Tibial plateau fracture surgery: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
No edit summary
No edit summary
 
(5 intermediate revisions by the same user not shown)
Line 4: Line 4:


==Overview==
==Overview==
Surgery is the mainstay of treatment for tibial plateau fractures. Fractures presenting with vascular injury as well as fracture dislocations should be managed emergently. The principles of definitive fixation for tibial plateau fractures include restoration of articular surface and mechanical axis alignment. The fracture fixation depends on fracture pattern.  Approach for the fracture depends on fracture pattern and type of implant preferred by the surgeon. The implant commonly used include percutaneous cancellous and raft screws, locking plate, anti-glide plate, and external fixators including Ilizarov ring fixator.
[[Surgery]] is the mainstay of treatment for tibial plateau fractures. [[Fractures]] presenting with [[vascular injury]] as well as [[fracture]] [[dislocations]] should be managed emergently. The principles of definitive [[fixation]] for tibial plateau fractures include restoration of [[articular surface]] and mechanical axis alignment. The [[fracture]] fixation depends on fracture pattern.  Approach for the fracture depends on fracture pattern and type of implant preferred by the surgeon. The implant commonly used include percutaneous [[cancellous]] and raft screws, locking plate, anti-glide plate, and external fixators including [[Ilizarov apparatus|Ilizarov]] ring fixator.


==Surgery==
==Surgery==
Surgery is the mainstay of treatment for tibial plateau fractures.
[[Surgery]] is the mainstay of treatment for tibial plateau fractures.


===Indications===
===Indications===
*Indications for fixation of tibial plateau fractures include:<ref name="pmid16118010">{{cite journal| author=Papagelopoulos PJ, Partsinevelos AA, Themistocleous GS, Mavrogenis AF, Korres DS, Soucacos PN| title=Complications after tibia plateau fracture surgery. | journal=Injury | year= 2006 | volume= 37 | issue= 6 | pages= 475-84 | pmid=16118010 | doi=10.1016/j.injury.2005.06.035 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16118010  }} </ref><ref name="pmid445923">{{cite journal| author=Schatzker J, McBroom R, Bruce D| title=The tibial plateau fracture. The Toronto experience 1968--1975. | journal=Clin Orthop Relat Res | year= 1979 | volume=  | issue= 138 | pages= 94-104 | pmid=445923 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=445923  }} </ref>
*Indications for fixation of tibial plateau fractures include:<ref name="pmid16118010">{{cite journal| author=Papagelopoulos PJ, Partsinevelos AA, Themistocleous GS, Mavrogenis AF, Korres DS, Soucacos PN| title=Complications after tibia plateau fracture surgery. | journal=Injury | year= 2006 | volume= 37 | issue= 6 | pages= 475-84 | pmid=16118010 | doi=10.1016/j.injury.2005.06.035 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16118010  }} </ref><ref name="pmid445923">{{cite journal| author=Schatzker J, McBroom R, Bruce D| title=The tibial plateau fracture. The Toronto experience 1968--1975. | journal=Clin Orthop Relat Res | year= 1979 | volume=  | issue= 138 | pages= 94-104 | pmid=445923 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=445923  }} </ref>
**Open fractures
**[[Fracture|Open fractures]]
**Compartment syndrome
**[[Compartment syndrome]]
**Vascular injury
**[[Vascular injury]]
**Lateral plateau fractures with
**Lateral plateau fractures with
***Articular step of > 3 mm
***[[Articular]] step of > 3 mm
***Condylar widening > 5 mm
***Condylar widening > 5 mm
***Coronal plane instability
***Coronal plane instability
**Displaced medial plateau fractures
**Displaced medial plateau [[fractures]]
**Bicondylar fractures
**Bicondylar [[fractures]]


===Initial Management===
===Initial Management===
*Fractures presenting with vascular injury as well as fracture dislocations should be managed emergently.  
*Fractures presenting with [[vascular injury]] as well as [[fracture]] [[dislocations]] should be managed emergently.  
*Compartment syndrome is an emergency which requires immediate four compartment fasciotomy regardless of the planned defnitive management.
*[[Compartment syndrome]] is an [[emergency]] which requires immediate four compartment [[fasciotomy]] regardless of the planned definitive management.
*Open fractures with gross contamination also warrant emergent management.
*Open [[fractures]] with gross [[contamination]] also warrant [[Emergency|emergent]] management.


