Document 6479940

■ Feature Article
S P OT L I G H T O N
hip and
knee
Open Reduction and Internal Fixation
of 117 Tibial Plateau Fractures
NABIL A. EBRAHEIM, MD; FADY F. SABRY, MD; STEVEN P. HAMAN, MD
abstract
This retrospective study evaluated the surgical management of 117 tibial
plateau fractures treated between 1990 and 1998. At last patient follow-up,
results were rated good to excellent in 94, fair in 13, and poor in 10 cases.
Follow-up radiographs showed degenerative changes in the lateral compartment in 29 cases. Other complications included five wound infections, two
deep venous thromboses, five delayed unions, and three nonunions.
Operative treatment of tibial plateau fractures is recommended as it enables
better alignment, meniscal access, and other soft-tissue injury repair.
ibial plateau fractures occur
when the proximal tibia experiences an excessive axial load.
The mechanism of injury and the energy
required to cause these fractures are age
dependent. Younger patients tend to sustain fractures secondary to high energy
such as a fall from a height or a motor
vehicle accident, while older patients
tend to sustain tibial plateau fractures
secondary to low energy such as from a
low-level fall or stumble.
The management of tibial plateau
injuries has long been a subject of controversy. The spectrum of treatment
ranges from simple casting1 and bracing
to skeletal traction and early motion2 to
open reduction and internal fixation.
Moreover, the appropriate treatment for
injuries of differing severity is unclear.
A brief review of the recent literature
reveals surgeons are exploring many different avenues of treatment for this fracture. Ali et al3 reported a 31% fixation
T
DECEMBER 2004 | Volume 27 • Number 12
failure rate for tibial plateau fractures in
their elderly population. Stevens et al4
demonstrated 92% of the tibial plateau
fractures treated surgically in patients
aged ⬍40 years had functional outcomes
comparable to age-matched controls.
However, they noted only 57% of their
older patients had such good functional
outcomes.
Weigel and Marsh5 evaluated highenergy fractures treated with external fixation and limited internal fixation. This
study supported the use of external fixation and there was no absolute need for
anatomic reduction.
Westmoreland et al6 examined the
biomechanical properties of screw fixation in tibial plateau fractures. They recommend the use of 3.5-mm screws in
subchondral and metaphyseal bone and
found no difference with 4.5-mm and
6.5-mm screws.
This study reviews the surgical treatment of 117 plateau fractures and exam-
ines trends in technique to aid surgeons in
the selection of management options.
MATERIALS AND METHODS
A total of 146 patients presented with
tibial plateau fractures between 1990 and
1998. Of these, 135 were treated with
open reduction and internal fixation.
Twenty-one patients were excluded
because of insufficient follow-up, leaving
114 patients (69 men and 45 women)
with 117 tibial plateau fractures for inclusion in the study.
Patient charts and radiographs were
examined retrospectively. Average
patient age was 43 years (range: 16-81
years). Fifty-seven fractures were located
on the left side, 54 were on the right side,
and 3 were bilateral. The mechanism of
injury was a motor vehicle accident in 54,
a fall from a height in 41, a pedestrian
struck by a motor vehicle in 12, and
sports-related accidents in 10 cases. All
patients were treated within 72 hours of
admission.
Preoperative anteroposterior, lateral,
and oblique radiographs were reviewed
to determine the fracture types, which
From the Department of Orthopedic Surgery,
Medical College of Ohio, Toledo, Ohio.
Reprint requests: Nabil A. Ebraheim, MD,
Department of Orthopedic Surgery, Medical
College of Ohio, PO Box 10008, Toledo, OH
43614.
1281
■ Feature Article
were classified according to Schatzker as
types I-VI.7 The indications for surgery
were dependent on the patient’s age, medical status, osteoporosis, degree of displacement and depression, activity level,
and occupation. The expected benefits of
surgery was discussed with all patients
prior to developing a treatment plan.
