Tibial plateau fractures disrupt a load-bearing articular surface that is central to knee alignment, stability, and movement. Although they account for a relatively small proportion of skeletal injuries, the consequences of inadequate treatment can be substantial, including chronic pain, instability, stiffness, malalignment, and post-traumatic osteoarthritis. The surgical challenge is greatest when the injury combines articular comminution with metaphyseal instability and extensive soft-tissue trauma.1

The Schatzker classification remains widely used because it provides a practical description of fracture morphology and increasing injury severity. Type V injuries involve both tibial condyles, whereas type VI fractures add metaphyseal-diaphyseal dissociation to the bicondylar articular injury. These patterns usually result from high-energy axial loading with a varus, valgus, or rotational component and are frequently accompanied by meniscal, ligamentous, and other skeletal injuries.2

Plain radiographs define the broad fracture pattern, but computed tomography is often needed to identify coronal fragments, depression, posterior column involvement, and the configuration of the medial condyle. This information is important because the morphology of the posteromedial fragment and the position of the principal fracture lines influence the choice of exposure, plate placement, and the need for bone grafting.3

The objectives of operative treatment are anatomical or near-anatomical restoration of the joint surface, reconstruction of the mechanical axis, stable fixation of the medial and lateral columns, and preservation of the soft-tissue envelope. These objectives should permit early knee motion without loss of reduction. External fixation and hybrid constructs remain useful when the soft tissues are severely compromised, but open reduction and internal fixation is commonly selected for closed bicondylar fractures once the skin and swelling allow safe surgery.4

A single lateral locking plate can be adequate in selected patterns, but it may not reliably control a displaced or comminuted medial column. Varus collapse, secondary displacement, and loss of condylar width are particular concerns when the medial fragment is not independently supported. Dual plating addresses this problem by stabilising both columns and distributing load across the reconstructed proximal tibia.5,6

The potential biomechanical advantage of dual plating must be weighed against the risk of additional dissection. Wound complications, infection, stiffness, and implant irritation have all been reported, particularly after high-energy injury or premature surgery through swollen soft tissues. Contemporary practice therefore emphasises staged decision-making, careful incision placement, limited periosteal stripping, and rehabilitation tailored to fixation stability and soft-tissue healing.7,8

Published series generally describe satisfactory union and functional recovery after dual plating, but reported results vary because of differences in fracture severity, surgical timing, incision strategy, scoring systems, and duration of follow-up.9,10 Evidence from prospective cohorts in Indian centres remains valuable because injury mechanisms, referral delays, rehabilitation access, and resource constraints may differ from those in larger international series.11,12

The present study prospectively evaluated adults with closed Schatzker type V and VI tibial plateau fractures managed with dual plating. Functional recovery was measured with the Knee Society Score, radiological alignment with the Rasmussen Radiological Assessment, and complications were recorded during follow-up. An exploratory analysis also examined whether radiological quality was associated with functional outcome.

AIMS AND OBJECTIVES

The primary aim was to evaluate the clinico-radiological and functional outcomes of closed Schatzker type V and VI tibial plateau fractures treated with dual plating.

The objectives were to describe the demographic and injury profile; assess postoperative knee function using the Knee Society Score; evaluate articular reduction and alignment using the Rasmussen Radiological Assessment; document associated injuries, fixation procedures, bone-grafting requirements, and complications; and explore the relationship between functional and radiological outcomes.

Study design and setting

A prospective observational study was conducted in the Department of Orthopaedics, Hassan Institute of Medical Sciences, Hassan, Karnataka, India. Patients presenting to the emergency department or admitted with a closed Schatzker type V or VI tibial plateau fracture were recruited from June 2023 to June 2024. Institutional Ethics Committee approval was obtained before recruitment, and written informed consent was taken from every participant.

Sample size

The minimum sample size was estimated using the single-proportion formula n = Z²pq/d². An expected proportion of 80.76% was used, with Z = 1.96, q = 1-p, and a relative precision of 20% of the expected proportion. The calculated minimum was 24 patients. To allow for incomplete observations and to improve the descriptive precision, 30 patients were enrolled and included in the final analysis.