===Principles of definitive fixation for tibial plateau fractures===
===Principles of definitive fixation for tibial plateau fractures===
*The principles of definitive fixation for tibial plateau fractures include:<ref name="pmid26043050">{{cite journal| author=Yoon RS, Liporace FA, Egol KA| title=Definitive fixation of tibial plateau fractures. | journal=Orthop Clin North Am | year= 2015 | volume= 46 | issue= 3 | pages= 363-75, x | pmid=26043050 | doi=10.1016/j.ocl.2015.02.005 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26043050  }} </ref>
*The principles of definitive fixation for tibial plateau fractures include:<ref name="pmid26043050">{{cite journal| author=Yoon RS, Liporace FA, Egol KA| title=Definitive fixation of tibial plateau fractures. | journal=Orthop Clin North Am | year= 2015 | volume= 46 | issue= 3 | pages= 363-75, x | pmid=26043050 | doi=10.1016/j.ocl.2015.02.005 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26043050  }} </ref>
**Restoration of articular surface and mechanical axis alignment.
**Restoration of [[articular surface]] and mechanical axis alignment.
**Balanced fixation using appropriate hardware.
**Balanced [[fixation]] using appropriate hardware.
**Operate only when soft tissues conditions are appropriate such as skin wrinkling and minimal blisters.
**Operate only when soft tissues conditions are appropriate such as skin wrinkling and minimal [[Blister|blisters]].
**Minimally invasive technique should be preferred.
**[[Minimally invasive procedure|Minimally invasive]] technique should be preferred.


===Fixation Techniques===
===Fixation Techniques===
Line 41: Line 41:
'''Percutaneous Screw Fixation'''
'''Percutaneous Screw Fixation'''
*Partially threaded cancellous screws are usually used.
*Partially threaded cancellous screws are usually used.
*This is followed by  early range of motion.
*This is followed by  early [[range of motion]].


'''Locking Plate'''
'''Locking Plate'''
Line 48: Line 48:


===Schatzker II and III fractures===
===Schatzker II and III fractures===
*The type II fractures pattern are common and associated with an articular step off that needs to be reduced.<ref>McNamara IR, Smith TO, Shepherd KL, Clark AB, Nielsen DM, Donell S, Hing CB (2015) Surgical fxation methods for tibial plateau fractures. Cochrane Database Syst Rev. 9:CD009679 </ref>
*The type II [[fractures]] pattern are common and associated with an articular step off that needs to be reduced.<ref>McNamara IR, Smith TO, Shepherd KL, Clark AB, Nielsen DM, Donell S, Hing CB (2015) Surgical fxation methods for tibial plateau fractures. Cochrane Database Syst Rev. 9:CD009679 </ref>
*The type III fractures pattern usually have only an articular step off which is not easily appreciated on x-rays.<ref>Khatri K, Sharma V, Goyal D, Farooque K (2016) Complications in the management of closed high-energy proximal tibial plateau fractures. J Traumatol 19(6):342–347</ref>
*The type III [[fractures]] pattern usually have only an articular step off which is not easily appreciated on [[x-rays]].<ref>Khatri K, Sharma V, Goyal D, Farooque K (2016) Complications in the management of closed high-energy proximal tibial plateau fractures. J Traumatol 19(6):342–347</ref>


