[Open reduction and internal fixation of lateral tibial plateau fractures with free subchondral 2.7 mm screws]

Subchondral rafting wires reduce tibial plateau fracture subsidence

PURPOSE

To determine if subchondral rafting wires retained as adjunctive tibial plateau fracture fixation affect postoperative articular subsidence.

METHODS

A retrospective cohort study was conducted at one Level 1 trauma center and one academic university hospital. Consecutive adults with closed, displaced OTA/AO 41B/C tibial plateau fractures treated between 2018 and 2023 with open reduction internal fixation were included. Patients who were not ambulatory, with contralateral injuries limiting weight bearing, and without follow-up radiographs of the injured extremity were excluded. The intervention was retention of subchondral rafting wires as definitive fixation. The primary outcome was linear articular surface subsidence between postoperative and follow-up AP knee radiographs. Linear subsidence was compared between groups using Welch's two sample t test. Associations of linear subsidence with patient, injury, and treatment characteristics were assessed by multivariable linear regression.

RESULTS

We identified 179 patients of a mean age of 44 ± 14 years, of whom 15 (8.4%) received subchondral rafting wires. Median follow-up was 121 days. No patients who received rafting wires as definitive implants experienced linear subsidence ≥ 2 mm, while 22 patients (13.4%) who did not receive rafting wires experienced linear subsidence ≥ 2 mm (p = 0.130). Subchondral rafting wires were associated with less linear subsidence (0.3 mm [95% confidence interval - 0.3-0.9 mm] vsersus 1.0 mm [- 0.9-2.9 mm], p < 0.001). The depth of linear subsidence was significantly associated on multivariable regression with male sex, depressed plateau area, active smoking, and retained rafting wires.

CONCLUSION

Subchondral rafting wires were associated with a small reduction in articular subsidence after internal fixation of tibial plateau fractures. Routine rafting wires may be useful for patients and fractures at high risk of articular subsidence.

Free subchondral screws in tibial plateau fractures: do they hinder a total knee arthroplasty? Strategies to prevent complications

Open reduction and internal fixation of extended lateral column tibial plateau fractures through a tibial condyle osteotomy and limited arthrotomy with the use of free subchondral locking screws is a straightforward and safe technique. However, these free subchondral screws are enclosed in the subchondral bone and therefore virtually impossible to remove after bone healing. The question arises whether these free subchondral screws might hinder a future total knee arthroplasty. In order to refute this, we retrospectively reviewed all surgically managed tibial plateau fractures in our tertiary center during one year and assessed the number, position and configuration of these in situ subchondral screws and K-wires. In addition, we performed a cadaver study, wherein we prepared 7 tibial plateaus for a total knee arthroplasty tibial component placement with free subchondral screws in situ. In this experiment, we demonstrated that free subchondral screws do not interfere with total knee arthroplasty, but they can increase operative time in some cases. We also provide recommendations to avoid difficulties and potential complications.

Two-level fixation with headless compression screws for tibial plateau fractures

PURPOSE

Reduction and fixation of tibial plateau fractures associated with small, "floating" intra-articular fragments proposes a challenge. We use fully threaded headless compression screws for (interfragmentary) fixation of such fragments before final plate fixation when standard fixation of intra-articular fragments with k-wires or lag screws is deemed insufficient. Our aim is to describe our technique and clinical experience of this two-level fixation.

METHODS

Between 2006 and 2021, 29 patients with a comminuted tibial plateau fracture were treated with this two-level fixation in this retrospective case series. Clinical baseline and surgical variables were collected for all patients. Clinical outcome variables were available for 28 patients with a median follow-up of 16.5 months (IQR 5-24). Functional outcomes were measured with the Knee Injury and Osteoarthritis Outcome Score (KOOS) and reported by 22 patients at a median of 5.2 years (IQR 3.5-9.8).

