Tibial Platau Fracture

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Anatomy

  • Medial plateau is:
      • Larger than lateral tibial plateau.
      • Concave surface.
      • Stronger – as mechanical axis passes medial to midline and medial plateau carries 60% of load, its subchondral bone is thicker and denser.
      • Medial meniscus is crescenteric in shape and covers a smaller area of the plateau.

 

  • Lateral plateau is:
      • Sits higher (overall 3° varus articular surface).
      • Smaller than medial tibial plateau.
      • Convex surface.
      • Lateral meniscus is semi-circular in shape and covers a greater area of the plateau.

Epidemiology

  1. Lateral plateau – 70%
  2. Medial plateau 15%
  3. Bicondylar 15%

Aetiology

  1. High energy
    • Young males
    • Schatzker I-III
  1. Low energy
    • Schatzker IV-VI

Classification

  • Schatzker classification is a good tool to give an idea about the severity and best way of management. It is of 6 grades:

 

  1. Type I – Split lateral plateau. Common lateral meniscus tear

a fracture of the lateral tibial plateau with a simple vertical split and no commonution

  1. Type II – Split-depression lateral plateau. Older patients following valgus force on axially loaded limb.

a fracture of the lateral tibial plateau with a vertical split and commonution

  1. Type III – Depression lateral plateau. Central depressions are more stable than lateral or posterior.

a fracture of the lateral tibial plateau with depression in the joint surface

  1. Type IV – medial plateau. High energy. Most commonly associated with neurovascular injury. May represent a reduced knee Fracture-dislocation. Ligament injuries common.

a fracture of the medial tibial plateau usually associated with a knee dislocation and neuro-vascular compromise

  1. Type V – Bicondylar. Pure axial load. Generally a small amount of metaphysis remains attached to joint.

a fracture of both medial and lateral tibial plateaus

  1. Type VI – Plateau + metaphyseal-diaphyseal dissociation.

a fracture of both medial and lateral tibial plateaus and tibial metaphysis

Treatment

Conservative measure which includes immobilization in an above knee plaster cast or a brace with no weight bearing is allowed using crutches or a walking frame for a period that can vary from 8 wks to few months till evidence of fracture union is shown on X-Ray. This method of treatment is becoming less favourable by both clinicians and patients due to the prolonged period of immobilisation.

Indications for open reduction and internal fixation (ORIF).

  1. Fracture features

 

  • Joint depression. 
    • Quite well tolerated – better tolerated on the lateral side than the medial side. 
    • Suggested accepted intra-articular steps range from 3mm-1cm.
    • Long-term studies show low rates of OA even with articular step.
    • Indication for ORIF (Millers):
      1. Medial – Any displacement or step
      2. Lateral - > 3mm step or 5mm displacement
  • Alignment
    1. Any varus
    2. > 5° valgus
  • Stability
    • < 10° varus/valgus in extension regardless of fracture pattern.
    • Instability / functional malalignment is much poorer tolerated.
    • This varus or valgus malalignment, or functional instability are probably the true indications for fixation.
  1. Open fracture.
  2. Neuro-Vascular injury.
  3. Compartment syndrome.
  4. Patients who could not cope with plaster of Paris or a Brace for the period of conservative treatment which could vary from 8 wks to few months duration of non weight bearing.

 

Techniques (traditional):

  • Combinations of:
    • Compression screws
    • Plates
      • Buttress plates
      • Locking plates
    • Ex-fix
      • Any wire should be at least 15mm from joint surface
  • Modern techniques minimise soft-tissue dissection
  • May utilise:
    • Indirect reductions – femoral distractors across the knee
    • Arthroscopic assistance
    • ‘Joysticks’
  • Post fixation asses for ligamentous injury –any Posterolateral corner injury should be addressed acutely, all other can wait

Incisions

  1. Extensile midline incision
  • Traditional approach
  • Easy salvage to TKR
  • Requires extensive soft-tissue dissection with associated wound complications
  1. Y-incision – NO

 

  • High rate of wound complications

 

  1. 2 incisions

 

  • Anterolateral
  • Posteromedial

 

Posteromedial approach

  1. Incision – Staring from adductor tubercle of distal femur, curving anteroinferior to finish 6cm below medial joint line
  2. Superficial dissection down to fascia raising skin flaps
  • The infrapatellar branch of saphenous nerve crosses the field – sacrifice it
  • The saphenous nerve itself is protected – it emerges between sartorius and gracilis
  1. Find anterior border of sartorius fascia and cut along it from its insertion, heading proximal
  • Found either distally at insertion, or proximally (hard to define at knee joint itself)
  • Flex the knee to allow sartorius to fall posterior. This will uncover gracilis and semitendinosus
  1. Retract pes tendons posterior – this will reveal the tibial insertion of MCL (deep and distal to anterior edge of sartorius
  2. Now:
  • Anterior to MCL
    • Make a medial parapatellar incision
    • Cut from proximally down to avoid cutting medial meniscus
  • Posterior to MCL
  1. Develop the plane between Medial head of gastrocnemius and the semimebranosus
  2. Blunt dissect medial head of gastrocnemius from the posterior capsule, almost to the midline
  3. Incise joint capsule – reveals posterior 1/3 of medial meniscus, and posteromedial tibial plateau. This will reveal the posterior joint capsule

 

Dr Al Muderis Technique:

As a result of extensive review of the literature and prolonged experience with various operative techniques used to fix different types of tibial plateau fractures Dr Al Muderis developed his preferred method to fix any kind of tibial plateau fracture. This technique utilizes arthroscopic technology (key hole surgery) to visualize the fracture and secure its accurate reduction then internal fixation using a pre-contoured peri-articular plate via a minimally invasive (small incision) technique.

 

Advantages of this technique include:

  1. It allows accurate reduction of the fracture since the arthroscopic camera provides direct visualization of all injured structures including intra-articular soft tissues such as both menisci and the cruciate ligaments.
  2. Minimize the soft tissue dissection and this preserves the vital blood supply to the injured tissue.
  3. Does not burn any bridges for potential future surgery such as total knee replacement since the scar is minimal and far away from the midline where the standard incision for total knee replacement is usually made, while the traditional anterolateral incision could compromise and the possibility of making a future midline incision since the skin bridge is very narrow, which compromise the blood supply to the flap that is created by the two incisions.
  4. Allows treatment of any meniscal tears at the same time of fracture fixation.
  5. Minimize the exposure field so decrease the chance of wound infection.
  6. Reduces surgical time if the steps of the procedure are properly followed.
  7. Very fast rehabilitation is allowed, which include partial weight bearing as of day one post surgery and the fast restoration of range of movement.
  8. No need for cast or bracing in vast majority of cases.

Photo Gallery

Surgical Video

Tibial Plateau Fractures are complicated injuries which have in the past required surgical measures resulting in large scars and soft tissue damage. For this, the Arthroscopically Assisted minimally invasive technique has been developed. Dr Al Muderis takes you through the steps involved in this very effective operation.

 

 

Recovery Videos

Tibial Plateau Fracture Surgery - 1 to 6 weeks post

 

 

Tibial Plateau Fracture Surgery - 2 to 6 weeks post