Tibial plateau fracture management: arthroscopically-assisted versus ORIF procedure - clinical and radiological comparison

[Translated article] Risk factors for infection of tibial plateau fractures

INTRODUCTION

Tibial plateau fractures are injuries prone to postoperative infection, with its reported incidence being higher than that of other fractures, between 5% and 12%. The primary objectives of this study were to quantify the postoperative infection rate of internal fixation of tibial plateau fractures (TPFs) and to identify the risk factors for this.

MATERIAL AND METHODS

Retrospective cohort study including patients who underwent TPF osteosynthesis between 2015 and 2020, in the same center. The study population was divided into two groups, according to the presence or absence of postoperative infection. Demographic variables related to the fracture, surgical parameters, as well as the need for reoperation were collected. Finally, in the case of debridement, the number of positive cultures and the pathogen responsible for the infection were collected, as well as the treatment applied.

RESULTS

One hundred and twenty-four patients were included, with a total of 14 infections (global infection rate of 11.3%). Risk factors for developing infection were open fractures (p=.002), Schatzker V and VI type fractures (p=.002) and the use of external fixation (p<.001). Regarding the surgical variables, only the longest ischemia time (p=.032) was identified as a risk factor. Staphylococcus aureus was the most frequently identified microorganism (43%), followed by Enterobacter cloacae (35.7%).

CONCLUSION

The overall infection rate after osteosynthesis of tibial plateau fractures was 11.3%. Different factors are associated with a higher risk of infection, including diabetes mellitus, open fractures, the use of external fixation, a higher grade in the Schatzker classification or a longer intraoperative ischemia time.

Risk factors for infection of tibial plateau fractures

INTRODUCTION

Tibial plateau fractures are injuries prone to postoperative infection, with its reported incidence being higher than that of other fractures, between 5% and 12%. The primary objectives of this study were to quantify the postoperative infection rate of internal fixation of tibial plateau fractures (TPF) and to identify the risk factors for this.

MATERIAL AND METHODS

Retrospective cohort study including patients who underwent TPF osteosynthesis between 2015 and 2020, in the same center. The study population was divided into two groups, according to the presence or absence of postoperative infection. Demographic variables related to the fracture, surgical parameters, as well as the need for reoperation were collected. Finally, in the case of debridement, the number of positive cultures and the pathogen responsible for the infection were collected, as well as the treatment applied.

RESULTS

One hundred and twenty-four patients were included, with a total of 14 infections (global infection rate of 11.3%). Risk factors for developing infection were open fractures (P=.002), Schatzker V and VI type fractures (P=.002) and the use of external fixation (P<.001). Regarding the surgical variables, only the longest ischemia time (P=.032) was identified as a risk factor. S. aureus was the most frequently identified microorganism (43%), followed by E. cloacae (35.7%).

CONCLUSION

The overall infection rate after osteosynthesis of tibial plateau fractures was 11.3%. Different factors are associated with a higher risk of infection, including diabetes mellitus, open fractures, the use of external fixation, a higher grade in the Schatzker classification or a longer intraoperative ischemia time.

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.

The use of arthroscopy does not increase the incidence of complications in the management of Schatzker IV-VI tibial plateau fractures

BACKGROUND AND OBJECTIVE

The use of arthroscopy for tibial plateau fractures type I, II and III according to Schatzker classification has increased, yet its employment for tibial plateau fractures Schatzker IV, V and VI is controversial due to the potential risk of compartment syndrome, deep vein thrombosis and infection. We aimed to compare the rate of operative and postoperative complications among patients with these types of tibial plateau fractures treated with and without arthroscopy at the time of definitive reduction and osteosynthesis.

METHODS

Retrospective cohort study. Patients with diagnosis of tibial plateau fracture Schatzker IV, V or VI who underwent reduction and definitive osteosynthesis with or without the use of arthroscopy were included. The development of compartment syndrome, deep vein thrombosis, and fracture-related infection was evaluated up to 12 months after the definitive surgery.

RESULTS

Two hundred eighty-eight patients were included: 86 with arthroscopic assistance and 202 without it. The overall complication rate in the group with and without arthroscopic assistance was 18.60% and 26.73%, respectively (P=.141). No statistical association was found between the use of arthroscopic assistance and the development of the analyzed complications.

DISCUSSION AND CONCLUSION

The use of arthroscopy to support reduction or addressing concomitant intra-articular injuries did not increase the risk of complications in patients with high-energy tibial plateau fractures at 12 months of follow up.

[Translated article] The use of arthroscopy does not increase the incidence of complications in the management of Schatzker IV-VI tibial plateau fractures

BACKGROUND AND OBJECTIVE

The use of arthroscopy for tibial plateau fractures type I, II and III according to Schatzker classification has increased, yet its employment for tibial plateau fractures Schatzker IV, V and VI is controversial due to the potential risk of compartment syndrome, deep vein thrombosis and infection. We aimed to compare the rate of operative and postoperative complications among patients with these types of tibial plateau fractures treated with and without arthroscopy at the time of definitive reduction and osteosynthesis.

