UNIVERSITY OF SEYCHELLES

Transcription

1 ASSESSMENT OF RESULTS OF DIFFERENT MODALITIES OF TRATMENTS IN FRACTURES OF TIBIAL PLATEAU DISSERTATION SUBMITTED TO THE UNIVERSITY OF SEYCHELLES (AMERICAN INSTITUTE OF MEDICINE (USAIM) IN FULFILLMENT OF THE REGULATION FOR THE AWARD OF M.Ch.(Orthopaedics) CERTIFICATION PROGRAMME EXAMINATION TO BE HELD IN JANUARY 2012 BY DR. PRAMOD P. RAJUSKAR GUIDE DR. RAJIV ARORA DEPARTMENT OF ORTHOPAEDICS ATHARV MEDICAL FOUNDATION & RESEARCH CENTER, SANGAMNER ATHARV ACCIDENT, EYE & GENERAL HOSPITAL SAIJYOT COMPLEX, LINK ROAD, SANGAMNER; DIST- AHMEDNAGAR i

2 C E R T I F I C A T E This is to certify that Dr. Pramod P. Rajuskar has prepared the dissertation titled, Assessment of Results of Different Modalities of treatments in Fractures of Tibial Plateau for the degree of M.Ch.(Orthopaedics) examination to be held in January 2012 The dissertation was done under my guidance and to my entire satisfaction. Dr. RAJIV ARORA M.S. (Orth.) D. Orth. H.O.D. & Guide DEPARTMENT OF ORTHOPAEDICS Atharv Medical Foundation & Research Center, Sangamner ATHARV HOSPITAL Sai-jyot Complex, Link Road, Sangamner; Dist- Ahmednagar , (MAHARASHTRA) - INDIA ii

3 ABSTRACT Assessment of Results of Different Modalities of Treatments in Fractures of Tibial Plateau Dr. Pramod P. Rajuskar Department of Orthopaedics, Atharv Hospital, Link Road, Sangamner; Ahmednagar, Maharashtra, India. Introduction: The knee joint is complex joint and is the commonly injured joint now a day because of increased vehicular trauma and sports related injuries. Being superficial joint and more exposed to external forces, this joint easily gets injured 5. Intra-articular fractures of proximal tibia are difficult to treat. Age, skin conditions, osteoporosis further increase the obstacles in the healing process. Various modalities of treatment are available but no ideal treatment has yet evolved. We started our study using different previous and recent methods for treatment of these fractures and studied the effectiveness of the different modalities of these treatments. Material and method: This is a prospective study, which includes 27 cases having tibial plateau fracture, treated in Atharv hospital in the period from February 2009 to August The criterion for selection of the cases was a radiologically demonstrable fracture of the tibial condyle with the fracture line extending into the articular surface of the knee joint. Patients with polytrauma and multiple fractures were excluded from the study. The fractures were classified using the method of Schatzker s classification. iii

4 Computerized Tomographic evaluation was done in cases which had more comminution and when x-ray was inconclusive. All of the cases in this study were treated operatively as articular surface reconstruction was the main consideration. There was no strict surgical protocol followed in treating these cases. Most of the cases were operated within 2 days of admission. The patient was suitably anaesthetized- regional or general as the case may be. Incisions used were medial or lateral parapatellar, midline or two separate for bicondylar fracture. Intra-articular alignment was obtained by elevation of depressed articular fragment with or without bone grafting and fixed with buttress plate and screws. Patients were evaluated for one year, with serial x-rays at 1,2,3,6 and 12 months. The results were evaluated using the functional grading of Rasmussen 25 et al. Observations: All the patients in our study underwent operative intervention in form of fixation. The RTA is the most common mode of injury present between the age group 22 yrs to 75 yrs with almost equal distribution in males and females. Type II fracture pattern (44.4%) is most common type of fracture followed by type VI (22.2%) then type V (14.8%). The treatment modality varies from CCS fixation, ORIF with fragment elevation with or without bone grafting and unilateral or dual buttress plating according to varying nature of the fracture pattern. iv

5 Those cases having increasing grades of fracture have undergone delayed weight bearing mobilization and outcome gradually decreased from excellent to poor with increasing grades of fracture pattern. Results of surgery are acceptable (92.6%) for the varying type of fractures except complication developed due to infection in terms of decreased ROM and stiffness which lead to poor results (7.4%). It is mandatory to delay the surgical procedure till the soft tissue condition improves. This may decrease the chances of complications like wound dehiscence and infection. Conclusion: In our series type II is the most common type of fracture pattern. Road traffic accidents are the main cause of injury with male and females are almost equally affected. CT scan with three dimensional reconstructions gives accurate idea of fracture geometry for preoperative planning for osteosynthesis. Result of various types surgeries are good for various patterns of fracture pattern except when complications developed in elderly patient with type VI fracture pattern in the form infection and stiffness which led to an unacceptable outcome. It appears that all these problematic cases in the entire series belong to type VI group so alternative modality of treatment should be strongly considered for such a fracture pattern group different from the modality which is used in this study, such as external fixation. Medial side buttress plating is always desirable in bicondylar fracture pattern with unstable medial condyle as otherwise it collapses into varus. However, varus deformity did not result in compromise of function. v

