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Geriatric tibial plateau fractures: Clinical features and surgical outcomes

Article  in  Journal of Orthopaedic Science · December 2015

DOI: 10.1016/j.jos.2015.09.008

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Journal of Orthopaedic Science

journal homepage: http://www.elsevier.com/locate/jos

Original article

Geriatric tibial plateau fractures: Clinical features and surgical

outcomes
Takaki Shimizu*, Takeshi Sawaguchi, Daigo Sakagoshi, Kenichi Goshima, Kenji Shigemoto,
Yu Hatsuchi
Department of Orthopaedics and Joint Reconstructive Surgery, Toyama Municipal Hospital, 2-1, Imaizumi-Hokubu, Toyama City, Toyama 939-8511, Japan

a r t i c l e i n f o a b s t r a c t

Article history: Background: Operative treatment of geriatric tibial plateau fractures is challenging and controversial.
Received 16 March 2015 There are few studies focusing on the clinical features and operative outcomes of tibial plateau fractures
Received in revised form in the elderly. Hence, this study aimed to investigate the clinical features and operative results of these
28 August 2015
fractures.
Accepted 27 September 2015
Methods: Thirty-three displaced tibial plateau fractures in patients >65 years old (mean age: 72.1 years,
Available online 6 December 2015
range: 65e94 years) were treated operatively. We investigated the mechanisms of injury, fracture types
according to the Schatzker classification, incidences of soft tissue injury, and postoperative complica-
tions. Clinical and radiographic data were analyzed in 23 patients at the last follow-up. The mean follow-
up period was 4.0 years (range: 1e13 years). Twenty-one patients were treated with open reduction and
internal fixation and evaluated using the Rasmussen clinical and radiologic scores. Two patients with
advanced osteoarthritis were treated primarily with total knee arthroplasty and assessed using the
Japanese Orthopaedic Association score for the knee osteoarthritis.
Results: Twenty-four patients (72.7%) were injured by low-energy trauma such as a simple fall. Four
patients had compartment syndrome and required fasciotomies. Rasmussen clinical and radiologic
scores were satisfactory in 85.7% and 81.0% of patients, respectively. Two patients treated primarily with
total knee arthroplasty showed no radiologic abnormality, and their Japanese Orthopaedic Association
scores were both 70 points.
Conclusions: Geriatric tibial plateau fractures, although mostly due to low-energy trauma, were often
accompanied with severe comminution and compartment syndrome. Postoperative results of open
reduction and internal fixation for this population were relatively good. Therefore, primary total knee
arthroplasty should only be considered for well-selected patients.
© 2015 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.

1. Introduction
Fractures of the tibial plateau have the potential to be devas-
tating injuries especially when they have significant displacement,
incongruity, knee instability and soft tissue involvement. Tibial
plateau fractures are relatively common injuries among elderly
patients. The treatment of geriatric tibial plateau fractures poses
additional challenges due to osteoporosis, preexisting degenerative
* Corresponding author. Wajima Municipal Hospital, Ha 1-1, Yamagishi-Machi,
Wajima City, Ishikawa 928-8585, Japan. Tel.: þ81 768 22 2222; fax: þ81 768 23
0634.
E-mail address: takaki.shimizu0928@gmail.com (T. Shimizu).
joint disease and coexisting medical problems [1]. Open reduction
and internal fixation (ORIF) of displaced tibial plateau fractures is
generally accepted as the standard of care in younger patients [2,3].
The problems after ORIF in the elderly include non-weight bearing
for an extended period of time, loss of fixation, medical complica-
tions secondary to immobilization, and post-traumatic arthritis
[4e6]. These difficulties have led several authors to propose the use
of total knee arthroplasty (TKA) for acute management of these
injuries [7e9]. However, few studies have focused on the features
of tibial plateau fractures in the elderly and clinical outcomes
following operative treatment. Therefore, this study aimed to
investigate the clinical features and surgical outcomes of geriatric
tibial plateau fractures.

http://dx.doi.org/10.1016/j.jos.2015.09.008
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2. Materials and methods Table 1

Criteria for Rasmussen clinical assessment.

