To analyse the functional outcome of the tibial condyle fractures treated with Minimally Invasive Plate Osteosynthesis (MIPO)

1. Presenter : Dr.B.Naveen ThiyaguPresenter : Dr.B.Naveen Thiyagu
Author : Prof SSK.MarthandamAuthor : Prof SSK.Marthandam
HOD & Director of Trauma Care ServicesHOD & Director of Trauma Care Services
Co-Authors :Co-Authors : Dr.D.Gokul Raj,Dr.D.Gokul Raj,
Dr.S.Sundar,Dr.S.Sundar,
Dr.N.JambuDr.N.Jambu
Sri Ramachandra Medical College & Research InstituteSri Ramachandra Medical College & Research Institute
(Deemed University) Chennai.(Deemed University) Chennai.

2. PRINCIPLES*PRINCIPLES*
 Limited exposure
 Indirect reduction methods
 Communition manipulated with vascularity intact
 Preservation of the periosteal vascularity
*Rockwood & Green’s Vth edition vol 1 pg 119.

3. AIMAIM
 To analyse the functional outcome of the tibialTo analyse the functional outcome of the tibial
condyle fractures treated with Minimallycondyle fractures treated with Minimally
Invasive plateosteosynthesis(MIPO)Invasive plateosteosynthesis(MIPO)

4. SHATZKER’S CLASSIFICATIONSHATZKER’S CLASSIFICATION
I II III IV V VI
No of cases : 1 1 2 1 14

5. MATERIAL & METHODSMATERIAL & METHODS
 Prospective study
 Follow Up : 4 mo to 28 mo Av : 16.5Follow Up : 4 mo to 28 mo Av : 16.5
monthsmonths
 Period of study : June 2002 toNov2004June 2002 toNov2004
 Total no. of cases: 19
 M : F : 8.5 : 18.5 : 1
 Age : 29 to 59 yrs Av :40.2 yrs
 Side R :L : 10 :9
 Mode Of Injury RTA :Fall : 17:2

6. EXCLUSION CRITERIAEXCLUSION CRITERIA
 Tibial condyle fractures
 Only Closed fractures were taken up
for the study
 Open tibial condyle fractures
 Schatzker type I fractures
 Patients who presented with
compartment syndrome & vascular injury
INCLUSION CRITERIAINCLUSION CRITERIA

7. INJURY SURGERY INTERVALINJURY SURGERY INTERVAL
Within 1 week -13 casesWithin 1 week -13 cases
1-2 weeks - 4 cases1-2 weeks - 4 cases
2-3weeks - 2 cases2-3weeks - 2 cases
0
2
4
6
8
10
12
14
< 1 week 1 - 2 weeks 2 - 3 weeks
Patients

8. SURGICAL TECHNIQUESURGICAL TECHNIQUE
 Under the guidance of image intensifier
closed reduction achieved by
ligamentotaxis either using longitudinal
traction or femoral distractor
 Incision was made as large as necessary
for the insertion of the plate,far from
fracture site
 Either T Buttress plate / L buttress plate
with or without 4.5 mm narrow DCP
slide in sub muscular plane
extraperiostealy
 The plate was then fixed with a minimum
of three screws on either side of the
fracture using image intensifier

9. CRITERIA FOR GRADING RESULTSCRITERIA FOR GRADING RESULTS
Rasmussen’s functional knee score*
Parameter
Points Acceptable
Unacceptable
Excellent Good Fair Poor
A. Subjective Complaints
a. Pain
No pain
Occasional ache, bad
weather pain
Stabbing pain in certain
positions
Afternoon pain, intense
constant around the knee after
activity
Night pain at rest.
b. Walking Capacity
Normal walking capacity (in
relation to age)
Walking outdoors at least 1
hour
Short walks outdoors > 15
minutes
Walking indoors only
Wheelchair/bedridden
6
5
4
2
0
6
4
2
1
0
5
6
4
4
2
2
0
1
** Paul j duwelius et al CORR NO 339, pp 47 – 57 . 1997Paul j duwelius et al CORR NO 339, pp 47 – 57 . 1997

10. Parameter Points Excellent Good Fair Poor
B. Clinical signs
a. Extension
Normal
Lack of extension (0o
– 10o
)
Lack of extension > 10o
b. Total range of motion
At least 140o
At least 120o
At least 90o
At least 60o
At least 30o
0
c. Stability
Normal stability extension and
20o
flexion
Abnormal instability
20o
flexion
Instability in extension < 10o
Instability in extension > 10o
Sum(minimum)
6
4
2
6
5
4
2
1
0
6
5
4
2
6
5
5
4
4
4
2
2
2
2
1
2
27 20 10 6

