|Year : 2018 | Volume
| Issue : 1 | Page : 311-316
Evaluation of operative results of displaced tibial plateau fractures
AlSayed M Zakei1, Amr S ElSayed1, Eid E H. Mohammed2
1 Orthopedic Surgery Department, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Orthopedic Surgery Department, Talkha Central Hospital, Mansoura, Egypt
|Date of Submission||31-Dec-2016|
|Date of Acceptance||11-Mar-2017|
|Date of Web Publication||14-Jun-2018|
Eid E H. Mohammed
Source of Support: None, Conflict of Interest: None
The aim of this study was to evaluate knee function in patients with displaced tibial plateau fractures treated with open reduction internal fixation and minimally invasive percutaneous plate osteosynthesis techniques.
Proximal tibial fracture is a common injury; these fractures represent surgical challenge because of the variety of fracture patterns and the associated soft tissue injuries. If not adequately treated, these fractures often cause persistent knee pain, arthritis, stiffness, and angular deformity.
Patients and methods
This prospective study was conducted on 30 tibial plateau fractures in 30 patients who were functionally and radiologically evaluated according to the knee scoring system. The cases were managed with open reduction and internal fixation with plate and screws and using minimally invasive percutaneous plate osteosynthesis. The entire limb (except the foot) and the ipsilateral iliac crest were prepped and draped into the surgical field under complete aseptic technique.
In this study, the majority of fractures occurred between the ages of 26 and 44 years with a mean ± SD of 37.6 ± 4.7 years, and the majority of fractures were found to be of type V (23.3%) and type VI (23.3%) according to the Schatzeker classification. In this study, we had 27 (90%) patients with no complications and three (10%) patients with infection who were treated with open reduction internal fixation. In this study according to Oxford and International Knee Documentation Committee knee scores, there was a highly significant difference between results after 1, 3, and 6 months. The end results were as follows: 59.3%, excellent; 37%, good; and 3.7%, fair.
Tibial plateau fractures occur due to high-energy trauma. The minimally invasive plate osteosynthesis technique is a good method for the treatment of tibial plateau fractures and it results in good clinical and functional outcome. The functional results of this fracture improve with time, reaching the maximum by 6 months. Despite anatomical joint reconstruction, development of osteoarthritis may still occur secondary to the initial articular cartilage and meniscal injury.
Keywords: postoperative results, tibia, tibial plateau fractures
|How to cite this article:|
Zakei AM, ElSayed AS, H. Mohammed EE. Evaluation of operative results of displaced tibial plateau fractures. Menoufia Med J 2018;31:311-6
|How to cite this URL:|
Zakei AM, ElSayed AS, H. Mohammed EE. Evaluation of operative results of displaced tibial plateau fractures. Menoufia Med J [serial online] 2018 [cited 2019 Aug 25];31:311-6. Available from: http://www.mmj.eg.net/text.asp?2018/31/1/311/234254
| Introduction|| |
Proximal tibial fracture is a common injury, with some of these fractures being caused by strong impact such as traffic accident and others being caused by the relatively weak impact of a fall in elderly people. These fractures represent surgical challenge because of the variety of fracture patterns and the associated soft tissue injuries. If not adequately treated, these fractures often cause persistent knee pain, arthritis, stiffness, and angular deformity ,.
Nonarticular proximal fractures account for 5–11% of the total number of tibial injuries. Fractures of the tibial plateau represent 1% of all fractures and 8% of fractures in elderly population,,.
The fracture morphology as described using the AO/OTA classification appears to be a particularly useful tool for the purpose of research and communication. Tibial plateau fractures are commonly classified using the Schatzker classification, which subdivides these injuries into six types. The Gustilo–Anderson and Tscherne classifications are used for open and closed injuries, respectively,,,,,,.
The factors determining prognosis in the high-energy proximal tibial fractures are as follows: the degree of articular depression, the extent and separation of the condylar fractures, diaphyseal–metaphyseal comminution and dissociation, and the integrity of the soft tissue envelope and the associated ligamentous injuries.