Operative procedures were performed
in a standard operating room under
regional or general anesthesia with a
tourniquet. Patients were first placed into
one of two groups, acceptable or unacceptable soft tissues. Patients with acceptable tissues included those with intact or
near intact envelopes with no blistering,
significant tension, or significant contamination. Patients with acceptable tissues
progressed to fixation. For patients with
soft-tissue compromise, procedures such
as debridement, fasciotomy, and external
fixation were performed first and patients
then were brought back to the operating
room under better conditions.
Selecting the mode of fixation was
individualized. Patients with poor soft tissues after the acute traumatic phase were
tracked to a less invasive procedure
regardless of the severity of the fracture,
while those patients with good soft tissues
were tracked to a more aggressive course
of treatment.
After the soft tissues and patients were
optimized, reduction of the articular surface was started with smooth Kirschner
wires and cannulated screws. Midline
skin incisions were used for types I-IV
fractures, and a Z incision was used for
types V and VI fractures.
In cases with joint depression, autogenous iliac bone graft was added for support, and the graft was further supported
with a plate. Plates were added to the side
of greatest involvement. In fractures with
both extensive medial and lateral involvement, two plates were used.
Next, the meniscus was inspected for
injury. If the injury became more complex, additional or longer plates were
added to address distal extension.
1282
until discharge from the hospital. At the
first postoperative office visit, sutures
were removed and therapy was started.
Patients were kept nonweight bearing for
at least 8 weeks, with active and passive
motion allowed as tolerated.
Data collected were evaluated using
the Rasmussen functional grading
system8 (Table 2). Trends also were
looked for to help surgeons predict patient
outcomes.
RESULTS
1
Figure 1: Illustration showing the different fixation
techniques used for repairing plateau fractures.
Postoperatively, a double-upright
hinged brace was applied, and a continuous passive motion machine was used
beginning on the first postoperative day
Final follow-up information reflected
patients’ status at their most recent clinic
visit. Average follow-up was 29 months
(range: 12-84 months). There were 27
(23%) type I, 36 (31%) type II, 11 (9%)
type III, 6 (5%) type IV, 22 (19%) type V,
and 15 (13%) type VI fractures treated by
open reduction and internal fixation
(Table 3). The most common mechanism
of injury was motor vehicle accident followed by a fall from a height and sportsrelated injury.
Thirty-nine (33%) fractures had concomitant soft-tissue injury. There were 23
(20%) meniscal tears, 13 (11%) anterior
cruciate ligament tears, and 3 (3%) poste-
TABLE 1
Fixation Method by Schatzker Type for 117 Tibial Plateau Fractures
Schatzker Type
Fixation Method
K-wires
Screws
K-wires & screws
Buttress plate
Buttress plate & K-wires
Buttress plate & screws
Buttress plate & compression
plate
Two buttress plates
Two buttress plates &
compression plate
Two buttress plates & K-wires
Two buttress plates & screws
Total
I
II
III
IV
V
VI
10
4
2
7
3
1
–
3
1
29
2
1
4
2
–
5
–
-
–
–
–
5
1
–
–
–
1
–
1
1
–
–
–
–
2
–
14
9
4
46
9
3
–
–
–
–
–
–
–
–
1
14
–
11
1
25
–
–
–
27
–
–
–
36
–
–
–
11
–
–
–
6
–
3
1
22
2
–
–
15
2
3
1
117
ORTHOPEDICS |
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TIBIAL PLATEAU FRACTURES | EBRAHEIM ET AL
TABLE 2
Rasmussen Functional Grading Criteria
Satisfactory
Subjective complaints
Pain
No pain
Occasional ache, bad weather pain
Stabbing pain in certain positions
Afternoon pain, intense, constant pain around
knee after activity
Night pain at rest
Walking capacity
Normal walking (in relation to age)
Walking outdoors at least 1 hour
Short walks ⬎15 minutes
Walking indoors only
Wheelchair or bedridden
Clinical signs
Extension
Normal
Lack of extension(0°-10°)
Lack of extension (⬎10°)
Total range of motion
At least 140°
At least 120°
At least 90°
At least 60°
At least 30°
0°
Stability
Normal stability in extension and 20° of flexion
Abnormal stability in 20° of flexion
Instability in extension (⬍10°)
Instability in extension (⬎10°)
Sum (minimum)
rior cruciate ligament tears. All but four
meniscal tears were repaired.
