Open Journal of Orthopedics and Rheumatology
Tibial Plateau Fractures: Therapeutic and Prognostic Aspects of Surgical Management
1Doctor, Orthopedic Surgeon-Traumatologist, Senegal
2Associate Professor, Orthopedic Surgeon-Traumatologist, Deputy Head of the Orthopedics-Traumatology Department, Dalal-Jamm National Hospital Center, Senegal
3Assistant Professor, Orthopedic Surgeon-Traumatologist, Dalal-Jamm National Hospital, Senegal
4Doctor, Orthopedic Surgeon-Traumatologist, Dalal-Jamm National Hospital, Senegal
5Full Professor, Head of the Orthopedic-Traumatology Department, Dalal-Jamm National Hospital, Senegal
Author and article information
Cite this as
Camara A, Daffe M, Dembele B, Diop M, Sow M, Sane AD. Tibial Plateau Fractures: Therapeutic and Prognostic Aspects of Surgical Management. Open J Orthop Rheumatol. 2025;10(1):026-031. Available from: 10.17352/ojor.000053
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© 2025 Camara A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Introduction
Tibial plateau fractures are breaks in the bone continuity affecting the metaphyseal-epiphyseal spongy bone at the upper end of the tibia, at least one of which divides the articular cartilage [1].
They account for 5% – 8% of lower limb fractures and 1% of fractures in adults. They are the result of high-energy trauma and are associated with soft tissue injuries in half of all cases [2], although low-energy mechanisms, such as sports injuries or falls from a standing height, can cause fractures of the proximal tibia.
These are joint injuries that present a wide spectrum of clinical manifestations and are frequently associated with long-term complications. The classification proposed by Schatzker, et al. in 1974 is the most widely used to describe injuries and guide management. However, this classification, based on conventional double-incidence X-rays, does not accurately take into account joint comminution and, in particular, posterior bone fragments. The injury mechanisms associated with these fractures are responsible for distinct injuries in all three planes of space [3].
As these fractures are intra-articular lesions, they must be treated in accordance with AO principles, which include anatomical reduction, absolutely stable fixation, repair of soft tissue lesions, and unlimited postoperative range of motion [4].
To limit morbidity and complications, lateral plating alone, instead of double plating, has been proposed as an alternative to limit soft tissue dissection and wound complications. Lateral plating alone may be an alternative for the elderly population to limit morbidity, but concerns remain regarding bone quality, fracture fixation, and secondary loss of reduction [5].
The objective of our study was to investigate the therapeutic and evolutionary aspects of surgical treatment for tibial plateau fractures.
Materials and methods
Type and duration of study
This was a prospective, single-center, descriptive study conducted over an 18-month period, from September 15, 2022, to March 15, 2024, in the Orthopedics-Traumatology Department of the CHNDJ.
Study material
Inclusion criteria: All patients aged 18 years and older who were admitted for a tibial plateau fracture, treated surgically, and followed up in the department during the study period were included in our study.
Exclusion criteria: The following were not included in this study: all patients treated orthopedically, patients who refused the treatment proposed by the department, patients lost to follow-up, and unusable records.
Study population: Our study included 32 male and female patients aged 18 years and older who met our inclusion criteria.
