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Avoiding Complications in Tibial Plateau Fractures
Henry Dolch DO Orthopaedic Trauma Service Cooper University Hospital
May 11, 2018
Disclosures
• None
2
Tibial Plateau Fractures
• 1% of all fractures • 42000 TBF in US in 2010 • Infection Rate 9.1% • 3900 TBF infections in US in 2010
Handbook of Fractures. Philadelphia : Wolters Kluwer 2015
• Lateral Plateau: 55-70% of fractures • Medial Plateau: 10-20% of fractures • Bicondylar Plateau: 10-30% of fractures
• CUH – 60% bicondylar Tibial Plateau
OTA Lecture Series
• Bimodal distribution – Young adults: high energy mechanism
• Highest in 5th decade • Male > Female
– Elderly: low energy mechanism • Osteoporotic bone • Female > Male
OTA Lecture Series
Mechanism
• Fall from standing height • MVA • MCC • Pedestrians Struck • Falls from significant heights • Car Surfing • ATV
OTA Lecture Series
Anatomy • Consist of medial and
lateral plateau – Medial larger – Medial lower
(concave) – Medial bone harder
(thus less likely to fracture)
– Lateral higher (convex)
– Lateral cartilage thicker (3 vs 4 mm)
OTA Lecture Series
Anatomy
Lateral
convex
Medial
concave
OTA Lecture Series
Mechanism of Injury - Valgus
• Valgus producing force – Lateral plateau
• Varus producing force – Medial plateau
• Axial compressive force – Bicondylar plateau
• Combination – High energy – Bicondylar plateau – Soft tissue injury
Mechanism of Injury - Varus • Valgus producing force
– Lateral plateau • Varus producing force
– Medial plateau • Axial compressive force
– Bicondylar plateau • Combination
– High energy – Bicondylar plateau – Soft tissue injury
Mechanism of Injury - Axial • Valgus producing force
– Lateral plateau • Varus producing force
– Medial plateau • Axial compressive force
– Bicondylar plateau • Combination
– High energy – Bicondylar plateau
Schatzker Classification • Type I: Split fracture of the lateral plateau • Type II: Split depression fracture of the lateral
plateau • Type III: Pure depression fracture of the lateral
plateau • Type IV: Medial plateau (possible fracture /
dislocation) • Type V: Bicondylar plateau fracture • Type VI: Plateau fracture with metaphyseal /
diaphyseal dissociation
Classification • Unicondylar fracture • Schatzker I, II, III • AO/OTA (41-B)
• Partial articular
Split Split-depression Central depression
Classification • Unicondylar fracture • Schatzker IV • AO/OTA (41-B)
• Partial articular • Medial plateau • Fracture / dislocation • Displaced, higher
energy • Vascular injury
concern
Split fracture, medial plateau
Classification • Bicondylar fracture • Schatzker V, VI
• V: Medial tibial plateau split and Lateral split depression
• VI: Plateau with metadiaphyseal dissociation
Bicondylar fracture Metadiaphyseal dissociation
Treatment Options • Nonoperative Mgmt • Limited ORIF • ORIF
– Single vs dual plating
• External Fixation – Unilateral vs TSF
• Staged ORIF after external fixation
Nonoperative Treatment Benefits - No surgical Risks - No implants Risks - Loss of reduction - Stiff knee – limited early motion
Limited ORIF
Benefits - Early motion - Limited Incision - Maintain fracture reduction
Risks - Infection - Hardware Complications - Loss reduction with inadequate fixation
ORIF Unicondylar
Lateral Plating Bone graft when necessary
ORIF Bicondylar
Managed with External Fixation Benefits - Soft Tissue Friendly, no incisions - low infection risk Risks - Higher Rate nonunion - Loss of reduction - Knee Stiffness
Complications • Loss of reduction • Infections • Post Traumatic DJD • Symptomatic Implants • Loss of knee motion • Peri-Implant Fracture • Wound Complications
• Wait for swelling to subside, + wrinkles • Do not operate through blisters • No midline incisions
– Dual incisions for bicondylar plateaus • Close fasciotomy wounds as soon as possible • Anatomic reduction, restore anatomic axis • Medial plates for medial fractures, lateral plates for lateral
fractures • Repair the meniscus
Avoiding Complications
• Wrinkle Test - Skin shows signs of wrinkling, indicates that soft tissue edema has resolved to an extent that soft tissue complications will be reduced
– No literature support but we all use it
• Do not operate through fracture blisters – Un-Roof blisters, Silvadene BID and operate when re-epithelialized
Skin Evaluation
JOT 2006
Midline Incisions
Higher infection rates Major skin complications Poor plate placement Higher risk nonunion due to soft tissue stripping
• 37 Bicondylar Tibial Plateaus • 23% Deep Infection Rate
Complications of internal fixation of tibial plateau fractures. Orthop Rev. 1994;23:149–154.
Young MJ, Barrack RL.
• 8 Bicondylar Tibial Plateaus • 7 of 8 deep infections (87.5%)
JOT 1987
DON’T USE A MIDLINE INCISION
• 83 Patients, 7 deep infections (8.4%)
• 62% satisfactory articular reductions • 91% satisfactory coronal alignment • 72% satisfactory sagittal alignment • 98% satisfactory condylar width.
Are Dual Incisions Safe?
