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