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Kraml N, Haslhofer DJ, Winkler PW, Stiftinger JM, Heidecke S, Kwasny O, Gotterbarm T, Klasan A. Tibial plateau fractures are associated with poor functional outcomes and a low conversion rate to total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2024; 32:1308-1316. [PMID: 38504506 DOI: 10.1002/ksa.12153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/21/2024] [Accepted: 03/05/2024] [Indexed: 03/21/2024]
Abstract
PURPOSE The aim of this study was to analyse the functional outcome and the conversion rate to total knee arthroplasty (TKA) after surgically treated tibial plateau fractures (TPF). METHODS All patients undergoing surgical treatment of TPF at a single institution between January 2003 and December 2019 were retrospectively reviewed. The Knee injury and Osteoarthritis Outcome Score (KOOS) and Tegner activity scale (TAS) were collected. The conversion rate to TKA was examined 2, 5, 7 and 10 years after surgical treatment of TPF. RESULTS Ninety-four patients, with a mean follow-up of 110.6 months (±60.0), were included in the functional outcome assessment. Mean KOOS scores were 75.4 for symptoms, 80.6 for pain, 84.3 for activities of daily living (ADL), 59.5 for sports and 61.3 for QOL. All subscales were significantly lower on the injured side compared with the contralateral leg. Lower KOOS was observed in patients with hardware removal and Schatzker type 5 and 6 injuries. Median TAS was postinjury (4) significantly lower than preinjury (5) (p < 0.001). The conversion rate to TKA was 6.3%, 10.9%, 11.7% and 12.2% after 2,5,7 and 10 years of follow-up, respectively. Patients undergoing TKA were older than patients with no conversion to TKA (2 years follow-up 53.8 vs. 64.5 years, p = 0.026). CONCLUSION TPFs decrease the function of the knee when compared with the contralateral side and to the preoperative condition. Bicondylar fractures are associated with worse functional outcomes. A conversion rate to TKA of 12.2% was found at 10 years follow-up. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Nikolaus Kraml
- Department for Orthopaedics and Traumatology, Kepler University Hospital GmbH, Johannes Kepler University Linz, Linz, Austria
| | - David J Haslhofer
- Department for Orthopaedics and Traumatology, Kepler University Hospital GmbH, Johannes Kepler University Linz, Linz, Austria
| | - Philipp W Winkler
- Department for Orthopaedics and Traumatology, Kepler University Hospital GmbH, Johannes Kepler University Linz, Linz, Austria
| | - Julian M Stiftinger
- Department for Orthopaedics and Traumatology, Kepler University Hospital GmbH, Johannes Kepler University Linz, Linz, Austria
| | - Svenja Heidecke
- Department for Orthopaedics and Traumatology, Kepler University Hospital GmbH, Johannes Kepler University Linz, Linz, Austria
| | - Oskar Kwasny
- Department for Orthopaedics and Traumatology, Kepler University Hospital GmbH, Johannes Kepler University Linz, Linz, Austria
| | - Tobias Gotterbarm
- Department for Orthopaedics and Traumatology, Kepler University Hospital GmbH, Johannes Kepler University Linz, Linz, Austria
| | - Antonio Klasan
- Department for Orthopedics and Traumatology, AUVA Graz, Graz, Austria
- Faculty of Medicine, Johannes Kepler University Linz, Linz, Austria
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Mesa L, Lufrano RC, Sajid MI, Flanagan C, Grewal IS, Bates P, Mir HR. Acute versus staged fixation of bicondylar tibial plateau fractures: a dual centre international study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1683-1690. [PMID: 38409547 DOI: 10.1007/s00590-023-03815-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 12/15/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Bicondylar tibial plateau fractures pose many treatment challenges due to their complex fracture patterns and associated soft tissue compromise. We aim to evaluate outcomes of acute ORIF (aORIF) versus staged ORIF (sORIF) of high energy bicondylar tibial plateau fractures. METHODS We retrospectively reviewed 186 patients at two high-volume Level I trauma centers. One hundred one patients underwent aORIF and 85 underwent sORIF between 2011 and 2019. Clinical outcomes of interest included operative time, wound dehiscence, superficial and deep infection, nonunion, flap coverage, arthrodesis, and early conversion to arthroplasty. RESULTS Patients had a median follow up of 12 months (6-98 months). The sORIF group had a higher ISS (p = 0.02) and a higher rate of open fractures (24.7% vs 11.9%, p = 0.03). The groups were statistically similar in other demographics and co-morbidities. Operative time was significantly shorter in the aORIF group (157 vs 213 min., p < 0.001). There was no statistical difference in wound dehiscence, deep infection, flap coverage, nonunion, unplanned reoperation, or post-traumatic arthritis between groups. However, aORIF was associated with a significantly lower rate of superficial infection (p = 0.01), arthroplasty (p = 0.003) and unplanned reoperation (p = 0.005). Subgroup analysis of only the 41C3 fractures showed a lower rate of superficial infections in the aORIF group (p = 0.04). No difference in complications was found between the fracture subgroups. CONCLUSION We found no increased risk of complications with aORIF compared to sORIF for bicondylar tibial plateau fractures. While not all injuries may be appropriate for aORIF, our results demonstrate the safety of aORIF when patients are properly selected by experienced fracture surgeons. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Lazaro Mesa
- Department of Orthopaedic Surgery, University of South Florida, Tampa, USA
| | - Reuben C Lufrano
- Orthopaedic Trauma Service, Florida Orthopaedic Institute, 5- Tampa General Circle, Tampa, FL, 33606, USA
| | - Mir Ibrahim Sajid
- Orthopaedic Trauma Service, Florida Orthopaedic Institute, 5- Tampa General Circle, Tampa, FL, 33606, USA
| | - Christopher Flanagan
- Department of Orthopaedic Surgery, University of South Florida, Tampa, USA
- Orthopaedic Trauma Service, Florida Orthopaedic Institute, 5- Tampa General Circle, Tampa, FL, 33606, USA
| | - Ishvinder S Grewal
- Orthopaedic Trauma Service, Florida Orthopaedic Institute, 5- Tampa General Circle, Tampa, FL, 33606, USA
| | | | - Hassan R Mir
- Department of Orthopaedic Surgery, University of South Florida, Tampa, USA.
- Orthopaedic Trauma Service, Florida Orthopaedic Institute, 5- Tampa General Circle, Tampa, FL, 33606, USA.
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Makaram NS, Param A, Clement ND, Scott CEH. Primary Versus Secondary Total Knee Arthroplasty for Tibial Plateau Fractures in Patients Aged 55 or Over-A Systematic Review and Meta-Analysis. J Arthroplasty 2024; 39:559-567. [PMID: 37572727 DOI: 10.1016/j.arth.2023.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 08/01/2023] [Accepted: 08/03/2023] [Indexed: 08/14/2023] Open
Abstract
BACKGROUND Total knee arthroplasty allows immediate postoperative weight-bearing and is increasingly recognized as a suitable treatment option for older patients who have tibial plateau fractures (TPFs). This systematic review evaluated the clinical and functional outcomes associated with primary versus secondary TKA for the treatment of TPFs in patients aged ≥55 years. METHODS Various databases were searched from inception to December 2021. Studies investigating outcomes of primary TKA (pTKA) as the initial treatment for TPFs in patients of mean age ≥55 years or those investigating outcomes of secondary TKA (sTKA) following any other primary treatment for TPFs were included. Quality of included studies was assessed using a methodological scale. Of 767 potentially relevant studies, 12 studies comprising 341 patients were included: 121 patients underwent (pTKA) and 220 patients underwent sTKA. There were 3 high-quality studies. Patients in the sTKA cohort were significantly younger at the time of TKA compared with those undergoing pTKA (mean 61.3 versus 72.2 years, P < .001, 95% confidence interval (CI) 8.2 to 13.6). RESULTS Intraoperative and postoperative complication rates were lower with pTKA; in particular, sTKA was associated with a significantly increased rate of stiffness requiring reintervention and patella tendon rupture. Functional outcome was greater after pTKA, but this did not reach statistical significance (85.2 versus 79.9%, P = .359, 95% CI -16.7 to 6.1). CONCLUSION Primary TKA was associated with lower complication rates than secondary TKA after TPF. In appropriate cases of TPF in older adults, it may be preferable to proceed with TKA as primary treatment rather than delaying until after fracture union or malunion.
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Affiliation(s)
- Navnit S Makaram
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; The University of Edinburgh, Edinburgh, United Kingdom
| | - Aava Param
- The University of Edinburgh, Edinburgh, United Kingdom
| | - Nicholas D Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Chloe E H Scott
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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Haslhofer DJ, Kraml N, Winkler PW, Gotterbarm T, Klasan A. Risk for total knee arthroplasty after tibial plateau fractures: a systematic review. Knee Surg Sports Traumatol Arthrosc 2023; 31:5145-5153. [PMID: 37792085 PMCID: PMC10598098 DOI: 10.1007/s00167-023-07585-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 09/07/2023] [Indexed: 10/05/2023]
Abstract
PURPOSE Tibial plateau fractures (TPFs) may lead to posttraumatic osteoarthritis and increase the risk for total knee arthroplasty (TKA). The aim of this systematic review was to analyse the conversion rate to TKA after TPF treatment. METHODS A systematic search for studies reviewing the conversion rate to TKA after TPF treatment was conducted. The studies were screened and assessed by two independent observers. The conversion rate was analysed overall and for selected subgroups, including different follow-up times, treatment methods, and study sizes. RESULTS A total of forty-two eligible studies including 52,577 patients were included in this systematic review. The overall conversion rate of treated TPF to TKA in all studies was 5.1%. Thirty-eight of the forty-two included studies indicated a conversion rate under 10%. Four studies reported a higher percentage, namely, 10.8%, 10.9%, 15.5%, and 21.9%. Risk factors for TKA following TPF treatment were female sex, age, and low surgeon and hospital volume. The conversion rate to TKA is particularly high in the first 5 years after fracture. CONCLUSION Based on the studies, it can be assumed that the conversion rate to TKA is approximately 5%. The risk for TKA is manageable in clinical practice. PROSPERO REGISTRATION NUMBER CRD42023385311. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- D J Haslhofer
- Department for Orthopedics and Traumatology, Med Campus III, Kepler University Hospital Linz, Krankenhausstrasse 9, 4020, Linz, Austria
- Faculty of Medicine, Johannes Kepler University Linz, Altenbergerstrasse 69, 4040, Linz, Austria
| | - N Kraml
- Department for Orthopedics and Traumatology, Med Campus III, Kepler University Hospital Linz, Krankenhausstrasse 9, 4020, Linz, Austria.
- Faculty of Medicine, Johannes Kepler University Linz, Altenbergerstrasse 69, 4040, Linz, Austria.
| | - P W Winkler
- Department for Orthopedics and Traumatology, Med Campus III, Kepler University Hospital Linz, Krankenhausstrasse 9, 4020, Linz, Austria
- Faculty of Medicine, Johannes Kepler University Linz, Altenbergerstrasse 69, 4040, Linz, Austria
| | - T Gotterbarm
- Department for Orthopedics and Traumatology, Med Campus III, Kepler University Hospital Linz, Krankenhausstrasse 9, 4020, Linz, Austria
- Faculty of Medicine, Johannes Kepler University Linz, Altenbergerstrasse 69, 4040, Linz, Austria
| | - A Klasan
- Faculty of Medicine, Johannes Kepler University Linz, Altenbergerstrasse 69, 4040, Linz, Austria
- Department for Orthopedics and Traumatology, AUVA Graz, Göstinger Straße 24, 8020, Graz, Austria
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Piccirilli E, Cariati I, Primavera M, Triolo R, Gasbarra E, Tarantino U. Augmentation in fragility fractures, bone of contention: a systematic review. BMC Musculoskelet Disord 2022; 23:1046. [PMID: 36457070 PMCID: PMC9717408 DOI: 10.1186/s12891-022-06022-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 11/24/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Osteoporosis is a complex multifactorial disease characterized by reduced bone mass and microarchitectural deterioration of bone tissue linked to an increase of fracture risk. Fragility fractures occur in osteoporotic subjects due to low-energy trauma. Osteoporotic patients are a challenge regarding the correct surgical planning, as it can include fixation augmentation techniques to reach a more stable anchorage of the implant, possibly lowering re-intervention rate and in-hospital stay. METHODS The PubMed database and the Google Scholar search engine were used to identify articles on all augmentation techniques and their association with fragility fractures until January 2022. In total, we selected 40 articles that included studies focusing on humerus, hip, spine, and tibia. RESULTS Literature review showed a quantity of materials that can be used for reconstruction of bone defects in fragility fractures in different anatomic locations, with good results over the stability and strength of the implant anchorage, when compared to non-augmented fractures. CONCLUSION Nowadays there are no recommendations and no consensus about the use of augmentation techniques in osteoporotic fractures. Our literature review points at implementing the use of bone augmentation techniques with a specific indication for elderly patients with comminuted fractures and poor bone quality.
