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Versorgung von Tibiakopffrakturen – arthroskopisch unterstützt. ARTHROSKOPIE 2023. [DOI: 10.1007/s00142-023-00590-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
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Structure-mechanical analysis of various fixation constructs for basicervical fractures of the proximal femur and clinical implications; finite element analysis. Injury 2023; 54:370-378. [PMID: 36529550 DOI: 10.1016/j.injury.2022.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 11/14/2022] [Accepted: 12/03/2022] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This present study was conducted to determine the structural-mechanical stability of various fixation constructs through finite element (FE) analysis following simulation of a basicervical fracture and to introduce the clinical implications. MATERIALS AND METHODS We simulated fracture models by using a right synthetic femur (SAWBONES®). We imported the implant models into ANSYS® for placement in an optimal position. Five assembly models were constructed: (1) multiple cancellous screws (MCS), (2) FNS (femoral neck system®), (3) dynamic hip screw (DHS), (4) DHS with anti-rotation 7.0 screw (DHS + screw), and PFNA-II (Proximal Femoral Nail Antirotation-II®). The femur model's distal end was completely fixed and 7° abducted. We set the force vector at a 3° angle laterally and 15° posteriorly from the vertical ground. Analysis was done using Ansys® software with von Mises stress (VMS) in megapascals (MPa) and displacement (mm) RESULTS: The displacements of the proximal femur were 10.25 mm for MCS, 9.66 mm for DHS, 9.44 mm for DHS + screw, 9.86 mm for FNS, and 9.31 mm for PFNA-II. The maximum implant VMS was 148.94 MPa for MCS, 414.66 MPa for DHS, 385.59 MPa for DSH + screw, 464.07 MPa for FNS, and 505.07 MPa for PFNA-II. The maximum VMS at the fracture site was 621.13 MPa for MCS, 464.14 MPa for DHS, 64.51 MPa for DHS + screw, 344.54 MPa for FNS, and 647.49 MPa for PFNA-II. The maximum VMS at the fracture site was in the superior area with the high point around the posterior screw in the MCS, anterosuperior corner in the DHS, the posteroinferior site of the FNS, and posterosuperior site around the entry point in the PFNA-II. In the DHS + screw, the stresses were distributed evenly and disappeared at the maximum VMS fracture site. CONCLUSION Based on the fracture site and implant's stress distribution, the model receiving the optimal load was a DHS + screw construct, and the FNS implant could be applied to anatomically reduced fractures without comminution. Considering the high-stress concentration around the entry point, a PFNA-II fixation has a high probability of head-neck fragment rotational instability.
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Boluda-Mengod J, Guimerà-García V, Olías-López B, Renovell-Ferrer P, Carrera I, Herrera-Pérez M, Pais-Brito JL. A proposal of a new algorithm for decision-making approaches in open reduction and internal fixation of complex tibial plateau fractures - SOTA algorithm (Spanish Orthopaedic Trauma Association). Injury 2021; 52 Suppl 4:S87-S98. [PMID: 34011441 DOI: 10.1016/j.injury.2021.03.064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The correct choice of surgical approaches in complex tibial plateau fractures is essential to achieve adequate reduction and fixation. Detailed fracture morphology and direction of columns displacement, that we have named the Main Deformity Direction (MDD), may aid in selecting the optimal surgical strategy. In this article we present a new algorithm based on MDD and column concepts. The aim of this study was to evaluate the outcomes of a group of tibial plateau fractures treated according to this algorithm. The secondary aim was to evaluate the incidence of the different MDD in our multicolumnar subgroup. PATIENTS AND METHODS Excluding isolated lateral one-column fractures, open fractures and patients not treated following this algorithm, 72 patients with tibial plateau fractures surgically treated with open reduction and internal fixation were collected retrospectively, from three trauma centers, from January 2015 to April 2019. Radiological assessment was performed to establish the columns involved and the MDD. Quality and maintenance of reduction and alignment, complications and functional outcomes were assessed. RESULTS Initial fracture analysis was performed in 72 patients (8 one-column, 35 two-column and 29 multicolumnar fractures). In the multicolumnar group, the posteromedial MDD was the most frequent pattern (17 of 29 patients). Four patients were excluded due to loss of follow-up, resulting 68 patients for final outcome analysis (7 one-column, 34 two-column and 27 multicolumnar). The average follow-up was 18 months (range: 6-52). Excellent/good outcomes were obtained in all one-column, 31 of 34 two-column and 25 of 27 multicolumnar fractures. Incomplete reduction was present in three patients. As complications, we had two loss of reduction, one conversion to knee arthroplasty, one nonunion and one deep infection. No patient presented neurological or vascular problems, knee instability or extension deficit. CONCLUSION Satisfactory results have been obtained following the principles of our algorithm. In addition to the anatomical involvement of columns and segments, we believe that identifying the Main Deformity Direction (MDD) provides useful information for decision-making, especially in multicolumnar fractures. The most frequent MDD in our multicolumnar subgroup was the posteromedial MDD, but more than one-third presented a different MDD, requiring different surgical strategies.
