Minimally Invasive Surgery of Tibial Plateau Fractures Reduces Incision-Healing Complications of Open Reduction and Internal Fixation

Ozdemir, Guzelali; Deveci, Alper; Arslantas, Emrah; Turan, Sualp; Ciliz, Asım

doi:10.5812/soj.63077

Guzelali Ozdemir

¹, Alper Deveci¹

, Emrah Arslantas¹

, Sualp Turan¹

, Asım Ciliz¹

1- Ankara Numune Research and Training Hospital, Orthopaedics and Traumatology Clinic, Altındag, Ankara, Turkey

Keywords: Minimally Invasive Surgical Procedures, Fracture, Complications

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Abstract

Results: Complete healing without incision-healing complications was reported in all patients from group A, whereas nine incision-healing complications were found in group B (P <; 0.001). The mean Lysholm scores of patients in group A and group B were 81.8 ± 1.72 and 76.3 ± 2.27, respectively (P = 0.06). Also, the mean fracture :union: time in group A and group B was 9.55 ± 0.46 and 10.25 ± 0.71, respectively (P = 0.41).

Copyright © 2018, Shafa Orthopedic Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited

1. Background

Tibial plateau fractures (TPFs) account for approximately 1% of all fractures (1). There is a higher incidence of TPF in males below 50 years compared to females, whereas after this age, the incidence increases in females and decreases in males. The highest frequency has been reported in the age range of 40 - 60 years in both genders (2). Nondisplaced TPF can be treated conservatively, whereas displaced fractures are conventionally treated with open reduction and internal fixation (ORIF) (1, 3, 4).

While various complications may occur in the operative treatment of TPF, the primary morbidities generally involve soft-tissue complications (5). In recent years, minimally invasive surgical (MIS) techniques have become more common in orthopedics and traumatology practice (6-8). These techniques may also reduce complications in the treatment of TPF. To the best of our knowledge, no controlled study has been performed to compare the outcomes of MIS techniques with conventional ORIF in the treatment of TPF.

2. Objectives

3. Methods

In this retrospective study, TPF patients treated with ORIF between January 2014 and June 2016 were included. The patients’ clinical and demographic data were extracted from the hospital records. All patients evaluated in this study had displaced TPF (Figure 1). The Schatzker classification system was used for classification of TPF (9). The inclusion criteria were as follows: 1) ORIF with plate-screw fixation for TPF treatment; 2) age above 18 years; and 3) minimum follow-up of one year. The patients were excluded from the study if they had open fractures.

Figure 1. A 62-year-old male patient treated with an MIS technique. A Schatzker type-V right TPF was observed in the preoperative radiographs (A and B); postoperative radiographs of the same patient 12 months after surgery (C and D).

The patients were divided into two groups according to the date marked for the change of treatment approach in our clinic. Therefore, it was not possible to have a matched distribution of Schatzker classification subtypes. Since February 2015, when wound healing problems, associated with the conventional approach, were obvious to the treatment team, the strategy changed to MIS techniques (Figures 2 and 3); before this change, all patients were being treated with the conventional approach. Finally, the patients were divided into two groups: MIS (group A) and conventional approach (group B).

Figure 2. The postoperative incision view in a 62-year-old male patient treated with an MIS technique for Schatzker type-V right TPF (A); clinical assessment of the same patient in the final follow-up session (B and C).

Figure 3. Incision-healing complication of a 55-year-old male patient treated with the conventional approach. He was treated with in-office debridement, local wound care, and oral antibiotics.

All operations were performed in the supine position with the use of a pneumatic tourniquet. For group A (MIS), a medial and/or lateral skin incision of approximately 4 - 6 cm was made. Fracture reduction and bone grafting, if necessary, were performed. Then, the anatomic plate was advanced to the tibial shaft and mini-incisions were made to insert the distal screws. In group B (ORIF), a medial and/or lateral skin incision of approximately 10 - 12 cm was made. Fracture reduction, bone grafting (if necessary), anatomic plate application, and insertion of distal screws were carried out in the same manner. In both groups, reduction and fixation were examined using plane radiographs. Following drain placement in the wound, the soft tissue and skin were closed layer by layer.

An above-the-knee plaster cast was applied to the operated extremity for one week after surgery. Active range of motion exercises were encouraged at the end of first postoperative week. The patients were allowed full weight-bearing after radiologically confirmed bone :union:. Fracture :union: was assessed radiologically with respect to the appearance of bony bridging between fracture fragments in both anteroposterior and lateral views (Figure 1).

