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Functional Outcomes of Severe Bicondylar Tibial Plateau Fractures Treated with Dual Incisions and Medial and Lateral Plates

Barei, David P., MD, FRCS(C)1; Nork, Sean E., MD1; Mills, William J., MD2; Coles, Chad P., MD, FRCS(C)3; Henley, M. Bradford, MD1; Benirschke, Stephen K., MD1

doi: 10.2106/JBJS.E.00907
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Supplementary Content

Background: Plate fixation of comminuted bicondylar tibial plateau fractures remains controversial. This retrospective study was performed to evaluate the perioperative results and functional outcomes of medial and lateral plate stabilization, through anterolateral and posteromedial surgical approaches, of comminuted bicondylar tibial plateau fractures.

Methods: Over a seventy-seven-month period, eighty-three AO/OTA type-41-C3 bicondylar tibial plateau fractures were treated with medial and lateral plate fixation through two exposures. Injury radiographs were rank-ordered according to fracture severity. Immediate biplanar postoperative radiographs were evaluated to assess the quality of the reduction. The Musculoskeletal Function Assessment (MFA) questionnaire was used to evaluate functional outcome.

Results: Twenty-three male and eighteen female patients (average age, forty-six years) who completed the MFA questionnaire were included in the study group. The mean duration of follow-up was fifty-nine months. Two patients had a deep wound infection. Complete radiographic information was available for thirty-one patients. Seventeen (55%) of those patients had a satisfactory articular reduction (≤2-mm step or gap), twenty-eight patients (90%) had satisfactory coronal plane alignment (medial proximal tibial angle of 87° ± 5°), twenty-one patients (68%) demonstrated satisfactory sagittal plane alignment (posterior proximal tibial angle of 9° ± 5°), and all thirty-one patients demonstrated satisfactory tibial plateau width (0 to 5 mm). Patient age and polytrauma were associated with a higher (worse) MFA score (p = 0.034 and p = 0.039, respectively). When these variables were accounted for, regression analysis demonstrated that a satisfactory articular reduction was significantly associated with a better MFA score (p = 0.029). Rank-order fracture severity was also predictive of MFA outcome (p < 0.001). No association was identified between rank-order severity and a satisfactory articular reduction (p = 0.21). The patients in this series demonstrated significant residual dysfunction (p < 0.0001), compared with normative data, with the leisure, employment, and movement MFA domains displaying the worst scores.

Conclusions: Medial and lateral plate stabilization of comminuted bicondylar tibial plateau fractures through medial and lateral surgical approaches is a useful treatment method; however, residual dysfunction is common. Accurate articular reduction was possible in about half of our patients and was associated with better outcomes within the confines of the injury severity.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

1 Department of Orthopaedic Surgery, Harborview Medical Center, University of Washington, Box 359798, 325 Ninth Avenue, Seattle, WA 98104-2499. E-mail address for D.P. Barei: barei@u.washington.edu

2 Orthopaedic Physicians Anchorage, 4100 Lake Otis Parkway, Suite 208, Anchorage, AK 99508

3 Division of Orthopaedic Surgery, Queen Elizabeth II Health Sciences Centre, H1 Site, Dalhousie University, Halifax, NS B3H 4R2, Canada

The ideal management of bicondylar fractures of the tibial plateau remains controversial1-8. Treatment goals include the satisfactory restoration of mechanical alignment, anatomic reduction of the articular surface, and stable fixation that allows an early range of motion of the knee; however, attaining these goals may not be directly correlated with improved patient outcomes. Specifically, several reports have suggested that residual articular incongruity of the tibial plateau does not compromise long-term functional outcomes9-16. Additionally, open reduction and internal fixation, particularly through the compromised soft-tissue envelope, has been associated with major wound complications17-19. Alternate methods of treatment for these serious injuries have therefore been suggested2,4,6-8,17,20-22.

Most reports of the functional outcomes of tibial plateau fractures have combined heterogeneous groups of patients and fracture patterns, and investigators reporting the outcomes of bicondylar fractures of the tibial plateau have frequently grouped injuries of varying severity. In general, because of the inherent relationship between the severity of an injury and the ability to obtain a satisfactory reduction, particularly of the articular surface, the impact of each of these variables on outcome has been difficult to assess23,24. The purposes of this study were to evaluate the perioperative results and functional outcomes following operative stabilization of comminuted intra-articular bicondylar fractures of the tibial plateau with medial and lateral plates through anterolateral and posteromedial surgical exposures. Indications for application of a medial plate included the need for neutralization of a displaced intra-articular fracture of the medial tibial plateau and/or neutralization of a medial metaphyseal-diaphysial disruption.

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Materials and Methods

This retrospective study was performed with the approval of our institution's human subjects review board.

