|Year : 2022 | Volume
| Issue : 3 | Page : 146-151
Comparison of dual plating with single lateral locking plate supplemented with two medial cannulated cancellous screws for AO type C tibial plateau fractures—An experience from central India
Nikhil Jain, Saurabh Agarwal, Abhishek Nagaich
Department of Orthopedics, MLB Medical College, Jhansi, Uttar Pradesh, India
|Date of Submission||01-Oct-2022|
|Date of Acceptance||07-Nov-2022|
|Date of Web Publication||15-Dec-2022|
Department of Orthopedics, MLB Medical College, Jhansi, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Type C tibial plateau fractures are complex injuries, and an ideal method for their treatment is still controversial. In the present study, we discuss the outcomes of Arbeitsgemeinschaft für Osteosynthesefragen (AO) type C tibial plateau fractures treated with dual locking plating and single lateral locking plate supplemented with two medial cannulated cancellous (CC) screws. Materials and Methods: This prospective study included 34 patients of AO type C tibial plateau fractures divided into two groups. Dual locking plating and single lateral locking plate supplemented with two medial CC screws were the treatment methods in group 1 and groups II, respectively. The patients were evaluated using the Rasmussen clinical grading system at 1 and 2 years postoperatively. Results: The range of motion (ROM) was observed as 121.0° ± 1.9° and 126.3° ± 2.6° in group II, whereas in group I, ROM was 112.5° ± 3.1° and 120° ± 1.5° at 1 and 2 years, respectively. Pain, walking capacity, and final outcome were significantly better in group II at 1 and 2 years postoperatively. No significant difference was observed in two groups in terms of radiological results. Conclusion: Lateral locking plate supplemented with two medial CC screws proves to be a better method to treat AO type C tibial plateau fractures in adults, with minimal complications.
Keywords: Cannulated cancellous screws, dual locking plate, Rasmussen scoring system, single lateral locking plate
|How to cite this article:|
Jain N, Agarwal S, Nagaich A. Comparison of dual plating with single lateral locking plate supplemented with two medial cannulated cancellous screws for AO type C tibial plateau fractures—An experience from central India. J Bone Joint Dis 2022;37:146-51
|How to cite this URL:|
Jain N, Agarwal S, Nagaich A. Comparison of dual plating with single lateral locking plate supplemented with two medial cannulated cancellous screws for AO type C tibial plateau fractures—An experience from central India. J Bone Joint Dis [serial online] 2022 [cited 2023 Feb 6];37:146-51. Available from: http://www.jbjd.in/text.asp?2022/37/3/146/363852
| Introduction|| |
Proximal tibia fractures accounts for 1% of all fractures and up to 8% in elderly age groups. Of these fractures, most common is lateral tibial plateau fractures accounting for 70% followed by medial and bicondylar tibial plateau fractures accounting for 15% each.
Tibia plateau fracture occurs when there is either varus or valgus force combined with axial load from femoral condyle., The location and amount of force applied decides the fracture pattern. Lateral plateau injury usually occurs following a low-energy load, whereas medial plateau or a combination of both medial and lateral fractures occurs due to high-energy axial loads. There is also soft-tissue damage in high-grade tibial plateau fractures. Orthopedic surgeon has several challenges to treat high-grade tibial plateau fractures.
Several fixation methods such as unilateral fixation with a single plate, dual-plate, a hybrid external fixator, or a less-invasive stabilizing system are currently being used for the treatment of tibial plateau fractures.,, All of these techniques have their own pros and cons, and there is no clear unanimity that which techniques have the best outcome. Dual plating provides greater mechanical strength than a single lateral locked plate,, whereas single lateral locked plate ensured reliable fixation.,,, Single lateral plating has been advocated as a means of decreasing the risk of skin and ligament damage and surgical site infection.,,
Medial support may become stronger in single lateral locking plating when supplemented with medial cannulated cancellous (CC) screws by decreasing the secondary displacement and varus collapse. Therefore, the aim of the present study was to evaluate the radiological and clinical outcomes of dual locking plate via two incision technique versus lateral locking plate supplemented with two medial CC screws in Arbeitsgemeinschaft für Osteosynthesefragen (AO) type C proximal tibial fractures. Our hypothesis was that single lateral plate supplemented with medial CC screws can provide stable fixation and prevent loss of reduction and varus collapse in all AO type 41C fractures, thus reducing the necessity of using dual plating and minimizing wound-related complications.
