Operative Treatment of 109 Tibial Plateau Fractures ... - ResearchGate

ORIGINAL ARTICLE
Operative Treatment of 109 Tibial Plateau Fractures:
Five- to 27-Year Follow-up Results
M. V. Rademakers, MD,* G. M. M. J. Kerkhoffs, MD, PhD,* I. N. Sierevelt, MSc,*
E. L. F. B. Raaymakers, MD, PhD,‡ and R. K. Marti, MD, PhD†
Objective: To analyze the long-term (5–27 years) functional and
radiologic results of surgically treated fractures of the tibial plateau.
Design: Retrospective study.
Setting: University hospital.
Patients and Methods: Two hundred two consecutive tibial
plateau fractures were included in this study. All fractures were
classified according to both the AO and the Schatzker classification.
There were 112 men and 90 women. The mean age at injury was
46 years (16 to 88). One hundred sixty-three patients had isolated
fractures and 39 had multiple fractures. A 1 year follow-up was done
in all 202 patients. One hundred nine of these patients also had an
additional long-term follow-up visit. Functional results of these 109
patients were graded with the Neer- and HSS-knee scores. Radiologic
results were graded with the Ahlbäck score. Statistical analysis was
performed by means of the SPSS data analysis program.
Results: An uneventful union was present at the 1 year follow-up in
95% of the patients, along with a mean knee ROM of 130 degrees
(range, 10–145 degrees). One hundred nine patients had a long-term
follow-up visit after a mean period of 14 years (range, 5–27 years).
The mean ROM at this time was 135 degrees (range, 0–145 degrees).
Functional results showed a mean Neer score of 88.6 points (range,
56–100 points) and a mean HSS score of 84.8 points (range, 19–100
points). Monocondylar fractures showed statistically significant better
functional results compared to bicondylar fractures. In 31% of the
patients, secondary osteoarthritis had developed but was well
tolerated in most (64% of the patients). Patients with a malalignment
of more then 5 degrees developed a moderate to severe grade of
osteoarthritis statistically significant more often (27% of the patients)
compared to patients with an anatomic knee axis (9.2%; MWU,
P = 0.02). Age did not appear to have any influence on the results.
Accepted for publication October 19, 2006.
From the *Academic Medical Center, Department of Orthopaedic Surgery,
Amsterdam, The Netherlands; †Klinik Gut, St. Moritz, Switzerland; and
‡Academic Medical Center, Department of Trauma Surgery, Amsterdam,
The Netherlands.
The authors did not receive grants or outside funding in support of their
research or preparation of this manuscript.
This manuscript does not contain information about medical devices.
Correspondence: M. V. Rademakers, MD, Academic Medical Center,
Department of Orthopaedic Surgery, Amsterdam, The Netherlands,
Hoorn, Noord Holland, Netherlands, 1621 AC (e-mail: lloyd.ricardol@
mayo.edu).
Copyright Ó 2006 by Lippincott Williams & Wilkins
Conclusion: Long-term results after open reduction and internal
fixation for tibial plateau fractures are excellent, independent of the
patient’s age.
Key Words: tibial plateau fracture, long-term results, internal fixation
(J Orthop Trauma 2007;21:5–10)
INTRODUCTION
Although tibial plateau fractures compose approximately
1% of all fractures, a unified treatment has not yet been
established. Additionally, long-term outcome after various
treatment protocols is not yet clear, despite the voluminous
discussion of different treatment protocols in the literature. 1–31
Recent studies assessing only surgically treated patients by
means of open reduction and internal fixation (ORIF) show
good results but have relatively small patient groups or shortterm
follow-up. 7,10,13,16,20,29,32,33
The primary aim of this study was to evaluate the
functional and radiologic long-term results of surgically treated
(ORIF) tibial plateau fractures. The secondary aim was to analyze
characteristics that had a significant influence on the
results.
PATIENTS AND METHODS
Between 1975 and 1995, 202 consecutive patients with
202 tibial plateau fractures were treated with ORIF at our
institutions.