METHODS

Retrospective cohort study. Patients with diagnosis of tibial plateau fracture Schatzker IV, V or VI who underwent reduction and definitive osteosynthesis with or without the use of arthroscopy were included. The development of compartment syndrome, deep vein thrombosis, and fracture-related infection was evaluated up to 12 months after the definitive surgery.

RESULTS

Two hundred eighty-eight patients were included: 86 with arthroscopic assistance and 202 without it. The overall complication rate in the group with and without arthroscopic assistance was 18.60% and 26.73%, respectively (p=.141). No statistical association was found between the use of arthroscopic assistance and the development of the analysed complications.

DISCUSSION AND CONCLUSION

The use of arthroscopy to support reduction or addressing concomitant intra-articular injuries did not increase the risk of complications in patients with high-energy tibial plateau fractures at 12 months of follow up.

Arthroscopic-assisted reduction and internal fixation for complex tibial plateau fracture: radiographic and clinical outcomes with 2- to 15-year follow-up

BACKGROUND

To investigate the radiologic and prognostic outcomes after using arthroscopic-assisted reduction and internal fixation (ARIF) in complex tibial plateau fractures with mid- to long-term follow-up.

METHODS

This retrospective study reviewed complex tibial plateau fractures that underwent ARIF from 1999 to 2019. Radiologic outcomes, including tibial plateau angle (TPA), posterior slope angle (PSA), Kellgren-Lawrence classification and Rasmussen radiologic assessment, were measured and evaluated. The prognosis and complications were assessed by the Rasmussen clinical assessment with a minimum follow-up of 2 years.

RESULTS

Ninety-two consecutive patients (mean age: 46.9 years) with a mean follow-up of 74.8 months (24-180) were included in our series. Using AO classification, there were 20 type C1 fractures, 21 type C2 fractures, and 51 type C3 fractures. All the fractures achieved solid union. TPA was maintained well on average at the last follow-up and showed no significant difference compared to postoperatively (p = 0.208). In the sagittal plane, the mean PSA increased from 9.3 ± 2.9° to 9.6 ± 3.1° (p = 0.092). A statistically significant increase in PSA was also noted in the C3 group (p = 0.044). Superficial or deep infection was noted in 4 cases (4.3%), and total knee arthroplasty (TKA) was performed in 2 cases (2.2%) due to grade 4 osteoarthritis (OA). Ninety (97.8%) and 89 (96.7%) patients had good or excellent results in the Rasmussen radiologic assessment and Rasmussen clinical assessment, respectively.

CONCLUSIONS

The complex tibial plateau fracture could be treated successfully using arthroscopy-assisted reduction and internal fixation. Most patients achieve excellent and good clinical outcomes with low complication rates. In our experience, a higher incidence of increased slope was noted, especially in type C3 fractures. Reduction of the posterior fragment should be done cautiously during the operation.

LEVELS OF EVIDENCE

Level III.

Comparison of clinical and radiographic outcomes of arthroscopic-assisted percutaneous fixation versus open reduction internal fixation of lateral tibial plateau fractures

PURPOSE

Treatment for tibial plateau fractures continues to evolve but maintains primary objectives of anatomic reduction of the joint line and a rapid recovery course. Arthroscopic-assisted percutaneous fixation (AAPF) has been introduced as an alternative to traditional open reduction internal fixation (ORIF). The purpose of the study is to compare clinical and radiographic outcomes in patients with low-energy Schatzker type I-III tibial plateau fractures treated with AAPF versus ORIF.

METHODS

A retrospective chart review was performed at a level 1 trauma centre to compare outcomes of 120 patients (57 AAPF, 63 ORIF) with low-energy lateral Schatzker type I-III tibial plateau fractures who underwent tibial plateau fixation between 2009 and 2018. Demographic information, injury characteristics, and surgical treatment were recorded. The main outcome measurements included reduction step-off, joint space narrowing, time to weight bearing, and implant removal.

RESULTS

There was no difference in age, gender distribution, BMI, ASA, Schatzker classification distribution, initial displacement, blood loss, and reduction step-off between the two groups (p > 0.05). Shorter tourniquet time (74.1 ± 21.7 vs 100.0 ± 21.0 min; p < 0.001), shorter time to full weight bearing (47.8 ± 15.2 vs. 69.1 ± 17.2 days; p < 0.001), and lower rate of joint space narrowing (3.5% vs. 28.6% with more than 1 mm, p < 0.001) were associated with the AAPF cohort, with no difference in pain, knee range of motion, or implant removal rate between the two cohorts.

