D R . O M P A R S H U R A M P A T I L

D R . G . N . P U N D K A RM . S . O R T H O P A E D I C S ,P R O F E S S O R A N D H E A D , D E P A R T M E N T O F O R T H O P A E D I C S ,D R . P D M M C ,A M R A V A T I

Comparative study of functional outcome of lateral locking plate fixation and dual plating in closed fracture’s of Schatzker’s Grade V of tibial condyles in adults.

Introduction

Constitutes 1% of all fractures

8% of all elderly fractures.

Body weight transmission through knee joint and leg, it plays a vital role in knee function and stability

The incidence of malunion, non-union and infections are relatively high in many reported series, causing significant long term disability.

Hence ,Soft tissue friendly approaches and minimally invasive techniques have improved outcome.

Aims and Objectives

Early mobilization of knee joint.

To assess the union of fractures after fixation.

To assess functional outcome, range of motion of knee joint after surgical management.

Materials and Methods

Prospective two year study was conducted at our institute

40 Patients of closed Bicondylar tibial plateau fractures(Schatzkers grade V) aged 18 years and above were selected randomly and treated by lateral locking plate fixation and dual plating in alternate cases.

Patients with pathological proximal tibial fractures other than osteoporosis and Patients who were medically unfit for surgery were excluded in this study.

Materials and Methods

After obtaining detailed history, complete general physical and systemic examination patients were subjected to relevant investigations and surgery.

Follow-up clinical and radiological evaluation done at 6 weeks ,12 weeks and six months,

Post operatively patients were followed upto six months and evaluated with Rassmussen functional grading score and Hospital for special surgery knee score

Radiological Investigation

X- Ray of the Knee joint and upper half of tibia anteroposterior, lateral view and oblique views

Computerized tomography scan with 3D reconstruction of knee joint , as per requirement.

Early management

Immobilization

Strict limb elevation

Skin or skeletal traction till tissue oedema resolves

Ice fomentation

Enzymatic oral preparations chymoral, bromelainand rutoside and antibiotics if required.

Types Of Treatment

Lateral locking plate fixation

Single incision with minimally invasive technique was used.

Dual plating

Dual incision technique

Dual incision technique

Dual Plating

Dual plating

Bicondylar tibia fracture with soft tissue complications

Lateral locking plate fixation

Lateral locking plate fixation

Post op three months

Functional evaluation Chart

Dual plating

Score Excellent Good Fair Poor

Rassmussenfunctional grading score

8 7 4 1

HSS knee score 8 8 3 1

Lateral locking plate fixation

Score Excellent Good Fair Poor

Rassmussenfunctional grading score

6 8 4 2

HSS knee score 5 8 5 2

Age incidence

Age group Patients

18-25 2

26-30 3

31-35 5

36-40 8

41-45 12

46-50 4

51-55 1

56-60 2

60 plus 3

Range of motion

Lateral locking plate Dual plates

<70 0 0

71-80 1 1

81-90 2 1

91-100 6 4

101-110 7 9

111-120 2 3

121-130 1 1

131-140 1 1

Complications of surgery and fracture

Early complications

Compartment syndrome

Soft tissue complications and wound healing

Common Peroneal nerve injury

Anterior cruciate ligament tear in posteromedial fracture

Late complications

Post traumatic joint stiffness

Secondary osteoarthritis

Ligamentous instability

Results

Mean time of surgery was after 12 days (2 to 34 days),

Average knee mobilization was started in 7 days(2 to 16),

The average time to healing fractures was 16 weeks (minimum 13 weeks , maximum 6 months).

The overall knee range of motion averaged 105°(range 70–135°) at the latest follow-up of average 8 months in both the groups.

Conclusion

Dual plating is the best modality of treatment available for bicondylar tibia fracture

Dual plating has more stabilty as compared to lateral locking plate fixation alone,

Early union of fracture and weight bearing exercises.

Prolonged non weight bearing over the knee joint was adviced to prevent early varus deformities.

Limitations

Dual plating has its own limitations like

Soft tissue complications

More blood loss

More surgery time than lateral locking plate alone.

Discussion of the tibial Condyle fractures

Schatzker Classification

Most widely used and familiar classification of tibialplateau fractures.

