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 Table of Contents  
ORIGINAL ARTICLES
Year : 2021  |  Volume : 36  |  Issue : 3  |  Page : 69-73

Mid-term comparative analysis of orthogonal versus parallel plating in bicondylar tibial plateau fracture


Department of Orthopedics, Institute of Medical Sciences (IMS), Banaras Hindu University (BHU), Varanasi, Uttar Pradesh, India

Date of Submission08-Jul-2021
Date of Acceptance30-Nov-2021
Date of Web Publication22-Dec-2021

Correspondence Address:
Rahul Patel
Department of Orthopedics, Institute of Medical Sciences (IMS), Banaras Hindu University (BHU), 7XFX+QRJ, Aurobindo Colony, Banaras Hindu University Campus, Varanasi 221005, Uttar Pradesh.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jbjd.jbjd_11_21

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  Abstract 

Background: Proximal tibial plateau involvement is one of the most common intra-articular fractures. Bicondylar fractures have both tibial plateaus fractures, usually with depressed fracture of lateral tibial plateaus, meniscal tears and anterior cruciate ligament avulsions. Internal fixation in bicondylar proximal tibia fractures using plating devices are usually done using lateral plate along with supplementary postero-medial plate (orthogonal plating) and lateral plate along with medial plate (parallel plating). Objectives: The comparison of functional and radiological outcomes. Materials and Methods: 60 cases of bicondylar tibia plateau fracture were included. Group A (orthogonal plating) were cases treated with orthogonal plating and Group B (parallel plating) were cases those treated with parallel plating. A clinic-radiological comparison of results of these two groups were done. Clinical evaluation for at least 6 months and radiographically for at least 1 year. Results: Our clinico-radiological result showed that knee range of motion (mean) (P = 0.002) and Hip-Knee-Ankle angle (HKA) were significantly better in group B while non-significant difference in Varus/valgus angulation, fracture union status, post-operative loss of reduction and residual articular surface depression, implant position and other surgery or implant related complications. Conclusions: Our mid-term results showed that treating above fractures with parallel plate resulted in better functional and radiological outcomes with an acceptable complication rate as compared to orthogonal plate

Keywords: Bicondylar tibial plateau fracture, proximal tibia fracture fixation, proximal tibia fracture fixation with orthogonal and parallel plating, proximal tibia plateau fracture, proximal tibial plateau fracture


How to cite this article:
Patel R, Sinha S, Arya RK, Mohaniya D, Manjhi B, Rastogi A. Mid-term comparative analysis of orthogonal versus parallel plating in bicondylar tibial plateau fracture. J Bone Joint Dis 2021;36:69-73

How to cite this URL:
Patel R, Sinha S, Arya RK, Mohaniya D, Manjhi B, Rastogi A. Mid-term comparative analysis of orthogonal versus parallel plating in bicondylar tibial plateau fracture. J Bone Joint Dis [serial online] 2021 [cited 2022 Jul 1];36:69-73. Available from: http://www.jbjd.in/text.asp?2021/36/3/69/333199




  Introduction Top


Proximal tibia plateau fracture is one of the most common intra-articular fractures. This comprises 1% of all fractures.[1] The incidence of such fractures is 10.3 per 100,000 people annually. The fracture patterns are very complex and may involve medial, lateral, or both the tibial plateaus, which may or may not include the posterior part. Bicondylar tibial plateau fracture is a relatively uncommon injury, with an incidence of 18%–39% of all proximal tibial fractures.[2] The majority of these fractures are caused due to high-speed motor vehicle accidents, violent trauma, and fall from height,[3] where fractures result from direct axial compression, usually with a valgus (more common) or varus moment and indirect shear forces.[4] The amount of energy involved at the time of injury determines the severity of the proximal tibial fracture.

Achieving a congruous joint surface and correct alignment by open reduction and stable internal fixation should be the goal to facilitate early knee mobilization and consequent good functional results. These fractures usually have poorer postop outcomes in terms of pain scores, length of hospital stay, postop infections, loss of reduction, and osteoarthritis progression. Different treatment options have been established in the last decades. Timing of surgery with minimal handling of soft tissue is very important to achieve good results and to prevent infection. Equally important is the patient’s compliance and good rehabilitation and full weight bearing should be delayed until union to prevent the articular collapse.

In addition to anatomic reduction, preservation of surrounding soft tissue has been shown to improve functional outcomes and reduce periosteal microvascular dysfunction. Therefore, implant systems and techniques that allow minimal invasive application are expected to provide preconditions for undisturbed fracture healing. Loss of articular reduction is prevented by either additional medial or lateral plating. Internal fixation in bicondylar proximal tibia fractures using plating devices is usually done using lateral plate along with supplementary posteromedial plate (orthogonal plating) and lateral plate along with medial plate (parallel plating).

