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abstract
Full article available online at ORTHOSuperSite.com. Search: 20120222-27
The operative treatment of complicated bicondylar fractures of the tibial plateau re-
mains a challenge to most surgeons. This retrospective study was designed to evaluate
the clinical and radiological outcomes of dual plating via a 2-incision technique for
the repair of complicated bicondylar tibial plateau fractures.
A series of consecutive patients with bicondylar tibial plateau fractures treated by open
reduction and internal fixation with a double buttress plate or a combination of lock-
ing plate and buttress plate via a 2-incision technique between March 2004 and March A
2008 were retrospectively analyzed. Radiological and clinical results and complica-
tions of the 2 different fixation methods were compared. Seventy-nine patients match-
ing the criteria of this study were followed up for at least 24 months. All of the fractures
healed, with 3 cases of deep infection, 7 cases of secondary loss of reduction, 3 cases
of secondary loss of alignment, and 10 cases of knee instability. At 24-month follow-
up, mean Hospital for Special Surgery scores were 77.869.4 and 79.067.9 in the
double buttress plate group and combination group, respectively. No significant differ-
ences in clinical or radiographic outcomes were found between the 2 groups, except
that the combination group needed less bone graft. Dual plating with 2 incisions pro-
vided good exposition for the reduction and fixation of complicated bicondylar tibial
plateau fractures. Using a combination of locking plate and buttress plate reduced the
amount of bone graft compared with the double buttress plate technique.
B
Figure: Preoperative anteroposterior (left) and lat-
eral (right) radiographs of a 32-year-old man with a
displaced bicondylar tibial plateau fracture that was
managed with double plating via a 2-incision tech-
nique (A). Immediate postoperative anteroposterior
Drs Zhang, Fan, Ma, and Sun are from the Department of Orthopaedic Surgery, Tangdu Hospital, (left) and lateral (right) radiographs showing satis-
the Fourth Military Medical University, Xi’an, Shaanxi Province, PR China. factory restoration of the congruity of the articular
Drs Zhang, Fan, Ma, and Sun have no relevant financial relationships to disclose. surface alignment of the lower extremity (B).
Correspondence should be addressed to: Si-guo Sun, MD, Department of Orthopaedic Surgery,
Tangdu Hospital, the Fourth Military Medical University, Xi’an, Shaanxi Province, 710038, PR China
(ssg916@fmmu.edu.cn).
doi: 10.3928/01477447-20120222-27
T
he operative treatment of compli- Inclusion criteria for this study were (1) cally debrided and profusely lavaged. The
cated bicondylar fractures of the acute and unilateral fractures and (2) dis- wound was closed primarily or after a
tibial plateau remains a challenge placed bicondylar tibial plateau fractures repeat irrigation and debridement within
to even the most experienced surgeons. (Orthopaedic Trauma Association types 48 to 72 hours, depending on the extent
Such injuries are usually the result of C1, C2, and C3) with at least 1 of the fol- of contamination and soft tissue damage.
high-energy trauma, and the manage- lowing features: an intra-articular step or Antibiotics (cefuroxime and metronida-
ment of such fractures is complicated by gap of .2 mm, extra-articular transla- zole) were prescribed for the first 5 days.
metaphyseal and articular comminution tion of .1.0 cm, or angulation of .10°. Clinical signs of soft tissue recovery in-
and the frequent occurrence of associated Exclusion criteria for this study were cluded decreased swelling, healing of
soft tissue injuries.1-3 The ideal fixation pathologic fractures, definitive surgery fracture blisters, and wrinkling of the skin
method remains controversial. Treatment .3 weeks after the injury, preexisting around the proximal tibia. Decisions re-
options include limited internal fixation joint disease (osteoarthritis, inflamma- garding fixation method (in the early stage
combined with tensioned-wire4-7 or hy- tory arthritis, or a prior fracture), severe of the study, most patients were fixed with
brid8-10 external fixation, fixed-angle im- systemic illness (active cancer, chemo- double buttress plates, whereas in the late
plants using percutaneous exposure and therapy, insulin-dependent diabetes mel- stage, most patients were fixed with a
reduction,11 lateral periarticular plates, litus, renal failure, hemophilia, or medi- combination of locking plate and buttress
and dual plating.11,12 Dual plating via a cal contraindication for surgery), open plate) and timing (5-14 days after trac-
2-incision technique has received recent growth plates, vascular injuries requiring tion) were guided by the chief surgeon’s
support because it allows for direct visu- repair (a Gustilo grade IIIC fracture), age (Y.Z.) experience and judgment.
alization of the articular reduction while older than 65 years, or severe head inju- All patients were treated by the same
minimizing the need of stripping the soft ries (initial Glasgow Coma Scale score team of surgeons (Y.Z., D.F., B.M., S.S.).
