Challenging Surgical Treatment of Displaced Articular Tibial Plateau Fractures: Do Early Knee Radiographic Features Have a Predictive Value of the Mid-Term Clinical Functional Outcomes?

Long-term follow-up of minimally invasive percutaneous plate osteosynthesis with double reverse traction repositor in patients with tibia plateau fracture: an analysis of at least seven years' outcomes

PURPOSE

This study aimed to evaluate long-term radiological and functional outcomes in tibia plateau fractures (TPFs) patients treated using minimally invasive percutaneous plate osteosynthesis (MIPPO) and Double Reverse Traction Repositor (DRTR).

METHODS

We reviewed 85 patients treated with MIPPO and DRTR at our hospital from January 2015 to December 2017. Radiologic outcomes, including tibial plateau angle (TPA), posterior slope angle (PSA), and Kellgren-Lawrence classification, were assessed, while functional outcomes were evaluated using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Short Form (SF)-36, and Hospital for Special Surgery Knee Score (HSS score). Data from medium follow-up (4.39 ± 0.58 years) and final follow-up (7.75 ± 0.53 years) were analyzed with the Wilcoxon signed-rank test.

RESULTS

We included 65 patients with three(4.62%), 26(40.00%), eight(12.31%), six(9.23%), 11(16.92%), and 11(16.92%) were Schatzker I- VI, respectively. The mean follow-up time was 7.75 ± 0.53 years, with surgery performed in 5.72 ± 2.37 days post-injury and mean operation time of 96.72 ± 31.15 min. Short-term complications included two superficial infections (3.08%). Significant improvements in functional outcomes were observed at final follow-up: range of motion was 138.38° ± 8.49°, enhancements in WOMAC scores, HSS knee scores, and SF-36 (P < 0.05). No further progression of osteoarthritis was observed (K-L classification) during seven-year follow-up (P = 0.655).

CONCLUSIONS

MIPPO with DRTR is a promising and safe technique for the TPFs, leading to satisfactory outcomes up to seven years postoperatively, especially in reducing the incidence for knee osteoarthritis.

Positive Results Using Variable Fixation in Medial Opening Wedge High Tibial Osteotomies in Patients with Unilateral Knee Osteoarthritis: An Observational Clinical Investigation

Background: Medial opening wedge high tibial osteotomy (HTO) treats medial knee osteoarthritis by realigning the knee joint, though it still carries quite a high risk of complications. A new Variable Fixation Locking Screw technology, designed to gradually reduce construct stiffness and promote bone healing, aims to address these issues. This observational study evaluates the safety and effectiveness of this innovative approach in improving clinical outcomes. Methods: Data were prospectively collected on a cohort of the first ten consecutive patients (over 18 years of age) who underwent corrective medial opening wedge high tibial osteotomy using Variable Fixation Locking Screws (VFLSs). The procedure followed the standard surgical technique, with osteotomies stabilized using a Tomofix plate and a combination of standard locking screws and VFLSs. This study aimed to evaluate outcomes such as fracture healing, patient safety, and procedural success at 6 and 12 weeks and at 6 months. Results: No complications, side effects, or need for implant removal were observed. By six months, 70% of patients showed radiographic and clinical healing, and 100% of patients achieved full functional recovery without any issues like length discrepancy, instability, pain, or joint stiffness. Conclusions: This first clinical observation study indicates that Variable Fixation Locking Screws are safe and effective for medial opening wedge high tibial osteotomies, showing promising results in reducing the risk of delayed closure or non-closure of the wedge. Further studies with a larger patient population are needed to confirm their effectiveness.

Efficacy of generic versus branded diacerein for treatment of knee osteoarthritis: A randomized control trial

BACKGROUND

Several studies have proved that diacerein effectively treats knee osteoarthritis (OA). All studies used branded diacerein. Recently, generic diacerein has been available in several countries, with limited studies comparing the efficacy of generic and branded diacerein for knee OA treatment.

METHODS

Among 200 eligible patients, 94 were randomized to take a daily 50 mg of generic diacerein (Diaceric®); group A or branded diacerein (Artrodar®); group B for treating mild to moderate knee OA. All patients were assigned 5-visit assessments and followed until 24 weeks. The primary outcome was a visual analog scale (VAS) on the motion. The secondary outcomes were 2 patient-report outcome measures (PROMs): the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index and the Short Form-12 (SF-12), as well as 3 performance-based measures (PBMs): 5-time sit to stand test (5 × SST), the time up and go test (TUGT), and the 3-minute walk test (3MWT).

RESULTS

There were 47 patients in group A and 47 in group B, with no patients lost for FU. Among all patients, 79.8% were female with a mean age of 63.2 years in group A and 64.8 years in group B. The Kellgren and Lawrence (KL) grade II was the most common in both groups. There were no differences in all demographic data. At 24-week follow-up (FU), both groups had significantly improved VAS, with a 12-week earlier improvement in the branded diacerein. In addition, the PBMs, including 5 × SST and 3MWT, significantly improved from 12-week FU in both groups, with insignificantly improved WOMAC and SF-12 and no serious adverse events in either group.

CONCLUSION

After a 24-week FU, the generic diacerein had similar efficacy as the branded diacerein in significantly improving VAS and PBMs: 5 × SST and 3MWT. However, the latter had a faster statistically improved VAS than the former.

Eosinophil-to-Lymphocyte Ratio and Eosinophil Count as New Predictive Markers for Osteoarthritis

Purpose

Despite the association between peripheral blood inflammatory biomarkers and a range of inflammatory diseases, the role of these biomarkers in osteoarthritis (OA) progression remains unclear. Additionally, whether alterations in these inflammatory markers impact the prognosis of OA patients remains an understudied area. The aim of our study was to investigate the specific associations between peripheral blood inflammatory markers and OA progression and OA-related mortality.

Methods

Data were obtained from the National Health and Nutrition Examination Survey (NHANES) database from 1999 through 2018. The primary outcomes were all-cause mortality, cardiac mortality, and renal disease mortality, with information on the corresponding mortality rates for each participant obtained through association with the National Death Index (NDI). Multivariate logistic regression models were used to examine the relationship between peripheral blood lymphocyte counts and OA, and restricted cubic spline (RCS) analysis was utilized to assess whether there was a nonlinear relationship with OA and mortality of OA patients. Interaction and stratified analyses were employed to explore the association between peripheral blood leukocyte counts and OA.

Results

This study included 1077 OA patients and 21,612 non-OA participants. In model 3 fully adjusted for covariates, eosinophil-to-lymphocyte ratio (ELR) and eosinophil (EOS) were positive risk factors promoting the development of OA (OR = 3.26, 95% CI: 1.49-7.14; OR = 1.79, 95% CI: 1.12-2.88). In stratified models for age, sex, BMI, smoking status, and alcohol consumption, the associations of ELR and EOS with OA were significantly different. RCS curves showed a J-shaped relationship between ELR and EOS and all-cause mortality in patients with OA. ELR was also found to significantly up-regulate cardiac mortality and renal mortality in patients with OA (OR = 3.92, 95% CI: 1.68-9.14; OR = 22.55, 95% CI: 6.55-77.70), while EOS was only significantly positively correlation (OR = 3.68, 95% CI: 1.94-7.01).

