A combined prone and supine approaches for complex three column tibial plateau fracture with posterolateral articular injury

Treatment of a collapse fracture of the anterolateral tibial plateau with a lateral locking plate and the Jail screw technique

BACKGROUND

To explore the advantages of a lateral tibial locking plate combined with Jail screw fixation in the treatment of anterolateral tibial plateau collapse fracture (ATPCF).

METHODS

A retrospective analysis was conducted on patients with ATPCFs admitted to our hospital from February 2019 to February 2023. Twenty-six patients were successfully included, including 15 males and 11 females, with an average age of 58.6 ± 7.8 years (range 45-68 years). All fractures were Schatzker type II fractures. After fracture reduction and fixation, a lateral locking titanium plate was placed through the anterolateral approach of the tibial plateau, and two screws of appropriate length were placed in the sagittal direction according to the Jail screw technique. Postoperative evaluation indices included surgery time, fracture healing time, the degree of tibial plateau collapse shown by computed tomography (CT) images at 3 days and 1 year after surgery, and the patient's knee range of motion at 1 year after surgery. The effects of fracture reduction and fixation before surgery, 3 days after surgery and 1 year after surgery were evaluated by the Rasmussen radiological score. The Hospital for Special Surgery (HSS) knee score was used to evaluate the knee joint function of patients at 1 year after surgery.

RESULTS

The average operation time was 64 ± 6.8 min (range 56-82 min). The fractures healed clinically at 13.8 ± 2.8 weeks (range 12-18 weeks) postoperation. After 15 ± 3.1 months (range 12-19 months) of average follow-up, all the patients were pain-free with a full range of motion and stable knees. At the 1-year postoperative assessment, the CT images showed no secondary collapse of the articular surface, the average knee range of motion was 136.3 ± 2.5° (range, -5° to 135°), the average Rasmussen radiological score was 16.2 ± 0.8 points, and the average HSS knee score was 93.6 ± 3.2 points.

CONCLUSIONS

The fixation of a anterolateral tibial plateau collapse fracture(ATPCF) using a lateral locking plate and the Jail screw technique has achieved good knee joint function, providing a new option for the treatment of ATPCFs. The clinical efficacy is satisfactory in the short term, avoiding secondary articular surface collapse.

Modified Oblique Lobenhoffer (MOL) approach for posterolateral and posteromedial column access in tibial plateau fractures: a detailed cadaveric anatomical study

BACKGROUND

Tibial plateau fractures involving posteromedial (PM) and posterolateral (PL) columns are complex injuries that require an appropriate approach. The management of the PL column in these cases can be controversial, and limitations using deep posteromedial interval approaches have been referenced. In this paper, a modification of the Lobenhoffer approach, designed to optimize the access to the PL column, is described in detail. The aim of this study was to assess the feasibility of this approach in a cadaveric anatomical study.

MATERIALS AND METHODS

In total, five fresh-frozen cadaveric specimens were used for detailed anatomical study surrounding the approach. Relationships with cutaneous and deep neurovascular structures were evaluated. The exposure area of the PL and PM columns using this approach was assessed.

RESULTS

The cadaveric study showed safe and adequate exposure. Oblique skin and fascia incision just medial to the posterior midline was safe to protect the medial sural cutaneous nerve and the small saphenous vein. Elevation of the popliteus and tibialis posterior muscles offered safe protection of the anterior tibial artery and popliteal neurovascular bundle during retractor placement. Adequate full proximal exposure of the PM and PL columns, including the posterolateral lateral (PLL) and posterolateral central (PLC) segments, was obtained in all specimens.

CONCLUSIONS

The Modified Oblique Lobenhoffer (MOL) approach can be a feasible option to access PL and PM columns in tibial plateau fractures.

LEVEL OF EVIDENCE

IV.

Limb position affects intraoperative assessment of condylar width

PURPOSE

We sought to define how changes in position and rotation of fluoroscopic imaging may affect the assessment of condylar widening intraoperatively.

METHODS

Thirty-three patients with tibial plateau fractures were prospectively identified and included in this study. Fluoroscopic images of the uninjured tibial plateau were obtained in (1) full extension and (2) slight flexion on foam ramp. Beginning with a plateau view, additional views of the tibial plateau were then obtained by rotating the fluoroscope around the knee in 5 degree increments up to 15 degrees in both internal and external rotation. Measurements of distal femoral condylar width (DFW), distal femoral articular width (FAW), proximal tibial articular width (TAW) and lateral plateau width (LPW) were performed.

