Prospective Evaluation of Functional Outcomes in Schatzker Type V–VI Proximal Tibia Fractures Managed with Locking Compression Plate Using Minimally Invasive Percutaneous Plate Osteosynthesis

Introduction

Proximal tibial fractures are significant intra-articular injuries that profoundly impact knee stability, alignment, and overall function ^[1,2]. Schatzker type V and VI fractures represent complex bicondylar injuries, frequently resulting from high-energy trauma such as road traffic accidents (RTAs) or falls from height ^{[3, 4]}. These fractures are commonly accompanied by extensive soft tissue damage, articular depression, and an increased risk of complications, which collectively render their management particularly challenging ^[5,6]. The primary objective in treating these fractures is to achieve anatomical reduction, restore joint congruity, and provide stable fixation while preserving the integrity of the surrounding soft tissue envelope ^[7]. Minimally invasive percutaneous plate osteosynthesis (MIPPO) using locking compression plates has gained prominence as an effective surgical technique, as it maintains fracture biology and minimizes surgical trauma ^[8,9]. By reducing periosteal stripping and preserving the blood supply, this approach facilitates early fracture healing and promotes superior functional recovery ^[10]. This study aims to comprehensively evaluate the functional outcomes and complication rates associated with the treatment of Schatzker type V and VI proximal tibial fractures using the MIPPO technique, thereby contributing to optimize management protocols for these complex injuries.

Materials and Methods

Results

This study evaluated the management of fractures using the anterolateral approach for minimally invasive plate osteosynthesis (MIPO) technique and assessed the functional outcomes. The majority of respondents (37.5%) are aged 31–40 years, followed by 41–50 years (30.0%) and 18–30 years (25.0%) as seen in Table 1. RTAs are the leading cause of injury, accounting for 90.0% of cases. The data show that Schatzker Type VI fractures are more common, accounting for 55.0% of cases, while Type V fractures make up 45.0%, as shown in Table 2. Based on the one-sample statistics and applying the Modified Rasmussen Criteria for functional assessment. At 1-month post-treatment, the mean score was 10.20 (SD = 6.005), which generally corresponds to a fair outcome according to the Modified Rasmussen Criteria. By 3 months, the mean score had significantly increased to 26.90 (SD = 2.085), indicating a shift toward a good to excellent functional outcome. At 1 month postoperatively, the majority of patients (82.5%, 33 cases) had a poor Rasmussen’s score, while 17.5% (7 cases) showed a fair outcome. However, by 3 months or more, there was a significant improvement in functional outcomes. 52.5% (21 cases) achieved an excellent score, and 37.5% (15 cases) attained a good score. Only 10% (4 cases) remained in the fair category, with no patients classified as having a poor outcome, reflecting a notable recovery over time as shown in Table 3.

Discussion

This study evaluated the management of fractures using the anterolateral approach for MIPO and assessed the functional outcomes. Relevant literature reports comparable outcomes. The analysis indicates that the majority of participants were male (85.0%), with females comprising 15.0%. The age distribution shows that 37.5% of respondents were aged 31–40 years, followed by 30.0% aged 41–50 years, and 25.0% aged 18–30 years. The data reveal that Schatzker Type VI fractures are more prevalent, accounting for 55.0% of cases, while Type V fractures constitute 45.0%, indicating a higher prevalence of severe tibial plateau fractures in the studied population. The study’s findings align with these observations, indicating a consistent pattern. At 1 month postoperatively, the functional outcome showed that 82.5% of patients had a poor outcome, while 17.5% achieved a fair outcome, reflecting limited functional recovery during the early postoperative period as the healing process continues as shown in Fig. 1. By 3 months postoperatively, there was significant improvement in the range of motion, with 87.5% of patients exhibiting good to excellent range of motion; 40.0% scored 5, and 47.5% scored 6. Only 5.0% reported moderate restriction (score 1), and 7.5% had mild limitations (score 3), indicating favorable recovery in joint mobility Fig. 2. Based on one-sample statistics, the mean score at 1-month post-treatment was 10.20 (SD = 6.005), generally corresponding to a fair outcome according to the Modified Rasmussen Criteria. By 3 months, the mean score significantly increased to 26.90 (SD = 2.085), indicating a shift toward a good to excellent functional outcome. Regarding fracture union, 25.0% (10 cases) achieved union within 12 weeks, suggesting a relatively expedited healing process. The majority, 40.0% (16 cases), attained fracture union by 14 weeks, indicating this as a common timeframe for bone healing. In addition, 22.5% (9 cases) experienced fracture union by 16 weeks, reflecting a moderate duration for recovery, while 12.5% (5 cases) required 18 weeks or longer to achieve union Fig. 3.

