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| ORIGINAL ARTICLE |
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| Year : 2018 | Volume
: 10
| Issue : 1 | Page : 29-33 |
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Necessity of dual plating in bicondylar tibial plateau fracture dislocations: A prospective case series
Abhishek P Bhalotia, Milind V Ingle, Maroti R Koichade
Department of Orthopaedics, Indira Gandhi Government Medical College, Nagpur, Maharashtra, India
| Date of Web Publication | 17-Aug-2018 |
Correspondence Address:
Dr. Abhishek P Bhalotia
Kudwa Lane, Deshbandhu Ward, Gondia - 441 601, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jotr.jotr_2_18
Background: Management of bicondylar tibial plateau fracture dislocations is a serious challenge in terms of soft-tissue complications, fracture morphology, early mobilization, and maintenance of alignment and reduction postoperatively. We have conducted a prospective study to evaluate the necessity of dual plating in these fractures to achieve articular reduction, early mobilization, and maintenance of alignment on long-term follow-up. Materials and Methods: A prospective study including 24 patients with bicondylar tibial plateau fracture dislocations were operated with dual plating through dual-incision approach. Patients were evaluated clinically and radiologically for a minimum period of 24 months. All patients were operated after a minimum period of 7 days, to prevent soft-tissue complications. Functional evaluation was done using Oxford knee score. Results: A total of 24 patients were operated with dual plating, including 20 males and 4 females with the mean age of 36 years. All cases united with mean healing time of 15.2 weeks, malunion was seen in one case. Functional outcome was assessed using Oxford knee score which was excellent in 21 cases (87.5%) and good in 3 cases (12.5%). Conclusion: Dual plating for bicondylar tibial plateau fracture dislocations is necessary to achieve articular congruity, stable fixation, early mobilization, and maintenance of limb alignment on long-term follow-up. The only concern is soft-tissue complications which can be minimized by waiting for adequate time preoperatively and meticulous surgical technique. Keywords: Dual plating, fracture dislocations, tibial plateau fractures
How to cite this article:
Bhalotia AP, Ingle MV, Koichade MR. Necessity of dual plating in bicondylar tibial plateau fracture dislocations: A prospective case series. J Orthop Traumatol Rehabil 2018;10:29-33 |
How to cite this URL:
Bhalotia AP, Ingle MV, Koichade MR. Necessity of dual plating in bicondylar tibial plateau fracture dislocations: A prospective case series. J Orthop Traumatol Rehabil [serial online] 2018 [cited 2023 Mar 27];10:29-33. Available from: https://www.jotr.in/text.asp?2018/10/1/29/239253 |
| Introduction | |  |
The management of bicondylar tibial plateau fracture dislocations still remains a challenge to most of the experienced orthopedic surgeons. Associated soft-tissue injury, comminution and complex fracture geometry usually the result of high-energy trauma further complicates the management of such fractures.[1],[2],[3] Outcome of these injuries depends on the maintenance of joint stability, congruity, and alignment with minimal complications so that joint can be mobilized early, the ideal fixation method still remains controversial.[4] Various options include definitive external fixation, less invasive stabilization system, single lateral locking plate constructs, dual plating with single incision, and dual plating with two-incision technique.[5] With improvement in the current concepts and approaches, management of this fracture has improved because it allows for better understanding of fracture geometry and fixation of posteromedial fragment.[6],[7],[8],[9]
Biomechanical cadaveric studies have demonstrated that dual plate fixation of these fractures allows less subsidence and loss of alignment as compared to single plate fixation.[10] Barei et al. have shown the presence of posteromedial fragment in 33% of these fractures based on computed tomography (CT) scan.[11] However, various studies have suggested high complication rates in fixation of these fractures through a single midline incision in the form of wound healing and sepsis.[12],[13],[14] This led to development of two-incision approach which allows for addressing the posteromedial and posterolateral fracture precisely and minimizing the wound complication rate.[15]
Dual plate fixation using locking or buttress plate through two-incision approach allows for anatomic joint reduction, adequate fixation, maintenance of alignment, and early rehabilitation to achieve better functional outcome. As fixed-angle constructs, we have assumed that locking plates might be able to reduce secondary loss of reduction and alignment in bicondylar tibial plateau fracture dislocations; therefore, locking plates in combination with buttress plates were used to fix bicondylar tibial plateau fracture dislocations in most of our patients in a dual-plating technique.