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Affiliation(s)
- Juan Boluda-Mengod
- Hospital Universitario Canarias (HUC), Carretera Ofra s/n., 38320, La Laguna, Tenerife, Spain; School of Medicine, Universidad de La Laguna (ULL), Campus de Ofra, s/n, 38071, La Laguna, Tenerife, Spain; Spanish Orthopaedic Trauma Association - The Orthopaedic Surgery and Traumatology Spanish Society (SOTA-SECOT), Calle Fernández de los Ríos, 108, 28015, Madrid, Spain.
| | - Vicente Guimerà-García
- Hospital Can Misses (HCM), Carrer de Corona s/n., 07800, Ibiza, Spain; Spanish Orthopaedic Trauma Association - The Orthopaedic Surgery and Traumatology Spanish Society (SOTA-SECOT), Calle Fernández de los Ríos, 108, 28015, Madrid, Spain.
| | - Beatriz Olías-López
- Hospital Universitario Canarias (HUC), Carretera Ofra s/n., 38320, La Laguna, Tenerife, Spain; Spanish Orthopaedic Trauma Association - The Orthopaedic Surgery and Traumatology Spanish Society (SOTA-SECOT), Calle Fernández de los Ríos, 108, 28015, Madrid, Spain.
| | - Pablo Renovell-Ferrer
- Consorcio Hospital General Universitario de Valencia (CHGUV), Avenida Tres Cruces, 2, 46014, Valencia, Spain; Spanish Orthopaedic Trauma Association - The Orthopaedic Surgery and Traumatology Spanish Society (SOTA-SECOT), Calle Fernández de los Ríos, 108, 28015, Madrid, Spain.
| | - Ion Carrera
- Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona, Carrer de Sant Quintí, 89, 08041, Barcelona, Spain; Spanish Orthopaedic Trauma Association - The Orthopaedic Surgery and Traumatology Spanish Society (SOTA-SECOT), Calle Fernández de los Ríos, 108, 28015, Madrid, Spain.
| | - Mario Herrera-Pérez
- Hospital Universitario Canarias (HUC), Carretera Ofra s/n., 38320, La Laguna, Tenerife, Spain; School of Medicine, Universidad de La Laguna (ULL), Campus de Ofra, s/n, 38071, La Laguna, Tenerife, Spain; Spanish Orthopaedic Trauma Association - The Orthopaedic Surgery and Traumatology Spanish Society (SOTA-SECOT), Calle Fernández de los Ríos, 108, 28015, Madrid, Spain.
| | - José Luis Pais-Brito
- Hospital Universitario Canarias (HUC), Carretera Ofra s/n., 38320, La Laguna, Tenerife, Spain; School of Medicine, Universidad de La Laguna (ULL), Campus de Ofra, s/n, 38071, La Laguna, Tenerife, Spain; Spanish Orthopaedic Trauma Association - The Orthopaedic Surgery and Traumatology Spanish Society (SOTA-SECOT), Calle Fernández de los Ríos, 108, 28015, Madrid, Spain.
