Maintenance of joint reduction and allograft incorporation in treating tibial plateau fractures. Retrospective case series using cortico-cancellous, non-irradiated, bone allograft

Abstract

Background: Restoring joint congruence and maintaining reduction until healing is imperative in treating tibial plateau fractures (TPF). The main objective of this study was to evaluate the feasibility of augmentation with impacted bone allograft (IBA) to prevent loss of reduction in tibial plateau fractures during healing and to evaluate its incorporation.

Methods: We retrospectively analyzed all patients with an acute, closed tibial plateau fracture (Schatzker II, III, IV) treated between 2010 and 2019 with open reduction and internal fixation (ORIF) and impacted bone allograft (IBA), with a minimum follow-up of 24 months. We evaluated the postoperative radiographs by drawing a line along the tibial axis and another perpendicular to the healthy plateau to measure the reduction and subsequent behavior. The incorporation of the allograft was evaluated by radiological analysis assessing its integration, non-union, resorption, or sclerosis. We used the clinical-radiological Rasmussen system and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) to objectify the outcomes.

Results: 78 TPFs were included, with a median age of 51.5 (40.7-62.2) years and a median follow-up of 66 (24-89) months. Two (2.5 %) patients presented loss of joint reduction (subsidence) during the follow-up regarding the achieved in the surgery. Seventy-six (94.7 %) patients presented integration, two (2.5 %) resorption, and one (1.3 %) sclerosis. Seventy-two (92.3 %) patients presented excellent and good results in the Rasmussen radiological score, and 72 (92.3 %) patients presented excellent or good clinical scores. The mean WOMAC at two years postoperatively was 15 ± 6.5.

Conclusion: Our results demonstrate that allograft is an adjuvant in maintaining a reduction in type II, III, and IV Schatzker's tibial plateau fractures. Low rates of loss of reduction during follow-up can be expected with its use.

Keywords: Allograft; Joint reduction; Tibia; Tibial plateau fracture.

Fig. 1

The method used in the measurements. Line tracing in the tibial axis and a line perpendicular to the healthy plateau. Black arrow: fracture subsidence. White arrow: condylar widening. Dotted line femorotibial axis.

Fig. 2

a: A purely depressed, comminuted fracture in an 80-year-old female patient. b: Immediate postoperative AP radiograph showing reduction achieved. c, d: AP and L radiograph at three months postoperatively showing the subsidence in the central and posterior area of the plate.

Fig. 3

a,b,c,d: Schatzker type III fracture, with significant subsidence and metaphyseal bone defect. e: AP X-ray showing reduction, internal fixation, and allograft impaction. f,g: AP X-ray at 6 and 12 months postoperative showing progressive allograft incorporation. h,i: 24 months postoperative showing maintenance of reduction and allograft incorporation.

Fig. 4

a: AP radiograph at 12 months postoperative showing sclerosis and radiolucent zone in the graft area, close to the bone window from where the graft was impacted. b: CT slice showing areas of increased allograft density (sclerosis) and a small resorption area (white circle).