For instance, Hohl in 1969 classified split, split depression, and central depression fractures.

Many surgeons may not be familiar with the numbers of the six types, but most are familiar with the meaning of the verbal descriptions of each type and this is an important advantage of the Schatzker classification.

Because the six types are typically treated differently, the classification fufills some of the goals of an ideal classification.

Schatzkers classification is most widely used and familiar classification of tibial plateau fractures.

Surgical management was advised for fractures with greater than 5mm displacement or greater than 5 degress of instability on varus valgus stress

Schatzker Classification

Type IV

Type V

Type VI

AO classification

References Rockwood and green page 1491Schatzkers classification of tibial condyle fractures. Kenneth. A. Egol and Kenneth J Koval , In: Fractures of proximal tibia : chapter 50 , Rockwood and

Green’s “Fractures in Adults”, Vol. 2, 6th edition, Lippincott Williams and Wilkins In: Fractures of tibia and fibula. chapter 52 , Rockwood and Green’s “Fractures in Adults”, Vol. 2, 7th

edition, Lippincott Williams and Wilkins Cole, Peter. MD*; Zlowodzke, Micheal MD+; Kregor, Philip J. MD+. Treatment of proximal tibial fractures

using the Less Invasive Stabilisation System: Surgical Experience And Early Clinical results in 77 fractures. Journal of orthopaedic trauma 18(8):528-535, September 2004.

Egol, Kenneth A. MD; Su, Edward MD; Tejwani, Nirmal C MD; Sims, Stephen H. MD; Kummer, Frederick J. PhD; Koval, Kenneth J. MD. Treatment of complex tibial plateau fractures using the less invasive stabilisation system plate: clinical experience and a laboratory comparison with double plating. Journal of trauma injury infection and critical care. 52(2):340-346 AUGUST 2004

Sommer, C.H; Wullschleger, M; Walliser, M; Bereiter, H; Leutenneger, A experience with locking compression plate in fracture treatment of osteoporotic bones. British journal of surgery, Vol 91(7) july2004 page 912.

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Kenneth Koval “Handbook of fractures” ch 37 tibial plateau “Comparison of unilateral locking plate fixation and dual plating in bicondylar tibia fracture” Meng Hsuan

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bicondylar tibial plateau fractures utilizing atwo-incision technique. J Orthop Trauma 2004;18:649-657 Boldin C, Fankhauser F, Hofer HP, et al. Three-year results of proximal tibia fractures treated with the

LISS. Clin Orthop Relat Res2006;445:222-229. Gosling T, Schandelmaier P, Muller M, et al. Single lateral locked screw plating of bicondylar tibial plateau

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References

Haidukewych G, Sems SA, Huebner D, et al. Results of polyaxial locked-plate fixation of periarticular fractures of the knee. J Bone Joint SurgAm 2007;89A:614-620.67.

Jiang R, Luo CF, Wang MC, et al. A comparative study of Less Invasive Stabilization System (LISS) fixation and two-incision double plating forthe treatment of bicondylar tibial plateau fractures. Knee 2008;15:139-143.

Marsh JL, Buckwalter J, Gelberman R, et al. Articular fractures: does an anatomic reduction really change the result? J Bone Joint Surg Am2002;84A:1259-1271.

Mueller KL, Karunakar MA, Frankenburg EP, et al. Bicondylar tibial plateau fractures: a biomechanical study. Clin Orthop Relat Res2003:189-195

Phisitkul P, McKinley TO, Nepola JV, et al. Complications of locking plate fixation in complex proximal tibia injuries. J Orthop Trauma2007;21:83-91

Ricci WM, Rudzki JR, Borrelli J Jr. Treatment of complex proximal tibia fractures with the less invasive skeletal stabilization system. J OrthopTrauma 2004;18:521-527

Watson JT, Phillips M, Karges D, et al. Lateral locking plates for the treatment of bicondylartibial plateau fractures: treatment protocol,indications, and results. Presented at the 23rd Annual Meeting OTA 2007, October 19, 2007, Boston, MA.

Sommer, C.H; Wullschleger, M; Walliser, M; Bereiter, H; Leutenneger, A experience with locking compression plate in fracture treatment of osteoporotic bones. British journal of surgery, Vol 91(7) july 2004 p. 912.

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