Surgical Management of Proximal Tibial Fracture With Locking Compression Plate.”

“SURGICAL MANAGEMENT OF PROXIMAL TIBIAL FRACTURE
WITH LOCKING COMPRESSION PLATE.”

by
DR.RAJESH.P M.B.B.S
Dissertation Submitted to the

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore,
in partial fulfillment of the requirements for the degree of
MASTER OF SURGERY
IN
ORTHOPAEDICS
Under the guidance of
Dr.SATISH KUMAR.C, M.B.B.S, M.S.ortho

Professor
DEPARTMENT OF ORTHOPAEDICS
VYDEHI INSTITUTE OF MEDICAL SCIENCES & RESEARCH CENTRE
#82,EPIP Area,Nallurahalli,Whitefield, Bangalore – 560066, INDIA.
2012
I
DECLARATION BY THE CANDIDATE
I hereby declare that this dissertation entitled “SURGICAL MANAGEMENT OF
PROXIMAL TIBIAL FRACTURE WITH LOCKING COMPRESSION PLATE.”
is a bonafide and genuine research work carried out by me under the guidance of
DR.SATISH KUMAR.C M.B.B.S, M.S.Ortho, Professor, department of orthopaedics,
Vydehi Institute of Medical Sciences & Research Centre, Bangalore.
Date: Signature of the Candidate
Place: Bangalore. Dr.RAJESH.P
II
CERTIFICATE BY THE GUIDE
This is to certify that the dissertation entitled “SURGICAL MANAGEMENT
PROXIMAL TIBIAL PLATEAU FRACTURE WITH LOCKING
COMPRESSION PLATE” is a bonafide research work done by Dr.RAJESH.P in
partial fulfillment of the requirement for the degree of M.S. ORTHOPAEDICS.
Date: Signature of the Guide
Place: Bangalore Dr.SATISH KUMAR.C M.B.B.S, M.S.Ortho

Professor
Department Orthopaedics
VIMS & RC.
III
ENDORSEMENT BY THE HOD, PRINCIPAL/HEAD OF THE
INSTITUTION
This is to certify that the dissertation entitled “SURGICAL
MANAGEMENT OF PROXIMAL TIBIAL PLATEAU FRACTURE WITH
LOCKING COMPRESSION PLATE.” is a bonafide research work done by
Dr.RAJESH.P under the guidance of Dr.SATISH KUMAR.C M.B.B.S, M.S.Ortho
Professor , Department of orthopaedics Vydehi Institute of Medical Sciences & Research
Centre, Bangalore.
Signature of Head of the Department Signature of the Principal
Dr. , Dr.MURALIDHAR.N Dr. M.R.Sandhya Belwadi MD.

B.SC, M.B.B.S, M.S, D(Ortho), Principal
Professor,&HOD VIMS & RC.
Department Orthopaedics
VIMS & RC.
Date: Date:
Place:BANGALORE Place:BANGALORE
IV
COPYRIGHT
Declaration by the Candidate
I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka shall
have the rights to preserve, use and disseminate this dissertation in print or electronic
format for academic / research purpose.
Date : Signature of the Candidate