'''Approach'''
'''Approach'''
*The incision is taken anterolaterally with elevation of the iliotibial band and tibialis anterior in continuity of Gerdy’s tubercle and a sub-meniscal approach to the articular surface.<ref>Johnson EE, Timon S, Osuji C (2013) Surgical technique:
*The [[incision]] is taken anterolaterally with elevation of the [[iliotibial band]] and [[Tibialis anterior muscle|tibialis anterior]] in continuity of [[Gerdy’s tubercle]] and a sub-[[Meniscal tear|meniscal]] approach to the [[articular surface]].<ref>Johnson EE, Timon S, Osuji C (2013) Surgical technique:
Tscherne-Johnson extensile approach for tibial plateau fractures.
Tscherne-Johnson extensile approach for tibial plateau fractures.
Clin Orthop Relat Res. 471(9):2760–2767</ref><ref>Solomon LB, Stevenson AW, Lee YC, Baird RP, Howie DW (2013) Posterolateral and anterolateral approaches to unicondylar posterolateral tibial plateau fractures: a comparative study. Injury 44(11):1561–1568</ref>
Clin Orthop Relat Res. 471(9):2760–2767</ref><ref>Solomon LB, Stevenson AW, Lee YC, Baird RP, Howie DW (2013) Posterolateral and anterolateral approaches to unicondylar posterolateral tibial plateau fractures: a comparative study. Injury 44(11):1561–1568</ref>
*This is followed by elevation of the articular surface, reduction of the condylar split if present.
*This is followed by elevation of the [[articular surface]], reduction of the condylar split if present.
*Finally fill the metaphyseal defect with bone graft or bone cement such as calcium phosphate cement.
*Finally fill the [[metaphyseal]] defect with [[Bone grafting|bone graft]] or [[bone cement]] such as [[calcium phosphate]] [[cement]].


'''Implants'''
'''Implants'''
Line 68: Line 68:


'''Arthroscopic-Assisted Reduction and Internal Fixation'''
'''Arthroscopic-Assisted Reduction and Internal Fixation'''
*Studies have shown that patients treated with this technique return to sport a lot sooner than those treated by standard open reduction and internal fixation.<ref>Robertson GAJ, Wong SJ, Wood AM (2017) Return to sport following tibial plateau fractures: a systematic review. World J Orthop 8(7):574–587</ref><ref>Caspari RB, Hutton PM, Whipple TL, Meyers JF (1985) The role of arthroscopy in the management of tibial plateau fractures. Arthroscopy 1985(1):76–82 </ref>
*Studies have shown that patients treated with this technique return to sport a lot sooner than those treated by standard [[Open reduction internal fixation|open reduction and internal fixation]].<ref>Robertson GAJ, Wong SJ, Wood AM (2017) Return to sport following tibial plateau fractures: a systematic review. World J Orthop 8(7):574–587</ref><ref>Caspari RB, Hutton PM, Whipple TL, Meyers JF (1985) The role of arthroscopy in the management of tibial plateau fractures. Arthroscopy 1985(1):76–82 </ref>


'''Balloon guided Inflation Tibioplasty'''
'''Balloon guided Inflation Tibioplasty'''
*It is a relatively new technique.
*It is a relatively new technique.
*In this technique, calcium phosphate or Poly methyl methacrylate (PMMA) -loaded balloon is used to indirectly reduce the articular surface under fuoroscopic guidance.<ref>Jentzsch T, Fritz Y, Veit-Haibach P, Schmitt J, Sprengel K, Werner CM (2015) Osseous vitality in single photon emission computed tomography/computed tomography (SPECT/CT) after balloon tibioplasty of the tibial plateau: a case series. BMC Med Imaging 15:56</ref>
*In this technique, [[calcium phosphate]] or Poly methyl methacrylate (PMMA) -loaded balloon is used to indirectly reduce the [[articular surface]] under [[Fluoroscopy|fluoroscopic]] guidance.<ref>Jentzsch T, Fritz Y, Veit-Haibach P, Schmitt J, Sprengel K, Werner CM (2015) Osseous vitality in single photon emission computed tomography/computed tomography (SPECT/CT) after balloon tibioplasty of the tibial plateau: a case series. BMC Med Imaging 15:56</ref>