CONCLUSION

AAPF may be a viable alternative to ORIF for the management of low-energy tibial plateau fractures with outcomes not inferior compared to the traditional ORIF method.

Current concepts review. Management of proximal tibial fractures

The management of proximal tibial fractures has evolved significantly in recent years. While the main goals of treatment - stability, restoration of the mechanical axis, and smooth articular surfaces - remain the same, methods have advanced substantially. In diagnostics, technical progress in CT and MR imaging has led to a better three-dimensional understanding of the injury. Newly developed classification systems such as the three-column concept of Luo et al. and the 10-segment concept of Krause et al. take this into account. Accordingly, there is a trend towards tailored approaches for particular fracture localizations. Parallel to this development, there is increasing evidence of the advantages of arthroscopically assisted surgical procedures. This Current Concepts article reviews classifications, diagnostics, treatment options as well as complications in fractures of the proximal tibia.

Outcomes of arthroscopic-assisted lateral tibial plateau fixation: a systematic review

PURPOSE

The purpose of this study is to evaluate and summarize the current literature on outcomes of arthroscopic-assisted tibial plateau fixation (AATPF) when applied for only lateral tibial plateau fractures.

METHODS

A comprehensive search of nine databases was conducted: ClinicalTrials.gov, Cochrane Library via Wiley, Embase and MEDLINE via Ovid, Global Index Medicus, PubMed, Scopus, SPORTDiscus via EBSCO, and Web of Science Core Collection. The study was performed in concordance with PRISMA guidelines. Studies eligible for inclusions included Schatzker I-III lateral tibial plateau fractures with a minimum of 6-month follow-up. Data extraction was performed by two authors independently using a predesigned form.

RESULTS

A total of 17 studies, 7 prospective and 10 retrospective, including 565 patients (age 15-82 years old) treated with AATPF were included in this review with follow-up ranging from 6 to 138 months. All 10 studies that used categorical functional outcomes demonstrated excellent/very good or good outcomes in > 90% of patients. When compared to patients managed with the traditional open reduction internal fixation (ORIF), patients treated with AATPF had statistically significantly better range of motion mean difference [5.21° (95% CI - 2.50 to 12.92, p < 0.0001)], lower blood loss [66.19 mL (95% confidence interval (CI) 32.54-99.84 mL, p < 0.0001)], shorter hospital stay [- 1.41 days (95% CI - 3.39 to 0.58 days, p < 0.0001)], better Hospital Special Surgery score [11.31 (95% CI 6.49-16.12, p < 0.0001)], and higher Rasmussen radiographic score [1.26 (95% CI - 0.72 to 3.23, p < 0.0001)].

CONCLUSION

AATPF is a promising treatment of lateral tibial plateau fractures with some advantages over the traditional ORIF.

LEVEL OF EVIDENCE

Therapeutic Level III.

Arthroscopically Assisted Percutaneous Screw Fixation of Tibial Plateau Fractures

Tibial plateau fractures account for approximately 1% to 2% of fractures in adults¹. These fractures exhibit a bimodal distribution as high-energy fractures in young patients and low-energy fragility fractures in elderly patients. The goal of operative treatment is restoration of joint stability, limb alignment, and articular surface congruity while minimizing complications such as stiffness, infection, and posttraumatic osteoarthritis. Open reduction and internal fixation with direct visualization of the articular reduction or indirect evaluation with fluoroscopy has traditionally been the standard treatment for displaced tibial plateau fractures. However, there has been concern regarding inadequate visualization of the articular surface with open tibial plateau fracture fixation, contributing to a fivefold increase in conversion to total knee arthroplasty². In addition, the risk of wound complications and infection has been reported to be as high as 12%^3,4. Knee arthroscopy with percutaneous, cannulated screw fixation provides a less invasive procedure with excellent visualization of the articular surface and allows for accurate reduction and fracture fixation compared with traditional open reduction and internal fixation techniques¹. Recent studies of arthroscopically assisted percutaneous screw fixation of tibial plateau fractures have reported excellent early clinical and radiographic outcomes and low complication rates^3,5,6.

Description

This technique involves the use of both arthroscopy and fluoroscopy to facilitate reduction and fixation of the tibial plateau fracture. Through a minimally invasive technique, the depressed articular joint surface is targeted with use of preoperative computed tomography (CT) scans and intraoperative biplanar fluoroscopy. Reduction is then directly visualized with arthroscopy and fixation is performed with use of fluoroscopy. Lastly, restoration of the articular surface is confirmed with use of arthroscopy after definitive fixation. Modifications can be made as needed.

Alternatives

The traditional method for fixation of displaced tibial plateau fractures is open reduction and internal fixation. Articular reduction can be visualized directly with an open submeniscal arthrotomy and an ipsilateral femoral distractor or indirectly with fluoroscopy.

