External fixation and limited internal fixation for complex fractures of the tibial plateau

Intra-articular elevating osteotomy for tibial plateau fracture malunion with intra-articular depression: Surgical technique and review

Open reduction with internal fixation is the gold standard treatment for tibial plateau fractures. However, some complications can be observed despite a well-established procedure. Apart from stiffness, malunion is the most frequent complication of tibial plateau fractures. These malunions may be intra-articular or extra-articular or combined. Intra-articular or extra-articular osteotomy is a good option to treat malunion in young and active patients without significant joint damage. When malunion is associated with extensive joint involvement or the initial cartilage damage has resulted in knee osteoarthritis, the surgical option is a total replacement of the knee joint with arthroplasty. We report the case of a patient with a tibial plateau fracture treated initially at a traditional bonesetter complicated at the end of the treatment with the persistent of the knee pain and limping.

Pathogens in FRI - Do bugs matter? - An analysis of FRI studies to assess your enemy

Fracture-related infection (FRI) is a devasting complication for both patients and their treating Orthopaedic surgeon that can lead to loss of limb function or even amputation. The unique and unpredictable features of FRI make its diagnosis and treatment a significant challenge. It has substantial morbidity and financial implications for patients, their families and healthcare providers. In this article, we perform an in-depth and comprehensive review of FRI through recent and seminal literature to highlight evolving definitions, diagnostic and treatment approaches, focusing on common pathogens such as Staphylococcus aureus, polymicrobial infections and multi-drug-resistant organisms (MDRO). Furthermore, multiple resistance mechanisms and adaptations for microbial survival are discussed, as well as modern evidence-based medical and surgical advancements in treatment strategies in combating FRI.

Acute versus staged fixation of bicondylar tibial plateau fractures: a dual centre international study

BACKGROUND

Bicondylar tibial plateau fractures pose many treatment challenges due to their complex fracture patterns and associated soft tissue compromise. We aim to evaluate outcomes of acute ORIF (aORIF) versus staged ORIF (sORIF) of high energy bicondylar tibial plateau fractures.

METHODS

We retrospectively reviewed 186 patients at two high-volume Level I trauma centers. One hundred one patients underwent aORIF and 85 underwent sORIF between 2011 and 2019. Clinical outcomes of interest included operative time, wound dehiscence, superficial and deep infection, nonunion, flap coverage, arthrodesis, and early conversion to arthroplasty.

RESULTS

Patients had a median follow up of 12 months (6-98 months). The sORIF group had a higher ISS (p = 0.02) and a higher rate of open fractures (24.7% vs 11.9%, p = 0.03). The groups were statistically similar in other demographics and co-morbidities. Operative time was significantly shorter in the aORIF group (157 vs 213 min., p < 0.001). There was no statistical difference in wound dehiscence, deep infection, flap coverage, nonunion, unplanned reoperation, or post-traumatic arthritis between groups. However, aORIF was associated with a significantly lower rate of superficial infection (p = 0.01), arthroplasty (p = 0.003) and unplanned reoperation (p = 0.005). Subgroup analysis of only the 41C3 fractures showed a lower rate of superficial infections in the aORIF group (p = 0.04). No difference in complications was found between the fracture subgroups.

CONCLUSION

We found no increased risk of complications with aORIF compared to sORIF for bicondylar tibial plateau fractures. While not all injuries may be appropriate for aORIF, our results demonstrate the safety of aORIF when patients are properly selected by experienced fracture surgeons.

LEVEL OF EVIDENCE

Level III.

Treatment of Schatzker Type VI Tibia Fractures Using Circular External Fixation: State of the Art, Surgical Technique and Results

BACKGROUND

Schatzker type VI tibia fractures are usually associated with infection and surgical wound-related problems. Circular external fixation (CEF) has been shown to minimize such complications.

METHODS

We pose a retrospective study of patients with Schatzker type VI fractures treated with CEF.

RESULTS

Twenty-two (22) patients were included (11M/11F) with a mean age of 60.1 ± 14.9 years. According to the AO/OTA classification, two fractures (9.1%) were A2, three (13.6%) were A3, and seventeen (77.3%) were C3. Three (13.6%) of them were open. The tissue damage observed in the nineteen (86.4%) closed fractures was classified according to Tscherne (four grade I, twelve grade II, and three grade III). The mean ex-fix time was 24.1 ± 5.1 weeks. None of the patients experienced deep infections, nonunion, or malunion. The mean ROM was 111.4 ± 17.8 degrees. Although stability was achieved in all cases, 50% of them suffered osteoarthritic degeneration. Four knees required TKR at a mean of 8.77 ± 5.58 years from trauma. The mean HHS knee score was 84.2 ± 10.3 points (excellent in fifteen (68.2%) cases, good in four (18.2%), and acceptable in three (13.6%)). The mean Rasmussen radiological score was 13.3 ± 3.5 (excellent in three (13.6%) cases, good in fifteen (68.2%), and acceptable in four (18.2%)). The mean SF-12 score was 35.1 ± 10.4 points on the physical scale and 53.0 ± 10.6 points on the mental scale.

