Journal of Orthopaedic Surgery 2012;20(1):37-41
Closed reduction and percutaneous screw
fixation for tibial plateau fractures
Radheshyam Sament,1 JC Mayanger,1 Sujit Kumar Tripathy,2 Ramesh Kumar Sen2
Department of Orthopaedics and Rehabilitation, JLN Medical College, Ajmer, India
Department of Orthopedics, Postgraduate Institute of Medical education and Research, Chandigarh, India
1
2
ABSTRACT
Purpose. To evaluate treatment outcomes of closed
reduction and percutaneous screw fixation for tibial
plateau fractures.
Methods. 48 men and 8 women aged 19 to 61
(mean, 36) years underwent closed reduction and
percutaneous screw fixation for closed tibial plateau
fractures with <5 mm depression. According to the
Schatzker classification, patients were classified
into type I (n=9), type II (n=22), type IV (n=5), and
type V (n=20). Closed reduction was achieved using
manual ligamentotaxis with traction in extension
under image intensifier control. Reduction was fixed
percutaneously with cancellous screws (6.5 mm) and
washers. Functional outcome (pain, walking capacity,
extension lag, range of motion, and stability) was
evaluated using the Rasmussen score. A total score of
28 to 36 was considered as excellent, 20 to 27 as good,
10 to 20 as fair, and <10 as poor.
Results. Patients were followed up for a mean of
2.8 (range, 1–4) years. The mean length of hospital
stay was 5 (range, 2–15) days. All the fracture united
radiographically after a mean of 3 (range, 2.5–4.2)
months. Respectively in Schatzker types-I, -II, -IV, and
-V fractures, outcomes were excellent in 6, 10, 2, and
2 patients, good in 2, 9, 3, and 14 patients, fair in 1, 3,
0, and 2 patients, and poor in 0, 0, 0, and 2 patients.
Outcome was satisfactory (good-to-excellent) in 89%,
86%, 100%, and 80% of the respective fracture types
of patients. The mean Rasmussen score was 25.7
for all patients; it was 27.7 for type I, 26.3 for type
II, 28.6 for type IV, and 23.4 for type V fractures. The
mean Rasmussen score was significantly lower in
12 patients with ligament injury than in 44 patients
without ligament injury (19.8 vs. 27.3, p<0.001). No
patient had any complication (infection, wound
dehiscence or hardware problem).
Conclusion. Closed reduction and percutaneous
screw fixation for tibial plateau fractures is
minimally invasive. It reduces the length of hospital
stay and costs, enables early mobilisation with
minimal instrumentation, and achieves satisfactory
outcomes.
Key words: bone screws; fracture fixation; tibial
fractures
Address correspondence and reprint requests to: Dr Sujit Kumar Tripathy, Department of Orthopaedics, Friarage Hospital,
Northallerton, North Yorkshire, DL6 1JG, UK. E-mail: [email protected]
R Sament et al.
Journal of Orthopaedic Surgery
INTRODUCTION
underwent closed reduction and percutaneous screw
fixation for closed tibial plateau fractures with <5
mm depression. 32 of them involved the right side.
The causes of injury included high-velocity road
traffic accident (n=25), motorcycle skid (n=18), direct
hit by car on the lateral side of the knee (n=7), and
fall from a height (n=6). According to the Schatzker
classification, patients were classified into type I
(lateral fracture) [n=9], type II (lateral fracture with
depression) [n=22, Fig.], type IV (any medial fracture)
[n=5], and type V (bicondylar fracture) [n=20, Fig.].
14 of the type-V fractures were caused by highvelocity road traffic accidents, whereas 9 and 7 of the
type-II fractures were caused by motorcycle skids
and direct hits by a car on the lateral side of the knee,
respectively. Associated injuries included fractures
of the fibula (n=11), tibial spine (n=5), patella (n=2),
tibial shaft (n=5), femoral shaft (n=4), forearm bones
(n=1), and head injury (n=4). Patients with type III
(lateral depression), type VI (fracture extending to
the metaphysis), severe comminution with >5 mm
depression, compartment syndrome, or vascular
injury were excluded. This study was approved
by the ethics committee of our hospital. Informed
consent was obtained from each patient.
Appropriate emergency treatment was given for
associated head, chest, and/or abdominal injuries
after haemodynamic stabilisation. Anteroposterior
and lateral radiographs of the knee joint were
obtained. Computed tomography was not performed
38
The lateral side of the knee joint is most commonly
injured during road traffic accidents, which results in
torn ligaments, sprains, and fractures of one or both
condyles.1 Tibial plateau fractures are intra-articular
fractures caused by high-velocity trauma. They
are usually associated with neurovascular injury,
compartment syndrome, compounding of fractures,
and crushing of soft tissues. Associated injuries at
and around the knee joint are more common and
severe in patients with fracture-dislocation.1,2
The treatment outcomes for tibial plateau
fractures are inconsistent.1–3 Closed reduction (based
on ligamentotaxis principles) and internal fixation
(with percutaneous cancellous screws and washers)
avoids the disadvantages of both operative and
conservative treatments. However, it is not suitable
for all types of tibial plateau fractures, particularly
grossly comminuted and depressed fractures,
Schatzker type-VI fractures, and open fractures.4,5 We
evaluated treatment outcomes of closed reduction
and percutaneous screw fixation for tibial plateau
fractures.