===Schatzker IV Fracture===
===Schatzker IV Fracture===
*The medial condyle fracture is often has a posteromedial component. <ref>Softness KA, Murray RS, Evans BG (2017) Total knee arthroplasty and fractures of the tibial plateau. World J Orthop 8(2):107–114</ref><ref>
*The medial condyle fracture is often has a posteromedial component. <ref>Softness KA, Murray RS, Evans BG (2017) Total knee arthroplasty and fractures of the tibial plateau. World J Orthop 8(2):107–114</ref><ref>*Coronal bicondylar tibial plateau fracture involving the posterior condyles has also been seen.
*Coronal bicondylar tibial plateau fracture involving the posterior condyles has also been seen.


'''Approach'''
'''Approach'''
*When these fractures has a coronal component, the buttress plate is placed from behind using a posteromedial approach.<ref>Moore TM (1981) Fracture-dislocation of the knee. Clin Orthop Relat Res 156:128–140</ref>
*When these fractures has a coronal component, the buttress plate is placed from behind using a posteromedial approach.<nowiki><ref>Moore TM (1981) Fracture-dislocation of the knee. Clin Orthop Relat Res 156:128–140</nowiki></ref>
*Percutaneous and minimally invasive open techniques may be used for more simple fracture patterns such as those involving the anteromedial condyle.
*Percutaneous and [[Minimally invasive procedure|minimally invasive]] open techniques may be used for more simple fracture patterns such as those involving the anteromedial condyle.


'''Implants'''
'''Implants'''
Line 88: Line 87:


===Schatzker V and VI===
===Schatzker V and VI===
*They are complex comminuted fractures often due to high-energy.<ref>Khatri K, Sharma V, Goyal D, Farooque K (2016) Complications in the management of closed high-energy proximal tibial plateau fractures. J Traumatol 19(6):342–347</ref>
*They are complex [[comminuted]] [[fractures]] often due to high-energy.<ref>Khatri K, Sharma V, Goyal D, Farooque K (2016) Complications in the management of closed high-energy proximal tibial plateau fractures. J Traumatol 19(6):342–347</ref>
*There is often require staged management of these fractures.
*There is often require staged management of these [[fractures]].
*Complication rates have been reported to be as high as 30% with these fracture patterns.
*[[Complications|Complication]] rates have been reported to be as high as 30% with these [[fracture]] patterns.


'''Approach'''
'''Approach'''
*Combined medial and lateral incisions are taken to address articular disruption.<ref>Maroto MD, Scolaro JA, Henley MB, Dunbar RP (2013) Management and incidence of tibial tubercle fractures in bicondylar fractures of the tibial plateau. Bone Joint J 95-B(12):1697–1702</ref><ref>Keightley AJ, Nawaz SZ, Jacob JT, Unnithan A, Elliott DS, Khaleel A (2015) Ilizarov management of Schatzker IV to VI fractures of the tibial plateau: 105 fractures at a mean follow-up of 7.8 years. Bone Joint J 97-B(12):1693–1697</ref>
*Combined medial and lateral incisions are taken to address articular disruption.<ref>Maroto MD, Scolaro JA, Henley MB, Dunbar RP (2013) Management and incidence of tibial tubercle fractures in bicondylar fractures of the tibial plateau. Bone Joint J 95-B(12):1697–1702</ref><ref>Keightley AJ, Nawaz SZ, Jacob JT, Unnithan A, Elliott DS, Khaleel A (2015) Ilizarov management of Schatzker IV to VI fractures of the tibial plateau: 105 fractures at a mean follow-up of 7.8 years. Bone Joint J 97-B(12):1693–1697</ref>
*Midline incisions though commonly not used, is preferred by some surgeons to cater for future need for conversion to arthroplasty to avoid  extensive soft tissue injury and de-vascularise fracture fragments.
*Midline [[Incision|incisions]] though commonly not used, is preferred by some surgeons to cater for future need for conversion to [[arthroplasty]] to avoid  extensive [[soft tissue injury]] and de-vascularise [[fracture]] fragments.
*The use of limited internal fixation and defnitive external fixation is supported by some surgeons as it minimizes soft tissue disruption, avoid complications and allow fracture union with decreased infection rates.
*The use of limited internal fixation and definitive external fixation is supported by some surgeons as it minimizes [[soft tissue]] disruption, avoid [[complications]] and allow [[fracture]] union with decreased [[infection]] rates.


