|Year : 2013 | Volume
| Issue : 1 | Page : 43-48
Management of closed tibial plateau fractures with percutaneous cancellous screw fixation
Tushar Agarwal, Anil Salgia, Samar Kumar Biswas, Sahil Sanghi, Subash Rajendra Puri
Department of Orthopaedics, Padmashree Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, India
|Date of Web Publication||14-Mar-2013|
Department of Orthopaedics, Padmashree Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune
Source of Support: None, Conflict of Interest: None
Background: Tibial plateau fractures, intra-articular in nature and caused by high-velocity trauma, constitute approximately 1% of all fractures. Primary goal in the management of proximal tibial articular fracture aims for a stable, congruous, pain-free, mobile joint. Objective: To study the technique, results, and complications of percutaneous cancellous screw fixation for tibial plateau fractures. Materials and Methods: Twenty-three men and seven women aged 18-65 years (mean = 36.8 years) underwent closed reduction and percutaneous screw fixation for closed tibial plateau fractures with <5 mm depression. According to the Schatzker classification, patients were grouped as type I (n = 18), type II (n = 4), type III (n = 0), type IV (n = 8), type V (n = 2), and type VI (n = 1). Closed reduction was achieved by manual ligamentotaxis technique under image intensifier control and fixed percutaneously with two cancellous screws (6.5 mm) with or without washers in a parallel fashion. Results: Functional outcome was evaluated using the Mason Hohl evaluation system. A total score of 19-24 was considered as excellent, 13-18 as good, 7-12 as fair, and <6 as poor. Outcomes were excellent in 10 patients, good in 15, fair in 4, and poor in 1 patient. Patients were allowed partial weight bearing with walker after 1 month and full weight bearing after radiological union in approximately 3-4 months. The mean period of hospital stay was 5 (range 2-15) days. All the fractures united radiologically after a mean of 3 (range 2.5- 5) months. Patients were evaluated at a mean of 3 years after injury. No patient had any complication like infection, wound dehiscence, or hardware problem. Conclusion: Percutaneous cancellous screw fixation for closed tibial plateau fractures is minimally invasive. It reduces hospital stay and cost, enables early mobilization with minimal instrumentation, and achieves satisfactory outcomes.
Keywords: Percutaneous cancellous screw fixation, schatzker classification, tibial plateau fracture
|How to cite this article:|
Agarwal T, Salgia A, Biswas SK, Sanghi S, Puri SR. Management of closed tibial plateau fractures with percutaneous cancellous screw fixation. Med J DY Patil Univ 2013;6:43-8
|How to cite this URL:|
Agarwal T, Salgia A, Biswas SK, Sanghi S, Puri SR. Management of closed tibial plateau fractures with percutaneous cancellous screw fixation. Med J DY Patil Univ [serial online] 2013 [cited 2018 Feb 23];6:43-8. Available from: http://www.mjdrdypu.org/text.asp?2013/6/1/43/108639
| Introduction|| |
Tibial plateau fractures constitute approximately 1% of all fractures.  They involve the knee joint and usually result from axial loading in combination with varus/valgus stress forces.  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.  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. , The primary goal in the treatment of proximal tibial articular fracture includes restoration of articular congruity, axial alignment, joint stability, and functional motion.  The treatment outcomes for tibial plateau fractures are inconsistent. ,, Closed reduction (based on ligamentotaxis principles) and internal fixation (with percutaneous cancellous screws) avoids the problems of both open surgery and conservative treatments. However, it is not suitable for all types of tibial plateau fractures, particularly grossly comminuted and severally depressed fractures and open fractures. ,
| Materials and Methods|| |
In our study, 30 cases were selected. We classified all fractures according to Schatzker's system. The inclusion criteria were: Schatzker type I, II, and IV fractures, articular step <8 mm, depressed fracture <5 mm. As an extended indication, we also used this technique in two type V and one type VI fracture. The exclusion criteria were: Depressed fractures >5 mm, articular step >8 mm, compound fractures and Schatzker's type III, V, and VI, fractures. On admission, all patients were investigated for skin condition, deformity, instability, any other associated injuries. X-rays, anteroposterior and lateral radiographs of the knee, usually show a plateau fracture [Figure 1]. 