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Frosch KH, Korthaus A, Thiesen D, Frings J, Krause M. The concept of direct approach to lateral tibial plateau fractures and stepwise extension as needed. Eur J Trauma Emerg Surg 2020; 46:1211-1219. [PMID: 32607776 PMCID: PMC7691307 DOI: 10.1007/s00068-020-01422-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/15/2020] [Indexed: 10/31/2022]
Abstract
Malreduction after tibial plateau fractures mainly occurs due to insufficient visualization of the articular surface. In 85% of all C-type fractures an involvement of the posterolateral-central segment is observed, which is the main region of malreduction. The choice of the approach is determined (1) by the articular area which needs to be visualized and (2) the positioning of the fixation material. For simple lateral plateau fractures without involvement of the posterolateral-central segment an anterolateral standard approach in supine position with a lateral plating is the treatment of choice in most cases. For complex fractures the surgeon has to consider, that the articular surface of the lateral plateau only can be completely visualized by extended approaches in supine, lateral and prone position. Anterolateral and lateral plating can also be performed in supine, lateral and prone position. A direct fixation of the posterolateral-central segment by a plate or a screw from posterior can be only achieved in prone or lateral position, not supine. The posterolateral approach includes the use of two windows for direct visualization of the fracture. If visualization is insufficient the approach can be extended by lateral epicondylar osteotomy which allows exposure of at least 83% of the lateral articular surface. Additional central subluxation of the lateral meniscus allows to expose almost 100% of the articular surface. The concept of stepwise extension of the approach is helpful and should be individually performed as needed to achieve anatomic reduction and stable fixation of tibial plateau fractures.
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Affiliation(s)
- Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Alexander Korthaus
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Darius Thiesen
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jannik Frings
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Wang Z, Lu Y, Wang Q, Song L, Ma T, Ren C, Li Z, Yang J, Zhang K, Zhang B. Comparison of the effectiveness and safety of intravenous and topical regimens of tranexamic acid in complex tibial plateau fracture: a retrospective study. BMC Musculoskelet Disord 2020; 21:739. [PMID: 33183258 PMCID: PMC7659088 DOI: 10.1186/s12891-020-03772-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 11/04/2020] [Indexed: 12/17/2022] Open
Abstract
Background Previous studies have demonstrated the effectiveness and safety of tranexamic acid (TXA) in orthopedic surgery. However, no study has investigated TXA in complex tibial plateau fracture surgery. Therefore, the purpose of this study was to confirm the safety and effectiveness of i.v. (intravenous) TXA and topical TXA. Material and methods This was a retrospective analysis of prospectively collected data. The control group received an equal amount of placebo (physiological saline solution); the i.v. group received 1.0 g TXA by intravenous injection before the tourniquet was inflated and before the surgical incision was closed, and the topical group received 3.0 g TXA in 75 mL of physiological saline solution 5 min prior to the final tourniquet release. Perioperative blood loss, vascular events, wound complications, and adverse reactions were compared among the three groups. The pain, knee function, and quality of life (QoL) assessments were based on their corresponding scoring systems. Results Baseline data were comparable for all groups. The i.v. group showed the best results for total blood loss (TBL) and hidden blood loss (HBL) (424.5 ± 49.4 mL and 219.3 ± 33.4 mL, respectively, all P values < 0.001). Patients in the i.v. group had lesser real Hb decrease than those in the control group (0.9 vs 1.5, P<0.001) and topical group (0.9 vs 1.2, P = 0.026). The blood coagulation level as measured using fibrinolysis (D-dimer) was lower in the i.v. group than in the control and topical groups on POD1 and POD3; however, this difference was not significant; the fibrin-degradation products also showed a similar trend. Patients in the topical group experienced less pain than those in the control group on POD2, POD4, and PO6W. The VAS pain score was 3.6 vs. 4.4 (POD2, P<0.05), 2.8 vs 3.3 (POD4, P<0.05), and 2.1 vs. 2.6 (PO6W, P<0.001) in the topical group vs control group, respectively. No significant differences were identified in vascular events, wound complications, adverse reactions, knee function, and QoL among the three groups. Conclusion To our knowledge, this is the first study that showed both i.v. TXA and topical TXA are safe and effective for complex tibial plateau fractures. The i.v. regimen effectively reduced blood loss during the perioperative period, whereas patients under the topical regimen had less vascular events, wound complications, and a lower incidence of adverse reactions compared to those in the i.v. group. Trial registration The trial was registered in the Chinese Clinical Trial Registry (ChiCTR-TRC-1800017754, retrospectively registered from 2018 to 01-01).