'''Implants'''
'''Implants'''
Line 102: Line 101:
*Percutaneous screws
*Percutaneous screws
*External Fixator
*External Fixator
*Ilizarov Fixator
*[[Ilizarov apparatus|Ilizarov]] Fixator


===Postoperative Care===
===Postoperative Care===
*There is a risk of potential disability in form of  chronic flexion contracture post-operatively.<ref name="pmid18571417">{{cite journal| author=Rossi R, Bonasia DE, Blonna D, Assom M, Castoldi F| title=Prospective follow-up of a simple arthroscopic-assisted technique for lateral tibial plateau fractures: results at 5 years. | journal=Knee | year= 2008 | volume= 15 | issue= 5 | pages= 378-83 | pmid=18571417 | doi=10.1016/j.knee.2008.04.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18571417  }} </ref>
*There is a risk of potential [[disability]] in form of  chronic flexion [[contracture]] post-operatively.<ref name="pmid18571417">{{cite journal| author=Rossi R, Bonasia DE, Blonna D, Assom M, Castoldi F| title=Prospective follow-up of a simple arthroscopic-assisted technique for lateral tibial plateau fractures: results at 5 years. | journal=Knee | year= 2008 | volume= 15 | issue= 5 | pages= 378-83 | pmid=18571417 | doi=10.1016/j.knee.2008.04.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18571417  }} </ref>
*Patients are placed in a hinged knee brace which is locked in extension.  
*Patients are placed in a hinged knee [[Brace (orthopaedic)|brace]] which is locked in [[extension]].  
*A padded bump in form of cotton roll is placed under the heel during the hospital stay and at home after discharge to maximize knee extension and decrease the chances of bed sores.
*A padded bump in form of cotton roll is placed under the [[heel]] during the hospital stay and at home after discharge to maximize knee [[extension]] and decrease the chances of [[Bedsore|bed sores]].


===Complications===
===Complications===
*The complications of the operative interventions include:<ref>Berkson EM, Virkus WW (2006) High-energy tibial plateau fractures. J Am Acad Orthop Surg 14(1):20–31</ref><ref>Softness KA, Murray RS, Evans BG (2017) Total knee arthroplasty and fractures of the tibial plateau. World J Orthop 8(2):107–114</ref>
*The [[Complication (medicine)|complications]] of the operative interventions include:<ref>Berkson EM, Virkus WW (2006) High-energy tibial plateau fractures. J Am Acad Orthop Surg 14(1):20–31</ref><ref>Softness KA, Murray RS, Evans BG (2017) Total knee arthroplasty and fractures of the tibial plateau. World J Orthop 8(2):107–114</ref>
**Compartment syndrome
**[[Compartment syndrome]]
**Vascular injuries
**[[Vascular injury|Vascular injuries]]
**Swelling and wound-healing problems
**[[Edema|Swelling]] and [[Wound healing|wound-healing]] problems
**Infections
**[[Infection|Infections]]
**Deep vein thrombosis
**[[Deep vein thrombosis]]
**Nerve injuries
**[[Nerve injury|Nerve injuries]]
**Knee stiffness
**[[Knee]] [[stiffness]]
**Knee instability
**[[Knee]] [[instability]]
**Angular deformities
**Angular [[Deformity|deformities]]
**Late collapse
**Late [[Collapse (medical)|collapse]]
**Malunion
**Malunion
**Osteoarthrosis
**[[Osteoarthritis|Osteoarthrosis]]