These factors are probably cumulative in negatively influencing the prognosis and result in arthritis, instability, or any dysfunction ,.
Anatomical joint reconstruction, axial alignment, and the relative stability of the proximal tibia allowing the earliest joint mobilization, while keeping complications to minimum, are the major goals in the treatment of proximal tibial fractures ,.
Instability is usually caused by joint surface deformity and less commonly by ligamentous disruption. It is well established that depressed articular fragments cannot be reduced through manipulation and traction alone.
If fracture displacement is great enough to produce joint instability, operative management should be selected .
The aim of this study was to evaluate operative results of displaced tibial plateau fractures (Schatzker types V and VI) clinically and radiologically in patients with open reduction internal fixation (ORIF) using traditional versus minimally invasive percutaneous plate osteosynthesis (MIPPO) techniques.
| Patients and Methods|| |
Thirty tibial plateau fractures in 30 patients were functionally and radiological evaluated according to the knee scoring system and treated. All cases were of intra-articular displaced plateau fractures. The mechanism of injury was a result of high-energy trauma in all patients. Patient selection, preoperative preparation, intraoperative technique, postoperative management, results, and complications were also assessed.
The cases were managed with open reduction and internal fixation using plate and screws and using MIPPO.
All male and female patients who were 45 years of age and younger, patients who had closed displaced tibial plateau fracture, patients who had previously undergone surgery for the fracture in the preceding 9–12 months in the form of ORIF with plate and screw and minimally invasive plate osteosynthesis (MIPO) were included in the study. Patients were classified according to the Schatzker classification.
All patients who were older than 45 years of age, patients with arthritic knee, and all patients with open tibial plateau fracture were excluded from the study.
The indication for this method of treatment was a bicondylar fracture, a dissociation of the shaft from the condyles with an intra-articular fracture, a medial tibial condylar fracture, a displaced lateral tibial condylar fracture, and associated soft-tissue injury. Soft-tissue injury was defined as abrasion, contusions, crushing, marked swelling, compartment syndrome, and neurovascular injury.
As these injuries occur often in the context of the multiply injured individual, initial management is usually directed toward general patient stabilization. This effort should be undertaken before any definitive treatment of the plateau fracture other than fracture splinting with a back slab, wound care, if any, and screening radiographs. After achieving hemodynamic stability, patients underwent physical and radiographic evaluation to fully assess their injuries.
Full history taking
Full history taking included age, sex, occupation, special habits, type of trauma, and medical diseases.
Local examination for tenderness, swelling, deformities, skin condition, and neurovascular status was carried out.
Investigations, including plain radiograph of the knee in anterior–posterior view and lateral and oblique views, were carried out for some cases.
Computed tomography scan of the knee was obtained for special cases to determine the degree of displacement of fracture.
Timing of surgery
The timing of surgery was variable depending on the magnitude of injury. Delay ranged between 1 and 12 days (average 10 days).
The objectives of treatment in tibial plateau fractures were to reduce the condyles to one another underneath the femoral condyles, avoid tilt, and avoid widening. Anatomical reduction of the joint surface is a secondary goal that is often accomplished percutaneously or through limited approaches based on the fracture line. Extensile incisions or tibial tubercle osteotomies were not performed. The final goal was to obtain a stable aligned mobile painless knee and to decrease the risk for post-traumatic osteoarthritis.
The technique of surgery was ORIF or MIPO. The anterolateral approach is the most common approach used to surgically reduce and internally fix, and it was used in 16 cases. Posteriomedial approach was used for seven cases. Combined anterolateral approach and posteriomedial approach was used for dual plating in four and three cases by MIPO.
Intravenous fluids and antibiotics third-generation cephalosporin vial of 1 g every 12 h were given for 5 days and then switched to oral antibiotics. Analgesics such as NSAID when needed, limb elevation over pillows, above knee posterior slab for 2 weeks, and active toe movement after recovery from anesthesia were started. Radiograph of the operated tibia including knee joint in both anterior–posterior and lateral view was checked.
The drain if present was removed after 48 h and the splint was changed. Skin sutures were removed on the 14th postoperative day depending upon the wound condition.