Rationale

Visualization of the articular surface is essential to achieve anatomic reduction of the joint line. Inspection of the posterior plateau is difficult with an open surgical approach. Arthroscopically assisted percutaneous screw fixation of a tibial plateau fracture may allow for improved restoration of articular surfaces through enhanced visualization. Less soft-tissue dissection is associated with lower morbidity and may result in less damage to the blood supply, lower rates of infection and wound complications, faster healing, and better mobility for patients. In our experience, this technique has been successful in patients with severe osteoporosis and comminution of depressed fragments. If total knee arthroplasty is required, we have also observed less damage to the blood supply and fewer surgical scars with use of this surgical technique.

Expected Outcomes

Arthroscopically assisted percutaneous screw fixation of a tibial plateau fracture facilitates anatomical reduction through a less invasive approach. Patients undergoing this method of tibial plateau fracture fixation are able to engage earlier in rehabilitation². Studies have shown early postoperative range of motion, excellent patient-reported outcomes, and minimal complications^7,8.

Important Tips

Arthroscopically assisted fixation can be applied to a variety of tibial plateau fractures; however, the minimally invasive approach is best suited for patients with isolated lateral tibial plateau fractures (Schatzker I to III) and a cortical envelope that can be easily restored. The cortical envelope refers to the outer rim of the tibial plateau. Fracture pattern and ligamentotaxis determine the cortical envelope, which can be evaluated on preoperative CT scans. In our experience, even depressed segments with a high degree of comminution may be treated with use of this technique with satisfactory results.Articular depression should be targeted with use of a preoperative CT scan and intraoperative fluoroscopy and arthroscopy.The surgeon should be careful not to "push up" in 1 small area; rather, a "joker" elevator or bone tamp should be utilized, moving anterior to posterior, which can be frequently assessed with arthroscopy.The intra-articular pressure of the arthroscopy irrigation fluid should be low (≤45 mm Hg or gravity flow), and the operative extremity should be monitored for compartment syndrome throughout the procedure.

Acronyms and Abbreviations

ACL = anterior cruciate ligamentK-wires = Kirschner wiresORIF = open reduction and internal fixationAP = anteroposteriorCR = computed radiography.

Outcomes following balloon tibioplasty versus conventional osteosynthesis techniques for Schatzker type III tibial plateau fractures: a systematic review

Introduction

Schatzker type III fractures of the tibial plateau require elevation of the depressed portions to regain articular congruity. Balloon tibioplasty has been used as an alternative to conventional metal instruments for elevation of the lateral tibial plateau. This study compared functional outcomes following balloon tibioplasty or conventional osteosynthesis techniques in patients with type III fractures of the tibial plateau.

Materials and methods

A systematic literature search was performed using PubMed, EMBASE, and Cochrane Library to identify studies published through March 29, 2021, pertaining to balloon tibioplasty or conventional osteosynthesis techniques for type III fractures. Non-human studies, opinion or editorial pieces, systematic reviews, case series (< 5 patients), and articles published in a non-English language were excluded. Primary outcomes were Rasmussen clinical score, range of motion, and Knee Society Score (KSS). A Joanna Briggs Institute (JBI) risk of bias assessment was performed for all studies.

Results

A total of 95 studies were identified, with 10 studies (and 132 total patients) meeting inclusion criteria: 1 study focused on balloon tibioplasty, 8 studies reported outcomes following conventional osteosynthesis, and 1 study compared outcomes of the two techniques. Mean follow-up times varied widely, from 4 to 76.3 months. Where reported, balloon tibioplasty resulted in good to excellent functional outcomes as indicated by Rasmussen clinical scores (mean 28.3 in a case series; mean 28.9 in a randomized controlled trial) and range of motion (≥ 140° in both studies) 1–2 years following surgery. KSS was not reported consistently enough for comparison. Studies ranged from low to high risk of bias according to the JBI assessment.

Conclusions

Balloon tibioplasty can lead to excellent functional outcomes in patients with depression fractures of the lateral tibial plateau. More research is needed to directly compare outcomes following treatment with balloon tibioplasty or conventional osteosynthesis techniques.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-02973-1.

Arthroscopy-Assisted Reduction Percutaneous Internal Fixation Versus Open Reduction Internal Fixation for Tibial Plateau Fracture: A Systematic Review and Meta-analysis

Background:

Arthroscopy-assisted reduction percutaneous internal fixation (ARIF) has emerged recently as an alternative treatment method in treating lower-energy tibial plateau fractures. To date, the comparison of clinical efficacy between ARIF and open reduction internal fixation (ORIF) is limited, with divergent conclusions.

