research lesion morphology and clinical outcomes type v and vi schatzker closed tibial plateau fractures fixed by plate

In fact, the fracture tibial plateau is not only a fragments offracture tibial plateau and extent of displaced fragments but also it is oftenaccompanied by depression fracture fragments

1 / Reason for this topics

Fractured tibia plateau is kind of lesion encountered proportion of 5 to 8%

of leg fractures Traffic accidents, labor accidents, sports accidents, accidentsactivities can cause fracture tibial plateau This type of fracture invasive joints,anatomical lesions often complex, directly affect the function of the knee Inaddition to bone damage, broken tibial plateau can incorporate many otherlesions of the knee joint, such as ligaments, bursae, meniscus, blood vessels andnerves

Some classifications are widely available, such as the classification of Hohl(1967), the Shatzker (1979), the AO-ASIF (1991) Many worldwideorthopedic and domestic surgeons use the Schatzker classification We can beseen, these classification systems are based on images of bone lesions onconventional x-ray In fact, the fracture tibial plateau is not only a fragments offracture tibial plateau and extent of displaced fragments but also it is oftenaccompanied by depression fracture fragments or more fracture complex lines,lesion images on conventional X-ray film in a number of cases not made clearand complete, the surgeon still have difficulty in choosing the method of bone

In recent years, with the support of the technical advances in the diagnosis,such as computerized tomography combined 3D renderings (3D) magneticresonance imaging, C-arm the assessment and identification exact imagedamage bones, joints, ligaments, meniscus, blood vessels, nerves as well assupport treatment interventions and reduction and fixed displaced fragmentsexactly under control by C-arm using L-shaped locking plate, helps to treatfractured tibial plateau achieved much progress to recover the maximumfunctional limb

Worldwide, the assessment and determine the significance of computerizedtomography compared with conventional X-ray in the diagnosis and treatment offractured tibial plateau have been done by many surgeons and publishedinternationally

In Vietnam, although there have been studies on the treatment of fracturedtibial plateau with the plate and screws, locking plate mechanism, externalfixator have been published many surgeons in the country [16], [20], [18] However, the comparison and evaluation of the lesions images of tibial plateaubased on conventional X-ray or computerized tomography in a systematicmanner with the number of big enough patients that is still problem manysurgeons concerned

There are many surgical methods that are applied, such as by openreduction internal fixation with plate and screws, closed or minimum openreduction of fractures and fracture fixation by external fixator frame or fixedscrews under the support of the C-arm …In general, each method hasadvantages and disadvantages However, according to some surgeons there ismore than 10% of fracture tibial plateau patients with surgical treatment has not

achieved the recovery anatomical morphology and of course, as well as therehabilitation function of joints failed.

From this fact, we have done a thesis with entitled " Research lesion morphology and clinical outcomes type V and VI Schatzker closed tibial plateau fractures fixed by plate "

2 / The objective of the thesis

- Survey morphology, degree lesions of fracture tibial plateau oncomputerized tomography and assessment of accuracy conventional X-raycompared with computerized tomography scans according to the Schatzkerclassification of fracture tibial plateau - Evaluation of clinical outcomes type Vand VI Schatzker closed tibial plateau fractures fixed by plate when combinedwith imaginal roles computerized tomography before surgery

3 / The significance of the thesis

- Contains scientific and practical for both paraclinical research and clinicalpractice Applications in paraclinical studies for the treatment of type complexfracture tibial plateau

- The thesis has significant news because so far, worldwidely, the treatment

of fracture tibial plateau is still a big challenge for the medicinal profession InVietnam, this thesis contributes to improving the understanding ofmorphological lesions and experienced fracture tibial plateau treatment

4 / Structure of the thesis

The thesis consists of 128 pages, including sections: Introduction (2 pages);Overview (33 pages); Subjects and research methods (21 pages); Researchresults (33 pages); Discuss (37 pages); Conclusion (2 pages) and the appendix

In the thesis has 34 tables, 49 pictures and three medical reports illustrations.References documentary: 121, including 21 Vietnamese and 100 documents inEnglish

