Keywords
tibial fractures - surgical procedures, operative - rehabilitation
Introduction
Tibial plateau fractures represent 1 to 2% of all fractures and approximately 8% of
fractures in the elderly.[1] The mechanism of injury consists of an axial force with the knee flexed. The position
of the knee (varus, valgus, or neutral) determines the location of the fracture in
the posterior column of the tibial plateau (medial, lateral, or both, respectively).[2] The incidence rate of posteromedial and/or posterolateral fractures is approximately
30%.[2]
[3]
[4]
[5]
[6]
[7]
Access to the posterior region of the knee is often considered a difficult task due
to the depth of the operative field and the presence of vascular and nervous elements
that pass through it. Approaches used in posterior tibial plateau fractures (PTPFs)
have undergone significant changes in recent years.[8]
Among the most used surgical access options for the treatment of posterior fractures,
some stand out, such as the direct posterolateral approach in S without fibular osteotomy,
the transfibular osteotomy approach, partial ostectomy of the fibular head, the direct
posteromedial approach in S, and, less frequently, the posteromedial reversed L-shaped
approach.[9]
[10]
[11]
The aim of the present study was to describe a case series of surgical treatment of
PTPF conducted using the posterior approach as described by Carlson,[9] analyzing, during the follow-up, the quality of the reduction and the functional
results obtained with this approach.
Methods
The present study was approved by the Ethics Committee (CAEE- 27128619.6.0000.5047).
During 2019, 11 patients were submitted to the Carlson[9] approach for PTPFs (through a posteromedial and posterolateral approach). All surgeries
were performed by two surgeons with expertise in knee fractures. All fractures were
classified by two expert knee fracture surgeons according to the Schatzker, Schatzker
and Kfuri, Hohl and Moore, Luo, and the Osteosynthesefragen/Association for the Study
of Internal Fixation (AO/ASIF) classification methods ([Table 1]).[4]
[5]
[6]
[7]
[8] All patients were followed up with regular clinical and radiological assessments.
Table 1
|
Patients
|
Age
|
Mechanism
|
Time until surgery (days)
|
Classification
|
|
Shatzker
|
Schatzker/Kfuri
|
Moore
|
AO/ASIF
|
Luo
|
|
1
|
47
|
Motorcycle accident
|
3
|
III
|
V P ML
|
I
|
41B2.2
|
Posterior column (medial and lateral)
|
|
2
|
30
|
Motorcycle accident
|
1
|
III
|
V P ML
|
I
|
41B2.2
|
Posterior column (medial and lateral)
|
|
3
|
23
|
Sports trauma
|
3
|
IV
|
V P ML
|
V
|
41C.1
|
Posterior column (medial and lateral)
|
|
4
|
19
|
Motorcycle accident
|
5
|
III
|
V P ML
|
IV
|
41B2.3
|
Posterior column (medial and lateral)
|
|
5
|
28
|
Motorcycle accident
|
2
|
III
|
V P ML
|
I
|
41B2.3
|
Posterior column (medial and lateral)
|
|
6
|
41
|
Motorcycle accident
|
2
|
III
|
V P ML
|
IV
|
41B2.2
|
Posterior column (medial and lateral)
|
|
7
|
19
|
Motorcycle accident
|
4
|
V
|
V P ML
|
V
|
41C1
|
Posterior column (medial and lateral)
|
|
8
|
22
|
Motorcycle accident
|
9
|
III
|
V P ML
|
IV
|
41B2.2
|
Posterior column (medial and lateral)
|
|
9
|
28
|
Motorcycle accident
|
18
|
II
|
V P ML
|
II
|
41B3.1
|
Posterior column (medial and lateral)
|
|
10
|
29
|
Motorcycle accident
|
12
|
V
|
V P ML
|
V
|
41C1
|
Posterior column (medial and lateral)
|
|
11
|
22
|
Motorcycle accident
|
10
|
II
|
V P ML
|
I
|
41B2.2
|
Posterior column (medial and lateral)
|
The American Knee Society Score (AKSS), American Knee Society Score/Function (AKSS/Function),
and the Lysholm score were used to check treatment results at 6 months after the fracture.
The patients underwent standard anteroposterior and lateral radiographs to assess
fracture healing during follow-up, and clinical healing was determined by the absence
of pain during full weight bearing.
Surgical Technique
Carlson[9] described two independent S-shaped approaches for the posteromedial and posterolateral
regions of the tibial plateau without fibular osteotomy. After carrying out the operating
room safety protocol and administering a prophylactic antibiotic (1 g of intravenous
cefazolin), the patient was submitted to spinal anesthesia.
