Periarticular fractures of proximal tibia called as tibial plateau fractures. Fractures pattern in the proximal tibia are dictated by the forces applied combined with the osseous anatomy of proximal tibia [1].

Tibial plateau fracture consists of 1.2% of all fractures and 8% of the all fractures in elderly [2,3]. Majority of these fractures occur in males (86.7%) and on right side (73.3%). These fractures involve the medial condyle in 10-23%, lateral condyle in 55-70% or both condyles in 11-30% of patients [4].

The classification of tibial plateau fractures organize these fractures according to their essence; namely, age of the patient, bone quality, the morphologic architecture of the fracture and the energy of the trauma. These classification can be descriptive, morphologic, diagnostic or prognostic and guide the surgeon to formulate the line of treatment. A number of systems are used to classify the tibial plateau fractures; however Schatzker, AO/ASIF and Sun and Luo classification are most useful and widely used.

Incidence of fracture of tibial plateau is increasing secondary to high velocity trauma due to road traffic accident or fall from height especially in our set up of hilly terrain. A number of patients with tibial plateau fracture are frequently presenting to the Department of Orthopaedic Surgery, Indira Gandhi Medical College, Shimla. These patients are being managed by different methods of treatment specific for the type of fracture. Keeping in view increased incidence of these fractures, controversies of management and high incidence of complications; it is worthwhile to analyze the Socio-demographic characteristics, Classifications and Clinical Parameters among patients of proximal tibial fractures treated with open reduction internal fixation with proximal tibial locking compression plate.

Aims and Objectives

To evaluate the Socio-demographic characteristics, Classifications and Clinical Parameters among patients of proximal tibial fractures treated with open reduction internal fixation with proximal tibial locking compression plate.

This study was carried out in the Department of Orthopaedic Surgery, Indira Gandhi Medical College, Shimla between August 2019 to October 2020 after taking clearance from hospital ethics committee. The study included operatively treated 25 patients of tibial plateau fracture out of which 21 were prospective who were operated between 1^st August 2019 to 31^st October 2020 and 4 were retrospective operated between 1^st January 2018 to July 2019.

Inclusion Criteria

• Patients above 18 years of age

• Patients with closed tibial plateau fractures 

• Tibial plateau fractures treated by proximal tibial locking compression plate

Exclusion Criteria

• Children having proximal tibia fracture with open growth plate

• Tibial plateau fractures treated by method other than proximal tibia locking compression plate

• Open fractures of tibial plateau

• Patient with pathological fractures of proximal tibia

All the tibial plateau fractures patient coming to Casualty Department of our hospital were assessed for skin condition, neurovascular status, associated injuries and general condition. A detailed history and thorough examination was taken in these cases. The tibial plateau fractures were classified as per antomical site, Schatzker's classification, AO/OTA classification and Sun and Luo CT based three column classification. All the patients of tibial plateau fractures who were treated by open reduction internal fixation with proximal tibia locking compression plate were included in the study.

These patients were investigated for the fitness for surgery and anaesthesia. Investigations included complete hemogram, erythrocyte sedimentation rate, random blood sugar/ fasting blood sugar, renal function test, liver function tests, electrolytes, chest x-ray (PA view) and electrocardiogram.

All these patients were planned for surgery at the earliest possible depending on skin condition and other associated medical comorbidities. Detailed preoperative counselling regarding anaesthesia, surgery, its complications and probable final outcome were explained to the patients and their attendants. Consent of the patient and his/her first degree relative was taken prior to the surgery.

In operation theatre patient was given subarachnoid block or general anesthesia as per anaesthetist decision. After anesthesia; patients were given supine or prone position as decided in preoperative planning. Part was thoroughly cleaned and draped with saline, betadine and spirit and painted with betadine. Draping of the leg and ipsilateral iliac crest was done separately for harvesting bone graft if needed. Pneumatic tourniquet was applied and inflated after elevation for 4-5 minutes. Standard anterolateral, anteromedial, posteromedial or direct posterior approaches were used depending on the type of fracture.

All the patients were followed up at regular interval of 6-8 weeks till complete fracture union occurred clinically and radiologically. During every follow up; clinical, functional and radiological evaluation was done. Clinically patients were observed for subjective complaints, wound healing and fracture site tenderness, range of motion of knee joint and functional results. Clinically satisfactory results implied no pain or occasionally mild pain, at least 90° of flexion, with lack of extension less than 10° and were able to pursue full activities with no interference in work.

For retrospective patients records were obtained from Medical Record Department of Indira Gandhi Medical College, Shimla. Record of all the patients was scrutinized and those patients who fulfilled the inclusion criteria were included in the study. These patients were called for follow up and their clinic-radiological details were recorded. Their clinical, radiological and functional results were assessed like that of prospective cases.

