Eur Orthop Traumatol (2014) 5:109–114 DOI 10.1007/s12570-013-0212-4

REVIEW ARTICLE

Management of high-energy bicondylar tibial plateau fractures by minimal internal fixation and the ilizarov frame: the knee function Mohamed M. H. El-Sayed & Ashraf A. Khanfour

Received: 22 February 2013 / Accepted: 11 June 2013 / Published online: 20 August 2013 # EFORT 2013

Abstract Background Management of comminuted bicondylar tibial plateau fractures remains a challenge to orthopedic surgeons. Studies of long-term outcomes of treatment of the tibial plateau have included a mixture of fracture types, including low-energy split and split-depressed fractures. Thus, the middle- to long-term results of management of high-energy fractures are still lacking. The aim of this study was to evaluate the knee function and development of arthrosis after a minimum of 3 years in high-energy tibial plateau fractures treated by the Ilizarov external fixator. Methods This is a retrospective study performed at an academically supervised level III, trauma center, in which percutaneous and/or limited open internal fixation and an Ilizarov frame were applied for displaced bicondylar high-energy tibial plateau fractures (Schatzker types V and VI, and Orthopedic Trauma Association types C1, C2, and C3). There were 55 patients in this study and they were followed for a minimum of 3 years. Completion of the Iowa knee score, and the Short Form-36 (SF-36) General Health Survey, was a must. Results After healing, none of the studied patients needed a secondary reconstructive procedure. The knee motion ranged between 15° of extension and 155° of flexion, with an average of 88 % of the total arc of the contralateral knee. The average Iowa knee score was 94 points (range, 65 to 100 points), at the final follow-up visit. Twenty-eight patients rated their outcome as excellent; 17, as good; and 10, as fair. All the studied patients returned to their previous original works. Thirty-five of them were performing strenuous labor. At the final followup visit, there were arthrosis grade 1 in the X-rays of 25 M. M. H. El-Sayed (*) Tanta University, Tanta, Egypt e-mail: [email protected] A. A. Khanfour Damanhour National Medical Institute, Damanhour, Egypt e-mail: [email protected]

patient, grade 2 in 10, grade 3 in 2, and no evidence of arthrosis was found in 18 X-rays (grade 0). Compared with the radiographic appearance 3 years after surgery, there was no evidence of progression of arthrosis in 42 patients, while arthrosis progressed for one grade in 13 patients. The SF-36 subscale scores were similar to those of age-matched controls. Conclusion Patients suffering from high-energy bicondylar tibial plateau fractures could be safely treated by minimal internal fixation and Ilizarov external fixation. This procedure has good prognosis for satisfactory knee function for up to 16 years of follow-up. The intra-articular displacement should be reduced properly, and only very minimal displacements are accepted. This leads to a better knee function and low arthrosis rate. Keywords High energy . Tibial plateu . Fracture . Minimal internal . External fixation . Ilizarov . Screws

Introduction Posttraumatic or secondary osteoarthritis may develop after a complex fracture of the tibial plateau as a result of the alteration of the osseous anatomy leading to altered knee mechanics and loss of cartilage and bone [1]. Posttraumatic osteoarthritis combined with a compromised soft tissue envelope can predispose the patient to a less satisfactory functional outcome after any type of surgical intervention [2–4]. Open reduction and internal fixation of these complex fractures have some major complications that may not only alter the final clinical outcome of management but also affect total knee replacement for these patients later on in life due to anatomical deformity, functional deficiency, and posttraumatic arthritis and may require solutions similar to revision surgery [5–12]. The ideal treatment of such complex fractures is still controversial [13–16]. Most studies in the literature have either combined heterogeneous groups of patients, and fracture patterns, or variable treatment techniques. In general, because of the

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inherent relationship between the severity of an injury and the ability to obtain a satisfactory reduction, particularly of the articular surface, the impact of each of these variables on outcome has been difficult to assess [17–22]. The purpose of this study was to evaluate the perioperative results and functional outcomes for high-energy tibial plateau fractures (Schatzker types V and VI) [23], managed by closed reduction and minimal internal fixation and application of an Ilizarov circular frame. Special attention was paid to knee function and patient satisfaction throughout the follow-up period.

