|Year : 2015 | Volume
| Issue : 2 | Page : 142-147
Comparative study of fixation of proximal tibial fractures by nonlocking buttress versus locking compression plate
Dhiraj Girish Patil1, Soumya Ghosh2, Arunima Chaudhuri3, Soma Datta4, Chinmay De2, Prasun Sanyal2
1 Department of Orthopedics, IMSR Medical College, Mayani, Satara, Maharashtra, India
2 Department of Orthopedics, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
3 Department of Physiology, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
4 Department of Pathology, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
|Date of Web Publication||6-May-2015|
Krishnasayar South, Borehat, Burdwan - 713 102, West Bengal
Source of Support: None, Conflict of Interest: None
Background: Management of tibial plate fracture represents a challenging problem in developing countries. Aims: To compare the results of treatment of tibial plateau fractures with conventional nonlocking buttress plates (BP group) and locking compression plates (LCPs). Materials and Methods: The study was conducted on 30 patients with intra-articular closed fractures of the proximal tibia who were alternately assigned to two different treatment protocol, conventional nonlocking BP group or locking plates (LP group). Results : Schatzker Type II fracture was found to be the commonest fracture type with 13 patients. Only lateral plating was done in 24 patients, and dual plating was done in 6 patients. In 8 patients, corticocancellous bone graft were used. On follow-up complications like superficial skin necrosis (two cases), infection (two cases), varus collapse (three cases) developed. Sixty percent in LCP group, 66.6% in buttress group fractures clinically united in the time period of 7-9 weeks and 73.3% in LCP group and 80% in buttress group radiological union occurred in a period of 12-15 weeks. The results were graded in accordance with Poul S. Rasmussen's grading system. During the follow-up, 73.3% in LCP group and 66.6% in buttress group had no pain after clinical union. 66.6% patients in LCP group and 73.3% in buttress group could perform normal walking. About 86.6%in each group had no lack of extension. Nine patients (60%) in LCP group and 10 patients (66.6%) had flexion of up to at least 140°. About 86.6% in LCP group and 80% in buttress group had a stable joint in extension. Conclusion: Considering its high cost, LP group should only be used, where it is more advantageous than conventional plate.
قاسلا ماظع روسك جلاع
ةيمانلا نادلبلا يف اريبك ايدحت ةيبوبنظلا ةحيفصلا روسك جلاع لثمي :ةساردلا ةيفلخ
جلاع ةقيرطو حوتفملا يديلقتلا جلاعلاب ةيبوبنظلا ةبضهلا روسك جلاع جئاتن ةنراقم :ةساردلا فادهأ.قلغملا ةيمحربلا ةحيفصلا
،ةبيرقلا قاسلا يف ةقلغم ةيلخاد روسك نم نوناعي اضيرم 30 ىلع ةساردلا تيرجأ :جهنملا و داوملا ىرخلأاو .حوتفملا يديلقتلا جلاعلا ةقيرطب تجلوع امهادحإ ،نيتيحلاع نيتعومجم ىلإ مهميسقت متةقلغملا ةيمعربلا ةحيفصلا ةقيرطب
.اعويش رثكلأا وهو روسكلا نم يناثلا عونلا نوناعي اضيرم 13 نأ ةساردلا ترهظأ :جئاتنلا
مدختسا امك ، ىضرم 6 ىلع جودزملا ءلاطلا قبطو اضيرم 24 ددعل يبناجلا ءلاطلا يرجأ دقو (دلجلا رخن ةيحطس :لثم تافعاضملا ضعب ترهظ ةعباتملا دعبو ،ىضرم ةينامثل يمظعلا معطلا:يتلأا ةساردلا جئاتن ترهظأو )تلااح ثللاث ( مدقتملا سوقتلا )ناتلاح (ىودعلا )ناتلاح
عيباسأ 9 1 نيب تحوارت ةدم يف تمحتلا ةيمعربلا ةحيفصلا ةعومجم نم %66و ةقلغملا روسكلا نم %60
تحوارت ةرتف يف ماحتللاا ثدح ىرخلأا ةعومجملا نم %80و ةقلغملا روسكلا ةعومجم نم %73.3 اعوبسأ 15 12 نيب
ةعومجم نم %73.3 تناك ةعباتملا للاخ نمو نيسومسارو لوب ماظنل ًاقفو جئاتنلا فينصت متو.روسكلا ماحتلا دعب اورعشي مل ةيمعربلا ةحيفصلا ةعومجم نم %66.6 و ةقلغملا روسكلا
ةيداع ةقيرطب يشملا نم اونكمت ىرخلأا ةعوجملا نم %73.3 و ةقلغملا روسكلا ةعومجم نم %66 86.6 % في المجموعتين لم يشعروا بنقص في التمدد وقد أظهر 9 مرضى من مجموعة الكسور المغلقة ) 60 %( و 10 مرضى من المجموعة الأخرى
%66 ( درجة انثناء وصلت إلى 140 درجة عل الاقل (
86.6 % من طريق العلاج المغلق و 80 % من المجموعة الأخرى كانت حالة تمدد المفصل عندهم مستقرة.