Place: Bangalore Dr.Rajesh.p
© Rajiv Gandhi University of Health Sciences, Karnataka
V
ACKNOWLEDGEMENT
When going gets tough : tough gets going ………..
This is how it unveiled and ended with smiles ……
I thank the Lord, ALMIGHTY for giving me the strength to perform all my duties.
At the onset, I thank all my patients who formed the back bone of this study without
whom this study would not have been possible.
It is indeed a great pleasure to recall the people who have helped me in completion of
dissertation. Naming all the people who have helped me in achieving this goal would be
impossible, yet I attempt to thank few, who have helped me in diverse ways.
It gives me immense pleasure to express my deep sense of gratitude and indebtedness that
I feel towards my teacher and guide Dr.SATISH KUMAR.C M.S.Ortho. Professor,
Department of Orthopaedics, VYDEHI INSTITUTE OF MEDICAL SCIENCES
&RESEARCH CENTRE for his valuable suggestions, guidance, great care and attention
to detail that he has so willingly shown in the preparation of this dissertation.
I acknowledge and express my humble gratitude and sincere thanks to my beloved
teacher, Dr.MURALIDHAR.N B.SC.M.B.B.S. M.S, D(Ortho), Professor and H.O.D.,
Department VYDEHI INSTITUTE OF MEDICAL SCIENCES &RESEARCH CENTRE
of Orthopaedics, for his constant help to undertake this study.
I owe a great deal of respect and gratitude to Dr.VISHWANATH.M.S. Professor,
VI
Dr.HIRANYA KUMAR, Professor, Dr.VIJAY KUMAR, Professor, for their.scholarly
suggestions and allround encouragement.
I am also thankful to,Dr.GIRISH.(M.S.Ortho), Dr. C.B.PATIL(M.S.Ortho),
Dr.SIDDALINGESHWAR.V.H(D.N.B.ortho), Dr.KRISHNA KUMAR.(M.S.Ortho),
Dr.NATRAJ (M.S.Ortho),for their whole hearted support for completing this dissertation.
I am extremely grateful to Mrs.KALPAJA. Director, Dr.KANTHA.S, M.S (anatomy)
Advisor Dr.Mrs.SANDHYA BELWADI. MD. Principal OF VYDEHI INSTITUTE OF
MEDICAL SCIENCES &RESEARCH CENTRE for their valuable help, co-operation,
intense support & encouragement and giving me the opportunity to purse post graduate
studies in this esteemed institution.
My sincere thanks to all my postgraduate colleagues for their whole hearted support
during this study period.
I thank my parent`s and family members for their blessings.
This dissertation would not have been possible but for all patients who have been very
co-operative with me during their stay in the hospital and also for taking great pains in
turning up for review on regular basis.
I place on record my sincere thanks to all.
Date: Signature of the candidate
Place:Bangalore Dr.rajesh.p
VII
LIST OF ABBREVIATIONS USED
A – Artery
ACL – Anterior cruciate ligament
AO – Arbeitsgemeinschaft for osteosynthese fragen
AP – Anteroposterior
ASIF – Association for the study of internal fixation
BP – Blood pressure
CPM – Continue passive movement
DCP – Dynamic compression plate
F – Female
Lab – Laboratory
Lat – Lateral
LC-DCP – Limited contact dynamic compression plate
LCP – Locking compression plate
LISS – Less invasive stabilizing system
M – Male
MIPO – Minimally invasive plate osteosynthesis
ORIF – Open reduction and internal fixation
PC-FIX – Point contact fixator
POP – Plaster of Paris
ROM – Range of motion
RTA – Road traffic accident
TPR – Temperature pulse rate respiratory rate
VIII
ABSTRACT
Background and Objectives: Incidence of fracture of the proximal tibial are
increasing regularly due to RTA. Being one of the major weight bearing joint of the
body fracture around it will be of paramount importance.
The recent development of LCP has revolutionized the treatment by over coming the
few drawback’s of conventional buttress plate. The LCP is an internal fixation system
which is an hybrid of LC-DCP and LISS. The LCP can be applied in three different
way a) As compression plate b) As combining compression and bridgeplating c) As
pure internal fixation (bridge plating).
Methods: We studied 30 patients involving proximal tibial fracture among them 23
patients with MIPO technique and 7 patients with ORIF technique.
Results: We followed up all the patients until union of fractures ranged from 12-24
weeks. The average time for union of fracture was 14 weeks ranged from 12-24
weeks, those plate bridge with the MIPO technique healed even earlier.We had total
4 complications include 1 knee joint stiffness, 1 post operative loss of reduction, 1
infection, and 1 case of knee instability.
Interpretation and Conclusion : The patient sample approximately reflected the
regular trauma patients encountered at our setup, fracture treated with bridge plating
and combined principle of conventional and internal fixation (bridge plating) healed
IX
rapidly by secondary fracture union and hence achieving strong union across the
fracture at a much earlier time compared to LCP as conventional plate. The MIPO
type of reduction and fixation was less time consuming, less soft tissue injury so
preserve the bone blood supply subsequently helps in healing of both soft tissue and
bone faster.
Key words :Lockingcompression plate;internal fixator;bridge plate;MIPPO.
X
TABLE OF CONTENTS
Page No.
1. INTRODUCTION 1-2
2. OBJECTIVES 3
3. REVIEW OF LITERATURE 4-47
4. METHODOLOGY 48-54
5. RESULTS 55-85
6. DISCUSSION 86-90
7. CONCLUSION 91-92
8. SUMMARY 93-94
9. BIBLIOGRAPHY 95-100
10. ANNEXURES
ANNEXURE I : CONSENT FORM
ANNEXURE II : PROFORMA
ANNEXURE III : MASTER CHART
XI
LIST OF TABLES
SL.NO TABELS PAGE NO
1 Age distribution 57
2 Sex distribution 58
3 Literality of fracture 59
4 Mode of injury 60
4 Type of fracture:schatzker`s classification 61
5 Associated injuries 62
6 Method of reduction and fixatation 63
7 Surgical approach 64
8 Union –duration 65
9 Range of motion 66
10 Clinical results 67
11 Complication 68
XII
LIST OF GRAPHS
SL.NO TABELS PAGE NO
1 Age distribution 57
2 Sex distribution 58
3 Literality of fracture 59
4 Mode of injury 60
4 Type of fracture:schatzker`s classification 61
5 Associated injuries 62
6 Method of reduction and fixatation 63
7 Surgical approach 64
8 Union –duration 65
9 Range of motion 66
10 Clinical results 67
11 Complication 68
XIII
LIST OF PHOTOGRAPHS
SL NO PHOTOGRAPH PAGE NO
1 Anatomy of knee joint 6,715
2 Schatzker fracture classificat 20
3 Instruments and implants 52
4 MIPPO technique 52-54
CLINICAL AND RADIOLOGICAL PHOTOGRAPHS
5 Patient number 9 73-76
9 Complication 85
XIV
INTRODUCTION:
The knee joint is one of three major weight bearing joints in the lower extremity. The
proximal tibial fractures are one of the commonest intraarticular fractures generally these
injuries falls into two broad categories, high energy fractures and low energy fractures.
The majority of tibial plateau fractures are secondary to high speed velocity accidents
and fall from height1 where fractures results from direct axial compression, usually with
a valgus (more common) or varus moment and indirect shear forces2. Extra-articular
fractures of the proximal tibia usually secondary to direct bending forces applied to the
metadiaphyseal region of the upper leg, older patients with osteopenic bone are more
likely to sustain depression type fracture because their subchondral bone is less likely to
resist axial directed loads3.
The aim of surgical treatment of proximal tibia fracture is to restore congruent articular
surfaces of the tibial condyles maintaining the mechanical axis and restoring ligamentous
stability eventually can achieve functional painless and good range of motion in the knee
joint.4
The various clinical studies established that bone beneath a rigid conventional plate are
thin and atropic which are prone for secondary displacement due to insufficient
buttressing and secondary fractures after removal of plate, fracture site take longer
period to osteosynthesis due to interruption of vascular supply to bone due to soft tissue
and periosteal stripping.
1
So there was the births of a new concept of biological fixation using the plates, otherwise
called minimally invasive plate osteosynthesis (MIPO). But this was difficult as
conventional plates needed to be accurately contoured to achieve good fixation,
osteoporosis also posed the same problem of poor fixation with conventional plates5.
This leads to the development of the internal fixators. Point contact-fix I later PC fix II.
As more and more concepts about biological fixation become clearer the innovation of
plates progressed lead to development of less invasive stabilizing system (LISS).
Research to combine these two methods has lead to the development of the AO locking
compression plate (LCP)6.
We conclude that this new system is technically mature and as it offers numerous fixation
possibilities and has proven to worth in complex fracture situations and in osteoporotic
bones.
2
OBJECTIVES:
1) To study the functional outcome of the fracture of proximal tibia.
2) To study the duration of union in proximal tibia fracture treated with LCP.
3
REVIEW OF LITERATURE
ANATOMY
The proximal tibia lies between the tibial shaft and knee joint.
A thorough understanding of anatomy of structures and biomechanics of knee, is very
important to plan for reduction, surgical management and post operative care to
determine the possible complications after injury to upper tibial region.
KNEE JOINT:
It consists of the relationship between (3) articulations
1. Patellofemoral
2. Tibiofemoral and
3. Tibiofibular
This triaxial joint is often exposed to forces in excess of five times the body weight. The
normal range of motion can be from 10° of hyperextension to 140° of flexion with 8°-12°
of rotation throughout the entire arc. The distal femur articulates with the proximal tibia
throughout its range of motion. The addition of medial and lateral menisci converts this
non confirming geometry into a joint capable of sustaining significant functional loading.
4
The tibial plateau is sloped in an anterior to posterior direction from 7°-10° and contains
a greater surface area on the medial plateau. The medial and lateral spinous processes
prevent translation and protect the interspinous insertion of the ACL.
The most posterior portion of the interspinous area (INTER CONDYLARIS TIBIA) is
not covered by articular cartilage. The true axis of rotation is somewhere between the
position of the tibial tubercle (10°-15° of external rotation) and the mid portion of the
tibia.
MEDIAL TIBIAL CONDYLE' :
 It is larger than the lateral condyle.
 Its superior surface articulates with the medial condyle of femur.
 The articular surface is oval and its long axis is anteroposterior.
 The central part of the surface is slightly concave.
1The peripheral part is flat and is separated from femoral condyle by the medial
meniscus. The posterior surface of the medial condyle has a groove.
LATERAL TIBIAL CONDYLE7:
It overhangs the shaft of the tibia more than the medial condyle.
The articular surface is nearly circular. The central part of the articular surface is concave
and the peripheral part is flat. It is separated from the femur by lateral meniscus.
5
The postero-inferior aspect of the lateral condyle articulates with the fibula through the
facet for fibula. Fibular facet is flat, circular and directed downwards, backwards and
laterally. The anterior aspect of the condyle bears flattened impression.
INTER CONDYLAR AREA :
 Roughened area on the superior surface between the articular surfaces of the two
condyles.
 It is narrowest at its middle where it is marked by an elevation termed the
“INTERCONDYLAR EMINENCE”.
6
 The intercondylar area gives attachment to the following structures from before
backwards.
 Anterior horn of the medial meniscus.
 Anterior cruciate ligament (ACL)
 Anterior horn of lateral meniscus.
 Posterior horn of lateral meniscus.
 Posterior horn of the medial meniscus
 Posterior cruciate ligament (PCL).
7
TUBEROSITY OF THE TIBIA :
It lies at the upper end of the shaft of the tibia on the anterior border. It is divided into a
smooth upper and a rough lower portion by a line or crest which marks the epiphyseal
line. The upper smooth portion provides attachment to the ligamentum patellae.
COMPARTMENTS: The compartments of the knee are -
1) Anterior
2) Medial
3) Lateral
4) Posterior
BLOOD SUPPLY TO THE JOINT :
It is the genicular circulation that is responsible for all structures about the knee joint.
Five arteries form this genicular anastomosis
1) The superior genicular.A
2) The medial genicular.A
3) The lateral inferior genicular.A
4) The lateral genicular. A
5) Anterior and posterior tibial recurrent arteries.
8
This supplies bone, capsule, and synovial membrane. This anastomosis is situated around
the patella, the lower end of femur and upper end of tibia.
1) Superficial part: Lies in the superficial fascia around the patella and the ligamentum
patellae
2) Deep part: On the femur and tibia. It is formed.
Medially by
1) Descending genicular. A
2) Superior medial genicular. A
3) Inferior medial genicular. A
Laterally by
1) Descending branch of lateral circumflex femoral A
2) Superior lateral genicular.A
3) Inferior lateral genicular.A
4) Anterior tibial recurrent.A
5) Posterior tibial recurrent.A
6) Circumflex fibular.A
Medial and lateral arteries are connected by long anastomosis which are
interconnected by horizontal anastomoses just above and below the patella.
9
ANASTOMOSES AROUND THE KNEE8:
 Descending genicular A-branch of femoral A.
 Descending branch of lateral circumflex A.
 Lateral genicular A-anastomosis connecting the above 2 arteries
 Medial genicular A.
 Medila inferior genicular A.
 Lateral inferior genicular A.
 Anterior tibial recurrent A.
 Circumflex fibular branch of posterior tibial A.
NERVE SUPPLY : All three nerves supply the knee joint
1. Femoral nerve through its branches to vasti especially vastus medialis.
2. Sciatic.N through genicular branches of common peroneal.N.
3. Obturator.N. through its posterior division.
LIGAMENTS9:
The Ligaments supporting the knee joint are :
1) Fibrous capsule
2) Ligamentum patellae
3) Tibial collateral ligament
4) Fibular collateral ligament
10
5) Oblique popliteal ligament
6) Arcuate popliteal ligament
7) Anterior cruciate ligament
8) Posterior cruciate ligament
9) Medial meniscus
10) Lateral meniscus
11) Transverse ligament.
11
MECHANICS OF KNEE JOINT:
The mechanical axis of the femur does not coincide with the anatomical axis since a line
traversing the centre of the hip joint and the centre of the knee forms an angle of 6° - 9°
with the axis of the shaft of the femur.
Because of the disparity between the lengths of the articular surfaces of the femoral
condyles and the tibial condyles, two types of motion during flexion and extension are
produced.
1) Ginglymus (hinge)
2) Trochoid (pivot joint) articulation.
The joint permits flexion and extension in the sagittal plane and some degree of internal
and external rotation when the knee is flexed and extended.
The complex flexion and extension motion is a combination of rocking and gliding.
The rocking motion is demonstrable in the first 20° of flexion, after which the motion
becomes predominantly of the gliding type.
The natural deflection outward of the tibia on the femur, at the knee joint produces
greater weight bearing stresses on the lateral femoral condyle than the medial. But
because the medial condyle of the femur is prolonged further forwards than the lateral
condyle, the vertical axis of rotation falls in a plane near the medial condyle9.
The ratio of rolling to gliding is not constant. The ratio is 1:2 in early flexion and about
1:4 by the end of flexion.
12
 Flexion and extension ranges from 0°-140°.
 Rotation ranges from 8°-12° with individual variation.
 5-10° of hyperextension is also possible.
 • Medial meniscus is more prone for injury because the anchorage of the medial
meniscus permits less mobility.
SCREW-HOME MOVEMENT :
The articular surface of the medial condyle is prolonged anteriorly, and as the knee
comes into fully extended position, the femur internally rotates until the remaining
articular surface on the medial condyle is in contact. The posterior portion of the lateral
condyle rotates forward laterally, thus providing a screwing home movement, locking the
knee in the fully extended position.When flexion is initiated unscrewing of the joint
occurs by external rotation of the femur on the tibia. Normal sagittal excursion of tibia
on the femur not more than 3-5mm.Normal varus and valgus motion at the knee, when
extended not more than 6°-8°.
13
14
PRINCIPLES:
The principles of surgical management of any intra articular fracture fixation are.......
1) Anatomical reduction-to maintain joint congruity and to prevent secondary
osteoarthritis.
2) Stable internal fixation.
3) Enbloc uplifting of depressed articular fragment and bone grafting.
4) Early mobilization, of the joint.
5) Defer weight bearing until complete fracture union.
15
TIBIAL PLATEAU FRACTURES:
INCIDENCE :
Fractures of tibial plateau constitute 1% of all fractures and 8% fractures in the elderly.
These fractures encompass many and varied fracture configurations that involve the
medial condyle (10-23%), lateral condyle (55-70%) or both (11-30%) with differing
degrees of articular depression and displacement.
NATURE OF VIOLENCE:
It can be either direct/Indirect.
DIRECT: Automobile accidents, which is one of most frequently encountered.
1) Road traffic accidents/ automobile accidents (high velocity trauma and low velocity