Conclusion

A significant relationship was found between ELR, EOS and OA. In addition, ELR and EOS were identified as potential predictors of mortality from different causes in patients with OA.

Clinical outcomes of arthroscopic suture fixation combined with loop plate vs. posterior approach open reduction and cannulated screw fixation for treating tibial avulsion fractures of the posterior cruciate ligament: a retrospective study

Background

Comparison of the efficacy of arthroscopic suture fixation combined with loop plate vs. the posterior approach involving open reduction and intramedullary nail fixation in treating posterior cruciate ligament tibial avulsion fractures (PCLTAFs).

Methods

A retrospective analysis was conducted on the clinical data of patients diagnosed with PCLTAF who were admitted to Northern Jiangsu People's Hospital between June 2019 and March 2022. Based on distinct surgical procedures, the patients were categorized into two groups: arthroscopic group (33 cases), involving a single bone tunnel, high-strength suture, loop plate, and anchor screw fixed under arthroscopy, and open reduction and internal fixation (ORIF) group (13 cases), involving a modified posterior medial approach and fixation using 1-2 cannulated screws. Key parameters, including surgical duration, postoperative fracture alignment, fracture-healing duration, range of motion changes, postoperative Lysholm scores, and VAS scores were documented and compared between the two groups.

Results

The study cohort comprised 46 patients, with 28 males and 18 females, and the median age was 29 years old (range: 15-69). There were no significant differences in the baseline characteristics, including knee Lysholm scores, between the two groups. The arthroscopic group exhibited significant improvement in all eight Lysholm score indicators (all P < 0.001). The total Lysholm score also exhibited significant improvement before and after surgery in both groups (P < 0.001). Following surgery, the arthroscopic group demonstrated improvements in all indicators, but had a slightly longer operating time compared to the ORIF group. No significant differences were observed in the Lysholm scores for the knee joint between the two patient groups before and after surgery (P > 0.05).

Conclusions

Arthroscopic suture fixation in conjunction with looped plate binding can significantly improve knee function and clinical effect for patients in the treatment of PCLTAF, promotingearly postoperative functional recovery of patients.

What influences post-operative opioid requirements for tibial fractures?

Introduction

Currently there are few opioid prescribing guidelines for orthopaedic fractures. Long-term post-surgical analgesia requirements, understandably, vary between orthopaedic cases. Our study aims to provide detailed information to clinicians and policy makers, on the opioid requirement associations for patients sustaining tibial fractures.

Methods

This study reviewed all patients sustaining an isolated tibial fracture at a major trauma centre that were operated on within 1 month of injury, from 2015 to 2022. The total opioid dosage used each month in morphine milligrams equivalents (MME) and the number of days opioids were used each month, within the first-year post-surgery were collected, representing the strength and coverage of opioid analgesia in the post-operative stage, respectively. We compared opioid strength and coverage requirements with types of definitive fracture fixations, location, fracture type and concurrent patient medical comorbidities to assess for any trends.

Results

A total of 1814 patients sustaining a combined of 1970 fractures were included in the study. Tibial plateau fractures had the highest opioid strength and coverage requirements in each month and the entire year (p < .05). Across all fracture locations, Ex Fix frame showed higher opioid strength and coverage requirements compared to both IM nailing and plate ORIF. With regard to opioid coverage in the presence of specific comorbidities, only chronic kidney disease (quotient: 1.37, 95% Confidence interval [95%CI] = 1.19-1.55, p = .002) and hypertension (quotient: 1.34, 95%CI = 1.14-1.53, p = .009) showed significance at the 1-year overall level. For opioid strength, Chronic Kidney Disease (quotient: 1.72, 95%CI = 1.41-2.03 p = .005) and COPD (quotient: 1.90, 95%CI = 1.44-2.36, p = .014), show significance at the 1-year overall level.

Conclusion

Our study details opioid requirements post-surgery amongst tibial fractures with subgroup analysis assessing opioid needs amongst specific fracture locations, types, surgical techniques and medical comorbidities. This framework aids clinicians in anticipating rehabilitation and assists in risk stratifying patients at injury onset.

The Knee injury and Osteoarthritis Outcome Score (KOOS) for lateral tibial plateau fractures- relevance, reliability and responsiveness

BACKGROUND

This study aimed to evaluate the patient-reported relevance, test-retest reliability, and responsiveness for each of the five KOOS subscales in patients with lateral tibial plateau fractures.

METHODS

Adult patients with surgically treated lateral tibial plateau fractures (AO 41B) were included. The primary outcome measure was the KOOS subscales: Pain, Symptoms, Activity of Daily Living (ADL), Sport and Recreational Activities (Sport/rec), and kne-related Quality of Life (QOL). The KOOS was repeated at 14 and 15 days, six weeks, and 6 and 12 months. Content validity was partly evaluated by patients ranking the relevance of all the items in the KOOS, test-retest reliability by an interclass correlation coefficient, and responsiveness by effect size and based on 3 pre-defined hypotheses related the the global rating of change.

RESULTS

Forty-one patients with a mean age of 54.8 years (ranging from 21 to 81 years) were included. The results showed an acceptable relevance of all the KOOS subscales. The test-retest reliability was moderate to high for all five subscales, with an interclass-correlation coefficient ranging from 0.6 to 0.9. At the 6- and 12-month follow-ups, the responsiveness showed large effect sizes for all the KOOS subscales, ranging from 0.9 to 2.1. Moderate to high correlations (r ≥ 0.4)was observed for the predefine hypotheses.

CONCLUSION

The KOOS questionnaire showed acceptable relevance, high test-retest reliability and acceptable responsivness within one year following a lateral tibial plateau fracture. More research is needed for further validation of psychometric properties of KOOS for patients with lateral tibial plateau fractures.

The biphasic role of the infrapatellar fat pad in osteoarthritis

Osteoarthritis (OA) is a progressive degenerative disease resulting in joint deterioration. It is a whole organ disease characterized by cartilage degeneration and varying degrees of synovitis, involving pathological changes in all joint tissues, such as cartilage, subchondral bone, ligaments, meniscus, synovium, and infrapatellar fat pad (IPFP). IPFP is the largest adipose tissue structure in the knee joint and is composed of fat cells, immune cells and blood vessels. Moreover, IPFP is located close to the cartilage and bone surface so that it may reduce the impact of loading and absorb forces generated through the knee joint, and may have a protective role in joint health. IPFP has been shown to release various cytokines and adipokines that play pro-inflammatory and pro-catabolic roles in cartilage, promoting OA progression. Intra-articular injections of IPFP-derived mesenchymal stem cells and exosomes have been shown to reduce pain and prevent OA progression in patients with knee OA. Previous studies have shown that IPFP has a biphasic effect on OA progression. This article reviews the latest research progress of IPFP, discusses the role and mechanism of IPFP in OA, provide new intervention strategies for the treatment of OA. This article will also discuss the handling of IPFP during the procedure of total knee arthroplasty.

Long- and short-term effectiveness of traditional Chinese exercises in improving the overall physical capacity of patients with knee osteoarthritis: A systematic review and meta-analysis

BACKGROUND

The increasing global popularity of traditional Chinese exercise (TCE) provides substantial evidence of its significant efficacy in treating knee osteoarthritis (KOA). To assess the impact of different types of TCE and varying exercise durations on KOA patients, we conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) on this topic.

