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EBM - Tibial Plateau Fractures - Dr.Chintan N. Patel
1) The document discusses evidence based medicine and presents a case study of a 37 year old male who sustained a lateral plateau comminuted depressed fracture of the left tibia after falling from a bike. 2) The patient underwent open reduction and internal fixation with a proximal tibial angular locking plate using a minimally invasive percutaneous plate osteosynthesis technique. 3) The goals of management were to elevate the depression, restore limb axis, provide rigid and absolute fixation, and allow early mobilization to improve outcomes and reduce post-traumatic osteoarthritis.
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Introduction to Evidence-Based Medicine (EBM) and its significance in patient care.
Detailed patient history including demographics, chief complaints, and clinical examination findings.
Diagnosis of fracture type and various classifications including Schatzker and AO/OTA classifications.
Discussion on surgical fixation methods for lateral plateau fractures, focusing on techniques used.
Post-operative protocol, management goals including knee stabilization and early mobilization.
Summary of various studies and articles highlighting the outcomes of surgical management of tibial plateau fractures.
Final thoughts on the importance of surgical treatment for optimal knee function.
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EBM - Tibial Plateau Fractures - Dr.Chintan N. Patel
- 1. EVIDENCE BASED MEDICINE PRESENTER :Dr CHINTAN N PATEL CHAIR PERSON : Dr R.R. BHANDANKAR Dept of Orthopaedics , J.N. Medical College and Dr. Prabhakar Kore Hospital and MRC, Belgaum
- 3. • Evidence basedmedicine (EBM) was originally defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.
- 4. History • Name :-XYZ • Age :- 37 • Sex :- Male • Address :- Chikodi • Occupation :- Teacher
- 5. Chief Complaints • Painin Left Knee • Swelling on Left Knee
- 6. History of PresentingIllness H/O RTA – Fall from Bike on 19/11/2016 at 1 pm near B.K. College, Chikodi and patient sustained injury over Left Knee. After the fall, patient was conscious but unable to bend the Left Knee and unable to walk and patient had Pain and swelling in Left Knee. No h/o- Head injury/loc/vomiting/ENT bleeding
- 7. Personal history • Diet: Mixed • Appetite : Unaltered • Sleep : Undisturbed • Bowel & Bladder : Unaltered and regular • Habbit : no addiction
- 8. Past history •H/o –DM present, on Insuline treatment since 7years, (20 IU Morning and 15IU Night) •No H/o - HTN/Asthma/TB/ Drug allergies •No H/o – any Hospitalization or long term medical •treatment (except for DM) Family history •No H/o – DM in family •No other significant family history Vitals – BP: 130/80 mm Hg – Pulse: 90 /min – Respiratory rate: 26 cycles/min – SpO2: 100%
- 9. Examination Inspection •Swelling and deformityseen over Left Knee •No visible external wounds •No muscle wasting •No visible scars or sinuses Palpation •All inspectory findings were confirmed •Tenderness present on Left knee – more on Lateral aspect, extending upto Proximal Tibia •Palpable swelling and deformity present •Restricted movements at Left Knee joint •No local rise of temperature
- 10. – Pelvic compressiontest was negative – Chest compression test was negative – B/L Toe movements + – Distal pulses were b/l palpable and equally felt – Motor and sensory examination was within normal limits
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- 12. DIAGNOSIS • Lateral Plateau– comminuted, depressed Fracture of Left tibia (Schatzker’s type 2)
- 13. CLASSIFICATION • Schatzker Classification •AO/OTA Classification • Hohl and Moore Classification • Posterior tibial plateau fracture : a new treatment-oriented classification
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- 25. Hohl and MooreClassification of proximal tibia fracture-dislocations Type I Coronal split fracture Type II Entire condylar fracture Type III Rim avulsion fracture of lateral plateau Type IV Rim compression fracture Type V Four-part fracture
- 26. Posterior tibial plateaufracture : a new treatment-oriented classification A. Type I-split fracture of posteromedial condyle B. Type II-split fracture of posterolateral condyle C. Type III-collapse fracture of posterolateral condyle D. Type IV-split and collapse fracture of posterolateral condyle E. Type V-split fracture of posteromedial condyle and collapse fracture of posterolateral condyle.
