Research lesion morphology and clinical outcomes type v and vi schatzker closed tibial plateau fractures fixed by plate

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1 INTRODUCTION 1 / Reason for this topics Fractured tibia plateau is kind of lesion encountered proportion of 5 to 8% of leg fractures. Traffic accidents, labor accidents, sports accidents, accidents activities can cause fracture tibial plateau. This type of fracture invasive joints, anatomical lesions often complex, directly affect the function of the knee. In addition to bone damage, broken tibial plateau can incorporate many other lesions of the knee joint, such as ligaments, bursae, meniscus, blood vessels and nerves ... Some classifications are widely available, such as the classification of Hohl (1967), the Shatzker (1979), the AO-ASIF (1991) ... Many worldwide orthopedic and domestic surgeons use the Schatzker classification. We can be seen, these classification systems are based on images of bone lesions on conventional x-ray. In fact, the fracture tibial plateau is not only a fragments of fracture tibial plateau and extent of displaced fragments but also it is often accompanied by depression fracture fragments or more fracture complex lines, lesion images on conventional X-ray film in a number of cases not made clear and complete, the surgeon still have difficulty in choosing the method of bone. In recent years, with the support of the technical advances in the diagnosis, such as computerized tomography combined 3D renderings (3D) magnetic resonance imaging, C-arm ... the assessment and identification exact image damage bones, joints, ligaments, meniscus, blood vessels, nerves ... as well as support treatment interventions and reduction and fixed displaced fragments exactly under control by C-arm using L-shaped locking plate, helps to treat fractured tibial plateau achieved much progress to recover the maximum functional limb. Worldwide, the assessment and determine the significance of computerized tomography compared with conventional X-ray in the diagnosis and treatment of fractured tibial plateau have been done by many surgeons and published internationally. In Vietnam, although there have been studies on the treatment of fractured tibial plateau with the plate and screws, locking plate mechanism, external fixator ... have been published many surgeons in the country [16], [20], [18] . However, the comparison and evaluation of the lesions images of tibial plateau based on conventional X-ray or computerized tomography in a systematic manner with the number of big enough patients that is still problem many surgeons concerned. There are many surgical methods that are applied, such as by open reduction internal fixation with plate and screws, closed or minimum open reduction of fractures and fracture fixation by external fixator frame or fixed screws under the support of the C-arm …In general, each method has advantages and disadvantages. However, according to some surgeons there is more than 10% of fracture tibial plateau patients with surgical treatment has not 2 achieved the recovery anatomical morphology and of course, as well as the rehabilitation function of joints failed. From this fact, we have done a thesis with entitled " Research lesion morphology and clinical outcomes type V and VI Schatzker closed tibial plateau fractures fixed by plate " 2 / The objective of the thesis - Survey morphology, degree lesions of fracture tibial plateau on computerized tomography and assessment of accuracy conventional X-ray compared with computerized tomography scans according to the Schatzker classification of fracture tibial plateau. - Evaluation of clinical outcomes type V and VI Schatzker closed tibial plateau fractures fixed by plate when combined with imaginal roles computerized tomography before surgery. 3 / The significance of the thesis - Contains scientific and practical for both paraclinical research and clinical practice. Applications in paraclinical studies for the treatment of type complex fracture tibial plateau. - The thesis has significant news because so far, worldwidely, the treatment of fracture tibial plateau is still a big challenge for the medicinal profession. In Vietnam, this thesis contributes to improving the understanding of morphological lesions and experienced fracture tibial plateau treatment. 4 / Structure of the thesis The thesis consists of 128 pages, including sections: Introduction (2 pages); Overview (33 pages); Subjects and research methods (21 pages); Research results (33 pages); Discuss (37 pages); Conclusion (2 pages) and the appendix. In the thesis has 34 tables, 49 pictures and three medical reports illustrations. References documentary: 121, including 21 Vietnamese and 100 documents in English. 