[Management of bicondylar fractures of the tibial plateau with unilateral fixed-angle plate fixation]

Triple-incision treatment of the posterior condylar triad in the lateral prone position

BACKGROUND

Posterior tibial plateau bicondylar fracture combined with anterior cruciate ligament injury, also known as the "Posterior Condylar Triad", is a regular combination injury. The traditional surgical strategy involves first fixing the posterior condyle in the prone position and then treating the anterior cruciate ligament avulsion injury after the patient turns over. This surgical strategy is cumbersome, requires multiple surgical preparations, prolongs the surgical time, and increases the patient's risk. Our centre proposed one lateral prone position with three incisions to treat the "Posterior Condylar Triad".

METHODS

This was a retrospective analysis of the clinical data of 11 "Posterior Condylar Triad" patients who underwent surgical treatment at our centre from February 2017 to August 2020. Using a unified surgical strategy, the patient rotates the limb in a lateral prone position. The posterior condyle fracture of the tibial plateau is treated through a posterior medial incision and posterior lateral Frosch approach. Finally, anterior cruciate ligament avulsion fracture is treated through a small incision on the medial side of the patella. All patients were encouraged to perform functional exercises of the knee joint early after surgery. The postoperative complications (deep vein thrombosis, poor wound healing, deep infection, internal fixation failure and fracture reduction loss) and knee joint function (knee joint range of motion, Lysholm score and SF36 scale) of the patients were recorded 1 year after surgery.

RESULTS

All patients' fractures healed smoothly, with an average fracture healing time of 17.0 weeks, ranging from 12 to 22 weeks. There were 2 patients with deep vein thrombosis (DVT) after the operation. One patient experienced wound fat liquefaction, and no patients reported serious complications, such as loss of fracture reduction, failure of internal fixation, or deep infection. One year after surgery, the average range of motion (ROM) of the affected limb's knee joint was 3.6-120.5°, the average Lysholm score was 86.7, ranging from 61 to 100, and the average SF36 score was 76.96, with a range of 52.45-94.75.

CONCLUSION

The "Posterior Condylar Triad" is a serious injury, and our proposed surgical strategy can simplify the surgical process, avoid large-scale changes in patient position during surgery, shorten surgical time, and reduce the risk of surgical anaesthesia, enabling patients to achieve good clinical prognosis.

The Intact Meniscal "Bucket-Handle" Technique to Expose Complex Lateral Tibial Plateau Fractures

There is no consensus on the optimal surgical approach to treat complex tibial plateau fractures, but careful selection of the appropriate surgical approach with clear access to the joint is crucial for successful anatomic reduction. Several articles have described techniques using a fibular or lateral femoral epicondylar osteotomy for improved visualization. Detachment of the anterior horn could facilitate treatment; however, inadequate reattachment of the anterior horn could hinder the healing process and create residual subluxation of the meniscus. This Technical Note describes a surgical technique to provide clear access to the articular surface for the treatment of complex lateral tibial plateau fractures by releasing the posterior meniscocapsular fibers up to the popliteus tendon and folding the lateral meniscus into the intercondylar notch, which exposes the articular surface.

Biomechanical analysis of tibial plateau posterolateral fracture fragment fixation and introduction of a lateral tibia plateau hook plate system

BACKGROUND

Fixing the posterolateral fragments of tibial plateau fractures has been challenging owing to potential neurovascular injuries and fibular head blocks. Several surgical approaches and fixation techniques have been reported, with distinct limitations. We propose a novel lateral tibia plateau hook plate system and compare its biomechanical stability with other fixation methods.

METHODS

Twenty-four synthetic tibia models were simulated to present posterolateral tibial plateau fractures. These models were randomly assigned to three groups. Group A models were fixed with the lateral tibia plateau hook plate system, Group B with variable-angle anterolateral locking compression plates, and Group C with direct posterior buttress plates. The models' biomechanical stability was evaluated using static (gradually increased axial compressive loads) and fatigue (cyclically loaded from 100 to 600 N for 2000 cycles each) tests.

RESULTS

Groups A and C models exhibited comparable axial stiffness, subsidence load, failure load, and displacement in the static test. Group A model exhibited higher subsidence and failure loads than Group B model. Groups A and C models exhibited comparable displacement at 100 N cyclic loading in the fatigue test. Group C model was more stable at higher loads. Group C model endured the highest subsidence cycle numbers, followed by Groups A and B models.

CONCLUSIONS

The lateral tibia plateau hook plate system provided similar static biomechanical stability as the direct posterior buttress plates and comparable dynamic stability under limited axial loading. This system is a potential posterolateral treatment choice owing to its convenience and safety, in treating tibia plateau fractures.

Anterolateral approach for posterolateral tibial plateau fractures

The posterolateral tibial plateau fracture is an uncommon intra-articular injury and mostly needed surgery. However, its surgical approach remains controversial. This manuscript describes an anterolateral approach to treat posterolateral tibial plateau fractures and evaluates the patient's functional outcomes. From June 2018 to July 2021 seventeen patients with posterolateral tibial plateau fractures were surgically treated through an anterolateral approach. The intraoperative and postoperative follow-up indicators were recorded. The reduction quality of fractures was assessed using Rasmussen radiological score, and postsurgical functional recovery was estimated using Rasmussen clinical score and Lysholm score. The mean follow-up interval was 28.71 ± 9.61 months (range 18-44). The surgery time and blood loss were 111.06 ± 15.62 min (range 85-140) and 118.12 ± 38.45 mL (range 80-250) separately. Postoperatively, the Rasmussen radiological score was 16.24 ± 2.33 (range 12-18). The average time of bone union was 14.29 ± 1.53 weeks (range 12-18). At the final follow-up, the average PTS and MPTA were 9.71 ± 2.76° (range 5-14°) and 86.82 ± 2.04° (range 84-90°) separately. A satisfactory articular reduction was achieved in 16 patients (94.1%). The final ROM was 123.29 ± 19.70° (range 60-142°). The Rasmussen clinical score and Lysholm score were 25.71 ± 5.74 (range 10-30) and 91.47 ± 6.50 (range 75-98) separately. Anterolateral approach has minimal risk of intraoperative neurovascular injuries in the popliteal fossa with satisfactory results. The hardware removal was also facilitated. This approach is feasible, safe and efficient.

Medial Head of the Gastrocnemius Tenotomy Through a Posteromedial Approach Significantly Improves Surgical Accessibility of the Tibial Plateau

OBJECTIVES

Compare accessible area of the posterior tibial plateau through a modified posteromedial (PM) approach before and after tenotomy of the medial head gastrocnemius. We report the outcomes of 8 patients who underwent gastrocnemius tenotomy during PM approach.

METHODS

A modified PM approach was performed on 10 cadaveric legs, and the surgically accessible area was outlined. Next, a medial head gastrocnemius mid substance tenotomy was completed, and the accessible area was again outlined. Tibia specimens were imaged in a micro-CT scanner to measure accessible surface area and linear distance along the joint line. In addition, 8 patients who underwent tenotomy for tibial plateau fracture had outcomes recorded.

RESULTS

The modified PM approach with tenotomy provided significantly more access to the posterior plateau than without tenotomy. The modified PM approach before tenotomy allowed access to 1774 mm 2 (SD = 274) of the posterior plateau surface and 2350 mm 2 (SD = 421, P < 0.0001) with tenotomy. A linear distance of 38 mm (SD = 7) and 57 mm (SD = 7, P < 0.00001) was achieved before and after tenotomy, respectively. In the clinical series, the average knee arc of motion was 116 degrees (95-135).

CONCLUSIONS

The modified PM approach with medial head gastrocnemius tenotomy significantly improves surgical access to the posterior plateau. Patients who received tenotomy have acceptable functional outcomes. This cadaveric study provides an alternative approach for treatment of posterolateral tibial plateau fractures which may mitigate damage to neurovascular structures.