Eligibility criteria

Adults aged 18-70 years with a closed Schatzker type V or VI tibial plateau fracture were eligible. Patients were excluded if they were younger than 18 years, had a Schatzker type I-IV fracture, an open fracture, vascular injury, poor skin condition at the proposed operative site, a pathological fracture, or declined consent.

Preoperative evaluation

The initial assessment documented age, sex, mechanism of injury, side, associated injuries, skin condition, and distal neurovascular status. Routine laboratory investigations, electrocardiography when indicated, and standard anteroposterior and lateral knee radiographs were obtained. Fractures were classified using the Schatzker system. Additional imaging was used when required for operative planning.

Operative management

All patients underwent open reduction and internal fixation with dual plating after clinical optimisation and assessment of the soft-tissue envelope. The articular surface and condylar width were restored, followed by stabilisation of the medial and lateral columns. Plate choice was adapted to fracture morphology and was recorded in the operative chart as a locking compression plate, lateral buttress plate, or medial buttress plate construct. Bone grafting was added when a metaphyseal defect required structural support. The interval between injury and definitive surgery was recorded for each patient.

Follow-up and rehabilitation

Patients were reviewed at approximately 3 weeks, 6 weeks, 3 months, 6 months, and 9 months. Follow-up included wound assessment, knee movement and stability, radiographs, functional scoring, and documentation of complications. Mobilisation and progression of weight bearing were guided by soft-tissue healing, radiological progression, and construct stability.

Outcome assessment

Functional outcome was evaluated with the Knee Society Score (KSS). The clinical knee component and functional component were each recorded, and a total score was calculated. Final results were categorised as excellent, good, fair, or poor according to the categories used in the study records. Radiological outcome was evaluated with the Rasmussen Radiological Assessment (RRA), which considers articular depression, condylar widening, and alignment; results were categorised as excellent, good, or fair. Complications recorded in the master chart included wound-related skin problems, knee stiffness, and malunion.

Statistical analysis

Data were entered in Microsoft Excel and analysed with SPSS Version 22. Continuous variables are presented as mean ± standard deviation or median with interquartile range when appropriate; categorical variables are presented as frequency and percentage. For the present manuscript, exploratory comparisons between Schatzker type V and VI fractures used the Mann-Whitney U test for continuous or ordinal outcomes and Fisher exact test for categorical outcomes. The relationship between total KSS and RRA score was assessed with Spearman rank correlation. All tests were two-sided, and p < 0.05 was considered statistically significant.

Patient and injury characteristics

Thirty patients were included. The mean age was 42.87 ± 12.31 years (range, 24-68 years), and the largest age group was 41-50 years. Men comprised 90.0% of the cohort. Road traffic accidents were the dominant mechanism, and the left knee was affected slightly more often than the right. Sixteen fractures were Schatzker type VI and 14 were type V. Eighteen patients (60.0%) had an associated injury, most commonly an anterior cruciate ligament tear, lateral collateral ligament tear, meniscal injury, or Colles fracture. The median interval from injury to surgery was 4 days (interquartile range, 4-6.75; range, 3-12 days).

Table 1. Baseline and injury characteristics of the study population

Table 2. Associated injuries

Operative profile

Fixation was recorded as locking compression plate based in 14 patients, lateral buttress plate based in 11, and medial buttress plate based in 5. Bone grafting accompanied fixation in 18 patients (60.0%).

The proportion requiring grafting was higher in type VI than type V fractures, reflecting the greater metaphyseal comminution in the more severe pattern.

Table 3. Recorded fixation procedure and bone grafting

Functional and radiological outcomes

The mean KSS clinical component was 80.43 ± 10.79 and the mean functional component was 75.50 ± 15.83. The mean total KSS was 155.93 ± 25.69, with a median of 162.

Excellent or good functional outcomes were recorded in 25 patients (83.3%). The mean RRA score was 15.00 ± 2.45, and 25 patients (83.3%) had an excellent or good radiological result.

