3. Osseous Anatomy
⢠Proximal Tibia
â widens into lateral and medial tibial flares
â flares lead to medial and lateral plateau (condyles)
â intercondylar eminence
â tibial tubercle (patellar tendon)
â Gerdyâs tubercle (ITB)
â proximal tib/fib joint
4. Osseous Anatomy
⢠Medial Plateau VS
â larger
â concave: frontďback
â sideďside
â lower than lateral side
â slopes posteriorly 10°
â cartilage 3mm
â medial condyle stronger
bone
â bears 75% of weight
⢠Lateral Plateau
â smaller
â convex: frontďback
â sideďside
â higher than medial
â slopes posteriorly 7°
â cartilage 4 mm
â softer bone
5. Meniscus
⢠Fibrocartilage
⢠lateral meniscus
â more circular than medial
â covers more of articular surface than medial
â attached to PCL via ligaments
⢠Humphry (anterior)
⢠Wrisberg (posterior)
â no attachment to LCL
â bears most of joint reactive force
7. Introduction/Mechanism of
Injury
⢠Mean age in most series of tibial plateau
fractures is about 55 years
â Large percentage over age 60
⢠Elderly population is increasing in numbers
â Fastest growing segment of US population
⢠Tibial plateau fractures comprise 8% of all
fractures in the elderly population (Hohl)
8. Mechanism of Injury
⢠Mechanism of injury is fall from standing
height in most patients
â MVA is increasing as % of fractures
â High energy fracture patterns increasing in this
age group!
⢠Most common fracture pattern is split-
depressed fracture of lateral tibial plateau
(80% of fractures)
9. Demographics of
Plateau Fractures
⢠1% of all fractures
⢠8% of all fractures in the elderly
⢠lateral plateau involved 55-70%
⢠medial plateau involved 10-20%
⢠both involved 10-30%
10. Mechanism
⢠Mechanism of injury is important when
considering treatment options, timing and
associated injuries
⢠remember⌠Force = Mass X Acceleration
⢠even if the xrays are similar, these are
completely different injuries
11. Evaluation
⢠Trauma Evaluation
â ABCs
â Associated Injuries
⢠Evaluation of Limb
â Gentle exam for knee stability
â Observation of soft tissues
â Neurovascular evaluation
â Evaluate for compartmental syndrome
⢠Imaging Evaluation
12. Physical Exam
⢠Soft Tissue Assessment
â Tscherne & Goetzen (closed injury)
⢠grade 0: minimal soft tissue damage/ indirect force
⢠grade 1: superficial abrasion/contusion via pressure from
within
⢠grade 2: deep, contaminated abrasion with localized
skin/muscle contusion: impending comp. syn.
⢠Grade 3: extensive skin contusion/crush: sobq avusion;
underlying muscle damage; decompensated cs
â Gustilo and Anderson (open injury)
13. Physical Exam
⢠Neurologic exam
â peroneal nerve!
⢠Vascular exam
â popliteal artery and medial plateau injuries
â beware the of the knee dislocation posing as a
fracture
â beware of posteriorly displaced fracture fragments
â ABI <0.9 urgent arterial study
14. Physical Exam
⢠Compartment syndrome
⢠KNEE STABILITY
â varus/valgus in full extension
â may require premedication
⢠aspiration of knee effusion/hematoma
⢠replace with lidocaine+marcaine
15. Evaluation of Soft Tissues
⢠Proximal and distal
tibia subcutaneous
⢠Soft tissue remains
compromised for at
least 7 days
⢠Early ORIF risks
wound
sloughď exposed
hardware
16. Evaluation
⢠Plain radiographs
â AP, lateral, ? oblique of knee on 17-inch
cassettes
â AP and lateral of entire tibia
â Traction radiographs
⢠Very helpful for complex fractures
⢠Traction can be applied by temporary spanning ex-
fix
â CT scan indications
⢠Fractures for which you are considering nonsurgical
care
⢠Complex fractures to assist in surgical planning
⢠Always obtain CT after applying traction
23. Computed Tomography
⢠Indications
â Fracture in an active patient for which you are
considering nonsurgical care
â Complex fracture
â To aid surgical planning of approach,
technique, screw position, etc.
⢠Indications for 3-D reconstructions
â Rare
⢠Rapid prototyping?
35. Surgical Indicatons
⢠Open Fracture â I&D, spanning ex-fix
⢠Extensive soft tissue contusion â spanning
ex-fix
⢠Closed fracture
â Varus/valgus instability of the knee
â Varus or valgus tilt of the proximal tibia
â Meniscal injury/previous mensicectomy
â Articular displacement or gapping???