METHODS

Two investigators extensively searched four electronic databases (PubMed, Embase, Cochrane, and Web of Science) from their inception until December 16, 2023, to identify all relevant RCTs on the use of TCE for KOA treatment. The included studies were assessed for risk of bias using the Cochrane Collaboration Risk of Bias Tool (CCRBT), and data analysis was performed using Stata 15.0.

RESULTS

A total of 20 RCTs, involving 1367 patients with KOA, met the inclusion criteria. Compared to the control group, TCE demonstrated significant improvement in three subscale scores of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) [Pain (SMD = -0.44; P = .0001); Stiffness (SMD = -0.35; P = .001); Physical function (SMD = -0.52; P = .0001)] and two subscale scores of the 36-item Short-Form (SF-36) [Physical score (WMD = 2.76; P = .001); Mental score (WMD = 2.49; P = .0001)] in KOA patients. Subgroup analysis showed that both long-term habitual exercise (over 12 weeks) and short-term exercise (within 12 weeks) were more effective than the control group in improving pain, joint stiffness, and physical function in KOA patients. Tai Chi, among the four TCE modalities analyzed, demonstrated improvements in all indicators.

CONCLUSION

Based on the results of our meta-analysis, it can be concluded that both long-term and short-term TCE interventions are effective in alleviating the main symptoms of KOA and improving patients' physical function. However, due to limited methodological quality and inconsistent outcome measures in the included RCTs, further high-quality RCTs with larger sample sizes and longer-term interventions are necessary to validate our findings before TCE can be recommended as a treatment for KOA.

Quality of life of survivors following road traffic orthopaedic injuries in Rwanda

Background

Road traffic injuries (RTI) pose a global public health threat, especially in low- and middle-income nations. These injuries typically cause orthopaedic problems that may negatively impair a person's physical and mental health and quality of life. Our study examined the quality of life of road traffic orthopaedic injuries (RTOI) survivors.

Methods

A cross-sectional study at five Rwandan referral hospitals, included 369 adult RTOI victims. Two years post-injury, participants completed the European Quality of life 5 Dimension 5 (EQ-5D-5L) and Visual Analogue Scale (VAS) Questionnaire between June 2 and August 31, 2022, with informed consent. Three EQ-5D-5L-VAS scores were used: low (0-40%), fair (41-60%), and excellent (61-100%). We used logistic regression analysis with a significance threshold of p < 0.05 to determine odds ratios (OR) and 95% CI.

Results

The RTOI victims had a mean age of 37.5 ± 11.26 years with sex ratio M:F:3:1. Usual activities (66.8%) and mobility (54.8%) were the most affected EQ-5D-5L dimensions. Residence, hospital stay, rehabilitation, and return to work affected mobility, usual activities, pain/discomfort, and anxiety/depression. The EQ-5D-5L/VAS score showed 34.95% poor QoL (0-40%) and 35.50% good QoL. Factors affecting QoL include level of education (OR = 1.66, p < <0.01), type of intervention (OR = 1.22, p = 0.003), rehabilitation (OR = 2.41, p < 0.01) and level of disability (OR = 196.41, p < 0.01). Mobility, self-care, usual activities, pain, comfort, anxiety, and depression vary moderately on Shannon's index.

Conclusion

The study highlights the significant impact of road traffic orthopaedic injuries (RTOI) on survivors' quality of life in Rwanda, revealing challenges in mobility and daily activities. Factors influencing quality of life include education level, medical intervention type, rehabilitation, and disability degree. The findings emphasize the need for tailored rehabilitation strategies and policy interventions to improve long-term outcomes for RTOI survivors.

Epidemiology and Risk Factors for Revision Total Knee Arthroplasty in Chinese Patients: A Retrospective Study in Changchun, Jilin Province, China

BACKGROUND Over the past decades, total knee arthroplasty (TKA) in China has increased substantially. Owing to a lack of a joint registry, there is restricted information concerning the epidemiology of TKA failures in China. We aimed to (1) investigate the etiology of TKA failures in a cohort of Chinese patients and (2) determine the related demographic and anthropometric risk factors in Jilin, China, to have a look at the actual situation. MATERIAL AND METHODS A total of 1927 primary and 109 revision TKAs performed between April 2014 and May 2022 were analyzed in this retrospective study. Patient demographics and anthropometric measures, the interval from primary TKA to revision procedures, and the mechanisms for primary TKA failure were evaluated. A chi-square test, unpaired t test, and multivariate logistic regression were used to investigate the relationships between different factors and TKA failures. RESULTS The leading failure mechanism was infection (53.3%), followed by aseptic loosening (21.5%), stiffness (15.0%), instability (3.7%), malposition (2.8%), periprosthetic fractures (2.8%), and extensor mechanism disruption (0.9%). Infection (59.7%) was the main reason for early revision. Aseptic loosening (43.3%) was the leading cause of late revision. The male ratio in infection patients was higher (35.1% vs 20.6%). The smoking rate in patients with revision and infection was higher (18.9%, 23.9% vs 7%) than in primary patients. There was no difference in BMI between groups. CONCLUSIONS The leading cause of revision TKA in Jilin, China, was infection, followed by aseptic loosening and stiffness. Sex and smoking history were associated with TKA failures in this region.

Chronic ACLD Knees with Early Developmental Cartilage Lesions Exhibited Increased Posterior Tibial Translation during Level Walking

OBJECTIVE

Early articular cartilage lesion (CL) is a vital sign in the onset of posttraumatic knee osteoarthritis (PTOA) in patients with anterior cruciate ligament deficiency (ACLD). Researchers have suggested that altered kinematics could accelerate CLs and, therefore, lead to the onset of PTOA. However, little is known about whether specific knee kinematics exist that lead to early CL in chronic ACLD knees. Level walking is the most frequent and relevant in vivo activity, which greatly impacts knee health. We hypothesized that the knee kinematics during level walking in chronic ACLD knees with early tibiofemoral CL would significantly differ from those of chronic ACLD knees without early tibiofemoral CL.

METHODS

Thirty patients with a chronic ACLD history, including 18 subjects with CLs and 12 subjects without CLs, and 35 healthy control subjects were recruited for the study from July 2020 to August 2022. The knee kinematic data during level walking were collected using a three-dimensional motion analysis system. The kinematic differences between groups were compared using statistical parametric mapping with one dimension for One-Way ANOVA. The cartilage statuses of the ACLD knees were assessed via MRI examination. The CLs distribution of subjects was evaluated using a modified Noyes scale and analyzed by chi-square tests.

RESULTS

ACLD knees with CLs had significantly greater posterior tibial translation (7.7-8.0mm, 12%-18% gait cycle GC, p = 0.014) compared to ACLD knees without CLs during level walking. ACLD knees with CLs had greater posterior tibial translation (4.6-5.5mm, 0%-23% GC, p < 0.001; 5.8-8.0mm, 86%-100% GC, p < 0.001) than healthy controls during level walking. In the group of ACLD knees with CLs, CL is mainly located in the back of the tibia plateau and front of load bearing area of the medial femoral condyle (p < 0.05).

