Orthopedics

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Trauma Update 

Treatment of Bicondylar Tibial Plateau Fractures With Lateral Locking Plates

Richard L. Uhl, MD; Jonathon Gainor, MD; Joel Horning, MD

Abstract

Bicondylar tibial plateau fractures present the orthopedic surgeon with several challenges. The need for restoration of the articular surface with open reduction internal fixation (ORIF) is well established. Equally, or perhaps more important, is prevention of breakdown of the soft tissues and postoperative infection following ORIF. Application of large medial and lateral plates commonly resulted in postoperative infection.

In an effort to reduce further damage to the soft tissues, a number of techniques and new implants have been developed. One promising technique involves the use of a single plate with locking screws, applied through a smaller lateral incision. Some biomechanical studies support the ability of such a plate to resist collapse of the medial column, while other biomechanical studies and clinical experience are less optimistic.

Careful evaluation of the fracture pattern and an understanding of what the implant can and cannot do, combined with protected postoperative weight bearing, may lead to better results in patients with these challenging injuries.

Fractures of the tibial plateau usually occur following an axial load from the femoral condyles onto the tibia with either a valgus or varus moment and the knee in full extension.1,2 The fracture pattern is dependent on the magnitude and location of force applied on the tibial plateau.2 Low-energy loads usually result in injury to the lateral plateau whereas the higher-energy axial loads often involve the medial plateau or a combination of both medial and lateral fractures.

Injuries involving both plateaus are usually accompanied by significant soft tissue injury, often resulting in severe swelling, blistering, and occasional full thickness tissue loss.3

Nondisplaced, stable fractures are treated nonoperatively. Cast immobilization, followed by early motion using a brace to protect the axial alignment leads to acceptable results in the majority of cases.4 Some studies show that restoration of the joint surface is paramount,5 while other studies found that articular surface disruption is less important in determining final outcome than the initial joint stability and alignment of the fracture during healing.6,7

Most bicondylar fractures require operative stabilization, as they are not usually stable or well-aligned, unless due to a low-energy trauma with minimally displaced fragments.8 Historically, displaced bicondylar fractures were treated with separate lateral and medial plates. A single, midline incision provided a convenient approach to dual plating of these fractures. However, the amount of soft tissue dissection needed to adequately expose the fracture through this approach devitalizes comminuted bone fragments and has been shown to have a high complication rate. Deep infection rate has been reported to be 73% to 80%.9,10

This has caused many surgeons to seek alternative treatment methods such as spanning external fixation or hybrid external fixation to minimize the injuries to the soft tissue while still stabilizing the fracture. The incidence of infection with external fixation is less.11

Barei et al12 described the benefits using two incisions for dual plating. They reported fewer complications and found that fracture reduction was facilitated by direct visualization through a posteromedial approach. The infection rate was lower at 8.4%, and they were able to effectively treat the infections with medical and/or surgical methods. One possible confounding variable to this study was the use of external fixation for initial stabilization of these fractures. The conclusion of this study was that temporary spanning external fixation, followed by (or in concert with) two-incision dual plating minimizes the soft tissue dissection which leads to a lower wound complication rate and less infection. This study, and others, has shown the benefit of a second posteromedial incision to directly visualize and buttress the medial tibial condyle, while at the same time preserving the soft tissue envelope.12,13

The advent of…

Bicondylar tibial plateau fractures usually include damage to the soft tissue, and efforts to fix both the lateral and medial columns with plates can result in tissue loss and infection.

Bicondylar tibial plateau fractures present the orthopedic surgeon with several challenges. The need for restoration of the articular surface with open reduction internal fixation (ORIF) is well established. Equally, or perhaps more important, is prevention of breakdown of the soft tissues and postoperative infection following ORIF. Application of large medial and lateral plates commonly resulted in postoperative infection.

In an effort to reduce further damage to the soft tissues, a number of techniques and new implants have been developed. One promising technique involves the use of a single plate with locking screws, applied through a smaller lateral incision. Some biomechanical studies support the ability of such a plate to resist collapse of the medial column, while other biomechanical studies and clinical experience are less optimistic.

Careful evaluation of the fracture pattern and an understanding of what the implant can and cannot do, combined with protected postoperative weight bearing, may lead to better results in patients with these challenging injuries.

Mechanism of Injury

Fractures of the tibial plateau usually occur following an axial load from the femoral condyles onto the tibia with either a valgus or varus moment and the knee in full extension.1,2 The fracture pattern is dependent on the magnitude and location of force applied on the tibial plateau.2 Low-energy loads usually result in injury to the lateral plateau whereas the higher-energy axial loads often involve the medial plateau or a combination of both medial and lateral fractures.