All 202 were prospectively documented with the
AO/ASIF system, and for all, a 1 year follow-up was achieved.
According to the AO-fracture documentation, all patients were
physically healthy before trauma.
Table 1 presents the fracture types and mechanisms of
injury. There were 112 men and 90 women. The mean age at
time of injury was 46 years (16–88). One hundred sixty-three
patients had isolated fractures and 39 had multiple fractures.
In 119 of the 202 patients, a long-term follow-up was
performed. Fifty-one patients died, 9 emigrated, 9 refused participation,
and 14 were untraceable. Ten patients were evaluated
but excluded from further analysis at long-term follow-up
because secondary salvage operations hampered evaluation
with functional knee scores (4 arthrodeses, 4 correction
osteotomies, 2 total knee arthroplasties), leaving a final total of
109 patients. The median hospital stay was 17 days (4–84).
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Rademakers et al J Orthop Trauma Volume 21, Number 1, January 2007
FIGURE 1. Case 1. A 34-year-old man who sustained a 41C3 fracture of the right leg as a result of a motor vehicle crash. A, Injury
anteroposterior radiograph. B, Postoperative anteroposterior radiograph. ORIF was done and intrinsic stability was created by
a cancellous bone graft. C, D, Anteroposterior and lateral radiographs 21 years after surgery. This patient had an excellent result
both for the Neer and HSS knee score (86 and 89, respectively), and there were no signs of secondary osteoarthritis. The patient
desired the hardware to be removed several years after surgery, though no pain was present.
Operative Technique
All patients were treated by ORIF performed by 12
surgeons. Indications for surgical treatment were a displacement
of the tibial plateau of at least 5 mm or a fracture-related
clinical instability of at least 5 degrees.
Patients were placed in the supine position, with the ability
to bring the knee to 90 degrees of flexion. For unicondylar
fractures, a straight parapatellar incision was used for fracture
exposure. After arthrotomy and extensive rinsing, the knee
joint was inspected for fracture patterns and damage of the
meniscus and ligaments. The anterior horn of the meniscus
was released to improve exposure and reinserted after fixation
of the fracture. No meniscectomy was performed. Cruciate
ligament avulsions were reattached by cerclage fixation. After
anatomic reduction, screw or plate fixation was used to stabilize
the fracture. Pure split fractures were fixed by screws and
antisliding washers. When additional support of the fracture
area was mandatory, an L-, T-, or semitubular plate was used
for buttressing. Impaction fractures were treated by elevating
the fragments from below with a bone impactor introduced
through the fracture or through a small cortical window. The
remaining bony defect was filled with autologous cancellous
bone grafts from the ipsilateral iliac crest, supported by screw
fixation through a buttress plate.
In bicondylar fractures, an additional medial incision
was made to facilitate anatomic reduction and buttressing
of the medial fragment. Thereafter, the lateral condyle could
be adapted to the anatomically reduced medial condyle. Exceptionally,
an osteotomy of Gerdy tubercle or fibular head
was used to reduce posterolateral impression fractures. 31 Postoperative
active and passive motion was started as soon as
possible.
Follow-up
One hundred nine patients were treated at the outpatient
clinic; they were asked to fill in a questionnaire (Neer- and
HSS-knee score), a physical examination was performed, and
radiographs were made (full-length standing views: AP, lateral,
and oblique). Knee laxity was tested manually by the same
2 main investigators. Trauma radiographs were classified
according to both the AO and the Schatzker classification. 27
Functional status at follow-up was evaluated using the Neer
score 34 and HSS knee score. 35 The Ahlbäck score 36 was used
for radiologic evaluation. Assessment of radiologic alignment
and joint congruency was performed manually by analysis of
both left and right 3-directional radiographs. A malunion was
defined as an unacceptable axial alignment (varus/valgus .5
degrees, rotation .10 degrees, shortening .2 cm) after full
consolidation. Scoring was performed by 2 authors not involved
in the initial treatment (resident orthopedic surgeons).
