Early intervention within 24 h using anterior midline single incision with dual plating for bicondylar tibial plateau fractures schatzker type v and vi: An analytical study

Prahalad Kumar Singhi; Sivakumar Raju; Vinoth Thangamani; Sudeep Kumar Velur Nagendra Reddy; Chidambaram Muthu

doi:10.4103/joasis.joasis_28_21

ORIGINAL ARTICLE

Year : 2021 | Volume : 18 | Issue : 2 | Page : 67-72

Early intervention within 24 h using anterior midline single incision with dual plating for bicondylar tibial plateau fractures schatzker type v and vi: An analytical study

Prahalad Kumar Singhi, Sivakumar Raju, Vinoth Thangamani, Sudeep Kumar Velur Nagendra Reddy, Chidambaram Muthu
Department of Orthopaedics and Traumatology, Preethi Institute of Medical Sciences and Research, Preethi Hospitals Pvt. Ltd., Madurai, Tamil Nadu, India

Date of Submission	30-Nov-2021
Date of Acceptance	04-Dec-2021
Date of Web Publication	27-Jan-2022

Correspondence Address:

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/joasis.joasis_28_21

Abstract

Introduction: Schatzker Type V and VI fractures are high-velocity injury; they are bicondylar fractures of proximal tibia with significant articular involvement multiple displaced condylar fracture lines, metaphysiodiaphyseal extension with comminution with high incidence of compartment syndrome and soft tissue injury. Span, scan and plan, and later open reduction and internal fixation with dual incision dual plating is gold standard; Midline incision is considered as history and associated with complications. Purpose: The purpose of the study is to evaluate functional outcome in Type V and VI Schatzker bicondylar tibial plateau fractures, with early intervention using anterior midline approach and Dual plating. Materials and Methods: We analyzed retrospectively 35 patients from 2015 to 2018 at our tertiary center. All patients were operated within 12–24 h of injury using anterior midline approach and dual plating. Patients were evaluated radiologically (coronal alignment using medial proximal tibial angle, sagittal alignment using posterior proximal tibial angle and condylar width) functional and clinical assessment was done using Rasmussen and visual analog scale scoring at regular intervals till the last follow-up. Results: Bony union was achieved at average of 14 weeks (12–20 weeks), 80% patient had excellent and good results. 22% of patient needed bone grafting which was done primarily and 11.1% patient required an additional split skin graft and flap surgery. Complications such as deep and superficial infection were seen in 8.5%, knee stiffness (range of motion <90°) in 8.5%, and varus/valgus malalignment in 14.4% was seen. None of our patients had deep vein thrombosis (DVT). Average of hospital stay was 5.6 days only. Conclusion: Early intervention with single-incision anterior midline approach with dual plating for complex Type V and VI Schatzker bicondylar tibial plateau fractures can still be considered as a method of treatment when intervened early. The excellent functional outcome in this study, lower rate of complications, less incidence of DVT and shorter hospital stay are well comparable to dual incision technique.

Keywords: Bicondylar tibial plateau fractures, dual plating, early intervention, functional outcome, single anterior midline incision, Type V and VI Schatzker

How to cite this article:
Singhi PK, Raju S, Thangamani V, Velur Nagendra Reddy SK, Muthu C. Early intervention within 24 h using anterior midline single incision with dual plating for bicondylar tibial plateau fractures schatzker type v and vi: An analytical study. J Orthop Assoc South Indian States 2021;18:67-72

How to cite this URL:
Singhi PK, Raju S, Thangamani V, Velur Nagendra Reddy SK, Muthu C. Early intervention within 24 h using anterior midline single incision with dual plating for bicondylar tibial plateau fractures schatzker type v and vi: An analytical study. J Orthop Assoc South Indian States [serial online] 2021 [cited 2023 Apr 1];18:67-72. Available from: https://www.joasis.org/text.asp?2021/18/2/67/336656

Introduction

Proximal tibia involves major weight-bearing joint surface of the knee and is a superficial bone. Tibial plateau fractures can range from a simple lateral split pattern to very complex bicondylar injuries that can be a source of great disability, classified according to Schatzker et al. 1971^[1] as Schatzker Type V and VI fracture. They are high-velocity injury with concomitant injury to other bones, organs, and neurovascular structure. They are bicondylar fracture with significant articular involvement multiple displaced condylar fracture lines, metaphysiodiaphyseal extension, and comminution, with high incidence of compartment syndrome and soft tissue injury.

Unsatisfactory results with both surgical and conservative line of treatment^{[1],[2],[3],[4],[5]} have posed challenges for even the most experienced Surgeon. Fracture management requires precise analysis of the injury and careful operative planning. The soft tissue envelope, fracture pattern, bone stock, degree of comminution, experience of the treating surgeon influence the decision making and treatment modality.

Tibial plateau fractures account for 1.3% of all fractures and bicondylar type fractures constitute 20%–40% of them. The mechanism of injury is believed to be varus, valgus forces, axial loading of the lower limb, and combination injuries.

