Introduction

The tibial plateau is amongst the most important weight bearing region of human body. Intra-articular fractures of the proximal end of tibia are serious complex injuries and difficult to treat. Proximal tibial fractures account for 1.2% of all fractures in adults [1]. Such injuries generally result due to high energy trauma, majority due to road traffic accidents and the rest are sports related or fall from height. As per the Schatzker classification Bicondylar Fracture fall under type V and VI [2].

Surgical fixation of bicondylar tibial plateau fracture is complicated because of metaphyseal and articular comminution and the frequent occurrence of associated soft tissue injuries. Treatment goals include, restoration of articular congruity and alignment in the lower extremity and preservation of soft tissues and achieving functional range of knee motion. To achieve these goals open reduction and internal fixation is mandatory. For open reduction and internal fixation of bicondylar tibial plateau fractures, several methods can be used like unilateral fixation with single plate, dual plating or bicolumnar plating, hybrid external fixator or a less invasive stablisation system(LISS).

Dual plating via two incision technique has received recent support because it allows for direct visualization of the articular reduction while minimizing the need for stripping off the soft tissue in the fracture area. With multitude of surgical procedures available, there still remains ambiguity regarding the ideal approach for bicondylar tibial plateau fractures. The aim of this study is to evaluate the functional outcome of dual plating via two incisions for bicondylar tibial plateau fractures.

Material and methods

A prospective analytical cohort study was undertaken in the Department of Orthopaedics, Hamidia Hospital, Bhopal. Twenty-eight patients aged between 18-65 years who presented with Schatzker type V or VI tibial plateau fractures during the period July 2014 to July 2016 were enrolled in the study.All patients were treated with dual plating - lateral plate through an anterolateral approach and a medial plate through an posteromedial approach. Patient with compound fracture, pathological fracture and with polytrauma were excluded from the study.

Patients were given initial Splintagein the form of above knee slabor calcaneal skeletal traction along with limb elevation for soft tissue swelling to subside. After taking patient’s consent, patient was posted for elective surgery under spinal anaesthesia. Institutional Antibiotic protocol was followed, all patients were operated under tourniquet. The medial column was fixed first through posteromedial approach followed by lateral column by anterolateral approach. Non-weight bearing mobilisation and quadriceps exercises were started on first post-operative day.Partial weight bearing was started after 6 weeks till fracture union. Thereafter, full weight bearing was started. Patients were followed up at regular interval with clinical and radiological assessment.

The most common associated injury in our series was ipsilateral fibula fracture. None of the patients had common peroneal nerve palsy in our study. Using Rasmussen’s functional criteria, 58% of the patients had excellent, 42% had good and none had poor or fair outcome. All had satisfactory results. The mean Rasmussen score was 26.57 at 16 weeks follow up. Partenheimer A, et al had an average score of 26.7 [5].

Chang wug oh et al reported similar good results with dual plating in 23 patients with unstable proximal tibia fractures [6]. Schatzker et al obtained 78% and 58% acceptable results in those operatively and non-operatively respectively [2]. Thus similar to other studies on dual plating our study also reported better Functional outcomes with bicolumnar plating. Union was achieved in all cases. The average time of union was 14.6 weeks. All the patients had union within 18 weeks.

George C. et al found the average union time in their study to be 14.3 weeks [7]. Cole, Peter A et al in their study of tibial plateau fixation using locking compression plate reported the average time of union to be 12.6 weeks with range of 6 to 21 weeks [8]. Time to union in our study was comparable to most other studies done on different modalities of surgical treatment.

In our study, Patients with associated fibular fracture had shorter time to union and better functional score as compared to patients who had intact fibula. Sarmiento et al found that fractures of both the condyle did not collapse further or angulate, when the proximal fibula was fractured and displaced. However medial condyle usually collapses creating varus deformity when the fibula is intact [9].

Soft tissue complications are a major concern in the treatment of bicondylar tibial plateau fractures with dual plates and have been reported to be as high as 23% to 100% with dual plates through a single incision [10,11].With advances in surgical technique, the deep infection rate has been reported to have reduced to 4.7% with dual plates through 2 incisions[12].

To minimize soft tissue stripping, small wire external fixators were explored for the treatment of tibial plateau fractures. Deep infection and osteomyelitis remain a significant problem, with rates between 7% and 13% [13].In our study, no patient had deep infection. There was 1 patient with superficial wound infection (3.5%) which responded to antibiotic treatment. Partenheimer A et al had 5.6% rate of superficial infections and 1.5% deep infections [5].

The infection rate in the current study was lower than previous reports. Gentle handling of the soft tissues with a non-traumatic technique allowed the compromised soft tissue to heal and helped reduce soft tissue complications and infection rate. 1 of our patients(3.5%) had hardware prominence where the plates or screws were prominent on medial side. Phisitkul P. et al also found hardware prominence with rates corresponding to our study [14]. The mean range of motion in our study was from 0-109⁰ at 16weeks follow up. 2 (7%) patients developed knee stiffness similar results were reported by Yercan et al[15].