Tibial Plateau

 

Schatzker Classification

 

I.  Lateral Spilt 

- seen in young patient

- lateral meniscus can be incarcerated in fracture

 

Tibial Plateau Schatzker 1Schat 1schat 1 ct

 

II.  Lateral Split Depression

- often seen in young patients with high energy injuries

- vary in severity

 

Schatzker 2 Split DepressionTibial Plateau Joint Depression

 

III.  Lateral Depression 

- central depression usually seen in elderly

- have to create lateral cortical window in order to elevate fragment

 

Tibial Plateau DepressionSchatzker IIISchatzker III

 

IV.  Medial plateau & intercondylar eminence 

- high velocity injury associated with ACL / LCL / CPN injury

- can be low injury / osteoporotic and often unreconstructable

 

Schatzker 4 Tibial PlateauTibial plateau Type IV

 

V.  Bi-condylar + intact metaphysis

- unstable

- requires ORIF

 

Schatzker VISchatzker 5 Bicondylar CT

 

VI.  Bi-condylar + metaphyseal fracture

- fracture separating metaphysis from diaphysis

- highest incidence of vascular injury

 

Schatzker 6 Schatzker 6 CT

 

3 column concept of tibial plateau fractures

 

Luo et al. Orthop Trauma 2010

- introduces the 3 column concept

- medial column / lateral column / posterior column

- posterior column can be splint into medial and lateral fragments (posterolateral / posteromedial)

- imporant as any surgery must address these fragments

- typically require additional posteromedial or posterolateral approaches

https://pubmed.ncbi.nlm.nih.gov/20881634/

 

Posterolateral Tibial Plateau3 column tibial plateau classification

 

Epidemiology

 

Most common is Type II split depression

- 80%

 

Type IV medial condyle

- 10 - 20%

 

Type V, VI bicondylar

- 10 - 20%

 

Age

- young people splits / wedges

- older people joint depression

 

Anatomy

 

Medial plateau larger than lateral

- medial is concave in sagittal plane (golf tee)

- lateral is convex & more proximal (golf ball)

 

Creates 3o of varus proximal tibia

- important to be created in any reconstructive tibial plateau surgery

 

Normal posterior slope

- 10o

 

Knee Normal AP

 

Lateral plateau is covered by meniscus

- tolerates incongruity better than medial plateau

 

Pathology

 

Lateral plateau more commonly fractures

- medial plateau more resistant to fracture

- due to its larger surface and increased weight bearing

- thicker stronger subchondral bone

- any fracture of medial plateau indicates high energy 

- high incidence of soft tissue complications & poor outcomes

 

Associated Injures

 

Meniscal injury

 

Stahl et al. J Orthop Trauma 2015

- 602 patients

- 30% had a lateral meniscus tear requiring intervention

- 45% in split depression Type II

https://pubmed.ncbi.nlm.nih.gov/25635356/

 

Ligament injury

 

Gardner et al. J Orthop Trauma 2005

- MRI of 103 patients with tibial plateau booked for surgery

- 57% complete tear of ACL

- 28% complete tear of PCL

- 29% complete tear of LCL

- 32% complete tear of MCL
https://pubmed.ncbi.nlm.nih.gov/15677922/

 

Tomas-Hernandez et al. Injury 2016

- case series of patients with anteromedial tibial plateua fractures

- these patients have posterolateral corner ligament injuries

https://pubmed.ncbi.nlm.nih.gov/27692105/

 

Compartment syndrome

 

Increased incidence in high energy injuries

- Type V and VI bicondylar fractures

- Type IV medial fracture dislcations

 

Gamulin et al. BMC Musculoskeletal Disorders 2017

- 28/265 (10%) tibial plateua fractures had compartment syndrome

- more common in higher grade tibial plateau fractures

- more comon in young patients

https://pubmed.ncbi.nlm.nih.gov/28720096/

 

Popliteal artery damage

 

CPN

 

Factors affecting outcome

 

1.  Severity of intial injury

2.  Residual Articular step

3.  Alignment

4.  Meniscus

5.  Instability

 

Blokker et al. CORR 1984

- >5 mm step 0% good or excellent results

- <5 mm 75% good or excellent results

- < 2 mm 85% good or excellent results

https://pubmed.ncbi.nlm.nih.gov/6546361/

 

Biz et al. Orthop Surg 2019

- worse outcomes with more severe injuries

- daily pain associated with residual articular step and malalignment

https://pubmed.ncbi.nlm.nih.gov/31755217/

 

Honkonen et al. J Orthop Trauma 1995

- meniscectomy during ORIF resulted in 74% osteoarthritis

- if meniscus intact or repaired, 37% osteoarthritis

https://pubmed.ncbi.nlm.nih.gov/7562147/

 

Management

 

Examination

 

NV examination

 

Soft tissue examination

- Tscherne / closed soft tissue injury classification

- Gustillo / open soft tissue injury classification

 

Exclude compartment syndrome

 

CT scan

 

Assess joint line

- predetermine fracture pattern before fixation

- will pick up medial condyle / bicondyle / metaphyseal fractures not seen on xray