Conclusion

This prospective observational study shows that MIPPO via the anterolateral approach improves function in tibial plateau fractures, especially Schatzker Type V and VI. Although 1-month postoperative outcomes were poor, with 82.5% showing suboptimal function, marked recovery occurred by 3 months, when 90% achieved good to excellent outcomes by modified Rasmussen criteria. The mean Rasmussen score improved from 10.20 ± 6.005 at 1 month to 26.90 ± 2.085 at 3 months. Fracture union occurred in all patients, and 65% healed within 12–14 weeks. Complications included knee stiffness (15%), infection (10%), and malunion (7.5%), but 67.5% had no complications. MIPPO is an effective technique with minimal morbidity.

Clinical Message

Locking compression plate fixation using the minimally invasive percutaneous plate osteosynthesis (MIPPO) technique offers a reliable solution for managing complex bicondylar proximal tibial fractures (Schatzker type V–VI). Despite poor early postoperative function, significant recovery is achieved by 3 months, with most patients regaining good to excellent knee function. The technique ensures stable fixation, timely fracture union, and preservation of soft tissue integrity, thereby minimizing complications. MIPPO should be considered a preferred approach in appropriately selected cases to optimize outcomes in high-energy tibial plateau injuries.

References

1. Choubisa R, Agarwal S, Meena DK, Sharma A, Prakash S. Minimally invasive percutaneous plate osteosynthesis in distal femur fractures using locking compression plate (LCP: A prospective study J Bone Joint Dis 2021;36:33-7.  Google Scholar |  PubMed
2. Jain M, Singla B, Mavani K. A prospective study of operative results of intra-articular fractures of proximal tibia Natl J Clin Orthop 2017;1:20-4.  Google Scholar |  PubMed
3. Jati S, Champawat V. A Midterm Analysis of Tibial Plateau Fractures: Functional Outcome and Incidence of Osteoarthritis in 240 Cases Zenodo: CERN European Organization for Nuclear Research; 2018  Google Scholar |  PubMed
4. Cho KY, Oh HS, Yoo JH, Kim DH, Cho YJ, Kim KI. Treatment of Schatzker type V and VI tibial plateau fractures using a midline longitudinal incision and dual plating Knee Surg Related Res 2013;25:77-83.  Google Scholar |  PubMed
5. Porrino J, Wyatt AR Fracture Fixation Oxford:Oxford University 2019 130-3.  Google Scholar |  PubMed
6. Pharaon SK, Schoch S, Marchand L, Mirza A, Mayberry J. Orthopaedic traumatology: Fundamental principles and current controversies for the acute care surgeon Trauma Surg Acute Care Open 2018;3:e000117.  Google Scholar |  PubMed
7. Rodham PL, Giannoudis VP, Kanakaris NK, Giannoudis PV. Biological aspects to enhance fracture healing EFORT Open Rev 2023;8:264-82.  Google Scholar |  PubMed
8. Shivalingaiah DK, Mahesh DU, John DB. Functional outcome in schatzker type V and VI tibial plateau fractures Natl J Clin Orthop 2018;2:109-12.  Google Scholar |  PubMed
9. Ramachandran M, Little DG. Orthopedic principles of fracture management In: Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism United States: Wiley 2018 588-92.  Google Scholar |  PubMed
10. Wise PM, Saiz AM, Haller J, Wenke JC, Schaer T, Schneider P, et al. Preclinical models of orthopaedic trauma: Orthopaedic research society (ORS) and orthopaedic trauma association (OTA) symposium 2022 OTA Int 2024;7 Suppl 2 e303.  Google Scholar |  PubMed

About the Authors

• 

  Dr. Mayank Uikey

• 

  Dr. Vishal Singh

• 

  Dr. Harshit Dahiya