TABLE 1. Fracture Characteristics
Fracture
Type
Motor
Vehicle
Crash
Pedestrian
Mechanism of Injury
Sports
Trauma
Domestic
Total
(%)
41 B1 11 4 12 21 48 (24)
41 B2 6 2 5 9 22 (11)
41 B3 19 12 15 23 69 (34)
41 C1 15 4 3 3 25 (12)
41 C2 11 3 1 0 15 (8)
41 C3 16 4 1 2 23 (11)
Total (%) 78 (39) 29 (14) 37 (18) 58 (29) 202 (100)
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Operative Treatment of 109 Tibial Plateau Fractures
Statistical Analysis
Data were analyzed by using 1-way analysis of variance
and Student t tests. Correlations were analysed using the
Pearson correlation coefficient. The x 2 test was used for
dichotomous variables. Statistical significance was determined
at a P , 0.05 level.
RESULTS
One-Year Results
At 1 year follow-up, 192 of the 202 patients (95%)
showed an uneventful consolidation of the fracture, and 10
patients (5%) had a complication of fracture healing (nonunion
or malunion). The mean knee ROM was 130 degrees (10–145
degrees). Working and sports activities were resumed in 109
(91%) and 75 patients (76%), respectively.
Complications (for 202 Patients)
Eleven patients (5.4%) developed a deep wound
infection within the first 2 weeks after treatment and were
treated by surgical debridement. Nine fully recovered. In the
remaining 2 patients, recurrent infections led to impaired
fracture healing (non-union) and finally an arthrodesis.
In 8 patients (4.0%), a malunion of the fracture
developed. Two asymptomatic patients decided not to be
treated. In 6 patients, there was a progressive valgus malalignment,
with secondary osteoarthritis. Reconstructive correction
osteotomy 37 was performed in 4 patients and an arthrodesis in 2.
Two patients with severe secondary osteoarthritis
received a total knee arthroplasty.
The 10 patients treated with an arthrodesis, a correction
osteotomy, or a total knee arthroplasty were rated as failures
(5%) and were excluded from further long-term analysis.
Long-Term Results (for 109 Patients)
Mean follow-up of 109 patients (54% eligible patients)
was 14 years (range, 5–27 years).
Functional Results
The mean ROM was 135 degrees (0–145 degrees).
Eighty-nine of the patients (82%) showed no anteroposterior
laxity (,5 mm ); 18 (17%), a clinical laxity of 5 to 10 mm; and
2 (1%), a laxity of greater than 10 mm. In 104 patients (95%),
no collateral instability was found (,5 degrees), and in 5 (5%)
clinical instability measured between 6 and 9 degrees.
Neer Score. The mean Neer score was 88.6 points
(56–100 points). Seventy-six patients (69.7%) were rated as
excellent, 27 (24.8%) good, and 6 (5.5%) fair.
HSS Knee Score. The mean HSS knee score was 84.8
points (19–100 points). Sixty-eight patients (62.4%) were
rated as excellent, 23 (21.1%) good, 10 (9.2%) fair, and 8
(7.3%) poor.
Radiologic Results
Seventy-five patients (69%) showed no signs of
secondary osteoarthritis (grade 0); 23 (21%), slight signs
(grade 1); 8 (7%), moderate signs (grade 2); and 3 (3%), severe
signs (grade 3). Seven of the 11 patients (64%) with
a moderate to severe grade of secondary osteoarthritis had
a good to excellent Neer score, and 5 (46%) had a good to
excellent HSS knee score.
Correlations
All 109 patients who had a follow-up visit were analyzed
for predictor variables influencing the long-term results.
Range of Motion
Correlation between mean ROM at 1 year follow-up and
latest follow-up was 0.63 (P , 0.001). Mean difference between
the ROM at 1 year and at latest follow-up was 5 degrees
(P , 0.001).
