Proximal tibial fractures are one of the most common fractures which is intra as well as extra articular. Proximal tibial fractures account for approximately 1% of all fractures1.Proximal tibial fractures account for 1% of all fractures and 8% in the elderly, predominantly affecting the lateral condyle, with higher incidence in men overall but more common in elderly women, particularly between ages 40 to 602.While high-energy trauma such as motor vehicle accidents cause the majority of proximal tibial fractures in men, most fractures in women are caused by low-energy mechanisms of injury such as falls during walking or cycling3. Low-energy injuries typically cause unilateral depression-type fractures, whereas high-energy injuries can lead to comminuted fractures with significant osseous, soft-tissue and neurovascular injuries4. Tibial condyle fractures result from multidirectional forces, with high-energy trauma often causing significant soft tissue and neurovascular damage alongside bony and ligament injuries5,6.Despite advancements in orthopedic trauma care, the optimal treatment for proximal tibial fractures remains debated due to their complexity and varied patterns7.Indirect reduction, introduced in 1988 by Mast et al., aimed to minimize surgical dissection by using ligamentotaxis, reduction aids, and redesigned plates to preserve soft tissue integrity and bony vascularity8.In the 1990s, Krettek et al. advanced Minimally Invasive Percutaneous Plate Osteosynthesis, promoting periosteal preservation with small incisions and fixed-angle locking plates for biologically friendly fracture fixation9,10.Surgical approaches for proximal tibial fractures are shifting towards minimally invasive techniques with limited fixation and shorter plates to reduce soft tissue complications and preserve perfusion11.Proximal tibial fractures can be managed non-surgically or surgically, with options including open reduction and internal fixation (ORIF), intramedullary nailing, and hybrid external fixation. ORIF with dual plating offers stable fixation but risks wound complications due to extensive soft tissue dissection. Intramedullary nailing minimizes soft tissue damage and preserves blood supply but has a significant risk of malalignment. Hybrid external fixation reduces soft tissue damage, minimizes infection risks, and allows early knee mobilization for improved cartilage regeneration and functional outcomes. This study aims to evaluate the effectiveness of hybrid external fixation in terms of functional recovery, soft tissue healing, and fracture union12–14. AIM To assess functional, radiological, biomechanical and biological outcome after application of hybrid external fixator in different types of proximal periarticular tibial fractures.

This prospective study was conducted at the trauma center of the Department of Orthopaedics, Sardar Patel Medical College and Associated Group of P.B.M. Hospitals, Bikaner, Rajasthan, India, from May 2022 to July 2024. A total of 37 patients undergoing the procedure were included in the study after obtaining ethical approval from the institutional ethical committee. The inclusion criteria were tibial plateau fractures Schatzker types V and VI with significant metaphyseal comminution (with or without diaphyseal extension), severe metaphyseal and subchondral comminution unsuitable for internal fixation, proximal 1/4 extra-articular tibial fractures with severe comminution, open proximal tibial fractures (Gustilo-Anderson Grade 1, 2, 3A, 3B, 3C), and proximal tibial fractures with compartment syndrome. Exclusion criteria included Schatzker types I, II, III, IV fractures, fractures older than two weeks, bilateral tibial plateau fractures, and fractures associated with neurological or paralytic disorders. A convenient sampling technique was employed for patient selection.

Table 1: Distribution cases according to age group Age Group Number Percentage 20-30 17 45.95 31-40 9 24.32 41-50 7 18.92 51-60 1 2.70 >60 3 8.11 Total 37 100.00 Mean 35.35 SD 12 In this study of 37 cases, the majority were aged 20-30 years (46%), followed by 31-40 years (24%), 41-50 years (19%), with fewer cases in the 51-60 (3%) and over 60 (8%) age groups, with an average age of 35±12.5 years. Table 2: Mean and SD of Hemoglobin Parameter Mean SD Hemoglobin 11.48 1.34 Platelet Count (Lakhs) 2.62 0.42 The study reported an average hemoglobin level of 11.48 g/dL and a mean platelet count of 2.62 lakh/mm³, both with minimal variation, indicating consistent blood health parameters among participants. In this study of 37 cases, the majority (54.05%) had Type 6 bicondylar fractures with intra-articular extension and metaphysio-diaphyseal comminution, while Type 5 and extra-articular tibial fractures accounted for 10.81% and 35.14%, respectively. Table 3: Distribution cases according to Interval B/W Injury And Surgery (Day) Mean SD INTERVAL B/W INJURY AND SURGERY (DAY) 7.41 2.59 The average interval between injury and surgery for the cases in this study was 7.41 days, with a standard deviation of 2.59 days. This suggests that while most surgeries occurred around a week after the injury, there was some variation, with some cases undergoing surgery sooner or slightly later than this average period. Table 4: Distribution cases according to Pre Operative Angulation PRE OPERATIVE ANGULATION Number Percentage Anterior 1 2.70 Posterior 7 18.92 Valgus 6 16.22 Valgus & anterior 4 10.81 Varus 6 16.22 Varus & anterior 2 5.41 Varus & Posterior 1 2.70 No 10 27.03 Total 37 100.00 Pre-operative angulation data showed a range of angular deformities, with posterior angulation (18.92%), valgus (16.22%), varus (16.22%), and various combined or isolated angulations in 27.03% of cases. Table 5: Distribution cases according to NEER’S KNEE SCORING SCALE (FOLLOW UP) NEERS KNEE SCORING SCALE (FOLLOW UP) Mean SD 1 Week 9.57 1.52 2 Weeks 10.97 1.61 6 Weeks 12.51 1.54 12 Weeks 13.65 1.51 18 Weeks 14.92 1.66 24 Weeks 16.14 1.69 Follow-up results using the Neer's Knee Scoring Scale show a consistent improvement in knee function over six months, with scores steadily increasing from an initial mean of 9.57 to 16.14.

