Journal of Orthopaedic Surgery 2012;20(1):37-41

Closed reduction and percutaneous screw fixation for tibial plateau fractures
Radheshyam Sament,1 JC Mayanger,1 Sujit Kumar Tripathy,2 Ramesh Kumar Sen2
1 2

Department of Orthopaedics and Rehabilitation, JLN Medical College, Ajmer, India Department of Orthopedics, Postgraduate Institute of Medical education and Research, Chandigarh, India

ABSTRACT Purpose. To evaluate treatment outcomes of closed reduction and percutaneous screw fixation for tibial plateau fractures. Methods. 48 men and 8 women aged 19 to 61 (mean, 36) years underwent closed reduction and percutaneous screw fixation for closed tibial plateau fractures with <5 mm depression. According to the Schatzker classification, patients were classified into type I (n=9), type II (n=22), type IV (n=5), and type V (n=20). Closed reduction was achieved using manual ligamentotaxis with traction in extension under image intensifier control. Reduction was fixed percutaneously with cancellous screws (6.5 mm) and washers. Functional outcome (pain, walking capacity, extension lag, range of motion, and stability) was evaluated using the Rasmussen score. A total score of 28 to 36 was considered as excellent, 20 to 27 as good, 10 to 20 as fair, and <10 as poor. Results. Patients were followed up for a mean of 2.8 (range, 14) years. The mean length of hospital stay was 5 (range, 215) days. All the fracture united

radiographically after a mean of 3 (range, 2.54.2) months. Respectively in Schatzker types-I, -II, -IV, and -V fractures, outcomes were excellent in 6, 10, 2, and 2 patients, good in 2, 9, 3, and 14 patients, fair in 1, 3, 0, and 2 patients, and poor in 0, 0, 0, and 2 patients. Outcome was satisfactory (good-to-excellent) in 89%, 86%, 100%, and 80% of the respective fracture types of patients. The mean Rasmussen score was 25.7 for all patients; it was 27.7 for type I, 26.3 for type II, 28.6 for type IV, and 23.4 for type V fractures. The mean Rasmussen score was significantly lower in 12 patients with ligament injury than in 44 patients without ligament injury (19.8 vs. 27.3, p<0.001). No patient had any complication (infection, wound dehiscence or hardware problem). Conclusion. Closed reduction and percutaneous screw fixation for tibial plateau fractures is minimally invasive. It reduces the length of hospital stay and costs, enables early mobilisation with minimal instrumentation, and achieves satisfactory outcomes.
Key words: bone screws; fracture fixation; tibial fractures

Address correspondence and reprint requests to: Dr Sujit Kumar Tripathy, Department of Orthopaedics, Friarage Hospital, Northallerton, North Yorkshire, DL6 1JG, UK. E-mail: sujitortho@yahoo.co.in

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INTRODUCTION The lateral side of the knee joint is most commonly injured during road traffic accidents, which results in torn ligaments, sprains, and fractures of one or both condyles.1 Tibial plateau fractures are intra-articular fractures caused by high-velocity trauma. They are usually associated with neurovascular injury, compartment syndrome, compounding of fractures, and crushing of soft tissues. Associated injuries at and around the knee joint are more common and severe in patients with fracture-dislocation.1,2 The treatment outcomes for tibial plateau fractures are inconsistent.13 Closed reduction (based on ligamentotaxis principles) and internal fixation (with percutaneous cancellous screws and washers) avoids the disadvantages of both operative and conservative treatments. However, it is not suitable for all types of tibial plateau fractures, particularly grossly comminuted and depressed fractures, Schatzker type-VI fractures, and open fractures.4,5 We evaluated treatment outcomes of closed reduction and percutaneous screw fixation for tibial plateau fractures. MATERIALS AND METHODS Between September 2006 and September 2008, 48 men and 8 women aged 19 to 61 (mean, 36) years
(a)