The approach begins with a smooth curvilinear S-shaped incision on the posteromedial
side of the knee ([Figure 1]), proceeding with careful dissection, due to the proximity of the saphenous nerve,
visualizing the insertion of the semimembranosus muscle, which is lifted with the
popliteal fascia, exposing the posteromedial plateau fracture. On the posterolateral
side of the knee, a similar S-shaped incision ([Figure 2]) is made over the femoral biceps muscle. The fibular nerve is identified on the
posterior side of the biceps femoris muscle, being exposed proximally and distally.
Then, the lateral head of the gastrocnemius muscle is retracted medially, allowing
the visualization of the soleus muscle insertion. The popliteal tendon can be moved
proximally, thus exposing the posterolateral plateau fracture. At this point, careful
positioning of the retractors is required. A Hohmann retractor must be placed directly
on the bone under direct visualization and verifying correct placement. For this,
a Langenbeck retractor is very useful. A Hohmann retractor may be placed in the posteromedial
cortical border. After visualizing the fracture, it is reduced and fixed with small
fragment conventional plates, 3.5-mm reconstruction plates, or T plates with or without
traction screws.
Fig. 1 (A) Anteroposterior and lateral radiographs showing a fracture of the posterior column
of the left tibial plateau. (B) Postoperative images of anteroposterior and lateral radiographs of the left knee
evidencing fracture reduction and internal fixation with a 3.5-mm T plate (Lateral) + 3.5
reconstruction plate (medial) + 3.5 reconstruction plate (central). (C and D) Intraoperative images showing a lateral Carlson incision in a posterolateral curvilinear
“S” shape. White arrow - Lateral head of the gastrocnemius muscle. Yellow arrow -
Fibular nerve. Blue arrow - Lateral head of the biceps femoris muscle.
Fig. 2 (A) Coronal section computed tomography, evidencing the lateral depression and medial
shear of the joint surface. (B) 3D reconstruction of computed tomography showing a posteromedial shear. (C) Carlson's “S”-shaped lateral and medial operative incision. (D and E) Postoperative anteroposterior and lateral radiographs revealing fracture.
After surgery, the patients remained without weight bearing on the operated limb for
3 weeks. Range-of-motion exercises were allowed from the first postoperative day.
Also, isometric strengthening exercises were commenced from day 1. No immobilizers,
braces, or orthoses were used.
Statistical Analysis
The data were analyzed using the IBM SPSS Statistics for Windows, Version 23.0 software
(IBM Corp., Armonk, NY, USA). Comparisons with p-values up to 0.05, with a 95% confidence interval, were considered significant. To
compare two paired groups, a non-parametric Wilcoxon signed-rank test was used.
Results
The mean follow-up period was 12 months (9–16 months), and all fractures had healed
by then. No discrepancies or deformities of the lower limbs were observed, nor did
any of the patients present superficial or deep infection. In all cases, dorsiflexion
strength of the ankle and toes was symmetrical to that of the non-operated limb ([Table 1]).
Of the 11 patients who took part in the study, 8 were male (72.7%). The primary mechanism
of trauma was motorcycle accident (90.9%), and the most prevalent side of fracture
was the right side (63.6%). In this study, the mean age of the participants was 28
years, ranging from 10 to 47 years ([Table 1]).
The mean duration of surgery was 100 minutes, varying between 70 and 130 minutes.
Conventional implants were used (3.5 non-locking plates) in most of the patients (90.90%).
Anatomical reduction was achieved in 72.7% of the participants, evaluated through
conventional X-ray examination. In 2 patients (18.18%) with bone failure, a bone graft
was inserted to cover the defect. In one case, the graft was harvested from the posterior
iliac crest, while in the other the graft was synthetic, using the Nanogel injectable
hydroxyapatite gel (Teknimed, L'Union, France) ([Table 2]).