RESULTS

LPW was decreased in flexion compared to extension at all degrees of rotation (p = 0.04-0.00001). There was a trend toward increasing LPW with increasing degrees of internal rotation which reached significance at 15˚ of internal rotation when the knee was flexed. On ANOVA, there was a significant difference of LPW with increasing degree of internal rotation when the knee was in flexion (p = 0.008), but not in extension. There were no differences in DFW, FAW, TAW and DFW/TAW at any point though LPW was decreased in flexion at all degrees of rotation. The FAW/TAW ratio was increased in flexion at all degrees of rotation.

DISCUSSION

The knee in flexion will underestimate the measurement of condylar width compared to the knee in full extension, by ~ 2 mm. Rotation of the knee, in comparison, did not have a significant effect on condylar width assessment.

LEVEL OF EVIDENCE

Diagnostic II.

Clinical Analysis of the Frosch Approach in the Treatment of Posterolateral Tibial Plateau Fractures Combined with Lateral Tibial Plateau Fractures

OBJECTIVE

The treatment of posterolateral tibial plateau fractures is difficult, and providing sufficient exposure and effective fixation is a challenge. There is great controversy regarding the surgical approach for posterolateral tibial plateau fractures. The purpose of the study was to investigate the clinical effects of open reduction and internal fixation using the Frosch approach for the treatment of posterolateral tibial plateau fractures combined with lateral tibial plateau fractures.

METHODS

Data from 19 patients with posterolateral tibial plateau fractures combined with lateral tibial plateau fractures treated from May 2018 to January 2022 were retrospectively analyzed. There were nine men and 10 women, ranging in age from 22 to 62 years, with an average age of 45.6 years. All patients were treated using the Frosch approach. Under direct vision, the posterolateral and lateral fractures were reduced, and full bone grafting was performed. We reshaped the oblique "T" shaped plate for the distal radius and placed it on the posterolateral tibial plateau to fix the posterolateral fractures. The lateral inverted "L" shaped locking plate was placed on the lateral tibial plateau to fix the lateral tibial plateau fractures. Within 2 weeks after the operation, the patients were instructed to perform knee joint function exercises within 90°. At the last follow-up, the Rasmussen radiological criteria were used to evaluate the effectiveness of fracture reduction and fixation. And the knee joint function was evaluated using Rasmussen functional score.

RESULTS

The operation time ranged from 100 to 180 min, with an average of 134.2 min; intraoperative blood loss ranged from 20 to 150 mL, with an average of 66.8 mL. The follow-up duration ranged from 14 to 58 months, with an average of 36.2 months. There were no complications, such as vascular or nerve injury or incision infection. Fracture healing was achieved in all patients, and the healing time ranged from 10 to 14 weeks, with an average of 11.2 weeks. During the follow-up period, there was no loosening or breakage of the internal fixation, varus or valgus deformity of the knee joint, re-collapse of the articular surface, or instability of the knee joint. At the last follow-up, the effectiveness of fracture reduction and fixation was excellent in 13 patients and good in six patients. And the knee joint function was excellent in 17 patients and good in two patients.

CONCLUSION

The Frosch approach for open reduction and internal fixation in the treatment of posterolateral tibial plateau fractures combined with lateral tibial plateau fractures has a definite clinical benefit and is worthy of promotion and application.

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.

Comparative Analysis of Posterior Approach Versus Anterior Approach for Posterior Tibial Plateau Fractures: A Systematic Review and Meta-analysis

BACKGROUND

Posterior tibial plateau fractures can lead to significant posttraumatic instability if not treated properly. It remains unclear which surgical approach achieves better patient outcomes. The objective of this systematic review and meta-analysis was to assess postoperative outcomes in patients undergoing anterior, posterior, or combined approach for posterior tibial plateau fractures.

METHODS

The PubMed, Embase, Web of Science, The Cochrane Library, and Scopus were searched for studies published before October 26, 2022, comparing anterior, posterior, or combined approaches for posterior tibial plateau fractures. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Outcomes included complications, infections, range of motion (ROM), operation time, union rates, and functional scores. Significance was set at p < 0.05. Meta-analysis was conducted with STATA software.

RESULTS

In total, 29 studies with a total of 747 patients were included for quantitative and qualitative analysis. Compared with other approaches, the posterior approach for posterior tibial plateau fractures was associated with a better ROM and shorter operative time. The complication rates, infection rates, union time, and hospital for special surgery (HSS) scores were not significantly different between surgical approaches.

