Arthroscopically assisted osteosynthesis of tibial plateau fractures in patients older than 55 years

Arthroscopically Assisted Osteosynthesis of Tibia1 Plateau Fractures in Patients Older Than 55 Years Willem H. Roerdink, M.D, Jacques Oskam M.D, and Pieter A. M. Vierhout M.D.

Purpose: To evaluate the end results of arthroscopically assisted osteosynthesis of tibia] plateau fractures in patients older than 55 years of age. Type of Study: Case series. Methods: Over a 5-year period, 201 consecutive patients presented with tibia] plateau fracture; 131 of these patients were treated with arthroscopically assisted osteosynthesis of the tibia] plateau. Inclusion in the retrospective analysis was limited to those patients older than 55 years at the time of injury and those who were available for follow-up at the time of the study. Thirty patients met these criteria. Results: Secondary

displacement occurred in 9 patients (30%) within I2 weeks after surgery. After a median follow-up of 3 years, 24 of 30 patients (80%) had an excellent or good clinical result according to the modified Rasmussen criteria. There was no difference in clinical outcome between the patients with or without secondary displacement of the fracture. Conclusions: Given the good clinical results. arthroscopitally assisted osteosynthesis has been shown to be highly efficient in the treatment of tibia] plateau fractures in the elderly. Key Words: Knee injuries-Tibia1 plateau fracture-Arthroscopy-Osteoporosis-Secondary displacement.

T

he goals of treatment for tibia1 plateau fractures are restoration of joint congruity, restoration of normal alignment, stabilization of the joint, and prevention of post-traumatic osteoarthrosis. i Obviously, these goals apply to both the younger and the older patient. However, from the age of 40 years and older, both sexes suffer bone loss leading to osteoporosis.’ Osteoporosis is known to compromise the result of anatomic restoration and adversely influence the functional outcome.’ Remarkably, there is only 1 study dealing exclusively with the operative treatment of the tibia1 plateau fracture in the elderly patient.3 This study reported an excellent or good clinical result in 23 of 32 patients (71%), and a fair or poor result in 9

From the Department of Surgery. University Hospital Groningen, Groningen (W.H.R., J.O.); and the Department of Truumatology, Medisch Spectrum Twente, Enschede (P.A.M. V.), The Netherlands. Address correspondence and reprint requests to Willem H. Roerdink, M.D., Department of Surgery, Universiv Hospital Groningen, P.O. Box 30.001, 9700 RB Groningen. The Netherlands. E-mail: roerdink. bouman @ wxs.nl 0 1999 by the Arthroscopy Association of North America 0749-8063/01/l 708-2551$35.00/O doi:10.1053/jars.2001.25339

826

Arthroscopy:

The Journal

of Arthroscopic

and Related

of 32 patients (29%) after open reduction and internal fixation3 Previous studies attribute important advantages to arthroscopically assisted minimal osteosynthesis. These studies claim that, in experienced hands, the arthroscopic procedure is swift and safe with little chance of complications such as wound infections or skin necrosis.“-* Furthermore, adjacent pathology of menisci, chondral tissue, and ligaments can easily be diagnosed and treated. The limited incisions and, consequently, the avoidance of extensive arthrotomy and preservation of proprioception allow faster rehabilitation.4-8 Given the state of the art, the advantages of arthroscopic knee surgery may even be more beneficial for the elderly patient with osteoporosis. In our clinic, we prefer to perform arthroscopically assisted osteosynthesis in elderly patients. This retrospective study was undertaken to analyze the end results of our policy and see whether arthroscopically assisted osteosynthesis of proximal tibia1 plateau fractures in patients older than 55 years is a safe and efficient mode of treatment. Because collapse of the tibia1 plateau following osteosynthesis is a frequently observed complication, another concern was to assess the incidence of secondary displacement and to ana-

Surgery,

Vol 17, No 8 (October),

2001:

pp 826-831

ARTHROSCOPIC

lyze etiologic factors contributing secondary displacement.

