대한골절학회지제 22 권, 제 3 호, 2009 년 7 월 Journal of the Korean Fractrure Society Vol. 22, No. 3, July, 2009 심한연부조직손상을동반한고에너지경골근위부골절에서의단계적치료 이승렬 * ㆍ양재훈ㆍ이준규ㆍ신현대ㆍ김경천ㆍ연규웅ㆍ김영모 충남대학교의과대학정형외과학교실, 성형외과학교실 * 목적 : 심한연부조직의손상을동반한고에너지근위경골골절에대해 1차외고정장치후, 2차금속판내고정술을시행하였던환자들을대상으로단계적수술법의유용성을알아보고자하였다. 대상및방법 : 2003년 3월부터 2007년 3월까지 1차외고정장치후 2차금속판내고정술을시행하였던 56예의고에너지근위경골골절환자들중, 1년이상추시가가능하였던 42예를대상으로하였다. 평균연령은 51.5 세였고, 남자 26예, 여자 16예였다. 평균추시시간은 32개월이었다. 최종추시에서골유합의방사선학적평가와기능적평가, 연부조직합병증에대해서조사를하였다. 결과 : 외고정장치후 2차금속내고정까지의기간은평균 14.9 일 (6 40) 이었다. 최종골유합기간은금속판고정술후평균 15 주였고, 최종추시에서평균슬관절가동범위는 110.8도 (6.2 117도) 였다. 31예에서금속판내고정술, 11예에서금속판내고정과함께연부조직재건술을시행하였다. 심부연부조직감염이 2예, 불유합 2예, 부정유합 1예, 슬관절강직이 1예에서발생하였다. 결론 : 심한연부조직의손상을동반한근위경골골절에대해 1차외고정장치시행후다음단계의수술환경을최대한적합하게만든상태에서 2차금속내고정을시행하여비교적적은감염률, 불유합등의결과를얻었다. 색인단어 : 근위경골골절, 고에너지손상, 연부조직손상, 외고정장치, 금속판고정술 Staged Management of High Energy Proximal Tibia Fractures with Severe Soft Tissue Damage Seung-Ryul Lee, M.D.*, Jae-Hoon Yang, M.D., June-Kyu Lee, M.D., Hyun-Dae Shin, M.D., Kyung-Cheon Kim, M.D., Kyu-Woong Yeon, M.D., Young-Mo Kim, M.D. Departments of Orthopaedic Surgery, Plastic and Reconstructive Surgery*, Chungnam National University School of Medicine, Daejeon, Korea Purpose: To find out the efficiency of two staged operation of patients with high energy proximal tibia fracture with severe soft tissue damage, the first step being external fixation, and the second, internal fixation with plates. Materials and Methods: The study group was the 42 patients who had followed for one year out of a group of 56, performed the first step external fixation and the second step internal fixation with plates retrospectively, from March 2003 to March 2007. The average age of the study group was 51.4, 26 men, and 16 women participating in this study. The average time of follow up was 32 months. In the final follow up, investigations of the radiological assessments and functional abilities of the bony fusion were carried out along with the complications of the soft tissue. Results: The duration after the first step external fixation until second step internal fixation to be performed was 14.9 (6 40) days in average. The final bone fusion took about 15 weeks, and according to the final follow up, the