Statistical Analysis

The collected data was entered into Microsoft excel spreadsheet, cleaned for errors and analyzed using the latest version of Statistical Package for Social Sciences software (SPSS). Qualitative variables were presented as frequencies and their percentages. Quantitative variables were described as means and their standard deviations. Data were collected and subjected to Student’s t tests, single factor ANOVA, Fischer’s exact test and Pearson correlation analysis. Spearmen’s test was used to evaluate the correlation between continuous variables. Chi-square/Fischer exact test were used for analysis of associations between different variables. Odds ratio for associations was calculated along with their 95% confidence interval. A p-value of <0.05 was considered as statistically significant.

The present study was aimed to evaluate the Socio-demographic characteristics, Classifications and Clinical Parameters among patients of proximal tibial fractures treated with open reduction internal fixation with proximal tibial locking compression plate. A total of 25 (21 prospective and 4 retrospective) patients were included in this study.

Sixty percent of the patients were between 31-60 years of age. Eighty four percent were males and remaining 16% patients were females with male to female ratio was 5.3:1. Mean age of males was 39.6±12.4 years and of females was 57.7±16.7 years with overall mean age of 42.5±14.4 years (Table 1).

Table 1: Distribution of Patients on the Basis of Age and Sex

Majority of patients were either farmers (36%) or were doing private job (36%).The most common mode of  injury for tibial plateau fractures was fall from height which was observed in 72% patients. Remaining 28% of the patients were injured due to road traffic accident. Majority (68%) of the patients had fracture on left side while in 32% patients, right side was affected. Eighty four percent patients had no associated injuries and only 16% had associated fracture of ipsilateral/contralateral extremities or had vertebral fracture (Table 2).

Table 2: Distribution of Patients on the Basis of Occupation, Mode of Injury, Side Injured and Associated Injury

Forty eight percent patients had Schatzker type 2 followed by Schatzker type 5 fracture in 24% patients. Type 3 and type 6 were least common. As per AO/OTA classification, majority (68%) of the fracture were type 41B3.Single column was involved in 44%. Involvement of two and three column was observed in 28% patients each (Table 3).

Table 3: Distribution of Patients on the Basis of Schatzker Type, AO/OTA Type and Sun and Luo Classification

Twenty four percent of the patients were operated within 24 hour of the injury and 92% within a week after sustaining injury. Only 2 (8%) patients were operated after 7 days; one patient presented late to the hospital as he was being managed conservatively in above knee cast by local private hospital and other patient was known case of coronary artery disease and was on antiplatelet therapy. The average interval between injury and surgery was 4.68±5.44 days. In majority (76%) of the patients anterolateral approach was used. Double incision approach i.e., anterolateral with posteromedial or direct posterior approach was required in 16% patients. Single incision anteromedial or posteromedial approach was used in 4% patients each. Bone grafting of lateral condylar void was done in 4 (16%) patients.

The mean duration of stay after surgery was 10.7±11.5 days. Sixty six percent patients were discharged within 7 days after surgery. Other patients had prolonged stay due to polytrauma, other associated fractures and wound complications. Four (16%) patients had other bony injury for which patients were also operated and had prolonged stay and one (4%) patient had wound related complications. Three (12%) patients were discharged on 14^th day after suture removal. In 84% patients, time of union was between 13 to 16 weeks. Mean time of union in our study was 14.2±1.4 weeks ranging from 9 weeks to 16 weeks (Table 4).

Table 4: Distribution of Patients on the Basis of Interval Between Injury and Surgery, Surgical Approach, Duration of Stay after Surgery and Time of Union

Mean union time increased with increasing severity of fracture as per all classification system, however it was not statistically significant in AO/OTA and Sun and Luo system. Overall mean union time of union for all patients was 14.2±1.4 weeks (Table 5).

Table 5: Mean Union Time According to Type of Fracture

The tibial plateau fractures are usually caused by high energy trauma and more commonly occur in young middle aged population. In 2013 study by Vasanand et al. [5] on surgical management of tibial plateau fractures found maximum patients were in age group 41-50 years with mean age of 41 years. Schütz et al. [6] in their study on treatment of tibial plateau fracture observed the mean age of 42 years. We observed that majority (32%) of our patients were between 41-50 years of age with mean age of 42.5 years. Predominance of these fractures in young and middle age population corresponds to the majority of the studies in literature.