TIBIAL

to the occurrence of

PLATEAU

RECONSTUCTION

TABLE

1.

ModiJed

Rusrnusset~ Criteria Assessmettt

821 for Chical Points

METHODS In the period from 1992 to 1996, a total of 201 consecutive patients presented with a tibia1 plateau fracture at the traumatology department of our hospital. Of those patients, 13 1 were treated with arthroscopically assisted osteosynthesis of the tibia1 plateau. Inclusion in the retrospective analyses was limited to those patients treated arthroscopically who were older than 55 years at the time of injury. Thirty of 201 patients ( 15%), 27 women and 3 men, with a mean age of 72 years (range. 57 to 92 years) were eligible for the study. Either an accidental fall or a traffic accident caused the injuries. One patient injured her knee while skiing. The diagnosis was made on the basis of the medical history, physical examination, and standard radiographs. One patient suffered a grade I open fracture. Computed tomography scanning with 3-dimensional reconstruction was performed in all 30 patients to determine the exact location of the impacted part of the tibia1 plateau, the extent of comminution, and the number of fracture fragments. Classification

and Definitions

Fractures were classified according to Schatzker et al.’ The distribution was as follows: 6 type I, 13 type II, 5 type III, 3 type IV, 2 type V, and 1 type VI fracture. One patient with a type II injury had an associated fracture of the neck of the fibula. While the patients were under anesthesia, the knee was cautiously tested preoperatively to assess stability of the knee joint. It appeared that instability of the knee was present in 21 of 30 patients, suggesting either an unstable fracture or ligamentous injury. Follow-up was performed by using the modified Rasmussen clinical and radiologic criteria.j The Rasmussen evaluation consists of the subjective state of the knee according to the patient, and the objective state of the knee assessed by knee extension, range of motion, stability and power of the quadriceps, and the assessment of standard radiographs (Tables 1 and 2).’ We used the Resnick and Niwoyama criteria for grading of post-traumatic osteoarthrosis (Table 3).i” Secondary displacement of the tibia1 plateau was defined as a progression of the condylar widening or articular depression of 5 mm or more.

Pain None Occasional Stabbing pain in certain positions Constant pain after activity Significant rest pain Walking capacity Normal walking capacity for age Walking outdoors > I hr Walking outdoors I5 min-I hr Walking outdoors < 15 min Walking indoors only Wheelchair/bedridden Knee extension Normal Lack of extension < IO” Lack of extension > IO’ Lack of extension >20” Total range of motion Full At least 120” At least 90” At least 60’ <60” Stability Normal stability in extension and 20” Rexion Abnormal instability in 20” Rexion Instability in extension IO” Power of quadriceps Grade 5 Grade 3 to 4 Grade <3 Maximum score Excellent Good Fair Poor

6 5 3 I -3 6 5 3 I 0 -3 4 2 0 -2 6 5 3 I -3 6 4 2 0 2 I -2 30 28-30 24-27 20-23 <20

Treatment In our hospital, the treatment of choice for all tibia1 plateau fractures is arthroscopically assisted reduction and minimal osteosynthesis. Also patients with nondisplaced fractures but with clear valgus or vat-us instability are operated on in order to restore stability and allow early rehabilitation. This means that a patient with a good radiologic score on preoperative radiographs (n = 4) may still be eligible for surgery. In our opinion, conservative treatment should be reserved for the very few cases in which there is a nondisplaced fracture without instability of the knee and without hemarthrosis. When the exact location of

828 TABLE

W. H. ROERDINK 2.

Modijed

Rastntrssett Assesstttetzt

Criteria

for

Rctdioloyic

Points Articular depression None <5mm 6-10 mm >I0 mm Condylar widening None <5 mm 6-10 mm >I0 mm Varus/valgus angulation None 20" Osteoarthrosis None/no progress Progression by I grade Progression by > 1 grade Excellent Good Fair Poor