Eighty-nine were closed and 28 were
open fractures. The popliteal artery was
injured and required repair in three
cases. Two peroneal and one sural nerve
injuries were encountered at the time of
presentation; all resolved without specific treatment.
Supracondylar fracture was the most
common associated injury (10 [9%]
cases) followed by fractured tibial shaft (8
[7%] cases). Knee dislocation was
DECEMBER 2004 | Volume 27 • Number 12
Unsatisfactory
Points
Excellent
Good
Fair
Poor
6
5
4
5
4
2
1
6
4
2
1
6
4
2
1
5
4
2
1
5
4
2
1
27
20
10
6
2
0
6
4
2
1
0
6
4
2
6
5
4
2
1
0
6
5
4
2
encountered in two (2%) cases, partial
patellar tendon avulsion in two (2%)
cases, and fractured pelvis in four
(3%)cases. Nineteen (8%) patients had
multitrauma injuries. There were 33
(28%) fractures in osteoporotic bone as
assessed on radiographs taken at the time
of injury.
According to Rasmussen functional
score,8 79 (68%) cases had an excellent
result, 15 (13%) had a good result, 13
(11%) had a fair result, and 10 (9%) had a
poor result. The latest follow-up radio-
graphs showed degenerative changes in
the lateral compartment in 29 (25%) cases.
Compartment syndrome developed in
27 (23%) cases and required fasciotomy.
Wound infection occurred in five patients
and was resolved in four cases with
repeated irrigation, debridement, and
intravenous antibiotics. Osteomyelitis
developed in the fifth case and was treated
by hardware removal, tobramycin-impregnated beads, intravenous antibiotics, and
application of Ilizarov external fixator and
autogenous bone grafting. Deep vein
1283
■ Feature Article
2A
2B
2C
2D
Figure 2: Preoperative CT images showing a typical injury (A and B). Postoperative radiographs showing supplementary external fixation (C) and a healed
plateau fracture (D).
TABLE 3
Treatment Results of 117 Tibial Plateau Fractures by Schatzker Type
Schatzker Type
Excellent
Good
Fair
Poor
Total
I
II
III
IV
V
VI
Total
23
2
–
2
27
30
5
1
–
36
6
3
1
1
11
4
–
2
–
6
9
5
5
3
22
6
1
4
4
15
78
16
13
10
117
thrombosis developed in two cases and
was resolved by anticoagulation therapy.
Delayed union occurred in five (4%)
cases; two of these were treated by adding
posteromedial autogenous bone graft and
electrical stimulation. Three cases were
united with conservative treatment. Two
cases went on to become nonunions. Two
cases were treated by hardware removal
and application of cancellous autograft
and a longer buttress plate. One case was
infected and developed osteomyelitis and
was treated as described previously. Two
cases had valgus angulation deformity
due to collapse of the lateral compartment
and were treated by opening osteotomy.
Radiographic evidence of degenerative
joint disease was noted in 26 (22%) cases.
Four cases had severe joint space narrow-
1284
ing; two of these cases eventually went on
to total knee arthroplasty. Twelve (10%)
cases had minor narrowing in joint space,
and 10 (9%) cases had moderate narrowing with osteophyte formation. There
were 33 cases of osteoporosis (28%) at
time of presentation. Figures 2 and 3 are
representative of two cases of tibial
plateau fractures.
DISCUSSION
The treatment of tibial plateau fractures
remains a topic of debate. Studies supporting either closed or open fixation methods
can be found in the literature. This series
represents the largest open reduction and
internal fixation series to date.
Touliatos et al9 reported an excellent
result in 57% of 49 patients, while
Lachiewicz and Funcik10 reported an
excellent result of 81% in their series of
43 patients. The excellent result in this
study was 69%. However, comparison
between these studies is not feasible as
each series had a different evaluation
method.