Not much studies have been done to compare the outcome of orthogonal and parallel plating of such fractures. This comparative study was designed to compare the mid-term results of operated bicondylar tibial plateau fractures treated with two fixation constructs.


  Materials and Methods Top


This was a prospective and retrospective study. This study was conducted from July 2018 to May 2020, with over 60 patients with bicondylar tibial fracture admitted from the emergency department and divided into two groups (A and B) with 30 patients in each group. Group A comprised cases treated with orthogonal plating and Group B comprised cases treated with parallel plating. Randomization for treatment was done in order to reduce bias.

Inclusion criteria

The inclusion criteria of the study included patients with closed bicondylar tibial plateau fracture, those who were of ages >18 years, those who had intact neurological and vascular status of the affected limb, and those who gave consent for the study.

Patients with posterior condyle fracture or posteromedial dislocations were excluded from the study.

Exclusion criteria

The exclusion criteria of the study included patients who were of ages <18 years or >6 years, those who had open fractures, those who had pathological fractures, those who had any comorbidity, and those who did not give consent for the study.

Patients with bilateral proximal tibia fractures or preexisting deformities in other limbs were also excluded from the study.

Plain radiograph of the affected limb was done for all the patients.

Preoperatively, plain radiographs were obtained to identify and classify the fracture pattern. Postoperatively in follow-up radiographs were done to check for the incidence of post-trauma secondary osteoarthritis, fracture union status, and other complications such as infection, loosening, or breaking of the implant.

The functional and radiological assessment of all the patients was done at 3 months, 6 months, 1 year, and 3 years of follow-up.

Results were assessed based on the following parameters:

  • Fracture union status and articular continuity.


  • Presence of osteoarthritis and other complications such as nonunion and malunion.


  • Range of motion in degree.


  • Computed tomography (CT) scans were done after duly splinting and spanning the fixator. Preop CT scans were obtained after swelling and impending compartment syndrome has been ruled out. Postoperatively CT scans were evaluated for the following:

    1. Alignment.


    2. Postoperative loss of reduction and residual articular surface depression.


    3. Change in posterior tibial slope (PTS).


    4. Varus/valgus angulation measured using lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), lateral distal tibial angle (LDTA), and hip–knee–ankle angle (HKA).


    5. Implant position.


    6. Loosening and breaking of screws.


    The contralateral normal limb served as a control to obtain these follow-ups, assuming that the values are similar on both sides of a normal individual.

    Postoperative rehabilitation

    Active quadriceps exercises were started immediately after surgery, followed by knee flexion and extension exercises after 1 to 3 weeks of surgery. After 10–12 weeks, partial weight bearing is allowed. Full weight bearing is allowed as per radiological union.

    Data such as age, gender, type of fracture, mechanism of injury, surgical procedure done, hospital stay, duration of immobilization, range of motion, union rate, and complications such as infection, nonunion, osteoarthritis, wound dehiscence, and loosening or breaking of the screw were recorded.


      Result Top


    Of 60 patients, 30 were included in Group A (orthogonal plating) and 30 in Group B (parallel plating). Clinical assessment was done at 3 months, 6 months, and 1 year of follow-up, whereas radiological assessment was done at least at 6 months to 3 years on every 6-month basis.{Table 1}

    Mean range of motion at knee joint was 109.1° ± 12.27° and 118.7° ± 10.39° in Group A and Group B, respectively, which was slightly higher in Group B patient (P = 0.002).

    The mean union time for Group A was 13.4 ± 2.58 weeks and for Group B it was 12.4 ± 1.52 weeks, which was almost equal and statistically not significant (P = 0.073).

    Majority of the patients were classified under AO type 41-C 2 (38.3%) followed by 41-C 1 (35%) and rest under 41-C 3 (26.6%).


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    Data analysis

    Mean PTS in Group A was 4.8° ± 2.9° and 6.7° ± 2.1° preoperatively and postoperatively, respectively, which was statistically not significant (P = 0.006). Mean posterior slope in Group B was 4.2° ± 2.4° and 6.9° ± 2.2° preoperatively and postoperatively, respectively, which was significant (P = 0.000). Posterior slope angle was better restored in Group B as compared with Group A statistically.


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    The results show that both groups have significant and almost equal improvements from preop to postoperative MPTA and preop to postoperative LDFA.

    There is no significant improvement in mean HKA in Group A from 0.71° ± 7.87° of varus preoperatively and –0.06° ± 3.53° of varus postoperatively (P = 0.658). Comparatively there is a significant improvement in mean HKA in Group B from –2.46° ± 5.45° of varus preoperatively to 1.15° ± 1.5° of varus postoperatively (P = 0.002), This indicates that operative effectiveness in parallel plating group for the patients is significantly better than the orthogonal group in terms of HKA.