trauma).
2) Falling from a height
3) Industrial accidents
4) Valgus stress/varus stress
5) Athletics
6) Assault.
16
INDIRECT : Trivial injures like
1) Stumbling
2) Twisting
3) Missing steps, etc.,
MECHANISM:
Fractures of the upper tibia occur opposite as a result of strong valgus or varus forces
with axial loading. Kennedy and Bailey have studied about the degree of fracture and the
amount of load given to the joint.
When a patient sustains varus or valgus force with an axial load, the respective femoral
condyle exerts both a shearing and a compressive force on the underlying tibial plateau.
This frequently results in a split fracture, a depressed fracture or both. Isolated split
fractures are virtually confined to adults with dense cancellous bone that is capable of
withstanding the compressive forces on the joint surface. With age, the strong cancellous
bone of the proximal tibia gradually becomes more sparse and is no longer able to
withstand the compressive forces. With impact loading, a depressed or split depressed
fracture results10.
The medial collateral ligament acts like a hinge as valgus forces drive the lateral femoral
condyle into the tibial plateau. The lateral collateral ligament acts in a similar way with
varus forces and causing medial plateau fractures. With the Magnetic Resonance Imaging
(MRI) in patients with upper tibial fractures, ligament injuries have been observed in a
17
higher percentage of patients. Thus in addition to the fracture, there may be an associated
medial collateral ligament or anterior cruciate ligaments injury may be present in lateral
plateau fracture, conversely, the tears of the lateral collateral ligament or cruciate
ligaments may be associated with fractures of the medial tibial plateau.
The location of the fracture depends on the degree of flexion/extension of the knee.
However when axial loads exceeds 8000 pounds, explosive severely comminuted
fractures were produced. This mechanism is thought to occur clinically in a fall from a
height on the extended knee.
Also direct injury to the upper part of the tibia, i.e., in the subcondylar (or) subchondral
or metaphyseal region may lead to a fracture without involving the articular surface.
These type of fractures may be due to road traffic accidents, assaults, etc.
PATHOLOGY OF FRACTURES OF TIBIAL PLATEAU:
Pure split fractures are commoner in young patients.
1. Depressed fractures and split depressed fractures are common in older patients.
2. The fracture line and degree of flexion of knee combined with valgus/varus strain and
axial loading contribute to determine the fracture line and the site of depression whether
it is anterior, middle or posterior.
3. Collateral ligament integrity and forces determine the type of fracture.
18
4. Pure axial loading or axial loading combined with varus/valgus stress determines the
type of bicondylar fractures.
5. Violent injuries are associated with ligament injures, vascular and nerve injures.
6. Direct injuries to the upper tibia can also lead to subcondylar fractures without
involving the articular surface.
Many factors can combine to produce various different types of fractures, their
combinations and complications.
19
FRACTURE CLASSIFICATION:
I.SCHATZKERS CLASSIFICATION10
TYPE I - PURE CLEAVAGE : A wedge shaped uncomminuted fragment is split off and
displaced laterally and downwards. This fracture is common in younger patients without
osteoporotic bone.
TYPE II - CLEAVAGE COMBINED WITH DEPRESSION: A lateral wedge is split
off, but in addition the articular surface is depressed down into the metaphysis. This tends
to occur in older people with osteoporotic bone.
TYPE III - PURE CENTRAL DEPRESSION: The articular surface is driven into the
plateau. The lateral cortex is intact. These tend to occur in osteoporotic bone.
TYPE IV - FRACTURES OF MEDIAL CONDYLE: These may be split off as a wedge
or may be comminuted and depressed. The tibial spines are often involved. These
fragments tend to angulate into varus.
TYPEV- BICONDYLAR FRACTURES: Both tibial plateau are split off. The
distinguishing feature is that the metaphysis and diaphysis retain continuity.
TYPE VI -PLATEAU FRACTURE WITH DISSOCIATION OF METAPHYSIS AND
DIAPHYSIS: A transverse or oblique fracture of the proximal tibia is present in
addition to a fracture one or both tibial condyles and articular surfaces.
20
SCHATZKER`S FRACTURE CLASSIFICATION
21
II. HOHL AND MOORES CLASSIFICATION11:
A. FRACTURE PATTERN
TYPE 1 : Split fractures of the lateral condyle
TYPE 2 : Lateral compression
TYPE 3 : Split with compression fracture
TYPE 4 : Total condylar fractures
TYPE 5 : Bicondylar fractures
22
B. FRACTURE – DISLOCATION PATTERNS12:
TYPE 1 : Coronal split fracture dislocation.
TYPE 2 : Entire condylar fracture dislocation.
TYPE 3 : Rim avulsion fracture dislocation.
TYPE 4 : Rim compression fracture dislocation.
TYPE 5 : Four part fracture dislocation.
23
Ill. A-O CLASSIFICATION OF TIBIAL PLATEAU FRACTURES13:
TYPE 1 : Wedge fractures
TYPE 2 : Depression fractures
TYPE 3 : Wedge and depression fractures
TYPE 4 : 'Y' and T' fractures/comminuted fractures of both the condyles.
24
25
INVESTIGATIONS:
Plain Radiograph :
 AP & Lateral views usually show a plateau fracture.
 In doubtful fracture 15° of AP Oblique view inclined caudally.
 Traction films and stress x-rays. To assess the efficacy of an applied
ligamentotaxis force14,15.
 Importance of anterior tibial plateau fractures stance phase during gait.
CT Scan:
Especially useful in determining the extent of injury, amount of articular depression but
gives limited information about the soft tissue status. CT with leg in traction to assess
Ligamentotaxis and also to assess the coronal fracture line and plan insertion of screws.
Magnetic resonance imaging:
 Delineates status of soft tissues like ligaments, menisci and capsules16.
 To know the amount of articular depression.
Arthroscopy:
 For evaluation of meniscal injury and also the treatment.
Angiography:
 Useful in High velocity injuries associated with vascular compromise.
26
MODALITIES OF TREATMENT OF TIBIAL PLATEAU FRACTURES:
The goals in treatment of a tibial plateau fracture are to obtain a stable, aligned, mobile
and painless joint and to minimize the risk of post-traumatic osteoarthritis17.if rational
treatment is to be instituted, the surgeon must have a sound knowledge of the
“personality” of the injury and a clear understanding of the knee examination, imaging
studies and must be familiar with a variety of technique for treating tibial plateau
fracture. selecting a method after a tibial plateau fracture depends on a number of factors
including mechanism of injury, type of fracture, displacement, depression and surgeon
factors. Often overlooked or underestimated are patient-related factors such as age of the
patient, level of activity, concurrent medical condition and level of expectation.
Schatzker has formulated the following principles of treatment18.
 Tibial plateau fracture immobilized for more than 4 weeks usually lead to some
degree of joint stiffness.
 Internal fixation of plateau fracture combined with immobilization of the knee
leads to even greater degrees of joint stiffness.
 Regardless of the method or technique of treatment, the knee joint must be
mobilized early.
 As long as joint mobility is preserved, secondary reconstructive procedures are
possible.
 Impacted articular fragment cannot be dislodged by traction or manipulation
alone, because there are no soft tissue attachments to lever them upward.
27
 Depressed articular surface defects do not fill in with hyaline cartilage and remain
as permanent defects, therefore any joint that is unstable as a result of joint
depression or displacement will remain unstable unless it is surgically corrected
I. Conservative :
1) Closed reduction and POP cast application.
2) Skeletal traction and immobilization
3) Functional Brace
II. Surgical:
1) Percutaneous cancellous screw fixation.
2) ORIF with cancellous screws and Bone grafting.
3) ORIF with Buttress plate and screws.
4) ORIF with Buttress plate and screws and Bone grafting.
5) External fixator/ Hybrid external fixator/ Ilizarov ring fixator.
6) Arthroscopic assisted internal fixation.
7) MIPPO (Minimal Invasive Percutaneous Plate Osteosynthesis) with LCP plating.
28
COMPLICATIONS OF TREATMENT OF TIBIAL PLATEAU FRACTURES:
The complications occur by virtue of fracture and also after the treatment. Most of the
complications are preventable. Preventive care begins with thorough examination of the
injured limb. Important aspects to detect are the peripheral neuro vascular injures that
may accompany with the upper tibial fractures, prompt treatment of these injuries usually
takes presidence over definite fracture treatment and often prevent catastrophic
complications.
A) Early Complications:
1) Bleeding
2) Wound infection /Dehiscence - Superficial or Deep
3) Sepsis
4) Compartment syndrome
5) Pain
6) Swelling
7) Knee stiffness
8) Nerve Injury (Lateral politeal. N)
9) Vascular Injury (Anterior tibial A)
10) Loss of fracture reduction
29
11) Limb length discrepancy
12) Deep vein thrombosis
b) Late Complications :
1) Wound Infection
2) Knee stiffness
3) Malunion
4) Knee instability - varus/valgus/anterior/posterior
5) Extensor lag
6) Angular deformities
7) Persisting pain/swelling
8) Redepression
9) Refracture
10) Delayed union
11) Non-union
30
SURGICAL APPROACHES
APPROACHES:
There are about 6 surgical approaches in tibial plateau fracture of which, most commonly
used ones are the anterolateral and anteromedial incisions depending on the lateral or
medial plateau respectively19. Others are single anterior midline incision as in TKR,
reverse Mercedes incision, medial and lateral incision, direct posterior / posteriomedial
incision20. One care to be taken while dealing with lateral plateau approach -not to go
more posterior as there is likely injury to lateral popliteal nerve and in addition, tibialis
anterior needs to be elevated subperiosteally in to from its attachment rather than splitting
into fibres.
Even in bicondylar fracture dual plating by open methods is not advised nowa-days
because of likely complication of wound dehiscence. In such cases the approach should
be on one side at which it is more comminuted or depressed and the intact soft tissue.
Two incisions over the knee joint are not advocated, if so the minimum distance between
them should be 5-7cm.
Direct posterior or posteromedial approach is used in coronal fractures, the incidence of
such fracture is very rare.
In all the cases periosteum should be elevated as minimal as possible, in doubtful cases,
joint needs to be opened and articular surface to be viewed. Before fixing the plate with
screws the wound is checked for approximation without tension or else the incision has to
be modified.
31
posterior approach lateral approach
Antero medial approach.
32
BIOLOGICAL FIXATION :
The rigid fixation of bone by using compression with conventional plate results in
primary union, this concept gained wide acceptance a couple of decade ago. However
cortical bone had always united by throwing callus before man had started interfering
with it. A new phenomena was observed in cases where successful osteosynthesis with
compression principle was made. This was the appearance of osteoporosis and termed as
“stress protection osteoporosis” it is due to avascularity and not stress protection21.
As the plate was tightened to obtain absolute rigidity the friction between the under
surface of the plate and the cortex of the bone increased many time resulting in
interference of the periosteal blood supply as long as the plate was there.
On the contrary, if the rigidity of the plate fixation was inadequate it leads to resorption at
the screw bone interface leading to non union.
Hence if we desire a good fixation with minimal interference to the biology of the bone,
this require a new thinking in the concept of implant as well as in the concept of internsal
fixation. This change of concept is what is termed as“Biological fixation”.
The concepts of biological fixation consists of22.
 Indirect reduction
 Adequate stability
 Preservation of osteogenic potential
 Limited bone – plate contact
33
Reducing the area of contact between plate and bone, as achieved by the limited contact
DCP (LC-DCP) design, significantly reduced the vascular change caused by pressure on
the cortex. However, the LC-DCP also has to be pressed against the bone in order to
create the friction needed to fulfill its function.
The first implant designed to fulfill the new requirements was the small point contact
fixator (PC-Fix). The PC-Fix was a narrow plate like implant with a specially designed
under surface having only small points that come into contact with bone.The screws were
self-tapping, unicortical and were available in one length only. The screw head locked
firmly in the plate hole with a fine thread.
While the PC-Fix had limited applications in the metaphyseal and articular area. The
LESS INVASIVE STABILIZATION SYSTEM (LISS) was conceived for precisely for
the distal femur and later for the proximal tibia. Its shape conforms to the anatomical
contours of the specific area of the bone23. Additional contouring is not required as the
plate fixator does not necessarily need to touch the bone. In addition to the locked
unicortical screws. This implant is designed and instrumented for application via
minimally invasive submuscular approach. The fracture should be adequately reduced
and aligned prior to the application of the LISS. This is especially true for the articular
components of the distal femur or proximal tibia which must be anatomically
reconstructed and held by plate independent lag screws. The LISS can accommodate long
fully threaded self-tapping screws that are locked in plate holes when drive home thereby
providing the attributes of a fixed angle device24.
34
LOCKING COMPRESSION PLATE (LCP):
A further refinement of internal fixator systems,with screw heads locking firmly into the
plate hole, has now been devised. This is a new plate hole configuration which brings to
this most valuable innovation the advantages of conventional plating for example.
Placement of a lag screw across the plate for certain fracture configurations. This is
achieved through a new design, the “combination” plate hole which can accommodate
either a conventional screw or the new “locking head screw (LHS)” which has a conical
threaded head.
DESIGN FEATURES OF LOCKING COMPRESSION PLATES25:
 The locking compression plates have these LC-DCP features
 50 deg of longitudinal screw angulation
 14 deg of transverse screw angulation
 Uniform hole spacing
 Load (compression) and neutral screw positions
 The locking compression plates have combination locking and compression holes
that allow placement of conventional cortex and cancellous bone screws on one
side or threaded conical locking screws on the opposite side of each hole.
 Tapered end for submuscular plate insertion, improving tissue viability.
 Limited-contact plate design reduces plate to bone contact limiting vascular
trauma.
35
 Holes in straight plates are oriented so that the compression component of the
hole is always directed towards the middle of the plate.
 Locking screw design.
The screw design has been modified from standard 4.5mm cortex screw design.
New features include:
Conical screw head:
Facilitate alignment to provide a secure screw plate fixation.
Large core diameter:
Improve bending and shear strength and distribute the load over a larger area
in the bone 4.0mm and 5.0mm locking screws, self tapping.
The locking screws mate with the threaded plate hole to form a fixed-angle construct.
The shallow thread profile of the locking screw results from large core diameter.
36
GENERAL PRINCIPLES OF INTERNAL FIXATION USING LCP:
Internal fixation using a combination of locking screws and standard screws.
 If a combination of cortex and locking screws is used, a cortex screw should be
inserted first to pull the plate to the bone.
 If locking screws have been used to fix a plate to a fragment, subsequent insertion of
a conventional screw in the same fragment without loosening and retightening the
locking screw is NOT RECOMMENDED.
 If a locking screw is used first, care should be taken to ensure that the plate is held
securely to the bone to avoid spinning of the plate about the bone.
 Once the metaphyseal fragment has been fixed with locking screws, the fracture can
be dynamically compressed using conventional screws in the DCU (Dynamic
Compression Unit) portion of the LCP hole.
 First, use lag screws to anatomically reconstruct the joint surfaces.
 The behaviour of a locking screw is not the same as that of a lag screw. With the
locked plating technique, the implant locks the bone segments in their relative
positions regardless of how they are reduced.
 A plate used as a locked plate does not produce any additional compression between
the plate and the bone.
 The unicortical insertion of a locking screw causes no loss of stability.
37
Depending on the desired functional the locking compression plate (LCP) can be applied
in three different ways:
1) LCP as a conventional dynamic compression plate.
2) LCP combining conventional and locked application.
