Function and Knee Range of Motion Plateau Six Months following Lateral Tibial Plateau Fractures

Development and Validation of a Mobile Phone Application for Measuring Knee Range of Motion

Knee range of motion (ROM) is an important indicator of knee function. Outside the clinical setting, patients may not be able to accurately assess knee ROM, which may impair recovery following trauma or surgery. This study aims to validate a smartphone mobile application developed to measure knee ROM compared to visual and goniometer ROM measurements. A knee ROM Android mobile application was developed to measure knee ROM. Patients ≥ 18 years old presenting to an orthopaedic clinic with native knee complaints were approached to participate. Knee ROM was measured bilaterally by an arthroplasty-trained surgeon using (1) vision, (2) goniometer, and (3) the mobile application. Measurements were compared in flexion and extension using a one-way analysis of variance with post hoc Tukey test (alpha = 0.05). Eighty-four knee ROM measurements (40 left, 44 right) were obtained in 47 patients. Median Kellgren-Lawrence grade from available radiographs was grade 3. In flexion, mobile application (117.6 ± 14.7 degrees) measurements were not significantly different from visual (116.1 ± 13.6 degrees) or goniometer (116.2 ± 13.6 degrees) measurements. In extension, mobile application (4.8 ± 7.3 degrees) measurements were significantly different from visual (1.9 ± 4.1 degrees) measurements on post hoc analysis (p < 0.01), while no differences were present compared to goniometer (3.1 ± 5.8 degrees) measurements. Our study found that a mobile application for evaluating knee ROM was noninferior to goniometer-based measurements performed by an arthroplasty-trained surgeon. Future studies will investigate this application's utility in (1) remote patient care, (2) accelerating recovery during rehabilitation, (3) detecting early postoperative complications including arthrofibrosis, and (4) adding additional functionalities to the application to provide more detail-oriented descriptive analyses of patient knee function.

Radiographic Evidence of Early Posttraumatic Osteoarthritis following Tibial Plateau Fracture Is Associated with Poorer Function

To determine if radiographic evidence of posttraumatic osteoarthritis (PTOA) following tibial plateau fracture correlates with poorer clinical and functional outcomes, patients with tibial plateau fractures were followed at 3, 6, and 12 months. All patients had baseline radiographs and computed tomography scan. Radiographs obtained at each follow-up were reviewed for healing, articular incongruence, hardware positional changes, and the development of postinjury arthritic change. Cohorts were determined based on the presence (PTOA) or absence (NPTOA) of radiographic evidence of PTOA. Demographics, fracture classification, complications, additional procedures, and functional status were compared between cohorts. Sixty patients had radiographic evidence of PTOA on follow-up radiographs at a mean final follow-up of 24.2 months. The NPTOA cohort was composed of 210 patients who were matched to the PTOA cohort based on age and Charlson comorbidity index. Mean time to fracture union for the overall cohort was 4.86 months. Cohorts did not differ in Schatzker classification, time to healing, injury mechanism, or baseline Short Musculoskeletal Function Assessment (SMFA). Patients with PTOA had a greater degree of initial depression and postoperative step-off, higher incidence of initial external fixator usage, higher rates of reoperation for any reason, and higher rates of wound complications. Associated soft tissue injury and meniscal repair did not coincide with the development of PTOA. Range of motion and SMFA scores were significantly worse at all time points in patients with PTOA. Although fracture patterns are similar, patients who required an initial external fixator, had a greater degree of initial depression or residual articular incongruity, underwent more procedures, and developed an infection were found to have increased incidence of PTOA. Radiographic evidence of osteoarthritis correlated with worse functional status in patients. The goal of surgery should be restoration of articular congruity and stability to mitigate the risk of PTOA, although this alone may not prevent degenerative changes. Patients with early loss of range of motion should be aggressively treated as this may precede the development of PTOA.