Between October 1994 and February 2001, all patients who had sustained an intra-articular fracture of the proximal part of the tibia were identified from a prospectively designed orthopaedic database. Since 1989, all fractures that have been operatively managed at our institution have been recorded in this database. Fractures are entered and coded according to the AO/OTA fracture classification system25 by orthopaedic trauma fellows trained in the use of this system. Data are stored and manipulated with use of a commercially available software program (Microsoft Access; Microsoft, Redmond, Washington). Three hundred and eight patients with a total of 319 bicondylar fractures of the tibial plateau were identified. One hundred and seventy-eight fractures had simple articular involvement (AO/OTA types 41-C1 and 41-C225) and were excluded. Thirteen fractures were treated with primary amputation, ten fractures were misclassified, five fractures were treated nonoperatively, and two were treated with staged arthroplasty. The medical record data were insufficient for twenty-eight additional fractures, and they were also excluded. The remaining eighty-three skeletally mature patients had sustained a total of eighty-three tibial plateau fractures, classified as AO/OTA type 41-C3, and they formed the eligible study population for this retrospective review. The patients' charts were reviewed to determine their age, gender, injury mechanisms, concurrent injuries, associated soft-tissue injuries, complications, and initial and definitive management.

There were fifty-two male and thirty-one female patients ranging in age from twenty-one to eighty-eight years (mean, forty-four years). Most injuries were the result of high-energy trauma including a fall from a height (twenty-five patients), an automobile collision (twenty-two), a motorcycle collision (twelve), an automobile-pedestrian accident (nine), and a sports-related injury (fifteen). Eleven fractures (13%) were open; according to the Gustilo and Anderson classification26,27, one was type II, seven were type III-A, two were type III-B, and one was type III-C. One patient sustained a closed injury with an associated disruption of the popliteal artery. Both patients with a dysvascular limb underwent urgent revascularization. Compartment syndrome was diagnosed and treated with fasciotomies in twelve patients (14%).

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Surgical Management

Open injuries were managed with irrigation of the open wound with sterile saline solution in the emergency department, followed by application of a sterile bandage and the administration of intravenous antibiotics and tetanus prophylaxis. Formal operative débridement was performed urgently as soon as the patient's general condition permitted. The mean time to débridement was ten hours and thirty-one minutes (range, two hours and twenty-five minutes to fifteen hours and twenty-five minutes). The time to débridement was defined as the time from the first documentation of the injury (at admission to our emergency department, at admission to the emergency department of an outside hospital prior to transfer, or as documented in ambulance time records) to the start time for the procedure. Temporary anterior spanning external fixation was applied in forty-two patients (51%) secondary to the severity of the local soft-tissue injury or associated life-threatening injuries. The decision to use temporary spanning external fixation was made by the attending surgeon, who considered factors such as the general condition of the patient and the presence of associated injuries, the amount of limb shortening and deformity, the presence of joint subluxation, and the local soft-tissue conditions. The timing of definitive fixation was based on the patient's medical stability and improvement in the soft-tissue swelling.

The eligible population consisted of eighty-three patients who were treated with dual plate fixation through two surgical exposures—an anterolateral exposure and a separate posteromedial exposure. The anterolateral exposure was performed with superficial and deep dissection centered over the Gerdy tubercle. The posteromedial exposure consisted of a skin incision approximately 1 cm posterior to the palpable posteromedial edge of the tibia with a proximal extension curving along the distal portion of the pes anserinus tendons. The deep fascia overlying the medial gastrocnemius muscle was incised dorsal to the pes anserinus tendons. The pes anserinus tendons were subsequently retracted anteriorly, and the medial gastrocnemius and popliteus muscles were elevated and retracted posteriorly, revealing the posteromedial aspect of the proximal part of the tibia. Dissection over the anteromedial surface of the tibia was minimized, and subperiosteal dissection was limited to the fracture margins and the area of anticipated plate placement. A submeniscal arthrotomy, combined with headlight illumination and the application of a femoral distractor, was typically performed laterally and/or medially to visualize the articular surface. Meniscal detachment or excision was not performed to improve visualization. Intraoperative fracture reduction was assessed with direct visualization and biplanar fluoroscopic images, with the goal being anatomic articular reduction and axial alignment. In all cases, conventional plate-and-screw fixation was used medially and laterally, with the definitive construct individualized; fixed-angle screw/plate devices were not yet available. Subarticular defects were filled with autograft, allograft, or bone-graft substitutes at the discretion of the attending surgeon (see Appendix). All traumatic peripheral meniscal detachments were repaired with suture at the time of wound closure. Central meniscal tears (i.e., radial, longitudinal tears) were débrided only if they were deemed to be unstable.

Perioperative intravenous antibiotics were routinely administered. Range-of-motion exercises and use of a continuous-passive-motion device were started with the supervision of a physical therapist once the incisions were sealed and dry. The patients were instructed to remain non-weight-bearing for a minimum of twelve weeks. Prophylaxis against deep venous thrombosis was administered according to a consistent protocol, with use of mechanical and pharmacologic techniques, during the perioperative period. All patients were routinely screened for deep venous thrombosis with Doppler ultrasound postoperatively.

