The Staged Treatment for Tibial Plateau Fractures and the Reconstruction of Lateral Column With Autogenous Iliac Bone: an Ecacy Analysis Report

Complications in treating comminuted tibial plateau fractures with extensive soft tissue damage are common. In this study, we discussed the effect of staged treatment in the reconstruction of the lateral column with autogenous iliac bone using case follow-up. Methods A retrospective analysis of 18 patients with comminuted tibial plateau fractures and extensive soft tissue damage from October 2016 to February 2020 who underwent staged treatment in our hospital. After the soft tissue damage repair, a large autologous iliac bone was used to reconstruct the lateral column of the tibial plateau.


Background
High-energy tibial plateau fractures are generally associated with severely fractured articular surface and surrounding bone, along with extensive soft tissue damage [1]. Patients with fractured articular surface and lateral column defect are generally di cult to treat. In this report, a large iliac bone was used to reconstruct the proximal lateral column of the tibia in a staged treatment of the complex tibial plateau fracture with extensive soft tissue damage. In this retrospective study, 18 patients receiving such surgery, with excellent results, were studied. A staged treatment represents a two pronged approach: rst comes the management of soft tissue (0-16 days after injury) and the second is the operation to x the fracture (16-21 days after injury). Out of the 18 cases mentioned in this report, 10 were males and 8 were females with an age range of 22-65 years old (average of 43.06 years old), average body mass index of 24.5 kg/m2; 3 cases of poor medial soft tissue, 2 cases of poor lateral soft tissue, and 10 cases of simultaneously poor medial and lateral soft tissue. According to the Tscherne classi cation of soft tissue injury [2], there were 13 cases of type C2 and 5 cases of type C3 among the 18 patients. During the management of soft tissue period, 4 cases underwent calcaneal traction and 14 cases underwent external xation. The fractures, on the other hand, were classi ed according to three separate classi cations. The AO/OTA classi cation identi ed all fractures as C3 injuries [3]. Alternately, the Schatzker classi cation [4] assigned 4 cases as Schatzker type V injuries and 14 cases as Schatzker type VI injuries. Lastly, the three-column tibial plateau classi cation categorized all fractures as three-column fractures. [5] The time from injury to operation in all fracture patients was between 14-21 days with an average of 16.78 days post injury. The preoperative classi cations were performed by a radiologist and two orthopedic physicians based on X-rays, preoperative CT [6], and the visual soft tissue conditions. All patient statistics are summarized in Table 1.

Pre-operation
Upon admission, all patients completed relevant examinations, had their affected limbs raised, and underwent dehydration treatment to prevent deep vein thrombosis. External xation or traction of the calcaneal tuberosity was performed to stabilize the fracture. This allowed for soft tissue recovery by restoring fracture length and alignment. Emergency incision and decompression was instantly performed in order to prevent compartment syndrome [7], and the cross-articular external xation was placed with the nail channel as far away as possible from the position of the second surgical incision [8]. The resulting wound was sutured one week after the incision decompression. The internal xation was performed within 16 days post injury after the skin swelling had subsided. In all patients, blisters appeared 24 hours after the injury, and reached a peak at 7 days after the injury. The blisters were continuously washed with a Revnauer-infused gauze, and larger blisters were suctioned with a sterile syringe. Among the 18 patients examined in this study, 5 were treated with emergency incision decompression.

Intraoperation
Either epidural anesthesia or general anesthesia was applied before the surgery. The affected limb was tied with a tourniquet. To begin the operation, a combined medial and lateral double incision was performed [9][10][11]. The lateral incision was initiated from the upper edge of the lateral tibial condyle and extended inwardly and downwardly to below the tibial tubercle [12]. This incision was about 15 cm long. Next, an arcuate incision was performed on the inner and posterior edge of the knee extending about 10 cm long.
Care was taken to maintain a skin bridge width > 8 cm between the two incisions [13]. Subsequently, the skin was cut sequentially beginning with the subcutaneous layer and continuing with the deep fascia, and the fracture ends were exposed through double incisions. The medial incision was used to x the inner posterior and medial columns [14], and the lateral incision was used to x the lateral columns.The surgical sequence was to rst reset the posterior medial and medial cortical bone before resetting the lateral region [15]. To that end, the collapsed cortical bone was opened and lifted. A horizontal cut was introduced to the collapsed articular surface at 1.0 cm below the cartilage with a wide osteotomy until it was at and leveled with the contralateral articular surface. Next, the iliac bone measuring 3X2X1 cm was xed to the contralateral side of the affected limb [16]. This was followed by horizontally inserting a large medial plate of the iliac bone facing the joint upward to lift the articular surface, which is equivalent to reconstructing the subchondral cortical bone of the tibial plateau.The lateral plate of the iliac bone was then removed, and the exposed cancellous bone was molded into a bone strip to tightly ll the condyle. Following this, the iliac bone column was used to vertically support the condyle, thereby reconstructing the lateral column. Cancellous bone was again used to compactly pack the surrounding space. Special attention was given to the double incisions linkage during the reduction, and the point-type reduction forceps was used to x the medial column and lateral column as a whole. Additionally, the width of the platform was maintained as close as possible to the anatomy. On occasion when resetting was di cult, the area was examined for broken bones or meniscus jams. The posterior medial side was xed and supported with a 3.5 system limited contact pressure steel plate [17] and a T-shaped steel plate. Alternately, the lateral side was xed with an L-shaped locking steel plate. In case of cruciate ligament avulsion fractures, one-stage steel wire xation was performed simultaneously. In order to prevent severe lateral column crushing, either a large amount of iliac or Kirschner needles resembling bamboo raft-like xed support was used for rm xation. All patients discussed in this study received autologous iliac bone grafts instead of allogeneic bone or arti cial bone.
Injury to the medial and lateral collateral ligaments were treated in stages, however, the meniscus rupture was repaired by in-situ suture instantly. Tibial plateau fractures, being intra-articular fractures, were anatomical reduced as much as possible during the operation. X-rays were taken during the operation next to a standard, with special attention given to maintaining articular surface atness and height recovery. This study was aware that non-standard uoroscopy can easily cause the illusion of a good reduction. Therefore, post xation, the knee joint lateral stress test was performed to evaluate the stability of the joint before the wound was washed and drained using the internal and external incisions, the joint capsule was repaired, and the wound was closed. The operation, on average, was completed within 90 minutes of the tourniquet placement. The intraoperative surgical xation parameters are shown in Table 2 (above), and images from a typical case (case 2) are presented in Fig. 1 and Fig. 2. (below).

