Tibial Plateau Fractures: Factors influencing outcomes May 20th 2013 Joel Melton BM, MSc, FRCS (Tr + Orth) Consultant Orthopaedic Surgeon, Cambridge University Hospitals
Overview Plateau Fractures Diagnosis Classifications Treatment goals Management decisions Surgical techniques Controversies Factors influencing outcome
Diagnosis History, Clinical examination, Special tests Minor, major or catastrophic injury May be subtle or obvious Remember other injuries Degree of soft tissue injury (inc. open)
Diagnosis special tests Plain radiography CT scan MRI? Diagnosis Fracture pattern Help with classification Assess joint displacement Guide need for operative intervention Guide the operative fixation plan and surgical approaches
Classification Jo Schatzker Types 1-6 Worsening severity by type May guide fixation techniques and likely outcomes
Types 1-6 Classification - Schatzker
Treatment goals G. Appley Reduce fracture, hold position and rehabilitate The AO group AO principles dictate: An intraarticular fracture must be anatomically reduced, fixed with rigid internal fixation, conferring absolute stability to the fracture, expecting primary bone healing and allowing early joint mobilisation
Treatment goals Applying this to plateau fractures: Assess patient first (general status, ATLS, compartments etc) Diagnosis Fracture pattern Degree of displacement Knee Joint position/disruption Leg Alignment Imaging, pre-operative planning, timing Hardware, surgical expertise, rehabilitation goals
Management decisions Operative vs non operative What degree of displacement can you accept? What is the patient like? Timing of surgery Soft tissue injury (bruising, swelling) What hardware? Why Which incisions? Minimally invasive? Fixation plans?
How can we influence outcome?
How can we influence outcome? Rehabilitation Treatment decisions Patient factors
How can we influence outcome? Patient factors Age, comorbidity Smoking,drugs Treatment decisions Conservative Surgical fixation Rehabilitation Cast,Brace, ROM Early ROM
Plateau fracture Operative management Conservative management
Plateau fracture Mal-reduced fracture Good reduction
Operative management Internal fixation External fixation
Operative management Internal fixation External fixation Screw Plate Circular frame/hybrid
External Fixation Hybrid fixation Non-hybrid fixation
Internal fixation Double plate Single plate
Double plating Double incision Single incision
Double incision Single incision
Dead bone sandwich?
MIPO (Minimally invasive plate osteosynthesis)
Bi-condylar injury pattern Double plating Single fixed angle device
Internal fixation Arthroscopic assisted Fluoroscopy
Internal fixation Meniscal repair No soft tissue procedure
Internal fixation Bone graft BG substitutes
Calcium phosphate paste
Rehabilitation Delayed Early ROM
So what outcomes are we getting?
Outcomes 49 pts, <40 no difference, >40 worse outcome 311 pts, 10 yr follow up. 13% had TKR 125 pts, < 10 yrs follow up. 26% OA on XR, 4% TKR
Latest review of current management of plateau fractures?
Latest review of current management of plateau fractures?
Summary Multiple issues effect outcome
Summary Patient factors Age, comorbidity Smoking,drugs Treatment decisions Conservative Surgical fixation Rehabilitation Cast,Brace, ROM Early ROM
G. Appley Reduce fracture, hold position and rehabilitate