CONCLUSION

Chronic anterior cruciate ligament deficient knees with cartilage lesions have increased posterior tibial translation compared to anterior cruciate ligament deficient knees without cartilage lesions and healthy subjects. The posterior tibial translation may play an important role in knee cartilage degeneration in ACLD knees. The increased posterior tibial translation and cartilage lesion characteristics may improve our understanding of the role of knee kinematics in cartilage degeneration and could be a helpful potential reference for anterior cruciate ligament deficient therapy, such as physical training to improve abnormal kinematic behavior.

An imageology-based feasibility study of plating posterolateral tibial plateau fractures via an anterolateral trans-fibular-head approach

BACKGROUND

There are many difficulties in the reduction and fixation of the tibial plateau fractures involving posterolateral quadrant using general plates via traditional approaches. By imaging the area above the fibulae capitulum, this study was performed to investigate the feasibility of the trans-fibular-head approach and to design an ideal anatomical plate.

METHODS

MRI and CT scans of the knee joint were collected from 205 healthy volunteers (103 males, 102 females). Gender and height were used to divide the volunteers into groups separately: (1) A1 group and A2 group according to gender, (2) B1 group and B2 group according to height. Based on the images, several parameters were defined and measured to describe the space above the head of the fibula. In addition, differences in these parameters between genders and height were compared.

RESULTS

The narrowest distance in the bony region was (10.96 ± 1.39) mm, (5.41 ± 0.97 mm) in the bone-ligament region. The narrowest distance of bony region in the A1 group was more than that in the A2 group (11.21 ± 1.62 mm, 10.85 ± 1.47 mm, p = 0.029). The narrowest distance of the bony region was (10.21 ± 1.42) mm and (11.65 ± 1.39) mm in the B1 group and B2 group, respectively (p = 0.002). The narrowest distance of the bone-ligament region was (5.39 ± 0.78) mm and (5.22 ± 1.21) mm in the A1 group and A2 group, respectively. No statistically significant differences were observed between the A1 group and the A2 group in terms of the narrowest distance of the bone-ligament region. In the B1 group, the narrowest distance of the bone-ligament region (5.18 ± 0.71 mm) was not significantly less than that (5.31 ± 0.91 mm) in the B2 group.

CONCLUSION

The space above the fibular capitellum was ample enough to place the plate for treating tibial plateau fractures involving posterolateral quadrant. The divisions of the lateral tibial plateau by 3-dimensional CT and the parameters of each region were crucial for providing guidance for designing the anatomical plate for the trans-fibular-head approach.

Knee arthroscopy has limited effects on relieving local symptoms of knee osteoarthritis: an analysis of data from the Osteoarthritis Initiative

BACKGROUND

Knee arthroscopy's efficacy in symptom improvement for knee osteoarthritis remains debated. In this study, we analyzed a multicenter database to investigate local symptom improvement.

METHODS

We extracted and analyzed the data of 163 patients from the Osteoarthritis Initiative cohort who underwent unilateral knee arthroscopy (UKA) and were followed up for at least 24 months. UKA patients were matched to non-UKA patients (n = 163) according to sex, age, abdominal circumference, and Kellgren-Lawrence grade. The verified KOOS questionnaires (knee catching, locking, grinding, or clicking) and common local symptoms (frequent knee pain, aching, or stiffness) were set as outcomes. Furthermore, we built a binary logistic regression model to examine the relationship between UKA and local symptom improvement and new-onset symptoms, adjusting for conservative therapeutic covariables (injection of steroids or transparent acid into the knee joint, oral chondroitin sulfate, amino glucose, or analgesics).

RESULT

Analysis showed that the UKA and non-UKA groups showed no obvious difference in the three knee symptoms, but the probability of new-onset grinding or clicking, and frequent knee pain, aching, or stiffness symptoms in the UKA group were respectively 5.82 and 5.65-fold higher than that in the non-UKA group. After analyzing conservative treatment data using a multiple imputation method, the results were consistent with previous regression analyses.

CONCLUSION

Compared to the non-UKA group, the UKA group showed no noticeable differences in the improvement of the three knee symptoms and showed an increased the probability of new-onset grinding or clicking and frequent knee pain, aching, or stiffness symptoms. Key Points • Knee arthroscopy may increase the probability of new-onset grinding or clicking and frequent knee pain, aching, or stiffness symptoms. • We found no difference in the improvement of local knee symptoms (knee catching, locking, grinding, clicking or frequent pain, aching, or stiffness) improvement between the two groups with or without knee arthroscopy.

Introduction of 3D-classification and its derived surgical sequence of Schatzker type IV tibial plateau fractures

INTRODUCTION

Schatzker IV tibial plateau fractures usually have a worse prognosis due to their high variability and the accompanied bony and soft tissue injuries. This study aimed to introduce an injury mechanism-based new classification of Schatzker IV tibial plateau fractures and evaluate its reliability. Additionally, this study aimed to evaluate the outcomes of operative Schatzker IV tibial plateau fractures treated according to the surgical sequences determined by the new classification.

MATERIALS AND METHODS

A total of 63 cases of operative Schatzker IV tibial plateau fractures that were treated following the new surgical sequences were enrolled in our study. The CT images of these patients were reviewed and classified twice according to the new 3D classification by 4 independent observers. The reliability of the classification was calculated through kappa analysis. The classification-determined surgical sequence was evaluated by observing the postoperative efficacy during the follow-up.

RESULTS

Both the intra-observer (the mean k = 0.897, CI 0.806-0.971) and inter-observer (the mean k = 0.883, CI 0.786-0.961) reliability of 3D-classification showed excellent agreement according to Landis and Koch. All the patients were followed up for 6-28 months (average 12.8 months). As for the evaluation of the postoperative efficacy, according to KSS, 53 cases were rated as excellent, 8 cases as good, and 2 cases as fair results.

CONCLUSIONS

The new proposed classification showed high intra-observer and inter-observer reliability in our study. The surgical sequence determined by the classification can help surgeons to acquire good reduction and rigid internal fixation. Therefore the new classification of Schatzker IV tibial plateau fractures and the derived surgical sequences are worthy of further popularization and application in clinical trials.

A comparative study of the efficacy of instrument-assisted soft tissue mobilization and massage techniques in patients with patellofemoral joint pain

Purpose

The aim of this study was to compare the clinical efficacy of instrument-assisted soft tissue mobilization (IASTM) and manipulative therapy Tui-na techniques in the treatment of patients with patellofemoral joint pain syndrome, and to evaluate their impact on pain relief, functional improvement, and joint range of motion.

Methods

In this study, 25 patients with patellofemoral pain syndrome were enrolled, comprising of an intervention group of 13 patients who received IASTM treatment and a control group of 12 patients who received Tui-na manipulation therapy. The treatment cycle lasted for 4 weeks, featuring two interventions per week. Before treatment, the visual analog pain scale (VAS) of the knee, Lysholm score of the knee, modified Thomas test (MTT), and maximum isometric strength of the extensor muscles of the lower limbs were measured and recorded for both groups. After the first and last treatments, the aforementioned indexes were reassessed, and the maximum isometric muscle strength of the lower extremity extensors was measured only after 4 weeks of treatment had been completed.

