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Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Combined plate and nail fixation of bicondylar tibial plateau fractures

David J. Wright a, Brent Etiz b, John A. Scolaro c,∗
a
Orthopaedic Resident, University of California, Irvine. Orange, CA USA
b
Medical Student, University of California, Irvine. Irvine, CA USA
c
Associate Professor, University of California, Irvine, 101 The City Drive South, Building 29A, Pavilion III – 2nd Floor, Irvine, Orange, CA, 92868, USA

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

Article history: Introduction: Bicondylar tibial plateau fractures with meta-diaphyseal comminution commonly have a
Accepted 4 July 2021 compromised soft tissue envelope. Combined plate-nail fixation is an emerging technique that utilizes
Available online xxx
a limited anterolateral approach for plate application and percutaneous incisions for placement of an
Keywords: intramedullary nail. This technique alleviates the need for a separate medial approach to the proximal
Bicondylar plateau tibia. We report a series of patients treated with this approach and outline the steps for implementation.
Tibia Methods: We performed a retrospective review of 18 consecutive patients treated with combination lat-
Plate
eral locked plating and intramedullary nailing at a single academic institution from 2016 to 2019. Of
Nail
these, 16 patients met inclusion criteria and were included in this study. All patients had AO/OTA type
41C2/C3 fractures. Primary outcomes included coronal plane and sagittal plane alignment at latest follow
up, rate of articular subsidence at latest follow up, and rate of postoperative infection.
Results: Of the 16 patients included, average followup was 8.2 months (range 0.1-29.7 months). At latest
follow-up, average coronal alignment ranged from 0.8±1.2 degrees of varus (maximum 4.0 degrees) to
1.4±1.7 degrees of valgus (maximum 4.0 degrees). Average sagittal alignment ranged from 0.8±1.1 de-
grees of procurvatum (maximum 3.0 degrees) to 0.6±1.2 degrees of recurvatum (maximum 4.0 degrees).
There was no radiographic evidence of articular subsidence at latest follow up for any patient. One pa-
tient (5.9%) presented at 141 days postoperatively with a draining wound and infection.
Conclusions: Combination plate-nail fixation is a viable option for treating patients with select bicondylar
tibial plateau fractures with meta-diaphyseal comminution. This case series with short-term followup
demonstrates acceptable radiographic and clinical outcomes, as well as rates of postoperative infection
and implant removal similar to those currently reported in the literature for other techniques used to
treat these fractures.
© 2021 Elsevier Ltd. All rights reserved.

Introduction
Bicondylar tibial plateau fractures are complex injuries. Treat-
ment goals include anatomic reconstruction of the articular sur-
face, restoration of coronal and sagittal plane alignment, and stable
fixation allowing for immediate range of motion. Many bicondylar
plateau fractures are the result of high energy trauma, and man-
agement of the soft tissue envelope is critical in order to avoid
complications.
Currently, many high energy tibial plateau fractures are treated
in a staged manner. Initial external fixation is followed by ad-
vanced radiographic evaluation and surgical planning [1–4]. Timing
of definitive surgical fixation is determined by the readiness of the
∗
Corresponding author.
E-mail address: jscolaro@hs.uci.edu (J.A. Scolaro).
soft tissues for the desired surgical approach(es). The anterolateral
approach is frequently used for fixation of bicondylar patterns, but
controversy remains regarding indications for a concurrent medial
or posteromedial approach. Initial results following use of the dual
incision technique reported an unacceptably high complication rate
[5]. More contemporary studies report a complication rate between
8-23% [1,6–8].
The combined use of a proximal tibial plate and intramedullary
nail has been described for the fixation of noncontiguous uni-
condylar tibial plateau and shaft fractures [9]. To our knowledge,
concurrent tibial plate and intramedullary nail fixation of intra-
articular bicondylar tibial plateau fractures, AO/OTA types 41C2/C3,
has not been described in the literature. This technique utilizes a
relatively small anterolateral surgical approach for reduction and
fixation of the articular surface with a proximal tibial locking plate,
followed by percutaneous placement of an intramedullary nail.

https://doi.org/10.1016/j.injury.2021.07.010
0020-1383/© 2021 Elsevier Ltd. All rights reserved.

