Open Reduction and Internal Fixation of Tibial Plateau Fractures



Open Reduction and Internal Fixation of Tibial Plateau Fractures


James A. Goulet, MD

Mark E. Hake, MD


Dr. Goulet or an immediate family member has received royalties from Zimmer and serves as a board member, owner, officer, or committee member of the American Orthopaedic Association. Dr. Hake or an immediate family member has stock or stock options held in Johnson & Johnson and Medtronic and has received research or institutional support from Zimmer.



INTRODUCTION

Fractures of the tibial plateau are challenging injuries. These fractures involve the joint surface and metaphysis of the proximal tibia and occur as a result of both high-energy and low-energy mechanisms. The severity of injury to the bone and surrounding soft tissue should be considered when deciding on the optimal course of treatment. Goals include anatomic reduction of the articular surface, restoration of the mechanical axis, stable fixation that allows early range of motion (ROM), preservation of the surrounding soft tissues, and avoidance of infection. Ligamentous repair or reconstruction also may be required to obtain a good outcome.


PATIENT SELECTION

Careful examination of the injured extremity is mandatory. Vascular injury, compartment syndrome, and open injuries should be noted and treated emergently. Knee stability and the condition of the soft-tissue envelope are vital in determining the imaging needed and timing involved in treatment.





CLASSIFICATION

The fracture pattern and severity of the soft-tissue injury will guide the decision about the optimal approach to use for reduction and stabilization. The two main classification systems used today describe the fracture pattern but do not take into account ligamentous injury or damage to the soft-tissue envelope, nor are they predictive of outcomes. The system described by Schatzker et al10 divides fractures into six types. In general, types I, II, and III are low-energy injuries that involve the lateral plateau, and types IV, V, and VI involve a higher-energy mechanism and medial condyle or bicondylar injury. The AO/OTA system classifies these fractures into extra-articular, partial articular, and complete articular, with further subdivisions based on the severity of the fracture.


PREOPERATIVE IMAGING

Plain radiographs of the injured knee, including AP and lateral views, are obtained, along with internal and external rotation oblique views. An AP view with the beam directed 10° caudal shows displacement at the articular surface most clearly. CT with sagittal and coronal reconstructions has been shown to affect the surgical plan in many cases because articular depression can be difficult to evaluate on plain radiographs11 (Figure 1). Obtaining preoperative MRI to evaluate for soft-tissue injury has become more common. Meniscal and ligamentous injuries have been shown to be common even in low-energy injuries. In a recent series of closed fractures evaluated arthroscopically, soft-tissue injuries were found in 70 of 98 cases (71%).12 Meniscal injuries occurred with all fracture types, whereas anterior cruciate ligament tears were more common in Schatzker type IV and VI fractures. MRI is helpful to evaluate the need for ligamentous repair or reconstruction before hardware is placed.

image VIDEO 76.1 Open Reduction and Internal Fixation of Tibial Plateau Fractures. Mark E. Hake, MD; James A. Goulet, MD (21 min)



Feb 2, 2020 | Posted by in ORTHOPEDIC | Comments Off on Open Reduction and Internal Fixation of Tibial Plateau Fractures

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