CONCLUSIONS

The posterior approach for posterior tibial plateau fractures offers advantages such as improved ROM and shorter operative time. However, there are concerns regarding prone positioning in patients with medical or pulmonary comorbidities and indications in polytrauma cases. Further prospective studies are needed to determine the optimal approach for these fractures.

LEVEL OF EVIDENCE

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

Supine Posterior Hoop Plating of Bicondylar Posterior Coronal Shear Tibial Plateau Fractures Without Fibular Osteotomy

Tibial plateau posterolateral fragments, especially those associated with articular depression, are difficult to capture and support with anteriorly or lateral based implants. Applying implants to the posterior plateau has traditionally involved a prone approach or fibular osteotomy, especially when access to both the medial and lateral sides is necessary, such as a bicondylar posterior coronal shear fracture pattern. By combining two previously described techniques for posterolateral rim plating and bicondylar hoop plating, we describe a novel technique to apply a posterior bicondylar hoop implant in the supine position without fibular osteotomy for bicondylar posterior coronal shear injuries.

The flexibility and convenience of using a standard orthopaedic table in peri-articular knee fractures: Allowing ligamentotaxis and improving imaging accessibility

Tibial plateau and distal femoral fractures are common injuries presenting a significant operative challenge. Complexity of the fracture often needs multi-planar surgical access. A combined two-staged procedure is frequently suggested both in supine and prone position to address this issue. However, this will significantly increase the operative time and eventually impact the outcome, in addition to the complications associated with prone positioning. In this study we used a standard orthopaedic table to position these patients in order to grant access to the postro-medial and a postro-lateral structures while the patient stays in supine setup, at the same time, giving the flexibility to change the alignment from valgus to varus and vice versa. This facilitates fracture reduction while addressing the anatomical structure of the knee. A further advantage is the unobstructed imaging access throughout the surgical fixation. This facilitates the reduction in operative time hence leading to a better outcome in these difficult fractures. We tested this positioning technique in more than 40 patients over a 4-year period at two different centres in the United Kingdome. We found that this approach is safe, reproducible and relatively easy to set up in the two centres.

A proposal of a new algorithm for decision-making approaches in open reduction and internal fixation of complex tibial plateau fractures - SOTA algorithm (Spanish Orthopaedic Trauma Association)

INTRODUCTION

The correct choice of surgical approaches in complex tibial plateau fractures is essential to achieve adequate reduction and fixation. Detailed fracture morphology and direction of columns displacement, that we have named the Main Deformity Direction (MDD), may aid in selecting the optimal surgical strategy. In this article we present a new algorithm based on MDD and column concepts. The aim of this study was to evaluate the outcomes of a group of tibial plateau fractures treated according to this algorithm. The secondary aim was to evaluate the incidence of the different MDD in our multicolumnar subgroup.

PATIENTS AND METHODS

Excluding isolated lateral one-column fractures, open fractures and patients not treated following this algorithm, 72 patients with tibial plateau fractures surgically treated with open reduction and internal fixation were collected retrospectively, from three trauma centers, from January 2015 to April 2019. Radiological assessment was performed to establish the columns involved and the MDD. Quality and maintenance of reduction and alignment, complications and functional outcomes were assessed.

RESULTS

Initial fracture analysis was performed in 72 patients (8 one-column, 35 two-column and 29 multicolumnar fractures). In the multicolumnar group, the posteromedial MDD was the most frequent pattern (17 of 29 patients). Four patients were excluded due to loss of follow-up, resulting 68 patients for final outcome analysis (7 one-column, 34 two-column and 27 multicolumnar). The average follow-up was 18 months (range: 6-52). Excellent/good outcomes were obtained in all one-column, 31 of 34 two-column and 25 of 27 multicolumnar fractures. Incomplete reduction was present in three patients. As complications, we had two loss of reduction, one conversion to knee arthroplasty, one nonunion and one deep infection. No patient presented neurological or vascular problems, knee instability or extension deficit.

CONCLUSION

Satisfactory results have been obtained following the principles of our algorithm. In addition to the anatomical involvement of columns and segments, we believe that identifying the Main Deformity Direction (MDD) provides useful information for decision-making, especially in multicolumnar fractures. The most frequent MDD in our multicolumnar subgroup was the posteromedial MDD, but more than one-third presented a different MDD, requiring different surgical strategies.