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KNEE Table of Contents   
Year : 2002  |  Volume : 36  |  Issue : 4  |  Page : 246-250
Minimal invasive osteosynthesis: a biological approach in treatment of tibial plateau fractures


Department of Orthopaedic Surgery, Physical Medicine, Paraplegia, and Rehabilitation, Pt. B.D. Sharma Post Graduate Institute of Medical Sciences Rohtak, India

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   Abstract 

Twenty five patients with 26 tibial plateau fractures were treated with closed reduction by ligamentotaxis and minimal internal fixation with screws / wires, under C-arm image intensifier control. Patients were evaluated at a mean of 26 months after injury. Union was achieved in all the fractures with an average duration of 12.08 weeks. The average range of motion was 107.8. Partial weight bearing was allowed approximately at 8-12 weeks (average 8.92 weeks) and full weight bearing after complete union of fracture (average 13.12 weeks). Ninety two percent of the patients had satisfactory outcome using Rasmussen's criteria. We conclude that the technique is more biological, requires less surgical time and hospital stay and is devoid of major complications and leads to a better functional outcome.

Keywords: Tibial plateau fractures- Biological- Minimal invasive osteosynthesis.

How to cite this article:
Sangwan S, Siwach R, Singh R, Mittal R. Minimal invasive osteosynthesis: a biological approach in treatment of tibial plateau fractures. Indian J Orthop 2002;36:246-50

How to cite this URL:
Sangwan S, Siwach R, Singh R, Mittal R. Minimal invasive osteosynthesis: a biological approach in treatment of tibial plateau fractures. Indian J Orthop [serial online] 2002 [cited 2018 Dec 17];36:246-50. Available from: http://www.ijoonline.com/text.asp?2002/36/4/246/35943

   Introduction Top


High energy complex tibial plateau fractures being intraarticular are usually associated with injury to ligaments, capsule and other soft tissues surrounding the joint. They present multifaceted problems of difficulty of achieving accurate joint reconstruction. The management of tibia plateau fractures has remained controversial and the objective of stable, pain free knee joint with a functional range of motion (ROM) eluded most of the treatment modalities. Non-operative modalities like casts [1] , braces [2] or traction [3],[4] A are complicated by inherent risks of poor functional results and prolonged hospital stay.

Open reduction and internal fixation has a significant complication rate. [5],[6] So a middle path of minimally invasive techniques of closed reduction by ligamentotaxis and stabilizing the fractures by limited internal fixations, is being developed and practiced to overcome the drawbacks of non-operative and operative modalities. [7],[8],[9],[10],[11] These techniques utilized percutaneous screws and Kirschner wires (K- wires) [7],[8],[9] external fixation frames, [10] or combination of external fixation with limited internal fixation [11] , to stabilize tibial plateau fractures. The minimally invasive technique of closed reduction by ligamentotaxis and fixation with percutaneous screws and K- wires, combines attributes to both operative and non-operative philosophies, is more biological and gives excellent functional results. [7],[8],[9] In lights of these benefits, we present our clinical results for this technique.


   Material and Methods Top


From January 1997 to December 1999, 25 patients with 26 tibial plateau fractures were treated by closed reduction by ligamentotaxis and percutaneous screw/K- wire fixation. The patients were aged from 21 to 50 years (average 35.5 years) with a male to female ratio of 11.5 to 1. The mechanisms of injury were traffic accident (21 patients), hit by animal (2 patients), fall from height (1 patient) and sport injury (1 patient). Ten patients suffered from additional major fractures and ipsilateral fracture shaft femur was the most common (20%). Other injuries included contralateral fracture shaft femur, fracture leg bones, supracondylar and medial condyle fracture femur, fracture neck femur, head injury and patellar tendon avulsion. The fractures were graded, using the criteria of Schatzker et al [5] , as type I (nine), type II (one), type IV Schatzker et al [5] , as type I (nine), type II (one), type IV (five), type V (two) and type VI (eight). The mean delay to surgery was 5.76 days (range 1-26 days).

Haemarthrosis, wherever significantly present was aspirated and limb was raised. Injured limb was initially splinted using a plaster of Paris (POP) back splint or in some patients by skin or skeletal traction (patients with associated shaft femur fracture or type VI fractures with marked comminution) till definitive management.