Fracture Type
For monocondylar type B fractures, 70 patients
sustained a fracture of the lateral condyle (Schatzker 1/2/3)
and 7 (9%) a fracture of the medial condyle (Schatzker 4). No
statistically significant functional differences were observed
when medial and lateral fractures were compared (MWU; P ¼
0.90 and 0.32).
Monocondylar fractures had a statistically better Neer
score compared to bicondylar fractures (MWU; P ¼ 0.04).
Mean Neer score for monocondylar fractures was 93 (40–100)
and for bicondylar fractures, 87 (42–100). No correlation was
found between fracture type, HSS knee score (MWU; P ¼ 0.08),
and Ahlbäck score (MWU; P ¼ 0.57).
Mean Neer and HSS knee score for the most complicated
fracture pattern, AO type 41C3 or Schatzker type 6 fractures
(n ¼ 15, or 14%), was 81.5 (42–94) and 80.2 (25–100),
respectively.
Age at Trauma
Age at time of trauma did not correlate (correlation
coefficient 0.27, P ¼ 0.004) with Neer score or HSS knee
score (correlation coefficient, 0.19; P = 0.043). Also, the
Ahlbäck score did not correlate with age at time of trauma
(MWU; P ¼ 0.25).
Duration of Follow-up
No correlation was found between duration of follow-up
and either Neer or HSS knee score (correlation coefficient, 0.1;
P ¼ 0.29 and 0.04, P ¼ 0.70, respectively). Also, the Ahlbäck
score did not correlate with the duration of follow-up (MWU;
P ¼ 0.88).
Knee Stability
Patients with an anteroposterior laxity greater than or
equal to 10 mm (n ¼ 2) did not have a higher Ahlbäck score
compared to those with a laxity less than 10 mm (n ¼ 107,
MWU; P ¼ 0.08). Patients with a collateral instability of
6 degrees to 9 degrees (n ¼ 9) did not score higher on the
Ahlbäck score compared to those with an instability less than
or equal to 5 degrees (n ¼ 100, MWU; P ¼ 0.08).
Anatomic Reduction
A step-off greater than 2 and less than or equal to 4 mm
(n ¼ 8) did not show a statistically significant difference in
development of secondary osteoarthritis compared to a stepoff
less than or equal to 2 mm (n ¼ 101, MWU; P ¼ 0.43).
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Rademakers et al J Orthop Trauma Volume 21, Number 1, January 2007
None of the patients had an articular step-off greater than 4 mm.
Patients with a condylar widening greater than 5 mm (n ¼ 3)
did not reveal statistically significantly different results compared
to condylar widening less than or equal to 5 mm (n ¼ 106,
MWU; P =0.95).
Axial Alignment
Eighty-three patients (74%) showed equal alignment of
the injured leg compared to the contralateral side, 18 (18%)
showed a valgus or varus malalignment of less than 5 degrees,
and 8 (7.3%), a malalignment between 5 degrees and 10 degrees.
Patients with a malalignment of more than 5 degrees
developed a moderate to severe grade of osteoarthritis statistically
significant more often (27% of the patients) compared to
patients with an anatomic knee axis (9.2%; MWU P ¼ 0.02).
Degree of Secondary Osteoarthritis Versus
Knee Function
Patients without signs of secondary osteoarthritis had
a statistically significantly higher Neer and HSS knee score
compared to patients with moderate to severe development
of secondary osteoarthritis (MWU; P ¼ 0.007, P ¼ 0.001,
respectively).
DISCUSSION
Optimal treatment of tibial plateau fractures has been an
issue of discussion for several decades. 1–31 Extensive research
has been performed analyzing functional and radiologic results
for nonoperative, as well as surgical, treatment methods.
Nonoperative treatment is advised for minimally displaced
closed fractures. Surgical treatment is advised for fractures
with greater than 5 mm displacement or greater than 5 degrees’
instability with varus or valgus stress. During the last decade,
studies analyzing surgically treated tibial plateau fractures
have shown good results. 7,10,13,16,20,29,32,33 However, because
these studies often were small groups of patients or relatively
short-term follow-up, a clear prognosis on long-term outcome
cannot be provided. In this study, we analyzed the long-term
functional and radiologic results of surgically treated (ORIF)
tibial plateau fractures and predictor factors influencing these
results.