We retrospectively reviewed 33 patients over the age of 65 years Subjective Points

with displaced tibial plateau fractures treated operatively at our A. Subjective complaints
institution between November 2000 and November 2013. a. Pain
There were 23 women (69.7%) and 10 men (30.3%). The mean No pain 6
age at the time of injury was 72.1 years (range 65e94 years). Occasional pain 5
Constant pain after activity 4
Mechanisms of injury, fracture types according to the Schatzker
Significant rest pain 0
classification [10], soft tissue injuries, and postoperative compli- b. Walking capacity
cations were evaluated. We defined a simple fall as a fall from Normal walking capacity (in relation to age) 6
height less than the standing height and defined high-energy Walking outdoors for at least 1 h 4
Short walks outdoors for >15 min 2
trauma as injuries sustained in a high-impact traffic accident or
Walking indoors only 1
fall from a height greater than the standing height. Simple fractures Wheel-chair/bedridden 0
were defined as type I, type II, and type III fractures according to the B. Clinical signs
Schatzker classification, and complex fractures were specified as a. Extension
type IV, type V, and type VI fractures. Normal 6
Lack of extension (0e10 ) 4
Clinical and radiographic data were analyzed in 23 patients (17
Lack of extension > 10 2
women, 6 men) at the last follow-up. Their mean age at the time of b. Total range of motion
injury was 70.7 years (range 65e88 years) and the mean follow-up 140 6
period was 4.0 years (range 1e13 years). Twenty-one patients were 120 5
treated with ORIF using locking plates except for 2 patients, who 90 4
60 2
were treated with conventional non-locking buttress plates. Allo- 30 0
graft was used in 1 case and b-tricalcium phosphate (OSferion®, c. Stability
Olympus, Tokyo) was used in 15 patients. All patients were advised Normal stability in extension and 20 of flexion 6
to start active and passive range-of-motion exercises on the second Abnormal instability 20 of flexion 5
Instability in extension < 10 4
day after operation. Compliant patients were allowed gradual
Instability in extension > 10 2
partial weight-bearing using crutches 6 weeks after surgery, and Maximum 30
full weight-bearing was permitted 10e12 weeks after surgery. Excellent 27e30
Noncompliant patients were engaged range-of-motion exercises Good 20e26
and muscular strength training for 8 weeks, then protected weight- Fair 10e19
Poor <10
bearing was started with the assistance of a walker.
Clinical and radiological results were evaluated using the Ras-
mussen clinical and radiologic scores [11] (Tables 1 and 2). Satis-
factory results were considered as either excellent or good, and statistically significant association between the magnitude of
unsatisfactory results were defined as either fair or poor. The re- trauma energy and fracture type (Table 3).
lationships between fracture type with energy of trauma, fracture
type with clinical results, and clinical results with radiologic results 3.3. Soft tissue injuries
were analyzed using the chi-square test (c2). Tests were considered
statistically significant if p value is less than 0.05. There were 6 menisci injuries (18.2%) and 2 medial collateral
Two patients with advanced osteoarthritis were primarily ligament injuries (6.1%). Four patients developed compartment
treated by TKA and assessed using the Japanese Orthopaedic As- syndrome and required fasciotomy. Three cases were caused by
sociation (JOA) score for the knee osteoarthritis. low-energy trauma, and 2 of these patients were on anti-coagulant
This study was approved by the institutional review board and therapy at the time of injury (Table 4).
informed consent was obtained from all patients.

Table 2
3. Results Criteria for Rasmussen radiologic assessment.

Subjective Points
3.1. Mechanism of injuries
A. Articular depression
Not present 6
Twelve patients were injured in traffic accidents, 1 experienced <5 mm 4
a fall from a height, 17 sustained simple falls, and 3 had other 6e10 mm 2
mechanisms of injury. Of the 12 patients injured in traffic accidents, >10 mm 0
B. Condylar widening
4 cases sustained low-impact traffic accidents such as being run
Not present 6
over by a very slow-moving vehicle and were regarded as low- <5 mm 4
energy traumas. Hence, there were 9 cases (27.3%) of high-energy 6e10 mm 2
trauma, and 24 cases (72.7%) of low-energy trauma. >10 mm 0
C. Angulation (valgus/varus)
Not present 6
3.2. Fracture types <10 4
10e20 2
>20 0
According to the Schatzker classification, 20 fractures were Maximum 18
simple and 13 were complex; more specifically, this study included: Excellent 18
4 type I, 12 type II, 4 type III, 2 type IV, 6 type V, and 5 type VI Good 12e17
fractures. Ten out of 13 cases (76.9%) with complex fractures Fair 6e11
Poor <6
occurred in the setting of low-energy trauma. There was no

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Table 3 Table 5
Association between energy of trauma and fracture type. There was no statistically Association between fracture type and clinical results. There was no association
significant association between energy of trauma and fracture type. between fracture type and clinical results.