In this study, the evaluation of patients
with suspected fractures around the knee
included a rigorous physical examination
and radiographic evaluation. Radiographic
evaluation started with AP and lateral
films, with computed tomography being
ordered if the fracture was identified but
difficult to completely assess. Magnetic
resonance imaging (MRI) was not routinely used.
Several authors who have studied the
use of MRI in tibial plateau fractures
believed MRI improved the reliability of
classification and changed their operative
plan 19% to 23% of the time.11-15
However, it is difficult to predict whether
patient outcome changed when MRI was
obtained.
In this study, after a fracture was identified, treatment options were discussed
with the patient. Patients with nondisplaced fractures were exclusively treated
conservatively with casts and braces;
these patients were monitored closely to
ensure reduction was maintained.
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3A
3B
3C
3D
3E
3F
Figure 3: Preoperative AP (A) and lateral (B) radiographs showing a tibial plateau fracture. Postoperative radiographs showing internal fixation of the fracture
(C), the healed fracture (D and E), and the healed fracture after hardware removal (F).
Multiple authors have demonstrated fracture braces can be used in patients with
tibial plateau fractures and reduction can
be maintatined.16-19
Patients with minimally displaced
fractures (⬍5 mm) were more difficult to
place in the appropriate treatment group.
Elderly patients with severe osteopenia
and poor medical health were treated conservatively; work by Keating20 supports
this treatment.
Elderly patients who had better bone
and were more active were treated surgically. Levy et al21 examined surgically
treated tibial plateau fractures in elderly
patients with an average follow-up of 11
years. Fifteen (79%) of 19 patients had
excellent or good results. The authors
DECEMBER 2004 | Volume 27 • Number 12
reported that in the elderly population,
internal fixation of tibial plateau fractures
was beneficial in achieving good functional results. Others also support this
approach.22
Patients with open injuries in this
study were treated with external, internal,
or a combination of both fixation types.
Only patients with at least partial internal
fixation were included in this study. The
type of fixation chosen was based on size
of the wound and the mechanism of
injury. Clean, small, low-energy open tibial plateau fractures were treated with
internal fixation. For all other fractures,
some form of at least temporary external
fixation was used.
Dendrinos et al23 reviewed their expe-
rience with high-energy tibial plateau
fractures. Depending on the condition of
the soft tissue, patients were treated with
Ilizarov fixators or internal fixation. All
fractures healed by an average of 14
weeks, and there were no cases of postoperative skin infection, osteomyelitis, or
septic arthritis.
Others have reported similar success
using internal fixation in high-energy and
often open fractures.9,24 This represents
the bulk of the fractures in this study,
which were significantly displaced (⬎5
mm) fractures with a good soft-tissue
envelope in active patients who had few if
any medical problems.
A majority of the fractures in this
study were Schatzker type II. In their
1285
■ Feature Article
What is already known on this topic
■ Studies show open reduction and internal fixation is an acceptable treatment
method for displaced tibial plateau fractures.
■ Meniscal injuries are seen in 20% of tibial plateau fractures.
What this article adds
■ This article reports on the largest series of patients.
■ We repaired all peripheral meniscal tears at the time of fracture repair.
■ This article supports the 20% meniscal injury rate.
■ Meniscal retraction from the ACL is helpful in fracture reduction.
series of 49 patients, Touliatos et al9
reported 12 type II fractures, which was
second only to type VI fractures (15). In
another series, Stokel and Sadasivan25
also reported the most common fracture
types to be type II (8) and type VI (8).
However, comparing results across studies is difficult.
In this study, excellent results were
obtained in 82% of type I, 83% in type II,
55% of type III, 67% of type IV, 43% of
type V, and 40% of type VI fractures. As
the fracture complexity increased, the rate
of poor results also increased (Table 3).
When measuring outcome, the greater the
comminution, the more unfavorable the
result. In addition, for type III fractures, in
which osteoporosis is a significant factor,
the number of excellent results was inferior to types I and II.
