Lesional and Therapeutic Aspects of Tibial Plateau Fractures at the BSS University Hospital Center in Kati ()
1. Introduction
Tibial plateau fractures are solutions of continuity of the epiphyseal-metaphyseal block of the upper end of the tibia of which at least one line enters the joint. In 1875 Richet singled them out as an entity apart from other tibial fractures [1]. A study carried out in 2018 at the CHU Gabriel Touré found a frequency of 1.13% [2]. These fractures are on the increase, especially affecting young and active subjects. They are twice as common in men as in women and extremely rare in children [3]. These fractures are frequent, representing 1% of all fractures and 25% of tibial fractures [4]. In 1980, in industrialized countries, the incidence of tibial plateau fractures was 123 per 10,000 inhabitants among women and 104 per 10,000 inhabitants among men [5]. The main etiologies remain dominated by accidents on public roads and sports accidents [3]. They are frequent and serious because of their joint nature. They threaten the stability and mobility of the knee and can compromise walking and standing [1]. In our country, very few studies have focused on tibial plateau fractures, although these fractures rank third among pelvic limb injuries [6]. Orthopedic treatment is a rare indication apart from non-displaced or slightly displaced forms. Surgical treatment is required in displaced forms, particularly in depression fractures. Early and stable osteosynthesis will provide better functional results after early rehabilitation. The aim of this work was to report the lesional and therapeutic aspects of tibial plateau fractures in our department.
2. Patients and Method
Our study was carried out at the University Hospital of Kati. This was a retrospective study over 36 months, from January 2019 to December 2021. The sampling was done taking into account the selection criteria of our study population. Our study concerned patients of all ages, male or female, admitted to the Orthopedics-Traumatology department of the CHU-Pr. BSS of Kati. Included in this study were patients treated for a tibial plateau fracture in our service and followed up for at least 10 months. Incomplete records and patients lost to follow-up were not included in this study. We used consultation registers, patient files and operating report registers. The epidemiological and clinical data analyzed were age, sex, affected side, etiology, mechanism of injury, pathological anatomy and associated lesions. The anatomopathological study of these fractures was carried out on a standard radiographic analysis of the face, profile and often of 3/4 external and internal. Some patients benefited from computed tomography, in order to better appreciate the lesions. The fractures were classified according to the Duparc and Ficat classification [7] [8] (Table 1). The slightly or non-displaced forms were treated orthopedically while the displaced forms were treated surgically. The minimum follow-up was 10 months. The results were evaluated by the anatomical criteria according to Mazas and Duparc and functional according to Merle d’Aubigne (Table 2 and Table 3). Data were analyzed with IBM SPSS
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Table 1. Classification of Duparc and Ficat.
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Table 3. Anatomical criteria of MAZAS and DUPARC.
statistics 22.0 software and entered into Microsoft Word 2016.
3. Results
The authors collected 71 cases of tibial plateau fractures. They accounted for 4.0% of all limb fractures, 5.8% of lower limb fractures and 33.8% of knee fractures in our department. The male sex was the most represented at 78.9% with a sex ratio of 3.7. The age group of [20 - 40] years was the most affected, i.e., 53.5%. The average age was 41 years with extremes of 17 and 82 years. The left side was affected (n = 47) and the right side (n = 24). The etiology was road traffic accident (n = 59) or 83.1%, domestic life accident (n = 10) and intentional blows and injuries (n = 2). The injury mechanisms (Table 4) were lateral compression (n = 24), sagittal compression (n = 21), axial compression (n = 5) and mixed compression (n = 1). The mechanism was unknown in 20 cases or 28.2%. The pathological types (Table 4) were lateral unituberosity fracture (n = 30), bituberosity fracture (n = 20), spinotuberosity fracture (n = 8), medial unituberosity fracture (n = 5), lateral spinotuberosity fracture (n = 4) and epiphyseal-metaphyseal diaphyseal fracture (n = 4). Associated lesions were mainly represented by distant bone (n = 13), knee ligament (n = 6), skin (n = 4) and nerve (n = 1) lesions. The treatment was orthopedic in 37 patients or 52.1% and surgical in 34 patients or 47.9%. The sociodemographic and clinical characteristics are summarized in Table 4. The orthopedic treatment was ensured by cruropedial plaster in 97.2% and 2.8% by transcalcaneal traction. The surgical implants (Figure 1 and Figure 2) used were the L-plates (n = 18), the T-plates (n = 13), the blade plate (n = 1), the screw (n = 1) and the fixator external (n = 1). The postoperative complications listed (Figure 3) were osteoarthritis (n = 6), instability (n = 5), vicious callus (n = 4), stiffness (n = 2), axial deviation (n = 2) and infection (n = 1). According to the functional criteria of PMA, our results were very good and good at 77.4%, Average at 14.1% and poor at 8.5%. According to the MAZAS and DUPARC anatomical criteria, our results were very good and good in 84.5% and bad in 15.5%.