36. Should You Operate on These
Fractures?
⢠âThe objective of treatment of tibial plateau
fractures is precise reconstruction of the
articular surface and stable fragment
fixation allowing early motionâ
⢠Do outcomes data support these objectives?
37. Should You Operate on These
Fractures?
⢠Tenet: patient outcome will vary directly
with the accuracy of the articular reduction
⢠The literature seems to indicate that
articular incongruity is tolerated fairly well
and that other factors may be more
important in determining outcome
38. Lucht et al (Acta Orthop Scand 1971; 42:366)
⢠109 fractures treated op and non-op
⢠3-10 mm articular depression
â 78% acceptable functional result
⢠> 10 mm articular depression
â 79% acceptable functional result
39. Ramussen (JBJS 1973; 55A:1331-1351)
⢠183 patients followed for 7.3 years
⢠Functional outcome no different in 40
patients with > 5 mm articular depression
than in those with < 5 mm
⢠No correlation between residual articular
depression and arthrosis
40. Lansinger et al (JBJS 1986; 68A:13-19)
⢠102 of Rasmussenâs 183 patients followed
for 20 years
⢠No change in functional outcomes from the
original study
7 yrs: 87% G or E 20 years: 90% G or E
⢠All 20 patients with 5-10 mm incongruity
had excellent results (including 9 with
instability of the knee)
41. Lansinger et al (JBJS 1986; 68A:13-19)
⢠All 5 patients with > 10 mm incongruity and
stable knees had G or E result
⢠Poor outcome occur only with combination
of:
â Central depressed condylar fragment
â > 10 mm articular incongruity
â Mediolateral instability of the knee
42. Koval et al (J Orthop Traum 1994; 6:340-346)
⢠18 patients followed 16 months
⢠Clinical results no different for patients with
anatomic (< 2 mm) or nonanatomic (> 2 mm)
reductions
⢠5 nonanatomic reductions:
⢠2 excellent, 3 good results
43. Blokker et al (Clin Orthop 1984; 182:193-199)
⢠60 patients followed for 39 months
⢠Adequacy of articular reduction strongly
associated with outcome
⢠Satisfactory results:
â Anatomic reduction 86%
â 1-4 mm step-off 75%
â > 5 mm step-off 0%
44. Blokker et al (Clin Orthop 1984; 182:193-199)
⢠To attain âsatisfactoryâ rating
⢠Satisfactory clinical result AND
⢠Satisfactory radiographic result
â Criterion for satisfactory radiographic result
was < 5 mm articular incongruity
⢠Patients with > 5 mm incongruity were
assigned an unsatisfactory result, regardless
of clinical outcome
45. Importance of Factors Other Than
Articular Congruity on Outcome
⢠The literature clearly indicates that other
factors are critically important to outcome:
â Angular malignment of the proximal tibia
â Resection of the meniscus
â Ligamentous instability
46. Angular Malalignment of the
Proximal Tibia
⢠Rasmussen (Acta Orthop Scand 1972; 43:566-572)
â Incidence of arthrosis:
⢠Valgus < 10o
14%
⢠Valgus > 10o
79%
â Any amount of varus angulation was bad
â Independent of articular congruity
47. Meniscectomy
⢠Jensen et al (JBJS 1990; 72B:49-52)
â Higher rate of arthrosis in patients who had
undergone meniscectomy at surgery
⢠Honkonen (J Orthop Traum 1995; 4:273-277)
â 70% arthrosis in patients who had undergone
meniscectomy
â results were independent of the amount of
articular incongruity
48. Ligamentous Instability
⢠Rasmussen (Acta Orthop Scand 1972; 43:566-572)
â 46% arthrosis in patients with mediolateral
instability (17% incidence in all others)
⢠Lansinger (JBJS 1986; 68A:13-19)
â Mediolateral instability a necessary condition
for a poor functional outcome
⢠Honkonen (J Orthop Traum 1995; 4:273-277)
â 69% arthrosis in patients with mediolateral
instability > 10o
49. Surgical Indicatons
⢠Open Fracture â I&D, spanning ex-fix
⢠Extensive soft tissue contusion â spanning
ex-fix
⢠Closed fracture
â Varus/valgus instability of the knee
â Varus or valgus tilt of the proximal tibia
â Meniscal injury/previous mensicectomy
â Articular displacement or gapping
61. Fixation Lateral Plateau
Fractures
⢠Traditional
â large fragment âLâ or âTâ buttress plate
â 6.5mm subchondral lag screws
â 4.5mm diaphyseal screw
⢠Current Recommendation
â small fragment fixation
â pre-contoured peri-articular plates
â clustered sudchondral k-wires
â˘
62. Biomechanics: Subchondral
Fixation
⢠3.5 mm raft construct allowed significantly less
displacement than 6.5 mm screw with axial load (2954
vs. 968 newtons/mm) Twaddle et al AAOs, 1997
⢠no difference in pull out strength between 6.5mm screws
and 3.5mm screws in subchondral bone Westmoreland
et al J Ortho Trauma 2002
⢠Subchondral clustered K-wires signicantly enhance load
tolerance depress articular surface Beris et al Bull Hosp
Joint Dis 1996
63. Large or Small Fixation for the
Lateral Plateau?
