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