Our results show that surgical treatment (ORIF) leads to
excellent functional and radiologic results. Continual monitoring
of these patients made it possible to assess the
progression of the knee function closely. Most patients have
resumed their daily activities as before the trauma and have
regained almost full flexion and extension of the knee joint
1 year after treatment. After an average of 14 years’ follow-up,
excellent results were observed in the majority of these
patients. In comparing short-term to long-term results, the
knee function is not likely to change significantly after 1 year.
Given this fact, we believe that results at 1 year are a good
prognostic indicator for future knee function.
Several predictor variables influencing results after
treatment have been described in the literature. Hsu et al 13
performed a study on 20 surgically treated patients with
a mean age at trauma of 66 years and follow-up of 50 months.
Using the modified Rasmussen score, they found satisfactory
results in 90% of the patients. Their conclusion was that for
elderly patients, the basic principles for surgical treatment are
the same as for young patients, though a more conservatively
orientated rehabilitation program is mandatory. Biyani et al 7
performed a similar study with 32 patients with a mean age at
trauma of 72 years and a mean follow-up of 3.7 years. Using
the Rasmussen score, satisfactory results were observed in
90% of the patients. They concluded that satisfactory results
can be obtained in carefully selected patients. In our study, no
correlation was found between age and functional or radiologic
results; excellent results were obtained in the majority of the
patients through the entire age spectrum.
Our study showed that fracture type influences the
functional results significantly (P ¼ 0.04). Bicondylar fractures
tend to show less favourable, though still good, results
compared to monocondylar fractures. Only a relatively small
percentage of the patients in our study (14%) had the most
complicated fracture pattern, AO type 41C3 or Schatzker type
6 fractures. In our opinion, this is because a great deal of our
study population incurred their fracture years ago when highenergy
traffic accidents were less common. We are aware of
the fact that this relatively low incidence of high-energy fractures
increases the change of skewing the functional outcomes,
though in our study these patients still scored a good result.
Previous studies reported the importance of stability of
the knee after treatment of tibia plateau fractures as one of the
most important predictors for future knee function. 38 This
underlines the main goal of treatment with ORIF, namely, to
create a stable and painless knee joint. Our study showed that
after ORIF, good stability in an anteroposterior, as well as
a mediolateral, direction is obtained in the majority of patients.
No significant correlations were found between stability and
the final results, but this is probably mainly because only
a small number of patients had a significant laxity.
The incidence of soft-tissue injuries in tibial plateau
fractures is high. In a prospective cohort study performed by
Gardner et al 39 103 patients with tibial plateau fractures were
evaluated for soft-tissue injuries by MRI. They found that only
1% showed complete absence of soft-tissue injuries, and
meniscal injuries were present in up to 91% of all patients.
Shepherd et al 40 showed a high prevalence of soft-tissue
injuries even in minimally displaced tibial plateau fractures.
The treatment of these soft-tissue injuries has been a debate for
several decades. It has become commonplace to create a stable
knee, ensuring early exercise and restoration of knee function
and minimizing the development of secondary osteoarthritis in
the long term. Honkonen, 41 in a 1994 article, described posttraumatic
osteoarthritis to be present in 44% of 131 cases.
Patients who underwent a meniscectomy showed a greater
prevalence of posttraumatic osteoarthritis (74%) compared to
patients whose meniscus was reattached (37%), which
furthermore implies the need for repair of soft-tissue damage.
Secondary osteoarthritis remains a problem after intraarticular
fractures of the knee. Marsh et al 38 performed
a review concerning the importance of anatomic reduction
with respect to articular fractures. They found that there is little
rationale for the premise that an anatomic reduction of the
articular surface is associated with obtaining a good clinical
outcome. They also stated that the cartilage injury sustained by
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Operative Treatment of 109 Tibial Plateau Fractures
the initial injury may be the most important factor that leads to
joint degeneration despite accurate reduction. Furthermore,
they underlined the fact that malalignment after treatment
contributes to a poor outcome after tibial plateau fractures.
