Skip to main content
SpringerLink
Log in

Early Revision Surgery for Tibial Plateau Non-union and Mal-union

  • Surgical Technique
  • Published:
HSS Journal ®

Abstract

Background

Although relatively rare, non-unions and mal-unions of tibial plateau fractures present significant challenges for the orthopedic surgeon. With careful pre-operative planning, tibial plateau mal-union or non-union revision surgery with intra-articular and varus opening osteotomies can provides good functional results when performed early (within 1 year) after primary surgical procedure.

Questions/Purposes

We present our treatment algorithm for approaching and treating non-union or mal-union of tibial plateau fractures. Our aim is to give surgeons treating these difficult injuries an overview of the pertinent literature as well as describe the challenges and pitfalls we have experienced when treating non-union or mal-union of tibial plateau fractures.

Methods

Using two case examples from our institution, one for mal-union and one for mal-reduction, we describe our treatment algorithm and surgical technique for managing these difficult injuries. We also provide a brief literature review outlining relevant studies and summarizing outcomes for similar injuries. A systematic literature review was conducted with the aim of determining the methods and outcomes commonly reported in the literature regarding revision surgery following tibial plateau non-union or mal-union. Due to the nature of revision surgery, there are no long-term randomized trials dealing with outcomes, but rather several smaller case series exist from which larger conclusions have to be drawn.

Results

To date, we have successfully treated approximately 35 patients with this technique, and clinical follow-up continues to show good functional outcomes with reduced pain and little radiographic evidence of arthritic changes. Restoring long leg alignment, anatomic reduction of the articular surface, and achieving stable internal fixation are paramount in achieving the best long-term outcome. Due to the shallow soft tissue envelope around the proximal tibia, and the tendency for these fractures to fall into progressive valgus collapse, these problems can seem intimidating and complex. However, with well-planned surgery and meticulous surgical technique, reliable healing can be achieved.

Conclusion

By outlining our method, we hope to provide other surgeons with an algorithm to guide clinical and operative decision making. These difficult injuries can be daunting to treat, but if performed before the onset of severe degenerative arthritis, early revision surgery, as we describe, can be a viable alternative to total knee arthroplasty, particularly in younger, more active patients.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9

Similar content being viewed by others

References

  1. Borelli J Jr, Prickett W, Song E, Becker D, Ricci W. Extraosseous blood supply of the tibia and the effects of different plating techniques: a human cadaveric study. J Orthop Trauma. 2002; 16: 691-695.

    Article  Google Scholar 

  2. Chan DB, Jeffcoat DM, Lorich DG, Helfet DL. Nonunions around the knee joint. International Orthopaedics. 2010; 34: 271-281.

    Article  PubMed  Google Scholar 

  3. Court-Brown CM, Caesar B. The epidemiology of fractures. In: Heckman JD, Buchholz RW, Court-Brown CM, eds. Rockwood and Greens Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott, Williams and Wilkins; 2006: 95-113.

    Google Scholar 

  4. Kerkhoffs G, Rademakers M, Altena M, Marti R. Combined intra-articular and varus opening wedge osteotomy for lateral depression and valgus malunion of the proximal part of the tibia: surgical technique. J Bone Joint Surg Am. 2009; 91: 101-115.

    Article  PubMed  Google Scholar 

  5. Kerkhoffs G, Rademakers M, Altena M, Marti R. Combined intra-articular and varus opening wedge osteotomy for lateral depression and valgus malunion of the proximal part of the tibia. J Bond Joint Surg Am. 2008; 90: 1252-1257.

    Article  Google Scholar 

  6. Krettek C, Hawi N, Jagodzinski M. Intracondylar segment osteotomy: correction of intra-articular malalignment after fracture of the tibial plateau. Unfallchirurg. 2013; 116(5): 413-426. German.

    Article  CAS  PubMed  Google Scholar 

  7. Marti RK, Verhage RA, Kerkhoffs GM, Moojen TM. Proximal tibial varus osteotomy. Indications, technique, and five to twenty-one-year results. J Bone Joint Surg Am. 2001; 83: 164-170.

    Article  PubMed  Google Scholar 

  8. Martinez A, Sarmiento A, Latta LL. Closed fractures of the proximal tibia treated with a functional brace. Clin Orthop. 2003; 417: 293-302.

    Google Scholar 

  9. Moore TM, Patzakis MJ, Harvey JP. Tibial plateau fractures, definition, demographics, treatment rationale, and long term results of closed traction management or operative reduction. J Orthop Trauma. 1987; 1(2): 97-119.

    Article  CAS  PubMed  Google Scholar 

  10. Stevens DG, Beharry R, McKee MD, et al. The long-term functional outcome of operatively treated tibial plateau fractures. J Orthop Trauma. 2001; 15: 312-320.

    Article  CAS  PubMed  Google Scholar 

  11. Toro-Arbelaez JB, Gardner MJ, Shindle MK, Cabas JM, Lorich DG, Helfet DL. Open reduction and internal fixation of intraarticular tibial plateau nonunions. Injury, Int. 2007; 38: 378-383.

    Article  Google Scholar 

  12. Watson JT, Schatzker J. Tibial plateau fractures. In: Browner BD, ed. Skeletal trauma: basic science, management, and reconstruction. 3rd ed. Philadelphia, Pa: Saunders; 2003: 2047-2130.

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Deparmentof Orthopaedic Surgery, Naval Medical Center Portsmouth, 620 John Paul Jones Blvd, Portsmouth, VA, 23708, USA

    Dominic L. Van Nielen MD & Christopher S. Smith MD

  2. Orthopaedic Trauma Service, Hospital for Special Surgery, New York, NY, 10021, USA

    David L. Helfet MD

  3. University of Amsterdam, Amsterdam, Netherlands

    Peter Kloen MD, PhD

Authors
  1. Dominic L. Van Nielen MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Christopher S. Smith MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. David L. Helfet MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Peter Kloen MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Christopher S. Smith MD.

Ethics declarations

Conflict of Interest

LT Dominic L. Van Nielen, MD, LCDR, Christopher S. Smith, MD, David L. Helfet, MD and Peter Kloen, MD, PhD, have declared that they have no conflict of interest.

Human/Animal Rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5).

Informed Consent

Informed consent was waived from all patients for being included in the study.

Required Author Forms

Disclosure forms provided by the authors are available with the online version of this article.

Disclaimers

The views expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the US Government.

Dr. Dominic Van Nielen and Dr. Christopher Smith are military service members. This work was prepared as part of their official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a US Government work as a work prepared by a military service member or employee of the US Government as part of that person’s official duties.

Additional information

Level of Evidence: Level IV: Surgical Technique

Research performed at Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands.

Electronic supplementary material

Below is the link to the electronic supplementary material.

ESM 1

(PDF 1224 kb)

ESM 2

(PDF 1224 kb)

ESM 3

(PDF 1224 kb)

ESM 4

(PDF 1224 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Van Nielen, D.L., Smith, C.S., Helfet, D.L. et al. Early Revision Surgery for Tibial Plateau Non-union and Mal-union. HSS Jrnl 13, 81–89 (2017). https://doi.org/10.1007/s11420-016-9529-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11420-016-9529-1

Keywords

Search

Navigation