In the Stokel and Sadasivan25 study,
type II fractures had the best outcome,
which is in agreement with the present
study. The worst results in the present
study occurred in the type VI injuries,
while in the Stokel and Sadasivan25 study,
type IV fractures had the worst outcome.
When all fractures were grouped, of the
20 in the and Sadasivan study, 65% had a
good or excellent outcome.
Schatzker et al7 described the adverse
effects of osteoporosis on the clinical
results. This finding was supported by the
present study, with 55% of type III fractures having a good to excellent result.
One weakness in the present study is
1286
the length of follow-up. The average follow-up was 29 months. Patient condition
could have deteriorated later and would
not have been taken into account.
Concomitant soft-tissue injuries with
tibial plateau fractures have been reported
in up to 56% of cases.26 In the present
series, 33% of cases had soft-tissue
injuries, with meniscal tears being the
most common soft-tissue injury. Bennett
and Browner26 also noted the leading softtissue injury to be meniscal tears, which
were tied with medial collateral injury in
their study. In their retrospective study,
Tscherne and Lobenhoffer27 reported a
21% incidence of lateral meniscal injury.
In a previously published study, we proposed anterior release and elevation of the
meniscus to address the fracture.28 In that
study, peripheral meniscal tears were found
20% of the time during exposure. We make
all attempts to repair these tears to help prevent osteoarthritis. Jensen et al29 demonstrated meniscectomy at time of surgery
carries a higher risk of osteoarthritis.
In the present series, 22% (26) of
patients showed degenerative changes.
Four patients showed severe narrowing of
the joint space. Two patients by last follow-up underwent total knee arthroplasty.
These two both had partial meniscectomy
at the time of initial surgery.
Vascular injury occurred in 2% of
patients. All vascular injuries were repaired
acutely without complication. Ottolenghi30
examined severe injuries about the knee
joint in 1377 patients and also reported a
2% incidence of vascular injury. He noted
the majority of the injuries to the popliteal
artery were due to plateau injuries.
Tscherne and Lobenhoffer27 reported a 3%
rate of vascular injury in 657 patients with
proximal tibia fractures. These reports
reinforce the importance of a careful vascular examination in patients with tibial
plateau fractures.
The incidence of multiple trauma was
approximately 16% in the present study.
In a study of 64 plateau fractures, Blokker
et al31 reported multiple trauma was present in 41% of the patients. This discrepancy may reflect referral patterns.
Delayed complications can be demoralizing for a surgeon after what appears to
be an uneventful immediate postoperative
period. Delayed union or nonunion are
common in tibial plateau injuries and can
be further complicated with infection. Five
cases of delayed union occurred in the 117
patients in this study; 2 of these cases went
on to become nonunions. The incidence of
nonunion in tibial plateau fractures has
been reported to be as low as 0%.32,33 The
rate in the present study was ⬍2%.
The concern of infection accompanies
these injuries. Mallik et al34 reported no
instances of infection with the use of
external fixator other than pin tract infection; in contrast, four of five patients treated with internal fixation developed deep
infection. In this study, infection developed in 5 of 117 cases and was successfully treated by debridement and intravenous antibiotics.
Work by Ballmer et al35 supports low
infection rates in patients treated with
open reduction and internal fixation; their
rate was zero in 17 patients. Work by
Hutson and Zych36 emphasized the difficulty with infection and external fixation
for periarticular fractures and reported an
infection rate of 13%. They recommended
early debridement and intravenous antibiotics.
CONCLUSION
Based on this series, open reduction
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TIBIAL PLATEAU FRACTURES | EBRAHEIM ET AL
and internal fixation is recommended for
tibial plateau fractures with significant
displacement. In selecting patients with
“acceptable” soft tissues, a reasonable
outcome can be expected, even in more
severe injuries. The systematic approach
to treatment described properly triages
and treats the injury compared with the
literature. The complication rate also is
low and in an acceptable range compared
to those reported in the literature.
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