Results

There was no significant difference in the basic information of the two intervention groups (p > 0. 05). After the first treatment and 4 weeks of treatment, the Lysholm score in both groups significantly improved (p < 0. 05), indicating that both interventions can improve the function of patients' lower limbs. However, the Lysholm score in the IASTM group significantly increased compared with that of the massage group after 4 weeks of treatment, indicating that its improvement in functional performance is superior. Both groups showed significant improvement in knee joint pain after the first treatment and 4 weeks of treatment (p < 0. 05), with the IASTM group having a lower VAS score and better pain improvement after 4 weeks of treatment. The strength of the two intervention groups significantly increased after the maximum isometric muscle strength test of the lower limb extensor muscles before and after 4 weeks of treatment (p < 0. 05). After the MTT test, the extension angle, deviation angle, and hip abduction angle of the tested legs in the two intervention groups were significantly reduced (p < 0. 001), indicating an improvement in lower limb joint mobility.

Conclusion

Instrument-assisted soft tissue mobilization treatment and Tui-na manipulation therapy significantly reduced pain, improved knee flexibility, and increased range of motion of the lower extremity in patients with PFPS. However, IASTM treatment significantly improved pain and function and sustained pain in the short to medium-term post-trial period.

Clinical trial registration

www.isrctn.com, ISRCTN88098928.

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.

Modified gastrocnemius splitting anatomic approach to the tibial plateau. Medium-term evaluation

BACKGROUND

Posterior tibial plateau fractures, including avulsion fractures of the posterior cruciate ligament (PCL) insertion, represent a challenge for the orthopedic trauma surgeon. These injuries have gained a new perspective both diagnostically and therapeutically after the regular use of multiplanar computed tomography. In the herein study, we describe the outcome of patients sustaining a tibial plateau fracture with posterior articular involvement treated by open reduction and internal fixation (ORIF) using our modified gastrocnemius splitting anatomic approach.

METHODS

This observational retrospective descriptive study was conducted at Complejo Medico de la Policia Federal Argentina Churruca-Visca. All patients were treated by ORIF by our team through our modified gastrocnemius splitting anatomic approach, and followed-up for a minimum of 12 months.

RESULTS

A total of 18 patients sustaining plateau fracture were treated by this approach. Satisfactory tomographic reduction with articular gap and/or step-off <2 mm was achieved in 16. The mean time to the return to activities of daily living was 192.2 days.

CONCLUSION

The modified gastrocnemius splitting anatomic approach represents a good alternative for the management of tibial plateau fractures involving the posterior quadrants.

Exploration of Simiao-Yongan Decoction on knee osteoarthritis based on network pharmacology and molecular docking

Use network pharmacology combined with molecular docking to study the effects of Simiao-Yongan Decoction (SMYAD) intervenes in Knee Osteoarthritis (KOA) related targets and signaling pathways, and explores the molecular mechanism of SMYAD in treating KOA. The active ingredients and targets of SMYAD, which concluded 4 traditional Chinese medicines, were screened in TCMSP, and the related gene targets of KOA were screened in the disease databases GeneCards, MalaCards, DisGeNET, and Comparative Toxicogenomics Database, and their intersection data were obtained after integration. And used Cytoscape 3.9.1, the software topologies the network diagram of "compound-drug-active ingredient-target protein-disease." Obtains the protein-protein interaction network diagram through STRING, and enriches and analyzes the obtained core targets. Carry out molecular docking matching verification on the main active ingredients and key targets of the drug. 106 active ingredients and 175 targets were screened from SMYAD to intervene in KOA, 36 core targets were obtained through protein-protein interaction screening, and 10 key targets played an important role. The enrichment results showed that the biological process of gene ontology mainly involved positive regulation of gene expression, negative regulation of apoptosis process, and positive regulation of apoptosis process. KEGG signaling pathway mainly involves AGE-RAGE signaling pathway in diabetic complications, TNF signaling pathway, hypoxia-inducible factor-1 signaling pathway, IL-17 signaling pathway. The pathway of Reactome mainly involves interleukin-4 and interleukin-13 signaling, cytokine signaling in immune system, immune system, apoptosis. Molecular docking showed that the mainly effective components of SMYAD can fully combine with TNF, IL1B, IL6, and CASP3. The results show that the main active ingredients and potential mechanism of action of SMYAD in the treatment of KOA have the characteristics of multiple targets and multiple pathways, which provides ideas and basis for further in-depth exploration of its specific mechanism.

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.

How to Choose the Appropriate Posterior Slope Angle Can Lead to Good Knee Joint Function Recovery in Total Knee Arthroplasty?

Objective

In this study, we aim to examine the effects of osteotomy under varying posterior slope angles on knee joint function recovery following knee arthroplasty.

Methods

We conducted a retrospective analysis from September 2015 to September 2018 on 240 patients who underwent knee arthroplasty three years previously. The study participants were categorized based on changes in the angle of the posterior slope before and after surgery: Group 1, > 5°; Group 2, 3°-5°; Group 3, 0°-3°; Group 4, -3°-0°; Group 5, < -3°. All participants were affected with knee osteoarthritis. The Knee Society Clinical Rating System (KSS) knee function score, Western Ontario and McMaster Universities Arthritis Index (WOMAC) knee function score, Visual Analogue Scale (VAS) pain score, and postoperative complications were measured 3 years after surgery.

Results

The level of pain experienced by the patients decreased significantly than before, with pain scores ranging from 1.0-3.0, and there was a statistical difference between groups (H = 93.400, P < 0.001). The KSS score increased, with group 5 having the lowest median score of 78.0 and group 2 having the highest median score of 97.0, and there was a statistical difference between groups (H = 164.460, P < 0.001). The WOMAC score was reduced, with the median score being 24.0, 11.0, 14.0, 20.0, and 26.0, in the five groups, respectively. Group 5 had the highest score, while Group 2 had the lowest score, and there was a statistically significant difference between groups (H = 164.223, P < 0.001). No symptoms such as periprosthetic femoral fracture, prosthetic loosening, or pad wear were detected in patients postoperatively.

Conclusion

Osteotomy at various posterior slope angles in total knee arthroplasty impacts postoperative knee function rehabilitation. An excessive increase or decrease in angle can have an impact on the postoperative recovery of knee function.

Association Between Power Doppler Ultrasound Signals and Chronic Pain After Total Knee Arthroplasty: A Cross-Sectional Explorative Study

Purpose

Some patients experience chronic postsurgical pain (CPSP) after total knee arthroplasty (TKA) despite the absence of clinical or radiographic abnormalities. Postoperative synovitis as a cause of CPSP after TKA has received limited research attention. This study aimed to investigate the relationship between synovitis after TKA and CPSP.

Patients and Methods

A total of 111 knees of 85 patients, with at least 1-year post-TKA follow-up, were assessed retrospectively and cross-sectionally. Power Doppler (PD) ultrasonography was used to detect the synovial hypervascularity associated with synovitis. The knee joint was divided into 15 areas, and PD signals were graded semi-quantitatively (0-3) in each area, the sum of which was defined as the total PD score. Clinical information regarding CPSP, including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscales, was recorded. The relationship between pain and PD ultrasonography findings was accessed. Patients were divided into two groups (CPSP+ and CPSP- groups) based on pain severity. Clinical information, including PD ultrasonography findings and other possible causes, was compared between the groups.