Keywords: Conventional nonlocking buttress plate, locking plates, tibial plateau fractures
|How to cite this article:|
Patil DG, Ghosh S, Chaudhuri A, Datta S, De C, Sanyal P. Comparative study of fixation of proximal tibial fractures by nonlocking buttress versus locking compression plate. Saudi J Sports Med 2015;15:142-7
|How to cite this URL:|
Patil DG, Ghosh S, Chaudhuri A, Datta S, De C, Sanyal P. Comparative study of fixation of proximal tibial fractures by nonlocking buttress versus locking compression plate. Saudi J Sports Med [serial online] 2015 [cited 2023 Jun 5];15:142-7. Available from: https://www.sjosm.org/text.asp?2015/15/2/142/156345
| Introduction|| |
Tibial plateau fractures (TPFs) are mainly caused by high energy mechanisms such as motor vehicle accidents, sports injury, fall from height and other less violent trauma occasionally produce them, especially in elderly osteoporotic patients. Posttraumatic or secondary osteoarthritis usually develops after fracture of the tibial plateau as a result of the alteration of the osseous anatomy leading to altered knee mechanics and loss of cartilage and bone. Proper management of the initial injury aims to obtain a stable, painless, mobile joint and to prevent the development of osteoarthritis. ,,
In the case of conventional screw-plate-bone construct, torque applied by the screw presses the plate over the cortex of the bone. So if any movement occurs between the components of this screw-plate-bone constructor pulls out strength of the screw decreases due to decreased bone density as in osteoporotic bone, there occurs failure of this construct leading to loss alignment of the fracture fragments. Moreover, since plates are placed firmly against the cortex, periosteal blood supply gets hampered, which may lead to necrosis of underlying bone. ,, To overcome this drawback, limited contact and point contact plates were developed to preserve the periosteal blood supply. ,,,, The use of locking plates (LP group) have been clearly demonstrated for comminuted intra-articular fractures, short segment periarticular fractures and fractures in osteoporotic bone, where they were proved to be superior to that of conventional plates. ,,,,
There are no absolute contraindications for the use of LP group, provided proper technique and principle are used during surgery. However, as these plates and locking screws are more costly than conventional screws and plates, LP group should only be used where they are more advantageous. Also, failure to follow the proper principle will lead to non- or mal-union. The present study was conducted to compare treatment of TPFs with conventional nonlocking buttress plates (BP group) and locking compression plates (LCPs) in a semi-urban population of a developing country.
| Materials and methods|| |
The study was conducted in Burdwan Medical College and Hospital. Thirty patients with intra-articular closed fractures of the proximal tibia after taking informed consent and institutional ethical clearance were alternately assigned two different treatment protocols, conventional nonlocking BP group or LP group. Patients who were treated within 4 weeks from the date of injury and with minimum 6 months of postoperative follow-up were included in this study.
In TPF, the patients were selected for the operation was those who had: Varus or valgus instability of 10° or more with the knee flexed < 20°; depression of articular surface more than 10 mm.
Patients having any associated fracture in the same limb; open fractures and fractures with vascular injury; extra articular proximal tibial fractures. Patients with serious medical comorbidities; patients who were operated more than 4 weeks after date of injury; patients who were found to have ligamentous injury intra-operatively were also excluded from the study.
Bone graft (autograft from the iliac crest) had been used in eight patients (26.6% cases) to prevent collapse of the articular surface.
All the patients were examined in detail and investigated as per proforma given. All the patients with history suggestive of high energy trauma were assessed according to ATLS protocol and managed.
After initial resuscitation, the patients were given jones bandage with long knee brace or long leg plaster slab according to the fracture pattern and soft tissue status. Elevation of limb over one or two pillows was allowed and encouragement given for active toe movements. Repeated examination to look for development of any features of compartment syndrome was done till definitive treatment was undertaken.
