Open Journal of Orthopedics, 2013, 3, 208-212
http://dx.doi.org/10.4236/ojo.2013.34038 Published Online August 2013 (http://www.scirp.org/journal/ojo)
Copyright © 2013 SciRes. OJO
Treatment of Complex Proximal Tibial Fractures (Types
V & VI of Schautzker Classification) by Double Plate
Fixation with Single Anterior Incision
Ebrahim Ghayem Hassankhani*, Farzad Omidi Kashani, Golnaz Ghayem Hassankhani
Orthopedic and Spine Surgery, Imam Reza Hospital, Mashad University of Medical Sciences, Mashad, Iran.
Email: *hasankhanie@mums.ac.ir, *eghasankhani@yahoo.com
Received June 1st, 2013; revised July 1st, 2013; accepted July 14th, 2013
Copyright © 2013 Ebrahim Ghayem Hassankhani et al. This is an open access article distributed under the Creative Commons At-
tribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is prop-
erly cited.
ABSTRACT
Background: complex proximal tibial fractures (Types V & VI of Schautzker classification) are the major problems in
orthopedic surgery and associated with high complication rates. There are many alternatives in treatment of these frac-
tures. Aim: to evaluate the results of double plating with single anterior incision in complex proximal tibial fractures
(Types V & VI of Schautzker classification). Methods and Materials: 22 patients (16 males and 6 females) with Types
V and VI of Schautzker classification of proximal tibial fractures (14 cases were Type V and 8 cases were Type VI)
were treated by double plating with single anterior incision method between May 2006 and May 2011. The bony and
functional outcome was evaluated according to Knee Society Score. Results: According to Knee Society Score, the re-
sults were as follows: excellent in 19 patients (86.4%), good in 2 patients (9.1%), fair in 1 patient (4/5%), and poor in
no patient (0%). Conclusion: the double plate fixation with single anterior incision is the best, effective and simple
procedure in treatment of complex proximal tibial fractures (Types V and VI of Schautzker classification).
Keywords: Proximal Tibial Fractures; Types V & VI of Schautzker Classification; Double Plate Fixation; Single
Anterior Incision
1. Background
Complex proximal tibial fractures (Types V & VI of
Schautzker classification) are the major problems in or-
thopedic surgery and associated with high complication
rates. These fractures include bicondylar injuries with
significant articular depression; multiple, displaced con-
dylar fracture lines; metadiaphyseal fracture extension
and comminution; and open wounds or extensive, closed
injuries [1-3]. Both the complexity and the soft-tissue
disruption of this subgroup of fractures contribute to the
high rate of unsatisfactory results which follow bo th non-
surgical and surgical management [4,5].
The goals of operative treatment of these fractures in-
clude anatomic reduction for restoration of articular con-
gruity and alignment, and stable fixation to allow early
motion.
Dual plating is preferred to other techniques in the set-
ting of a significantly displaced fracture of the articular
surface, especially in cases with significantly depressed
fragments [6,7].
This technique, when performed through a single,
midline extensile or double incision with wide stripping
of the proximal tibia, has been associated with deep in-
fection, wound dehiscence, and soft tissue complications
in 23% to 100% of patien ts [8-11].
The two most common complications of double plat-
ing with two or single incision are; th e co mpro mised skin
and soft tissue envelope, which invites a high rate of
complications following attempted open reduction and
internal fixation, and poor bone quality and comminuted
fracture patterns creating difficulty in achieving stable
fixation [3,7,9-11].
The purpose of th is study was to evaluate the resu lts of
double plating with single anterior midline incision in
complex proximal tibial fractures (Types V & VI of
Schautzker classification) and compare this rate to other
series in the literature.
*Corresponding a uthor.
Treatment of Complex Proximal Tibial Fractures (Types V & VI of
Schautzker Classification) by Double Plate Fixation with Single Anterior Incision
Copyright © 2013 SciRes. OJO
209
2. Methods and Materials
22 patients (16 males and 6 females) with Complex
proximal tibial fractures were treated by double plating
with single anterior midline incision between May 2006
and May 2011.
