Tibial Plateau Fractures: Factors influencing outcomes

May 20th 2013

Joel Melton BM, MSc, FRCS (Tr + Orth)

Consultant Orthopaedic Surgeon, Cambridge University Hospitals

Overview

Plateau Fractures

Diagnosis

Classifications

Treatment goals

Management decisions

Surgical techniques

Controversies

Factors influencing outcome

Diagnosis

History, Clinical examination, Special tests

Minor, major or catastrophic injury

May be subtle or obvious

Remember other injuries

Degree of soft tissue injury

(inc. open)

Diagnosis – special tests

Plain radiography

CT scan Diagnosis

Fracture pattern

Help with classification

Assess joint displacement

Guide need for operative intervention

Guide the operative fixation plan and surgical approaches

MRI ?

Classification

Jo Schatzker

Types 1-6

Worsening severity by type

May guide fixation techniques and likely outcomes

Classification - Schatzker

Types 1-6

Treatment goals

G. Appley – Reduce fracture, hold position and rehabilitate

The AO group

AO principles dictate:

An intraarticular fracture must be anatomically reduced, fixed with rigid internal fixation, conferring absolute stability to the fracture, expecting primary bone healing and allowing early joint mobilisation

Treatment goals

Applying this to plateau fractures: Assess patient first (general status, ATLS,

compartments etc)

Diagnosis

Fracture pattern

Degree of displacement

Knee Joint position/disruption

Leg Alignment

Imaging, pre-operative planning, timing

Hardware, surgical expertise, rehabilitation goals

Management decisions

Operative vs non operative

What degree of displacement can you accept?

What is the patient like?

Timing of surgery

Soft tissue injury (bruising, swelling)

What hardware? Why

Which incisions? Minimally invasive?

Fixation plans?

How can we influence outcome?

How can we influence outcome?

Rehabilitation

Patient factors

Treatment decisions

How can we influence outcome?

Patient factors

• Age, co-morbidity

• Smoking,drugs

Treatment decisions

• Conservative

• Surgical fixation

Rehabilitation

• Cast,Brace, ROM

• Early ROM

Influencing outcome

Plateau fracture

Operative management

Conservative management

Influencing outcome

Plateau fracture

Mal-reduced fracture

Good reduction

Influencing outcome

Influencing outcome

Operative management

Internal fixation

External fixation

Influencing outcome

Operative management

Internal fixation

Screw Plate

External fixation

Circular frame/hybrid

Influencing outcome

Influencing outcome

External Fixation

Hybrid fixation

Non-hybrid fixation

Influencing outcome

Influencing outcome

Internal fixation

Double plate

Single plate

Influencing outcome

Double plating

Double incision

Single incision

Influencing outcome

Double incision

Single incision

Influencing outcome

Dead bone sandwich?

Influencing outcome

MIPO (Minimally invasive plate osteosynthesis)

Influencing outcome

Bi-condylar injury

pattern

Double plating

Single fixed angle device

Influencing outcome

Influencing outcome

Internal fixation

Arthroscopic

assisted Fluoroscopy

Influencing outcome

Influencing outcome

Internal fixation

Meniscal repair

No soft tissue

procedure

Influencing outcome

Influencing outcome

Internal fixation

Bone graft BG

substitutes

Influencing outcome

Calcium phosphate paste

Influencing outcome

Influencing outcome

Rehabilitation

Delayed Early ROM

So what outcomes are we getting?

Outcomes

49 pts, <40 no difference, >40 worse outcome

311 pts, 10 yr follow up. 13% had TKR

125 pts, < 10 yrs follow up. 26% OA on XR, 4% TKR

Latest review of current management of plateau

fractures?

Latest review of current management of plateau

fractures?

Summary

Multiple issues effect outcome

Summary

Patient factors

• Age, co-morbidity

• Smoking,drugs

Treatment decisions

• Conservative

• Surgical fixation

Rehabilitation

• Cast,Brace, ROM

• Early ROM

G. Appley – Reduce fracture, hold position and rehabilitate