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n Feature Article

Treatment of Complicated Tibial Plateau


Fractures With Dual Plating Via a 2-incision
Technique
Yong Zhang, MD; De-gang Fan, MD; Bao-an Ma, MD; Si-guo Sun, MD

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

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n Feature Article

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

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Complicated Tibial Plateau Fractures | Zhang et al

achieved. In the double buttress plate


group, the medial and lateral plateaus
were fixed with buttress plates. In the
combination plates group, a locking plate
was used on the side with relatively more
severe fracture comminution, and the
other side was fixed with a buttress plate.
Plain radiographs were taken to verify
A B C
adequate articular reduction and implant
placement. The menisci and cruciate liga-
ments were examined and identified, and
soft tissue injuries were repaired if pos-
sible.
In open fractures, incisions were based
on the fracture pattern and location of the
traumatic wounds. The goal was to limit
the creation of large laps and to minimize
D E F
soft tissue stripping.
Figure: Preoperative anteroposterior (left) and lateral (right) radiographs of a 32-year-old man with a
All patients had a similar postop- displaced bicondylar tibial plateau fracture that was managed with double plating via a 2-incision tech-
erative regimen and were followed up at nique (A). Immediate postoperative anteroposterior (left) and lateral (B) radiographs showing satisfactory
regular intervals for at least 24 months. restoration of the congruity of the articular surface alignment of the lower extremity. Twelve-month post-
Range of motion (ROM) exercises were operative anteroposterior (left) and lateral (right) radiographs showing bony union of the fractures (C).
Twenty-three-month postoperative anteroposterior (left) and lateral (right) radiographs after the plates
started with the supervision of a physical were removed at the request of the patient showing secondary loss of reduction and alignment and osteo-
therapist once the incisions were sealed arthritis (D). Plain radiograph showing a tibial plateau angle of 85° and posterior slope angle of 21° (E).
and dry. A hinged brace was used for 12 Despite mild pain in the knee, the patient was satisfied with the results (F).
to 16 weeks if the anterior cruciate liga-
ment (ACL) was injured. Patients were in-
structed to remain nonweight bearing for plateau and the perpendicular line of the >1 of the expected variables were ,5,
a minimum of 6 weeks, and then partial anterior tibial cortex) on lateral radio- and the linear-by-linear association was
weight bearing was allowed. Full weight graphs (Figure); tibial plateau angle >90° used when >3 categorical variables were
bearing was not allowed until bony heal- or <80° or posterior slope angle >15° or under consideration (eg, mechanism of
ing was seen on radiographs. During the <25° was considered indicative of ma- injury). A P value ,.05 was considered
follow-up period, fracture healing time lalignment. Secondary loss of reduction significant.
and postoperative complications were re- was defined as an increase of 2 mm of
corded. Radiographs during the immedi- intra-articular step-off, and secondary loss Results
ate postoperative and subsequent follow- of alignment was defined as an increase of Ninety-eight patients met the criteria
up period were reviewed for all patients. 3° malalignment when compared with the for this study, and 79 patients were fol-
Knee function evaluation was performed first postoperative radiograph. Bony union lowed for at least 24 months. The data of
at 24 months according to Hospital for was defined radiographically by the treat- these 79 patients were analyzed. Of the 79
Special Surgery (HSS) scores.14 ing surgeon as >3 cortical unions dur- patients, 41 were fixed with a double but-
Malreduction of the articular surface ing the follow-up period. Nonunion was tress plate and 38 were fixed with a com-
was defined as an intra-articular step-off defined as no evidence of healing after 9 bination of locking plate and buttress plate.
of at least 2 mm measured on scaled ra- months. No significant difference existed regarding
diographs. Alignment of the proximal tib- A chi-square test was used for cat- follow-up time, mechanism of injury, frac-
ia was determined by measuring the tibial egorical variables between the 2 groups. ture type, open fracture grade, age, sex dis-
plateau angle (the medial angle between A traditional Pearson’s chi-square test tribution, and associated injuries between
the tangential line and anatomic axial of was used when statistical conditions were the 2 groups (Table 1). No significant dif-
the tibia) on anteroposterior radiographs met. Student’s t test was used for con- ferences existed regarding operative time,
and the posterior slope angle (the angle tinuous variables, such as age and ROM. tourniquet time, blood loss, and soft tis-
between the tangential line of medial Fisher’s exact test was used in cases when sue injury repairing between the 2 groups.