40° internal and external oblique views should be obtained. Internal oblique view profiles the lateral plateau, whereas external oblique view projects the medial condyle and plateau. Computed tomography was not performed 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. Twenty-four patients were operated within 2 days of injury and six patients were operated after 7 days of injury because of edema and bad skin condition. During this period, limb elevation, magnesium sulfate dressings, immobilization with lower tibial pin traction in BB splint was given. After giving anesthesia, patients were positioned supine on angle frame on radiolucent top, and intravenous antibiotic was given half an hour before starting surgery; pneumatic tourniquet was tied, and Scrubbing, painting and draping of the limb were done. Reduction was done using Esmarch bandage [Figure 2] tied from toes to above knee, with more pressure given in area of upper end tibia and reduction held with pointed clamp [Figure 3] checked under C-Arm [Figure 4]; if required, gentle tapping with hammer was done on medial or lateral condyle depending upon fracture configuration. In cases of fracture combined with depression, an incision was made on the anterior aspect of tibia, centering the fracture site. , Under image intensifier, a cortical hole was made in the anterior cortex through which narrow spike was introduced to elevate the depressed fracture. Reduction was held in place and then the guide wire was passed through which CC screw was introduced. The criteria for acceptable reduction were: <8 mm of articular step and < 5 mm of articular depression.
Guide wire was passed from lateral to medial side fixing both the condyles and directed perpendicular to the fracture line; length of guide wire was checked under C-Arm [Figure 5]. The guide wire was advanced to engage far cortex, with stab knife skin incision taken; cannulated drill bit of 3.7 mm was used over the guide wire to make and then screw length was assessed. Partially threaded 6.5-mm cannulated cancellous screw with or without washer passed over guide wire, compression at fracture site occurs during final tightening. Screw position and articular surface was checked under C-Arm. In a similar fashion, as per fracture configuration, if required, the other screws were passed parallel to the first [Figure 6]. Stab incision was closed and sterile dressing applied; RJ bandage was given and limb kept elevated over BB splint.
|Figure 6: Other screw passed parallel and reduction check under image intensifier|
Click here to view
Check X-ray was taken [Figure 7]. Limb elevation was done and IV antibiotic was given for 24 h; limb was watched for soakage and Distal Neuro-vascular deficit. Non-weight-bearing walking with crutches was started on 2 nd day. Patient was discharged on 3 rd postoperative day. Active knee movements were started from day 4. Advice on discharge was to keep the limb elevated and continue non-weight-bearing walking with crutches.
First follow-up was done on 4 th post-op day; RJ bandage and wound inspection was done. Patient was advised to use short-hinged knee brace with patella open up and was started with knee bending. On the 10 th post-op day, the sutures were removed. Patient was encouraged for non-weight-bearing and knee bending for 6 weeks. Check X-ray was taken. Radiological assessment was done for redisplacement/loss of reduction. Third follow-up was after 8 weeks for clinico-radiological assessment and 50% weight bearing started was increased to 75% after 15 days [Figure 8]. After 3 months, full weight bearing was allowed after clinico-radiological union [Table 1].
Thereafter, patients were followed up every 3-4 months for 1-4 years (mean 3 years) for any complications. Grading of results was done as per Mason Hohl evaluation system depending on anatomical (radiological) [Table 2] and functional (clinical) [Table 3] assessment; the overall results were graded as per [Table 4].
| Results|| |
Our study of 30 tibial plateau fractures confirmed the findings of various studies that percutaneous cancellous screw fixation technique is an excellent treatment modality. Typical postoperative results are shown in [Figure 8] and [Figure 9]. We observed these fractures in the age group ranging from 18 to 65 years (mean 34.7 years with an SD of 9.58 years). There were 23 male and 7 female patients, who were mostly affected by road traffic accidents. Most common mode of injury (23) was road traffic accidents; the second most common mode of injury was fall from height (5), which was followed by sports injury (2). We also found the following associated injuries in the patients: fracture upper end fibula (17), supracondylar fracture femur (2), ankle fracture (1), and calcaneal fracture (1). One patient had impending compartment syndrome.