The objective of the treatment remains to achieve anatomical intraarticular reduction, stable fixation with functional range of movement of the knee joint. The degree of soft tissue injury will guide the treatment plan. Methods of treatment include conservative treatment (cast immobilization and functional braces), percutaneous wires with external fixators or circular fixators (Ilizarov), open reduction, and internal fixation with plating on lateral and medial side also using single or dual incision. The routine protocol remains temporary stabilization, limb elevation, ice compression, till the soft tissue swelling has come down, and plan for dual plating using dual incision.

We performed this study to evaluate the functional outcome in Type V and VI Schatzker bicondylar tibial plateau fractures, with early intervention using anterior midline approach and dual plating.

Methods and Materials

We at our center performed a retrospective analysis of the patients presented within 24 h of the injury, using single-incision anterior midline approach reducing the fractures achieving intraarticular alignment and fixing with dual plate from January 2015 to October 2018.

Inclusion criteria

Type V and VI Schatzker proximal tibia fracture presented within 24 h of injury either close or Grades I and II open injuries.

Exclusion criteria

Type V and VI Schatzker tibial plateau fracture with compartment syndrome or delayed presentation.

Grade III open tibia fracture, with vascular injury or unstable polytrauma patient where primary damage control orthopedic procedure was done.

Patient is not willing for the procedure.

Patients were taken up for the surgery at earliest usually within 12–24 h of the injury and we have not waited for the swelling to come down. Thorough evaluation applying ATLS protocol was done, with continued neurovascular observation and monitoring for the signs of compartment syndrome. Imaging using X-rays anteroposterior (AP), lateral views also of a hip and ankle joint, computed tomography scan was done; it allows assessment of fracture pattern particular the intraarticular comminution, magnetic resonance imaging (MRI) is useful to assess the ligamentous and soft tissue injury is rarely needed. Arterial Doppler and MRI angiography are useful in cases with neurovascular injuries.

All patients were approached with an anterior midline incision extending from suprapatellar region to well below the level of the fracture. Meticulous full-thickness soft tissue flap is elevated both on medial and lateral side as needed; IT band is divided proximally; intra articular visualization is done by submeniscal approach if needed, then tibialis anterior is subperiosteally elevated, intra articular fracture alignment is done and stabilized with K-wires temporarily and fixed with lateral locking compression plate or hockey stick plate or locking plate. The displaced posteromedial and medial condyle were reduced indirect technique and fixed with T-buttress plate medially sliding the plate through the pes anserinus without damaging it and medial collateral ligament, under image intensifier. Primary bone graft harvested from ipsilateral iliac crest and in few cases, synthetic bone graft (Tricalcium phosphate - Triosite) was used to pack the void after reduction. Stability and range of movement were confirmed after fixation. Patient was immobilized in long knee brace for 4 weeks with intermittent range of motion exercised and static quadriceps and hamstring strengthening exercised. Partial weight bearing and then full weight bearing was allowed depending upon the fracture union [Figure 1].

Figure 1: Type VI Schatzker in a postpolio limb single incision dual plating also metal exit done with excellent outcome

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The associated injuries were managed accordingly.

Our study included 35 patients of which 30 were male and 5 were female, 63% had RTA, majority of them were motor vehicle accidents and few were dash board injuries and 37% had accidental fall and other mode of injuries. 16.8% of the patients presented with Grades I and II open fractures and rest were closed injuries. Most of the patients presented to our hospital within the first 6–12 h of injury and were taken up for surgery at earliest. Average age of the patient was 41.5; maximum was 67 years and minimum 27 years. 9 patients had right-sided fracture and 16 patients had left tibia fracture. Primary bone grafting was done to fill the void after reduction in about 22% of patients. Fasciotomy was done to achieve closure and also to release the compartment pressure in around 11%. Average hospital stay was 5.6 days; maximum was 17 days and minimum 5 days.

Patients were regularly followed up initially every 15 days till 2 months then every month till 6 months and every 3 months later on [Figure 2] and [Figure 3].

Figure 2: Type VI Schatzker with fracture dislocation reduced and fixed with anterior midline incision with excellent outcome for such complex fractures

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Figure 3: Schatzker type IV proximal tibia fracture with reversal of posterior slope, corrected intraoperatively and dual plated with excellent outcome

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Radiological assessment was done by AP and lateral view at 6, 12, 18, 24 weeks and as needed to assess radiological union and alignment of the fracture, coronal alignment using medial proximal tibial angle in AP view (87° ± 5°) sagittal alignment using posterior proximal tibial angle in lateral view (9° ± 5°) and condylar width (0–5 mm).^{[4],[5],[6],[7],[8],[9],[10]}

Clinical and functional outcomes were assessed using Rasmussen criteria and visual analog scale (VAS) scoring system during the latest follow-up visits.

