Advertisement

Biomechanical analysis of dual versus lateral locked plating in elderly bicondylar tibial plateau fractures: Does medial comminution matter?

      Abstract

      Objective

      To assess dual plating versus lateral locked plate fixation of bicondylar tibial plateau fractures in an elderly cadaveric model with and without medial bone loss

      Participants

      10 pairs of elderly (range 78–93 years of age) fresh frozen tibias.

      Intervention

      Bicondylar tibial plateau fractures were created reproducing AO/OTA 41 C1 (without medial bone loss) and C2 fractures (with medial bone loss). Cadavers were randomized to 4 different groups. Groups 1 and 2 were 41 C1 fractures and fixated with either dual or lateral plating, respectively. Groups 3 and 4 were fixated in a similar fashion with medial metaphyseal bone loss (41 C2 fracture) with dual plating Group 3 and lateral plating group 4. Lateral plating consisted of a 3.5 mm 5-hole lateral plate (ALPS, ZimmerBiomet) with 6 bicortical locking screws proximally and two diaphyseal screws. Dual plating groups underwent lateral plating and additional 3.5 mm 5-hole posteromedial 1/3 tubular plate (ZimmerBiomet) placed at the apex of the fracture with two shaft screws and one unicortical screw proximally. Specimens were tested in a Mechanical Testing System (MTS) machine loading both condyles.

      Outcome measurements

      Specimens were loaded to 300 N and coronal alignment obtained. Specimens were then cycled from 100 N to 700 N for 5000 cycles at 2 Hz. Average axial displacement, maximal displacement, average force and coronal alignment after 5000 cycles were recorded. Lastly, force to failure was recorded at 100 N/sec.

      Results

      Mean axial displacement was 4.21 mm ranging from 3.12 mm in group 1 to 5.92 mm in group 4 (P = 0.51). Failure force averaged 3340 N ranging from 4342 N in group 1 to 2433 N in group 4 (P = 0.36). Maximal displacement ranged from 3.69 mm in group 1 to 7.37 mm in group 4 (P = 0.21). Change in coronal alignment ranged from 0.98° in group 1 to 1.97° in group 4 (P = 0.45). No statistically significant difference was noted between all four groups for all data points.

