SJAMS 43B 750 754 Thesis Tibial Plateau
SJAMS 43B 750 754 Thesis Tibial Plateau
SJAMS 43B 750 754 Thesis Tibial Plateau
*Corresponding author
Dr. Pradeep Kumar Saini
Email: [email protected]
Abstract: Recently minimally invasive procedures are now gaining popularity in orthopaedic surgeries as they limits soft
tissue infection at fracture site and have fewer complications. These procedures reduce morbidity and avoid many of the
complications of both conservative and operative treatment and can have faster rehabilitation. The present prospective
study was carried out in Department of Orthopaedics, Deendayal Upadhyaya Hospital, and New Delhi between October
2007 to June 2010. The study included 33 patients of tibial plateau fracture. Relevant clinical history was taken and
comprehensive physical examination with local examination was done. A thorough radiological evaluation was done by
taking X -ray knee including leg AP view, Lateral view, Oblique view (Internal and External), Tibial plateau view (10-15
degree caudally tilted) and Traction view. SCHATZKERS classification was used to classify tibial plateau fracture. The
patients were treated by pre-operative skeletal traction and minimal soft tissue dissection using minimally invasive
methods. Implants used were buttress plates and screws, cancellous cannulated partially threaded screws and
Arbeitsgemeinschaft fr Osteo synthesefragen (AO) tubular external fixators. Finally, the plate was slide extra
periosteally through a very short incision. In results the most common fracture in our series was Schatzkers type II
fracture (nine patients) followed by type VI (eight patients) followed by type V (six patients).Age range was between 24
to 61 years with majority of patients in 26 to 35 years of age group. All cases with type I and type IV fractures had
excellent results. Seven cases (78%) of type II fractures had excellent results and rest 2 cases (22%) had good result. One
case of both type V and type VI fracture had fair result. Only one case (3%) in our series of Type VI fracture had poor
result. The overall functional end results in the follow up were 66.7% excellent, 23.3% good, 6.7% fair and 3.3% poor. In
conclusion the Minimal invasive surgery for tibial pleateau fractures was associated with high rate of success across all
categories of Schatzkers type fracture. An acceptable functional end result was obtained in 96% of the patients.
Keywords: Tibia Fracture; Less invasive; Minimally Invasive Surgery; SchatzkerS Type Fracture.
INTRODUCTION
Fractures involving the proximal tibia affect
knee function and stability [1]. These fractures can be
either intra-articular (plateau) or extra-articular
(proximal fourth). Fractures of tibial plateau represent
only 1% to 2% of all fractures but account for
approximately 8% of fractures occurring in elderly [2].
Articular fractures of proximal end of tibia not only
involve the articular cartilage itself but can also involve
the epiphysis, the metaphysic and in more severe
injuries diaphysis as well. These fractures can be quite
challenging to manage as they are notoriously difficult
to reduce, align and stabilize, have skin and soft tissue
wound
Pradeep Kumar Saini et al., Sch. J. App. Med. Sci., March 2016; 4(3B):750-754
minimal skin and soft tissue dissection, percutaneous
screws and external fixators.
MATERIALS AND METHODS
The present prospective study was carried out
in Department of Orthopaedics, Deendayal Upadhyaya
Hospital, and New Delhi between October 2007 to June
2010. The study included 33 patients of tibial plateau
fractures. Three patients were excluded from final
analysis because they were lost in follow up. The
remaining 30 patients were included in the study.
Relevant clinical history was taken and comprehensive
physical examination with local examination was done.
A thorough radiological evaluation was done by taking
X -ray Knee including leg AP view, Lateral view,
Oblique view (Internal and External), Tibial plateau
view (10-15 degree caudally tilted), Traction view. CT
scan with Saggital reconstruction was done in case of
articular disruption in patients who could afford.
SCHATZKERS classification was used to classify
tibial plateau fracture.
Preoperative evaluation:
Preoperative evaluation and pre-anaesthetic
check-up was done. In the time-period between the time
of admission of the patient in the hospital to the time of
operation, patient was kept on lower tibial pin traction
on Bohler Braun (BB) splint or pillow. This helped in
reduction of fracture by ligamentotaxis and also helped
in soft tissue healing.
Patient positioning:
Patients were positioned supine and tourniquet
was applied. Image intensifier was positioned properly
and fracture site was visualized in AP and Lateral view.
Application of Schanz pin and femoral distractor:
One Schanz pin was inserted into femoral
condyle and another Schanz pin was inserted into mid
tibial shaft 10-15cm distal to fracture site, and through
which femoral distractor was applied and knee joint
distracted. It helped in reduction by ligamentotaxis.
