The clinical feature and treatment strategy of tibial plateau fractures sustained with hyperextension varus

Abstract

Objective To explore the clinical features and treatment strategies of tibial plateau fractures sustained with hyperextension varus. Methods Data of 11 patients of tibial plateau fractures with hyperextension varus treated from January 2008 to November 2017 were retrospectively analyzed. There were 7 males and 4 females with an average age of 41.2 years old (range, 25-67 years). Injuries were caused by falling down in 7 cases, traffic accident in 3 cases, and falling from height in 1 case, respectively. On the basis of Luo's three columns classification in tibial plateau, there were 9 cases of medial column fracture and 2 cases of medial combined with posterior column fracture. Six cases were concomitant with fibular head fracture and 2 cases with the injury of common peroneal nerve. Preoperative magnetic resonance imaging showed that there were anterior cruciate ligament injury in 3 cases, posterior cruciate ligament injury in 4 cases, medial meniscus injury in 5 cases, lateral meniscus injury in 3 cases, medial collateral ligament injury in 6 cases, iliotibial band injury in 2 cases and posterolateral complex injury of the knee joint in 9 cases, respectively. All tibial plateau fractures were treated firstly by open reduction and internal fixation via medial approach of the knee. The medial meniscuses and collateral ligaments were explored, in which of them there were 2 medial meniscuses with the marginal tear been sutured simultaneously. Then the knee joints which were still unstable after the examination of stable tests in 6 cases with posterolateral complex injuries were repaired surgically via lateral approach. Fibular head fractures were fixed with anchor nails or cannulated screws in 6 cases. The ruptured posterior cruciate ligaments in 2 cases were reconstructed with autologous tendon transplantation under endoscopy. Results All the patients were followed up for an average period of 16.2 months (range, 12-22 months). All fractures were healed in 10-20 weeks with an average time of 16.5 weeks. The range of extension of the affected knee joint in all patients was 0° and the average flexion was 135° (range, 120°-145°) one year after surgery. The average flexion of affected knee in 4 cases which were only treated with the tibial plateau fracture without the mild ligament injuries was 137° (range, 132°-145°) and the average flexion of affected knee in 7 cases who were treated with tibial plateau fracture and severe posterolateral complex included posterior cruciate ligaments completely broken with reconstruction was 132° (range, 120°-140°). According to Rasmussen radiographic evaluation, the average score of all patients was 16.3 (range, 14 to 18) and clinical outcomes were rated with excellent in 10 cases and good in 1. The excellent and good rate was 100% (11/11). The mean of the hospital for special surgery (HSS) score was 86.7 (range, 79-96) and the functional scores were excellent in 9 cases, good in 2 cases thus the excellent and good rate was 100% (11/11). Both varus stress test 30° and dial test were positive in one case considered for the ligament laxity postoperatively who didn’t accept further treatment and the stabilization tests were negative in the other 10 cases. There were no intraoperative complications in all patients such as neurovascular injury. No incision infection, failure of the implants and fracture nonunion occurred postoperatively. Traumatic arthritis of the affected knee occurred one year after surgery in 1 case who had no obvious pain after treated with oral medicine. Conclusion The hyperextension varus injuries of the knee are rare clinically. The posterolateral complex should be evaluated thoroughly for this injury pattern. If it's necessary, the posterolateral structures must be repaired surgically after the tibial plateau fractures are fixed. Key words: Tibial fractures; Ligaments; Fracture fixation, internal