The knee joint is a complex structure frequently subjected to injury from rising vehicular accidents and athletic traumas. Its position and susceptibility to external influences render it especially vulnerable to injury. The interaction of its weight-bearing function, intricate ligamentous support, and joint congruence are the primary factors rendering fractures in this region a substantial concern for surgeons, leading to functional impairments in patients. [ 2] Tibial plateau fractures pertain to the superior segment of the tibia and extend into the knee joint. Schatzker’s types I-IV fractures are classified as low-velocity, post-traumatic fractures, whereas types V and VI are linked to high-velocity injuries, frequently accompanied by further complications. The prognosis of these injuries primarily hinges on the surgeon's proficiency and the surgical technique employed. [3] Conventional methods utilizing external fixation or hybrid fixators to realign tibial anatomy have become relatively prevalent, yet they entail inherent risks, including septic arthritis, infection at pin sites, and patient non-compliance.[4] Conversely, contemporary apparatuses, including locking plate systems and sophisticated internal fixation techniques such as MIPO (minimally invasive plate osteosynthesis), have transformed the management of high-energy tibial plateau fractures. Dual plating provides substantial reinforcement to both tibial condyles, effectively averting medial and varus collapse.[5] Due to their complexity and the accompanying soft tissue and tendon injuries, the treatment of proximal tibial fractures remains challenging. The surgical intervention for these fractures seeks to restore and preserve normal knee function by physically realigning the joint surfaces, maintaining the mechanical axis, ensuring ligament stability, and safeguarding a pain-free, functional range of motion. [6] This research aims to evaluate the functional outcomes of dual plating in the management of intra-articular proximal tibial fractures.

Study Design and Setting

This was a prospective observational study conducted at PG Institute and Aurobindo Institute of Medical Sciences, following approval from the institutional ethical committee. All participants provided informed written consent prior to inclusion in the study.

Study Population

The study included 30 patients over the age of 18 years who presented to the emergency and outpatient departments with intra-articular proximal tibial fractures. Sampling was done based on patients who met the inclusion criteria.

Inclusion Criteria

Participants were selected based on the following criteria:

1. Patients with Schatzker Type IV, V, or VI tibial plateau fractures as defined by the Orthopedic Trauma Association.
2. Closed fractures.
3. Age > 18 years.

Exclusion Criteria

Patients were excluded if they presented with:

• Polytrauma
• Head injuries
• Fractures associated with vascular injuries
• Fractures with compartment syndrome
• Severe soft tissue damage
• Fractures in the same lower limb
• Medically unfit for surgery
• Infected proximal tibial fractures

Clinical Evaluation and Follow-Up

All patients underwent detailed clinical and radiological evaluation upon presentation. Socioeconomic and functional status was also assessed. Post-surgical follow-up was conducted at 1 month, 3 months, and 6 months, with evaluations including radiological healing, functional status, and complication monitoring. The Oxford Knee Score was used to assess functional outcomes pre- and post-operatively.

Preoperative Preparation

All patients received preoperative intravenous antibiotics following a sensitivity test. Surgery was performed under strict aseptic precautions.

Surgical Technique

Patients were placed in the supine position with a sandbag under the ipsilateral gluteal region and a bolster under the affected knee to facilitate an anterolateral approach. Under C-arm guidance, longitudinal traction was applied for indirect fracture reduction, and fragments were temporarily stabilized using percutaneous K-wires.

• Medial Condyle Repair with fixation: Generally performed first unless comminuted, in which case the lateral condyle was addressed first to restore length.
• Posteromedial An 8 cm incision was made along the posterior border of the tibia between medial head of gastrocnemius and hamstring. Careful dissection preserved the saphenous nerve, long saphenous vein, and pes anserinus structures. A longitudinal incision through the pes anserinus allowed access to the tibia. The gastrocnemius muscle was bluntly dissected and separated from the tibial surface
• Fracture fragments were anatomically reduced under C-arm guidance. Any particular depression was elevated using a bone punch and filled with bone graft as necessary. A 3.5 mm proximal tibia posterior medial locking plate was used to secure the fragments.

