Treatment of Associated Soft-Tissue Injuries

Introduction

Historically, restoring the bony architecture in tibial plateau fractures has been the focus of surgical management. While this remains the primary objective in treatment algorithms, management of the soft-tissue structures around the knee has become a secondary objective. Failure to address soft-tissue compromise can lead to continued pain or instability to the knee. This chapter focuses on the nature of the soft-tissue problem, recognizing the entire extent of injury, and surgical techniques to address specific ligament or meniscal pathology.

Not Just a Bone Injury

The bones provide very little stability to the knee joint, in comparison to other highly constrained joints like the hip. Instead, the knee relies on a variety of soft-tissue structures to provide stability of this hinge joint. Ligaments, capsule, and the menisci provide important static stabilizers, and injury can result in instability and poor long-term outcomes. As a result, treatment plans that focus only on the bone, without addressing soft tissues, can fail to restore stability and may lead to a less than functional knee. Despite our best efforts in the treatment of tibial plateau fractures, patients continue to have pain, instability, deformity, wound complications, and stiffness.

In the past, management of the soft tissues primarily focused on the skin and handling of the soft tissues during surgical management. The routine use of temporary external fixation and delaying definitive internal fixation until the inflammatory response of the soft tissues has resolved have led to lower wound complications. ^{, , ,} While this tactic has certainly helped in managing the soft tissue, it only addresses part of the problem. More recently, an increased focus on the ligaments and menisci has been the topic of more clinical research.

While high-energy mechanisms are more commonly associated with soft-tissue injuries, low-energy injuries can also affect the ligaments and menisci. When angular, rotational, and axial loads are applied to the knee, both static and dynamic stabilizing structures can be injured. A large axial load is not as common in lower-energy mechanisms, but patients can certainly be exposed to rotational or angular loads. ^,