Chapter 1:OVERVIEW 1.1 A NATOMICAL CHARACTERISTIC OF BONY TIBIAL PLATEAU AND KNEE JOINT

1.1.1 Anatomy and bone structure tibial plateau

Angle of medial tibial plateau about 87 ± 2 - 5 °, tilt angle of about 9 ± 5 °

1.1.2 Outline of the anatomy in the knee region

Joint area include: medial femur condyle and medial tibial plateau; lateralfemur condyle and lateral tibial plateau; joint area between the posterior patellaand femur condyle

Ligaments, synovial bursae system:

Ligaments: Ligament system of front, posterior, colateral ligaments andcruciate ligaments systems

1.1.3 Popliteal region: includes triangle thigh and tibia

Filling ingredients in the popliteal: arteries, veins and nerves

1.1.4 Motion function of knee

Range of motion of the knee: flexion: 135 - 140º, extension: 0º

1.2 Cause, mechanism, and morphology of fracture tibial plateau

The leading cause of fractured tibial plateau which is concerned by manysurgeons is traffic accident, followed by accidents at work, sport accidents, etc

1.2.2 Mechanism fractured tibial plateau

- Power down from femoral condyle to tibial plateau

- Tibial plateau impact on hard objects directly

1.2.3 Morphological of fractured tibial plateau

Classification of morphological fracture of Hohl (1967) include: 6 types Morphological fracture of Schatzker classification (1979), including 6 type:

Type I: fracture lateral tibial plateau wedge-shape.

Type II: fracture lateral tibial plateau combined with subsided tibial plateau Type III: fractured subsided tibia in the middle of lateral tibial plateau Type IV: fracture medial tibial plateau

Type V: fractured both tibial plateau with continuity of tibial plateau and the

diaphysis

Type VI: fractured both tibial plateau combined with incontinuity of tibialplateau and the diaphysis

AO-ASIF classification (1991) 3 types: type A, B, C

Classification of Honkonen S E (1992) divided into 7 categories

1.3 Roles computerized tomography and magnetic resonance imagine

1.3.1 Role of computerized tomography

In 1987, Dias JJ has studied 16 cases of fracture tibial plateau with 3 type

of imagines: X-ray, tomography X-ray in two dimensions and computerizedtomography He discovered some fracture bony walls on computerizedtomography but undetectable on conventional X-ray

In 2000, acorrding to Wicky S et al, fracture is appreciated correctly ondiagnosis based on conventional X-ray films were 18/42 patients (43%)

In 2001, Hackl W et al suggest that up to 40% change classification typebacause conventional X-ray no detectable fracture line

2002, Yacoubian SV 52 comparative diagnostic between conventional ray and computerized tomography see that the change in diagnosis was 6%

X-In 2004, Macarini L has concluded 3D re-create morphology was veryuseful in sorting fracture tibial plateau and preoperative evaluation

In 2009, Higgins T F et al studied the morphology of posterior fragments

in medial tibial plateau on computerized tomography: appearance ratio offragments is 59%, the average height is 4.2mm, fragment and fracture surfacearea of the medial tibial plateau 25% respectively

1.4 Treatment of fracture tibial plateau

1.4.1 Cast treatment

Böhler L, representative for the classic groups, often treat fractures tibialplateau by cast

1.4.2 Surgical treatment

Methods of open reduction internal fixation

In 1939, Landelius used fixed wires to fix in surgical tibial plateau firstly

1973, Rasmussen has treated 204 cases fractured tibial plateau The result:very good: 60%; good: 27%; pretty: 8%; bad 5%

In 1979, Schatzker assessed 10 cases tibial fracture type V, VI by surgery.Acceptable results were: 8 cases, not acceptable: 2 cases

In 1983, Blokker C P analysis of results of surgical treatment openreduction fixation under AO principles of fracture 14 cases of tibial plateaufracture The authors found that preoperative subsided articular surface < 5mmhad the better results with cases that subsided before surgery > 5 mm