The purpose of this prospective study was to evaluate the clinical and radiological outcomes of dual plating through a two-incision technique for treating bicondylar tibial plateau fracture dislocations.
| Materials and Methods | | |
This study was conducted after taking approval by the Institutional Ethics Committee and patients were operated after taking written informed consent. The study was conducted from 2013 to 2016 in which patients with bicondylar tibia plateau fracture dislocations were operated after appropriate clinical examination to rule out neurovascular injury and radiological screening with radiographs and CT with three-dimensional image reconstruction to understand fracture morphology. Soft-tissue injury was classified using Tscherne classification in all patients and managed according to severity.[16] AO Type C3 and Schatzker Type V and VI were included in the study.[1] All patients with fractures without dislocation were given posterior slab support with limb elevation and analgesia and those with fracture dislocations and severe soft-tissue injury were treated with skeletal traction with 3–5 kg weight over Bohler–Braun splint. Patients were operated after a minimum interval of 7 days for soft-tissue recovery and subsidence of swelling. Patients with unicondylar fractures, compound fracture, pathological fracture, and fractures with vascular injury and patient with medical contraindication were excluded from the study.
All patients were operated in supine position and under fluoroscopic guidance. Fixation starts with posteromedial approach in figure of four positions by taking curvilinear incision 1 cm posterior to the posteromedial border of tibia, utilizing plane between medial head of gastrocnemius posteriorly and pes anserinus anteriorly. Apex of the fractured fragment was exposed and provisional reduction done by extending the knee along with valgus force and held using pointed reduction clamps and Kirschner wires. Definitive fixation was done using either distal end radius plate or posteromedial anatomical locking plate in buttress mode, proximal screws were not inserted and reduction confirmed with fluoroscopy.
After making patient supine, anterolateral fixation was started using anterolateral approach with MIPO principles. Articular reduction was confirmed and provisionally held with K-wires and pointed reduction clamps. If any articular depression found, was addressed by elevation and confirmation of reduction using submeniscal arthrotomy. Void filled with autologous iliac crest bone graft in most of the cases. Definitive fixation was done either with anatomical locking hockey plate with 6-mm cancellous screws or anatomical locking raft plate with 4-mm cancellous screws. Final alignment and reduction confirmed with fluoroscopy if required proximal screws through posteromedial contruct inserted by changing position to figure of four. In one of our case with posterolateral fragment with comminution, the fixation was done using modified posterolateral approach without fibular osteotomy as described by Frosch et al.[17] Tourniquet released and hemostasis achieved, after taking wound lavage closure done in layers and compression dressing applied. Postoperatively, neurovascular examination was done immediately, and after 2 h, limb elevation and active toe movements were started to subside swelling as early as possible.
As per the patient's tolerance to pain, passive range of motion (ROM) exercises encouraged from the first point of dispensing (POD). Wound check done on the third POD and patients discharged if there is no complication. Patients were followed up for suture removal on 14th POD and sutures removed, active ROM exercises along with quadriceps strengthening started and early ambulation with crutches encouraged in nonweight-bearing mode. On 6th week follow-up, clinical and radiological screening was done and patients were treated with partial weight bearing along with ROM and endurance exercises unless any complication found. On 12th week follow-up, full weight bearing started as dual-plate construct was quite stable and adequate healing was expected. Patients were followed up 2 monthly from here onward till 1 year and 3 monthly afterward till completion of 2 years which was the minimum follow-up criteria for the study.
Functional outcomes of all patients were assessed clinically be measuring ROM, laxity on stress tests, Oxford knee score, and wound complications and radiologically by looking for signs of union and malalignment or secondary loss of reduction. Consolidation of at least three cortices was considered as union and no signs of healing for 6 consecutive months were considered to be nonunion. Malreduction or malalignment is defined as intrarticular step-off over 2 mm or angulation more than 5° in either frontal or sagittal plane, respectively. Malalignment was considered as abnormal and was measured using method described by Paley et al.[18]
| Results | | |
Twenty-four patients met the inclusion criteria for our study and were operated with dual-plating technique through two-incision approach using locking or buttress plate after adequate healing of soft tissues. Road traffic accident was the most common mode of injury and all cases belong to high-velocity trauma. Mean age group of patient was 36 with range from 24 to 58, including 20 males and 4 females. All patients belong to Shazker Type V and VI classification along with coronal fracture and dislocation patterns. Concomitant injury was seen in 11 cases which include ipsilateral shaft femur fracture, ipsilateral shaft ulna fracture, tibial tuberosity fracture, common peroneal nerve palsy, and distal end radius fracture [Table 1]. All these injuries were treated along with tibial plateau fracture and neurolysis was done for common peroneal nerve palsy which recovered at the end of 7 months.
