Download A posteromedial approach for open reduction and internal fixation of

ORIGINAL STUDY
Acta Orthop. Belg., 2016, 82, 258-264
A posteromedial approach for open reduction and internal fixation
of posteromedial tibial plateau fracture
Hong-wei Chen, Jun Pan, Xian-hong Yi, Yi-xing Huang
From the Department of Orthopaedic Surgery, Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
The aim of this study was to evaluate the clinical out­
comes of patients with posteromedial tibial plateau
fractures treated by open reduction and internal fixa­
tion (ORIF) through a posteromedial approach.
Thirty-six patients with posteromedial tibial plateau
fracture underwent ORIF through a posteromedial
approach and were retrospectively analyzed. Pre­
operative X-ray pictures and CT images were
­obtained. And there were 11 cases of posteromedial
tibial plateau fracture and 25 cases of posteromedial
and posterolateral tibial plateau fracture. All the
­patients were treated surgically with posteromedial
approach. The clinical outcomes were assessed
­according to the Rasmussen knee function grading
system.
The patients were followed-up for an average of
17.5 months (range, 12-32 months). All the fractures
attained satisfactory reduction. No major complica­
tions were observed. According to the Rasmussen
knee function grading system, the results were graded
as excellent in 21 cases, good in 13 cases, fair in 2 cas­
es. The rate of excellent and good results was 94.4%.
The posteromedial approach in our opinion is the best
option to treat the posteromedial tibial plateau frac­
tures because it can provide direct visualization of the
fracture site and avoid dissection of neurovascular
bundle in the popliteal fossa area with minimal soft
tissue injury.
Keywords : tibial plateau fracture ; posteromedial
approaches ; internal fixation ; buttress plate.
No benefits or funds were received in support of this study.
The authors report no conflict of interests.
chen-.indd 258
INTRODUCTION
Posteromedial tibial plateau fracture is not rare in
clinical practice. It has been underappreciated previously. With the popular application of computed
tomography (CT) and three dimensional (3-D) reconstruction in assessment of tibial plateau fractures, increasing attention has been paid to the posteromedial tibial plateau fracture (1-6,8-11,15). This
kind of fracture is very unstable, and it is often
accompanied with obvious articular surface dis­
placement (9). Most authors advocate open reduction and internal plate fixation (ORIF) for the treatment. Although a great deal of efforts have been
made to develop surgical approaches to manage this
kind of fracture in the past few decades, controversy
still remains over the optimal surgical approach.
n Hong-wei Chen, MD.
Department of Orthopedic Surgery, Yiwu Central Hospital,
Yiwu, China.
n Jun Pan, MD.
n Xian-hong Yi, MD.
n Yi-xing Huang, MD, PhD.
Department of Orthopaedic Surgery, Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.
Correspondence : Yi-xing Huang, Department of Orthopaedic Surgery, Second Affiliated Hospital of Wenzhou Medical
University, 109 Xueyuan Road, Wenzhou, China.
E-mail : [email protected]
© 2016, Acta Orthopædica Belgica.
Acta Orthopædica Belgica, Vol. 82 - 2 - 2016
21/06/16 11:24
259
h.-w. chen, j. pan, x.-h. yi, y.-x. huang
Several surgical approaches such as the anterior
approach, the anteromedial approach, the posterior
approach have been recommended. However, each
technique has its shortcoming, such as damage of
the soft tissues caused by dissection, obstructing exposure of fracture fragment, impairment of blood
supply to the soft tissues, and risk of injuring the
neurovascular structures (2-5,8). In order to overcome these shortcomings, we attempted to use a
posteromedial approach for the treatment when the
posteromedial tibial plateau was involved. The aim
of our study was to evaluate the clinical outcomes
of our patients with posteromedial tibial plateau
fractures through this approach.