Influence of reduction quality on functional outcome and quality of life in the surgical treatment of tibial plateau fractures: A retrospective cohort study

BACKGROUND

Despite a substantial improvement in the operative treatment of tibial plateau fractures, the surgical procedure remains controversial and is generally challenging, as patients may develop postoperative arthritis and functional impairment of the knee joint.

HYPOTHESIS

In the surgical treatment of tibial plateau fractures the intraoperative reposition quality has the greatest influence on the postoperative outcome, whereby misalignments of≥2mm lead to a worse result.

PATIENTS AND METHODS

Forty-one patients with tibial plateau fractures were postoperatively examined. The operative treatment was performed under reduction control using an intraoperative 3D C-arm. The follow-up collective was divided into two groups depending on the intraoperative reduction result. The postoperative results were then evaluated using the following parameters: Lysholm score, Rasmussen score, Tegner score, SF-36 score, range of motion and pain level.

RESULTS

Group 1 (articular surface incongruencies<2mm) tended to achieve a better result in all scores than group 2 (articular surface incongruencies≥2mm), in the Lysholm score (p=0.039), in the comparison of the range of motion (p=0.012) and the pain level (p=0.039) this was significant. Group 1 achieved an average of 90.71 points (group 2: 78.74) in the Lysholm score. The average range of motion of the knee joint was 138.93° in group 1 (group 2: 127.78°). The average value of the current pain level in group 1 was 1.14 (group 2: 2.63).

DISCUSSION

Both study groups achieved a very good result compared to the available literature. It appears that reduction quality - which can be analyzed with intraoperative 3D imaging - plays the most important role in postoperative quality of life and functional outcome. Intraoperative adjustments of the reduction should therefore be performed on joint surface irregularities with a size above 2mm.

LEVEL OF EVIDENCE

III; retrospective case control study.

Feasibility of the modified inverted L-shaped approach for posterolateral tibial plateau fracture: A retrospective study

Approaches for treating posterolateral tibial plateau fractures vary among surgeons, and the inverted L-shaped approach is a known option. This article aims to introduce a new modified posterolateral inverted L-shaped approach for isolated posterolateral tibial plateau fractures and study its feasibility. Medical records of patients with posterolateral tibial plateau fractures were reviewed. Plain radiographs were obtained during the follow-up period, and the hospital for special surgery (HSS) score was used to assess the function of the injured limb. Perioperative complications were recorded and followed-up. In total, 32 patients with posterolateral tibial plateau fractures were treated using a modified posterolateral approach. The mean age of the patients was 44 ± 11 years (28-64 years). All patients successfully underwent surgery and were followed-up for a mean duration of 13 ± 2 months (10-16 months). On plain radiographs, fracture lines were fuzzy 3 months after surgery and disappeared 12 months after surgery. No perioperative complications occurred during the follow-up period. The HSS score was evaluated 12 months after surgery, and the mean score was 91 ± 5 points (81-97 points), including 25 excellent cases and 7 good cases. The modified posterolateral inverted L-shaped approach has the advantages of small soft tissue dissection, fracture reduction under direct vision, easy internal fixation, and a lower risk of neurovascular injury. This approach is feasible for the treatment of isolated posterolateral tibial plateau fractures, and further high-quality randomized control trials are required to confirm its clinical efficacy.

Comparison Between Treatment of Bicondylar Tibial Plateau Fractures With or Without Posterolateral Fragments Using Posteromedial and Anterolateral Approaches

BACKGROUND

The best surgical approach for treating posterolateral fragments in tibial plateau fractures remains controversial. This study compared the radiological and functional outcomes of bicondylar tibial plateau fractures, with or without posterolateral fragments, treated using the same posteromedial and anterolateral approaches.

METHODS

Twenty-six patients with 27 bicondylar tibial plateau fractures were surgically treated between June 2006 and February 2020. The patients were divided into two groups: with posterolateral fragments (PL group) and without posterolateral fragments (non-PL group). All patients were treated with the combined posteromedial and anterolateral approach. Knee function was assessed using the Lysholm score and by measuring the range of motion (ROM). Fracture reduction was assessed using Rasmussen radiological scores.

RESULTS

Fifteen bicondylar fractures were classified in the PL group and 12 in the non-PL group. No significant difference was found in the ROM and Lysholm scores between the groups. No significant difference was noted in Rasmussen radiological scores between the groups.

CONCLUSION

Using the combined posteromedial and anterolateral approach, bicondylar tibial plateau fractures with posterolateral fragments achieved reasonable functional and radiological outcomes compared to those without a posterolateral fragment. This combined approach enabled an adequate visualization and reduction of posterolateral fragments. These standard approaches may be adequate for most bicondylar tibial plateau fractures with posterolateral fragments.

Determination of outcomes of complex upper end tibial fractures in squatting and cross leg sitting South Asian population

INTRODUCTION

Treatment of complex upper end tibial fractures has always been a challenge to orthopaedic surgeons. Though the roentgenogram results are satisfactory, the clinical and functional outcomes especially in terms of squatting/cross-leg sitting after long term follow-up are little known. Hence, we have done this study with a primary aim to assess the clinico-radiological and functional outcomes after operative fixation (mostly by locking plates) in complex upper end tibial fractures and a secondary aim to analyze correlation between functional outcome scores/range of motion (ROM) and the ability to squat & sit cross-legged in post-operative period.

MATERIALS AND METHODS

This prospective study included a total of 33 patients who were mainly treated with locking plates. In the follow-up, patients were assessed clinico-radiologically and outcome measurements were determined using the Tegner-Lysholm (T-L) Knee Score. Patients were categorized according to their ability to squat/sit cross-legged and a subgroup analysis was performed by comparing mean ROM and T-L score in each group.

RESULTS

Majority of patients were in young and adult age group with a male to female ratio of 4.5:1. The average age was 42.39 ±14.64 years. Road traffic accident was the most common mode of injury. Average time interval between injury and surgery was 5.8±4.4 days. All the fractures united by 5-9 months. Mean ROM and T-L score at last follow-up were 120.94°±13.63° and 88.12±7.24 respectively. Average shortening, varus and valgus deformity were 0.43±0.09 cm, 2.12°±0.62° and 1.06°±0.45° respectively. 14 patients (42.42%) were able to squat and 15 (45.45%) were able to sit cross-legged postoperatively. Upon subgroup analysis, difference of mean ROM in those who could squat/sit cross-legged was found statistically significant (p≤0.05), however the difference in mean functional scores was not significant (p≥0.05).

CONCLUSION

Complex upper tibial fractures are a difficult entity to deal with. Anatomical locking plates take care of the alignment, articular congruity as well as ligamentous balancing thus giving good mid-term outcomes after ORIF/MIPO. However, applicability of the present functional outcome scores in assessing squatting/cross leg sitting remains doubtful. More weightage needs to be given to these activities to evaluate the outcome in South Asian population.

Outcome after polyaxial locking plate osteosynthesis in proximal tibia fractures: a prospective clinical trial

Background

The aim of this study was to evaluate the clinical and/or radiologic outcome using different polyaxial locking plates for the treatment of proximal tibia fractures, the Non-Contact-Briding plate (NCB-PT®) by Zimmer or the Variable Angle Locking Compression Plate (VA-LCP®) by Synthes.

Methods

This study enrolled 28 patients with proximal tibia fractures (AO/ OTA 41 B-C) and indication for locking plate osteosynthesis. All patients were treated with a polyaxial locking plate system. Depending on the fracture morphology, patients were either treated with a NCB-PT® or VA-LCP®. The implant was chosen according to the surgeon’s experience and preference, in case of a higher degree of comminution the tendency was observed to use the NCB-PT® plate. After a time interval of 12 months postoperative we conducted clinical (e.g. range of motion, the Rasmussen score) and radiological (e.g. primary/secondary loss of reduction) follow-ups.

Results

Patients provided with the NCB-PT® (9 patients) showed longer operation time, use of longer implants, longer interval from injury to surgery and lower clinical scores after the 12 months follow-up compared with the VA-LCP® group (19 patients). Interestingly, the results showed no significant differences regarding the clinical and radiologic outcome.