range of motion of the knee was around 110.8 degrees (6.2 117 degrees). In 31 cases, only the internal fixation was performed, while in 11 cases, soft tissue reconstruction was carried out with the internal fixations. As for the complications there were 2 cases of deep soft tissue infection, 2 cases of nonunion, 1 case of malunion and 1 case of knee joint stiffness. Conclusion: In cases of proximal tibia fracture with severe soft tissue damage, external fixation was important to secure the safety of the fracture, carry forward the anatomical alignment, plan the soft tissue safety and manage the wound to decrease 통신저자 : 김영모대전시중구대사동 640 번지충남대학교의과대학정형외과학교실 Tel:042-280-7352 ㆍ Fax:042-252-7098 E-mail:osdr69@cnu.ac.kr 접수 : 2008. 11. 2 심사 ( 수정 ): 2008. 12. 12 게재확정 : 2009. 5. 3 Address reprint requests to:young-mo Kim, M.D. Department of Orthopaedic Surgery, Chungnam National University School of Medicine, 640, Daesa-dong, Jung-gu, Daejeon 301-721, Korea Tel:82-42-280-7352 ㆍ Fax:82-42-252-7098 E-mail:osdr69@cnu.ac.kr 152
심한연부조직손상을동반한고에너지경골근위부골절에서의단계적치료 153 the number of microbial in the next operation, which is the internal fixation with plates. Key Words: Proximal tibia fracture, High energy injury, Soft tissue injury, External fixator, Plate fixation 서 심한연부조직손상및분쇄를동반한경골근위부의관절내골절또는근위골간단분쇄골절은고에너지손상인경우가많고, 이들골절들의치료에서는연부조직의빠른회복이동반된골절치료를위해무엇보다중요하다. Watson 등 25) 에의하면근위경골골절의예후결정요소로관절면의부조화 (step off), 과골절선 (condylar fracture lines) 의분리정도, 골간단-골간의분리정도, 연부조직의상태등을기술하였다. 기존의수상직후시행한개방적정복술및내고정술시에는창상합병증이 11 88% 로상당히높이보고되어 12,13,16,17,24,28) 최근에는 1차외고정장치유지후 2차내고정술시행이고에너지근위경골골절치료에서우수한치료법으로대두되는바 8,9), 저자들은수상후 1차외고정장치를시행하여골절주변의연부조직상태가회복된시점에서 2차내고정술을시행하였던환자들을대상으로임상결과를알고보고자하였다. 론 대상및방법 2003년 3월부터 2007년 3월까지 1차외고정장치후 2 차금속판을이용한내고정을시행한 56예의환자들중 1 년이상추시가가능하였던 42예를대상으로하였다. 평균연령은 51.5 (23 74) 세였고, 남자 26예, 여자 16예였다. 평균추시시간은 32 (6 52) 개월이었다. 관절면을침범한골절은 AO-OTA 분류에서 B3가 1예, C1이 2예, C2가 16 예, C3가 13예였다, 관절면침범이없는근위경골골간단의분쇄골절은 10예였고, 모두 AO-OTA 분류에서 A3에해당하였다. 개방성골절이 21예, 폐쇄성골절이 21예였으며, 개방성골절의분류는 Gustalio 8) 분류에서 grade I 1예, II 2예, IIIA 7예, IIIB 9예, IIIC 2예였다. 폐쇄성골절 1예와개방성골절 1예에서내원당시구획증후군이진단되어외고정장치시행시근막절제술을시행하였다. 외고정장치시행후금속내고정술까지 6 40일이소요되었다 ( 평균 14.9일 ) (Table 1). 근위경골주변의개방성골절, 연부조직의심한부종과수포형성등이보이는심한연부조직손상이동반된경우 5) 내원직후, 외고정장치 (EBI, Biomet, USA) 를이용하여원위대퇴골간부의외측면과원위경골전내측을연결하여근위경골골절을안정화시키는 1차수술을시행하였다. 