Abstract
Background
Tibial plateau fractures can indeed be quite complex, and their management is critical for ensuring optimal outcomes. The management of subchondral cavities following the elevation of depressed plateau fragments is challenging. There are various options to manage the defect, autologous cortico-cancellous bone transfer, bone graft substitutes, and modification of internal fixation techniques in order to minimize the degree of subchondral collapse and articular incongruity
Materials and methodology
A longitudinal prospective study was conducted at our institute. All patients with closed Schatzker type 2 and 3 tibial plateau fractures with articular depression <20 mm were alternatively assigned into two groups, by matching fracture types. Without bone graft, the group underwent treatment in the form of open reduction and plating for lateral condyle fracture. The bone graft group underwent additional bone grafting apart from plating. Each group had 20 patients. Patients were followed at regular intervals of 1 month, 3 months, 6 months, 12 months, and until fracture union.
Results
By comparing our results between the two groups, we found that there was no significant difference between groups with and without bone grafting for internal fixation of depressed <20 mm type II and type III tibial plateau fractures. The functional and radiological outcomes, time to union, and complication rates were similar in the two groups, and there was no statistically significant difference between the groups.
Conclusion
For osteosynthesis of depressed tibial plateau fractures, Schatzker type 2 and type 3 with depression of <20 mm, internal fixation without bone graft is a viable option. There is no statistically significant difference in functional and radiological outcomes between bone grafting and non bone grafting group.
Keywords: Schatzker’s, Tibial plateau, Osteosynthesis, Sub-chondral, T & L plate, Lateral plate, Raft screw, Bone graft, Graft substitutes, Articular depression, Cancellous graft
Introduction
Tibial plateau fractures are known to occur following trivial trauma in elderly patients, whereas in younger patients, they tend to happen following high-energy trauma. The lateral tibial plateau is involved in 55% to 70% of cases, with medial plateau or bicondylar involvement accounting for the remaining 10% to 30% of cases [1]. Functional outcome following treatment is influenced mainly by the range of knee motion, joint stability, and pain [2]. There is a consensus about the need for accurate reduction and stable internal fixation of these fractures. Several techniques of fixation have been used but the goal remains the same, obtaining a stable joint which permits an early range of motion that promotes preservation of articular cartilage [3–5].
Tibial plateau fractures can indeed be quite complex, and their management is critical for ensuring optimal outcomes. Effective management of subchondral cavities following the elevation of depressed plateau fragments remains debatable. There are various options to manage the defect: autologous cortico-cancellous bone transfer, bone graft substitutes, and modification of internal fixation techniques to minimize the degree of subchondral collapse and articular incongruity.
The usual technique in managing the subchondral cavities has been cortico-cancellous autograft harvested from the iliac crest [6]. However, studies show that autologous bone grafting adds to the post-operative morbidity ranging from 8.6 to 20.6% [7]. Other options include the use of synthetic bonegraft substitutes. The synthetic bone graft substitutes like calcium phosphate and calcium sulphate have been validated by clinical studies [8].
Some studies show that these subchondral cavities can be managed without using grafts. Karunakar et al. [3] studied the biomechanics of four types of fixation constructs for split depression fractures of the tibial plateau and found that there was no statistical difference between the construct. The construct with subchondral raft screws were more resistant to compression loads. For split depression tibial plateau fractures, Kulkarni et al [9] studied the outcomes following fixation of lateral tibial condyle split depression using periarticular raft screws through a plate and found that fixation construct is a feasible option either used with or without bone graft or substitute [9].
To the best of our knowledge, no study to date has compared the outcomes following internal fixation with and without bone grafting in patients with depressed tibial plateau fractures type II and type III. The aim of this present study was to compare the functional outcome of depressed tibial plateau fractures fixed internally without the use of bone grafts and those with the use of bone grafts.
Materials and Methods
After obtaining institution ethics committee clearance, a longitudinal prospective study was done at our institute for a period of 2 years. The aim of the present study was to compare the outcome of a tibial plateau fracture with or without a bone graft. All patients presenting to the emergency medicine department and out-patient orthopaedic clinics with closed tibial plateau fractures, patients with tibial plateau fractures in the age group 18 years and above, Schatzker types 2 and 3 tibial plateau fractures with articular depression < 20 mm were included in the study. Patients with open tibia plateau fractures, associated fractures, neurovascular injury, and Schatzker types 1, 4, 5, and 6 were excluded from the study.