PATIENTS AND METHODS
Patients series
A retrospective review of posteromedial tibial plateau
fractures treated with a posteromedial approach from
March 2005 to November 2011 was performed at our institution. This study was approved by the local ethics
committee. The inclusion criteria were as follows :
(1) posteromedial tibial plateau fracture which was demonstrated by CT scans, (2) treatment with ORIF through
a posteromedial approach and (3) the patients who received follow-up postoperatively. Seven cases lost to
follow-up were excluded from the study. A total of
36 patients met the inclusion criteria for analysis. There
were 23 males and 13 females, with an average of
40.1 years (range, 21-70 years). The mechanism of injury
was a road traffic in 19 patients, a fall from height in 10,
a simple fall in 5, and a sports-related injury in 2 cases.
Time from injury to surgery was 6.8 days in average
(range, 2-16 days). Preoperative X-ray pictures and CT
images were obtained. Based on the Schatzker classification (13), there were 11 cases of posteromedial tibial plateau fracture (type VI) and 25 cases of posteromedial and
posterolateral tibial plateau fracture (type V). Among
these patients, anterior cruciate ligament (ACL) injuries
resulted from avulsion of intercondylar eminence were
seen in 19 cases, compartment syndrome occurred in
1 case and multi-systemic compound injuries presented
in 7 cases.
Surgical technique
Under general anesthesia or continuous epidural anesthesia, the patient was placed in prone position with a
Fig. 1. — Schematic drawing of the posteriormedial approach
between the Muscle Semimembranosus and the medial head of
Muscle Gastrocnemius of right knee in prone position.
high thigh pneumatic tourniquet applied. The knee joint
was held slightly flexed by a bump under the ankle. A
6-8 cm longitudinal incision was made along the border
of the medial head of Muscle Gastrocnemius muscle,
ending at the level of the knee joint line. The lateral border of Muscle Semimembranosus and the medial border
of Muscle Gastrocnemius were exposed by blunt dissection. After blunt dissection, the Muscle Semimembranosus was retracted medially and the medial head of Muscle
Gastrocnemius was retracted laterally. Care must be taken not to injure the important neurovascular structures in
the popliteal fossa area, which were located between the
two heads of Muscle Gastrocnemius. To identify the superior border of Muscle Popliteus, incise the muscle and
detach subperiosteally to expose the entire posteromedial
fracture fragment (Fig. 1). If required for better exposure
and placement of the plate, the tibial insertion of Muscle
Semimembranosus could be dissected accordingly. For
further distal exposure, the medial border of the Muscle
Soleus also could be partially detached. Once the fracture
site was clearly exposed, a good reduction could be
achieved by hyperextension with axial traction and pushing the fragment with the assistance of a periosteal elevator. Kirschner wires were used for the temporary fixation
and intra-operative C-arm fluoroscopy control was used
to assess the reduction. Cannulated screws, buttress
plates or reconstruction plates could be used for fixation.
Screws were carefully measured to prevent penetration
through the anterior tibial cortices. Correct plate fixation
required 2-3 screws fixation distal to the fracture line. As
for the associated ACL injury, reduction and fixation
were performed under arthroscopic assistance.
Acta Orthopædica Belgica, Vol. 82 - 2 - 2016
chen-.indd 259
21/06/16 11:24
posteromedial tibial plateau fracture
Postoperative treatment
The postoperative rehabilitation was started 2–3 days
after surgery, including functional exercises of Muscle
Quadriceps and ankle joint, and flexion/extension exercises of knee joint by using a continuous passive motion
machine twice a day. Non-weight bearing under the
­assistance of crutches was permitted usually 5 days after
surgery. Partial weight bearing was allowed 6 weeks after surgery, and full weight bearing was initiated at 3 to
5 months when union was obtained.
Assessment methods
The clinical outcomes were assessed according to the
Rasmussen knee function grading system (12). Five parameters (pain, walking capacity, lack of extension,
range of motion, and stability of the knee joint) were included for evaluation, each with a full score of 6 points.
Based on the total score of each patients , the function
was graded as excellent (≥ 27 points), good (2026 points), fair (10–19 points), and poor (6-9 points).