Purpose:

To review studies on the clinical efficacy of ARIF and ORIF in the treatment of tibial plateau fracture.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

A search was conducted using the PubMed, Web of Science, Cochrane Library, and EMBASE databases between inception and August 20, 2020, for retrospective and prospective studies evaluating ARIF versus ORIF in the treatment of tibial plateau fracture. We identified 6 clinical studies that met the inclusion criteria, with 231 patients treated with ARIF and 386 patients treated with ORIF. The risk of bias and the quality of evidence of the included studies were assessed. The 2 treatment types were compared in terms of clinical results and complications by using odds ratios (ORs), mean differences (MDs), or standardized mean differences (SMDs), with 95% confidence intervals (CIs). Heterogeneity among studies was quantified using the I² statistic.

Results:

The quality of the studies was high. Compared with ORIF, treatment with ARIF led to better clinical function (SMD = 0.31; 95% CI, 0.14 to 0.48; I² = 15%; P = .0005), shorter hospital stay (MD = –2.37; 95% CI, –2.92 to –1.81; I² = 0%; P < .001), and more intra-articular lesions found intraoperatively (OR = 3.76; 95% CI, 1.49 to 9.49; I² = 66%; P = .005). There were no complications or significant differences between the techniques in the radiological evaluation of reduction.

Conclusion:

Compared with ORIF, the ARIF technique for tibial plateau fractures led to faster postoperative recovery and better clinical function and the ability to find and treat more intra-articular lesions during the operation. However, the radiological evaluation of reduction and complications were not significantly different between the 2 groups.

Increased Articular Exposure of the Lateral Tibial Plateau with a Midline Lateral Parapatellar Arthrotomy Compared to an Anterolateral Submeniscal Arthrotomy: a Cadaveric Study

PURPOSE

To quantitatively compare the articular exposure of the proximal tibia with a lateral parapatellar arthrotomy through a straight midline incision (ML) versus a lateral submeniscal arthrotomy through a curvilinear anterolateral incision (AL).

METHODS

Eight surgical approaches (4 ML and 4 AL) were performed on 4 fresh cadavers. Access to key articular landmarks was assessed, including divisions of the lateral meniscus, lateral tibial spine, and anterior cruciate ligament. The boundary of the exposed articular surface of the tibia was marked, and the proximal tibias were then stripped of soft tissues. A calibrated digital image was taken of each proximal tibia, and exposed articular surface area was calculated with ImageJ software (NIH, Bethesda, MD). Statistical analysis was performed using a two-sample t-test.

RESULTS

Average articular surface area exposed was 2.2 times greater through the midline approach compared with the anterolateral approach (11.2 vs 5.1 cm², p = 0.010). All key anatomic landmarks were directly visualized through the midline approach in each specimen. Complete visualization of the lateral meniscus posterior horn, lateral tibial spine, and anterior cruciate ligament was not accomplished through the anterolateral approach in any specimen.

CONCLUSIONS

The midline approach provides more extensive articular exposure of the lateral tibial plateau compared with the anterolateral approach. This improved exposure may offer an advantage when treating fractures not amenable to arthroscopic or minimally invasive techniques. It may be of most use when treating fractures with extension into the posteromedial quadrant of the lateral plateau, fractures with extensive comminution of the lateral plateau, or fractures with complex lateral meniscus tears and fractures with tibial spine involvement.

Solving the enigma of posterolateral tibial plateau fractures, the clue protocol

The study aim is to evaluate functional and radio- logical outcomes following a suggested protocol based on the four-column classification for management of posterolateral column tibial plateau fractures. A prospective cohort study was performed in level I academic center on 42 patients with mean age of 36 years (22-59). Eleven patients had isolated posterolateral column fractures whereas 31 patients had associated columns fractures. According to the suggested protocol, all cases of isolated posterolateral column fracture started treatment via arthroscopic evaluation of soft tissue injuries (menisci and liga- ments), arthroscopically assisted reduction and inter- nal fixation by rafting screws followed by ORIF if plating was needed. If associated with other columns fractures, columns were fixed sequentially in an anti-clockwise direction starting from anteromedial column. Average follow up was 26 months. Mean time to union was 16.3 (12-22) weeks. No radiological evidence of loss of coronal or sagittal alignment was detected at final follow up. Five patients had an average depression of 5 millimeters that did not need further intervention at this short-term follow up. Mean KOOS was 81 (72- 88). The average knee range of motion was (0° - 127°). One patient had temporary common peroneal nerve injury, one patient had deep infection and two had superficial wound infection. implementing the suggested protocol gives good to excellent radiological and functional results as regard posterolateral tibial plateau fracture. A larger study group with longer follow up is needed.

A posterolateral sheared fracture of the tibial plateau: a case presentation

Background

Among tibial plateau fractures, one specialized type is the posterolateral column fracture. There are few published studies on posterolateral tibial plateau fractures with a sheared fragment that was wedged into the intercondylar fossa without the anterior cruciate ligament (ACL) rupture. According to our research, this case presentation is the first to describe in detail the treatment and long-term follow-up for this uncommon subtype of posterolateral tibial plateau fracture.

