Recovery of knee function following fracture
of the tibial plateau
P. Gaston,
E. M. Will,
J. F. Keating
From The Royal
Infirmary of
Edinburgh,
Edinburgh, Scotland
" P. Gaston, FRCSEd(Orth),
Consultant Orthopaedic
Surgeon
" E. M. Will, MCSP, Research
Physiotherapist
" J. F. Keating,
FRCSEd(Orth), Consultant
Orthopaedic Surgeon
Royal Infirmary of
Edinburgh, Little France, Old
Dalkeith Road, Edinburgh
EH16 4SU, UK.
Correspondence should be
sent to Mr J. F. Keating;
e-mail:
john.keating@ed.ac.uk
©2005 British Editorial
Society of Bone and
Joint Surgery
doi:10.1302/0301-620X.87B9.
16276 $2.00
J Bone Joint Surg [Br]
2005;87-B:1233-6.
Received 17 January 2005;
Accepted 31 March 2005
VOL. 87-B, No. 9, SEPTEMBER 2005
We assessed the functional outcome following fracture of the tibial plateau in 63
consecutive patients. Fifty-one patients were treated by internal fixation, five by combined
internal and external fixation and seven non-operatively. Measurements of joint movement
and muscle function were made using a muscle dynamometer at three, six and 12 months
following injury. Thirteen patients (21%) had a residual flexion contracture at one year. Only
nine (14%) patients achieved normal quadriceps muscle strength at 12 months, while 19
(30%) achieved normal hamstring muscle strength. Recovery was significantly slower in
patients older than 40 years of age. We conclude that there is significant impairment of
movement and muscle function after fracture of the tibial plateau and that the majority of
patients have not fully recovered one year after injury.
Loss of movement and reduced muscle func- Table I. Demographic and injury details
tion affects recovery after intra-articular frac- Variable Number of patients
tures.1 Movement has been shown to en- Gender
courage the healing of articular cartilage in an Men 34
animal model.2 Fractures of the tibial plateau Women 29
are relatively common and often occur in an Age (yrs)
Mean (range) 45 (16 to 81)
active population.3 Weakness of the muscles < 40 30
controlling the knee joint, especially the quad- > 40 33
riceps, is a common complication.4-6 Func- Mechanism of injury
Low energy 34
tional recovery following ligamentous injury
Simple fall 15
to the knee has been well documented.7 How- Sport 12
ever, there is only one published retrospective Direct blow 7
study evaluating functional recovery after frac- High energy 29
RTA* motorcycle 11
ture of the tibial plateau.8 The aim of this study
RTA pedestrian 10
was to evaluate the recovery of knee move- RTA car occupant 4
ment, and the strength of the quadriceps and Fall from height 4
hamstring muscles prospectively, in the first Shatzker grade9
I 9
year after fracture of the tibial plateau.
II 23
III 12
Patients and Methods IV 11
Between May 1996 and December 2001, all V 3
VI 5
patients who were admitted with an isolated Treatment
fracture of the tibial plateau were considered for Non-operative 7
inclusion in the study. Exclusion criteria included ORIF† 51
a fracture elsewhere in the limb, a contralateral ORIF + external fixation 5
lower limb fracture, and multiple trauma. * RTA, road traffic accident
† ORIF, open reduction and internal fixation
We entered 63 patients into the study, with a
mean age of 45 years (16 to 81). Details of the
injuries are shown in Table I. Shatzker’s classi-
fication system9 was used. Seven fractures were The patients who did not have external fixa-
treated non-operatively, 51 were treated by tion were mobilised in a hinged knee brace
internal fixation and the five type VI fractures allowing full extension and 90˚ of flexion for
were treated by minimal internal fixation aug- the first six weeks. They were advised to
mented with external fixation. remain non-weight-bearing for four weeks,
1233
1234 P. GASTON, E. M. WILL, J. F. KEATING

120 70
110
100 60
90
Peak torque (Nm)

Peak torque (Nm)

50
80
70 40
60
50 30
40 Uninjured
20 Uninjured
30 Injured Injured
20 10
10
0 0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 0 1 2 3 4 5 6 7 8 9 10 11 12 13
Months after injury Months after injury

Fig. 1 Fig. 2

Peak torque values for quadriceps (bars indicate 95% confidence inter- Peak torque values for hamstrings (bars indicate 95% confidence inter-
vals). vals).