 

Temporary Spanning External Fixation

 

Knee Spanning Ext Fix

 

Tibial Plateau Temporary External Fixator APTibial Plateau Temporary External Fixator Lateral

 

Indications

- open fracture

- complex pattern / shortening / malalignment

- poor soft tissues / extreme swelling

 

Advantages

- pulls out to length with ligamentotaxis

- allows soft tissues to settle / swelling resolves

- subsequent surgery easier and safer

 

Construction

- 2 x 5 mm half pins anterior / anterolateral femur

- 2 x 5mm half pins anterior tibia far from incision

- apply under flouroscopy guidance / reduce / apply traction

- 2 x anterior rods

- slight flexion

 

AO Foundation Surgical Technique

https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/proximal-tibia/complete-articular-fracture-fragmentary-articular/bridging-external-fixator-temporary

 

Definitive Management

 

Indications for surgery

 

1.  Step > 2mm

2.  Malalignment

 

Type I

 

Percutaneous fixation

- beware trapped lateral meniscus

- consider arthroscopic inspection initially

- difficult to see because of haematoma 

- also risk of compartment syndrome so need careful fluid management

 

Tibial Plateau Schatzker 1 Percutaneous ScrewsTibial Plateau Schatzker 1 Percutaneous screws Lateral

 

Type II Split Depression

 

Tibial Plateau ORIF

 

Timing

- blisters epithelialised

- skin wrinkled

- 2-3 weeks

 

Set up

- prone on radiolucent table

- knee flexed over bolster or triangle

- tourniquet, antibiotics

- remove frame, scrub leg and apply sterile dressings to pin sites to remove from operative field

- some surgeons leave frame on to aid reconstructive surgery

- may need to use femoral distractor

 

Approach

 

Anterolateral Approach KneeTibia Anterolateral Approach 2

 

Anterolateral approach

- lateral longitudinal incision

- split ITB proximally

- open anterior fascia distally and elevate tibialis anterior from tibia

- perform submeniscal arthrotomy by incising capsule and coronary ligament from proximal tibia

- elevate capsule / ligament / and lateral meniscus via 1 vicryl stay sutures

- inspect joint and lateral meniscus via varus force

- can use femoral distractor

 

Technique

- elevate and restore joint line

- compress with bone reduction forcep

- stabilise joint line with 2 x 6.5 mm cannulated partially threaded screws

- check fluoroscopy

- restore alignment via application anatomically contoured 4.5 mm locking plate

- often use BG or substitutes under depression fractures laterally

 

Stability

- must assess at end of operation

 

Type III Depression

 

Type III tibial plateauType III tibial plateauType III tibial plateau ORIFType III tibial pateau ORIF III

 

Technique

 

Anterolateral approach

- visualise joint line

- create cortical window

- elevate fracture

- support with bone graft (autograft / allograft / bone substitute)

 

Type IV Medial Condyle

 

Technique

 

Medial approach

- make incision 1 cm from posterior edge of tibia

- release and reflect MCL posteriorly

- partially release pes anserinus / reflect inferiorly

- T plate

- can slide under the pes

 

Schatzker 4 Medial Plate0001Schatzker 4 Medial Plate0002

 

Type V Bicondylar

 

Options

1. Medial and Lateral plating

2. Circular Fixator

 

Canadian Orthopedic Trauma Society JBJS Am 2006

- RCT of ORIF (two plates) with circular external fixation in 83 knees

- comparable fracture reduction in both

- no difference in outcomes

- reduced blood loss / hospital stay / infection / reoperation with external fixation

- 7/40 (18%) of patients undergoing ORIF had an infection

https://pubmed.ncbi.nlm.nih.gov/17142411/

 

Zhao et al. Int J Surg 2017

- meta-analysis of external fixation v ORIF for complex tibial plateua fractures

- no difference in DVT/PE, outcomes, deep infection between two groups

- external fixation does have an overall higher rate of infections due to pin site infections

https://pubmed.ncbi.nlm.nih.gov/28089798/

 

1. Medial and Lateral Plating

 

Technique

- depends on which of the three columns affected

- anterolateral approach for lateral column

- posteromedial appraoch for medial / posterior column

 

Tibial Plateau Bicondylar ORIF APTibial Plateau Bicondylar ORIF Lateral

 

2. Circular external Fixation

 

Indications

- poor soft tissues

- compound wound

 

Technique

- hybrid fixation

- wire fixation proximally

- pin fixation distally

- use olive wires to compress fracture fragments

- place wires 14mm from joint surface to avoid placing intra-articular

 

Schatzker VI Ilizarov

 

Type VI Bicondylar with Metaphyseal Fracture

 

Technique

- long locking plate minimally invasive with locking jig / MIPO

- proximal lag screws

- ensure correct alignment

- often use small medial buttress plate

 

Tibial Plateau Schatzker 6 ORIF APTibial Plateau Schtazker 6 ORIF LateralSchatzker 6 ORIF APSchatzker 6 ORIF Lateral.jpg