3) LCP as pure internal fixator (bridge plating)
1) LCP as conventional plate:
The LCP can be used as conventional plate with conventional screws. It may then have
one of five function; i.e, compression, bridging, buttress, protection, and tension band.
With the use of an accentric drill guide, axial compression can be obtained or a lag screw
can be placed through any plate hole. This classical fixation is still applicable for articular
fracture and in simple type A and B, fracture in the metadiaphyseal area, where
anatomical reduction and absolute stability is recommended and can easily be achieved
without wide exposure. Other indications are closed wedge osteotomies as well as
delayed and nonunions, where absolute stability is recommended. The LCP can also be
used as a plate to protect a lag screw fixation. If only locking head screws are used then
this could be considered to be a protecting internal fixator.
38
2) LCP combining conventional and locked application:
Here both techniques are employed (combination technique) using conventional lag
screws as well as locked screws26.
In articular fractures requiring an anatomical reduction and fixation by interfragmentary
compression lag screws may be essential for the reconstruction of any articular
components. At the same time the locking head screw provides angular stability, helping
to prevent secondary displacement in case of metaphyseal comminution or other bony
deficiency. The term “combination” describes the combination of the two described
biomechanical principles use of a combination of interfragmentary compression and the
internal-fixator method (bridging). A combination technique does not mean combining
different type of screws. This hybrid use of both type of screws (standard and locked
screw) can be considered in the following situations:
 Reduction onto the plate in case of a residual axial malalignment of a fracture mostly
in the frontal plane. Malalignment of the plate with respect to the long axis.
These exist two indications for the combination technique
 Articular fracture with a multifragmentary fracture extension into the diaphysis:
anatomical reduction and inter fragmentary compression of the articular component,
bridging of the reconstructed joint block to the diaphysis (flexible by the internal
fixator method).
 Segmental fracture with two different fracture patterns (one simple and one
multifragmentary).Compression principle for simple fracture and internal fixator
(bridging) principle for the multifragmentary fracture.
39
3) LCP as pure internal fixator (bridge plating)26:
The LCP can be used as a pure locked internal fixator based on the principle of relative
stability by bridging the fracture zone. Here, locking head screws are used exclusively.
After indirect reduction, the complex type C fracture zone is not exposed but bridged by a
long, locked plate. Preserving vascularity in combination with internal splinting allows
rapid fracture healing with external callus formation. The fracture bone should be
appropriately aligned before the LCP is applied. While temporarily, inserted conventional
cortex screws may be used as a reduction aid or to approximate a large fragment, little or
no contouring of the plate is needed.
The typical indications for this technique are
 Multifragmentary fracture in the diaphysis and metaphysis.
 Open-wedge osteotomies (eg. proximal tibia)
 Periprosthetic fracture
 Delayed change from external fixator to definite internal fixation.
Using these different principle of fracture treatment leads to different types of fracture
healing. Under certain circumstances, the two different principle of absolute and relative
stability may be in compatible. Therefore, it is advisable to use only one of the two
method in one fracture zone, either in a compression method or as internal fixator.
These locked internal fixators (PC fix, LISS, LCP) are ideal for the MIPO technique of
fracture fixation. The pre conditions for internal fixation by MIPO are:
 Indirect closed reduction without exposure of the fracture.
40
 Small incision for insertion of implants
 Elastic bridging of fracture zone with a locked internal fixator (eg. LISS, LCP).
 Implants with minimal bone contact. Slightly elevated plate from the bone surface to
eliminate any miss match of the pre-contoured plate to the anatomy of the bone.
 Self drilling and self tapping locking head screws for mono-cortical insertion.
 Self tapping screws for bicortical insertion.
 Relative stability increases callus formation.
The use of fixed-angle locking metaphyseal plate and screw construct for articular and
periarticular injuries has become common place. Given the restraints of bone stock in the
epiphyseal region or possibly with misplacement of the plate, the use of these fixed angle
device may produce varus or valgus malalignment.
In that cases washers may be used to elevate(or shim) the plate from the diaphyseal
segment in order to correct alignment. After shimming washer(s) have been used to
correct alignment, locking screws can be used further along the diaphysis to impart
stability to the construct. Other alternative to this technique would be bending the plate
(not all plate materials are amenable to this) or use of a “polyaxial” locking fixation.
The polyaxial locking plates that allow screw angulation and end-point locking have
become available. Studies says that the variable-axis locking plates performed well, with
a high rate of fracture union and no evidence of varus collapse due to failure of the
polyaxial screw fixation in a series of complex fractures about the knee.
41
CLINICAL BENEFITS OF LOCKING COMPRESSION PLATE4:
1. The plate and screws from one stable system and the stability of the fracture
depends on the stiffness of the construct. Locking the screw into the plate to
ensure angular as well as axial stability, eliminate the possibility for the screw to
toggle slide or be dislodged and thus strongly reduces the risk of post operative
loss of reduction.
2. Multiple angle stable screw fixation in the epi and metaphyseal region, allows for
fixation of many fractures that are not treatable with standard devices.
3. Improved stability in multifragmentary complex fractures, which have bone loss –
double plating avoided.
4. The fixed angle stability avoids subsidence of fixation in metaphyseal areas. This
allows for less precise contouring of the plate, as fixation depends of plate screw
construct rather than friction between plate bone interface.
5. Improved biology for healing lead to better clinical outcome and faster healing.
6. Better fixation in osteoporotic bone, especially in epi and metaphyseal areas.
Divergent locked screws improve the pull out resistance of the entire construct also these
locked screws have a higher core-diameter so resist bending force at the screw cortex
junction.
7. No or less need for primary bone graft as more fractures fixed with bridging
technique with elastic fixation leads to formation of good callus.
8. Fractures with sever soft tissue injuries.
42
9. In situations where the MIPO technique is indicated or possible, because accurate
contouring of the plate is not mandatory.
43
REVIEW OF LITERATURE:
The fracture of proximal tibia which extend into the knee joint can produce major
disability. At university of Lowa authors began treating tibial plateau fractures with early
application of a cast brace. They encouraged early motion, weight bearing to tolerance
and unrestricted activities using crutches or other supports only when necessary lead to
improved knee function.27
Percutaneous fixation offers its best in isolated undisplaced fractures, split unicondylar
fractures and in elderly osteoporotic bone. The advantages are decreased operative time,
less blood loss, smaller incision, short hospital stay and early rehabilitation.28
In the early half of the 20th century an author reported two studies having satisfactory
percentage of good to excellent short and long term results with surgical method of
treatment.29
In another published study of 159 cases of tibial plateau fracture of all types, treated by
conservative (46%) and surgery (54%), evaluated by How and Luck method reported
good excellent result in surgery (84%) than conservative method (62%).30
Roberts in 1968 reported 100 cases of tibial condyle fractures treated by conservative and
surgical. The result were good in 72% conservative, 80% traction mobilization and 81%
surgical. He advocate early mobilization preservation for menisci and repair of torn
ligaments for best results.31
Schatzkar32 in 1979, reported 70 cases of tibial plateau fracture of all types treated by
conservative (56%) and surgical (44%) with average follow up of 28 months. Acceptable
44
results were obtained in 58% of cases of conservative group and 78% by open
methods.Fracture treated by ORIF with buttress plate and bone grafting achieved 88%
acceptable results.
A study of 278 cases of tibial plateau fracture with an average follow up of 2.5 years, all
treated by surgical methods. 89% acceptable result when surgery was done by
inexperienced surgeons, 97% when done by experienced. They concluded the prognosis
improve with the experience and with accurate reconstruction of articular surface. They
also said post traumatic osteoarthritis was directly proportional to the amount of
displacement.33
Lausinger O34 in 1986 did a 20 yrs follow-up of his earlier study extended in a series of
260 fractures of one of both condyles. 90% of the patients achieved an excellent good
results and 10% achieved fair or poor results. The inferior results were seen in unstable
split with depressed fractures.
There is an another report35 of treating 212 tibial plateau fracture of all types. They
concluded that a medial unicondylar fracture with any displacement and all medially
tilted bicondylar fracture should be operated upon. In fracture of lateral condyle ORIF is
indicated when lateral tilt or valgus malalignment >5deg, articular step off > 3mm or
condylar widening > 3mm.
Sommer et al published the results of the first general study of various locking
compression plates in 2003. In their prospective study, they treated 144 patients with 169
fractures involving tibia (57), humerus (45), radius (19), and femur (18) and assessed the
patients for 1 year. In 130 fractures the healing took place in the expected period without
45
any complications. A total of 27 complications occurred (19 patients) including implant
loosening / pull out (5 patients). Plate failure (4 patients) non-union (1 patient), secondary
fractures immediately adjacent to implant after a subsequent injury (5 patients) and
infection(2patients). Analysis by the experts concluded that the mechanical complications
arose entirely from technical errors of application.No purely implant related
complications occurred. They concluded that the LCP was a technically mature and has
proven its worth in complex fracture situations and in revision operations after the failure
of other implants.5
Gonzailez HY et al studied 122 injuries in 113 patients treated with the LCP and LISS.
They found that despite the large number of open and comminuted fractures no serious
complications such as deep infections, nonunions, vascular lesions or deep venous
thrombosis were noted. Also then concluded that the proven value of these systems (LCP
and LISS) in complex fracture situations and revisions surgeries. They found the
procedure to be safe and reliable.36
Cole in 2004 studied treatment of proximal tibia fractures using the less invasive
stabilization system in 77 fractures. The LISS system consists of a pre-contoured,
anatomically shaped plate that can be inserted with a minimally invasive technique and of
screws that can be locked within the plate37
Thomas F et al in 2007 did an study on shimming a locking plates with washer to correct
axial alignment. The autor has used this in three cases of highly comminuted proximal
tibial injuries all fractures have healed uneventfully and all patients had full range of
46
movement at 6-8 months measuring average 125 degree and side to side alignment by 2-4
degree.38
George Haidukewych, Stephen A, David Huebner, Daniel Horwitz and Bruce Levy
conducted prospective study between 2003 and 2005 on 54 patients with a total 56
fractures were treated with a polyaxial locked plate of fixation system. There were 25
distal femoral fractures and 31 proximal tibial fracture. Functional outcome accessed
with knee society score, 94% of the fractures united. There were no mechanical
complications must importantly there was no evidence of varus collapse as a result of
polyaxial screw failure. There were 3 deep infection and one aseptic nonunion. No plate
fractured and no screw cut out39.
Horesh Z in 2006 stated that the use of Ilizarov external fixation in the management of
complex tibial plateau fractures results in satisfactory out come as an alternative to the
traditional tibial plateau open surgery. This minimal invasive intervention allowed the
surgeons to reduce and fixate the tibial articular surface with out further damaging the
soft tissue envelope40.
Snow,martyn;Thompson in feb 2008 concluded LCP has mechanically superior to the
low contact DCP when used as a bridging plate and tested in axial compression41.
Fitzpatrick DC, Doornik J, in feb 2009 stated that in osteoporetic bone locking plate
improves the fixation and strength under axial loading42
47
METHODOLOGY
The study was carried out in vydehi institute of medical sciences and research center
Bangalore from 2009 to 2011 The total number of cases studied were 30 with the
youngest 18yrs and oldest 65 yrs.
The intention of this dissertation was to study the treatment of proximal tibial fracture
with locking compression plate to obtain a stable, painfree, mobile joint, to prevent the
development of osteoarthritis.
Inclusion criteria:
 Adult (aged over 18 yrs) both male and female
Exclusion criteria:
 Patient aged below 18 yrs
 Type II and III compound fractures
On admission demographic data was recorded and thorough history and clinical
examination was done. We assessed the soft tissue injuries even in the closed fractures
followed by radiological assessment of the fracture with Schatzker’s classification.
48
As soon as the operation was planned, certain routine procedures like
1. Use of preoperative antibiotics and continued till the removal of suture.
2. Stabilize the patient haemodynamically and physical fitness for surgery was
obtained.
3. Preoperative planning for selection of plate. Approach MIPO technique or open
reduction and internal fixation.
4. In our series, all fractures are reduced with traction in fracture table with C-arm
guidance.
5. To check for any associated fracture.
We treated 30 patients with minimally invasive plate osteosynthesis and 5 patients with
open reduction and internal fixation.
The approach was either anteromedial or anterolateral or MIPPO incision.
The primary difference with the locking compression plate is the method of locking head
screw insertion. Here since the locking head of the screw has to get locked in the locking
part of the combihole. The direction of the drilling has to be perfect. Hence drilling for all
locking head screws has to be after fixing the screw in drill sleeve.
We also made sure that whenever using the non locking regular screw in the fixation.
They were inserted prior to the insertion of the locking screws.
49
Postoperative:
In the immediate postoperative period. Care was given to the general condition, fluid
balance, IV antibiotic and analgesics as per the protocol. This helped us to mobilize the
patient faster.
Mobilization:
Whenever stable internal fixation was achieved, the patient was mobilized after 48 hrs
after removal of the drains, for 2-3 days the range of motion allowed was 0-200 from the
5th day the range of motion was gradually allowed to be increased to 900 more after
suture removal full range of movement was allowed.
Whenever there was doubt about the stable fixation. External splinting in the form of
plaster of Paris slab was given for support and advised to do static quadriceps exercises.
Continue passive motion exercise (CPM) were done daily with temporarily removal of
slab under careful supervision and splint reapplied. Partial weight bearing was delayed
until 6 weeks and full weight bearing allowed after 12-16 weeks.
Follow up:
The first follow up was usually between 4-6 weeks and later on patients were followed up
at regular interval of 4-6 weeks till complete fracture union.
50
During follow up:
1. The course of fracture healing was documented radiologically with minimum 6
wks interval. The moment of complete healing was defined as radiologically
complete bone regeneration at fracture site.
2. Evaluation of any possible loss of reduction.
3. Assessment and analysis of any complication.
Follow up of out patients ranged from 12 weeks to 60 weeks.
51
PATIENT POSITION IN OT:
LOCKING SCREWS: LOCKING PLATE &DRILL BIT:
52
REDUCTION UNDER C-ARM:
INSERTING THE PLATE UNDER C-ARM:
53
LOCKING SCREWS UNDER C-ARM:
CLOSURE:
54
RESULTS
We studied 30 patients with 30 proximal tibial fracture who were treated with locking
compression plate
GRAPH : 1
70
60
50
40
30
20
10
0
< 20 21 - 40 > 40
Age in years
TABLE:1
AGE IN YEARS NUMBER OF PATIENTS %

