Session II - Tibia
Fri., 10/8/04 Tibia, Paper #13, 11:29 am
Fracture Dislocation of the Knee: A Prospective Evaluation of Fracture Fixation and Early Ligament Reconstruction with the Use of a Hinged External Fixator
Purpose: High-energy tibial plateau fractures are frequently associated with significant soft tissue injuries involving the knee. Detection of multi-ligament knee injuries associated with tibial plateau fractures can be difficult as a result of limitations in the physical examination of the knee. Unrecognized fracture dislocations frequently lead to stiff and painful knees, with or without instability, as a result of poor patient rehabilitation secondary to pain and instability. The purpose of this study was to report on a series of patients treated prospectively with early fracture stabilization, followed by ligament repair or reconstruction within the first month, with the addition of a hinged external fixator spanning the knee with early knee motion and aggressive rehabilitation.
Methods: After obtaining Institutional Review Board approval, patients who sustained tibial plateau fractures associated with multi-ligament knee injuries were enrolled in an outcome study that used an early stabilization and early rehabilitation treatment protocol. All patients had their tibial plateau fracture stabilized with use of open reduction and internal fixation within 1 week of injury. Ligament repair or reconstruction was delayed until 2 to 4 weeks following injury to allow for both soft tissue healing around the knee and for healing of the capsule prior to arthroscopy. At the time of ligament surgery, a Compass Knee Hinge (CKH, Smith & Nephew, Memphis, Tennessee) was placed to help stabilize the knee. Range of motion was begun with a CPM machine on the first postoperative day, with a goal of 90 of flexion within 2 weeks following surgery. Patients were allowed to bear weight as tolerated with the CKH locked in extension. Outcomes have included physical examination results: range of motion, ligament stability, analog pain scale; radiographic healing of the fracture; and outcome scores (Lysholm knee score, International Knee Documentation Committee [IKDC] score, and SF-36).
Results: Fifty-four patients were enrolled in this study and have had a minimum of 6-month follow-up. The average age of our patients was 39.9 years (range, 18 to 78). There were 31 men and 19 women, with four patients sustaining bilateral fracture dislocations. The AO/OTA fracture classification of our tibial plateau fractures was 37 41C and 17 41B fractures. Classification with use of the Schatzker system yielded the following types: I, 2; II, 9; IV, 6; V, 7; and VI, 30. Ligament injuries were classified by using a modification of the Schenck classification. Thirteen patients were V.1 with one cruciate ligament intact. The remaining 41 knees had bi-cruciate injuries, with one isolated bi-cruciate (V.2), 26 bi-cruciate plus one corner (V.3), and 14 bi-cruciates plus both corners torn (V.4). The range for extension was 0 to 6, with 66 to 150 for flexion. Three knees out of 54 had flexion of less than 100. Clinical follow-up was a mean of 23.2 months, with a range of 6 to 55 months. Forty-six of these fractures (42 patients) had a minimum of 12-month follow-up (mean, 24.5), and will be the subject of the outcome data in this study. Injury Severity Scores ranged from 9 to 38, with a mean of 14.1. Range of motion in our patients was a mean of 0.5 to 120.9. In addition to the ligament injuries, 27 patients sustained meniscal injuries. All of the fractures in this study united with no secondary procedures necessary to obtain union. Complications in this patient population included four peroneal nerve injuries, one case of heterotopic ossification, one deep infection, one fracture that required revision, and one vascular injury that required emergent bypass. Final Lysholm knee scores ranged from 50 to 100, with a mean of 84.5. Objective IKDC scores yielded the following results: A (normal knee), 10; B (near normal knee), 28; C (abnormal), 8; and D (severely abnormal), 0. Subjective IKDC scores ranged from 29.9 to 96.6, with a mean of 59.1 points. Analog pain scale results yielded a final mean score of 2.4, with a range of 0 to 9; this scale was based on 0 for no pain and 10 for the most severe pain a patient has ever experienced. Employment status was obtained on 40 of the 45 patients with more than 1-year follow-up. Twenty-five (63%) have returned to their prior job, three (8%) have returned to full duty at a different job, three (8%) have returned to light duty only, and 9 (23%) have not returned to employment.
Conclusion/Significance: Fracture dislocation of the knee is a severe injury that has often been associated with very poor outcome. In our series, we used aggressive surgical fixation of both the fracture and the knee soft tissue injuries within the first month of injury, and then supplemented that with a hinged external fixator. The CKH allows stabilization of both the fracture and the ligament reconstructions while aggressive rehabilitation and knee motion is pursued. Although many challenges remain with these patients, including loss of motion and pain, our results with early functional rehabilitation have been very gratifying compared with most published results. Our patients have generally achieved functional motion of the knee with good stability. Although pain has not been completely eliminated, it is reported at a tolerable level by most patients. Nearly 80% have returned to some type of work, with nearly two-thirds returning to their former occupation. Knee function based on both the IKDC and the Lysholm knee scores is good in most patients. We have found early stabilization of both the fracture and ligament injuries with CKH supplementation and early functional rehabilitation to be challenging, but yields good results in most patients.