Surgical Technique: During the operation, patient was positioned supine and tourniquet was used in cases where bone grafting was done. The part was cleaned and drapped in such a manner that the limb was free for manipulation during the operation. Actual technique varied according to the type of fracture. Reduction of fracture was done by closed methods using principle of ligamentotaxis. Valgus or varus strain was applied along with traction, either in flexion or extension of knee as per the need of the individual case. Patellar or compression clamp was used, whenever necessary to bring together the fracture fragments. After confirming the reduction under C-arm image intensifier, fracture fixation was done.

Pure cleavage or wedge type of fractures were stabilized using percutaneous screws or Kirschner wires or combination [Figure 1(a)],[Figure 1(b)]. In case of cleavage combined with depression type of fracture, under tourniquet, an incision was made on the anterolateral aspect centering the fracture site. After minimally reflecting the soft tissues, a cortical window was made and depressed articular fragments were elevated followed by bone grafting in the resultant cavity. Under image intensifier elevation was confirmed and the condyle was fixed with a Kirschner wire and 6.5 mm cancellous lag screw with a washer. Bicondylar fractures were managed by closed reduction and fixation with cross Kirschner wires introduced under C-arm image intensifier. If necessary to achieve reduction, Kirschner wire was introduced into the fracture fragment and manipulation was done to achieve reduction. On satisfactory reduction, the K- wire was introduced further to engage opposite cortex to fix the fragment. Similarly another K- wire was introduced from other side. In cases where dissociation of diaphysis and metaphysis was there (type VI fractures), in addition to limited internal fixation to maintain the articular congruity as described above, some form of external support in the form of POP splint or across the knee external fixation was used.

The patients were followed up monthly for first 4 months and then every 3-4 months, for one year and then yearly. The patients were reviewed at mean of 26 months after injury (range 7-43 months). Rasmussen's [12] criteria was used to evaluate the final outcome.


   Results Top


The average duration of hospitalization was 6 days (range 2-17 days). Most common implants used for fixation were 6.5 mm cancellous screws (11 patients), combination of screws and K- wire (9 patients) and only K- wire (5 patients). No preoperative arthrotomy, menisectomy or ligament repair was done. In 19 patients postoperative external support was given in form of POP back slab (16 patients) and across the knee fixator (3 patients). Average time gap between operation and partial weight bearing was 8.92 weeks (range 8-12 weeks). Patients with associated injuries like neck and shaft femur had delayed weight bearing. Clinical and radiological union was achieved in average of 12.08 weeks [Figure 1(c)] (range 11-16 weeks). Most of the patients (92%) were allowed complete weight bearing at 11-14 weeks and only two patients (8%) had delayed complete weight bearing (one patient with ipsilateral neck fracture and second with ipsilateral shaft with medial condyle femur fracture). Average time gap for complete weight bearing was 13.12 weeks. Most of patients (60%) had 120 or more range of motion and one patient had less than 90 range of motion. Average range of motion was 107.8. Sixteen patients had no pain, 8 patients had occasional pain and only one patient had stabbing pain. Nineteen patients had normal walking capacity and one patient had restriction of walking. Normal extension of knee was observed in 21 patients and lack of extension (5-10) was there in 4 patients. Only two patients had instability at last follow up.

Final end results as per the Rasmussen's criteria were excellent 12, good 11, fair 2 and no poor result. Final end results were satisfactory in 23 (92%) cases and average score was 24.24.

Complications included inadequate reduction in one patient leading to grade II osteoarthrosis, infection and loosening of screw requiring screw removal in one patient, pin site infection in one patient and restricted range of motion of knee in one patient. Two patients had mild varus (2 and 5) deformity when compared with the contralateral knee. No non-union, wound dehiscence, compartment syndrome or nerve palsy was observed. Two patients required screw removal at 12 and 18 months respectively as head or tip was pinching the patients.