6 ACKNOWLEDGEMENT I am highly indebted to Dr. Rajiv Arora, Head of Unit of Orthopaedics Department, Atharv Hospital, Sangamner, for his valuable guidance, encouragement and constant help during my study and preparation of my dissertation. I am also grateful to Dr.Nikhil Likhate, for timely guidance and valuable suggestion for the preparation of this study. I express my sincere thanks to Dr. Milind Modak, Dr. Ranjit Deshmukh, Dr. Amol Rege, Dr. Sachin Tapasvi, Dr. Ashish Babhulkar, Dr. Sushrut Badve, for their valuable suggestion and constant help and encouragement. My sincere thanks to my friend & colleague Dr. Sachin Choudhari for his whole hearted support and help in preparation of this dissertation. I am grateful to my brothers Mr. Yogesh and my wife Dr. Mrs. Deepti who were involved preparation of this dissertation. I am thankful to Mr. Salunke DNB Co-ordinator for helping me in preparation of this dissertation. Lastly I thank to all my patients who have given me their utmost co-operation and made this study possible. Dr. Pramod Rajuskar vi

7 ABBREVIATION AND KEY TO MASTER CHART DOA- Date of admission ROM - Range of movement DOD- Date of discharge RTA Road traffic accident Med - Medial Lat Lateral CR- Closed reduction B/K- Below knee A/K- Above knee M- Male F- Female R- Right L- Left OA- Osteoarthritis INF- Infection Ex Fix- External Fixator UE- Upper end FWB- Full weight bearing ORIF- Open reduction and internal fixation B/L- Bilateral WK- Weeks DOM Domestic F/U- Follow up EV- Elevation Fig. - Figure CCS- Cannulated cancellous screw BG- Bone graft MCL- Medial collateral ligament ACL- Anterior cruciate ligament PCL-Posterior cruciate ligament DCP- Dynamic compression plate LCP- Locking compression plate Buttress P/S- Buttress plate and screws. vii

8 TABLE OF CONTENTS Sr. No. Description List of Tables List of Figures Page No. ix x 1 Introduction 1 2 Review of Literature 2 3 Surgical anatomy of knee joint 8 4 Biomechanics of knee joint 17 5 Classification of tibial plateau fractures 22 6 Various modalities of treatment 25 7 Aims and Objectives 34 8 Materials and methods 35 9 Observation and Results Discussion Conclusion Bibliography Appendix a) Proforma b) Master chart viii

9 LIST OF TABLES Sr. No. Description Page No. 1 Characteristics of menisci 15 2 Rasmussen scoring 40 3 Sex incidence 45 4 Mode of injury 46 5 Distribution of fracture pattern 46 6 Modalities of treatment 47 7 Treatment for type I 47 8 Treatment for type II 47 9 Treatment for type III Treatment for type IV Treatment for type V Treatment for type VI Knee movements Complications Results 49 ix

10 LIST OF FIGURES Sr. No. Description Page No. 1 Anterior view of knee 11 2 Posterior view of knee 11 3 Medial view of knee 13 4 Lateral view of knee 13 5 Intra-articular structures of knee 15 6 Superior view of proximal tibia 16 7 Movement of knee 17 8 Rolling and gliding movement of tibia 18 9 Axis of the lower extremity Schatzker s classification Mechanism of injury to knee Instruments Surgical technique Case no.15- Schatzker s type II Case no.25 Schatzker s type V Case no. 26 Schatzker s type V Case no. 7 Schatzker s type VI Case no.21 Schatzker s type IV Sex incidence Distribution of fracture pattern Results Comparison to literature MIPPO surgical technique 53 x

11 INTRODUCTION The knee joint is complex joint and is the commonly injured joint now a day because of increased vehicular trauma and sports related injuries. Being superficial joint and more exposed to external forces, this joint easily gets injured 5. Intra-articular fractures of proximal tibia are difficult to treat. Age, skin conditions, osteoporosis further increase the obstacles in the healing process. Various modalities of treatment are available but no ideal treatment has yet evolved. At the Chicago Orthopedic society in 1956 Manson Hole has rightly mentioned that these fractures are tough Complex kinematics of its weight bearing position and complex ligamentous stability and articular congruency are the main reason why these fractures are of concern to surgeon and cause disability to the patients. Various studies have been carried out and different treatment modalities have been advised, consensus has not been reached. As these are problem fractures we have undertaken a study on the management of tibial condylar fractures. The mobility and stability of the lower limbs mostly depends upon the integrity of knee joint. With an aim of achieving a stable, well aligned, mobile joint with minimum articular irregularities, we started our study using different previous and recent methods for treatment of these fractures. 1

12 REVIEW OF LITERATURE Various modalities for the treatment of tibial plateau have been proposed. Earlier the treatment of these fractures was mostly by closed reduction and immobilization with plaster cast. Lambotte 6 wires and screws. in 1890 treated oblique tibial intra articular fractures with Keetley 6 in 1899 described open reduction and wires for lateral condylar fractures. Sir Robert Jones 26 in 1920 noted in an article by W.H. Threthowan, the importance of realigning the intra articular fractures of proximal tibia by open reduction and fixation by bone pegs and long screws. He also mentioned the need for elevating the depressed fragments from the tibial shaft. Wilsons and Jacobs 31 in 1952 used the articular surface of the patella for replacing the severely depressed comminuted fractures of lateral condyle. A Graham Apley 1 in 1956 studied 60 cases of lateral condyle fractures with long term results. He managed these fractures conservatively with skeletal traction and physiotherapy without any internal fixation. One year follow up of 41 patients, 22 were excellent, 15 good and 7 fair and 1 poor. He recommended early motion with traction as a satisfactory method for the management of lateral condyle fractures. 2