The patients’ follow-up visits were scheduled every two weeks for the first month and then every month until the third month; after the third month, the follow-up intervals changed to every three months. Incision-healing complications were classified based on severity (Table 1) (10). Functional outcomes were evaluated using the Lysholm scale at the end of the first year (11).

Table 1. Definitions of Incision-Healing Complications

Stage
1	None	Complete healing without incision complications
2	Minor without additional treatment	Suture, granuloma, suture abscess, and skin-edge necrosis without any need for intervention
3	Minor with additional treatment	Additional office visits, in-office debridement, local wound care, and oral/topical antibiotics
4	Major	Formal operative intervention for any incision complication

3.1. Statistical Method

Statistical analysis was performed using SPSS version 22.0 for Windows. Descriptive statistics were presented as mean, standard deviation, and minimum/maximum values for numerical variables (age, duration of :union:, and scores) and as number and percentage for categorical variables (Schatzker grade, exposure, side, and gender). Mann-Whitney U test was used to evaluate significant associations between variables. Correlations were evaluated using Spearman’s correlation coefficient test. P <; 0.05 was considered statistically significant.

4. Results

Each group consisted of 20 patients. The mean age of patients was 46.8 ± 2.85 years in group A and 50.3 ± 2.41 years in group B (P = 0.35). The patients’ demographic and clinical characteristics are listed in Table 2. No significant difference was observed between the clinical and demographic characteristics of the two groups.

Table 2. The Demographic and Clinical Characteristics of TPF Patients

Variables	Group A (MIS) (n = 20)	Group B (Conventional) (n = 20)
Gender
Male	16	13
Female	4	7
Age, y	46.8 ± 2.85	50.3 ± 2.41
Range	19 - 75	31 - 66
Side
Right	9	9
Left	11	11
Comorbidity
DM	2	1
HT	6	5
None	12	14
Schatzker classification^a
Type 1	5 (25)	3 (15)
Type 2	6 (30)	5 (25)
Type 3	4 (20)	3 (15)
Type 4	3 (15)	4 (20)
Type 5	1 (5)	3 (15)
Type 6	1 (5)	2 (10)
Skin incisions^a
Medial	3 (15)	4 (20)
Lateral	14 (70)	11 (55)
Double	3 (15)	5 (25)
Classification of incision-healing complications^a
Stage 1	20 (100)	11 (55)
Stage 2	0 (0)	7 (35)
Stage 3	0 (0)	2 (10)
Stage 4	0 (0)	0 (0)
Total incision complications
Stage 2 + 3 + 4	0	9
Lysholm score	81.8 ± 1.72	76.3 ± 2.27
Range	62 - 90	60 - 90
Fracture :union: time, mo	9.55 ± 0.46	10.25 ± 0.71
Range	8 - 15	5 - 18

Abbreviations: DM, diabetes mellitus; HT, hypertension; MIS, minimally invasive surgery; TPF, tibial plateau fractures.

^aValues are expressed as No. (%).

In group A, complete healing without incision complications was reported in all cases. In group B, nine incision-healing complications were observed (P <; 0.001); the incision-healing complications are presented in Table 2. Optimal bone healing was achieved in all TPF patients in both groups. The Lysholm scores and fracture :union: time were not significantly different between the groups (P = 0.06 and P = 0.41, respectively).

5. Discussion

Recently, MIS techniques have become popular because of their advantages. MIS techniques particularly reduce complications in the treatment of different fractures and have major impacts on the outcomes (6-8). The results of this study demonstrated that MIS techniques applied for internal fixation of TPF can provide similar results to the conventional approach in terms of functional scores and fracture :union: over one year of follow-up. However, MIS techniques were found to be superior, especially in terms of incision-healing problems.

Nondisplaced TPF can be treated conservatively, whereas surgery is usually indicated for displaced fractures (1, 3, 4). The treatment goal for TPF is anatomic reduction and stable fixation to allow early joint rehabilitation. Although ORIF allows anatomic reduction and stable fixation, the surgical approach has been reported to cause a higher rate of complications, including incision-healing problems and infection (12, 13). Following surgical treatment of TPF, incision-healing problems are common and devastating complications, which may lead to deep infections. Careful timing of surgery, extraperiosteal dissection, and limited dissection of comminuted bone fragments are likely to decrease complications (14).