Patients and methods This study was performed at an academically supervised University Hospital (a referral, level III trauma center). Our Institution’s Human Subject Review Board approved this research. Between May 1995 and Dec. 2011, there were 67 cases treated with this technique. Twelve patients were lost during the follow-up period and only 55 completed the study and were followed for a minimum of 3 years. The age of the patients at time of presentation ranged from 21 to 51 years, with a mean of 41 years. There were 46 males, and only nine females included. The mechanism of injury is shown in Table 1. All the included patients suffered from closed injuries. Patients with open fractures were excluded from this study. The right lower limb was affected in 39 patients, and the left side was traumatized in 16 patients. The fractures were classified at presentation as in Table 2. In our center, this technique was also indicated closed fractures with compartment syndrome, skin abrasions, bullae, contusions, and/or severe swelling (grades I and II, Oestern and Tscherne criteria [24]). In this study, only high-energy bicondylar high-energy tibial plateau fractures were included, namely Schatzker types V and VI (Fig. 1). Exclusion criteria Patients with open fractures, severe soft tissue injury, patients with pathological fractures, medical contraindications for surgery, open growth plates, and/or neurovascular injury that Table 1 The mechanism of injury in the studied cases

Falling form height Motor vehicle accident Motor vehicle pedestrian accident Falling of a heavy object on the leg Total

No. of patients

Percent

8 31 14 2 55

14.5 56.4 25.5 3.6 100

Table 2 Classification of the studied fractures according to Schatzker et al. [21] and the AO/OTA (R) classifications

Schatzker et al. [21] AO/OTA (R)

Type

No. of Patient

Percent

V VI C1 C2

39 16 2 43

70.9 29.1 3.6 78.2

C3

10

18.2

needed repair (Gustilo grade IIIC fractures), and neglected fractures for more than 14 days, were excluded from this study. The time lapse between trauma to surgery ranged from 6 h to 5 days, with a mean of 3 days. The index surgery was performed for all the included patients. Under general or spinal anesthesia, the fracture was reduced by closed means under fluoroscopic guidance (C-arm). Special attention was paid to the reduction of the articular surface. If this was not achieved by ligamentotaxis, and closed manipulation under image, limited open reduction was performed to reduce the articular surface properly. Anatomic reduction to less than 2 mm displacement of the articular surface was performed and always checked. After proper initial reduction in both anteroposterior (AP) and lateral views, minimal internal fixation was performed using 6.5 cannulated or cancellous partially threaded screws, through minimal skin incisions. Proper mechanical axis alignment was checked, and then the Ilizarov frame was mounted in position. We bridged the knee in all our studied cases because we only used this technique in highenergy, unstable fractures with severe comminution. This long frame, across the knee, allowed for early partial weight bearing without any risk of loss of the initial reduction of these unstable fractures. Only one complete ring was applied to the distal femur. The construct was looked in knee extension for 4–8 weeks, to allow for soft tissue healing, as well as, to permit immediate partial assisted weight bearing. Then the frame was unlocked (allowing the hinges to move) to permit knee flexion. In few patients (ten cases), the femoral ring was removed after about 3 months, to allow for a better knee flexion range, and to avoid impingement between the rings behind the knee. The average operative time was about 119 min, ranging from 95 to 185 min. The average blood loss in this study was 30 mL (10 to 170 mL). The hospital stay was between 2 to 14 days (average 4 days). Broad-spectrum antibiotics were given according to the severity of the initial injury and extent of soft tissue damage. Antibiotics were given again in some cases of pin tract infection according to the severity of the condition and guided by the results of the culture and sensitivity tests. Fifteen of the studied cases had suffered from associated injuries. Seven of them were polytrauma patients. No bone grafting was used for any of the studied cases.