Conclusions

The small number of patients as well as the heterogeneity of fractures constitute a limitation of this study. Nevertheless, the differentiated use of implants is associated with comparable clinical and radiological outcomes. This trial emphasizes the need for further prospective randomised trials with higher patient numbers.

Trial registration

Retrospectively registered 21.12.2020. Registration number NCT04680247.

A modified Frosch approach for posterior tibial plateau fractures: Technical note and case series

Achieving the best possible articular congruity following a tibial plateau (TP) fracture is associated with better long-term functional outcomes; TP has an essential role in the movements of the knee joint and is well established that a not optimal reduction leads to articular instability and early osteoarthritis. In recent times, 3D reconstruction from CT scan has greatly contributed to improve the surgical treatment of these fractures since an accurate preoperative plan gives the possibility to decide the best interventional strategy before the surgical incision. Reduction of the posterior part of tibial plateau is not easily achievable with standard surgical access. Several posterolateral approaches, proposed by authors such as Frosch and Lobenhoffer, have been described over the years; these approaches can be divided into 2 groups: with or without osteotomy of the fibula. Main disadvantages of these techniques are the large skin incision, the difficulty of exposing the lateral face of the tibia, the high frequency of damages of the posterolateral TP corner, and in some cases the necessity of performing fibular head osteotomy . The surgical approach presented in this paper is a simple innovation of the well-known Frosch approach: skin incision is about 12 centimeters in length and runs in a "S" shape with the center positioned over the head of the fibula. It starts 2 centimeters laterally to the tibial crest 6 centimeters below the tibial tuberosity and is directed proximally, curving posteriorly at the level of fibular head and returning straight in the most proximal part; it terminates 4 centimeters posteriorly the lateral femoral condyle. This innovative approach allows the trauma surgeon to achieve an optimal exposure and control of posterior tibial plateau fractures, with the great advantage of being able to treat the lateral tibial plateau with the same surgical incision.

Fibular Neck Osteotomy Approach in Treatment of Posterolateral Tibial Plateau Fractures: A Retrospective Case Series

Background

The surgical strategies for posterolateral tibial plateau fractures are still inconsistent. Although a number of operative approaches were previously reported for surgical treatment of fractures of the posterolateral column in the tibial plateau, some approaches fail to provide direct visualization of the articular surface and do not allow enough space to access the posterolateral area of the lateral tibial plateau, thereby leading to unsatisfactory reconstruction of the knee and poor articular activity.

Material/Methods

We retrospectively reviewed records of 21 patients who underwent fibular neck osteotomy approach for posterolateral fractures. Radiographs taken during follow-up were used to evaluate the quality of fracture reduction and lower-limb axis. The Tegner-Lysholm score was used to assess patient functional performance. Complications, including incision infection, osteotomy nonunion, peroneal nerve injury, and fragment displacement, were evaluated.

Results

We included 12 males and 9 females, with an age range of 27–67 years (mean age, 42.43 years). No intraoperative complications or postoperative complications were found. The mean operative duration was 128.05 min (range: 86–167 min). No patients were lost to clinical or radiographic follow-up. All patients had complete follow-up (range: 13–28 months, mean: 19.57 months). Anatomical fracture reduction was achieved in 14 patients. Radiological limb alignment was restored in all patients. The mean Tegner-Lysholm score was 87.07 (range: 74–95) and the average knee society score (KSS) was 91.67 (range: 86–94) at the final follow-up.

Conclusions

In this retrospective study, the results suggest that the fibular neck osteotomy approach is a good choice for treatment of posterolateral tibial plateau fractures.

Arthroscopically assisted and three-dimensionally modeled minimally invasive rim plate osteosynthesis via modified anterolateral approach for posterolateral tibial plateau fractures

AIM

The aim of this study was to describe a new, closed, arthroscopically-assisted reduction of posterolateral tibial plateau fractures with minimally invasive plate osteosynthesis using a plate pre-contoured over a 3D-model based on a CT-scan of the injured tibial plateau and positioned by using a minimal anterolateral approach.

METHODS

A five to six centimeter long curvilinear incision was made over the Gerdy's tubercle. After subcutaneous dissection, the fascia was incised, the ileo-tibial band was split, and the dissection was extended posteriorly. The knee was flexed to 90° and the space between the fibular collateral ligament and the posterolateral plateau rim (para-FCL space) was created. A variable-angle locking compression plate contoured on a 3D-model was inserted flush to the tibial plateau rim. Two cortical screws were placed to ensure support under the area of depression as far posteriorly as possible. Two additional screws were implanted, and a cortical screw was used for the most anterior screw hole. The custom pre-contoured plate based on a person-specific 3D-model, associated with arthroscopy reduction, provides a supporting and containing effect to the posterolateral periarticular fragments and allows a minimally invasive plate osteosynthesis fixation to be performed. This guarantees a proper reduction and fixation without the described limitations and risks associated with the classic approaches.

CONCLUSIONS

This approach should be considered to treat fractures of the posterolateral plateau, isolated or associated with medial tibial plateau fractures, as it could improve the outcome in terms of lower associated risks, better reduction and fixation, and faster and improved patient recovery.

Automatic estimation of morphological characteristics of proximal tibia for precise plate treatment using model matching

Plate treatment is currently the standard treatment of proximal tibia fracture. Morphological characteristics can help orthopedic surgeons understand anatomic information of tibia and choose well-matched plate for reducing difficulties in plate treatment. However, manual measurement of morphological characteristics of patient's tibia is time-consuming and labor-intensive. Therefore, this study proposes an automatic method to accurately estimate the morphological characteristics of patient's tibia for assisting plate treatment. In the off-line stage, an average shape with typical characteristics was computed from 422 tibia models, and the morphological characteristics of the average shape were measured by the orthopedic surgeon. In the on-line stage, the point's correspondence between the average shape and every tibia model was created by the proposed morphable model matching method firstly. Then, the morphological characteristics of tibia for every patient were estimated automatically based on the point's correspondence and characteristics of average shape. The effectiveness of the method was validated by comparing the manual measured and automatic-estimated characteristics. In addition, the basic experiments of virtual and real plate implantation preliminarily confirmed that the automatic-estimated morphological characteristics were helpful for plate treatment. In all, we propose an automatic and accurate estimation method of morphological characteristics for a large-scale library of Chinese tibia models, which provides orthopedic surgeons with scientific and quantitative description of tibia.

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.

The effect of coronal splits on the structural stability of bi-condylar tibial plateau fractures: a biomechanical investigation

INTRODUCTION

Surgical treatment of bi-condylar tibial plateau fractures is still challenging due to the complexity of the fracture and the difficult surgical approach. Coronal fracture lines are associated with a high risk of fixation failure. However, previous biomechanical studies and fracture classifications have disregarded coronal fracture lines.

MATERIALS AND METHODS

This study aimed to develop a clinically relevant fracture model (Fracture C) and compare its mechanical behavior with the traditional Horwitz model (Fracture H). Twelve samples of fourth-generation tibia Sawbones were utilized to realize two fracture models with (Fracture C) or without (Fracture H) a coronal fracture line and both fixed with lateral locking plates. Loading of the tibial plateau was introduced through artificial femur condyles to cyclically load the fracture constructs until failure. Stiffness, fracture gap movements, failure loads as well as relative displacements and rotations of fracture fragments were measured.

RESULTS

The presence of a coronal fracture line reduced fracture construct stiffness by 43% (p = 0.013) and decreased the failure load by 38% from 593 ± 159 to 368 ± 63 N (p = 0.016). Largest displacements were observed at the medial aspect between the tibial plateau and the tibial shaft in the longitudinal direction. Again, the presence of the coronal fracture line reduced the stability of the fragments and created increased joint incongruities.

CONCLUSIONS

Coronal articular fracture lines substantially affect the mechanical response of tibia implant structures specifically on the medial side. With this in mind, utilizing a clinically relevant fracture model for biomechanical evaluations regarding bi-condylar tibial plateau fractures is strongly recommended.