Postoperative
Antibiotic cefuroxime was routinely provided after the operation, 2 g/time, 2 times/day, NSAID Sanalgesics was administered intravenously, low-molecular-weight heparin calcium was applied for anticoagulation treatment continuously for 3 weeks post surgery, and the wound dressing was changed aseptically once every 3 days depending on exudation. On the second day after the operation, the patients were encouraged to perform ankle pump and quadriceps exercises along with knee exion and extension exercises, under the guidance of an attending doctor. The range of active exion and extension was 100°-0°.The stitches were removed 2 weeks after the surgery. The patients walked with crutches without weight on the affected leg within 6 weeks, and were gradually able to place weight on the affected leg after 3 months. The postoperative follow-up time was between 8-40 months, with an average time of 23.44 months. The average HSS knee score [18] was 86.72. All patients achieved complete bone healing, as evidenced by X-ray, 6 months after surgery. This study had 2 cases of traumatic osteoarthritis and 3 cases of quadriceps atrophy.
The postoperative score and bone healing judgment were completed in cohort by 2 rehabilitation physicians and 1 orthopedic physician.

Discussion
Tibial plateau fractures resulting from high-energy injuries require a careful and extensive preoperative examination. In fact, Barei et al. reported discrepancies between CT plain scan and X-ray diagnosis [19]. Based on our report, a CT scan is essential after traction external xation placement. It allows for a comprehensive understanding of the fracture morphology, degree of comminution, and displacement, therefore, making it critical for determining the surgical approach. A two pronged or staged approach is necessary due the extensive soft tissue damage caused by tibial plateau high-energy injuries. In the rst-stage of treatment, the calcaneal traction or trans-articular external xator placement can be applied to reduce the patient's pain and alleviate further vascular and nerve injury, thereby facilitating soft tissue management. In the second stage, internal xation can be performed to treat the damaged bone. Skin abrasions and multiple blisters that follow high energy injuries peak around 7 days post injury and take about 16 days to heal. It is imperative that the reconstruction surgery occurs within 3 weeks of injury to avoid resetting complications.
Tibial plateau fractures with severe soft tissue damage are commonly categorized in the classi cation Schatzker V and Schatzker VI. Out of the 18 cases examined in this study, 14 were classi ed as Schatzker VI. Internal double-plate xation enhances fracture stability. Meanwhile, the use of autologous iliac bone to reconstruct the lateral column provides a good guarantee for stability and anatomical reduction. Unlike allograft usage, autologous iliac bone grafting does not induce an immune rejection. Therefore, the tibial platform can be reconstructed safely with autologous free iliac bone. Our investigation has revealed that the iliac bone block can not only support the articular surface, but also reduce stress. After the completion of the iliac bone transplantation, the locking screw can be used to x the iliac bone, the remaining tibial platform, and the internal xation together to fully ensure the stability of the tibial plateau after reconstruction. Fortunately, the structure of the autogenous ilium is similar to that of the tibial plateau. The arc-shaped depression of the inner plate of the iliac bone is similar to the shape of the tibial condyle; the arc structure and bone quality of the iliac crest is similar to the edge of the tibial plateau; and the migration structure of the iliac crest to the inner plate of the ilium is similar to that of the tibial plateau edge to the tibial plateau. Therefore, the correspondence of these series of organizational structures fully coincides with the anatomical needs of the iliac reconstruction of the tibial plateau. Furthermore, the autologous large iliac bone can easily be used for height adjustment and metaphysic xation during the operation, thereby playing a crucial role in restoring force line and maintaining stability.
Since tibial plateau fracture is an intra-articular fracture, it is essential to perform anatomical reduction of the articular surface to reduce incidences of traumatic arthritis post surgery. Multiple studies have demonstrated that the pressure distribution in the knee joint changes signi cantly upon a > 1.5 mm collapse of the articular surface, and the local pressure increases signi cantly when the articular surface collapse reaches > 3 mm [20]. In either of these cases, the joint varus becomes deformed and leads to instability of the knee joint [21]. Yet another group of studies have established that the accurate reduction and strong xation of articular cartilage can assist in the healing of the cartilage in the form of hyaline cartilage. Based on our results and that of others, the reconstruction of the tibial plateau with the iliac bone graft can successfully reduce the articular surface and the collapsed bone, and early functional exercises can be achieved with strong internal xation. Finally, quadriceps atrophy and traumatic knee arthritis can also be reduced, periarticular tissue adhesion can be prevented, and knee function can be restored to the maximum extent using such an approach.
In summary, a complex tibial plateau fracture with extensive soft tissue damage can be successfully remedied using a staged treatment. The lateral column reconstruction using a large iliac bone can restore the lower limb force line, ensure smooth articular surface, restore platform width, and assist in the locking plate xation.
We acknowledge that this study had some limitations; including Tscherne soft tissue classi cation limitations [22], small number of cases, non-diverse age population, and a short follow-up.