100 100
90 90
80 80
70
Recovery (%)

70
Recovery (%)

60 60
50 50
40 40
30 Quadriceps 30 Quadriceps
Hamstrings Hamstrings
20 20
10 10
0 0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 0 1 2 3 4 5 6 7 8 9 10 11 12 13
Months after injury Months after injury

Fig. 3 Fig. 4

Percentage muscle recovery after fracture of the tibial plateau (bars indi- Percentage muscle recovery for patients treated by open reduction and
cate 95% confidence intervals). internal fixation (bars indicate 95% confidence intervals).

100
100 90
90
80
80
Recovery (%)

70
70
Recovery (%)

60
60
50
50
40
40
30 Age < 40 yrs 30
Age > 40 yrs Shatzker I, II, III
20 20
Shatzker IV, V, VI
10 10
0 0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 0 1 2 3 4 5 6 7 8 9 10 11 12 13
Months after injury Months after injury

Fig. 5 Fig. 6

Percentage quadriceps recovery by age (bars indicate 95% confidence Percentage recovery by Shatzker grade9 (bars indicate 95% confidence
intervals). intervals).

THE JOURNAL OF BONE AND JOINT SURGERY

 RECOVERY OF KNEE FUNCTION FOLLOWING FRACTURE OF THE TIBIAL PLATEAU
and partial weight-bearing for a further two. Progression to
full-weight-bearing began at six weeks when the brace was
removed. All had a standard physiotherapy regime, which
was continued for 12 weeks after injury. None was lost to
follow-up.
Any complications were recorded at each visit. The range
of movement in the injured and uninjured limbs was mea-
sured using a goniometer. Muscle function was assessed
using a Biodex System 2 dynamometer (Biodex Medical
Systems Inc, Shirley, New York). This measured isokinetic
peak torque (PT), total work (TW) and average power (AP)
for knee flexion and extension. Each evaluation consisted of
an active warm-up period followed by 5, 10 and 15 repeti-
tions respectively carried out at three different speeds 90,
180 and 270˚ per second.10,11 The values for the uninjured
limb were measured for comparison. A research physiother-
apist (EMW) measured the range of movement and carried
out all the isokinetic tests. The measurements were taken at
three months, six months and 12 months after the injury.
For the purposes of this study only peak torque at the
medium speed of 180˚ per second is used since it has been
shown in a previous study that there is a very strong cor-
relation between all three parameters (PT, TW and AP) and
at all dynamic speeds.10 This correlation has been found by
other authors.11
Statistical analysis was carried out using SPSS software
(SPSS Inc, Chicago, Illinois). A paired-sample t-test was
used for comparing parameters at different time intervals
and a one-sample t-test was used for assessing differences
between groups at one time point. Values for p < 0.05 were
regarded as significant. The results were presented graphi-
cally with the corresponding 95% confidence intervals (CI).
Results
Fifty-two patients (82%) had > 100˚ knee flexion and 39
(62%) had an extension deficit of < 5˚ at three months. By
one year, 13 (21%) patients still had an extension deficit
≥ 5˚.
The values of PT for the quadriceps and hamstring
muscles at each time point are shown in Figures 1 and 2.
There was no significant change in the values for the un-
injured limb over the period of study. We used the un-
injured limb as the control, with the value achieved in the
injured limb expressed as a percentage of that in the un-
injured limb. By this method, the level of recovery in the in-
jured limb was generated at each time point.
Figure 3 shows the percentage recovery for both muscle
groups. Quadriceps recovery lags behind the hamstrings at
all time points. The mean extension torque is only 77% of
the uninjured side by 12 months compared with 90% for
flexion. These differences between quadriceps and ham-
strings were significant at both six months (p < 0.01) and
one year (p < 0.001). Only nine (14%) patients achieved
normal quadriceps muscle strength at 12 months while 19
(30%) achieved normal hamstring muscle strength by this
time. Figure 4 shows the percentage recovery for the 51
VOL. 87-B, No. 9, SEPTEMBER 2005
1235
patients who were treated by open reduction and internal
fixation and is similar to that for the whole group (Fig. 3).
All subsequent analyses were for quadriceps recovery
only. Patients under 40 years of age recovered faster than
those older than 40 years of age at each time point (Fig. 5).
One year after the injury patients under 40 had regained
85% of their quadriceps strength, the older group had
regained 74% (p < 0.05). Patients with more complex frac-
