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Krause M, Korthaus A, Frings J, Berninger MT, Drenck TC, Eggeling L, Akoto R, Frosch KH. Letter to the editor of: "posterior tibial plateau impaction fractures are not associated with increased knee instability: a quantitative pivot shift analysis". Knee Surg Sports Traumatol Arthrosc 2023:10.1007/s00167-023-07361-8. [PMID: 36947235 PMCID: PMC10356670 DOI: 10.1007/s00167-023-07361-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 02/21/2023] [Indexed: 03/23/2023]
Affiliation(s)
- M Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany.
| | - A Korthaus
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - J Frings
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - M T Berninger
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - T C Drenck
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
| | - L Eggeling
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
| | - R Akoto
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
| | - K H Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
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Krause M, Frosch KH. [Change in the treatment of tibial plateau fractures]. Unfallchirurg 2022; 125:527-534. [PMID: 35380266 DOI: 10.1007/s00113-022-01165-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The treatment of tibial plateau fractures has experienced a number of very different conceptual developments in recent years, not only with respect to technical innovations but also against the background of changing fracture patterns and the growing requirements of patients. OBJECTIVE What developments in recent years have had a significant impact on current treatment strategies for tibial plateau fractures? METHODS Narrative review of publications listed in PubMed on the topic of treatment of complex tibial plateau fractures. RESULTS While the two-dimensional classifications are becoming less important, computed tomography (CT)-based three-dimensional assessment of fracture progression and an access strategy based on it are coming to the fore. Direct dorsal approaches have been shown to be superior, particularly in the case of relevant posteromedial and/or posterolateral fracture involvement. The step-by-step approach extension via specific osteotomies of ligamentous attachments also enables a needs-dependent and fracture-dependent complete joint visualization and reduction control. In the treatment of geriatric tibial plateau fractures, primary treatment with endoprostheses is becoming increasingly more important to enable early mobilization under full load bearing with significantly shorter rehabilitation times. CONCLUSION Modern developments in the context of fracture treatment around the tibial plateau have led to a relevant reduction of infections and improved surgical outcomes; however, the high demands and the improved understanding of fractures still underline the great challenge in the treatment of complex fracture patterns.
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Affiliation(s)
- Matthias Krause
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | - Karl-Heinz Frosch
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.,Abteilung für Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Hamburg, Hamburg, Deutschland
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Guttowski D, Krause M, Püschel K, Kolb JP, Hartel M, Frosch KH. Improved Visualization by Central Subluxation of the Lateral Meniscus in Comminuted Lateral Tibial Plateau Fractures. J Knee Surg 2021; 34:1408-1412. [PMID: 32413932 DOI: 10.1055/s-0040-1709518] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The goal of surgical reconstruction of comminuted tibial plateau fractures is an anatomical reconstruction and stable fixation of the articular surface. This can be difficult due to poor visualization of the posterolateral and central segments of the articular surface of the proximal tibia. To improve visualization, the lateral approach can be extended with an osteotomy of the femoral epicondyle. In most cases, use of the extended lateral approach allows the whole lateral plateau to be visualized. Nevertheless, in some cases, an osteotomy alone is not enough to expose the entire fracture, especially the central segments of the tibial plateau. For these specific cases, we developed an additional technical trick that significantly improves articular visualization; the lateral meniscocapsular fibers are dissected allowing for central subluxation of the lateral meniscus, while leaving the anterior and posterior roots intact. With central subluxation of the lateral meniscus in comminuted tibial plateau fractures, the joint surface can be completely visualized, allowing an anatomical reduction even in highly complex fractures.
