Session VII - Tibia

Tibial Plateau Fractures: Functional Outcome and Incidence of Osteoarthritis in 156 Cases

Anis Dosani, FRCS; Peter V. Giannoudis, MD; Asad Ali Syed, FRCS; Manish Agarwal, FRCS; Stuart J. Matthews, FRCS; Malcolm R. Smith, MD, FRCS; St. James' University Hospital, Leeds, United Kingdom

Purpose: We determined the long-term outcome and incidence of osteoarthritis in patients who had tibial plateau fractures.

Methods: From January 1994 to December 2000, 156 consecutive adult patients who had tibial plateau fractures were treated in our institution. Details such as the patient's age, sex, ISS, type of fracture, whether the fracture was open or closed, method of fixation, incidence of delayed union, nonunion, the time to union, necessity for additional procedures, complications, and length of hospital stay were recorded and analyzed. Thirty-one patients either died or were lost to follow-up and were excluded. Fractures were classified on the basis of the Schatzker classification according to the CT protocol. The mean hospital stay was 2 weeks (range, 1 to 20). After discharge from the hospital, all the patients were observed in the outpatient fracture clinic with regular clinical and radiologic assessment. Particular emphasis was given to determining the impact of these complex injuries on the quality of life of the patients and on the incidence of osteoarthritis. The American Knee score was used for functional assessment. The mean follow-up was 16.8 months (range, 6 to 66).

Results: Of the 125 patients, 73 were men and 52 were women; the mean age was 52 years (range, 17 to 94) and the mean ISS was 20 (range, 6 to 52). Twenty-nine patients had associated injuries (5 had a head injury). The majority of patients sustained their injuries during traffic accidents. There were 31 type 1, 42 type 2, 21 type 3, 9 type 4, 6 type 5, and 16 type 6 tibial plateau fractures. Seven were open fractures (one Gustilo grade I, three grade IIIa, and three grade IIIb). Of 101 fractures that were treated operatively, 12 were stabilized initially with an AO hybrid frame and cannulated screws, 15 were treated with cannulated screws only, 69 were treated with internal fixation (buttress plate), 3 were treated with double plating, and 2 fractures were treated with a combination of internal fixation and a Hoffman external fixator. An iliac crest bone graft was required in 63 patients. Soft tissue coverage was required in 5 patients. There were 2 cases of compartment syndrome, 19 cases of superficial infection, and 12 cases of deep infection. Overall, 14 patients were subjected to a second operative procedure (6 patients had removal of metal work, one underwent removal of metal work and application of a hemicallotasis device, and 7 patients underwent arthroscopy). Nine patients underwent a third procedure (five had removal of metal work, one had application of a hemicallotasis device, and three underwent debridement and curettage of the discharging sinus). Five patients required total knee replacement and one had revision arthroplasty. There were 12 cases of residual varus, 10 cases of valgus deformity, and 5 cases of leg length discrepancy (two of 2.5 cm, two of 2 cm and 1.5 cm, respectively). All the fractures but two progressed to union (one is currently awaiting a total-knee replacement). Functional assessment according to the American Knee assessment score was good in 86 patients (68.8%), fair in 30 patients (24.0%), and poor in 9 (7.2%). Excellent joint reduction and alignment was initially achieved in 94 patients but reduced to 71 at the time of union. Evidence of radiologic osteoarthritis was present in 33 of 125 patients 26.4%). A poor correlation between presence of radiologic osteoarthritis and functional outcome was noted (P <0.05).

Discussion/Conclusion: In this series of patients, 116 (92.8%) had a good or fair outcome. The overall incidence of osteoarthritis was 26.4%, but there was no correlation to functional outcome. These data support the view that with progression from type I to type VI fractures, there is a higher incidence of loss of previous occupation, need for additional procedures, poorer American Knee Scores, and greater incidence of osteoarthritis. This outcome reflects the severity of the injury and prognosis, which is especially evident among patients with Schatzker type 5 and 6 fractures. Complex tibial plateau fractures continue to be a major cause of morbidity.