Treatment of Complex Proximal Tibial Fractures (TypesV & VI of Schautzker Classification) by Double Plate Fixation with Single Anterior Incision

doi:10.4236/ojo.2013.34038

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Open Journal of Orthopedics, 2013, 3, 208-212

http://dx.doi.org/10.4236/ojo.2013.34038 Published Online August 2013 (http://www.scirp.org/journal/ojo)

Treatment of Complex Proximal Tibial Fractures (Types

V & VI of Schautzker Classification) by Double Plate

Fixation with Single Anterior Incision

Ebrahim Ghayem Hassankhani*, Farzad Omidi Kashani, Golnaz Ghayem Hassankhani

Orthopedic and Spine Surgery, Imam Reza Hospital, Mashad University of Medical Sciences, Mashad, Iran.

Email: *[email protected], *[email protected]

Received June 1st, 2013; revised July 1st, 2013; accepted July 14th, 2013

tribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is prop-

erly cited.

ABSTRACT

Background: complex proximal tibial fractures (Types V & VI of Schautzker classification) are the major problems in

orthopedic surgery and associated with high complication rates. There are many alternatives in treatment of these frac-

tures. Aim: to evaluate the results of double plating with single anterior incision in complex proximal tibial fractures

(Types V & VI of Schautzker classification). Methods and Materials: 22 patients (16 males and 6 females) with Types

V and VI of Schautzker classification of proximal tibial fractures (14 cases were Type V and 8 cases were Type VI)

were treated by double plating with single anterior incision method between May 2006 and May 2011. The bony and

functional outcome was evaluated according to Knee Society Score. Results: According to Knee Society Score, the re-

sults were as follows: excellent in 19 patients (86.4%), good in 2 patients (9.1%), fair in 1 patient (4/5%), and poor in

no patient (0%). Conclusion: the double plate fixation with single anterior incision is the best, effective and simple

procedure in treatment of complex proximal tibial fractures (Types V and VI of Schautzker classification).

Keywords: Proximal Tibial Fractures; Types V & VI of Schautzker Classification; Double Plate Fixation; Single

Anterior Incision

1. Background

Complex proximal tibial fractures (Types V & VI of

Schautzker classification) are the major problems in or-

thopedic surgery and associated with high complication

rates. These fractures include bicondylar injuries with

significant articular depression; multiple, displaced con-

dylar fracture lines; metadiaphyseal fracture extension

and comminution; and open wounds or extensive, closed

injuries [1-3]. Both the complexity and the soft-tissue

disruption of this subgroup of fractures contribute to the

high rate of unsatisfactory results which follow bo th non-

surgical and surgical management [4,5].

The goals of operative treatment of these fractures in-

clude anatomic reduction for restoration of articular con-

gruity and alignment, and stable fixation to allow early

motion.

Dual plating is preferred to other techniques in the set-

ting of a significantly displaced fracture of the articular

surface, especially in cases with significantly depressed

fragments [6,7].

This technique, when performed through a single,

midline extensile or double incision with wide stripping

of the proximal tibia, has been associated with deep in-

fection, wound dehiscence, and soft tissue complications

in 23% to 100% of patien ts [8-11].

The two most common complications of double plat-

ing with two or single incision are; th e co mpro mised skin

and soft tissue envelope, which invites a high rate of

complications following attempted open reduction and

internal fixation, and poor bone quality and comminuted

fracture patterns creating difficulty in achieving stable

fixation [3,7,9-11].

The purpose of th is study was to evaluate the resu lts of

double plating with single anterior midline incision in

complex proximal tibial fractures (Types V & VI of

Schautzker classification) and compare this rate to other

series in the literature.

*Corresponding a uthor.

Treatment of Complex Proximal Tibial Fractures (Types V & VI of

Schautzker Classification) by Double Plate Fixation with Single Anterior Incision

209

2. Methods and Materials

22 patients (16 males and 6 females) with Complex

proximal tibial fractures were treated by double plating

with single anterior midline incision between May 2006

and May 2011.