13 Rasmussen S. Poul 25 and Gothenburg in 1973 followed a series of 260 fractures of one or both condyles. The main indication for surgical treatment was evidence of instability of extended knee. They treated 44% of patients with either closed traction reduction or internal fixation using a wire loop or open reconstruction of joint surface using autogenous bone grafts. Follow up of 87% of these had an acceptable knee function. Moore and Harvey 24 in 1974 demonstrated the use of tibial plateau view with central ray directed at angle of 105 to the tibial crest. This permits more accurate assessment of the initial depression of the articular surface. Schatzker and McBroom 26 in 1979 considered that open reduction with anatomical restoration of articular cartilage produces best results. In their study of 70 patients they obtained 78% acceptable results in the operated group as compared 58% in the non operated group. Drennan D.B. 10 et al in 1979 reviewed 61 displaced fracture of tibial plateau treated by closed manipulation, reduction and immobilization for 6 weeks in a well moulded hip spica. He observed that 85% of patients achieved good or excellent results objectively. Bowes in 1982 and Hohl³ reviewed 52 tibial plateaus out of 110 fractures for more than one year. Non surgical treatment was used in 72% of fractures; cast in 51% and traction in 21% ORIF was used in 28%. Overall results were acceptable in 84% of patients. They mentioned the use of cast bracing in 31% of cases either as a primary treatment or after open reduction. 3

14 Blokker² et. al in1984 reviewed 60 tibial plateau fractures 38 of these fractures were treated by open reduction and internal fixation and 22 treated by closed methods. 75% of the patients had satisfactory results. They considered that the single most important factor in predicting the outcome in a patient with tibial plateau fracture was adequacy of reduction. The method of achieving the reduction and the length of immobilization period of the knee was not crucial. J. J. Dias 8 et. al in 1987 recommended CT scanning for evaluation of the degree of comminution, for classifying and measuring the displacement of fracture. Duwelius and Connoly¹¹ in 1988 compared the functional and roentgen graphic results in 100 plateau fractures. In 96 patients treated at 3 teaching hospitals, 73 fractures were treated by closed methods and early mobilization. They concluded that the long term x-ray picture evaluation did not co-relate with the functional end results. Delamarter. R, Hohl.M 7, in 1989 analyzed 306 tibial fractures in relation to the use of a cast brace in 141 patients, which were treated with application of brace as the primary form of treatment or after open reduction or traction. They followed 91 patients in whom 85% of patients had maintained fracture position. 82 patients maintained fracture alignment with less than 5 o of deformity. They concluded that cast brace could be effective in all types of tibial plateau fractures and can allow early mobilization and in some cases weight bearing also. 4

15 Jensen S et al 17 in 1990 evaluated long term result of 109 tibial fractures;61 treated by skeletal traction and early knee movement and 48 treated by surgery with average follow up of 70 months. They concluded that conservative treatment is valid alternative to surgery that it should be reserved for cases, where operation is not feasible. Honkanen S. E and Jarvien M.J 15 in1992 analyzed 131 fractures of tibial condyles in 130 patients using modification of Schatzker, Mc Broom and Bruce at an average of 7.6 years after injury. 55 (42%) factures were treated conservatively and 76 (58%) were treated operatively. In conservatively treated cases subjective results were acceptable in 49% of cases, functional results in 60% and clinical result in 52.7% cases. In operative cases they were 57.9%, 73.7% and 52.6% respectively. Tscherene and Loben 29 in 1993 studied 190 out of 255 cases concluded that open reduction and internal fixation with the objective being, precise reconstruction of the articular surface, stable fragment fixation and allowing early motion and repair of all concomitant lesion, achieved good results even in extremely difficult fractures after open reduction. Marsh J. L et al 22 in 1995, treated 21 complex fractures of the tibial plateau with closed reduction, inter fragmentary screw fixation of the articular fragments and application of unilateral half pin external fixators. They considered this external fixation as a satisfactory treatment for complex plateau fractures. Kumar et al 5 in 1996 described the use of fibular head auto graft for the treatment of severely comminuted bicondylar fractures of the tibia that cannot be treated with standard technique of lag screw fixation and buttress plating. 5

16 In 2002 Dennis P. Weigel and J. Lawrence Marsh 34, studied the long-term outcomes of treatment of high-energy fracture of the tibial plateau that had been treated with a uniform technique of external fixation and assessed the function of the knee and the development of arthrosis at a minimum of five years after injury. Thirty patients with a total of thirtyone fractures of the tibial plateau were treated with a monolateral external fixator and limited internal fixation of the articular surface. Follow-up data on twenty-four knees in twenty-three patients were obtained at a mean of ninety-eight months. Twenty patients (twenty knees) returned specifically for the study, at which time they completed an Iowa Knee Score questionnaire and a Short Form-36 (SF-36). Thirteen patients rated their outcome as excellent; six, as good; and three, as fair. They concluded that patients with a high-energy fracture of the tibial plateau treated with external fixation have a good prognosis for satisfactory knee function in five years after injury. In 2003 Ali, Ahmad M.; Burton, Maria 35 ; studied the outcome of the surgical treatment of displaced bicondylar tibial plateau fractures in patients >60 years old. All patients were treated with limited articular reconstruction and percutaneous intrafragmentary screw fixation, followed by neutralization with a stable beam-loading external fixator and early mobilization. At mean follow-up of 38 months (range 18 to 51 months), bony union was achieved in all patients. According to Rasmussen's system, 9 of 11 (82%) scored satisfactory results. Radiographic redisplacement was found in three severely comminuted cases resulting in >/=10[degrees] of valgus malunion. One patient received a corrective osteotomy while still in the fixator. Another needed TKA. They concluded that ring external fixation, as a beam-loading 6

