Tibial plateau fractures. A review of operative treatment using AO technique

Costs and Complications of Single-Stage Fixation Versus 2-Stage Treatment of Select Bicondylar Tibial Plateau Fractures

OBJECTIVES

To determine the differences in costs and complications in patients with bicondylar tibial plateau (BTP) fractures treated with 1-stage definitive fixation compared with 2-stage fixation after initial spanning external fixation.

DESIGN

Retrospective cohort study.

SETTING

Level 1 Trauma Center.

PATIENTS/PARTICIPANTS

Patients with OTA/AO 41-C (Schatzker 6) BTP fractures treated with open reduction internal fixation.

INTERVENTION

Definitive treatment with open reduction internal fixation either acutely (1 stage) or delayed after initial spanning external fixation (2 stage).

MAIN OUTCOME MEASURES

Wound healing complications, implant costs, hospital charges, Patient-Reported Outcomes Measurement Information System (PROMIS), reoperation, nonunion and infection.

RESULTS

One hundred five patients were identified over a three-year period, of whom 52 met the inclusion criteria. There were 28 patients in the 1-stage group and 24 patients in the 2-stage group. Mean follow-up was 21.8 months, and 87% of patients had at least 12 months of follow-up. The mean number of days to definitive fixation was 1.2 in the 1-stage group and 7.8 in the 2-stage group. There were no differences between groups with respect to wound healing or any other surgery-related complications. Functional outcomes PROMIS were similar between groups. Mean implant cost in the 2-stage group was $10,821 greater than the 1-stage group, mostly because of the costs of external fixation. Median hospital inpatient charges in the 2-stage group exceeded the 1-stage group by more than $68,000 for all BTP fractures and by $61,000 for isolated BTP fractures.

CONCLUSIONS

Early single-stage treatment of BTP fractures is cost-effective and is not associated with a higher complication rate than 2-stage treatment in appropriately selected patients.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Autograft transfer from the ipsilateral femoral condyle in depressed tibial plateau fractures

Introduction :

The rationale for operative treatment of depressed tibial plateau fractures is anatomic reduction, stable fixation and grafting. Grafting options include autogenous bone graft or bone substitutes.

Methods :

The autograft group included 18 patients with depressed tibial plateau fractures treated with autogenous bone grafting from the ipsilateral femoral condyle following open reduction and internal fixation. According to Schatzker classification, there were 9 type II, 4 type III, 2 type IV and 3 type V lesions. The average time to union and the hospital charges were compared with the bone substitute group. The latter included 17 patients who had an excellent outcome following treatment of split and/or depressed lateral plateau fractures, using a similar surgical technique but grafting with bone substitutes (allografts).

Results :

Excellent clinical and radiological results were detected in the autograft group after an average follow-up of 28 months (range 12-37). The average time to union in the autograft group was 14 weeks (range 12-16), while in the bone substitute group it was 18 weeks (range 16-20). The mean total cost was 1276 Euros for the autograft group and 2978 Euros for the bone substitute group.

Discussion :

The use of autogenous graft from the ipsilateral femoral condyle following open reduction and internal fixation of depressed tibial plateau fractures provided enough bone to maintain the height of the tibial plateau and was not associated with any donor site morbidity. Using this method, the surgical time was not significantly elongated and the rehabilitation was not affected. It also exhibited faster fracture healing without postoperative loss of reduction and it was less expensive than the use of bone substitutes.

Return to sports activity after tibial plateau fractures: 89 cases with minimum 24-month follow-up

BACKGROUND

Tibial plateau fractures requiring surgery are severe injuries. For professionals, amateurs, and recreational athletes, tibial plateau fractures might affect leisure and professional life.

HYPOTHESIS

Athletic patients will be affected in their sporting activity after a tibial plateau fracture. Despite a long rehabilitation time and program, physical activity will change to low-impact sports.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 89 consecutive patients (age range, 14-76 years) were included in the study and were surveyed by a questionnaire. Inclusion criteria were surgical treatment of tibial plateau fractures between 2003 and 2009 with a minimum follow-up of 24 months. The sporting activity was determined at the time of injury, 1 year postoperatively, and at the time of the survey at an average of 52.8 months postoperatively. The clinical evaluation included the Lysholm score, the Tegner activity scale, the activity rating scale (ARS), and a visual analog scale (VAS) for pain perception. Fractures were classified and analyzed using both the Arbeitsgemeinschaft für Osteosynthesefragen (AO) and the Schatzker classifications.