In 1992, Benirschke S K retrospective study of 14 patients with fracturedtibial plateau Schatzker types V, VI and open fracture type II and III according

to the Gustilo grading were treated surgical fixation Results infection rate is1%, 10 patients had excellent results, 2 patients with gratifying results, 2patients had poor results

In 1994, Georgiadis GM treated for a 4 patients with fracture tibial plateaucontained two fragments in the posterior wall As a result, the bones healed inplace correctly, all patients have range of motion: Extension/Flexion: 0° - 5° /0/120° - 145°

In 2004, Barei D P reported using two incision Results showed deepinfection 8.4%, 3.6% septic arthritis, 1 patient did not heal of bone

In 2006, Barei DP treated bony fixation with two plate and two incision of

51 cases of fracture tibial plateau Results: 90% to be satisfied with the angle ofmedial tibial plateau is 87± 5 ° 68% achieved angle of tilt posterior is 9 ± 5 °

In 1999, Pham Thanh Xuan [21] evaluated the results of surgical treatment

of plate and screws for 41 cases fractured tibial plateau from type I to type VIaccording to the Schatzker classification Results: 85.5% excellent and good,bad and average of 14.5% Schatzker types V, VI cases had average and badresults

In 2010, Thai Tuan evaluate treatment outcomes of 25 patients with closedfractures tibial plateau Schatzker type V, VI fixed by plate and screws:excellent and good results was 84%, 16% average and bad.

In 2011, Vu Nhat Dinh assess treatment outcomes for 32 patients withfractured tibial plateau type V, VI according to Schatzker classification, weretreated with the plate and screws Results: 3 patients infected surface, varus orvalgus: 6 patients Range of motion of the knee: > 125 ° (22 patients), from 100-124° (3 patients), and from 90 - 99° (1 patient)

In 2012, Nguyen Van Luong reported the initially results of 16 patients,who were closed fractured tibia plateau from type 1 to type 6, were fixation bylocking-plate Results: 15 patients with excellent and good, average 0 patientand bad 1 patient

Chapter 2: SUBJECTS AND METHODS 2.1 RESEARCH SUBJECTS

126 cases of trauma to the knee with fractured tibial plateau

2.1.1 Criteria for patient selection

Patient selection criteria for one researched target

- There are enough conventional X-rays imagine and CT-Scanner for everytibial plateau

Patient selection criteria for two researched target

- Closed fractured tibia plateau types V, VI Schatzker with age >= 16 are fixedwith plate and screw

- There are enough conventional X-rays imagines pre and post-operation

- There are enough CT-Scanners pre-operation

- No injury skin around the knee

- If the patients have combined diseases, were examined and concluded to allowoperation

- There are no contraindications for anaesthesia

2.1.2 Exclusion criteria from the study group

- The absence of a conventional Xrays imagine or CT-Scanners

- The pathological fractured tibial plateau

- There are a available deformities at the fractured tibia limb, injury sequelaeaffecting function of the limb

- Patients with systemic disease is contraindicated with operation

- The case of the combined with tored ACL and PCL no reconstruction withfixed tibial plateau at the same time

2.2 METHODOLOGY OF RESEARCH:

Retrospective and prospective research, cross-sectional descriptive uncontrolled

2.2.1 Selection of sample size:

Accoding to calculate, to complete the one and two researched target requiredsample size included 119 patients with fractured tibial plateau

2.2.2 General Information

- Personal characteristics of the research subjects

- Distribution of age, gender, cause

- Take conventional X-rays by digital machine, take CT-Scanner the distalfemur and tibial plateau

2.2.3 Research morphological lesions on conventional Xrays and Scanner:

CT-* Research morphological lesions tibial plateau include: fractured lateral

tibial plaeau(Schatzker I, II, III), fractured medial tibial plaeau (Schatzker IV)and fractured both of tibial plaeau (Schatzker V, VI) with the characteristiclesions as following: fractured morphology, degree of subsidence, subsidenceareas, number of fractured fragments and assessing the accuracy of conventionalXrays versus CT-Scanner according to the Schatzker classification