⢠No significant difference between fixation strengths
small vs large frament (Hubbard et al. A J Ortho, 1999)
⢠Karunaker et al. J Ortho Trauma 2002
â No significant difference in overall stiffness between: large
fragment; periarticular small fragment plate; 3.5 mm
subchondral screws with separate 1/3 semitubular anti-glide
plate
â local depression stiffness > with 3.5 mm vs 6.5 mm screws
80. Hybrid External Fixation
Results
⢠Duration external fixation 12-16 weeks
⢠ROM: 100-120°
⢠knee score average 80-90 on 100 point scale
⢠complications
â nonunion 5%
â angular malunion 10%
â deep infection 5%
â PIN TRACT INFECTION COMMON
81. Hybrid External Fixation
Pin Tract Infections
⢠Generally respond to antibiotics + pin care
⢠may result in septic joint (10%)
⢠Ways to avoid septic joint:
â stable fracture reduction (impact metaphysis)
â keep pins >15mm from joint
â beware cavity communicating metaphysis joint
â gentle post op ROM to avoid pin irritation
â aggressive investigation post op knee effusion
â consider cross joint adjunct fixation
82. Temporary Knee Spanning External
Fixation with delayed ORIF
⢠Acute: femur tibia external fixation
â reduction via ligamentotaxis
â pins in tibia at least 5cm from distal fracture line
⢠CT scan
⢠ORIF when soft tissue recovers
â up to 3 weeks!!!
â Double plating
â unilateral locked plate
93. Locked Plate- Results
⢠52 proximal tibia fractures
⢠31/52 bicondylar plateau
⢠18/52 open injuries
⢠1 nonunion
⢠4 malunion
⢠average range of motion 2-116°
⢠2 infections (both grade 3B)
Stannard et al. OTA 2001
94. Locked Plate- Results
⢠75 bicondylar plateau fractures
⢠16/75 open injuries
⢠6 delayed unions: 4/6 union with bone graft
⢠1 deep infection
⢠9 loss of fixation: 8/9 technique related
⢠78% good/excellent results (Rasmussen)
Gosling, Krettek et al. OTA, 2002
95. Can I Synthesize this Information
into Clear Guidelines?
⢠Articular incongruity 5 mm or less
⢠Stable knee in full extension
⢠Normal varus/valgus alignment
⢠Non-operative Care!
97. Can I Synthesize this Information
into Clear Guidelines?
⢠Articular displacement > 5 mm AND
⢠More than 10 degress varus/valgus
instability to exam in full extension
⢠Operative Care!
98. Can I Synthesize this Information
into Clear Guidelines?
⢠Articular displacement > 5 mm AND
⢠Knee stable to varus/valgus stress in full
extension
⢠Favor non-operative care
99. Can I Synthesize this Information
into Clear Guidelines?
⢠Varus or valgus tilting of proximal tibia
more than 5 degrees
⢠Operative Care!
100. Postoperative Management
⢠Immediate PROM/AROM of knee
⢠Shower beginning 48 hours after surgery
â Ok to shower with ex-fix in place
⢠Routine Pin site care (if ex-fix)
⢠TDWB for 8-12 weeks
⢠Sutures out in 2 weeks
⢠Xrays in 4-6 weeks
101. Outcomes
⢠See slides 27-39 in this presentation
⢠Outcome depends on:
â Varus valgus stability of the knee
â Varus/valgus alignment of the proximal tibia
â Presence of an intact meniscus
â Articular congruity (to a lesser extent)
102. Treatment Goals
⢠Focus on restoring stability and proximal
tibial alignment to the knee, rather than
restoring anatomic alignment of the
articular surface at all costs
⢠Use minimally invasive techniques, when
possible
⢠Other techniques are preferable to hybrid
ex-fix
⢠Move the knee early in all patients!