Bicondylar Tibial Plateau Fractures: Comparison of Early Results witha Locking Plate Compared with Medial and Lateral Plating

Session VII - Tibia

Sat., 10/12/02 Tibia, Paper #51, 5:08 PM

Bicondylar Tibial Plateau Fractures: Comparison of Early Results with a Locking Plate Compared with Medial and Lateral Plating

William J. Ertl, MD; Douglas G. Smith, MD; Harborview Medical Center, University of Washington, Seattle, Washington, USA

Purpose: Bicondylar tibial plateau fractures can be the result of a high-energy load in the coronal or sagittal planes or both. Surgical stabilization has been suggested with plating of the reduced lateral fracture fragment along with medial stabilization, either by plating or with external fixation. New plating devices have been developed that may allow adequate reduction and stabilization with lateral plating alone. We present the early results of bicondylar tibial plateau fractures (AO/OTA 41C) stabilized with a laterally placed locking plate and no medial stabilization for the proximal tibia compared with the results of a group of patients who received medial and lateral plating.

Methods: A review of the orthopaedic trauma database at a level I trauma center identified patients with AO/OTA 41C fracture patterns. Records of all patients that had been stabilized with a locking plate (Synthes LISS plate or Synthes proximal locking tibial plate) were tabulated. Injury patterns were characterized, and these patients were matched with a second group who had medial and lateral stabilization. Surgical data included the number of primary procedures needed to attain stabilization, the number of secondary procedures that occurred after stabilization was achieved, and total estimated blood loss. Early results included time to healing, complications (superficial/deep infections, delayed union, nonunion, deep vein thrombosis) and range of motion. Alignment of the fracture and joint congruity were measured at the time of surgery and compared with the alignment at the time of clinical and radiologic healing. Statistical analysis of the data was then performed. The null hypothesis was that there would be no difference between the two study groups.

Results: Over a 31-month period, 189 fractures classified as AO/OTA 41C were identified. Thirty-two fractures in 31 patients were treated with lateral plating using only a locking proximal tibial plate. Four patients were excluded because of inadequate follow-up. Twenty-five of 27 patients (group 1) were then matched according to their injury pattern with 25 patients (group 2) who had undergone medial and lateral stabilization. A total of 15 women and 35 men with an average age of 43.8 years (range, 21 to 81) were identified. Surgical data were essentially identical for primary operations (average, 2.1 for each group; range, 1 to 6 in group 1; 1 to 5 in group 2) and secondary procedures (average, 0.4 for each group; range, 0 to 3 each group). Average total estimated blood loss for group 1 was 345 cc and was 720 cc for group 2 (P = 0.0004 by two-sample t-test). Average time to bony healing was 14.4 weeks for patients in group 1 (range, 6.3 to 39 weeks) and13.5 weeks for group 2 (range, 7.07 to 23.4 weeks) and was not statistically significant (P = 0.61 by two-sample t-test). Alignment at surgery and bony union was 0.2^o of valgus, neutral in the sagittal plane with congruent joints for group 1. Group 2 alignment was 1.3° of varus, neutral in the sagittal plane with congruent joints at the time of surgery compared with 1.7^o of varus with neutral sagittal alignment and congruent joint surfaces at bony union. There was no statistical difference between the two groups (P = 0.17 postoperatively and 0.095 at bony union by two-sample t-test). Range of motion at bony union for group 1 averaged 1.6^o to 111^o, and for group 2 the average was 4^o to 105^o and was not statistically significant. Deep vein thrombosis occurred in five patients for each group. Superficial wound infections totaled three among group 1 and 4 among group 2. Two patients among group 1 had a diagnosis of osteomyelitis and were treated; there were none in group 2.

Conclusions: Early results of a new approach to bicondylar tibial plateau fractures are similar to those of a technique considered a standard method of treatment. Surgical effort, time to healing, alignment, joint congruity, range of motion, and complications appear to be similar. Total estimated blood loss, however, was statistically significant between the two groups and may play an overall role in the poly-traumatized patient.

Discussion: Bicondylar tibial plateau fractures can be challenging to manage. Treatment plans have been directed at stabilizing both the medial and lateral fractures of the plateau. When reduction of the medial side can be attained, then lateral plating with a locking plate may be an alternative with results similar to those of medial and lateral plating for these patients. Further long-term studies are required with validated functional assessment outcome measures.