All patients who met our inclusion criteria were alternatively assigned to two different groups using an alternating sampling method, ensuring that the fracture types matched according to the Schatzker classification [10]. First group (bone graft group) of the patients received treatment in the form of open reduction, bone grafting and plating. Second group (without bone graft) of patients, received only open reduction and plating. Sample size calculation was done based on the previous studies, by keeping the power of study at 95%. The present study was done for a period of 2 years on 40 patients. Each group had 20 patients each.
Informed written consent was obtained from all selected study subjects, affirming their understanding and agreement to participate in the study. This process ensured that the patients were fully aware of the nature of the study, including the procedures involved, potential risks, and anticipated benefits. Data collection followed a structured format, including patient history, mode of injury, smoking, alcohol consumption status, and clinical examination. A standardized protocol was employed for history taking, documenting modes of injury, smoking, and alcohol consumption. Clinical assessments were conducted, along with preoperative X-rays and CT imaging.
Open reduction of the fracture was done by the standard anterolateral approach. The lazy “S”-shaped incision was made from 2 to 3 cm proximal to the joint line and extended 3 cm below the inferior margin of the tibial tubercle. Access to the subchondral bone was done through a cortical window or fenestration in the metaphyseal bone. The elevator was then inserted to lift the depression en bloc. The reduction was achieved and confirmed under c-arm guidance intraoperatively. The fracture was stabilized with a plate (T plate or anatomical lateral plates) and raft screws (2–3). In the bone grafting group, patients underwent a procedure where an additional cancellous graft harvested from the iliac crest was utilized. This grafting technique involved the extraction of cancellous bone from the iliac crest, which was then applied to the site of the tibial plateau fracture. Patients were advised non-weight bearing for 3 weeks, next 3 weeks partial weight bearing and full-weight bearing with mobility aids for 2 weeks, followed by unaided full-weight bearing mobilization.
Patients were followed at regular intervals 1 month, 3 months, 6 months, 12 months, and until fracture union. Regular radiographs of the knee AP and lateral view were done during follow-up. Parameters like VAS, Rasmussen’s functional and radiological criteria were used for assessment [11]. Rasmussen’s functional criteria involved assessing the following parameters, (1) pain following the procedure (2) walking capacity 3) knee extension (4) stability and (5) power of the quadriceps. After assessing the parameters, scoring was done with < 20 scores being poor, 20–23 scores being fair, 24–27 scores being good and 28–30 scores being excellent. Rasmussen’s Radiological criteria involved assessing (1) articular depression (2) condylar widening (3) Valgus-Varus angulation (4) osteoarthrosis—< 5 score was considered as poor, 5–6 as fair, 7–8 as good score and 9–10 as excellent score.
Statistical Analysis
The data entry was done in a Microsoft Excel spreadsheet. The quantitative data was represented as their mean ± SD. The paired t-test and chi-square test were used for analyzing quantitative data and categorical data, respectively. The significance threshold of the p-value was set at < 0.05. All analysis was carried out using SPSS software version 22.0.
Results
The study comprises of 40 patients, with 20 patients in each bone graft group and without bone graft group. In the present study, 70% of the patients were male and 30% were female. The bone graft group had 20 patients, and the mean age of the participants was 42.60 ± 11.40 years. Among the cases who did not have bone grafts, the mean age of the participants was 35.80 ± 10.61 years. The mechanism of injury was road traffic accidents in 70% of cases and fall from a height in 30% of cases. 12 cases of Schatzker type 2 without bone grafting were compared with 12 cases of Schatzker type 2 with bone grafting, and 8 cases of Schatzker type 3 without bone grafting were compared with 8 cases of Schatzker type 3 with bone grafting.
Among those who had bone grafting, 10% were smokers, and among those who did not receive bone grafting, 15% were smokers. There was no significant difference between the two groups regarding the prevalence (P = 0.63) of smoking habits. Among those who had bone grafting, 25% of the cases had diabetes mellitus. Among those who did not have bone grafting, 20% of the cases had diabetes mellitus. The difference was not significant P = 0.70.
In the group without bone grafts, the mean VAS score in the post-OP period was found to be 5.65 ± 0.58, and it decreased gradually. In the group who had a bone graft, the mean VAS score was found to be 7.0 ± 0.01 in the immediate post-OP period (Table 1).
Table 1.
VAS score
| Post-operative (Day 1) |
Post-operative (Day 3) |
Follow-up 1 month |
Follow-up 3 month |
Follow-up at union | |
|---|---|---|---|---|---|
| Bone grafting | 7.0 ± 0.01 | 5.55 ± 0.51 | 2.65 ± 0.48 | 2.0 ± 0.1 | 0.90 ± 0.30 |
| Without bone grafting | 5.65 ± 0.58 | 4.05 ± 0.75 | 1.10 ± 0.30 | 1.20 ± 0.41 | 0.0 ± 0.0 |
In the present study, the mean duration of fracture union observed was found to be 16.37 ± 5.54 weeks (Table 2). The time of fracture union was 16.85 ± 6.10 weeks among the cases who had bone graft (Fig. 1A–D), and it was 15.99 ± 5.03 weeks among the cases who did not have bone graft (Fig. 2A–D). The difference was not statistically significant (P = 0.82).