{|
{|
|
|
[[File:Tibial Plateau fracture CT 1.jpeg|300px|thumb|CT scan of Tibia coronal view with intra articular commintution. Source: Case courtesy by: [[User:Rohan Bhimani|Dr. Rohan A. Bhimani]]]]
[[File:Tibial plateau CT 2.gif|300px|thumb|CT scan of Tibia coronal view with intra articular commintution. Source: Case courtesy by: [[User:Rohan Bhimani|Dr. Rohan A. Bhimani]]]]
|
|
[[File:Tibial Plateau CT.gif|300px|thumb|CT scan of Tibia AP view. Source: Case courtesy by: [[User:Rohan Bhimani|Dr. Rohan A. Bhimani]]]]
[[File:Tibial Plateau CT.gif|300px|thumb|CT scan of Tibia AP view. Source: Case courtesy by: [[User:Rohan Bhimani|Dr. Rohan A. Bhimani]]]]
|
|
[[File:Tibial plateau fracture intra op 1.jpeg|300px|thumb|CT scan of Tibia AP view. Source: Case courtesy by: [[User:Rohan Bhimani|Dr. Rohan A. Bhimani]]]]
[[File:CT tibial plateau final.gif|300px|thumb|CT scan of Tibia AP view. Source: Case courtesy by: [[User:Rohan Bhimani|Dr. Rohan A. Bhimani]]]]
|
[[File:Tbial plateau intra-op2.png|300px|thumb|Intra-operative fixation of tibial plateau fracture. Source: Case courtesy by: [[User:Rohan Bhimani|Dr. Rohan A. Bhimani]]]]
|-
|-
|
|
[[File:Intra-op tibial plateau 2.jpeg|300px|thumb|Intra-operative fixation of tibial plateau fracture. Source: Case courtesy by: [[User:Rohan Bhimani|Dr. Rohan A. Bhimani]]]]
[[File:Surgery 6 intraop.gif|300px|thumb|Intra-operative fixation of tibial plateau fracture. Source: Case courtesy by: [[User:Rohan Bhimani|Dr. Rohan A. Bhimani]]]]
|
|
[[File:Intra-op tibial plateau 3.png|300px|thumb|Intra-operative fixation of tibial plateau fracture. Source: Case courtesy by: [[User:Rohan Bhimani|Dr. Rohan A. Bhimani]]]]
[[File:Intraop tibia.gif|300px|thumb|Intra-operative fixation of tibial plateau fracture with bone graft in the defect. Source: Case courtesy by: [[User:Rohan Bhimani|Dr. Rohan A. Bhimani]]]]
|-
|
|
[[File:Surgery 10.png|300px|thumb|Intra-operative fixation of tibial plateau fracture. Source: Case courtesy by: [[User:Rohan Bhimani|Dr. Rohan A. Bhimani]]]]
[[File:Surgery 10.png|300px|thumb|Intra-operative fixation of tibial plateau fracture. Source: Case courtesy by: [[User:Rohan Bhimani|Dr. Rohan A. Bhimani]]]]

Latest revision as of 16:24, 5 February 2019

Tibial plateau fracture Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Tibial plateau fracture from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography and Ultrasound

CT scan

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Interventions

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Tibial plateau fracture surgery On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Tibial plateau fracture surgery

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Tibial plateau fracture surgery

CDC on Tibial plateau fracture surgery

Tibial plateau fracture surgery in the news

Blogs on Tibial plateau fracture surgery

Directions to Hospitals Treating Psoriasis

Risk calculators and risk factors for Tibial plateau fracture surgery

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

Overview

Surgery is the mainstay of treatment for tibial plateau fractures. Fractures presenting with vascular injury as well as fracture dislocations should be managed emergently. The principles of definitive fixation for tibial plateau fractures include restoration of articular surface and mechanical axis alignment. The fracture fixation depends on fracture pattern. Approach for the fracture depends on fracture pattern and type of implant preferred by the surgeon. The implant commonly used include percutaneous cancellous and raft screws, locking plate, anti-glide plate, and external fixators including Ilizarov ring fixator.

Surgery

Surgery is the mainstay of treatment for tibial plateau fractures.