Fracture types Total Clinical results Total

Complex (types IV, V, and VI) Simple (types I, II, and III) Satisfactory Unsatisfactory

Energy of trauma Fracture types

Low 10 14 24 Complex (types IV, V, and VI) 6 2 8
High 3 6 9 Simple (types I, II, and III) 11 2 13
Total 13 20 33 Total 17 4 21

c2 ¼ 0.190; P ¼ 0.663. c2 ¼ 0.297; P ¼ 0.586.

There was no statistically significant association between the

3.4. Postoperative complications
fracture type and clinical results (Table 5), or between clinical and
radiologic results (Table 6).
Two out of 21 patients (9.5%) treated with ORIF had post-
Two patients treated primarily with TKA showed no radiologic
operative loss of reduction, but both patients had articular
abnormality, and their JOA scores were both 70 points.
depression < 4 mm. None of the patients in our series required
conversion to TKA due to progression of osteoarthritis following
ORIF. 3.6. Case presentations

3.5. Radiologic and clinical outcomes
Complete bony unions occurred in all cases. Radiographs at last
follow-up showed mean articular depression of 1.1 mm (0e4 mm),
condylar widening of 1.8 mm (0e9 mm), and angulation of 3.8
(0e14 ). According to the Rasmussen radiologic score, there were 6
excellent, 11 good, 4 fair, and no poor results. The mean Rasmussen
radiologic score was 14.7 of a possible 18 (10e18).
Postoperative mean flexion was 135 (110e150 ) and extension
was 1.8 (10 to 0 ). According to the Rasmussen clinical score,
there were 11 excellent, 7 good, 2 fair, and 1 poor results. The mean
Rasmussen clinical score was 26.7 of a possible 30. Two of 3 pa-
3.6.1. Case 1
An 88-year-old woman fell from standing height and sustained a
Schatzker type II fracture (Fig. 1aeh). Radiographs show lateral and
posterior split fragments. Computed tomography shows lateral
articular depression. Although it was a low-energy trauma, the
patient was accompanied with compartment syndrome and
required fasciotomy. External fixation was applied on the same day.
Table 6
Association between clinical and radiologic results. There was no statistically sig-
nificant association between clinical and radiologic results.
Radiologic results Total

tients had unsatisfactory clinical scores attributed to limited Satisfactory Unsatisfactory

walking capacity caused by preoperatively existing spinocerebellar Clinical results
degeneration and cerebral hemorrhage occurred during the follow- Satisfactory 14 3 17
up period. The other patient developed postoperative osteoarthritis Unsatisfactory 3 1 4
due to progression of valgus deformity which resulted in unsatis- Total 17 4 21

factory clinical score. c2 ¼ 0.114; P ¼ 0.736.

Table 4
Overall results of open reduction and internal fixation.

Patients Age/sex Follow-up Energy of trauma Schatzker Complication Anti-coagulant Radiologic Clinical
(months) classification therapy outcome (score) outcome (score)

1 88/F 31 Low II Compartment syndrome þ Fair (14) Good (27)