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The Ilizarov frame was of special value in Schatzker type VI, where the fracture extended to the metaphyseal area and metaphyseal dissociation was present. The time in the Ilizarov frame (application to removal) was an average of 139 days (95 to 165 days). Assisted partial weight bearing was encouraged immediately after surgery and took place in all the cases after an average of 4 days (1 to 15 days). Physiotherapy and rehabilitation programs were tailored according to the initial fracture type, comorbidity, and the severity of any associated injuries. It included active and passive exercises under the supervision of a consultant of physiotherapy. Radiographic evaluation of the studied cases included standard AP and lateral views on admission, and CT scan for better understanding and evaluation of the geometry of the fracture for all the included cases. The maximum amount of articular surface displacement or joint line depression was measured in millimeters. Immediate postoperative X-rays were done and any residual articular step-offs were measured and recorded. X-rays on monthly basis till solid union was assured every 3 months for a year afterwards, and every 6 months till the final followup visit. At the final follow-up visit, plain X-rays of both knees in standing position were made and the arthrosis, if any, was evaluated and recorded as follows: grade 0, indicating no evidence of arthrosis; grade 1, small spurs with no joint space narrowing; grade 2, osteophytes with some joint space narrowing; and grade 3, complete loss

Fig. 1 a Preoperative AP and lat views of a closed bicondylar tibial plateau fracture, Schatzker type VI, of the left side of a 36-year-old male submitted to a high-energy trauma. b Failed trial of closed reduction under C-arm imaging, followed by mini-open reduction for anatomic reduction of the articular surface and minimal internal fixation. c Immediate postoperative AP and lat views showing minimal internal

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of the joint space [24]. The follow-up period ranged from 3 to 16 years with a mean of 10.5 years. Clinical evaluation At the final follow-up visit, the patient was examined thoroughly, and the range of knee flexion was recorded. The knee joint was examined for any swelling, signs of inflammation or infection, pain, instability in all movements, limb length discrepancy, and was compared to the healthy side. Finally, all the patients were asked to complete the short form-36 (SF-36), and the Iowa knee score questionnaires, to access the effect of the fracture on the daily life activities of the patient and his or her satisfaction with the technique, with special emphasis on the knee function [25, 26]. Statistical analysis To examine the relationships between risk factors and outcome variables, the Kendall rank correlation was used to adjust for tied ranks resulting from identical values. The level of significance was set at p<0.05. This means that the probability that the Wilcoxon signed-rank or the Kendall rank correlation coefficient equals zero (the null hypothesis) is <0.05. To account for the multiple variables, a multivariate adjustment was tested with use of the Cochran–Mantel– Haenszel statistics. Again, significance was set at p<0.05.

fixation and an Ilizarov external fixator. d Clinical presentation of the patient during the follow-up period, while weight bearing was allowed. e AP and lat views after frame removal showing complete fracture healing and grade 0 arthrosis. f Clinical photo showing knee flexion immediately after frame removal only 6 months from the fracture incidence. g Clinical photo after frame removal

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Results Healing of the fracture occurred in all the studied cases after an average of 17 weeks (13–21 weeks). Nonunion was not recorded in this study, and none of the patients needed any secondary procedure to enhance union, such as bone grafting or pulsed electromagnetic field stimulation. The Final follow-up examination reveled that the range of knee extension was from −10° to 15°, with an average of 5° of knee extension. The knee flexion range was from 90° to 155°, with an average of 125°. The average knee arc of motion was 88 % compared to the normal side (between 55 to 100 %). The knee function and arthrosis was always compared to the healthy side. Mild knee effusion was found in 11 patients (20 %), with no evidence of meniscal injury or instability. Varus stress test was positive (GII, 5–10 mm) in five patients on examination, with no complaint of instability. Limb length discrepancy was not recorded in this study. Pain on walking was recorded in five patients (9 %), with an antalgic gait, especially after long distances; those five patients were treated conservatively, using mild analgesics on need basis, and physiotherapy, and none of them underwent any secondary surgical procedure during the follow-up period. Nine of the studied cases (16.3 %) used walking aids; four due to pain, two were obese females and used it for stability and fear of falling down, while another two patients had had recent trauma and fractures of the contralateral side at the time of the last follow-up, and the final patient used it for better stability as he suffered from bilateral osteoarthritis not related to the fracture. All the other patients walked freely. All the studied patients were back to their same original jobs at the final follow-up visit. There were minor complications encountered in this study including pin tract infection in 23 patients (41.8 %), and was attributed to the long duration in the frame as well as poor patient compliance. They were all of grades I and II and were treated properly without affecting the final outcome of the patient. Pin breakage took place in three patients (5.4 %), after another traumatic incident during walking, and they were removed and replaced. Mild depression took place in another two female patients (5.4 %), due to the long duration in the frame, and was treated by a specialized psychoanalyst, and the treatment plan was continued without the need for frame removal. After a mean of 10.5 years of follow-up, 28 patients rated their outcome as excellent; 17, as good; and 10, as fair. The average Iowa knee score at the final follow-up visit was 94 points (ranged between 65 and 100 points). The SF-36 scores for the 55 patients were individually compared with agematched norms derived from a normative database [25]. The totals for the individual patients were averaged and compared with the age-matched normative value for each of the eight subscales (physical function, physical role, bodily pain, general health, vitality, social function, emotional rule, and mental health). The average score for physical

