Tibial plateau fractures occur when a varus or valgus stress is applied to the knee in conjunction with axial loading. Younger individuals sustain this fracture through high-energy mechanisms such as motor vehicle accidents, pedestrian strikes, or falls from heights. In older individuals, it typically occurs due to their poor bone quality and a low-energy fall. , This section will focus on the sequelae and complications involved in the treatment of these fractures. Complications/sequelae include but are not limited to wound healing problems, deep infection, compartment syndrome, neurovascular injury, posttraumatic osteoarthritis (PTOA) of the ipsilateral knee and ankle, knee instability, arthrofibrosis, loss of muscle function/strength around the knee, ankle, and foot, malunion, nonunion, and loss of limb. For the sake of clarity, we will focus here on four of the most common and devastating problems: compartment syndrome, wound healing issues, arthrofibrosis, and PTOA. Complications can be minimized through proper history and physical examination (bearing in mind the mechanism of injury and overall amount of energy imparted to cause fracture), consideration of the soft-tissue health and whether staged treatment is necessary, and excellent surgical technique with a focus on anatomic reduction using limited incisions and meticulous soft-tissue handling. ,
Acute compartment syndrome (ACS) most often occurs following a fracture or crush injury to a limb. Following an injury, accumulation of blood and other tissue fluids results in significant swelling within the myofascial compartment. This accumulation of fluid results in venous hypertension and transudation of further fluid into the compartment. The progressive increase in compartment fluid causes an increase in pressure, which may result in tissue ischemia and necrosis without prompt intervention. Treatment for ACS involves urgent fasciotomy with the release of skin and muscle fascia to allow a reduction in compartment pressure.
Fractures about the tibia and specifically bicondylar tibial plateau fractures have an increased incidence of severe soft-tissue injury and are associated with ACS. , Patients who are male and younger have been found to be at increased risk of ACS following tibial plateau fracture. Clinical signs of compartment syndrome that are generally well accepted are pain that is out of proportion to what should be expected, pain with passive stretch of the involved muscle, and paresthesias in the distribution of sensory nerves within the compartment. However, when used as a screening test, these clinical signs and symptoms have been shown to have low sensitivity when diagnosing ACS. If the clinical signs are at all in question regarding a diagnosis of ACS, then intramuscular pressures should be obtained. Numerous studies advocate for the use of routine intramuscular pressures in the general diagnosis of compartment syndrome. , Others advocate for the use of serial intramuscular pressures that provide more information regarding absolute changes in compartment pressures and changes in perfusion pressures. McQueen et al. found a sensitivity of 94% and a specificity of 98% when using continuous anterior compartment measurements, and a diagnosis of ACS was made when patients’ differential pressure remained less than 30 mmHg for more than 2 hours. At the author’s institution, clinical signs and symptoms are typically used for diagnosis of ACS. If physical examination and patient symptoms are in question, then intramuscular pressures are taken at the anterior and posterior compartments with fasciotomies performed when a 30-mmHg threshold for absolute compartment pressures and a perfusion pressure of less than 30 mmHg result.
Our bias is to have more false positives and err on the side of surgical release rather than watchful waiting. A delayed diagnosis/treatment of ACS can result in significant morbidity for the patient, not to mention legal repercussions for the treating team. A two-incision technique to release all four compartments is utilized to allow for evaluation of muscle viability and adequate debridement as necessary in all four compartments of the lower leg ( Fig. 8.1 ). A knee spanning external fixator is routinely placed at the time of fasciotomies to allow for fracture stabilization and allows the patient to mobilize if other injuries are not present. Vessel loops, rubber bands, or prolene sutures can be utilized at the fasciotomy sites in a “roman sandal” configuration to allow for skin tension but also permit swelling and expansion of wound as needed ( Fig. 8.2 ). Multiple second look evaluations may be required, and definitive closure with fracture fixation must not occur until the soft-tissue envelope permits, with all necrotic tissue removed and wounds able to undergo either delayed closure or split-thickness skin grafting.