 

Posterolateral Tibial Plateau Fractures

 

Definition

- fracture in posterior half of lateral tibial plateau

- very difficult to access with standard anterolateral approach

 

Posterolateral Tibial PlateauPosterolateral Tibial PlateauPosterolateral Tibial PlateauPosterolateral Tibial Plateau

 

Posterolateral Tibial PlateauPosterolateral Tibial PlateauPosterolateral Tibial Plateau

 

Options

1. Trans-fibular neck osteotomy + anterolateral approach

2. Posterolateral approach + anterolateral approach

 

1. Transfibular osteotomy

- incision based on fibular

- divide ITB

- expose CPN under biceps femoris

- release CPN completely from fibular neck and protect

- maintain ligamentous attachments to fibular head

- predrill fibula for later intra-medullary screw

- chevron osteotomy at fibular neck

- reflect fibular head posteriorly and superiorly on biceps / LCL attachments

- place posterolateral buttress plate

- expose anterolateral tibia and place standard anterolateral plate as needed

- stabilize tibio-fibular joint with screws from fibular into tibia / fibular screw

 

Pires et al. Injury 2016 Article PDF

https://www.otcbrazil.com.br/wp-content/uploads/2017/10/Transfibular-Injury-publicado.pdf

 

2.  Posterolateral approach

- single incision

- identify, release and protect the CPN

- posterolateral window is below CPN

- gastrocnemius posteriorly, tibia and popliteus anteriorly

- ligate inferior geniculate artery on the popliteus

- may need to partially release popliteus tendon and repair later

- place buttress plate posteriorly

- make standard anterolateral window for anterolateral plate

 

Vumedi video

https://www.vumedi.com/video/the-posterolateral-approach-without-fibula-osteotomy-for-posterolateral-column-fractures-of-the-tibi/

 

Posteromedial Tibial Plateau Fractures

 

Tibial Plateau Type VTibial Plateau Type V ORIF APTibial Plateau Type V ORIF Lateral

 

Posteromedial approach and buttress plate

- Burks modified posterior approach

- put leg over triangle, can let let flop out to get to medial side

- incision based upon posteromedial tibia

- interval between semimembranosus and medial head of gastrocnemius

- medial head of gastrocnemius retracted laterally

- hamstring tendons retracted medially

- place blunt homann gently across back of tibia to expose fracture

- subperiosteal release of the popliteus muscle

- place posterior anti-glide buttress plate

 

Posteromedial approach knee 1Posteromedial approach knee 2

 

Posteromedial approach knee 3Posteromedial plate

 

Vumedi video

https://www.vumedi.com/video/orif-of-bicondylar-tibial-plateau-fractures/

 

Vumedi video

https://www.vumedi.com/video/the-direct-posterior-approach-to-posteromedial-tibial-plateau-fractures/

 

Arthroscopy assisted Tibial Plateau ORIF

 

Advantages

- direct visualisation of joint surface restoration

 

Indications

- Type III depression

 

Contra-indications

- Type IV / V / VI

- risk of compartment syndrome

- ROM < 110o

 

Technique

 

Athroscopy Techniques PDF and videos

https://www.arthroscopytechniques.org/article/S2212-6287(19)30028-3/fulltext

 

Rehabilitation

 

Hinged Brace

NWB 8 weeks

 

Complications

 

Infection

 

Shao et al. Int J Surg 2017

- systematic review infection rate 9.9%

- risk factors open fractures, compartment syndrome, longer operative times, smoking, external fixation

https://pubmed.ncbi.nlm.nih.gov/28385655/

 

Osteoarthritis

 

Wasserstein et al. JBJS Am 2014

- incidence of TKR 10 years post injury of 7.8% compared to 1.8% in matched cohort

- more likely with older patients and more severe fractures

https://pubmed.ncbi.nlm.nih.gov/24430414/

 

Collapse / Malunion

 

Tibial Plateau Collapse Malunion Tibial Plateau Collapse Malunion

 

Option

 

1. Distal femoral varus osteotomy and fresh osteochondral allograft

 

Tibial Plateau MalunionTibial Plateau Malunion 2

 

 

Lateral Tibial Plateau MalunionDFVO and osteochondral allograft

 

Abolghasemian et al. JBJS Am 2019

- long term follow up of fresh osteochondral allograft transplantation

- large post traumatic osteochondral defects > 3 cm diameter and > 1 cm in depth

- graft survivorship was 90% at 5 years, 79% at 10 years, 64% at 15 years, and 47% at 20 years

https://pubmed.ncbi.nlm.nih.gov/31220027/

 

2. TKR

 

Tibial Plateau OA TKR0001Tibial Plateau OA TKR0002

 

Scott et al. Bone Joint J 2015

- 31 patients with tibial plateau fracture requiring TKR at a mean of 24 months

- matched to a cohort of primary OA undergoing TKR

- increased rate of wound complications and stiffness in tibial plateau cohort

- otherwise, no significant difference in postoperative outcomes between the two groups

https://pubmed.ncbi.nlm.nih.gov/25820894/