The fractures were classified using the Schautzker

classification, and open fractures were classified accord-

ing to the method of Gustilo and coworkers. 14 cases

were Type V and 8 cases were Type VI of Schautzker

classification. 5 patients had open fracture (3 cases were

Type I and 2 cases were Type II of Gustilo classifica-

tion). There were 16 males and 6 females with a mean

age of 35 years (19 to 67).

5 patients suffered from additional injury (limb frac-

tures, head, chest or abdomin a l injury).

20 patients were treated by one stage surgery and 2 pa-

tients were treated by two stage surgery (debridement

and then plate fixation) due to open Type II Gustilo frac-

ture.

All patients had anterior-posterior (AP) and lateral ra-

diographs as well as CT scans to identify each of the bi-

condylar fractures.

Definitive fixation by double plating with single ante-

rior midline incision technique was performed after the

soft tissue injury had improved. The time from injury to

definitive fixation varied widely (range: 2 to 15 days) as

a result of variable degree of soft tissue compromise

noted at initial presentation.

Closed fractures were treated with single anterior mid-

line incision and double plate fixation.

Open fractures were managed by two stage surgery

initially with irrigation and debridement and then by fix-

ation.

The technique for fixation was as follow: With an an-

terior midline incision the proximal tibial fractures were

exposed. A transverse submeniscal arthrotomy was per-

formed to expose the articular surface at both sides. De-

pressed fragments were elevated and then supported with

bone graft. L or T buttress or proximal metaphysial LCP

plates were applied once anatomic reduction had been

achieved. Plain radiographs were taken in the operating

room to verify adequate articular reduction and plate's

placement (Figures 1 and 2).

After surgery, the leg was supported and elevated with

a posterior above-knee splint until soft tissue swelling

resolved. Knee motion was started on the 3rd day with a

CPM machine.

The patients were discharged with a posterior splint

and were seen in an out-patient department after 15

days until the stitches and the posterior splint were

removed. They were maintained on non-weight-bear-

ing ambulation for 3 months. Serial radiographic ex-

amination of the knee and the tibia in AP and lateral

Figure 1. A 32-years-old man with Type V of Schautzker

tibial platu fracture in motorcycle accident.

Figure 2. After surgical treatment by double plate fixation

with single anterior incision te chnique .

planes was performed at 6 weeks, 3 months, 6 months,

and 1 year post-operatively for follow-up of the frac-

ture healing.

In 8 patients autologous bone graft was needed at the

time of surgery due to bone loss after elevation of de-

pressed fragments. The bony and functional outcome was

evaluated according to Knee Society Score.

3. Results (Table 1)

In all 22 patients the fracture had un ion with the average

time up to 15 weeks (range12 - 23). None of the patients

developed joint infection. 2 patients had superficial in-

fection, which was suppressed with daily care and anti-

biotics.

None of the patients developed a varus or valgus de-

formity and leg-length discrepancy. None of the patients

underwent a second operative procedure.

One patient had deep venous thrombosis (DVT) that

required admission to the intensive care unit and antico-

agulation therapy. 2 patients had significant pain requir-

ing analgesics.

2 patients had noticeable limping. 16 patients achieved

ability to perform previous activities of daily living

(ADL) and returned to th eir previou s work, 4 p atient s got

ability to perform previous activities of daily living

(ADL) and previous work with minimal difficulty, and 2

Treatment of Complex Proximal Tibial Fractures (Types V & VI of

Schautzker Classification) by Double Plate Fixation with Single Anterior Incision

210

Table 1. Clinical data of 22 patients with complex proximal

tibial fractures (Types V & VI of Schautzker classification)

treated by double plate fixation with single anterior inci-

sion.

Data Number of patients

Type of fracture (Schautzker)

Type VI 8

Type V 14

Sex

Female 6

Male 16

Side of fracture

Left 12

Right 8

Left & Right 2

Complications

Infection 2

Residual deformity 0

Shortening > 2/5 cm 0

Returned to previous work 20

Changed work 2

Unable work 0

Significant pain 2

Noticeable limp 2

Loss of knee motion > 15D 3

patients had significantly limited activities of daily liv ing

(ADL) and required a change from previous work.

According to Knee Society Score, the results were as

follows: excellent in 19 patients (86.4%), good in 2 pa-

tients (9.1%), fair in 1 patient (4/5%), and poor in no

patient (0%) (Table 2).

