|Year : 2022 | Volume
| Issue : 1 | Page : 8-13
Clinical and radiological evaluation of proximal tibia fracture fixed with variable angle proximal tibial interlocking plate: A prospective observational study
Sudhanshu Shekhar, Ankit Pranjal
Department of Orthopedic Surgery, Asian Institute of Medical Sciences, Faridabad, Haryana, India
|Date of Submission||09-Sep-2021|
|Date of Decision||23-Dec-2021|
|Date of Acceptance||19-Jan-2022|
|Date of Web Publication||15-Mar-2022|
House No-D/7, Ajanta Colony, Keshri Nagar, Patna - 800 024, Bihar
Source of Support: None, Conflict of Interest: None
Background: Tibial plateau fractures are complex injuries produced by high- or low-energy trauma and principally affect young adults. In view of the ever-increasing high-velocity road traffic accidents, there is an increase in complex, multifragmentary periarticular fractures of the tibia. The goal of proximal tibial fracture treatment is to obtain the early union of fracture in the most acceptable anatomical position with the early and maximum functional return of activity. The use of more modern implants with locking screws and precontoured locking plates provides better stability and may further improve outcome. In this regard, this study was undertaken to study the functional outcome and radiological outcome of closed proximal tibial fracture Schatzker's type I, II, and III treated with variable angle-locking compression plate (VA-LCP). Methods: A hospital-based prospective study was undertaken among the 54 adult patients with closed proximal tibial fracture Schatzker's type I, II, and III requiring surgical intervention and treated by VA-LCP. A predesigned, self-administered pro forma was designed to keep the objectives of the study at the center point. The patients were categorized based on their relevant age, gender, fracture type, and complications. Qualitative data were represented in the form of frequency and percentage. The final outcome was obtained using modified Rasmussen clinical and radiological score as well as the total healing period of the subjects followed up for a period of 24 weeks. All care and caution were exercised while utilizing the patient data for the current research as outlined in the hospital guidelines pertaining to the usage of patient data for this study, and confidentiality was maintained throughout. Results: The maximum study population belonged to the age group of 50–59 years, which comprised about 44.5%. 26 (48.2%) of the tibial fractures were diagnosed to have Schatzker's type II fractures followed by 15 (27.7%) type III and 13 (24.1%) type I. Group I (30–39 years) showed faster healing with a mean healing period of 18.6 ± 1.9 weeks, followed by Group II (40–49 years) with a mean healing period of 19.6 ± 4.1. Mechanical failure (7, 12.9%) and some secondary complications (12, 22.2%) were also observed during follow-up in the outpatient department. At the end of follow-up, 35 patients (64.8%) had excellent clinical result, 19 (35.2%) had good clinical result, and no patient had a poor functional outcome. For the radiological assessment, there were 29 patients (53.8%) with excellent, 18 (33.3%) with good, 7 (12.9%) with fair, while none with poor results. Conclusion: Treatment of proximal tibial fractures is challenging because of limited soft tissue cover and less vascularity. There are various treatment options for these fractures starting from closed reduction with casting to open reduction and internal fixation with a plate. The excellent functional results and lack of soft tissue complications suggest that a VA-LCP should be considered as an option in tibial plateau fractures. A balance between anatomical reduction and soft tissue stripping is required to avoid any complications.
Keywords: Internal fixation, Rasmussen score, Schatzker's type fractures, tibial fracture
|How to cite this article:|
Shekhar S, Pranjal A. Clinical and radiological evaluation of proximal tibia fracture fixed with variable angle proximal tibial interlocking plate: A prospective observational study. J Orthop Dis Traumatol 2022;5:8-13
|How to cite this URL:|
Shekhar S, Pranjal A. Clinical and radiological evaluation of proximal tibia fracture fixed with variable angle proximal tibial interlocking plate: A prospective observational study. J Orthop Dis Traumatol [serial online] 2022 [cited 2023 Mar 30];5:8-13. Available from: https://jodt.org/text.asp?2022/5/1/8/339676
| Introduction|| |
Treatment for proximal tibial plateau fractures is difficult, especially when metaphyseal comminution is associated with osteoporosis and soft tissue injury. The tibial plateau involves weight-bearing, and restoration of joint congruity is important to preserve the normal function of the knee. The traditional treatment of tibia fractures has been long-term immobilization in plaster of Paris (POP) cast and functional cast brace, which in itself is an invitation to well-known “fracture disease.” Schatzker's type II fractures with severe depression of the articular surface require open reduction to elevate the depressed fragment with a bone tamp through a cortical window in the metaphysis, followed by rigid internal fixation [Figure 1]. To maintain the reduction, the subchondral void is usually filled with cancellous autografts, allografts, or bone substitutes. Autografting is associated with donor-site morbidity, risk of infection, increased surgical time, and blood loss, whereas allografting is associated with the risk of disease transmission, low initial stability in the metaphyseal defects, and inadequate incorporation of the graft to host bone.
|Figure 1: (a and b) Preoperative X-ray of the knee showing anteroposterior and lateral view|
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Currently, surgeons have a variety of options and implants in their armamentarium for the treatment of these fractures. The newer techniques include partially threaded cancellous screws, conventional open reduction and plating, and minimally invasive percutaneous plate osteosynthesis with locking compression plate (LCP).