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Radiographic Assessment of Reduction

Two orthopaedic trauma fellowship-trained surgeons (D.P.B. and W.J.M.), blinded to the results of the outcome assessments, independently evaluated the quality of fracture reduction on the intraoperative and immediate postoperative biplanar radiographs of the proximal part of the tibia on the basis of four radiographic parameters: articular reduction, sagittal alignment, coronal alignment, and condylar width. Full-length standing radiographs were not used to evaluate axial alignment. The radiographs were then reviewed jointly and, in cases in which the interpretations were discordant, agreement was reached by consensus. As determined a priori, articular reduction was scored as satisfactory if there was a ≤2-mm step or gap28-30, coronal alignment was considered satisfactory if the medial proximal tibial angle was 87° ± 5°30-32, sagittal alignment was considered satisfactory if the posterior proximal tibial angle was 9° ± 5°31,33, and condylar width was considered satisfactory if it was 0 to 5 mm30. Radiographic magnification was accounted for during assessment of the articular surface and condylar width. Reductions outside of these parameters were considered to be unsatisfactory. Each parameter was considered as an equal contribution to the overall reduction quality.

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Injury Severity Analysis

Two additional orthopaedic trauma fellowship-trained surgeons (S.E.N. and C.P.C.) independently assessed the anteroposterior and lateral radiographs of the injury to determine its severity. These radiographs were digitized and randomly placed into a computer software program (Microsoft Power-Point) to facilitate reordering manipulations. The reviewers were blinded to the identities of the patient and the treating surgeon, the result of the outcome assessment, and the adequacy of the operative reduction. They were allowed to view the radiographs as many times as necessary to distinguish the injury patterns according to severity, but they completed this task within twenty-four hours. Each injury was then independently rank-ordered23,24 in ascending numeric order with larger numbers representing more severe injuries. The observers ranked all fractures, taking into consideration the radiographic features that they believed to be important in the overall assessment of fracture severity, including predicted treatments and outcomes. The observers were not given any other specific guidelines but instead relied on their clinical experience in managing these fractures.

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Outcome Assessment

The functional outcomes were evaluated with the Musculoskeletal Function Assessment (MFA), a functional outcomes measure. The patients were located with use of their most recent hospital contact information, and the MFA was sent by mail. When the MFA data could not be collected by mail, a questionnaire was completed either during the most recent clinic visit or during a telephone interview by an independent, trained medical interviewer who was not involved in patient treatment. The MFA is a musculoskeletal quality-of-life outcome index consisting of ten categories, from which a total score can be calculated34. MFA values range from 0 to 100 points, and lower scores indicate higher levels of overall function. The MFA has been determined to be valid, reliable, and consistent34-37. It has been validated for use for trauma patients, and it includes evaluation of the entire musculoskeletal system.

Because the MFA is not a limb or injury-specific outcome assessment tool, the presence of multisystem and/or multiple orthopaedic injuries of varying severity may produce a confounding effect. To minimize this effect, patients with multiple injuries were stratified, according to the severity of their associated injuries, into four groups. In Group 1, the injury was confined to the proximal tibial plateau and fibula. In Group 2, the patients had associated fractures that either were managed nonoperatively or were managed operatively solely to allow mobilization but would otherwise have been managed nonoperatively. Patients in Group 3 had associated fractures that included intra-articular fractures requiring operative management on the basis of their own characteristics. Group 4 included patients with multisystem injuries, defined as an Injury Severity Score (ISS)38,39 of ≥18. Patients in Groups 1 and 2 were then combined and considered to have an isolated injury. Patients in Groups 3 and 4 were combined and considered to have associated polytrauma. Several patient and injury characteristics, including patient age, the presence of multiple injuries, infectious complications, the radiographic severity of the injury, the adequacy of the reduction, and the presence of a medial articular injury, were then reviewed to determine their impact on functional outcomes (MFA scores).

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Data Analysis

Fisher exact and chi-square tests were used to compare demographic and injury characteristics between the eligible study population and the final study group. Parametric and nonparametric correlations were performed to compare independent variables with total MFA dysfunction scores. Linear regression analysis was used to assess different variables that had been hypothesized to be predictive of total MFA dysfunction scores. The Student t test was performed to compare normative MFA scores with the MFA scores in the study population. The weighted kappa statistic was used to assess the interobserver reliability of the injury severity rankings.

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Results

Of the eighty-three patients (eighty-three AO/OTA type-41-C3 tibial plateau fractures), forty-two (51%) completed the MFA questionnaire. The scores were plotted, and visual inspection of the data identified one patient with an exceptionally high MFA score (79 points). This patient had recently undergone cardiac valve-replacement surgery, a major confounding variable, and was excluded from further analysis. The remaining forty-one patients formed the study group.

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Injury Characteristics

The study population with complete data included twenty-three men and eighteen women ranging in age from twenty-one to seventy-two years (mean, forty-six years). The mean duration of follow-up was fifty-nine months (4.9 years) (range, thirty to 104 months). The mechanisms of injury included a fall from a height (fourteen patients), an automobile or motorcycle collision (fourteen), an automobile-pedestrian accident (four), and a sports-related injury (nine). There were five open injuries, which were classified as type III-A (three patients), type III-B (one patient), and type III-C (one patient), according to the system of Gustilo and Anderson26,27. Four patients had a compartment syndrome. The mean delay from the day of the injury to the day of the definitive surgical treatment was nine days (range, zero to thirty days) in the series as a whole. This delay was twelve days (range, two to thirty days) for the twenty-four patients (59%) who were treated with temporary knee-spanning external fixation prior to definitive fixation compared with four days (range, zero to ten days) for the patients who were not treated with temporary external fixation (p < 0.01).