underwent closed reduction and percutaneous screw fixation for closed tibial plateau fractures with <5 mm depression. 32 of them involved the right side. The causes of injury included high-velocity road traffic accident (n=25), motorcycle skid (n=18), direct hit by car on the lateral side of the knee (n=7), and fall from a height (n=6). According to the Schatzker classification, patients were classified into type I (lateral fracture) [n=9], type II (lateral fracture with depression) [n=22, Fig.], type IV (any medial fracture) [n=5], and type V (bicondylar fracture) [n=20, Fig.]. 14 of the type-V fractures were caused by highvelocity road traffic accidents, whereas 9 and 7 of the type-II fractures were caused by motorcycle skids and direct hits by a car on the lateral side of the knee, respectively. Associated injuries included fractures of the fibula (n=11), tibial spine (n=5), patella (n=2), tibial shaft (n=5), femoral shaft (n=4), forearm bones (n=1), and head injury (n=4). Patients with type III (lateral depression), type VI (fracture extending to the metaphysis), severe comminution with >5 mm depression, compartment syndrome, or vascular injury were excluded. This study was approved by the ethics committee of our hospital. Informed consent was obtained from each patient. Appropriate emergency treatment was given for associated head, chest, and/or abdominal injuries after haemodynamic stabilisation. Anteroposterior and lateral radiographs of the knee joint were obtained. Computed tomography was not performed

(b)

Figure

Schatzker (a) type-II and (b) type-V tibial plateau fractures fixed with percutaneous cannulated cancellous screws.

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unless there was articular depression. Lower tibial pin traction was applied and the limb was rested over a Bohler-Braun splint. Patient characteristics, injury mechanism, injury pattern (based on Schatzker classification), distal neurovascular status, and associated injuries were recorded using a predesigned proforma. Patients were operated on as soon as they were medically fit. Surgery was delayed for 7 to 12 days in 4 patients with blisters or persistent tense swelling. Excluding these 4 patients, the mean delay in surgery was 2 (range, 15) days. A preoperative template was prepared using traction radiographs. Closed reduction was achieved using manual ligamentotaxis with traction in extension under image intensifier control. A femoral distractor was used in 12 patients with comminution. Both sides of the proximal tibia were thumped to dislodge the depressed articular fragment. Reduction was held temporarily with one- or 2-pointed reduction forceps, and then fixed percutaneously with cancellous screws (6.5 mm) and washers. The direction and the number of screws (2) used were based on the fracture pattern and

orientation. Articular congruency was checked under a C-arm in anteroposterior and lateral views. The limb was then immobilised in a groin-to-ankle slab (cylinder slab). The rehabilitation protocol was standard for all patients. Patients were encouraged to perform isometric quadriceps exercises, ankle pump, and toe movements. Analgesia and antibiotics were given. The slab was removed after 3 weeks, and the knee joint was examined for tenderness, swelling, and instability. Gradual knee bending and extension exercises were advised with nonweight-bearing crutch walking for further 3 weeks. Partial and full weight bearing was allowed at week 6 and week 12, respectively. Patients were followed up at months 6 and 12 and annually thereafter. At the final follow up, functional outcome (pain, walking capacity, extension lag, range of motion, and stability) was evaluated using the Rasmussen score6 (Table). The maximum score for each item was 6. A total score of 28 to 36 was considered as excellent, 20 to 27 as good, 10 to 20 as fair, and 6 to 10 as poor.

Table Patient distribution according to the Schatzker classification and Rasmussen scoring system Rasmussen scoring system* Score Schatzker classification for tibial plateau fractures (no. of patients) I (n=9) Pain No pain Occasional pain, bad weather pain Throbbing pain in certain position Constant pain after activity Pain at rest Walking capacity Normal Can walk outdoor for at least one hour Can walk outdoor for 15 minutes Can walk indoor only Wheelchair bound/bedridden Extension lag Normal 010 >10 Range of motion 140 120 90 60 30 0 Stability Normal in extension & 20 flexion Instability in 20 flexion Instability in 10 extension Instability in >10 extension 6 5 4 2 0 6 4 2 1 0 6 4 2 6 5 4 2 1 0 6 5 4 2 4 4 0 1 0 7 1 1 0 0 8 1 0 6 2 1 0 0 0 8 1 0 0 II (n=22) 4 13 2 3 0 15 5 2 0 0 19 3 0 8 11 3 0 0 0 18 1 1 2 IV (n=5) 2 3 0 0 0 2 3 0 0 0 3 2 0 2 3 0 0 0 0 4 1 0 0 V (n=20) 0 12 4 4 0 4 11 3 2 0 16 2 2 4 13 1 2 0 0 14 1 2 3