Case presentation

A 46-year-old female injured her right knee when she was riding a motorbike and was diagnosed with a posterolateral sheared tibial plateau fracture with a wedge-shaped fragment inserted into the femoral intercondylar fossa. The fracture was repaired with open reduction internal fixation surgery. The patient’s recovery was followed for four years. The degree of healing as indicated by clinical and radiological examinations was substantial. The patient exhibited an excellent range of motion for the repaired knee (0-145°) and little discomfort. The Lysholm score was 96, the hospital for special surgery score was 98, the Rasmussen clinical assessment was 28, and the Rasmussen radiological assessment was 18.

Conclusion

This study revealed that a posterolateral sheared tibial plateau, as seen in this case, can be reset and fixed sufficiently to achieve excellent long-term postoperative recovery.

Comparison of outcomes of ORIF versus bidirectional tractor and arthroscopically assisted CRIF in the treatment of lateral tibial plateau fractures: a retrospective cohort study

Background

Lateral tibial plateau fractures (TPFs) are often treated with conventional open reduction and internal fixation (ORIF) through standard anterolateral sub-meniscal arthrotomy. There has been increasing support for “bidirectional rapid redactor” device-assisted closed reduction and internal fixation (CRIF) for treating TPFs. The aim of the present study is to compare the clinical and radiological outcomes between CRIF and ORIF procedures.

Methods

We performed a retrospective cohort study of 55 lateral TPF patients (Schatzker types I–III) who accepted surgical treatment at our trauma level 1 center between January 2016 and January 2018. They were divided into the CRIF group (32 patients) and the ORIF group (23 patients) based upon the different surgical protocols. The patients’ clinical outcome analysis was evaluated by using the Knee Society Score (KSS) and Rasmussen’s clinical score. For radiological assessment, changes in tibial plateau width (TPW), articular depression depth (ADD), medial proximal tibial angle (MPTA), and posterior tibial slope angle (PTSA) were evaluated using radiographs and computed tomography (CT) scan.

Results

The CRIF group had a mean follow-up of 28.9 months, and the ORIF group had a mean follow-up of 30.7 months (p>0.05). Furthermore, there was no statistically significant difference in terms of age, gender, injury mechanism, follow-up time, time interval from injury to surgery, and Schatzker classification in the two groups. With respect to the clinical outcomes including the KSS score and Rasmussen’s clinical score, there was also no significant difference (p>0.05). Nevertheless, the CRIF group had lower intra-operative blood loss, shorter hospitalization days, and better range of movement of the knee joint than the ORIF group (p<0.05). Furthermore, CRIF had better radiological results when compared to the ORIF group using Rasmussen’s radiological score (p<0.05), although no significant difference was observed in TPW, ADD, MPTA, and PTSA between the two groups (p>0.05).

Conclusion

The present study showed that CRIF could achieve comparable clinical outcomes and better radiological results for treating lateral TPFs as compared with conventional ORIF.

Trends and Complications of Arthroscopic-Assisted Tibial Plateau Fracture Fixation: A Matched Cohort Analysis

Purpose

To determine trends in arthroscopic-assisted tibial plateau fracture fixation (AATPFF), to evaluate trends in the overall rate of tibial plateau fracture fixation, and to compare postoperative complications between AATPFF and traditional tibial plateau fixation.

Methods

A retrospective review of patients undergoing AATPFF and traditional tibial plateau fixation was conducted using the Humana Inc. administrative database from 2007 to 2016. A 1:1 propensity match was utilized to match patients in the 2 study groups based on age, sex, obesity, diabetes, hypertension, chronic obstructive pulmonary disease, depression or anxiety, and smoking history. Postoperative complications were grouped as minor medical complications, major medical complications, surgical complications, emergency department visits, and reoperation. Linear regression analysis was used to assess trends and Pearson's χ² test was used to compare postoperative complications with statistical significance defined as P < .05.

Results

In total, 522 patients underwent AATPFF and 3920 patients underwent traditional tibial plateau fracture fixation. There was a 4-fold increase in the use of AATPFF over the study period (P = .0173). Similarly, there was an increase in the utilization of traditional tibial plateau fracture fixation, although to a lesser extent (1.33-fold). After propensity matching, the traditional fixation group demonstrated significantly higher rates of minor medical complications (8.2% vs 2.7%, P = .0002), major medical complications (9.9% vs 4.6%, P = .0018), surgical complications (13.2% vs 2.7%, P < .0001), and emergency department visits (21.4% vs 13.5%, P < .0001) within 90 days of surgery compared with the AATPFF group. There was no difference in reoperation rates within 90 days between the 2 groups (2.9% vs 3.6%, P = .85).

