Five-Year Risk of Conversion to Total Knee Arthroplasty After Operatively Treated Periarticular Knee Fractures in Patients Over 40 Years of Age

Tibial plateau fractures are associated with poor functional outcomes and a low conversion rate to total knee arthroplasty

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.

Distal femur fractures: basic science and international perspectives

Distal femur fractures are challenging injuries to manage, and complication rates remain high. This article summarizes the international and basic science perspectives regarding distal femoral fractures that were presented at the 2022 Orthopaedic Trauma Association Annual Meeting. We review a number of critical concepts that can be considered to optimize the treatment of these difficult fractures. These include biomechanical considerations for distal femur fixation constructs, emerging treatments to prevent post-traumatic arthritis, both systemic and local biologic treatments to optimize nonunion management, the relative advantages and disadvantages of plate versus nail versus dual-implant constructs, and finally important factors which determine outcomes. A robust understanding of these principles can significantly improve success rates and minimize complications in the treatment of these challenging injuries.

Risk for total knee arthroplasty after tibial plateau fractures: a systematic review

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.

Mismatch between Clinical-Functional and Radiological Outcome in Tibial Plateau Fractures: A Retrospective Study

BACKGROUND

The evaluation of tibial plateau fractures (TPF) encompasses the assessment of clinical-functional and radiological parameters. In this study, the authors aimed to investigate the potential correlation between these parameters by utilizing both the clinical-functional and the modified radiological Rasmussen score.

METHODS

In this retrospective monocentric study conducted at a level-I trauma center, patients who underwent surgery between January 2014 and December 2019 due to a TPF were included. The clinical-functional Rasmussen score prior to the injury, at 1-year postoperatively, and during the last follow-up (minimum 18 months) was assessed using a standardized questionnaire. Additionally, the modified radiological Rasmussen score was determined at the 1-year postoperative mark using conventional radiographs in two planes.

RESULTS

A total of 50 patients were included in this study, comprising 40% (n = 20) men, and 60% (n = 30) women, with an average age of 47 ± 11.8 years (range 26-73 years old). Among them, 52% (n = 26) had simple fractures (classified according to Schatzker I-III), while 48% (n = 24; according to Schatzker IV-VI) had complex fractures. The mean follow-up was 3.9 ± 1.6 years (range 1.6-7.5 years). The functional Rasmussen score assessed before the injury and at follow-up showed an "excellent" average result. However, there was a significant difference in the values of complex fractures compared to before the injury. One year postoperatively, both the clinical-functional score and the modified radiological score demonstrated a "good" average result. The "excellent" category was more frequently observed in the functional score, while the "fair" category was more common in the radiological score. There was no agreement between the categories in both scores in 66% of the cases.

CONCLUSIONS

The data from this retrospective study demonstrated that patients with TPF are able to achieve a nearly equivalent functional level in the medium-term after a prolonged recovery period, comparable to their pre-injury state. However, it is important to note that the correlation between clinical-functional and radiological parameters is limited. Consequently, in order to create prospective outcome scores, it becomes crucial to objectively assess the multifaceted nature of TPF injuries in more detail, both clinically and radiologically.

High Prevalence of Persistent Measurable Postoperative Knee Joint Laxity in Patients with Tibial Plateau Fractures Treated by Open Reduction and Internal Fixation (ORIF)

The development of post-traumatic osteoarthrosis after tibial plateau fracture (TPF) is multifactorial and can only be partially influenced by surgical treatment. There is no standardized method for assessing pre- and postoperative knee joint laxity. Data on the incidence of postoperative laxity after TPF are limited. The purpose of this study was to quantify postoperative laxity of the knee joint after TPF. Fifty-four patients (mean age 51 ± 11.9 years) were included in this study. There was a significant increase in anterior-posterior translation in 78.0% and internal rotation in 78.9% in the injured knee when compared to the healthy knee. Simple fractures showed no significant difference in laxity compared to complex fractures. When preoperative ligament damage and/or meniscal lesions were present and surgically treated by refixation and/or bracing, patients showed higher instability when compared to patients without preoperative ligament and/or meniscal damage. Patients with surgically treated TPF demonstrate measurable knee joint laxity at a minimum of 1 year postoperatively. Fracture types have no influence on postoperative laxity. This emphasizes the importance of recognizing TPF as a multifaceted injury involving both complex fractures and damage to multiple ligaments and soft tissue structures, which may require further surgical intervention after osteosynthesis.

Risk Factors for Nonunion of Distal Femur Fractures

OBJECTIVES

To determine patient, fracture, and construct related risk factors associated with nonunion of distal femur fractures.

