Introduction

When treating intra-articular fractures such as Tibial Plateau fractures, the goal is to obtain a stable joint permitting early range of motion for cartilage nourishment and preservation [1]. Various treatment modalities have been used over the years, with mixed results. These include traction or closed treatment with cast bracing. Surgical procedures including circular frames [1], percutaneous screw fixation, open reduction/internal fixation (ORIF) and arthroplasty have also been advocated.

More recent techniques such as the use of fixed angle devices, arthroscopically-assisted reduction and the use of novel grafting methods to address articular depression, constantly gain popularity amongst orthopaedic surgeons. Post-traumatic osteoarthritis occurs after traumatic injury to the joint, most commonly following injuries that disrupt the articular surface, or injuries that lead to joint instability [2].

The clinical observation that the presence of residual incongruity at the time of fracture healing could lead to joint stiffness and long-term morbidity [3] has established the restoration of articular congruity as the key principle on the management of these injuries.[4]

Despite anatomical joint reconstruction, development of osteoarthritis may still occur secondary to the initial articular cartilage and meniscal injury [5,6]. In young patients this could be detrimental as it can lead to total knee replacement at an early age.

In addition, these fractures may have significant socio-economic influence. In order to assess the effect of these injuries on functional outcome and development of OA, we started a prospective study in 2007 and reviewed its mid-term results of tibial plateau fractures treated in our institution.

Materials and Methods

From May 2007 to May 2017, 267 adult patients with tibial plateau fractures underwent surgical treatment at our center. 27 patients were lost to follow-up and were excluded from the final analysis. Thus, 240 patients (174 males, 66 females, mean age 48 [range 21–69 years) form the basis of this report. Out of 240 patients 31 patients were treated with Percutaneous cancellous screw fixation method, 21with ORIF with cancellous screws, 98 with ORIF with buttress plate, 90 with Locking compression plate.

Results

Average time for union was 12 weeks (9-20 weeks) We had no case of non-union in our series.Mean duration of follow up was 8.4 years (6.2-9.7 years). 67 patients under went fixation with bone grafting after elevation of articular depression.

Table 1: Type of fracture

Table 2: Age In year

Table 3: Amount of Articular Depression

Table 4: Frequency of method of treatment

Table 5 : Rasmussen Clinical Assessment at final follow-up

Table 6 : Rasmussen Radiological Assessment at final follow-up

Discussion

The management of tibial plateau fractures is a challenging task for the surgeon, as they are often associated with a number of complications [7]. It has been well documented that instability due to articular incongruity predisposes to uneven loading and early Osteoarthritis [1,8]. It is not surprising therefore that minimally displaced tibial plateau fractures had the best results when open or closed methods of reduction were used, followed by early range of knee motion.

Rademakers and colleagues evaluated 109 patients with tibia plateau fractures who had an average follow-up period of 14 years to determine the long-term functional outcome of operatively treated tibia plateau fractures [9]. The authors also reported complications, one of which was secondary osteoarthritis. They reported a 5% incidence of secondary osteoarthritis that necessitated reconstructive surgery (total knee arthroplasty, realignment osteotomy, knee arthrodesis).

our study consisted of 240 patients (174 males & 66 females). Mean age was 48 years (21-69 years). Mean duration of follow up was 8.4 years (6.2-9.7 years). Out of 240 patients 31 patients were treated with Percutaneous cancellous screw fixation

method, 21with ORIF with cancellous screws, 98 with ORIF with buttress plate & 90 with ORIF with Locking compression plate. 67 patients under went fixation with bone grafting after elevation of articular depression. 182 patients (76%) had right sided tibial plateau fracture whereas 58 patients (24%) had left side affected. Average time for union was 12 weeks (9-20 weeks).

In our study Rasmussen clinical scoring system showed excellent results in around 34% (82) of the patients, 53% (127) had good,9% (22) fair and 4% (9) poor results. Out of 240 patients 78 (32.5%) developed OA knee (including Kellgren and Lawrence grade 1) which is a significant number of patients.

36% of patients treated with Cannulated Cancellous Screw developed OA knee, 35.7% of patients treated with buttress plate developed OA knee and 26.6% of patients treated with Locking compression plate developed OA knee. This difference may be due to superiority of LCP in maintaining reduction till osteosynthesis because of its angular locking capability.

With increase in schatzker type & amount of articular depression the number of patients developing Osteo arthritis increased, schatzker Type I 16 % vs schatzker Type VI 54% and no articular depression 9.5% vs > 5mm articular depression 46 %.