<20 1 3.3
21 -40 19 63.3
>40 10 33.4
TOTAL 30 100.0
In our study the youngest patient was 20yrs old and the oldest was 55 yrs .Most of the patients
belong to 21-40 yrs of age group who are more prone for RTA.
55
TABEL:2
GENDER DISTRIBUTION OF PATIENTS STUDIED
GENDER NUMBER OF PATIENTS %

MALE 25 83.4
FEMALE 5 16.6
TOTAL 30 100
GRAPH:2
FEMALE
16.6 %
MALE
FEMALE
MALE
83.4 %
In our study most of the patient were male. It reflects that outdoor population were more prone
for the proximal tibial fractures.
56
TABLE: 3
LATERALITY OF FRACTURE
SIDE INVOLVED NUMBER OF PATIENTS %

RIGHT 19 63.4
LEFT 11 36.6
TOTAL 30 100
GRAPH:3
LEFT
36.6
RIGHT RIGHT
63.4
LEFT
In our series there is right side predominance compared to the left side.
57
TABEL:4
MODE OF INJURY
MODE OF INJURY NUMBER OF PATIENTS %

FALL 9 30
RTA 21 70
TOTAL 30 100
GRAPH:4
FALL
30 %
FALL
RTA
RTA
70 %
In our study it shows that tibial fractures are more prone in RTA.
58
TABEL:5
TYPE OF FRACTURE
TYPE OF FRACTURE NUMBER OF PATIENTS %

I 5 16.6
II
III
IV 8 26.6
V 6 20.0
VI 10 33.3
GRAPH:5
Type of fracture
10
9
8
7
6
5 Series 1
4
3
2
1
0
I II III IV V VI
TYPE OF FRACTURE
In our series the majority of the fracture were found to be type IV,V and VI fracture types which
are usually associated with high velocity RTA.
59
TABLE:6
ASSOCIATED INJURIES
ASSOCIATED INJURIES NUMBER OF PATIENTS %

