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Presenter : Dr.B.Naveen ThiyaguPresenter : Dr.B.Naveen Thiyagu
Author : Prof SSK.MarthandamAuthor : Prof SSK.Marthandam HOD & Director of Trauma Care ServicesHOD & Director of Trauma Care Services
Co-Authors : Co-Authors : Dr.D.Gokul Raj, Dr.D.Gokul Raj, Dr.S.Sundar,Dr.S.Sundar,
Dr.N.JambuDr.N.Jambu Sri Ramachandra Medical College & Research Institute Sri Ramachandra Medical College & Research Institute (Deemed University) Chennai.(Deemed University) Chennai.
PRINCIPLES*PRINCIPLES*
Limited exposure Indirect reduction methods Communition manipulated with vascularity intact Preservation of the periosteal vascularity
*Rockwood & Green’s Vth edition vol 1 pg 119.
AIMAIM
To analyse the functional outcome of the tibial To analyse the functional outcome of the tibial
condyle fractures treated with Minimally condyle fractures treated with Minimally
Invasive plateosteosynthesis(MIPO)Invasive plateosteosynthesis(MIPO)
SHATZKER’S CLASSIFICATIONSHATZKER’S CLASSIFICATION
I II III IV V VI
No of cases : 1 1 2 1 14
MATERIAL & METHODSMATERIAL & METHODS Prospective study Follow Up : 4 mo to 28 mo Av : 16.5 Follow Up : 4 mo to 28 mo Av : 16.5 monthsmonths Period of study : June 2002 toNov2004June 2002 toNov2004
Total no. of cases: 19 M : F : 8.5 : 18.5 : 1 Age : 29 to 59 yrs Av :40.2 yrs Side R :L : 10 :9
Mode Of Injury RTA :Fall : 17:2
EXCLUSION CRITERIAEXCLUSION CRITERIA
Tibial condyle fractures Only Closed fractures were taken up for the study Open tibial condyle fractures Schatzker type I fractures Patients who presented with compartment syndrome & vascular injury
INCLUSION CRITERIAINCLUSION CRITERIA
INJURY SURGERY INTERVALINJURY SURGERY INTERVAL
Within 1 week -13 casesWithin 1 week -13 cases
1-2 weeks - 4 cases1-2 weeks - 4 cases2-3weeks - 2 cases2-3weeks - 2 cases
0
2
4
6
8
10
12
14
< 1 week 1 - 2 weeks 2 - 3 weeks
Patients
SURGICAL TECHNIQUESURGICAL TECHNIQUE Under the guidance of image intensifier
closed reduction achieved by ligamentotaxis either using longitudinal traction or femoral distractor
Incision was made as large as necessary for the insertion of the plate,far from fracture site
Either T Buttress plate / L buttress plate with or without 4.5 mm narrow DCP slide in sub muscular plane extraperiostealy
The plate was then fixed with a minimum
of three screws on either side of the
fracture using image intensifier
CRITERIA FOR GRADING RESULTSCRITERIA FOR GRADING RESULTSRasmussen’s functional knee score*
ParameterPoints Acceptable Unacceptable
Excellent Good Fair Poor
A. Subjective Complaints a. Pain No pain Occasional ache, bad weather pain Stabbing pain in certain positions Afternoon pain, intense constant around the knee after activity Night pain at rest.