• Lateral Condyle Repair with fixation: Managed via an anterolateral approach using an S-shaped incision starting 5 cm above the joint line, curving laterally over Gerdy’s tubercle. After elevating the tibialis anterior muscle and incising the joint capsule, the fracture was reduced and stabilized with a proximal tibia lateral locking compression plate. Bone grafting was performed where depression of the articular surface was evident.

Table 1: Participant Demographics

Table 1 presents the demographic characteristics of the 30 participants included in the study. The group comprised 17 males (56.7%) and 13 females (43.3%). In terms of age distribution, 3 participants (10%) were between 18–29 years, 12 (40%) were aged 30–49 years, and the largest group, 15 participants (50%), fell within the 50–65 years range. The average follow-up duration for participants was 6 months, with a range spanning from 3 to 8 months.

Table 2: Fracture and Surgical Details

The study involved a variety of tibial plateau fracture types, with the majority being Type V fractures observed in 15 patients, followed by 5 cases each of Type VI bicondylar fractures and Schatzker Type IV fractures. The average time from injury to surgery was 9.2 days, ranging between 6 and 15 days. Hospital stays averaged 8 days, with durations varying from 5 to 24 days. The mean surgical time was recorded at 90.67 ± 4.18 minutes. Additionally, primary bone grafting was performed in 6 individuals to support fracture healing.

Table 3: Recovery and Functional Outcomes

Table 3 summarizes the recovery and functional outcomes of the study participants. On average, full unprotected weight-bearing was achieved at 18.5 weeks, ranging from 14 to 22 weeks, while fracture healing occurred around 11 weeks. The average Oxford Knee Score at the final follow-up was 45.72 ± 1.5, indicating generally favorable functional results. In terms of outcome distribution, 15 patients (50%) achieved exceptional results, 12 (40%) had good outcomes, 2 (6.67%) showed acceptable outcomes, and only 1 patient (3.33%) had a poor result, with a score of 19.

Table 4: Complications

Table 4 outlines the complications encountered during the study and their corresponding management. Superficial infections occurred in 4 patients and were successfully treated with empirical antibiotics over a two-week period. Two patients developed deep infections, which were managed with debridement and vacuum-assisted closure (VAC) dressings. One patient experienced a knee flexion deformity of less than 10°, which was addressed through knee mobilization exercises. Notably, there were no cases of non-union, implant failure, or reduction loss observed in the study.

Surgeons have historically faced difficulties with unstable intraarticular fractures known as highenergy bicondylar tibial plateau fractures (Schatzker types IV, V, and VI).

Anatomic reduction of the fracture fragments, preservation of the surrounding soft tissues, joint congruity, and avoidance of sequelae such as infection and malalignment are the objectives of surgical treatment for these fractures.[15]

The literature has offered a number of fixation techniques, such as double buttress plate fixation, single lateral locking plate fixation, hybrid external fixation, and external fixation.

There has long been discussion on the best surgical method for tibial plateau fractures.[16]

Both the medial and lateral tibial condyles must be reduced and stabilized in order to treat Schatzker types IV, V, and VI fractures.

The dual plate approach offers mechanical stability and efficient fixation by stabilizing both of the tibia's columns.[17]

Compared to utilizing a single lateral locking plate, studies have demonstrated that dual plate fixation has a lower subsidence rate and a higher biomechanical strength. Similar results were seen in our investigation; physiotherapy was able to correct the fixed flexion deformity that only one patient had.

The use of dual plate fixation is supported by research by Barei et al. and Yoo et al., which reports excellent functional outcomes for complicated tibial plateau fractures.[18]

By contrast, our research revealed that 40% of patients had good functional outcomes and 60% of patients had exceptional results. Malalignment after surgery has been noted in other studies as well. Neogi et al. reported post-operative malalignment in 3 cases (10.9%) in the single plate group and 2 cases (6.2%) in the dual plate group. In our study, malalignment with delayed loss occurred in one case (3.33%) due to varus collapse, although this patient's functional outcome was good at the final follow up.[19]

The requirement for significant soft tissue dissection, which raises the possibility of wound complications, is one drawback of dual plate fixation.

