Does single locked plating provide a standard treatment Modality for bicondylar tibial plateau fractures? A prospective study

Abstract

Background: Bicondylar tibial plateau fractures present a therapeutic challenge to the orthopaedic trauma surgeon, both in terms of the osseous injury as well as the concomitant soft-tissue insult. Double Plating with single incision or dual incisions provide more insult to the compromised soft tissue. However, single locking plate combines the technical advantages of an angular stable plate with those of the modern biological plating technique. Methods: The Study was held at Razi Orthopedic hospital in Kuwait. Between May 2012 and November 2013, 20 patients with a mean age of 37.65 years (Range from 24-57 years) with bicondylar tibial plateau fractures with or without metaphyseal extension. Patients were diagnosed clinically, checked with standard X-rays, CT was done for all cases. Patients were treated by single lateral anatomically contoured locked plate through LISS or Polyaxial locking plate systems with or without additional screws from medial side. Radiological evaluation and functional assessment was done according to the Rasmussen Knee score. Patients were followed-up for an average of 12 months. Results: Union was achieved in all patients with a mean knee range of motion of 1.5°-130° (range: 0°-10° for extension lag, range: 100°-135° for flexion). The mean Functional Rasmussen Knee score at 6 month follow up (25.32±1.53 SD) ranged from (23.0-28.0). The mean Functional Rasmussen Knee score at last follow-up was (28.33±1.57 SD) ranged between (25.0-30.0) with significant P value (P value<0.001). The mean Anatomical Rasmussen Knee score at 6 month follow up (16.11±1.56 SD) ranged from (14.0-18.0). The mean Anatomical Rasmussen Knee score at last follow-up was (16.67±1.37 SD) ranged from (14.0-18.0) with insignificant P value (P value 0.096 ). Of the 20 patients, one patient had wound related problems, one patient had preoperative compartment syndrome, one patient suffered from hardware irritation and one patient had fixation failure upon which revision with double plating done for him. Conclusions: Surgical treatment of bicondylar tibial plateau fractures with the single lateral locked plate that was evaluated in our study can lead to a good functional and anatomical outcome and considered an effective system for providing fracture stabilization provided that the correct surgical technique is used. Awareness of potential hardware complications is essential. Level of Evidence: Level IV, Prospective Therapeutic Study

The Comparative Analysis of Single Plating Versus Double Plating in the Treatment of Unstable Bicondylar Proximal Tibial Plateau Fractures

“…Limited soft tissue dissection and the submuscular application of a plate with the insertion of percutaneous screws through guide arms in cases of single plating help in the preservation of vascularity and soft tissue integrity by reducing additional further insult to the soft tissue [16,28,29]. This method reduces the intraoperative time effectively with better patient compliance [17].…”

“…Single plating does not, however, have the ability to fix every unstable bicondylar tibial plateau fracture and has its limitations. One or more of the following conditions, or a combination of them, have been reported in cases of tibial plateau fractures: medial intraarticular fracture line, small comminuted medial plateau fragment, medial articular fracture with a coronal component, and a posteromedial fragment [17]. Bicondylar tibial plateau fractures were reported to have a 28.8%-59% incidence rate of the posteromedial fragment [30].…”

“…When used laterally, one locking plate with a set angle might not be able to hold the posteromedial fragment effectively. The strength of the fixation may not be sufficient to counteract the displacement force, even if locking screws through the lateral plate hold the posteromedial fragment [17,18,28]. In cases of tibial plateau fractures with a coronal medial fracture line, the direction of locked screws is fixed and is mostly parallel rather than perpendicular to a coronal fracture line.…”

“…A single lateral locking plate prevents the stripping of soft tissue for the additional medial plate with limited dissection. Percutaneous screw insertion through the guide arm in cases of a single fixed-angle locking plate applied laterally effectively engages the medial fragment to support the medial plateau and prevent varus collapse [15][16][17]. The failure of a single locking plate has been reported in cases of bicondylar tibial plateau fracture where there is a presence of medial articular fracture having a coronal component with a posteromedial fragment [17].…”