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Affiliation(s)
- Dario Guttowski
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Krause
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Klaus Püschel
- Department of Forensic Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Philipp Kolb
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian Hartel
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Frosch KH, Korthaus A, Thiesen D, Frings J, Krause M. The concept of direct approach to lateral tibial plateau fractures and stepwise extension as needed. Eur J Trauma Emerg Surg 2020; 46:1211-1219. [PMID: 32607776 PMCID: PMC7691307 DOI: 10.1007/s00068-020-01422-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/15/2020] [Indexed: 10/31/2022]
Abstract
Malreduction after tibial plateau fractures mainly occurs due to insufficient visualization of the articular surface. In 85% of all C-type fractures an involvement of the posterolateral-central segment is observed, which is the main region of malreduction. The choice of the approach is determined (1) by the articular area which needs to be visualized and (2) the positioning of the fixation material. For simple lateral plateau fractures without involvement of the posterolateral-central segment an anterolateral standard approach in supine position with a lateral plating is the treatment of choice in most cases. For complex fractures the surgeon has to consider, that the articular surface of the lateral plateau only can be completely visualized by extended approaches in supine, lateral and prone position. Anterolateral and lateral plating can also be performed in supine, lateral and prone position. A direct fixation of the posterolateral-central segment by a plate or a screw from posterior can be only achieved in prone or lateral position, not supine. The posterolateral approach includes the use of two windows for direct visualization of the fracture. If visualization is insufficient the approach can be extended by lateral epicondylar osteotomy which allows exposure of at least 83% of the lateral articular surface. Additional central subluxation of the lateral meniscus allows to expose almost 100% of the articular surface. The concept of stepwise extension of the approach is helpful and should be individually performed as needed to achieve anatomic reduction and stable fixation of tibial plateau fractures.
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Affiliation(s)
- Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Alexander Korthaus
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Darius Thiesen
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jannik Frings
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Krause M, Alm L, Berninger M, Domnick C, Fehske K, Frosch KH, Herbst E, Korthaus A, Raschke M, Hoffmann R. Bone metabolism is a key factor for clinical outcome of tibial plateau fractures. Eur J Trauma Emerg Surg 2020; 46:1227-1237. [PMID: 33151357 PMCID: PMC7691299 DOI: 10.1007/s00068-020-01537-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 10/28/2020] [Indexed: 11/10/2022]
Abstract
Purpose Given that tibial plateau fractures (TPF) are rare, they may pose a challenge to the treating surgeon due to their variety of complex fracture patterns. Numerous studies have identified potential fracture-specific, surgery-related, and patient-related risk factors for impaired patient outcomes. However, reports on the influence of bone metabolism on functional outcomes are missing. Methods In a retrospective multicenter cohort study, 122 TPF of 121 patients were analyzed with respect to radiological and clinical outcomes (Rasmussen) with a mean follow-up of 35.7 ± 24.9 months. The risk factor assessment included bone metabolism-affecting comorbidities and medication.
Results The findings showed that 95.9% of the patients reported a good-to-excellent clinical outcome, and 97.4% reported a good-to-excellent radiological outcome. Logistic regression revealed that potentially impaired bone metabolism (IBM) was an independent risk factor for the clinical (p = 0.016) but not the radiological outcome (Table 4). Patients with 41-type B fractures and a potential IBM had a seven times higher risk to present a fair-to-poor clinical outcome [OR 7.45, 95 CI (4.30, 12.92)]. The most common objective impairment was a limited range of motion in 16.4% of the patients, especially in 41-type C fractures (p = 0.06). The individual failure analysis additionally identified surgery-related options for improvement. Conclusion This study demonstrated that potential IBM was an independent risk factor for a poor-to-fair clinical outcome.
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Affiliation(s)
- Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martini Str. 52, 20246, Hamburg, Germany.