According to reports, the prevalence of deep wound infections with dual plate fixation ranges from 4.7% to 8.4%.

The deep infection rate of 3.33% that we discovered in our investigation was similar to the 3.12% that Neogi et al. reported.

Three individuals (6.66%) experienced superficial infections, but they healed with extended antibiotic therapy.[20]

Overall, 30% of patients in our study had superficial or deep infections, which is a little higher proportion. This is probably because individuals from low socioeconomic backgrounds tend to be less hygienic.

The most frequent side effect of dual plate fixation is infection, which can be avoided by handling tissues carefully and by waiting five to six days after the accident to allow for better skin health and less tissue edema.

Our study's mean Oxford Knee Score was 45.72±1.5, which is lower than other studies', like the one by Ebrahim Ghayem Hassankhani et al., which revealed 86.4% great outcomes with ORIF and plating.[21]

Twelve (40%) of the thirty patients had good outcomes (average score of 36.5), two (6.67%) had acceptable results (average score of 25.5), one (3.33%) had bad results, and fifteen (50%) had excellent results (average score of 45).

The study demonstrates that the kind of fracture, appropriate reduction, and fixation all affect the treatment results for Schatzker type 4, 5, and 6 proximal tibial fractures.

Clinical, functional, and radiological results from high velocity tibial plateau fractures are typically favorable. Dual plating offers stable fixation and reduces complications for complex, unstable fractures, whereas early mobilization and the application of posteromedial plating aid in preventing varus Collapse.

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3. Neogi DS, Trikha V, Mishra KK, Bandekar SM, Yadav CS. Comparative study of single lateral locked plating versus double plating in type C bicondyylar tibial plateau fractures. Indian J Orthop 2015;49:193-8
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7. Gosling T, Schandelmaier P, Marti A, Hufner T, Partenheimer A, Krettek C. Less invasive stabilization of complex tibial plateau fractures: a biomechanical evaluation of a unilateral locked screw plate and double plating. J Orthop Trauma. 2004; 18(8): 546- 51. doi: 10.1097/00005131-200409000-00011
8. Prasad GT, Kumar TS, Kumar RK, Murthy GK, Sundaram N. Functional outcome of Schatzker type V and VI tibial plateau fractures treated with dual plates. Indian J Orthop. 2013;47(2):188-94. doi: 10.4103/0019-5413.108915
9. Bhalotia AP, Ingle MV, Koichade MR. Necessity of dual plating in bicondylar tibial plateau fracture dislocations: A prospective case series. J Orthop Traumatol Rehabil. 2018; 10(1): 29-33. doi: 10.4103/jotr.jotr_2_18
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11. Oh CW, Oh JK, Kyung HS, Jeon IH, Park BC, Min WK, et al. Double plating of unstable proximal tibial fractures using minimally invasive percutaneous osteosynthesis technique. Acta Orthop. 2006; 77(3): 524-30. doi: 10.1080/17453670610012548
12. 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 Relat Res. 2013; 25(2): 77-83. doi:10.5792/ksrr.2013.25.2.77
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15. Neogi DS, Trikha V, Mishra KK, Bandekar SM, Yadav CS. Comparative study of single lateral locked plating versus double plating in type C bicondylar tibial plateau fractures. Indian J Orthop. 2015; 49(2): 193-8. doi: 10.4103/0019-5413.152478
16. Biomechanical analysis of bicondylar tibial plateau fixation: how does lateral locking plate fixation compare to dual plate fixation? Higgins TF, Klatt J, Bachus KN. J Orthop Trauma. 2007;21:301–306
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19. 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 Relat Res 2013; 25(2): 77-83.
20. Kulwinder Singh, Dr. Manjeet Singh, Dr. RakeshGautam. Functional Outcome of Surgical Management of Tibial Plateau Fractures: Case Series of 30 Cases. International Journal of Science and Research (IJSR) 2015; 4 (9): 905-909.
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