   Discussion Top


Ever since the earliest documentable description of tibial plateau fractures, various treatment methods have evolved ranging from splinting, traction, cast bracing to open reduction and internal fixation, with each method having its merits and demerits. [1],[2],[3],[4],[5] The ideal outcome after a tibial plateau fracture is a stable, pain free, non osteoarthritic knee with a functional range of motion. There is a universal agreement that accurate restoration of joint surface, stable fixation and early knee motions are equally important. [13],[14] To overcome the demerits of both the operative and non-operative philosophies and to combine the beneficial attributes of these, minimally invasive techniques are being developed and utilized. [7],[8],[9],[10],[11],[15]

All the fractures in the present study were managed by closed ligamentotaxis and using limited internal fixation. Although it is easier to achieve accurate reduction by open methods, but it has its own limitations. [5],[6] Proponents of open reduction also emphasize that menisectomy or any ligamentous repair, if required can be done at the time of open reduction, but the increased risk of osteoarthrosis after menisectomy has been reported. [17] Minimal internal fixation has benefits of minimum hardware problems, less skin and soft tissue handling, minimum chances of infection [7],[9],[10],[11] . Achieving reduction by close ligamentotaxis has its own share of complications eg. inadequate reduction, necessity of image intensifier C-arm and radiation exposure. We observed inadequate reduction in one case, although clinical score was acceptable but patient had grade II osteoarthrosis after 2.1 year of follow up. Long term functional results may not be good in this case. But these advantages of this method of reduction, in terms of better final clinical and functional results for the patients can not be ignored.

The minimal internal fixation using K- wires or screws is a very suitable method for Schatzker type I, II, IV and V fractures, where a large fragment need to secured. In case of type II fractures, after elevation of surface, the split off lateral wedge shaped fragment can be secured with a screw and washer. Washer acts as a one hole plate, giving a buttress effect. [8] We have no experience with type III fractures and as regards to type VI fractures where dissociation of diaphysis and metaphysis is there, screw or K- wires can be used for intraarticular fracture, but for the metaphysis-diaphysis dissociation, additional support is necessary. We have used cross K- wires either along with external fixation (3 cases) or POP back slab (5 cases) to take care of the metaphyseal-diaphyseal dissociation. [9],[11],[18]

Patients were allowed complete weight bearing only on evidence of union, with an average of 13.12 weeks. The discrepancy of average time of union and weight bearing is due to the fact that most of the patients had associated injuries and could not be made ambulatory early.

There was no case of skin necrosis, impaired sensation in the skin or wound gaping as usually reported with series of open reduction and internal fixation. [5],[6],[19] No case of deep vein thrombosis was observed as the patients were mobilized early, in contrast to the treatment by traction methods. [13] There was one patient of deep infection and subsequent loosening of implant. Less incidence of infection (4%) is due to aseptic techniques, minimum soft tissues handling, small incision and minimum duration of surgery. This gives the method an edge over the open methods where extensive exposures are made and lot of hardware is used especially in bicondylar fractures. [9] Two patients needed screw removal after union at 12 and 18 months respectively since screw head/tip started pinching them. Two cases (8%) with varus deformity had intact fibula. Scheerlink et al [9] observed 5 to 10 of this axial malalignment in 15.8% of their patients. Only two cases during follow up examination showed instability of the knee, but none had symptoms relevant to instability or meniscal abnormality. This may be related to the fact that the patients bone has absorbed most of the energy that would have been directed at these soft tissue elements. [18] Furthermore, perarticular fibrosis after soft tissue injuries around the knee may be responsible for the absence of symptoms relevant to instability.

Most of the patients were pain free and had normal walking capacity. These observation correlate well with those of reported in literature. [7],[20] Good range of motion (average 107.8) at knee can be attributed, to early knee motion. [14] Open reduction increases fibrosis and thus decrease subsequent range of motion, but this difficulty is minimally seen with less invasive methods. [7],[10]

Although the series is small, but the results are extremely satisfactory and encouraging in 92% of patients (excellent 48% and good in 44%); same experiences have been reported in the literature with similar methods of treatment. [7],[11],[15] Percutaneous and minimal fixation methods are more biological, require less surgical time, hospital stay, have minimum complications and have a good functional outcome. As a result the economic loss to the patient and ultimate cost of treatment are much less. The various techniques of minimal fixation can be, combined to overcome the individual shortcomings of a particular technique according to the demand of an individual fracture, for a better ultimate functional outcome.

