1. Surgical principles of treatment for tibial plateau fractures
Obada B., Serban Al.O., Botnaru V., Alecu Silvana-Crina
Orthopaedic-Traumatology Clinic of Constanta, Romania
Objective
The study aim to establish some clear principles of therapeutic approach, so as the current therapeutic moment not to become a simple stage to a future knee arthroplasty.
Material. Methods.
64 tibial plateau fractures were studied from Jan 2012 to Dec 2013 and followed-up for minimum period of 6 months. The systematisation of the casuitry was made using Schatzker and AO classifications. Arthrosis risk was evaluated using Kellgren/Lawrence score. Functional evaluation of the knee was made using Lysholm score.
Results. Discussions.
Mandatory imagistic investigations for preoperative planning
Xray, CT, CT3D, MRI
Treatment objectives
anathomic reconstruction
stable fixation
vascularity preservation
early mobilisation
Demographic profile
Criteria No
Mean age (years)
46 (20-67)
Mean follow-up (month) 11
Sex (male/female)
39/25
Low /high energy trauma
19/45
Falling from height 34
Car accident 21
Other etiologies 9
Type 41B 36
Type 41C 28
MRI at 1 year after surgery
Lateral meniscus lesions
53%
Medial meniscus lesions
19%
ACL lesions
21%
Osteosynthesis methods
Provisional ExFix 6
CRIF
Cannulated screws 8
ORIF
1 plate
nonblocking 16
blocking 13
2 plates 11
1 nonblocking + 1 blocking 10
Bone graft 14
Important aspects to consider
Depression – submeniscal approach, checked in frontal and sagital view
Correct width of the plateau after reduction – anathomic relation with condyles, butress effect of the plate
Metaphiseal fixation – one plate for each columne (medial and lateral)
Subchondral deffect – bone graft
Soft tissue monitorisation (Schatzker V,VI and AO 41C)
Crucial question – When is the optimal surgical moment?
Delay period of time was between 7-12 days.
Damage control
Provisional external fixation ensure:
bone and soft tissue stability
control length, axis, rotation
indirect reduction through ligamentotaxis
Indications for ExFix:
unstable fractures
risk of compartmental syndrome
soft tissue lessions
Surgical approaches
anterolateral, posteromedial, posterior
Fracture 41-B1, Schatzker IV, postero-internal fragment. Locking plate osteosynthesis.
41-C2, Schatzker V, 2 locking plates. 6 months after surgery. Full weight bearing.
41-C2, Schatzker V –postoperative and at 6 months.
41-C3, Schatzker VI. ExFix, locking plate.
41-C3, Schatzker V. 2 locking plates. 3, 6 months after surgery. Algodistrophy
Radiologic evaluation of arthrosis at 1 year after surgery
41-C2, Schatzker VI. ExFix, locking plate.
41-C3, Schatzker VI. 1 locking and 1 nonlocking plates. 6, 9 months after surgery.
Functional evaluation of knee at 1 year after surgery
41-B3, Schatzker II. Locking plate and bone graft after 1 year.
41-C2, Schatzker V – 2 nonlocking plates at 1 year.
41-C2, Schatzker V – 1 locking and 1 nonlocking plates at 1 year.
41-B3, Schatzker II. Nonlocking plate, bone graft. Aspects at 1 year.
Conclusions
A correct surgical management of tibial plateau fractures will give excellent anatomical reduction and rigid fixation to restore articular congruity, facilitate early motion, reduce arthrosis risk and hence to achieve optimal knee function. The choice of optimal surgical methods, proper approach and implant is made personalised in relation to fracture type according Schatzker and AO classification. There is no significant difference reagarding arthrosis risk for the type B and C fractures. Arthrosis is generally well tolerated.