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function was lower than the age-matched normative value, and this was found to be significant (p=0.001). Radiographic results The initial X-rays of 45 patients, showed intra-articular surface displacement with an average of 9 mm (2 to 32 mm). Accurate measurement was not possible in ten patients due to the bad quality of the preoperative X-rays. This was significantly reduced to an average of 3 mm (1 to 6 mm) in the immediate postoperative X-rays. Correlation between the initial intra-articular fragment displacement and the final degree of arthrosis was found to be significant (p value=0.011). Also, the initial displacement and the residual displacement were significantly correlated to each other (r=0.74)

Discussion The treatment goals of high-energy bicondylar tibial plateau fractures include the satisfactory restoration of mechanical alignment, anatomic reduction of the articular surface, and stable fixation that allows an early range of motion of the knee. However, achieving these goals may not be directly correlated with improved patient outcomes. Specifically, several reports have suggested that residual articular incongruity of the tibial plateau does not compromise long-term functional outcomes [27]. In addition, open reduction and internal fixation, particularly through the compromised soft tissue envelope, has been notably associated with major wound complications, and more unplanned repeated surgical interventions and their severity [28]. Although dual plating is biomechanically proven to be the best stabilization option, skin necrosis and deep wound infection occurred at a high rate with open reduction and trials of internal fixation due to the severe soft tissue damage dissipated through the soft tissues from the original trauma as well as the dissection and the open reduction maneuvers used to reduce these types of fractures [29]. Young and Barrack reported infection in seven of eight patients with bicondylar tibial plateau fractures treated with medial and lateral buttress plates through an anterior incision, with two patients requiring amputation [29]. In studies of bicondylar fractures treated similarly, Moore et al. reported deep infection or dehiscence in eight of 11 patients and Mallik et al. found infection complications in four of five such injuries [28, 30]. Therefore, alternative methods of treatment for these serious injuries have always, therefore, been looked for. Management of these fractures using external fixation with and without minimal internal fixation by plates or screws were found in the literature. Schatzker types V and VI fractures usually have significant soft tissue injuries; therefore, definitive treatment with an external fixator may be appropriate. Limited articular reconstruction, followed by neutralization with an external fixator can provide excellent results [31].

