Plating tibial plateau fractures

Modificeret af Frank Damborg.

Baseret på AO foredrag af

Cong-Feng Luo, CN

AOT Advanced Principles Course

Principles for soft-tissue management

• Wait for the soft tissue!!

• Staged treatment if ORIF of tibial plateau

fracture

Principles for definitive fixation

• Fully understand the fracture,

especially the 3-D construct

• Anatomically restore the

articular surface—no structural

articular defect

• Stable fixation to maintain the

alignment

Understand the fracture

• AO Classification

• Schatzker classification

• CT / 3-D construct

3-Column-concept. Luo CF, Sun H, Zhang B, et al. Three-column fixation for complex tibial plateau fractures. J Orthop Trauma. 2010 Nov;24(11):683-92.

3-Column classification

• Column fracture—breakage of

corresponding cortex

(compression/tension fracture)

• Localize the articular surface

depression

• Pure depression of articular

surface (Schatzker type III)—

“zero column fracture”

3-Column-concept.

Morphology and injury mechanism

Varus +

extension Valgus +

extension

Flexion

Principles for approach selection

• Biomechanics of fixation

• Depressed articular

fragment

• Soft-tissue tolerance

Principle for plate fixation

• Buttress fixation is preferred for

column fractures

• Main buttress plate is chosen

according to the injury

mechanism

• Bridging is used for comminuted

metaphyseal fractures

Lateral column fracture Valgus extension mechanism

L

Posterior column fracture

M

Flexion

mechanism

Depression

Depression

Proximal

Medial column fracture

Extension varus mechanism

2 column fractures

• Understanding the fracture is essential for decision making and definitive fixation

• If not too comminuted combination ORIF surgery with 2 plates and 2 approaches are possible

Bone graft

• Often needed for

articular defect

• Grafting technique

can reduce the

amount of bone graft

• Bone substitute can

be considered

Comminuted 2 and 3-

Column fracture

medial

posterior

Varus

flexion

mechanism

The result of ORIF for this type of injury is not satisfactory Papagelopoulos PJ, Partsinevelos AA, Themistocleous GS et al. Complications after tibia plateau fracture surgery. Injury. 2006 Jun;37(6):475–484.

Epub 2005 Aug 22. Review

Take-home messages

• Fully understanding the fracture is essential for decision making and definitive fixation

• Approach selection and fixation should take into account the soft tissue, mechanism of injury, and 3-D morphology

• 3-column classification provides a way of planning the treatment of tibial plateau fractures

• ORIF and EX-fix supplements each other

Supplerende slides:

If ORIF surgery for 2 or 3 collum fx:

Approach: midline + posteriomedial

Midline

approach

Posteriomedial approach

Fracture window

1-year

follow up

Dual plating

Schatzker type V, VI—2 or 3-column fracture

3-Column fracture

Flexion varus mechanism

Floating position

A

P