Clinical Comparison of the "Windowing" Technique and the "Open Book" Technique in Schatzker Type II Tibial Plateau Fracture

Abstract

Objective: Surgical treatment for Schatzker type II tibial plateau fractures remains challenging and requires high-quality research. The aim of the study is to compare the "windowing" and "open book" techniques for the treatment of Schatzker type II tibial plateau fractures.

Methods: In this prospective study, all patients with Schatzker type II tibial plateau fractures between January 2014 and December 2017 were managed by open reduction and internal fixation using an anterolateral incision approach. "Windowing" group included 78 patients (53 men and 25 women), with an average age of 57.7 ± 13.5 years, who underwent the "windowing" technique, in which the procedure was performed through a small cortical window against the depressed zone of the lateral plateau. The "open book" group included 80 patients (56 men and 24 women), with an average age of 54.8 ± 12.4 years, who underwent the technique. The clinical outcomes included the Rasmussen classification of knee function and grading of post-traumatic arthritis. The radiographic outcome (x-ray and computed tomography [CT]) was the reduction quality of the lateral plateau based on the modified Rasmussen radiological assessment. The patient-reported outcome was visual analogue scale (VAS) scores.

Results: The mean follow-up time for the158 patients was 32 months (range, 24-42 months). The time elapsed from injury to surgery in "windowing" group and "open book" group were 3.7 ± 1.2 (range, 1-10 days) and 3.5 ± 1.4 days (range, 1-11 days), respectively, with no significant difference between the groups (P > 0.05). The operation times did not differ significantly between the "windowing" group (61.0 ± 8.3 min, range, 45-120 min) and the "open book" group (61.2 ± 10.4 min, range, 40-123 min) (P > 0.05). After surgery, CT revealed five (6.4%) and 15 (18.8%) cases of articular depression in the "windowing" and "open book" groups, respectively. Significant differences were observed in the articular depression of tibial plateau fractures between the groups (P < 0.05). However, condylar widening or valgus/varus did not differ significantly between the groups. Furthermore, no significant differences in knee function were observed during follow-up (P > 0.05). VAS scores were similar between the groups at 24 months after surgery (P > 0.05). There were significant differences in the number of severe post-traumatic arthritis (grades 2 and 3) cases between the groups (P < 0.05).

Conclusions: The "windowing" and "open book" techniques are both effective for the treatment of Schatzker type II tibial plateau fractures. However, the "windowing" technique provides better reduction quality, leading to a satisfactory prognosis.

Keywords: Knee function; Schatzker classification; Tibial plateau fracture; “Open book” technique; “Windowing” technique.

Fig. 1

Characteristics of split‐depressed tibial plateau fractures on computed tomography (CT). The upper and lower parts show the transverse and coronal sections of the tibial plateau fracture, respectively. The fracture zone is shown in red, and the line of depression is shown in green (asterisk: zone of articular depression involved in the split fragment)

Fig. 2

Images and illustrative diagrams of the operative procedures for split‐depressed fractures of the lateral tibial plateau. (A) A cortical window 5 below the area of depression (“windowing” technique; arrow: bone cortex of the window). (B) Lateral fragment hinges open like a book, exposing the depressed articular surface and cancellous bone of the central depression (“open book” technique; arrow: lateral fragment). (C) Illustrative diagrams of the “windowing” technique for type II Schatzker type II fractures. (D) Illustrative diagrams of the “open book” technique for type II Schatzker type II fractures

Fig. 3

Flowchart demonstrating patient selection and analysis

Fig. 4

Two cases of Schatzker type II tibial plateau fracture. (A–D) Case 1 (male, 56 y/o, vehicle accident) underwent surgery involving the “windowing” technique. (E–H) Case 2 (female, 42 y/o, vehicle accident) underwent surgery involving the “open book” technique. (A) and (E) Preoperative anteroposterior (AP) radiograph. (B) and (F) Preoperative lateral radiograph. (C) and (G) Postoperative AP radiograph at 24 months. (D) and (H) Postoperative lateral radiograph at 24 months

Fig. 5

Images of split‐depressed lateral tibial plateau fractures before and after surgery. (A) and (B) Preoperative computed tomography showing a split‐depressed lateral tibial plateau fracture. (C) and (D) Postoperative computed tomography showing fracture fixation using an anatomical locking plate. Mal reduction (articular depression) is visible on the articular surface of the split fragment. (E) and (F) Postoperative images at 24 months after surgery showing blurred fracture lines and post‐traumatic arthritis (grade 2)