3 2 I

0 3 2 I 0 3 2 I 0

I 0 -I 9-10 7-8 5-6 <5

the impacted part of the tibia1 plateau was confirmed by arthroscopic inspection, an incision under the joint was made to give access to the underlying cortex. Fenestration of the tibia1 condyle allowed access to the impacted fragments. The impacted fragments were then pushed up and reduced to achieve congruity of the joint surface. Arthroscopic inspection of the tibia1 plateau ensured alignment of the chondral tissue. The defect in the proximal tibia was filled with a bone plug from the pelvic crest in 4 patients. In 8 patients older than 75 years, the gap was filled with palaces (methyl methacrylate), which has the advantage of enabling the elderly patient to moblize within a week after surgery. If it was estimated that a small defect was present, no bone substitution was used (n = 18). Finally, fixation with cancellous lag screws or, when there was insufficient support from the cortex, a buttress plate and screws, was accomplished according to the A0 principles (Fig 1). If, after osteosynthesis, instability of the knee joint was present with injury of the collateral ligament as well, the collateral ligament was reconstructed. With the arthroscope pointing at the capsular hematoma and using transillumination, a guided skin incision was made on the outside of the knee. At that time, the arthroscopic procedure ended and reconstruction of the ligament was performed.

ET AL.

The first 2 weeks postoperatively, patients were mobilized on crutches and a continuous passive motion machine was used. If the patient was walking with crutches. a brace was applied to prevent the fracture from collapsing if the patient were to fall. Full weight bearing was allowed after 6 weeks postoperatively. Follow-up Radiologic assessment was done preoperatively, within 5 days postoperatively. and every 4 weeks until full weight bearing was achieved. The final clinical and radiologic evaluation of the reconstructed tibia1 plateau took place after a median follow-up period of 3 years (range, 2 to 5 years). Statistics By using the Fisher Exact test. we examined whether or not the use of bone substitution had an effect on the incidence of secondary displacement. Furthermore, a difference in the clinical Rasmussen score of patients with and without secondary displacement of the reconstructed tibia1 plateau was tested using the Wilcoxon rank-sum test; P < .05 was considered statistically significant. RESULTS The average hospital stay was 20 days (range. 7 to 58 days), and the average time to full weight bearing was 9 weeks (range, 2 to 16 weeks). Arthroscopic inspection revealed concomitant pathology of menisci (n = 12) collateral ligaments (n = 2), or cruciate ligaments (n = 2) in 14 (46%) patients. Except for 1

TABLE

3.

Restzick

and Niwoyttmt of Osteonrthrosis

Grade 0 None Grade I Minimal joint space narrowing Mild sclerosis Grade 2 Moderate narrowing, osteophytes Moderate subchondral sclerosis Moderate bony aberration Intra-articular osseous bodies Grade 3 Marked joint space narrowing Bony collapse Severe subchondral sclerosis Marked deformity Severe bony aberration

Criteria

,for

Grctdittg

ARTHROSCOPIC

TIBIAL

PLATEAU RECONSTUCTION

829

FIGURE1. Preoperative and postoperative radiographs of a 57-year-old woman who suffered a unilateral tibia1 plateau fracture (Schatzker type II) after being hit by a car as a pedestrian. Arthroscopic inspection ensured alignment of the tibia1 plateau after reduction of the fracture. Fixation was performed with 2 cancellous lag screws.

wound infection that was treated with conservative measures, no serious postoperative complications were recorded. In particular, compartment syndrome of the leg, a serious complication after irrigating the knee joint during arthroscopy, did not occur. Radiologic

Results

Within 5 days postoperatively, standard radiographs showed 6 excellent, 13 good, 9 fair, and 2 poor radiologic results (Table 4). Of 20 patients with severely displaced fractures and a poor preoperative radiologic score, 9 patients improved to a fair radiologic result and 9 patients to a good or excellent result. Of the 4 patients with a good preoperative radiologic score, 3 patients improved to an excellent radiologic result and 1 patient maintained a good radiologic score. The radiologic Rasmussen score was not worsened by the procedure in any of the 30 patients (Table 4).