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Affiliation(s)
- Eleonora Piccirilli
- grid.413009.fDepartment of Orthopaedics and Traumatology, “Policlinico Tor Vergata” Foundation, Viale Oxford 81, 00133 Rome, Italy ,grid.6530.00000 0001 2300 0941Department of Clinical Sciences and Translational Medicine, “Tor Vergata” University of Rome, Via Montpellier 1, 00133 Rome, Italy
| | - Ida Cariati
- grid.6530.00000 0001 2300 0941Department of Clinical Sciences and Translational Medicine, “Tor Vergata” University of Rome, Via Montpellier 1, 00133 Rome, Italy
| | - Matteo Primavera
- grid.413009.fDepartment of Orthopaedics and Traumatology, “Policlinico Tor Vergata” Foundation, Viale Oxford 81, 00133 Rome, Italy
| | - Rebecca Triolo
- grid.413009.fDepartment of Orthopaedics and Traumatology, “Policlinico Tor Vergata” Foundation, Viale Oxford 81, 00133 Rome, Italy
| | - Elena Gasbarra
- grid.413009.fDepartment of Orthopaedics and Traumatology, “Policlinico Tor Vergata” Foundation, Viale Oxford 81, 00133 Rome, Italy
| | - Umberto Tarantino
- grid.413009.fDepartment of Orthopaedics and Traumatology, “Policlinico Tor Vergata” Foundation, Viale Oxford 81, 00133 Rome, Italy ,grid.6530.00000 0001 2300 0941Department of Clinical Sciences and Translational Medicine, “Tor Vergata” University of Rome, Via Montpellier 1, 00133 Rome, Italy
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García Vélez DA, Headford M, Suresh KV, Liberatos PM, Bledsoe G, Revak T. Biomechanical analysis of dual versus lateral locked plating in elderly bicondylar tibial plateau fractures: Does medial comminution matter? Injury 2022; 53:3109-3114. [PMID: 36028376 DOI: 10.1016/j.injury.2022.08.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 07/29/2022] [Accepted: 08/16/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess dual plating versus lateral locked plate fixation of bicondylar tibial plateau fractures in an elderly cadaveric model with and without medial bone loss PARTICIPANTS: 10 pairs of elderly (range 78-93 years of age) fresh frozen tibias. INTERVENTION Bicondylar tibial plateau fractures were created reproducing AO/OTA 41 C1 (without medial bone loss) and C2 fractures (with medial bone loss). Cadavers were randomized to 4 different groups. Groups 1 and 2 were 41 C1 fractures and fixated with either dual or lateral plating, respectively. Groups 3 and 4 were fixated in a similar fashion with medial metaphyseal bone loss (41 C2 fracture) with dual plating Group 3 and lateral plating group 4. Lateral plating consisted of a 3.5 mm 5-hole lateral plate (ALPS, ZimmerBiomet) with 6 bicortical locking screws proximally and two diaphyseal screws. Dual plating groups underwent lateral plating and additional 3.5 mm 5-hole posteromedial 1/3 tubular plate (ZimmerBiomet) placed at the apex of the fracture with two shaft screws and one unicortical screw proximally. Specimens were tested in a Mechanical Testing System (MTS) machine loading both condyles. OUTCOME MEASUREMENTS Specimens were loaded to 300 N and coronal alignment obtained. Specimens were then cycled from 100 N to 700 N for 5000 cycles at 2 Hz. Average axial displacement, maximal displacement, average force and coronal alignment after 5000 cycles were recorded. Lastly, force to failure was recorded at 100 N/sec. RESULTS Mean axial displacement was 4.21 mm ranging from 3.12 mm in group 1 to 5.92 mm in group 4 (P = 0.51). Failure force averaged 3340 N ranging from 4342 N in group 1 to 2433 N in group 4 (P = 0.36). Maximal displacement ranged from 3.69 mm in group 1 to 7.37 mm in group 4 (P = 0.21). Change in coronal alignment ranged from 0.98° in group 1 to 1.97° in group 4 (P = 0.45). No statistically significant difference was noted between all four groups for all data points. CONCLUSION The results of this study demonstrate that a lateral locked plate may offer an alternative means of fixation in AO/OTA 41 C1 and C2 fractures.
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Affiliation(s)
| | | | | | | | - Gary Bledsoe
- Department of Biomechanical Engineering, United States
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Donovan RL, Smith JRA, Yeomans D, Bennett F, Smallbones M, White P, Chesser TJS. Epidemiology and outcomes of tibial plateau fractures in adults aged 60 and over treated in the United Kingdom. Injury 2022; 53:2219-2225. [PMID: 35367077 DOI: 10.1016/j.injury.2022.03.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 02/20/2022] [Accepted: 03/22/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Tibial plateau fractures are common in older adults, often resulting from low-energy falls. Although lower limb fragility fracture care has evolved, the management of tibial plateau fractures in older patients remains poorly researched. This study aimed to define the epidemiology, treatment and outcomes of tibial plateau fractures in patients aged over 60 years. METHODOLOGY Patients aged 60 years or older with a tibial plateau fracture who presented to a single trauma center between January 2008 and December 2018 were identified. Incomplete records were excluded. Epidemiological data, fracture classification, injury management, radiological outcomes, complications, and mortality were assessed via retrospective case note and radiograph review. Local ethics approval was obtained. RESULTS Two-hundred and twenty patients with a mean age of 74 years (range 60-100) were included. 73% were female and 71% of injuries were sustained following low-energy falls. Median follow up was three months. 50% of fractures involved the lateral plateau. 60% of injuries were treated non-operatively. 76% of patients had their weight-bearing restricted for the first six weeks, with little difference between operatively and non-operatively managed patients. 8% of all patients required subsequent knee replacement. All-cause mortality at 30-days and one-year were 2% and 5% respectively. CONCLUSION The majority of tibial plateau fractures in the over 60s are sustained from low-energy trauma. Management is relatively conservative when compared with younger cohorts. The data reported brings up questions of whether surgical treatment is beneficial to this patient group, or whether restricted weight bearing is either possible or beneficial. Prospective, multi-center comparative trials are needed to determine whether increased operative intervention or different rehabilitation strategies purveys any patient benefit.
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Affiliation(s)
- Richard L Donovan
- Musculoskeletal Research Unit, Level 1 Learning and Research Building, Southmead Hospital, University of Bristol, Bristol BS10 5NB, United Kingdom; North Bristol NHS Trust, Southmead Road, Bristol BS10 5NB, United Kingdom.
| | - James R A Smith
- North Bristol NHS Trust, Southmead Road, Bristol BS10 5NB, United Kingdom
| | - Daniel Yeomans
- North Bristol NHS Trust, Southmead Road, Bristol BS10 5NB, United Kingdom
| | - Fenella Bennett
- North Bristol NHS Trust, Southmead Road, Bristol BS10 5NB, United Kingdom
| | - Matthew Smallbones
- North Bristol NHS Trust, Southmead Road, Bristol BS10 5NB, United Kingdom
| | - Paul White
- University of the West of England, Coldharbour Lane, Bristol BS16 1QY, United Kingdom
| | - Tim J S Chesser
- North Bristol NHS Trust, Southmead Road, Bristol BS10 5NB, United Kingdom
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Tuncez M, Akan I, Seyfettinoğlu F, Çetin Tunçez H, Dirim Mete B, Kazımoğlu C. Is It Necessary To Add Soft Tissue Injury to the Classification in Tibial Plateau Fracture Management? Cureus 2022; 14:e22236. [PMID: 35340472 PMCID: PMC8929476 DOI: 10.7759/cureus.22236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2022] [Indexed: 11/22/2022] Open
Abstract
Background A gold standard classification for the treatment of tibial plateau fractures with soft tissue injury has not been established yet.This study aimed to evaluate the usability of a novel modified classification that can provide preoperative information to the surgeon about soft tissue injuries in tibial plateau fractures. Methodology A total of 36 patients with tibial plateau fractures were included in the study. Patients’ age, gender, and affected sides were recorded. Injuries to the medial meniscus, lateral meniscus, anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament, and lateral collateral ligament were examined with preoperative magnetic resonance imaging. Soft tissue injuries were arranged according to the novel modified classification based on the Schatzker classification. Results The mean age of the study participants was 45 (19-76) years; 72% of the patients were men and 28% were women. Moreover, 44% and 56% of the patients had broken the right and left tibial plateaus, respectively. At least one soft tissue injury was detected in 29 (81%) patients. In 14 (39%) patients, two or more soft tissue injuries were observed. All patients were arranged according to the novel modified classification regarding ligament and meniscus injuries. Conclusions With this novel modified classification system, we think that having better information about the preoperative condition of the soft tissue injuries can change the surgical strategy in patients with tibial plateau fractures.
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Morbidity and Mortality After Surgical Management of Tibial Plateau Fractures in Octogenarians. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2021; 5:01979360-202110000-00015. [PMID: 34705803 PMCID: PMC8553240 DOI: 10.5435/jaaosglobal-d-21-00109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 09/17/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Because the geriatric population continues to increase in number, the incidence of geriatric tibial plateau fractures in octogenarians is projected to increase. The functional and physiological status varies within this population. The purpose of this study was to compare the complications after surgical management of tibial plateau fractures in patients aged 65 to 79 years with those in patients aged 80 to 89 years. METHODS In this retrospective cohort study, data were collected from the National Surgical Quality Improvement Program database for the years 2006 to 2018. The Current Procedural Terminology codes and International Classification of Diseases codes were used to identify all tibial plateau fractures that were treated with open reduction and internal fixation. Patients were divided into two groups: 65- to 79-year-old group and 80- to 89-year-old group. Primary and secondary outcomes were studied and included the 30-day mortality. Univariate and multivariate analyses were done with a statistical significance set at P < 0.05. RESULTS In total, 718 patients with tibial plateau fractures who underwent open reduction and internal fixation were included in this study. Of these, 612 were aged 65 to 79 years, and 106 were aged 80 to 89 years. On multivariate analysis, patients aged 80 to 89 years were at increased risk of postoperative anemia requiring transfusion (odds ratio 2.83; 95% confidence interval 1.37 to 5.84; P = 0.005) and extended length of hospital stay (odds ratio 2.72; 95% confidence interval 1.64 to 4.51; P < 0.001) in comparison with patients aged 65 to 79 years. CONCLUSION In appropriately selected octogenarian patients, surgical management of tibial plateau fractures was associated with greater risks of transfusion and longer hospital stay. However, comparisons of the rates of late complications and reoperations remain unknown.