Conclusions

The incidence of tibial plateau fracture fixation is increasing, however, use of AATPFF is increasing at a faster rate compared to traditional techniques. Furthermore, the addition of knee arthroscopy to fracture fixation does not increase the risk of complication, reoperation, or emergency department visit within 90 days.

Level of Evidence

III, retrospective matched cohort.

Effect of fracturoscopy on the incidence of surgical site infections post tibial plateau fracture surgery

PURPOSE

Surgical treatment of tibial plateau fracture (TPF) is common. Surgical site infections (SSI) are among the most serious complications of TPF. This multicentre study aimed to evaluate the effect of fracturoscopy on the incidence of surgical site infections in patients with TPF.

METHODS

We performed a retrospective multicentre study. All patients with an AO/OTA 41 B and C TPF from January 2005 to December 2014 were included. Patients were divided into three groups: those who underwent arthroscopic reduction and internal fixation (ARIF), and those who underwent open reduction and internal fixation (ORIF) with fracturoscopy, and those treated with ORIF without fracturoscopy. The groups were compared to assess the effect of fracturoscopy. We characterised our cohort and the subgroups using descriptive statistics. Furthermore, we fitted a logistic regression model which was reduced and simplified by a selection procedure (both directions) using the Akaike information criterion (AIC). From the final model, odds ratios and inclusive 95% confidence intervals were calculated.

RESULTS

Overall, 52 patients who underwent fracturoscopy, 48 patients who underwent ARIF, and 2000 patients treated with ORIF were identified. The rate of SSI was 0% (0/48) in the ARIF group and 1.9% (1/52) in the fracturoscopy group compared to 4.7% (93/2000) in the ORIF group (OR = 0.40, p = 0.37). Regression analyses indicated a potential positive effect of fracturoscopy (OR, 0.65; 95% CI, 0.07-5.68; p = 0.69).

CONCLUSION

Our study shows that fracturoscopy is associated with reduced rates of SSI. Further studies with larger cohorts are needed to investigate this.

LEVEL OF EVIDENCE

Level III.

INTER- AND INTRA-OBSERVER RELIABILITY OF SCHATZKER, AO, AND LUO CLASSIFICATIONS FOR TIBIAL PLATEAU FRACTURES

OBJECTIVE

To verify inter- and intra-observer agreement of three classification systems for tibial plateau fractures - Schatzker, AO/ASIF, and Luo's - among orthopedic surgery residents.

METHODS

This cross-sectional study was conducted with 29 observers. Radiographic and tomographic imaging of the knee of 15 patients presenting with fractures were evaluated. After six weeks, the test was reapplied. The level of agreement was calculated by the Kappa index.

RESULTS

In test 1, inter-observer agreement of all residents, according to the Kappa index, for Schatzker classification was 0.226, for AO 0.431, and Luo's 0.319. In test 2, values were 0.316, 0.333, and 0.347, respectively (p < 0.001). Regarding intra-observer analysis, the mean Kappa indexes of 1^st-year residents were: Schatzker, 0.20; AO, 0.32; and Luo's, 0.3. For 2^nd-year residents, means were: 0.51, 0.58, and 0.38, respectively. As for 3^rd-year, results were 0.42, 0.42, and 0.41, respectively (p < 0.001).

CONCLUSION

AO/ASIF showed a better reproducibility than other classifications, with substantial inter- and intra-observer agreement. We also found a stronger agreement among 2^nd- and 3^rd-year residents. Level of Evidence III, Diagnostic Studies - Investigating a Diagnostic Test.

An Injectable Strong Hydrogel for Bone Reconstruction

For treating bone defects in periarticular fractures, there is a lack of biomaterial with injectable characteristics, tough structure, and osteogenic capacity for providing a whole-structure support and osteogenesis in the defect area. An injectable hydrogel is an ideal implant, however is weak as load-bearing scaffolds. Herein, a new strategy, i.e., an in situ formation of "active" composite double network (DN), is raised for the preparation of an injectable strong hydrogel particularly against compression. As a demonstration, 4-carboxyphenylboronic acid grafted poly(vinyl alcohol) (PVA) is crosslinked using calcium ions to provide a tough frame while bioactive glass (BG) microspheres are associated by poly(ethylene glycol) to obtain an interpenetrated inorganic network for reinforcement. The injected PVA/BG DN hydrogel gains compressive strength, modulus, and fracture energy of 34 MPa, 0.8 MPa, and 40 kJ m^-2 , respectively. Then, the properties can be "autostrengthened" to 57 MPa, 2 MPa, and 65 kJ m^-2 by mineralization in 14 days. In vivo experiments prove that the injected DN hydrogel is more efficient to treat femoral supracondylar bone defects than the implanted bulk DN gel. The work suggests a facile way to obtain a strong hydrogel with injectability, cytocompatibility, and tailorable functionality.