3 Chapter 1:OVERVIEW 1.1. ANATOMICAL CHARACTERISTIC OF BONY TIBIAL PLATEAU AND KNEE JOINT 1.1.1. Anatomy and bone structure tibial plateau Angle of medial tibial plateau about 87 ± 2 - 5 °, tilt angle of about 9 ± 5 ° 1.1.2. Outline of the anatomy in the knee region Joint area include: medial femur condyle and medial tibial plateau; lateral femur condyle and lateral tibial plateau; joint area between the posterior patella and femur condyle. Ligaments, synovial bursae system: Ligaments: Ligament system of front, posterior, colateral ligaments and cruciate ligaments systems. 1.1.3. Popliteal region: includes triangle thigh and tibia Filling ingredients in the popliteal: arteries, veins and nerves 1.1.4. Motion function of knee Range of motion of the knee: flexion: 135 - 140º, extension: 0º. 1.2 Cause, mechanism, and morphology of fracture tibial plateau The leading cause of fractured tibial plateau which is concerned by many surgeons is traffic accident, followed by accidents at work, sport accidents, etc. 1.2.2. Mechanism fractured tibial plateau - Power down from femoral condyle to tibial plateau. - Tibial plateau impact on hard objects directly. 1.2.3. Morphological of fractured tibial plateau Classification of morphological fracture of Hohl (1967) include: 6 types. Morphological fracture of Schatzker classification (1979), including 6 type: Type I: fracture lateral tibial plateau wedge-shape. Type II: fracture lateral tibial plateau combined with subsided tibial plateau Type III: fractured subsided tibia in the middle of lateral tibial plateau Type IV: fracture medial tibial plateau Type V: fractured both tibial plateau with continuity of tibial plateau and the diaphysis. Type VI: fractured both tibial plateau combined with incontinuity of tibial plateau and the diaphysis. AO-ASIF classification (1991) 3 types: type A, B, C Classification of Honkonen S. E (1992) divided into 7 categories 1.3. Roles computerized tomography and magnetic resonance imagine 1.3.1. Role of computerized tomography In 1987, Dias JJ has studied 16 cases of fracture tibial plateau with 3 type of imagines: X-ray, tomography X-ray in two dimensions and computerized tomography. He discovered some fracture bony walls on computerized tomography but undetectable on conventional X-ray. In 2000, acorrding to Wicky S et al, fracture is appreciated correctly on diagnosis based on conventional X-ray films were 18/42 patients (43%). 4 In 2001, Hackl W et al suggest that up to 40% change classification type bacause conventional X-ray no detectable fracture line. 2002, Yacoubian SV 52 comparative diagnostic between conventional Xray and computerized tomography see that the change in diagnosis was 6%. In 2004, Macarini L has concluded 3D re-create morphology was very useful in sorting fracture tibial plateau and preoperative evaluation. In 2009, Higgins T .F et al studied the morphology of posterior fragments in medial tibial plateau on computerized tomography: appearance ratio of fragments is 59%, the average height is 4.2mm, fragment and fracture surface area of the medial tibial plateau 25% respectively. 1.4. Treatment of fracture tibial plateau 1.4.1. Cast treatment Böhler L, representative for the classic groups, often treat fractures tibial plateau by cast. 1.4.2. Surgical treatment Methods of open reduction internal fixation In 1939, Landelius used fixed wires to fix in surgical tibial plateau firstly. 1973, Rasmussen has treated 204 cases fractured tibial plateau. The result: very good: 60%; good: 27%; pretty: 8%; bad 5%. In 1979, Schatzker assessed 10 cases tibial fracture type V, VI by surgery. Acceptable results were: 8 cases, not acceptable: 2 cases. In 1983, Blokker C. P analysis of results of surgical treatment open reduction fixation under AO principles of fracture 14 cases of tibial plateau fracture. The authors found that preoperative subsided articular surface < 5mm had the better results with cases that subsided before surgery > 5 mm. In 1992, Benirschke S. K retrospective study of 14 patients with fractured tibial plateau Schatzker types V, VI and open fracture type II and III according to the Gustilo grading were treated surgical fixation. Results infection rate is 1%, 10 patients had excellent results, 2 patients with gratifying results, 2 patients had poor results. In 1994, Georgiadis GM treated for a 4 patients with fracture tibial plateau contained two fragments in the posterior wall. As a result, the bones healed in place correctly, all patients have range of motion: Extension/Flexion: 0° - 5° / 0/120° - 145°. In 2004, Barei D. P reported using two incision. Results showed deep infection 8.4%, 3.6% septic arthritis, 1 patient did not heal of bone. In 2006, Barei DP treated bony fixation with two plate and two incision of 51 cases of fracture tibial plateau. Results: 90% to be satisfied with the angle of medial tibial plateau is 87± 5 °. 