Active toe movement after recovery from anesthesia is started. Static quadriceps exercises were started on the second day. The patients were allowed intermittent knee mobilization once the skin sutures and posterior splint were removed, usually after 14 days. Partial weight-bearing was delayed until at least 6 weeks and full weight-bearing was not allowed until evidence of union was seen on radiographs (usually by 12–16 weeks).
Routine follow-up visits were scheduled at 2 weeks, 1, 3, and 6 months for all patients as a routine part of monitoring. Clinical and radiographic results were assessed and outcome measures were applied at final follow-up. The results were evaluated using Oxford and International Knee Documentation Committee (IKDC) knee evaluation scores.
| Results|| |
The age of the patients ranged from 26 to 44 years with a mean ± SD of 37.6 ± 4.7 years [Table 1].
The study showed that proximal tibial fracture was more frequent in road traffic accidents (RTA).
There was a highly significant difference between results after 1, 3, and 6 months as regards changes in oxford score (P < 0.001) [Table 2].
There was a highly significant difference between results after 1, 3, and 6 months as regards changes in IKDC score (P < 0.001) [Table 3].
|Table 3: Results according to International Knee Documentation Committee|
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There was a nonsignificant difference between different age groups as regards the results (P > 0.05). There was no significant difference between mode of injury as regards the results (P > 0.05). There was a significant difference between type of fracture according to the Schatzker classification as regards the results (P < 0.05) [Table 4].
|Table 4: Relation between type of fracture according to the Schatzker classification and resuwlts|
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| Discussion|| |
The management of intra-articular fractures in the tibial plateau is inherently complex. The complexity of high-energy tibial plateau fractures and their association with significant injuries of the soft tissues around the knee joint has been well described .
Such fractures (Schatzker types V and VI) previously had been treated with extensive approaches and double plating to prevent axial collapse. This type of treatment results in severe soft tissue stripping, bone devitalization, and very often leads to a high incidence of infection, osteomyelitis, and nonunion .
During the last two decades, the evolution of new techniques and devices has led many surgeons to apply the principles of biologic osteosynthesis and minimally invasive surgery for the treatment of comminuted tibial plateau fractures. Circular frames and transfixion wire fixation, although initially used for lengthening, correction of deformities, and nonunion, gave promising results when their applications expanded to fracture care .
Circular fixators facilitate a better overall reduction and interfragmental compression. The use of olive wires offers a unique adjustability of the fixation system, capable of reducing and maintaining small intra-articular fragments, correcting angular deformities, and treating different patterns of fractures .
Ring-tensioned wire frames provide mechanical stability of the fracture comparable to dual plating internal fixation and superior metadiaphyseal purchase and support, compared with hybrid frames with half pins or screws .
The excellent stabilization of the fracture allows early ambulation of the patients with partial weight-bearing, even in comminuted fractures. The beneficial biologic influence of the early weight-bearing on osseous healing has been previously proven .
The major problems of the skin wound, fracture blisters, subcutaneous hemorrhage, or extensive bruising must be overcome before any conventional surgery is undertaken. However, they are not obstacles for the safe application of the circular fixators. Small pin circular or hybrid fixators can be placed irrespective of the skin condition. Any additional bone necrosis is minimized because the periosteal and endosteal blood supply are not further damaged. Finally, the circular fixator is a three-dimensional apparatus that takes into consideration the variables as they arise. Unsatisfactory alignment of the limb and redisplacement of the fracture are not uncommon complications after internal or hybrid fixation of comminuted tibial plateau fractures .
El Barbary et al.  managed 30 tibial plateau fractures (Schatzker type VI) in 29 patients. There were 21 closed and nine open fractures. All fractures were the result of high-energy trauma.
Thirty-eight patients with high-energy tibial plateau fractures were treated by Kataria et al.  using circular external fixator: 34 were closed, whereas four were open. Twenty-two were of type VI and 16 were of type V according to the Schatzker classification.