이때, 경골에삽입되는 Schanz screw의위치는추 후경골근위부에삽입될금속판의길이를고려하여충분히하방에위치하도록하였다. 외고정장치후, 폐쇄성골절의경우, 경과관찰시연부조직의종창의현저한감소와함께피부의주름이다시보일때, 골절부위수포의재상피화가보일때, 골절부위주변의연부조직종창이감소할때내고정을시행하는것을원칙 20,21,24,26,27) 으로하였고, 개방성골절의경우연부조직의충분한변연절제술후, 괴사조직의제거가충분하다고생각되는시점에서가능한빨리금속판내고정술과연부조직재건을시행하는것을원칙 4,7 9,11 13,16) 으로하였다. 2 차금속판내고정수술시 27 예에서외측잠김금속나사판 (locking compression plate, Synthes, Swiss), 5 예에서외측잠김금속나사판과경골내측에금속판 (maybone plate, IQL, Germany) 또는 LCP L 지지금속판 (LCP L-buttress plate, Synthes, Swiss) 의이중금속판을, 4 예에서관절주위금속판 (periarticular plate, Zimmer, USA) 과 K 강선을이용한내고정술을, 5 예에서관절주위금속판 (periarticular plate, Zimmer, USA) 을, 2 예에서 LCP L 지지금속판 (LCP L plate, Synthes, Swiss) 과경피적나사못을, 1 예에서내측에 LCP L 지지금속판 (LCP L-buttress plate, Synthes, Swiss) 만을, 1 예에서외측지지금속판 (buttress plate, Synthes, Swiss) 을이용하여고정하였다. 내고정술시골결손이있거나불유합가능성이예상되었던 5 예에서자가골반골을이용한골이식술을, 3 예에서탈무기질화된골기질 (demineralized bone matrix) 을삽입하였다. 손상기전은고에너지손상으로오토바이사고가 10 예, 보행자사고가 15 예, 운전자사고가 13 예, 낙상 4 예였으며, 동측의하지손상이 6 예에서있었으며슬개골과족근내과골절이 1 예, 슬개골골절이 1 예, 대퇴간부골절 1 예, 원위 Table 1. Summary of cases AO/OTA type Case Grade I Grade II Open Fx. Grade III A B C Closed Fx. A3 10 1 0 2 2 1 4 B3 1 0 0 0 0 0 1 C1 2 0 0 1 0 0 1 C2 16 0 1 1 4 0 10 C3 13 0 1 2 3 1 2 Total 42 cases 1 2 7 9 2 24
154 이승렬, 양재훈, 이준규, 신현대, 김경천, 연규웅, 김영모 Fig. 1. 53 year-old man with a proximal tibia fracture (AO/OTA type C2) by a pedestrian traffic accident. (A, B) Preoperative anteroposterior and lateral radiographs showing the comminution and the lateral condylar depression, (C) and the swelling of knee joint and surrounding soft tissues were severe. (D, E) External fixation was performed after the day of accident, and these postoperative radiographs shows well aligned fracture fragments. (F, G) Internal fixation was performed after 17 days, and these radiographs shows firm fixation with a lateral periarticular plate and additional K-wire fixation to preserve the articular line of the knee. 경골골절 1예, 원위족근내과골절 1예, 골반골골절 1 예등이었으며 1예에서는동측의견갑골골절, 1예에서는경막하출혈이동반되었으며 2예에서는요추부의압박골절이었다. 모든환자에서응급실내원후환자의상태가허락되는대로즉시외고정장착을시행하였다 (Fig. 1A E). 개방성골절의경우 Gustalio 8) I, II에서는외고정장치시개방창세척후 2차내고정술시봉합을시행하였고, IIIA의 7예와 IIIB 9예, IIIC 2예의경우개방창에대한철저한세척및변연절제술을 2차금속판내고정술및연부조직재건술을시행하기전까지수술실에서시행하고, 습윤드레싱을유지하였다 (Fig. 2A F) 4,12). IIIA 골절환자에서발생한구획증후군의 1예에서는외고정장치장착과함께근막절개술을시행하였고, 위와동일한방법으로습윤드레싱으로유지하였다. 