Reoperation strategy of malunited tibial plateau fracture

Abstract

Objective To explore the revision strategy of the malunited tibial plateau fracture and to analysis the main points of four common revision operations and the clinical effect. Methods From January 2012 to December 2016, 18 patients (5 males and 13 females) aged 35-60 years (average 49.7 years) underwent tibial plateau revision surgery in our hospital were collected. The time from the second revision operation to the first operation was 2-24 months (average 10.4 months). Our revision strategies were as follows: Firstly, to determine whether there is an infection or not. If there was infection, we changed the original internal fixation to external fixator to control infection. Secondly, todetermine whether the patient could suffer re-reduction and internal fixation. If the patient was older (>65 years old) or with severe local bone defect, total knee arthroplasty should be performed. Thirdly, patients were divided into four operation modes according to the tibial plateau fracture malunion type: 1. the original fracture line osteotomy; 2. the tibial tubercle + original fracture line osteotomy; 3. tibial metaphyseal window-rod reduction; 4. the osteotomy of fibula head and original fracture line osteotomy. Results All patients were followed up for 12-30 months (average 16.8 months), and the operation time was 120-300 min (average 185 min). 2 cases were infected before operation and the original internal fixation were removed to instead of external fixator;1 patient underwent total knee arthroplasty; 3 cases were treated with metaphyseal open window-rod reduction and internal fixation; 6 cases were operated with the original fracture line osteotomy and internal fixation; 4 cases were treated with tibial tubercle osteotomy+original fracture line osteotomy and internal fixation; 2 patients underwent fibular head osteotomy+ original fracture line osteotomy and internal fixation. All patients achieved bony union at the last follow-up. The healing time was 3-6 months (mean 3.6 months). The postoperative knee Rasmussen score was 19-29 (average 22.9), compared with average 14.4 points before operation (t=-10.169, P=0.001). The postoperative range of motion of knee joint was 60-110 degrees (mean 94.5 degrees), compared with average 55 degrees before operation (t=-5.773, P=0.001). The post-operative VAS pain score was average 1.1 points, compared with average 4.2 points before operation (t=8.960, P=0.001). Fracture reduction was excellent in 12 cases and good in 5 cases, with the excellent and good rate of 100%. 3 patients still had 2mm collapse on the articular surface, while 3 patients still had mild valgus (less than 5 degrees). There were 2 cases of superficial infection of the wound surface after operation. Conclusion It was difficult to revise the malunion of tibial plateau fracture and it was necessary to make a detailed operation plan before the operation. Satisfactory clinical effects could be obtained for the patients by correct revision strategy. The key to success was the proper revision strategy which was adopted according to the different characteristics of the tibial plateau fracture malunion of the patients. Key words: Tibial fracture; Intra-articular fractures; Osteotomy; Joint deformities, acquired; Reoperation