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 Table of Contents  
RETROSPECTIVE COHORT STUDY
Year : 2022  |  Volume : 5  |  Issue : 3  |  Page : 180-184

Posteromedial tibial plateau fractures – Functional outcome of posteromedial buttress plating with precontoured locking plate using modified lobenhoffer approach


1 Department of Orthopaedics, Government (TD) Medical College, Alappuzha, Kerala, India
2 Department of Orthopaedics, IGIMS, Patna, Bihar, India

Date of Submission06-Mar-2022
Date of Decision24-May-2022
Date of Acceptance29-May-2022
Date of Web Publication1-Sep-2022

Correspondence Address:
Kumar Chandan
Department of Orthopaedics, IGIMS, Patna, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodp.jodp_22_22

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  Abstract 


Posterior tibial plateau fractures have a complex intra-articular fracture pattern, representing approximately 1.2% of all fractures. The occurrence of the posteromedial shear fragment is relatively common in high-energy tibial plateau fractures. Aims and Objectives: To study the role of posteromedial plating in the management of complex tibial plateau fractures with a posteromedial fragment. Materials and Methods: Only patients with posteromedial fracture patterns alone are taken into account. Twenty cases above 20 years of age, from the patient, admitted to Government Medical College, Thrissur, with posteromedial fragment in tibial plateau fractures that were operated were undertaken for the study. The patients were followed up for 2 years. Results: Of the 20 patients with posteromedial tibial plateau fractures from X-ray and computed tomography scan of the knee joint, all patients were treated with precontoured posteromedial buttress plating using single anatomical locking plate. We analyzed patients with Rasmussen scoring postoperatively. In our analysis, among 20 patients, the functional score was excellent in 14, good in 5, fair in 1, and poor in none. There was one patient with compartment syndrome who had developed a mild surgical site infection that later resolved. No excessive collapse is seen postoperatively since locked plate is used. Four patients had transient paraesthesia of the saphenous nerve; both resolved completely.

Keywords: Locking plate, Rasmussen's criteria, tibial condyle posteromedial plating


How to cite this article:
Unnikrishnan J, Chandan K, Bindulal V A. Posteromedial tibial plateau fractures – Functional outcome of posteromedial buttress plating with precontoured locking plate using modified lobenhoffer approach. J Orthop Dis Traumatol 2022;5:180-4

How to cite this URL:
Unnikrishnan J, Chandan K, Bindulal V A. Posteromedial tibial plateau fractures – Functional outcome of posteromedial buttress plating with precontoured locking plate using modified lobenhoffer approach. J Orthop Dis Traumatol [serial online] 2022 [cited 2022 Dec 3];5:180-4. Available from: https://jodt.org/text.asp?2022/5/3/180/355242




  Introduction Top


Tibial plateau fractures have a complicated intra-articular fracture pattern, representing approximately 1.2% of all fractures.[1] Fracture reduction can be a challenge to experienced hands and the soft-tissue conditions are intolerant of careless dissection. Fractures which involve the articular cartilage of the proximal tibia often require open reduction and internal fixation to restore the joint surfaces and the alignment of the limb. The advent of computed tomography (CT) and its three-dimensional reformation (3D) has allowed for an accurate assessment of this fracture pattern. The advent of computed tomography (CT) and its three-dimensional reformation (3D) has allowed for an accurateassessment of this fracture pattern[2],[3],[4] Luo et al. described the morphology of this fracture based on the CT scan.[5] These studies help to understand the geometry of this fracture pattern. The three-column classification demonstrates higher interobserver reliability and can be used as a supplement to the conventional Schatzker classification, especially in the complex and posterior comminuted tibial plateau fractures. Furthermore, the three-column classification is clinically relevant and, to some degree, can instruct the surgeon in preoperative planning.[5],[6] The occurrence of the posteromedial fragment is relatively common in high-energy tibial plateau fractures and that the use of a posteromedial approach with direct fracture visualization, anatomic reduction, and absolute stability appears to result in satisfactory outcomes. Hence now, posteromedial column fractures should be considered unstable, as fractures in this area tend to undergo displacement even at low flexion angles in contrast to anterior column fractures, although they may initially appear to be nondisplaced after injury.[6]

