Session II - Tibia
Fri., 10/8/04 Tibia, Paper #12, 11:23 am
Results of Operative Treatment for Schatzker Type V and VI Tibial Plateau Fractures
Purpose: We evaluated the subjective and functional outcomes and compared them with the radiographic results of operatively treated Schatzker Type V and Type VI fractures.
Methods: Between 1999 and 2003, 82 patients (85 fractures) underwent operative treatment of Schatzker type V (16 fractures) or Schatzker type VI (69 fractures) tibial plateau fractures (OTA types 41B and 41C). There were 58 men and 24 women with an average age of 51 (range, 18 to 80 years). Fourteen (16%) were open injuries. The mechanism of injury was a motor vehicle collision (13), fall from a height (30), pedestrian struck (31), or sports-related (8); 13 % of the injuries were work-related. Nine patients had ipsilateral associated lower extremity trauma and two had pelvic fractures. Sixty-seven fractures underwent staged operative stabilization with preliminary use of bridging external fixation. One patient had a below-the-knee amputation because of a mangled extremity. Definitive stabilization involved a plate and screws in 83 fractures and a skinny wire external fixator in one fracture. A lateral meniscus tear was documented and repaired in 10 patients. After surgery, patients were allowed early range of knee motion with nonweightbearing ambulation on the injured extremity for 12 weeks. One-year minimum follow-up was obtained for 65 patients and included physical and radiologic evaluation and functional assessment with the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire. Statistical analysis was performed with use of a Mann-Whitney U test. A P value 0.05 was significant.
Results: Sixty-five patients with 68 fractures were available at a 12-month minimum follow-up (range, 12 to 43). For the purpose of this analysis, we divided the study population into two groups: those who underwent staged operative stabilization with bridging external fixation prior to definitive fixation (group I), those that did not (group II). Group I consisted of 55 patients with 58 fractures, 14 extremities of which were open. The total arc of knee motion averaged 112°, and the WOMAC scores averaged 77.0 (range, 0 to 203) in this group. Complications in this group included two peroneal nerve palsies, three superficial infections, and one deep infection. Four patients with four fractures in this group experienced radiographic loss of reduction/collapse at their latest follow-up. Group II consisted of 10 patients with 10 fractures. The total arc of knee motion averaged 121.4°, and the WOMAC scores averaged 94.4 (range, 0 to 197) for these patients. Complications documented include two nonunions and one malunion. Plate and screw were reported as prominent (but not symptomatic) in two patients. There was no radiographic evidence of loss of reduction/collapse at the latest follow-up. Radiographically, 19 (29%) patients (17 who were initially bridged) demonstrated evidence of posttraumatic osteoarthritis. The total arc of knee motion averaged 101.7°, and the WOMAC score averaged 84.0 (range, 22 to 189) in these patients. One patient had radiographic evidence of collapse at the latest follow-up; 46 patients had no evidence of osteoarthritis at the latest follow-up. The total arc of knee motion averaged 115.1°, and WOMAC scores averaged 78.8 (range, 0 to 203) in these patients. These differences were not significant.
Conclusion: High-energy fractures of the tibial plateau continue to present a challenge for both the surgeon and the patient in their recovery and rehabilitation. We found that four patients (9.5%), all in treatment group I, experienced loss of reduction postoperatively. Nineteen patients (29%) went on to demonstrate early radiographic evidence of osteoarthritis (17 patients from treatment group I). These results did not prove significantly different among the two treatment groups. The WOMAC scores in all groups of patients in our series matched those in the literature associated with pathologic conditions of the knee.
Significance: Our results demonstrate moderate results with operative treatment of these severe injuries. We did not find a correlation between radiographic and functional outcome as measured by the WOMAC. Patients with these more complex tibial plateau fractures should be counseled as to what is expected in the short term with regards to functional outcome.