MATERIALS AND METHODS
Between September 2006 and September 2008, 48
men and 8 women aged 19 to 61 (mean, 36) years
(a)
(b)
Figure
Schatzker (a) type-II and (b) type-V tibial plateau fractures fixed with percutaneous cannulated cancellous screws.
Vol. 20 No. 1, April 2012
Closed reduction and percutaneous screw fixation for tibial plateau fractures
unless there was articular depression. Lower tibial
pin traction was applied and the limb was rested
over a Bohler-Braun splint. Patient characteristics,
injury mechanism, injury pattern (based on Schatzker
classification), distal neurovascular status, and
associated injuries were recorded using a predesigned
proforma.
Patients were operated on as soon as they were
medically fit. Surgery was delayed for 7 to 12 days in
4 patients with blisters or persistent tense swelling.
Excluding these 4 patients, the mean delay in surgery
was 2 (range, 1–5) days. A preoperative template
was prepared using traction radiographs. Closed
reduction was achieved using manual ligamentotaxis
with traction in extension under image intensifier
control. A femoral distractor was used in 12 patients
with comminution. Both sides of the proximal tibia
were thumped to dislodge the depressed articular
fragment. Reduction was held temporarily with
one- or 2-pointed reduction forceps, and then fixed
percutaneously with cancellous screws (6.5 mm) and
washers. The direction and the number of screws
(≥2) used were based on the fracture pattern and
orientation. Articular congruency was checked under
a C-arm in anteroposterior and lateral views. The
limb was then immobilised in a groin-to-ankle slab
(cylinder slab).
The rehabilitation protocol was standard for
all patients. Patients were encouraged to perform
isometric quadriceps exercises, ankle pump, and toe
movements. Analgesia and antibiotics were given.
The slab was removed after 3 weeks, and the knee
joint was examined for tenderness, swelling, and
instability. Gradual knee bending and extension
exercises were advised with non–weight-bearing
crutch walking for further 3 weeks. Partial and full
weight bearing was allowed at week 6 and week 12,
respectively. Patients were followed up at months 6
and 12 and annually thereafter.
At the final follow up, functional outcome (pain,
walking capacity, extension lag, range of motion,
and stability) was evaluated using the Rasmussen
score6 (Table). The maximum score for each item
was 6. A total score of 28 to 36 was considered as
excellent, 20 to 27 as good, 10 to 20 as fair, and 6 to
10 as poor.
Table
Patient distribution according to the Schatzker classification and Rasmussen scoring system
Rasmussen scoring system*
Pain
No pain
Occasional pain, bad weather pain
Throbbing pain in certain position
Constant pain after activity
Pain at rest
Walking capacity
Normal
Can walk outdoor for at least one hour
Can walk outdoor for 15 minutes
Can walk indoor only
Wheelchair bound/bedridden
Extension lag
Normal
0º–10º
>10º
Range of motion
≥140º
≥120º
≥90º
≥60º
≥30º
0º
Stability
Normal in extension & 20º flexion
Instability in 20º flexion
Instability in 10º extension
Instability in >10º extension
Score
39
Schatzker classification for tibial plateau fractures
(no. of patients)
I (n=9)
II (n=22)
IV (n=5)
V (n=20)
6
5
4
2
0
4
4
0
1
0
4
13
2
3
0
2
3
0
0
0
0
12
4
4
0
6
4
2
1
0
7
1
1
0
0
15
5
2
0
0
2
3
0
0
0
4
11
3
2
0
6
4
2
8
1
0
19
3
0
3
2
0
16
2
2
6
5
4
2
1
0
6
2
1
0
0
0
8
11
3
0
0
0
2
3
0
0
0
0
4
13
1
2
0
0
6
5
4
2
8
1
0
0
18
1
1
2
4
1
0
0
14
1
2
3
* Scores of 28 to 36 indicate excellent, 20 to 27 good, 10 to 20 fair, and 6 to 10 poor
40
R Sament et al.
RESULTS
Patients were followed up for a mean of 2.8 (range,
1–4) years. The mean length of hospital stay was
5 (range, 2–15) days. All the fractures united
radiographically after a mean of 3 (range, 2.5–4.2)
months. Respectively in Schatzker types-I, -II, -IV, and
-V fractures, outcomes were excellent in 6, 10, 2, and
2 patients, good in 2, 9, 3, and 14 patients, fair in 1, 3,
0, and 2 patients, and poor in 0, 0, 0, and 2 patients.
Outcome was satisfactory (good-to-excellent) in 89%,
86%, 100%, and 80% of the respective fracture types
of patients (Table). The mean Rasmussen score was
25.7 for all patients; it was 27.7 for type I, 26.3 for type
II, 28.6 for type IV, and 23.4 for type V fractures.
