Combining Plate and Ilizarov Fixation for Tibial Fracture in a 95-Year-Old Woman: A Case Report

Introduction

As healthy life expectancy increases and the world’s aging population expands [1], the number of patients undergoing total knee arthroplasty (TKA) to maintain activities of daily living (ADL) is also growing [2]. As the risk of fracture due to osteoporosis increases with age [3], the number of patients with periprosthetic fractures has also inevitably increased [4]. Older individuals commonly exhibit delayed fracture healing due to decreased bone metabolism, impaired angiogenesis, and compromised inflammatory responses [5]. Hip fractures in elderly patients often result in significant loss of mobility and independence in activities of daily living (ADL), with only about 40–60% regaining pre-fracture function and 10–20% requiring institutional care within a year [6]. Although similar large-scale outcome data are scarce for periprosthetic tibial fractures, maintaining ADL is particularly challenging in these cases because of concomitant osteoporotic bone and the presence of prosthetic components, often limiting standard fixation options. Early weight-bearing is generally restricted, further contributing to the risk of functional decline. Tibial shaft fractures are among the most common long-bone fractures and are typically managed with intramedullary nailing (IMN), which offers stable fixation and allows early mobilization in adults. According to a Cochrane review summarized by Johal et al, approximately 90% of orthopedic trauma surgeons prefer IMN for tibial shaft fractures due to its favorable outcomes regarding union rates and functional recovery [7]. However, in cases involving periprosthetic tibial fractures after total knee arthroplasty (TKA), the use of IMN is precluded by the presence of prosthetic components, making treatment decisions more complex [8]. Alternative options such as locking plate fixation or circular external fixation are considered, each with advantages and limitations depending on the fracture pattern and patient-specific factors. Among these, the Ilizarov external fixation technique provides circular, multiplanar stability with minimal soft-tissue disruption, allowing for early postoperative weight-bearing. It is particularly advantageous in patients with osteoporosis or periprosthetic fractures, where conventional internal fixation may be biomechanically insufficient [9]. Notably, Nozaka et al reported successful treatment of a periprosthetic tibial fracture after TKA in an elderly patient using Ilizarov external fixation alone without internal fixation [9]. Here, we describe the case of a 95-year-old woman with a periprosthetic tibial shaft fracture after TKA, successfully treated with open reduction, augmentation plating, and Ilizarov external fixation, achieving immediate full weight-bearing, favorable alignment, preservation of joint function, and reliable bone union without major complications.

Case Report

PRESENTATION AND ADMISSION:

A 95-year-old woman who had undergone bilateral TKA was transferred to our hospital because of right lower-leg pain and difficulty in walking after falling down the stairs. She had a history of hypertension, diabetes mellitus, and chronic heart failure, but no dementia. Her height was 140.0 cm, weight was 57.2 kg, and body mass index (BMI) was 29.2. Before her fall, she had been independent in her ADL and could walk independently indoors and with a cane outdoors. On initial examination, the injury was confined to the right lower extremity, which was deformed, although the skin was intact. No findings were suggestive of nerve or vascular injury. Radiographs showed a right periprosthetic tibial shaft fracture after TKA (AO classification 42A1b, Felix classification [8] Type III) (Figure 1A). She was admitted to the hospital on the same day as the injury, after closed reduction and stabilization with a splint (Figure 1B).

SURGICAL TREATMENT:

On the 6th day after the injury, considering her advanced age and the need to facilitate early weight-bearing, surgical fixation was performed. We internally fixed the fracture with an augmentation plate and immobilized the tibia using an Ilizarov external fixator. Although the blisters that had developed in the area adjacent to the fracture during the waiting period had healed by the day before surgery, a skin incision was made to avoid this previously damaged area (Figure 2A). We performed open reduction of the fracture under direct vision, fixed with an augmentation locking plate (A.L.P.S. Distal Fibula Plating System, 7-hole composite locking plate; proximal thickness 2.8 mm, distal thickness 1.9 mm; ZIMMER BIOMET), and immobilized using an Ilizarov external fixator (Figure 2B).

POSTOPERATIVE COURSE:

Full weight-bearing ambulation started the day after surgery due to sufficient stability at the fracture site (Figure 3). There were no serious wound complications postoperatively. A superficial pin-site infection was observed during the postoperative course, but was cured by oral antibiotics and daily irrigation procedures. Computed tomography taken 4 months after surgery showed bone union (Figure 4A), and the Ilizarov external fixator was removed. One year after surgery, plain radiographs showed bone union without displacement or deformation (Figure 4B). The range of motion of the knee joint was 0° extension, 120° flexion; the range of motion of the ankle joint was 38° dorsiflexion, 22° plantarflexion; and the patient was able to walk independently (Figure 5).

Discussion

This case demonstrates that combining Ilizarov external fixation with augmentation plating can provide stable fixation and enable immediate postoperative weight-bearing in very elderly patients with periprosthetic tibial shaft fractures, and shows that even in patients with severe osteoporosis and advanced age, functional recovery and early mobilization can be safely achieved with appropriate surgical strategies.