Many authors have recommended arthroscopy-assisted techniques and external fixator applications (3, 15-18). Each of these techniques has its limitations, such as need for special equipments and experience. In a case report by Li et al. a Schatzker type-VI TPF was successfully treated with an MIS technique (19). Moreover, treatment of depressed, displaced, or unstable TPF via open conventional techniques provided satisfactory results (20, 21).

In the current study, the outcomes of MIS techniques were compared to the conventional approach in TPF patients, who were treated by ORIF with plate-screw application; our results are consistent with the literature. On the other hand, the complication rate in the MIS group was very low, compared to the literature (12, 13, 20-22). Weimann et al. described a minimally invasive reconstruction technique of lateral TPF and compared it with the conventional osteosynthesis technique. The results indicated that the minimally invasive reconstruction and conventional techniques had similar biomechanical properties (23).

In the review of literature, no previous report was found to include a control group for ORIF in TPF treatment with MIS techniques. To the best of our knowledge, this is the first clinical study on this subject. However, there are some limitations in our study, primarily the retrospective design and limited number of samples. The patients were separated into two groups according to the date marked for the change of treatment approach in our clinic; therefore, it was not possible to have a matched distribution of Schatzker classification subtypes. In addition, Schatzker type-V and type-VI TPFs are associated with extensive soft tissue damage, leading to higher complication rates as reported in the literature (24-26); this could be considered another limitation of our study.

Based on our observations, MIS techniques can be recommended to promote their widespread use in reducing incision-healing problems. In the light of these results, the superiority of MIS to ORIF techniques can be suggested in the treatment of TPF. However, further prospective studies are needed with a larger sample size.