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Unfortunately, most of the studies included several fracture types and a mixture of low-energy as well as high-energy fractures. It is difficult to compare the results of management of tibial plateau fractures between different centers because, the inclusion criteria vary significantly, some of the studies included only closed fractures, some included only low-energy fractures, others included only a certain age limit. Moreover, several modalities of management were proposed even in the same article including conservative, minimal internal fixation, double plating, external fixation, and combinations of different modalities. Furthermore, most of the reported studies have short-term follow-up period, and were only concerned with fracture healing, and only few reports reported the knee function and patient satisfaction with this type of management [32]. In this study, 55 out of 67 patients completed the study and were followed for a mean of 10.5 years to evaluate knee function as well as patient satisfaction after this type of treatment. Although only closed Schazker types V and VI fractures were included in this study, favorable (excellent or good) results took place in 45 (81.8 %) of the patients. This was of particular importance since only high-energy comminuted bicondylar tibial plateau fractures were studied. In addition, the average Iowa knee score at the final follow-up visit was 94 points (ranged between 65 and 100 points), and the average knee arc of motion was 88 % compared to the normal side (between 55 and 100 %) at the final follow-up examination. Based on the results of this study, anatomic reduction of the articular surface to less than 2 mm displacement is of critical importance to achieve a better knee function, and eventually a favorable clinical end results. This was obtained by closed indirect methods in 38 cases (69 %). On the other hand, limited open reduction was performed in 17 cases (31 %). Early ambulation and a skillful physiotherapy and rehabilitation programs would attain better knee functions in these severely injured patients. Although this study included only high-energy tibial plateau fractures (Schatzker types IV and V) only, this procedure provided comparable favorable outcomes to similar studies with mixed types of patients. This minimal internal fixation augmented with Ilizarov external fixation was of utmost importance and was found very useful in cases with skin problems such as contusions, bullae, and bruises. In such patients, internal fixation and osteosynthesis is considered risky, with notable high risk of major complications. Better knee function for patients prone to these types of complex fractures and severe soft tissue injuries could be assured by early surgical intervention, proper restoration and anatomic reduction of the articular surface, minimizing additional soft tissue trauma or dissection, early knee mobilization, and a specialized physiotherapy program. It was concluded that minimal internal fixation after initial closed or mini-open reduction, augmented by an Ilizarov external fixation, could be considered as an adequate alternative for management of

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severely displaced high-energy bicondylar tibial plateau fractures.

References 1. Marmor L (1979) The Marmor modular knee in traumatic arthritis. Orthop Rev 8:35–44 2. Roffi RP, Merritt PO (1990) Total knee replacement after fractures about the knee. Orthop Rev 19:614–620 3. Stark E, Stucken C, Trainer G, Tornetta P 3rd (2009) Compartment syndrome in Schatzker type VI plateau fractures and medial condylar fracture-dislocations treated with temporary external fixation. J Orthop Trauma 23(7):502–506 4. Chan YS (2011) Arthroscopy-assisted surgery for tibial plateau fractures. Chang Gung Med J 34(3):239–247, Review 5. Civinini R, Carulli C, Matassi F, Villano M, Innocenti M (2009) Total knee arthroplasty after complex tibial plateau fractures. Chir Organi Mov 93(3):143–147 6. Ballard BL, Antonacci JM, Temple-Wong MM, Hui AY, Schumacher BL, Bugbee WD, Schwartz AK, Girard PJ, Sah RL (2012) Effect of tibial plateau fracture on lubrication function and composition of synovial fluid. J Bone Joint Surg Am 94(10):e641–e649 7. Vermeire J, Scheerlinck T (2010) Early primary total knee replacement for complex proximal tibia fractures in elderly and osteoarthritic patients. Acta Orthop Belg 76(6):785–793 8. Larson AN, Hanssen AD, Cass JR (2009) Does prior infection alter the outcome of TKR after tibial plateau fracture? Clin Orthop Relat Res 467(7):1793–1799 9. Zhang Y, Fan DG, Ma BA, Sun SG (2012) Treatment of complicated tibial plateau fractures with dual plating via a 2-incision technique. Orthopedics 35(3):e359–e364 10. Weaver MJ, Harris MB, Strom AC, Smith RM, Lhowe D, Zurakowski D, Vrahas MS (2012) Fracture pattern and fixation type related to loss of reduction in bicondylar tibial plateau fractures. Injury 43(6):864–869 11. Nikolaou VS, Tan HB, Haidukewych G, Kanakaris N, Giannoudis PV (2011) Proximal tibial fractures: early experience using polyaxial locking-plate technology. Int Orthop 35(8):1215–1221 12. Yoo BJ, Beingessner DM, Barei DP (2010) Stabilization of the posteromedial fragment in bicondylar tibial plateau fractures: a mechanical comparison of locking and nonlocking single and dual plating methods. J Trauma 69(1):148–155 13. Babis GC, Evangelopoulos DS, Kontovazenitis P, Nikolopoulos K, Soucacos PN (2011) High energy tibial plateau fractures treated with hybrid external fixation. J Orthop Surg Res 6:35 14. Thomas C, Athanasiov A, Wullschleger M, Schuetz M (2009) Current concepts in tibial plateau fractures. Acta Chir Orthop Traumatol Cech 76(5):363–373, Review 15. Krupp RJ, Malkani AL, Roberts CS, Seligson D, Crawford CH 3rd, Smith L (2009) Treatment of bicondylar tibial plateau fractures using locked plating versus external fixation. Orthopedics 32(8) 16. Galla M, Riemer C, Lobenhoffer P (2009) Direct posterior approach for treatment of posteromedial tibial head fractures. Oper Orthop Traumatol 21(1):51–64, German 17. DeCoster TA, Willis MC, Marsh JL, Williams TM, Nepola JV, Dirschl DR, Hurwitz SR (1999) Rank order analysis of tibial plafond fractures: does injury or reduction predict outcome? Foot Ankle Int 20:44–49 18. Williams TM, Nepola JV, DeCoster TA, Hurwitz SR, Dirschl DR, Marsh JL (2004) Factors affecting outcome in tibial plafond fractures. Clin Orthop Relat Res 423:93–98