68% achieved angle of tilt posterior is 9 ± 5 °. In 1999, Pham Thanh Xuan [21] evaluated the results of surgical treatment of plate and screws for 41 cases fractured tibial plateau from type I to type VI according to the Schatzker classification. Results: 85.5% excellent and good, bad and average of 14.5%. Schatzker types V, VI cases had average and bad results. 5 In 2010, Thai Tuan evaluate treatment outcomes of 25 patients with closed fractures tibial plateau Schatzker type V, VI fixed by plate and screws: excellent and good results was 84%, 16% average and bad. In 2011, Vu Nhat Dinh assess treatment outcomes for 32 patients with fractured tibial plateau type V, VI according to Schatzker classification, were treated with the plate and screws. Results: 3 patients infected surface, varus or valgus: 6 patients. Range of motion of the knee: > 125 ° (22 patients), from 100 -124° (3 patients), and from 90 - 99° (1 patient). In 2012, Nguyen Van Luong reported the initially results of 16 patients, who were closed fractured tibia plateau from type 1 to type 6, were fixation by locking-plate. Results: 15 patients with excellent and good, average 0 patient and bad 1 patient. 6 Chapter 2: SUBJECTS AND METHODS 2.1. RESEARCH SUBJECTS 126 cases of trauma to the knee with fractured tibial plateau 2.1.1. Criteria for patient selection Patient selection criteria for one researched target - There are enough conventional X-rays imagine and CT-Scanner for every tibial plateau. Patient selection criteria for two researched target - Closed fractured tibia plateau types V, VI Schatzker with age >= 16 are fixed with plate and screw. - There are enough conventional X-rays imagines pre and post-operation. - There are enough CT-Scanners pre-operation. - No injury skin around the knee. - If the patients have combined diseases, were examined and concluded to allow operation. - There are no contraindications for anaesthesia 2.1.2. Exclusion criteria from the study group - The absence of a conventional Xrays imagine or CT-Scanners. - The pathological fractured tibial plateau. - There are a available deformities at the fractured tibia limb, injury sequelae affecting function of the limb. - Patients with systemic disease is contraindicated with operation. - The case of the combined with tored ACL and PCL no reconstruction with fixed tibial plateau at the same time. 2.2. METHODOLOGY OF RESEARCH: Retrospective and prospective research, cross-sectional descriptive uncontrolled. 2.2.1. Selection of sample size: Accoding to calculate, to complete the one and two researched target required sample size included 119 patients with fractured tibial plateau. 2.2.2. General Information - Personal characteristics of the research subjects - Distribution of age, gender, cause. - Take conventional X-rays by digital machine, take CT-Scanner the distal femur and tibial plateau. 2.2.3. Research morphological lesions on conventional Xrays and CTScanner: * Research morphological lesions tibial plateau include: fractured lateral tibial plaeau(Schatzker I, II, III), fractured medial tibial plaeau (Schatzker IV) and fractured both of tibial plaeau (Schatzker V, VI) with the characteristic lesions as following: fractured morphology, degree of subsidence, subsidence areas, number of fractured fragments and assessing the accuracy of conventional Xrays versus CT-Scanner according to the Schatzker classification. 7 2.2.4. Results of treatment 2.2.5. Some of techniques and evaluation criteria 2.2.5.1. Process of taken CT-Scanner the knee 2.2.5.2. Measure degree of subsidence on conventional Xrays imagine - Method of Lansinger O, Dias J. J Method 2.2.5.3. Method of measurement angle of tibial plateau 2.2.5.4. Assess lesions of soft tissue - According Tscherne H, there are 4 degrees 2.2.5.5. Evaluation of knee degeneration - By the standards of Tscherne H 2.2.6. Surgical Procedures Prepare patients. Spinal anesthesia. 2.2.7. Assessment results 2.2.7.1. Evaluation results of morphological research - Fractured location, fractured lines, degree of subsidence (millimetre), subsidence areas (anterior, center, posterior) and the relationship between the , degree of subsidence and subsidence areas by Kappa coefficient. - Evaluate the accuracy of conventional Xrays versus CT-Scanner about degree of subsidence, number of fractured fragments, subsidence areas, diagnose using Kappa coefficient. 2.2.7.2. Evaluation of results Close results: according to the standard of Larson-Bostman include: - Very good: no displaced fractures, straight axis, healing incision immediately. - Good: Angle of the fractures toward lateral or anterior <5°, toward posterior or medial <10°, short limb < 10mm. Healing incision immediately. - Average: Angle of the fractures toward lateral or anterior >5°, toward posterior or medial >10°, short limb > 10mm. Surface infections at the incision. - Less: Angle of the fractures like average standard but there is displaced rotation. Deep infected incision, bone infections, fistula of pus. The results far: ≥ 12 months postoperatively. By the function standards of Rasmussen: Very Good: 27 - 30 points; Good: 20 - 26 points; Average: 10 - 19 points; Poor: <10 points. By the Xrays standards of Rasmussen: Very good: 18 points; Good: 12 - 16 points; Average: 6 - 12 points; Poor < 6 points. 