ACS is a dangerous complication that can occur with tibial plateau fractures. Early diagnosis is critical to prevent significant morbidity for the patient. Surgeons must be aware of patients who are at increased risk, specifically those who are involved in high-energy accidents sustaining bicondylar tibial plateau fractures with significant displacement and obvious soft-tissue injury. Specific attention must be paid to the soft-tissue envelope at the initial evaluation. Additionally, heightened awareness is necessary regarding pain that is out of proportion to what should be expected, pain with passive stretch of the involved compartment, and paresthesias in the distribution of sensory nerves within the compartment. Surgeons must remain vigilant in diagnosis and perform compartment release when indicated.
Wound Healing Issues
Complications from wound healing and their associated infections continue to be a significant source of morbidity in orthopedic trauma surgery. In the case of tibial plateau fractures, where the mechanism tends to be associated with significant soft-tissue damage in the form of inflammation and swelling, there is a relatively high incidence of wound complications that can have a drastic impact on acute and long-term surgical outcomes.
Wound healing is a multifactorial process whose variants include the wound bed itself, the surrounding tissue, as well as the biology of the host individual. Wounds heal through either primary intention, usually by means of suture or adhesives allowing for scar formation, and its resultant maturation. In some instances, primary intention as a means of closure either fails or is not achievable, either due to the character of the wound or its contamination from the mechanism of injury. In these instances, when primary closure and healing is not realistic, closure by secondary intention is necessary. Wound healing through secondary intention is achieved through the formation of granulation tissue over a vascular soft-tissue bed. In certain injuries, where the individual is at higher risk for dehiscence or infection in the setting of primary closure, the secondary intention is the superior method of wound healing as it may avoid surgical complications. Secondary wound healing presents a challenge as it relates to fracture care due to retained hardware and bacterial biofilm formation.
An issue that can add to the complexity of management with tibial plateau fractures is the development of fracture blisters in high-energy injuries. These blisters are sentinels of soft-tissue damage beneath them and are concerning due to increased risk of infection and as a possible hindrance to surgical approach for definitive fracture management, as well as increased time to operation. These blisters are either clear filled or blood filled and are theorized to form due to the separation of the dermis and epidermis at the time of injury. This skin separation leads to edema, venous stasis/thrombosis, development of epidermal necrosis, and the eventual formation of blisters. A histological study of these blisters has demonstrated that the contents of the clear-filled blisters are sterile transudate and those of the blood-filled blisters are hemorrhagic.
Despite a lack of extensive investigation into management or clinical outcomes of fracture blisters, there are multiple management options. Some surgeons elect to allow them to rupture on their own. The obvious limitation to this being in the event that the blister overlies the desired incision site, there could be a delay in surgical fixation of the underlying fracture. On histological examination of blisters that have healed without issue and those that have developed wound complications, the main factor leading to wound complications was the lack of re-epithelialization or false epithelialization of the blister bed. Tolpinrud et al. demonstrated that simple unroofing of these blisters leads to almost immediate colonization of the blister transudate and blister bed by skin flora, including Staphylococcus epidermidis and S. aureus shortly after unroofing. In addition, Tolpinrud et al. demonstrated that unroofing the blister to the edge of healthy tissue and applying Silvadene twice a day with associated dry dressing changes resulted in 90% of their patient cohort healing without wound issues. Most recently, there was investigation into utilization of negative pressure wound therapy with sterile saline instillation (NPWT-id) in the management of both ankle and tibial plateau fractures. Hasegawa et al. theorized that the mechanism of the NWPT allows for faster re-epithelization, reduction of soft-tissue swelling, and faster time to surgery. In their limited case study, there was no incidence of complications related to wound healing.