| Materials and Methods|| |
For the purpose of the study, all patients with posttraumatic closed AO type C proximal tibia fractures visiting to the Department of Orthopedics at MLB Medical College, Jhansi (UP), India, during January 2017–December 2019 were included. Patients with open fracture, or pathological fractures, associated neurovascular injury or any other associated fracture/injury requiring operative intervention were excluded from the study. Written and informed consent was taken from all the patients participating in the study. All the standard protocols were followed as per institute’s ethical committee policy.
Biplanar radiographs and magnetic resonance imaging of the involved knee were done in all patients. Patients were divided into two groups, based on simple random sampling. All even number patients were included in group I and all odd number patients in group II. Group I patients were treated with dual (medial and lateral) locking plate, and group II patients were treated with single lateral locking plate supplemented with two medial CC screws. All cases were operated by the same surgeon. All patients were given above knee plaster slab and were operated on the same day or next day, unless hindered by significant swelling. Patients with massive swelling at presentation were kept with their limb elevated on Bohler Braun splint and started with ice fomentation. They were operated upon, once swelling subsided.
All surgical procedures were performed under spinal anesthesia. Patients were placed in the supine position on the fluoroscopic table. Tourniquet was used in all patients.
Dual locking plate (group I)
An anterolateral incision was made, which starts 3 cm above the patella proximally and extended distally below the inferior margin of the fracture site. Fascial incision was made parallel to the anterior border of the iliotibial tract. Incise the capsule longitudinally and detach the lateral meniscus to visualize the superior surface of tibial plateau. Extensor muscles from the anterolateral aspect of the condyle were stripped. The depressed fracture fragments were elevated and reduced. Temporary fixation was done with multiple small Kirschner wires. A precontoured locking plate (stainless steel 316L make) was applied to anterolateral tibial condyle and fixed with appropriate size locking screws. A posteromedial approach was used to expose the medial plateau. A slightly curved incision was made starting from medial epicondyle and extending toward the posteromedial edge of the tibia. The incision was extended further as needed both proximally and distally. After the opening of fascia, the incision was made between the medial gastrocnemius and semimembranosus and then between medial collateral ligament and posterior oblique ligament. The depressed fracture fragments were elevated and reduced and temporarily fixed with multiple small Kirschner wires. Bone grafting was used, whenever required, to fill the void. Precontoured buttress T or L locking plate was fixed with locking screws of appropriate length [Figure 1].
|Figure 1: Preoperative x-ray showing AO type C tibial plateau fracture (a), immediate postoperative (b), 2-year follow-up x-ray (c), and clinical picture of the patient after 2-year follow-up (d)|
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Lateral locking plate supplemented with two medial CC screws (group II)
Lateral tibial plateau was treated by locking compression plate as explained earlier. Medial tibial plateau stability was achieved using two partially threaded 6.5 mm CC screws passed percutaneously from medial tibial condyle after achieving reduction with the help of reduction forceps and K-wires under image control [Figure 2]. Lateral plating was followed by medial percutaneous CC screws. Bone grafting was also done in this group when necessary.