연부조직의종창의현저한감소와함께피부의주름이다시보일때, 골절부위수포의재상피화가보일때, 골절부위주변의연부조직종창이감 소할때 21,24,26,27) 2차금속판내고정을시행하였다 (Fig. 1F, G). 금속판내고정시관절면의부조화를다시정복하였고, 개방창은앞서언급하듯 IIIB 이상의연부조직결손에대해서는성형외과전문의가금속판내고정술직후전층피부이식 (full thickness skin graft), 유리피판 (free flap), 도상피판 (island flap), 근피판술 (muscle flap) 등을이용하여처리하였다 (Fig. 2G, H). 연부조직성형술을시행한환자들에서는연부조직이충분히안정화된후관절운동을시행하였고 3,12,20), 그외의환자들에서는술후 3일간장하지반석고붕대고정후, 술후 4일째부터비체중부하상태에서능동적슬관절운동을시작하였고, 술후 7일째추시단순방사선사진촬영후술후사진과비교하여차이가없을시수동적슬관절운동을시작하였다. 전예에서퇴원시슬개건체중부하보조기 (PTB orthosis) 를착용시키고퇴원시켰다. 퇴원후부터골유합이시작되는시점까지는 3주에 1회씩외래에서방사선촬영을시행하였고, 방사선사진상골유합의시작이확인된이후
155 심한 연부 조직 손상을 동반한 고 에너지 경골 근위부 골절에서의 단계적 치료 Fig. 2. 45 year-old man with a proximal tibia fracture (AO/OTA type C3, open GIIIb) by a motorcycle traffic accident. Preoperative anteroposterior and lateral radiographs showing the splitting of the tibial condyle and severe comminuted, displaced fragments. (A, B) The soft tissue defect was about 25 10 cm as shown, (C, D) and after copious irrigation and wide marginal debridement was performed at operation room, external fixation was performed immediately. (E, F) Internal fixation was performed after 9 days, and anterolateral thigh free flap was performed by plastic surgeons concurrently. (G, H) The radiographs shows fixation with lateral periarticular plate medial locking compression plate and relatively preserved articular surface of the knee. 부터는 부분 체중 부하를 시작하면서 2개월 간격으로 외래 추시 하였다. 불유합의 예를 제외하고 방사선학적 완전 골 유합이 이루어진 시점에서 전 체중 부하 운동을 시켰으며 관절 가동 범위를 측정하였다 (Fig. 3, Fig. 4). 결 Fig. 3. The 12 months follow up (A) anteroposterior and (B) lateral radiographs of the patient described in Fig. 1. The articular surface was congruent and union was achieved successfully. The range of motion was 5 to 120 degree, and patient had mild pain on knee when forceful flexion and extension was performed. 과 최종 골 유합 기간은 금속판 고정술 후 평균 15주였으 며 최종 추시에서 평균 슬관절 가동 범위는 완전 신전 위 를 0도 하였을 때 평균 110.8도 (6.2 117도)였다. 불유합 의 2예를 제외한 전 예에서 1 mm 내의 관절면 부조화 (step off)를 얻었으며 과 골절선의 분리, 골간단-골단의 분 리 역시 내고정을 통해 정복하였으며 추시를 통한 관찰에 서 정복 정도의 변화는 관찰되지 않았다25,26,28). 개방성 골절 IIIB 9예에서 임시 외고정 장치 시행기간 부종 감소, 수포 소멸, 청결한 육아 조직의 생성 유도, 창