All the patients of our study were treated operatively by either LCP or conventional buttress (nonlocking) plate osteosynthesis. We used 6.5 mm cannulated cancellous screws; T and L shaped medial, lateral and side specific 4.5 mm BP group and 4.5 mm locking compression. We used 4.5 mm cortical screws for fixing the plate to the shaft of tibia. Screws used in cancellous area: 6.5 mm cancellous screws, 5 mm locking screws.
Good quality radiographs were taken in all the patients. The type of fracture and degree of comminution was assessed. Local skin conditions were also assessed properly (e.g., presence of ecchymosis, blisters and abrasions) for planning of skin incision and exposure.
Limbs with gross swelling, blisters (impending compartment syndrome) were initially treated with above knee plaster of Paris slab and elevation of limb, administration of antiinflammatory drugs till the swelling and blisters got reasonably subsided before surgery. Preanesthetic check-up was done properly with blood reports, electrocardiogram, chest X-ray, cardiologist's and physician's reports.
Spinal anesthesia/epidural anesthesia was administered. Tourniquet was used in all cases. All operations were done under image intensifier.
The anterolateral parapatellar approach was used most frequently because of the frequency of lateral TPFs. Incision: With the knee in 30° flexion an antero lateral curved incision starting 3 cm above the patella proximally and extending distally below the inferior margin of the fracture site (in between Gerdy's tubercle and fibula). Any depression in the articular surface was looked for. A small cortical window was made below the depressed part and is elevated by slow and meticulous pressure by a periosteal elevator or punch.
Midline anterior approach
A longitudinal midline incision was made, beginning 3 cm above the superior pole of the patella and extending distally just lateral to the crest of the tibia far enough to expose the proximal shaft fracture. Subperiosteally the soft tissues were dissected from the more comminuted condyle, creating full-thickness flaps. The dissection proceeded from the midline to the periphery. Submeniscal incisions are made to expose the joint. If the exposure of the joint was not adequate, the patellar tendon was incised in a Z fashion, and the patella was retracted proximally .
Articular depression if present was elevated using artery forceps or a punch and hammer through the same exposure under image guidance, and resultant cavity was filled with bone graft from ipsilateral iliac crest.
Then the lateral tibial condylar fragment was replaced to lock the articular fragments together. The lateral margin of the articular surface reduced under the femoral condyle for support. As the fragments were elevated and reduced, temporarily fixed them with multiple small Kirschner wires. A contoured T or L BP group lateral tibial BP group/LCP was applied for definitive fixation. This plate was applied to the anterolateral tibial condyle and contoured precisely to conform to the condyle and proximal metaphysis. It was secured to the condyle with appropriate cancellous screws/locking screws of sufficient length to engage the opposite medial cortex. Cortical/locking screws (4.5 mm/5 mm) were used to attach the plate to the shaft of the tibia.
If the fracture consisted of only one or two large fragments with little or no comminution and little central depression, internal fixation with cancellous screws had been used to achieve articular reduction and interfragmentary compression. If the lateral cortical bone was fragile and osteoporotic, a washer was used to prevent the head of the screw from losing fixation. If a cancellous screw was used, it was long enough to engage the cortex of the opposite condyle securely. Pin or screw was inserted from the lateral side of the lateral fragment directly transverse to the longitudinal axis of the tibia and in the posterior and medial direction, catching the medial tibial cortex.
If the meniscus had been detached peripherally, it was sutured back to its coronary ligament attachment. If the iliotibial band had been reflected from its insertion at the Gerdy's tubercle, it was reattached.
If the displacement of the peripheral rim was slight and central depression of the condyle was the main deformity, an anterior cortical window was removed with its proximal edge about 1.3 cm distal to the articular surface. A small thin periosteal elevator was inserted through the window into the cancellous subchondral bone, and the depressed fragments were elevated to the normal level of the articular surface. Defect was then filled with cancellous bone as just described. The wound was closed in layer over a suction No. 10 or No. 12 Romovac drain. The limb was kept immobilized in a long knee brace and kept elevated over one or two pillows.
Anatomical reduction through extensive exposures and rigid fixation with dual BP group/unilateral LCP had been done for the treatment of bicondylar TPFs and fractures with dissociation of metaphysis and diaphysis. Open reduction and internal fixation were done preferably on the day of injury or else were delayed for 7-10 days until edema and soft tissue reaction have subsided. If the surgery was delayed, the patient was placed on temporary calcaneal or distal tibial traction.