Aims and objectives

All displaced posteromedial tibial plateau fractures should be surgically stabilized and buttressed using plate to restore joint congruity and prevent late subluxation and early arthritis. The aim is to study the role of posteromedial plating in the management of complex tibial plateau fractures with a posteromedial fragment


  Materials and Methods Top


Twenty cases above 20 years of age, from the patient, admitted to Government medical college, Thrissur, with posteromedial fragment in tibial plateau fractures that were operated for 2-year study period were undertaken for the study. All patients were men with a mean age of 30 years (20–65 years). No patient had any preoperative neurovascular damage. One patient developed compartment syndrome which was managed by mini-open fasciotomy.

All patients had limb elevation and temporary splinting with above-knee slabs. Ice fomentations were given when there was diffuse swelling at the fracture site. Preoperative evaluation included plain radiography and anteroposterior and lateral views with CT scans of the affected knee. The fractures were classified according to Schatzker classification[7],[8] with X-rays and the three-column classification using CT scans [Figure 1],[Figure 2],[Figure 3]. Based on CT scan, surgical decision-making was done. Only patients with posteromedial fractures in CT scans were included in the study. Fractures extending to other columns in the CT scan were excluded. They were operated with plate osteosynthesis and the results were analyzed using Rassmussen's knee score.[9]
Figure 1: Schatzker classification[7]

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Figure 2: Three-column classification[8]

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Figure 3: Three-dimensional CT scan. CT: Computed tomography

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Modified Lobenhoffer approach to gain access to the posteromedial plateau was used. With the patient in the lazy lateral position with operating leg beneath the nonoperating side, with sandbag below the opposite pelvis, when necessary, as part of a combined medial and lateral reconstruction for a bicondylar fracture. The skin incision is inverted' L'shaped, made along the medial head of the gastrocnemius muscle extending from the medial femoral epicondyle proximally to the posterior border of the tibia 6–8 cm beyond the tip of the posteromedial fragment distally. The deep interval is between the gastrocnemius muscle which is retracted posteriorly and the pes anserinus, which is retracted anteriorly. Medial gastrocnemiusis subperiosteally elevated to reach the fracture site [Figure 4] and [Figure 5]. When the fragment is large, and noncomminuted, the reduction can be achieved at the level of the metaphysis and verified at the joint line via fluoroscopy or by direct observation. After applying axial traction in extension and valgus, direct pressure is applied over the apex of fracture fragment for reduction. Reduction can be maintained with a Kirschner wire and a pointed reduction clamp. Depression of the medial condyle is elevated if necessary. A specific precontoured posteromedial plate (manufacturer: Titanium, orthotech) is used in all the cases and when optimally positioned is well suited to resist deforming forces. The plate is placed directly over the area of maximal displacement at the apex of the fracture, nonlocking hole is tightened first for the buttress effect. Reduction and fixation were checked with image intensifier. Wound closed in layers with suction drain.
Figure 4: Skin incision

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Figure 5: Deep dissection

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Postoperatively, knee brace was given and Range of motion exercises started after 3 weeks to allow fracture fragments to become sticky. Weight-bearing is delayed till 3 months. Radiographs were taken every 6 weeks till union. All cases were followed up for at least 1 year.