Arthroscopically assisted reduction and internal fixation (ARIF) versus open reduction and internal fixation (ORIF) for lateral tibial plateau fractures: a comparative retrospective study

Background

This study aims to explore if the arthroscopically assisted reduction and internal fixation (ARIF) technique is superior to the traditional open reduction and internal fixation (ORIF) technique in the treatment of tibial lateral plateau fractures.

Methods

Forty patients with tibial plateau fractures (Schatzker type I–III) treated with ARIF or ORIF from 2012 to 2017 were included in this retrospective study. All patients received pre-operative radiographs and CT scans. The patients were divided into two groups (ARIF or ORIF). All patients had a minimum follow-up of 12 months and an average follow-up of 44.4 months. The clinical and radiographic outcomes were evaluated according to the Knee Society Score (KSS) and the modified Rasmussen radiological score.

Results

Satisfactory clinical and radiological results were found in 39 out of 40 (97.5%) patients. KSS and modified Rasmussen radiological score were significantly better in ARIF group. The mean KSS was 92.37 (± 6.3) for the ARIF group and 86.29 (± 11.54) for the ORIF group (p < 0.05). The mean modified Rasmussen radiographic score was 8.42 (± 2.24) for the ARIF group and 7.33 (± 1.83) for the ORIF group (p = 0.104). Worst clinical and radiological results were related to concomitant intra-articular lesions (p < 0.05). Meniscal tears were found and treated in 17 out of 40 (42.5%) patients. The overall complication rate was 10%.

Conclusions

Both ARIF and ORIF provided a satisfactory outcome for the treatment of Schatzker I–III tibial plateau fractures. However, ARIF led to better clinical results than ORIF. No statistically significant differences were found in perioperative complications, radiological results, and post-traumatic knee osteoarthritis.

Level of evidence

Level III

Revisiting the Schatzker classification of tibial plateau fractures

Tibial plateau fractures have a broad spectrum of presentations, depending on the mechanism and energy of the trauma. Many classification systems are currently available to describe these injuries. In 1974, Schatzker proposed a classification based on a two-dimensional representation of the fracture. His classification with the six-principles types became one of the most utilized classification systems for tibial plateau fractures. More than four decades after this original publication, we are revisiting each fracture type in the light of information made available by computed tomography, which today comprises a standard tool in assessing articular fractures. The classification we are proposing relies on the fact that the tibial plateau has two anatomical columns, lateral and medial. We are introducing a virtual equator which splits the articular surface in the coronal plane. The equator divides each column into two quadrants, the anterior (A) and the posterior (P). Unicondylar fracture types (I to IV) have now additional modifiers A (anterior) and P (posterior) to describe the exact spatial location of the primary fracture plane. Bicondylar fracture types (V and VI) have the modifiers (A and P) of the main fracture plane for each column, and lateral (L) and medial (M) to denote the column. We are introducing the concept of the main fracture plane. Recognition of the exact location of the principal fracture plane is essential for preoperative planning of patient positioning, surgical approach and for determining where to apply the hardware to achieve stable fixation. The new three-dimensional classification is based on the template of the original Schatzker classification. It covers the mechanism of the injury, the energy of the trauma, the morphologic characteristics of the fracture and its location in three dimensions.

Arthroscopic-assisted balloon tibioplasty versus open reduction internal fixation (ORIF) for treatment of Schatzker II-IV tibial plateau fractures: study protocol of a randomised controlled trial

INTRODUCTION

Arthroscopic-assisted balloon tibioplasty is an emerging technology that has shown advantages in recovering depression of the articular surface. However, studies evaluating clinical outcomes between arthroscopic-assisted balloon tibioplasty and traditional open reduction internal fixation (ORIF) are sparse. This is the first randomised study to compare arthroscopic-assisted balloon tibioplasty with ORIF, and will provide guidance for treating patients with Schatzker types II, III and IV with depression of the medial tibial plateau only.

METHODS AND ANALYSIS

A blinded randomised controlled trial will be conducted and a total of 80 participants will be randomly divided into either the arthroscopic-assisted balloon tibioplasty group or the ORIF group, at a ratio of 1:1. The primary clinical outcome measures are the knee functional scores, Rasmussen radiological evaluation scores and the quality of reduction based on postoperative CT scan. Secondary clinical outcome measures are intraoperative blood loss, surgical duration, visual analogue scale score after surgery, hospital duration after surgery, complications and 36-Item Short-Form Health Survey score.

ETHICS AND DISSEMINATION

This study has been reviewed and approved by the Institutional Review Board of the Second Affiliated Hospital of Wenzhou Medical University (batch: 2017-12). The results will be presented in peer-reviewed journals after completion of the study.

TRIAL REGISTRATION NUMBER

NCT03327337, Pre-results.