2.2.8. Analysis and data processing: Data entry and obtained by the Excel software, analysis data by software R (R Core Team 2013). 8 Chapter 3: STUDY RESULTS 3.1. INJURY MORPHOLOGY 3.1.1. Study group characteristics: Study results: 41 patients with lateral tibial plateau fractures (mean age: 36.7 ± 12.4 yo). 10 patients with medial tibial plateau fractures (mean age: 34.5 ± 15.5) , 75 patients with bicondylar tibial plateau fractures (mean age: 39.7 ± 13.1 ). Right knee: 54 cases, Left knee: 72 cases. Type Schatzker V, VI have highest mean age. There is no difference of age between groups p = 0.035. - Main causes of injuries are Moto vehicle accidents 89.7 %. 3.1.1. Lateral tibial plateau fracture characteristics:(type Schatzker 1, 2, 3) Split fractures: 37 cases. Pure depression fractures: 4 cases. Table 3.3: Comparison of fragment amounts between XRAY CT scan Fragment amounts XRAY (n = 41) CT scan (n = 41) 1 fragment 34 (82.9%) 22 (53.65%) 2 fragments 7 (17.1%) 14 (34.15%) ≥ 3 fragments 0 (0%) 5 (12.2%) Cases 41 (100%) 41 (100%) The study reported poor match of fragment amounts between XRAY and CT scan, K = 0.072. Table 3.4. comparison of depression level between XRAY and CT scan Depression (mm) XRAY CT scan No depression 16 8 1 - 4 mm 10 7 5 - 9 mm 8 14 10 - 19 mm 6 11 20 mm 1 1 cases 41 41 - On CT SCAN, LTP depression are 33 cases, depression level ≥ 5mm are 26 cases (63.4%). Table 3.5: Correlation between LTP fracture depression levels and sites on CT scan (n = 33) Depression Depression sites Cases (n) level (mm) anterior central Posterior 1 - 4 mm 3 3 1 7 5 - 9 mm 4 4 6 14 10 - 19 mm 3 3 5 11 20 mm 0 1 0 1 cases (n) 10 11 12 33 - The more tibial depression level increase, The more central and posterior areas affected 11/33 cases. 9 3.1.3. Medial tibial plateau fracture characteristics (Schatzker 4) Split fractures: 10 cases. Table 3.6: Comparison of fragment amounts between XRAY CT scan (n = 10) Fragment amounts XRAY CT SCAN 1 fragment 10 5 2 fragments 0 5 cases 10 10 - Medial tibial plateau fracutes are most likely not comminuted. And most of them are big fragments. Table 3.7: Medial tibial plateau depression level Depression level (mm) Xray CT scan No depression 9 4 1- 4 mm 1 3 5 - 9 mm 0 2 10 - 19 mm 0 1 Cases 10 10 - Difficult to identify fracture depression on XRAY. Table 3.8: Correlation between fracture depression levels and sites on CT scan Depression Depression sites cases levels (n = 6) anterior central posterior (mm) 1 – 4 mm 2 0 2 4 5 – 9 mm 0 1 0 1 15mm 1 0 0 1 Sum 3 1 2 6 - Depression occurs to every sites. Depression areas are large, and mainly downdisplaced fragments 3.1.4. Bicondylar tibial plateau fracture characteristics: (Schatzker V, VI) 3.1.4.1. fracture types: - Fractures type 1: 50.6%. Match ratios between XRAY vs CT SCAN: 36/38 cases (90,1%). - Fractures type 2: 28% Match ratios between XRAY vs CT SCAN: 19/21 cases (90%). - Fractures type 3: 8%, Match ratios between XRAY vs CT SCAN 4/6 : (66%). - Fractures type 4: 9,4%, Match ratios between XRAY vs CT SCAN 5/7: (71,4%). - Fractures type 5: 4%, Match ratios between XRAY vs CT SCAN: 100%. 10 3.1.4.2. Lateral tibial plateau fractures type Schatzker V, VI Table 3.9: Lateral tibial plateau fracture fragments on CT SCAN Type fractures Type V Type VI combined (n = 47) (n = 28) (n = 75) Fragment amounts 1 fragment 25 (53.2%) 4 (14.3%) 29 (38.7%) 2 fragments 16 (34.0%) 10 (35.7%) 26 (34.7%) 3 fragments 6 (12.8%) 14 (50.0%) 20 (26.4%) analysis Chi-square = 16.01. d.f. = 2 P < 0.001 There is significant difference between fragments of 2 types, p < 0.001. Table 3.10: Fracture fragment detection at the posterior wall of LTP Fragment Xray CT scan amounts Type V Type VI Combined Type V Type VI combined (n = 47) (n = 28) ( n = 75) ( n = 47) ( n = 28) ( n = 75) 0 44 28 72 30 8 38 fragment (93%) (100%) (96%) (63.8%) (28.6%) (50.7%) 1 3 0 3 16 20 36 fragment (6.4%) 0.0% (4.0%) (34%) (71.4%) (48.0%) 2 1 0 1 fragments (2.1%) (0.0%) (1.3%) analysis Fisher = 1, d.f. = 1, p = 0.289 Fisher = 1, d.f. = 1, p = 0.01 Fractures at the posterior wall of LTP of both type V and VI are 49.3%. Table 3.11: LTP depression level comparison on Xray and CT scan. Depression X ray CT scan level (mm) Loại V Loại VI Kết hợp Loại V Loại VI Kết hợp mean 1.8 ± 3.4 3.1 ± 3.3 2.3 ± 3.4 3.7 ± 3.9 5.6 ± 3.3 4.4 ± 3.8 (mm) (mm) (mm) (mm) (mm) (mm) analysis F = 5.72, d.f = 1.73, P = 0.019 F = 7, d.f = 1.73, p = 0.01 Mean depression level between type V and VI are different, p = 0.01. 