There were 28 men (87.5%) and 4 women (12.5%) with a sex ratio of 7. The mean age of our patients was 43.8 ± 14.2 years, with extremes of 22 and 73 years. The most affected age group was 36 to 45 years (37.5%), followed by 26 to 36 years (28.1%). The most common socio-professional groups in our series were manual workers (31.3%), followed by delivery drivers (18.8%), shopkeepers (12.5%), and teachers/Koranic teachers (12.5%). Road traffic accidents were the most frequent cause of injury, accounting for 87.5%, followed by domestic accidents, accounting for 6.3%. Most of our patients came from Guédiawaye (37.5%), Pikine (15.6%), and Keur Massar, Malika (9.4%). We found 34.4% of lateral compression associated with valgus, and mixed mechanisms in 18.7%. Direct impact accounted for 25% of mechanisms. High blood pressure was the most common personal medical history, found in 9.4% of patients. The right knee was the most affected in our series, with 65.6% of cases; and the left knee in 34.4% of cases. Closed fractures were the most common, accounting for 81.3%. Skin lacerations were observed in 18.3% of cases; type II was the most common, accounting for 50%, followed by type III and type I, accounting for 33.3% and 16.7%, respectively. All of our patients underwent standard frontal and lateral knee X-rays, followed by oblique (3/4) X-rays in all cases (100%). However, only 59.8% of patients underwent knee CT scans. In our series, Schatzker types II and VI were the most common, each accounting for 28.1%, followed by type I with 18.7%. Fractures of the proximal end of the fibula were the most common in our series, accounting for 68.4% of cases, with fractures of the femur coming in second place with 15.7% of cases.
Study materials: Our data were collected from information provided by medical records, hospitalization records, surgical report records, and a pre-established survey form.
Methods
Parameters studied: In our series, the following aspects were studied:
Therapeutic aspects: From a therapeutic standpoint, we addressed the following treatments:
Medical treatment: All our patients received analgesics, anticoagulants, and antibiotics. Patients with open fractures received tetanus prophylaxis.
Surgical treatment: The study focused on the following parameters: time to treatment, patient placement, type of anesthesia, approches, surgical technique (type of surgical treatment), post-operative care, rehabilitation, length of hospital stay, and immediate post-operative complications.
Evolving aspects
(Clinical and paraclinical): Our patients were assessed in terms of: Anatomy, Function, Complications,
Evaluation of results: Table 1 shows the parameters studied for the functional assessment of our patients according to the criteria of Merle d'Aubignée and Mazas.
Data entry and analysis
Our data were entered using Word and Excel 2016 software and analyzed using Epi Info version 7.2.2.
Results
Therapeutic aspects
Medical treatment: All our patients received medical treatment with analgesics (1 g of paracetamol for infusion + 100 mg of tramadol for injection every six hours) and anticoagulants for injection once a day subcutaneously, as well as antibiotics for injection 1 g/125 mg three times a day. Six patients with open fractures received tetanus serum and vaccine (SAT, VAT), representing 18.75%, and four (04) patients with a history of hypertension continued their antihypertensive treatment, representing 12.5%.
Time to treatment: The time to treatment was 2 to 6 days in 56.2% of our patients, less than or equal to 1 day in 18.8% of patients, and greater than or equal to 7 days in 25% of patients.
Installation: For open fractures, patients were positioned on a standard table with a cushion under the ipsilateral buttock, a tourniquet at the root of the thigh, and the ipsilateral iliac crest was prepared in advance and within the surgical field for a possible cortico-cancellous bone graft (Figure 1). For closed fractures, they were placed in the supine position with or without a tourniquet at the root of the thigh.
Image intensifier: Of the 32 patients, only 13 (40.6%) underwent surgery with the use of an image intensifier.
Anesthesia: All patients received regional anesthesia in the form of spinal anesthesia, i.e., 100%.
Approaches: We approached the fractures via the anterolateral approach in 74% of cases. The double approach was used in 13% of cases, and the medial approach was used in 13% of cases.
Type of surgical treatment: Lateral screw plate was used in 53.1% of our patients, external fixator combined with screw fixation in 15.6% of patients, external fixator alone in 12.5% of patients, double screw plate and medial screw plate combined with screw fixation in 9.4% of patients each
We correlated the types of fractures, the type of osteosynthesis, and the approach (Table 2, Figures 1,2).
According to the Schatzker classification, we recorded nine (09) type II cases, representing 28%, and two (02) type III cases, representing 6.3%, which underwent augmentation with cortical-cancellous bone grafting.
Postoperative care
Postoperatively, all patients continued treatment with analgesics, antibiotics, and anticoagulants.