RESULTS

At the time of injury, 88.8% of all patients were engaged in sports compared with 62.9% 1 year postoperatively and 73.0% at the time of the survey. Of the professional or competitive athletes (n = 11 at the time of injury), only 2 returned to competition at the time of the survey. The number of different sporting activities declined from 4.9 at the time of injury to 3.6 at the time of the survey (P < .001). The sports frequency and the activity duration per week, being 2.8 sessions and 4.5 hours at the time of injury, respectively, declined to 2.4 sessions and 3.8 hours (P < .001 and P = .007, respectively) at the time of the survey, respectively. The Lysholm score (98.7 points before accident) and the VAS for pain perception (0.2 before accident) illustrated significant declines to 76.6 points for the Lysholm score and 2.6 for the VAS (P < .001 and P < .001, respectively) at the time of the survey. The high-energy traumas, Schatzker IV to VI, had significant worse results in the clinical scores compared with the low-energy traumas (Lysholm, P < .001; Tegner, P = .027).

CONCLUSION

The majority of patients could not return to their previous level of activity, and for patients playing competitive sports, this injury can be a career ender. Overall, we noticed a postinjury shift toward activities with less impact. However, at the time of the survey, 73% of all patients were engaged in sports.

Medial gastrocnemius muscle flap for treating wound complications after double-plate fixation via two-incision approach for complex tibial plateau fractures

BACKGROUND

In medical literature, few articles have reported the treatment of wound complications occurring after double-plate fixation via a two-incision approach for complex tibial plateau fractures. A retrospective study was conducted to evaluate the efficacy of a medial gastrocnemius muscle flap transfer in treating this complicated disability.

METHODS

We treated 16 consecutive adult patients, including 6 cases of wound complications without previous deep infection and 10 cases of wound complications with deep wound infection. A one-stage medial gastrocnemius muscle flap transfer was performed after excision of gangrened eschar in cases with wound complication after fracture fixation without infection. A staged flap transfer was performed after debridement and antibiotic administration in cases with wound complication after fracture fixation and wound infection. Bone grafting supplementation was performed in cases where a sequestrectomy had been performed.

RESULTS

All 16 patients were followed up for an average of 31 months (range, 13-50 months). The wound complications were successfully treated in 93.8% (15/16) of patients by medial gastrocnemius flap transfer. The fracture healed in 93.8% (15/16) of patients within an average period of 17.2 weeks (range, 10-51 weeks). One patient had gastrocnemius muscle necrosis with fracture nonunion and was treated with free vascularized muscle and osseous flap transfers. Knee function was satisfactory in 62.5% (10/16) of patients.

CONCLUSION

Medial gastrocnemius muscle flap transfer is a reliable technique for treating wound complications that occur after double-plate fixation via a two-incision approach in the treatment of complex tibial plateau fractures. A high success rate of wound healing with bone union can normally be achieved. We, therefore, recommend its widespread use in candidate patients.

New trends and techniques in open reduction and internal fixation of fractures of the tibial plateau

The operative treatment of displaced fractures of the tibial plateau is challenging. Recent developments in the techniques of internal fixation, including the development of locked plating and minimal invasive techniques have changed the treatment of these fractures. We review current surgical approaches and techniques, improved devices for internal fixation and the clinical outcome after utilisation of new methods for locked plating.

Plating treatment for tibial plateau fractures: a biomechanical comparison of buttress and tension band positions

INTRODUCTION

The load tolerance of conventional plate treatment for bicondylar tibial plateau fractures with the buttress and the tension band positions was compared from biomechanical viewpoints.

MATERIALS AND METHODS

Fourteen left synthetic tibiae divided into two groups were tested. T-plates in the buttress group were placed on the medial tibial subcondyle and T-plates in the tension band group were placed on the lateral tibial subcondyle. All specimens were evaluated with a Material Testing System (MTS) machine. A linear variance displacement transducer gauge was placed on the medial tibial subcondyle. The anatomic axis of the synthetic femur and the tibia was maintained at 6 degrees varus in the frontal plane. The MTS actuator was set to increase displacement at 3 mm/min. All specimens were evaluated to failure. The relative motion and the ultimate failure load (UFL) between both groups were compared.

RESULTS

The buttress group had significantly less displacement than the tension band group following the incrementally increased loading (p < 0.001). At failure, the buttress group also had a higher UFL (p < 0.001) and less displacement (p = 0.009) than the tension band group.

CONCLUSION

All medial tibial condylar fragments achieved improved stabilization from the medial aspect of the proximal tibia by conventional plates. When conventional plates cannot be placed medially due to skin ailments, lateral placement of conventional plates may have the insufficient stability. Protected weight bearing should be followed strictly.