2.2.4 Results of treatment

2.2.5 Some of techniques and evaluation criteria

2.2.5.1 Process of taken CT-Scanner the knee

2.2.5.2 Measure degree of subsidence on conventional Xrays imagine

- Method of Lansinger O, Dias J J Method

2.2.5.3 Method of measurement angle of tibial plateau

2.2.5.4 Assess lesions of soft tissue

- According Tscherne H, there are 4 degrees

2.2.5.5 Evaluation of knee degeneration

- By the standards of Tscherne H

2.2.6 Surgical Procedures

Prepare patients

Spinal anesthesia

2.2.7 Assessment results

2.2.7.1 Evaluation results of morphological research

- Fractured location, fractured lines, degree of subsidence (millimetre),subsidence areas (anterior, center, posterior) and the relationship between the ,degree of subsidence and subsidence areas by Kappa coefficient

- Evaluate the accuracy of conventional Xrays versus CT-Scanner aboutdegree of subsidence, number of fractured fragments, subsidence areas, diagnoseusing Kappa coefficient

2.2.7.2 Evaluation of results

Close results: according to the standard of Larson-Bostman include:

- Very good: no displaced fractures, straight axis, healing incision immediately

- Good: Angle of the fractures toward lateral or anterior <5°, toward posterior

or medial <10°, short limb < 10mm Healing incision immediately

- Average: Angle of the fractures toward lateral or anterior >5°, toward posterior

or medial >10°, short limb > 10mm Surface infections at the incision

- Less: Angle of the fractures like average standard but there is displacedrotation Deep infected incision, bone infections, fistula of pus

The results far: ≥ 12 months postoperatively.

By the function standards of Rasmussen: Very Good: 27 - 30 points; Good:

20 - 26 points; Average: 10 - 19 points; Poor: <10 points

By the Xrays standards of Rasmussen: Very good: 18 points; Good: 12 - 16points; Average: 6 - 12 points; Poor < 6 points

2.2.8 Analysis and data processing:

Data entry and obtained by the Excel software, analysis data by software R(R Core Team 2013)

Chapter 3: STUDY RESULTS 3.1 INJURY MORPHOLOGY

3.1.1 Study group characteristics:

Study results: 41 patients with lateral tibial plateau fractures (mean age: 36.7 ±12.4 yo) 10 patients with medial tibial plateau fractures (mean age: 34.5 ± 15.5), 75 patients with bicondylar tibial plateau fractures (mean age: 39.7 ± 13.1 ).Right knee: 54 cases, Left knee: 72 cases Type Schatzker V, VI have highestmean age There is no difference of age between groups p = 0.035

- Main causes of injuries are Moto vehicle accidents 89.7 %

3.1.1 Lateral tibial plateau fracture characteristics:(type Schatzker 1, 2, 3)

Split fractures: 37 cases Pure depression fractures: 4 cases

Table 3.3: Comparison of fragment amounts between XRAY CT scan

Fragment amounts XRAY (n = 41) CT scan (n = 41)

Table 3.4 comparison of depression level between XRAY and CT scan

Depression sites Cases (n)

3.1.3 Medial tibial plateau fracture characteristics (Schatzker 4)

Split fractures: 10 cases

Table 3.6: Comparison of fragment amounts between XRAY CT scan

Table 3.7: Medial tibial plateau depression level

- Difficult to identify fracture depression on XRAY

Table 3.8: Correlation between fracture depression levels and sites on CT scan

3.1.4.2 Lateral tibial plateau fractures type Schatzker V, VI

Table 3.9: Lateral tibial plateau fracture fragments on CT SCAN

Type fractures

Fragment amounts

Type V (n = 47)

Table 3.10: Fracture fragment detection at the posterior wall of LTP

Fragment

amounts

Type V(n = 47)

Type VI(n = 28)

Combined( n = 75)

Type V( n = 47)

Type VI( n = 28)

combined( n = 75)0

fragment

44(93%)

28(100%)

72(96%)

30(63.8%)

8(28.6%)

38(50.7%)1

fragment

3(6.4%)

00.0%

3(4.0%)

16(34%)

20(71.4%)

36(48.0%)2

fragments

1(2.1%)

0(0.0%)

1(1.3%)analysis Fisher = 1, d.f = 1, p = 0.289 Fisher = 1, d.f = 1, p = 0.01Fractures at the posterior wall of LTP of both type V and VI are 49.3%

Table 3.11: LTP depression level comparison on Xray and CT scan.