Depressed fragments were elevated and were supported with autogenous iliac bone grafts if required. Using fluoroscopic guidance, the fractures were reduced and held with large bone reduction clamps. Kirschner wires were used as temporary fixation. Then a contoured large fragment BP group/LCP was applied to the tibial metaphysis and extended it down the tibial shaft far enough to securely stabilize the fracture. Large cancellous screws were inserted in the proximal part of the BP group, and the distal portion was attached with cortical screws. Medial BP group was applied first; the fracture was assessed for stability. If additional stability was needed, a precontoured BP group was placed over the lateral side alternatively a single LCP was applied on the lateral side. Once the fracture had been adequately stabilized, all temporary fixation devices were removed. The meniscus was sutured to the coronary ligament attachments. If the patellar tendon had been divided, it was repaired. The capsular incisions were closed with interrupted sutures and the skin, and subcutaneous tissue was closed over suction drains. The extremity was placed in a posterior plaster splint with the knee flexed 30°.
The operated lower limb was kept elevated in a compression bandage and long knee brace over a pillow in immediate postoperative period. The patients were encouraged static quadriceps, foot and ankle exercises from first postoperative day as far as the pain permitted. The drain was removed after 48 h.
Nonweight bearing walking started on 5 th or 6 th postoperative day with axillary crutch support in younger and middle aged patients and with walker support in elderly patients up to approximately 6 weeks postoperative period. Long knee brace and bandages were discarded after 3 weeks of operation. Then partial weight bearing was started after 6 weeks postoperative period till 12 weeks. Full weight bearing walking started after approximately 12 weeks postoperative period depending upon fracture type and radiological progress.
Routine follow-up done with proper rehabilitation protocol with proper clinical and radiological assessment-at 2 weeks, 6 weeks, 3 months, 6 months, 12 months, 18 months and in between if required. The patient were assessed regarding any symptom like pain, swelling, extension lag, range of motion (ROM) of knee, stability, valgus/varus deformity, depression of articular surface/collapse, condylar widening, wound healing, neurological status and any complication.
The final results were evaluated in terms of severity of fractures, functional recovery and anatomical evaluation, postoperative complications like infection, mal union, nonunion and implant failure. The results were graded as per grading system of Poul S. Rasmussen. ,
| Results|| |
Thirty patients (15 in LCP group and 15 in BP group, which were randomly selected) of different types of TPFs of age group 22-66 years with mean age of 43.4 years had been selected in this study. Maximum patients (56.6%) were in age group of 41-50 years. Males were more frequently affected than females (male:female = 3:1).The most common mode of injury was motor vehicle accidents (in 63.3% patients), and the rest were injured by fall from height (23.3%) and domestic falls (13.3%). Right side (63.3%) was found to be more commonly injured than the left side (36.6%). Schatzker Type II fracture was found to be the commonest fracture type with 13 patients (43.3%), with Type VI being the 2 nd most common type (30%), Type V ranked 3 rd (13.3%). Type I fracture were least common (3.3%). Most of the patients (40%) underwent surgery within 4-6 days of injury. Mean time elapsed was 8.1 days (Standard deviation 4.8). Only lateral plating was done in 24 patients (80%), and dual plating was done in 6 patients (20%). In 8 patients (26.6%) corticocancellous bone graft (autograft from the iliac crest) were used. On follow-up, we found some complications like superficial skin necrosis (two cases), infection (two case), varus collapse (three cases). Maximum number (60% in LCP group, 66.6% in buttress group) of fractures clinically united in the time period of 7-9 weeks and in maximum number of cases (73.3% in LCP group and 80% in buttress group) radiological union occurred in a period of 12-15 weeks. Mean time of union was 12.8 weeks in both groups with a standard deviation of 2.5 in LCP and 2.4 in BP group. The results were graded in accordance with Poul S. Rasmussen's (1973) grading system. Maximum number of follow-up patients (73.3% in LCP group and 66.6% in buttress group) had no pain after clinical union. Ten (66.6%) patients in LCP group and 11 (73.3%) in buttress group could perform normal walking. Thirteen patients (86.6%) in each group had no lack of extension. Nine patients (60%) in LCP group and 10 patients (66.6%) had flexion of up to at least 140°. Maximum number of patients (86.6% in LCP group and 80% in buttress group) had a stable joint in extension. The Mean Functional score in LCP group was 27.7, with Standard Deviation of 4.2. The mean anatomical score in LCP group was 16.8 with standard deviation 2.8. The mean functional score in BP group was 27.6, with a standard deviation of 4.3. The mean anatomical score in BP group was 16.9 with a standard deviation of 2.2.
| Discussion|| |
Out of 30 patients, varus collapse occurred in 2 patients of the LCP group (13.3%) and 1 patient in BP group (6.6%). In BP group (Type VI fracture treated by dual plating) it occurred due to loosening of the screws. In LCP group (both Type V fracture) it occurred due to inadequate fixation (only lateral condylar) without any additional medial plating. Both these cases were retrospectively found to have coronal split leading to a postero-medial fragment, which could not be reduced using fixed angled LP group as supported by literature. Hence, we conclude that a single lateral LP group is good alternative option in case of Schatzker Type VI fractures, but in case of bicondylar fractures it should be supplemented with a medial support.
