2002 - University of Washington Bone and Joint Sources

Complications Associated With Internal Fixation of
Comminuted, Bicondylar Tibial Plateau Fractures
DAVID P. BAREI, M.D., F.R.C.S.(C), SEAN E. NORK, M.D., WILLIAM J. MILLS, M.D.,
STEPHEN K. BENIRSCHKE, M.D., AND M. BRADFORD HENLEY, M.D., M.B.A.
Complex bicondylar tibial
plateau fractures are highenergy
injuries that often occur
in polytraumatized patients. Articular
depression, sagittal and coronal plane
condylar separation, and detachment of
the metaphysis from the diaphysis are
defining fracture characteristics.
Marked swelling, abrasions,
compartmental syndrome, and open
wounds commonly occur. Treatment
goals include accurate articular
reconstruction, restoration of knee
stability, reestablishment of condylar
width, maintenance of the normal
mechanical axis, and stable fixation.
Treatment techniques include isolated
lateral plating, small wire external
fixation with or without limited
internal fixation, lateral plating
combined with medial external
fixation, and double plating.
Unfortunately, medial and lateral
plating, particularly through a single
anterior incision, has been associated
with high wound complications and
deep sepsis. Double plating through
separate medial and lateral incisions
may minimize anteromedial soft tissue
dissection and decrease significant
wound complications. The purpose of
this study is to report the complications
and infection rate associated with
double plating complex tibial plateau
fractures stabilized through two
incisions.
MATERIALS AND METHODS
Over a 79 month period, all patients
sustaining an intra-articular fracture of
the proximal tibia were collected from
a prospectively designed orthopaedic
database and reviewed retrospectively.
This search identified 308 patients with
319 bicondylar tibial plateau fractures.
Ten fractures were misclassified, leaving
309 fractures eligible for review. One
hundred and seventy-eight fractures
had simple articular involvement (AO/
OTA type 41-C1 and 41-C2) and were
excluded. Thirteen fractures were
treated with primary amputation, five
were treated non-operatively, two were
treated with staged arthroplasty, 13
fractures were excluded for various
reasons, and 8 fractures with
insufficient data for review were also
excluded. The remaining 90 patients
sustained 90 complex tibial plateau
fractures (AO/OTA type 41-C3) and
formed the study group. All 90 patients
were treated with plate fixation through
two operative approaches. The use of
a single midline anterior surgical
approach was abandoned prior to the
study period.
There were 57 male and 33 female
patients with a mean age of 44.03 years
(range, 21 to 88 years). Twelve fractures
were open (13.3%) and classified as
type II (1 patient), type IIIA (8
patients), type IIIB (2 patients), and
type IIIC (1 patient). Compartmental
syndrome was diagnosed and treated
with fasciotomies in 12 patients
(13.3%). Temporary anterior spanning
external fixation was performed in 45
patients (50%) secondary to the
severity of the local soft tissue injury
or associated life-threatening injuries.
The average interval from injury to
definitive surgical treatment was 8.98
days (range, 0 - 40 days).
Technique
Medial column fixation through a
posteromedial approach is typically
performed first. The incision is placed
approximately one centimeter posterior
to the posteromedial edge of the tibial
metaphysis, then parallels the sartorius
and pes tendons proximally.
Subperiosteal dissection is limited to
the fracture edges and anticipated plate
position. Disruption of the soft tissues
on the anteromedial aspect of the tibia
is avoided. The posteromedial plateau
and metaphyseal fracture components
are reduced, provisionally held, and
stabilized with a posteromedial plate.
Lateral column fixation is
performed using a standard
anterolateral approach. A longitudinal
skin incision is made one centimeter
lateral to the tibial crest curving laterally
over Gerdy’s tubercle and extending
proximally in a longitudinal fashion to
the lateral femoral epicondyle. The
iliotibial band is incised in line with the
skin incision and mobilized from
Gerdy’s tubercle. A sub-meniscal
arthrotomy is performed followed by
provisional articular and metadiaphyseal
reconstruction.
Subchondral defects are bone grafted.
Buttress plate fixation of the lateral
column is performed with the proximal
screws strategically placed to support
articular comminution. Supervised
knee motion is started when the
incisions are secure. Patients remain
non-weightbearing for a minimum of
twelve weeks.
RESULTS
Non-Septic Complications
Non-septic complications included
one nonunion at the proximal tibial
meta-diaphysis requiring bone grafting
and revision plating. Thirteen patients,
exclusive of those with infections,
required delayed (greater than six
months from injury) implant removal
for relief of local symptoms. Two of
these patients also underwent resection
of heterotopic ossification to improve
knee motion. Six patients required a
knee manipulation for extension
contracture, and one patient
underwent tendo-Achilles lengthening
for an equinus contracture. Seventeen
patients incurred significant deep
venous thromboses (DVT). No patient
was diagnosed with pulmonary
embolism. There were no deaths.
Septic Complications
Deep wound infections occurred in
seven patients (7.78%), two of which
were associated with septic arthritis.
Two of the seven infections occurred in
patients who sustained open injuries.
One patient declined surgical or
medical management of his infection.
The remaining six patients had clinical
resolution after an average of 4
additional procedures (range 1 to 7
procedures) combined with antibiotic
therapy.
Two patients sustained vascular
injuries and were treated with vascular
reconstruction and prophylactic
fasciotomy. The presence of an open
injury, compartmental syndrome, the
12 2002 ORTHOPAEDIC RESEARCH REPORT