Table 2
|
Patients
|
Duration of surgery (in minutes)
|
Bone graft
|
Fixation type
|
Quality of the reduction
|
Complications
|
|
1
|
70'
|
No
|
3.5 T plate (lateral) + 3.5 T plate (medial)
|
Anatomical
|
No
|
|
2
|
93'
|
No
|
3.5 T plate (lateral) + 3.5 T plate (medial)
|
Anatomical
|
No
|
|
3
|
130'
|
Yes (iliac)
|
3.5 T plate (lateral) + 3.5 T plate (medial)
|
Anatomical
|
No
|
|
4
|
100'
|
No
|
3.5 T plate (lateral) + 3.5 T plate (medial)
|
Anatomical
|
No
|
|
5
|
112'
|
No
|
3.5 T plate (lateral) + 3.5 T plate (medial) - locking
|
Anatomical
|
No
|
|
6
|
83'
|
Yes (synthetic)
|
3.5 T plate (lateral) + 3.5 T plate (medial) + cannulated screw
|
Anatomical
|
No
|
|
7
|
97'
|
No
|
3.5 T plate (lateral) + 3.5 reconstruction plate (medial) + 3.5 reconstruction plate
(central)
|
Anatomical
|
No
|
|
8
|
72'
|
No
|
3.5 T plate (lateral) + compression screws (medial)
|
3 mm Lateral depression
|
No
|
|
9
|
107'
|
No
|
Cannulated screws (lateral) + reconstruction plate 3.5 (medial)
|
4 mm lateral depression
|
Injury of the superficial branch of the fibular nerve
|
|
10
|
111'
|
No
|
3.5 T plate (lateral) + 3.5 reconstruction plate /compression screw (medial)
|
1 mm lateral depression
|
No
|
|
11
|
125'
|
Yes (synthetic)
|
3.5 T plate/3.5 cannulated screws (lateral) + 3.5 reconstruction plate (medial)
|
Anatomical
|
No
|
Six of 11 patients had their fractures classified as Schatzker III; two as Schatzker
II, two as Schatzker V, and one as Schatzker IV. All patients had their fractures
classified as Schatzker/Kfuri V P ML ([Table 1]).
The results of the scores (Lysholm, AKSS, AKSS/Function, and Lysholm) and the range
of motion after 6 months of procedure can be seen in [Table 3]. No postoperative complications were observed.
Table 3
|
Patients
|
Lysholm*
|
AKKS**/AKKS Function***
|
ROM
|
Reduction/Alignment
|
Complications
|
|
Pre-injury
|
6 months
|
|
1
|
100
|
90
|
96/100
|
0–117
|
Anatomical/Maintained
|
No
|
|
2
|
100
|
94
|
97/100
|
0–123
|
Anatomical/Maintained
|
No
|
|
3
|
100
|
85
|
90/100
|
0–115
|
Anatomical/Maintained
|
No
|
|
4
|
100
|
95
|
88/100
|
0–100
|
Anatomical/Maintained
|
No
|
|
5
|
100
|
99
|
100/100
|
0–125
|
Anatomical/Maintained
|
No
|
|
6
|
100
|
95
|
100/100
|
0–125
|
Loss of 2 mm/ Maintained
|
No
|
|
7
|
100
|
99
|
95/100
|
0–125
|
Anatomical/Maintained
|
No
|
|
8
|
100
|
84
|
92/90
|
0–113
|
3 mm lateral depression/ Maintained
|
No
|
|
9
|
100
|
85
|
95/100
|
0–123
|
4 mm lateral depression/ Maintained
|
No
|
|
10
|
100
|
96
|
100/100
|
0–125
|
1 mm lateral depression/ Maintained
|
No
|
|
11
|
100
|
96
|
100/100
|
0–125
|
Anatomical/Maintained
|
No
|
When analyzing sex, the female patients presented longer mean duration of surgery.
The Wilcoxon signed-rank test did not indicate significant difference between sexes
for the AKSS (p = 0.295), AKSS/Function (p = 0.6831), and Lysholm (p = 0.0637) scores.
Discussion
The prognosis of tibial plateau fractures is related to the quality of anatomical
reduction of the joint surface and stable osteosynthesis to enable early knee mobilization.[12] The treatment of PTPFs is challenging, and several approaches have been described
for the treatment of these fractures, including the Carlson approach.[9]
Wang et al.
[13] reported an approach that can be used for posterior shearing tibial plateau fractures,
a procedure that is technically demanding and presents a risk for iatrogenic vascular
injury due to the traction required to allow for visualization.[14] Lobenhoffer[15] described a transfibular approach for the treatment of posterolateral tibial plateau
fractures. At the same time, Frosch et al.[16] proposed the posterolateral route with anterolateral and posterolateral arthrotomies,
without osteotomy of the fibular neck, to treat combined fractures of the anterolateral
and posterolateral zones of the tibial plateau. The partial ostectomy of the head
of the fibula was described by Yu et al.[10] for the treatment of tibial plateau fractures, with preservation of the insertion
of the lateral ligament complex of the knee. Good visibility is a positive aspect
of the approach described by Yu; however, this access increases patient morbidity
due to the addition of a fracture. He et al.[11] reported an extended posteromedial reversed L-shaped approach, without tenotomy
of the gastrocnemius head, whereas Hu et al.[17] described a supra-fibular-head approach without fibular osteotomy for the treatment
of PTPFs.