Sixteen patients (39%) had associated meniscal injuries diagnosed at the time of the open reduction and internal fixation. Fifteen patients demonstrated a peripheral tear of the lateral meniscus, and two of them had sustained concomitant radial tears of the lateral meniscus in association with peripheral detachment. One patient had a complex tear of the medial meniscus.

With the numbers studied, there were no significant differences between the eighty-three patients in the eligible study population and the forty-one patients in the final study group with regard to age (p = 0.29), gender distribution (p = 0.48), or the occurrence of open injury (p = 0.87), compartment syndrome (p = 0.58), meniscal injury (p = 0.96), or deep septic complications (p = 0.72).

Twenty-eight patients were considered to have had an isolated injury (Groups 1 and 2). Four of these patients had an associated minor orthopaedic fracture: two of them had a distal radial fracture, one had a contralateral humeral shaft fracture, and one had a contralateral proximal fracture of the fibular shaft. The two distal radial fractures and the humeral shaft fracture were managed operatively to aid in mobilization. Thirteen patients were considered to have sustained polytrauma, with five of them having an ISS of ≥18. Eight additional patients with an ISS of <18 were also considered to have polytrauma because of an associated major intra-articular fracture (Table I).

TABLE I - Patient Data
Case Age (yr) MFA Score (points) Injury Group* Associated Skeletal Fractures
1 32 17 1
2 33 21 1
3 33 36 1
4 36 40 1
5 37 5 1
6 39 7 1
7 39 24 1
8 39 28 1
9 39 54 1
10 42 31 1
11 43 36 1
12 44 17 1
13 45 17 1
14 46 6 1
15 46 17 1
16 48 39 1
17 49 11 1
18 51 21 1
19 52 3 1
20 54 11 1
21 70 8 1
22 56 6 1
23 56 62 1
24 55 12 1
25 54 19 2 Contralateral humeral shaft
26 55 18 2 Distal part of contralateral radius
27 57 5 2 Distal part of contralateral radius
28 70 8 2 Proximal part of contralateral fibular shaft
29 21 16 3 Ipsilateral calcaneus (intra-articular); ipsilateral talar neck/body
30 34 44 3 Contralateral talar neck, contralateral patella, ipsilateral femoral shaft, distal part of ipsilateral tibial shaft
31 37 41 3 Distal part of contralateral femur (intra-articular), contralateral tibial plateau
32 52 42 3 Distal part of ipsilateral femur (intra-articular)
33 53 25 3 Contralateral tibial pilon
34 56 48 3 Distal part of ipsilateral femur (intra-articular)
35 58 1 3 Contralateral calcaneus (intra-articular)
36 72 10 3 Contralateral calcaneus (intra-articular)
37 35 43 4 Contralateral tibial plateau + vascular injury, ipsilateral greater tuberosity + gleno-humeral dislocation, contralateral ulnar shaft
38 36 31 4 Pelvic ring disruption, distal part of ipsilateral humerus (intra-articular), ipsilateral radial/ulnar shaft
39 39 53 4 Contralateral clavicle, cervical and thoracic spine injury without neurologic deficit, ipsilateral femur (extra-articular supracondylar)
40 41 24 4 Contralateral tibial shaft, contralateral clavicle and scapula body
41 52 28 4 Cervical and thoracic spine injury without neurologic deficit
*
1 = injury confined to the proximal tibial plateau and fibula (n = 24), 2 = associated fractures managed nonoperatively or fractures managed operatively solely to allow mobilization (would have otherwise been managed nonoperatively) (n = 4), 3 = associated fractures including intra-articular fractures that required operative management on the basis of their own characteristics (n = 8), and 4 = Injury Severity Score (ISS) ≥18 (n = 5). Patients in Groups 1 and 2 were considered to have only an isolated injury, and patients in Groups 3 and 4 were considered to have associated polytrauma
Complete radiographic data unavailable (n = 10)

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Complications

Deep septic wound complications were defined as purulence occurring deep to the iliotibial band laterally or to the deep muscular investing fascia medially. Such a complication developed in two patients, one of whom had involvement of the knee joint. Both of these infections were diagnosed within fourteen days after the time of definitive fixation. Both patients had sustained closed injuries, but one of them had a dysvascular limb requiring emergent revascularization with a prophylactic lower-extremity four-compartment fasciotomy. The two patients were treated with intravenous antibiotics as well as a total of nine operative débridements (mean, 4.5) and removal of the internal fixation after fracture union. Superficial wound complications, defined as infections that were clinically isolated to the subcutaneous layer superficial to the iliotibial band or to the deep investing fascia, were noted in three additional patients. Two of these patients were managed with local dressing changes and oral antibiotics, and one patient was treated with operative débridement and perioperative intravenous antibiotics followed by oral antibiotics.

