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[Treatment of complex bicondylar fractures of the tibial plateau by semi-circular anterior diaphyseal-epiphyseal plate].

PURPOSE
One third of all tibial plateau fractures are bicondylar, and some of them have posterior separation and metaphyseal comminution. In these cases, it may be difficult to reconstruct at the same time tibial axis, bone continuity and articular surface. The authors propose a new method for the treatment of these fractures.


METHOD
Reduction is facilitated by permanent extension using a transcalcaneal pin. Knee approach involves elevation of the anterior tibial tuberosity (ATT). The new plate used is available for each side. It presents an epiphyseal surrounding anterior part applied on the epiphysis above the ATT and a vertical part applied medially. All the separated fragments are temporarily stabilized by pins which are used to guide the definitive plate. For this an aiming plate duplicating the epiphyseal part of the definitive plate is used to insert the pins. Then, the definitive plate is slided without removing the pins. The pins also guide cannulated screws.


MATERIAL AND RESULTS
Out of 32 tibial fractures treated from January 1994 to June 1996, 3 cases were operated on using this method. All 3 cases have a frontal separation fracture, cartilage depression and metaphyseal complex fracture. Perfect articular reconstitution, fusion and axis were obtained. A fourth case was a proximal tibial fracture, very close to a total knee prosthesis.


DISCUSSION
Complex bicondylar fractures are one of the most difficult fractures to treat. Identification of the lesions should be envisioned before operation and especially the separated posterior fragments. The peroperative extension combined with the anterior approach with ATT elevation provided a complete view of intra articular fracture and correction of the axis. The semi-circular anterior plate allowed the fixation of all the fragments, and furthermore, the original procedure using temporary pins to guide the definitive plate has avoided to loose the reduction.