Please cite this article as: D.J. Wright, B. Etiz and J.A. Scolaro, Combined plate and nail fixation of bicondylar tibial plateau fractures,
Injury, https://doi.org/10.1016/j.injury.2021.07.010
JID: JINJ
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D.J. Wright, B. Etiz and J.A. Scolaro
Fig. 1. Anteroposterior (A) and lateral (B) radiographs of a 41-year-old male in-
volved in a motorcycle collision showing a proximal tibia fracture with metaphyseal
comminution and a depressed lateral plateau.
This technique eliminates the need for a medial surgical approach
and fixation by providing intramedullary support to resist varus
failure. One of the primary advantages of the technique is preser-
vation of the subcutaneous medial soft tissue envelope, which is
commonly traumatized. The limited surgical footprint needed for
lateral plate and intramedullary nail placement may decrease the
complication rate associated with use of a standard dual inci-
sions approach. Furthermore, the time between injury and defini-
tive treatment may be shortened, expediting rehabilitation and de-
creasing hospital length of stay. In this study, we describe our sur-
gical technique and experience in a series of 18 consecutive pa-
tients treated with combined pre-contoured lateral locked plat-
ing and intramedullary nailing for intra-articular bicondylar tibial
plateau fractures.
Surgical technique
Pre-operative evaluation
Initial evaluation of any patient with a bicondylar tibial plateau
fracture begins with an appropriate history and physical examina-
tion. A full neurovascular examination of the limb is mandatory
and should be documented. Given the high-energy nature of many
of these injuries, particular attention should be given to evaluation
of the associated soft tissue injury as well as signs and/or symp-
toms of compartment syndrome. Standard anteroposterior (AP) and
lateral radiographs of the affected extremity are then be obtained
(Fig. 1A-B). For length-unstable injuries, we employ a staged man-
agement protocol beginning with application of a knee-spanning
external fixator. Following restoration of limb length, alignment,
and rotation with the use of an external fixator, a postoperative
CT is obtained to further evaluate the fracture morphology and aid
in pre-operative planning for definitive fixation.
Selection for combined plate nail fixation is based on multi-
ple factors. First, the technique is considered when there has been
marked injury to the soft tissues about the proximal tibia that
may delay or prohibit a medial-sided exposure. In closed fractures,
soft tissue injuries commonly manifest as abrasions, ecchymosis, or
subcutaneous degloving (Fig. 2A-B). The subcutaneous position of
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Fig. 2. Clinical photos showing lateral (A) and medial (B) soft tissues following ini-
tial external fixation. The medial soft tissue envelope was characterized by marked
abrasions and a subcutaneous degloving injury.
the anteromedial surface of the tibia results in added risk for soft
tissue complications following definitive fixation utilizing a medial
approach. Therefore, evaluation of the anteromedial soft tissues is
one of the critical factors in selecting patients for combined plate-
nail fixation.
Next, close evaluation of the AP and lateral radiographs is per-
formed. Bicondylar tibial plateau fractures with metaphyseal com-
minution and relatively simple intra-articular pathology are ideal
candidates for this technique. Furthermore, patterns that have a
large medial plateau fragment are ideal. Knee fracture dislocations
in which there is a medial plateau fragment that requires a direct
anatomic reduction and fixation with a medial sided buttress plate
are not desirable patterns for this technique.
Axial, coronal, and sagittal CT imaging is then closely evaluated
(Fig. 3A-C). The anterior aspect of the proximal tibia is evaluated
to ensure that the anticipated intramedullary nail start point is not
within a zone of comminution, contiguous with a displaced artic-
ular fragment on either the medial or lateral plateau, or in a posi-
tion that may induce malreduction. Next, the anterior tibial cortex
and tibial tubercle are evaluated to ensure that the nail will not
displace these fragments (when present) or prevent maintenance
of nail position within the proximal segment. Finally, the medial
plateau is carefully evaluated. As noted, if a posteromedial frac-
ture fragment is displaced or the size/morphology is such that it
cannot be adequately captured by a laterally based proximal tib-
ial locking plate, then a separate medial approach and implant is
indicated [10]. A posteromedial fracture fragment does not neces-
sarily preclude fixation with a plate and nail. However, if a for-
mal approach is made on the medial side, then fixation will com-
monly proceed with a plate, alleviating the need for an additional
intramedullary implant. Relative indications and contraindications
to plate-nail fixation of bicondylar tibial plateau fractures are sum-
marized in Fig. 4.
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Fig. 3. Axial (A), sagittal (B) and coronal (C) computed tomography images showing lateral plateau depression and bicondylar involvement of the fracture.
Fig. 4. Relative indications and contraindications when considering combined plate-nail fixation of intra-articular proximal tibia fractures.
Surgical fixation
At the time of surgical fixation, general anesthesia with phar-
macologic skeletal relaxion is administered. The patient is posi-
tioned supine on a radiolucent table with a bump under the ipsi-
lateral ischium. If the patient has previously been placed in an ex-
ternal fixator, the clamps and bars are removed, and the half pins
are left in place for possible use with an intraoperative external
fixator or universal distractor. After preparation and draping of the
leg, fixation commences with a standard anterolateral approach to
the proximal tibia including a sub-meniscal window, if needed, for
direct visualization of the articular reduction. Fixation priority is
given to the articular surface. Any direct articular reduction of the
lateral plateau can be performed from this approach (Fig. 5A-B).
If a medial-sided injury is amenable to percutaneous clamp place-
ment and/or fixation, this is subsequently performed following lat-
eral articular reduction. All provisional or definitive fixation should
be placed in a subchondral location, outside of the anticipated pre-
contoured plate or intramedullary nail position.
Next, a standard anterolateral proximal tibial locking plate is
placed in a submuscular fashion along the anterolateral surface of
the tibia (Fig. 5C). The length of the plate should span the meta-
physeal comminution by a minimum of three holes. Direct or in-
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direct reduction techniques are then used to restore length align-
ment and rotation to the extra-articular metaphyseal/diaphyseal
component of the fracture. Proximal fixation then occurs in the
most proximal row of the plate. Locking or nonlocking screws can
be utilized based on surgeon preference, fracture morphology, and
bone quality. Distally, unicortical locking or nonlocking screws are
placed in a percutaneous manner into the lateral cortex of the tib-
ial diaphysis. If the plate is utilized to assist in the reduction of
the tibial shaft, a bicortical screw can be used initially and then
exchanged for a unicortical screw prior to nail placement. A mini-
mum of two distal screws are required for provisional fixation.
After both intra-articular and extra-articular reduction have
been achieved and provisional plate fixation is complete, the in-
tramedullary nail is placed. The authors prefer a semi-extended
approach to minimize manipulation of the limb, decrease the
procurvatum deformity commonly seen in proximal tibia fracture
patterns with hyperflexion of the knee, and provide a percuta-
neous approach which is relatively remote from the zone of injury
compared to an infra-patellar technique. The knee is placed over
a small radiolucent triangle or bump and a standard suprapatellar
incision is made (Fig. 5D). The extended entry cannula is placed
in a retropatellar fashion and tibial nailing proceeds with stan-
dard placement of the starting guidewire, proximal entry reamer,
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Fig. 5. Intraoperative lateral fluoroscopic images of the proximal tibia showing initial joint depression (A), elevation of the joint surface with a curved bone tamp (B),
provisional subchondral wire placement and positioning of lateral proximal tibia plate (C) and initiation of tibial nailing with three posterior screws within top row of plate
and unicortical shaft screws.