Eight patients (20%) had a deep venous thrombosis diagnosed with ultrasound Doppler examination. Three of these thromboses were distal to the knee, and five involved the venous system proximal to the knee. Definitive management consisted of therapeutic anticoagulation with oral warfarin or with subcutaneous low-molecular-weight heparin for three to six months depending on the extent of the thrombus or other associated risk factors. There were no clinically apparent pulmonary emboli.

Ten patients (24%), exclusive of those with deep septic complications, required removal of implants for relief of local symptoms. Manipulation of the injured knee with the patient under general anesthesia was performed prior to fracture union in two patients to improve motion.

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Radiographic Assessment

Of the forty-one patients in the study group, thirty-one (76%) had satisfactory injury radiographs, preoperative computed tomographic scans, and immediate postoperative radiographs available for review.

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Fracture Characteristics

Axial computed tomography scans with coronal and sagittal reformations were used to evaluate injury to the articular surface. Twenty-one patients (68%) had a fracture involving the articular surface of the medial tibial plateau (see Appendix). Seven of these medial articular fractures were comminuted, and the remaining fourteen demonstrated a simple medial articular fracture pattern. Thirty patients (97%) had comminution of the articular surface of the lateral tibial plateau. One patient did not have a fracture line that traversed the articular surface of the lateral tibial plateau but had sustained a comminuted articular injury of the medial plateau with metaphyseal-diaphyseal separation.

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Reduction Quality

Seventeen patients (55%) had a satisfactory articular reduction (≤2-mm step or gap). Thirteen patients (42%) demonstrated articular malreduction of between 3 and 5 mm, and one patient demonstrated articular malreduction of 6 mm. Twenty-eight patients (90%) had satisfactory coronal plane alignment. Two patients had a medial proximal tibial angle of 80° and were considered to have varus malalignment. One patient demonstrated a medial proximal tibial angle of –5° and was considered to have valgus malalignment. Twenty-one patients (68%) demonstrated satisfactory sagittal plane alignment. One patient who had a posterior proximal tibial angle of 20° and one who had an angle of 16° were considered to have procurvatum malalignment. The remaining seven patients demonstrated posterior proximal tibial angles ranging from 3° to –6° (mean, 0.43°) and were considered to have recurvatum malalignment. All thirty-one patients demonstrated a satisfactory tibial plateau width. Sixteen patients demonstrated satisfactory reductions of all four radiographic parameters, five patients demonstrated satisfactory reductions of three parameters, eight patients demonstrated satisfactory reductions of two parameters, and three patients demonstrated a satisfactory reduction of only one parameter.

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Fracture Severity

Use of the weighted kappa statistic demonstrated substantial interobserver agreement (κ = 0.66)40 in the two rank-order assessments of fracture severity; thus a single average rank for each injury was calculated and was considered as a single variable for the subsequent outcome analysis.

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Outcome Assessment

The mean MFA score for the forty-one patients was 26.05 points (range, 1 to 62 points), with impact on leisure (mean score, 50 points), employment (mean score, 41 points), and general movement (mean score, 37 points) identified as the most affected MFA domains. Activities using the hands (mean score, 5 points) and activities of daily living (mean score, 9 points) were the least affected domains. Age and the presence of polytrauma (the categorical variable of groups 3 and 4 combined) were associated with a higher (worse) MFA score (p = 0.034 and p = 0.039, respectively). When age and associated polytrauma were controlled, regression analysis demonstrated that a satisfactory articular reduction was significantly associated with a lower (better) MFA score (p = 0.029). With the numbers studied, coronal alignment (p = 0.899), sagittal alignment (p = 0.076), tibial plateau width, and the presence of a medial articular injury (p = 0.28) were not associated with the MFA score. Although it was not significant, there was a trend toward lower MFA scores (p = 0.067) with an increasing number of radiographic parameters that were considered satisfactory. Rank-order fracture severity was found to be significantly predictive of MFA outcome (p < 0.001), but interestingly, with the numbers studied, no association was found between fracture severity and the presence of a satisfactory articular reduction (p = 0.21).

In this small sample of subjects, no significant association could be identified between the MFA score and the presence of a deep septic complication (p = 0.33), open fracture (p = 0.071), fasciotomy for compartment syndrome (p = 0.494), meniscal injury (p = 0.152), or surgical delay until definitive fixation (p = 0.096). There was no significant difference in MFA scores between the patients treated with and those treated without spanning external fixation (p = 0.29). In addition, no significant difference in MFA scores was noted between the patients with and those without complete radiographic data (p = 0.97).

Compared with uninjured patients (MFA score, 9.3 points)37, patients in whom a C3 bicondylar tibial plateau fracture had been treated with the described operative method demonstrated significant residual dysfunction (p < 0.0001) at a mean of fifty-nine months postoperatively.