The variable angle-locking compression plate (VA-LCP) is part of the VA-LCP periarticular plating system, which merges variable angle-locking screw technology with conventional plating techniques [Figure 2]. The VA-LCP has many similarities to standard locking fixation methods, with a few important improvements. Variable angle-locking screws provide the ability to create a fixed-angle construct while also allowing the surgeon the freedom to choose the screw trajectory before “fixing” the angle of the screw. A fixed-angle construct provides advantages in the osteopenic bone or multifragmentary bridge-plated fractures where screws do not rely on the plate to bone compression to resist the patient load. Many studies studied the functional outcome after conventional plating techniques, but studies on VA-LCP are relatively scarce. The present research was thus planned to study the clinical and radiological outcomes of the proximal tibia fracture fixed with a variable angle proximal tibial interlocking plate.
|Figure 2: (a and b) Postoperative X-ray of the knee showing anteroposterior and lateral view|
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Aims and objectives
- To study the functional and radiological outcomes of closed proximal tibial fracture Schatzker's type I, II, and III treated with variable angle proximal tibial interlocking plate
- To delineate any advantage or disadvantage of the use of VA-LCP in the proximal tibia fracture
- To study the complications of closed proximal tibial fractures treated by variable angle proximal tibial interlocking plate.
| Materials and Methods|| |
A prospective observational study was conducted at the department of orthopedics of our institute from October 2018 to January 2020. All patients of both genders between 18 and 70 years of age group were admitted to our hospital with closed proximal tibial fractures (Schatzker's type I, II, and III) were included in our study. After admission, the general condition of the patient was assessed with regard to hypovolemia, clinical examination for ligament injury was done, and associated orthopedic or other systemic injuries and resuscitative measures were taken accordingly. X-ray and computed tomographic (CT) scan of the knee were done. Preoperative arterial and venous Doppler was done in all patients and reports were normal.
All the patients were given preliminary management by temporary above knee POP slab and medical management was done. The patients then were taken for definitive fixation after a variable period depending upon swelling and skin condition. We followed anterolateral approach to the proximal tibia. A straight incision was taken lateral to the patella. Deep fascia was opened anterior to the iliotibial tract, the proximal attachment of the tibialis anterior muscle was released and knee joint was exposed. Open reduction done and fixed by variable angle proximal tibial interlocking plate [Figure 3]. Wound was closed in layer and knee brace was given. Interoperable data were recorded.
Postoperative knee brace was given. Nonweight-bearing ambulation was done for 4 weeks, and static quadriceps and passive knee range of motion (ROM) exercise were started the next day. Knee brace was removed and partial weight-bearing was started after 4 weeks, and after 12 weeks, full weight-bearing was started. In each follow-up, data were recorded as per Rasmussen scoring system.
Data collection was on paper. The patients participating in the study were contacted only by the persons involved in the study. All the patient-specific data were kept in strict confidence. Patient identifiable data (name, personal details, etc.) were not presented in the journal or any public forum.
The informed consent process was initiated before the individual agreeing to participate in the study and continuing throughout the individual's study participation. The form provided to them had all the information required for the patient to understand their role in the study. It contained a description of the study procedures. It was in a language understandable by each member of the study population. Ethical clearance was granted by the ethical committee of our institute.
| Results|| |
In gender distribution, males showed little faster healing than females as the mean healing time of males was 19.9 ± 3.8 weeks as compared to those of females (20.8 ± 3.6). However, in age distribution, Group I (30–39 years) showed faster healing with a mean healing period of 18.6 ± 1.9 weeks, followed by Group II (40–49 years) with a mean healing period of 19.6 ± 4.1, and a somewhat similar trend was followed in Group III (50–59 years) and Group IV (>60 years) with a mean healing period of around 20 weeks [Table 1].
Some complications during follow-up in the outpatient department were seen such as mechanical failure (7, 12.9%) and some secondary complications (12, 22.2%). Implant irritation was mostly observed mechanical complication in our cases, while secondary complications included nonunion (2, 3.7%), superficial infection (3, 5.6%), deep vein thrombosis (DVT, 2, 3.7%), delayed union (2, 3.7%), and soft tissue debridements (3, 5.6%) [Table 2].