      Conclusion

      The results of this study demonstrate that a lateral locked plate may offer an alternative means of fixation in AO/OTA 41 C1 and C2 fractures.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Ali A.M.
        • El-Shafie M.
        • Willett K.M.
        Failure of fixation of tibial plateau fractures.
        J Orthop Trauma. 2002; 16: 323-329
        • Ali A.M.
        • Burton M.
        • Hashmi M.
        • Saleh M.
        Treatment of displaced bicondylar tibial plateau fractures (OTA-41C2&3) in patients older than 60 years of age.
        J Orthop Trauma. 2003; 17: 346-352
        • Barei D.P.
        • Nork S.E.
        • Mills W.J.
        • Henley M.B.
        • Benirschke S.K.
        Complications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision technique.
        J Orthop Trauma. 2004; 18: 649-657
        • Barei D.P.
        • Nork S.E.
        • Mills W.J.
        • Coles C.P.
        • Henley M.B.
        • et al.
        Functional outcomes of severe bicondylar tibial plateau fractures treated with dual incisions and medial and lateral plates.
        J Bone and Joint Surg Am. 2006; 88-A: 1713-1721
        • Barei D.P.
        • O'Mara T.J.
        • Taistman L.A.
        • Dunbar R.P.
        • Nork S.E.
        Frequency and fracture morphology of the posteromedial fragment in bicondylar tibial plateau fracture patterns.
        J Orthop Trauma. 2008; 22: 176-182
        • Biyani A.
        • Reddy N.S.
        • Chaudhury J.
        • Simison A.J.M.
        • Klenerman
        The results of surgical management of displaced tibial plateau fractures in the elderly.
        Injury. 1995; 26: 291-297
        • Chang H.
        • Zhu Y.
        • Zheng Z.
        • Chen W.
        • Zhao S.
        • Zhang Y.
        Meta-analysis shows that highly comminuted bicondylar tibial plateau fractures treated by single lateral locking plate give similar outcomes as dual fixation.
        International Orthop. 2016; 40: 2129-2141
        • Dougherty P.J.
        • Kim D.G.
        • Meisterling S.
        • Wybo C.
        • Yeni Y.
        Biomechanical comparison of bicortical versus unicortical screw placement of proximal tibia locking plates: a cadaveric model.
        J Orthop Trauma. 2008; 22: 399-403
        • Egol K.A.
        • Su E.
        • Tejwani N.C.
        • Sims S.H.
        • Kummer F.J.
        • Koval K.J.
        Treatment of complex tibial plateau fractures using the less invasive stabilization system plate: clinical experience and a laboratory comparison with double plating.
        J Trauma. 2004; 57: 340-346
        • Egol K.A.
        • Tejwani N.C.
        • Capla E.L.
        • Wolinsky P.L.
        • Koval K.J.
        Staged management of high-energy proximal tibia fractures (OTA types 41): the results of a prospective, standardized protocol.
        J Orthop Trauma. 2005; 19: 448-455
        • Ehlinger M.
        • Rahme M.
        • Moor B.K.
        • DiMarco A.
        • Brinkert D.
        • et al.
        Reliability of locked plating in tibial plateau fractures with a medial component.
        Orthop Trauma Surg Res. 2012; 98: 173-179
        • Gaunder C.L.
        • Zhao Z.
        • Henderson C.
        • McKinney B.R.
        • Stahel P.F.
        • Zelle B.A.
        Wound complications after open reduction and internal fixation of tibial plateau fractures in the elderly: a multicentre study.
        International Orthop. 2019; 43: 461-465
        • Gausden E.
        • Garner M.R.
        • Fabricant P.D.
        • Warner S.J.
        • Shaffer A.D.
        • Lorich D.G.
        Do clinical outcomes correlate with bone density after open reduction and internal fixation of tibial plateau fractures.
        Arch Orthop Trauma Surg. 2017; 137: 755-760
        • Gosling T.
        • Schandelmaier P.
        • Marti A.
        • Hufner T.
        • Partenheimer A.
        • Krettek C.
        Less invasive stabilization of complex tibial plateau fractures: a biomechanical evaluation of a unilateral locked screw plate and double plating.
        J Orthop Trauma. 2004; 18: 546-551
        • Gosling T.
        • Schandelmaier P.
        • Muller M.
        • Hankemeier S.
        • Wagner M.
        • et al.
        Single lateral locked screw plating of bicondylar tibial plateau fractures.
        Clin Orthop Rel Res. 2006; 439: 207-214
        • Higgins T.F.
        • Klatt J.
        • Bachus KN.
        Biomechanical analysis of bicondylar tibial plateau fixation: how does lateral locking plate fixation compare to dual plate fixation?.
        J Orthop Trauma. 2007; 21: 301-306
        • Higgins T.F.
        • Kemper D.
        • Klatt J.
        Incidence and morphology of the posteromedial fragment in bicondylar tibial plateau fractures.
        J Orthop Trauma. 2009; 23: 45-51
        • Horwitz D.S.
        • Bachus K.N.
        • Peters C.L.
        A biomechanical analysis of internal fixation of complex tibial plateau fractures.
        J Orthop Trauma. 1999; 13: 545-549
        • Kim C.W.
        • Lee C.R.
        • An K.C.
        • Gwak H.C.
        • Kim J.H.
        • et al.
        Predictors of reduction loss of tibial plateau fracture surgery: focusing on posterior coronal fractures.
        Injury. 2016; 47: 1483-1487
        • Krappinger D.
        • Struve P.
        • Smekal V.
        • Huber B.
        Severely comminuted bicondylar tibial plateau fractures in geriatric patients: a report of 2 cases treated with open reduction and postoperative external fixation.