Soft tissue injury prediction using joint depression in computed tomography in AO 41B lateral tibial plateau fractures

Tibial plateau fractures are usually associated with soft tissue injury. This study aimed to use the extent of joint depression and lateral widening in computed tomography (CT) to predict the soft tissue injury accompanying fractures.The study included 23 patients with type Arbeitsgemeinschaft für Osteosynthesefragen-classified 41B fractures. Demographics, mechanism of injury, age, gender, and injury sites were assessed. Post-traumatic radiography, magnetic resonance imaging (MRI), and CT were obtained. MRI evaluated the meniscal, cruciate, and collateral ligament injuries, and CT measured the extent of joint depression and lateral widening in millimeters using digital imaging software. The relationship between joint depression, lateral widening, and soft tissue injuries was statistically analyzed. Of the 23 patients, 17 (74%) were males and 6 (26%) were females. Lateral meniscus injuries increased and the risk of bucket handle lateral meniscus tears increased as the CT joint depression exceeded 12 mm (p < 0.05). Joint depression of <5.9 mm was associated with medial meniscus injury (p < 0.05). The mean distribution examination of all soft tissue injuries and joint depression revealed no statistically significant difference between the groups (p > 0.05). Increased joint depression in lateral tibial plateau fractures increases the risk of lateral meniscus bucket handle tear, and decreased joint depression increases the risk of medial meniscus injury. Accordingly implementing the treatment plan and patient management will improve the clinical outcomes.

Effects of Surgical Treatment Guided by the Three-Column Classification Method on Knee Joint Function and Postoperative Complications in Patients with Tibial Plateau Fractures

Many patients with tibial plateau fractures present with various degrees of soft tissue contusion and severely damaged articular surface, ligament, and vascular nerves, and thus how to treat this kind of patient has become one of the great difficulties in clinical practice. Therefore, we aim to investigate the effects of surgical treatment guided by the three-column classification method on knee joint function and postoperative complications in patients with tibial plateau fractures. A total of 120 patients with three-column tibial plateau fractures admitted to our hospital from January 2018 to January 2019 were selected and divided into group A (n = 60) and group B (n = 60). Among them, the group A patients were treated with an anterior lateral approach in floating positions combined with reduction plate internal fixation with an L-shaped approach in the posteromedial joint, while the patients in group B received reduction plate internal fixation with a knee midline incision in supine positions. After that, the perioperative indexes, knee function scores, the MOS item short-from health survey (SF-36) scores, complication rate (CR), and overall treatment efficacy of the patients were compared between the two groups. The perioperative indexes in group A were significantly better than those in group B (P < 0.001); the knee function scores and SF-36 scores in group A were significantly higher than those in group B (P < 0.001); the CR in group A was significantly lower than that in group B (P < 0.001); the treatment efficacy in group A was significantly better than that in group B (P < 0.05). The three-column classification method, with highly instructive significance in tibial plateau fracture surgery, can improve treatment efficacy and reduce the incidence of complications, which is worthy of application and promotion in clinical practice.

Is It Necessary To Add Soft Tissue Injury to the Classification in Tibial Plateau Fracture Management?

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.

[Open reduction and internal fixation with plate via posteromedial approach of retaining pes anserinus tendon in the treatment of tibial plateau fracture]

OBJECTIVE

To compare the effects of cutting and retaining the pes anserinus tendon on effectiveness following tibial plateau fracture.

METHODS

A clinical data of 40 patients with tibial plateau fracture treated with open reduction and internal fixation with plate via posteromedial approach between January 2015 and January 2020 was retrospectively analyzed, including 18 patients retained the pes anserinus tendon (study group) and 22 patients cut the pes anserinus tendon (control group) during operation. There was no significant difference in gender, age, side of affected knee, cause of injury, Schatzker classification, time from injury to operation, and associated ligament injury between the two groups ( P>0.05). The operation time, intraoperative blood loss, hospital stay, anatomic reduction rate, incidence of complications, fracture healing time, knee flexion and extension range of motion at 2 weeks and 12 months, and knee extension range of motion at 3 months after operation were recorded and compared between the two groups. The visual analogue scale (VAS) score was used to evaluate the early postoperative pain improvement at 1, 3, and 14 days after operation and hospital for special surgery (HSS) score was used to evaluate the improvement of knee function at 3, 6, and 12 months after operation.