Radiological and functional results were classified in four categories as per modified Rasmussen criteria. Of the 54 cases, 35 patients (64.8%) had excellent result, 19 (35.2%) had good result, and no patients had a poor functional outcome. For the radiological assessment, there were 29 patients (53.8%) with excellent results, 18 (33.3%) with good, 7 (12.9%) with fair, while none with poor [Table 3].
|Table 3: Distribution of patients based on the according to Rasmussen grading|
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| Discussion|| |
In a fixed-angle locking construct, the screws are inserted perpendicular to the screw hole, which might limit the amount of screw purchase into the fractured fragment. Variable-angle constructs were designed to overcome this shortcoming. In addition, variable-angle constructs are being used to avoid joint penetration and screw convergence, which might result in conflicting of the screws seen in fixed-angle constructs.
Proper preoperative planning was performed, including standard history-taking, examination of the patient to find out other associated injuries including knee ligament injury and neurovascular assessments and complete radiological examinations such as X-ray and CT of the knee. CT scan was mandatory for all severe tibial plateau fractures. Three-dimensional reconstructive CT was needed in some cases to visualize the fracture fragments.
In the present study, the mean healing time of male was 19.9 ± 3.8 weeks as compared to those of female (20.8 ± 3.6) with a mean healing period of around 20 weeks. A study by Girisha et al. shows that in the overall cohort, the mean duration for wound healing was 14 ± 1.68 weeks. This is less than our findings; however, a study by Alraheem et al. shows that the mean time to fracture healing was 27.9 weeks which is greater than our present study. Fracture healing time depends on many factors including fracture type, patient feature, and many other factors. Group I (30–39 years) showed faster healing with a mean healing period of 18.6 ± 1.9 weeks, followed by Group II (40–49 years) with a mean healing period of 19.6 ± 4.1, and a somewhat similar trend was followed in Group III (50–59 years) and Group IV (>60 years) with a mean healing period of around 20 weeks.
Fracture depression and displacement are the most important factors affecting surgical management of the standard tibial plateau fractures. If left untreated, depression results in joint incongruity, valgus deformity, and a sense of instability. The tibial plateau fractures can be associated with peroneal nerve injury, vascular injury, compartment syndrome, DVT, contusion, crush injury to the soft tissues, meniscus, cruciate, medial collateral ligament injury, and open wound. The force that produces medial or lateral tibial plateau fracture may lead to associated collateral ligament injuries.
A study of 31 cases with proximal tibial fractures was treated with a polyaxial locked plate system conducted by Haidukewych et al. in 2007 and observed that 94% of the fractures united with no mechanical complications. Most importantly, there was no evidence of varus collapse as a result of polyaxial screw failure. It was also concluded that polyaxial locking plates offer more fixation versatility without an apparent increase in mechanical complications or loss of reduction. As far as the present study is concerned, some complications during follow-up in the outpatient department were seen such as mechanical failure (7, 12.9%) and some secondary complications (12, 22.2%). Implant irritation was mostly observed mechanical complication in our cases.
Nonunion was established in one patient (1.8%). Similar study by Deokate et al. showed nonunion in three patients (8.3%). In nonunion, additional surgeries were performed: bone grafting through a minimally invasive incision. On the follow-up X-ray, there was a loss of reduction of the middle fragment in one case. Revision surgery to correct this loss of reduction was not performed because the loss of reduction did not affect the length and alignment of the tibia and the entire construct seemed to have a stable and balanced fixation. There was a significant delay in healing at the diaphyseal gap.
Deep vein thrombosis
DVT is a well-known but feared complication following surgery to the lower extremities, especially in a prolonged trauma case. The incidence of DVT was observed in two patients aged 62 years and 69 years with an overall incidence rate of 3.7%. Another similar study by Nikolaou et al. showed complications occurred in only three patients (5.5%). Both patients were diagnosed with Schatzker's type III fracture. Patients with trauma to the lower extremities are at a high risk of developing DVTs. Those individuals need a more aggressive workup and require early endovascular intervention to prevent recurring DVTs or chronic venous insufficiency. Anticoagulant therapy and an interdisciplinary approach should be favored.
In the present study, in terms of pain, 53.7% of the patients did not show any signs of pain at all during the time of first follow-up. 31.5% of the patients reported occasional pain while the remaining 14.8% of the patients reported stabbing pain in a certain position. A study by Tahririan et al. showed that the mean visual analog scale pain score was significantly lower in the locking plate group compared with the nonlocking plate group (4.45 ± 2.50 vs. 6.00 ± 2.59, P = 0.046). A study by Kale et al. showed that a complaint of pain at 3 months was given by 11 (22%) cases, while at the end of 6 months, pain was experienced in only 3 (6%) cases.