NONE 27 90
PRESENT 3 10
ACL INJURY 1 3.3
PATELLA FRACTURE 1 3.3
BOTH BONE FRACTURE 1 3.3
FOREARM
TOTAL 30 100
GRAPH:6
ASSOCIATED INJURIES
30
25
20
15
NUMBER OF PATIENTS
10
0
NONE ACL INJURY PATELLA BOTH BONE
FRACTURE FRACTURE
FOREARM
60
TABE:7
METHOD OF REDUCTION AND FIXATION
Method of reduction Number of patients %

MIPPO 23 76.6
ORIF 7 23.4
TOTAL 30 100
GRAPH:7
METHOD OF REDUCTION ANDFIXATION
25
20
15 METHOD OF REDUCTION
ANDFIXATION
10
0
MIPPO ORIF
We used MIPPO technique in 23 patients both blood losss and soft tissue damage are less
compared to ORIF technique. wound healing also better and faster compared to ORIF technique.
61
TABEL:8
SURGICAL APPROCH
Side Number of patients %

Anteromedial 17 56.6
Anterolateral 13 43.4
Total 30 100
GRAPH:8
surgical approch
Anteromedial
Anterolateral
We preferred anteromedial approach for 17 patients for fracture with medial condylar
displacement and MIPPO technique of reduction and fixation is essential.
62
TABEL:9
UNION-DURATION
Duration -weeks No:of patients %

>16 4 13.3
12-16 24 80.0
<12 2 6.7
GRAPH:9
UNION-DURATION
25
20
15
UNION-DURATION
10
0
>16 WEEKS 12-16 WEEKS <12 WEEKS
In our series most fracture union occurred between 12-16 weeks.
63
TABEL:10
RANGE OF MOTION
RANGE OF MOTION NUMBER OF PATIENTS %

>120 20 66.7
90-120 7 23.3
<90 3 10.0
TOTAL 30 100
GRAPH:10
RANGE OF MOTION
25
20
15
RANGE OF MOTION
10
0
>120 90-120 <90
In our series most patients had range of motion >1200
64
TABEL :11
CLINICAL RESULTS
Clinical results No.of cases %

Excellent 21 70
Good 7 23.3
Poor 2 6.4
Total 30 100
GRAPH:11
clinical results
25
20
15
clinical results
10
0
Excellent Good Poor
In our series the clinical outcome of most of the patients was excellent. Which was done by
MODIFIED HOHL AND LUCK EVALUATION method. 07 patients with good and o2 patients with
poor.
65
TABEL:12
COMPLICATION
COMPLICATION NUMBER OF PATIENTS %

NONE 26 86.7
KNEE STIFNESS 1 3.3
KNEE INSTABILITY 1 3.3
IMPLANT FAILURE 1 3.3
INFECTION 1 3.3
TOTAL 30 100
GRAPH:12
COMPLICATION
30
25
20
15 COMPLICATION
10
0
NO KNEE KNEE IMPLANT INFECTION
STIFFNESS INSTABILITY FAILURE
In our series we had 26 patients with no complication. one patient with knee stiffness due to
associated patella fracture, one with knee instability due to associated ACL injury ,one implant
failure due to sever osteoporetic bone and infection,and one had infection post-op.
66
MODIFIED HOHL AND LUCK EVALUATION METHOD
Grade Lack of Range of Valgus or varus Walking Pain
extension movement instability distance
(degrees) (degrees) (degrees) (M)
Excellent ( all of 0 >120 <5 >3000 None
the following)
Good (Not more >0 <90 >5 <1000 Mild on
than one of the activity
following)
Fair (not more >5 <75 >5 <1000 Moderate
than 2 of the on activity
following) or
intermittent
at rest
Poor All
results
worse
than fair
67
OSTEOARTHROSIS SCALE
GRADE DEFINITION
Grade 0 No Osteoarthrosis
Grade 1 Discrete narrowing of joint space
Grade 2 Marked narrowing of joint space plus osteophyte formation
Grade 3 Marked joint space narrowing, osteophytes, subchondral cyst, and
sclerosis
Grade 4 Severe joint destruction
ASSOCIATED INJURIES :
 Ipsilateral patella fracture treated with total patellectomy.
 Both bone fracture forearm treated with ORIF with plate and screws.
 Anterior cruciate ligament injury in one patient advised to undergo ACL
reconstruction after 6 months of the definitive fracture surgery.
68
Statistical Methods: Descriptive statistical analysis has been carried out in the present
study. Results on continuous measurements are presented on MeanSD (Min-Max) and
results on categorical measurements are presented in Number (%). Significance is
assessed at 5% level of significance. The following assumptions on data is made,
Assumptions: 1. Dependent variables should be normally distributed, 2. Samples drawn
from the population should be random, Cases of the samples should be independent.
Student “t” test (two tailed, dependent) has been used to find the significance of study
parameters on continuous scale within each group. Chi-square/Fisher Exact test has been
used to find the significance of study parameters on categorical scale between two or
more groups.
1.Chi-Square Test: The chi-square test for independence is used to determine the
relationship between two variables of a sample. In this context independence
means that the two factors are not related. In the chi-square test for independence
the degree of freedom is equal to the number of columns in the table minus one
multiplied by the number of rows in the table minus one 