[Clinical observation of 3.5 mm T support plate fixation for simple posterolateral tibial plateau fracture by posterolateral inverted L-shaped approach]

Objective

To summarize the effectiveness of 3.5 mm T support plate fixation for simple postero-lateral tibial plateau fractures by posterolateral inverted L-shaped approach.

Methods

Between March 2011 and January 2016, 13 patients with simple posterolateral tibial plateau fracture were treated with 3.5 mm T support plate fixation by posterolateral inverted L-shaped approach. Of 13 cases, 6 were male and 7 were female, aged 28 to 52 years (mean, 43 years). The left side was involved in 5 cases and the right side in 8 cases. The causes of injury were traffic accidents in 6 cases, falls in 3 cases, and falling from height in 4 cases. All of patients had fresh closed fracture by X-ray, CT three dimensional reconstruction, and MRI. According to Schatzker classification, 4 cases were rated as type II and 9 cases as type III. The time between injury and operation was 5-9 days (mean, 7 days).

Results

One case had incision skin necrosis, which was cured after debridement and skin grafting; and primary healing was obtained in the other cases. The patients were followed up 10-16 months (mean, 13 months). The X-ray film showed that the fracture line was blurred at 3 months after operation, and disappeared at 12 months after operation. There was no complications of wound infection, major neurovascular injury, loosening or breakage of internal fixation, and dislocation of joint surface. The Hospital for Special Surgery (HSS) knee function score was 94 (range, 89-97) at last follow-up; all were excellent.

Conclusion

The 3.5 mm T support plate fixation by posterolateral inverted L-shaped approach is one of preferred surgical method for the treatment of simple posterolateral tibial plateau fractures.

Rim Plate Augmentation of the Posterolateral Bare Area of the Tibial Plateau Using a 3.5-mm Precontoured Locking Compression Plate: A Cadaveric Study

OBJECTIVE

To evaluate the effectiveness of an additional rim plate [3.5-mm precontoured locking compression plate (LCP)] for stabilizing the posterolateral fragment in lateral tibial plateau fractures.

METHODS

Standard lateral locking plates [either a proximal tibial plate (PTP) or a proximal tibial locking plate (PTLP)] were applied to 40 matched pair knees from 20 fresh-frozen cadavers followed by the application of a secondary rim plate [variable angle LCP (VALCP)] posterior laterally.

RESULTS

The mean ratio of supported articular surface in the PTP group was 0.692, whereas that in the PTLP group was 0.569. This difference was statistically significant (P < 0.001). Additional rim plating with a VALCP could only be performed for 27 of 40 knees; 8 of 20 knees in the PTP group and 5 of 20 knees in the PTLP group could not be fitted with a VALCP due to anatomic limitations. For the total standard plating group alone, the mean ratio of supported articular surface was 0.596, whereas the mean ratio of supported articular surface with additional rim plating was 0.798 (P < 0.001). In contrast, additional rim plating was possible for more knees that received a PTLP than a PTP. Ultimately, there was no significant difference in the ratio of supported articular surface after additional rim plating between the 2 different types of standard plates (P = 0.087).

CONCLUSION

Our results identified a bare area in the posterolateral corner of the lateral plateau that was unsupported by rafting screws following conventional, 3.5-mm, precontoured LCP plating. Thus, additional rim plating may be useful for treating plateau fractures with a posterolateral fragment.

Anterolateral tibial plateau osteotomy as a new approach for the treatment of posterolateral tibial plateau fracture: A case report

RATIONALE

It is challenging to visualize and reduce a posterolateral tibial plateau fracture through an anterolateral approach as the tibial plateau fragments are often covered by the fibular head and ligamentous structures.

PATIENT CONCERNS

In this case report, we describe a patient with a depression fracture of the posterolateral quadrant combined with a split fracture of the posteromedial quadrant and an avulsion fracture of the tibial intercondylar eminence.

DIAGNOSES

Tibial plateau fracture(AO type 41-B3).

INTERVENTIONS

A posteromedial approach combined with an anterolateral approach and an osteotomy involving the proximal tibiofibular joint of the tibial plateau was used to expose, reduce, and fix the fracture.

OUTCOMES

There was no risk of injury to the common peroneal nerve or ligaments. The patient is recovering well and is satisfied with the function of the injured knee.

LESSONS

We recommend anterolateral tibial plateau osteotomy for the treatment of posterolateral tibial plateau fractures in clinical practice.

The pivotal role of the coronal fracture line for a new three-dimensional CT-based fracture classification of bicondylar proximal tibial fractures

INTRODUCTION

Classical fracture classifications (AO/OTA, Schatzker) are commonly used to characterize bicondylar proximal tibial fractures. However, none of these classifications allows for a treatment algorithm. The aim of our study was to use 3D appearance of these fractures in CT imaging to improve the clinical value of the classification.

MATERIALS AND METHODS

3D appearance of 81 CT scans of bicondylar proximal tibial fractures were systematically analyzed and were classified in 3 subtypes, based on the fracture lines orientation. The novel classification was compared for reliability and for clinical relevance with AO and Schatzker classification.

RESULTS

A total of 159 fracture lines were identified which were most frequently oriented in sagittal (89/159), and in coronal (41/159) direction. Based on the orientation of the major fracture lines three fracture types were defined. A special emphasis was drawn to the coronal fracture line of the medial plateau leading to a surgical treatment algorithm. Interobserver reliability was analyzed for all 81 patients resulting in an excellent reliability of К=0.936 for the 3D classification scheme compared to К=0.720 for the AO/OTA, К=0.785 for the Schatzker classification. Correlations with clinical parameters were only observed for the 3D classification.

DISCUSSION

The presented classification scheme based on the 3D geometry of bicondylar proximal tibial fractures demonstrates a good reliability of clinical relevance.

Intramedullary Nailing with a Suprapatellar Approach and Condylar Bolts for the Treatment of Bicondylar Fractures of the Tibial Plateau

Background

Bicondylar tibial plateau fractures have been treated with either plating or external fixation techniques, with conflicting results. A recently introduced technique involving the combined use of intramedullary nailing via a suprapatellar approach and condylar bolts could represent a new pathway toward better treatment of this severe injury.

Methods

The present report describes a retrospective and prospective study of all 17 patients (age range, 25 to 75 years) who were admitted under the author's care for the treatment of a closed, bicondylar tibial plateau fracture between 2013 and 2015. All patients consented to undergo fixation of the fracture with intramedullary nailing through a suprapatellar approach and with use of condylar bolts. The reconstructed articular surface was supported with freeze-dried allograft that had been previously soaked in concentrated bone marrow. The patients were followed at regular intervals, and the results were assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS).

Results

All patients were followed for at least 1 year (average and standard deviation, 25.23 ± 8.95 months; range, 12 to 46 months). All fractures united clinically and radiographically between 10 and 22 weeks (average, 15.1 ± 2.91 weeks), with no instances of neurovascular complication, infection, or implant failure. One patient underwent early revision of the fixation because of unsatisfactory reduction of the articular surface, and 1 patient had secondary fracture displacement. One condylar bolt was removed after fracture healing because of irritation at the insertion site. However, all patients regained knee motion without physiotherapy and all were fully weight-bearing by the fifth postoperative month.

Conclusions

The short and intermediate-term results associated with the use of the proposed technique appear to be satisfactory. However, the effectiveness of the technique should be reassessed with long-term studies as well as comparative studies involving other fixation techniques.

Level of Evidence

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

[Quality of life and job performance resulting from operatively treated tibial plateau fractures]

BACKGROUND

The aim of this article is to present the functional results and the effect on quality of life of surgically treated tibial plateau fractures in physically active and working patients with multiple and serious injuries. In addition, the relationships between functional and radiological outcome were evaluated and compared with activity in daily and professional life.

PATIENTS AND METHODS

In all, 41 injured patients were followed up a mean of 47 months after surgical treatment and examined with radiological, functional, as well as quality of life score.

RESULTS

In the radiological scoring, a mean value of 72 points (max 100 points) was achieved. In the activity score, there was an average of 63.5 points (max 100 points). When evaluating the health-related quality of life, an average score of 69.6 points was achieved. There was a significant relationship between radiological and activity scores and the radiological and life quality scores. Furthermore, the relationship between activity and quality of life scores was considered significant. Surgeon's influence on the functional outcome could be confirmed.