DESIGN

Retrospective cohort study.

SETTING

Academic Level I trauma center.

PARTICIPANTS

Patients 18 years and older presenting with OTA/AO 33A and 33C distal femur fractures from 2004 to 2020. A minimum follow-up of 6 months was required for inclusion. OTA/AO 33B and periprosthetic fractures were excluded, 438 patients met inclusion criteria for the study.

MAIN OUTCOMES

The primary outcome of the study was fracture nonunion defined as a return to the OR for management of inadequate bony healing. Patient demographics, comorbidities, injury characteristics, fixation type, and construct variables were assessed for association with distal femur fracture nonunion. Secondary outcomes include conversion to total knee arthroplasty, surgical site infection, and other reoperation.

RESULTS

The overall nonunion rate was 13.8% (61/438). The nonunion group was compared directly with the fracture union group for statistical analysis. There were no differences in age, sex, mechanism of injury, Injury Severity Score, and time to surgery between the groups. Lateral locked plating characteristics including length of plate, plate metallurgy, screw density, and working length were not significantly different between groups. Increased body mass index [odds ratio (OR), 1.05], chronic anemia (OR, 5.4), open fracture (OR, 3.74), and segmental bone loss (OR, 2.99) were independently associated with nonunion. Conversion to total knee arthroplasty (TKA) ( P = 0.005) and surgical site infection ( P < 0001) were significantly more common in the nonunion group.

CONCLUSION

Segmental bone loss, open fractures, chronic anemia, and increasing body mass index are significant risk factors in the occurrence of distal femoral nonunion. Lateral locked plating characteristics did not seem to affect nonunion rates. Further investigation into the prevention of nonunion should focus on fracture fixation constructs and infection prevention.

LEVEL OF EVIDENCE

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

A review of Risk Factors for Post-traumatic hip and knee osteoarthritis following musculoskeletal injuries other than anterior cruciate ligament rupture

Post-traumatic osteoarthritis (PTOA) is a common form of osteoarthritis that might occur after any joint trauma. Most PTOA publications mainly focus on anterior cruciate ligament (ACL) injuries. However, many other traumatic injuries are associated with PTOA, not only for the knee but also for the hip joint. We aim to identify and summarize the existing literature on the musculoskeletal injuries associated with knee and hip PTOA and their risk factors in determining those with a worse prognosis, excluding ACL injuries. Despite the narrative nature of this review, a systematic search for published studies in the last twenty years regarding the most relevant injuries associated with a higher risk of PTOA and associated risk factors for OA was conducted. This review identified the six more relevant injuries associated with knee or hip PTOA. We describe the incidence, risk factors for the injury and risk factors for PTOA of each. Meniscal injury, proximal tibial fracture, patellar dislocation, acetabular, femoral fractures and hip dislocations are all discussed in this review.

Risk Factors for Wound Complications Following Conversion TKA after Tibial Plateau Fracture

INTRODUCTION

The purpose is to investigate the incidence of wound complications for total knee arthroplasty (TKA) following tibial plateau open reduction and internal fixation (ORIF).

MATERIALS AND METHODS

A prospective arthroplasty registry was queried for patients with CPT codes for primary TKA, tibial plateau ORIF, removal of hardware (ROH), and diagnosis of post-traumatic arthritis. Patients were included if they had undergone tibial plateau ORIF and subsequent TKA. Chart review was performed to obtain demographic, clinical and post-operative information.

RESULTS

Twenty-one patients were identified, with average age of 56.23 ± 13.2 years at time of tibial plateau ORIF and 62.91 ± 10.8 years at time of TKA. Seven (33.3%) patients had a tibial plateau fracture-related infection (FRI). Eight (38.1%) patients underwent ROH prior to TKA. Seven (33.3%) patients' TKA incision incorporated the prior plateau incisions. Eight (36.4%) patients developed wound complications following TKA and 5 (23.8%) developed an acute periprosthetic joint infection (PJI) following TKA and had the plateau incision incorporated into the TKA incision. FRI history did not increase the rate of wound complications but did increase the rate of ROH prior to TKA.

CONCLUSIONS

Previous FRI involving tibial plateau repair surgery doesn't correlate with PJI after conversion TKA for post traumatic OA. Surgeon-controlled factors such as staged ROH and incision placement can help reduce the rate of wound complications following TKA performed after tibial plateau ORIF.

LEVEL OF EVIDENCE

Prognostic Level IV.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-022-00709-1.

