1

Association of position of

reduction and lower limb

alignment with subsidence after

internal fixation of tibial plateau

fractures in elderly patients. Department of Orthopaedics, Geisinger Medical Center, Danville, PA

Amrut Borade, Harish Kempegowda,

Jove Graham,

Michael Suk, Daniel S. Horwitz.

2

Background Subsidence after tibial plateau fractures in elderly

Tibial plateau fractures have been reported to occur in as

much as 10% of all fractures in elderly osteoporotic

patients.

Subsidence is the collapse of the articular cartilage due to

resorption of the subchondral bone.

Subsidence is commonly reported between 3 to 6 months

after internal fixation with some reports as high as 85%

incidence in patients > 60 years age.

Goff T, Kanakaris NK, Giannoudis PV. Use of bone graft substitutes in the management of tibial plateau

fractures. Injury. 2013 Jan;44 Suppl 1:S86-94

Ali AM, El-Shafie M, Willett KM. Failure of fixation of tibial plateau fractures. J Orthop Trauma. 2002

May;16(5):323-9.

3

Background Role of overreduction in treatment of tibial plateau fractures

Due to high rate of failure of fixation in the patients > 60

years age, benefits of restoring the articular congruency of

tibial plateau have been argued against the risk of failure

and complications.

Limited goal of restoration of alignment and stability in

the elderly patients has been recommended.

Ali AM, El-Shafie M, Willett KM. Failure of fixation of tibial plateau fractures. J Orthop Trauma. 2002

May;16(5):323-9.

4

Background Role of overreduction in treatment of tibial plateau fractures

Intraoperative over-reduction is a step practiced by some

orthopaedic surgeons in view of achieving better final articular

anatomy.

Over-reduction is nothing but intraoperative elevation of the

fractured tibial plateau relative to the other.

Lower limb malalignment has been speculated to be a risk

factor for subsidence but the association has not been clearly

established.

5

Background Hypotheses

Postoperative position of the reduction is associated with the

final tibial plateau height reached.

Lower limb malalignment is associated with the occurrence of

subsidence.

6

Patients and Methods

99 patients older than 50 years of age with Schatzker I to V

tibial plateau fractures which were internally fixed with plating

were included.

Retrospective review of the patient charts along with

immediate postoperative (non-weight bearing) and final follow

up (full weight bearing) radiographs was done.

7

Patients and Methods

To measure the tibial plateau

height difference, the anatomic

axis of the tibia was drawn and

perpendiculars to this axis were

drawn along the lateral and

medial tibial plateaus.

Subsidence was measured as a

change in the height difference

from immediate postoperative

state to the final follow up state

as described by Boraiah et al.

Boraiah S, Paul O, Hawkes D, et al. Complications of recombinant human BMP-2

for treating complex tibial plateau fractures: a preliminary report. Clin Orthop

Relat Res. 2009 Dec;467(12):3257-62.

8

Patients and Methods

Both the perpendiculars typically overlap in anatomic

reduced state.

Relative elevation of the operated tibial plateau over the

nonoperated one was designated as `over-reduction` and

relative depression as `under-reduction`.

9

Patients and Methods

>3 mm subsidence was considered `significant` as described by

Ali et al.

For all isolated unicondylar fractures, association between the

immediate postoperative reduction (over-reduction/anatomic

reduction/under-reduction) and the final articular state reached

was evaluated.

10

Patients and Methods

Knee alignment was measured as

the angle formed by the femur with

the tibia at the center of the tibial

spine (FTAt) as described by

Moreland et al.

Moreland JR, Bassett LW, Hanker GJ. Radiographic analysis of

the axial alignment of the lower extremity. J Bone Joint Surg Am.

1987 Jun;69(5):745-9

11

Patients and Methods

Angles < 20 valgus and > 40 of valgus were considered as

malalignment, taking into consideration the studies of

association of knee malalignment with knee arthritis.

Brouwer GM, van Tol AW, Bergink AP, Belo JN, Bernsen RM, Reijman M, Pols HA, Bierma-Zeinstra SM.

Association between valgus and varus alignment and the development and progression of radiographic

osteoarthritis of the knee. Arthritis Rheum. 2007 Apr;56(4):1204-11.

McDaniel G, Mitchell KL, Charles C et al. A comparison of five approaches to measurement of anatomic knee

alignment from radiographs. Osteoarthritis Cartilage. 2010 Feb;18(2):273-7.

12

Results Patient Demographics

Total number of patients, N

99

Males, N (%)

30 (30%)

Age in years, Mean (SD)

62 (11)

BMI, Mean (SD)

No. of patients with BMI < 30

No. of patients with BMI ≥ 30

30.7 (6.6)

53

46

Total weeks of followup, Median (IQR)

46 (32, 88)

Mechanism of injury, N (%)

Low Energy

High Energy

67 ( 67%)

33 ( 33%)

Schatzker classification, N (%)

1

2

3

4

5

18 (18%)

47 (47%)

3 (3%)

13 (13%)

22 (22%)

13

Results

Over reduction was effective in achieving better final anatomic

state (p < 0.0001).

Anatomic

Reduction at

immediate

postop

(n=11)

Overreduction at

immediate postop

(n=47)

p-value

Overreduced at final

follow-up, N (%)

0 (0%)

22 (47%)

<0.0001

Anatomic Reduction

at final follow-up, N

(%)

0 (0%)

8 (17%)

Underreduced at

final follow-up, N(%)

11 (100%)

17 (36%)

14

Results

Of 21 patients with no malalignment there were 11 patients

(52%) who had significant subsidence. In comparison, of the

78 patients with malalignment there were 57 patients (73%)

who had significant subsidence.

Knee malalignment appears to be associated with significant

subsidence (odds ratio 2.47, 95 % CI 0.92- 6.65) approaching

statistical significance (p= 0.07).

15

Discussion

Prominent Findings of our study:

Over-reduction appears beneficial in achieving

better final articular anatomy.

Knee malalignment appears to be associated with

the occurrence of subsidence.

16

Discussion

Prioritization of the restoration of overall knee joint alignment

and stability over the intraoperative restoration of smooth

articular surface has been recommended in literature.

Lansinger O, Begman B, Korner L, Andersson GB (1986) Tibial condylar fractures: a twenty-year

follow-up. J Bone Joint Surg Am 68:13–19.

17

Discussion

Decrease in the occurrence of genu varus or valgus with

prevention of joint depression has been reported.

Also, development of accelerated arthritis due to the

malalignment of the knee joint has been observed.

In light of these findings, over-reduction of the tibial plateau

appears beneficial in achieving better final articular anatomy

and hence may have protective effect against the arthritis.

Hsu CJ, Chang WN, Wong CY. Surgical treatment of tibial plateau fracture in elderly patients. Arch Orthop Trauma Surg.

2001;121(1-2):67-70.

18

Discussion

Intraoperative over-reduction would be a tactical step

with protective effect against progression of arthritis

by prevention of severe joint depression.

Use of biological cement, protective weight bearing,

overreduction of the involved tibial plateau and use of

femoral distractor to achieve the overreduction can be

justified in patients with knee malalignment.

19

Discussion

Small sample size is the major limitation of our study.

20

Conclusion

Subsidence after internal fixation of tibial plateau fractures is a

common complication in elderly patients.

Over-reduction appears beneficial in achieving better final

articular anatomy and hence may have protective effect against

progression of arthritis.

The findings of our study suggest that joint depression, knee

malalignment and arthritis appear to augment each others`

progression.

21