Results

The WOMAC pain subscale was significantly correlated with the total PD score and maximum PD grade (r=0.3977, p<0.0001; r=0.2797, p=0.0029; respectively). The CPSP+ group had a significantly higher maximum PD grade and total PD score than the CPSP- group (median [interquartile range]: 2 [1, 2] vs 1 [1, 2], p=0.0001; 6 [2, 11] vs 2 [1, 4], p=0.0002; respectively). Multiple and logistic regression analyses showed that the total PD score was an independent factor for the WOMAC pain subscale (β=0.3822, 95% confidence interval [CI]=0.1460, 0.6184, p=0.00176) and CPSP (odds ratio=1.19, 95% CI=1.01, 1.41, p=0.0424).

Conclusion

This study indicated a possible association between the total PD score and chronic pain after TKA; however, further studies are needed to corroborate these findings.

Bicondylar tibial plateau fracture dislocations with an intact anterolateral cortical rim: A surgical technique

A displaced medial tibial plateau fracture with central and lateral impaction, but an intact anterolateral cortical rim, is an uncommon variant of bicondylar tibial plateau fracture that presents a number of challenges. Without a lateral metaphyseal fracture line to work through, it is challenging to address central and lateral impaction. Previously published techniques for addressing this fracture pattern describe an intra-articular osteotomy of the lateral plateau to aid visualization and reduction, or use a posterolateral approach to the proximal tibia with or without an osteotomy of the proximal fibula. This study presents a technique which utilizes standard dual incision approaches and does not involve an intra-articular osteotomy of the lateral tibial plateau or a posterolateral approach. A case series was conducted evaluating radiographic and functional outcomes of 8 patients.

Robotic-Assisted Total Knee Arthroplasty Utilizing NAVIO, CORI Imageless Systems and Manual TKA Accurately Restore Femoral Rotational Alignment and Yield Satisfactory Clinical Outcomes: A Randomized Controlled Trial

Background and objectives: The introduction of novel techniques in total knee arthroplasty (TKA) aiming to enhance outcomes and satisfaction of the procedure is constantly ongoing. In order to evidence a priority of one, we have conducted a randomized controlled trial with the aim of comparing patient-reported functional outcomes, radiographic outcomes and intraoperative measures between imageless (NAVIO and CORI), robotic-assisted (ra)- TKA (ra-TKA) and manual TKA (mTKA) for primary knee osteoarthritis (KOA). Materials and Methods: A total of 215 patients with the diagnosis of KOA of the knee were randomly assigned to one of the three groups: NAVIO (76 patients) or CORI (71 patients) robotic-assisted TKA, or manual technique (68 patients) TKA. The primary outcome (Knee Injury and Osteoarthritis Outcome Study [KOOS]), Visual Analogue Scale (VAS), Range of motion (ROM), femoral component rotational alignment and the secondary outcomes (surgery time, blood loss, complications, and revision at 12 months after surgery) were compared between three groups. KOOS and VAS were collected at particular follow up visits from each patient individually and ROM in flexion and extension was assessed during the physical examination. Femoral component rotational alignment was measured on the CT scan performed postoperatively utilizing the Berger's method. Statistical significance was set at p < 0.05. Results: Both the ra-TKA groups and mTKA group displayed significant improvements in the majority of the functional outcome scores at 12 months. Despite having more prominent surgery time (NAVIO: mean +44.5 min in comparison to mTKA and CORI: mean +38.5 min in comparison to mTKA), both NAVIO and CORI tend to achieve highly accurate femoral component rotational alignment with mean radiographic scores in NAVIO vs. CORI vs. mTKA of 1.48° vs. 1.33° vs. 3.15° and lower blood loss (NAVIO: 1.74; CORI: 1.51; mTKA: 2.32. Furthermore, the investigation revealed the significant difference in femoral component rotational alignment between mTKA-NAVIO and mTKA-CORI and significantly different KOOS scores in NAVIO vs. CORI vs. mTKA of 87.05 vs. 85.59 vs. 81.76. Furthermore, the KOOS analysis showed between group significant statistical differences, but did not reach minimal clinically significant difference. There were no differences in postoperative ROM and VAS. There were no differences in complications between groups. Conclusions: To achieve a successful TKA, the precise tool and individualised objective is of great importance. The results suggest satisfactory results after both ra-TKA methods and mTKA. Ra-TKA and mTKA stand for a safe and reliable treatment method for OA. Patients reported excellent alleviation in functional outcomes and the radiological results revealed that the better precision does not necessarily lead to a better outcome. Therefore, ra-TKA does not imply strong enough advantages in comparison to the manual method, especially in terms of cost-efficiency and surgical time.

Precise Patellar Tendon Insertion Protection and Osteotomy Surface Advantage of Transtibial Tuberosity-High Tibial Osteotomy

OBJECTIVE

Medial opening wedge high tibial osteotomy (HTO) is successful in the treatment of knee osteoarthritis with medial compartment stenosis and tibial varus deformity, but patella infera is the main complication. This study aims to design a new medial tibial open osteotomy scheme, transtibial tuberosity-high tibial osteotomy (TT-HTO), which can fully protect the patellar tendon insertion. In addition, the area of the osteotomy surface and wedge volume were evaluated in TT-HTO, biplanar distal tibial tuberosity osteotomy (biplanar-DTO), and uniplanar-DTO to evaluate the potential advantages of this technology in bone healing.

METHODS

The tibial tubercle was divided into four equal sections from proximal to distal, which were defined as zones A, B, C, and D. From September to December 2020, the imaging examinations of 200 patients (95 males and 105 females) with a mean age of 40.6 years (range 19-60 years) were evaluated to observe the zonation of the tibial tubercle where the insertion of the patellar tendon is located. Then, 59 patients (23 males and 36 females) with a mean age 59.6 years (range 43-77 years), for a total of 69 knees (32 right and 37 left), who underwent routine knee surgery were observed and verified. According to the position of the patellar tendon insertion, TT-HTO was designed. Fifteen tibial sawbones were divided equally into three groups: TT-HTO; biplanar-DTO; and uniplanar-DTO. The total area of the osteotomy surface was compared using the graph paper method. The wedge volume at wedge heights of 10 mm was compared among osteotomy types using the plasticine Archimedes principle. One-way repeated-measures analysis of variance was used to compare the total area of the osteotomy surface and the wedge volume.

RESULTS

The osteotomy line of TT-HTO passes through the boundary point of zones B and C of the tibial tubercle to fully protect the insertion point of the patellar tendon. The total area of the osteotomy surface in TT-HTO and biplanar-DTO was significantly larger than that in uniplanar-DTO (P < 0.05). The wedge volume in uniplanar-DTO was significantly smaller than that in TT-HTO and biplanar-DTO (P < 0.05). No significant differences in the osteotomy surface and the wedge volume were identified between TT-HTO and biplanar-DTO.

CONCLUSION

TT-HTO can protect the patellar tendon insertion and avoid postoperative patella infera. The osteotomy surface is large and located in an area of cancellous bone, which ensures its good healing characteristics.

