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Tibial Plateau Fractures: Factors influencing outcomes
May 20th 2013
Joel Melton BM, MSc, FRCS (Tr + Orth)
Consultant Orthopaedic Surgeon, Cambridge University Hospitals
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Overview
Plateau Fractures
Diagnosis
Classifications
Treatment goals
Management decisions
Surgical techniques
Controversies
Factors influencing outcome
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Diagnosis
History, Clinical examination, Special tests
Minor, major or catastrophic injury
May be subtle or obvious
Remember other injuries
Degree of soft tissue injury
(inc. open)
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Diagnosis – special tests
Plain radiography
CT scan Diagnosis
Fracture pattern
Help with classification
Assess joint displacement
Guide need for operative intervention
Guide the operative fixation plan and surgical approaches
MRI ?
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Classification
Jo Schatzker
Types 1-6
Worsening severity by type
May guide fixation techniques and likely outcomes
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Classification - Schatzker
Types 1-6
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Treatment goals
G. Appley – Reduce fracture, hold position and rehabilitate
The AO group
AO principles dictate:
An intraarticular fracture must be anatomically reduced, fixed with rigid internal fixation, conferring absolute stability to the fracture, expecting primary bone healing and allowing early joint mobilisation
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Treatment goals
Applying this to plateau fractures: Assess patient first (general status, ATLS,
compartments etc)
Diagnosis
Fracture pattern
Degree of displacement
Knee Joint position/disruption
Leg Alignment
Imaging, pre-operative planning, timing
Hardware, surgical expertise, rehabilitation goals
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Management decisions
Operative vs non operative
What degree of displacement can you accept?
What is the patient like?
Timing of surgery
Soft tissue injury (bruising, swelling)
What hardware? Why
Which incisions? Minimally invasive?
Fixation plans?
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How can we influence outcome?
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How can we influence outcome?
Rehabilitation
Patient factors
Treatment decisions
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How can we influence outcome?
Patient factors
• Age, co-morbidity
• Smoking,drugs
Treatment decisions
• Conservative
• Surgical fixation
Rehabilitation
• Cast,Brace, ROM
• Early ROM
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Influencing outcome
Plateau fracture
Operative management
Conservative management
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Influencing outcome
Plateau fracture
Mal-reduced fracture
Good reduction
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Influencing outcome
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Influencing outcome
Operative management
Internal fixation
External fixation
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Influencing outcome
Operative management
Internal fixation
Screw Plate
External fixation
Circular frame/hybrid
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Influencing outcome
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Influencing outcome
External Fixation
Hybrid fixation
Non-hybrid fixation
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Influencing outcome
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Influencing outcome
Internal fixation
Double plate
Single plate
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Influencing outcome
Double plating
Double incision
Single incision
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Influencing outcome
Double incision
Single incision
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Influencing outcome
Dead bone sandwich?
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Influencing outcome
MIPO (Minimally invasive plate osteosynthesis)
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Influencing outcome
Bi-condylar injury
pattern
Double plating
Single fixed angle device
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Influencing outcome
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Influencing outcome
Internal fixation
Arthroscopic
assisted Fluoroscopy
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Influencing outcome
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Influencing outcome
Internal fixation
Meniscal repair
No soft tissue
procedure
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Influencing outcome
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Influencing outcome
Internal fixation
Bone graft BG
substitutes
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Influencing outcome
Calcium phosphate paste
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Influencing outcome
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Influencing outcome
Rehabilitation
Delayed Early ROM
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So what outcomes are we getting?
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Outcomes
49 pts, <40 no difference, >40 worse outcome
311 pts, 10 yr follow up. 13% had TKR
125 pts, < 10 yrs follow up. 26% OA on XR, 4% TKR
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Latest review of current management of plateau
fractures?
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Latest review of current management of plateau
fractures?
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Summary
Multiple issues effect outcome
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Summary
Patient factors
• Age, co-morbidity
• Smoking,drugs
Treatment decisions
• Conservative
• Surgical fixation
Rehabilitation
• Cast,Brace, ROM
• Early ROM
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G. Appley – Reduce fracture, hold position and rehabilitate