Early neurovascular monitoring and staged total solution surgical treatment of tibial plateau frac-ture-dislocation

Abstract

Objective To evaluate early neurovascular monitoring and staged total solution surgical treatment of tibial plateau fracture-dislocation including sub-acute fracture and ligament repair/reconstruction. Methods Seventy-eight patients (81 knees) with tibial plateau fracture-dislocation accepted surgical treatment between July 2010 and June 2014. They were 53 males and 25 females, 19 to 51 years of age (average, 37.8 years). According to Schatzker classification, there were 16 cases (16 knees) of type Ⅱ, and 31 ones (31 knees) of type Ⅳ, 6 ones (6 knees) of type Ⅴ and 4 ones (4 knees) of type Ⅵ. There were 21 impaction fractures with rim avulsion (24 knees) which could not be categorized by Schatzker classification. All the patients were treated according to the damage control-based management algorithm. Early neurovas-cular monitoring was conducted. Open reduction and internal fixation of the fracture and ligament repair/re-construction were performed after the conditions of blood vessels and soft tissue were stabilized. The stability and range of motion of the knee joint were assessed postoperatively. Results Of this series, 71 patients (74 knees) were followed up for an average of 40.2 months (from 24 to 71 months). Of the fractures of Schatzker type Ⅱ, Schatzker type Ⅳ, Schatzker types Ⅴ, Schatzker types Ⅵ and impaction fractures with rim avulsion, respectively, the common peroneal nerve injury and popliteal artery injury occurred in 15.4% (2/13), 17.2% (5/29), 60.0% (3/5) , 66.7% (2/3) and 45.8% (11/24) while the ligament injury occurred in 46.2% (6/13), 20.7% (6/29), 60.0% (3/5) , 66.7% (2/3) and 83.3% (20/24). The post-operative KT-1000 measurement of mean side-to-side difference of anterior drawer laxity at 30 degrees was 1.6 mm. By TELOS stress radiological measurement, the average side-to-side difference of posterior drawer laxity at 90 degrees was 2.3 mm; the valgus was 0.8 mm at 0 degree and 1.5 mm at 30 degrees; the varus at 0 degree was 1.2 mm and 2.2 mm at 30 degrees. The post-operative Lysholm scores averaged 85.1 points (from 72 to 95 points); the Tegner scores averaged 6.5 points (from 4 to 8 points). 91.5% (65/71) of the patients returned to their pre-injury level of activity or one Tegner grade lower. There were no extension restriction and the mean flexion loss was 15.5 degrees. Conclusions Early evaluation of neurovascular condition should be emphasized in management of tibial plateau fracture-dislocation to preserve the limb. Once the conditions of vessels and local soft tissue are stable, total solution including open reduction and internal fixation of the facture and ligament repair/reconstruction in one surgery should be considered to shorten the rehabilitation period. Usually, the posteromedial complex injury should be repaired and the posterior cruciate ligament and the posterolateral complex should be reconstructed by all means. Key words: Tibial fractures; Knee joint; Fracture fixation, internal; Bone plates