11. POST OPERATIVE PROTOCOLPOST OPERATIVE PROTOCOL
 Mobilisation of knee and ankle started once the post op painMobilisation of knee and ankle started once the post op pain
subsidedsubsided
 Non weight bearing walk was permitted from 3rd podNon weight bearing walk was permitted from 3rd pod
 Sutures removed on 10th/12th podSutures removed on 10th/12th pod
 Non weight bearing walk for a minimum period of 6 weeksNon weight bearing walk for a minimum period of 6 weeks
 Partial weight bearing until 3 monthsPartial weight bearing until 3 months
 Full weight bearing after radiological unionFull weight bearing after radiological union

12. OVER ALL RESULTSOVER ALL RESULTS
Results No. of
patients
Percentage
Excellent 12 63.16%
Good 4 21.05%
Fair 2 10.53%
Poor 1 5.26%
Total 19 100%
84.21%
15.8%
0
20
40
60
80
100
Patients
Excellent
Good
Fair
Poor

13. Results No. of patients Percentage
Excellent 9 64.29%
Good 2 14.29%
Fair 2 14.29%
Poor 1 7.14%
Total 14 100%
SHATZKER’S TYPE VI RESULTSSHATZKER’S TYPE VI RESULTS
0
20
40
60
80
100
Patients
Excellent
Good
Fair
Poor

14. Type No. of
patients
Results
Type II 1 Excellent
Type III 1 Excellent
Type IV 2 Good
Type V 1 Good
SHATZKER TYPE II,III,IV,V RESULTSSHATZKER TYPE II,III,IV,V RESULTS

15. SURGERY TIME INTERVAL & RESULTSURGERY TIME INTERVAL & RESULT
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
24 - 48hrs 3 - 7 days > 7 days
Excellent
Good
Fair
Poor
 Patients treated with early fixation and early mobilization have good /
excellent results irrespective of the fracture type

16. FRACTURE UNIONFRACTURE UNION
13-18 weeks : 17 cases.13-18 weeks : 17 cases.
19-23 weeks : 1 case.19-23 weeks : 1 case.
24-28 weeks : 1 case.24-28 weeks : 1 case.
0
20
40
60
80
100
Cases
13 - 18 weeks
19 - 23 weeks
24 - 28 weeks
Average time to fracture healing was
16.32 wks . (Krettek et al -16Wks).

17. Case no 1 : Mr.E , 53/M H/O RTA, and sustainedCase no 1 : Mr.E , 53/M H/O RTA, and sustained
Right side Shatzker type VIRight side Shatzker type VI
Pre op Immed post op
2 ½ mo 1year 10 mo

18. Functional Outcome:Functional Outcome: ExcellentExcellent
Rasmussen’s Score : 29Rasmussen’s Score : 29

19. Case no : 2 Mr . S , 34 / M H/o RTA , and sustainedCase no : 2 Mr . S , 34 / M H/o RTA , and sustained
left sided , Shatzker VIleft sided , Shatzker VI
Pre op Immed post op
7 mo 10 mo

20. Active SLRROM –O-130 deg
Functional outcome :Functional outcome : GoodGood
Rasmussen’s score : 26Rasmussen’s score : 26

21. Case no 3.Mr . J 45/M H/o RTA , and sustainedCase no 3.Mr . J 45/M H/o RTA , and sustained
right sided ,Shatzker type VIright sided ,Shatzker type VI
Pre op Immed post op 8 wks 3 mo
7 mo After implant removal

22. ROM :10 –135deg Active SLR Ant drawers +ve
Extensor lag
Functional Outcome :Functional Outcome : FairFair
Rasmussen’s Score : 19Rasmussen’s Score : 19

23. Case no 4. Mrs. M 35/F H/o Fall from height , andCase no 4. Mrs. M 35/F H/o Fall from height , and
sustained Left sided, Shatzker type VI .sustained Left sided, Shatzker type VI .
Pre op Imm.post op
1 yr 2 mo

24. ROM :20 –110 deg
Extensor lag
She was not able to squat
Functional Outcome : PoorFunctional Outcome : Poor
Rasmussan’s Score : 9Rasmussan’s Score : 9 ..
Varus deformity

25. CONCLUSIONCONCLUSION
 Good range of movements in knee, averaging 122 deg.Good range of movements in knee, averaging 122 deg.
 Patients treated with early fixation and early mobilizationPatients treated with early fixation and early mobilization
have Excellent / good results irrespective of the fracture typehave Excellent / good results irrespective of the fracture type
 No Incidence of Non UnionNo Incidence of Non Union
 No secondary bone graftingNo secondary bone grafting
 84 %84 % Excellent to good functional resultsExcellent to good functional results
 78% Excellent to good functional results in high energy78% Excellent to good functional results in high energy
tibial condyle fractures (tibial condyle fractures (Shatzker’s typeVIShatzker’s typeVI )

26. COMPLICATIONSCOMPLICATIONS
Complication No.of
Patients
Case no.
Superficial
Infection
1 16
Knee stiffness 1 8
Implant
Loosening
2 5,14
Varus deformity 2 5,11