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Prall WC, Kusmenkov T, Rieger M, Haasters F, Mayr HO, Böcker W, Fürmetz J. Radiological Outcome Measures Indicate Advantages of Precontoured Locking Compression Plates in Elderly Patients With Split-Depression Fractures to the Lateral Tibial Plateau (AO41B3). Geriatr Orthop Surg Rehabil 2021; 12:21514593211043967. [PMID: 34671507 PMCID: PMC8521727 DOI: 10.1177/21514593211043967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 08/12/2021] [Accepted: 08/17/2021] [Indexed: 11/16/2022] Open
Abstract
Background Split-depression fractures to the lateral tibial plateau (AO41B3) often feature severe joint surface destructions. Precontoured locking compression plates (LCPs) are designed for optimum support of the reduced joint surface and have especially been emphasized in reduced bone quality. A lack of evidence still inhibits their broad utilization in elderly patients. Thus, aim of the present study was to investigate the implant-specific radiological outcomes of AO41B3-fractures in young versus elderly patients. Methods The hospital’s database was screened for isolated AO41B3-factures, open reduction and internal fixation (ORIF), and radiological follow-up ≥12 months. CT-scans, radiographs, and patients’ records were analyzed. Patients were attributed as young (18–49) or elderly (≥50 years). Additional subgrouping was carried out into precontoured LCP and conventional implants. The Rasmussen Radiological Score (RRS) after 12 months was set as primary outcome parameter. The RRS postoperatively and the medial proximal tibial angle (MPTA) postoperatively and after 12 months were secondary outcome parameters. Results Fifty nine consecutive patients were included (26 young, 38.2 ± 7.8 years; 33 elderly, 61.3 ± 9.4 years). There were no significant differences regarding mean size and depression depth of the lateral joint surface fragments. Prior to implant-specific subgrouping, the radiological outcome measures revealed no significant differences between young (RRS = 7.7 ± 1.7; MPTA = 90.3 ± 2.3°) and elderly (RRS = 7.2 ± 1.7; MPTA = 90.5 ± 3.3°). After implant-specific subgrouping, the radiological outcome revealed significantly impaired results in young patients with conventional implants (RRS(C) = 6.9 ± 1.6, RRS(LCP) = 8.5 ± 1.5, P = .015; MPTA(C) = 91.5 ± 1.9°, MPTA(LCP) = 89.1 ± 2.1°, P = .01). The effect was even more pronounced in elderly patients, with highly significant deterioration of the radiological outcome measures for conventional implants compared to precontoured LCP (RRS(C) = 5.7 ± 1.6, RRS(LCP) = 8.2 ± .8, P < .001; MPTA(C) = 92.6 ± 4.2°, MPTA(LCP) = 89.2 ± 1.4°, P = .002). Conclusion Utilizing precontoured LCP in the treatment of AO41B3-fractures is associated with improved radiological outcomes. This effect is significant in young but even more pronounced in elderly patients. Consequently, precontoured LCP should closely be considered in any AO41B3-fracture, but especially in elderly patients.
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Affiliation(s)
- Wolf C Prall
- Division of Knee, Hip and Shoulder Surgery, Schoen Clinic Munich Harlaching, Academic Teaching Hospital of the Paracelsus Medical University (PMU), Salzburg, Austria.,Department of General, Trauma and Reconstructive Surgery, Munich University Hospital, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Thomas Kusmenkov
- Department of General, Trauma and Reconstructive Surgery, Munich University Hospital, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Maximilian Rieger
- Division of Knee, Hip and Shoulder Surgery, Schoen Clinic Munich Harlaching, Academic Teaching Hospital of the Paracelsus Medical University (PMU), Salzburg, Austria
| | - Florian Haasters
- Division of Knee, Hip and Shoulder Surgery, Schoen Clinic Munich Harlaching, Academic Teaching Hospital of the Paracelsus Medical University (PMU), Salzburg, Austria.,Department of General, Trauma and Reconstructive Surgery, Munich University Hospital, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Hermann O Mayr
- Division of Knee, Hip and Shoulder Surgery, Schoen Clinic Munich Harlaching, Academic Teaching Hospital of the Paracelsus Medical University (PMU), Salzburg, Austria.,Department of Orthopaedics and Trauma Surgery, Freiburg University Hospital, Albert-Ludwigs-University, Freiburg, Germany
| | - Wolfgang Böcker
- Department of General, Trauma and Reconstructive Surgery, Munich University Hospital, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Julian Fürmetz
- Department of General, Trauma and Reconstructive Surgery, Munich University Hospital, Ludwig-Maximilians-University (LMU), Munich, Germany
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Sharma D, Thahir A, Sharma V, Krkovic M. The Cambridge Experience With Tibial Plateau Fractures in Older Adults: A Case Series. Cureus 2021; 13:e13311. [PMID: 33738157 PMCID: PMC7958933 DOI: 10.7759/cureus.13311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Complex tibial plateau fractures (TPFs) represent a significant treatment challenge for any Orthopaedic surgeon. Current literature suggests that significantly displaced TPFs in the elderly require operative fixation, an operation that is associated with serious complications including septic and post-operative arthritis. As a result, these patients are five times more likely to require a total knee replacement (TKR). We present a case series of five elderly patients with complex TPFs who made serendipitous recoveries while awaiting operations. Their fractures were deemed so severe that they were being considered for TKR instead of fixation. We discovered their surprising functional improvements while they were being reviewed pre-operatively and decided to delay operating. We are currently unaware of any cases in the literature that have reported such findings. In total, five patients presented in 2019 with closed, varus/valgus stable fractures. They were managed non-operatively in hinged-knee braces, progressively weight-bearing with a minimum follow-up of 10 months. Oxford Knee Scores (OKS) were recorded at zero and four months after their injury. All patients were female with an average age of 69 years. Average fracture depression - 8.48mm, average fracture split - 8.66mm, average OKS reduction - 19%. All patients were able to mobilise independently at four months follow-up. Our results suggest that non-operative management can be considered as primary management in elderly patients with significantly displaced TPFs. Should this fail, or they develop arthritis, a TKR can be performed. This carries two benefits: the patient avoids the significant complications associated with fixation and should a TKR be required, it can more easily be performed in a patient without metalwork in-situ. We feel that the results from this case series might offer insight into a new treatment strategy and continue to closely follow these patients.
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Affiliation(s)
- Dhiraj Sharma
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, GBR
| | - Azeem Thahir
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, GBR
| | - Vivek Sharma
- Department of Trauma and Orthopaedics, Norfolk and Norwich University Hospitals Foundation Trust, Norwich, GBR
| | - Matjia Krkovic
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, GBR
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Telis AL, Tucker DW, Compton E, DeSanto DJ, Carney JJ, Scolaro JA, Marecek GS, Lee AK. Treatment of tibial plateau fractures with a novel fenestrated screw system for delivery of bone graft substitute. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:1321-1327. [PMID: 33486537 DOI: 10.1007/s00590-021-02871-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/08/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of this study was to describe the incidence of subsidence in patients with AO/OTA 41 (tibial plateau) fractures which were repaired with a novel fenestrated screw system to used to deliver CaPO4 bone substitute material to fill the subchondral void and support the articular reduction. METHODS Patients with unicondylar and bicondylar tibial plateau fractures were treated according to the usual technique of two surgeons. After fixation, the Zimmer Biomet N-Force Fixation System®, a fenestrated screw that allows for the injection of bone substitute was placed and used for injection of the proprietary calcium phosphate bone graft substitute into the subchondral void. For all included patients, demographic information, operative data, radiographs, and clinic notes were reviewed. Patients were considered to have articular subsidence if one or more of two observations were made when comparing post-operative to their most recent clinic radiographs: > 2 mm change in the distance between the screw and the lowest point of the tibial plateau, > 2 mm change in the distance between the screw and the most superior aspect of the plate. Data were analyzed to determine if there were any identifiable risk factors for complication, reoperation, or subsidence using logistic regression. Statistical significance was set at p < 0.05. RESULTS 34 patients were included with an average follow-up of 32.03 ± 22.52 weeks. There were no overall differences between height relative to the medial plateau or the plate. Two patients (5.9%) had articular subsidence. Six patients (15.2%) underwent reoperation, two (6%) for manipulations under anaesthesia due to arthrofibrosis, and four (12%) due to infections. There were 6 (19%) total infections as 2 were superficial and required solely antibiotics. One patient had early failure. CONCLUSION Use of a novel fenestrated screw system for the delivery of CaPO4 BSM results in articular subsidence and complication rates similar to previously published values and appears to be a viable option for addressing subchondral defects in tibial plateau fractures. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Alexander L Telis
- Department of Orthopaedic Surgery, Providence Sacred Heart Medical Center and Children's Hospital, Spokane, WA, USA
| | - Douglass W Tucker
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Edward Compton
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Donald J DeSanto
- Department of Orthopaedic Surgery, University of California Irvine, Orange, CA, USA
| | - John J Carney
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - John A Scolaro
- Department of Orthopaedic Surgery, University of California Irvine, Orange, CA, USA
| | - Geoffrey S Marecek
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Adam K Lee
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.
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Prall WC, Rieger M, Fürmetz J, Haasters F, Mayr HO, Böcker W, Kusmenkov T. Schatzker II tibial plateau fractures: Anatomically precontoured locking compression plates seem to improve radiological and clinical outcomes. Injury 2020; 51:2295-2301. [PMID: 32650982 DOI: 10.1016/j.injury.2020.07.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 05/01/2020] [Accepted: 07/05/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The design of anatomically precontoured locking compression plates (LCP) allows the placement of angular stable screws right underneath the reduced joint surface fragments. To date, there is a lack of evidence supporting the broad utilization of these implants in split depression fractures to the lateral tibial plateau. Thus, aim of the present matched pair retrospective cohort study was to investigate the radiological and clinical outcomes of anatomically precontoured LCP compared to conventional plate and screw osteosynthesis in Schatzker II fractures. MATERIAL AND METHODS The institutional databank was searched for Schatzker II fractures from 2010 to 2016. Patients that underwent open reduction and internal fixation with anatomically precontoured 3.5 mm LCP or conventional 4.5 mm l-shaped plates and screws were included. CT scans and radiographs were analyzed. Details of the operative procedures and secondary events were collected. A matched pair analyses was conducted in a best fit manner. The primary outcome parameter was the Rasmussen Radiological Score approximately one year postoperatively. Secondary outcome parameters were the medial proximal tibial angle (MPTA), the Rasmussen Clinical Score and the WOMAC Score after a follow up of at least three years. RESULTS A total of 50 patients was included. Patient age, gender distribution, size and depression depth of the lateral joint surface fragments, frequency of utilizing bone grafts or substitutes and lateral meniscus repair as well as subsequent implant removal were comparable across the groups. Immediately postoperatively, the Rasmussen Radiological Score revealed no differences. After a mean of 64.2 weeks, the radiological outcome was significantly better in the LCP 3.5 group (RRS 8.2 vs. 6.3 points, p<0.001; MPTA 89.5 vs. 92.0°, p = 0.001). After a mean clinical follow-up of 4.5 years, the Rasmussen Clinical Score (22.9 vs. 27.8 points, p<0.001) and the WOMAC score (24.3 vs. 16.0 points, p = 0.04) revealed significantly impaired results in the conventional group. CONCLUSION Anatomically precontoured LCP prevent the subsidence of the reduced joint surface fragments more sufficiently and allow for improved patient outcomes compared to conventional plates and screws. The utilization of anatomically precontoured LCP should therefore closely be considered for internal fixation of any split depression fractures to the lateral tibial plateau.
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Affiliation(s)
- W C Prall
- FIFA Medical Centre of Excellence, Division of Knee Hip and Shoulder Surgery, Schoen Clinic Munich Harlaching, Harlachinger Str. 51, 81547 Munich, Germany; Academic Teaching Hospital of the Paracelsus Medical University (PMU), Strubergasse 21, 5020 Salzburg, Austria; Department of General, Trauma and Reconstructive Surgery, Munich University Hospital, Ludwig-Maximilians-University (LMU), Nussbaumstr. 20, 80336 Munich, Germany.