ture configurations (Schatzker types 4 to 6) had worse
quadriceps recovery initially, but there was no difference at
one year (Fig. 6). Gender and mechanism of injury had no
influence on the level or speed of recovery.
There were three superficial wound infections, which
responded to antibiotic therapy. One deep infection re-
quired removal of the metalwork. There were three com-
partment syndromes which were all recognised early and
treated with fasciotomy. No patient required muscle debri-
dement. Two patients developed deep venous thrombosis
and one patient had a common peroneal nerve palsy.
Discussion
The findings of this study indicate that quadriceps function
is impaired for a considerable period following a fracture of
the tibial plateau. We found that only 14% of patients
achieved normal quadriceps muscle strength at one year,
while only 30% had restoration of normal hamstring
muscle strength at this time. Quadriceps strength recovered
more slowly than hamstring strength throughout the period
of follow-up. Older age was associated with a significantly
slower return of quadriceps strength. These are similar find-
ings to those previously reported for diaphyseal fractures of
the tibia.9 None of the other demographic or injury factors
affected the recovery of muscle strength in this study. We
also found that more than 20% of patients had significant
residual knee stiffness one year after injury.
To our knowledge, this is the first prospective study to
use an objective outcome measure to assess function after
fractures of the tibial plateau. The Biodex dynamometer
has been shown to be a reliable device for assessing muscle
function and isokinetic dynamometry has been validated in
the literature.12-14 We have previously reported the use of
this technique in other types of injury.10,15
A limitation of this study is the small numbers in some of
the demographic subgroups which increases the possibility
of a type II error with some true differences not being
detected. In Figure 6, those patients with more severe frac-
ture patterns were weaker at their initial assessment but
achieved the same level by one year. The initial difference
was not statistically significant, possibly because there were
very few of these more complex fractures. However, it is
possible that there may be a difference in the rate of recov-
ery of muscle function following the more severe fracture
patterns. Another possible criticism is the use of the
uninjured limb as the control. It has been reported that
there are few differences between the right and left limb in
terms of muscle strength, even in those whose sport
1236 P. GASTON, E. M. WILL, J. F. KEATING
involves the predominant use of one lower limb for kick-
ing.13 We believe that the relative strength of the injured
limb at any given time after trauma is of importance to our
patients, because this is how they would naturally assess
their own recovery. No other measures of outcome such as
functional scoring systems were used in this study. How-
ever, we believe isokinetic measurements are a useful
research tool. The results give clinicians objective data of
what happens to the function of muscles following injury,
enabling them to advise patients accordingly.
There are few reports of objective functional outcomes
after fractures of the lower limb in the literature. Most are
retrospective and the findings are, therefore, not directly
comparable with our own.16-19 We can only find one other
study looking at muscle strength after fracture of the tibial
plateau.8 In this study, the mean torque deficit in the quad-
riceps of the injured limb was 16% at 180˚, while the cor-
responding deficit in the hamstrings was 8%. While these
results are similar to our own, this was a retrospective study
and the functional outcome assessments were made at a
mean of seven years after injury, which may limit the clini-
cal relevance of the findings.
In conclusion, patients with a fracture of the tibial pla-
teau can be advised that there is a 20% risk of residual stiff-
ness at one year and, in the majority of cases, recovery of
muscle function will still be incomplete at this stage. Quad-
riceps recovery was only complete in 14% of cases at one
year. Older patients can expect a slower recovery.
No benefits in any form have been received or will be received from a commer-
cial party related directly or indirectly to the subject of this article.
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THE JOURNAL OF BONE AND JOINT SURGERY