CONCLUSION

The functional and the radiological results were moderate. Quality of life was permanently affected by the consequences of tibial plateau fracture in 12 patients; 11 patients were not re-employed. However, the quality of life was assessed as good or very good and 28 patients had returned to work. The quality of life was firmly linked to the radiological and functional parameters, which tended to be influenced by the quality of the primary surgical treatment when looking at the overall population.

A combined approach for the treatment of lateral and posterolateral tibial plateau fractures

INTRODUCTION

The treatment of tibial plateau fractures involving the lateral and posterolateral column is a demanding and fine surgical challenge. The purpose of this study was to evaluate the safety and clinical efficacy of combined approach for the treatment of lateral and posterolateral tibial plateau fractures.

METHODS

A prospective study was performed in 17 patients with lateral and posterolateral tibial plateau fractures between January 2009 and December 2012. There were 12 males and 5 females with a mean age of 40 years. All of them received dual-plate fixation through the combined approach, with the patients in a floating position. The combined approaches included a conventional anterolateral approach and an inverted L-shaped posterolateral approach. Operation time, intraoperative blood loss, fracture healing time, Hospital for Special Surgery (HSS) knee score, knee flexion and extension range of motion, and complications were recorded to evaluate treatment effects.

RESULTS

There were no intraoperative complications related to this technology. Mean operation time was 144min with a mean intraoperative blood loss volume of 233mL. The mean follow-up was 23 months. All 17 patients had good postoperative fracture healing. Mean union time was 12 weeks. At the final follow-up, the average HSS score was 92.5, with the average knee flexion of 125° and an average knee extension of 2°. Two patients had complications in postoperative incisions with aseptic fat liquefaction. After thorough debridement, second-stage wounds healing were achieved. No neurovascular injury occurred. No collapse of reduced articular surface was detected.

CONCLUSIONS

The combined approach with dual-plate offers direct and complete surgical exposure and provide an effective method for the treatment of lateral and posterolateral tibial plateau fractures.

An extended anterolateral approach for posterolateral tibial plateau fractures

PURPOSE

The best approach for treating posterolateral tibial plateau fractures remains controversial. The clinical results of an extended anterolateral approach on such fractures are discussed in this study.

METHODS

Between 2010 and 2011, ten patients with posterolateral tibial plateau fracture were treated using an extended anterolateral approach with a proximal tibial locking compression plate. The epidemiological data, operation details, and clinical outcomes over 26.4 ± 2.3 months (range 24-30 months) of follow-up were prospectively collected and analyzed.

RESULTS

The average surgical duration was 91.5 ± 18.7 min (range 80-130 min). An anatomic reduction rate of 90 % (9/10) was observed although one patient with a lateral comminuted fracture and dislocation presented a 2-mm joint surface depression postoperatively. The average fracture healing time was 10.6 ± 1.8 weeks (range 8-14 weeks), with an average hospital for special surgery knee score of 95.3 ± 6.5 points (range 80-100 points), an average knee flexion of 119.8° ± 17.2° (range 95°-140°) and an average knee extension of 2.1° ± 2.1° (range 0°-6°). No complications were found.

CONCLUSIONS

The extended anterolateral approach with a proximal tibial compression plate offers direct and complete surgical exposure and may provide an effective method for the surgical treatment of posterolateral tibial plateau fractures.

LEVEL OF EVIDENCE

Therapeutic, Level IV.

Osseous vitality in single photon emission computed tomography/computed tomography (SPECT/CT) after balloon tibioplasty of the tibial plateau: a case series

Background

The minimally invasive, balloon-assisted reduction and cement-augmented internal fixation of the tibial plateau is an innovative surgical procedure for tibial plateau fractures. The close proximity of balloons and cement to the knee joint poses a potential risk for osteonecrosis; especially in the case of thin bone lamellae. However, there are no studies about the vitality of the cement-surrounding tissue after these tibioplasties. Therefore, our goal was to assess the osseous vitality after cement-augmented balloon tibioplasty using single photon emission computed tomography/computed tomography (SPECT/CT) in a series of patients.

Methods

This case series evaluated available consecutive patients, whose tibial plateau fractures were treated with balloon-assisted, cement-augmented tibioplasty and received a SPECT/CT. Primary outcome variables were osseous vitality on SPECT/CTs according to the semiquantitative tracer activity analysis. The mean uptake of eight tibial regions of interest was referenced to the mean uptake count on the same region of the contralateral leg to obtain a count ratio. Osteonecrosis was defined as a photopenic area or cold defect. Secondary variables included clinical and radiological follow-up data. Statistics were carried out in a descriptive pattern.

Results

Ten patients with a mean age of 59 years and a mean follow up of 18 months were included. Calcium phosphate (CaP) substitute bone cement was used in 60 % and polymethyl methacrylate mixed with hydroxyapatite (PMMA/HA) bone cement in 40 %. Normal to high SPECT/CT activity without photopenic areas were observed in all patients and the mean tracer activity ratio was four, indicating vital bone in all patients. There were no postoperative infections and only one 57 year old patient with hemineglect and CaP cement showed failed osseous consolidation. The mean Tegner and Lysholm as well as the Lysholm scores were three and 80, respectively.

Conclusions

This novel study about cement-augmented balloon tibioplasties showed that osseous vitality remains intact according to SPECT/CT analysis; irrespective of the type of cement and even in the presence of thin bone lamellae. This procedure was safe and well-suited for lateral tibial plateau fractures in particular. Surgeons may consider using PMMA/HA bone cement for void filling in elderly fracture patients without concern about bone viability.

[Tibial plateau fractures in winter sports. Current treatment options]

BACKGROUND

Tibial plateau fractures overall and especially in winter sports are rare. However, the incidence in recent years is increasing. In a retrospective study from 2009-2012, we found 52 injuries affiliated with winter sports. Noticeable was the high rate of severe injury patterns. In 20 of the 52 cases, there were complete articular or bicondylar fractures (38 %). In 25 cases (48 %), fragment dislocation corresponding to the Moore classification was observed.

METHODS

The operative algorithm was based on the initial soft tissue damage and the type of fracture. A two or more stage procedure with first line soft tissue management and temporary external fixation stabilization was performed 12 times. The final internal osteosynthesis was based on the morphology of the fracture, i.e., direct exposition and stabilization of relevant fracture patterns. In 24 cases (46 %), there was a need for two (or more) approaches. In the anterior aspect of the tibial head, customary implants were used; posterior pathologies were stabilized with low-dimension implants.

RESULTS

Summarizing with regard to the literature, there is a more discriminating view of tibial plateau fractures, regarding all relevant fracture patterns. Thus, different options in operative access and choice of implants can be made.

Combined lateral femoral epicondylar osteotomy and a submeniscal approach for the treatment of a tibial plateau fracture involving the posterolateral quadrant

Exposure of a tibial plateau fracture involving the posterolateral quadrant is challenging, and several approaches for treating these fractures have been introduced. However, these approaches may have limited applicability, and they can potentially cause neurovascular, musculotendinous, or ligamentous injury of the posterolateral corner. Lateral femoral epicondylar osteotomy has been used for meniscal transplantation, total knee arthroplasty, and the treatment of posterolateral articular disorders of the femur and tibia. We encountered a case of a tibial plateau fracture involving the posterolateral quadrant without an anterior-extending fracture line. We successfully exposed, reduced, and fixed the fracture using combined lateral femoral epicondylar osteotomy and a submeniscal approach. This combined modality can be used as an alternative surgical technique for the treatment of tibial plateau fractures involving the posterolateral quadrant.

Incidence and fracture morphology of posterolateral fragments in lateral and bicondylar tibial plateau fractures

OBJECTIVES

This study aimed to evaluate the incidence and morphologic features of posterolateral fragments in lateral and bicondylar tibial plateau fractures.

DESIGN

This study used retrospective chart and computed tomography (CT) reviews.