| | - M Rieger
- FIFA Medical Centre of Excellence, Division of Knee Hip and Shoulder Surgery, Schoen Clinic Munich Harlaching, Harlachinger Str. 51, 81547 Munich, Germany; Academic Teaching Hospital of the Paracelsus Medical University (PMU), Strubergasse 21, 5020 Salzburg, Austria
| | - J Fürmetz
- Department of General, Trauma and Reconstructive Surgery, Munich University Hospital, Ludwig-Maximilians-University (LMU), Nussbaumstr. 20, 80336 Munich, Germany
| | - F Haasters
- FIFA Medical Centre of Excellence, Division of Knee Hip and Shoulder Surgery, Schoen Clinic Munich Harlaching, Harlachinger Str. 51, 81547 Munich, Germany; Academic Teaching Hospital of the Paracelsus Medical University (PMU), Strubergasse 21, 5020 Salzburg, Austria; Department of General, Trauma and Reconstructive Surgery, Munich University Hospital, Ludwig-Maximilians-University (LMU), Nussbaumstr. 20, 80336 Munich, Germany
| | - H O Mayr
- FIFA Medical Centre of Excellence, Division of Knee Hip and Shoulder Surgery, Schoen Clinic Munich Harlaching, Harlachinger Str. 51, 81547 Munich, Germany; Academic Teaching Hospital of the Paracelsus Medical University (PMU), Strubergasse 21, 5020 Salzburg, Austria; Department of Orthopaedics and Trauma Surgery, Freiburg University Hospital, Albert-Ludwigs-University, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - W Böcker
- Department of General, Trauma and Reconstructive Surgery, Munich University Hospital, Ludwig-Maximilians-University (LMU), Nussbaumstr. 20, 80336 Munich, Germany
| | - T Kusmenkov
- Department of General, Trauma and Reconstructive Surgery, Munich University Hospital, Ludwig-Maximilians-University (LMU), Nussbaumstr. 20, 80336 Munich, Germany
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Wong MT, Bourget-Murray J, Johnston K, Desy NM. Understanding the role of total knee arthroplasty for primary treatment of tibial plateau fracture: a systematic review of the literature. J Orthop Traumatol 2020; 21:7. [PMID: 32451839 PMCID: PMC7248151 DOI: 10.1186/s10195-020-00546-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 04/24/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Surgical fixation of tibial plateau fracture in elderly patients with open reduction and internal fixation (ORIF) provides inferior outcomes compared with younger patients. Primary total knee arthroplasty (TKA) may be of benefit in elderly patients with a combination of osteoporotic bone and metaphyseal comminution. However, there continues to be conflicting evidence on the use of TKA for primary treatment of tibial plateau fracture. This systematic review was performed to quantify the outcomes and perioperative complication rates of TKA for primary treatment of tibial plateau fracture. MATERIALS AND METHODS A comprehensive search of MEDLINE, Embase, and PubMed databases from inception through March 2018 was performed in accordance with PRISMA guidelines. Two reviewers independently screened papers for inclusion and identified studies featuring perioperative complications and outcomes of primary TKA for tibial plateau fracture. Weighted means and standard deviations are presented for each outcome. RESULTS Seven articles (105 patients) were eligible for inclusion. All-cause mortality was 4.75 ± 4.85%. The total complication rate was 15.2 ± 17.3%. Regarding outcomes, Knee Society scores were most commonly reported. The average Knee Society Knee Score was 85.6 ± 5.5, while the average Knee Society Function Score was 64.6 ± 13.7. Average range of motion at final follow-up was 107.5 ± 10.0°. CONCLUSIONS Primary TKA for select tibial plateau fractures has acceptable clinical outcomes but does not appear to be superior to ORIF. It may be appropriate to treat certain geriatric patients with TKA to allow for early mobilization and reduce the need for reoperation. Other factors may need to be considered in deciding the optimal treatment. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Murray T Wong
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, North Tower, Foothills Medical Centre, 1403 29 St NW, Calgary, T2N 2T9, AB, Canada.
| | - Jonathan Bourget-Murray
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, North Tower, Foothills Medical Centre, 1403 29 St NW, Calgary, T2N 2T9, AB, Canada
| | - Kelly Johnston
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, North Tower, Foothills Medical Centre, 1403 29 St NW, Calgary, T2N 2T9, AB, Canada
| | - Nicholas M Desy
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, North Tower, Foothills Medical Centre, 1403 29 St NW, Calgary, T2N 2T9, AB, Canada
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16
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Mthethwa J, Chikate A. A review of the management of tibial plateau fractures. Musculoskelet Surg 2018; 102:119-127. [PMID: 29043562 DOI: 10.1007/s12306-017-0514-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 10/08/2017] [Indexed: 06/07/2023]
Abstract
Tibial plateau fractures form a wide spectrum of injuries presenting varying challenges to the trauma surgeon. The prognosis of this injury spectrum is largely dependent on the management of each particular configuration, and the literature is as a result littered with a number of management strategies with limited consensus. The aim of this review is to provide a concise guide to the trauma surgeon based on newer and classical peer-reviewed publications in international orthopaedic journals. A PubMed search was conducted to identify peer-reviewed publications within the last 10 years and expanded to identify classic papers pertaining to the Schatzker classification. The focus was on articles based on management techniques, controversies and recent developments. The management of specific injury patterns is based on the Schatzker classification which is a widely accepted traditional classification system. Whilst there is a general consensus on the ultimate goal of a stable anatomic reduction in this subset of fractures, there continues to be a number of controversies surrounding issues including pre-operative imaging, initial assessment and definitive management of specific injury patterns, some of which do not conform to the original Schatzker classification. The majority of fractures will require operative management, and with whatever management strategy employed, the main emphasis is on respecting the soft tissue envelope. There remains a paucity of prospective randomised controlled trials comparing the different available operative techniques.
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Affiliation(s)
- J Mthethwa
- Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF, UK.
| | - A Chikate
- Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF, UK
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Costs and Complications of Single-Stage Fixation Versus 2-Stage Treatment of Select Bicondylar Tibial Plateau Fractures. J Orthop Trauma 2018; 32:327-332. [PMID: 29920192 DOI: 10.1097/bot.0000000000001167] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine the differences in costs and complications in patients with bicondylar tibial plateau (BTP) fractures treated with 1-stage definitive fixation compared with 2-stage fixation after initial spanning external fixation. DESIGN Retrospective cohort study. SETTING Level 1 Trauma Center. PATIENTS/PARTICIPANTS Patients with OTA/AO 41-C (Schatzker 6) BTP fractures treated with open reduction internal fixation. INTERVENTION Definitive treatment with open reduction internal fixation either acutely (1 stage) or delayed after initial spanning external fixation (2 stage). MAIN OUTCOME MEASURES Wound healing complications, implant costs, hospital charges, Patient-Reported Outcomes Measurement Information System (PROMIS), reoperation, nonunion and infection. RESULTS One hundred five patients were identified over a three-year period, of whom 52 met the inclusion criteria. There were 28 patients in the 1-stage group and 24 patients in the 2-stage group. Mean follow-up was 21.8 months, and 87% of patients had at least 12 months of follow-up. The mean number of days to definitive fixation was 1.2 in the 1-stage group and 7.8 in the 2-stage group. There were no differences between groups with respect to wound healing or any other surgery-related complications. Functional outcomes PROMIS were similar between groups. Mean implant cost in the 2-stage group was $10,821 greater than the 1-stage group, mostly because of the costs of external fixation. Median hospital inpatient charges in the 2-stage group exceeded the 1-stage group by more than $68,000 for all BTP fractures and by $61,000 for isolated BTP fractures. CONCLUSIONS Early single-stage treatment of BTP fractures is cost-effective and is not associated with a higher complication rate than 2-stage treatment in appropriately selected patients. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Yaacobi E, Sanchez D, Maniar H, Horwitz DS. Surgical treatment of osteoporotic fractures: An update on the principles of management. Injury 2017; 48 Suppl 7:S34-S40. [PMID: 28882375 DOI: 10.1016/j.injury.2017.08.036] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The treatment of osteoporotic fractures continues to challenge orthopedic surgeon. The fragility of the underlying bone in conjunction with the need for specific implants led to the development of explicit surgical techniques in order to minimize implant failure related complications, morbidity and mortality. From the patient's perspective, the existence of frailty, dementia and other medical related co-morbidities induce a complex situation necessitating high vigilance during the perioperative and post-operative period. This update reviews current principles and techniques essential to successful surgical treatment of these injuries.
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Affiliation(s)
- Eyal Yaacobi
- Department of Orthopaedic Surgery, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA, USA
| | - Daniela Sanchez
- Department of Orthopaedic Surgery, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA, USA
| | - Hemil Maniar
- Department of Orthopaedic Surgery, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA, USA
| | - Daniel S Horwitz
- Department of Orthopaedic Surgery, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA, USA.
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Is "Early Total Care" a Safe and Effective Alternative to "Staged Protocol" for the Treatment of Schatzker IV-VI Tibial Plateau Fractures in Patients Older Than 50 Years? J Orthop Trauma 2017; 31:e400-e406. [PMID: 28938234 DOI: 10.1097/bot.0000000000000995] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare "Early Total Care" (ETC) with "Staged Protocol" (SP) for the treatment of Schatzker IV-VI tibial plateau fractures in patients older than 50 years regarding safety and effectiveness. DESIGN Retrospective cohort study. SETTING An academic level 1 US trauma center. PATIENTS/PARTICIPANTS Eighty-one patients older than 50 years with Schatzker grade IV-VI tibial plateau fractures were included. INTERVENTION Fifty-three patients were treated under SP with immediate external fixation followed by definitive internal fixation. Twenty-eight patients were treated under ETC with immediate internal fixation. MAIN OUTCOME MEASUREMENTS Comparison of perioperative findings, time to bony and clinical union, soft-tissue and bony complications, radiological outcome, and secondary procedures. RESULTS The 2 groups were comparable without significant difference regarding age, sex, side of involvement, body mass index, smoking status, American Society of Anesthesiologist classification, associated injuries, comorbidities, follow-up duration, and fracture classification. No statistically significant difference was found regarding the perioperative complications, quality of reduction, time to union, Rasmussen score at union or at the final follow-up, soft-tissue/bony complications, and the rate of the secondary procedures. CONCLUSION ETC seems to be a safe, efficacious, and effective alternative to the SP for the treatment of some Schatzker IV-VI fractures in patients older than 50 years. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Gausden E, Garner MR, Fabricant PD, Warner SJ, Shaffer AD, Lorich DG. Do clinical outcomes correlate with bone density after open reduction and internal fixation of tibial plateau fractures. Arch Orthop Trauma Surg 2017; 137:755-760. [PMID: 28391428 DOI: 10.1007/s00402-017-2679-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The operative management of tibial plateau fractures in elderly patients has historically led to inconsistent results, and these clinical outcomes were thought to be associated with poor bone quality often in elderly patients. The goal of this study was to investigate the relationship between bone density and subjective clinical outcome scores after open reduction and internal fixation of tibial plateau fractures. MATERIALS AND METHODS This is a retrospective cohort study from a single-surgeon conducted at an Academic, Level 1 Trauma Center. A preoperative computed tomography (CT) scan was obtained for all patients. Bone density of the distal femur was quantified with Hounsfield units (HU) as measured on axial CT scans. Inter-rater reliability of HU measurements was assessed using interclass correlation coefficients. Regression models controlling for age were used to identify relationships between bone density (HU) and the following variables: articular subsidence and 1-year subjective clinical outcomes scores [Knee Outcome Survey Activities of Daily Living Scale (KOS-ADLS), and Short-Form-36 (SF-36) physical and mental component scores (PCS, MCS)]. RESULTS Sixty-one patients with a mean age of 59.3 years (range 27-85 years) and a minimum of 12 months of clinical follow-up were included in the study. The majority of the fractures (32 of 61) were classified as Schatzker II tibial plateau fractures, and there were 13 Schatzker V fractures, 11 Schatzker VI fractures, 2 Schatzker IV fractures and 1 Schatzker 1 fracture. HU measurements demonstrated an almost perfect inter-observer reliability (ICC = 0.97). Age was negatively correlated with HU measurements (r = -0.51, p < 0.001), and using a geriatric cut-off of 65 years of age, the geriatric group had a lower mean HU compared to the non-geriatric group (78.2 versus 114.8, p = 0.018). There was no significant relationship between bone quality, as assessed by distal femoral HU, and any subjective clinical outcome score. CONCLUSIONS Inferior bone mineral density alone does not appear to affect clinical outcomes 1 year postoperatively when bone grafting is used to restore osseous voids. Poor bone quality should not be used as an indication for non-operative management of tibial plateau fractures.