In our study most of the patients of the proximal tibial fractures were in the age group of 20-30 years, representing 46% of cases. This pattern aligns with the studies conducted by Subash et al. (2021)15 and Dhanasekaran et al. (2020)16, which similarly noted a high incidence of such fractures among young adults. This demographic trend is largely due to the lifestyle, activities of younger individuals, who are more likely to engage in high-risk activities, such as driving/physically intense sports, making them more susceptible to highenergy trauma like road traffic accidents. The involvement of the right knee in 54% of cases compared to 46% for the left knee Patel et al. (2021)17 observed an almost equal distribution of left and right knee fractures. While there isn’t a strong predilection for either side, the slight predominance of right knee involvement may correlate with collision pattens in India patients mainly left sided vehicles. These findings reflect the randomness in injury mechanics rather than an anatomical predisposition. The near-equal distribution supports the need for equally versatile approaches in treating tibial fractures, irrespective of the side of involvement. Additionally in our series, the mean hemoglobin level of 11.48 g/dl and platelet counts of 2.62 lakh/mm³ provide a baseline health parameter for the participants which is similar in the study conducted by Hegde et al. (2021)18 that emphasized the importance of maintaining adequate baseline health parameters, particularly hemoglobin levels, as it directly affects healing outcomes. Low preoperative hemoglobin levels may contribute to delayed recovery and increase the risk of complications. The X-ray findings in our study were as follows. The proximal leg bones in which Bicondylar intra-articular extension with metaphysio diaphysial comminution (Type 6) have (54.05%), fracture proximal leg bones (Tibia with fibula) extra articular upper 3rd (18.92%), fracture proximal leg bone (Tibia) extra articular upper 3rd (16.22%) and additionally Bicondylar with intra-articular extension (Type 5) (10.81%). This is in line with findings by Aggarwal et al. (2006)19, who observed a high frequency of proximal tibial fractures with comminution. Our study also noted cases of intra-articular fractures (40.81%) and fractures complicated by compartment syndrome (5.41%) points toward complex injuries. This method provides both the stability needed for bone healing and protection for vulnerable soft tissues, which is essential for managing the multifaceted injury profiles indicated in our X-ray findings. In our study, the mean time between injury and surgery were 7.41 days, with a standard deviation of 2.59 days. This delay aligns with the findings of Babis et al. (2011)20 and Prabhakar et al. (2018)21, who suggested a standard waiting period which allows soft tissue swelling to reduce before surgery for better results. An early surgery in the presence of significant soft tissue swelling is often associated with poor outcomes, including higher infection risks and delayed wound healing. Thus by a standard approach, a waiting period allows stabilization of the soft tissue environment, reducing the risk of complications in hybrid fixation. The fracture patterns found in our study were bicondylar intra articular extension with metaphyseal involvement (54.05%), extra articular tibial fractures (35.14%) and additionally bicondylar with intra articular extension type V (10.81%) a pattern also reported by Dhanasekaran et al. (2020)16 and Sudhanshu et al. (2024)22. Bicondylar fractures with metaphyseal extension are often challenging due to the involvement of both condyles and the metaphyseal region, demanding a fixation method that can stabilize multiple fracture lines while preserving soft tissues. This study documented a variety of preoperative angular deformities, with posterior, valgus, and varus angulations being the most common. Sudhanshu et al. (2024)22 and Patel et al. (2021)17 similarly reported that cases of tibial fractures frequently presented with diverse angulation deformities required precise correction during surgery. Proper correction of these angulations is critical, as residual malalignment can impair knee function and lead to secondary complications such as joint instability and arthritis. The progressive improvement in Neer’s Knee Scoring Scale were noticed over the Ist week to 24 weeks, reflects a steady recovery trajectory of knee function. Subash et al. (2021)15 and Juneja et al. (2022)23 also reported similar patterns of gradual functional recovery with hybrid external fixation. This trend underscores the hybrid fixator's role in supporting long-term functional recovery by allowing early knee movements, which is essential for minimizing stiffness and improving joint mobility over time.

The study concludes that hybrid external fixation is an effective method for treating complex proximal tibial fractures, especially in cases involving severe soft tissue compromise. The fixator allows early mobilization, provides stable fixation and maintains soft tissue integrity, making it a preferred choice for managing Schatzker V and VI fractures in high-energy trauma cases. With a minimal rate of complications and satisfactory functional outcomes, hybrid external fixation emerges as a viable option that balances fracture stabilization and soft tissue preservation, thus supporting optimal recovery in complex fracture management. This approach is particularly advantageous in resourcelimited settings where it provides a flexible, effective alternative to traditional fixation methods.

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