SETTING

The study was conducted in a university hospital.

PATIENTS

All patients in whom lateral and bicondylar tibial plateau fractures had been diagnosed from May 2005 to December 2011 were reviewed.

MAIN OUTCOME MEASUREMENTS

Two hundred seventy-eight OTA type B and type C tibial plateau fractures were identified using a retrospective chart review. Of the 197 patients who underwent CTs before surgery, 7 CTs were excluded because they had no sagittal or axial view, and the remaining 190 cases were enrolled to determine the incidence and morphologic characteristics of posterolateral fragments. The parameters for the morphologic evaluation included the lateral major articular fracture angle, posterior major articular fracture angle, diagonal distance, lateral anteroposterior distance (LAPD), posterior horizontal distances, posterior cortical height, sagittal fracture angle, and articular surface area. The displacement of posterolateral fragment was measured on axial image and classified as none, minor, or major by a gap of 5 mm.

RESULTS

The incidence of posterolateral fragments included 84 cases (44.2%). Based on the OTA fracture classification system, 37 type B (35.9%) and 47 type C (54%) posterolateral fragments were identified. The mean lateral major articular fracture angle was 12.69 degrees (range, -56.02 to 72.44 degrees), and the mean posterior major articular fracture angle was 19.13 degrees (range, -39.47 to 61.10 degrees). The average diagonal distance was 32.75 mm (range, 15.03-59.14 mm). The LAPD averaged 10.22 mm (range, -11.18 to 31.17 mm), and the mean posterior horizontal distance was 22.93 mm (range, 4.1 to 49.95 mm). The average posterior cortical height was 31.12 mm (range, 10.84-63.93 mm), and the average sagittal fracture angle was 78.48 degrees (range, 41.69-105.12 degrees). The mean articular surface area was 522.18 mm2 (14.5%) of the total tibial articular surface.

CONCLUSIONS

Posterolateral fragments are not uncommon in lateral and bicondylar tibial plateaus. This fragment has an inverted conical shape that is in a vertically oriented pattern and occupied nearly one-third of the surface area of the lateral tibial plateau. The preoperative CT measurement, especially for the LAPD, can be used for determining the best fixation strategy for the posterolateral fragment.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcome of angular stable locking plate fixation of tibial plateau fractures Midterm results in 101 patients

BACKGROUND

Articular reconstruction and stable fixation of tibial plateau fractures and its various subtypes continue to represent a surgical challenge. Only few trials have studied results following angular stable plate fixation. The present study aimed to investigate the clinical, radiological, functional and quality of life results following tibial plateau fractures using angular stable plate fixation.

MATERIALS AND METHODS

101 patients were retrospectively studied using functional (ROM; KSS; VAS), radiographic (osteoarthritis score, loss of reduction) and quality of life (WOMAC; Lysholm) scores. There were 46 males and 55 females. The average of patients was 51 years (range 22-77 years). Study groups were assigned according to the AO fracture classification.

RESULTS

Mean followup was 57 ± 30 months. Fracture type distribution revealed a significantly (P < 0.001) increased number of type B- (62.4%) compared to C-fractures. Functional assessment showed a significantly better total KSS (84.1 ± 15.6 vs. 74.7 ± 18.0; P = 0.01) as well as ROM (active: 124°±17° vs. 116°±15°, P = 0.014; passive: 126°±18° vs. 118 ± 14°, P = 0.017) in the B-fracture group. VAS was found to be markedly higher (P = 0.0039) following type C-fractures. Rating osteoarthritis secondary to a tibial plateau fracture as a function of injury severity (r = 0.485; P < 0.001) and relating the loss of reduction to the grade of evolving osteoarthritis (r = 0.643; P < 0.001) a positive correlation was found. Quality of life showed significantly improved results for Lysholm score (P = 0.004) following B-fractures with low overall values for the WOMAC score.

CONCLUSION

Presented data provide sufficient evidence that anatomic restoration of tibial plateau fractures with angular stable plate fixation result in decreased loss of reduction and declined incidence of posttraumatic osteoarthritis, thereby providing acceptable mid to long term outcome.

Open reduction and internal fixation of posterolateral tibial plateau fractures through fibula osteotomy-free posterolateral approach

OBJECTIVE

To evaluate the outcome of patients with posterolateral tibial plateau fractures after open reduction and internal fixation with a fibula osteotomy-free posterolateral approach.

DESIGN

Retrospective chart and operation note review.

SETTING

A medical college-affiliated tertiary hospital.

MATERIALS AND METHODS

A retrospective chart and radiographic review of posterolateral tibial plateau fractures treated with a posterolateral approach between January 2006 and July 2010 was performed. The primary (ie, the total Rasmussen function score) and secondary (ie, the postoperative infection, knee deformity, and complications) outcomes were analyzed.

RESULTS

A total of 32 patients were identified for this study. Patients were followed for an average of 18.2 months (range, 12-36 months); the total Rasmussen function score was 24.8 ± 2.9 points. The results were rated as excellent (≥27 points) in 19 patients, good (20-26 points) in 11, and fair (10-19 points) in 2 patients. No wound infections, screw loosening or implant fracture, and nonunion, deformity, or fracture redisplacement were seen. Stretch injury of the common peroneal nerve was found in 1 patient, who obtained recovery 2 months after additional conservative management.

CONCLUSIONS

Adequate open reduction and internal fixation with a fibula osteotomy-free posterolateral approach can attain a satisfactory clinical outcome for patients with posterolateral tibial plateau fractures.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comparison of outcome of unilateral locking plate and dual plating in the treatment of bicondylar tibial plateau fractures

BACKGROUND

Tibial plateau fracture (TPF) includes different fracture patterns with varied degrees of articular depression and displacement. Many kinds of fixators, including newly designed plate with locking screws, were applied to treat these complicated fractures. We intended to follow up the surgical outcomes of (1) unilateral locking plate, (2) classic dual plates, or (3) hybrid dual plates for TPF.

MATERIALS AND METHODS

We retrospectively reviewed 76 patients with TPF, Schatzker types V and VI, who we operated from June 2006 to May 2009 in our institute. Excluding patients who expired due to other medical conditions and without complete follow-up, 45 patients were sorted out in this series. The scheme of surgical intervention was designed by visiting staff, and 15 patients, as group I, were treated with unilateral locking plate. The other 19 patients, as group II, were treated with classic dual plates. The residual 11 patients, as group III, were treated with hybrid dual plates (one lateral approach locking compression plate (LCP) + medial anti-gliding plate). All patients were under periodic F/U at about 6 weeks interval for at least 18 months postoperatively.

RESULTS

In group I, 13 cases achieved solid bony union without obvious traumatic OA change, limitation of ROM, or malalignment. In groups II and III, 15 and 10 patients reached the same goal, respectively. By analysis of the recorded parameters with statistical software (SPSS 12.0), there were five parameters with significant difference, including Schatzker classification, operation time, staged treatment or not, hospitalization period, and hardware impingement.

CONCLUSIONS

There was no significant statistical difference of union rate between these three groups in our series. Based on our clinical follow-up, several key points were emphasized: (1) Soft tissue problems should be kept in mind, and usage of locking plate can reduce the discomfort of hardware impingement effectively. (2) The single lateral approach technique for TPF with locking plate results in less operation time and shorter hospitalization period. (3) If the medial buttress cannot be established by reduction of the lateral fracture, then open reduction of the medial side is necessary and buttresses the medial fragment by dual plates.

Mono- versus polyaxial locking plates in distal femur fractures: a prospective randomized multicentre clinical trial

PURPOSE

Treatment of complex fractures of the distal femur utilizing monoaxial locking plates (e.g. Less Invasive Stabilisation System, LISS®, Synthes) is considered to be superior to conventional plating systems. Due to the limitation that the thread forces the screw into pre-determined positions, modifications have been made to allow screw positioning within a range of 30° (Non Contact Bridging, NCB®-DF, Zimmer). For the first time, this multicenter prospective randomized clinical trial (RCT) investigates the outcome of LISS® vs. NCB®-DF treatment following complex fractures of the distal femur.