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Discussion

Treatment strategies for high-energy tibial plateau fractures remain controversial. Medial and lateral plate fixation of these injuries, typically performed with use of an anterior midline surgical incision, has been associated with unacceptably high rates of wound complications17-19, which has prompted recommendations for alternative methods of reduction and stabilization2,4,6-8,17,20-22. The results of the present study indicate that bicondylar tibial plateau fractures with articular comminution have a significant negative effect on functional outcomes, with most of the detrimental consequences involving leisure, employment, and general mobilization. While increased fracture severity, as assessed with the rank-order technique, was strongly associated with worse functional outcomes in this group, the ability to obtain a satisfactory articular reduction was significantly associated with improved MFA scores.

Comparing the functional results of this study with those reported in the recent literature is complicated by the use of differing classification schemes, outcome measures, and treatment techniques. The results of the current study corroborate the findings of Kumar and Whittle41 and those of Marsh et al.4, and they identify a correlation between a lower functional outcome score and an inaccurate articular reduction. Increasing age and the presence of polytrauma were both independently associated with higher (worse) MFA scores. When these variables were accounted for, regression analysis showed that a satisfactory articular reduction was significantly associated with a lower (better) MFA score (p = 0.029). While no other single radiographic parameter was significantly associated with the MFA score, it is likely that the relatively small numbers of patients who demonstrated unsatisfactory coronal and sagittal malalignment and unsatisfactory condylar width may have resulted in underpowered statistical assessments of these variables. A rank-order analysis of the severity of injury followed by examination of this severity with use of a regression model failed to demonstrate any significant relationship between the severity of injury and the adequacy of articular reduction (p = 0.21) but showed a significant association between the injury severity and MFA score (p < 0.001). As suggested by Marsh et al.4, this implies that both the quality of the articular reduction and the severity of the initial injury have an impact on the MFA score. Furthermore, the fact that the injuries that were ranked as more severe did not result in worse articular reductions suggests that a satisfactory articular reduction, despite a severe injury pattern, still has a positive effect on the functional outcome as measured by the MFA.

Although all of the fractures were classified as AO/OTA type C3, there were still variations in the fracture patterns. We chose to utilize the rank-order method to assess these variations, as this technique had been demonstrated previously to be reliable for stratifying injury severity23,24 by allowing the observers to integrate a variety of injury characteristics while avoiding the constraint imposed by the ordered grouping of commonly used classification systems. While use of this technique has not been previously reported for the assessment of tibial plateau fractures, we believe it to be useful for stratifying the degree of severity of fractures with an otherwise homogeneous pattern, as increased subgrouping of fracture types within the AO/OTA fracture classification system appears to result in poor interobserver reliability42. The inherent relationship between the severity of an injury and the ability to obtain a satisfactory reduction, particularly of the articular surface, hampers the ability to determine the impact of each of these variables on outcome23,24. The rank-order technique allowed us to separate the effect of articular reduction from that of increasing comminution so that we could assess the effect of each.

In the current study, medial plate fixation was used to neutralize displaced fractures traversing the articular surface of the medial tibial plateau and/or to neutralize the medial metaphyseal-diaphyseal disruption component of the injury. The use of laterally applied fixed-angle devices has now predominantly eliminated the need for supplemental medial fixation to neutralize the metaphyseal-diaphyseal injury component. These implants, however, have not eliminated the need for the second posteromedial approach to reduce and stabilize displaced medial plateau articular disruptions. This was recently illustrated in a series of AO/OTA type-C tibial plateau fractures treated with lateral locked plate fixation43. In that series, Gosling et al. identified three patients with a loss of reduction secondary to failure to reduce and/or stabilize a posteromedial articular fracture fragment. Future investigations into the frequency and morphology of medial articular fracture fragmentation in bicondylar fracture patterns may further define the role of the posteromedial exposure. Similarly, while the ability of a locked plate to stabilize the proximal tibial metaphyseal-diaphysial disruption appears to be well accepted, the ability of these implants to neutralize displaced articular segments remains largely unproven.

This study had several limitations. Several reports have suggested that the accuracy and reproducibility of plain radiographic measurements of articular congruity may be suboptimal44-49. While improved measurement accuracy has been demonstrated with computed tomography scanning46,47, only preoperative computed tomography scans were performed for the patients in this study so that potentially improved radiographic accuracy was not available to us postoperatively. Unlike the plain radiographic measurements that were identified as having suboptimal validity in other reports, the reduction parameters evaluated in this study were continuous data that had been ordered into a dichotomous response, essentially decreasing the tolerance limits of the parameters that were evaluated. This may have increased the validity of our radiographic assessments, but those measurements still represent a limitation of our study. Similarly, the fact that full-length standing radiographs were not made may have been a source of error in our determination of the adequacy of coronal alignment. Additionally, no long-term clinical assessment, such as an evaluation of the range of motion of the knee or an examination of knee stability, was performed for these patients. While weight-bearing restrictions were recommended to lessen the potential for articular subsidence and loss of axial alignment, long-term radiographs to assess arthrosis, residual limb alignment, or loss of articular reduction were not made. Furthermore, we did not assess the patients' socioeconomic status, level of education, or type of employment, which, along with several other unknown factors, may be confounding variables associated with these injuries. Finally, nearly half of our patients could not be located or were unwilling to participate in the study, potentially resulting in a biased study population. Similarly, the incomplete radiographic data on the patients with adequate follow-up further limit the robustness of these results and conclusions. Despite these limitations, the fracture characteristics in the study group were similar to those in the eligible study population, and the rate of follow-up was similar to that commonly reported in the trauma literature, particularly with this duration of follow-up48,49.