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Affiliation(s)
- Elizabeth Gausden
- Hospital for Special Surgery, 535 E. 70th St, New York, NY, 10021, USA
| | - Matthew R Garner
- Department of Orthopaedic Trauma, Penn State Bone and Joint Institute, Hershey S. Medical Center, 500 University Drive, H089, Hershey, PA, 17033, USA.
| | - Peter D Fabricant
- Hospital for Special Surgery, 535 E. 70th St, New York, NY, 10021, USA
| | - Stephen J Warner
- Hospital for Special Surgery, 535 E. 70th St, New York, NY, 10021, USA
| | - Andre D Shaffer
- Hospital for Special Surgery, 535 E. 70th St, New York, NY, 10021, USA
| | - Dean G Lorich
- Hospital for Special Surgery, 535 E. 70th St, New York, NY, 10021, USA.,New York Presbyterian Hospital, Weill Cornell Medical College, 520 E. 70th St, New York, NY, 10021, USA
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Moran E, Zderic I, Klos K, Simons P, Triana M, Richards RG, Gueorguiev B, Lenz M. Reconstruction of the lateral tibia plateau fracture with a third triangular support screw: A biomechanical study. J Orthop Translat 2017; 11:30-38. [PMID: 29662767 PMCID: PMC5866407 DOI: 10.1016/j.jot.2016.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 12/15/2016] [Accepted: 12/16/2016] [Indexed: 11/29/2022] Open
Abstract
Background Split fractures of the lateral tibia plateau in young patients with good bone quality are commonly treated using two minimally invasive percutaneous lag screws, followed by unloading of the knee joint. Improved stability could be achieved with the use of a third screw inserted either in the jail-technique fashion or with a triangular support screw configuration. The aim of this study was to investigate under cyclic loading the compliance and endurance of the triangular support fixation in comparison with the standard two lag-screw fixation and the jail technique. Methods Lateral split fractures of type AO/OTA 41-B1 were created on 21 synthetic tibiae and subsequently fixed with one of the following three techniques for seven specimens: standard fixation by inserting two partially threaded 6.5 mm cannulated lag screws parallel to each other and orthogonal to the fracture plane; triangular support fixation-standard fixation with one additional support screw at the distal end of the fracture at 30° proximal inclination; and jail fixation-standard fixation with one additional orthogonal support screw inserted in the medial nonfractured part of the bone. Mechanical testing was performed under progressively increasing cyclic compression loading. Fragment displacement was registered via triggered radiographic imaging. Results Mean construct compliance was 3.847 × 10-3 mm/N [standard deviation (SD) 0.784] for standard fixation, 3.838 × 10-3 mm/N (SD 0.242) for triangular fixation, and 3.563 × 10-3 mm/N (SD 0.383) for jail fixation, with no significant differences between the groups (p = 0.525). The mean numbers of cycles to 2 mm fragment dislocation, defined as a failure criterion, were 12,384 (SD 2267) for standard fixation, 17,708 (SD 2193) for triangular fixation, and 14,629 (SD 5194) for jail fixation. Triangular fixation revealed significantly longer endurance than the standard one (p = 0.047). Conclusion Triangular support fixation enhanced interfragmentary stability at the ultimate stage of dynamic loading. However, the level of improvement seems to be limited and may not legitimate the intervention with an additional third screw.
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Affiliation(s)
| | - Ivan Zderic
- AO Research Institute Davos, Davos, Switzerland
| | - Kajetan Klos
- Department for Foot and Ankle Surgery, Catholic Clinic of Mainz, Mainz, Germany
| | - Paul Simons
- Department for Foot and Ankle Surgery, Catholic Clinic of Mainz, Mainz, Germany
| | - Miguel Triana
- Fundatión Cardioinfantil, Universidades el Bosque y Fundación Universitaria de Ciencias de la Salud, Bogota, Colombia
| | | | | | - Mark Lenz
- Department of Trauma, Hand and reconstructive Surgery, University Hospital Jena, Jena, Germany
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Abstract
Tibial plateau fractures are common in the elderly population following a low-energy mechanism. Initial evaluation includes an assessment of the soft tissues and surrounding ligaments. Most fractures involve articular depression leading to joint incongruity. Treatment of these fractures may be complicated by osteoporosis, osteoarthritis, and medical comorbidities. Optimal reconstruction should restore the mechanical axis, provide a stable construct for mobilization, and reestablish articular congruity. This is accomplished through a variety of internal or external fixation techniques or with acute arthroplasty. Regardless of the treatment modality, particular focus on preservation and maintenance of the soft tissue envelope is paramount.
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Affiliation(s)
- Joshua C Rozell
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Krishna C Vemulapalli
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Joshua L Gary
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Derek J Donegan
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
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Abstract
There are an increasing number of fragility fractures, which present a surgical challenge given the reduced bone quality of underlying osteoporosis. Particularly in aged patients, there is a need for early weight bearing and mobilization to avoid further complications such as loss of function or autonomy. As an attempt to improve fracture stability and ultimate healing, the use of biomaterials for augmentation of osseous voids and fracture fixation is a promising treatment option. Augmentation techniques can be applied in various locations, and fractures of the metaphyseal regions such as proximal humerus, femur, tibia and the distal radius remain the most common areas for its use. The current review, based on the available mechanical and biological data, provides an overview of the relevant treatment options and different composites used for augmentation of osteoporotic fractures.
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Bagherifard A, Jabalameli M, Hadi H, Rahbar M, Minator Sajjadi M, Jahansouz A, Karimi Heris H. Surgical Management of Tibial Plateau Fractures With 3.5 mm Simple Plates. Trauma Mon 2016; 21:e26733. [PMID: 27626010 PMCID: PMC5003498 DOI: 10.5812/traumamon.26733] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Revised: 04/24/2015] [Accepted: 06/28/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Tibial plateau fractures can be successfully fixed utilizing 3.5 mm locking plates. However, there are some disadvantages to using these plates. OBJECTIVES In the current prospective study, we investigated the outcome of treating different types of tibial plateau fractures with 3.5 mm simple plates which, to our knowledge, has not been evaluated in previous studies. MATERIALS AND METHODS Between 2011 and 2013, 32 patients aged 40 ± 0.2 years underwent open reduction and internal fixation for tibial plateau fractures with 3.5 mm simple plates. The patients were followed for 16.14 ± 2.1 months. At each patient's final visit, the articular surface depression, medial proximal tibial angle, and slope angle were measured and compared with measurements taken early after the operation. The functional outcomes were measured with the WOMAC and Lysholm knee scores. RESULTS The mean union time was 13 ± 1.2 weeks. The mean knee range of motion was 116.8° ± 3.3°. The mean WOMAC and Lysholm scores were 83.5 ± 1.8 and 76.8 ± 1.6, respectively. On the early postoperative and final X-rays, 87.5% and 84% of patients, respectively, had acceptable reduction. Medial proximal tibial and slope angles did not change significantly by the last visit. No patient was found to have complications related to the type of plate. CONCLUSIONS In this case series study, the fixation of different types of tibial plateau fractures with 3.5 mm simple non-locking and non-precontoured plates was associated with acceptable clinical, functional, and radiographic outcomes. Based on the advantages and costs of these plates, the authors recommend using 3.5 mm simple plates for different types of tibial plateau fractures.
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Affiliation(s)
- Abolfazl Bagherifard
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, IR Iran
| | - Mahmoud Jabalameli
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, IR Iran
| | - Hosseinali Hadi
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, IR Iran
| | - Mohammad Rahbar
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, IR Iran
| | - Mohammadreza Minator Sajjadi
- Taleghani Hospital Research Development Unit, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Mohammadreza Minator Sajjadi, Taleghani Hospital Research Development Unit, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran. Tel: +98-2133542008, Fax: +98-2133542020, E-mail:
| | - Ali Jahansouz
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, IR Iran
| | - Hossein Karimi Heris
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, IR Iran
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Abstract
Arthrofibrosis after periarticular fractures can create clinically significant impairments in both the upper and lower extremities. The shoulder, elbow, and knee are particularly susceptible to the condition. Many risk factors for the development of arthrofibrosis cannot be controlled by the patient or surgeon. Early postoperative motion should be promoted whenever possible. Manipulations under anesthesia are effective for a period of time in certain fracture patterns, and open or arthroscopic surgical debridements should be reserved for the patient for whom nonoperative modalities fail and who has a clinically significant deficit.
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Affiliation(s)
- Ian McAlister
- Department of Orthopaedic Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Stephen Andrew Sems
- Department of Orthopaedic Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Shimizu T, Sawaguchi T, Sakagoshi D, Goshima K, Shigemoto K, Hatsuchi Y. Geriatric tibial plateau fractures: Clinical features and surgical outcomes. J Orthop Sci 2016; 21:68-73. [PMID: 26671570 DOI: 10.1016/j.jos.2015.09.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 08/28/2015] [Accepted: 09/27/2015] [Indexed: 02/09/2023]
Abstract
BACKGROUND Operative treatment of geriatric tibial plateau fractures is challenging and controversial. There are few studies focusing on the clinical features and operative outcomes of tibial plateau fractures in the elderly. Hence, this study aimed to investigate the clinical features and operative results of these fractures. METHODS Thirty-three displaced tibial plateau fractures in patients >65 years old (mean age: 72.1 years, range: 65-94 years) were treated operatively. We investigated the mechanisms of injury, fracture types according to the Schatzker classification, incidences of soft tissue injury, and postoperative complications. Clinical and radiographic data were analyzed in 23 patients at the last follow-up. The mean follow-up period was 4.0 years (range: 1-13 years). Twenty-one patients were treated with open reduction and internal fixation and evaluated using the Rasmussen clinical and radiologic scores. Two patients with advanced osteoarthritis were treated primarily with total knee arthroplasty and assessed using the Japanese Orthopaedic Association score for the knee osteoarthritis. RESULTS Twenty-four patients (72.7%) were injured by low-energy trauma such as a simple fall. Four patients had compartment syndrome and required fasciotomies. Rasmussen clinical and radiologic scores were satisfactory in 85.7% and 81.0% of patients, respectively. Two patients treated primarily with total knee arthroplasty showed no radiologic abnormality, and their Japanese Orthopaedic Association scores were both 70 points. CONCLUSIONS Geriatric tibial plateau fractures, although mostly due to low-energy trauma, were often accompanied with severe comminution and compartment syndrome. Postoperative results of open reduction and internal fixation for this population were relatively good. Therefore, primary total knee arthroplasty should only be considered for well-selected patients.
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Affiliation(s)
- Takaki Shimizu
- Department of Orthopaedics and Joint Reconstructive Surgery, Toyama Municipal Hospital, 2-1, Imaizumi-Hokubu, Toyama City, Toyama 939-8511, Japan.
| | - Takeshi Sawaguchi
- Department of Orthopaedics and Joint Reconstructive Surgery, Toyama Municipal Hospital, 2-1, Imaizumi-Hokubu, Toyama City, Toyama 939-8511, Japan
| | - Daigo Sakagoshi
- Department of Orthopaedics and Joint Reconstructive Surgery, Toyama Municipal Hospital, 2-1, Imaizumi-Hokubu, Toyama City, Toyama 939-8511, Japan
| | - Kenichi Goshima
- Department of Orthopaedics and Joint Reconstructive Surgery, Toyama Municipal Hospital, 2-1, Imaizumi-Hokubu, Toyama City, Toyama 939-8511, Japan
| | - Kenji Shigemoto
- Department of Orthopaedics and Joint Reconstructive Surgery, Toyama Municipal Hospital, 2-1, Imaizumi-Hokubu, Toyama City, Toyama 939-8511, Japan
| | - Yu Hatsuchi
- Department of Orthopaedics and Joint Reconstructive Surgery, Toyama Municipal Hospital, 2-1, Imaizumi-Hokubu, Toyama City, Toyama 939-8511, Japan
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Boureau F, Benad K, Putman S, Dereudre G, Kern G, Chantelot C. Does primary total knee arthroplasty for acute knee joint fracture maintain autonomy in the elderly? A retrospective study of 21 cases. Orthop Traumatol Surg Res 2015; 101:947-51. [PMID: 26589193 DOI: 10.1016/j.otsr.2015.09.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 09/21/2015] [Accepted: 09/28/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Due to poor results and failure encountered in osteosynthesis of peri-articular fracture of the knee, arthroplasty may be suggested to osteopenic elderly subjects. All osteosynthesis techniques entail loss of independence and are associated with elevated mortality. No studies definitively establish better management of such fractures. HYPOTHESIS Total arthroplasty provides better autonomy after peri-articular fracture of the knee. MATERIAL AND METHOD Seventy-nine patients aged over 65years were operated on for peri-articular fracture of the knee between April 2008 and March 2013. In 21 cases, treated by a single surgeon, total knee arthroplasty was performed in view of osteopenia or osteoarthritis. Mean age was 79years (range, 68-96years). There were 10 distal femoral and 11 proximal tibial fractures. Mean follow-up was 31months (range, 9-68months). Cases of pathologic fracture, failed osteosynthesis and non-operative management were excluded. All patients showed severe osteopenia on radiology and half already had advanced osteoarthritis. RESULTS One-year mortality was 14%. At last follow-up, the revision rate was 9.5%. Fifteen patients were followed up. Mean Parker score fell from 7.2 (range, 2-9) preoperatively to 4.6 (range, 0-9) at last follow-up, indicating loss of independence. At follow-up, mean IKS score was 116.6 (range, 0-192) with mean IKS knee score of 78.4 (range, 0-100) and IKS function score of 38.2 (range, 0-100). Mean Oxford score was 36/60 (range, 18-53). Global IKS and IKS function scores were significantly better in case of ASA-2 than ASA-3 (P<0.05). There was no difference between femoral and tibial fractures in terms of IKS or Oxford score or loss of independence. DISCUSSION Total knee arthroplasty can be considered for peri-articular fracture of the knee in osteopenic geriatric patients. Although surgical revision was less frequent than after osteosynthesis and resumption of weight-bearing was immediate, autonomy was still impaired. Mortality was comparable to other reports. LEVEL OF EVIDENCE IV, retrospective study.
