Open Reduction and Internal Fixation of 117 Tibial Plateau Fractures

Transcription

1 SPOTLIGHT ON 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 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. Tibial 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 casting 1 and bracing to skeletal traction and early motion 2 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 al 3 reported a 31% fixation failure rate for tibial plateau fractures in their elderly population. Stevens et al 4 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 Marsh 5 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 al 6 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 examines 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 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: 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 DECEMBER 2004 Volume 27 Number

2 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. 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 TABLE 1 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 system 8 (Table 2). Trends also were looked for to help surgeons predict patient outcomes. RESULTS Final follow-up information reflected patients status at their most recent clinic visit. Average follow-up was 29 months (range: 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- Fixation Method by Schatzker Type for 117 Tibial Plateau Fractures Schatzker Type Fixation Method I II III IV V VI Total K-wires Screws K-wires & screws Buttress plate Buttress plate & K-wires Buttress plate & screws Buttress plate & compression plate 1 1 Two buttress plates Two buttress plates & compression plate 2 2 Two buttress plates & K-wires 3 3 Two buttress plates & screws 1 1 Total ORTHOPEDICS

3 TIBIAL PLATEAU FRACTURES EBRAHEIM ET AL TABLE 2 Rasmussen Functional Grading Criteria Satisfactory Unsatisfactory Points Excellent Good Fair Poor Subjective complaints Pain No pain 6 Occasional ache, bad weather pain 5 Stabbing pain in certain positions Afternoon pain, intense, constant pain around knee after activity 2 Night pain at rest 0 Walking capacity Normal walking (in relation to age) 6 Walking outdoors at least 1 hour Short walks 15 minutes 2 Walking indoors only 1 Wheelchair or bedridden 0 Clinical signs Extension Normal 6 Lack of extension(0-10 ) Lack of extension ( 10 ) 2 Total range of motion At least At least At least At least 60 2 At least Stability Normal stability in extension and 20 of flexion 6 Abnormal stability in 20 of flexion Instability in extension ( 10 ) 4 Instability in extension ( 10 ) 2 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 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 radiographs 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 DECEMBER 2004 Volume 27 Number

4 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 I II III IV V VI Total Excellent Good Fair Poor Total 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 narrowing; 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 al 9 reported an excellent result in 57% of 49 patients, while Lachiewicz and Funcik 10 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 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 ORTHOPEDICS

5 TIBIAL PLATEAU FRACTURES EBRAHEIM ET AL 3A 3B 3C 3D 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). 3E 3F Multiple authors have demonstrated fracture braces can be used in patients with tibial plateau fractures and reduction can be maintatined 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 Keating 20 supports this treatment. Elderly patients who had better bone and were more active were treated surgically. Levy et al 21 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 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 al 23 reviewed their experience 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 DECEMBER 2004 Volume 27 Number

6 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 al 9 reported 12 type II fractures, which was second only to type VI fractures (15). In another series, Stokel and Sadasivan 25 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 Sadasivan 25 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 Sadasivan 25 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 al 7 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 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 Browner 26 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 Lobenhoffer 27 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 al 29 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. Ottolenghi 30 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 Lobenhoffer 27 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 al 31 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 al 34 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 al 35 supports low infection rates in patients treated with open reduction and internal fixation; their rate was zero in 17 patients. Work by Hutson and Zych 36 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 1286 ORTHOPEDICS