In the case of tibial plateau fractures, frequently there is a period of immobilization preceding surgery to decrease soft-tissue swelling due to increased complications with acute fixation. This period of immobilization and allowing swelling to subside prior to surgery can absolutely be used to the surgeon’s advantage with concomitant management of the fracture blisters ( Fig. 8.3 ). Ultimately, the management of fracture blisters is a surgeon’s preference as no best management strategy has been proven.
The prevalence of surgical site infections (SSIs) and wound dehiscence in tibial plateau fractures have historically ranged anywhere from 5% to 80% with a mean of 27% after open reduction and fixation and most recently, reports of an 18% deep infection rate after open reduction and fixation of high-energy tibial plateau fractures. Due to a high incidence of complications from these injuries, there has been significant investigation and research in the realm of how to manage the wounds from the initial insult and surgical fixation. In many cases, these injuries are approached with staged management to optimize surgical outcomes. While the management of these surgical complications is far from algorithmic, there are emerging techniques, technology, and materials that can be a great aid in these potentially debilitating injuries and complications.
One of these emerging methods is NPWT. In cases of primary intention, NPWT reduces edema, increases perfusion, and augments the apposition of wound edges. NPWT aids secondary intention by increasing the speed at which these wounds heal and by allowing stability of the wounds margins. NPWT promotes granulation tissue formation, lessens the bacterial concentration, and increases the expression of intracellular signaling molecules that promote angiogenesis and healing, such as vascular endothelial growth factor and platelet-derived growth factor. The net effect being positively augmented healing with the use of NPWT at macroscopic and microscopic levels.
Recently, there have been numerous studies comparing NPWT to traditional dressings in closed incisions in orthopedic trauma. These cases were primarily of the lower extremity. These studies found that utilization of NPWT decreased the incidence of superficial SSI, deep SSI, and wound dehiscence. It was also found that the use of NPWT can decrease the overall risk of infection of open fractures and increase the rate of healing in these traumatic injuries. , One reason for this could be due to the fact that when using NPWT, there is a decreased need for dressing changes, which is a significant opportunity for contamination of the wound by healthcare workers. While there have been acceptable results in the study of NPWT as a modality for management of surgical wounds in the trauma setting, there are many instances where traditional dressings and NPWT fail to meet the needs of the wound, and in these instances, various tissue grafts and/or flap coverage remains a mainstay of management. ,
In conclusion, management of wounds in the setting of tibial plateau fractures can be a difficult surgical issue, and there is not always a clear-cut way to address the problem. While there have been significant advances in the field of wound management in the setting of tibial plateau fractures, each case must be addressed in light of the wound itself, the mechanism by which the injury was inflicted, and the patients’ underlying medical comorbidities. Current management indicates not only staged fixation of the bony insult but also the soft-tissue insult using the vast array of recent medical advances to achieve the best surgical outcome for the patient.
Inflammation about the knee joint secondary to injury, surgery, or infection can result in excessive collagen production and adhesions that cause decreased joint motion and pain. Approximately 3% to 18% of patients develop a stiff knee following tibial plateau fracture fixation. Decreased knee motion can cause difficulty with activities of daily living as these typically occur in the flexion-extension range of 10 to 120 degrees (raising from a chair, climbing stairs, descending stairs). Kugelman et al. found nonwhite ethnicity, older age, higher body mass index (BMI), and polytrauma to be independent predictors for decreased range of motion following operative treatment of tibial plateau fracture 6 months post surgery. Others have found that increased time in a temporizing external fixator or bilateral tibial plateau fractures can lead to decreased knee range of motion requiring treatment. ,
Nonoperative management begins with aggressive physical therapy; however, if the patient is failing to progress with physical therapy and flexion remains less than 90 degrees, then manipulation under anesthesia is warranted. Haller et al. demonstrated that earlier time to manipulation (mean 2.9 months) leads to greater return in knee motion versus later manipulation (mean 4.86 months). Continuous passive motion (CPM) has been employed to prevent arthrofibrosis postoperatively. Hill et al. found that 48 hours post surgery, there was increased range of motion when using CPM; however, long-term outcomes showed no difference in motion. In contrast, Haller et al. found that the use of CPM to be associated with decreased development of arthrofibrosis with the mean follow-up of 6 months.