The fractures were classified using the Schautzker
classification, and open fractures were classified accord-
ing to the method of Gustilo and coworkers. 14 cases
were Type V and 8 cases were Type VI of Schautzker
classification. 5 patients had open fracture (3 cases were
Type I and 2 cases were Type II of Gustilo classifica-
tion). There were 16 males and 6 females with a mean
age of 35 years (19 to 67).
5 patients suffered from additional injury (limb frac-
tures, head, chest or abdomin a l injury).
20 patients were treated by one stage surgery and 2 pa-
tients were treated by two stage surgery (debridement
and then plate fixation) due to open Type II Gustilo frac-
ture.
All patients had anterior-posterior (AP) and lateral ra-
diographs as well as CT scans to identify each of the bi-
condylar fractures.
Definitive fixation by double plating with single ante-
rior midline incision technique was performed after the
soft tissue injury had improved. The time from injury to
definitive fixation varied widely (range: 2 to 15 days) as
a result of variable degree of soft tissue compromise
noted at initial presentation.
Closed fractures were treated with single anterior mid-
line incision and double plate fixation.
Open fractures were managed by two stage surgery
initially with irrigation and debridement and then by fix-
ation.
The technique for fixation was as follow: With an an-
terior midline incision the proximal tibial fractures were
exposed. A transverse submeniscal arthrotomy was per-
formed to expose the articular surface at both sides. De-
pressed fragments were elevated and then supported with
bone graft. L or T buttress or proximal metaphysial LCP
plates were applied once anatomic reduction had been
achieved. Plain radiographs were taken in the operating
room to verify adequate articular reduction and plate's
placement (Figures 1 and 2).
After surgery, the leg was supported and elevated with
a posterior above-knee splint until soft tissue swelling
resolved. Knee motion was started on the 3rd day with a
CPM machine.
The patients were discharged with a posterior splint
and were seen in an out-patient department after 15
days until the stitches and the posterior splint were
removed. They were maintained on non-weight-bear-
ing ambulation for 3 months. Serial radiographic ex-
amination of the knee and the tibia in AP and lateral
Figure 1. A 32-years-old man with Type V of Schautzker
tibial platu fracture in motorcycle accident.
Figure 2. After surgical treatment by double plate fixation
with single anterior incision te chnique .
planes was performed at 6 weeks, 3 months, 6 months,
and 1 year post-operatively for follow-up of the frac-
ture healing.
In 8 patients autologous bone graft was needed at the
time of surgery due to bone loss after elevation of de-
pressed fragments. The bony and functional outcome was
evaluated according to Knee Society Score.
3. Results (Table 1)
In all 22 patients the fracture had un ion with the average
time up to 15 weeks (range12 - 23). None of the patients
developed joint infection. 2 patients had superficial in-
fection, which was suppressed with daily care and anti-
biotics.
None of the patients developed a varus or valgus de-
formity and leg-length discrepancy. None of the patients
underwent a second operative procedure.
One patient had deep venous thrombosis (DVT) that
required admission to the intensive care unit and antico-
agulation therapy. 2 patients had significant pain requir-
ing analgesics.
2 patients had noticeable limping. 16 patients achieved
ability to perform previous activities of daily living
(ADL) and returned to th eir previou s work, 4 p atient s got
ability to perform previous activities of daily living
(ADL) and previous work with minimal difficulty, and 2
Treatment of Complex Proximal Tibial Fractures (Types V & VI of
Schautzker Classification) by Double Plate Fixation with Single Anterior Incision
Copyright © 2013 SciRes. OJO
210
Table 1. Clinical data of 22 patients with complex proximal
tibial fractures (Types V & VI of Schautzker classification)
treated by double plate fixation with single anterior inci-
sion.
Data Number of patients
Type of fracture (Schautzker)
Type VI 8
Type V 14
Sex
Female 6
Male 16
Side of fracture
Left 12
Right 8
Left & Right 2
Complications
Infection 2
Residual deformity 0
Shortening > 2/5 cm 0
Returned to previous work 20
Changed work 2
Unable work 0
Significant pain 2
Noticeable limp 2
Loss of knee motion > 15D 3
patients had significantly limited activities of daily liv ing
(ADL) and required a change from previous work.
According to Knee Society Score, the results were as
follows: excellent in 19 patients (86.4%), good in 2 pa-
tients (9.1%), fair in 1 patient (4/5%), and poor in no
patient (0%) (Table 2).
