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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 37  |  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


Department of Orthopedics, MLB Medical College, Jhansi, Uttar Pradesh, India

Date of Submission01-Oct-2022
Date of Acceptance07-Nov-2022
Date of Web Publication15-Dec-2022

Correspondence Address:
Nikhil Jain
Department of Orthopedics, MLB Medical College, Jhansi, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jbjd.jbjd_30_22

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  Abstract 

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 Top


Proximal tibia fractures accounts for 1% of all fractures and up to 8% in elderly age groups.[1] 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.[2]

Tibia plateau fracture occurs when there is either varus or valgus force combined with axial load from femoral condyle.[3],[4] The location and amount of force applied decides the fracture pattern.[4] 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.[5],[6],[7] 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,[8],[9] whereas single lateral locked plate ensured reliable fixation.[10],[11],[12],[13] Single lateral plating has been advocated as a means of decreasing the risk of skin and ligament damage and surgical site infection.[14],[15],[16]

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 Top


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.

Surgical technique

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[17] [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.[18]
Table 1: Rasmussen 30-points clinical grading system

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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.

Statistical analysis

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 Top


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.
Table 2: Clinical details of the patients

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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 Top


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.[19] 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.[20] Wu and Tai[21] supported medial buttressing in fracture with medial component. Yoo et al.[8] 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.[7] However, there is a higher risk of loss of reduction and malunion in lateral locking plate alone than dual plating.[7],[13] Lee et al.[22] 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.[23] 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.,[12] Mueller et al.,[24] and Higgins et al.[13] 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.[12],[25],[26] Ehlinger et al.[27] 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 Top


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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jacofsky DJ, Haidukerwych GJ Tibia plateau fractures. In: Scott WN, editor. Insall & Scott Surgery of the Knee. Philadelphia: Churchill Livingstone; 2006. p. 1133-46.  Back to cited text no. 1
    
2.
Blokker CP, Rorabeck CH, Bourne RB Tibial plateau fractures. An analysis of the results of treatment in 60 patients. Clin Orthop Relat Res 1984;182:193-9.  Back to cited text no. 2
    
3.
Koval KJ, Helfet DL Tibial plateau fractures: Evaluation and treatment. J Am Acad Orthop Surg 1995;3:86-94.  Back to cited text no. 3
    
4.
Roberts JM Fractures of the condyles of the tibia. An anatomical and clinical end-result study of one hundred cases. J Bone Joint Surg Am 1968;50:1505-21.  Back to cited text no. 4
    
5.
Berkson EM, Virkus WW High-energy tibial plateau fractures. J Am Acad Orthop Surg 2006;14:20-31.  Back to cited text no. 5
    
6.
Tejwani NC, Hak DJ, Finkemeier CG, Wolinsky PR High-energy proximal tibial fractures: Treatment options and decision making. Instr Course Lect 2006;55:367-79.  Back to cited text no. 6
    
7.
Jiang R, Luo CF, Wang MC, Yang TY, Zeng BF A comparative study of less invasive stabilization system (LISS) fixation and two-incision double plating for the treatment of bicondylar tibial plateau fractures. Knee 2008;15:139-43.  Back to cited text no. 7
    
8.
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;69:148-55.  Back to cited text no. 8
    
9.
Jiang R, Luo CF, Zeng BF Biomechanical evaluation of different fixation methods for fracture dislocation involving the proximal tibia. Clin Biomech (Bristol, Avon) 2008;23:1059-64.  Back to cited text no. 9
    
10.
Mueller KL, Karunakar MA, Frankenburg EP, Scott DS Bicondylar tibial plateau fractures: A biomechanical study. Clin Orthop 2003;412:189-95.  Back to cited text no. 10
    
11.
Gösling T, Schandelmaier P, Marti A, Hufner T, Partenheimer A, Krettek C Less invasive stabilization of complex tibial plateau fractures: A biomechanical evaluation of a unilateral locked screw plate and double plating. J Orthop Trauma 2004;18:546-51.  Back to cited text no. 11
    