In our study, a moderate to severe degree of posttraumatic
osteoarthritis was present in 11% of all patients and
varus or valgus malalignment was a good predictor variable
for the development of secondary osteoarthritis. Secondary
arthritis developed in 9.2% of the patients with a near anatomic
knee axis and in 27% of the patients with a malalignment of
5 degrees or more (P = 0.02).
Our results also show a strong correlation between the
development of secondary osteoarthritis and the functional
results at follow-up. Patients with no or mild secondary
osteoarthritis had good to excellent functional results in most
cases, whereas patients with a higher degree of secondary
osteoarthritis have a greater risk of developing less optimal
functional results. However, almost half of the patients with
a moderate to severe grade of secondary osteoarthritis still had
good to excellent functional results.
Wound infections remain a serious problem in the
treatment of tibia plateau fractures, with infection rates ranging
from 3% to 32%. 6,8,14,18,20,22,27,42–44 Barei et al 45 performed
a study analyzing the complications after ORIF with a
2-incision technique in patients with high-energy tibial plateau
fractures. In 8.4% of 83 patients, a deep wound infection developed
that required an average of 3.3 additional procedures to
clinical resolution. They state that with proper timing of the
internal fixation and precise tissue handling, high-energy tibial
plateau fractures can be safely treated by dual plating. In our
study, it became apparent that when both the incision and
amount of metal used were minimized, complications were not
frequent. Less invasive surgery of tibial plateau fractures has
recently been developed to overcome this problem and appears
to show satisfactory early results, with infection rates between
3.7% and 13.3%. 46–48 Future analysis has to prove that the
long-term results with less invasive surgery are equal to those
obtained with formal ORIF.
The authors recognize the retrospective nature of this
study as a limitation but believe that the long-term follow-up
of this large patient population does provide useful information
about ORIF of tibial plateau fractures.
CONCLUSION
In our experience, careful open surgical reduction and
stable internal fixation of tibial plateau fractures shows excellent
functional and radiologic results at long-term follow-up.
Previous literature on this subject has described short- and
medium-term follow-up, but this study shows that the majority
of the patients regain excellent knee function during an average
of 14 years’ follow-up post surgery. Therefore, for patients
with tibial plateau fractures who have a displacement of the
tibial plateau of at least 5 mm or a fracture-related clinical instability
of at least 5 degrees, we recommend treatment by
ORIF. Last, the functional scores of the injured knee 1 year
postoperatively adequately predict future knee function for
years to come.
REFERENCES
1. Carlson DA. Posterior bicondylar tibial plateau fractures. J Orthop
Trauma. 2005;19:73–78.
2. Ebraheim NA, Sabry FF, Haman SP. Open reduction and internal
fixation of 117 tibial plateau fractures. Orthopedics. 2004;27:1281–1287.
3. Piper KJ, Won HY, Ellis AM. Hybrid external fixation in complex tibial
plateau and plafond fractures: an Australian audit of outcomes. Injury.
2005;36:178–184.
4. Katsenis D, Vasilis A, Panayiotis M, et al. Minimal internal fixation
augmented by small wire transfixion frames for high-energy tibial plateau
fractures. J Orthop Trauma. 2005;19:241–248.
5. El Barbary H, Abdel GH, Misbah H, et al. Complex tibial plateau
fractures treated with Ilizarov external fixator with or without minimal
internal fixation. Int Orthop. 2005;29:182–185.
6. Benirschke SK, Agnew SG, Mayo KA, et al. Immediate internal fixation
of open, complex tibial plateau fractures: treatment by a standard protocol.
J Orthop Trauma. 1992;6:78–86.