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Affiliation(s)
- F Boureau
- Service de traumatologie, hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille cedex, France; Université Lille-Nord-de-France, Lille, France.
| | - K Benad
- Service de traumatologie, hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille cedex, France; Université Lille-Nord-de-France, Lille, France
| | - S Putman
- Service de traumatologie, hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille cedex, France; Université Lille-Nord-de-France, Lille, France
| | - G Dereudre
- Service de traumatologie, hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille cedex, France; Université Lille-Nord-de-France, Lille, France
| | - G Kern
- Service de traumatologie, hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille cedex, France; Université Lille-Nord-de-France, Lille, France
| | - C Chantelot
- Service de traumatologie, hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille cedex, France; Université Lille-Nord-de-France, Lille, France
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Tibial plateau fractures in the elderly. CURRENT ORTHOPAEDIC PRACTICE 2015. [DOI: 10.1097/bco.0000000000000302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Elective removal of implants after open reduction and internal fixation of Tibial Plateau fractures improves clinical outcomes. Arch Orthop Trauma Surg 2015; 135:1491-6. [PMID: 26264713 DOI: 10.1007/s00402-015-2299-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Tibial plateau fractures are common injuries often treated with open reduction and internal fixation. We have noted improved patient satisfaction following implant removal for these patients. The purpose of this study was to assess the effect of removal of surgical implants after union on patient reported outcomes. MATERIALS AND METHODS All patients at our Level 1 Trauma Center undergoing open reduction an internal fixation by the senior surgeon are offered enrollment into a prospective registry and have clinical outcomes recorded at follow-up [Knee Outcomes Survey (KOS), Lower Extremity Functional Scale (LEFS), Short Form-36 Physical and Mental Component Summary (SF-36 PCS, SF-36 MCS), and Visual analog pain scale (VAS)]. Routinely, removal of surgical implants is offered after fracture union resulting in two cohorts: those who had undergone elective removal of surgical implants and those who had not. Outcome scores were compared before and after implant removal as well as between the two study populations at final follow-up. RESULTS Seventy-five patients were identified as having 12 month outcome scores: 36 (48%) had retained implants; 39 (52%) had implants removed. KOS and LEFS outcomes improved significantly after implant removal (p < 0.05). Clinical outcomes (KOS, SF-36 PCS) were also significantly better in patients who had implants removed compared to those that did not at final follow-up (p < 0.05). There was no statistical difference seen in VAS pain scores. CONCLUSIONS The results of this study indicate that patients who have elective removal of their surgical implants after open reduction and internal fixation of a tibial plateau fracture have improved clinical outcomes after removal and also demonstrate significantly better outcomes than those who have retained implants at final follow-up. Patients who are unhappy with their clinical result should be counseled that removal of the implant may improve function, but may not improve pain.
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Kojima K, Gueorguiev B, Seva G, Stoffel K, de Oliveira RG, Eberli U, Nicolino T, Lenz M. Biomechanical evaluation of interfragmentary compression at tibia plateau fractures in vitro using different fixation techniques: a CONSORT-compliant article. Medicine (Baltimore) 2015; 94:e282. [PMID: 25569643 PMCID: PMC4602845 DOI: 10.1097/md.0000000000000282] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Reliable osteosynthesis of intraarticular fractures depends on lasting interfragmentary compression. Its amount differs in the applied fixation method. The interfragmentary compression of cancellous and cortical lag screws and angle stable locking plates was quantified in an osteoporotic and non-osteoporotic synthetic human bone model.A split fracture of the lateral tibia plateau (AO/OTA type 41-B1.1) was mimicked by an osteotomy in right adult synthetic human tibiae with hard or soft cancellous bone. Specimens were fixed with either two 6.5 mm cancellous, four 3.5 mm cortical lag screws, or 3.5 mm LCP proximal lateral tibia plate preliminary compresed by a reduction clamp (n = 5 per group). A pressure sensor film was used to register the interfragmentary compression. One-way analysis of variance (ANOVA) with Bonferroni post hoc correction was performed for statistical analysis (p < 0.05).Interfragmentary compression under reduction clamp was 0.59 ± 0.12 MPa in the non-osteoporotic and 0.55 ± 0.14 MPa in the osteoporotic group. The locking plate itself maintained the compression in non-osteoporotic (0.53 ± 0.11 MPa) and osteoporotic bone (0.50 ± 0.14 MPa). Four 3.5 mm cortical lag screws provided a compression of 1.69 ± 0.65 MPa in non-osteoporotic bone, being not significantly different to the osteoporotic bone group (1.43 ± 0.47 MPa, P = 1.0). Two 6.5 mm cancellous lag screws showed a significantly higher compression in non-osteoporotic (2.1 ± 0.59 MPa) compared to osteoporotic (0.77 ± 0.21 MPa, P < 0.01) bone.Angle stable locking plates maintained the compression preliminarily applied by a reduction clamp. Two 6.5 mm cancellous lag screws are especially suited for non-osteoporotic bone, whereas four 3.5 mm cortical screws exhibited comparable compression in both bone qualities.
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Affiliation(s)
- K Kojima
- From the Department of Orthopaedics and Traumatology, Faculty of Medicine, University of Sao Paulo, Brazil (KK, GS, GdO); AO Research Institute, Davos, Switzerland (BG, GS, UE, TN, ML); University of Basel, Cantonal Hospital Baselland, Liestal, Switzerland (KS); Department of Orthopaedics and Traumatology, Italian Hospital of Buenos Aires, Argentina (TN); and Department of Trauma, Hand and Reconstructive Surgery, University Hospital Jena, Germany (ML)
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Sferopoulos NK. Autograft transfer from the ipsilateral femoral condyle in depressed tibial plateau fractures. Open Orthop J 2014; 8:310-5. [PMID: 25317215 PMCID: PMC4192835 DOI: 10.2174/1874325001408010310] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 08/31/2014] [Accepted: 09/03/2014] [Indexed: 11/24/2022] Open
Abstract
Introduction : The rationale for operative treatment of depressed tibial plateau fractures is anatomic reduction, stable fixation and grafting. Grafting options include autogenous bone graft or bone substitutes. Methods : The autograft group included 18 patients with depressed tibial plateau fractures treated with autogenous bone grafting from the ipsilateral femoral condyle following open reduction and internal fixation. According to Schatzker classification, there were 9 type II, 4 type III, 2 type IV and 3 type V lesions. The average time to union and the hospital charges were compared with the bone substitute group. The latter included 17 patients who had an excellent outcome following treatment of split and/or depressed lateral plateau fractures, using a similar surgical technique but grafting with bone substitutes (allografts). Results : Excellent clinical and radiological results were detected in the autograft group after an average follow-up of 28 months (range 12-37). The average time to union in the autograft group was 14 weeks (range 12-16), while in the bone substitute group it was 18 weeks (range 16-20). The mean total cost was 1276 Euros for the autograft group and 2978 Euros for the bone substitute group. Discussion : The use of autogenous graft from the ipsilateral femoral condyle following open reduction and internal fixation of depressed tibial plateau fractures provided enough bone to maintain the height of the tibial plateau and was not associated with any donor site morbidity. Using this method, the surgical time was not significantly elongated and the rehabilitation was not affected. It also exhibited faster fracture healing without postoperative loss of reduction and it was less expensive than the use of bone substitutes.
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Affiliation(s)
- N K Sferopoulos
- 2 Department of Orthopaedic Surgery, Aristotle University of Thessaloniki, "G. Gennimatas" Hospital, 54635 Thessaloniki, Greece
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32
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Onderko LL, Rehman S. Treatment of articular fractures with continuous passive motion. Orthop Clin North Am 2013; 44:345-56, ix. [PMID: 23827837 DOI: 10.1016/j.ocl.2013.04.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This article presents a review of the basic science and current research on the use of continuous passive motion therapy after surgery for an intra-articular fracture. This information is useful for surgeons in the postoperative management of intra-articular fractures in determining the best course of treatment to reduce complications and facilitate quicker recovery.
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Affiliation(s)
- Laura Lynn Onderko
- Department of Orthopaedic Surgery, Temple University Hospital, 3401 N. Broad Street, Philadelphia, PA 19140, USA
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Bohm ER, Tufescu TV, Marsh JP. The operative management of osteoporotic fractures of the knee. ACTA ACUST UNITED AC 2012; 94:1160-9. [DOI: 10.1302/0301-620x.94b9.28130] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This review considers the surgical treatment of displaced fractures involving the knee in elderly, osteoporotic patients. The goals of treatment include pain control, early mobilisation, avoidance of complications and minimising the need for further surgery. Open reduction and internal fixation (ORIF) frequently results in loss of reduction, which can result in post-traumatic arthritis and the occasional conversion to total knee replacement (TKR). TKR after failed internal fixation is challenging, with modest functional outcomes and high complication rates. TKR undertaken as treatment of the initial fracture has better results to late TKR, but does not match the outcome of primary TKR without complications. Given the relatively infrequent need for late TKR following failed fixation, ORIF is the preferred management for most cases. Early TKR can be considered for those patients with pre-existing arthritis, bicondylar femoral fractures, those who would be unable to comply with weight-bearing restrictions, or where a single definitive procedure is required.
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Affiliation(s)
- E. R. Bohm
- Concordia Hip & Knee Institute, 301-1155 Concordia Avenue, Winnipeg, Manitoba R2K 2M9, Canada
| | - T. V. Tufescu
- Health Sciences Centre, AD401, 820
Sherbrook Street, Winnipeg, Manitoba
R3A 1R9, Canada
| | - J. P. Marsh
- University of Manitoba, AD401, 820
Sherbrook Street, Winnipeg, Manitoba
R3A 1R9, Canada
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Parratte S, Bonnevialle P, Pietu G, Saragaglia D, Cherrier B, Lafosse JM. Primary total knee arthroplasty in the management of epiphyseal fracture around the knee. Orthop Traumatol Surg Res 2011; 97:S87-94. [PMID: 21802385 DOI: 10.1016/j.otsr.2011.06.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 04/19/2011] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Over the past few years the use of arthroplasty was broadened to treating complex epiphyseal fractures at the shoulder and elbow joints. Similar trends to treat this type of fractures at the knee are less documented. Based on a multicenter retrospective series study, the aims of this work is to evaluate the short term clinical results of total knee prostheses in the management of comminuted epiphyseal fractures around the knee, to identify the technical issues and fine tune the indications. MATERIAL AND METHODS Following the initiative of the French Hip and Knee Society (SFHG) and the Traumatology Study Group (GETRAUM), 26 charts from eight different centers in France were included in this multicenter retrospective series. Inclusion criteria were: primary total knee arthroplasty (TKA) in the management of complex articular fractures involving the proximal end of the tibia or distal end of the femur. Surgical features were identified and complications were analyzed. The assessment protocol at last follow-up was standardized and included patient demographic data, analysis of the Parker and IKS scores. RESULTS During the immediate postoperative period, six patients (23%) reported a general complication and four patients (15%) a local arthroplasty-related complication. At last follow-up (mean 16.2 months), the overall final Parker score was 6.3 (a mean decrease of 1.7) and the mean IKS knee score was 82 points for a mean function score of 54 points. DISCUSSION Primary TKA is a suitable management option for complex fractures in autonomous elderly patients suffering from knee osteoarthritis. The key technical details of this procedure should be respected and meticulously planned to achieve optimal results and limit the risk of complications. This risk in these acute complex fractures remains higher than after conventional TKA but comparable to that observed after TKA for post-traumatic arthritis. LEVEL OF EVIDENCE IV; retrospective cohort study.
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Affiliation(s)
- S Parratte
- Orthopaedic and Arthritis Surgery Center, Surgical Center for Osteoarthritis treatment, Pr Argenson's Department, St Marguerite Hospital, 270, boulevard Sainte-Marguerite, 13009 Marseille, France.