Conversion Total Knee Arthroplasty After Tibial Plateau Fixation Is Associated With Lower Reimbursement, Greater Complication Rates, and Similar Opioid Use

Objective

Total knee replacement after previous open reduction and internal fixation for tibial plateau fracture (conversion total knee) increases the complexity of the procedure and the complication rate. However, very little research exists to report on opioid use and cost associated with total knee arthroplasty (TKA) following tibial plateau fracture fixation as compared to primary TKA patients with no history of tibial plateau fracture. The aim of this study is to compare the differences in opioid use, reimbursements, and complication rates between patients with and without a history of tibial plateau fracture undergoing TKA.

Methods and materials

This is a retrospective large database review study. The study included patients across the country and in various clinical settings including, but not limited to, institutions, primary and tertiary care centers, and private practice. The PearlDiver database was reviewed for patients undergoing TKA between 2010 and 2019. Patients who underwent TKA following surgical repair of a tibial plateau fracture were identified using Common Procedural Terminology (CPT) codes and the appropriate International Classification of Diseases Ninth and Tenth Revision (ICD-9, ICD-10) codes. This group was then matched by age, gender, Charleston Comorbidity Index (CCI) score, Elixhauser Comorbidity Index (ECI) score, obesity, tobacco use, and diabetes to a group of similar patients who underwent TKA with no history of tibial plateau fracture. Opioid use over the episode of care, evaluated by morphine milligram equivalents (MME), and 30-day reimbursed cost were compared between groups using an unequal variance t-test. Complication rates at 30 days, 90 days, and one year postoperatively, and revision rates at one and two years postoperatively were compared using the odd’s ratio (OR) with 95% confidence intervals (95%CI).

Results

The episode of care cost for TKA was significantly lower for patients with a history of tibial plateau fracture ($11,615 ± $15,704) than it was for patients without a history of tibial plateau fracture ($16,088 ± $18,573) (p = 3.56E-14). At 30 days after knee arthroplasty, patients with a history of tibial plateau fracture had significantly more episodes of dehiscence (OR 2.665 [95% CI 1.327-5.351]; p = 0.006) and surgical site infection (SSI) (OR 1.698 [95% CI 1.058-2.724]; p = 0.028), which was significant at 90 days postop for both dehiscence (OR 1.358 [95% CI 0.723-2.551]; p = 0.001) and SSI (OR 1.634 [95% CI 1.100-1.802]; p = 0.015), as well as mechanical complications of the implant device (OR 2.420 [95% CI 1.154-5.076]; p = 0.019). There was no significant difference in the number of opioids prescribed postoperatively to patients with a history of tibial plateau fracture (2218 ± 3255 MME) compared to those without prior tibial plateau fracture (2400 ± 4843 MME) (p = 0.258). However, there was a small but statistically significant increase in the number of days postoperatively patients with a history of tibial plateau fracture were prescribed opioids (11.99 ± 7.73 days) compared to non-tibial plateau fracture patients (11.15 ± 7.18 days) (p = 0.004).

Conclusion

Patients with a history of tibial plateau fracture who then underwent conversion TKA have a lower reimbursed cost of TKA but a higher postoperative risk for dehiscence, mechanical complications, and surgical site infections. There is no significant difference in postoperative opioid use between the two groups.

Radiological Outcome Measures Indicate Advantages of Precontoured Locking Compression Plates in Elderly Patients With Split-Depression Fractures to the Lateral Tibial Plateau (AO41B3)

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.

Characteristics of patients requiring early total knee replacement after surgically treated lateral tibial plateau fractures-A comparative cohort study

PURPOSE

The primary aim of the present study was to compare basic characteristics of patients requiring early treatment with TKR and patients not requiring TKR within 3 years following a lateral tibial plateau fracture.

METHODS

Comparative cohort study. From December 2013 to November 2016, 56 patients were included. Five patients required a TKR within the first 3 years. We compared the basic characteristics (age, gender, BMI, comorbidity, osteoporosis, fracture classification, soft tissue injuries and trauma mechanism) between patients.

RESULTS

Comparing baseline characteristics of the two groups of patients shows a higher rate of females (56.4% vs 80%), a higher BMI (25.9 vs 29.9), a higher rate of patients with diabetes (8% vs 20%), a higher rate of the fracture type AO 41-B1 (8% vs 80%) and a higher rate of soft tissue injuries (46% vs 100%). Age, smoking status and preoperative maximum joint depression were comparable between the two groups.

CONCLUSIONS

Female gender, severe comorbidity, obesity, osteopenia, fracture type AO 41-B and soft tissue injuries were associated to early total knee replacements following surgically treated lateral tibial plateau fractures.