Session VII - Tibia

Internal Fixation of Comminuted, Bicondylar tibial Plateau Fractures

David P. Barei, MD; Sean E. Nork, MD; Stephen K. Benirschke, MD; M. Bradford Henley, MD, Harborview Medical Center, Seattle, WA

Purpose: The treatment of complex high-energy tibial-plateau fractures remains controversial. Open reduction and internal fixation with double plates through a single anterior midline incision has been associated with high complication rates. The purpose of this study was to report the complications and infection rate associated with double plating complex 41-C3 tibial plateau fractures through 2 incisions.

Materials and Methods: Over a 5-year period from May 1994 to April, 1999, 166 patients with 170 bicondylar tibial plateau fractures were treated at our institution. One hundred seven patients with 111 fractures had simple articular involvement (OTA type 41-C1 and 41-C2) and were excluded. These patients were treated by a variety of methods including hybrid external fixation, unicondylar plating and external fixation, isolated unicondylar plating, percutaneous fixation, and limited internal fixation with anterior external fixation. Eight additional patients had insufficient data for review, and 4 patients were treated with primary amputation. The remaining 47 patients formed the study group and had complex 41-C3 tibial plateau fractures treated with internal fixation through 2 approaches. The surgical approaches used in these patients were anterolateral and posteromedial. The use of a single midline anterior surgical approach was abandoned prior to the study period. There were 31 male and 16 female patients, ranging in age from 18 to 88 years (mean 42.3 years). The mechanisms of injury were accidents involving a fall from a height in 16, motor vehicles in 13, motorcycles in 8, a pedestrian versus motor vehicle in 5, and other injuries in 5 patients.

Results: Eleven fractures were open (23%) and classified according to Gustilo as type II (n = 2), type IIIA (n = 7), and type IIIB (n = 2). Compartmental syndrome was diagnosed and treated with fasciotomies in 4 patients. The average interval from injury to surgical treatment was 6.4 days (range 0 to 40 days). Temporary spanning external fixation prior to definitive fixation was used in 14 patients. Deep wound infections occurred in 5 patients. Deep infections included 1acute infection 3 weeks postoperatively and 4 delayed infections at 3 to 24 months. One patient declined surgical management for his infection and was lost to follow-up. The remaining 4 patients had resolution of their infections after an average of 1.5 additional procedures (range 1 to 2 procedures) combined with intravenous antibiotics. One patient developed a nonunion at the proximal tibial diaphysis that required bone grafting and revision plating. Other secondary surgical procedures included removal of hardware in 7 patients, a knee manipulation in 1 patient, and release of an equinus contracture in 1 patient. Additional complications included a varus malunion of 10 degrees in 1 patient.

Discussion: Comminuted bicondylar tibial plateau fractures remain a treatment dilemma. The soft tissue injury is typically severe, and open methods often require significant surgical dissection. Because of reports of deep infection in up to 87.5% of patients after open reduction and double plating through a single approach, alternative methods have been recommended, including lateral open reduction and internal fixation combined with medial external fixation, limited internal fixation and external fixation, hybrid external ring fixation, and small wire external fixation. However, an accurate reconstruction of the articular surfaces in comminuted fractures often requires an open reduction. In many of these fractures, medial plateau articular involvement occurs with lateral plateau comminution, prompting a second surgical approach. In addition, the need for a medial column buttress in bicondylar injuries may make a medial approach necessary. A single anterior midline surgical approach for both the medial and lateral plateaus has been associated with an unacceptably high wound complication and deep infection rate and has been abandoned at our institution.

Conclusions: Comminuted bicondylar tibial plateau fractures can be successfully treated with double plating. The deep infection rate (10.6%) remains significant with this procedure but responds well to surgical management. The use of two incisions, temporary spanning external fixation, and avoidance of extensive soft tissue dissection and stripping may contribute to a lower infection and wound complication rate.