Two patients of lateral condyle fracture with fibular fracture showed redisplacement of fragment. Other injuries were treated independently. We found oblique views very much informative especially for posterolateral, posteromedial displacement or articular depression, which help to plan the position and direction of screws to be used for fixation. Ligamentous injuries could not be assessed due to pain.
Twenty-four patients were operated within 2 days of injury; for others we had to wait for 7 days for edema to subside, soft tissue injury to heal, and skin condition to improve. Even after 7 days, open reduction internal fixation would not have been possible due to skin condition; therefore, we opted for percutaneous screw fixation. The evaluation of the results according to the grading is given in [Table 5].
| Complications|| |
All complications were minor and manageable [Table 6].
| Discussion|| |
Tibial plateau fractures are a cause of high-energy intraarticular fractures, which is a cause of ongoing management problems and remains challenging for orthopedic surgeons even in the present day. Tibial plateau fracture being intraarticular complicates the treatment plan. Our goal here is to obtain a stable, pain-free, non-osteoarthritis knee joint permitting early range of motion. 
Previous treatment methods proposed for fracture of the tibial condyles include extensile exposure with arthrotomy and reconstruction of the joint surface with plate and screw fixation, Which is expensive and an open procedure. ,
Severe or complex tibial plateau fractures are more commonly seen in the younger age group due to high-energy trauma. Closed treatments of these injuries have achieved little success in reducing depressed or displaced fracture fragments. This necessities open treatment in most of the displaced and unstable fractures. It is extremely important to do a stable fragment fixation and ligament repair in order to regain the complete range of motion. Despite anatomical joint reconstruction, development of osteoarthritis may still occur secondary to the initial articular cartilage and meniscal injury.
Conservative treatment is generally reserved for patients with minimally displaced fractures or in those who cannot bear the stress of surgery. Conservative treatment includes treatment with plaster or ankle traction, followed by active movements of knee when pain subsides. This decreases the risk but cannot achieve radiological alignment. This type of treatment is recommended in elderly patients where the demand is less. In young patients and sports persons, exact articular alignment is necessary.
Closed reduction by manual ligamentotaxis and percutaneous cancellous screw fixation is less invasive, and thus early mobilization of the joint can be started avoiding knee stiffness; however, these are based on indirect reduction techniques and are limited to depression less than 5 mm. ,,,
In our study, there were 26.4% excellent, 50.00% good, 20.00% fair, and 3.6% poor results, which is comparable to the study done by Sament et al.  After evaluating the results, we found that treatment of tibial plateau fracture requires detailed consideration of the following. We initially assessed ligamentous instability under anesthesia. We found in our study 33% of cases had associated ligamentous injury, three type I, two type II, and five type IV, which is comparable to the results reported by Rasmussen  who also showed that ligament injuries occur in 10-33% of tibial plateau fractures. All ligament injuries were treated conservatively.  We used Eshmarch bandage to help in reduction, which we found very helpful to decrease displacement. We used pointed reduction clamps for final reduction, as suggested by Kankate and Singh,  with satisfactory results. We have not used intraoperatively arthroscopic evaluation for the reduction or to repair any meniscal injury. According to series of Lobenhoffer and Schulze, arthroscopic reduction had no advantages over reduction under fluoroscopic control.  We also have found fluoroscopic assisted percutaneous fixation as good as arthroscopic assisted one. We found that two half-threaded (16 mm or 32 mm) 6.5-mm cannulated cancellous screws give sufficient stability. We agree with Koval and Sanders in that the number of screws, whether two, three, or four, does not matter. 