| | - Lena Alm
- BG Trauma Hospital Hamburg, Hamburg, Germany
| | - Markus Berninger
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martini Str. 52, 20246, Hamburg, Germany
| | - Christoph Domnick
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Kai Fehske
- Department of Orthopaedic Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martini Str. 52, 20246, Hamburg, Germany
| | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Alexander Korthaus
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martini Str. 52, 20246, Hamburg, Germany
| | - Michael Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Reinhard Hoffmann
- Department of Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt Am Main, Frankfurt am Main, Germany
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Krause M, Frings J, Isik H, Frosch KH. Comparison of extended lateral approaches to the tibial plateau: The articular exposure of lateral epicondyle osteotomy with and without popliteus tendon vs. fibula osteotomy. Injury 2020; 51:1874-1878. [PMID: 32482428 DOI: 10.1016/j.injury.2020.05.038] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 03/06/2020] [Accepted: 05/07/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Comminuted lateral tibial plateau fractures pose a challenge to surgeons, with non-anatomical reductions in 70-89%, involving the posterolateral articular surface. The purpose of this study was to examine the posterolateral joint visibility, using lateral extended approaches, such as the lateral femoral epicondyle osteotomy or the fibula osteotomy. Further, the study aimed to compare the combined osteotomy of the femoral footprints of the lateral collateral ligament (LCL) and popliteus tendon (PLT) to the isolated osteotomy of the femoral LCL footprint or the fibula osteotomy, in terms of posterolateral joint accessibility. METHODS Extended lateral (femoral or fibular LCL osteotomy) and posterolateral (additional femoral osteotomy of the PLT tendon) approaches were performed on twelve human cadaver knees. After preparation of each surgical approach, the visible articular surface was marked with diathermy. The tibial plateau was disarticulated and the markings were measured digitally with open-source processing software. Differences in mean values were tested with a paired t-test (p ≤ 0.05). RESULTS The greatest articular exposure was achieved with the fibula osteotomy (1011.52 ± 227.05 mm2 [86.64 ± 4.84%] compared to the combined osteotomy of LCL and PLT (p = 0.036) or LCL alone (p<0.001). The lateral femoral epicondyle osteotomy of the LCL including the PLT (937.45 ± 237.84 mm2 [80.29 ± 8.25%]) exposed a significantly larger articular surface of the lateral tibial plateau than without the PLT (755.71 ± 183.06 mm2 [64.73 ± 6.51%], p < 0.001). CONCLUSION In direct comparison, the fibula osteotomy provides the largest articular visualization, however at cost of a considerably larger soft tissue damage. While the lateral femoral epicondyle osteotomy of LCL and PLT increases lateral articular visualization, it omits the risk of neurovascular or posterolateral soft tissue damage and therefore represents an important extended approach to treat comminuted lateral plateau fractures.
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Affiliation(s)
- Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.
| | - Jannik Frings
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.
| | - Hüseyin Isik
- Department of Trauma and Reconstructive Surgery, Asklepios Clinic St. Georg, Hamburg, Germany.
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.
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Alm L, Frings J, Krause M, Frosch KH. Intraarticular osteotomy of malunited tibial plateau fractures: an analysis of clinical results with a mean follow-up after 4 years. Eur J Trauma Emerg Surg 2020; 46:1203-1209. [PMID: 32712774 PMCID: PMC7691306 DOI: 10.1007/s00068-020-01440-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/13/2020] [Indexed: 11/25/2022]
Abstract
Purpose Malunions are a common complication after tibial plateau fractures (TPF), leading to stiffness, pseudo-instability and posttraumatic osteoarthritis. The purpose of this study was to analyse the clinical outcome after intraarticular osteotomy of malunited TPF and to perform a failure analysis. Methods Between 2013 and 2018, 23 patients (11 males, 12 females; 43.8 ± 12.8 years) with intraarticular osteotomy after malunited TPF were included in the retrospective study. Clinical examination and postoperative scores were collected with a minimum follow-up of 24 months. Malunion was measured on pre- and postoperative CT scans and localized according to the 10-segment classification while the leg axis in the frontal plane was measured pre- and postoperatively on long leg standing radiographs. Results Excellent and good clinical outcome was achieved in 73.9% (n = 17) of the cases and patient related outcome improved significantly (Tegner 3.3 ± 1.6–5 ± 1.8, p < 0.001; clinical Rasmussen 14.6 ± 3.8–24.9 ± 4.4, p < 0.001). Radiological parameters also improved as an intraarticular step-off was reduced from 9 ± 3.8 to 0.6 ± 0.8 mm (p < 0.001) and a lower limb malalignment from 7.2 ± 4.8° to 1.5 ± 1.9° (p = 0.003). Failure analysis showed that an impaired clinical result correlated with a postoperative extension (n = 3, p < 0.001) and flexion deficit (n = 4, p = 0.035). Conclusion Intraarticular osteotomy of malunited TPF lead to good clinical results with significant clinical and radiological improvement in most cases while an impaired patient outcome correlated with a limited range of motion. This study is the first failure analysis of intraarticular osteotomy after malunited TPF published up to now.
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Affiliation(s)
- Lena Alm
- Department of Trauma and Orthopaedic Surgery, Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
| | - Jannik Frings
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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