114 19. Rademakers MV, Kerkhoffs GM, Sierevelt IN, Raaymakers EL, Marti RK (2007) Operative treatment of 109 tibial plateau fractures: five to 27 year follow-up results. J Orthop Trauma 21(1):5–10 20. DeCoster TA, Nepola JV (1988) el-Khoury GY.: Cast brace treatment of proximal tibial fractures. A ten-year follow-up study. Clin Orthop Relat Res 231:196–204 21. Schatzker J, McBroom R, Bruce D (1979) The tibial plateau fracture. The Toronto experience 1968–1975. Clin Orthop 138:94–104 22. Markhardt BK, Gross JM, Monu JU (2009) Schatzker classification of tibial plateau fractures: use of CT and MR imaging improves assessment. Radiographics 29(2):585–597, Review 23. Muller ME, Nazarian S, Koch P, Schatzker J (1990) The comprehensive classification of fractures of long bones. Springer, New York 24. Oestern HJ, Tscherne H (1984) Pathophysiology and classification of soft tissue injuries associated with fractures. In: Tscherne H, Gotzen L (eds) Fracture with soft tissue injuries. Springer, New York, p 6 25. Marsh JL, Smith ST, Do TT (1995) External fixation and limited internal fixation for complex fractures of the tibial plateau. J Bone Joint Surg Am 77:661–673

Eur Orthop Traumatol (2014) 5:109–114 26. Ware JE Jr, Snow KK, Kosinksi M, Gandek B (1993) SF-36 health survey. Manual and interpretation guide. The Health Institute, New England Medical Center, Boston, pp 10.6–10.7 27. Jensen DB, Rude C, Duus B, Bjerg-Nielsen A (1990) Tibial plateau fractures. A comparison of conservative and surgical treatment. J Bone Joint Surg Br 72:49–52 28. Mallik AR, Covall DJ, Whitelaw GP (1992) Internal versus external fixation of bicondylar tibial plateau fractures. Orthop Rev 21:1433–1436 29. Young MJ, Barrack RL (1994) Complications of internal fixation of tibial plateau fractures. Orthop Rev 23:149 30. Moore TM, Patzakis MJ, Harvey JP (1987) Tibial plateau fractures: definition, demographics, treatment rationale, and long-term results of closed traction management or operative reduction. J Orthop Trauma 1:97–119 31. Ali AM, Burton M, Hashmi M, Saleh M (2003) Treatment of displaced bicondylar tibial plateau fractures (OTA- C2&3) in patients older than 60 years of age. J Orthop Trauma 17:346–352 32. ElBarbary H, Abdel Ghani H, Misbah H, Salem K (2005) Complex tibial plateau fractures treated with Ilizarov external fixator with or without minimal internal fixation. Int Orthop 29(3):182–185