|Figure 2: Preoperative x-ray showing AO type C tibial plateau fracture (a), immediate postoperative (b), 2-year follow-up x-ray of the patient treated with lateral plating supplemented with two medial CC screws (c), and clinical picture of the patient after 1-year follow-up (d)|
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Postoperatively patients were immobilized in a long knee brace for 2 weeks. Quadriceps strengthening and knee range of motion (ROM) exercises were started from postoperative day 3. Partial weight bearing was started at 10–12 weeks as per patient’s tolerance, followed by full weight bearing upon radiological evidence of union. Patients were followed up at 6 weeks, 3 months, 6 months, 1 year, and 2 years. The patients were evaluated clinically using the Rasmussen 30-point clinical grading system [Table 1] at 1 and 2 years postoperatively. Radiological evaluation was based on bony union and the reduction status of the tibial plateau. Bony union was defined as radiological union in at least three cortices. No evidence of healing after 6 months was considered to be nonunion. Intraarticular step-off of 2 mm or more, or a frontal or sagittal plane malalignment of more than 5°, was considered to be unsatisfactory reduction.
No complications were found in any patient treated with lateral locking plated combined with CC screw in the present study, whereas two patients from group I developed superficial wound infection and two developed deep infection.
The Rasmussen scores at the first- and second-year follow-up were compared using two-sided paired sample “t” test. Scores in groups I and II were compared using Mann–Whitney U test. P value < 0.05 was considered to be significant.
| Results|| |
There were 17 (11 male and 6 female) patients in group I and 17 (7 male and 10 female) patients in group II. The mean age of patients was 43.78 ± 19.46 years in group I and 39.88 ± 13.81 years in group II. There was no significant difference between the mean age and gender of patients in two groups (P = 0.510 and 0.1005, respectively). The mean union time of fracture in group I and group II was 14.83 ± 2.22 weeks and 14.19 ± 2.83 weeks, respectively. Two patients got superficial infection and two patients developed deep infection in group I, which was managed with extended period of antibiotics. However, no complications were observed in group II. [Table 2] demonstrates the clinical details of the patient.
Significant improvement in pain (P = 0.04), walking capacity (P = 0.00), ROM (P = 0.00), stability (P = 0.02), and final results (P ≤ 0.0001) was observed after 2 years when compared with that of after 1 year in group I. However, in group II, there was a significant improvement in walking capacity (P = 0.00), ROM (P = 0.00), and final results (P ≤ 0.0001) at 2 years when compared with that at 1-year follow-up [Table 3]. ROM was observed as 112.5° ± 3.1° and 120° ± 1.5° in group I, whereas in group II, ROM was 121.0° ± 1.9° and 126.3° ± 2.6° at 1 and 2 years, respectively.
|Table 3: Comparison of functional scores at two time intervals in both groups|
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Mann–Whitney U test was done to see the difference of different scores in two treatment groups, and we observed that pain (P < 0.05), walking capacity (P < 0.05), and final results (P < 0.05) in group II were significantly better than group I at both 1 and 2 years postoperative follow-up [Table 4]. There was no significant difference in clinical signs, stability, and ROM in these two groups at both follow-ups (P > 0.05).
|Table 4: Comparison of functional scores in both groups at two time intervals|
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The mean surgical time in group I and group II was 83.6 ± 12.2 min and 64.3 ± 18.2 min, respectively, which was statistically significant (P = 0.003). The average blood loss in group I and group II was 80 mL and 45 mL, respectively (P = 0.001). The average hospitalization period in group I and group II was 14 days and 8 days, respectively.
Immediate postoperative roentgenograms showed the satisfactory reduction. Reduction status was determined by measuring the medial proximal tibial angle (MPTA) and posterior slope angle. The mean MPTA was 91.5° ± 2.0° and 90.2° ± 2.9° in groups I and II, respectively. The mean posterior slope angle was 10.2° ± 3.2° and 9.8° ± 2.1° in groups I and II, respectively [Table 5]. Subsequent postoperative anteroposterior roentgenogram of the knee was taken at intervals until bony union occurred and then taken at 1 and 2 years after the operation. There was no significant difference in two groups in terms of MPTA (P = 0.052) and posterior slope angle (P = 0.692) at 2 years postoperatively.