4. Discussion

The most common difficulties are faced by the surgeon

while dealing with intra-articular proximal tibial frac-

tures are the compromised skin and soft tissue envelope,

which invites a high rate of complications following at-

tempted open reduction and internal fixation, and poor

bone quality and comminuted fracture patterns creating

difficulty in achieving stable fixation [3,7,9-12].

Treatment options include non-operative treatment

using traction, casts or braces, hybrid, ring, or uniplanar

external fixation; fixed angle implants utilizing percuta-

Table 2. The results of 22 patients with complex proximal

tibial fractures (Types V & VI of Schautzker classification)

treated by double plate fixation with single anterior incision

according to Knee Society Score.

Results

Grade Number of patients percent

Excellent 19 86.4

Good 2 9.1

Fair 1 4/5

Poor 0 0

Total 22 100

neous exposure and reduction; dual plating with one or

two incision, arthroscopically assisted fixation and mi-

nimal percutaneous pinning, lateral plating and medial

fixator, and minimally invasive techniques (LISS sys-

tem ) [1,2,5,11,13-17].

Regardless of treatment technique the reported com-

plications include: wound breakdown; deep infection,

deep vein thrombosis; compartment syndrome; non-un-

ion; myositis ossifican; peroneal palsies; hardware fail-

ure; and arthrofibrosis [7,18-20].

Non-operative treatment using traction, casts or braces

has been reported to produce poor functional results,

have prolonged hospital stays and complicated by the

loss of redu ct ion [1 2].

Arthroscopically assisted fixation and minimal percu-

taneous pinning have also been reported to give good

results but these modalities are suitable for simple split

depression and local compression fr actures [17,21].

Open double plate fixation has been reported to be as-

sociated with the complication of wound dehiscence and

infection [10,22,23].

Hybrid fixation systems have not good functional an d

bony results, and give increased risk of pin tract infection

and prolonged courses of treatment [23-28].

Some studies have reported that open lateral plating

and medial fixator in complex bicondylar fractures of the

tibia give good functional results minimizing soft tissue

complications [13].

Currently, minimally invasive techniques (LISS sys-

tem) are used commonly by orthopaedic surgeons, and

there have been reports of good results in tibia plateau

fractures being treated exclusively by this technique.

This system minimizes the surgical complications by

decreasing the soft-tissue stripping, to provide a rigid

fracture reduction and to respect the post-traumatic soft-

tissue injury [15,29,30].

To minimize the surgical complication especially in-

fection, staged treatment is necessary in open complex

Treatment of Complex Proximal Tibial Fractures (Types V & VI of

Schautzker Classification) by Double Plate Fixation with Single Anterior Incision

211

proximal tibial fractures [31]. In this study 2 patients

with open Type II Gustilo fractures were treated by two

stage surgery (debridement and then plate fixation).

Anatomical knee joint reduction, the relative stability

and alignment of the proximal tibia allowing the earliest

knee mobilization, while keeping complications to a mi-

nimum rate, are the major goals in the treatment of com-

plex proximal tibial fractures [27,32].

In order to obtain stability of bicondylar and complex

proximal tibial fractures, reduction and fixation of both

medial and lateral columns is necessary. Dual plating

successfully gives a good stability by buttressing both

columns; but high rate of complications associated with

this open techniqu e is reported [10,11].

Steven N., et al. reported wound dehiscence and infec-

tion in proximal tibial fractures treated with double plate

fixation [33]. In our study superficial infection was ob-

served in 2 cases and no sof t tissue breakdown was noted.

We also had good functional and bony results.

In this study, our results demonstrate a lower risk for

deep infection and soft tissue complications, good func-

tional and bony results in complex proximal tibial frac-

tures when compared to earlier reports about other tech-

niques.

5. Conclusion

The double plate fixation with single anterior incision is

the best, effective and simple procedure in treatment of

complex proximal tibial fractures (Types V and VI of

Schautzker classification) with lower risk for deep infec-

tion and good results when compared to other reported

techniques.

6. Acknowledgements

The authors thank orthopaedic research center group for

their assistance.

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