Fig. 6. Fluoroscopic views showing tibial nail placement (A) as well as AP (B) and lateral (C) fluoroscopic images showing completion of fixation with the remainder of
proximal-row screws and conversion of distal unicortical shaft screws to bicortical shaft screws placed anterior to the nail.

ball tipped guidewire, and medullary reamers. Once the nail length
and diameter have been selected, the nail is then passed over the
guidewire and positioned to the desired depth. In most cases our
preference is to place the nail such that the proximal end of the
nail lies just distal to the proximal row of screws in the plate. Af-
ter nail placement, proximal interlocking bolts are placed in the
available positions. A minimum of two bolts, positioned along dif-
ferent axes, are recommended (Fig. 6A). Distally, the nail is locked
statically.
Once the nail has been placed, the remaining screws in the
proximal row of the plate are placed in standard fashion. Addi-
tional distal screws within the metaphyseal section of the plate can
be placed around the nail, if desired. Finally, the distal unicortical
screws are revisited. A lateral fluoroscopic view of the distal end
of the plate is obtained. When possible, one or more of the unicor-
tical screws is converted to a bicortical nonlocking screw directed
anterior or posterior to the nail (Fig. 6B-C). Final fluoroscopic ra-
diographs are then obtained, and the knee joint and surgical in-
cisions are thoroughly irrigated (Fig. 7A-C). Closure is performed
according to the surgeon’s preference. If half pins remain in the
femur or tibia they are removed at this time and sterile dressings
are placed.
Post operatively, the patient is placed in a soft dressing. Periop-
erative antibiotics and chemical venous thromboembolic prophy-
laxis are given as indicated. We utilize a protocol that allows for
immediate range of motion of the knee. Weight bearing is initiated
based on degree of articular injury. Generally, patients remain non-
weight bearing for 6 – 12 weeks and are subsequently progressed