4. Discussion
This was a retrospective study of 71 patients operated on for tibial plateau fracture. Surgery for tibial plateau fractures accounted for 5% of surgeries in our department. The injury mechanisms were mainly represented by lateral and sagittal compressions. The high frequency of the indirect mechanism by lateral
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Table 4. Sociodemographic and clinical characteristics of patients.
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Figure 2. Lateral unituberosal fracture operated with L-plate, consolidated.
compression has been mentioned by several authors [9] [10]. The high frequency of the lateral compression mechanism can be explained by the fact that the knee is a joint very exposed to various attacks. Its bone architecture favors this type of mechanism. It should also be noted that the mechanism was unknown in 28.2% of cases, our patients poorly specified the mechanism due to the violence of the trauma and the lesion association. Lateral unituberosity and bi-tuberosity fractures were the most frequent pathological types in our series, respectively 42.2% and 28.2%. Our results were comparable to those of Chan Y.S. et al. [11] and Yacoubian et al. [12] who respectively had 39% and 29% of lateral unituberosity fractures. This high frequency could be linked to the existence of an area of weakness in the lateral tibial plateau. The most frequent associated lesions were remote bone lesions, 54.2%, and knee ligament lesions, 25%. The overall rate of osteosynthesis in our series was 47.9%. This rate is lower than those of Da et al. [2], Honkonen and Järvinen [13], and Koulali et al. [14] with respectively 59.7%, 58% and 68%. Surgical treatment is the treatment recommended by the majority of authors [1] [15]. It is for them the only one capable of reducing a significant depression, of fixing a separation in a stable manner and thus obtaining an assembly allowing immediate mobilization. The frequent use of the screwed plate could be explained by the stability and solidity of the fixation it offers. A bone graft was necessary in 11.49% of cases during the osteosynthesis in order to fill the metaphyseal defect created by the lifting of the hollow plate. It involved a corticocancellous graft taken from the ipsilateral iliac crest. This attitude is consistent with the literature as noted by Koulali et al. [14] and Le Huec [16]. The choice of osteosynthesis material strongly depended on the type of fracture and the stability offered by the latter. In our study, 79.4% of operated patients were treated with a screwed plate. We noted 25.5% of complications. These complications were dominated by osteoarthritis (33.3%), instability (22.2%) and malunion of the knee (16.6%). The orthopedic treatment was responsible for 37.8% of complications. On the other hand, 11.7% of complications were recorded after the surgical treatment. This result suggests that the indication for surgical treatment should be extended as much as possible in tibial plateau fractures, even in non-displaced forms. Solid osteosynthesis after anatomical reduction will allow early mobilization which will considerably reduce the rate of complications. According to the functional criteria of PMA, our results were very good and good at 77.4%. Our functional results are similar to those of Koulali et al. [14], Sawadogo et al. [17] and Kassé NA et al. [18], who had respectively 67%, 79% and 88% very good and good results. According to the anatomical criteria of MAZAS and DUPARC, our results were classified as very good and good in 84.5%. Our work has limits. This is a single-center retrospective study that has certain biases in data collection. The workforce is small and the recoil is weak. The latter can influence the evaluation of the anatomical complications of these fractures. Satisfactory functional results at the start could deteriorate later. On the other hand, the results of this study are consistent with data published in developing countries. Multicenter studies with large numbers and a significant follow-up are necessary to compare our results.
5. Conclusion
It appears in this study that fractures of the tibial plateaus are frequent and serious because of their articular nature. Lateral and sagittal compressions were the most evoked injury mechanisms. Lateral unituberosity and bi-tuberosity fractures were the most frequent pathological types. The functional and anatomical results were significantly better with the surgical treatment. This is why the indication for surgical treatment must be extended as much as possible in tibial plateau fractures, even in non-displaced forms.