Knee: Tibia plateau bicondylar fractures

Bicondylar tibial plateau fractures are severe injuries. I have personally treated surgically more than a dozen high-grade tibial plateau fractures, and I feel entirely comfortable with their management.

A few remarks:

  1. Two separate surgical incisions, and 2 separate plates are usually needed to stabilize these fractures.
  2. Some degree of posttraumatic arthritis develops virtually in 100% of these cases.
  3. Some degree of pain always remains, even after full healing.
  4. Post-surgical management consists of immediate physical therapy with the goal of restoring range of motion, but weight bearing must be extremely gradual in order to not risk early loss of fixation.

Posttraumatic arthritis develops because the knee joint is directly involved by the fracture and because of the imperfections that persist in the joint surface of the tibia. In addition, the meniscus always sustains injuries of varying extent in cases of tibia plateau fractures.

A couple of case studies from patients who have given me permission.

Case study 1

Young man with a bicondylar plateau injury.

Note below the depression of the lateral plateau (green arrows), the abnormality of the medial plateau (red arrows), and a small fracture of the lateral femoral condyle (yellow arrow).

CT shows the amount of comminution better.

The CT slice on the right shows the involvement of the medial tibial plateau.

Surgery consists of medial and lateral approach to the plateau, with reduction of the fracture fragments, impaction of bone graft (usually allograft), followed by stabilization of the fragments with plate + screws.

My recommended rehabilitation routine for these fractures consists of:

  1. Gentle range of motion immediately after surgery.
  2. Non weight bearing for 2 months
  3. Gradual increase of weight bearing status starting at 2 months.

Xrays below show maintained alignment at 6 months after surgery. Patient at this point is pain free and gait is normalized.

Arthritis is a realistic expectation in the future.

Case 2

This is the case of a middle aged man with a bicondylar tibia plateau fracture, sustained in a vehicular accident.

The leg was very swollen, and definitive surgery had to be postponed. Immediate surgery could have resulted in unclosable wounds. Instead, temporary realignment and stability was provided with an external fixator apparatus. A cast would be inadequate, it would not allow easy examination of the skin.

Below you can see fluoroscopy images after the external fixator nuts were tightened.

A CT was then done to better understand the anatomy of this fracture. The two main fracture lines form a "+" sign through the proximal tibia.

Definitive surgery was done 2 weeks later. The following xrays were done immediately after surgery.

Patient left hospital 3 days later. Physical therapy was done, with active-assisted motion. Weight bearing was not allowed for the first 3 months.

Patient recovered well and healed his fracture.

Patient regained good range of motion, but relatively decreased compared to a normal knee. In the following pictures, the patient is able to actively straighten and flex his knee while sitting in a chair.

Infection is something that is always a potential problem after orthopedic surgery. In this case, the patient had an episode of cellulitis first noted at 4 months after surgery. He was treated in consultation with an infectious disease specialist, antibiotics were then continued for another 6 weeks.

Below are xrays at 8 months after the injury.

At that point, the patient had been walking well, bearing full weight, and happy with his knee. Pain was occasional and mild. Very good outcome for a very bad fracture of the tibial plateau.

The patient then developed another episode of cellulitis, and at that point hardware removal was recommended because of the possibility of deep infection.

Following are xrays at 1 year. At this point hardware has been removed. Posttraumatic arthritis is evident, but without pain complaints. The patient however walks well, has minimal loss of flexion, full extension, and is happy about the outcome.

Posttraumatic arthritis is always a concern after such injuries. Treatment in such cases may necessitate a knee replacement operation. Although often times patients feel well and do not feel the need for a knee replacement, as a surgeon I advise my patients to expect one, as a last resort treatment.

Why not do a knee replacement from the get go, you may ask, since it also is a much simpler operation? The answer is this: A knee replacement does not last forever, and many patients with tibia plateau fractures are young. In addition, in the case described here, at the time of the original injury the bone stock was inadequate, unable to accept a regular knee prosthesis.