17 system applied in a neutralizing mode, is a safe, stable, and reliable technique for the treatment of displaced bicondylar tibial plateau fractures in elderly patients. In 2004 James H Lubowitz, Wylie S. Elson, Dan Guttmann 36 studied arthroscopic management of tibial plateau fractures and concluded that arthroscopy is a valuable tool for the assessment of tibial plateau fractures and is the treatment of choice for associated intra-articular pathology. In addition, all arthroscopic reduction and internal fixation (ARIF) is recommended for type III fractures and is a consideration for types I, II, and IV. In 2006, Barei D P, Nork S E, Mills W J 37, et al studied 83 bicondylar fracture treated with medial and lateral plate fixation through two exposures. Out of 83, 23 male and 18 females with mean follow-up of 59 months were included in the study. Two patients had deep infection. Seventeen (55%) of those patients had satisfactory articular reduction, 28 patients (90%) had satisfactory coronal plane alignment and 31 patients had satisfactory tibial plateau width. They concluded that satisfactory articular reduction was significantly associated with a better musculoskeletal functional assessment score. Medial and lateral plate stabilization of comminuted bicondylar tibial plateau fracture through medial and lateral surgical approach was a useful treatment method. 7

18 SURGICAL ANATOMY OF KNEE JOINT The field of surgery of the knee has rapidly increased in the scope in the past decade through the basic and clinical research of many individuals. Current approach and techniques are based upon improved knowledge of functional anatomy, applied biomechanics. The knee is the largest and most complex joint of the body. It consist of three partially separate compartments; patellofemoral, medial tibiofemoral and lateral tibiofemoral. Although serving an important insertion point for lateral ligaments of the knee, the fibula head does not articulate with the knee joint. The knee is composed of: Osseous structures Extra-articular structures Intra-articular structures OSSEOUS STRUCTURES Femoral Condyles The femoral condyles are two rounded prominences that are eccentrically curved, anteriorly the condyles are somewhat flattened, which creates a large surface area for contact and weight transmission. The condyles project very little in front of the femoral shaft but markedly so behind. The articular surface of the medial condyle is longer than that of lateral condyle but the lateral condyle is wider. The long axis of lateral condyle is oriented essentially along the sagittal plane, whereas the medial condyle usually is about a 22-degree angle to the sagittal plane 18. 8

19 Tibial Plateau The proximal tibia is expanded in the transverse axis, providing an adequate bearing surface for the body weight transmitted through the lower end of femur. It comprises of two prominent masses, the medial and lateral condyles. Two condyles are separated by an irregularly roughened non-articulating intercondylar area consisting of the medial and lateral tibial spines. Anterior and posterior to the intercondylar eminence are the area that serves as attachment sites for cruciate ligaments and menisci. The condyles project backwards a little so as to overhang the upper part of the posterior surface of the shaft. Medial condyle is larger and the upper articular surface is oval in outline. The lateral condyle overhangs the shaft especially at its posterolateral part. The articular surface is nearly circular in its outline and is slightly hollowed in its central part. The articular surfaces on the plateau are not equal, the lateral being wider than the medial. The medial plateau shows no significant concavity in the coronal plane and the lateral plateau showing a slight concavity. In the sagittal plane, the lateral plateau appears convex and the medial plateau appears concave. Thus neither plateau provides much assistance in stabilising the knee. According to Bohler 20, tibial plateau slopes posteroinferiorly 5-10 degrees from horizontal, with the plane of the articular surface forming an angle of 76 +/- 3.6 degrees with the tibial crest. 9

20 Patella Patella, a triangular sesamoid bone in the extensor mechanism, is situated between the quadriceps tendon and patellar tendon. The proximal wider portion is the base of the patella and the distal pole is narrow called the apex. EXTRA ARTICULAR STRUCTURES The extra articular structures comprises of musculotendinous units and ligamentous units. Musculotendinous units: These are made up of : i) Quadriceps femoris Anteriorly ii) Gastrocnemius Posteriorly Politeus iii) Semimembranosus Semitentendinosus Medially Gracilis Sartorius iv) Bicep femoris Laterally Iliotibial band 10

21 Figure - 1 Figure

22 Ligamentous Structures: The capsule is a sleeve of fibrous tissue extending from the patella and patellar tendon anteriorly above the medial, lateral and posterior extent of the joint. The attachments to the bony structures are juxtra articular. The menisci are firmly attached medially and less so laterally. The medial capsule is more distinct and well defined than its lateral counterpart. The capsular structures along with the medial and lateral extensor expansions of the powerful quadriceps musculature are the principal stabilizing structures anterior to the transverse axis of the joint. The capsule is reinforced by the collateral ligaments and medial and lateral hamstring muscles as well as the popliteus muscle and the iliotibial band posterior to the transverse axis. The tibial collateral ligament is long, rather narrow, well delineated structure lying superficial to the medial capsule inserting 7 to 10 cms below the joint line on the posterior one half of the medial surface of the tibial metaphysis deep to pes anserinus tendons. It provides the principle stability to valgus stress. The lateral or fibular collateral ligament attaches to the lateral femoral epicondyle proximally and to the fibular head distally. It is of prime importance in stabilizing the knee against varus stress with the knee in extension. As the knee goes into flexion, the lateral collateral ligament becomes less influential as a varus stabilizing structure. 12