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.

Use of a Minimally Invasive Traction Repositor versus Conventional Manual Traction for the Treatment of Tibial Fractures: A Comparative Study from a Tertiary Hospital in China

Background

Closed reduction and intramedullary nail fixation of tibial fractures may not utilize a fracture table or reduction aids like a femoral distractor, and only manual traction will help aid the reduction process. This study aimed to describe and further investigate the effectiveness of an originally designed minimally invasive traction repositor (MITR) for the treatment of tibial fractures.

Methods

From January 2018 to April 2021, a total of 119 eligible patients with tibial shaft fractures were included and retrospectively assigned to two groups according to different reduction methods: MITR group vs conventional manual traction (CMT) group. The baseline characteristics between the two groups were comparable, including age, gender, BMI, residence, smoking history, drinking history, injury mechanism, fracture type, ASA, method of anesthesia, and surgical delay (all P > 0.05). The operation time, fracture reduction duration, intraoperative blood loss, fluoroscopy time, number of intraoperative fluoroscopies, VAS, HSS, fracture healing time, and complications were compared.

Results

All patients completed the follow-ups with an average of 18.5 months (range 12-42 months). The operation time, fracture reduction duration, intraoperative blood loss, fluoroscopy time, and number of fluoroscopies were significantly decreased in the MITR group (all P < 0.05). At one month postoperatively, the VAS score was statistically lower in the MITR group (1.8±0.8) than in the CMT group (2.6±1.5). At 6 months postoperatively, the HHS score was statistically higher in the MITR group (90.8±2.3) than in the CMT group (86.4±3.8). We observed no statistical difference in the mean fracture healing time, bone nonunion, implant failure, and infection between the two groups (all P > 0.05).

Conclusion

Compared with CMT, MITR facilitates the minimally invasive treatment of tibial fractures and has the advantages of operation time, fracture reduction duration, intraoperative blood loss, fluoroscopy time, number of fluoroscopies, and satisfactory VAS and HSS scores.

Diagnosis and Treatment of Schatzker Type II Tibial Plateau Fracture with An Isolated Bone Fragment: A Case Report and Literature Review

BACKGROUND

An isolated bone fragment from the posterolateral tibial plateau retrieved from the patellofemoral compartment is a rarely seen Schatzker type II tibial plateau fracture and is prone to misdiagnosis. To the best of our knowledge, this injury mechanism has not been previously described.

CASE PRESENTATION

A 63-year-old female sustained left knee pain and activity limitation after falling off an electric bicycle. Local hospital ignored the intra-articular bone fragment and failed to provide effective treatment. This case described an uncommon Schatzker type II tibial plateau fracture with an isolated bone fragment, its physical examination and radiological findings, the potential injury mechanism, and surgical protocol.

CONCLUSIONS

Combining the physical examination and radiological findings to evaluate the potential injury mechanism is important for developing an appropriate surgical protocol.

Flexion Tibial Plateau Fractures: 3-dimensional CT Simulation-based Subclassification by Injury Pattern

Objective

To identify different injury patterns of flexion tibial plateau fractures (FTPFs) with 3D CT simulation technology. The association between these hypothesized injury patterns and concomitant injuries was also investigated.

Methods

The tibial plateau fracture cases of 297 patients consecutively treated at our trauma center from August 2016 to December 2018 were reviewed retrospectively. A total of 108 patients with FTPFs were enrolled. 3D CT simulation technology was used to reconstruct the position of the knee joint at the time of tibial plateau fracture. The 3D segments for the tibia and femur were created separately, the tibial 3D segment was aligned with the articular surface of the femoral condyle, and then the corresponding injury patterns were deduced. The magnitudes of translation and rotation incurred after the segments were repositioned were calculated by Mimics software. The associations between the hypothesized injury patterns and concomitant injuries were compared.

Results

FTPFs were classified into two groups according to the fracture region: unicondylar FTPFs (type I) and bicondylar FTPFs (type II). According to the injury patterns simulated in this study, these two types of FTPFs were further subclassified into five subgroups. Type I FTPFs were categorized into two subtypes based on the degree of rotation in the coronal plane (varus < 0°; valgus > 0°): pure flexion‐varus fractures (type IA, −10.23° ± 2.11°, 3.7%, 4/108) and pure flexion‐valgus fractures (type IB, 11.54° ± 2.63°, 26.9%, 29/108). Type II FTPFs were divided into three subgroups based on the degree of rotation in the axial plane (internal rotation >10°; flexion‐neutral −10° to 10°; external rotation <−10°): flexion‐neutral fractures (type IIA, 2.01° ± 3.43°, 13.0%, 14/108), flexion‐internal rotation fractures (type IIB, 23.66° ± 6.17°, 35.2%, 38/108) and flexion‐external rotation fractures (type IIC, −16.23° ± 4.27°, 21.3%, 23/108). The incidence of posterolateral quadrant collapse fractures among type IIB fractures was significantly increased relative to that of type IIC fractures (P < 0.001). The incidence of posterolateral quadrant split fractures, anterolateral quadrant fractures and proximal fibular fractures among type IIC fractures was significantly higher than that among type IIB fractures (P < 0.001). The number of these concomitant injuries significantly differed between type IIB and type IIC fractures (P < 0.001).

Conclusion

3D CT simulation‐based subclassification according to the pattern of injury can help surgeons better understand FTPFs and select an appropriate treatment strategy.

Dilemma of Supra- or Infrapatellar Tibial Nailing: Anterior Knee Pain vs. Intra-Articular Damage

AIM

Intramedullary nailing (IMN) is widely accepted as the treatment of choice for tibial fractures, and a suprapatellar method has been described to prevent common problems associated with the typical infrapatellar IMN technique, such as anterior knee pain. However, in the suprapatellar technique, injury to intra-articular structures is a concern. The aim of this study was to compare the clinical and radiological results of suprapatellar and infrapatellar IMN in terms of union, complications, and function.

METHODS

A retrospective evaluation of 61 patients who had undergone suprapatellar (n = 29, Group A) or infrapatellar (n = 31, Group B) tibial IMN was conducted. For the suprapatellar group, magnetic resonance imaging scans were acquired on the sixth month follow-up. Complications, radiological findings, functional outcomes, surgery duration, and differences in a range of motion (ROM) were compared.

RESULTS

Surgery duration was significantly shorter in Group A (81 mins vs. 107 mins, p < 0.001), and visual analog scale (VAS) values were significantly higher in Group B (0.17 vs. 1.62, p < 0.001). In Group A, the patients' Lysholm scores were significantly higher (95.6 vs. 92, p=0.006). In terms of anterior knee pain, none was experienced in Group A (0%), while 11 patients (26.1%) reported about it in Group B. There were no statistically significant differences between the two groups in SF-36 score (p=0.925), the radiographic union scale in tibial (RUST) fractures score (p=0.454), union time (p=0.110), or ROM (p=0.691). In Group A, two cases of patellofemoral cartilage degeneration were observed.