Despite the different proportions between the studies, it can be observed in the present
manuscript that the leading mechanism of injury was motorcycle accidents (90.9%),
and only one patient suffered a sports-related injury, contrasting with the study
published by Albuquerque et al.,[1] who, in their epidemiological survey on tibial plateau fractures, found that, among
the 239 patients analyzed, the main mechanism of injury was falls from heights, reported
in 96 patients. In a retrospective study conducted by Xiang et al.,[3] the authors described the morphological characteristics of tibial plateau fractures
in 242 patients and found that 36 of them presented posterolateral fractures. The
mechanisms of injury included falling to the ground (9 patients), electric scooter
injuries (8 patients), motor vehicle accidents (13), blow by a heavy object (2), and
unknown causes (4).
In a study by Solomon et al.,[18] plates with fixed-angle screws were used, in addition to Norian bone graft substitutes
(DePuy Synthes/Johnson & Johnson, USA) for filling bone defects, with satisfactory
results in 100% of the patients, according to Rasmussen and Lysholm criteria.[19] Ehlinger et al.,[20] in a retrospective study comparing the use of 3.5-mm and 4.5-mm plates for tibial
plateau fractures, recommended the use of 3.5-mm plates, corroborating with Hasan
et al.,[21] in a biomechanical study, evidenced that there are no differences between 4.5-mm
and 3.5-mm plates for tibial plateau fractures. In the present study, we used non-locking
implants such as 3.5-mm fragment plates, 3.5-mm reconstruction plates, or 3.5-mm T
plates and, in only one patient, a locking plate. Non-locking implants cost less and
are available in the public health system, yielding a potentially reproducible technique.
Considering the complexity of PTPFs, we believe that the results obtained in the present
study are encouraging, with 95.72% of them presenting excellent results as measured
by the AKSS, with a mean AKSS/Function of 99.1 ± 3 (90–100), and Lysholm scores with
a median of 95.0 ± 5.6 (84-99). These results are similar to those described by Solomon
et al.,[19] who reported satisfactory results in 100% of the patients, according to the Lysholm
criteria.
Fractures of the posterior tibial plateau can be addressed using different approaches;
however, through this study, we were able to observe that the Carlson[9] approach can be used safely, with low morbidity and good functional outcomes. These
good functional results are largely related to the anatomical reduction of the fracture.
In tibial plateau fractures, long-term functional levels, anatomical joint reduction,
fixation stability, and early joint mobilization remain the objective of articular
fracture osteosynthesis. Residual spacing between the tibial condyles, with consequent
widening of the tibial articular surface, promotes abnormal contact relationships
with the femoral condyles, favoring the emergence of posttraumatic arthritis. Similarly,
poor alignment of the tibial condyles in reference to tibial diaphysis favors degenerative
joint disease, by promoting deviation from the mechanical axis.[12]
Stiff knee is a frequent complication when initial postoperative joint mobilization
care is not emphasized in rehabilitation protocols.[11]
[12]
[14] No pseudoarthrosis was observed. The Carlson approach[9] showed encouraging functional results, and low complication rates.
Another point that is important to emphasize is that since the Carlson approach[9] is used only for PTPFs, the patients in this study, classified according to the
Schatzker-Kfuri system, were 100% posterior fracture pattern.
There were some limitations in this study that require consideration. One of them
was the limited sample size, which did not allow us to demonstrate complete safety
of the procedure. The absence of a prolonged follow-up comprises another limiting
factor since it hampers the analysis of long-term complications. Detailed functional
evaluation obtained during the medium-term follow-up confirms the safety of the procedure,
and the absence of postoperative complications. Also, in functionally analyzing only
fractures with a specific type of injury, we did not compare them with other forms
of tibial plateau fractures (anterior), or even with different types of access for
PTPFs. Finally, all surgical procedures were performed by only two surgeons, without
randomization, a fact that hinders the evaluation of good functional results by others.
Prospective controlled studies with a larger sample size are necessary to obtain more
robust conclusions. Therefore, the follow-up of the patients in this study will be
maintained in order to evaluate results with a longer follow-up time, with the inclusion
of further patients.
Conclusion
The Carlson approach for posterior fractures of the tibial plateau can be considered
safe, presenting a low complication rate and satisfactory functional results.