In our study, we treated 30 patients with displaced tibial plateau fracture. Most of the patients had Schatzker types V and VI. All patients were functionally evaluated according to the knee scoring system and treated using MIPPO and open reduction and internal fixation with plate and screws.
In our series, the youngest patient was 28 years of age and the oldest was 43 years of age; the age of the patients ranged from 26 to 44 years with a mean ± SD of 37.6 ± 4.7 years. Most of the patients were male.
Walia  published the role of locking compression plate in long bone fractures in adults.
Raza et al.  published the outcome of the MIPO technique for tibial plateau fractures on 41 patients with a mean age of 40 years (range, 19–75 years), and they also found that the majority of fractures occurred in male population (85%) (35 male and 6 female).
Ehlinger et al.  had performed a retrospective study on reliability of locked plating in tibial plateau fractures with a medial component in 20 patients between 2005 and 2008, with a mean age of 47 years.
In this study, proximal tibial fracture was more frequent in RTA. The majority of the fractures were found to be of type V and type VI. There were no patients having associated injuries. Ricci et al.  reported that, according to the AO classification, 18 (47.4%) patients had type 41A3 fracture, 12 (31.6%) patients had type 41C2, and 8 (21%) patients had type 41C3 fractures.
In this study, the ORIF technique is the most used one for fracture reduction and fixation. Kataria et al.  performed limited open reduction in eight (21%) cases and bone graft in ten (26.3%) cases of 38 cases they treated. They had used no internal fixation in their series but they used olive wires only.
In the series by Catagni et al. , limited open reduction was performed in 40 of the 59 (71.4%) cases and there was no need for grafting in any patient.
We had 27 patients with no complications and three patients with infection. Oh et al.  reported the following complications: two cases of mild malalignments (varus <10), one case of superficial infection, two cases of screw breakage, and one case of screw back-out. Ehlinger et al.  reported that four patients had fixed knee flexion with a mean of 6.2° (5°–10°).
In our study, there were highly significant differences between changes after 1, 3, and 6 months as regards changes in Oxford score and IKDC score. There were nonsignificant differences between different age groups, both sexes, modes of injury, techniques of fixation, and associated injuries as regards the results. However, there was a significant difference between type of fracture according to the Schatzker classification as regards the results.
Oh et al.  published that the final results were evaluated according to Rasmussen score: 21 patients had excellent or good clinical results (overall 91.3% acceptable result), and two patients had fair results (8.7% unacceptable result).
Ricci et al.  published that locking plates provide excellent fixation in difficult situations such as comminuted fractures, osteoporotic fractures, and periarticular fractures.
Brosset et al.  reported that 92% were fully weight-bearing after 2 months, and concluded that a medial opening wedge high tibial osteotomy without grafting can be stabilized with a locking plate and used to treat medial tibiofemoral knee osteoarthritis in an active subject with genu varum.
Raza et al.  reported that the functional outcome according to Rasmussen functional score was excellent in 18 patients, good in 19 patients (90.24% acceptable results), and fair in four patients (9.76% unacceptable results).
Ehlinger et al.  reported that the mean Lysholm score was 94.1 (73–100; median, 98) and the mean Hospital for Special Surgery score was 93.6 (74–99; median, 97). They concluded that a single lateral locking plate ensured good outcomes in patients with proximal articular fractures of the tibia having a medial component.
| Conclusion|| |
Tibial plateua fractures occur due to high-energy trauma, axial loading, and varus, valgus applied forces leading to articular depression, malalignment leading to increase risk for post-truamatic osteoarthritis.
The MIPO technique is a good method for the treatment of tibial plateau fractures where it results in good clinical and functional outcome. The functional results of this fracture improve with time, reaching the maximum by 6 months.
Various treatment modalities have been used over the years, including circular frame percutaneous screw fixation ORIF arthroscopically assisted reduction, and the use of novel grafting methods to address articular depression.
Despite anatomical joint reconstruction, development of osteoarthritis may still occur secondary to the initial articular cartilage and meniscal injury.
Good planning, rigid fixation, and articular reduction to obtain a stable aligned, mobile joint minimize the risk for post-traumatic osteoarthritis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]