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Surgeon discusses strategies in proximal tibial fracture treatment
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ISTANBUL — Orthopaedic surgeons should treat proximal tibial fractures individually based on fracture classification, intra-articular involvement and patient factors, based on a presentation by Christos Garnavos, MD, PhD, at the EFORT Congress, here.
“Fractures that occur in this area are grossly heterogeneous and their prognosis depends on intra-articular involvement and severity, the degree of fracture comminution and extension, the condition of the soft-tissue envelope, osteoporosis and patient’s age and comorbidities,” Garnavos said.
Concurrent problems with proximal tibia fractures include contusion of the soft tissue envelope surrounding the proximal tibia, and ligamentous and meniscal injuries. The latter can occur in up to 80% of these cases. ACL and PCL injuries are seen in 35% and 10% of cases, respectively.
Timing of treatment
Images: Garnavos C
Some surgeons prefer immediate treatment of meniscal and ligamentous injuries while others advocate for “active neglect” or delayed surgery.
“It is not totally wrong to defer and delay treatment for meniscal and ligamentous injuries due to the background of an acute and often severe bone injury,” Garnavos said. “Many of these injuries can be very well dealt with at a second time where the bony injury will have been healed, while some may not require anything at all.”
Garnavos noted that select minimally displaced proximal metaphyseal and condylar fractures could be managed conservatively with a knee brace and graduated weight bearing. However, he said most extra- and intra-articular proximal tibia fractures will require operative intervention with plating (open reduction and internal fixation [ORIF] or minimal invasive plate osteosynthesis [MIPO]) or external fixation techniques.
Regarding extra-articular proximal tibial fractures, Garnavos said some orthopaedists originally reported that they do not respond well to intramedullary (IM) nailing — a problem addressed by altering the nail design and modifying the surgical technique. Today’s IM nails offer more locking screws that are located as proximal as possible, and a proximal Herzog bend that ends up within the short proximal fragment. The surgical technique focuses on the use of “blocking” screws and an optimal entry hole location, Garnavos told Orthopaedics Today Europe.
Intra-articular fracture management
Regarding intra-articular proximal tibial fractures, 55% to 70% of them occur on the lateral plateau and 10% to 30% are bicondylar with open fractures comprising 1% to 3% of these fractures. Tibial plateau fractures require meticulous preoperative planning. Articular reduction is mandatory and should be done intraoperatively with arthroscopy, fluoroscopy or direct visualization, Garnavos said.
“Operative treatment of the tibial plateau fracture is a ‘must’ because we must restore the anatomy very well and stabilize the reduced fracture in order to allow immediate mobilization of the knee joint and early weight bearing of the leg,” Garnavos said.
Simple Schatzker type I tibial plateau fractures are usually treated with cannulated screws, however Garnavos proposed the use of compression bolts which, by definition, offer stronger fixation.
Schatzker type II, III and IV tibial plateau fractures are generally treated with buttress plating with or without bone grafting, according to Garnavos, while Schatzker type V and VI bicondylar fractures are treated with ORIF with conventional plates, MIPO with locking plates and external fixators with hybrid or Ilizarov-type frames, and other methods.
External fixation can be used as a temporary/spanning device in severe bicondylar fractures where a severe contusion of the soft tissue envelope surrounds the knee and proximal tibia.
Garnavos noted that despite a trend toward MIPO, which minimizes surgical trauma, some controversy remains regarding the benefits of locked plating for the management of bicondylar proximal tibial fractures. He said this is due to the unexpectedly high complication rates with locking plates reported in the last 5 years to 10 years.
At the meeting, Garnavos presented an alternative technique he published in 2011 for the management of bicondylar fractures of the tibial plateau. It is intended for fractures with minimal depression of the articular surface, uses IM nailing and compression bolts and, according to Garnavos, has such advantages as minimal invasiveness, axial loading of the leg to allow early rehabilitation, being the treatment of choice for extended or segmental fractures, using a mid-line main incision that accommodates a future knee arthroplasty, and allows easy implant removal, if needed. It can be an attractive option for open fractures of the proximal tibia with articular involvement.
The technique is performed in two main steps. The first is percutaneous reduction and fixation of the articular fracture with one or two compression bolts inserted from medial to lateral at a mid-posterior position just underneath the articular surface. This is done under image intensifier control. The surgeon fixes the metadiaphyseal part of the fracture with closed IM nailing as if it was extra-articular.
Garnavos said the IM nail entry portal plays an important role in avoiding the use of additional aids or technical tricks to restore and maintain fracture alignment. Based on Garnavos’ study on this topic, the portal should be as proximal as possible. The coronal level should have a lateral or medial parapatellar location depending on which side the metaphyseal fracture more approximates the knee joint on the antero-posterior radiographic view. Such an entry portal location can be attained with the knee in maximum flexion, he said.
The biomechanical properties of nail/compression bolt fixation of bicondylar tibial plateau fractures were tested and compared to the fixation with traditional dual plating and modern lateral locking plate techniques of identical fractures, in a study that Garnavos, Lasanianos NG, and colleagues published. They wrote, “The proposed new technique ... demonstrates a flexural behavior similar to single lateral locking plates while ... maintains a rigid intra-articular stability similar to the stiff dual buttressing plating technique.”
“However, there had been some problems,” Garnavos said in his presentation. “The free hanging position of the leg used to obtain the optimum location of the entry portal for the IM nail prohibits the undisturbed antero-posterior view with the image intensifier during the insertion and final positioning of the nail. Furthermore, elevation of the leg by an assistant with the nail and its handle in situ could displace the fracture and lead to unacceptable alignment in severely comminuted fractures.”
These problems could be avoided with retropatellar insertion of the nail to bypass the patella. It allows for undisturbed antero-posterior and lateral views with the knee joint stabilized in a semi-extended position, Garnavos said. “I am aware that such a proposal could be considered as being ‘beyond the limits’,” he added. – by Jeff Craven
- References:
- Garnavos C. Management of proximal tibial fractures. Presented at: EFORT Congress. June 5-8, 2013; Istanbul.
- Lasanianos NG. Injury. 2013; doi:10.1016/j.injury.2013.03.013.
- For more information:
- Christos Garnavos, MD, PhD, can be reached at Evangelismos General Hospital, Ypsilanti 45-47, Athens 10676, Greece; email: cgarn@otenet.gr.
Disclosure: Garnavos has no relevant financial disclosures.