Treatment of Bicondylar Tibia Plateau Fractures Using Locked Plating Versus External Fixation

Abstract

Feature Article Free Ryan J. Krupp, MD; Arthur L. Malkani, MD; Craig S. Roberts, MD; David Seligson, MD; Charles H. Crawford III, MD; Langan Smith, BS Bicondylar tibial plateau fractures can be difficult to treat due to the extent of articular cartilage, metaphyseal bone, and soft tissue injury. The purpose of this study was to compare the outcomes of open reduction and locked plating vs fine-wire external fixation of 58 consecutive bicondylar tibial plateau fractures at a level I trauma center. All bicondylar tibial plateau fractures were classified as Schatzker V/VI or AO/OTA type 41C. Twenty-eight patients in one group were treated using a locked plating system, and 30 patients in another group were treated with a hybrid or circular external fixation frame. The 2 groups were similar demographically. When compared with external fixation, locked plating was associated with a decreased time to union (5.9 vs 7.4 months), decreased incidence of articular malunion (7% vs 40%; P=.003), decreased knee stiffness (4% vs 13%), and decreased overall complications (27% vs 48%). The Schatzker VI subgroup accounted for 25 of the 27 complications (93%) in the locked plating group and 40 of the 48 complications (83%) in the external fixation group. We reserve the use of external fixation devices in the treatment of tibial plateau fractures to span the fracture site until the patient is amenable to definitive fixation with locked plating. Injuries involving an intra-articular bicondylar fracture of the proximal tibia are notoriously difficult to treat.^1,2 These injuries are often associated with significant soft tissue and bony injury, which results in a high complication rate and poor clinical outcome. Common complications include infection, wound breakdown, joint stiffness, joint instability, malunion, nonunion, and post-traumatic arthrosis. Historically, closed treatment of displaced tibial plateau fractures including traction and immobilization resulted in unacceptably high rates of malunion and joint stiffness.² With advancements in internal fixation principles, operative treatment modalities were explored but were often associated with high complication rates. Difficulties arose in finding a balance between adequate surgical exposure and protection of the compromised soft tissue environment. Anatomic reduction and stable fixation often required extensive exposure of both the medial and lateral aspects of the proximal tibia that led to problems with wound healing and infection in the compromised soft tissue environment.^1,3-10 Because of these soft tissue problems, minimal internal fixation and external fixation techniques have been reported with some success.^10-20 Problems with these minimally invasive techniques include inadequate reduction, unstable fixation, and pin tract complications. Recent advancements in angle-stable locking plate technology has allowed for a new approach to these difficult fractures.^3,21-26 Locking plates allow the surgeon to place a biomechanically stable internal fixator on the lateral side of the proximal tibia through a limited surgical exposure. This technique will potentially allow for anatomic reduction and stable internal fixation while minimizing soft tissue problems often associated with the subcutaneous medial border of the proximal tibia. Whether this soft tissue-preserving technique will improve the clinical outcome of patients is yet to be determined. The purpose of this study was to determine if the clinical outcomes of patients with bicondylar tibial plateau fractures treated with open reduction and internal locking plate fixation (ORIF) are better than those achieved with external fixation alone. From January 2000 to August 2004, all bicondylar tibia plateau fractures (Schatzker type V/VI or AO/OTA type 41C) occurring at a level I trauma center were retrospectively reviewed. Each of the injuries was treated by 1 of 3 staff orthopedic traumatologists. Eight of these fractures were treated using Synthes standard locking plates (Paoli, Pennsylvania) and 20 were treated using the Less Invasive Stabilization System (LISS), compared with 30 fractures treated with external fixation, either hybrid or circular frames, which were used at our institution along with conventional plating. With the… Bicondylar tibial plateau fractures can be difficult to treat due to the extent of articular cartilage, metaphyseal bone, and soft tissue injury. The purpose of this study was to compare the outcomes of open reduction and locked plating vs fine-wire external fixation of 58 consecutive bicondylar tibial plateau fractures at a level I trauma center. All bicondylar tibial plateau fractures were classified as Schatzker V/VI or AO/OTA type 41C. Twenty-eight patients in one group were treated using a locked plating system, and 30 patients in another group were treated with a hybrid or circular external fixation frame. The 2 groups were similar demographically. When compared with external fixation, locked plating was associated with a decreased time to union (5.9 vs 7.4 months), decreased incidence of articular malunion (7% vs 40%; P=.003), decreased knee stiffness (4% vs 13%), and decreased overall complications (27% vs 48%). The Schatzker VI subgroup accounted for 25 of the 27 complications (93%) in the locked plating group and 40 of the 48 complications (83%) in the external fixation group. We reserve the use of external fixation devices in the treatment of tibial plateau fractures to span the fracture site until the patient is amenable to definitive fixation with locked plating. Injuries involving an intra-articular bicondylar fracture of the proximal tibia are notoriously difficult to treat.^1,2 These injuries are often associated with significant soft tissue and bony injury, which results in a high complication rate and poor clinical outcome. Common complications include infection,...