4
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Fig. 7. Final AP (A) and lateral (B) plain radiographs showing final plate and nail fixation construct. Clinical image (C) showing limited anterolateral approach and percuta-
neous incisions utilized for fixation.
to full weight bearing (Fig. 8). The broad steps of the surgical tech-
nique are summarized in Fig. 9.
Case series
Methods
We performed a retrospective review of consecutive patients
with proximal tibia fractures treated with this technique at a single
academic institution from 2016 to 2020. Institutional Review Board
Approval was obtained for this study. Exclusion criteria included
extra-articular fracture patterns (AO/OTA 41A-type fractures) and
fractures treated with adjunctive mini fragment plate(s) or an iso-
lated rim-plate in addition to intramedullary nailing. A total of 18
patients met inclusion criteria. Two patients were excluded after
further radiographic review deemed their injuries to be predom-
inantly extra-articular fracture patterns (AO/OTA type 41A frac-
tures). The remaining 16 patients were included in the study. Pri-
mary outcomes included coronal plane and sagittal plane align-
ment at latest follow up, rate of articular subsidence at latest fol-
low up, and rate of postoperative infection. Alignment measures
were based on the best available AP and lateral radiographs at lat-
est follow up for each patient. As most patients did not have x-
rays of the contralateral uninjured extremity, 3 degrees of proximal
tibial varus and 7 degrees of posterior tibial slope were used as
reference values. Varus/valgus and procurvatum/recurvatum were
measured relative to these reference values. Secondary outcomes
included time to temporizing fixation, time to definitive fixation,
rate of compartment syndrome, estimated blood loss during defini-
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tive fixation, weightbearing restrictions after surgery, knee range of
motion and incidence of knee pain at latest follow up, rate of ra-
diographic union, time to radiographic union, and rate of implant
removal. Radiographic union was defined as bridging callus seen
on at least 3 of 4 corticies assessed by AP and lateral views. Other
patient and demographic factors including age, gender, BMI, frac-
ture classification, open fracture, and smoking status were also in-
cluded.
Results
Sixteen patients were included in the final analysis (7 fe-
males, 9 males, average age 52.1±17.4 years old). Average BMI was
26.4±4.2 kg/m2 . Six patients were active smokers at the time of in-
jury. There were 8 AO/OTA type 41C2 fractures and 8 AO/OTA type
41C3 fractures. There were 3 open fractures. There were no cases
of compartment syndrome. Thirteen patients underwent temporiz-
ing external fixator placement at an average of 0.92 days after in-
jury (range 0-2 days). The remaining 3 patients were managed in
long leg splint or knee immobilizer until definitive fixation. Aver-
age time to definitive fixation was 6.3±3.6 days after injury (range
2-17 days). Average estimated blood loss was 306±144ml.
Average follow up was 8.2 months (range 0.1-29.7 months). At
latest follow-up, average coronal alignment ranged from 0.8±1.2
degrees of varus (maximum 4.0 degrees) to 1.4±1.7 degrees of
valgus (maximum 4.0 degrees). Average sagittal alignment ranged
from 0.8±1.1 degrees of procurvatum (maximum 3.0 degrees) to
0.6±1.2 degrees of recurvatum (maximum 4.0 degrees). There was
no radiographic evidence of articular subsidence at latest follow up
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Fig. 8. AP (A) and lateral (B) radiographs at final one year follow up showing main-
tenance of reduction and complete fracture healing.
for any patient. One patient (5.9%) who initially presented with an
Oestern and Tscherne 3 closed injury treated initially with knee
Fig. 9. Surgical flowchart outlining the steps of the surgical technique beginning with articular reduction, followed by metaphyseal reduction, anterolateral plate fixation,
nail placement, and completion of plate fixation.
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immobilizer and definitively fixed 10 days later, presented at 141
days postoperatively with a draining wound and infection. This was
treated with debridement and irrigation, removal of implants, and
medial gastrocnemius flap. There were no other infections in this
series.
All patients were initially made non-weightbearing on the oper-
ative extremity except for one polytraumatized 88-year-old patient
who was made weightbearing as tolerated immediately follow-
ing definitive fixation. This patient subsequently died of associated
traumatic injuries on postoperative day 9. Knee range of motion
data was available for 11 patients at latest follow up with an aver-
age of 112±29 degrees total arc of motion. Seven patients (41.1%)
had persistent knee pain at latest follow up ranging from 2/10-7/10
on the visual analog scale. Two patients (11.7%) underwent subse-
quent implant removal (one for infection as discussed above, and
one for symptomatic proximal interlocking screws). One patient
(5.9%) developed arthrofibrosis of the knee joint and subsequently
underwent arthroscopic lysis of adhesions 2 years after definitive
fixation. Knee range of motion for this patient at latest follow up
was 0-125 degrees. One patient (5.9%) developed a postoperative
deep venous thrombosis in the common femoral vein without ev-
idence of pulmonary embolism on CT angiogram. One additional