11 Table 3.12: depression sites of latera tibial plateau Depression site Xray CT scan Type V Type VI combined (n = 47) (n = 28) (n = 75) anterior 3 1 4 (6.4%) (3.6%) (5.3%) posterior 1 0 1 (2.1%) (0.%) (1.3%) central 0 1 1 (0.%) (3.6%) (1.3%) Whole plateau 1 8 9 (2.1%) (28.6%) (12%) no depression 42 18 60 (89.4%) (64.2%) (80%) analysis Fisher = 1, d.f. = 1, p < 0.001 Type V Type VI Combine (n = 47) (n = 28) (n = 75) 7 2 9 (14.9%) (7.1%) (12.0%) 13 8 21 (27.7%) (28.6%) (28.0%) 8 11 19 (17.0%) (39.3%) (25.3%) 2 5 7 (4.3%) (17.9%) (9.3%) 17 2 19 (36.2%) (7.1%) (25.4%) Fisher = 1, d.f. = 1, p = 0.002 depression sites of LTP: central and posterior are 53.3% 3.1.4.3. MTP injuries type V and VI Table 3.13: fragment amounts on CT scan (n = 75) Type fragment amounts 1 fragments 2 fragments 3 fragments cases analysis Type V n = 47 Type VI n = 28 Combined n = 75 27 (57.4%) 9 (32.1%) 36 (48.0%) 16 (34.0%) 16 (57.1%) 32 (42.7%) 4 (8.5%) 3 (10.7%) 7 (9.3%) 47 28 75 Fisher = 1, d.f. = 1, p = 0.082 MTP fractures have less fragments. Table 3.14: Fragments in posterior wall fractures of MTP Fragment Xray CT scan amounts Type V Type V I Combined (n = 47) (n = 28) ( n = 75) 41 27 68 0 (87.2%) (96.4%) (90.7%) fragment 6 1 7 1 (9.3%) fragments (12.8%) (3.6%) Annalysis Fisher = 1, d.f = 1, p = 0.246 Type V TypeVI Combined ( n = 47) ( n = 28) ( n = 75) 23 18 41 (48.9%) (64.3%) (54.7%) 24 10 34 (51.1%) (35.7%) (45.3%) Chi-squar =1.67, d.f=1, p=0.197 Fragments in posterior wall fractures of MTP type V, VI are 45.3%. 12 Table 3.15: Depression level of MTP Depression level(mm) Mean Type V 1.0 ± 2.7 (mm) Xray Type VI Combine d 0.9 ± 2.2 0.9 ± 2.5 (mm) (mm) CT scan Type V Type VI Combine d 1.9 ± 2.0 ± 3.2 2.0 ± 3.6 3.8 (mm) (mm) (mm) - MTP depression level comparison on Xray and CT scan. With K = 0,54 Table 3.16: MTP depression site comparison Depression Xray sites Type V Type VI Combined (n = 47) (n = 28) (n = 75) Anterior 1 1 2 (2.1%) (3.6%) (2.7%) Posterior 3 1 4 (6.4%) (3.6%) (5.3%) Central 0 0 0 (0.0%) (0.0%) (0.0%) Whole 1 3 4 (2.1%) (10.7%) (5.3%) No 42 23 65 depression (89.4%) (82.1%) (86.6%) cases 47 28 75 Annalysis Fisher = 1, d.f = 1, p <=0.001 CT scan Type V Type VI Combined (n = 47) (n = 28) (n=75) 2 0 2 (4.3%) (0.0%) (2.7%) 6 6 12 (12.8%) (21.4%) (16.0%) 4 3 7 (8.5%) (10.7%) (9.3%) 3 1 4 (6.4%) (3.6%) (5.3%) 32 18 50 (68.1%) (64.2%) (66.7%) 47 28 75 Fisher = 1, d.f = 1, p = 0.001 - In comparrison with CT SCAN, XRAY cannot detect depression less than 20%. 3.1.4.4. Tibial spine injuries - ACL avulsion is 6.66% (5/75 cases), PCL is 1.33 % (1/75 cases). 3.1. 5. Reliability of Schatzker classification Table 3.17: Schatzker classification of tibial plateau fractures. Type Xray CT scan Type 1 16 8 Type 2 21 29 Type 3 4 4 Type 4 18 10 Type 5 40 47 Type 6 27 28 cases 126 126 Diagnosis match between Xray and CT scan is 86.61%, K = 0.83 13 3.2. Surgical treatment 3.2.1. Age, gender distribution 62 fracture cases type Schatzker V, VI were surgically treated with plating techniques include: type Schatzker V: 35 cases, type Schatzker VI: 27 cases. Males are 37 (59.7%) and females are 25 (40.3%). Mean ages: 40.11 ± 13.45 y.o. - Injury causes: Motor vehicle accidents type V, VI. Most are motorbike accidents. 3.2.2. Combined injuries - Soft tissue injuries degree 0 are 55 cases, of 88.7%. - There is no significant difference of soft tissue injuries between 2 types, p = 0,64. - ACL avulsion injuries are found in 5/62 cases. (8.0%). - Fibular head fractures are found in 23 cases. (33.6%). - There is significant difference of combined injury degree between type Schatzker V and VI, p = 0.002. 3.2.3. The time from tibial plateau fractures to surgical treatment - The time from tibial plateau fractures to surgical treatment are 4 to 9 days. There is no significant difference of waiting time for surgery between 2 groups, p = 0.111. 3.2.4. Surgical approach, fracture fixation plates, plating sites, surgical time and post-op drainage - Surgical approach: lateral: 9 cases, medial: 31 cases, combined both: 22 cases. - Plates used: 1 plate: 43 cases (69.4%). 2 plates: 19 cases (30.6%). - Mean surgical time of study group are 79.4 ± 23.2 minutes. - Mean drainage fluid volume are 120.4 ± 107.3 ml. 3.2.5. Post-op accidents and complications - There is only 1 case with incision superficial infection. 3.2.6. Results 3.2.6.1. results after 3 months post-op: 62 cases are followed up in the first 3 months with following results: - Primary incision healing: 100%. Post-op suture removal from 12 to 14 days. Mean range of knee flexion at 3 month post-op are 117.3° ± 16.4°. - Time for post-op knee motion exercises are 6.3 ± 6.2 days. Time for post – op weight bearing on surgical legs are 5.2 ± 0.9 weeks. There is significant difference of post-op weight bearing time between type Schatzker V and VI, p < 0.001. - Time for bone healing grade III are 15.1 ± 1.6 weeks. 