from injury to the surgery was mentioned in four studies as less than 3 days [5, 11] or 7 days [4, 14] in hybrid fixator group, whereas in Ilizarov group, eight studies’ average duration was 2.7 days [15–17, 19, 23–26] and two studies also mention cases operated a week after injury [15, 25]. All the baseline parameters were almost comparable.

Procedure: Accurate reduction of the condyles aligning with the shaft and reduction of the articular surface is done. Based on the type of fracture, to hold the reduction use of K wires or some surgeons use percutaneous fixation with CC screws, some surgeons also do minimal incision to check for articular congruity. Proximal small periarticular fragments are fixed with two to three 1.8 mm transfixion wires parallel to knee joint, duly tensioned and fixed with proximal ring placed at the level of the fibular head, one wire transfixing fibula with tibia. Wires tensioned to 110 kg. Insertion of olive wires is done at 60 degrees divergence for interfragmentary compression. Reduction of the metaphysis to the diaphysis was achieved by indirect means. Next step differs in hybrid and Ilizarov fixators.

In hybrid fixator, proximal ring is full or half or 5/8th ring. The distal fragment was fixed with three/four 5.0 mm Schanz pins. These pins are connected with 2–3 tubular rods connected to the ring frame (Fig. 1).

In Ilizarov fixator, rings are connected by struts/rods. Second ring shall be placed 2–3 cm below fracture and third ring distally transfixing fibula 3 cm above the articular surface. In case of need for femoral fixation, two rings can be added to the construct with hinged rods over the knee joint in case of doubtful stability (Fig. 2).

Hybrid fixator provides the option for future reconstructive procedures when necessary, giving a chance to the operating surgeon to operate early. Duration of surgery was mentioned in one study [11] which was 51.33 min, in hybrid fixator, but two studies [15, 26] have mentioned as 167 min in Ilizarov fixator. Less operating time helps the orthopedician in places with high case load and less resources. Union was seen at an average of 16 weeks in eight studies [4–7, 9–12, 14] of hybrid fixator, and six studies [16, 17, 19, 20, 24, 25] of Ilizarov fixator had union at an average of 16.05 weeks.

The post-operative protocol was not clear in most of the studies in both groups as very few studies in the Ilizarov method mentioned casting or bracing [17, 24, 26]. Rehabilitation protocols varied greatly in the studies within the same management method and between the two methods. It was very difficult to compare the parameters of weight-bearing and the knee range of motion. Hence, for convenience, we have categorized the movement as early, which is less than a week, and delayed, which is more than a week. The summary and observation have been included in Table 3 and the discussion part.

Range of movement was started in less than 1 week in seven studies [5, 6, 8, 9, 11, 13, 14] in hybrid fixator and six studies in Ilizarov [18–22, 25]. Range of movement was started in more than 1 week in three studies in hybrid fixator [4, 10, 12] and three studies in Ilizarov [17, 20, 23].

Full weight-bearing started on post-operative day one was mentioned only in three studies [15, 16, 18] in Ilizarov group, but none have mentioned full/partial weight-bearing within a week in hybrid fixator group, stability of hybrid fixator biomechanically is less as compared to Ilizarov fixator. In hybrid fixator, full weight-bearing was done in 12 weeks in one study [13], after callus formation in one study [9], and 19 weeks in two studies [4, 10], and in Ilizarov group, full weight-bearing was done within 4 weeks in four studies [19, 22, 23, 26] and beyond 1 month in three studies [17, 20, 25]. Time to full weight-bearing was more delayed in hybrid fixator studies. Partial weight-bearing was started early in most of the studies in both groups. Partial weight-bearing was done in 6 weeks in two studies [9, 13], 10 weeks in one study [10], 12.5 weeks in one study [4] in hybrid fixator studies and within 4 weeks in nine studies [17, 19–26] in Ilizarov studies.

Eight studies [4, 6, 9–14] had an average frame time of 14.09 weeks in hybrid fixator studies and average of 14 weeks as mentioned in six studies [15, 19–22, 26] in Ilizarov studies. The average union time of eight studies [4–7, 9–12] was 16 weeks in hybrid fixator studies, whereas in Ilizarov group, average was 16.05 weeks [16, 17, 19, 20, 24, 25] in six studies. Long-term follow-up was seen in nine Ilizarov studies [16–20, 22–24, 26] with an average of 34.2 months, as compared to hybrid fixator group with an average of 20.7 months in seven studies [4–6, 10, 11, 13, 14].