- 28. Surgical Treatment Split DepressionFractures (Schatzker 2)
- 29. Fixation of LateralPlateau Fractures • Traditional – large fragment “L” or “T” buttress plate – 6.5mm subchondral lag screws – 4.5mm diaphyseal screw • Current Recommendation – small fragment fixation – pre-contoured peri-articular plates – clustered sudchondral k-wires •
- 30. Biomechanics: Subchondral Fixation • 3.5mm raft construct allowed significantly less displacement than 6.5 mm screw with axial load. (2954 vs. 968 newtons/mm) Twaddle et al AAOs, 1997 • No difference in pull out strength between 6.5mm screws and 3.5mm screws in subchondral bone. Westmoreland et al J Ortho Trauma 2002 • Subchondral clustered K-wires signicantly enhance load tolerance of depressed articular surface. Beris et al Bull Hosp Joint Dis 1996
- 31. Large or SmallFixation for the Lateral Plateau? • No significant difference between fixation strengths small vs large frament (Hubbard et al. A J Ortho, 1999) • Karunaker et al. J Ortho Trauma 2002 – No significant difference in overall stiffness between: large fragment; periarticular small fragment plate; 3.5 mm subchondral screws with separate 1/3 semitubular anti-glide plate
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- 33. Lateral Split DepressionPlateau Fixation with Clustered K-wires
- 34. What we havedone???
- 35. Post-op X-rays AP and lateral view OR +IF with PROXIMAL TIBIAL ANGULAR LOCKING PLATE - single-incision anterolateral approach and Minimally Invasive Percutaneous Plate Osteosynthesis (MIPPO) technique
- 36. GOALS FOR MANAGEMENT •Elevate the depression – using osteotome, bone tamp, curette or cannulated drill and impactor systom followed by stabilization with K-wire/ Cannulated screw and Calcium phosphate cement or Bone Graft. • Early Mobilization -continuous passive mobilization and knee bending upto 90 degrees and full extension within 5 to 7 days. -Pt is mobilized with knee brace locked in extension for 6 weeks. -Strict Non Weight Bearing for 12 weeks. • Restore limb axis • Compression of split • Rigid and absolute fixation
- 37. ARTICLE 1 :Indian Journal of Orthopaedics (November 2015 | Vol. 49 | Issue 6) The present study provides sufficient evidence that the treatment of tibial plateau fractures using angular-stable plate fixation results in 73.3% excellent to good functional outcome. Present data provide sufficient evidence that anatomical restoration of tibial plateau fractures with angular stable plate fixation result in decreased Loss of Reduction and declined incidence of Post Traumatic Osteoarthritis, thereby providing acceptable mid to long term outcome. “Angular stable locking plate fixation of tibial plateau‑ fractures-clinical and radiological midterm results in 101 patients”
- 38. ARTICLE 2: The Journalof Bone and Joint Surgery VOL. 91-B, No. 4, APRIL 2009 Newer biological techniques and the development of locked-plate technology have improved outcomes, lowered the rates of revision and lessened the occurrence of deep soft-tissue infections. In a study of 69 high-energy fractures of the tibial plateau treated by unilateral locked plating only one deep infection was observed. However, despite the use of a locking technique, loss of reduction was seen in 13% of the fractures. New trends and techniques in open reduction and internal fixation of fractures of the tibial plateau
- 39. ARTICLE 3 :ISRN ORTHOPAEDICS ( International Scholarly Research Notices) Published 16 March 2014 Comparison of Functional Outcomes of Tibial Plateau Fractures Treated with Nonlocking and Locking Plate Fixations: A Nonrandomized Clinical Trial The prospective study showed superiority of locking plate to nonlocking plate methods with regard to knee scores and VAS pain scores indicating more improvement in Knee Functional Score and minimizing Postoperative Pain using the locking plate method.
- 40. ARTICLE 4 : INTERNATIONAL JOURNALOF CARE OF THE INJURED November 2010 Volume 41, Issue 11, Pages 1178–1182 Tibial plateau fractures: Internal fixation with locking plates and the MIPO technique A cohort of 58 proximal tibial fractures, surgically treated, from January 2004 to June 2007, was retrospectively reviewed Internal fixation with locking plates, following the principles of MIPO (Minimally Invasive Percutaneous Osteosynthesis), provides satisfactory fracture reduction with good results regarding the mid-term clinical outcome.
- 41. ARTICLE 5 : International Journalof Science and Research (IJSR) Volume 4 Issue 9, September 2015 Functional Outcome of Surgical Management of Tibial Plateau Fractures: Case Series of 30 Cases In all 30 cases they used either percutaneus cannulated cancellous screws or T buttress /L buttress /LCP (Proximal Tibial Locking Compression Plate) plate depending upon the type of fracture. Schatzker type II cases were treated with plating with or without bone grafting. All patients in this group had good to excellent results.
- 42. Take Home Message •Surgical treatment when indicated (particularly in depressed and displaced fractures) is advantageous to get a stable knee. • The surgical management of tibial plateau fractures is challenging and gives excellent anatomical reduction & rigid fixation to restore articular congruity, facilitate early knee motion by reducing post-traumatic osteoarthritis and thus achieving optimal knee function.
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