Eleven patients were having complaints of palpable screw head and four of them had painful bursa over the same. We had to remove the implants in two of them within 18 months to relieve their symptoms. One patient had loosening of screw, but his fracture was united. During 2 years follow-up, we came across four patients with osteoarthritis of knee. All these were having initial displacement and ligamentous instability.  We agree with Schatzker et al.'s report that initial fracture type and injury is important in determining the final outcome. 
| Conclusion|| |
We found that percutaneous screw fixation for Schatzker type I, II, and IV fractures is an excellent treatment alternative to open reduction internal fixation (ORIF) or conservative management. Percutaneous cancellous screw fixation for closed tibial plateau fractures is minimally invasive, hence less morbid than ORIF. It reduces hospital stay and cost. It enables early mobilization with minimal instrumentation, and achieves satisfactory outcomes without any anatomical deformity or functional impairment as often seen with conservative management.
| References|| |
|1.||Carlson DA. Posterior bicondylar tibial plateau fractures. J Orthop Trauma 2005;19:73-8. |
|2.||Terry Canale S. Tibial Plateau Fractures. In: Campbell's Operative Orthopaedics. Pennsylvania: Mosby Elsevier; 1998, p. 2094-109. |
|3.||Hohl M. Articular fractures of the proximal tibial. In: Evarts CM, editor. Surgery of the musculoskeletal system. New York: Churchill-Livingstone; 1993. p. 3471-97. |
|4.||Schatzker J. Fracture of the tibial plateau. In: Schatzker J, Tile M, editors. The rationale of operative fracture care. Berlin: Springer-Verlag; 1987. p. 279-95. |
|5.||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;15:312-20. |
|6.||Sangwan SS, Siwach RC, Singh R, Mittal R. Minimal invasive osteosynthesis: A biological approach in treatment of tibial plateau fractures. Indian J Orthop 2002;36:246-50. |
|7.||Shete K, Sancheti P, Kamdar R. Role of Esmarch bandage and percuteneous cannulated cancellous screws in tibial condylar fracture. Indian J Orthop 2006;40:173-6. |
|8.||Pawar Eknath D, Goenkaharshit K. A bilological approach in treatment of tibial plateau fractures by minimal invasive fixation. J Mahrashtra Orthop Assoc 2012;7. Available from: http://moajournal.com/wp/wp-content/uploads/2012/01/tibi-plateau-fracture-final.pdf [Last assessed on 2012 Oct 29]. |
|9.||Ravindarnath VS, Kumar M, Murthy GV. A new device for percutaneous elevation of the depressd fractures of tibial condyles. J Orthop Case Report 2012;2:24-6. available from: http://www.jocr.co.in/wp/2012/04/11/a-new-device-for-percutaneous-elevation-of-the-depressed-fractures-of-tibial-condyles/ [Last assessed on 2012 Oct 29]. |
|10.||Sament R, Mayanger JC, Tripathy Sujit K, Sen RK. Closed reduction and percutaneous screw fixation for tibial plateau fracture. J Orhtop Surg (Hong Kong) 2012;20:37-41. |
|11.||Rasmussen PS. Tibial condylar fractures. J Bone Joint Surg Am 1973;55:1331-50. |
|12.||Kankate RK, Singh P, Ekiott DS. Percutaneous plating of the low energy unstable tibial plateau fractures: A new technique. Injury 2001;32:229-32. |
|13.||Lobenhoffer P, Schul M, Gerich T. Closed reduction/percutaneous fixation of tibial plateau fractures: Arthroscopic versus fluoroscopic control of reduction. J Orthop Trauma 1999;13:426-31. |
|14.||Koval KJ, Sanders R, Borrelli J, Helfet D. Indirect reduction and percutaneous screw fixation of displaced tibial plateau fracture. J Orthop Trauma 1992;6:340-6. |
|15.||Mitchell MD. Healing of articular cartilage in intraarticular fracture (rabbits) J Bone Joint Surg Am. 1980;62(4):628-34. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]