A prospective study of surgical management of dual plating of bicondylar tibial plateau fracture

INTRODUCTION

Tibial condyles with their articular surface forms major part of the knee joint, plays an important role in weight transmission and mobility. The proximal tibia fractures account for 1% of all the fractures, with increase in high velocity traffic accidents the incidence of proximal tibia fractures is also increasing.¹ The goal of treating these bicondylar tibial plateau fractures is to bring back the functional mobility to pre injury status. Hence near anatomical reduction of articular surface, maintenance of mechanical axis and anatomical alignment has to be achieved with stable fixation and early mobilization.² If these high velocity intra/peri articular fractures are not treated properly there will be high degree incidences of malunion, non-union, peri-op infections, varus collapse of the medial condyle, ligamentous instability, malalignment of the axis, articular incongruity leading to post traumatic arthritis. If these bicondylar tibial fractures treated with single plate and lag screw there is high chance of varus collapse, loss of reduction and malunion. Hence a need for fixing both the condyles using separate plate has been advocated, although locked plates have answered the medial collapse problems and locking plates are efficient in holding back coronal fragments. Our study is done to know the clinical outcome of intra and extra articular fracture of distal end of radius treated with open reduction and internal fixation by plating through a volar approach and to study the complications associated with this treatment modality.

METHODS

This study is a clinical observational and prospective study conducted at Department of Orthopaedics at Great eastern medical school and hospital from January 2018 to January 2019. Informed consent was obtained for all the patients in study.

Inclusion criteria

Inclusion criteria were all skeletal mature patients with proximal tibia fracture schatzker type V and VI (>18 years), AO Muller type 41-C1, 41-C2, 41-C3 and gustilo-Anderson type I and II compound proximal tibial fractures patients willing to participate in study.

Exclusion criteria

Exclusion criteria were tibialunicondylar plateau fractures {type I, II, III, IV type of Schatzker classification}, patients with Gustilo - Anderson Type 3 compound proximal tibial fractures, skeletally immature patients, patients with pathological proximal tibial fractures apart from osteoporosis and delayed presentation of fractures more than 2 weeks.

On admission, demographic data was recorded and a thorough history was taken to assess mode of injury and associated co-morbidities. General systematic and local examination were done to asses other associated injuries and open wounds followed by radiological evaluation in AP and lateral views.

Once the diagnosis is confirmed and patient notified about the fracture and need for surgery. His consent is taken and pre op planning done.

Patients were received in the casualty and initially stabilised. Then intramuscular analgesics were given. The injured lower limb was immobilized in an above knee splint and anteroposterior, lateral, oblique X-rays (if required) were taken. Then with minimal traction an above knee slab was applied. Distally the slab was slit open for checking distal pulses. Three-dimension computed tomography was done to assess the fracture pattern. If required calcaneal pin traction was applied for soft tissue injury to heal. Adequate time was given for soft tissue to heal around (5–14 days). Clinical signs of soft tissue recovery included decreased swelling, absence of fracture blisters, wrinkling of skin around proximal tibia.

Complete blood count, ECG, blood urea and serum creatinine, FBS, HBA1C, HIV and HBSAG profiles, blood grouping was done ECG, 2D-ECHO Where necessary, were taken. Selection of appropriate sizes of LCP plates, posterior medial and medial plates and screws, with their corresponding instruments. Appropriate antibiotics and pre-anaesthetic medications were given.

Surgical procedure: Preoperatively IV antibiotics Inj cefeperazone 1g and sulbactum 500 mg were given after test dose as prophylaxis. The patient in supine position with folded pillow under knee and a sand bag under ipsilateral gluteal region for anterolateral approach and a sand bag under contralateral hip with figure of four position of ipsilateral leg for posteromedial approach. First indirect fracture reduction was achieved with longitudinal traction, under C-arm guidance. Percutaneous K wires were used to hold the fragments in reduction. We typically fix medial tibial condyle first. If medial condyle is comminuted, we fix lateral condyle to achieve length. Through posteromedial approach to proximal tibia with approximately 6 cm incision over posteromedial border of proximal tibia. After opening subcutaneous fat, the long saphenous vein and saphenous nerve identified and preserved. Pes anserinus expansions identified. Tibia approached after incising pes anserinus longitudinally in the line of skin incision. The gastronemics muscle was gently freed from posteromedial surface by blunt dissection. The fracture fragments visualized, reduced under c arm guidance. If there was articular depression a bone punch was used to elevate the depressed portion and the void was filled with bone graft. The reduced fragments were fixed with 3.5 mm proximal tibia posterior medial locking plate. The lateral condyle fracture was approached antero laterally. “S” shaped incision was made starting 5 cm proximal to joint line curving the incision anteriorly over gerdy’s tubercle and extend it distally 1cm lateral to anterior border of tibia. Joint capsule was incised. Tibialis anterior was elevated by blunt dissection. Under C arm guidance, fracture reduced and fixed with proximal tibia lateral locking compression plate. If depression was present in articular surface, elevation followed by bone grafting was done if necessary. A drain was kept for both wounds with help of Y connector.