14 Time 3.23: Results of tibial plateau fracture reduction after 3 months postop Angle (degrees ) Type V Type VI Combined Result (n=35) (n=27) (n=62) analysis Pre-op tibial 85.6º ± 6.0º 88.3º ± 7.0º plateau angulation Post-op op tibial 88.6º ± 3.7º 89.1º ± 3.0º plateau angulation Pre-op declination 13.1º ± 6.3º 12.5º ± 6.3º Post-op declination 9.8º ± 4.8º 11.3º ± 4.9º 86.8º ± 6.6º P = 0.077 88.8º ± 3.4º P = 0.8 12.9º ± 6.3º 10.5º ± 4.8º P = 0.289 P = 0.289 - Satisfied reduction for MTP angulation are 82.1%, declination are 81.4%. Primary results: based on Larson - Bostman standards: Excellent: 32.2%, good: 1.6% 3.2.6.2. Long term results ≥ 12 months Only 53 cases were evaluated in long term. Long term results: Table 3.24: Post-op follow-up time Follow-up years 1 year 2 year 3 year 4 1year 6 year 1 (1.88%) Cases (n = 53) 6 (1.28) 24 (45.34%) 17 (32.1%) 5 (9.4%) Mean follow-up time are 26.3 months. Table 3.25: Pain scores Patient complaination No pain Occasional pain Local pain Pain while waliking. Pain at night rest Mean scores Analysis Type V (n = 29) Type VI (n = 24) Combined (n = 53) 16 (55.2%) 6 (25.0%) 22 (41.5%) 11 (37.9%) 16 (66.7%) 27 (50.9%) 0 (0.0%) 2 (8.3%) 2 (3.8%) 1 (3.4%) 0 (0.0%) 1 (1.9%) 1 (3.4%) 0 (0.0%) 1 (1.9%) 5.6 ± 0.6 5.2 ± 0.6 5.4 ± 0.6 Fisher = 4.89, d.f = 1.51, p = 0.32 - only 2 cases with severe pain. 15 Table 3.26: walking ability Walking ability Walking< 15 min. Walking < 60 min Normal walking Walking in house Wheelchair use Mean scores Analysis Type V Type VI Combined (n = 29) (n = 24) (n = 53) 1 (3.4%) 2 (8.3%) 3 (5.7%) 7 (23.7%) 9 (47.5%) 16 (30.7%) 21 (72.9%) 12 (50.0%) 33 (63.5%) 0 (0.0%) 1 (4.2%) 1 (1.9%) 0 0 0 5.4 ± 1.1 4.7 ± 1.5 5.1 ± 1.3 Fisher = 3.25, d.f =1.51, p = 0.077 - There is no significant difference between 2 groups, p = 0,077. Table 3.27: knee extension Knee extension Knee extension limit > 10° Knee extension limit < 10º (4 points) Normal extension (6 points) Type V (n = 29) 0 2 (6.9%) Type VI (n = 24) 0 2 (8.3%) Combined (n = 53) 0 4 (7.5%) 27 (93.1%) 22 (91.7%) 49 (92.5%) -There are 4 cases with knee extension limit because there are no improvement of tibial plateau declination compared to properation.. Table 3.28: knee flexion Knee flexion Type V Type VI Combined (n = 29) (n = 24) (n = 53) < 90º (2 points) 0 1 1 from - < 120° (4 points) 1 1 2 120º - < 140 °(5 points) 12 9 21 ≥ 140º (6 poits) 16 13 29 Mean flexion range 133,6° - Mean flexion range are 133.6º (min 80º, max 145º). Table 3.29: Knee stability Knee stability Type V Type VI (n = 29) (n = 24) Stable at 20° flexion 28 (96.6%) 22 (91,7%) position 50 (94.3%) Unstable at < 10° 0 (0.0%) 1 (4.2%) extension position Unstable at >10° 1 (3.4%) 0 (0.0%) extension position Unstable at 20° flexion 0 (0.0%) 1 (4.2%) position Mean points 5.9 ± 0.4 5.9 ± 0.4 Combined (n = 53) 1 (1.9%) 1 (1.9%) 1 (1.9%) 5.9 ± 0.4 16 Knee instability were caused by residual tibial plateau depression and malalignment. Functional results following Rasmussen standards. Excellent: 81.1%, good: 15.1%, fair: 3.8%. Table 3.30: Xray results following Rasmussen standards Evaluation index Type V Type VI combined (n = 29) (n = 24) (n = 53) Tibial plateau enlargement. < 5mm > 5mm normal Articular step-off (points) 4 points 6 points Malalignment (points) 4 points 6 points 0.0 3.6% (1) 96.4% (28) (n = 29) 13.8% (4) 86.2% (25) (n = 29) 6.9% (2) 93.1% (27) 4.2% (1) 0.0% (0) 95.8% (23) (n = 24) 20.8% (5) 79.2% (19) (n = 24) 12.5% (3) 87.5% (21) Xray results of 53 cases: excellent: 75.5%, good: 24.5%. 1.9% (1) 1.9% (1) 96.2% (51) (n = 53) 17.0% (9) 83% (44) (n = 53) 9.4% (5) 90.6% (48) 17 Chapter 4: DISCUSSION 4.1. CHARACTERISTICS RESEARCH GROUP Average age fractured tibial plateau in the study was 38.3 ± 13.08 years old. 89.7% fractured tibial plateau causes by traffic accidents, largely due to the motorcycle accident. 4.2 MORPHOLOGICAL LESIONS 4.2.1. Lesion of lateral plateau (I, II, III Schatzker group) On computerized tomography imagines, isolated fractured tibial plateau with the morphological lesions following: - Fragments no subsided was 19.5%, fragments together with subsidence 70.7% and pure depression fracture 3.2%. The research results showed on computerized tomography imagines that fragments together with subsidence accounted for most of the types of fractured tibial lateral plateau. According to Schatzker classification, it is type II. - Fractures of the two fragments is 46.35%. the poor suitable of some fragments between X-rays imagines and computerized tomography with k = 0.072, so the X-ray imagines reveal not exactly fractured fragments. Because fracture with two fragments accounted so high, so we must pay attention when performed percutaneous screws on the surgery. Screws go between two surface of fragments easily. - The rate of fractured posterior wall after combining fractured tibial lateral plateau is 18.9%. - Subsidence of lateral tibial plateau more than 5mm is 63.4%. On conventional X-ray imagines, the fractured tibial lateral plateau with subsided more than ≥ 5mm will rise appearance the fragments at the posterior wall. And the more subsided degrees increase, the more subsided area increase at the posterior. Therefore, when we find that the sudsided fragment ≥ 5mm, the patients should be taken computerized tomography. 