2

 (Oi  Ei ) 2
,
Ei
Where Oi is Observed frequency and Ei is Expected frequency With (n-1) df
The assumptions of Chi-square test:
The chi-square test, when used with the standard approximation that a chi-square
distribution is applicable, has the following assumptions:
 Random sample: A random sampling of the data from a fixed distribution
or population.
69
 Sample size (whole table): A sample with a sufficiently large size is
assumed. If a chi square test is conducted on a sample with a smaller size,
then the chi square test will yield an inaccurate inference. The researcher,
by using chi square test on small samples, might end up committing a
Type II error.
 Expected Cell Count: Adequate expected cell counts. Some require 5 or
more, and others require 10 or more. A common rule is 5 or more in all
cells of a 2-by-2 table, and 5 or more in 80% of cells in larger tables, but
no cells with zero expected count. When this assumption is not met, Fisher
Exact test or Yates' correction is applied.
2.Fisher Exact Test: The Fisher Exact Test looks at a contingency table which displays
how different treatments have produced different outcomes. Its null hypothesis is
that treatments do not affect outcomes-- that the two areindependent. Reject the
null hypothesis (i.e., conclude treatment affects outcome) if p is "small".
The usual approach to contingency tables is to apply the 2 statistic to each cell of the
table. One should probably use the 2 approach, unless you have a special reason. The
most common reason to avoid 2 is because you have small expectation values.
Fisher Exact test (rxc tables)
Let there exist two such variables and , with and observed states, respectively.
Now form an matrix in which the entries represent the number of observations in
70
which and . Calculate the row and column sums and , respectively, and the
total sum
of the matrix. Then calculate the conditional probability of getting the actual matrix given
the particular row and column sums, given by
which is a multivariate generalization of the hypergeometric probability function.
3.Student t-test for paired comparisons
Definition: Used to compare means on the same or related subject over time or in
differing circumstances.
Assumptions: The observed data are from the same subject or from a matched subject
and are drawn from a population with a normal distribution.
Characteristics: Subjects are often tested in a before-after situation (across time, with
some intervention occurring such as a diet), or subjects are paired such as with twins, or
with subject as alike as possible.
Test: The paired t-test is actually a test that the differences between the two
observations is 0. So, if D represents the difference between observations, the
hypotheses are: Ho: D = 0 (the difference between the two observations is 0) and Ha: D
0 (the difference is not 0)
71
The test statistic is t with n-1 degrees of freedom. If the p-value associated with t is low
(< 0.05), there is evidence to reject the null hypothesis. Thus, you would have evidence
that there is a difference in means across the paired observations.
( x1  x 2)
t
s/ n
, where s   (di  d ) 2
/ n  1 ,and di is the difference formed for each
pair of observations
4.Significant figures
+ Suggestive significance (p value: 0.05<p<0.10)
* Moderately significant (p value: 0.01<p 0.05)
** Strongly significant (p value: p0.01)
Statistical software: The statistical software namely SAS 9.2, SPSS 15.0, Stata 10.1,
MedCalc 9.0.1, Systat 12.0 and R environment ver.2.11.1 were used for the analysis of
the data and Microsoft Word and Excel have been used to generate graphs, tables etc.
72
Case number:9 PRE- OP
AP LATERAL
IMMEDIATED POST-OP
AP LATERAL
73
FOLLOW-UP: 3 MONTHS
AP LATERAL
6-MONTHS:
LATERAL AP
74
9-MONTHS:
AP LATERAL
12 –MONTHS
AP LATERAL
75
RANGE OF MOVEMENTS:AFTER 12-MONTHS
EXTENSION
FLEXION
76
Case number:11
AP LATERAL
IMMEDIATED POST-OP
LATERAL AP
77
AFTER 14 MONTHS:
AP LATERAL
AFTER 14 MONTHS: IMPLANT REMOVAL
IMMEDIATE POST-OP :
AP LATERAL
78
AFTER IMPLANT REMOVAL:
EXTENSION
FLEXION
79
Case number: 19 pre-op
AP LATERAL
c-arm immage per-op wound closure
80
IMMEDIATE POST-OP
AP LATERAL
FOLLOW UP- 3 MONTHS
AP LATERAL
81
FOLLOW-UP 6 MONTHS
LATERAL AP
FLEXION SURGICAL SCAR:HEALED
82
Case number:23
PRE-OP
AP LATERAL
IMMEDIATE POST-OP:
AP LATERAL
83
9-MONTHS FOLLOW-UP
AP LATERAL
FLEXION EXTENSION
84
COMPLICATION:
complication
 We had one cases of any purely implant related complication like screw
Loosening, plate failure.
 Average time for union of fracture was 14 weeks (range from 16-24 weeks).
 One patient with knee joint stiffness is due to associated with ipsilateral patella
fracture and due to lack of postoperative mobilization.
 One patient with knee instability due to associated anterior cruciate ligament
injury.
 One patient developed deep infection of operative site were plate removed and
treated with antibiotic and above knee pop cast applied later, fracture united at 24
weeks.
85
DISCUSSION
Proximal tibial fractures, one of the commonest intraarticular fractures, incidence of this
fractures are increasing regularly due to RTA and at the same time surgical treatment
options for the same are also being modified continuously. Any fracture around the
weight bearing joint like knee joint is of paramount importance as would result in
significant morbidity and quality of life.
Hence the treatment of proximal tibial fractures has become a challenge for the
orthopaedic surgeons.
To overcome this difficulties and to early restoration of strength of bone and function of
knee joint with minimal injury to soft tissue the innovators developed new technologies
called MIPO and locking compression plate system.
Keeping our aims of the study at high, we presented the clinical study of surgical
treatment of 30 proximal tibial fractures. The analysis of the results were made in terms
of age of patients, sex distribution. Occupation of patient, laterality of fracture, mode of
violence, analysis of the types, method of reduction and fixation, surgical approach and
complications.
The majority of fracture occured between the age of 18-65 yrs with maximum incidence
involving the productive age group 20-40 yrs (63.3%). Boune in 1981 also found that the
majority of the patients are aged between 15-55 yrs with an average of 38.5 years.
86
Correlated well with the study, Seppo also showed age incidence 20-60 years with an
average of 39.8 years which correlates with the present study.
In our series majority of the patients were males 80%, this can be attributed to our Indian
setup where the female population largely work indoor and do not travel muchthis
correlates with the study done by s.sidharthan,A sujith in 2006 where males were more
prone.43
Occupationally proximal tibial fractures were seen in people with high level of activity,
movement and travel. It is most commonly seen with people who travel more.
In our study the commonest mode of injury being the road traffic accident 70% other
being fall from height 30%.In laterality of the fracture right being 63.4% .
In this series we studied 30 cases of out of them most of the patients fall into
type IV, type V and type VI schatzker’s classification. Different authors use different
criteria for the surgical management of these fractures. SEPPO E. Honkonen conducted
130 tibial plateau fractures taking into consideration of
 Condylar widening of > 5mm
 Lateral condyle step off > 3mm
 All medial condylar fracture
87
In our series the indications for the surgery were the same standard indications as for the
tibial plateau fractures. 3mm depression was considered as an indications for surgery in
our series.44
Name of the authors Year Amount of depression
Burri24 1979 1mm
Hohln32 1979 5mm
David segal 33 1991 5mm
Seppo E 26 1993 3mm
Our series 2011 3mm
In our series we used MIPO technique for reduction and fixation in 23 patients 76.6%. In
which both duration of procedure and soft tissue injuries are less compare to ORIF
technique, wound healing also better and faster compare to ORIF technique but it
demands more surgical techniques.
In our series we approached with antero medial incision in 17 patients this approach need
less soft tissue stripping from bone can contour plate to bone appropriately and easy to
perform MIPPO technique and we preferred antero lateral approach in 13 patients with
lateral condylar displacement fracture and soft tissue injury on medial side of proximal
tibia
88
In our series we had no cases of any purely implant related complications and average
time for union of fracture was 14 weeks.
In our series one patient developed knee stiffness due to patella fracture treated with
patellectomy and physiotherapy and regain 700 of flexion another patient present with
knee joint instability at end of 6 months of postoperative period he was treated with ACL
reconstruction and physiotherapy and he regained an range of movement from complete
extension to 900 of flexion.
In our series one patient developed deep infection by 7th postoperative day secondary to
uncontrolled diabetes and skin infection in thigh region, he was treated with IV
antibiotics (ceftriaxone and amikacin), implant removal and above knee pop cast
application, subsequently infection was controlled and fracture union occurred at an end
of 24 weeks postoperatively.
In our series one patient developed loss of reduction with collapse of medial condyle at
end of 08 weeks of postoperative period treated with above knee pop cast for 12 weeks
subsequently fracture united with minimal depression of medial condyle. Another patient
developed varus deformity due to collapse of medial condyle at 09 weeks of
postoperative period due to early weight bearing he was treated with application of above
knee pop cast for 2 weeks and adviced to wear knee brace while walking.
89
In our series one patient had associated anterior crutiate ligament injury he was treated
with above knee pop cast till fracture union and adviced to wear knee support while
walking and to undergo ACL repair in subsequent days.
The period of immobilization was again individualized depending on the Stability of
fixation. The benefits of early knee mobilization include reduced incidence of knee
stiffness and improved cartilage healing (regeneration) and promotion of good callus
formation and remodeling.
Inspite of all these complications we are able to achieve 70% excellent result and 23.33%
good result (over all 85.7%, acceptable results) with our standard surgical care. In
addition we had 6.4% poor results in term of functional outcome. These results are
comparable and on par with other documented standard studies.
Rambold 1992 93% acceptable
Seppo E 1993 85% satisfactory
Joseph Schatzkar 1986 85% satisfactory
Our study 2011 85% satisfactory
In one patient we removed implant after 1 yr of fracture union.
90
CONCLUSION
At the end of our study, following conclusions could be drawn from the treatment of
proximal tibial fracture with locking compression plate.
 Proximal tibial fracture are increasing with the increase in Road traffic accidents.
 These fracture need optimum treatment as most of them involved the productive
men.
 Preoperative soft tissue status and their repair at right time significantly changes
the outcome.
 The anchorage of the locking head screw was found to be excellent even in
osteoporotic bone. Drilling the holes for the locking head screw should always be
through a screw-in drill sleeve.
 While bridging a fracture, care must be taken to select a strong plate and leave
atleast 2-3 plate hole, without inserting screws over the fracture. This prevent the
stress concentration and achieves an elastic fixation which is very essential for
secondary fracture union.
 Even in osteoporotic bone, bone graft is not essential for defect in metaphyseal
region as LCP internal fixator system act as single implant and prevent collapse of
fracture intraoperatively and postoperatively subsequently bone deficient will heal
by callus formation.
 When LCP used as combined principle of fixation we can reconstruct tibial
plateau with compression and prevent it from collapse by bridging principle.
91
 Fractures treated with MIPO healed rapidly by secondary fracture union and
hence achieving strong bone union across the fracture at a much earlier time
compared to open reduction and internal fixation due to less soft tissue injury
leads to minimal blood supply interruption to proximal tibia.
Thus we conclude that the locking compression plate system with its various type of
fixation act as a good biological fixation including in difficult fracture situations.
92
SUMMARY
We studied 30 patients with proximal tibial fracture with locking compression plate at
vydehi institute of medical sciences and recerch center.The study was done from 2009 to
2011
 Age of the patients ranged from 18-65 yrs with most of patients belong to 20-40yrs of
age group who are more prone for RTA.
 The majority of the patients were male (M : F = 25 : 5)
 The sample size reflected the population visiting the trauma section of our
department.
 The majority of the fractures were found to be type IV, type V, type VI and
schatzker’s classification which are usually associated with high velocity RTA.
 Both ORIF and MIPO was used as the method of reduction and fixation, 23 patients
were treated with MIPO technique.
 All patients were followed up ranging from 16 weeks to 64 weeks until fracture union
occur.
 Average time for union of fracture was 14 weeks ranged from (12-20weeks) those
treated by bridge plating with the MIPO technique healed even earlier than ORIF
technique.
 Three different principle of fixation were done using the LCP, viz compression,
bridging and combined.
 Complications were encountered in 4 patients and include knee joint stiffness (1),
implant failure(1), infection (1), and knee instability (1).
93
 Implant related complication were noted in 1 patient with sever osteoporetic bone (viz
screw loosening screw breakage plate failure).
 We found that the locking screw had excellent hold even in the osteoporotic bones.
 We noted a strong bone bridging across the fracture site even in comminuted fracture
which were fixed with elastic fixation (bridge plating) using the MIPO technique.
This could possibly suggest an early implant removal when compared to conventional
plating.
 We also suggest that the proper understanding principles of LCP and MIPO technique
with preoperative planning of surgery can give good biological fixation for proximal
tibial fractures.
94
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INFORMED CONSENT FORM
do hereby give my informed consent for the research programme as a part of M.S.
Dissertation being carried out at Department of Orthopaedics, VIMS & RC, Bangalore.
I have been explained about the details of the research programme in the language I
understand.
I have voluntarily given this informed consent for publication of data and I will not make
any claims what so ever against any individual or the institution in the process of this
research programme, if anything untoward happens in the process.
SIGNATURE OF THE WITNESS SIGNATURE OF THE PATIENT
NAME & ADDRESS NAME & ADDRESS
101
ANNEXURE – I
PROFORMA
For surgical management of Tibial Plateau fracture by locking compression plate.
Name : IP No. :
Age and Sex : DOA :
Occupation : DOS :
Address : DODIS :
Presenting complaint :
Pain, swelling, loss of function (movement of knee), inability to walk (bearing weight)
since ---------- on Right/Left leg.
History of the injury :
Date of time of injury :
Mode of injury : Direct / indirect. Automobile accident, Trival, Fall from height,
stumbling, Assault, slipping, industrial, twist, valgus/varus stress,
missing steps, athletics, ect..
Any treatment received:
History of massage:
102
Pain :
Site :
Onset :- Sudden / gradual
Nature :-continuous / intermittent
Related to movement :- increased or remaine same
Was patient able to walk soon after the injury (or) carried to hospital
General physical examination :
Built / Nourishment : Obese, moderate, poor
Signs : Anaemia, Jaundice, Clubbing, cyanosis, pallor
Lymphadenopahty : General / Local
Pulse – Rate, Rhythm, Volume
BP-
Systemic Examination :
CVS Other joint functions
RS Spine
P/A CNS
103
Local Examination :
Right / Left leg
A) Inspection :
a) Attitude / deformity
b)swelling - Site
Size
Shape
Extent
c) Shortening
d) Skin :
Oedema, Ecchymosis, Bruise, Abbration, Wasting.
e) Popliteal fossa :
f) Compound injury if any
B) Palpation:
a) Local tenderness
b) Bony irregularity
c) Abnormal movement
104
d) Crepitus
e) Pain elicited by manipulation
f) Transmitted movements
g) Swelling
h) Valgus / varus deformity
i) Instability
j) Ligament injury
Measurement :
Shortening - Apparent
True
Complication :
Associated injury
Vascular injury
Neurological injury
Ligament injury
105
Management :
Reception at casualty / OPD
First aid slab / cast
Traction
Associated injury
Investigation :
Urine - Albumin, Sugar, Microscopy
Blood - Hb%, TC, DC, ESR, FBS/PPBS. Blood urea, serum creatinine blood
grouping, HIV/HBSAs
ECG chest x-ray
X ray of knee :
1) AP view
2) Lateral view
3) Oblique view at 400 (medial and lateral)
4)AP view with beam angled 10-150
CT/ MRI of knee joint / Arthroscopy if required
106
Treatment :
Reception in casualty :
General condition of the patient – fluid / blood
To the fracture - Manipulative reduction
-Attempted / unattempted
- Pop immobilization:
- Radiological examination:
Operative Treatment :
Time between injury and operation:
Date and time of operation:
Indication:
Anaesthesia: Spinal : GA :
Tourniquet used:
Approach:
Operative findings:
Type of plate / screw:
Bone grafting:
107
Any other problem encountered:
Comment:
Post operative treatment :
Antibiotic and analgesic:
Transfusion : Fluid, Blood
Post operative - Limb position:
External splint / cast / fixator duration :
Check x-ray : Date, report:
Date of suture Removal : wound:
Active motion started on
Partial weight bearing on :
Full weight bearing on :
Complication :
Early complication :
1) Bleeding, 2) Wound infection 3) Sepsis 4) Compartment syndrome 5) Pain
6) Swelling 7) Knee stiffness 8) Nerve injury (lat popliteal) 9)Vascular injury (Ant
tibral) 10) Loss of fracture reduction 11) Limb length discreptency 12) Deep vein
108
thrombosis.
Late complication :
1) Wound infection 2) Knee stiffness 3) Malunion, 4) Knee instability varus / valgus
/anterior / posterior 5) Exterior lag 6) Angular deformity 7) Persisting pain/swelling 8)
Redepression 9) Refracture 10) Delayed union 11) Non union.
Assessment at the time of discharge :
1) Wound 5) Any other complaints
2) Range of movement 6) Advice given
3) Shortening 7) Discharged on
4) Check x-ray - date
- report
Follow up:
Clinical and Radiological assessment
1) 6 wk
2) 12-14 wks
3) 6 months
4)1 year
Criteria for evaluation of results by points (at the end of 6 months)
1) Pain - Rest pain, pain with walk Points
109
2) Walking capacity - Normal / limping
3) Extension of leg - Extension upto normal of limitation
4) Range of motion - full range / restriction
5) Stability - On varus/valgus stress
-Anterior and posterior drawer test
- Mac Murrey test
6)Radiological .
110
Master Chart
MODE SIDE SCHATZ METHOD OF FRACTURE
sl. OF KER REDUCTION UNION CLINICAL
no NAME AGE SEX IP-NO OCCUPATION INJURY #TYPE ASSOCIATED INJURY &FIXATION APPROCH ROM (WEEKS) RESULTS COMPLICATION
1 Shubughosh 48 M 1229764 heavy work RTA Right I nil MIPPO antero lateral >120 14 weeks excellent none
2 Reddy praad 45 M 1062584 heavy work Right I nil MIPPO antero lateral >120 14 weeks excellent none
3 Bajede Dutta 44 M 1062769 heavy work RTA Right V nil ORIF antero lateral >120 13 weeks excellent none
4 Rahimi 29 F 1063136 house wife RTA Right VI nil MIPPO antero lateral >120 14 weeks excellent none
5 Yasabha 28 F 1074480 student RTA Right V nil ORIF antero medial >120 14 weeks excellent none
6 Manas pande 24 M 1094919 student FALL Right VI ACL MIPPO antero lateral <90 13 weeks good instability
7 A.V.Gurnamarao 46 M 1099717 heavy work RTA Left IV nil MIPPO antero lateral >90 16 weeks good none
8 Bhaskar 37 M 1107619 heavy work RTA Left IV nil MIPPO antero lateral >120 14 weeks excellent none
9 Ramesh 39 M 1114734 heavy work FALL Right VI nil MIPPO antero lateral >120 13 weeks excellent none
10 Vanajakshi 40 F 1131449 house wife RTA Left VI nil MIPPO antero lateral >120 18 weeks excellent none
11 Prashanth 36 M 962649 heavy work FALL Right VI nil ORIF antero lateral <90 17 weeks good none
12 Santhosh 29 M 973543 light work RTA Right I nil MIPPO antero lateral >120 12 weeks excellent none
13 Prakash 31 M 985243 heavy work RTA left IV nil MIPPO antero lateral >90 14 weeks excellent none
Both Bone Fracture
14 Gopal Reddy 53 M 1017998 light work FALL Right V Fore Arm MIPPO antero medial >120 13 weeks excellent none
15 Rajanna 27 M 1034680 heavy work FALL Right I nil MIPPO antero lateral >90 14 weeks good none
111
16 Pavom 20 M 1302561 student RTA right VI nil ORIF antero medial >90 13 weeks good none
17 M.chlapathi 55 M 130646 light work RTA left IV nil MIPPO antero lateral >90 14 weeks good none
18 Madhaesh 32 M 1321668 heavy work RTA Left V nil MIPPO antero medial >120 14 weeks excellent none
19 Nandala adikan 45 M 1338881 heavy work RTA Right VI nil MIPPO antero lateral >120 13 weeks excellent none
20 Nityalaroy 22 M 1338754 student RTA Left I nil MIPPO antero lateral >120 14 weeks excellent none
21 Puttaswamy 38 M 1262502 heavy work RTA right IV nil ORIF antero medial >120 16 weeks excellent none
22 Adiralam 41 M 1356941 heavy work RTA Right I nil MIPPO antero lateral >120 14 weeks excellent none
23 Birappa 55 M 1364329 light work FALL Left VI nil ORIF antero lateral >90 18 weeks good none
24 Srinivas 25 M 1262814 student RTA Right V nil MIPPO antero medial >120 13 weeks excellent none
25 Priya 32 F 1274549 house wife FALL Left IV nil MIPPO antero lateral >120 14 weeks excellent none
26 Ambika 22 F 136600 student RTA Right IV nil MIPPO antero lateral >120 11 weeks excellent none
27 Anjanroot 29 M 1154490 heavy work RTA Right V nil MIPPO antero medial >120 14 weeks excellent none
28 Inprajit pal 33 M 11595142 light work FALL Right VI nil MIPPO antero lateral >90 16 weeks good none
29 Venkatesh 43 M 1185604 heavy work RTA Right IV patella fracture ORIF antero lateral <90 14 weeks fair knee stiffness
30 Bapaji biswas 23 M 1201345 student RTA Left I nil MIPPO antero lateral >120 11 weeks excellent none
112