        J Orthop Trauma. 2008; 22: 652-657
        • Karunakar M.A.
        • Egol K.A.
        • Peindl R.
        • Harrow M.E.
        • Bosse M.J.
        • Kellam J.F.
        Split depression tibial plateau fractures: a biomechanical study.
        J Orthop Trauma. 2002; 16: 172-177
        • Lee M.H.
        • Hsu C.J.
        • Lin K.C.
        • Renn J.H.
        Comparison of outcome of unilateral locking plate and dual plating in the treatment of bicondylar tibial plateau fractures.
        J Orthop Surg Res. 2014; 9: 62
        • Lee T.C.
        • Huang H.T.
        • Lin Y.C.
        • Chen C.H.
        • Cheng Y.M.
        • et al.
        Bicondylar tibial plateau fracture treated by open reduction and fixation with unilateral locked plating.
        Kaohsiung J Med Sci. 2013; 29: 568-577
        • McGonagle L.
        • Cordier T.
        • Link B.C.
        • Rickman M.S.
        • Solomon L.B.
        Tibia plateau fracture mapping and its influence on fracture fixation.
        J Orthop Traumatol. 2019; 20: 1-6
        • Molenaars R.J.
        • Mellema J.J.
        • Doornberg J.N.
        • Kloen P.
        Tibial plateau fracture characteristics: computed tomography mapping of lateral, medial, and bicondylar fractures.
        J Bone Joint Surg Am. 2015; 97: 1512-1520
        • Molenaars R.J.
        • Solomon L.B.
        • Doornberg J.N.
        Articular coronal fracture angle of posteromedial tibial plateau fragments: a computed tomography fracture mapping study.
        Injury. 2019; 50: 489-496
        • Mueller K.L.
        • Karunakar M.A.
        • Frankenburg E.P.
        • Scott D.S.
        Bicondylar tibial plateau fractures: a biomechanical sutdy.
        Clin Orthop Rel Res. 2003; 412: 189-195
        • Rademakers M.V.
        • Kerkhoffs M.J.
        • Sierevelt I.N.
        • Raaymakers E.
        • Marti R.K.
        Operative treatment of 109 tibial plateau fractures: 5 to 27 year follow-up results.
        J Orthop Trauma. 2007; 21: 5-10
        • Rasmussen P.S.
        • Gothenburg M.D.
        Tibial condylar fractures: impairment of knee joint stability as an indication for surgical treatment.
        J Bone Joint Surg Am. 1973; 55-A: 1331-1350
        • Ratcliff J.R.
        • Werner F.W.
        • Green J.K.
        • Harley B.J.
        Medial Buttress versus lateral locked plating in a cadaver medial tibial plateau fracture model.
        J Orthop Trauma. 2007; 21: 444-448
        • Ruffolo M.R.
        • Gettys F.K.
        • Montijo H.E.
        • Seymour R.B.
        • Karunakar M.A.
        Complications of high energy bicondylar tibial plateau fractures with dual plating through 2 incisions.
        J Orthop Trauma. 2015; 29: 85-90
        • Schatzker J.
        • McBroom R.
        • Bruce D.
        The tibial plateau fracture. The toronto experience 1968–1975.
        Clin Orthop Rel Res. 1979; : 94-104
        • Shimizu T.
        • Sawaguchi T.
        • Sakagoshi D.
        • Goshima K.
        • Shigemoto K.
        • Hatsuchi Y.
        Geriatric tibial plateau fractures: clinical features and surgical outcomes.
        J Orthop Sci. 2016; 21: 68-73
        • Stannard J.P.
        • Wilson T.C.
        • Volgas D.A.
        • Alonso J.E.
        The less invasive stabilization system in the treatment of complex fractures of the tibial plateau: short-term results.
        J Orthop Trauma. 2004; 18: 552-558
        • Stevens D.G.
        • Beharry R.
        • McKee M.D.
        • Waddell J.P.
        • Schemistsch E.H.
        The long-term functional outcome of operatively treated tibial plateau fractures.
        J Orthop Trauma. 2001; 15: 312-320
        • Su E.P.
        • Westrich G.H.
        • Rana A.J.
        • Kapoor K.
        • Helfet D.L.
        Operative treatment of tibial plateau fractures in patients older than 55 years.
        Clin Orthop Rel Res. 2004; 421: 240-248
        • Unno F.
        • Lefaivre K.A.
        • Osterhoff G.
        • Guy P.
        • Broekhuyse H.M.
        • et al.
        Is early definitive fixation of bicondylar tibial plateau fractures safe? An observational cohort study.
        J Orthop Trauma. 2017; 31: 151-157
        • Van Dreumel R.L.
        • Van Wunnick B.P.
        • Janssen L.
        • Simons P.C.
        • Janzig H.M.
        Mid- to long-term functional outcome after open reduction and internal fixation of tibial plateau fractures.
        Injury. 2015; 46: 1608-1612
        • Weaver M.J.
        • Harris M.B.
        • Strom A.C.
        • Smith R.M.
        • Lhowe D.
        • et al.
        Fracture pattern and fixation type related to loss of reduction in bicondylar tibial plateau fractures.
        Injury. 2012; 43: 864-869
        • Weigel D.P.
        • Marsh J.L.
        High-energy fractures of the tibial plateau: knee function after longer follow-up.
        J Bone Jt Surg Am. 2002; 84-A: 1541-1551
        • Yao Y.
        • Lv H.
        • Zan J.
        • Zhang J.
        • Zhu N.
        • Ning R.
        • et al.
        A comparison of lateral fixation versus dual plating for simple bicondylar fractures.
        Knee. 2015; 22: 225-229
        • Yoo B.J.
        • Beingessner D.M.
        • Barei D.P.
        Stabilization of the posteromedial fragment in bicondylar tibial plateau fractures: a mechanical comparison of locking and nonlocking single and dual plating methods.
        J Trauma. 2010; 69: 148-155
        • Young M.J.
        • Barrack R.L.
        Complications of internal fixation of tibial plateau fractures.
        Orthop Rev. 1994; 23: 149-154