RESULTS

The patients in both groups were followed up 12-15 months with an average of 12.8 months. There was no significant difference in operation time, intraoperative blood loss, and fracture healing time between the two groups ( P>0.05). The hospital stay in the control group was significantly longer than that in the study group ( t=8.339, P=0.000). There was no significant difference in the anatomic reduction rate (90.9% vs. 83.3%) between the control group and the study group ( χ ²=0.058, P=0.810). There were 1 case of proximal tibial osteomyelitis, 3 cases of skin necrosis, 3 cases of traumatic arthritis, and 2 cases of lower deep venous thrombosis after operation in the control group, and 1 case of metaphyseal nonunion, 2 cases of traumatic arthritis, and 1 case of lower deep venous thrombosis in the study group, showing no significant difference in the incidence of complications (40.9% vs. 22.2%) between the two groups ( χ ²=1.576, P=0.209). In the study group, knee flexion and extension range of motion at 2 weeks and 12 months and knee extension range of motion at 3 months after operation were significantly better than those of the control group ( P<0.05). VAS scores and HSS scores in both groups improved with time after operation ( P<0.05), in addition, the HSS score and VAS score of the study group were significantly better than those of the control group ( P<0.05).

CONCLUSION

Compared with traditional pes anserinus tendon cutting group, pes anserinus tendon retaining group can significantly reduce postoperative short-term pain, improve postoperative knee range of motion and knee function within 1 year after operation.

Bone metabolism is a key factor for clinical outcome of tibial plateau fractures

Purpose

Given that tibial plateau fractures (TPF) are rare, they may pose a challenge to the treating surgeon due to their variety of complex fracture patterns. Numerous studies have identified potential fracture-specific, surgery-related, and patient-related risk factors for impaired patient outcomes. However, reports on the influence of bone metabolism on functional outcomes are missing.

Methods

In a retrospective multicenter cohort study, 122 TPF of 121 patients were analyzed with respect to radiological and clinical outcomes (Rasmussen) with a mean follow-up of 35.7 ± 24.9 months. The risk factor assessment included bone metabolism-affecting comorbidities and medication.

Results

The findings showed that 95.9% of the patients reported a good-to-excellent clinical outcome, and 97.4% reported a good-to-excellent radiological outcome. Logistic regression revealed that potentially impaired bone metabolism (IBM) was an independent risk factor for the clinical (p = 0.016) but not the radiological outcome (Table 4). Patients with 41-type B fractures and a potential IBM had a seven times higher risk to present a fair-to-poor clinical outcome [OR 7.45, 95 CI (4.30, 12.92)]. The most common objective impairment was a limited range of motion in 16.4% of the patients, especially in 41-type C fractures (p = 0.06). The individual failure analysis additionally identified surgery-related options for improvement.

Conclusion

This study demonstrated that potential IBM was an independent risk factor for a poor-to-fair clinical outcome.

Intraarticular osteotomy of malunited tibial plateau fractures: an analysis of clinical results with a mean follow-up after 4 years

Purpose

Malunions are a common complication after tibial plateau fractures (TPF), leading to stiffness, pseudo-instability and posttraumatic osteoarthritis. The purpose of this study was to analyse the clinical outcome after intraarticular osteotomy of malunited TPF and to perform a failure analysis.

Methods

Between 2013 and 2018, 23 patients (11 males, 12 females; 43.8 ± 12.8 years) with intraarticular osteotomy after malunited TPF were included in the retrospective study. Clinical examination and postoperative scores were collected with a minimum follow-up of 24 months. Malunion was measured on pre- and postoperative CT scans and localized according to the 10-segment classification while the leg axis in the frontal plane was measured pre- and postoperatively on long leg standing radiographs.

Results

Excellent and good clinical outcome was achieved in 73.9% (n = 17) of the cases and patient related outcome improved significantly (Tegner 3.3 ± 1.6–5 ± 1.8, p < 0.001; clinical Rasmussen 14.6 ± 3.8–24.9 ± 4.4, p < 0.001). Radiological parameters also improved as an intraarticular step-off was reduced from 9 ± 3.8 to 0.6 ± 0.8 mm (p < 0.001) and a lower limb malalignment from 7.2 ± 4.8° to 1.5 ± 1.9° (p = 0.003). Failure analysis showed that an impaired clinical result correlated with a postoperative extension (n = 3, p < 0.001) and flexion deficit (n = 4, p = 0.035).

Conclusion

Intraarticular osteotomy of malunited TPF lead to good clinical results with significant clinical and radiological improvement in most cases while an impaired patient outcome correlated with a limited range of motion. This study is the first failure analysis of intraarticular osteotomy after malunited TPF published up to now.