Secondary displacement occurred in 9 of 30 patients (30%) within an average time of 9 weeks postoperatively (range, 2 to 12 weeks). Interestingly, secondary displacement was observed in 1 of 12 (8%) patients who were treated with bone substitution. In patients in whom we applied neither bone cement nor a bone graft, secondary displacement occurred in 8 of 18 patients (44%). This difference was statistically significant (P = .049). At follow-up, the final radiologic results were excellent in 4 patients, good in 10 patients, fair in 10 patients, and poor in 6 patients. At the time of surgery, 16 patients suffered from pre-existing mild to moderate osteoarthrosis. Two patients were classified as having severe osteoarthrosis, which means that preoperative radiographs showed marked joint space narrowing with severe subchondral sclerosis or one of the other distinctive features described in Table 3. According to the Resnick and

TABLE 4. Results (No. of Patients) According to the Modijed Rasmussen Criteria Follow-up (3 yr) Rasmussen Score Excellent Good Fair Poor

Preoperative Radiologic

Postoperative Radiologic

Follow-up (8 wk) Radiologic

Radiologic

0 4 6 20

6 13 9 2

5 10 12 3

4 10 10 6

clinical 12 12 3 3

830

W. H. ROERDINK

Niwoyama criteria,‘0 osteoarthrosis progressed by 1 grade in 6 patients and by 2 or more grades in 2 patients. One patient with a radiographically good result but with severe pre-existing osteoarthrosis was subjected to a total knee arthroplasty after 2 years. Clinical

Results

The outcome of the final clinical evaluation was 12 excellent, 12 good, 3 fair, and 3 poor results. Thus, a good or excellent clinical result was achieved in 24 of 30 patients (80%). Furthermore, the median clinical Rasmussen score of patients without secondary displacement was 9.0 (PZ5 = 7.5 and P,, = 9.8), while the median clinical score of patients with a secondary displacement was 8.7 (PZ5 = 7.25 and P,5 = 9.8). The difference between the 2 groups was not statistically significant (P = S7). DISCUSSION

To our knowledge, this is the first study dealing exclusively with tibia1 plateau fractures in patients older than 55 years of age treated arthroscopically. A good or excellent clinical result was achieved in 24 of 30 patients (80%). These results are in accordance with earlier results reported on open reconstruction of the tibial plateau in patients of the same age group (7 1%).3 They are also comparable with the good functional results achieved in younger patients with arthroscopic surgery.5.8.11.12Despite the favorable functional results at follow-up, it was also observed that, within 12 weeks after surgery, secondary displacement occurred in 9 patients (30%). Thus, one of the goals of operative treatment, i.e., restoration of joint congruity, has regretfully not been achieved in all patients. This is illustrated by the moderate radiologic results at follow-up. Nevertheless, normal alignment, stabilization of the joint, and good functional recovery could be achieved arthroscopically in the majority of cases. Secondary displacement and breaking out of implants frequently occurs after reduction and fixation of a fracture in osteoporotic bone.1.13v14Secondary displacement of an osteoporotic tibia1 plateau may occur as a result of mechanical pressure or loss of bone mass in the fracture. Another factor that may explain the occurrence of secondary displacement is whether or not the defect in the proximal tibia was treated with bone graft or substitution material. Displacement of the fracture after surgery occurred more often in patients where no bone plug or bone cement was used. No studies have been published (according to Med-

ET AL.