* Scores of 28 to 36 indicate excellent, 20 to 27 good, 10 to 20 fair, and 6 to 10 poor

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RESULTS Patients were followed up for a mean of 2.8 (range, 14) years. The mean length of hospital stay was 5 (range, 215) days. All the fractures united radiographically after a mean of 3 (range, 2.54.2) months. Respectively in Schatzker types-I, -II, -IV, and -V fractures, outcomes were excellent in 6, 10, 2, and 2 patients, good in 2, 9, 3, and 14 patients, fair in 1, 3, 0, and 2 patients, and poor in 0, 0, 0, and 2 patients. Outcome was satisfactory (good-to-excellent) in 89%, 86%, 100%, and 80% of the respective fracture types of patients (Table). The mean Rasmussen score was 25.7 for all patients; it was 27.7 for type I, 26.3 for type II, 28.6 for type IV, and 23.4 for type V fractures. In 11 patients with a fibular head fracture (fixed with one extra screw), outcome was excellent in 5, good in 5, and fair in one. Their mean Rasmussen score was not significantly different from that in the 45 patients without such a fracture (26.53.3 vs. 25.54.8, p>0.05, independent sample t test). In 12 patients with ligament injury, 5 had anteroposterior instability (caused by tibial spine injury) and 7 had mediolateral instability (caused by a collateral ligament tear). Their outcomes were good in 5 and fair or poor in 7. Their mean Rasmussen score was significantly lower than that in the 44 patients without such knee instability (19.85.7 vs. 27.32.5, p<0.001, independent sample t test). No patient had any complication (infection, wound dehiscence, and hardware problem). DISCUSSION Tibial plateau fractures are difficult to treat because of their intra-articular nature, cancellous bone involvement, and proximity to a major weight bearing joint. Open reduction and internal fixation achieve better outcomes for split and depressed fractures with >5 mm displacement, bicondylar fractures with >4 mm displacement, and depressed fractures of the medial condyle,4,7 whereas traction and immobilisation achieve excellent-to-good outcomes in 75%8 to 80%9 of patients before development of surgical techniques for such fractures. The limitations of conservative treatment are inadequate reduction of the articular surface, ineffective limb alignment control, and prolonged hospitalisation and recumbency, which causes quadriceps atrophy and range of movement restriction. Operative treatment restores articular congruity, axial alignment, and joint stability, and enables early mobilisation while decreasing the risk of post-traumatic arthritis.7

Nonetheless, operative treatment compromises soft tissues, devascularises bone fragments, and may be complicated by infection, implant failure, and wound dehiscence. Thus, it is not indicated for all types of tibial plateau fractures. Closed reduction and percutaneous screw fixation is minimally invasive and thus reduces the length of hospital stay and costs.5 It is indicated in patients with a large peripheral fragment (i.e. Schatzker type-I, -II and -IV fractures). Patients with depressed fractures of >5 mm (Schatzker type-VI factures) and severe comminution should be treated with open reduction and internal fixation (using a screw-plate construct and bone grafting), as closed reduction is not feasible. In our study, patients with Schatzker type-V (bicondylar) fractures were indirectly reduced with a femoral distractor or manual ligamentotaxis. The articular condyle was then reduced to the shaft and fixed with screws. Such patients achieved relatively poor outcome and should have been treated with open reduction and internal fixation with plate and screw. Irrespective of treatment modality, early mobilisation (no later than 4 weeks) is essential to prevent knee stiffness.2 Impacted articular fragments cannot be dislodged by traction or manipulation alone as there is no soft-tissue attachment.2 In our study, patients with depressed fractures (type III) were excluded, as it is difficult to achieve articular congruency by traction or manipulation. In 27 patients with closed tibial plateau fractures treated with percutaneous cancellous screws and washers,10 the mean Rasmussen score was 25 (range, 1530) after a mean follow up of 35 months; outcome was excellent in 37%, good in 52%, and unacceptable in 11% of patients; unacceptable outcomes were likely due to minimal (rather than rigid) fixation for comminuted or depressed fractures. In addition, a few patients had loss of knee range of motion owing to delayed knee mobilisation.10 In 16 patients with lateral tibial plateau fractures treated with percutaneous fixation under fluoroscopic control, 15 achieved good-toexcellent Rasmussen score and one with a lateral split fracture developed chronic pain in the medial joint line caused by chondral degeneration.11 Our patients achieved comparable outcomes. Femoral distractors have been used to indirectly reduce the articular surface in patients with tibial plateau fractures.12,13 The Esmarch bandage has also been used, even for Schatzker type-III fractures.5 The fragment was manipulated by gentle hammering and then fixed with percutaneous screws; outcomes were excellent in 33%, good in 50%, fair in 13%, and poor in 3% of patients.5 In our study, manual ligamentotaxis successfully reduced fractures with