RESULTS

Reduction was anatomic or good in 82% of cases, fair in 14%, and a malreduction in 4%. Arthrosis was graded as grade 0 in 25% of cases, 1 in 39%, 2 in 21%, and 3 in 14%. Flexion was 110 degrees (IQR 100-130). Five patients had an extension deficit of 5 to 10 degrees. Median KOOS for symptoms and stiffness was 69 points (IQR 45-78), for pain 71 (IQR 45-88), for ADL 85 (IQR 52-95), for sports 30 (IQR 11-55), and for quality of life 34 (IQR 19-56).

CONCLUSION

The use of fully threaded headless compression screws is a simple and helpful addition in the treatment of comminuted tibial plateau fractures.

Subchondral Rafting Plate for the Treatment of Fragmented Articular Central Depression Tibial Plateau Fracture Patterns: Case Series and Technical Illustration

Articular depression is a significant component of lateral tibial plateau fracture patterns. Current literature supports the use of subchondral rafting screws, either placed through a plate or not. However, articular comminution has been associated with increased articular subsidence despite an adequate screw-joint distance. We report four cases that underwent the subchondral rafting plate technique for fragmented articular central depression lateral tibial plateau fractures. Clinical and radiographic evaluations were performed at the last follow-up. The mean follow-up was 18 months. All patients healed the fracture without any significant articular subsidence or loss of reduction. This case study hints that this novel technique is a potentially safe and cost-effective strategy to be incorporated in the daily practice of the orthopedic trauma surgeon, especially in certain challenging circumstances when a salvage procedure is required due to lateral tibial plateau fracture malreduction and the unavailability of anatomically designed locking plates.

A new strategy to fix posterolateral depression in tibial plateau fractures: Introduction of a new modified Frosch approach and a "Barrel hoop plate" technique

AIMS

The articular congruity of tibial plateau has been stressed to be associated with the long-term function outcomes. Approach selection and fixation pattern to manipulate the posterolateral (PL)-depression of tibial plateau are both key issues which trauma surgeons should focus on. In order to provide a strong purchase of PL-depression, we developed a new modified Frosch approach and a "Barrel hoop plate" technique to provide bony reconstruction of PL-depression.

MATERIALS AND METHODS

Eleven consecutive patients of tibial plateau fractures involved in PL-depression were surgically treated at our single level-I trauma center. Our newly designed "Barrel hoop plate" was used to fix the PL-depression via a modified Frosch approach. The demography and treatment information were summarized of all the patients. X-ray and CT-scan of the knee joint were used to assess the reduction after operation. Besides evaluation of the HSS knee score, medial tibial plateau angle(mTPA), posterior slope angle(PSA) and articular step-off were measured to assess the malreduction degrees.

RESULTS

The average operation time was 123 ± 20 min. The mean blood loss was 148 ± 45 mL. The fractures were healed radiographically at 13 ± 1 weeks post-operation. After 15 ± 2 months follow-up, all the patients were pain-free with full range of motion and stable knees. Radiologically, good fracture reduction was achieved in all cases. According to the final assessment, the mTPA, m-PSA and l-PSA were 85° ± 2°, 11° ± 5° and 10° ± 6°, respectively. The average range of motion was 128° ± 10°in flexion and 4° ± 4° in extension, and the average HSS score was 91 ± 3.

CONCLUSION

Our new approach is a modification of the Frosch approach with a decreased soft tissue exposure and a low risk of neurovascular vessel injury. The concurrent application of the "Barrel hoop plate" technique could not only provide a reconstruction of the PL tibial plateau, but also hoop the ruptured tibia plateau rim and secure the depression as a raft. This new technique prevented the PL-tibial plateau reduction loss and the made the patients' early range of motion come true.

Extended lateral column tibial plateau fractures. How do we do it?

We describe the operative management of extended lateral column fractures according to the revised three-column classification approach in a step-by-step fashion. We show that direct reduction and stable fixation of extended lateral column tibial plateau fractures via a limited arthrotomy and tibia condyle osteotomy, with the use of free subchondral 2.7 mm locking screws is a reliable technique. Subsequently, diverging VA-LCP locking screws further improve the structural properties. It is a straightforward technique and the single lateral approach (Lazy-S) facilitates direct reduction of the articular surface and stable fixation of the fracture fragments under direct vision with good radiological and fair functional outcome.