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Evangelopoulos DS, Heitkemper S, Eggli S, Haupt U, Exadaktylos AK, Benneker LM. Percutaneous cement augmentation for the treatment of depression fractures of the tibial plateau. Knee Surg Sports Traumatol Arthrosc 2010; 18:911-5. [PMID: 20012938 DOI: 10.1007/s00167-009-1003-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2009] [Accepted: 11/13/2009] [Indexed: 11/26/2022]
Abstract
The management of insufficiency fractures of the tibial plateau in osteoporotic patients can be very challenging, since it is difficult to achieve a stable fixation, an essential condition for the patients' early mobilization. We present a minimally invasive technique for the treatment of proximal tibial plateau fractures, "tibiaplasty", using percutaneous polymethylmethacrylate augmentation. Five osteoporotic patients (7 fractures) with a non-traumatic insufficiency tibial plateau fracture were treated with this technique at the authors' institution from 2006 to 2008. The patients' median age was 79 (range 62-88) years. The intervention was performed percutaneously under general or spinal anesthesia; after the intervention, immediate full weight bearing was allowed. The technique was feasible in all patients and no complications related to the intervention were observed. All patients reported a relevant reduction in pain, were able to mobilize with full weight bearing and would undergo the operation again. No secondary loss of reduction or progression of arthrosis was observed in radiological controls; no revision surgery was required. Our initial results indicate that tibiaplasty is a good treatment option for the management of insufficiency in tibial plateau fractures in osteoporotic patients. The technique is minimally invasive, safe and allows immediate mobilization without restrictions. In our group of patients, we found excellent early to mid-term results.
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Affiliation(s)
- D S Evangelopoulos
- Department of Orthopedic Surgery, Inselspital, University of Bern, 3010, Bern, Switzerland
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Frattini M, Vaienti E, Soncini G, Pogliacomi F. Tibial plateau fractures in elderly patients. Musculoskelet Surg 2009; 93:109-14. [PMID: 19876712 DOI: 10.1007/s12306-009-0038-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Accepted: 10/09/2009] [Indexed: 10/20/2022]
Abstract
Tibial plateau fractures are complex injuries which, if not adequately treated, can lead to invalidating sequelae. They constitute on average about 1% of all fractures, and up to 8% in patients over 65 years, and can be caused by both high- and low-energy trauma. Unlike in younger subjects, treatment of tibial plateau fractures in the elderly is not univocal and depends on the patient's functional needs, bone quality and systemic comorbidities. In this retrospective study, 49 patients with a mean age of 72 years, who underwent surgical treatment of a tibial plateau fracture, were assessed by the Rasmussen's clinical and radiological grading systems. Clinical and radiographic outcomes were satisfactory in 75.5 and 59.1% of cases, respectively. Data were also analyzed, in terms of fracture type, age and gender, to detect any statistically significant correlation between these parameters and clinical and radiographic outcomes.
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Affiliation(s)
- Marco Frattini
- Section of Orthopedic, Traumatology and Functional Rehabilitation, Department of Surgical Sciences, University of Parma, Parma Hospital, Parma, Italy
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Severely comminuted bicondylar tibial plateau fractures in geriatric patients: a report of 2 cases treated with open reduction and postoperative external fixation. J Orthop Trauma 2008; 22:652-7. [PMID: 18827597 DOI: 10.1097/bot.0b013e318188d6a2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
We present 2 cases of C3-type fractures of the tibial plateau in geriatric patients. Our treatment concept--in particular the use of postoperative external fixation--is not yet described in the recent literature and includes initial external fixation, internal fixation after soft tissue consolidation using a median incision, filling of the metaphyseal comminution zone with allogenic cancellous bone obtained from a femoral head, anteromedial and anterolateral fixed-angle double plating, and external fixation postoperatively until osseous healing. The described treatment plan does not provide a valid alternative for the treatment of bicondylar fractures in younger patients. It may be an option for the treatment of C3-type fractures in geriatric patients only.
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Bovine cancellous xenograft in the treatment of tibial plateau fractures in elderly patients. INTERNATIONAL ORTHOPAEDICS 2008; 33:779-84. [PMID: 18365191 DOI: 10.1007/s00264-008-0526-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2008] [Accepted: 01/28/2008] [Indexed: 10/22/2022]
Abstract
The objective was to evaluate the efficacy of xenografts to improve the outcomes in elderly patients with tibial plateau fractures. Nineteen cases with a mean age of 74 years were followed prospectively from 1998 to 2003. Six patients each belonged to Schatzker types III, IV and V and one patient belonged to type II. Open reduction with fixation and xenograft impaction was carried out. Clinical and radiological union was assessed including infection rate, incorporation of the xenograft and average collapse of the fracture. The average union time was 20 weeks. No patient had wound infection and all had excellent incorporation of the xenograft with union. The average collapse was 4 mm on follow-up. This series shows the use of only an xenograft in acute fixation of these fractures with favourable outcome. Furthermore, it reduces operative time, bleeding and associated co-morbidities, which is of more significance in an elderly age group.
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Partenheimer A, Gösling T, Müller M, Schirmer C, Kääb M, Matschke S, Ryf C, Renner N, Wiebking U, Krettek C. [Management of bicondylar fractures of the tibial plateau with unilateral fixed-angle plate fixation]. Unfallchirurg 2007; 110:675-83. [PMID: 17497119 DOI: 10.1007/s00113-007-1271-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND This study was initiated to evaluate early results of a locked screw plate for unilateral fixation of bicondylar fractures of the tibial plateau. Emphasis was laid on malreduction, secondary loss of reduction, union rate, and infection. MATERIAL AND METHODS A case series of patients with AO/ASIF 41-C type fractures treated with the less invasive stabilization system for the proximal lateral tibia (LISS PLT) were prospectively followed up until 11-13 months after surgery. Malreduction and malalignment were defined as an intra-articular step-off of 2 mm or more or as a malalignment in the frontal or sagittal plane of more than 5 degrees. RESULTS Sixty-eight patients with 69 fractures were involved. Fourteen fractures were open. Primary bone grafting was performed in 13 patients. Significant malreduction was seen in 16 patients. Sixty-two (91%) patients returned for follow-up. All but one fracture healed eventually. The number of infections was low (4 superficial, 1 deep). Nine patients had a significant loss of reduction. Of 54 patients outcome scores were good to excellent in 47 patients on the Lysholm score (average 87.2) and in 44 patients on the Rasmussen score (average 26.7). CONCLUSION We concluded that unilateral locked screw plating is a good alternative in the treatment of problematic fractures of the tibial plateau that are associated with soft tissue damage and metaphyseal comminution. The reduction technique for exact alignment is demanding.
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Rademakers MV, Kerkhoffs GMMJ, Sierevelt IN, Raaymakers ELFB, Marti RK. Operative treatment of 109 tibial plateau fractures: five- to 27-year follow-up results. J Orthop Trauma 2007; 21:5-10. [PMID: 17211262 DOI: 10.1097/bot.0b013e31802c5b51] [Citation(s) in RCA: 173] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To analyze the long-term (5-27 years) functional and radiologic results of surgically treated fractures of the tibial plateau. DESIGN Retrospective study. SETTING University hospital. PATIENTS AND METHODS Two hundred two consecutive tibial plateau fractures were included in this study. All fractures were classified according to both the AO and the Schatzker classification. There were 112 men and 90 women. The mean age at injury was 46 years (16 to 88). One hundred sixty-three patients had isolated fractures and 39 had multiple fractures. A 1 year follow-up was done in all 202 patients. One hundred nine of these patients also had an additional long-term follow-up visit. Functional results of these 109 patients were graded with the Neer- and HSS-knee scores. Radiologic results were graded with the Ahlbäck score. Statistical analysis was performed by means of the SPSS data analysis program. RESULTS An uneventful union was present at the 1 year follow-up in 95% of the patients, along with a mean knee ROM of 130 degrees (range, 10-145 degrees). One hundred nine patients had a long-term follow-up visit after a mean period of 14 years (range, 5-27 years). The mean ROM at this time was 135 degrees (range, 0-145 degrees). Functional results showed a mean Neer score of 88.6 points (range, 56-100 points) and a mean HSS score of 84.8 points (range, 19-100 points). Monocondylar fractures showed statistically significant better functional results compared to bicondylar fractures. In 31% of the patients, secondary osteoarthritis had developed but was well tolerated in most (64% of the patients). Patients with a malalignment of more then 5 degrees developed a moderate to severe grade of osteoarthritis statistically significant more often (27% of the patients) compared to patients with an anatomic knee axis (9.2%; MWU, P = 0.02). Age did not appear to have any influence on the results. CONCLUSION Long-term results after open reduction and internal fixation for tibial plateau fractures are excellent, independent of the patient's age.
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Affiliation(s)
- M V Rademakers
- Academic Medical Center, Department of Orthopaedic Surgery, Amsterdam, The Netherlands. [corrected]
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41
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Nourissat G, Hoffman E, Hémon C, Rillardon L, Guigui P, Sautet A. [Total knee arthroplasty for recent severe fracture of the proximal tibial epiphysis in the elderly subject]. ACTA ACUST UNITED AC 2006; 92:242-7. [PMID: 16910606 DOI: 10.1016/s0035-1040(06)75731-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE OF THE STUDY Bone comminution, serious cartilage damage, and the poor mechanical quality of osteoporotic bone create a difficult challenge for osteosynthesis of joint fractures in the elderly subject. Poor results with certain hip, elbow and shoulder fractures have lead certain authors to propose emergency arthroplasty in selected cases. We report our experience with four knee arthroplasties implanted for recent severe fracture of the proximal tibial epiphysis in elderly subjects. MATERIAL AND METHODS Four independent patients aged over 75 years presented a severe comminutive fracture of the proximal epiphysis of the tibia (Three Schatzker 5, one Schatzker 4). After obtaining the patients' informed consent, early knee arthroplasty was performed. A long-stem cemented tibial piece was used on which the epiphysis was reconstructed. Implants providing support for ligament deficits were used in all cases. Immediate weight-bearing was authorized. RESULTS Follow-up ranged from two to seven years. The IKS function score (15, 60, 100, 100) depended on the patient's general status. The IKS knee score was excellent for three knees (90, 95, 95), and fair in one (45). Re-operations were not needed in any of the patients. All x-rays showed bone healing with correctly aligned limbs (less than 2 degrees deformation). There were no lucent lines at last follow-up. DISCUSSION Early arthroplasty for complex fractures of the proximal epiphysis of the tibia is a realistic option. Using a cemented long-stem tibial piece ensures primary stability sufficient for early weight-bearing before bone healing. Use of a constrained prosthesis, or better a hinged prosthesis, can be questioned but avoids the difficulty of ligament balance on an osteoporotic knee with a destroyed joint surface. None of the patients required reoperation and the results in terms of pain were excellent. The overall outcome depends on the general status of the patient.
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Affiliation(s)
- G Nourissat
- Service de Chirurgie Orthopédique, Hôpital Saint-Antoine, Paris
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42
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Walz M, Auerbach F, Kolbow B, Junker T. Minimal-invasive Versorgung monokondylärer Tibiakopffrakturen. Unfallchirurg 2006; 109:367-76. [PMID: 16435100 DOI: 10.1007/s00113-005-1052-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Treatment of displaced tibial plateau fractures is often complicated by high-energy trauma and soft tissue damage. Therefore, numerous techniques such as indirect or arthroscopically controlled reduction and percutaneous osteosynthesis have been described to reduce the additional surgical trauma. MATERIAL AND METHODS Twenty-three fractures (AO type 41-B2/3, Schatzker type II-IV) were treated with percutaneous, fluoroscopically guided reduction combined with small fragment osteosynthesis using a radius T-plate. In none of the patient was cancellous bone graft performed. Only in one case was arthrotomy necessary because of uncertain image intensification findings in an obese patient. One revision was done for a 4-mm step caused by an over reduced rim fragment. Fracture healing and full weight bearing were achieved after 8-12 weeks. Neither secondary displacement nor implant loosening was seen under primary functional treatment without immobilization. RESULTS Functional recovery showed a mean ROM of 114 degrees after 6 weeks and 121 degrees after 3 months. The radius T-plate offers enough stability to allow primary functional treatment due to early recovery of joint motion. Percutaneous reduction and small fragment osteosynthesis is a less invasive approach in the treatment of displaced monocondylar tibial plateau fractures.
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Affiliation(s)
- M Walz
- Abteilung für Unfall-, Hand- und Wiederherstellungschirurgie, Klinikum Uelzen.