Indications

Initial Management

Principles of definitive fixation for tibial plateau fractures

  • The principles of definitive fixation for tibial plateau fractures include:[3]
    • Restoration of articular surface and mechanical axis alignment.
    • Balanced fixation using appropriate hardware.
    • Operate only when soft tissues conditions are appropriate such as skin wrinkling and minimal blisters.
    • Minimally invasive technique should be preferred.

Fixation Techniques

The fracture fixation depends on fracture pattern.

Schatzker I Fractures

  • The type I fractures carry the best prognosis.

Percutaneous Screw Fixation

  • Partially threaded cancellous screws are usually used.
  • This is followed by early range of motion.

Locking Plate

  • They offer no biomechanical advantage.
  • They do permit earlier weight bearing.

Schatzker II and III fractures

  • The type II fractures pattern are common and associated with an articular step off that needs to be reduced.[4]
  • The type III fractures pattern usually have only an articular step off which is not easily appreciated on x-rays.[5]

Approach

Implants

  • The implants used for fixation include:[8]
    • Subchondral raft of screws
    • Antiglide plate
    • Peri-articular fixed angle locking plate
    • Rim plate to stabilize posterolateral fractures

Other Options

Arthroscopic-Assisted Reduction and Internal Fixation

Balloon guided Inflation Tibioplasty

Schatzker IV Fracture

  • The medial condyle fracture is often has a posteromedial component. [12][13]
  • Percutaneous and minimally invasive open techniques may be used for more simple fracture patterns such as those involving the anteromedial condyle.

Implants

  • Locking plate
  • Buttress Plate
  • Percutaneous cancellous and raft screws

Schatzker V and VI

Approach

  • Combined medial and lateral incisions are taken to address articular disruption.[15][16]
  • Midline incisions though commonly not used, is preferred by some surgeons to cater for future need for conversion to arthroplasty to avoid extensive soft tissue injury and de-vascularise fracture fragments.
  • The use of limited internal fixation and definitive external fixation is supported by some surgeons as it minimizes soft tissue disruption, avoid complications and allow fracture union with decreased infection rates.

Implants

  • Locking plate
  • Antiglide Plate
  • Percutaneous screws
  • External Fixator
  • Ilizarov Fixator

Postoperative Care

  • There is a risk of potential disability in form of chronic flexion contracture post-operatively.[17]
  • Patients are placed in a hinged knee brace which is locked in extension.
  • A padded bump in form of cotton roll is placed under the heel during the hospital stay and at home after discharge to maximize knee extension and decrease the chances of bed sores.

Complications

CT scan of Tibia coronal view with intra articular commintution. Source: Case courtesy by: Dr. Rohan A. Bhimani
CT scan of Tibia AP view. Source: Case courtesy by: Dr. Rohan A. Bhimani
CT scan of Tibia AP view. Source: Case courtesy by: Dr. Rohan A. Bhimani
Intra-operative fixation of tibial plateau fracture. Source: Case courtesy by: Dr. Rohan A. Bhimani
Intra-operative fixation of tibial plateau fracture with bone graft in the defect. Source: Case courtesy by: Dr. Rohan A. Bhimani
Intra-operative fixation of tibial plateau fracture. Source: Case courtesy by: Dr. Rohan A. Bhimani
Post-operative X-ray of tibial plateau fracture. Source: Case courtesy by: Dr. Rohan A. Bhimani