In 11 patients with a fibular head fracture (fixed
with one extra screw), outcome was excellent in 5,
good in 5, and fair in one. Their mean Rasmussen
score was not significantly different from that in
the 45 patients without such a fracture (26.5±3.3 vs.
25.5±4.8, p>0.05, independent sample t test).
In 12 patients with ligament injury, 5 had
anteroposterior instability (caused by tibial spine
injury) and 7 had mediolateral instability (caused by
a collateral ligament tear). Their outcomes were good
in 5 and fair or poor in 7. Their mean Rasmussen score
was significantly lower than that in the 44 patients
without such knee instability (19.8±5.7 vs. 27.3±2.5,
p<0.001, independent sample t test). No patient had
any complication (infection, wound dehiscence, and
hardware problem).
DISCUSSION
Tibial plateau fractures are difficult to treat because
of their intra-articular nature, cancellous bone
involvement, and proximity to a major weight bearing
joint. Open reduction and internal fixation achieve
better outcomes for split and depressed fractures
with >5 mm displacement, bicondylar fractures
with >4 mm displacement, and depressed fractures
of the medial condyle,4,7 whereas traction and
immobilisation achieve excellent-to-good outcomes
in 75%8 to 80%9 of patients before development
of surgical techniques for such fractures. The
limitations of conservative treatment are inadequate
reduction of the articular surface, ineffective limb
alignment control, and prolonged hospitalisation and
recumbency, which causes quadriceps atrophy and
range of movement restriction. Operative treatment
restores articular congruity, axial alignment, and
joint stability, and enables early mobilisation while
decreasing the risk of post-traumatic arthritis.7
Journal of Orthopaedic Surgery
Nonetheless, operative treatment compromises soft
tissues, devascularises bone fragments, and may be
complicated by infection, implant failure, and wound
dehiscence. Thus, it is not indicated for all types of
tibial plateau fractures.
Closed reduction and percutaneous screw fixation
is minimally invasive and thus reduces the length
of hospital stay and costs.5 It is indicated in patients
with a large peripheral fragment (i.e. Schatzker
type-I, -II and -IV fractures). Patients with depressed
fractures of >5 mm (Schatzker type-VI factures) and
severe comminution should be treated with open
reduction and internal fixation (using a screw-plate
construct and bone grafting), as closed reduction is not
feasible. In our study, patients with Schatzker type-V
(bicondylar) fractures were indirectly reduced with
a femoral distractor or manual ligamentotaxis. The
articular condyle was then reduced to the shaft and
fixed with screws. Such patients achieved relatively
poor outcome and should have been treated with open
reduction and internal fixation with plate and screw.
Irrespective of treatment modality, early
mobilisation (no later than 4 weeks) is essential to
prevent knee stiffness.2 Impacted articular fragments
cannot be dislodged by traction or manipulation
alone as there is no soft-tissue attachment.2 In our
study, patients with depressed fractures (type III)
were excluded, as it is difficult to achieve articular
congruency by traction or manipulation. In 27
patients with closed tibial plateau fractures treated
with percutaneous cancellous screws and washers,10
the mean Rasmussen score was 25 (range, 15–30) after
a mean follow up of 35 months; outcome was excellent
in 37%, good in 52%, and unacceptable in 11% of
patients; unacceptable outcomes were likely due to
minimal (rather than rigid) fixation for comminuted
or depressed fractures. In addition, a few patients
had loss of knee range of motion owing to delayed
knee mobilisation.10 In 16 patients with lateral tibial
plateau fractures treated with percutaneous fixation
under fluoroscopic control, 15 achieved good-toexcellent Rasmussen score and one with a lateral split
fracture developed chronic pain in the medial joint
line caused by chondral degeneration.11 Our patients
achieved comparable outcomes.
Femoral distractors have been used to indirectly
reduce the articular surface in patients with tibial
plateau fractures.12,13 The Esmarch bandage has also
been used, even for Schatzker type-III fractures.5 The
fragment was manipulated by gentle hammering
and then fixed with percutaneous screws; outcomes
were excellent in 33%, good in 50%, fair in 13%,
and poor in 3% of patients.5 In our study, manual
ligamentotaxis successfully reduced fractures with
Vol. 20 No. 1, April 2012
Closed reduction and percutaneous screw fixation for tibial plateau fractures
a peripheral fragment, whereas a femoral distractor
successfully reduced fractures with comminution
using an indirect technique. Guarded thumping
on both sides of proximal tibia helped dislodge the
depressed fragment. The depressed fragment can be
elevated using an arthroscopy, which also enables
direct visualisation of the articular congruency.
41
Arthroscopic reduction is superior to closed reduction
and broadens the indications of minimally invasive
percutaneous fixation. Nonetheless, it needs expertise
and infrastructure. Percutaneous cancellous screw
fixation with arthroscopic elevation of the depressed
articular fragment is a favourable treatment modality
for tibial plateau fractures.14
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