JOT 2004
DUAL INCISIONS ARE SAFE
Lateral Plating Medial Fracture
Medial Fractures need medial plating
• Biomechanical study • medial buttress plate provides significantly
greater stability in static loading, and a trend toward improved stability with cyclic loading.
JOT 2007
• Immediate postoperative malalignment and delayed loss of alignment
• Single Plating 10.34 and 17.24% • Dual Plating 6.25% and 0%
Isolated Lateral Plating Bicondylar Tibial Plateau Fractures
Bicondylar Fractures require dual plating
Hardware Complications • Tenderness over lateral plates
• Prominent Screws
• Broken Implants
• Be aware of symptomatic implants and remove when fracture healed
• Assure fracture union on CT prior to implant removal
Post Traumatic Osteoarthritis
JBJS 2015
• 31 patients, 24 ORIF, 7 nonop
• Higher wound
complications, persistent stiffness, higher revision rates in ORIF group
• Similar patient
reported outcomes
• 62 TKA • 96% survivorship 15 yrs for aseptic
loosening • 82% survivorship 15 yrs for any
revision
• Complications – 6 stiffness – 3 wound breakdown – 2 superficial infection – 2 deep infection – 2 patellar subluxation – 1 hematoma – 1 reflex sympathetic dystrophy – 1 DVT – 1 MCL Tear
Higher Complications rates than primary TKA, but satisfactory results
Restore Articular Congruity
• 41 depressed tibial plateau fractures • Evaluated with CT • Residual Joint incongruity < 2.5 mm
had smaller losses in knee range of motion (P = 0.000), better Oxford (P = 0.006), Iowa (P = 0.003), and KOOS symptom (P = 0.011) and pain (P = 0.001) scores.
• Restoration mechanical axis was not found to be significant except for KOOS score for ADL
JOT 2017
Restore the Joint and the alignment
Don’t forget the meniscus
• Tibial plateau fractures with repaired meniscus had similar outcomes to those fractures without meniscal tears
• More depression has higher risk of meniscal tear
Literature Review Infection Unpublished data
Many studies have shown multiple risk factors for deep infection
Risk factors for Infection • Modifiable
– Fasciotomy Closure – External Fixation – Fixation Construct – Operative Time – PO Antibiotics – Length of Stay
• Non-Modifiable – Age – BMI – Alcohol Abuse – Homelessness – Smoking (???) – Compartment Syndrome – Fracture Pattern – Open Fracture (???)
As surgeons, we have some control of the modifiable risk factors
Fasciotomy Wounds
• Higher Rate SSI (25% vs 8%) • Delay Fasciotomy Wound
Closure 7% increase infection per day
Injury 2017
Close or cover fasciotomy wounds as soon as possible
External Fixation
• 655 fractures • 34 deep infections • Use of external fixation is a
modifiable risk factor But do not hesitate to use external fixation when clinically warranted
• 81 pts, Shatzker IV-VI • 53 Staged, 28 ETC
– Staged – ORIF when soft tissues allow
– ETC – once medically clear • No difference in outcomes
including ROM, infections, soft tissue complications, etc
• All Shatzker IV-VI do not need external fixation
• ETC > Age 50 is safe and should be
considered to decrease risk of infection secondary to external fixation
JOT 2017
• 302 pts, 43 deep infections • Modifiable Risk factor
– 2 incisions and 2 plates
• Only Study to show dual plating increases infections
– Could be related to operative time
JOT 2012
2 incisions and 2 plates still standard of care
Operative Time
Injury 2013 European Journal of Orthopaedic Surgery Traumatology
• 309 fractures, 7.8% infection rate • Mean operative time infection 2.8
hours • Mean operative time no infection
2.2 hours
• 251 fractures, 7.8% infection rate • Operative time independent
predictor of infection
Comminuted bicondylar plateau fractures are challenging to fix within 2.2 hours
• Be aware of time • Avoid unnecessary delays
Other non-published risk factors • 141 closed fractures,
13 (9.2%) infections – Non ICU length of stay
>18 days – Lack of postoperative
antibiotics
• Both independent risk factors for deep infection
• Dual Occupancy Rooms – Trended toward
significance for deep infection
Non published Data
Open Fractures • Cannot be controlled • Surgeon can control
– Debridement – Soft Tissue
management – Timing – Antibiotic use
Smoking • Post surgical
modification • Smoking cessation
education
BJR 2013
Summary • Dual Incisions • Correct plates for fracture patterns • Close fasciotomy wounds ASAP • Watch your operative time • Restore the joint and axis • Operate through safe skin • External Fixation when needed • Adequate debridement of open fractures • Stop smoking
My Pearls • ORIF as soon as soft tissue allows,
preferably before 2 weeks • Bicondylar plateaus need 2 or
more plates • Start medial, restore joint
– Usually simpler fracture pattern
• Lateral plate goes lateral, avoid anterior placement
– Will direct screws incorrectly – Can cause prominent anterolateral
hardware
• Watch your time • Use external fixation as reduction
tool
• Close fasciotomy wounds ASAP • If skin graft necessary, perform
ORIF and skin graft at same time • Medial plates for medial fractures • Don’t forget the tibial tubercle
– Use AP lag screws – Use anterior plates only if necessary
• Can be very prominent
• Bone graft when necessary – Cancellous cubes – Calcium Phosphate
• Smoking Counseling • Early Motion • Look at the meniscus, repair if
needed
Thank You
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