Results

Average follow-up duration was 42 months, minimum duration 36 months and maximum of 70 months. We had the mean VAS score of 1.5 and excellent to good functional outcome in 80% of our patients and the 20% had fair outcome. The bony union was achieving at an average of 14 weeks (12–20). The average medial proximal tibial angle was 89.5° and posterior proximal tibial angle of 5.5°. The mean range of movement of the knee is from 0° to 115°.

None of our patients had extensor lag, 2 patients had mild fixed flexion deformity of 5°–10° because of the preexisting osteoarthritic changes. We had no nonunion or delayed union as primary bone grafting was done in 8 patients (22.5%). Primary fasciotomy was done in 2 patients to achieve wound closure and release the compartment pressures, and later split skin graft was done on 4^th postoperative day. Two patients had skin gapping which needed secondary flap procedure and was also done on 6 or 7^th postoperative day.

Superficial (2 patients) and deep (1 patient) infection (8.5%) was seen and was appropriately managed with debridement and antibiotics. None of our patient had any deep vein thrombosis (DVT) reported. The average hospital stay was only 5.6 days.

Discussion

Bicondylar (Schatzker type V and VI) tibial plateau fractures are complex high-velocity injuries with compromised soft tissue. Most publications suggest dual plating^[11] with dual incision or hybrid external fixator.^{[8],[18],[19]} Few papers supporting midline anterior approach with dual plating^[12],[19] have encouraged us to take up this method of treatment in our study; we had an excellent outcome with limited complications, which is a part and parcel of such injuries.

The midline approach has the advantage to provide complete exposure of the fracture pattern by lifting long full-thickness soft-tissue flap which also enables to do fasciotomy of anterior, medial, and also sometimes posterior compartment and achieve dual plate fixation and obtain satisfactory closure also midline incision enables future arthroplasty procedure. The proponents of dual approach have reported lower rates of complications such as infection and wound gapping.^[13],[14]

A paper from Barei et al.^[11] which included 83 patients of Type V and VI Schatzker treated with dual incision dual platting followed up over a period of 77 months has reported deep wound infection of 8.4%, septic arthritis of 3.2%, fasciotomy was done in 14.5% of patients, 19.3% patient developed nonfatal DVT, 9% had coronal malalignment, 28% had sagittal malalignment. The average interval from injury to definitive treatment was 9.2 days (range: 0–40 days). The definitive surgery was delayed to an average of 14 days (3–40 days) [Table 1]. The two independent reports by Moore's et al.,^[4] Young and Barrack, Mallik et al.^[3] reported deep infections 73%, 87.5% and 80%, respectively, after medial and lateral plating.

Table 1: Comparison of our study with dual incision and plating by David P. Barey et al.^[11]

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High complication rates^[15],[16] have been reported with open reduction and plate fixation in Type V, VI tibial plateau fractures has prompted alternative methods of stabilization like hybrid fixators, limited juxta articular fixation combined with external fixator, JESS fixators where articular congruity was achieved by indirect technique or limited incisions and axial alignment was maintained with external fixators. Deep infection rate of 0%–13% has been reported with this kind of management with significant residual articular incongruity posttraumatic arthrosis and lowered functional outcome [Table 2].

Table 2: Comparison of our study with other studies using single midline incision and dual plating

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The primary goal of open reduction internal fixation was to achieve accurate articular metaphysiodiaphyseal alignment, enable early range of movement at the knee and ankle joint.^[17],[20]

Our results in comparison to the above are well comparable and much satisfactory. Fasciotomy was done only in two patients because the surgical approach itself allows the decompression of fracture hematoma and release of pressure in most of the compartments. We had no case of DVT reported and the average hospital stay was only 5.6 days (5–17 days). Hence, this suggests to be a valid and effective treatment option for complex bicondylar tibial plateau fractures who presents early where the compartment syndrome has not set in.

The dual plate fixation provides greater stability by reconstruction of lateral and medial column reduces the rate of subsidence and malalignment. The advent of locking plates has further enhanced the stability and outcome of the fractures. The indirect reduction of medial articular surface and further stabilization with the medial plate provides equivalent stability to that of posteromedial approach and plating which is definitely indicated in significantly displaced posteromedial fragment.

None of our patient had neurovascular injury but impending compartment syndrome was noticed in about 25% of our patients.

Significant high rate of DVT was noticed in the previous studies because of long immobilization and waiting period, none of our patient had DVT because of early surgical intervention and stabilization.

Advantages of single anterior midline incision are:

Provide complete exposure of the fracture enables reduction and dual fixation
Evacuation of hematoma compartment decompression and fasciotomy
Obtains satisfactory closure
Enables future arthroplasty procedure
Gentle handling of the soft tissue and full-thickness long flaps can avoid it (complications such as infection and wound gapping).

Conclusion

Early intervention with single midline anterior approach with dual plating for complex Type V and VI Schatzker tibial plateau fractures is still a valid and excellent method of treatment with excellent functional outcome, lower rate of complications, less incidence of DVT, and shorter hospital stay.

Ethical clearance

Institutional ethical clearance obtained.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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