Post-operative protocol

Well-padded sterile dressing was done. Knee was not immobilized. Drain was removed on 48 hrs. Post-operative period. Active knee mobilization was encouraged as much as the patient could tolerate. Suture removal was done on 12th post-operative day with advice to follow up for next 6 months. Patient was discharged with non-weight bearing crutch walking.

Follow up

Patient was reviewed in outpatient department every 4 weeks and X-rays were taken every month for first 6 months to assess union Partial weight bearing was started after 8 weeks. Full weight bearing was allowed after radiological evidence of bony union was achieved. At every follow up, operative site was examined for wound dehiscence and radiological evaluation was done to assess fracture union and any loss of reduction and implant related failure After 6 months patients were reviewed every 2 months. Knee function was assessed and scored according to

Sample size estimation

Total no of cases studied were 30

Sample size = Zα2 x P(1-P) d 2 Zα2= std normal variate at 95% 1.96 P=prevalence d=absolute error eg: Prevalence of tibia fractures=1%

5% error 3.8416×0.01×0.99=0.038032=15 0.0025

Minimum sample size required is 15. 30 cases have been selected for this study

Data were collected and saved in MS Excel spreadsheet & analysed by suitable SPSS software. An unpaired Student's t-test was used to test the significance of means of all qualitative parameters. Categorical parameters analysed by chi- square tests.

RESULTS

This study included 30 patients with tibial plateau fractures diagnosed with Schatzker type V and VI. Most of the patients in our study are males in the age group of 30-40 years.

From the above data it shows that type V and VI tibial plateau fracture is common in age group of 30-39 yrs. of age group. Most of the fractures on the left side compared to right side.

Most common mode of injury was RTA, most common among males in the age group of the 30-39 years of age group.

Time of surgery: the average period from day of injury to surgery was 5.3 days with a range between 3 to 9 days.

Most common complication is knee stiffness among 4 patients which was overcome with strict physiotherapy regimen, two patients had superficial wound infection which was given treated with wound debridement and antibiotic prophylaxis according to culture sensitivity. One patient had skin necrosis, split skin grafting was done. Which improved with regular saline dressing.

Table to be added table 9: components of clinical outcome criteria. Honkonen Jarvinen criteria was used for evaluating clinical, functional and Radiographic results HJ clinical outcome.

None of the patients had extension lag. The average knee flexion was 125.9° with range from 95° to 135°. The reason for fair range of motion in two patients was poor adherence to physiotherapy.

The average thigh atrophy was 0.09 cm with range from 0–1 cm. There was grade1 antero posterior instability in 4 patients

All 30 patients were able to walk excellent. 28 patients had excellent stair climbing function but it was impaired in 2 patients due to pain. 23 patients were able to squat well while it was impaired in 7 patients due to pain. 20 patients were able to jump normally and it was impaired due to pain in 6 patients. 3 patients were able to jump only with the aid of un injured leg. 1 patient was not able to jump. 20 patients were able to duck walk normally and 5 patients were able to keep only a few steps. 4 patients were able to keep only one step 1 patient was unable to do. Graph to be added graph 8: functional outcome results

HJ Radiological outcome 26 patients scored excellent and 4 patients had scored well with <5° plateau tilt compared to opposite side. All 30 patients had excellent results with no varus /valgustilt. 22 patients did not have any articular step off. 8 patients had 1-3 mm articular step. 21 patients had no condylar widening. 9 patients had condylar widening of 1-5 mm. 20 patients did not have any joint space narrowing, 10 patients had 50% joint space narrowing.

DISCUSSION

High energy intra-articular fractures involving the tibial plateau still remain a challenge to orthopaedic surgeons. Road traffic accident is the most common cause of these fractures. In order to reconstruct the stable and painless mobile knee, still needs an expertise and sufficient technical knowledge. These fractures still are challenge for reduction in order to maintain the articular congruity, prevent varus collapse, and prevent the early onset of the secondary osteoarthritis in these complex tibial plateau fractures. Operative treatment remains the optimum treatment for early mobilization, various methods of fixation have been described like external fixation, hybrid fixator, plating through a single midline incision, plating using Mercedes Benz incision. Historically using a poor technique to fix these high-velocity fractures using dual plates fixation using the single incision like Mercedes Benz incision is associated with the many complications this has led to Ilizarov, hybrid external fixator system being employed to treat these fractures. The use of the laterally applied LCP which acts as a fixed angle device were associated with the complication like varus collapse of the medial fragment, as they were stabilised by screws. This raised the question of sustainability of the fixation by isolated lateral plating which further paved way for the dual plating via two incision technique.