Prediction of Soft-Tissue Injuries in Schatzker II Tibial Plateau Fractures based on Measurements of Plain Radiographs

BACKGROUND

Split-depression fractures of the lateral tibial plateau (Schatzker II) are associated with a significant risk of capsuloligamentous and meniscal injury. We hypothesized that the amount of fracture depression and widening on anteroposterior (AP) plain radiographs would correlate with the incidence of injury to these structures on magnetic resonance imaging (MRI).

METHODS

Sixty-two consecutive patients with Schatzker II tibial plateau fractures had a knee x-ray series and MRI preoperatively. AP plain radiographs were measured for lateral joint line depression and condylar widening, and MRIs were evaluated for injury to soft-tissue structures around the knee. For each structure, the threshold of depression and widening that led to the greatest disparity in soft-tissue injury was determined. Multiple logistic regressions were applied to calculate whether depression and/or widening above the thresholds were predictive for injury to individual soft-tissue structures.

RESULTS

When depression was greater than 6 mm and widening was greater than 5 mm, lateral meniscal injury occurred in 83% of fractures, compared with 50% of fractures with less displacement (p < 0.05). When either depression or widening was at least 8 mm, medial meniscal injury occurred more frequently (depression 53%, p < 0.05; widening 78%, p < 0.05; versus neither 15%). Lateral collateral ligament and posterior cruciate ligament tears were not seen with minimally displaced fractures (< 4 mm), but the incidence of injury approached 30% with increasing displacement.

CONCLUSIONS

Due to the limited availability of MRI in some centers, correlation of lateral condylar depression and widening, as measured on plain radiographs, to injury of various soft-tissue structures may be extremely helpful in planning open or arthroscopic treatment methods. Using these guidelines, Schatzker II fractures with depression or widening approaching 5 mm deserve heightened vigilance in diagnosing and treating these concomitant soft-tissue injuries.

Bicondylar tibial plateau fractures: a biomechanical study

The optimal treatment of bicondylar tibial plateau fractures remains controversial. The current study was designed to answer the following questions: (1) can a lateral fixed angle plate provide similar construct stability to dual plating techniques and (2) does the size of the medial buttress plate used in dual plating techniques have an effect on construct stability? Bicondylar tibial plateau fractures were created, reduced, and instrumented in a matched pair design using a cadaveric simulated bicondylar tibial plateau fracture model. Tibias were instrumented with one of three constructs: a lateral periarticular plate and posteromedial small fragment dynamic compression plate, a lateral periarticular plate and posteromedial (1/3)-tubular plate, or a lateral fixed angle plate. Biomechanical testing was done to determine construct stiffness, maximum load to failure, and medial condylar displacement for each of the three constructs. There was no significant difference measured between the two dual plating constructs and the lateral fixed angle plate for overall construct stiffness or with respect to medial condylar fragment displacement. A lateral fixed angle plate may have clinical applications in the treatment of bicondylar tibial plateau fractures.

High-energy fractures of the tibial plateau. Knee function after longer follow-up

BACKGROUND

Studies of the long-term outcomes of treatment of fractures of the tibial plateau have included wide mixtures of fracture types and mostly low-energy split and split-depression fractures. The long-term results of treatment of high-energy intra-articular proximal tibial fractures are unknown. The purpose of this study was to assess the function of the knee and the development of arthrosis at a minimum of five years after injury in a consecutive series of patients in whom a high-energy fracture of the tibial plateau had been treated with a uniform technique of external fixation.

METHODS

Between July 1988 and December 1994, thirty patients with a total of thirty-one fractures of the tibial plateau were treated with a monolateral external fixator and limited internal fixation of the articular surface. Follow-up data on twenty-four knees in twenty-three patients were obtained at a mean of ninety-eight months. Twenty patients (twenty knees) returned specifically for the study, at which time they completed an Iowa Knee Score questionnaire and a Short Form-36 (SF-36) general health survey, a physical examination was performed, and weight-bearing radiographs were made. The results of the SF-36 evaluations for fourteen patients and the Knee Scores for twelve were compared with those obtained five years previously, at two to four years after the injury.

RESULTS

After healing, no patient required a secondary reconstructive procedure. The range of motion of the knee averaged 3 degrees of extension to 120 degrees flexion, which was an average of 87% of the total arc of the contralateral knee. The average Iowa Knee Score was 90 points (range, 72 to 100 points). For twelve patients, the Iowa Knee Score previously recorded at two to four years averaged 92 points, as did the score at the time of the latest follow-up. Thirteen patients rated their outcome as excellent; six, as good; and three, as fair. Fifteen patients were working, and ten of them were performing strenuous labor. Radiographs showed no evidence of arthrosis in fourteen knees, grade-1 arthrosis in three, grade-2 in three, and grade-3 in two. Compared with the radiographic appearance two to four years after injury, there was no evidence of progression of arthrosis in eighteen knees and one grade of progression in four. The SF-36 subscale scores were similar to those of age-matched controls. The fourteen patients who had previous SF-36 scores had no deterioration of these scores.