Line) in which bone substitution has been proven to prevent secondary displacement. However, it seems that bone substitution creates additional stability in an osteoporotic proximal tibia. Despite the assumed beneficial effects of bone substitution, statistical analysis in this study showed no significant differences in clinical outcome between patients with or without a secondary displacement of the tibia1 plateau. In other words, secondary displacement of the fracture does not seem to affect the ultimate outcome of knee function in this group of patients. The philosophy behind arthroscopic knee surgery is prevention of additional surgical trauma to the knee joint by using a minimally invasive approach. As a result, the incidence of postoperative infection decreases and prolonged immobilization is avoided. In our patients, there were no serious infections. Another advantage of arthroscopic surgery is a clear visualization of concurrent injury to menisci, chondral tissue, and ligaments.6.7.15 In this respect, the high incidence of associated intra-articular injury that we found in our study compared with open reduction and fixation (46% v 3%, respectively) is remarkable.’ Treatment of meniscal tears and suturing of ligaments improve the ultimate results by preventing instability and osteoarthrosis. I6 Therefore, diagnosing and treating associated intra-articular injury is a worthwhile additional advantage of arthroscopy as compared with open repair. Based on this observational study and the good functional results we achieved without suffering serious complications, arthroscopically assisted osteosynthesis has been shown to be highly efficient for tibia1 plateau fractures in the elderly. Acknowledgment: The authors thank Dr. J van der Palen, clinical epidemiologist at Medisch Spectrum Twente. for his assistance in the statistical analysis. REFERENCES I. Schatzker J, McBroom R, Bruce D. The tibia1 plateau fracture: The Toronto experience I968- 1975. C/in Orrhop 1979; I38:94104. 2. Riggs BL, Melton LJ III. Involutional osteoporosis. N EqI J Med 1986;314:1676-1686. 3. Biyani A, Reddy NS, Chaudhury J, Simison AJM, Klenerman L. The result of surgical management of displaced tibia1 plateau fractures in the elderly. bljuv 1995;5:29 l-297. 4. Vierhout PAM. Tibia1 plateau and spine fractures. In: McGinty JB, Caspari RB, Jackson RW, Poehling GG, eds. Opernrive arthroscopy. Philadelphia: Lippincott-Raven, 1996:589-595. 5. Vierhout PAM, Smulders BHN, Hohmann FR, Stapert JWJL. Hoogendam IJ, Kummer EW. Reconstruction of the tibia1 plateau fracture under arthroscopic control without arthrotomy. Ned Tijdschr Geneeskd I99 1; I35:893-896. 6. Caspari RB. Hutton PMJ, Whipple TL, Meyers JF. The role of

ARTHROSCOPIC arthroscopy

in the management of tibia] plateau fractures. 1985:1:76-82. Jennings JE. Arthroscopic management of tibia] plateau fractures. Arrhmw~py 1985: I: 160-168. Guanche CA, Markman AW. Arthroscopic management of tibia] plateau fractures. Arthroscopy 1993;9:467-47 I. Rasmussen P. Tibia] condylar fractures: Impairment of knee joint stability as an indication for surgical treatment. J Borer Join/ Surg Am 197355: l33l-1350. Resnick D. Niwoyama G. Dicr,~~mis of borw and joint disorders. Philadelphia: WB Saunders, 198 I ; 1276. Houben PFJ. Linden van der ES, Wildenberg van den FAJM. Stapert JWJL. Functional and radiological outcome after intraarticular tibia1 plateau fractures. lnjuq 1997;28:459-462. Arthroscopy

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12. Scheerlinck T, Ng CS, Handelberg F. Casteleyn PP. Mediumterm results of percutaneous, arthroscopically assisted osteosynthesis of fractures of the tibia1 plateau. J Bone Joint Surg Br 1998;80:959-964. 13. Lachiewicz PF. Funcik T. Factors influencing the results of open reduction and internal fixation of tibia1 plateau fractures. Clirl Orlhop I990:259:2 1O-2 IS. 14. Honkonen SE. Indications for surgical treatment of tibia1 condyle fractures. Clirt Orthop 1994;302: 199-205. IS. Buchko GM, Johnson DH. Arthroscopy assisted operative management of tibia1 plateau fractures. C/in Orfhop 1996;322: 29-36.

16. Honkonen SE. Degenerative arthritis after tures. J Orrhop Trnunm 1995;9:273-277.

tibia1 plateau

frac-