Local care was provided until the sutures were removed.
After a follow-up X-ray, the knee was mobilized the day after surgery, and patients were then mobilized with the aid of a pair of canes without support.
A removable splint (Zimmer splint) protected the osteosynthesis with a screw plate for a period of up to three weeks.
Rehabilitation
Rehabilitation began the day after surgery with knee mobilization and isometric quadriceps contraction and continued with physical therapy until the fracture had healed in all of our patients.
Immediate postoperative complications
We recorded three cases of postoperative infection (75%) and one case of skin necrosis (25%).
Evolution
At a mean follow-up of 12 months, 24 of the 32 patients were evaluated.
Overall results
Anatomical: The average time to bone healing in our series was 12 weeks, ranging from 8 to 16 weeks.
According to the criteria of Merle d'Aubignée and Mazas, our overall anatomical results were very good in 29.2% of cases, good in 50% of cases, and average in 20.8% of cases. We did not record any poor anatomical results in our series (Table 3).
Functional: According to the criteria of Merle d'Aubignée and Mazas, our overall functional results were very good in 33.3%, good in 62.5%, and average in 4.2%. We did not record any poor functional results in our series (Table 4).
Complications: We recorded two (02) cases of knee stiffness, one (01) case of malunion of the lateral tibial plateau, three (03) cases of knee osteoarthritis, and three (03) cases of necrosis of the lateral tibial plateau as late complications.
Analytical results
Results according to the anatomopathological type of tibial plateau fractures and the Merle d'Aubignée and Mazas functional score.
We established a correlation between the anatomopathological types of tibial plateau fractures and the Merle d'Aubignée and Mazas functional score. We found 100% very good results in type I. We also collected one case of average results in our series (Table 5).
Results according to surgical treatment of tibial plateau fractures and complications (secondary and late)
We collected three (03) cases of proximal tibial necrosis only in surgical treatment with screw plates. However, we recorded two (02) cases of knee stiffness, one (01) case of malunion, and three (03) cases of knee osteoarthritis in surgical treatment using external fixation alone or combined with screw fixation (Table 6).
Discussion
Therapeutic aspects
The average time to treatment was 3 days in our series. This was relatively short compared to the time found in several series [6-8].
This result can be explained by the availability of implants and an experienced surgical team on the one hand, and the occurrence of skin complications such as wounds, making treatment much more urgent on the other.
In our series, the anterolateral approach was used in 74% of cases. The medial approach and the double approach each accounted for 13%.
These results corroborate those found in the literature, which show a predominance of the anterolateral approach [9-12].
In our series, this could be explained by the frequency of types I–III, which justified the indication for the anterolateral approach.
We performed 100% of the surgical treatment in our series. Zhou X, et al. [7] and JIANG W [13] also reported 100% surgical treatment in their respective series.
Lateral screw plates were used in 53.1% of our patients, external fixators combined with screws were used in 15.6% of cases, external fixators alone were used in 12.5% of cases, and double screw plates were used in 9.4% of patients.
Our results are similar to several series in the literature, which also found a predominance of lateral screw plates alone [11-12].
However, Hörmandinger C, et al. [4] performed double screw plates in 73.2% of their series.
Our results may be explained by the predominance of Schatzker types I–III, which justified the indication for lateral screw plates alone.
In our series, the average length of hospital stay was 4.6 days, with extremes ranging from 1 to 54 days. Fakoor M, et al. [14] reported an average length of stay of 5.8±9.3 days, with extremes ranging from 3 to 29 days.
Our results may be explained by complications such as surgical site infections in some patients, and the transfer of one patient to the intensive care unit before the fracture was treated following multiple trauma, on the other hand.
Evolving aspects
The average bone consolidation time in our series was 12 weeks, ranging from 8 to 16 weeks. This result is comparable to those found in several series. Biswas B, et al. [11] found the following results in their series: ORIF 14 ± 2.71 weeks MIPPO 12.49 ± 1.96 weeks.