7. Biyani A, Reddy NS, Chaudhury J, et al. The results of surgical
management of displaced tibial plateau fractures in the elderly. Injury.
1995;26:291–297.
8. Boszotta H, Helperstorfer W, Kolndorfer G, et al. [Long-term results of
surgical management of tibial head fractures]. Aktuelle Traumatol. 1993;
23:178–182.
9. Gausewitz S, Hohl M. The significance of early motion in the treatment of
tibial plateau fractures. Clin Orthop Relat Res. 1986;135–138.
10. Gerich T, Blauth M, Witte F, et al. [Osteosynthesis of fractures of the
head of the tibia in advanced age: a matched-pair analysis]. Unfallchirurg.
2001;104:50–56.
11. Glauser T, Abdel Baki GR, Noesberger B. [Long-term results of
surgically treated tibial plateau fractures]. Helv Chir Acta. 1987;54:477–
481.
12. Honkonen SE. Indications for surgical treatment of tibial condyle
fractures. Clin Orthop Relat Res. 1994;199–205.
13. Hsu CJ, Chang WN, Wong CY. Surgical treatment of tibial plateau
fracture in elderly patients. Arch Orthop Trauma Surg. 2001;121:67–70.
14. Jensen DB, Rude C, Duus B, et al. Tibial plateau fractures: a comparison
of conservative and surgical treatment. J Bone Joint Surg Br. 1990;72:
49–52.
15. Kiefer H, Zivaljevic N, Imbriglia JE. Arthroscopic reduction and internal
fixation (ARIF) of lateral tibial plateau fractures. Knee Surg Sports
Traumatol Arthrosc. 2001;9:167–172.
16. Keating JF. Tibial plateau fractures in the older patient. Bull Hosp Jt Dis.
1999;58:19–23.
17. Koval KJ, Helfet DL. Tibial plateau fractures: evaluation and treatment.
J Am Acad Orthop Surg. 1995;3:86–94.
18. Lachiewicz PF, Funcik T. Factors influencing the results of open reduction
and internal fixation of tibial plateau fractures. Clin Orthop Relat Res.
1990;210–215.
19. Lansinger O, Bergman B, Korner L, et al. Tibial condylar fractures:
a twenty-year follow-up. J Bone Joint Surg Am. 1986;68:13–19.
20. Levy O, Salai M, Ganel A, et al. The operative results of tibial plateau
fractures in older patients: a long-term follow-up and review. Bull Hosp Jt
Dis. 1993;53:15–16.
21. Maheson M, Colton CL. Fractures of the tibial plateau in Nottingham.
Injury. 1988;19:324–328.
22. Moore TM, Patzakis MJ, Harvey JP. Tibial plateau fractures: definition,
demographics, treatment rationale, and long-term results of closed traction
management or operative reduction. J Orthop Trauma. 1987;1:97–119.
23. Porter BB. Crush fractures of the lateral tibial table: factors influencing the
prognosis. J Bone Joint Surg Br. 1970;52:676–687.
24. Rasmussen PS. Tibial condylar fractures: impairment of knee joint
stability as an indication for surgical treatment. J Bone Joint Surg Am.
1973;55:1331–1350.
25. Roberts JM. Fractures of the condyles of the tibia: an anatomical and
clinical end-result study of one hundred cases. J Bone Joint Surg Am.
1968;50:1505–1521.
26. Roerdink WH, Oskam J, Vierhout PA. Arthroscopically assisted
osteosynthesis of tibial plateau fractures in patients older than 55 years.
Arthroscopy. 2001;17:826–831.
27. Schatzker J, McBroom R, Bruce D. The tibial plateau fracture: the Toronto
experience 1968–1975. Clin Orthop Relat Res. 1979;94–104.
q 2006 Lippincott Williams & Wilkins 9

Rademakers et al J Orthop Trauma Volume 21, Number 1, January 2007
28. Scheerlinck T, Ng CS, Handelberg F, et al. Medium-term results of
percutaneous, arthroscopically-assisted osteosynthesis of fractures of the
tibial plateau. J Bone Joint Surg Br. 1998;80:959–964.