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43
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Gardner MJ, Yacoubian S, Geller D, Pode M, Mintz D, Helfet DL, Lorich DG. Prediction of Soft-Tissue Injuries in Schatzker II Tibial Plateau Fractures based on Measurements of Plain Radiographs. ACTA ACUST UNITED AC 2006; 60:319-23; discussion 324. [PMID: 16508489 DOI: 10.1097/01.ta.0000203548.50829.92] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Split-depression fractures of the lateral tibial plateau (Schatzker II) are associated with a significant risk of capsuloligamentous and meniscal injury. We hypothesized that the amount of fracture depression and widening on anteroposterior (AP) plain radiographs would correlate with the incidence of injury to these structures on magnetic resonance imaging (MRI). METHODS Sixty-two consecutive patients with Schatzker II tibial plateau fractures had a knee x-ray series and MRI preoperatively. AP plain radiographs were measured for lateral joint line depression and condylar widening, and MRIs were evaluated for injury to soft-tissue structures around the knee. For each structure, the threshold of depression and widening that led to the greatest disparity in soft-tissue injury was determined. Multiple logistic regressions were applied to calculate whether depression and/or widening above the thresholds were predictive for injury to individual soft-tissue structures. RESULTS When depression was greater than 6 mm and widening was greater than 5 mm, lateral meniscal injury occurred in 83% of fractures, compared with 50% of fractures with less displacement (p < 0.05). When either depression or widening was at least 8 mm, medial meniscal injury occurred more frequently (depression 53%, p < 0.05; widening 78%, p < 0.05; versus neither 15%). Lateral collateral ligament and posterior cruciate ligament tears were not seen with minimally displaced fractures (< 4 mm), but the incidence of injury approached 30% with increasing displacement. CONCLUSIONS Due to the limited availability of MRI in some centers, correlation of lateral condylar depression and widening, as measured on plain radiographs, to injury of various soft-tissue structures may be extremely helpful in planning open or arthroscopic treatment methods. Using these guidelines, Schatzker II fractures with depression or widening approaching 5 mm deserve heightened vigilance in diagnosing and treating these concomitant soft-tissue injuries.
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Split Depression Posterolateral Tibial Plateau Fracture: Direct Open Reduction and Internal Fixation. ACTA ACUST UNITED AC 2005. [DOI: 10.1097/01.btk.0000187521.70585.05] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gosling T, Schandelmaier P, Muller M, Hankemeier S, Wagner M, Krettek C. Single lateral locked screw plating of bicondylar tibial plateau fractures. Clin Orthop Relat Res 2005; 439:207-14. [PMID: 16205161 DOI: 10.1097/00003086-200510000-00036] [Citation(s) in RCA: 145] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We prospectively followed a case series of 68 patients with 69 AO/ASIF 41-C-type fractures treated with the Less Invasive Stabilization System for the proximal lateral tibia. We assessed malreduction, secondary loss of reduction, and infection rates in patients with a locked screw plate for unilateral fixation of bicondylar fractures. Sixty-two (91%) patients returned for final followup (range, 11-13 months). Malreduction and malalignment were defined as an intraarticular step-off of 2 mm or greater, or as a malalignment in the frontal or sagittal plane greater than 5 degrees . Fourteen fractures were open. Primary bone grafting was done in 13 patients. Significant malreduction was seen in 16 patients. There were four superficial infections and one deep infection. One fracture did not heal, and nine patients had substantial loss of reduction. Unilateral locked screw plating is a good alternative for treatment of problematic fractures of the tibial plateau that are associated with soft tissue damage and metaphyseal comminution. The reduction technique for exact alignment is demanding.
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Affiliation(s)
- T Gosling
- Hannover Medical School, Hannover, Germany.
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46
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Su EP, Westrich GH, Rana AJ, Kapoor K, Helfet DL. Operative treatment of tibial plateau fractures in patients older than 55 years. Clin Orthop Relat Res 2004:240-8. [PMID: 15123954 DOI: 10.1097/01.blo.0000119247.60317.bc] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Surgical treatment of tibial plateau fractures in the older patient poses an additional challenge because of the underlying condition of the bone and articular surface. We sought to identify risk factors for poorer outcomes in the operative treatment of displaced tibial plateau fractures in older patients. Thirty-nine displaced tibial plateau fractures in patients 55 years and older were treated operatively. Patients were evaluated objectively with Rasmussen clinical and radiologic scoring techniques, and the Short Musculoskeletal Function Assessment and the Short-Form 36 self-assessment instruments. The Rasmussen clinical and radiologic scoring systems, used on average 2.54 years postoperatively, found acceptable results in 87.2% and 82.1% of patients, respectively. The fracture classification of Schatzker was not predictive of results. External fixation was associated with significantly poorer results. Increasing age was associated with poorer clinical and self-assessment scores, although preexisting degenerative joint disease was not. The results from the Short-Form 36 indices were not significantly worse for our study patients. The average Short Musculoskeletal Function Assessment score of our study patients indicated poorer function for mobility than a normative group. Operative treatment of this injury in this population can result in favorable outcomes as evaluated by clinical, radiographic, and self-assessment criteria.
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Affiliation(s)
- Edwin P Su
- Hospital for Special Surgery-Weill Medical College of Cornell University, New York City, NY 10021, USA
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47
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Ali AM, Burton M, Hashmi M, Saleh M. Treatment of displaced bicondylar tibial plateau fractures (OTA-41C2&3) in patients older than 60 years of age. J Orthop Trauma 2003; 17:346-52. [PMID: 12759639 DOI: 10.1097/00005131-200305000-00005] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To investigate the outcome (clinical, radiographic, and general health status) of the surgical treatment of displaced bicondylar tibial plateau fractures (OTA-41C) in patients >60 years old. DESIGN Prospective cohort study. SETTING Limb reconstruction service, university teaching hospital. PATIENTS Eleven consecutive patients >60 years old with a mean age of 72 years (range 60 to 90 years). The indications for surgery were displaced bicondylar tibial fractures, open fractures, and fractures with severe soft tissue injury. INTERVENTION All patients were treated according to a standard protocol, which involved limited articular reconstruction and percutaneous intrafragmentary screw fixation, followed by neutralization with a stable beam-loading external fixator and early mobilization. MAIN OUTCOME MEASUREMENTS The clinical outcome was assessed using Rasmussen's system and the Iowa knee score. For general health assessment, the anglicized SF-36 was used. Radiographic assessment was performed for redisplacement and angulation on digitized radiographs. RESULTS After a mean follow-up of 38 months (range 18 to 51 months), bony union was achieved in all patients. Seven of 11 patients started full weight bearing 2 to 6 weeks postoperatively. According to Rasmussen's system, 9 of 11 (82%) scored satisfactory results. Radiographic redisplacement was found in three severely comminuted cases resulting in >/=10 degrees of valgus malunion. One patient received a corrective osteotomy while still in the fixator. Another needed TKA. Limited knee flexion was found in three patients with cross knee fixation. Superficial pin site infection occurred in five patients, but there were no cases of deep infections or septic arthritis. CONCLUSIONS All-ring external fixation, as a beam-loading system applied in a neutralizing mode, is a safe, stable, and reliable technique for the treatment of displaced bicondylar tibial plateau fractures in elderly patients.
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Affiliation(s)
- Ahmad M Ali
- Oldchurch Hospital, Romford, Essex, United Kingdom.
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Lobenhoffer P, Gerich T, Witte F, Tscherne H. Use of an injectable calcium phosphate bone cement in the treatment of tibial plateau fractures: a prospective study of twenty-six cases with twenty-month mean follow-up. J Orthop Trauma 2002; 16:143-9. [PMID: 11880775 DOI: 10.1097/00005131-200203000-00001] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the potential benefit of a new injectable mineral bone cement (Norian SRS, Cupertino, CA, USA) for the treatment of tibial plateau fractures OTA types 41.B2-B3 and C3. DESIGN Prospective study with established protocol. SETTING University hospital; university teaching hospital. PATIENTS Twenty-six patients gave informed consent to participate in this study and were available for follow-up examinations. All patients had sustained intraarticular tibial plateau fracture types OTA B2-B3 and C3. All cases were followed with a mean follow-up time of 19.7 months (6 to 36 months, median eighteen months). INTERVENTION Twenty-five cases were treated with open reduction, osteosynthesis with screws or plate, and injection of Norian SRS in the subchondral bone defect. One case had closed reduction, screw osteosynthesis, and percutaneous cement injection. MAIN OUTCOME MEASUREMENTS Radiographs in two planes were evaluated prospectively at six, twelve, and twenty-six weeks postoperatively and at last follow-up using Rasmussen's radiologic score. Clinical parameters were measured at the same time intervals using Lysholm's and Tegner's knee scores. RESULTS Two cases required early wound revisions because of sterile drainage. Two cases developed partial loss of reduction of the fracture between four and eight weeks after surgery, requiring revision surgery in one case (total complication rate 15.3 percent). No other patients had complications, and all other fractures healed without any displacement. The high mechanical strength of the cement allowed early weight bearing after a mean postoperative period of 4.5 weeks (1 to 6 weeks). CONCLUSIONS An injectable mineral bone cement with high initial mechanical strength was used to fill bone defects in unstable tibial plateau fractures with good success. This material offers new perspectives in the treatment of tibial plateau fractures.
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Affiliation(s)
- P Lobenhoffer
- Department for Trauma and Reconstructive Surgery, Henriettenstiftung Hannover, Germany
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49
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Ali AM, Yang L, Hashmi M, Saleh M. Bicondylar tibial plateau fractures managed with the Sheffield Hybrid Fixator. Biomechanical study and operative technique. Injury 2001; 32 Suppl 4:SD86-91. [PMID: 11812481 DOI: 10.1016/s0020-1383(01)00165-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The two main challenges in the management of bicondylar tibial plateau fractures are: Firstly, the compromised skin and soft tissue envelope which invite a high rate of complications following attempted open reduction and dual plating. Secondly, poor bone quality and comminuted fracture patterns, which create difficulty in achieving stable fixation. Although dual plating is considered to be the best mechanical method of stabilizing these complex fractures, there remains concern regarding the high rate of complications associated with extensive soft tissue dissection, required for the insertion of these plates in an already compromised knee. The Sheffield Hybrid fixator (SHF) technique offers a solution to the two main problems of these difficult fractures by minimizing soft tissue dissection, since bone fragments are reduced and fixed percutaneously, and providing superior cancellous bone purchase with beam loading stabilization for comminuted fractures. Our biomechanical testing showed the SHF with four tensioned wires to be as strong as dual plating and able to provide adequate mechanical stability in the fixation of bicondylar tibial plateau fractures. This was confirmed clinically by a prospective review of the use of the SHF at our centre, for managing complex and high-energy tibial plateau fractures with a good final outcome and no cases of deep infection or septic arthritis.
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Affiliation(s)
- A M Ali
- Academic Orthopaedic and Traumatic Surgery Unit, Limb Reconstruction Service, Clinical Sciences Centre, Northern General Hospital NHS Trust, University of Sheffield, Herries Road, Sheffield S5 7AU, UK
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Roerdink WH, Oskam J, Vierhout PA. Arthroscopically assisted osteosynthesis of tibial plateau fractures in patients older than 55 years. Arthroscopy 2001; 17:826-31. [PMID: 11600979 DOI: 10.1016/s0749-8063(01)90005-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the end results of arthroscopically assisted osteosynthesis of tibial plateau fractures in patients older than 55 years of age. TYPE OF STUDY Case series. METHODS Over a 5-year period, 201 consecutive patients presented with tibial plateau fracture; 131 of these patients were treated with arthroscopically assisted osteosynthesis of the tibial plateau. Inclusion in the retrospective analysis was limited to those patients older than 55 years at the time of injury and those who were available for follow-up at the time of the study. Thirty patients met these criteria. RESULTS Secondary displacement occurred in 9 patients (30%) within 12 weeks after surgery. After a median follow-up of 3 years, 24 of 30 patients (80%) had an excellent or good clinical result according to the modified Rasmussen criteria. There was no difference in clinical outcome between the patients with or without secondary displacement of the fracture. CONCLUSIONS Given the good clinical results, arthroscopically assisted osteosynthesis has been shown to be highly efficient in the treatment of tibial plateau fractures in the elderly.
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Affiliation(s)
- W H Roerdink
- Department of Surgery, University Hospital Groningen, Groningen, The Netherlands.
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