23 Figure - 3 Figure

24 INTRAARTICULAR STRUCTURES: These consist of the cruciate ligaments and the menisci. The two cruciate ligaments, anterior and posterior provide stability in the sagittal plane. They are extra synovial in location but intracapsular. Anterior Cruciate Ligament: It is made up of bundles of fibres, which are taut in various degrees of knee flexion and extension. The average length of ACL is 3.8 cm and the average width is 1.1cm. The tibial attachment is in front of anterior tibial spine. It is the primary stabilizer against anterior displacement of tibia. Posterior Cruciate Ligament: It is the primary stabilizer against posterior displacement of the tibia on the femur. It is almost vertical in its alignment in sagital plane. In the coronal plane it passes obliquely upwards and medially to its femoral attachment. The length of PCL is 3.8 cms and the width is slightly bigger than ACL about 1.3 cms and is more robust. 12 The two cruciate ligament complex is taut in all degrees of knee motion and maintains contact pressure between femoral and tibial condyle

25 Figure - 5 Menisci These are wedge shaped semicircular fibrocartilaginous structures, two in number; medial and lateral present between femoral and tibial condyles. Characteristics of menisci: Table -1 C-shaped Medial More circular Lateral Posterior horn wider than Anterior More or less equal width Covers more of articular surface Less mobile More mobile 15

26 The peripheral areas of the menisci are attached to the capsule and divided into meniscofemoral and meniscotibial portions. Figure

27 BIOMECHANICS OF KNEE JOINT Functional stability of the knee is provided by both passive and active stabilizers. The passive stabilizers include the ligaments around the knee, osseous congruity and the menisci. The active stabilizers are the muscles that surround the knee. (A) KINEMATICS Range of Movement (ROM): ROM of the knee ranges from of (recurvatum) extension to of flexion. Functional range of movement is from near full extension to about 90 0 of flexion. Rotation varies with position of flexion. At full extension there is minimal rotation. At 90 0 flexion, 45 0 of external rotation and 30 0 of internal rotation are possible. Abduction and adduction are essentially 0 0. (Figure - 7) Figure

28 2. Joint motion: Flexion and extension of knee involves both rolling and gliding motions (Figure - 8). The femur internally rotates during last 15 0 of extension ( Screw home mechanism). Posterior roll back of the femur on the tibia during knee flexion increases maximum knee flexion. The axis of rotation of the intact knee passes through medial femoral condyle. Figure - 8 (B) KINETICS 21 Extension is by the quadriceps mechanism, through the patellar apparatus; the hamstring muscles are primarily responsible for flexion at the knee. 18

29 1. Knee stabilizers: - Although bony contours have a role in knee stability, it is the ligaments and muscles of the knee that play the major role. 2. Joint forces:- a) Tibiofemoral: joint surfaces in the knee are subjected to a loading force equal to three times the body weight in level walking and up to four times body weight while climbing steps. The menisci share in load transmission. b) Patellofemoral: the patella aids in knee extension by increasing the lever arm and in stress distribution. The joint has the thickest cartilage in the body and it bears the most loads. Loads are proportional to the ratio of quadriceps force to knee flexion. The quadriceps provides an anterior subluxating force at range of motion. 3. Axes :- (Figure - 9) a) The mechanical axis:- femoral head to center of ankle b) Vertical axis:- from centre of gravity to ground c) Anatomic axis:- along the shaft of femur and tibia 19

30 Relationships:- Mechanical axis is at 3 0 valgus from vertical axis. Anatomic axis of femur is at 6 0 valgus from mechanical axis (Figure - 9). Anatomic axis of tibia is at varuses from mechanical axis. Figure - 9 In normal stance 75 to 90 % of load is borne on medial portion of knee. 20

31 When injury to the articular cartilage is penetrating, it disrupts the function of the proteoglycan, which affects the mechanism for support of compressive load. As long as the collagen network is intact, the chondrocytes can regenerate the proteoglycan matrix. But when the collagen network is disrupted, the defect is filled with a fibro cartilaginous tissue, which does not have the type or content of normal proteoglycan. The result is that more than half of such defects undergo degenerative changes by 6-12 months after injury. The meniscal function is part of load-bearing mechanism of the knee. These two c shaped structures transmit 30-70% of load across the knee. Complete menisectomy reduces the contact area by 50-70%. In addition the shock absorption capacity is also significantly reduced (20% or more) and the load per unit area is increased by 2 or 3 times. Meniscus also improves lubrication by distributing the fluid during weight bearing. 21

32 CLASSIFICATION OF FRACTURE SCHATZKERS CLASSIFICATION Figure

33 23

34 MECHANISM OF INJURY Figure

35 VARIOUS MODALITIES OF TREATMENT a. Closed Manipulation Above Knee cast Cast Brace The technique of close reduction is usually combined manoeuver. Traction to the leg, adduction or abduction at the knee and sometimes lateral compression for more severely displaced fractures; the force of such manipulations may be augmented by using a traction table and compression clamp. Paul J. Duwelius¹¹ et al used heavy longitudinal fraction applied with the patient on a fracture table. An assistant applies varus loading to the knee. The depressed tibial plateau margins are elevated by ligamentotaxis or by the pull of capsule and ligaments attached to the fragments. Closed reduction is often successful in type I, IV and V fractures which have no articular surface depression. An above knee well moulded plaster cast is applied for six weeks. Mobilization started at six weeks and weight bearing is delayed till the evidence of union is seen radiologically, usually by 12 weeks. The underlying assumptions for maintaining the reduction in plaster presumably are 11 : 1) Osteoarthritis will inevitably follow a fracture into the joint, unless the reduction is perfect and is perfectly maintained by rigid immobilization until union is complete. 2) Rigid immobilization is necessary to permit healing of associated ligamentous damage. 25

