tibial plateau fractures - cuh · pdf filetibial plateau fractures: factors influencing...
TRANSCRIPT
Tibial Plateau Fractures: Factors influencing outcomes
May 20th 2013
Joel Melton BM, MSc, FRCS (Tr + Orth)
Consultant Orthopaedic Surgeon, Cambridge University Hospitals
Overview
Plateau Fractures
Diagnosis
Classifications
Treatment goals
Management decisions
Surgical techniques
Controversies
Factors influencing outcome
Diagnosis
History, Clinical examination, Special tests
Minor, major or catastrophic injury
May be subtle or obvious
Remember other injuries
Degree of soft tissue injury
(inc. open)
Diagnosis – special tests
Plain radiography
CT scan Diagnosis
Fracture pattern
Help with classification
Assess joint displacement
Guide need for operative intervention
Guide the operative fixation plan and surgical approaches
MRI ?
Classification
Jo Schatzker
Types 1-6
Worsening severity by type
May guide fixation techniques and likely outcomes
Classification - Schatzker
Types 1-6
Treatment goals
G. Appley – Reduce fracture, hold position and rehabilitate
The AO group
AO principles dictate:
An intraarticular fracture must be anatomically reduced, fixed with rigid internal fixation, conferring absolute stability to the fracture, expecting primary bone healing and allowing early joint mobilisation
Treatment goals
Applying this to plateau fractures: Assess patient first (general status, ATLS,
compartments etc)
Diagnosis
Fracture pattern
Degree of displacement
Knee Joint position/disruption
Leg Alignment
Imaging, pre-operative planning, timing
Hardware, surgical expertise, rehabilitation goals
Management decisions
Operative vs non operative
What degree of displacement can you accept?
What is the patient like?
Timing of surgery
Soft tissue injury (bruising, swelling)
What hardware? Why
Which incisions? Minimally invasive?
Fixation plans?
How can we influence outcome?
How can we influence outcome?
Rehabilitation
Patient factors
Treatment decisions
How can we influence outcome?
Patient factors
• Age, co-morbidity
• Smoking,drugs
Treatment decisions
• Conservative
• Surgical fixation
Rehabilitation
• Cast,Brace, ROM
• Early ROM
Influencing outcome
Plateau fracture
Operative management
Conservative management
Influencing outcome
Plateau fracture
Mal-reduced fracture
Good reduction
Influencing outcome
Influencing outcome
Operative management
Internal fixation
External fixation
Influencing outcome
Operative management
Internal fixation
Screw Plate
External fixation
Circular frame/hybrid
Influencing outcome
Influencing outcome
External Fixation
Hybrid fixation
Non-hybrid fixation
Influencing outcome
Influencing outcome
Internal fixation
Double plate
Single plate
Influencing outcome
Double plating
Double incision
Single incision
Influencing outcome
Double incision
Single incision
Influencing outcome
Dead bone sandwich?
Influencing outcome
MIPO (Minimally invasive plate osteosynthesis)
Influencing outcome
Bi-condylar injury
pattern
Double plating
Single fixed angle device
Influencing outcome
Influencing outcome
Internal fixation
Arthroscopic
assisted Fluoroscopy
Influencing outcome
Influencing outcome
Internal fixation
Meniscal repair
No soft tissue
procedure
Influencing outcome
Influencing outcome
Internal fixation
Bone graft BG
substitutes
Influencing outcome
Calcium phosphate paste
Influencing outcome
Influencing outcome
Rehabilitation
Delayed Early ROM
So what outcomes are we getting?
Outcomes
49 pts, <40 no difference, >40 worse outcome
311 pts, 10 yr follow up. 13% had TKR
125 pts, < 10 yrs follow up. 26% OA on XR, 4% TKR
Latest review of current management of plateau
fractures?
Latest review of current management of plateau
fractures?
Summary
Multiple issues effect outcome
Summary
Patient factors
• Age, co-morbidity
• Smoking,drugs
Treatment decisions
• Conservative
• Surgical fixation
Rehabilitation
• Cast,Brace, ROM
• Early ROM
G. Appley – Reduce fracture, hold position and rehabilitate