Tibial plateau fractures are commonly seen in active and productive age group especially in males. Incidence of males was reported to be 80% by Girisha et al. [7] in 2017, 90% by Vasanand et al. [5] in 2013 and 75% by Wu et al. [8] in 2015 in their studies of tibial plateau fractures. We also observed male prepondrence in our study as 84% of our patients were males that corresponds to majority of the studies in literature. The main reason for male predominance in our study was due to more involvement of male in outdoor activities as they are the main earning members of family.

Occupationally, tibial plateau fractures are seen in people with high level of activity, movement and travel. Dasaraiah et al. [9], in their study on evaluation of surgical management of tibial plateau fractures found high incidence (53.4%) of these fractures in occupations associated with increased mobility like businessmen and employees. In our study, these fractures were most commonly seen in farmers (36%), private job (36%) and government employees (8%). Most of the population lives in rural area and depends on local farming or they have to travel to far off places in search of employment for their livelihood.

High velocity accidents and fall from height are the major modes of trauma responsible for tibial plateau fractures. Study conducted by Egol et al. [10] on staged management of high energy proximal tibia fractures found that majority of the patient had fracture due to fall from height followed by road side accident. In our study commonest mode of trauma was fall from height. Difficult hilly terrain and tough geographical area of our study population may be responsible for these falls as most of these patients have to work in these difficult areas.

Dasaraiah et al. [9] conducted a study of surgical management of tibial plateau fractures and observed that majority of the patients sustained injury on the left side. Study by Prasad et al. [11] also observed left side was involved in 63.4% of patients. We also observed left side predominance in our study as 68% patients had fracture on left side.

Schatzker classification with six principle types is one of the most utilised classification system for tibial plateau fractures. Study done by Hohl et al. [12] reported lateral condyle fractures in 50 to 70% and bicondylar involvement seen in 10-30%. Rasmussen reported 70% of the injuries affecting lateral condyle. In our study majority (48%) of fractures were found to be of Schatzker type 2 involving the lateral condyle and 32% cases were type 5 and type 6 involving both the condyles. Incidence of bicondylar fractures was towards the higher side in our study because high energy trauma due to falls is common in hilly areas.

The Orthopaedic Trauma Association and the AO Foundation published a unified classification system. Study by Elsoe et al. [13], on the population based epidemiology of tibial plateau fractures; reported that most common type of fracture was AO type 41B3 and the second most common was 41C3. In our study as per AO/OTA classification majority of fractures were type 41B3 (68%) followed by 41C3 (12%) which corresponds to various epidemiological studies on tibial plateau fractures.

Three column fixation is a new concept useful in treating complex tibial plateau fractures especially useful in injuries involving the posterior column. Single column was involved in 44% cases and involvement of two and three column was observed in 28% patients each.

Gavhale et al. [14] conducted a study on tibial plateau fractures treated with locking compression plate and found that 36% patients had other bony injuries. We observed in our study that 16 percent of the patients had assosciated injury which is well within range reported in literature. Associated injuries along with tibial plateau fractures have affected the final results due to prolonged immobilisation and delay in postoperative rehabilitation.

Moradya et al. [15] in study of tibial plateau fractures treated with locking tibial plate observed that most (81%) of patients were operated within 1 week of injury with average time of 4 days between injury and surgery. Study conducted by Kumar et al. [16], on management of proximal tibia fractures using posteromedial locking compression plate found that 86.6% of the patients were operated within 1 week of injury. In our study 92% of patients were operated within 7 days of injury and the average interval between injury and surgery was 4.6 days. 24% of our patients were operated within 24 hours of injury. Only 2(8%) patients were operated after 7 days as one (4%) presented late to the hospital and other one had some fitness issues.

Union time of tibial plateau fractures depend on the complexity of fracture and quality of reduction. Most of the authors had reported the union time between 12 and 17 weeks in their studies. Chen et al. [17], in a study on posterior tibial plateau fractures observed the average union time of 12 weeks. Sethiya et al. [18] conducted a study on management of proximal tibia fractures by locking compression plate and observed that most (83.4%) of the fractures were united by 12-15 weeks. In our study 80% of the fractures were united between 13-16 weeks and had mean time of union was 14.2 weeks.

Majority of patients were young and in active age group, males farmers or private job workers by occupation, had Involvement of left extremity, had fall as a Mode of injury, had associated skeletal injuries, operated within 7 days of injury and were discharged within 7 days after surgery. According to Schatzker classification-type II and type V were most common type. Partial articular (41B3) and 41C3 (complete articular) were the most common AO/OTA type. Majority of the patient had single column involvement according to Sun and Luo classification.

Limitation

The limitation of our study was less number of cases, short follow up periods and patients were operated by different senior surgeons.

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