Table 2.
Fracture union with and without bone graft
| With bone graft | Without bone graft | Total | ||||
|---|---|---|---|---|---|---|
| N | % | N | % | N | % | |
| < 12 weeks | 7 | 35 | 7 | 35 | 14 | 35 |
| 12 – 24 weeks | 11 | 55 | 12 | 60 | 23 | 57.5 |
| > 24 weeks | 2 | 10 | 1 | 5 | 3 | 7.5 |
| Mean | 16.85 ± 6.10 weeks | 15.99 ± 5.03 weeks | 16.37 ± 5.54 weeks | |||
| Chi square test = 0.37, P = 0.82, Not statistically significant | ||||||
Fig. 1.
Case operated with ORIF with plating with bone grafting group. A Pre-operative AP & Lateral radiographs of the knee which shows Type 2 Schatzker lateral tibial condyle fracture. B: Preoperative CT scan of the knee, including coronal, axial and sagittal cuts, confirms the diagnosis, reveals the fracture pattern, and shows tibial side articular depression < 20 mm. C Immediate postoperative radiograph showing fracture treated with buttress plate with raft screws with bone graft. D X-rays at end of fracture union
Fig. 2.
Case with ORIF with Plating. A Pre-operative AP and Lateral radiographs of the knee which shows Type 3 Schatzker lateral tibial condyle fracture. B Preoperative CT scan of the knee confirming the diagnosis and shows tibial depression < 20 mm. C Immediate postoperative radiograph showing fracture treated with buttress plate with raft screws without bone graft. D X-rays at end of fracture union
The mean Rasmussen functional criteria at union in those with bone grafting was 28.15 ± 1.66 and those without bone grafting was 27.55 ± 1.53. Both groups showed similar functional outcomes, and this observation was not statistically significant (P = 0.72) (Table 3). It was observed at the union that Rasmussen’s radiological criteria for those with bone grafting (8.40 ± 0.50) and without bone grafting (7.90 ± 0.96) were found to be similar. This observation was not statistically significant (P = 0.53) (Table 4).
Table 3.
Rasmussen’s functional Criteria
| Bone grafting | Without bone graft | P value | ||||
|---|---|---|---|---|---|---|
| N | % | N | % | |||
| Follow-up at union | Excellent (28–30) | 14 | 70.0 | 15 | 75 | 0.72 |
| Good (24–27) | 6 | 30.0 | 5 | 25.0 | ||
| Fair (20–23) | 0 | 0.0 | 0 | 0.0 | ||
| Poor (< 20) | 0 | 0.0 | 0 | 0.0 | ||
Table 4.
Rasmussen’s radiological criteria
| Bone grafting | Without bone graft | ||||
|---|---|---|---|---|---|
| N | % | N | % | ||
| Follow-up at union | Excellent (9–10) | 8 | 40.0 | 10 | 50.0 |
| Good (7–8) | 12 | 60.0 | 10 | 50.0 | |
| Fair (5–6) | 0 | 0.0 | 0 | 0.0 | |
| Poor (< 5) | 0 | 0.0 | 0 | 0.0 | |
Discussion
Restoring the anatomy and function of the joint is crucial while treating intra-articular fractures around the knee. Open reduction and internal fixation of the depressed lateral condyle fractures of the tibia is important to achieve anatomical reduction and to restore joint congruency. The objective of the present study was to compare the functional outcome of depressed tibial plateau fractures, operated without the use of bone grafts and those with the use of bone grafts.
In the study done by Rajappan R et al. [12], the average time of fracture union was found to be around 15.2 weeks, and this observation was in near consonance with the present study. The mean duration of fracture union observed in the present study was found to be 16.37 ± 5.54 weeks. The present study showed that there was no statistically significant difference across the groups, and the groups stood comparable.