156 이승렬, 양재훈, 이준규, 신현대, 김경천, 연규웅, 김영모 상관리를통해내고정술시행시에적합한상태로호전시킨후 13,23,26) 1예에서전층피부이식술을, 5예에서전외측대퇴의유리피판이식술을, 박근피판이식술을 1예, 비복근피판이식술을 1예, 도상피판술을 1예에서시행하여수상당시의연부조직을재건하였다. 1예에서비골신경손상으로외고정장치시행시비골신경탐색술 4,29) 을시행하였고내고정시도상피판술을시행하였으며최종추시에서비골신경손상은거의정상으로회복되었다. IIIC의 2예모두에서슬와동맥손상이확인되었고, 외고정장치시행과동시에동맥재건술을시행하였으며, 2차금속판내고정시 1예에서는도상피판술을 1예에서는비복근피판이식술을시행하였다 (Table 2). 심부연부조직감염은 2예 (4%) 에서발생하였고, 이중 1예는폐쇄성골절, AO/OTA 분류에서 C3로외고정장치 시행 15일후금속판내고정술을시행하였으나 CRP가상승하고창상피열소견을보여시행한균배양검사에서 Staphylococcus epidermidis 가동정되어 6주간의정맥항생제요법으로완치되었다. 골유합이완성된 18주후에금속판제거술을시행하였다. 1예는 Gustalio 8) IIIA 개방성골절, C2 골절로외고정장치시행시개방창의변연절제술까지시행했던환자로외고정후 8일째금속판내고정술을시행한환자로내고정시행후정맥항생제요법에도불구하고연부조직감염및괴사소견을보여변연절제술의지속적시행후 10개월만에치유되었다. 1예 (2%) 에서슬관절구축이있었으며폐쇄성골절, A3 골절로내고정후관절가동범위 20 70 도로측정되었다. 이는환자의동통및동반손상으로인하여초기에능동및수동관절운동을시행하지못했던것이주된원인으로판단된다. 불유합이 2예 (4%) 였으며 1예는폐쇄성 C2 골절로외측의잠김나사금속판을, 내측에는소형골금속판으로내고정, 자가골, 동종골이식술시행하였으나금속물이완과다발성의골절편불유합으로내고정 12개월만에인공슬관절치환술을시행하였고, 다른 1예는 Gustalio 8) II 개방성골절, C3 골절로금속판내고정술시행 20주후에도불유합소견을보여탈무기질화된골기질삽입후 7주에골 Table 2. Types of soft tissue reconstructions Open Fx. AO/OTA type Grade III B C Fig. 4. The 30 months follow up (A) anteroposterior and (B) lateral radiographs of the patient described in Fig. 2. The articular surface was congruent and union was achieved successfully. The range of motion was 0 to 130 degrees, but the patient suffered in pain when full weight bearing was performed. A3 C2 C3 Gastrocnemius flap 1 case *Free flap 1 case Full-thickness skin graft 1 case *Free flap 1 case Gracilis flap 1 case Island flap 1 case Gastrocnemius flap 1 case *Free flap 2 cases Gastrocnemius flap 1 case No Gastrocnemius flap 1 case Table 3. Summary of complications Open Fx. AO/OTA type Grade II Grade III A B C Closed Fx. A3 No Malunion 1 case No No Stiffness 1 case C2 No Deep soft tissue infection 1 case No No Nonunion 1 case C3 Nonunion 1 case No No No Deep soft tissue infection 1 case Total 7 cases 1 case 2 cases No No 4 cases