RESULTS
The patients were followed-up for an average of
17.5 months (range, 12-32 months). All the fractures attained satisfactory reduction (Fig. 2a-f).
There was no wound infection or necrosis, screw
loosening or breakage of implant, nonunion, varus/
valgus deformity, and fracture redisplacement. One
patient experienced numb in the posteroinferior of
the affected leg, and recovered completely after
3 months of conservative treatment. According to
the Rasmussen knee function grading system, the
total scores were 24.5 ± 2.6 points in average (range,
13-30 points). The mean pain scores were 4.8 ±
0.3 points, mean walking capacity scores 5.3 ±
0.5 points, mean lack of extension scores 5.3 ±
0.7 points, mean range of motion scores 5.0 ±
0.8 points, mean stability of the knee joint scores
5.5 ± 0.2 points. And the results were graded as
­excellent in 21 cases, good in 13 cases, fair in 2 cases. The rate of excellent and good results was 94.4%.
DISCUSSION
In the past, most authors believed that posteromedial tibial plateau fracture was rare and difficult
260
to treat (8). With the increasing use of CT scan and
3-D reconstruction in patients with tibial plateau
fractures, it was found that this kind of fracture was
not rare (2,9). In a study of Barei et al (2), a posteromedial fragment was observed in nearly one third of
the bicondylar plateau fractures evaluated. Higgins
et al (9) studied 111 CT scans of bicondylar tibial
plateau fractures, and they found that 65 cases involved posteromedial tibial plateau fragments, with
an incidence of 59%. Some authors believed that
the posteromedial tibial plateau fragment resulted
from the avulsion fracture of semimembranosus
tendon insertion site due to the stress on the knee
joint in hyperextension (1). However, we believe
that it is a split fracture caused by the impact on the
posterior plateau from the femoral condyle with the
knee subjected to vertical or varus stress in flexed or
semi-flexed position (4,16). And when the stress is
violent or in combination with a torsional force, the
tibia has a tendency to dislocate anteriorly from the
femur, which may lead to the ACL injury.
The posteromedial tibial plateau fracture has several unique characteristics. The fracture fragment is
relatively big. Barei et al (2) found that the surface
area of fracture
​​
fragment was 58% (19-98%) of the
medial plateau surface and 23% (8-47%) of the entire plateau articular surface. Higgins et al (9) revealed that the average area of bone fragment was
25% of entire tibial plateau articular surface. The
sagittal angle of fracture fragment is large and the
displacement of articular surface is usually more
than 5 mm (9,15). For these reasons, this kind of
fracture is very unstable so that the conservative
treatment is difficult to obtain stability after fixation. The posteromedial tibial plateau fracture is a
vertical split fracture not a compression fracture,
even in the osteoporotic patients. It was often associated with the ACL injury. In this study, there were
19 cases of avulsion fractures of the ACL tibial insertion, with an incidence of 53%. Reduction and
fixation could be performed in one-stage surgery
under arthroscopic assistance. For the complete
ACL tear, second-stage reconstruction following
fracture healing was recommended. As for the
meniscal tear, arthroscopic suture repair or partial
meniscectomy was recommended. Arthrotomy was
not necessary in most cases for the exposure and
Acta Orthopædica Belgica, Vol. 82 - 2 - 2016
chen-.indd 260
21/06/16 11:24
261
h.-w. chen, j. pan, x.-h. yi, y.-x. huang
a
b
Fig. 2. — A 33-year-old female patient with left posteromedial and posterolateral tibial plateau fracture.
a,b. Preoperative X-ray pictures of anteroposterior and lateral views.
reduction of the fracture. The reduction could be
­assessed by intraoperative fluoroscopy. For those
cases with malreduction, it was necessary to open
the articular capsule to achieve an anatomical reduction.
