Session VII - Tibia

*High-Energy Tibial-Plateau Fractures: Knee Function at Longer Follow-up

J. L. Marsh, MD (a,b-EBI Medical); Dennis Weigel, MD, University of Iowa Hospitals and Clinics, Iowa City, IA

Introduction: Recent studies report the short-term results of treating high-energy tibial plateau fractures with external fixation and limited internal fixation, but there are no data about how knees treated in this way function after longer follow-up. Our purpose was to assess the pain, function, health-related quality of life, and the development of arthrosis at 5 to 12 years after injury and compare these measures to those obtained 2 to 4 years after injury.

Methods: Between 1989 and 1994 we treated 30 patients with high-energy tibial- plateau fractures with a uniform technique of external fixation and limited internal fixation. Twenty-four knees in 22 patients were identified and evaluated at a clinical visit for the purposes of this study, an average of 97 months after injury. Patients completed a questionnaire, two generalized health status measures (SMFA and SF-36), had a physical examination, and weight-bearing radiographs of the involved joint. Iowa knee scores were compiled. All fractures were classified using the AO/OTA method and Schatzker classification. Radiographs of the knee were analyzed for post-traumatic degenerative arthritis using a 4-grade scale.

Results: The average age of patients was 49 (range, 32-69); there were 18 men and 4 women. Six of the fractures were open (Type II-1, IIIA-3, IIIB-1, IIIC-1). Using the AO classification, the majority were C3 fractures (2-B3, 1-C1, 7-C2, 14-C3), and 21 were Schatzker VI type fractures. The average Iowa Knee Score was 91(72-100). Among the 14 patients with sequential data, the Iowa Knee Score was 93 at 38 months, and 94 at the current follow-up. Range of motion averaged 120^o of flexion, and no patient had difficulty with knee instability. Radiographic arthrosis was minimal (Grade 0-10, I-10, II-2, III-3). Of the 14 patients from the previous study, arthrosis progressed one grade in 4 and remained unchanged in 10. Ten patients were laborers, 5 were non-laborers, 4 patients were not working, and 2 patients were disabled. The SF-36 subscale score for physical function was below age matched norms. There were no other statistically significant differences between the other 7 subscale scores when compared to age matched norms. There was no change in SF-36 scores between 38 months and 113 months post-injury. Injury severity and quality of reduction tended to predict the development of arthrosis, but there was no correlation between arthrosis and the clinical measures.

Conclusions: High-energy fractures of the tibial plateau result in relatively small long-term effects on knee function, patient pain, and health related quality of life. Most patients have satisfactory knee stability, a good range of motion, and either no arthrosis or mild non-progressive arthrosis. The knee score averages 90 and most patients are able to work. The knee scores and SF-36 do not deteriorate over time. Reconstructive procedures were not required in any patients. These generally favorable outcomes and lack of progressive arthrosis should be considered when deciding among treatment options and advising patients on their prognosis.