36 The fracture is maintained in an above knee plaster cast for about six weeks. Then plaster is removed and mobilization of the knee joint is allowed, the limb is maintained non weight bearing until about 10 to 12 weeks, when radiography shows good evidence of union. Delamater 7 and Hohl used cast brace for the maintenance of reduction. Duawelius and Conolly 11 treated the fractures that were stable to stress testing with cast bracing after close reduction. They concluded that cast bracing not only allowed early mobilization and in some cases weight bearing, but it also consistently produced an excellent range of motion, maintained fracture position and adequately controlled varus and valgus alignment. b. Skeletal traction with early mobilization 1 The treatment of tibial plateau fractures by traction and exercises without fixation is simple and satisfactory. Use of traction for tibial condyle fractures usually produces good early motion but often there are significant residual deformities and instability that leads to degenerative change or arthritis. The technique of Treatment:- Under anesthesia, the knee joint is aspirated, the fracture is reduced by using longitudinal traction through a Steinmann pin inserted 1 or 2 inches below the fracture and compression is given at the knee. Traction of about 10 lbs is applied and the foot end of the bed is raised on blocks. Within a few days knee mobilization exercises are started, once the patient is able to raise the leg from the bed. At six weeks traction is removed and the patient is mobilized non weight bearing for six weeks after which gradual weight bearing is started. 26

37 The method of traction and exercises permits movement without allowing abduction strain so that any associated damage to the medial ligament is able to heal. Apley¹ states that any residual deformity after a lateral condyle fracture is valgus and a valgus knee from whatever cause hardly ever gives rise to clinical osteoarthritis. c. Closed reduction and percutaneous cancellous screw fixation: Displaced type I and IV fractures which have no articular surface depression and are reducible by closed methods are amenable to this type of treatment. Preoperative MRI and arthroscopy helps in recognizing any meniscal injuries and any articular surface depression if present 33. Image intensifier is mandatory in accurate placement of implants. d. Extensile exposure with arthrotomy and reconstruction of joint surface and stabilization with 5,9,2,29 1) Cancellous screws 2) Buttress plate and screws Augmentation with bone graft done whenever required. The aim of open reduction is maximal anatomic reduction and rigid internal fixation. There is no universal agreement on the amount of articular depression or plateau step off that dictates the need for operative treatment. All authors agree that depressed articular fracture fragments will not change by manipulation or traction alone. An important factor affecting long term prognosis is the ability to maintain the normal relationship of the femoral condyles on the tibial plateau 27. Rasmussen and colleagues 25 demonstrated a high co-relation of 27

38 post traumatic osteoarthritis with a residual condylar widening or significant incongruity between the tibial plateau surface and femoral condyles. Malalignment of the tibial condyles in relation to the tibial shaft also affects the outcome after fracture. Open reduction and internal or external fixation is the treatment of choice for displaced incongruous, unstable or malaligned tibial plateau fractures. A thorough planning is important for achieving the necessary aims. Multiple paper drawings are helpful to arrive at optimal fixation construct and also clarify the need for supplemental bone grafts and availability of proper implants. Figure

39 Absolute indications for surgical treatment of tibial plateau fractures are 9 : 1) An open fracture 2) Associated compartment syndrome 3) Acute vascular injury 4) Irreducible fractures All types of fractures which are not reducible by closed methods, need to be reduced by exposing the fracture using appropriate approach depending upon the type of fracture and visualizing the reduction by an inframeniscal arthrotomy. Depressed articular fragments are elevated through a cortical window (in type III) or by retracting the split condyle fragment (in type II) and the resultant defect filled with autogenous bone grafts, bones from bone bank or bone graft substitutes (hydroxylapatite) and the fragments are fixed with cancellous screws or a buttress plate. Type IV fractures are often unstable and are generally treated with open reduction and fixation with screws and or medial buttress plate. Severe complex tibial plateau fractures that include the type V and type VI fractures are usually treated by open reduction and internal fixation. The amount of comminution and the soft tissue trauma should be evaluated prior to open reduction to avoid complications. 29

40 Figure - 13 Surgical Technique Figure - 14 CASE NO

41 31

42 e. Arthroscopy guided joint surface reconstruction and percutaneus screw/ external fixator stabilization The fractures amenable to arthroscopy reduction and internal fixation are type I, II and III plateau fractures. The likely advantages are: Provides direct visualization of the intra-articular fracture More accurate reduction of the fracture Decreased morbidity compared with arthrotomy Facilitates diagnosis and treatment of meniscal and Ligamentous injuries Permits thorough joint lavage to remove loose fragments. The fractures are later stabilized using percutaneous screws or plates and screws. f) Joint reconstruction and stabilization with external fixator: Ring type (Ilizarov) 5,16,22 Tubular type External fixation using either half pin fixator or ring fixator has been advocated as definitive fixation for type V and type VI condylar fractures. (Cancellous cannulated screws are used as accessory fixation for the articular surface). An external fixator placed below the knee can maintain articular surface reduction, axial alignment and also allow early motion. The advantage is its minimal invasiveness: thus reducing the wound complications. The half pin (joint bridging) uniplanor fixators have advantage in open plateau fractures for management until definitive fixation is done. Associated ligamentous and meniscal injuries are treated as and when present either conservatively or by secondary repair depending upon the severity of the injury. 32

43 g) Use of locked plates Locking plates are indicated in high energy, those with severe comminution and in osteoporotic fractures. It acts like internal splint. Isolated lateral locked plating may offer a more biological approach to bicondylar fracture and may provide viable alternative to dual plating in fractures with tenuous soft tissues. 33