Managing subchondral cavities following the elevation of depressed tibial plateau fragments is still debatable. The usual technique has been a cortico-cancellous autograft harvested from the iliac crest [6]. However, autologous bone grafting adds to the post-operative morbidity. Younger and Chapman [7] found a major complication rate of 8.6%, such as infection, prolonged wound drainage, large hematoma, sensory loss, unsightly scars and pain lasting more than 6 months, and a minor complication rate of 20.6%, such as superficial infection, minor wound problems, and temporary sensory loss. Alternatives to autologous iliac crest bone grafting includes the use of bone graft substitutes and modifications of internal fixation techniques to minimize the degree of subchondral collapse and articular surface incongruity. McNamara et al. [13] found adequate evidence to suggest avoiding donor site complications by using bone substitutes. Russell and Leighton [14] found that calcium phosphate cement was superior to autogenous bone graft in terms of the prevention of subsidence in tibial plateau fractures.
There are studies which show these subchondral cavities can be managed without using graft. Karunakar et al [3] studied the biomechanics of types of constructs for fixation of split depression fractures of the tibial plateau—the L-buttress plate; four 3.5 mm subchondral raft screws with an anti-glide plate, both constructs were studied with and without graft. They found that there was no significant difference in the general construct stiffness between the constructs, and constructs with raft screws were more resistant to compression loads. Weimann et al. [5] demonstrated the minimally invasive three-screw ‘jail technique’ in lateral tibial plateau fractures. The extra screw from the anterior surface at an angle of 90° below the standard two-screw reconstruction was used in the tibial plateau, which showed significantly higher loading tolerance in comparison to the conventional technique associated with a decreased incidence of screw cut-out through the cancellous bone.
Kulkarni et al. [9] concluded that fixing the depressed fragment in the lateral tibial plateau fracture using raft screws with or without bone graft is a feasible option, and obtained a Rasmussen radiological score of excellent in 27 patients, good and fair in 9 and 2 respectively. In the same study, the Rasumussen clinical score was excellent, good, and fair in 15, 21 and 2 patients respectively. In the present study, the Rasmussen clinical score in the bone grafting group was excellent in 14 patients, and good in 6 patients. The Rasmussen clinical score in without bone grafting group was excellent in 15 patients, and good in 5 patients. However, there was no statistical difference with respect to the functional and radiological scoring systems in the groups.
Ahmed Abd El-Samad et al. [15] conducted a study to evaluate the clinical, radiographic, and functional results in depressed tibial plateau fractures type II and type III with depression (< 1.5 cm) by using buttress plate and screws or screws alone, without using bone graft and concluded that there is no statistical difference observed between groups. This was similar to our study, which showed no statistically significant difference between groups with respect to clinical and radiological outcomes.
Among various studies done on complications following tibial fractures, they have observed that the incidence of deep to superficial infections was 4–10%, and this finding is in consonance with the present study findings [11, 16, 17]. In the present study, none of the participants had complications like skin necrosis, post-traumatic arthritis, or tibial shortening. Among the cases who had bone graft one patient had a malunion. Superficial surgical site infections were seen in one patient without a bone graft and in two patients with a bone graft. They healed without further sequelae.
In the study done by Rajappan R et al. [12] the incidence of surgical site infection was found to be 16.6%, and it was observed to be way higher than the incidence observed in the present study, the reason of which might be because of more severe injuries among the study participants when compared to the present study. In the study conducted by Polat B et al. [6], they stated that early post-operative motion was found to be an important factor in reducing knee joint stiffness, synovial adhesions, etc., which influences the range of movement in the knee joint.
Our study has several strengths. These include age- and fracture-matched groups, comprehensive data collection, and the assessment of multiple preoperative, intraoperative, and postoperative parameters. Additionally, we ensured regular follow-up of patients, which adds value to the study. However, there are some limitations. The sample size was relatively small, which may impact the generalizability of the findings. Furthermore, the follow-up period was relatively short, limiting our ability to observe delayed presentations or assess long-term outcomes, such as the development of degenerative arthritis.
Conclusion
For osteosynthesis of depressed tibial plateau fractures, Schatzker type 2 and type 3 with depression of < 20 mm, internal fixation without bone graft is a viable option. There is no statistically significant difference in outcome by adding bone graft. The functional and radiological outcomes, time to union, and complication rates were similar in the two groups.
Acknowledgements
We thank Hosmat hospitals and Dr Chandramma Dayanada Sagar Institute of Medical Education Research (CDSIMER), Dayananda Sagar University, Harohalli, Ramanagara, for the support and help in conducting the study.
Funding
This research did not receive any specific grant from the funding agencies in the form of public, commercial or not-for-profit sectors.
Data availability
Not applicable.
Declarations
Conflict of Interest
Dr Sunil lakshmipura Krishnamurthy, Dr K Barath K, Dr M N Kumar, declare that they have no conflict of interest.
Ethical Approval
This article does not contain any studies with human or animal subjects performed by the any of the authors
Informed Consent
Informed consent was obtained from all individual participants included in the study.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Data Availability Statement
Not applicable.