2.3 ± 3.4(mm)

3.7 ± 3.9(mm)

5.6 ± 3.3(mm)

4.4 ± 3.8(mm)analysis F = 5.72, d.f = 1.73, P = 0.019 F = 7, d.f = 1.73, p = 0.01Mean depression level between type V and VI are different, p = 0.01

Table 3.12: depression sites of latera tibial plateau

Depression

site

Type V(n = 47)

Type VI(n = 28)

combined(n = 75)

Type V(n = 47)

Type VI(n = 28)

Combine(n = 75)

(6.4%)

1(3.6%)

4(5.3%)

7(14.9%)

2(7.1%)

9(12.0%)

(2.1%)

0(0.%)

1(1.3%)

13(27.7%)

8(28.6%)

21(28.0%)

(0.%)

1(3.6%)

1(1.3%)

8(17.0%)

11(39.3%)

19(25.3%)Whole plateau 1

(2.1%)

8(28.6%)

9(12%)

2(4.3%)

5(17.9%)

7(9.3%)

no depression 42

(89.4%)

18(64.2%)

60(80%)

17(36.2%)

2(7.1%)

19(25.4%)analysis Fisher = 1, d.f = 1, p < 0.001 Fisher = 1, d.f = 1, p = 0.002depression sites of LTP: central and posterior are 53.3%

3.1.4.3 MTP injuries type V and VI

Table 3.13: fragment amounts on CT scan (n = 75)

Table 3.14: Fragments in posterior wall fractures of MTP

Fragment

amounts

Type V (n = 47)

Type V I (n = 28)

Combined ( n = 75)

Type V ( n = 47)

TypeVI ( n = 28)

Combined ( n = 75)

0

fragment

41 (87.2%) (96.4%)27 (90.7%)68 (48.9%)23 (64.3%)18 (54.7%)41

1

fragments

6 (12.8%) (3.6%)1 (9.3%)7 (51.1%)24 (35.7%)10 (45.3%)34

Annalysis Fisher = 1, d.f = 1, p = 0.246 Chi-squar =1.67, d.f=1, p=0.197

Fragments in posterior wall fractures of MTP type V, VI are 45.3%

Table 3.15: Depression level of MTP

Depression

level(mm)

TypeV

0.9 ± 2.2(mm)

0.9 ± 2.5(mm)

1.9 ±3.8(mm)

2.0 ± 3.2(mm)

2.0 ± 3.6(mm)

- MTP depression level comparison on Xray and CT scan With K = 0,54

Table 3.16: MTP depression site comparison

Depression

sites

Type V(n = 47)

Type VI(n = 28)

Combined(n = 75)

Type V(n = 47)

Type VI(n = 28)

Combined(n=75)

(2.1%)

1(3.6%)

2(2.7%)

2(4.3%)

0(0.0%)

2(2.7%)

(6.4%)

1(3.6%)

4(5.3%)

6(12.8%)

6(21.4%)

12(16.0%)

(0.0%)

0(0.0%)

0(0.0%)

4(8.5%)

3(10.7%)

7(9.3%)

(2.1%)

3(10.7%)

4(5.3%)

3(6.4%)

1(3.6%)

4(5.3%)No

depression

42(89.4%)

23(82.1%)

65(86.6%)

32(68.1%)

18(64.2%)

50(66.7%)

Annalysis Fisher = 1, d.f = 1, p <=0.001 Fisher = 1, d.f = 1, p = 0.001

- In comparrison with CT SCAN, XRAY cannot detect depression less than20%

3.1.4.4 Tibial spine injuries

- ACL avulsion is 6.66% (5/75 cases), PCL is 1.33 % (1/75 cases)

3.1 5 Reliability of Schatzker classification

Table 3.17: Schatzker classification of tibial plateau fractures.