|Table 5: Comparison of radiological outcomes of the patients in two groups|
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| Discussion|| |
The treatment of complex tibial plateau fractures requires an unwarranted effort of surgeons in order to avoid complications. Fracture causes severe injuries that could result in early osteoarthritis, ligamentous injury, lifelong pain, and disability. These complications occur in knees with improperly restored plateau surface and extremity axis. With an incidence rate ranging from 10% to 30% of all tibial plateau fractures, AO type C is one that is difficult to manage. The results from our study showed that ROM, pain, walking capacity, and final outcome were significantly better in group II at 1- and 2-year postoperative follow-up, thus proving the superiority of single lateral plate with medial CC screws over dual plating. Also, percutaneous screw fixation causes less postoperative wound complications.
There is no consensus on the merits of single plate over dual plate or vice versa. Reviewing the literature, we see that in high-grade tibial plateau fractures, isolated lateral plating is insufficient in maintaining axial alignment. Wu and Tai supported medial buttressing in fracture with medial component. Yoo et al. advocated dual plating in highly complex tibial plateau fractures.
Lateral locking plate fixation for high-grade tibial plateau fractures has the benefit of a single lateral incision, and therefore, there is no devascularization of the medial fragment and reduced wound complications. However, there is a higher risk of loss of reduction and malunion in lateral locking plate alone than dual plating., Lee et al. did open reduction and fixation with unilateral locked plating to directly reduce the fracture in 15 patients with bicondylar plateau fracture, but despite of having low malreduction, there was a high fixation loss. They suggested that unilateral locked plating has limitations in treating patients with selective patterns of bicondylar tibial plateau fractures. Weaver et al. published the treatment outcome of 129 bicondylar tibial plateau fractures treated with lateral locked plating alone and 11 patients treated with dual plating. In their study, there was a little loss of reduction when lateral locked plating was employed alone in patients with a single medial fracture fragment or with a sagittal medial fracture line. When they used lateral locked plating in the presence of a medial coronal fracture line, there was a significantly higher rate of subsidence compared to those with no medial fracture line.
Contrary to above, studies by Gosling et al., Mueller et al., and Higgins et al. supported that dual plating and single lateral locked plating produced similar outcomes under experimental conditions. Some concluded that lateral locking plate can provide adequate stability even in comminuted tibial plateau fractures and may offer an efficient alternative to additional medial buttressing, thus avoiding further soft-tissue stripping.,, Ehlinger et al. conclude that a single lateral locking plate with or without additional CC screws ensures good clinical and functional outcome in patients with complex articular fractures of the proximal tibia having a medial component. The addition of medial CC screws provides strong fixation in coronal medial fracture lines.
Therefore to reduce the risk of loss of reduction and malunion, medial fragment stability can be provided via two multidirectional percutaneous CC screws in combination with a lateral locking plate under image guidance. Two medial screws are sufficient to maintain the alignment of complex medial fragment, as most part of the stabilization is provided by the polyaxial screws through the lateral locking plate. Traditional method of open reduction and medial plating requires extensive exposure, which may compromise soft-tissue further and devascularize the bone fragments, leading to infection. CC screw insertion being a percutaneous procedure produces no additional risk of soft-tissue or skin damage.
Our study had certain limitations as a maximum follow-up period was 2 years, so late osteoarthritis of knee joint could not be assessed, as it would need a longer follow-up. Also, patients with ligament injuries were not included in the study, as it would have significantly affected the clinical outcome. Patients with ligament injury required secondary procedure for ligament reconstruction. Medical comorbidities such as osteoporosis, diabetes mellitus, etc., were not taken into consideration.
| Conclusions|| |
In conclusion, lateral locking plate supplemented with two medial CC screws provides a better option to treat AO type C tibial plateau fractures especially with more than one sagittal plane medial fracture line, including coronal or complex medial fracture lines in adults. Percutaneous insertion of screws medially produces better results, with minimal complications, when compared with dual plating.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/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.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]