One problem with lower-limb fractures in older people is the decline in ADL after treatments. Bed rest reduces muscle strength by 5% per day [10]. An extended period of non-weight-bearing and a delay in getting out of bed can cause disuse syndrome, and as the decline in ADL becomes more severe, the prognosis worsens [11]. The treatment goals for periprosthetic tibial shaft fracture after TKA in elderly patients are 2-fold: secure internal fixation and early weight-bearing. Achieving these objectives can minimize the decline in ADL [12].

In the treatment algorithm for periprosthetic tibial fractures after TKA proposed by Lombardo et al [13], internal fixation or the combination of closed reduction and external fixation is selected if there is no implant loosening.

Internal fixation methods for tibial shaft fractures include fixation with an intramedullary nail (IMN) or plate. IMNs are advantageous for regaining early weight-bearing [14], but in the case after TKA, nail insertion is influenced by the tibial component. Devendra et al reported that to insert an IMN, a bone stock of 2.0 cm in width is required anterior to the tibial tray and its cement mantle [15]. However, it was unfeasible to obtain such a large bone stock in our case. Furthermore, in an elderly patient with osteoporosis, the stress applied during nail insertion could easily lead to an iatrogenic fracture. With plate fixation, stable fixation can be obtained by inserting screws into the proximal bone fragment through 8 or more cortical areas; minimally invasive plate osteosynthesis (MIPO) can also be used to avoid soft-tissue disorders, but early weight-bearing is difficult [16]. Although double plating on the bilateral sides might provide fixation that allows for early weight-bearing [17], in elderly patients, skin atrophy and decreased extensibility can easily lead to soft-tissue disorders [18], and this fixation method should be avoided, even in MIPO. Revision arthroplasty using a long stem can be an alternative to internal fixation [19]. However, it results in even more bone stock loss and requires advanced expertise.

In this case, the Ilizarov external fixator was selected as the optimal treatment to allow early weight-bearing and minimize soft-tissue damage. The Ilizarov external fixator provides a fixation strength similar to a double plate [17]. To treat lower-leg fractures in young patients with a mean age of 37.8 years, the Ilizarov external fixator was reported to have achieved bone healing without any nonunion and delayed union [20], but Iliopoulos et al found that older patients with a mean age of 71.2 years (all patients were older than 65 years) required reoperation in 5.4% of the cases because of nonunion [21].

When using an Ilizarov external fixator for long-bone fractures, it has been reported that inserting an additional intramedullary pin [22] or fixing the fracture with a lag screw [23] rather than using an Ilizarov external fixator alone can result in stable bone union. Nozaka et al also reported successful treatment of a periprosthetic tibial fracture in an 84-year-old woman using Ilizarov external fixation alone [9]. Although their patient had severe osteoporosis and multiple comorbidities, bone healing was achieved without internal fixation. However, the fracture was reduced by ligamentotaxis without open exposure, and the external fixator spanned the knee joint, which can temporarily limit postoperative joint motion. Similarly, Kouzelis et al reported successful management of a neglected open tibial fracture with significant soft-tissue loss in a 65-year-old patient using Ilizarov external fixation combined with bone- and soft-tissue-lengthening techniques, achieving satisfactory bone healing and functional recovery [24]. Although their report addressed a different fracture type and patient age group, it highlights the versatility of Ilizarov fixation in complex lower-limb trauma. In contrast, our case involved partial comminution and more severe bone fragility in a 95-year-old patient. Therefore, we opted for open reduction and additional internal fixation with a locking plate to ensure more stable fixation and reliable bone union while preserving joint mobility. Compared to previous reports such as Nozaka et al, our case involved greater age (95 vs 84 years), more complex fracture morphology, and the necessity of open reduction. Unlike previous cases that applied Ilizarov fixation alone, we combined open reduction and augmentation plating to achieve stronger fixation while preserving joint motion. This approach enabled immediate full weight-bearing and functional recovery without significant soft-tissue complications, highlighting the potential advantages of combining fixation methods in very elderly, frail patients.

In this case, an augmentation plate was combined with an Ilizarov external fixator because of the risk of bone union failure in an elderly patient with partial comminution and bone fragility. In particular, due to severe osteoporosis in this very elderly patient, we considered that stronger internal fixation was necessary rather than supplemental fixation with only pins or Kirschner wires. Additionally, we believed that direct fracture reduction and rigid plate fixation would contribute to more reliable bone healing [16]. As a result, even in this 95-year-old patient, stable bone union, early weight-bearing, and recovery of pre-injury activities of daily living were achieved without soft-tissue complications. Furthermore, previous research by Pawik et al demonstrated that patients treated with Ilizarov external fixation for tibial nonunion achieved symmetrical load distribution comparable to that of healthy individuals, supporting the biomechanical advantage of this fixation method in restoring functional stability and enabling safe early weight-bearing [25].

In addition to the patient’s advanced age, this case is characterized by the successful application of combined open reduction, augmentation plating, and Ilizarov external fixation for a periprosthetic tibial shaft fracture. This approach enabled immediate full weight-bearing, achievement of satisfactory alignment, and reliable bone union, highlighting its value as a treatment strategy for similarly complex cases in very elderly patients with severe osteoporosis.

Conclusions

Ilizarov external fixation combined with a plate is a useful surgical option for periprosthetic tibial shaft fractures after TKA in elderly patients with severe osteoporosis and comminution. This approach provides rigid stabilization, enables early full weight-bearing, and facilitates recovery of pre-injury activities of daily living.