METHODS

Since June 2008, 27 patients with a fracture of the distal femur (AO ASIF 33-A-C and periprosthetic fractures) were enrolled in this study by four university trauma centres in southern Germany. Clinical (e.g. range of motion, Oxford knee score, Tegner score) and radiological (e.g. axis deviation, secondary loss of realignment) follow-ups were conducted one and six weeks, as well as three, six, and 12 months after the operation.

RESULTS

This study comprises data of 27 patients (8 male, 19 female; 15 NCB®-DF, 12 LISS®). Polyaxial osteosynthesis using the NCB® system tended to result in better functional knee scores and a higher range of motion. Interestingly, fracture union tended to be more rapid using the polyaxial plating system.

CONCLUSIONS

We present the analysis of a multicenter prospective RCT to compare the monoaxial LISS® vs. the polyaxial NCB®-DF treatment following complex fractures of the distal femur. NCB®-DF treatment tended to result in better functional and radiological outcomes than LISS® treatment.

LEVEL OF EVIDENCE

Level I.

Posterolateral and anterolateral approaches to unicondylar posterolateral tibial plateau fractures: a comparative study

BACKGROUND

Lateral tibial plateau fractures that are located posterolaterally are difficult to reduce through an anterolateral surgical approach because of the lack of direct visualisation of the fracture. This study compared the results of unicondylar posterolateral tibial plateau fractures in two patient cohorts: one treated through a posterolateral direct approach and the other through an anterolateral indirect approach.

PATIENTS AND METHODS

All nine patients admitted to our hospital, a tertiary care, urban, public hospital in Australia, from 2007 to 2010 with unicondylar posterolateral tibial plateau fractures were treated through a direct posterolateral transfibular approach and prospectively studied. All eight patients admitted from 2004 to 2007 with unicondylar posterolateral tibial plateau fractures were treated through an indirect anterolateral approach and retrospectively reviewed. Fracture reduction and maintenance of reduction were assessed radiographically over 2 years. Knee function was assessed clinically and using the Lysholm score.

RESULTS

Fractures managed through a direct posterolateral transfibular approach were reduced with no measurable articular step on standard radiography and had no loss of reduction over time. By contrast, fractures treated through an indirect anterolateral approach had a median postoperative articular step of 5.5mm (interquartile range=4.5). These displacements worsened over time in six of the eight patients. At 2 years, patients treated through a direct approach had significantly better Lysholm scores than those treated through an indirect approach.

CONCLUSION

This study suggests that a direct posterolateral transfibular approach to unicondylar posterolateral tibial plateau fractures results in improved reduction, stabilisation and functional outcomes at early follow-up compared to an indirect anterolateral approach.

Medium-term results after complex intra-articular fractures of the tibial plateau

BACKGROUND

To present the medium-term results of intra-articular, bicondylar AO/OTA classification type C fractures of the tibial plateau in a retrospective study at a level-1 trauma center in 22 patients with 23 fractures.

METHODS

Demographic data for the patients and details of current clinical and radiological follow-up findings were obtained to assess range of motion, clinical stability and alignment of the knee, and posttraumatic arthrosis (Kellgren/Lawrence score). Functional outcomes were assessed using the Lysholm score, Knee Injury and Osteoarthritis Outcome Score (KOOS), and International Knee Documentation Committee (IKDC) form.

RESULTS

Patients' mean age was 46 years (range 20-67 years). Leading causes of the fractures were high-energy traffic accidents and falls. There were seven C1, seven C2, and nine C3 fractures. ORIF was performed in 20 patients; in two patients an external fixator and in one patient cannulated screws alone were used. In 13/22 patients, an angle-stable locking plate (Less Invasive Stabilization System, LISS) was used for osteosynthesis. The mean follow-up period was 67 months (range 36-109 months). The overall complication rate was 39.1%, including four infections and four cases of pseudarthrosis (17.4%). The average flexion of the injured knee was significantly lower in comparison with the contralateral side (124.9° vs. 135.2°). Knee stability did not differ statistically significantly. Current radiographs revealed no signs of posttraumatic arthrosis in 30.4% of cases, mild signs in 34.8%, clear signs in 26.1%, and severe signs in 13% using the Kellgren and Lawrence scale. The average Lysholm score was 66.2 points, and the average KOOS score was 67.84. One patient was in category A, and 2 were in category B in the IKDC overall categories, whereas 5 patients were in category C and 14 were even in category D.

CONCLUSIONS

Complex articular tibial plateau fractures are associated with a high rate of complications, continue to have a severe impact on function in the injured knee, lead to early post-traumatic arthrosis, and result in long-lasting subjective symptoms for the patients.

The risk of injury to the anterior tibial artery in the posterolateral approach to the tibia plateau: a cadaver study

BACKGROUND

Posterolateral tibial plateau shear fractures often require buttress plating, which can be performed through a posterolateral approach. The purpose of this study was to provide accurate data about the inferior limit of dissection.

METHODS

Forty unpaired cadaver adult lower limbs were used. The anterior tibial artery was identified because it coursed through the interosseous membrane. The perpendicular distance from the lateral joint line and fibula head to this landmark was measured.

RESULTS

The anterior tibial artery coursed through the interosseous membrane at 46.3 ± 9.0 mm (range 27-62 mm) distal to the lateral tibial plateau and 35.7 ± 9.0 mm (range 17-50 mm) distal to the fibula head.

CONCLUSIONS

Displaced posterolateral tibial plateau fractures require anatomic reduction and stabilization with a buttress plate. This can be achieved by gaining access to the posterolateral tibial cortex. The distal limit of this dissection can be as little as 27 mm distal to the lateral tibial plateau. Dissection in this region should be carried out with caution.

Minimally invasive and open surgical treatment of proximal tibia fractures using a polyaxial locking plate system: a prospective multi-centre study

PURPOSE

The purpose of this study was to determine whether a polyaxial locking plate of the latest generation (NCB PT(®), Zimmer Inc.) which can be applied both open and minimally invasively, can be used as a routine method of treatment for proximal tibia fractures.

METHODS

Eighty-six patients (35 women, 51 men; mean age 51 years) were enrolled in this prospective multicentre trial. Ninety-six percent of the fractures were intra-articular (AO type B and C); 36 % were treated open and 64 % minimally invasively. Follow-up was obtained three, six and 12 months after surgery.

RESULTS

No implant failure occurred. At 12 months, the functional result using a knee-specific score was good to excellent in 95 %, and 99 % of the fractures were radiologically healed.

CONCLUSION

The system is a versatile implant for proximal tibia fracture treatment. Polyaxiality and a specific locking mechanism are compatible with different fracture patterns. The minimally invasive technique effectively protects soft tissues but should not be performed at the expense of fracture reduction. Early functional results and complication rate are comparable to those in the literature.

Arthroscopic-assisted removal of proximal tibia locking plates

We present a new technique to remove plates from the proximal tibia arthroscopic-assisted with all advantages of the minimally invasive surgery and the possibility to treat concomitant intraarticular pathologies. The initial results (n = 7) are promising with an increase of the Lysholm score in all cases studied [preop. median 78 (range 32–100), postop. median 89 (range 60–100)]. In conclusion, arthroscopic-assisted hardware removal at the proximal tibia is feasible and may provide patients with all the benefits of minimal-invasive hardware removal. The described technique can be recommended for all surgeons familiar with arthroscopic surgery.

Minimally invasive plate osteosynthesis for tibial plateau fractures

PURPOSE

To evaluate radiological and clinical outcome of minimally invasive plate osteosynthesis (MIPO) for tibial plateau fractures.

METHODS

35 men and 6 women aged 19 to 75 (mean, 40; standard deviation [SD], 14) years underwent MIPO for displaced tibial plateau fractures. According to the Schatzker system, the tibial plateau fractures were classified as types I (n=3), II (n=9), III (n=11), IV (n=6), V (n=7), and VI (n=5). Six patients had open fractures; 2 of them underwent debridement before MIPO. 10 patients needed additional bone grafting. Radiological (at immediate postoperation) and clinical (at the 12-month follow-up) assessments based on the Rasmussen anatomic and functional scoring system were recorded using a proforma. Patients with acceptable and unacceptable outcomes were compared in terms of age.

