Treatment of complex tibial plateau fractures with improved three combined approaches

Objective To evaluate the outcomes of open reduction and internal fixation of complex tibial plateau frac-tures with improved three combined approaches. Methods In the period from July 2014 to February 2016, 7 complex tibial pla-teau fractures underwent surgical treatment. These patients included 5 male and 2 female, aged from 24 to 68 years old (average, 39.7±15.3 years). According to Schatzker classification, they were all of type V. And all of type 41B-3.1 by AO/OTA classification. All these fractures were exposed and reduction via three combined approaches. First let the patients lied in lateral prone position, expose the anterolateral and the posterolateral of the tibial plateau, and fix the fractures of the posterior in the posterolateral ap-proach, then fix the fractures of the lateral in the anterolateral approach. Then turn the patients to supine position, fix the fractures of the medial in the anteromedial incision. All patients received regular reexamination. The knee function was evaluated at the fi-nal follow-up using The Hospital for Special Surgery (HSS) score, the activity of the knee was evaluated by Lysholm score, and the stability of the knee was checked by Lachmantest and Pivot-shift test. The tibial plateau angle, the posterior slope angle and Ras-mussen X-ray score were assessed on the X-ray films. Results The average time of operation is (3.3±0.9) h, and the hemorrhage volume in operation was (341±106) ml for the 7 patients. The wounds of 6 patients healed by (11.8±1.3) days, while the wound of the rest one of them occurred fat liquefaction after operation who is very fat (BMI>30) and suffered from diabetes. His wound healed by 21 days. These patients obtained follow-ups of 8 to 14 months (average, 11.4±2.8 months). The average full weight-bear-ing time was 2-3 months (average, 2.5±0.4 months). The fractures healed after 8 to 16 weeks (average, 11.1±2.8 weeks). No dis-placement of the fractures or breakage of the implants occurred in our series. Nobody has activity limitation of the knee or pain be-cause of the implant, and no never symptoms were noted postoperatively, so we would not take out the implant for these patients. The mean HSS score was 93.1±4.8 (range, from 85 to 100) at the final follow-up, and the excellent rate is 100%. The Lysholm score was 97.1±3.6 (range, from 90 to 100) at the final follow-up. The Lachman test and the Pivot-shift test were negative in our pa-tients, and the mean knee flexion was 128.6±12.8°(range, from 105°to 140°). The fractures were all anatomical reduction by the X-ray after operation, and there had being no displacement of the fractures or breakage of the implants occurred during the follow-up period. The mean posterior slope angle was 8.29±2.87° (range, from 4 °to 12°), which was 8.71±2.63° (range, from 5 °to 14°) 6 months after operation. The mean tibial plateau angle was 86.00±1.41° (range, from 84 °to 88°), which was 86.43±1.62° (range, from 84 °to 89°) 6 months after operation. The mean Rasmussen X-ray score was 16.86±1.57 (range, from 14 to 18), which was 16.57±1.51 (range, from 14 to 18) 6 months after operation, and the excellent rate are 100%. Conclusion For the complex tibial plateau fractures which simultaneous involved the medial, the lateral and the posterior, the improved three combined approaches showed the advantages of the convenient operation, the satisfactory results of reduction and fixation, and the less trauma and sec-ondary damage, and could be worth for clinic. Key words: Tibial fractures; Knee joint; Fracture fixation, internal