The Knee Society Score showed excellent, good, fair, and poor outcomes in 53.9%, 29%, 5.9%, and 7.6% cases as noted in two studies [21, 25] on average in Ilizarov studies, whereas in hybrid fixator studies, functional scores of excellent, good, fair, and poor in 48.9%, 36.45%, 8.85%, and 5.8% cases were seen in two studies [4, 5]. Rasmussen score in hybrid fixator group was mentioned in six studies [6, 8, 9, 11, 13, 14] of functional scores of excellent, good, fair, and poor in 48.5%, 36.7%, 7.38%, and 00%, and in Ilizarov group, scores of excellent, good, fair, and poor in 53.3%, 40.9%, 5.2%, and 0% cases were noted in three studies [15, 21, 23]. Combined good and fair results are almost comparable in both groups for both the scoring system. The average range of movement at the knee was 97 degrees in eight studies [4–6, 8–11, 14] of hybrid fixator group and an average was 104 degrees as mentioned in nine studies [15, 17–20, 22, 23, 25, 26] of Ilizarov group. Only a 10-degree difference was seen in both groups but as Ilizarov group of studies had long-term follow-up, the values might have improved during the follow-ups.

Pin tract infection was average 17.8% in all studies of hybrid fixator group and 28.5% of all fractures in ten studies [15–18, 20, 21, 23–26] in Ilizarov group which was higher probably because of a greater number of trans-osseus elements in Ilizarov fixator group along with knee spanning which can increase the incidence. Malunion was 5.5% average in all studies of hybrid fixator group and 2.3% in all studies of Ilizarov group, and non-union mentioned in ten studies [4–11, 13, 14] had 1.5% on an average in hybrid fixator group and 0.2% of all studies of Ilizarov group probably because of more stable fixation in Ilizarov group with knee spanning.

In light of the observations and analysis outlined above, we can thoughtfully give the following statements: The external fixator is a widely accepted temporary treatment for fractures, effectively allowing soft tissues to heal while ensuring the fracture remains aligned and properly lengthened. Once the soft tissue condition has improved, internal fixation is clearly the more patient-friendly choice compared to leaving an external fixator in place for an extended period. But external fixators offer benefits over open reduction and internal fixation, including lower infection rates, better soft tissue management, and reduced blood loss. When considering quality of life, especially regarding mobility, external fixators—particularly Ilizarov fixators—empower patients to regain their independence swiftly, often enabling them to walk the day after the procedure. In contrast, patients with internal fixation are required to refrain from bearing weight on the affected limb until bone union is fully achieved. It is crucial to acknowledge that while external fixation is an effective treatment option, it does present certain challenges. Patients often find the fixator cumbersome, and its success hinges on strong cooperation from both the patient and their family. Regular care and maintenance of the pin sites are essential to ensure optimal outcomes. Furthermore, it is important to recognize that external fixation can carry a social stigma not associated with internal fixation, which can affect the patient’s overall experience. By understanding these factors, we can make well-informed decisions regarding treatment options.

The advantages and disadvantages of external fixators are significant and should be carefully considered. A hybrid fixator provides considerable benefits, including the option for future reconstructive procedures such as plastic or vascular surgeries when necessary. This capability allows the operating surgeon to intervene sooner, which is crucial in many cases. Furthermore, the reduced operating time associated with hybrid fixators is especially beneficial in settings with high patient volumes and limited resources. Moreover, the hybrid fixator involves fewer trans-osseous elements compared to the Ilizarov frame, resulting in a lower incidence of pin tract infections. In addition, pin removal can typically be performed in an outpatient setting, enhancing patient comfort and convenience. However, it is essential to recognize the drawbacks.

Research indicates that the time to achieve full weight-bearing is generally longer with hybrid fixators due to their biomechanical stability being inferior to that of the Ilizarov fixator. Patients with Ilizarov frames can often begin weight-bearing as early as the day after surgery, while those with hybrid fixators face an increased risk of malunion and non-union, particularly if they bear weight prematurely. As such, partial weight-bearing should only be initiated upon confirmation of osseous union, and full weight-bearing must be deferred until complete union is achieved.

Conclusion

Fractures that require external fixators include those with intra-articular comminution, with or without metaphyseal comminution. This encompasses fractures with inadequate soft tissue coverage, open fractures needing plastic surgical intervention, and those that demand an interim procedure to maintain length and alignment during the soft tissue healing process. In addition, external fixators are essential in cases of vascular repair, providing necessary stability to the knee and ensuring immobilization.

Hybrid fixators and Ilizarov fixators can effectively manage proximal tibia fractures, delivering comparable results in union time, frame time, and functional scores. While there are minor differences in complication rates, the evidence supports that both options are viable. However, to establish a more robust understanding, it is essential to conduct additional comparative and randomized controlled trials with extended follow-ups and standardized outcome measures.

Declarations

Conflict of Interest

There is no conflict of interest.

Ethical Approval

This article does not contain any studies with human or animal subjects performed by any of the authors.

Informed Consent

For this type of study informed consent is not required.