As far as walking capacity is concerned, in the present study, 72.2% of the cases had restored normal walking capacity while none of the patients were bedridden and neither of them was forced to use a wheelchair after the successful management. Similar study by Chintawar et al. also showed that majority of patients, i.e., about 75%, started walking in 18–20 weeks.
In the present study, 75.9% of the patients had normal knee extension at the end of the follow-up period while the remaining 24.1% of them had a minor lack of extension, i.e., <10'. Similar study by Moradiya DN et al. also showed the mean loss of extension in the knee: 7.20° (range 5°–20°) and mean knee flexion: 112.79 (range 10°–160°). A study by Chintawar et al. showed that the range of knee flexion was 100°–146°, with a mean flexion of 136° which is comparable with our study. In a study by Naveen et al., the mean knee flexion range was found to be 120.8.
Range of motion
In our present study, during the time of the first assessment (at 6 weeks) of ROM, 42.3% had achieved a good amount of ROM (at least 120') while 57.4% of the subjects achieved a fair amount of ROM (at least 90'). Further, significant improvement was observed in all the 54 subjects and had achieved full ROM in function at the end of the follow-up period following the surgical intervention of medial or bicondylar tibial plateau fractures [Figure 4]a and [Figure 4]b. A study by Kale et al. shows that ROM less than 90° at 3rd month was seen in 14% cases while 42.5% had ROM over 110°. ROM less than 90° at the 6th month was seen in 6% of cases while 82% had ROM over 110°. Improvement in the ROM is in accordance with our study. Kayali et al. showed that the mean ROM for the injured and uninjured sides was 133.75° (range: 120°–145°) and 137° (range: 130°–145°), respectively. There was no significant difference with respect to knee joint ROM at the last visit. A study by Parikh et al. showed in this study that there were four patients (13.33%) with restriction of knee range of movement. Bhalotia et al. in their study showed that ROM more than 130° was achieved in 21 cases at the end of the 12th week, in the rest of the three cases, it was between 110° and 130°.
Medial proximal tibial angle and its application
In the context of deformity correction, the medial proximal tibial angle (MPTA) is the frequently referenced angle. It is measured using simple methods from the knee radiographs, with a normal value of 87° (range: 85°–90°). This angle can represent the correct angle for use in the osteotomy and is usually seen during the operation under fluoroscopic control. Importantly, the MPTA can be used to detect the correction angle change and recurrent varus deformity during the follow-up period.
In the present study, 68.5% had no articular depression while the rest 31.5% had <5 mm articular depression. Fracture depression and displacement are the most important factors affecting surgical management of the standard tibial plateau fractures. If left untreated, depression results in joint incongruity, valgus deformity, and a sense of instability. A study by Moradiya DN et al. showed that five patients developed articular depression of >5 mm during follow-up. Articular depression was not significant enough in any patient to affect knee ROM. A study by Honkonen SE et al. showed mean articular depression of 3 mm. A study by Segal et al. showed that mean articular depression was 5 mm. The findings of these studies are in concordance with our study that articular depression is less than 5 mm in most of the study subjects.
In our present study, 29.6% of the patients exceeded condylar widening of more than 5 mm but less than 10 mm while 70.4% of the patients had less than 5 mm of condylar widening at the end of the follow-up period. A study by Tahririan et al. showed that a widening of the articular surface of more than 2 mm was found in 5 cases which are in accordance with our study.
The main mechanism of injury is a varus or valgus load along with or without an axial load. In the present study, there was no evidence of varus-valgus deformity in 75.9% of the patients while the remaining 24.1% showed signs of valgus deformity at the end of the follow-up period. A study by Gracitelli et al. showed that 19 cases (47.5%) presented valgus displacement of the head and 16 (40%), varus. Four patients (10%) did not present any displacement of the head (only of the tubercle), and 1 (2.5%) had a translation without angular displacement. A study by Tahririan et al. showed that 11 cases (26.8%) were outside the normal range (82°–92°) and were considered malaligned, of whom 11 (9 nonlocking and 2 lockings) were with a valgus angulation (i.e., >92°) and 1 with a varus angulation (i.e., <82°). A study by Nikolaou et al. showed that there is no evidence of varus deformity in study subjects. A study by Parikh et al. showed that four patients had a union in varus while the same number of patients had a union in valgus.
| Conclusion|| |
The satisfactory functional results and lack of soft tissue complications suggest that this method should be considered in the tibial plateau fractures. The surgical strategy is useful as the imaging study results were stable over time and the short-term clinical outcomes were satisfactory. Of course, we suggest further long-term follow-up including a large number of patients to conclude even better.
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
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]