patient (5.9%) developed a pulmonary embolism on hospital day 2.
Both were treated with therapeutic anticoagulation without subse-
quent development of postoperative hematoma or bleeding issues.
Ten patients had at least 3-month follow up. Of these, all achieved
radiographic union at an average of 132 days postoperatively and
were allowed to begin weightbearing as tolerated at an average of
87 days postoperatively.
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Discussion
The combined use of plates and nails have been described pre-
viously in tibial injuries where a proximal plateau and more distal
shaft fracture co-exist but do not communicate [9]. The combined
use of a periarticular proximal tibia plate and nail in the proximal
tibia for bicondylar fractures has yet to be described to our knowl-
edge. We have utilized this technique in 16 patients with AO/OTA
41C2/C3 bicondylar tibial plateau fractures. In these patterns, the
intramedullary nail functions to support metaphyseal comminu-
tion, prevent varus collapse and act as a surrogate for a medial sur-
face implant. The technique is especially useful in injuries where
medial support is desired, and a medial surgical approach and im-
plant placement is undesirable due to associated soft tissue injury.
In addition, this technique preserves the periosteum and soft tis-
sue along the medial side of the subcutaneous proximal tibia and
avoids the need for a surface implant in an area that can be highly
symptomatic for patients.
The necessity for a medial approach and support in biocondylar
tibial plateau fractures continues to be the subject of debate. Early
biomechanical studies provided information on both the ability of
lateral locking plates to support the medial plateau, and the rela-
tive support gained by a medial implant [11,12]. This has also been
evaluated clinically in multiple studies [13,14]. Unfortunately, pat-
tern variance in bicondylar tibial plateau fractures makes it diffi-
cult to definitively state which injuries are adequately treated with
a single lateral locking plate, and which require dual plate fixation.
Implementation of the combined plate and nail technique is con-
sidered with fractures in which metaphyseal comminution or lack
of osseous contact along the medial tibial column increase the risk
of varus failure. In extra-articular proximal tibia fractures, locking
tibial intramedullary nails have been compared to dual plate con-
structs in both biomechanical and finite element analyses [15,16].
No study to date has compared the relative difference between an
anterolateral plate and tibial nail construct to a dual plating con-
struct as described here.
Apart from the benefits to fracture stability, preservation of the
soft tissues around the proximal tibia is another proposed bene-
fit of this technique. Although many bicondylar tibial plateau frac-
tures are treated in a staged manner, the period of time between
external fixation and definitive fixation is highly variable and may
be prolonged if multiple approaches are needed. Select bicondy-
lar tibial plateau fractures may be amenable to immediate fixation
[17,18]. Using only a limited anterolateral approach and additional
percutaneous incisions for implant placement, this technique may
expedite definitive care of some injuries. In addition, it has been
shown that some fractures of the tibial plateau are amenable to an
immediate weight bearing protocol [19]. With stable articular fixa-
tion and an intramedullary nail in place, this technique may create
an opportunity for earlier weight bearing in some fractures as the
nail is positioned directly in line with the mechanical axis of the
limb.
Utilization of the combined plate-nail technique can be limited
by individual fracture patterns. Careful pre-operative radiographic
evaluation of the injury is essential. Anatomic articular reduction
and stable metaphyseal fixation are prioritized. As such, if the nail
start point, placement, or fixation compromises either goal, then
the technique is not recommended. Relative construct cost must
also be considered with the use of an intramedullary nail instead
of a medial plate and screw construct. This difference varies by
implant, manufacturer, and institutional financial agreements. Ad-
ditionally, the technique requires additional procedural considera-
tions for most surgeons. However, minimally invasive plate fixation
of proximal tibia fractures and intramedullary tibial nailing are fa-
miliar.
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Injury xxx (xxxx) xxx
In conclusion, use of a combined proximal tibial plate and
intramedullary nail for select bicondylar tibial plateau fractures,
specifically those with simple intra-articular involvement and me-
dial comminution, is a safe and effective technique. The technique
can be especially beneficial when preservation of the medial soft
tissue envelope is desired. This case series with short-term follow
up demonstrates acceptable radiographic and clinical outcomes, as
well as rates of postoperative infection and implant removal sim-
ilar to those currently reported in the literature for other tech-
niques used to treat these fractures. Future work will focus on the
benefit of this construct to fixation strength, as well as the effect it
may have on timing of definitive surgery and patient weight bear-
ing.
Declaration of Competing Interest
None.
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