44 AIMS AND OBJECTIVE 1. To evaluate the end results of tibial plateau fractures treated in Sanjeevan Hospital by various surgical modalities 2. To evaluate the effectiveness of the different modalities of the treatment and their complications. 34

45 MATERIAL AND METHODS It is a prospective study. 27 cases having tibial plateau fracture, treated in Atharv hospital in the period between Feb.2010 till Aug 2011 were included in this study. The criterion for selection of the cases was a radiologically demonstrable fracture of the tibial condyle with the fracture line extending into the articular surface of the knee joint. Patients with polytrauma and multiple fractures were excluded from the study. The fractures were classified using the method of Schatzker s classification. MANAGEMENT IN CASUALITY On admission the patient was thoroughly assessed clinically. The cause of injury was inquired; vitals parameters were checked; associated head, neck, chest, abdominal injuries were looked for. On local examination skin condition noted, fracture blisters; haemarthrosis; open or closed; distal neurovascular compromise; any signs of compartment syndrome noted. Any other associated limb injury or bony injury was noted. According to the general condition and vital parameters intravenous access was sought for and intravenous fluids given accordingly. Other bony injuries were immobilized and appropriately treated. SURGICALLY TREATED GROUP In the prospective study of 27 cases depression more than 2-4 mm or split in either sagittal or coronal plane was indication for surgery. Computerized Tomographic evaluation was done in cases which had 35

46 more comminution and when x-ray was inconclusive and MRI was done in suspected ligamentous and soft tissue injuries. All of the cases in this study were treated operatively as articular surface reconstruction was the main consideration. There was no strict surgical protocol followed in treating these cases. Most of the cases were operated within 2 days of admission. If articular cartilage and meniscal injuries were noted in MRI, then arthrotomy was undertaken. The patient was suitably anaesthetized-regional or general as the case may be. Surgery was performed in supine position under tourniquet control. Incisions used were medial or lateral parapatellar, midline or two separate for bicondylar fracture. Recommended A-O technique of fracture fixation was used. IMPLANTS USED FOR INTERNAL FIXATION OF TIBIAL CONDYLAR FRACTURE: BUTRESSS PLATE: The widening ends of long bone consist of large amount of cancellous bone. Such bone is comparatively weaker and has tendency of axial deviation or bending under the effect of compressive or shearing force. A lag screw cannot prevent the deformity and in order to supplement the fixation a buttress plate is essential to prevent collapse. Types : T plate L plate Hockey stick plate T plate has a horizontal and vertical limb. It is thin plate and helps in preventing a thin cortex or defect in cancellous bone from collapsing. L plate is of 2 types left and right offset with a double bend to fit onto the plateau. Hockey stick plate is stout and stronger and majority of times used to buttress lateral plateau. 36

47 Locking compression plate Locking compression plates are indicated for certain high energy bicondylar fractures, those with severe comminution and in osteoporotic fractures. Laterally based locking plate offers an alternative to an additional medial plate or external fixator for support of the medial column in bicondylar fractures 33. Interfragmentary compression cannot be achieved by locked plates; supplementary use of Interfragmentary screws may be required to prevent loss of reduction and to ensure adequate compression of the fragment 33. SCREWS 1. Cortical screws mm diameter of various lengths 2. Cancellous screws:- 16mm, 32mm partially threaded and fully threaded 3. Locking screws Cortical screws have a thick core with narrow thread and are used for purchase in cortical bone Cancellous screws have a thin core with wide and deep threads and used for purchase in epiphyseal and metaphyseal areas of bone Full threaded screws acts as fastening device for the plate. Partially threaded screws are used as lag screws to achieve compression of fractured articular surface. OPERATIVE PROTOCOLS: CENTRAL DEPRESSION FRACTURE:- A window is made in the metaphyseal area below the depressed fragment, the depressed fragment elevated and autogenous corticocancellous bone graft packed beneath. Autogenous bone graft was harvested from the 37

48 anterior aspect of the iliac crest. Fragment and graft were stabilised with cancellous screws or plate fixation. SPLIT AND DEPRESSED FRACTURE:- Surgical intervention is necessary in a fracture more than 2-4 mm spilt and depressed. The depressed fragment is elevated and autogenous bone grafts from iliac crest are put and split is reduced and reduction is held with Kirschner wires. The fragments are then fixed with suitable plates and cancellous and cortical screws. TOTAL CONDYLAR DEPRESSION:- Fracture of medial or lateral condyle needs appropriate reduction as malunion may develop with varus or valgus malaligment. The depressed plateau is elevated, articular surface reconstructed and fixed with buttress plate. BICONDYLAR FRACTURE:- A mid line or two incision technique is used for reduction of both the condyles. Arthotomy is done for inspection of ligament injury or meniscal injury. Menisectomy done if indicated. Depending upon comminution fixation is done by L, T or hockey stick plate or locked plates and cancellous screws. Dual plating can be done if other side is unstable where collapse may occur. POST OPERATIVE CARE In all the surgeries wounds were closed over suction drains. The drains were removed after 48 hrs. 38

49 Above knee slab or removable knee brace with leg elevation given to decrease the pain and edema Injectable antibiotics given for 3 to 5 days Static quadriceps exercises and ankle pump exercise started on second day The patients with stable fixation were allowed intermittent knee mobilization once the wound pain subsided, early in type I, II and III in 5 to 10 days and late in type V and VI in 14 days or later depending upon comminution of fracture. Stitches are removed on ten to twelve days and progressive muscle strengthing exercises along with passive exercises instituted. Knee immobilisation with brace or above knee cast was used in cases with ligamentous injuries for 4 to 6 weeks. Weight bearing is deferred until evidence of union is seen on x-rays (usual by weeks) The patient was followed up every 4 weeks for a period of one year. Partial weight bearing was started from weeks depending upon the fracture configuration and correlation with the x-ray. Full range of motion is expected at 8-10 weeks after discharge. The results were evaluated using the functional grading of Rasmussen 25 et al. 39