  Results Top


Seventeen patients were males and three were females. All fractures resulted from road traffic accidents. Surgical fixation was undertaken within 48 h of injury due to fear of compartment syndrome. Of 20 patients, all were followed for at least a minimum period of 6 months to the maximum period of 22 months. Of these 20 patients with posteromedial tibial plateau fractures from X-ray and CT scan of the knee joint, precontoured posteromedial locking plate is used in all patients. Postoperative protocol was based on bony union radiologically where full weight-bearing was advised only after a minimum of 12 weeks. We analyzed patients with Rasmussen's scoring is based on functional criteria. In our analysis among 20 patients, the functional score was excellent in 14, Good in 5, Fair in 1, and poor in none ofthe patients [Table 1] and [Figure 6],[Figure 7],[Figure 8],[Figure 9],[Figure 10],[Figure 11]. There was one patient with compartment syndrome who had developed a mild surgical site infection that later resolved. No excessive collapse is seen postoperatively since locked plate is used. Four patients had transient paraesthesia of the saphenous nerve; both resolved completely [Figure 12] and [Figure 13].
Figure 6: Preoperative X-ray and 3D CT scan (case no 1). 3D CT: Three-dimensional computed tomography

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Figure 7: Postoperative X-ray (case No 1)

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Figure 8: Preoperative X-ray and 3D CT scan (case no 2). 3D CT: Three-dimensional computed tomography

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Figure 9: Postoperative (case no 2)

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Figure 10: ROM in patient with excellent outcome

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Figure 11: ROM in patient with fair outcome

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Figure 12: compartment syndrome (case no 13)

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Figure 13: superficial wound infection (case no 13)

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Table 1: Rasmussen's functional scoring[9]

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  Discussion Top


The proximal tibial articular surface is one of the critical load-bearing areas of the human body. Fracture of this area can occur due to a combination of axial loading and valgus or varus applied forces. Stability of the joint, alignment of the lower limb, and motion of the knee joint are severely affected as a result of tibial plateau fracture. The more energy applied to the limb; more complex is the fracture. In general, higher Schatzker types of fractures were categorized as high-energy related. These X-ray-based classifications are insufficient to determine the severity of the fracture, particularly in patients with posterior column fractures after high-energy trauma.[7] Luo's CT-based three-column classification is clinically relevant and can instruct the surgeon in preoperative planning.

Some fracture patterns can only be evident in a CT scan. Knee instability will result if these injuries are left untreated. The optimized treatment protocol should include assessing and reconstructing the stability apparatus of all columns in the primary fixation of fractures. Therefore, tibial plateau fractures are now commonly classified according to the three-column theory using 3D CT together with the Schatzker classification, and fixation is planned accordingly. A posteromedial fragment in CT scan warrants fixation.[8],[10],[11]

Shear fractures of the posteromedial tibial plateau need special attention while treating proximal tibial fractures. Efforts must be taken to buttress the fragment posteriorly to achieve anatomical reduction and early mobilization of the knee. Locked plate prevents collapse while performing knee movements and also during weight-bearing. In our study, 90% of patients achieved excellent to good results which are in concordance with most other studies evaluating fixation of posteromedial fractures.[12],[13] Even though some studies show there is no difference in complication rate using an anterior mid-line incision for fixation of posteromedial fractures, we feel it involves unnecessary soft tissue stripping in case of an isolated posteromedial fracture.[12]

Moore et al., reported that nine of 11 patients treated by medial and lateral plating through an anterior incision became infected or had wound problems.[14]

Through the Modified Lobenhoffer approach, one can reach the fracture site easily without much soft-tissue devitalization. It helps in the easier placement of the posteromedial buttress plate also. In our case series, we encountered only one wound infection which is in par with other studies.[12],[15] Carlson treated five patients with posterior bicondylar tibial plateau fractures by direct fracture exposure and fixation through posteromedial and posterolateral incisions. A posterior plate is covered by a large muscular envelope and is not palpable, unlike direct medial plating.[14],[15]

Regarding the anatomical locking plate, a standard AO plate or its Indian replica provided adequate fixation and support in all our cases. This may be due to the constant large posteromedial condylar fragment which is most often the case, unlike a comminuted anterior plateau fracture. No need of a specialized plate was needed, as described by some studies.[6]


  Conclusion Top


Posteromedial buttress plating using anatomical precontoured plate through a modified Lobenhoffer approach is a safe, easy, and effective procedure in the management of posteromedial shear fractures of the tibial plateau.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/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.