We concluded that the severity of an injury to the tibial plateau is associated with the functional outcome. The results of this study also suggest that a satisfactory articular reduction with use of the described surgical technique positively affects patient outcome. No association between the adequacy of the articular reduction and the severity of the injury was identified, suggesting that patients with more severe injuries can still receive satisfactory articular reductions. Patients with a comminuted bicondylar fracture of the tibial plateau demonstrate substantial residual functional dysfunction after treatment compared with the general population. Satisfactory surgical restoration of the articular component of these injuries improves patient outcomes within the confines of the overall injury severity.

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Appendix

Radiographs of two patients in this series are available with the electronic versions of this article, on our web site at jbjs.org (go to the article citation and click on “Supplementary Material”) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM). ▪

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at the Department of Orthopaedic Surgery, Harborview Medical Center, Seattle, Washington

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References

1. 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.
2. Dendrinos GK, Kontos S, Katsenis D, Dalas A. Treatment of high-energy tibial plateau fractures by the Ilizarov circular fixator. J Bone Joint Surg Br. 1996;78: 710-7.
3. Gaudinez RF, Mallik AR, Szporn M. Hybrid external fixation of comminuted tibial plateau fractures. Clin Orthop Relat Res. 1996;328: 203-10.
4. Marsh JL, Smith ST, Do TT. External fixation and limited internal fixation for complex fractures of the tibial plateau. J Bone Joint Surg Am. 1995;77: 661-73.
5. Ries MD, Meinhard BP. Medial external fixation with lateral plate internal fixation in metaphyseal tibia fractures. A report of eight cases associated with severe soft-tissue injury. Clin Orthop Relat Res. 1990;256: 215-23.
    6. Stamer DT, Schenk R, Staggers B, Aurori K, Aurori B, Behrens FF. Bicondylar tibial plateau fractures treated with a hybrid ring external fixator: a preliminary study. J Orthop Trauma. 1994;8: 455-61.
    7. Watson JT. High-energy fractures of the tibial plateau. Orthop Clin North Am. 1994;25: 723-52.
      8. Weiner LS, Kelley M, Yang E, Steuer J, Watnick N, Evans M, Bergman M. The use of combination internal fixation and hybrid external fixation in severe proximal tibia fractures. J Orthop Trauma. 1995;9: 244-50.
      9. Lucht U, Pilgaard S. Fractures of the tibial condyles. Acta Orthop Scand. 1971; 42: 366-76.
      10. Rasmussen PS. Tibial condylar fractures. Impairment of knee joint stability as an indication for surgical treatment. J Bone Joint Surg Am. 1973;55: 1331-50.
        11. Jensen DB, Rude C, Duus B, Bjerg-Nielsen A. Tibial plateau fractures. A comparison of conservative and surgical treatment. J Bone Joint Surg Br. 1990;72: 49-52.
          12. Duwelius PJ, Connolly JF. Closed reduction of tibial plateau fractures. A comparison of functional and roentgenographic end results. Clin Orthop Relat Res. 1988;230: 116-26.
            13. Honkonen SE. Degenerative arthritis after tibial plateau fractures. J Orthop Trauma. 1995;9: 273-7.
              14. Koval KJ, Sanders R, Borrelli J, Helfet D, DiPasquale T, Mast JW. Indirect reduction and percutaneous screw fixation of displaced tibial plateau fractures. J Orthop Trauma. 1992;6: 340-6.
                15. Weigel DP, Marsh JL. High-energy fractures of the tibial plateau. Knee function after longer follow-up. J Bone Joint Surg Am. 2002;84: 1541-51.
                  16. Marsh JL, Buckwalter J, Gelberman R, Dirschl D, Olson S, Brown T, Llinias A. Articular fractures: does an anatomic reduction really change the result? J Bone Joint Surg Am. 2002;84: 1259-71.
                  17. Mallik AR, Covall DJ, Whitelaw GP. Internal versus external fixation of bicondylar tibial plateau fractures. Orthop Rev. 1992;21: 1433-6.
                  18. 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: 97-119.
                    19. Young MJ, Barrack RL. Complications of internal fixation of tibial plateau fractures. Orthop Rev. 1994;23: 149-54.
                    20. Mikulak SA, Gold SM, Zinar DM. Small wire external fixation of high energy tibial plateau fractures. Clin Orthop Relat Res. 1998;356: 230-8.
                    21. Murphy CP, D'Ambrosia R, Dabezies EJ. The small pin circular fixator for proximal tibial fractures with soft tissue compromise. Orthopedics. 1991;14: 273-80.
                      22. Watson JT, Coufal C. Treatment of complex lateral plateau fractures using Ilizarov techniques. Clin Orthop Relat Res. 1998;353: 97-106.