4. Discussion
The most common difficulties are faced by the surgeon
while dealing with intra-articular proximal tibial frac-
tures are the compromised skin and soft tissue envelope,
which invites a high rate of complications following at-
tempted open reduction and internal fixation, and poor
bone quality and comminuted fracture patterns creating
difficulty in achieving stable fixation [3,7,9-12].
Treatment options include non-operative treatment
using traction, casts or braces, hybrid, ring, or uniplanar
external fixation; fixed angle implants utilizing percuta-
Table 2. The results of 22 patients with complex proximal
tibial fractures (Types V & VI of Schautzker classification)
treated by double plate fixation with single anterior incision
according to Knee Society Score.
Results
Grade Number of patients percent
Excellent 19 86.4
Good 2 9.1
Fair 1 4/5
Poor 0 0
Total 22 100
neous exposure and reduction; dual plating with one or
two incision, arthroscopically assisted fixation and mi-
nimal percutaneous pinning, lateral plating and medial
fixator, and minimally invasive techniques (LISS sys-
tem ) [1,2,5,11,13-17].
Regardless of treatment technique the reported com-
plications include: wound breakdown; deep infection,
deep vein thrombosis; compartment syndrome; non-un-
ion; myositis ossifican; peroneal palsies; hardware fail-
ure; and arthrofibrosis [7,18-20].
Non-operative treatment using traction, casts or braces
has been reported to produce poor functional results,
have prolonged hospital stays and complicated by the
loss of redu ct ion [1 2].
Arthroscopically assisted fixation and minimal percu-
taneous pinning have also been reported to give good
results but these modalities are suitable for simple split
depression and local compression fr actures [17,21].
Open double plate fixation has been reported to be as-
sociated with the complication of wound dehiscence and
infection [10,22,23].
Hybrid fixation systems have not good functional an d
bony results, and give increased risk of pin tract infection
and prolonged courses of treatment [23-28].
Some studies have reported that open lateral plating
and medial fixator in complex bicondylar fractures of the
tibia give good functional results minimizing soft tissue
complications [13].
Currently, minimally invasive techniques (LISS sys-
tem) are used commonly by orthopaedic surgeons, and
there have been reports of good results in tibia plateau
fractures being treated exclusively by this technique.
This system minimizes the surgical complications by
decreasing the soft-tissue stripping, to provide a rigid
fracture reduction and to respect the post-traumatic soft-
tissue injury [15,29,30].
To minimize the surgical complication especially in-
fection, staged treatment is necessary in open complex
Treatment of Complex Proximal Tibial Fractures (Types V & VI of
Schautzker Classification) by Double Plate Fixation with Single Anterior Incision
Copyright © 2013 SciRes. OJO
211
proximal tibial fractures [31]. In this study 2 patients
with open Type II Gustilo fractures were treated by two
stage surgery (debridement and then plate fixation).
Anatomical knee joint reduction, the relative stability
and alignment of the proximal tibia allowing the earliest
knee mobilization, while keeping complications to a mi-
nimum rate, are the major goals in the treatment of com-
plex proximal tibial fractures [27,32].
In order to obtain stability of bicondylar and complex
proximal tibial fractures, reduction and fixation of both
medial and lateral columns is necessary. Dual plating
successfully gives a good stability by buttressing both
columns; but high rate of complications associated with
this open techniqu e is reported [10,11].
Steven N., et al. reported wound dehiscence and infec-
tion in proximal tibial fractures treated with double plate
fixation [33]. In our study superficial infection was ob-
served in 2 cases and no sof t tissue breakdown was noted.
We also had good functional and bony results.
In this study, our results demonstrate a lower risk for
deep infection and soft tissue complications, good func-
tional and bony results in complex proximal tibial frac-
tures when compared to earlier reports about other tech-
niques.
5. Conclusion
The double plate fixation with single anterior incision is
the best, effective and simple procedure in treatment of
complex proximal tibial fractures (Types V and VI of
Schautzker classification) with lower risk for deep infec-
tion and good results when compared to other reported
techniques.
6. Acknowledgements
The authors thank orthopaedic research center group for
their assistance.
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