Table 4. Functional and radiological outcome measures

Exploratory comparison by fracture type

Type VI fractures underwent definitive surgery later than type V fractures (median 6.5 versus 4 days, p < 0.001), consistent with their greater injury severity and soft-tissue burden.

Type V fractures had numerically higher total KSS and RRA scores, but the score differences did not reach statistical significance with non-parametric testing. All 14 type V fractures had good or excellent functional and radiological categories, compared with 11 of 16 type VI fractures (68.8%); this difference was significant on Fisher exact testing (p = 0.045).

Table 5. Exploratory outcomes according to Schatzker fracture type

KSS, Knee Society Score; RRA, Rasmussen Radiological Assessment. Mann-Whitney U test for continuous outcomes and Fisher exact test for categorical outcomes.

Association between radiological and functional results

There was a strong positive correlation between the RRA score and total KSS (Spearman rₛ = 0.709, p < 0.001). Patients with better restoration of articular alignment and condylar geometry therefore tended to have better pain, stability, mobility, and functional scores. Neither age nor interval to surgery showed a statistically significant monotonic correlation with total KSS in this small cohort.

Complications

Six patients (20.0%) had at least one complication recorded in the master chart. Four patients had a wound-related skin complication, three developed knee stiffness, and two had malunion; some patients had more than one event. Complications were more frequent in type VI fractures, although the difference was not statistically significant. No nonunion or implant failure was recorded in the study chart.

Table 6. Complications recorded during follow-up

This prospective study found that dual plating provided favourable short-term clinical and radiological outcomes in most adults with closed Schatzker type V and VI tibial plateau fractures. More than four-fifths of patients achieved good or excellent KSS and RRA categories, and the radiological score showed a strong positive association with total knee function. The results support the principle that accurate restoration of the articular surface and proximal tibial alignment is central to recovery after bicondylar plateau injury.

The demographic pattern reflected the high-energy nature of the fractures. The cohort was predominantly male, and two-thirds of injuries followed road traffic accidents. Similar male predominance and trauma mechanisms have been reported in prospective dual-plating series from India and other middle-income settings.5,7,13 The mean age in the present cohort was in the early forties, indicating that these injuries commonly affect economically active adults and can therefore produce substantial personal and socioeconomic disability.

Type VI fractures formed a slight majority. These injuries combine bicondylar articular disruption with metaphyseal-diaphyseal dissociation and often require more time for soft-tissue optimisation and planning. In the present analysis, the median interval to surgery was significantly longer for type VI fractures than for type V fractures. This difference should not be interpreted as a harmful delay; rather, it likely reflects deliberate postponement until swelling and skin condition were suitable for definitive fixation.

The functional findings compare favourably with earlier studies. Rohra and colleagues reported sustained good functional and radiological outcomes after dual plating at a minimum three-year follow-up.5 Cho et al. and Prasad et al. also described reliable knee function and union after dual-plate fixation of type V and VI fractures.6,7 The present rate of good or excellent KSS outcome was 83.3%, which lies within the range reported by several prospective Indian cohorts.11,13,14,15 Direct numerical comparison remains difficult because previous authors used different measures, including Oxford Knee Score, Rasmussen functional score, Honkonen-Järvinen criteria, and range-of-motion thresholds.

Radiological outcome was good or excellent in 83.3% of patients. This is clinically important because residual depression, condylar widening, and coronal malalignment alter load transmission across the knee and may accelerate degenerative change. Khatri et al., Jagdev et al., and Prabhakar et al. similarly reported that stable fixation of both columns can maintain reduction and produce satisfactory radiological results.11,12,13 Mid-term data from Vasiliadis et al. also showed that acceptable radiological alignment can coexist with low pain and restoration of daily activities.10

The observed correlation between RRA and KSS adds an important dimension to the descriptive results. A Spearman coefficient of 0.709 indicates that patients with better radiographic restoration tended to have better overall knee scores. Although functional recovery is also affected by cartilage damage, meniscal and ligament injury, muscle strength, pain behaviour, and rehabilitation, the result reinforces the surgeon’s ability to influence outcome through reduction quality and alignment. The association should be interpreted cautiously because both scores were measured in the same small cohort and the study was not powered specifically for correlation.