Surgical options for treatment of arthrofibrosis include arthroscopic lysis of adhesions or an open debridement with or without a Judet quadricepsplasty. According to Middleton et al., arthroscopic lysis of adhesions correlated with significantly improved overall range of motion at 12 weeks, improved flexion at 12 weeks, as well as improved extension at 12 weeks. Additionally, patients who had previously undergone external fixation had significantly improved motion at 12 weeks following lysis of adhesions. The Judet quadricepsplasty procedure can be used as a last line of treatment for complex knee stiffness. This involves sequential release of restricting adhesions until desired motion is achieved. Release includes resection of intra-articular adhesions (through a medial arthrotomy or arthroscopically) and a lateral incision used to free up lateral retinaculum, release of pin site adhesions, and extraperiosteal release of adhesions to vastus lateralis, vastus intermedius, and rectus femoris. Fractional lengthening of fascia lata, debulking of fibrotic vastus intermedius, and overabundant fracture callus may be necessary as well. The procedure has been found to have a high complication rate (extensor lag, wound dehiscence, deep infection) cited as high as 23%. In a retrospective case series of 11 patients, Bidolegui et al. were able to increase knee flexion from a preoperative mean of 36 degrees to a mean of 98 degrees following a modified Judet quadricepsplasty combined with physical therapy.
Does a tibial plateau fracture doom the patient to advanced PTOA and need for an arthroplasty? This clinical debate continues, with the literature clearly acknowledging the radiographic development of arthrosis; however, the clinical outcomes are more varied. Ostrum stated that many lateral tibial plateau fractures do not progress to severe PTOA and do not require total knee arthroplasty (TKA). Ostrum stated that the “literature does not support the belief that an intra-articular tibial plateau fracture will progress to arthritis.” Scott et al. reported a 3.3% conversion rate to TKA following periarticular knee fractures with risk factors, including female sex, tibial plateau fractures (versus distal femur), and obesity. Snoeker et al. utilized a young adult cohort study to demonstrate a sixfold increase in arthrosis following any injury to the knee, including meniscal pathology, anterior cruciate ligament tears, and fractures. What are the factors that contribute to clinical outcomes, PTOA, and the need for TKA after intraarticular tibial plateau fracture?
Dirschl et al. stated that articular incongruity was well tolerated after tibial plateau fractures. They noted that there is “little support in the literature for the assertion that accurate reduction of tibial plateau fractures, particularly to tolerances <2 mm, is critical for a good clinical outcome.” Baumlein et al. reported increased rates of radiographic osteoarthritis in the entire cohort of skiers examined in all compartments of the knee; however, at a mean follow-up of 10.3 years, the Hospital for Special Surgery (HSS) knee score was 96.5 (range 74–100), suggesting satisfactory functional outcomes. Giannoudis et al. noted that articular incongruities were well tolerated for tibial plateau fractures. These authors noted that other factors (features only partially related to articular reduction, e.g., joint stability, retention of the meniscus, and coronal plane alignment) were more important in determining the outcome than articular step-off alone. Of the 11 studies reviewed, five showed no effect on the outcome comparing articular step-off and no step-off. Of the other six studies, one showed acceptable results with a step-off of less than 10 mm, and another study showed inferior results with a step-off of more than 10 mm. Wilde stated that preserving the normal alignment of the knee was critical to the end result of the treatment of tibial plateau fractures. He further noted, “Joint depression, per se, if not associated with malalignment, does not necessarily cause poor results.” In terms of the effect of joint stability, he noted that joint depression in a stable knee was not necessarily associated with a poor result, but a depression of more than 4 mm did have an effect on outcome. Ehlinger et al. reviewed 13 patients who were surgically treated for a Schatzker type IV-VI tibial plateau fracture after a mean follow-up of 39.1 months. The average Lysholm score was 94.1, the mean HSS score was 93.6, and all patients previously employed returned to work after 4.5 months. Five patients were noted to have an articular step-off of more than 2 mm, yet all 13 patients demonstrated no radiographic evidence of osteoarthritis at final evaluation.