CONCLUSIONS

Patients with a high-energy fracture of the tibial plateau treated with external fixation have a good prognosis for satisfactory knee function in the second five years after injury. The knee joint cartilage appears to be tolerant of both the injury and mild-to-moderate residual articular displacement, which was associated with a low rate of severe arthrosis.

Split depression tibial plateau fractures: a biomechanical study

OBJECTIVE

To determine the biomechanical characteristics of four different fixation constructs for split depression fractures of the lateral tibial plateau (OTA classification 41B3.1).

DESIGN

Laboratory investigation using a cadaveric simulated split depression tibial plateau fracture model.

SETTING

Split depression tibial plateau fractures were created, reduced, and instrumented in a matched pair design. Specimens were tested for stiffness using a materials testing machine.

INTERVENTION

Tibias were instrumented with an L-buttress plate, four 3.5-millimeter subchondral raft screws with an antiglide plate, an L-buttress plate with cancellous allograft, or four 3.5-millimeter subchondral raft screws placed through a periarticular plate.

MAIN OUTCOME MEASUREMENTS

Vertical subsidence of the lateral tibial plateau was measured for the entire construct and for the local depression. The relative medial and lateral condylar tilt with central loading was also measured.

RESULTS

There was no significant difference between the four fixation methods for overall longitudinal stiffness of the proximal tibial fracture fixation construct (range, 2,026 to 2,666 newtons per millimeter). The local depression stiffness for the raft-periarticular plate and raft-antiglide plate were 425 newtons per millimeter and 342 newtons per millimeter, respectively, versus 243 newtons per millimeter and 210 newtons per millimeter for the two large fragment buttress constructs. There was no significant difference between the local depression stiffness for the two raft constructs. There was no significant difference between the local depression stiffness for the two buttress plate constructs. Local depression stiffness was found to be significantly greater for the raft-periarticular plate construct when compared with the large fragment buttress plate construct without bone graft (p = 0.0314). Condylar tilt data showed a significant difference between the medial tilt observed in the prefracture specimen and the lateral tilt observed after fixation (p less-than-or-equal 0.017) for all constructs.

CONCLUSIONS

There was no significant difference in the overall construct stiffness between the four fixation constructs. Fixation constructs with a raft of subchondral screws were more resistant to local depression loads. This supports the use of a raft construct when a central depression is a significant component of the overall fracture pattern. Condylar tilt data showed a persistent weakness in the postfixation lateral plateau regardless of fixation construct when compared with the intact specimen. This supports the current clinical practice of delayed weight-bearing for ten to twelve weeks.

Split fractures of the lateral tibial plateau: evaluation of three fixation methods

A laboratory study was performed to compare the stability and ultimate strength of three standard fixation techniques for split-type lateral tibial plateau fractures. The three methods of fixation were (a) three 6.5-mm cancellous lag screws with washers; (b) two 6.5-mm cancellous lag screws with washers and an additional antiglide 4.5-mm cortical screw with washer; and (c) six-hole L-shaped buttress plate. Twelve pairs of embalmed mildly osteopenic lower extremities were used. Simulated split-type lateral tibial plateau fractures were created, reduced, and then instrumented in a matched pair design. The instrumented specimens were axially loaded to determine resistance to displacement, cyclically loaded to 10,000 cycles to determine dynamic stability, and then loaded to failure. There were no statistically significant differences found between resistance to displacement or failure strength as a function of either fragment size or sample bone density. On the basis of biomechanical stability, there appears to be no difference between the three fixation techniques tested. The results of this study suggest that use of an antiglide screw or buttress plate does not offer an advantage over lag screw fixation alone for the treatment of split type lateral tibial plateau fractures.

Tibial Plateau Fractures: Evaluation and Treatment

The goal of tibial plateau fracture management is a stable, well-aligned, congruent joint, with a painless range of motion and function. Minimally displaced stable fractures should be treated with protected mobilization. The treatment of displaced tibial plateau fractures, however, remains controversial. Surgical reduction and stabilization of displaced tibial plateau fractures, when indicated, requires careful evaluation of both the "personality" of the fracture and the soft-tissue envelope. The timing of surgery and the handling of the soft tissue in this region are critical to treatment success. After restoration of a congruent joint surface, bone grafting and buttress plating are usually needed to allow early range of motion and optimize treatment outcome.