tissues in the fracture area, especially ,8) or other neurological conditions that The technique for fixation of closed frac-
when significant displacement in the pos- would interfere with rehabilitation. This tures was similar to that described by Barei
teromedial fragment or articular depres- study was approved by the hospital Ethics et al.13 Fixation of the medial column was
sion of the medial plateau exists. Committee. performed first, using an incision made 1
As fixed-angle implants, locking plates Injury and postoperative radiographs cm posterior to the posteromedial border
are mostly used in metaphyseal fractures. and computed tomography (CT) scans of the tibial metaphysis, with dissection
We assumed that locking plates might be were used to identify each bicondylar through the interval between the pes anse-
able to reduce secondary loss of reduc- fracture. Associated injuries and postoper- rinus tendons and the medial head of the
tion in bicondylar tibial plateau fractures; ative wound complications were recorded. gastrocnemius. When the medial plateau
therefore, locking plates in combination Data pertinent to postoperative functional fracture contained a sagittal split involv-
with buttress plates were used to fix bi- status were also recorded. Deep infections ing the articular surface, the fracture site
condylar tibial plateau fractures in some were defined as those that extended below was entered and the coronary ligaments
of our patients in a dual-plating technique. the fascia; superficial infections remained were elevated to expose the medial menis-
The purpose of this retrospective above the fascia. cus and the depressed joint surface. This
study was to evaluate the clinical and ra- required splitting of the medial collateral
diological outcomes of dual plating via a Surgical Technique ligament in line with its fibers. The an-
2-incision technique for treating compli- Patients with open wounds underwent terolateral incision was started 1 to 2 cm
cated bicondylar tibial plateau fractures. surgical debridement within 8 hours of lateral to the patella and extended distally
The results using a double buttress plate injury and subsequently received tetanus over Gerdy’s tubercle and 1 cm lateral to
and a combination of locking plate and prophylaxis and intravenous antibiotics. the crest of the tibia. A transverse sub-
buttress plate were also compared. All patients were managed with trans- meniscal arthrotomy was performed to
calcaneal skeletal traction for adequate expose the articular surface. Subperiosteal
Materials and Methods time to allow soft tissue healing. The leg dissection was limited to the fracture mar-
A series of consecutive patients with was elevated. Mannitol (20% m/v, 0.2 g/ gins and the region of anticipated plate
bicondylar tibial plateau fractures and op- kg, twice daily) and b-aescine (30 mg application. Depressed fragments were
eratively treated in our orthopedic depart- daily) were admitted intravenously for 3 elevated and supported with autograft har-
ment via the 2-incision dual-plating tech- to 7 days. Physical therapy was also per- vested from iliac crest or allograft.
nique between March 2004 and March formed to facilitate soft tissue healing. Buttress plates or locking plates were
2008 were retrospectively analyzed. For open fractures, the wound was radi- applied once anatomic reduction had been
Bone graft used in the locking plate group Fractures healed in an average of 14.1 group. Complications included infection,
was significantly less than that used in the weeks in the double buttress plate group loss of reduction and alignment, and in-
buttress plate group (Table 2). and 13.7 weeks in the combination plate stability of the knee. No significant dif-
ference existed regarding the time of
fracture healing or rate of complications
Table 1
between the 2 groups (Table 3). All su-
Demographic Data and Injury Characteristics perficial infections were treated by local
care of the incisions and oral antibiotics.
Buttress Plate Group Combination Group
(n541) (n538) P Three patients who developed deep infec-
Mean follow-up, mo .135
tion healed after replacement of plates
27.963.7 26.962.4
with an external fixator, repeat irrigation,
Mean patient age, y 37.767.9 37.067.6 .697
debridement, and intravenous antibiotics;
Sex, No. .708
2 of the patients required local gastrocne-
Male 38 36 mius muscle flap coverage. All 3 patients
Female 3 2 required bone graft in the final reconstruc-
AO/OTA type, No. .489 tion operation because of the bone loss
C1 2 1 due to vigorous debridement during the
C2 9 5 treatment of infection.
C3 30 32 No malreduction or malalignment was
Gustilo grade, No. .517
measured on the first postoperative radio-
graphs. At 24-month follow-up, secondary
Type I 2 0
loss of reduction was found in 4 patients
Type II 1 2
in the double buttress plate group and 3
Type IIIA 1 1 patients in the combination plate group;
High-energy trauma, No. 37 34 .790 secondary loss of alignment was found in
Associated injury, No. 2 patients in the double buttress plate group
Cruciate ligament injury 9 8 .923 and 1 patient in the combination plate
Collateral ligament injury 5 5 .900 group. Loss of tibial plateau angle was 3°
Meniscal injury 7 6 .878 to 8°. Knee instability was found in 6 pa-
Abbreviation: AO/OTA, Association for Osteosynthesis/Association for the Study of Internal
tients in the double buttress plate group and
Fixation. 4 patients in the combination plate group.
One patient in the double buttress plate
group had a severely unstable knee despite
Table 2 primary collateral ligament and secondary
ACL and posterior cruciate ligament (PCL)
Surgical Details
repair due to the severity of injury to his
Buttress Plate Group Combination Group ligaments. At 24-month follow-up, early
(n541) (n538) P arthritis with joint space narrowing was
Mean total operative time, min 180.3612.7 176.2611.4 .136 found in 9 patients in the double buttress
Mean tourniquet time, min 113.7610.4 111.6610.0 .369 plate group and 8 patients in the combina-
tion plate group according to the radiograph
Mean perioperative blood 381.7621.6 377621.5 .346
loss, mL presentation. Most of these patients had mi-
Primary bone graft, No. 31 20 .003a nor pain in the knee, and 1 patient in the
Meniscal repair, No. 5 5 .900
double buttress plate group and 1 patient in
the combination group had medium pain.
Primary cruciate ligament 6 4 .785
repair, No. At 24 months postoperatively, the HSS
Primary collateral ligament 5 5 .900 score was 77.869.4 and 79.067.9 in the
injury, No. double buttress plate and combination
a
P,.05. plate groups, respectively, and the differ-
ence was not significant (Table 3).
Discussion
The treatment of complicated bicondy- Table 3
tion. The bone graft, not the choice of in- 1968-1975. Clin Orthop Relat Res. 1979; Stabilization System (LISS) fixation and
(138):94-104. two-incision double plating for the treat-
ternal fixation device, affected the occur- ment of bicondylar tibial plateau fractures
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