| Objective: Tibial plateau fractures account for1%of all body fractures,of which10%-30%are complex tibial plateau fractures of type Ⅳ-Ⅵaccording to the Schatzker classification. However, how to treat this kind offracture in a safety and effective way remains controversial. The generaloperative treatment principal of intra-articular injury is anatomic reduction,rigid fixation and early movement. And the goals of the operative treatment ofcomplex tibial plateau fractures are as follows:1.to recover the alignment ofthe lower extremity.2.to mainten the stability of the knee joint.3.to reconstructthe integrality of the articular surface. There were numerous therapies to dealwith tibial plateau fractures, for instance,single unilateral locking plate, classictwo-incision with double plates, combination of hybrid or circle externalfixation and MIPPO technique and so on. However, each method has its owndisadvantage. The method of single unilateral locking plate can cause varusmalalignment; classic two-insion with double plates technique can rigidlyfixate the fracture, but its major disadvantage includes great invasion and highinfection rate; external fixation can be a valuable option, but infection alwaysleads to failure. Some literatures has reported that complex tibial fracturetreated with MIPPO technique had a satisfactory outcome. Our study aimed toassess the outcome of complex tibial plateau fractures that were treated withthe Minimal Invasive Percutaneous Plate Osteosynthesis(MIPPO) technique.Methods: A retrospective view of our trauma center from January2010to December2011,24patients with consecutive complex tibial plateaufractures were treated with MIPPO technique in.All of these patients areincluded in the study.Among them, Twenty-three had unilateral fractures, andone had bilateral fractures. There were6Schaztker-Ⅳ,14 Schaztker-Ⅴ,and5Schaztker-Ⅵ injuries. And according to AO/OTAclassification, there were7AO/OTA type B and18AO/OTA type C. Inclusioncriteria for this study were: age≥18and≤60years old; the history ofhigh-energy injury; acute injury(definitive surgery less than14days); closefractures; and the type Ⅳ-Ⅵ fractures according to the Schaztkerclassification. Exclusion criteria for this study were: old fractures(definitivesurgery more than2weeks);open fractures; pathologic fractures; fracturescombined with vascular or nerve injury; and severe medical disease. Allfractures were treated with MIPPO technique.After epidural anesthesia or general anesthesia, the procedure wasperformed in the supinate position. The tourniquet(the pressure was300Hg)was placed around the proximal end of the thign,and a padding under theinjuried knee joint to keep it a little flexion. After that, anteromedial incisionwas performed, which was4-6centimeters long, and the medial plateau wasreduced with indirect reduced technique. After that, trans-subcutaneous platefixation was performed to stabilize the fracture, which depended on the lagscrew and plate flexibility. Then, through the posterolateral incision wasperformed to reduce and fixate the lateral plateau using a longer plate. If theposterior plateau fractured, an inverted L-shaped incision was performed toexpose the posterior plateau, in the end, reduction and fixation were done.Asfor the Schatzker Ⅳ fracture, It was enough to reduce and fixate the medialplateau. All the manipulations were done under the fluoroscopic. After thefixation, the injuried knee joint routinely went under the lateral stress testand drawer test to evaluate the stability of the joint and the alignment of thelower extremity. Subcutaneous tissue and skin were closed over suctiondrainages. A continuous passive motion machine was used in the hospital for48hours after the surgery. Partial weightbearing began at the sixthpostoperative week. Full weightbearing began at the twelfth postoperativeweek.Postoperative plain films were used to assess the reduction of thefractures, and evaluate the lower extremity alignment and the range of knee motion(ROM). Finally, the HSS score was used to quantify the functionaloutcome at the12thmonth afteroperation. The criteria for a satisfactory resultwere:1.＞90°of knee flexion,2.＜5°of varus or valgus angulation,3.noradiographic evidence of arthrosis,4.no limp, and5. no use of walking aids. Ifany one of these criteria were not met, the result was deemed unsatisfactory.Result: The mean time of afteroperation follow-up for these cases was12thmonth.18patients acquired the anatomical reduction,7patients with anaverage residual joint depression of2.4㎜(range1-4㎜),,1case with valgusangulation was9°,no case was found with vagus angulation. The mean rangeof extending knee arch was2.3°(range0-4°),and the flexion knee arch was127°(range94-134°).Only two cases had superficial infection and weretreated with3day's intravenous antibiotics, then both of them were recovered,and there was no deep wound infection and skin necrosis.4cases was foundnumbness of anterior aspect of the leg, but all of them were recovered afterone month. The mean HSS score was86.7(range74-98).22patients(88%)weresatisfied with their outcomes at the12thmonth follow-up.Conclusion: Less invasion, faster healing of the incision, fewercomplications such as infection, better functional outcome, all of which areadvandages of MIPPO technique to treat patients with complex tibial plateaufractures. Above all, in order to acquire the satisfactory long-term results, thesurgeon should bear in mind:firstly, assess the condition of the soft tissue,staged management is recommended to allow the recovery of the soft tissuebefore the operation, the Minimal Invasive technique should be utilized in theoperation.Secondly, the surgeon should not ingore the anatomicalreduction,correcting the alignment of lower extremity, keeping the stability ofthe knee joint, reconstructing the integrity of the articular surface and usingthe autogenous bone grafts to fill up the depression if necessary; finally, rigidfixation to permit early function exercises is of great importance.So we shouldchoose this method to treat complex tibial plateau fracture as long as thecondition permits. |
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