    In terms of mean articular depression, both groups show significant improvement as mean articular depression

    Complications

    Two patients of Group A and one of Group B developed wound infection after surgery. Two patients recovered with antibiotics but one patient required debridement and removal of implant.

    One patient of Group A developed skin allergy after 10–12 months of the surgery for which medical management and implant removal was done.

    Six patients in Group A and three patients in Group B showed posttraumatic arthritis.

    Three patients presented peri-implant fracture in which one distal to the level of the implant because of the re-trauma 1 year after the surgery, which was managed conservatively with above knee cast and two proximal to the level of implant, for which open reduction and internal fixation was done.


      Discussion Top


    The treatment of bicondylar tibial plateau fractures remains debated. In coronal type of proximal tibia fracture, it is difficult to fix its fragments rigidly with medial or lateral plate fixation; therefore, buttress plating or direct fixation of fragments through the posteromedial, posterolateral, or posterior approach should be considered. However, we selectively excluded such complex fractures.

    A rigid fixation depending on the fracture patterns helps in the early recovery of range of movement. As explained by a study done by Sinha et al.,[5] posterior tibial plateau fractures with anterolateral plate with supplementary posteromedial plate resulted in better functional and radiologic outcomes with an acceptable complication rate as compared to anterolateral plate alone. However, in Shatzker’s type V/VI fracture, there is less consensus on the relative merits of orthogonal or parallel plate constructs for the fixation.

    As per results of the study, which aims to decipher mid-term results of bicondylar proximal tibia fracture fixation based on clinico-radiological outcomes. Functionally knee range of movements achieved was restored better in the parallel plating group.

    In this study, in Group A (orthogonal plating) the average knee flexion was 109.1° ± 12.27° as compared to that of Group B (parallel plating) 118.7° ± 10.39°; however, number of patients showing range of motion more than 120° were 13 in parallel group, whereas only 3 in orthogonal group. This differences depend on the approach used, a release of medial gastrocnemius and poor popliteus handling results in loss of flexion. The study done by Sinha et al.[5] revealed similar ROM in the previous work. Another study done by El-Alfy et al.[6] followed 24 patients with bicondylar tibial plateau fractures involving the posteromedial fragment treated by dual or lateral plating average knee motion at the final follow-up was 110°.

    In view of posterior tibial plateau injury, which is supposed to be more traumatic and involves healing by fibrosis in posterior capsule, the loss of terminal flexion can be explained. Hence, being invasive and time taking the orthogonal plating leads to restriction of deep flexion.

    Prasad et al.[7] had reported all patients treated with dual plate had average knee flexion of 120°. Four patients had extension lag of less than 5°. In our study, we started active knee extension exercises like straight leg raise, seated knee extension, and isometric quadriceps exercises right after 1 day of surgery; as a result, none of our patients had knee extension lag. Another study done by Patel et al.,[8] in which they followed 30 patients of proximal tibial fractures, surgically treated with a combination of locking plate and or buttress plate, showed that the mean range of knee flexion was 110° at final follow-up in their study. Supporting our findings, Cho et al.[9] studied the treatment of Schatzker Type V and VI tibial plateau fractures using a midline longitudinal incision and dual plating and found that at the final follow-up the mean range of motion of the knee joint was 122.5°. The mean flexion contracture was 2.5° and the mean further flexion was 125°.

    Change of approach to the fracture does not significantly impair fracture healing. However, certain difficulties with soft-tissue handling may cause problems, for example, pes handling in medial approach.

    In this study, fracture union time had no significant difference (P = 0.073), and mean union time was 13.4 ± 2.58 (weeks) and 12.4 ± 1.52 (weeks) in Group A and Group B, respectively. Our results are also supported by studies conducted by Prasad et al.,[7] who found that that union occurred in 8–22 weeks (average 14 weeks). Lee et al.[10] reported there was no statistically significant difference of union rate between these groups. There were no cases of reoperation due to delayed union or non-union.

    A study conducted by Neogi et al.[11] showed fracture union occurred in both methods by around 4 months and as fracture remodeling completes by 2 years we believe that the change in alignment due to the procedure per say should not occur after that. Another study conducted by Kumar et al.[12] at 46 patients treated with single lateral plate showed all the fractures united in 16.93 weeks (range 18–23 weeks) with malunion observed in 4 cases. Changes in articular parameters and axis deviations have been studied by few researchers, for example, Cho et al.,[9], who revealed that bony union occurred approximately 4 months after surgery.

    Among all these radiological parameters, there was no significant difference when we compared MPTA, LDFA between both orthogonal and parallel groups (P > 0.05).

    A total 71.2% reduction in the articular depression was noticed in Group A, whereas in Group B a total of 87.5% in the articular defect reduction was noticed. Both the groups showed a significant reduction and excellent articular surface congruity. But in group B, fracture site was easily accessible, better fracture visualization and easy to pass a tamp for reducing articular step off through medial incision, hence we could achieve better articular reduction. The most common site of articular depression was in the lateral condyle. HKA was another parameter taken for the radiological comparison, showing a significant difference between both the groups.