Which were controlled by targeted antibiotic therapy after pus was collected for culture and antibiogram; 01 case of skin necrosis, or 5.3%, where a necrosectomy was performed and guided healing was achieved.
In the long term, we recorded 02 cases of knee stiffness, or 10.5%, where patients underwent knee mobilization under general anesthesia until 90° flexion and full extension were achieved. Three cases of knee osteoarthritis and three cases of proximal tibial necrosis, each representing 15.8%, and one case of lateral tibial plateau malunion (varus <10°), representing 5.3%. These latter complications did not benefit from surgical correction, but all these patients received treatment for pain and/or inflammation.
In the literature, similar cases have been reported by several authors: Mekkaoui M.J.El, et al. [15], Akhil Kumar K [16] Dingamnodji M, et al. [12].
Proximal tibial necrosis is a complication that is often found in patients who have undergone surgery for a lateral tibial plateau fracture. It can be idiopathic or iatrogenic. The latter has risk factors that are either primary (severity of the injury, aggressiveness of the surgical procedure) or secondary (age, osteoporosis, corticosteroid therapy, metabolic disease).
Sané AD, et al. [17] reported a case of lateral proximal tibial necrosis in a case study.
In our series, lateral proximal tibial necrosis could be explained by the rupture of blood vessels supplying the lateral tibial plateau following trauma and/or surgical treatment.
In addition, Sarangi G, et al. [18] reported one case of septic pseudarthrosis in their series. Sameer MM, et al. [6] recorded only two cases of medial-lateral instability as complications, which were treated with knee braces.
Our results can be explained by the presence of open fractures, three of which progressed to postoperative infection and one to skin necrosis. One patient had a femorotibial fixation with an external fixator for eight weeks. At a mean follow-up of 12 months, we evaluated 24 patients who responded to the call. Our overall functional results were very good in 33.3%, good in 62.5%, and fair in 4.2%. Our overall anatomical results were very good in 29.2%, good in 50%, and fair in 20.8%. We did not record any poor functional or anatomical results in our series.
Dingamnodji M, et al. [12] found 45.7% very good results and 42.9% good functional results. The anatomical criteria were good in 62.9%.
The absence of poor functional and anatomical results in our series may be attributed to the quality of the synthesis (anatomical reduction, solid fixation) as well as early mobilization and continued physical therapy until consolidation.
Conclusion
Tibial plateau fractures are epiphyseal-metaphyseal fractures of the proximal end of the tibia, which have been increasing steadily since the widespread use of motorized two-wheeled vehicles as a means of public transportation. They occur mainly in young males and are often the result of high-energy trauma causing complex injuries.
We conducted an 18-month prospective, single-center study from September 15, 2022, to March 15, 2024, at the Dalal Jamm National Hospital Center, involving 32 patients with an average age of 43 years who were admitted for tibial plateau fractures and treated and followed up in the department during the study period.
Males were the most affected in 87.5% of cases, and the most common circumstances of occurrence were road traffic accidents in 87.5% of cases. The right knee was the most affected in 65.6% of cases; Schatzker type II and type VI were the most common, each accounting for 28.1% of cases. Associated injuries were dominated by fractures of the head and neck of the fibula, accounting for 68.4%.
Treatment was surgical, with lateral screw fixation performed in 53.1% of cases. The anterolateral approach was the most commonly used, accounting for 74% of cases.
At a mean follow-up of 12 months, we evaluated 24 patients who responded to the call. We used the Merle d'Aubignée and Mazas functional score and anatomical criteria. Our overall anatomical results were very good and good in 79.2% of cases, and the overall functional results were very good and good in 95.8% of cases.
The functional evaluation found 10.5% knee stiffness.
The anatomical evaluation found: 15.8% knee osteoarthritis, 15.8% proximal tibial necrosis, and 5.3% malunion.
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