7 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. REFERENCES 1. DeCoster TA, Nepola JV, el-khoury GY. Cast brace treatment of proximal tibia fractures. A 10-year follow-up study. Clin Orthop. 1988; 231: Apley AG. Fractures of the tibial plateau. Orthop Clin North Am. 1979; 10: Ali AM, El-Shafie M, Willett KM. Failure of fixation of tibial plateau fractures. J Orthop Trauma. 2002; 16: Stevens DG, Beharry R, McKee MD, Waddell JP, Schemitsch EH. The long-term functional outcome of operatively treated tibial plateau fractures. J Orthop Trauma. 2001; 15: Weigel DP, Marsh JL. High-energy fractures of the tibial plateau. Knee function after longer follow-up. J Bone Joint Surg Am. 2002; 84: Westmoreland GL, McLaurin TM, Hutton WC. Screw pullout strength: a biomechanical comparison of large-fragment and smallfragment fixation in the tibial plateau. J Orthop Trauma. 2002; 16: Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto experience Clin Orthop. 1979; 138: Rasmussen PS. Tibial condylar fractures. Impairment of knee joint stability as an indication for surgical treatment. J Bone Joint Surg Am. 1973; 55: Touliatos AS, Xenakis T, Soucacos PH, Soucacos PN. Surgical management of tibial plateau fractures. Acta Orthop Scand Suppl. 1997; 275: Lachiewicz PF, Funcik T. Factors influencing the results of open reduction and internal fixation of tibial plateau fractures. Clin Orthop. 1990; 259: Yacoubian SV, Nevins RT, Sallis JG, Potter HG, Lorich DG. Impact of MRI on treatment plan and fracture classification of tibial plateau fractures. J Orthop Trauma. 2002; 16: Holt MD, Williams LA, Dent CM. MRI in the management of tibial plateau fractures. Injury. 1995; 26: Colletti P, Greenberg H, Terk MR. MR findings in patients with acute tibial plateau fractures. Comput Med Imaging Graph. 1996; 20: Kode L, Lieberman JM, Motta AO, Wilber JH, Vasen A, Yagan R. Evaluation of tibial plateau fractures: efficacy of MR imaging compared with CT. AJR Am J Roentgenol. 1994; 163: Barrow BA, Fajman WA, Parker LM, Albert MJ, Drvaric DM, Hudson TM. Tibial plateau fractures: evaluation with MR imaging. Radiographics. 1994; 14: Brown GA, Sprague BL. Cast brace treatment of plateau and bicondylar fractures of the proximal tibia. Clin Orthop. 1976; 119: Scotland T, Wardlaw D. The use of cast-bracing as treatment for fractures of the tibial plateau. J Bone Joint Surg Br. 1981; 63: Drennan DB, Locher FG, Maylahn DJ. Fractures of the tibial plateau. Treatment by closed reduction and spica cast. J Bone Joint Surg Am. 1979; 617: Delamarter R, Hohl M. The cast brace and tibial plateau fractures. Clin Orthop. 1989; 242: Keating JF. Tibial plateau fractures in the older patient. Bull Hosp Jt Dis : Levy O, Salai M, Ganel A, Mazor J, Oran A, Horoszowski H. The operative results of tibial plateau fractures in older patients: a longterm follow-up and review. Bull Hosp Jt Dis. 1993; 53: Hsu CJ, Chang WN, Wong CY. Surgical treatment of tibial plateau fracture in elderly patients. Arch Orthop Trauma Surg. 2001; 121: Dendrinos GK, Kontos S, Katsenis D, Dalas A. Treatment of high-energy tibial plateau fractures by the Ilizarov circular fixator. J Bone Joint Surg Br. 1996; 78: Watson JT. High-energy fractures of the tibial plateau. Orthop Clin North Am. 1994; 25: Stokel EA, Sadasivan KK. Tibial plateau fractures: standardized evaluation of operative results. Orthopedics. 1991; 14: Bennett WF, Browner B. Tibial plateau fractures: a study of associated soft tissue injuries. J Orthop Trauma. 1994; 8: Tscherne H, Lobenhoffer P. Tibial plateau fractures. Management and expected results. Clin Orthop. 1993; 292: Padanilam TG, Ebraheim NA, Frogameni A. Meniscal detachment to approach lateral tibial plateau fractures. Clin Orthop. 1995; 314: Jensen DB, Rude D, Duus B, Bjerg-Nielsen A. Tibial plateau fractures. A comparison of conservative and surgical treatment. J Bone Joint Surg Br. 1990; 72: Ottolenghi CE. Vascular complications in injuries about the knee joint. Clin Orthop. 1982; 165: Blokker CP, Rorabeck CH, Bourne RB. Tibial plateau fractures. An analysis of the results of treatment in 60 patients. Clin Orthop. 1984; 182: Moore TM, Patzakis MJ, Harvey JP. Tibial plateau fractures: definition, demographics, treatment rationale, and long-term results of closed traction management or operative reduction. J Orthop Trauma. 1987; 1: Gill TJ, Moezzi DM, Oates KM, Sterett WI. Arthroscopic reduction and internal fixation of tibial plateau fractures in skiing. Clin Orthop. 2001; 383: Mallik AR, Covall DJ, Whitelaw GP. Internal versus external fixation of bicondylar tibial plateau fractures. Orthopaedic Review. 1992; 21: Ballmer FT, Hertel R, Notzli HP. Treatment of tibial plateau fractures with small fragment internal fixation: a preliminary report. J Orthop Trauma. 2000; 14: Hutson JJ Jr, Zych GA. Infections in periarticular fractures of the lower extremity treated with tensioned wire hybrid fixators. J Orthop Trauma. 1998; 12: DECEMBER 2004 Volume 27 Number