Knee and tibia: A tibia plateau nonunion

This is a case of a 42 year old female who was treated for a plateau fracture by a well regarded traumatologist at one of the major university hospitals of Chicago. After surgery she participated in a rehab program, and eventually she was progressed to full weight bearing. Somewhere along the way there must have been a disconnect, and she stopped following up with the original doctor.

She presented to my clinic with continued and worsening pain more than a year after her surgery, unable to walk, referred to me by another patient. She had been told, correctly, that she might need a knee replacement one day. And so she asked for a knee replacement on the first appointment with me.

Here are the xrays on presentation:

The problem here is obvious, in that the fracture has not healed. Xrays show a nonunion. There is a nonunion of the plateau to the shaft, and there is a nonunion of the tubercle, which explains the dysfunction of her extensor mechanism.

In addition, there is posttraumatic arthritis of the lateral plateau, and the knee is collapsing into varus deformity.

Glossary

A nonunion is a fracture that has not healed and will not heal. In practice, if a fracture has not healed in about 6 months, it probably will never heal.

I explained the diagnosis to the patient. I checked and was comforted by the fact that there was no infection. I recommended bone grafting and revision surgery, and I explained that the knee replacement would have to be done at a later time. We planned revision fracture surgery.

In revision surgery, I proceeded to remove the lateral plate, remove the nonunion through a separate medial incision, and repair the tibial tubercle with fiberwire. I took a large amount of iliac crest graft and impacted it in the nonunion. This is all pretty standard orthopedics. I applied a medial plate for stability. The medial plate would be easier to remove during the eventual knee replacement.

The patient eventually healed this fracture. For the first three months I prescribed active assisted motion in physical therapy. I allowed her to bear partial weight at 2 months, full weight at 4 months. At 1 year from her revision fracture surgery, both the tubercle and the metaphysis are nontender, united. She walks with only mild pain and no visible limp, despite the impressive lateral compartment arthritis. A knee replacement is not in the near future.

These xrays are from the anniversary of her surgery.

This case represents several issues:

  1. Orthopedics, and medicine in general, is not an exact science. Some fractures do not heal, for reasons that elude the medical profession.
  2. Things that seem clear to the physician, are often not clear to the patient. No matter how many times a physician explains things, there is always potential for misunderstanding. This is something that bothers me, and that's why I have gotten into the habit of saying more, rather than less, to the patients. That's why I have this web site as well. In particular, many patients do not fully understand that plates and screws serve only to hold the bone in place temporarily as it heals. The mere application of a steel plate is not the end of the treatment, it is only the beginning. Think of a plate as a "cast" applied directly to the bone.
  3. Duration of follow up after fracture surgery. Most fractures heal by 2-3 months, and at times it may seem that the orthopedic doctor is making you follow up just to collect the copay. That is not so. Complications do occur, and as a patient you are well advised to keep your appointments and call your doctor promptly if you have any problems.
  4. Doctor shopping. As a patient, you have choices, and thank God for that. But when a bone is not healing quickly, do not be quick to blame your doctor. Seeking another opinion is always wise, but in the end you must realize that medicine is not an exact science. There is always some uncertainty and some unpredictability.