Injuries involving both plateaus are usually accompanied by significant soft tissue injury, often resulting in severe swelling, blistering, and occasional full thickness tissue loss.3

Treatment Options

Nondisplaced, stable fractures are treated nonoperatively. Cast immobilization, followed by early motion using a brace to protect the axial alignment leads to acceptable results in the majority of cases.4 Some studies show that restoration of the joint surface is paramount,5 while other studies found that articular surface disruption is less important in determining final outcome than the initial joint stability and alignment of the fracture during healing.6,7

Figure 1A: AP radiograph showing a bicondylar tibial plateau fracture with reasonable alignment of the medial fragment prior to ORIF Figure 1B: Lateral radiograph showing a bicondylar tibial plateau fracture with reasonable alignment of the medial fragment prior to ORIFFigure 2A: Coronal CT reconstruction demonstrating alignment of the medial spike and the establishment of a buttress to help resist varus bendingFigure 2B: Sagittal CT reconstruction demonstrating alignment of the medial spike and the establishment of a buttress to help resist varus bending
Figure 1: Case 1. AP (A) and lateral (B) radiographs showing a bicondylar tibial plateau fracture with reasonable alignment of the medial fragment prior to ORIF. Figure 2: Case 1. Coronal (A) and sagittal (B) CT reconstructions demonstrating alignment of the medial spike and the establishment of a buttress to help resist varus bending.

Most bicondylar fractures require operative stabilization, as they are not usually stable or well-aligned, unless due to a low-energy trauma with minimally displaced fragments.8 Historically, displaced bicondylar fractures were treated with separate lateral and medial plates. A single, midline incision provided a convenient approach to dual plating of these fractures. However, the amount of soft tissue dissection needed to adequately expose the fracture through this approach devitalizes comminuted bone fragments and has been shown to have a high complication rate. Deep infection rate has been reported to be 73% to 80%.9,10

This has caused many surgeons to seek alternative treatment methods such as spanning external fixation or hybrid external fixation to minimize the injuries to the soft tissue while still stabilizing the fracture. The incidence of infection with external fixation is less.11

Barei et al12 described the benefits using two incisions for dual plating. They reported fewer complications and found that fracture reduction was facilitated by direct visualization through a posteromedial approach. The infection rate was lower at 8.4%, and they were able to effectively treat the infections with medical and/or surgical methods. One possible confounding variable to this study was the use of external fixation for initial stabilization of these fractures. The conclusion of this study was that temporary spanning external fixation, followed by (or in concert with) two-incision dual plating minimizes the soft tissue dissection which leads to a lower wound complication rate and less infection. This study, and others, has shown the benefit of a second posteromedial incision to directly visualize and buttress the medial tibial condyle, while at the same time preserving the soft tissue envelope.12,13

The advent of locking plate technology offered further hope of preserving soft tissues by using one implant applied through a single, lateral incision. Locking plates form a fixed angle device which should, at least theoretically, act as a cantilever to prevent the collapse of the medial condyle which occurs when nonlocking screws move in relation to the side plate.

Numerous biomechanical studies have shown increased resistance to bending when a single plate with locking screws is used to fix a bicondylar fracture compared to a single plate with conventional screws.14-16 However, the addition of a medial plate further improves the stability of the construct.17-19

The real clinical question is whether the increased resistance to cantilever bending afforded by a locked versus convention plate is sufficient to prevent medial collapse outside of the biomechanics laboratory. Initially this was felt to be the case, but reports have surfaced that although better than plates with conventional screws, a fracture treated with a single, lateral, locked plate is still susceptible to collapse into varus over time.20,21

Figure 3A: AP radiograph showing the competed ORIF using a lateral plate without medial fixation Figure 3B: Lateral radiograph showing the competed ORIF using a lateral plate without medial fixationFigure 4A: AP radiograph showing a bicondylar tibial plateau fracture with loss of the medial buttress, as indicated by the displaced spike seen on the lateral viewFigure 4B: lateral radiograph showing a bicondylar tibial plateau fracture with loss of the medial buttress, as indicated by the displaced spike seen on the lateral view
Figure 3: Case 1. AP (A) and lateral (B) radiographs showing the competed ORIF using a lateral plate without medial fixation. The intact medial buttress was sufficient to resist the varus bending moments. The patient remained nonweight bearing for 10 weeks. Figure 4: Case 2. AP (A) and lateral (B) radiographs showing a bicondylar tibial plateau fracture with loss of the medial buttress, as indicated by the displaced spike seen on the lateral view.