심한연부조직손상을동반한고에너지경골근위부골절에서의단계적치료 157 유합소견을보였다. 부정유합은 1예에서발생하였으며, 전방각형성이 13도, 경골단축이 1.5 cm, 15주에골유합소견을보였으며관절가동범위는 120도 (0 120도) 였다 (Table 3). 고찰 경골근위부관절내골절은그자체로치료가복잡한데다가동반된연부조직손상에대한치료역시골절에대한치료만큼중요하여동반된연부조직손상을간과할경우불량한치료결과를얻는것으로보고된바있다 1,13,15,27,29). 연부조직의중증손상을동반한근위경골골절에대한치료로관혈적정복술과금속판또는나사못을이용한고정술, 제한적개방정복과경피적나사못삽입술, 또는혼성, 원형외고정장치를이용한간접적정복술과같은다양한치료방법이소개되어왔다 2,5 8,11,13,14,16 18,20,22). 1차외고정장치의개념은약 10년전역학적, 해부학정렬을도모하며추후합병증을줄인다고하여알려지기시작하였고 8,19,23), 최근 1차외고정후 2차금속물을이용한정복술이고에너지 Pilon 골절 15) 에서소개되어왔으며 Patterson 과 Cole 등 16) 은이런가교외고정을이용한방법으로 77% 의우수한결과를보고하였다. Sirkin 등 22) 은이와유사한방법으로연부조직문제를완전히없앨수있었다고발표하였다. 저자들은고에너지경골근위손상에대한명확한지침을설정하고이에따라내원당일또는다음날임시외고정시행후연부조직의회복상태를파악하면서 2차금속물을이용한고정술을시행하였던바, 골또는연부조직감염은 2예, 4% 로줄일수있어상당히우수한결과였다. Mikulak 등 11) 은 24예의고에너지 Schatzker 등 21) 제6형골절에서원형금속강선과내고정을시행한결과 2예의비골신경마비, 2예의금속물과연관된감염, 7예의표재성핀주위감염, 1예의골수염, 1예의관절구축을보고하였다. Young 과 Barrack 29) 은경골양과복합골절에서양측의이중금속판으로치료한환자의 88% 에서연부조직감염을보고하였으며이들은편측금속판에비해감염이증가했다고서술하고있으나아마도연부조직손상이내고정을견뎌낼상태로회복되지않은상태임을간과한것으로생각된다. Covall 등 10) 은 7년간 32예의경골양과골절환자에게수상급성기에개방적정복술과내고정술을동시에시행한바 42% 연부조직감염을보고하였고추후에는혼성외고정장치그리고 / 또는제한적관절경적내고정술의조합으로지침을변경하였다. 본연구에서슬관절의가동범위는평균 110.8도 (6.2 117) 도로 Egol 등 4) 에의한연구에서의 106도와유의한차이가없는우수한결과를얻었으며, Ilizarov 외고정장치와 최소침습내고정술을시행한 Guadinez 등의평균가동범위 85 도, Weddell 등 28) 의 83 도보다우수하였다. 1 차외고정을통해슬관절을건너는 (Bridging external fixation) 상태에서골절부위의내고정이가능하도록연부조직의면밀한관리를통해내고정시연부조직의봉합또는재건이가능하도록하자는개념이본연구의주된치료방법이었고, 연구결과자체로만보았을때효과적인치료방법중하나일것이다. 본연구의제한점은 1 차외고정장착없이관혈적정복과금속내고정을시행한대조군이없다는점이며역시, 외고정을시행하지않은채지연된내고정을시행한군과의비교가없다는점이다. 또한본연구에사용된외고정장치는상대적으로무겁고, 방사선비투과성이라는점도단점이고, 내고정시명확한삽입물의종류를일관되게하지못한점도있으나이는골절이같은분류에속하더라도다양한양상을가지기때문에저자들의판단에따라환자에게가장알맞은것을선택했기때문이다. 또한골절과동반된관절내의연부조직즉, 전방및후방십자인대와측부인대, 반월상연골등의손상에대해서는언급을하지않았다는점이다. 결 심부연부조직의손상을동반한근위경골의골절시 1 차외고정을통해슬관절을, 1 차외고정을통해슬관절을건너는 (Bridging external fixation) 상태에서골절부위의내고정이가능하도록연부조직의면밀한관리를통해수일후지연된내고정시감염등의연부조직과관련된문제에서특히이방법이유용하며술후관절가동범위도우수한결과를나타내어유용한치료방법이라생각된다. 론 참고문헌 1) Anglen JO, Healey WV: Tibial plateau fractures. Orthopedics, 11: 1527-1534, 1988. 2) Blokker CP, Rorabeck CH, Bourne RB: Tibial plateau fractures. An analysis of the results of treatment in 60 patients. Clin Orthop, 182: 193-199, 1984. 3) Delamarter RB, Hohl M, Hopp E Jr: Ligament injuries associated with tibial plateau fractures. Clin Orthop Relat Res, 250: 226-233, 1990. 4) Egol KA, Tejwani NC, Capla EL, Wolinsky PL, Koval KJ: Staged management of High-energy proximal tibia fracture (OTA types 41): the results of a prospective, standardized protocol. J Orthop Trauma, 19: 448-455,
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