Type V fractures showed numerically higher functional and radiological scores than type VI fractures. All type V injuries were classified as good or excellent in both outcome domains, whereas five type VI injuries had fair or poor functional and/or radiological results. This difference is biologically plausible because metaphyseal-diaphyseal dissociation, comminution, and soft-tissue injury are greater in type VI fractures. However, the continuous score comparisons did not reach statistical significance with non-parametric testing, and the subgroup findings should therefore be regarded as exploratory rather than definitive.

Bone grafting was required in 60% of patients. Metaphyseal voids are common after elevation of depressed fragments, and filling these defects can support the reconstructed surface until union. The study records did not specify graft material or quantify defect size, preventing assessment of whether grafting independently influenced outcome. Nonetheless, the high use of grafting is consistent with the complex fracture morphology treated in this cohort and with reports describing dual plates with supplementary grafting in selected cases.14,16

Complications occurred in six patients. Wound-related skin problems were the most frequent event, followed by stiffness and malunion. These complications are recognised after high-energy tibial plateau fractures because the initial injury compromises the soft-tissue envelope and prolonged immobilisation can limit motion. Previous series have reported superficial infection, deep infection, stiffness, and malalignment at variable rates.9,10,12 The absence of recorded nonunion or implant failure is encouraging, but the sample is too small to exclude uncommon adverse events.

The study supports several practical points. First, dual plating should not be viewed merely as the placement of two implants; success depends on understanding fracture morphology, selecting exposures that protect skin bridges, restoring the joint surface and condylar width, and supporting the medial column. Second, timing should be dictated by soft-tissue readiness rather than an arbitrary early target. Third, stable fixation must be linked to structured knee mobilisation and progressive weight bearing. These principles are consistent with comparative work showing that both incision strategy and soft-tissue management influence outcome.4,18

This study has strengths. It was prospective, focused exclusively on closed Schatzker type V and VI fractures, used a single treatment strategy, and assessed both functional and radiological domains. The master chart permitted a patient-level analysis and demonstrated a clinically coherent relationship between radiographic and functional scores.

The limitations are important. The sample was small and derived from one institution, which limits generalisability and statistical power. There was no comparison group treated with a single plate, external fixation, or another method. The dissertation did not provide serial KSS and RRA values at each follow-up, detailed range-of-motion data, time to union, patient-reported quality-of-life measures, or postoperative computed tomography. The exact configuration of the two plates, graft material, rehabilitation adherence, and grading of wound complications were not consistently documented. Follow-up was insufficient to evaluate post-traumatic osteoarthritis, late implant symptoms, or conversion to arthroplasty. Finally, exploratory analyses were performed from the master chart and should be confirmed in a larger, prospectively specified study.

Future research should include multicentre cohorts with standardised three-column fracture mapping, CT-based reduction assessment, clearly defined soft-tissue protocols, and serial patient-reported outcome measures. Comparative studies should stratify by posterior column involvement and type VI dissociation rather than grouping all bicondylar fractures together. Longer follow-up is needed to determine whether early radiological quality predicts post-traumatic arthritis and durable function.

Dual plating produced good-to-excellent functional and radiological outcomes in 83.3% of patients with closed Schatzker type V and VI tibial plateau fractures. Functional outcome was strongly associated with radiological alignment, supporting meticulous articular reduction and stable fixation of both columns. Wound-related problems, stiffness, and malunion remained relevant complications, particularly in the more severe type VI pattern.

Dual plating is therefore a reliable option for complex bicondylar tibial plateau fractures when the soft-tissue condition is respected and rehabilitation is initiated in a structured manner. Larger comparative studies with standardised techniques and longer follow-up are required before firm conclusions can be drawn regarding superiority over other fixation strategies.

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