Suggested Treatment Protocol

Based on the above reports and our clinical experience, we offer the following treatment protocol for fixation of bicondylar tibial plateau fractures:

Protect the soft tissues. If there is significant bruising, swelling, or blistering of the soft tissue envelope, a spanning external fixator to align and distract the fragments is applied and left in place until the swelling subsides and the blisters heal. Prevention of further damage to the soft tissues is the most import initial consideration in these fractures.

Assess the medial fracture for stability against varus collapse. If reduction of the lateral fracture leads to a stable reduction of the medial side as seen on the lateral radiograph, then lateral locked plating alone may be sufficient.

Reduce the medial buttress with a second, posterior medial approach. If the medial buttress can not be established by reduction of the lateral fracture, then open reduction of the medial side is necessary.

Buttress the medial fragment, if needed. Apply a small medial buttress plate to support the medial fragment or leave the external fixator in place to neutralize the varus forces.

Figure 5: Intraoperative fluoroscopy view showing reduction of the medial spike with the lateral fixation in place
Figure 5: Case 2. Intraoperative fluoroscopy view showing reduction of the medial spike with the lateral fixation in place.
Figure 6A: AP radiograph showing collapse
Figure 6B: Lateral radiograph showing collapse
Figure 6: Case 2. AP (A) and lateral (B) radiographs showing collapse into varus (A) and some loss of medial buttress reduction (B). The patient had full, painless range of motion once the fracture healed.

Case Reports

Case 1

This patient had a bicondylar fracture in which the buttress of the medial fragment fracture line is stable when reduced to the shaft. The fracture was adequately stabilized with a lateral locking plate (LISS, Synthes, Paoli, Pennsylvania). The patient remained strictly nonweight bearing for 10 weeks postoperatively (Figures 1-3).

Case 2

Although the medial condyle fragment was initially reduced during surgery, the oblique nature of the fracture line allowed some loss of reduction and medial collapse postoperatively. The patient had bilateral lower extremity injuries and was to be nonweight bearing on both for 10 weeks (Figures 4-6).

Case 3

This patient has a displaced bicondylar fracture with displacement of the medial fragment. The oblique medial fracture line was reduced and buttressed with a small anti-glide plate to prevent loss of reduction (Figures 7, 8).

Figure 7A: Coronal CT reconstruction of a comminuted bicondylar tibial plateau fracture
Figure 7B: Sagittal CT reconstruction of a comminuted bicondylar tibial plateau fracture
Figure 7: Case 3. Coronal (A) and sagittal (B) CT reconstructions of a comminuted bicondylar tibial plateau fracture with loss of the medial buttress.

Discussion

Studies done before locking plates became popular demonstrated that dual plating offered more secure fixation of bicondylar tibial plateau fractures. The surgical dissection required was often not kind to the injured soft tissues, and significant complications were common. The introduction of locking plate technology seemed to offer a new option to preserve the soft tissue in high energy tibial plateau fractures.

Early studies, which looked at locked lateral plating versus conventional dual plate techniques, showed no difference between the two constructs. However, some subsequent biomechanical studies and clinic experience questioned the stability of a single lateral plate as the solution for all bicondylar tibial plateau fractures.

Figure 8A: Radiograph showing reestablishment of the medial buttress using a small anti-glide plate applied through a second posterior medial approach
Figure 8B: Radiograph showing reestablishment of the medial buttress using a small anti-glide plate applied through a second posterior medial approach
Figure 8: Case 3. AP (A) and lateral (B) radiographs showing reestablishment of the medial buttress using a small anti-glide plate applied through a second posterior medial approach.

The results of these studies demonstrate subsidence of the medial condyle with cyclic loading. This subsidence was reduced by using a second, posteromedial plate to buttress the medial fragment.

Cyclic loading of bicondylar tibial plateau fractures also shows that neither lateral locking alone nor dual-plate treatment facilitated early return to weight bearing. Therefore, some have suggested that prolonged nonweight bearing in the postoperative period may help prevent the subsidence.

Conclusion

Bicondylar tibial plateau fractures require restoration of both the lateral and medial columns of the tibia. In select cases, this can be accomplished by using a single, lateral, locking plate. In most cases, however, would benefit from a small posterior medial plate to buttress the medial column.

References

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Authors

Drs Uhl, Gainor, and Horning are from the Division of Orthopaedic Surgery, Albany Medical College, Albany, New York.

Drs Uhl, Gainor, and Horning have no relevant financial relationships to disclose. The Orthopedic Residency of Albany Medical College receives educational support from Synthes, USA (Paoli, Pennsylvania).

Correspondence should be addressed to: Richard L. Uhl, MD, Division of Orthopedic Surgery, 1367 Washington Ave, Ste 200, Albany, NY 12206.

10.3928/01477447-20080501-30

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