4.2.2. Lesions in the medial tibial plateau (Schatzker type IV) Fractures of the isolated medial tibial plateau accounted for 7.9% of the type of fracture tibial plateau, with following morphological lesions: - Fracture with fragments, fewer fragments but usually large fragments. Percentage of fragment at posterior wall of tibial plateau 4/10 cases and fragments usually go down. - Subsided at the medial tibial plateau is not much, but fragments often tilt toward medial. Therefore need to properly assess lesions. Reduction to correct the tilt fragments is very important. According to some authors recommend using a plate to fix fracture fragment at medial tibial plateau. - Subsidence in the medial tibial plateau happens at front and center and posterior surface plateau. We found that the assessment fracture medial tibial plateau by conventional X-ray imagines is not difficult and does not require taking computerized tomography. However, when fracture medial tibial plateau with the fragment at 18 the posterior wall should be taken computerized tomography to locate the exact position to have the correct path with a fracture fragment. 4.2.3. Lesions in both of the tibial plateau (Schatzker V, VI) 4.2.3.1. Morphological fracture In this study, fracture type V, VI 75/126 cases, accounting for the proportion (59.5%). There were 5 morphological fracture following: Morphological fracture type 1: fractured line comes from a lateral tibial plateau then go down to the tibial epiphysis and split into two fractured lines, the first lines go out the lateral and second lines toward the medial tibial plateau. For this type of fracture, lateal tibial plateau surface has many small fragments and often subsided. The lateral tibial plateau is separated from the tibial diaphysis. Lateral tibial plateau surface is less likely to break and be tilt to the medial, made subluxation knee lateraly, is the most common type of fracture. Shown impulsing mechanisms. Morphological fracture type 2: fractured lines derived from inter-spikes tibial with two fracture lines going down the epiphysis and come out to both sides medial and lateral tibial plateau. This type of fracture, both of two tibial surfaces be less fracture and subsidence equaly. Two fragments of tibial plateau can move posterior angle deviation. This type of fracture accounted for 28%, the second frequency. This mechanism is fractured by the force put on both femoral condyle to tibial plateau. Morphological fracture type 3: fractured lines comes from two tibial plateau go straight down the epiphysis and made fracture. For this fracture type, both tibial surface are often fractured fragments and fractured fragments were sinking into epiphysis. The rate of this type of fracture accounted for 8%. Morphological fracture type 4: fractured line comes from two inter-spikes tibial go straight down the diaphysis and make fractured of two tibial plateau at the epiphysis or diaphysis. For this type of fracture, both of tibial are splited widely and tend to tilt to on both sides. Tibial plateau’s surface are often less broken bones. This type of fracture rate of 9.4% and appropriate diagnosis between the conventional X-ray imagines and computerized tomography is 71.4%. Morphological fracture type 5: fractured line breaks come from lateral tibial plateau and go into the epiphysis and ends at the medial wall of the medial tibial plateau. This is a simple fracture. Lateral tibial plateau’s surface without 3rd fractured fragment. Fragment of medial tibial plateau tends to be pulled away from the epiphysis of the bone. This type of fracture rates in this study was 4% and the rate of appropriate diagnosis between conventional imagines and computerized tomography is 100%. Can outline morphological fracture both tibial plateau as follows: 19 Figure 4.1. Morphological fracture both tibial plateau 4.2.3.2. Lesions of the lateral tibial plateau (Schatzker V, VI) The degree of lesions the tibial plateau on computerized tomography as follows: Types of fracture with many fragments and fragment are often small. The rate of fracture in the posterior lateral tibial plateau is 49.3%. The average subsidence of lateral tibial plateau: 3.7 ± 3.9 mm. Subsidence area usually at the posterior and center. This research suggest that surgical should be reduced fracture