The current literature suggests that articular step-off following intraarticular fractures of the tibial plateau is less of a determinant of outcome when the step-offs are small (4 mm or less), and the fracture involves mainly the lateral tibial plateau.
Variables Other Than Articular Step-off
Dirschl et al. noted that the tibial plateau has thicker articular cartilage than many other joints and that the effect of factors other than articular reduction, such as knee instability, malalignment, and meniscectomy, was more important to the outcome. Ostrum also noted that certain plateau fractures (e.g., medial tibial plateau fractures and those having had an excision of the meniscus) have a much poorer prognosis. Rademakers et al. reported a 31% incidence of radiographic arthritis after operatively treated tibial plateau fractures at 14 years, but most were asymptomatic. However, results were much worse with malalignment of more than 5 degrees. Twenty-seven percent of patients reported moderate to severe symptoms. A study of 73 patients following tibial plateau fracture with a mean follow-up of 54 months demonstrated a correlation with valgus malalignment of more than 5 degrees and advanced osteoarthritis along with a depression of more than 2 mm. Interestingly, the valgus malalignment or articular depression had no effect on outcome scores.
Multiple studies demonstrate poorer clinical, radiographic, and functional outcome scores with increasing fracture classification number using the Schatzker classification. Prasad et al. reviewed 40 Schatzker type V and VI tibial plateau fractures treated with dual plating with 4-year follow-up and showed good clinical outcomes in association with good radiographic outcomes. All patients had a final radiographic articular step-off of less than 2 mm, good coronal and sagittal plane alignment, and mean condylar width of less than 5 mm. Final clinical outcome was assessed by the Oxford Knee Score. Thirty-two of 40 had a final score of more than 30 (excellent), and only 8 patients had a score between 20 and 29 (good).
Clearly, there is an association between arthrosis and articular fracture/injury. Wasserstein et al. utilized a cohort analysis to determine a significant increase in TKA risk with an overall hazard ratio of 5.29. Higher rates of TKA were associated with increasing age, bicondylar fracture, and greater comorbidities. A Denmark study by Elsoe et al. noted that 5.7% of 7950 patients who suffered a tibial plateau fracture were managed with a TKA within 13.9 years, a 3.5 times higher hazard ratio than a match cohort without articular fracture. According to van Dreumel, 40.6% (39/71) of proximal tibia fractures developed radiographic arthrosis at 1 year, noting an increase in those with bicondylar fractures (57.5%); yet, there was no correlation to functional outcome measures obtained. Mattiassich et al. evaluated 31 patients at 3 years and 22 years following a tibial plateau fracture documenting deterioration in functional outcomes over time; however, 10 patients (32%) developed no radiographic evidence of arthritis, and at the long-term follow–up, 10 patients had the best scores possible on a clinical examination scale. Some patients developed severe symptoms, while others remained the same or even improved at long-term follow-up. The study did not comment or examine the etiology of their findings as the vast variety of outcome scores are likely multifactorial. However, it appears that malalignment and articular step-off of more than 2 to 4 mm may contribute significantly to the development of posttraumatic arthritis and poorer clinical outcomes after tibial plateau fracture. Because articular step-offs in the tibial plateau are well tolerated, nonarticular step-off factors (malalignment, ligamentous stability) seem to be more important factors in determining outcome for the fractured tibial plateau and the knee joint as a whole. The literature continues to demonstrate that end-stage osteoarthritis following a tibial plateau fracture remains relatively rare. More information on posttraumatic arthritis after tibial plateau fracture can be found in Chapter 9 .