Because of instability, ORIF is advocated (24,6,11). For the anterior approach, it required extensive separation of the medial capsular ligament and
osteotomy of the tibial tubercle in order to expose
the posterior portion of the knee (5). The injuries
were severe and it still had difficulties in exposing
the posteromedial fracture fragment through this
approach. Hsieh et al (8) used anteromedial ap-
proach for the treatment of 8 patients with posteromedial tibial plateau fractures. They believed that
the anteromedial approach can avoid injuries to the
neurovascular structures in the popliteal fossa area,
flexion contracture of the knee joint and other complications. However, semitendinosus and semimembranosus muscles obstructed the anteromedial
approach. When stripping posteriorly, it was also
easy to injure the medial collateral ligament. And
the possible disturbance of blood supply to the soft
tissues would increase, especially when the soft
­tissues around the knee had suffered high energy
­injury. Because the posteromedial tibial plateau
Acta Orthopædica Belgica, Vol. 82 - 2 - 2016
chen-.indd 261
21/06/16 11:24
posteromedial tibial plateau fracture
c
262
d
c,d. Preoperative 3D CT reconstruction images of lateral and posterior views.
fracture fragments are located posteriorly, some
­authors used posterior approach, such as described
by Trickey in the 1960s, which were more demanding and involved dissection of the neurovascular
bundle (4,14). This would increase the difficulty and
risk of operation. In order to protect the neurovascular structures, Bendayan et al (3) described a posteromedial second incision to reduce and stabilize a
displaced posterior fragment. Direct visualization
and satisfactory reduction were achieved. However,
this technique required splitting the medial head of
Muscle Gastrocnemius, which would result in injury to this muscle.
How to stabilize the posteromedial tibial plateau
fracture remains controversial. Hsieh et al (8) placed
lag screws from anterior to posterior for fixation of
posteromedial tibial plateau fracture in 8 cases and
the results were satisfactory. But most authors believed that it was prone to loss of reduction with the
only use of lag screws when the f­racture fragment
was big (3,11). Gosling et al (7) demonstrated that
lateral locking screw plate could provide stabilization of the medial fracture fragment. However, the
directions of screws were predetermined based on
the design of the plate. The screws were usually
in parallel with the fracture line of posteromedial
Acta Orthopædica Belgica, Vol. 82 - 2 - 2016
chen-.indd 262
21/06/16 11:24
263
h.-w. chen, j. pan, x.-h. yi, y.-x. huang
e
f
e,f. Postoperative X-ray pictures of anteroposterior and lateral views showed the posteromedial tibial plateau fracture was anatomically reduced and stabilized with a buttress plate.
­fragment (3). Therefore, satisfactory fixation cannot
be achieved. In a biomechanical study, Yoo et al (15)
revealed that posteromedial tibial plateau fracture
fragments tolerated higher loads by using the lateral
3.5-mm conventional non-locking proximal tibial
plate and posteromedial 1/3 tubular plate fixation.
The fixation of fracture fragment by placement of
the lateral locking screws was unreliable and the
rate of failure was very high. Zeng et al (16) compared anteroposterior lag-screws fixation, antero-
medial limited contact dynamic compression plate
fixation, lateral locking plate fixation and posterior
T-buttress plate fixation for the posteromedial tibial
plateau fracture. It was confirmed that the posterior
T-buttress plate fixation was biomechanically the
most stable in-vitro fixation method for postero­
medial tibial plateau fracture. To date, many satisfactory results of posterior buttress plate fixation in
clinical practice were reported (4,6,11). The results
of our study were also satisfactory. There was no
Acta Orthopædica Belgica, Vol. 82 - 2 - 2016
chen-.indd 263
21/06/16 11:24
posteromedial tibial plateau fracture
internal fixation failure or fracture redisplacement.
Nevertheless, the buttress plate is difficult to accurately shape and fit to the fracture site because the
outline of the posteromedial tibial plateau is irregular and the transition zone of metaphysis has a great
curvature.