12.
Gosling T, Schandelmaier P, Muller M, Hankemeier S, Wagner M, Krettek C Single lateral locked screw plating of bicondylar tibial plateau. Clin Orthop 2005;439:207-14.  Back to cited text no. 12
    
13.
Higgins TF, Klatt J, Bachus KN Biomechanical analysis of bicondylar tibial plateau fixation: How does lateral locking plate fixation compare to dual plate fixation? J Orthop Trauma 2007;21:301-6.  Back to cited text no. 13
    
14.
Beck M, Gradl G, Gierer P, Rotter R, Witt M, Mittlmeier T [Treatment of complicated proximal segmental tibia fractures with the less invasive stabilization locking plate system]. Unfallchirurg 2008;111:493-8.  Back to cited text no. 14
    
15.
Biggi F, Di Fabio S, D’Antimo C, Trevisani S Tibial plateau fractures: Internal fixation with locking plates and the MIPO technique. Injury 2010;41:1178-82.  Back to cited text no. 15
    
16.
Boldin C, Finkhauser F, Hofer HP, Szyzkowitz R Three year results of proximal tibia fractures treated with LISS. Clin Orthop 2006;445:222-9.  Back to cited text no. 16
    
17.
Raza H, Hashmi P, Abbas K, Hafeez K Minimally invasive plate osteosynthesis for tibial plateau fractures. J Orthop Surg (Hong Kong) 2012;20:42-7.  Back to cited text no. 17
    
18.
Paley D, Herzenberg JE, Tetsworth K, McKie J, Bhave A Deformity planning for frontal and sagittal plane corrective osteotomies. Orthop Clin North Am 1994;25:425-65.  Back to cited text no. 18
    
19.
Barei DP, Nork SE, Mills WJ, Henley MB, Benirschke SK Complications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision technique. J Orthop Trauma 2004;18:649-57.  Back to cited text no. 19
    
20.
Waddell JP, Johnston DW, Neidre A Fractures of the tibial plateau: A review of ninety-five patients and comparison of treatment methods. J Trauma 1981;21:376-81.  Back to cited text no. 20
    
21.
Wu CC, Tai CL Plating treatment for tibial plateau fractures: A biomechanical comparison of buttress and tension band positions. Arch Orthop Trauma Surg 2007;127:19-24.  Back to cited text no. 21
    
22.
Lee TC, Huang HT, Lin YC, Chen CH, Cheng YM, Chen JC Bicondylar tibial plateau fracture treated by open reduction and fixation with unilateral locked plating. Kaohsiung J Med Sci 2013;29:568-77.  Back to cited text no. 22
    
23.
Weaver MJ, Harris MB, Strom AC, Smith RM, Lhowe D, Zurakowski D, et al. Fracture pattern and fixation type related to loss of reduction in bicondylar tibial plateau fractures. Injury 2012;43:864-9.  Back to cited text no. 23
    
24.
Mueller KL, Karunakar MA, Frankenburg EP, Scott DS Bicondylar tibial plateau fractures: A biomechanical study. Clin Orthop Relat Res 2003;412:189-95.  Back to cited text no. 24
    
25.
Egol KA, Su E, Tejwani NC, Sims SH, Kummer FJ, Koval KJ Treatment of complex tibial plateau fractures using the less invasive stabilization system plate: Clinical experience and a laboratory comparison with double plating. J Trauma 2004;57:340-6.  Back to cited text no. 25
    
26.
Stannard JP, Wilson TC, Volgas DA, Alonso JE The less invasive stabilization system in the treatment of complex fractures of the tibial plateau: Short-term results. J Orthop Trauma 2004;18:552-8.  Back to cited text no. 26
    
27.
Ehlinger M, Rahme M, Moor BK, Di Marco A, Brinkert D, Adam P, et al. Reliability of locked plating in tibial plateau fractures with a medial component. Orthop Traumatol Surg Res 2012;98:173-9.  Back to cited text no. 27
    


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