2 77/F 13 High I e e Excellent (18) Excellent (27)
3 76/F 68 High III e e Good (16) Excellent (28)
4 75/F 49 Low V e e Good (12) Good (26)
5 74/M 118 Low II e e Good (14) Good (28)
6 72/F 24 Low IV e e Good (16) Poor (22)a
7 70/F 14 High II Loss of reduction (4 mm articular depression) e Good (14) Good (23)
8 69/M 65 High I Compartment syndrome, meniscus injury þ Excellent (18) Excellent (29)
9 69/M 80 High II Meniscus injury, MCL injury e Good (12) Fair (26)b
10 67/F 81 Low VI Compartment syndrome e Fair (10) Excellent (28)
11 67M 22 Low I e e Excellent (18) Excellent (30)
12 67/F 30 Low II e Good (16) Excellent (30)
13 66/M 37 Low V Meniscus injury e Fair (11) Good (25)
14 65/F 84 Low VI e e Good (12) Excellent (29)
15 65/F 17 Low III MCL injury e Good (16) Fair (22)
16 65/M 14 Low V e Excellent (18) Excellent (30)
17 65/F 33 High II Meniscus injury e Good (16) Good (26)
18 65/F 19 High V e þ Fair (10) Excellent (29)
19 70/F 18 Low II Loss of reduction (2 mm articular depression) e Excellent (18) Excellent (29)
20 65/F 35 High II e e Excellent (18) Excellent (29)
21 65/F 45 Low VI Compartment syndrome e Good (12) Good (25)

ORIF open reduction and internal fixation, TKA total knee arthroplasty, MCL medial collateral ligament.
a
Unsatisfactory clinical score attributed to limited walking capacity caused by cerebral hemorrhage.
b
Unsatisfactory clinical score attributed to limited walking capacity caused by spinocerebellar degeneration.

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 T. Shimizu et al. / Journal of Orthopaedic Science 21 (2016) 68e73
Fig. 1. Case 1. a, b An 88-year-old woman fell from standing height and sustained a
Schatzker type II fracture. c, d, e Computed tomography: posterolateral split fragment,
lateral articular depression, collapsed fracture site. f, g, h Three years postoperatively:
no articular depression, no condylar widening, FTA 161 (14 valgus deformity
compared with contralateral side).
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71
After gaining soft tissue recovery, open reduction and internal
fixation was performed. First, we elevated impacted articular sur-
face and fixed with rafting plate. Then, we approached poster-
omedially and fixed posterior fragment with buttress plate.
Radiographs 3 years after surgery show no articular depression or
condylar widening nor osteoarthritic change. However, there re-
mains 14 valgus deformity. Therefore, radiologic score is Fair but
clinical score is Good.
3.6.2. Case 2
An 84-year-old woman fell from standing height and sustained a
Schatzker type V fracture (Fig. 2aef). Radiographs show bicondylar
fracture with advanced osteoarthritis. Computed tomography
shows bicondylar fracture, medial articular depression. This case
was primarily treated by total knee arthroplasty. Full weight
bearing was started at 4 weeks after surgery. Radiographs 5 years
after surgery show no radiologic abnormality and the JOA score is
70 points.
4. Discussion
Treatment of geriatric tibial plateau fractures is challenging
despite improved surgical techniques and increased variety of fix-
ation systems due to osteoporosis, concomitant joint degeneration,
and increased surgical complication risk.
We selected patients >65 years of age because there is signifi-
cant reduction in bone mineral density of the proximal tibia in
women >60 years old [12]. In our study, more fractures occurred in
women (69.7%) and were caused by low-energy trauma (72.7%),
while most prior studies of the elderly had a higher proportion of
men and high-energy trauma cases [1,13e15]. Therefore, we believe
that our study more accurately reflects the clinical features of most
geriatric tibial plateau fractures due to bone fragility and soft tissue
instability.
Although most injuries resulted from low-energy trauma, there
were high percentages of Schatzker type IV, V, and VI fractures with
severe comminution or compartment syndrome. There were no
statistically significant associations between the energy of trauma
and fracture type or between fracture type and clinical results.
These findings indicate that the Schatzker fracture classification
was not predictive of the energy of the trauma or clinical outcomes
in elderly patients. In young patients, higher Schatzker classes
occur in the setting of high-energy trauma, and higher fracture
classification is thought to predict poorer outcomes. However,
decreased bone strength in geriatric tibial plateau fractures may
decrease the relevance of the Schatzker classification [1].
Prior studies report that ligamentous or meniscal injuries are
less common in elderly patients, whereas the incidence of liga-
mentous injury is 20e70% and meniscal injury is 20e90% in
younger adults [16e19]. Hsu reported that, in fractured osteopo-
rotic bones in the elderly, osteoporotic bone tissue absorbs most of
the mechanical energy in trauma, resulting in much less ligamen-
tous or meniscal injury [13]. Similar to prior studies, we had lower
incidence of ligamentous or meniscal injuries. However, we had
relatively high frequency of compartment syndrome. Patients on
anti-coagulant therapy should be carefully monitored for signs of
developing compartment syndrome.
Prior studies focusing on the results of ORIF of tibial plateau
fractures in elderly patients had 60e90% satisfactory results using
radiographic and clinical criteria [1,13e15,20,21]. In our study,
clinical and radiologic outcomes were satisfactory in 85.7% and
81.0% of patients, respectively. There was no significant association
between clinical and radiologic outcomes, similar to previous re-
ports [1,15,20]. This may reflect the tibial plateau's tolerance of in-
congruity [22] and that ligaments and menisci are often preserved in
72 T. Shimizu et al. / Journal of Orthopaedic Science 21 (2016) 68e73