 
  References Top

1.
Ariffin HM, Mahdi NM, Rhani SA, Baharudin A, Shukur MH. Modified hybrid fixator for high-energy Schatzker V and VI tibial plateau fractures. Strategies Trauma Limb Reconstr 2011;6:21-6.  Back to cited text no. 1
    
2.
Higgins TF, Kemper D, Klatt J. Incidence and morphology of the posteromedial fragment in bicondylar tibial plateau fractures. J Orthop Trauma 2009;23:45-51.  Back to cited text no. 2
    
3.
Barei DP, O'Mara TJ, Taitsman LA, Dunbar RP, Nork SE. Frequency and fracture morphology of the posteromedial fragment in bicondylar tibial plateau fracture patterns. J Orthop Trauma 2008;22:176-82.  Back to cited text no. 3
    
4.
Markhardt BK, Gross JM, Monu JU. Schatzker classification of tibial plateau fractures: Use of CT and MR imaging improves assessment. Radiographics 2009;29:585-97.  Back to cited text no. 4
    
5.
Zhu Y, Yang G, Luo CF, Smith WR, Hu CF, Gao H, et al. Computed tomography-based Three-Column Classification in tibial plateau fractures: Introduction of its utility and assessment of its reproducibility. J Trauma Acute Care Surg 2012;73:731-7.  Back to cited text no. 5
    
6.
Jian Z, Ao RG, Zhou JH, Jiang XH, Yu BQ. Modified anatomic locking plate for the treatment of posteromedial tibial plateau fractures. Orthop Surg 2020;12:1605-11.  Back to cited text no. 6
    
7.
Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and dislocation classification compendium-2018. J Orthop Trauma 2018;32 Suppl 1:S1-170.  Back to cited text no. 7
    
8.
Luo CF, Sun H, Zhang B, Zeng BF. Three-column fixation for complex tibial plateau fractures. J Orthop Trauma 2010;24:683-92.  Back to cited text no. 8
    
9.
Fischer-Rasmussen T, Jensen PE. Proprioceptive sensitivity and performance in anterior cruciate ligament-deficient knee joints. Scand J Med Sci Sports 2000;10:85-9.  Back to cited text no. 9
    
10.
Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto experience 1968-1975. Clin OrthopRelatRes. Jan-Feb 1979. Volume - Issue 138 - p 94-104.  Back to cited text no. 10
    
11.
Rossmann M, Fensky F, Ozga AK, Rueger JM, Mardian S, Russow G, et al. Tibial plateau fracture: Does fracture classification influence thechoice of surgical appr. Eur J Trauma EmergSurg.2020:46. https://doi.org/10.1007/s00068-020-01388-z(online).  Back to cited text no. 11
    
12.
Söylemez MS, Cepni SK, Kemah B, Batar S. Posteromedial plate application using medial midline incision for complex tibia plateau fractures: A retrospective study. BMC Musculoskelet Disord 2022;23:129.  Back to cited text no. 12
    
13.
Zhang J, Yin B, Zhao J, Li Y, Yin P, Guo T. Combined lateral peripatellar and posteromedial approaches for Schatzker type IV tibial plateau fractures involving posteromedial plane: A prospective study. BMC Musculoskelet Disord 2020;21:229.  Back to cited text no. 13
    
14.
Moore TM, Patzakis MJ, Harvey JP. Tibial plateau fractures: Definition, demographics, treatment rationale, and long-term results of closed traction management or operative reduction. J Orthop Trauma 1987;1:97-119.  Back to cited text no. 14
    
15.
Carlson DA. Posterior bicondylar tibial plateau fractures. J Orthop Trauma 2005;19:73-8.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]
 
 
    Tables

  [Table 1]



 

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