29. Stevens DG, Beharry R, McKee MD, et al. The long-term functional
outcome of operatively treated tibial plateau fractures. J Orthop Trauma.
2001;15:312–320.
30. Tscherne H, Lobenhoffer P. Tibial plateau fractures: management and
expected results. Clin Orthop Relat Res. 1993;87–100.
31. Waldrop JI, Macey TI, Trettin JC, et al. Fractures of the posterolateral
tibial plateau. Am J Sports Med. 1988;16:492–498.
32. Houben P, Wijnen R, Wildenberg F. Operatieve behandeling van
tibiaplateaufracturen: resultaten op middellange termijn [Dutch]. Ned
T Geneeskunde. 1995:49–53.
33. Houben PF, van der Linden ES, van den Wildenberg FA, et al. Functional
and radiological outcome after intra-articular tibial plateau fractures.
Injury. 1997;28:459–462.
34. Neer CS, Grantham SA, Shelton ML. Supracondylar fracture of the adult
femur: a study of one hundred and ten cases. J Bone Joint Surg Am. 1967;
49:591–613.
35. Insall JN, Dorr LD, Scott RD, et al. Rationale of the Knee Society clinical
rating system. Clin Orthop Relat Res. 1989;13–14.
36. Ahlbäck S. Osteoarthrosis of the knee: a radiographic investigation. Acta
Radiol Diagn (Stockh). 1968;(Suppl 277):7–27.
37. Marti RK, Verhagen RAW. Upper tibial osteotomy for osteoarthritis of the
knee. Surg Tech Orthop Traumatol. 2001;55:1–6.
38. Marsh JL, Buckwalter J, Gelberman R, et al. Articular fractures: does an
anatomic reduction really change the result? J Bone Joint Surg Am. 2002;
84A:1259–1271.
39. Gardner MJ, Yacoubian S, Geller D, et al. The incidence of soft tissue
injury in operative tibial plateau fractures: a magnetic resonance imaging
analysis of 103 patients. J Orthop Trauma. 2005;19:79–84.
40. Shepherd L, Abdollahi K, Lee J, et al. The prevalence of soft tissue
injuries in nonoperative tibial plateau fractures as determined by magnetic
resonance imaging. J Orthop Trauma. 2002;16:628–631.
41. Honkonen SE. Degenerative arthritis after tibial plateau fractures.
J Orthop Trauma. 1995;9:273–277.
42. Bowes DN, Hohl M. Tibial condylar fractures: evaluation of treatment and
outcome. Clin Orthop Relat Res. 1982;104–108.
43. Duwelius PJ, Connolly JF. Closed reduction of tibial plateau fractures:
a comparison of functional and roentgenographic end results. Clin Orthop
Relat Res. 1988;116–126.
44. Young MJ, Barrack RL. Complications of internal fixation of tibial plateau
fractures. Orthop Rev. 1994;23:149–154.
45. Barei DP, Nork SE, Mills WJ, et al. Complications associated with internal
fixation of high-energy bicondylar tibial plateau fractures utilizing a twoincision
technique. J Orthop Trauma. 2004;18:649–657.
46. Cole PA, Zlowodzki M, Kregor PJ. Less invasive stabilization system
(LISS) for fractures of the proximal tibia: indications, surgical technique
and preliminary results of the UMC Clinical Trial. Injury. 2003;34(Suppl 1):
A16–A29.
47. Schutz M, Kaab MJ, Haas N. Stabilization of proximal tibial fractures
with the LIS-System: early clinical experience in Berlin. Injury. 2003;
34(Suppl 1):A30–A35.
48. Stannard JP, Wilson TC, Volgas DA, et al. Fracture stabilization of
proximal tibial fractures with the proximal tibial LISS: early experience in
Birmingham, Alabama (USA). Injury. 2003;34(Suppl 1):A36–A42.
10 q 2006 Lippincott Williams & Wilkins