References

1. Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury. 2006;37(8):691-7. doi: 10.1016/j.injury.2006.04.130. [PubMed: 16814787].
2. Elsoe R, Larsen P, Nielsen NP, Swenne J, Rasmussen S, Ostgaard SE. Population-Based Epidemiology of Tibial Plateau Fractures. Orthopedics. 2015;38(9):e780-6. doi: 10.3928/01477447-20150902-55. [PubMed: 26375535].
3. Chen HW, Liu GD, Wu LJ. Clinical and radiological outcomes following arthroscopic-assisted management of tibial plateau fractures: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2015;23(12):3464-72. doi: 10.1007/s00167-014-3256-2. [PubMed: 25246171]. [PubMed Central: PMC4661207].
4. Jiwanlal A, Jeray KJ. Outcome of posterior tibial plateau fixation. J Knee Surg. 2016;29(1):34-9.
5. Haller JM, Holt D, Rothberg DL, Kubiak EN, Higgins TF. Does Early versus Delayed Spanning External Fixation Impact Complication Rates for High-energy Tibial Plateau and Plafond Fractures? Clin Orthop Relat Res. 2016;474(6):1436-44. doi: 10.1007/s11999-015-4583-4. [PubMed: 26481122]. [PubMed Central: PMC4868151].
6. Krettek C, Bachmann S. [Pilon fractures. Part 2: Repositioning and stabilization technique and complication management]. Chirurg. 2015;86(2):187-201. quiz 202-3. doi: 10.1007/s00104-014-2917-5. [PubMed: 25673229].
7. Basile A, Albo F, Via AG. Comparison Between Sinus Tarsi Approach and Extensile Lateral Approach for Treatment of Closed Displaced Intra-Articular Calcaneal Fractures: A Multicenter Prospective Study. J Foot Ankle Surg. 2016;55(3):513-21. doi: 10.1053/j.jfas.2015.11.008. [PubMed: 26810127].
8. Xia S, Lu Y, Wang H, Wu Z, Wang Z. Open reduction and internal fixation with conventional plate via L-shaped lateral approach versus internal fixation with percutaneous plate via a sinus tarsi approach for calcaneal fractures - a randomized controlled trial. Int J Surg. 2014;12(5):475-80. doi: 10.1016/j.ijsu.2014.03.001. [PubMed: 24607889].
9. Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto experience 1968--1975. Clin Orthop Relat Res. 1979;(138):94-104. [PubMed: 445923].
10. Bishop ME, Comer CD, Kane JM, Maltenfort MG, Raikin SM. Open Repair of Acute Achilles Tendon Ruptures: Is the Incidence of Clinically Significant Wound Complications Overestimated? Foot Ankle Orthopaed. 2017;2(2):2.4730114176998E+14. doi: 10.1177/2473011417699834.
11. Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med. 1982;10(3):150-4. doi: 10.1177/036354658201000306. [PubMed: 6896798].
12. Young MJ, Barrack RL. Complications of internal fixation of tibial plateau fractures. Orthop Rev. 1994;23(2):149-54. [PubMed: 8196973].
13. Moore TM, Patzakis MJ, Harvey JP. Tibial plateau fractures: definition, demographics, treatment rationale, and long-term results of closed traction management or operative reduction. J Orthop Trauma. 1987;1(2):97-119. [PubMed: 3333518].
14. Papagelopoulos PJ, Partsinevelos AA, Themistocleous GS, Mavrogenis AF, Korres DS, Soucacos PN. Complications after tibia plateau fracture surgery. Injury. 2006;37(6):475-84. doi: 10.1016/j.injury.2005.06.035. [PubMed: 16118010].
15. Itokazu M, Matsunaga T. Arthroscopic restoration of depressed tibial plateau fractures using bone and hydroxyapatite grafts. Arthroscopy. 1993;9(1):103-8. [PubMed: 8442816].
16. Guanche CA, Markman AW. Arthroscopic management of tibial plateau fractures. Arthroscopy. 1993;9(4):467-71. [PubMed: 8216581].
17. Chen XZ, Liu CG, Chen Y, Wang LQ, Zhu QZ, Lin P. Arthroscopy-assisted surgery for tibial plateau fractures. Arthroscopy. 2015;31(1):143-53. doi: 10.1016/j.arthro.2014.06.005. [PubMed: 25125382].
18. Ozkut AT, Poyanli OS, Ercin E, Akan K, Esenkaya I. Arthroscopic Technique for Treatment of Schatzker Type III Tibia Plateau Fractures Without Fluoroscopy. Arthrosc Tech. 2017;6(1):e195-9. doi: 10.1016/j.eats.2016.09.023. [PubMed: 28409100]. [PubMed Central: PMC5382260].
19. Li DQ, Song DY, Ni JD, Ding ML, Huang J. A case report of Schatzker type VI tibial plateau fracture treated with double reverse traction closed reduction combined with minimally invasive percutaneous plate osteosynthesis technique: A case report. Medicine (Baltimore). 2017;96(45). e8394. doi: 10.1097/MD.0000000000008394. [PubMed: 29137023]. [PubMed Central: PMC5690716].
20. Savoie FH, Vander Griend RA, Ward EF, Hughes JL. Tibial plateau fractures. A review of operative treatment using AO technique. Orthopedics. 1987;10(5):745-50. [PubMed: 3588420].
21. Lachiewicz PF, Funcik T. Factors influencing the results of open reduction and internal fixation of tibial plateau fractures. Clin Orthop Relat Res. 1990;(259):210-5. [PubMed: 2208858].
22. Kuzyk PR, Guy P, Kreder HJ, Zdero R, McKee MD, Schemitsch EH. Minimally invasive hip fracture surgery: are outcomes better? J Orthop Trauma. 2009;23(6):447-53. doi: 10.1097/BOT.0b013e3181acc505. [PubMed: 19550233].
23. Weimann A, Heinkele T, Herbort M, Schliemann B, Petersen W, Raschke MJ. Minimally invasive reconstruction of lateral tibial plateau fractures using the jail technique: a biomechanical study. BMC Musculoskelet Disord. 2013;14(1):120.
24. Khatri K, Sharma V, Goyal D, Farooque K. Complications in the management of closed high-energy proximal tibial plateau fractures. Chin J Traumatol. 2016;19(6):342-7. [PubMed: 28088939]. [PubMed Central: PMC5198935].
25. Devkota P, Manandhar HK, Khadka PB, Mainali LP, Khan JA, Acharya BM, et al. Less invasive stabilization system for the management of proximal tibia fractures. Eur J Orthop Surg Traumatol. 2014;24(6):993-8. doi: 10.1007/s00590-013-1365-0. [PubMed: 24253959].
26. Ruffolo MR, Gettys FK, Montijo HE, Seymour RB, Karunakar MA. Complications of high-energy bicondylar tibial plateau fractures treated with dual plating through 2 incisions. J Orthop Trauma. 2015;29(2):85-90. doi: 10.1097/BOT.0000000000000203. [PubMed: 25050747].

Subject: Knee surgery
Received: 2019/09/9 | Accepted: 2018/08/15 | Published: 2018/08/15

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