and subsidence fragments at the posterior wall area.. 4.2.3.3. Lesions of the medial tibial plateau (Schatzker V, VI) The degree of lesions the medial tibial plateau in include: Types of fracture with few fragments and fragment are often large.. The rate of fracture in the posterior wall medial tibial plateau was 45.3%. The average subsidence of medial tibial plateau was 2.0 ± 3.6 mm. Subsidence of medial tibial plateau is often posterior side. Some surgeon found that fracture medial tibial plateau with the fracture posterior fragment is kind of unstable fracture, secondary displaced easily and should be fixed by surgery or immobilization by cast or splint. Through research, we found that computerized tomography has proven to be a valuable tool in the diagnosis of fractured tibial plateau. It’s advantages compared with conventional X- ray include: a more accurate description of the location and number of fragments, fracture line, settlement and subsidence areas of the tibial plateau. For this type of fracture is taken computerized tomography both tibial plateaus is essential. 4.2.4. Evaluation of the Schatzker classification According to Schatzker classification, comparing on diagnosis of fracture tibial plateau between conventional X-ray imagines and computerized tomography there are 17 cases (13.49%) were classified changes, most are from type I to type II, followed by from type IV to type V and a case of changing from V to VI because undetectable subsidence and fractures in conventional Xray imagine. These lesions are only detected when take computerized tomography. So if not taken computerized tomography, we won’t see the whole lesions of the tibial plateau. Through research, we found that the classification of Schatzker fracture tibial plateau based on conventional X-ray imagines with high accuracy. The appropriate diagnosis between conventional X-ray imagines versus computerized tomography reached: 86.51%. 20 4.3. RESULTS OF SURGICAL TREATMENT Short-term results: 62 cases with 62 fractured tibial plateau were evaluated according to the standard of Larson-Bostman: very good achieved: 59.7% (37 cases), good: 38.7% (24 cases) and average 1.6% (1 case). Situation of incisions: healed completely, suture should be cut 12 days after surgery for preventing from dilation or split the incision. No cases of deep infection. Only 1 case of superficial infections. In our opinion, the cause of infection depends on many factors, but there are two factors that should be more concerned: - Skin at the tibial plateau area was damaged without treatment stability but conducted operations. - Invasive soft tissue so much, extend operation time because reduction in correction perfectly, create favorable conditions for wound infections easily. - Not completely drain. -For a good reduction results, should be measure tibial angle preoperation and preoperative planning, good preparation equipments and tools preoperative. Especially on reductive problems with control C-arm is very important. For our experience, surgery should wait until the skin of the knee healed completely. During surgery, we manipulate so gently limited action causing damaged to the tissue of skin. For fracture medial tibial plateau with a posterior-medial fracture fragment should be used plate to fix. The plate acts as a base for the fracture fragments not displaced fractures and limit of subsidence tibial plateau. On the issue of bone graft: we are not bone graft although gaps remain, of course, space is not large, these patients did not pressure us early compression. We rely on the theoretical basis of calcified hematoma drives and many practical cases porous bones in the bone plate to another baseball has created a fracture bones in place. The long-term results Knee pain after surgery: despite the pain any degree also reflect function knee is not normal. In our opinion, the cause of pain is the inflammation and adhesive of soft tissue at surgical area, together with the stick patella and femoral condyle that limit joint mobility. Joint’s surface was still subsidence. We see, these elderly patients after fracture tibial plateau and operated. Despite good functional results, the patients did not dare walk a lot because of fear of an fall or accident again. We also interventional advocate to elevate tibial plateau as degree of subsidence ≥ 3mm. To limit secondary subsidence, we needs reduction, elevate tibial plateau perfectly and fixed tibial plateau stabilizing and snugly. Long-term follow-up for detection of knee osteoarthritis after fractured tibial plate is essential. The number of our patients with the mean follow-up time was 26.3 ± 11.5 months but do not have any patient was osteoarthritis. We thought that we had reducted subsidence by surgery and good rehabilitation as
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