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Affiliation(s)
- Zhimeng Wang
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, No. 555, East Youyi Road, Xi'an, 710000, Shaanxi, China.,Department of Orthopaedics and Trauma, The Second Affiliated Hospital of Xi'an Medical College, No. 167, East Textile Road, Xi'an, 710000, Shaanxi, China
| | - Yao Lu
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, No. 555, East Youyi Road, Xi'an, 710000, Shaanxi, China.,The Key Laboratory of Biomedical Information Engineering of Ministry of Education, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, 710049, People's Republic of China.,Bioinspired Engineering and Biomechanics Center (BEBC), Xi'an Jiaotong University, Xi'an, 710049, China
| | - Qian Wang
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, No. 555, East Youyi Road, Xi'an, 710000, Shaanxi, China
| | - Leilei Song
- Qinghai University, Xi'ning, 810000, Qinghai, China
| | - Teng Ma
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, No. 555, East Youyi Road, Xi'an, 710000, Shaanxi, China
| | - Cheng Ren
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, No. 555, East Youyi Road, Xi'an, 710000, Shaanxi, China
| | - Zhong Li
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, No. 555, East Youyi Road, Xi'an, 710000, Shaanxi, China
| | - Jiarui Yang
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, No. 555, East Youyi Road, Xi'an, 710000, Shaanxi, China
| | - Kun Zhang
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, No. 555, East Youyi Road, Xi'an, 710000, Shaanxi, China.
| | - Bing Zhang
- Department of Orthopaedics and Trauma, The Second Affiliated Hospital of Xi'an Medical College, No. 167, East Textile Road, Xi'an, 710000, Shaanxi, China.
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Krause M, Alm L, Berninger M, Domnick C, Fehske K, Frosch KH, Herbst E, Korthaus A, Raschke M, Hoffmann R. Bone metabolism is a key factor for clinical outcome of tibial plateau fractures. Eur J Trauma Emerg Surg 2020; 46:1227-1237. [PMID: 33151357 PMCID: PMC7691299 DOI: 10.1007/s00068-020-01537-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 10/28/2020] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martini Str. 52, 20246, Hamburg, Germany.
| | - Lena Alm
- BG Trauma Hospital Hamburg, Hamburg, Germany
| | - Markus Berninger
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martini Str. 52, 20246, Hamburg, Germany
| | - Christoph Domnick
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Kai Fehske
- Department of Orthopaedic Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martini Str. 52, 20246, Hamburg, Germany
| | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Alexander Korthaus
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martini Str. 52, 20246, Hamburg, Germany
| | - Michael Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Reinhard Hoffmann
- Department of Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt Am Main, Frankfurt am Main, Germany
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Extended approach to the lateral tibial plateau with central meniscal subluxation in fracture repair: feasibility and first clinical and radiographic results. Eur J Trauma Emerg Surg 2020; 46:1221-1226. [PMID: 32865596 PMCID: PMC7691302 DOI: 10.1007/s00068-020-01467-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/18/2020] [Indexed: 11/11/2022]
Abstract
Purpose Anatomic reduction in tibial plateau fractures remains to be demanding. For further visualisation of and approach to the joint surface an extended lateral approach using a lateral femoral epicondyle osteotomy and subluxation of the lateral meniscus was recently described. First clinical and radiographic mid-term results of this technique are presented in this feasibility study. Method Ten complex tibial plateau fractures treated with extended lateral approach and lateral meniscal subluxation were prospectively analysed. Clinical and radiographic results were objectified according to the Rasmussen scores. Results After a median follow-up of 8.6 (IQR 4.3) months good to excellent clinical and radiographic results were noted. The clinical Rasmussen Score showed a median of 25 (IQR 2.8) and radiographic a median of 17 (IQR 2.0) points. Conclusion Good to excellent clinical and radiological scores were obtained after using an extended lateral approach with lateral femoral epicondyle osteotomy and central meniscus subluxation. No approach specific complications could be observed. Electronic supplementary material The online version of this article (10.1007/s00068-020-01467-1) contains supplementary material, which is available to authorized users.
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