CONCLUSION

If performed with sufficient expertise, the suprapatellar IMN technique is a safe, reliable technique with a low frequency of anterior knee pain for treating tibial fractures. There is no clear evidence that it causes damage to intra-articular structures. The possibility of patellofemoral cartilage degeneration due to this technique should be further evaluated by prospective studies including pre- and postoperative radiologic assessments.

Does Time to Theatre Affect the Ability to Achieve Fracture Reduction in Tibial Plateau Fractures?

Surgical management of displaced tibial plateau fracture (TPF) is often delayed due to accompanying soft tissue injuries sustained at the time of injury. The primary aim of this study was to assess the effect of time to surgery on fracture reduction in cases of TPF. The secondary aim was to assess the effect of preoperative demographics and residual articular step on Lysholm Scores and Knee Injury and Osteoarthritis Outcome Scores (KOOS) following fixation. Patients between 2006 and 2017, managed by a single surgeon, were prospectively enrolled in the study. Reduction of articular step, defined as <2 mm, was assessed by a single blinded examiner. A total of 117 patients were enrolled, 52 with Schatzker II, 4 with Schatzker IV, and 61 with Schatzker VI fractures. Patients were followed up to a mean of 3.9 years. Analysis showed that the ability to achieve fracture reduction was negatively influenced by time to theatre, with the odds of achieving reduction decreasing 17% with each subsequent day post injury (p = 0.002). Furthermore, an increased time to theatre was associated with a reduced Lysholm score at one year (p = 0.01). The ability to achieve fracture reduction did not influence PROMs within the study period. We conclude that delay in surgical fixation negatively affects fracture reduction in TPF and may delay recovery. However, residual articular step does not necessarily influence PROMs over the mid-term.

Alignment adjustment using the Valgus stress technique can increase the surgical accuracy of novice surgeons during medial opening-wedge high Tibial osteotomy

Background

The purpose of this study was to compare the degree of accuracy of coronal alignment correction with use of the “alignment adjustment under valgus stress technique” between expert and novice surgeons during medial opening-wedge high tibial osteotomy (MOWHTO).

Methods

Forty-eight patients who underwent MOWHTO performed by an expert surgeon (expert group) and 29 by a novice surgeon (novice group) were enrolled in analysis. During surgery, lower-extremity alignment was corrected using the “alignment adjustment under valgus stress technique”. Normocorrection was defined as a weight-bearing line ratio between 55 and 70% and the correction accuracy was compared between expert and novice groups using the ratio of normocorrection to outliers. The clinical outcomes were also compared using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 1 year after surgery.

Results

The undercorrection rate was 14.6% in the expert group and 13.8% in the novice group, while the overcorrection rate was 2.1% in the expert group and 3.4% in the novice group. In the ratio of normocorrection to outliers, no difference was found between the two groups at the one-year follow-up visit (83.3% in the expert group vs. 82.8% in the novice group; p > 0.05). Also, no significant differences were seen in WOMAC subscores immediately preoperatively and at 1 year after surgery (all p > 0.05).

Conclusion

Adhering to the “alignment adjustment under valgus stress technique” protocol enabled novice surgeons to achieve similar surgical accuracy as that of an expert surgeon in coronal alignment during MOWHTO.

Level of evidence

Level III.

Predictors of a placebo response in patients with hand osteoarthritis: post-hoc analysis of two randomized controlled trials

BACKGROUND

Placebo can have a significant therapeutic effect in patients with hand osteoarthritis (OA). This aim of the study is to identify factors associated with a clinically meaningful placebo response in patients with hand OA.

METHODS

This post-hoc analysis of two double-blind, placebo-controlled, randomized trials (RCTs) investigating the efficacy of GCSB-5 or diacerein as treatments for hand OA analyzed the efficacy of a placebo. Clinical and laboratory factors associated with a clinically meaningful response, defined as an improvement in the Australian/Canadian Osteoarthritis Hand Index (AUSCAN) pain score > 10 at 4 weeks relative to baseline, were identified.

RESULTS

The mean improvement in the AUSCAN pain score was - 6.0 ± 20.3, with marked variation between 143 hand OA patients (range: - 76.4 to 33.2). A clinically meaningful improvement was observed in 54 (37.8%) patients. Placebo responders had worse AUSCAN pain scores (55.7 ± 19.7 vs. 43.6 ± 21.6, p = 0.001) and a worse AUSCAN stiffness (68.2 ± 20.5 vs. 57.5 ± 24.5, p = 0.008) at baseline than non-responders. Improvements in pain correlated with the baseline pain level (Pearson r = - 427, p < 0.001). Structural joint changes such as tender, swollen, enlarged, or deformed joint counts did not differ between placebo responders and non-responders. In a multivariable analysis, only baseline AUSCAN pain was associated with a clinically meaningful placebo response (OR: 1.054, 95% CI [1.019-1.089], p = 0.002).

CONCLUSIONS

High levels of pain at baseline are predictive of a clinically meaningful placebo response in patients with hand OA. Further studies are needed to optimize and utilize the benefit of placebo responses in patients with hand OA.

Epidemiological Study of Tibial Plateau Fractures Combined with Intercondylar Eminence Fractures

OBJECTIVE

To investigate the epidemiological characteristics of tibial plateau fractures combined with intercondylar eminence fractures and identify the risk factors.

METHODS

This retrospective study enrolled patients with tibial plateau fractures who were treated in the third hospital of Hebei Medical University from January 2015 to December 2018; 1020 patients (693 [68%] men and 327 [32%] women) meeting the inclusion and exclusion criteria had a mean age of 45.2 ± 13.8 years. In total, 506 (50%) cases were left injuries, 495 (48%) were right injuries, and 19 (2%) were bilateral injuries. Among them, 458 (44.9%) with a mean age of 47.0 ± 13.9 years had intercondylar eminence fractures, including 324 men and 134 women. A total of 562 (55.1%) patients were identified without intercondylar eminence fractures, including 369 (65.7%) men and 193 (34.3%) women with an average age of 43.8 ± 13.6 years. The distribution characteristics of tibial plateau fractures with intercondylar eminence involved were identified. The potential associations among fractures and various other factors, such as age, gender, occupation, and mechanism of injury, were explored.

RESULTS

The highest proportion age group of tibial plateau fractures included the ages 35-54 years, with more men than women for both age groups. For males, the highest proportion age group was 35-44 years, and for females, it was 55-64 years (χ 2 = 71.336, P < 0.01). According to Schatzker classification, type IV tibial plateau fractures had the highest risk of intercondylar eminence being involved (70.6%) without significance with type V (69.5%) and VI (68.2%) but with greater significance with types I (11.9%), II (39.2%), and III (9.4%, χ 2 = 280.187, P < 0.01). Multiple analysis showed that simple fractures, including types I, II, and III (OR 0.108, 95% CI: 0.080-0.145), were less likely to involve intercondylar eminence fractures than complex fractures, including types IV, V, and VI. Patients aged >74 years were more likely to have intercondylar eminence fractures compared with other age groups. Retired patients (OR 4.332, 95% CI: 1.147-16.362) were more likely to have fractured intercondylar eminence.

CONCLUSION

The current study revealed the characteristics of tibial plateau fractures, especially those involving intercondylar eminence fractures, as well as their proportion, distribution, and risk factors, which can be used as reference data for clinical assessment and surgical protocol selection.