    The mean HKA in orthogonal group (A) showed insignificant improvement, whereas in the parallel group(B) it showed a significant improvement in mechanical axis of the affected limb probably due to better articular reduction, less soft-tissue damage, and additional medial support of the medial plate that prevented varus collapse of the proximal tibia fracture.

    We investigated the overall benefits in both the groups in terms of the fracture healing rate, clinico-radiological and perioperative morbidity, and patient-related outcomes and compared them. The results are slightly better in parallel plating group. Because of the better exposure of the fracture site and easy accessibility of the fractured part from medial incision, the operative time was less and there were less blood loss and reduced length of hospital stay, which are the potential advantages of parallel plating.

    Our study has certain limitations like we have a relatively small sample size. Mean follow-up duration is short as it was aimed toward functional and radiological outcome. We ought to follow these cases for long, for posttraumatic osteoarthritis, regarding implant-related problems like allergy and metallosis, deformities as they may still happen with both the groups, and at that time or at the time of implant removal or revision.


      Conclusion Top


    The postoperative functional and radiological outcomes indicate that surgical management is a feasible treatment option for bicondylar proximal tibial plateau fractures. Our mid-term results showed that treating bicondylar proximal tibial plateau fractures with parallel plate resulted in better functional and radiologic outcomes with an acceptable complication rate as compared to orthogonal plate.

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.

    Declaration of patient consent

    The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.



     
      References Top

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    Watson JJ, Wiss AD. Fractures of proximal tibia and fibula. In: Bucholz RW, Heckman JD, editors. Rockwood and Green’s Fractures in Adults. 5th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2001. p. 1799-839.  Back to cited text no. 1
        
    2.
    Molenaars RJ, Mellema JJ, Doornberg JN, Kloen P. Tibial plateau fracture characteristics: Computed tomography mapping of lateral, medial, and bicondylar fractures. J Bone Joint Surg Am 2015;97:1512-20.  Back to cited text no. 2
        
    3.
    Schulak DJ, Gunn DR. Fracture of the tibia plateaus. Clin Orthop 1975;109:166-77.  Back to cited text no. 3
        
    4.
    Koval KJ, Hulfut DL. Tibial plateau fracture: evaluation and treatment. J Am Acad Orthop Surg1995;3:86-94.  Back to cited text no. 4
        
    5.
    Sinha S, Singh M, Saraf SK, Rastogi A, Rai AK, Singh TB. Fixation of posterior tibial plateau fracture with additional posterior plating improves early rehabilitation and patient satisfaction. Indian J Orthop 2019;53:472-8.  Back to cited text no. 5
    [PUBMED]  [Full text]  
    6.
    El-Alfy B, Ali AM, El-GAnin EA. Bicondylar tibial plateau fractures involving the posteromedial fragment. Acta Orthop Belg 2016; 82:298-304.  Back to cited text no. 6
        
    7.
    Prasad GT, Kumar TS, Kumar RK, Murthy GK, Sundaram N. Functional outcome of Schatzker type V and VI tibial plateau fractures treated with dual plates. Indian J Orthop 2013;47:188-94.  Back to cited text no. 7
      [Full text]  
    8.
    Patel M, Sharma J, Jakhar S. Functional outcome of dual plate osteosynthesis in type V & VI proximal tibial fracture. Indian J Orthop Surg2017;3:78-83  Back to cited text no. 8
        
    9.
    Cho K-Y, Oh H-S, Yoo J-H, Kim D-H, Cho Y-J, Kim K-I. Treatment of Schatzker type V and VI tibial plateau fractures using a midline longitudinal incision and dual plating. Knee Surg Relat Res 2013;25:77-83.  Back to cited text no. 9
        
    10.
    Lee M-H, Hsu C-H, Lin K-C, Renn J-H. Comparison of outcome of unilateral locking plate and dual plating in the treatment of bicondylar tibial plateau fractures. J Orthop Surg Res 2014;9:62.  Back to cited text no. 10
        
    11.
    Neogi DS, Trikha V, Mishra KK, Bandekar SM, Yadav CS. Comparative study of single lateral locked plating versus double plating in type C bicondylar tibial plateau fractures. Indian J Orthop2015;49:193-8.  Back to cited text no. 11
    [PUBMED]  [Full text]  
    12.
    Kumar S, Gupta A, Gill S, Kumar D, Singh J, Pulkesh S. Results of single lateral locked plate in complex Schatzker type V and VI tibial plateau fractures using minimally invasive fixation technique-surgical experience in 46 fractures. IOSR J Dental Med Sci2016;15:59-64.  Back to cited text no. 12
        



     
     
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