Surgical Management of Proximal Tibial Fracture With Locking Compression Plate.”

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“SURGICAL MANAGEMENT OF PROXIMAL TIBIAL FRACTURE

WITH LOCKING COMPRESSION PLATE.”

Dissertation Submitted to the

Under the guidance of

Dr.SATISH KUMAR.C, M.B.B.S, M.S.ortho

I hereby declare that this dissertation entitled “SURGICAL MANAGEMENT OF

PROXIMAL TIBIAL FRACTURE WITH LOCKING COMPRESSION PLATE.”

DR.SATISH KUMAR.C M.B.B.S, M.S.Ortho, Professor, department of orthopaedics,

Vydehi Institute of Medical Sciences & Research Centre, Bangalore.

Date: Signature of the Candidate

Place: Bangalore. Dr.RAJESH.P

This is to certify that the dissertation entitled “SURGICAL MANAGEMENT

PROXIMAL TIBIAL PLATEAU FRACTURE WITH LOCKING

COMPRESSION PLATE” is a bonafide research work done by Dr.RAJESH.P in

partial fulfillment of the requirement for the degree of M.S. ORTHOPAEDICS.

Date: Signature of the Guide

Place: Bangalore Dr.SATISH KUMAR.C M.B.B.S, M.S.Ortho

This is to certify that the dissertation entitled “SURGICAL

MANAGEMENT OF PROXIMAL TIBIAL PLATEAU FRACTURE WITH

LOCKING COMPRESSION PLATE.” is a bonafide research work done by

Dr.RAJESH.P under the guidance of Dr.SATISH KUMAR.C M.B.B.S, M.S.Ortho

Professor , Department of orthopaedics Vydehi Institute of Medical Sciences & Research

Signature of Head of the Department Signature of the Principal

Dr. , Dr.MURALIDHAR.N Dr. M.R.Sandhya Belwadi MD.

Declaration by the Candidate

format for academic / research purpose.

Date : Signature of the Candidate

© Rajiv Gandhi University of Health Sciences, Karnataka

When going gets tough : tough gets going ………..

This is how it unveiled and ended with smiles ……

whom this study would not have been possible.

I feel towards my teacher and guide Dr.SATISH KUMAR.C M.S.Ortho. Professor,

Department of Orthopaedics, VYDEHI INSTITUTE OF MEDICAL SCIENCES

to detail that he has so willingly shown in the preparation of this dissertation.

I acknowledge and express my humble gratitude and sincere thanks to my beloved

teacher, Dr.MURALIDHAR.N B.SC.M.B.B.S. M.S, D(Ortho), Professor and H.O.D.,

Department VYDEHI INSTITUTE OF MEDICAL SCIENCES &RESEARCH CENTRE

of Orthopaedics, for his constant help to undertake this study.

I owe a great deal of respect and gratitude to Dr.VISHWANATH.M.S. Professor,

suggestions and allround encouragement.

I am also thankful to,Dr.GIRISH.(M.S.Ortho), Dr. C.B.PATIL(M.S.Ortho),

Dr.SIDDALINGESHWAR.V.H(D.N.B.ortho), Dr.KRISHNA KUMAR.(M.S.Ortho),

I am extremely grateful to Mrs.KALPAJA. Director, Dr.KANTHA.S, M.S (anatomy)

Advisor Dr.Mrs.SANDHYA BELWADI. MD. Principal OF VYDEHI INSTITUTE OF

MEDICAL SCIENCES &RESEARCH CENTRE for their valuable help, co-operation,

studies in this esteemed institution.

during this study period.

I thank my parent`s and family members for their blessings.

turning up for review on regular basis.

I place on record my sincere thanks to all.

Date: Signature of the candidate

ACL – Anterior cruciate ligament

AO – Arbeitsgemeinschaft for osteosynthese fragen

ASIF – Association for the study of internal fixation

CPM – Continue passive movement

DCP – Dynamic compression plate

LC-DCP – Limited contact dynamic compression plate

LCP – Locking compression plate

LISS – Less invasive stabilizing system

MIPO – Minimally invasive plate osteosynthesis

ORIF – Open reduction and internal fixation

PC-FIX – Point contact fixator

POP – Plaster of Paris

ROM – Range of motion