50 Table-2 40

51 CASE NO Figure

52 CASE NO - 26 Figure

53 CASE NO. 7 Figure

54 CASE NO.-21 Figure

55 OBSERVATIONS AND RESULTS Age incidence The age ranged between years Males years Females years Average 48.2 years Sex incidence Table-3 Males 14 52% Females 13 48% SEX INCIDENCE 48% 52% MALES FEMALES Figure

56 Mode of injury Table - 4 RTA % DOM Distribution of fracture pattern Table - 5 Type of fracture No. of patients Percentage I 2 7.4% II % III 2 7.4% IV 1 3.7% V % VI % Majority of the cases from this study were type II (44.4%), next were type VI (22.2%) Figure

57 Modalities of treatment Table - 6 CCC fixation 3 ORIF+EV+ Buttress P/S 11 ORIF+EV+BG Buttress P/S 10 Dual plating 3 Total 27 Type of treatment according to fracture pattern Type I Table-7 Modality of treatment No. of patients CCS fixation 2 Type II Table-8 Modality of treatment No. of patients CCS fixation 1 ORIF+EV+ Buttress P/S 7 ORIF+EV+BG Buttress P/S 4 Type III Table-9 Modality of treatment No. of patients ORIF+EV+BG Buttress P/S 2 Type IV Table-10 Modality of treatment No. of patients ORIF+EV+ Buttress P/S 1 47

58 Type V Table-11 Modality of treatment No. of patients ORIF+EV+ Buttress P/S 1 ORIF+EV+BG Buttress P/S 3 Type VI Table-12 Modality of treatment No. of patients ORIF+EV+ Buttress P/S 2 ORIF+EV+BG Buttress P/S 1 Dual plating 3 Hospital stay in days Minimum 3 days Maximum 32 days Mobilization in days Minimum 3 days Maximum 20 days Weight bearing in weeks Minimum 12 wks Maximum 28 wks Knee movement Table-13 >120 degree degree 3 <90 degree 1 Complications Table-14 Pain 3 Infection 2 ROM < 90 degree 1 Varus 2 Arthritis 2 48

59 Results Table- 15 Results No. of patients percentage Excellent % Acceptable Good % 92.6% Fair 1 3.7% Unacceptable Poor 1 3.7% 7.4% Acceptable Unacceptable 92.6% 7.4% Figure

60 Most of the cases in study were due to RTA and type II fracture pattern was most commonly found pattern in our study. Intra-articular pathology was found in two patients on MRI of type VI fractures where lateral condyle of tibia displaced lateral to lateral femoral condyle and associated with torn lateral meniscus for which lateral partial menisectomy done through arthrotomy. Patients who had type I and type II fractures were mobilized early and allowed early ROM and early weight bearing. Patients who had type V and type VI fractures were gradually mobilized and weight bearing was delayed. Figure

61 DISCUSSION The main purpose of the study is to evaluate outcome of the surgery of the study group; hence all the patients that included in the study are of the operative group. We have not included any conservatively managed group. Traction, bracing and external fixator are not done in any of the patient as this is not considered as a preferred modality of the treatment. Our study shows the effectiveness of the operative treatment as the articular surface was restored anatomically and fixed with suitable implant for early mobilization. Type I fractures 2 in number (7.4 %) are operated because the displacement of articular surface was more than 2mm. Most of these cases are of RTA. Postoperatively these patients are immobilized in brace and active ROM started on third postoperative day and weight bearing is allowed as early as possible (avg.11 wks). These patients achieved full ROM without any deformity and excellent result. Type II fractures are 12 in number (44.4%). These fractures are the most common group in our study. All of these patients are operated with elevation of the depressed fragment, bone grafting and reduction of fracture and fixed with buttress plate. Those patients who have minimum displacement and comminution, bone grafting is not done. Two of these patients showed collapse, out of which one is elderly (no. 2, 72 yrs) with osteoporosis and other is young (no.19, 38 yrs) with severe comminution and inappropriate grafting (big size graft) leading to displacement of fracture fragment. Postoperative follow up of these groups showed good to excellent result. 51

62 Type III fractures are present in 2 patients (7.4%). One of these patients is operated one week late because x-ray was inconclusive on day one and continued to have pain on active ROM. CT was showing depression more than 2mm, so underwent elevation of plateau, bone grafting and cancellous screw fixation. In another patient lateral plateau was depressed hence lateral plateau is buttressed with plate. Both the patients showed excellent result. We have only one (3.7%) case of type IV fracture (no.21). This patient is operated with elevation of the medial plateau and fixed with two cancellous screws. This patient is mobilized late so as to prevent collapse of the fracture fragment and varus deformity as the strength of the construct is inadequate. Outcome is excellent. (Rasmussen 25 et al score- 28) Type V fractures are 4 in number (14.8%). Most of these fractures are displaced and comminuted. All of the patients are treated with buttress plate from one side, either medial or lateral depending on the comminution. One of the four patients (no.26) is treated with medial buttress plate by MIPPO technique as lateral plateau was undisplaced with intact fibula (Figure -23). One patient showed varus deformity (no.2) because of collapse of medial side as that side was not buttressed. All of the patients have good to excellent function. (Rasmussen25 et al) 52

63 MIPPO TECHNIQUE Figure