In conclusion, the posteromedial approach is in
our opinion the best option to treat the posteromedial tibial plateau fracture because it can provide
direct visualization of the fracture site and avoid
dissection of neurovascular bundle in the popliteal
fossa area with minimal soft tissue injury. As a result, satisfactory reduction, stable internal fixation
and good functional outcomes can be attained by
using this technique.
REFERENCES
1. Al-Humadi M, Fulkerson EW, Egol KA. Semi­
membranosus tendon mediated avulsion fracture of the
posteromedial tibial plateau. J Trauma 2009 ; 66 : E1-3.
2. Barei DP, O’Mara TJ, Taitsman LA, Dunbar RP,
Nork SE. Frequency and fracture morphology of the
posteromedial fragment in bicondylar tibial plateau fracture
patterns. J Orthop Trauma 2008 ; 22 : 176-82.
3. Bendayan J, Noblin JD, Freeland AE. Posteromedial
second incision to reduce and stabilize a displaced posterior
fragment that can occur in schatzker V bicondylar tibial
plateau fractures. Orthopedics 1996 ; 19 : 903-4.
4. Bhattacharyya T, McCarty LP 3rd et al. The posterior
shearing tibial plateau fracture : treatment and results via a
posterior approach. J Orthop Trauma 2005 ; 19 : 305-10.
5. Fernandez DL. Anterior approach to the knee with
osteotomy of the tibial tubercle for bicondylar tibial
fractures. J Bone Joint Surg Am 1988 ; 70 : 208-19.
264
6. Galla M, Riemer C, Lobenhoffer P. Direct posterior
approach for the treatment of posteromedial tibial head
fractures. Oper Orthop Traumatol 2009 ; 21 : 51-64.
7. Gösling T, Schandelmaier P, Marti A, Hufner T,
Partenheimer A, Krettek C. Less invasive stabilization of
complex tibial plateau fractures : a biomechanical evalua­
tion of a unilateral locked screw plate and double plating.
J Orthop Trauma 2004 ; 18 : 546-51.
8. Hsieh CH, Huang HT, Liu PC, Lu CC, Chen JC,
Lin GT. Anterior approach for posteromedial tibial plateau
fractures. Kaohsiung J Med Sci 2010 ; 26 : 130-5.
9. Higgins TF, Kemper D, Klatt J. Incidence and morphology
of the posteromedial fragment in bicondylar tibial plateau
fractures. J Orthop Trauma 2009 ; 23 : 45-51.
10.Lobenhoffer P, Gerich T, Bertram T, Lattermann C,
Pohlemann T, Tscheme H. Particular posteromedial and
posterolateral approaches for the treatment of tibial head
fractures (German). Unfallchirurg 1997 ; 100 : 957-67.
11. Luo CF, Sun H, Zhang B, Zeng BF. Three-column
fixation for complex tibial plateau fractures. J Orthop
Trauma 2010 ; 24 : 693-6.
12.Rasmussen PS. Tibial condylar fractures. Impairment of
knee joint stability as an indication for surgical treatment.
J Bone Joint Surg (Am) 1973 ; 55 : 1331-50.
13.Schatzker J, McBroom R, Bruce D. The tibial plateau
fracture. The Toronto experience 1968-1975. Clin Orthop
Relat Res 1979 ; 138 : 94-104.
14.Trickey EL. Rupture of the posterior cruciate ligament of
the knee. J Bone Joint Surg(Br) 1968 ; 50 : 334-41.
15.Yoo BJ, Beingessner DM, Barei DP. Stabilization of the
posteromedial fragment in bicondylar tibial plateau fractures : a mechanical comparison of locking and non­locking
single and dual plating methods. J Trauma 2010 ; 69 : 14855.
16.Zeng ZM, Luo CF, Putnis S, Zeng BF. Biomechanical
analysis of posteromedial tibial plateau split fracture
fixation. Knee 2011 ; 18 : 51-4.
Acta Orthopædica Belgica, Vol. 82 - 2 - 2016
chen-.indd 264
21/06/16 11:24