In two patients in BP group (13.3%) had superficial skin necrosis and two had infection (13.3%). All these four cases were treated by dual plates using single midline anterior approach. Maximum number of patients (60% in LCP group and 66.66% in buttress group) clinically united within 6-8 weeks, but radiologically united in period of 12-16 weeks (73.2% in LCP group and 80% in buttress group). Out of 30 patients, 23 patients (12 in LCP group and 11 in BP group) had an excellent result, 4 patients (1 in LCP group and 3 in BP group) had a good result.
The mean anatomical score of LCP group was less due to two fair results occurring in cases of bicondylar fractures treated with single lateral LP group. We found that the patients with residual depression and condylar widening had acceptable functional results, but less than excellent. Mean functional score ± standard deviation in LCP group was 27.7 ± 4.2. Mean Functional score ± standard deviation was in BP group was 27.6 ± 4.3. The differences between results in LCP group and BP group were not statistically significant.
In studies by Manidakis et al. in 2010  outcome was good in 86 cases (69%), fair in 30 (24%) and poor in 9 (7%). One hundred and one patients were treated surgically and 24 conservatively. It was not a single surgeon's series, and it was of a retrospective nature. Our study was prospective, and patients were operated by same surgeons but the follow-up time was short.
A total of 30 patients having proximal tibial fractures were managed by Biswas et al. in 2014  and the procedure carried out was closed manipulative reduction and stabilization with mini external fixator. Out of 30 cases, 13 had excellent, 14 cases good, and 3 showed fair results. It was found that Type V and VI of Schatzker's classification have lesser outcome type of fractures. Thirty-two cases of TPFs treated by various modalities were studied by Vasanad et al. in 2013.  The selected patients evaluated thoroughly: Clinically and radiologically, were taken for surgery, after the relevant lab investigations. The indicated fractures were treated as per the Schatzker's types accordingly with closed reduction internal fixation, with percutaneous cannulated cancellous screws, open reduction internal fixation with BP group with or without bone grafting, external fixator. The knee ROM was excellent to very good, gait and weight bearing after complete union was satisfactory. Redepression in one case, malunion in two cases, knee stiffness in three, wound dehiscence in two cases.
Sixty-five cases of complex (Schatzker Type V and VI) TPFs were treated with the double-BP group fixation by Yu et al. in 2009  through two separate plate incisions. All 54 patients were healed, and the treatment achieved greater than 90% of satisfactory-to-excellent rates of reduction. The mean time of bone union was 15.4 weeks, and the mean time of full weight-bearing was 18.7 weeks. At the final follow-up visit, no patients showed knee instability; the mean ROM was 107.6°.
Twenty-two patients 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 by Hassankhani et al.  The bony and functional outcome was evaluated according to Knee Society Score. Results: According to Knee Society Score, the results 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%).
Ten patients with Schatzker type V and VI TPFs treated with dual plating were analyzed by Cho et al. in 2013.  The mean visual analog scale score was 2.2 points, and the mean Knee Society function score was 85 points at the final follow-up. The mean flexion contracture was 2.50, and the mean further flexion was 1250. It took an average of 4 months until bony union occurred. Lee et al.  retrospectively reviewed 76 patients with TPF, Schatzker Types V and VI. Fifteen patients, as Group I, were treated with unilateral LP group. The other 19 patients, as Group II, were treated with classic dual plates. The residual 11 patients, as Group III, were treated with hybrid dual plates (one lateral approach LCP + medial anti-gliding plate). In Group I, 13 cases achieved solid bony union without obvious traumatic OA change, limitation of ROM or malalignment. In groups II and III, 15 and 10 patients reached the same goal, respectively.
| Conclusion|| |
Locking plate is not a panacea for fracture fixation. Knowing the biomechanical principles, proper indication and surgical techniques are very important for its successful use. Considering its high cost, LP group should only be used, where it is more advantageous than conventional plate.
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