b. Walking Capacity Normal walking capacity (in relation to age) Walking outdoors at least 1 hour Short walks outdoors > 15 minutes Walking indoors only Wheelchair/bedridden
6 5
4
2
0
6 4 2
1 0
5
6
4
4
2
2
0
1
** Paul j duwelius et al CORR NO 339, pp 47 – 57 . 1997Paul j duwelius et al CORR NO 339, pp 47 – 57 . 1997
Parameter Points Excellent Good Fair Poor
B. Clinical signs a. Extension Normal Lack of extension (0o – 10o) Lack of extension > 10o
b. Total range of motion At least 140o
At least 120o
At least 90o
At least 60o
At least 30o
0
c. Stability Normal stability extension and 20o flexion Abnormal instability20oflexion Instability in extension < 10o
Instability in extension > 10o
Sum(minimum)
6 4 2
6 5 4 2 1 0
6 5 4 2
6
5
5
4
4
4
2
2
2
2
1
2
27 20 10 6
POST OPERATIVE PROTOCOLPOST OPERATIVE PROTOCOL
Mobilisation of knee and ankle started once the post op pain Mobilisation of knee and ankle started once the post op pain subsidedsubsided
Non weight bearing walk was permitted from 3rd podNon weight bearing walk was permitted from 3rd pod
Sutures removed on 10th/12th podSutures removed on 10th/12th pod
Non weight bearing walk for a minimum period of 6 weeksNon weight bearing walk for a minimum period of 6 weeks
Partial weight bearing until 3 monthsPartial weight bearing until 3 months
Full weight bearing after radiological unionFull weight bearing after radiological union
OVER ALL RESULTSOVER ALL RESULTS
Results No. of patients
Percentage
Excellent 12 63.16%
Good 4 21.05%
Fair 2 10.53%
Poor 1 5.26%
Total 19 100%
84.21%
15.8%
0
20
40
60
80
100
Patients
ExcellentGoodFairPoor
Results No. of patients Percentage
Excellent 9 64.29%
Good 2 14.29%
Fair 2 14.29%
Poor 1 7.14%
Total 14 100%
SHATZKER’S TYPE VI RESULTSSHATZKER’S TYPE VI RESULTS
0
20
40
60
80
100
Patients
ExcellentGoodFairPoor
Type No. of patients
Results
Type II 1 Excellent
Type III 1 Excellent
Type IV 2 Good
Type V 1 Good
SHATZKER TYPE II,III,IV,V RESULTSSHATZKER TYPE II,III,IV,V RESULTS
SURGERY TIME INTERVAL & RESULTSURGERY TIME INTERVAL & RESULT
00.5
11.5
22.5
33.5
44.5
5
24 - 48hrs 3 - 7 days > 7 days
ExcellentGoodFairPoor
Patients treated with early fixation and early mobilization have good / excellent results irrespective of the fracture type
FRACTURE UNIONFRACTURE UNION
13-18 weeks : 17 cases.13-18 weeks : 17 cases.19-23 weeks : 1 case.19-23 weeks : 1 case.24-28 weeks : 1 case.24-28 weeks : 1 case.
0
20
40
60
80
100
Cases
13 - 18 weeks19 - 23 weeks24 - 28 weeks
Average time to fracture healing was 16.32 wks . (Krettek et al -16Wks).
Case no 1 : Mr.E , 53/M H/O RTA, and sustained Case no 1 : Mr.E , 53/M H/O RTA, and sustained Right side Shatzker type VIRight side Shatzker type VI
Pre op Immed post op
2 ½ mo 1year 10 mo
Functional Outcome: Functional Outcome: ExcellentExcellent Rasmussen’s Score : 29 Rasmussen’s Score : 29
Case no : 2 Mr . S , 34 / M H/o RTA , and sustained Case no : 2 Mr . S , 34 / M H/o RTA , and sustained left sided , Shatzker VIleft sided , Shatzker VI
Pre op Immed post op
7 mo 10 mo
Active SLRROM –O-130 deg
Functional outcome : Functional outcome : GoodGood Rasmussen’s score : 26 Rasmussen’s score : 26
Case no 3.Mr . J 45/M H/o RTA , and sustained Case no 3.Mr . J 45/M H/o RTA , and sustained right sided ,Shatzker type VIright sided ,Shatzker type VI
Pre op
Immed post op 8 wks 3 mo
7 mo After implant removal
ROM :10 –135deg Active SLR Ant drawers +ve
Extensor lag
Functional Outcome : Functional Outcome : FairFairRasmussen’s Score : 19Rasmussen’s Score : 19
Case no 4. Mrs. M 35/F H/o Fall from height , and Case no 4. Mrs. M 35/F H/o Fall from height , and sustained Left sided, Shatzker type VI .sustained Left sided, Shatzker type VI .
Pre op Imm.post op
1 yr 2 mo
ROM :20 –110 deg
Extensor lag
She was not able to squat
Functional Outcome : PoorFunctional Outcome : PoorRasmussan’s Score : 9Rasmussan’s Score : 9 . .
Varus deformity
CONCLUSIONCONCLUSION Good range of movements in knee, averaging 122 deg. Good range of movements in knee, averaging 122 deg.
Patients treated with early fixation and early mobilization Patients treated with early fixation and early mobilization have Excellent / good results irrespective of the fracture typehave Excellent / good results irrespective of the fracture type
No Incidence of Non UnionNo Incidence of Non Union
No secondary bone graftingNo secondary bone grafting
84 %84 % Excellent to good functional results Excellent to good functional results
78% Excellent to good functional results in high energy 78% Excellent to good functional results in high energy tibial condyle fractures (tibial condyle fractures (Shatzker’s typeVIShatzker’s typeVI )
COMPLICATIONSCOMPLICATIONS
Complication No.of Patients
Case no.
Superficial Infection
1 16
Knee stiffness 1 8
Implant Loosening
2 5,14
Varus deformity 2 5,11