Reduction of fracture was done through 2 Kirschner
wires used as joy stick:
Fracture was reduced using Kirschner wire in
the split fragment as a joy stick. Split fragment was
elevated and reduced under image guidance, and after
maintaining the articular surface of tibia, fragments
were held in that position using another Kirshner wire
through which the cancellous cannulated screw was
inserted. Fractures with depression were reduced by
elevation of the depression by making cortical window
on tibial metaphyseal region opposite to the fracture
site. From that window depressed surface was elevated
using bone tamps and punches and fixed temporarily
with multiple Kirschner wires. Following articular
surface elevation the void left by impacted cancellous
751
Pradeep Kumar Saini et al., Sch. J. App. Med. Sci., March 2016; 4(3B):750-754
7th follow-up - 9th month of surgery and finally the 8th
follow-up at 1 year of surgery
Antero-posterior and Lateral radiographs were
obtained at follow-up visits. AP radiographs were used
to determine coronal plane deformity (varus or valgus).
The Lateral radiographs were used to determine sagittal
plane deformity (flexion and extension). Change in
alignment was defined as greater than five degrees
change in angular measurement between the
postoperative and follow-up radiographs. Malalignment
was defined as ten degrees or more of angular
deformity. Rotational alignment was measured
clinically at follow-up visits with normal rotation being
equal to the contralateral side. Union was defined as
pain free full weight bearing in absence of tenderness or
motion at the fracture site with presence of bridging
callus across at least one cortex of the fracture site on
each the AP and Lateral views. Non-union was defined
as absence of progressive fracture healing for three
consecutive months extending beyond six months from
the injury.
Partial weight bearing with the help of walker
or crutches was allowed when the fracture showed an
evidence of union. Full weight bearing was allowed
after clinical and radiological confirmation of fracture
union in both AP and Lateral X-ray films.
Post-operative clinical assessment:
It was done according to modified Rasmussen
system assessing pain, walking capacity, range of
motion and stability and final results were evaluated.
Any complications were noted.
RESULTS
It was a prospective study in which 33 patients
with tibial plateau fracture treated by minimal invasive
surgeries were included of which three patients were
lost in follow-up and they were excluded from the
study. Hence final study comprises of 30 patients, who
came for a regular follow-up for minimum six months.
Average follow-up of patients ranged from six months
to 24 months (Mean=11.8 months, SD=5.13, n=30).
Of the 30 cases, 26 patients were male (87%)
and four were female (13%) varying between ages of 24
years to 61 years (mean age 40.1 years). The main
mode of injury was road traffic accident followed by
slip in bathroom. Out of 30 patients selected 22
sustained injury due to road traffic accident (73%),
three sustained injury due slip in bathroom (10%), three
sustained trauma by fall on road and two sustained
injury due to fall from height (7%). Out of 30 patients 7
patients (23%) sustained associated injuries like fracture
radius and ulna, fracture shaft of tibia, fracture
calcaneum etc. Right lower limb was involved in 17
patients (57%) while in 13 patients (43%) left lower
Pradeep Kumar Saini et al., Sch. J. App. Med. Sci., March 2016; 4(3B):750-754
patients out of 30 cases (26.67%). One case required
operative management.
Among the various scores obtained in our
study as per the Modified Rasmussens criteria, the
average pain score was 4.13. Majority of patients (87%)
had either no pain or occasional pain. No patient had
constant pain and only one patient had pain during mild
activity. The average walking capacity score was 4.43.
Majority of patients (67%) had normal walking and 20
% cases could do more than 1 hour outdoor walking.
One patient (3%) required aid to walk and one patient
was confined to wheel chair. The average range of
motion score was 4.23. Majority of patients (47%) had
full range of motion. Overall 25 patients (83%) had
more than 1200 range of motion at knee. Only one
Pradeep Kumar Saini et al., Sch. J. App. Med. Sci., March 2016; 4(3B):750-754
had good result. One case of both type V and type VI
fracture had fair result. Only one case (3%) in our series
of Type VI fracture had poor result. The overall
functional end results in the follow-up study were
66.7% excellent, 23.3% good, 6.7% fair and 3.3% poor.
An acceptable functional end result therefore was
obtained in 96% of the patients.
CONCLUSION
We obtained a very high rate of success using
the technique in our series across all categories of
Schatzkers type fracture. Further adequately powered
randomized controlled studies are warranted to establish
the outcome in a large multicentric trial.
7.
8.
9.
10.
REFERENCES:
1. Keogh P, Kelly C, Cashman WF, McGuiness AJ,
O'Rourke SK; Percutaneous screw fixation of tibial
plateau fractures. Injury 1992; 23(6):387389.
2. Moore T; Fracture dislocation of the knee. Clin
Orthop 1981; 156:128-14
3. Barei DP, Nork SE, Mills WJ, Henley MB,
Benirschke SK; Complications associated with
internal fixation of high-energy bicondylar tibial
plateau fractures utilizing a two-incision technique.
J Orthop Trauma, 2004; 18(10):649-657.
4. Egol KA, Tejwani NC, Capla EL, Wolinsky PL,
Koval KJ; J Orthop Trauma. 2005; 19 (7):448-55.
5. Dirschl DR, Dawson PA; Injury severity
assessment in tibial plateau fractures. Clin Orthop
Relat Res 2004; 423:8592.
6. Rademakers MV, Kerkhoffs GMMJ, Sierevelt IN,
Raaymakers E.L.FB, Marti RK; Operative
treatment of 109 tibial plateau fractures: five- to
11.
12.
13.
754