A two incision double-plating technique is being recommended by the Association for osteosynthesis/Association for the Study of Internal Fixation for the treatment of bicondylar tibial plateau fractures.³ In our study males predominate the female with the ration of 3.75:1, which shows the more active life style involving the high velocity injury. Which are in accordance with the series of 14 patients reported by Eggli et al in which 10 were male and 4 were female (Table 1).³ Among 30 patients most common mode of injury being the road traffic accident, left side being more commonly involved than right side, we had 19 schatzker type VI and 11 schatzker type, When AO classification was considered most common type was AO 41C3 followed by AO41C2, and AO41C1 (Table 2 and Figure 1). Our study used Honkonen Jarvinen criteria for radiological, functional, clinical outcome which showed excellent to good result (Table 3). Our study reported Honkonen Jarvinen clinical outcome to be 86% excellent, 11.7% good and 1.7% fair. The functional outcome was 81% excellent, 13% good, 5% fair and 1% poor. The Radiological outcome showed 79.28% excellent, 20.72% good, 0.70% fair results (Table 4 and 5).

Most common complication encountered in the study was the knee stiffness (13.3%) in 4 patients associated with poor compliance with protocols and follow up, further superficial wound infection noticed in two patients (10%) who were taken up for wound debridement. Skin necrosis was another complication noticed in 1 (3%) our study which was dealt with regular saline dressing, skin grafting was done (Figure 2). One implant has been removed at the end of study with complete union, we noticed knee stiffness has predominately affects outcome than the wound infection or the skin necrosis, there was no cases of non-union and all fractures had either united or were uniting by the end of 1-year follow-up. There were also no cases of implant related failures like screw back out or implant breakage.

Tul B Pun et al in his study reported the outcome of 17 tibial plateau fractures.⁹ of which were managed by dual plating and 8 managed by hybrid ex fix. Based on Honkonen Jarvinen criteria all patients could walk, climb stairs, jump, 90% could squat, 50% could duck walk. 85% had plateau tilt <2 mm. No major infection.⁸ Ebrahim Ghayem Hassankhani et al in his study reported 22 patients with tibial plateau fractures treated with dual plating. The outcome was assessed based on knee society score. 86. 4% had excellent.⁹ 1% had good, 4. 5% had fair and no one showed poor results.⁹ Neogi et al in their study have shown that the dual plating for bicondylar tibial fracture has better outcome than a single lateral locking plate as dual plating gives better anatomical reduction of the proximal tibia (Table 6).¹⁰

Limitations

Small sample size is one of limitations followed by short term study.

CONCLUSION

From present study high velocity tibial plateau fracture have excellent to good clinical, functional and radiological outcome. Early mobilisation of the joint provides good range of motion. Posteromedial plating provides a buttress to posteromedial fragment and thereby prevents varus collapse. The patients with good soft tissue cover should undergo anatomical reduction and rigid fixation immediately without deferring time. This is a short term study and need long term follow up to predict the further outcome.

We conclude that dual plating is ideal for all bicondylar tibial plateau fracture of Schatzker type V and VI with appropriate timing of surgery and understanding the anatomy, LCP system, appropriate technique with dual incision, the complication can be minimized, giving excellent to good results.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

REFERENCES

1. 1. Marsh JL, Karam MD. Tibial plateau fractures: chapter 55 Rockwood and Green fracture in adults 8thediton vol 2Wolters Kluwer health 2015
2. 2. Prasad GT, Kumar ST, Kumar RK, Murthy GK, Nandkumar Sundaram Functional outcome of Schatzker type V and VI tibial plateau fractures treated with dual plates Indian Journal of Orthopaedics: March. 2013:47:2.
3. 3. Zhang Y. Treatment of Complicated Tibial Plateau fractures with Dual Plating via 2 incision technique," Orthosupersite.com; 2012:35;3.
4. 4. Eggli et al. Unstable Bicondylar Tibial Plateau Fractures : A Clinical Investigation. J Orthop Trauma. 2008;22:673–9.
5. 5. Honkonen SE, Jarvinen MJ. Classification of fractures of the tibial condyles. J Bone Joint Surg Br. 1992;74:840‐7
6. 6. Barei DP, Nork SE, Mills WJ, Coles CP, Henley MB, Benirschke SK. Functional outcomes of severe bicondylar tibial plateau fractures treated with dual incisions and medial and lateral plates. JBJS. 2006;88(8):1713-21.
7. 7. Rohra N, Suri HS, Gangrade K. Functional and Radiological Outcome of Schatzker type V and VI Tibial Plateau Fracture Treatment with Dual Plates with Minimum 3 years follow-up: A Prospective Study. J Clinic Diagnost Res. 2016;10(5):RC05-10
8. 8. Pun TB. Outcome of Schtazkers type 5 and type 6 fractures. Ind J Orthopaed. 2014;48:1.
9. 9. Hassankhani EG. Treatment of Complex Proximal Tibial fractures (Type 5 & 6 Scatzker Classification) by Double Plate fixation with Single Anterior Incision. J Orthopaed. 2013;3:208-12.
10. 10. Neogi DS, Trikha V, Mishra KK, Shiva, Bandekar M, Yadav CS. Comparative study of single lateral locked plating versus double plating in type C bicondylartibial plateau fractures. Ind J Orthopaed. 2015;49:2.