                      23. DeCoster TA, Willis MC, Marsh JL, Williams TM, Nepola JV, Dirschl DR, Hurwitz SR. Rank order analysis of tibial plafond fractures: does injury or reduction predict outcome? Foot Ankle Int. 1999;20: 44-9.
                      24. Williams TM, Nepola JV, DeCoster TA, Hurwitz SR, Dirschl DR, Marsh JL. Factors affecting outcome in tibial plafond fractures. Clin Orthop Relat Res. 2004; 423: 93-8.
                      25. Fracture and dislocation compendium. Orthopaedic Trauma Association Committee for Coding and Classification. J Orthop Trauma. 1996;10 Suppl 1: v-ix, 1-154.
                      26. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58: 453-8.
                      27. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984;24: 742-6.
                      28. Brown TD, Anderson DD, Nepola JV, Singerman RJ, Pedersen DR, Brand RA. Contact stress aberrations following imprecise reduction of simple tibial plateau fractures. J Orthop Res. 1988;6: 851-62.
                      29. 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.
                        30. Honkonen SE. Indications for surgical treatment of tibial condyle fractures. Clin Orthop Relat Res. 1994;302: 199-205.
                        31. Paley D. Principles of deformity correction. Berlin: Springer; 2002.
                        32. Cooke TD, Li J, Scudamore RA. Radiographic assessment of bony contributions to knee deformity. Orthop Clin North Am. 1994;25: 387-93.
                        33. 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.
                        34. Martin DP, Engelberg R, Agel J, Snapp D, Swiontkowski MF. Development of a musculoskeletal extremity health status instrument: the Musculoskeletal Function Assessment instrument. J Orthop Res. 1996;14: 173-81.
                        35. Martin DP, Engelberg R, Agel J, Swiontkowski MF. Comparison of the Musculoskeletal Function Assessment questionnaire with the Short Form-36, the Western Ontario and McMaster Universities Osteoarthritis Index, and the Sickness Impact Profile health-status measures. J Bone Joint Surg Am. 1997;79: 1323-35.
                          36. Engelberg R, Martin DP, Agel J, Obremsky W, Coronado G, Swiontkowski MF. Musculoskeletal Function Assessment instrument: criterion and construct validity. J Orthop Res. 1996;14: 182-92.
                            37. Engelberg R, Martin DP, Agel J, Swiontkowski MF. Musculoskeletal function assessment: reference values for patient and non-patient samples. J Orthop Res. 1999;17: 101-9.
                            38. Baker SP, O'Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14: 187-96.
                            39. Baker SP, O'Neill B. The injury severity score: an update. J Trauma. 1976; 16: 882-5.
                            40. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33: 159-74.
                            41. Kumar A, Whittle AP. Treatment of complex (Schatzker Type VI) fractures of the tibial plateau with circular wire external fixation: retrospective case review. J Orthop Trauma. 2000;14: 339-44.
                            42. Swiontkowski MF, Sands AK, Agel J, Diab M, Schwappach JR, Kreder HJ. Interobserver variation in the AO/OTA fracture classification system for pilon fractures: is there a problem? J Orthop Trauma. 1997;11: 467-70.
                            43. Gosling T, Schandelmaier P, Muller M, Hankemeier S, Wagner M, Krettek C. Single lateral locked screw plating of bicondylar tibial plateau fractures. Clin Orthop Relat Res. 2005;439: 207-14.
                            44. Martin J, Marsh JL, Nepola JV, Dirschl DR, Hurwitz S, DeCoster TA. Radiographic fracture assessments: which ones can we reliably make? J Orthop Trauma. 2000;14: 379-85.
                            45. Kreder HJ, Hanel DP, McKee M, Jupiter J, McGillivary G, Swiontkowski MF. X-ray film measurements for healed distal radius fractures. J Hand Surg [Am]. 1996;21: 31-9. Erratum in: J Hand Surg [Am]. 1996;21:532.
                              46. Borrelli J Jr, Goldfarb C, Catalano L, Evanoff BA. Assessment of articular fragment displacement in acetabular fractures: a comparison of computerized tomography and plain radiographs. J Orthop Trauma. 2002;16: 449-57.
                              47. Cole RJ, Bindra RR, Evanoff BA, Gilula LA, Yamaguchi K, Gelberman RH. Radiographic evaluation of osseous displacement following intra-articular fractures of the distal radius: reliability of plain radiography versus computed tomography. J Hand Surg [Am]. 1997;22: 792-800.
                              48. Vallier HA, Nork SE, Benirschke SK, Sangeorzan BJ. Surgical treatment of talar body fractures. J Bone Joint Surg Am. 2003;85: 1716-24.
                              49. Vallier HA, Nork SE, Barei DP, Benirschke SK, Sangeorzan BJ. Talar neck fractures: results and outcomes. J Bone Joint Surg Am. 2004;86: 1616-24.
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