 
   References Top

1.Drennan DB, Locher FG, Maylahn DJ. Fractures of tibial plateau - treated by closed reduction and spica cast. J Bone Joint Surg [Am] 1979; 61-A: 989-95.  Back to cited text no. 1    
2.Scotland T, Wardlaw D. The use of cast bracing in tratment of fracture of tibial plateau. J Bone Joint Surg [Br] 1981; 63-B: 575-8.  Back to cited text no. 2    
3.Apley AG. Fracture of tibial plateau. Ortho Clin North Am 1979; 10: 61-65.  Back to cited text no. 3    
4.Apley AG. Fractures of the lateral tibial condyle treated by skeletal traction and early mobilization. A review of 60 cases with specific reference to long term results. J Bone Joint Surg [Br] 1956; 38-B: 699-708.  Back to cited text no. 4    
5.Schatzker J, McBroom R, Bruce D. The tibial plateau fracture: the Toronto experience 1968-1975. Clin Orthop 1979; 138: 94-104.  Back to cited text no. 5    
6.Young MJ, Barrack RL. Complications of internal fixation of tibial plateau fractures. Orthop Rev 1994; 23: 149-154.  Back to cited text no. 6    
7.Keogh P, Kelly C, Cashman WF, McGuinness AJ, O'Rourke SK. Percutaneous screw fixation of tibial plateau fractures. Injury 1992; 23: 388-90.  Back to cited text no. 7    
8.Duwelius PJ, Rangitsh MR, Colville MR, Scottwall T. Treatment of tibial plateau fractures by limited internal fixation. Clin Orthop 1997; 339: 47-57.  Back to cited text no. 8    
9.Scheerlink T, Ng CS, Handelberg F, Casteleyn PP. Medium-term results of percutaneous, arthroscopically assisted osteosynthesis of fractures of the tibial plateau. J Bone Joint Surg [Br] 1998; 80-B: 959-64.  Back to cited text no. 9    
10.Mikulak SA, Gold SM, Zinar DM. Small wire external fixation of high energy tibial plateau fractures. Clin Orthop 1998; 356: 230-38.  Back to cited text no. 10    
11.Marsh JL, Smith ST, Do TT. External fixation and limited internal fixation for complex fractures of the tibial. J Bone Joint Surg [Am] 1995; 77-A: 661-73.  Back to cited text no. 11    
12.Rasmussen PS. Tibial condylar fractures: Impairment of knee joint stability as an indication for surgical treatment. J Bone Joint Surg [Am] 1973; 55-A: 1331-4.  Back to cited text no. 12    
13.Blokker CP, Rorabeck CH, Bourne RB. Tibial plateau fractures. An analysis of the results of treatment in 60 patients. Clin Orthop 1984; 182: 193-9.  Back to cited text no. 13    
14.Gausewitz S, Hohl M. The signifcance of early motion in the treatment of tibial plateau fractures. Clin Orthop 1986; 202: 135-8.  Back to cited text no. 14    
15.Lansinger O, Bergman B, Korner L, Andersson GBJ. Tibial condylar fractures: A twenty year follow up. J Bone Joint Surg [Am] 1986; 68-A: 13-19.  Back to cited text no. 15    
16.Schatzker J. Fractures of the tibial plateau. In: Schatzker J, Tile M (editors). The Rationale of Operative Orthopaedic Care. New York: Springer-Verlag. 1988: 279-95.  Back to cited text no. 16    
17.Jensen DB, Rude C, Duus B, Bjerg-Nielsen A. Tibial plateau fractures. A comparison of conservative and surgical treatment. J Bone Joint Surg [Br] 1990; 72-B: 49-52.  Back to cited text no. 17    
18.Gaudinez RF, Mallick AR, Szporn M. Hybrid external fixation of comminuted tibial plateau fractures. Clin Orthop 1996; 328: 203-10.  Back to cited text no. 18    
19.Porter BB. Crush fractures of the lateral tibial condyles - Factors influencing prognosis. J Bone Joint Surg [Am] 1970; 52-A: 676-87.  Back to cited text no. 19    
20.Koval KJ, Sanders R, Borrelli J et al. Indirect reduction and percutaneous screw fixation of displaced tibial plateau fractures. J Orthop Trauma 1992; 6: 340-46.  Back to cited text no. 20    

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Correspondence Address:
SS Sangwan
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    Abstract
    Introduction
    Material and Methods
    Results
    Discussion
    References
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