RESULTS

The mean Rasmussen anatomic score was 15.1 (SD, 2.2; range, 10-18); the mean Rasmussen functional score was 25.3 (SD, 3.2; range, 14-29); and the mean range of knee motion was 118 (SD, 10; range, 90-140) degrees. Anatomic outcome was excellent in 10, good in 28, and unacceptable in 3 patients (one each had Schatzker type-I, -II, and -III fractures). 27 (71%) of the 38 patients with acceptable anatomic outcome were aged 45 years or younger, whereas 2 (67%) of the 3 patients with unacceptable anatomic outcome were aged 60 years or older (p=0.001). Functional outcome was excellent in 18, good in 19, and unacceptable in 4 patients (2 had Schatzker type-III and another 2 had Schatzker type-I or -II fractures). 37 of the patients had a range of knee motion of 120 degrees or more; 27 (73%) of them were aged 45 years or younger, whereas 3 (75%) of the 4 patients with unacceptable functional outcome were aged 60 years or older (p=0.001).

CONCLUSION

MIPO for tibial plateau fractures achieved good outcome with minimal soft-tissue complications. Older age was the predictor of unacceptable outcome.

The management of complex fractures of the proximal tibia with minimal intra-articular impaction in fragility patients using intramedullary nailing and compression bolts

BACKGROUND

Intra-articular fractures of the proximal tibia that extend to the meta-diaphyseal part of the bone represent a severe injury, especially if they occur in osteoporotic patients. Current treatment modalities include either internal fixation with traditional or modern plating techniques or external fixation with circular frames or hybrid systems. However, problems and complications related with these techniques are increasing with age and future reconstructive operations, such as arthroplasty, may be jeopardised.

METHOD

This is a prospective pilot study about a novel type of osteosynthesis for complex intra-articular proximal tibial fractures without significant articular impaction in patients over 60 years of age. Within a period of 54 months, eight patients underwent fixation of such fractures with condylar compression bolts and intramedullary nailing.

RESULTS

The follow-up period was from 12 to 50 months (mean 24.7 months). There were no neurovascular complications, wound infections, delayed unions or nonunions. All patients had their fractures healed without secondary displacement or malalignment. At the final follow-up, all patients had full extension of the knee joint whilst the flexion ranged from 125 to 140°. The mean new Oxford Knee score was calculated to be 43.75 points.

CONCLUSIONS

The management of selected osteoporotic complex intra-articular fractures of the proximal tibia with compression bolts and intramedullary nailing offers specific advantages and, in the present pilot study, provided promising results. These results should be validated and confirmed with larger case series and comparison studies in the future.

High energy tibial plateau fractures treated with hybrid external fixation

Management of high energy intra-articular fractures of the proximal tibia, associated with marked soft-tissue trauma, can be challenging, requiring the combination of accurate reduction and minimal invasive techniques. The purpose of this study was to evaluate whether minimal intervention and hybrid external fixation of such fractures using the Orthofix system provide an acceptable treatment outcome with less complications. Between 2002 and 2006, 33 patients with a median ISS of 14.3 were admitted to our hospital, a level I trauma centre, with a bicondylar tibial plateau fracture. Five of them sustained an open fracture. All patients were treated with a hybrid external fixator. In 19 of them, minimal open reduction and stabilization, by means of cannulated screws, was performed. Mean follow-up was 27 months (range 24 to 36 months). Radiographic evidence of union was observed at 3.4 months (range 3 to 7 months). Time for union was different in patients with closed and grade I open fractures compared to patients with grade II and III open fractures. One non-union (septic) was observed (3.0%), requiring revision surgery. Pin track infection was observed in 3 patients (9.1%).

Compared to previously reported series of conventional open reduction and internal fixation, hybrid external fixation with or without open reduction and minimal internal fixation with the Orthofix system, was associated with satisfactory clinical and radiographic results and limited complications.

Tibial plateau fractures: internal fixation with locking plates and the MIPO technique

Proximal tibial fractures are difficult lesions to treat because of the involvement of the articular surface, the often occurring comminution, and the precarious condition of the soft tissues, especially following high-energy trauma. Aim of the treatment is to restore the congruence of the articular surface supporting the tibial plateau cartilage which is usually depressed; to fix the fracture with a stable device; to allow early rehabilitation. We present our treatment strategy, utilising closed or open reduction and internal fixation, angle-stable polyaxial plates, immediate osteointegration, when necessary, with autologous bone graft or other osteoconductive material augmented with autologous platelet gel. Surgery is soft-tissue dependent in terms of timing, and it is usually performed directly or under supervision of an experienced surgeon utilising, whenever possible, a tissue sparing technique. A cohort of 58 proximal tibial fractures, surgically treated, from January 2004 to June 2007, was retrospectively reviewed. Fractures were classified according the OTA/AO classification. The assessment of the functional outcome with the use of the Rasmussen score identified good to excellent results in 78% of the cohort 12 months post-surgery. Internal fixation with locking plates, following the principles of MIPO (Minimally Invasive Percutaneous Osteosynthesis), provides satisfactory fracture reduction with good results regarding the mid-term clinical outcome.

A new posterolateral approach without fibula osteotomy for the treatment of tibial plateau fractures

The selection of a surgical approach for the treatment of tibia plateau fractures is an important decision. Approximately 7% of all tibia plateau fractures affect the posterolateral corner. Displaced posterolateral tibia plateau fractures require anatomic articular reduction and buttress plate fixation on the posterior aspect. These aims are difficult to reach through a lateral or anterolateral approach. The standard posterolateral approach with fibula osteotomy and release of the posterolateral corner is a traumatic procedure, which includes the risk of fragment denudation. Isolated posterior approaches do not allow sufficient visual control of fracture reduction, especially if the fracture is complex. Therefore, the aim of this work was to present a surgical approach for posterolateral tibial plateau fractures that both protects the soft tissue and allows for good visual control of fracture reduction. The approach involves a lateral arthrotomy for visualizing the joint surface and a posterolateral approach for the fracture reduction and plate fixation, which are both achieved through one posterolateral skin incision. Using this approach, we achieved reduction of the articular surface and stable fixation in six of seven patients at the final follow-up visit. No complications and no loss of reduction were observed. Additionally, the new posterolateral approach permits direct visual exposure and facilitates the application of a buttress plate. Our approach does not require fibular osteotomy, and fragments of the posterolateral corner do not have to be detached from the soft tissue network.

Open reduction and fixation of medial Moore type II fractures of the tibial plateau by a direct dorsal approach

INTRODUCTION

Moore type II Entire Condyle fractures of the tibia plateau represent a rare and highly unstable fracture pattern that usually results from high impact traumas. Specific recommendations regarding the surgical treatment of these fractures are sparse. We present a series of Moore type II fractures treated by open reduction and internal fixation through a direct dorsal approach.

PATIENTS AND METHODS

Five patients (3 females, 2 males) with Entire Condyle fractures were retrospectively analyzed after a mean follow-up period of 39 months (range 12-61 months). Patient mean age at the time of operation was 36 years (range 26-43 years). Follow-up included clinical and radiological examination. Furthermore, all patient finished a SF36 and Lysholm knee score questionnaire.

RESULTS

Average range of motion was 127/0/1 degrees with all patients reaching full extension at the time of last follow up. Patients reached a mean Lysholm score of 81.2 points (range 61-100 points) and an average SF36 of 82.36 points (range 53.75-98.88 points). One patient sustained deep wound infection after elective implant removal 1 year after the initial surgery. Overall all patients were highly satisfied with the postoperative result.

CONCLUSION

The direct dorsal approach to the tibial plateau represents an adequate method to enable direct fracture exposure, open reduction, and internal fixation in posterior shearing medial Entire Condyle fractures and is especially valuable when also the dorso-lateral plateau is depressed.