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a peripheral fragment, whereas a femoral distractor successfully reduced fractures with comminution using an indirect technique. Guarded thumping on both sides of proximal tibia helped dislodge the depressed fragment. The depressed fragment can be elevated using an arthroscopy, which also enables direct visualisation of the articular congruency.

Arthroscopic reduction is superior to closed reduction and broadens the indications of minimally invasive percutaneous fixation. Nonetheless, it needs expertise and infrastructure. Percutaneous cancellous screw fixation with arthroscopic elevation of the depressed articular fragment is a favourable treatment modality for tibial plateau fractures.14

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1. Hohl M. Articular fractures of the proximal tibial. In: Evarts CM, editor. Surgery of the musculoskeletal system. New York: Churchill-Livingstone; 1993:347197. 2. Schatzker J. Fracture of the tibial plateau. In: Schatzker J, Tile M, editors. The rationale of operative fracture care. Berlin: Springer-Verlag; 1987:27995. 3. Stevens DG, Beharry R, McKee MD, Waddall JP, Schemitsch EH. The long-term functional outcome of operatively treated tibial plateau fractures. J Orthop Trauma 2001;15:31220. 4. Sangwan SS, Siwach RC, Singh R, Mittal R. Minimal invasive osteosynthesis: a biological approach in treatment of tibial plateau fractures. Indian J Orthop 2002;36:24650. 5. Shete K, Sancheti P, Kamdar R. Role of Esmarch bandage and percuteneous cannulated cancellous screws in tibial condylar fracture. Indian J Orthop 2006;40:1736. 6. Rasmussen PS. Tibial condylar fractures. Impairment of knee joint stability as an indication for surgical treatment. J Bone Joint Surg Am 1973;55:133150. 7. Weigel DP, Marsh JL. High-energy fractures of the tibial plateau. Knee function after longer follow-up. J Bone Joint Surg Am 2002;84:154151. 8. De Mourgues G, Chaix D. Treatment of fracture of the tibial plateau [in French]. Rev Chir Orthop Reparatrice Appar Mot 1964;50:10322. 9. Apley AG. Fractures of the tibial plateau. Orthop Clin North Am 1979;10:6174. 10. Mathur H, Acharya S, Nijhawan VK, Mandal SP. Operative results of closed tibial plateau fractures. Indian J Orthop 2005;39:10812. 11. Lobenhoffer P, Schulze M, Gerich T, Lattermann C, Tscherne H. Closed reduction/percutaneous fixation of tibial plateau fractures: arthroscopic versus fluoroscopic control of reduction. J Orthop Trauma 1999;13:42631. 12. Mast J, Jakob R, Ganz R. Reduction with distraction. In: Mast J, Jakob R, Ganz R, editors. Planning and reduction technique in fracture surgery. Berlin: Springer-Verlag; 1989:13042. 13. Koval KJ, Sanders R, Borrelli J, Helfet D, DiPasquale T, Mast JW. Indirect reduction and percutaneous screw fixation of displaced tibial plateau fractures. J Orthop Trauma 1992;6:3406. 14. Keogh P, Kelly C, Cashman WF, McGuinness AJ, ORourke SK. Percutaneous screw fixation of tibial plateau fractures. Injury 1992;23:3879.