low-energy trauma. This finding also highlights the limitation of the

Rasmussen radiologic score; this scoring method does not consider
the location of the articular depression or the extent of joint surface
involved [1]. There were some cases of persistent valgus or varus
deformity due to difficulty in obtaining perfect reduction of severely
comminuted fracture patterns or collapsed fracture sites. In order to
minimize deformity, the surgeon needs to reconstruct large bony
defects in severely collapsed fractures in the elderly. It is important
to focus on achieving alignment of the lower extremity, and not
solely focus on articular surface reduction.
Loss of reduction is common following fixation of fractures of
the tibial plateau and occurs in 30e79% of elderly adults [21,23].
The significant associations with loss of reduction are age > 60
years, premature weight-bearing, osteoporosis, comminution, and
significant initial displacement [23]. Most prior studies have used
non-locking plates or screws alone for fixation. In our series, lock-
ing plates were used in all cases except for 2, and only 2 (9.5%)
patients had slight loss of reduction. Locking plates provide better
fixation and lead to less reduction failure. Loss of reduction or
inadequate reduction and fixation may result in progression of
arthritis and occasionally require TKA. Rates of conversion to TKA
are relatively low, ranging from 0% to 7.9% in short term follow-up
(2.6e5.1 years) [1,15,20,21]. There was no case requiring conversion
to TKA in our study.
The limitations of ORIF in the elderly include non-weight-
bearing for long period of time, loss of reduction due to poor
bone quality, medical complications secondary to immobilization,
possibility of conversion to TKA for post-traumatic arthritis, and
poor outcomes of TKAs performed as secondary procedures
following initial treatment with ORIF [4e6]. Some cases of geriatric
tibial plateau fractures are associated with advanced arthritis.
These difficulties have led several authors to promote the use of
TKA in the acute management of these injuries for early weight-
bearing, improved results, and avoidance of further procedures
[7e9]. It is not easy to clarify the indication for the management of
geriatric tibial plateau fractures because there are wide varieties
among individuals, such as biological age, pre-injury activity,
compliance, bone quality and degree of comminution. Hence, we
need to decide the treatment taking these factors into consider-
ation. Basically, ORIF is the first choice given the relatively good
outcomes of ORIF for geriatric tibial plateau fractures reported in
the literature and our study. However, primary TKA is indicated
those with advanced osteoarthritis or unreconstructable severe
comminution [24]. On the other hand, surgery is rarely indicated
for bed ridden patients.
The limitations of this study include small sample size, relatively
short-term follow-up and we have not assessed pre- and post-
operative functional changes.
In conclusion, many geriatric tibial plateau fractures, although
mostly due to low energy trauma, may be accompanied by severe
comminution and compartment syndrome. Patients on anti-
coagulant therapy should be carefully examined for compartment
syndrome. Surgical outcomes of ORIF for geriatric tibial plateau
fractures were relatively good, and primary TKA should be
considered only for well-selected patients.

Conflict of interest

The authors declare that they have no conflict of interest.

Fig. 2. Case 2. An 84-year-old woman fell from standing height and sustained a
Schatzker type V fracture. a, b Preoperative radiographs: bicondylar fracture, advanced
osteoarthritis. c, d Computed tomography: bicondylar fracture, medial articular References
depression. e, f Radiographs 5 years after primary total knee arthroplasty: no radiologic
abnormality.
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