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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).

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Complicated Tibial Plateau Fractures | Zhang et al

Discussion
The treatment of complicated bicondy- Table 3

lar tibial plateau fractures resulting from Complications and Outcomes


high-energy trauma is challenging due to
severe comminution, damage to the ar- Buttress Plate Group Combination Group
(n541) (n538) P
ticular surface, and associated soft tissue
Union rate, % 100 100 1.000
injuries. Although follow-up times in the
current study were not adequate to obtain Mean radiographic healing 14.161.4 13.762.5 .257
time, w
long-term outcomes, the 24-month results
Complications, No.
are satisfactory according to the HSS
Superficial infection 4 2 .743
scores, with a low rate of complications.
Soft tissue complications are a major Deep infection 2 1 .947
concern in the treatment of bicondylar Loss of reduction 4 3 .916
tibial plateau fractures with dual plates Loss of alignment 2 1 .947
and have been reported to be as high as Instability
23% to 100%15-17 with dual plates through Mild 3 2 .930
a single incision. With advances in surgi- Medium 2 2 .663
cal technique, the deep infection rate has Severe 1 0 .970
been reported to have reduced to 4.7%
Arthritis with joint space 9 8 .923
with dual plates through 2 incisions.11 To narrowing
minimize soft tissue stripping, small wire Mean ROM, deg
external fixators were explored for the
Flexion 119.969.6 121.267.1 .496
treatment of tibial plateau fractures. Deep
Extension 4.362.9 4.162.3 .7427
infection and osteomyelitis remain a sig-
Arc of motion 115.6612.1 117.169.0 .536
nificant problem, with rates between 7%
and 13%.5,8,9 The deep infection rate in Mean HSS score 77.869.4 79.067.9 .570
the current study was 3.8% (3/79), which Abbreviations: deg, degrees; HSS, Hospital for Special Surgery; ROM, range of motion.
was lower than previous reports. We be-
lieve that gentle handling of the soft tis-
sues with a nontraumatic technique and a spective study conducted by the Canadian Dual plating is preferred to fixed-angle
staged surgery allowed the compromised Orthopaedic Trauma Society reported that implants in a significantly displaced frac-
soft tissue to heal before definitive fixa- a circular external fixator yielded similar ture of the medial articular surface.11,19
tion and helped reduce soft tissue com- clinical outcomes but with fewer compli- A 2-incision double-plating technique
plications and infection rate. All patients cations.4 However, insufficient fracture is recommended by the Association for
in the current study were managed with reduction due to poor visualization and Osteosynthesis/Association for the Study
transcalcaneal skeletal traction for 5 to superficial or pin tract infections concerns of Internal Fixation for the treatment of
14 days during the first stage, which also many orthopedic surgeons. bicondylar tibial plateau fractures.18
helped to restore leg alignment and main- Less Invasive Stabilization System Because locking plates provide angle
tain soft tissue length while facilitating fixation offers the advantages of indirect stability, we hypothesized that using lock-
healing and preventing further soft tissue fracture reduction, percutaneous sub- ing plates instead of buttress plates may
damage. muscular implant placement, and a fixed help prevent secondary loss of reduc-
The goals of operative treatment for angle structure. Several studies have re- tion and alignment. However, our results
bicondylar tibial plateau fractures are to ported encouraging results with this tech- showed no significant difference between
reconstruct the congruity of the articu- nique11,19; however, favorable reports are the double buttress plate group and the
lar surface, restore normal alignment of often only from case series. Gosling et al19 combination group in the rate of sec-
the lower extremity, and provide stable evaluated the Less Invasive Stabilization ondary loss of reduction and alignment.
fixation to allow for early knee joint System used alone to treat 69 bicondylar Further review showed that all patients
ROM.2,15,18 Several fixation techniques tibial plateau fractures and reported that with secondary loss of reduction or align-
have been explored for the treatment of 16 patients had a significant malreduc- ment received no or insufficient bone graft
such fractures. A recent multicenter pro- tion and 9 patients had a loss of reduction. during open reduction and internal fixa-

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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
2. Watson JT. High-energy fractures of the
rence of secondary loss of reduction and [published online ahead of print January 24,
tibial plateau. Orthop Clin North Am. 1994;
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3. Weigel DP, Marsh JL. High-energy fractures
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2623.
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A comparison of four models of total knee-
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