All patients were operated between 7 and 15 days with mean of 9.5 days to injury. Associated comorbidities include diabetes mellitus, hypertension, and ischemic heart disease. The mean operating time was 92 min with range from 70 min to 118 min. Autologous bone grafting was done in 6 patients, all of the fractures healed with average time of 15.2 weeks. Nonunion was not seen in any of the cases, secondary loss of alignment or malunion was seen in one case which was <5° varus and the patient was functionally satisfied [Figure 1] and [Figure 2]. ROM more than 130° was achieved in 21 cases at the end of 12th week, in rest of the three cases, it was between 110° and 130°, which may be due to poor compliance with rehabilitation protocol. Knee stiffness (ROM <90°) was not seen in any of the cases, which was one of the goals of this study. Deep infection was not seen in any of the cases, superficial infection was seen in one case which was managed with oral antibiotics and dressing. | Figure 1: (a) Preoperative X-ray Case 1 anteroposterior view. (b) Preoperative X-ray Case 1 lateral view. (c) Postoperative X-ray Case 1 anteroposterior view. (d) Postoperative X-ray Case 1 lateral view. (e) Union X-ray Case 1 anteroposterior view. (f) Union X-ray Case 1 lateral view
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 | Figure 2: (a) Preoperative X-ray Case 2 anteroposterior view. (b) Preoperative X-ray Case 2 lateral view. (c) Postoperative X-ray Case 2 anteroposterior view. (d) Postoperative X-ray Case 2 lateral view. (e) Union X-ray Case 2 anteroposterior view. (f) Union X-ray Case 2 lateral view
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Functional outcome was measured with the help of Oxford Knee Score, which was excellent (87.5%) in 21 cases and good (12.5%) in rest of the three cases [Table 2]. At final follow-up, none of the patients has any varus or valgus laxity. Posttraumatic arthritis was not seen in any of the cases, but it would be early to say that considering mean follow-up of 28 months. Extension lag was seen in two patients which were <10°. Secondary procedures were not required in any of the cases. The overall complication rate was much low considering dual plate fixation, infection (4.16%), neurovascular (0%), nonunion (0%), and malunion (4.16%) [Table 3].
| Discussion | | |
The management of bicondylar tibial plateau fracture dislocations is challenging, considering soft-tissue complications, fracture comminution and morphology, and delayed complications such as varus collapse, stiffness, and arthritis.[19],[20],[21],[22] The goal of anatomic reduction and stable fixation can be achieved with plating but with associated complications such as soft-tissue healing and implant failure. With better understanding of fracture morphologies such as coronal split and posteromedial fragment, most of the surgeons have employed dual plating in these fractures to avoid secondary loss of alignment and reduction. Historically, it has been done with a single midline incision which was associated with soft-tissue complications ranging from 23% to 100%.[12],[13],[14] With the development of new approaches and techniques, soft-tissue complications have been reduced to 4.7% with dual plating through double-incision approach.[15]
Association for osteosynthesis/association for the study of internal fixation has recommended dual plating for fixation of bicondylar tibial plateau fracture dislocations.[23] We have employed same principles in our study and found that the functional outcome is good to excellent in most of the cases. Single plating for these fractures has shown postoperative malreduction rate of 15%–23%, which is not acceptable and will lead to long-term disability.[24],[25] Biomechanical cadaveric study performed by Higgins et al. demonstrated that dual-plate fixation allows better maintenance of postoperative reduction and alignment compared to single lateral locked plating.[10] Barei et al. have demonstrated the presence of posteromedial fragment in 33% of these cases and achieved excellent functional outcome using two plates through two incisions.[7],[11] The routinely applied approach in most of these cases is combination of anterolateral and posteromedial which allows sufficient skin bridge to allow wound healing and prevent wound complications.
Our experience suggests that adequate preoperative interval along with meticulous surgical technique and aggressive postoperative rehabilitation is a key to good functional outcome for these fractures. In our study, we did not have any case of nonunion, infection, and secondary loss of alignment was also seen in one case each with mean healing time of 15.2 weeks which is comparable to all standard studies till now. The limitation of our study is less number of cases and short follow-up.
| Conclusion | | |
The functional outcome of dual plating with two incisions in bicondylar tibial plateau fracture dislocations is encouraging with minimal soft-tissue complications. The functional outcome depends on early rehabilitation to achieve full ROM which can be possible with the biomechanical stability provided with dual-plate fixation. Secondary loss of reduction and alignment is none to minimal in patients with dual-plate construct as seen in this study. The postoperative complications can be reduced by proper timing of surgery, good soft-tissue care intraoperatively and postoperatively. The overall functional and radiological outcomes at the end of 1 year are excellent to good in most of the cases which indicates that this technique is a good treatment option for bicondylar tibial plateau fracture dislocations.
Informed consent
Written informed consent was obtained from each patient included in the study.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]
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