References

  1. ↑ Papagelopoulos PJ, Partsinevelos AA, Themistocleous GS, Mavrogenis AF, Korres DS, Soucacos PN (2006). "Complications after tibia plateau fracture surgery". Injury. 37 (6): 475–84. doi:10.1016/j.injury.2005.06.035. PMID 16118010.
  2. ↑ Schatzker J, McBroom R, Bruce D (1979). "The tibial plateau fracture. The Toronto experience 1968--1975". Clin Orthop Relat Res (138): 94–104. PMID 445923.
  3. ↑ Yoon RS, Liporace FA, Egol KA (2015). "Definitive fixation of tibial plateau fractures". Orthop Clin North Am. 46 (3): 363–75, x. doi:10.1016/j.ocl.2015.02.005. PMID 26043050.
  4. ↑ McNamara IR, Smith TO, Shepherd KL, Clark AB, Nielsen DM, Donell S, Hing CB (2015) Surgical fxation methods for tibial plateau fractures. Cochrane Database Syst Rev. 9:CD009679
  5. ↑ Khatri K, Sharma V, Goyal D, Farooque K (2016) Complications in the management of closed high-energy proximal tibial plateau fractures. J Traumatol 19(6):342–347
  6. ↑ Johnson EE, Timon S, Osuji C (2013) Surgical technique: Tscherne-Johnson extensile approach for tibial plateau fractures. Clin Orthop Relat Res. 471(9):2760–2767
  7. ↑ Solomon LB, Stevenson AW, Lee YC, Baird RP, Howie DW (2013) Posterolateral and anterolateral approaches to unicondylar posterolateral tibial plateau fractures: a comparative study. Injury 44(11):1561–1568
  8. ↑ Yu B, Han K, Zhan C, Zhang C, Ma H, Su J (2010) Fibular head osteotomy: a new approach for the treatment of lateral or posterolateral tibial plateau fractures. Knee 17(5):313–318
  9. ↑ Robertson GAJ, Wong SJ, Wood AM (2017) Return to sport following tibial plateau fractures: a systematic review. World J Orthop 8(7):574–587
  10. ↑ Caspari RB, Hutton PM, Whipple TL, Meyers JF (1985) The role of arthroscopy in the management of tibial plateau fractures. Arthroscopy 1985(1):76–82
  11. ↑ Jentzsch T, Fritz Y, Veit-Haibach P, Schmitt J, Sprengel K, Werner CM (2015) Osseous vitality in single photon emission computed tomography/computed tomography (SPECT/CT) after balloon tibioplasty of the tibial plateau: a case series. BMC Med Imaging 15:56
  12. ↑ Softness KA, Murray RS, Evans BG (2017) Total knee arthroplasty and fractures of the tibial plateau. World J Orthop 8(2):107–114
  13. ↑ *Coronal bicondylar tibial plateau fracture involving the posterior condyles has also been seen. Approach
    • When these fractures has a coronal component, the buttress plate is placed from behind using a posteromedial approach.<ref>Moore TM (1981) Fracture-dislocation of the knee. Clin Orthop Relat Res 156:128–140
  14. ↑ Khatri K, Sharma V, Goyal D, Farooque K (2016) Complications in the management of closed high-energy proximal tibial plateau fractures. J Traumatol 19(6):342–347
  15. ↑ Maroto MD, Scolaro JA, Henley MB, Dunbar RP (2013) Management and incidence of tibial tubercle fractures in bicondylar fractures of the tibial plateau. Bone Joint J 95-B(12):1697–1702
  16. ↑ Keightley AJ, Nawaz SZ, Jacob JT, Unnithan A, Elliott DS, Khaleel A (2015) Ilizarov management of Schatzker IV to VI fractures of the tibial plateau: 105 fractures at a mean follow-up of 7.8 years. Bone Joint J 97-B(12):1693–1697
  17. ↑ Rossi R, Bonasia DE, Blonna D, Assom M, Castoldi F (2008). "Prospective follow-up of a simple arthroscopic-assisted technique for lateral tibial plateau fractures: results at 5 years". Knee. 15 (5): 378–83. doi:10.1016/j.knee.2008.04.001. PMID 18571417.
  18. ↑ Berkson EM, Virkus WW (2006) High-energy tibial plateau fractures. J Am Acad Orthop Surg 14(1):20–31
  19. ↑ Softness KA, Murray RS, Evans BG (2017) Total knee arthroplasty and fractures of the tibial plateau. World J Orthop 8(2):107–114

Template:WH Template:WS

Retrieved from "https://www.wikidoc.org/index.php?title=Tibial_plateau_fracture_surgery&oldid=1545684"