CONCLUSIONS

CEF has shown itself to be a valid treatment for patients with Schatzker type VI fractures, particularly for those where the fracture is comminuted, severely displaced, open, or associated with severe soft tissue damage.

Top 50 Cited Papers on Tibial Plateau Fracture Management: A Bibliometric Analysis and Review

Purpose

The orthopaedic surgeons, especially the young budding surgeons should have a well-balanced knowledge of the past evidence as well the current evidence in the literature for the appropriate as well as optimum management of tibial plateau fractures. Bibliometric analysis of the top-cited papers on tibial plateau fracture management can help know their concurrent interests, deficiencies and conflicting issues regarding their management. This study aimed to identify the 50 most cited research articles in tibial plateau research and analyse their characteristics.

Methods

We searched the Thompson Reuters Web of Science database for articles relevant to tibial plateau fracture and prepared a list of top 50 cited articles that included original articles and review articles concerning tibial plateau fractures. The included articles were analysed for contributing journals, corresponding author's country, publication year, cumulative citations, annual citations, citation trends over time, level of evidence and a qualitative review.

Results

The search strategy resulted in 2263 articles. The top 50 cited articles were published from 1974 to 2014 and belonged to 12 journal sources. There were 47 original articles and 3 review articles. The average citations per article were 126.2, and the annual citations per article were 6.478 per year. The top-cited articles were relevant to the strategies in the management, classification, fracture reduction, articular restoration, types and number of fixation devices, surgical approaches, associated menisco-ligamentous injuries and applicability of bone grafts/substitutes in tibial plateau fractures.

Conclusion

The current bibliometric analysis summarises the top-cited evidence concerning tibial plateau fractures and can be a potential resource for reviewing and locating the same. The analysis shows that most top-cited evidence belongs to the year 2000 onwards. Also, recent articles have a higher annual citation rate. A limited number of journals and mostly, western countries have contributed to the top-cited evidence. Whilst the top-cited evidence has touched several aspects of tibial plateau fractures, it is in the form of level IV case series. It needs better prospective evidence to establish sound recommendations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-023-00932-4.

Bicondylar Tibial Plateau Fractures: What Predicts Infection?

OBJECTIVES

The purpose of this study was to identify the patient, injury, and treatment factors associated with infection of bicondylar plateau fractures and to evaluate whether center variation exists.

DESIGN

Retrospective review.

SETTING

Eighteen academic trauma centers.

PATIENTS/PARTICIPANTS

A total of 1,287 patients with 1,297 OTA type 41-C bicondylar tibia plateau fractures who underwent open reduction and internal fixation were included. Exclusion criteria were follow-up less than 120 days, insufficient documentation, and definitive treatment only with external fixation.

INTERVENTION

Open reduction and internal fixation.

MAIN OUTCOME MEASUREMENTS

Superficial and deep infection.

RESULTS

One hundred one patients (7.8%) developed an infection. In multivariate regression analysis, diabetes (DM) (OR [odds ratio] 3.24; P ≤ 0.001), alcohol abuse (EtOH) (OR 1.8; P = 0.040), dual plating (OR 1.8; P ≤ 0.001), and temporary external fixation (OR 2.07; P = 0.013) were associated with infection. In a risk-adjusted model, we found center variation in infection rates (P = 0.030).

DISCUSSION

In a large series of patients undergoing open reduction and internal fixation of bicondylar plateau fractures, the infection rate was 7.8%. Infection was associated with DM, EtOH, combined dual plating, and temporary external fixation. Center expertise may also play a role because one center had a statistically lower rate and two trended toward higher rates after adjusting for confounders.

LEVEL OF EVIDENCE

Level IV-Therapeutic retrospective cohort study.

Hybrid Fixation of Open Distal Humerus Fracture With Acute Loss of Lateral Articular Condyle

Acute, major articular bone loss associated with an open fracture is an uncommon injury. These injuries typically occur after high-energy trauma and are challenging to treat. Various approaches to treatment include allografts, prosthetic composite structures, custom implants, and total joint arthroplasty. These treatment options provide a wide array of variability in outcomes, costs, and challenges, especially in young and active patients. Two patients presented to our institution with open elbow injuries that included structural bone loss of the lateral column including the entire capitellar articular surface and a portion of the lateral trochlea. With the limited portions of bone available, the surgical principles for distal humerus fracture of articular repair followed by medial and lateral column restoration were followed. Each patient was treated with repair of the residual remnant of the articular surface. Then, repair of the columns of the distal humerus was performed by using a combination of internal fixation and hinged external fixation. In both cases, a plate was inserted to repair the medial column and a hinged external fixation was applied laterally to protect the lateral column. Immediate motion was allowed and progressed within each patient's tolerance. The lateral, hinged external fixator was removed at 8 weeks after injury and converted to a lateral column plate fixed distally into the lateral portion of the residual trochlea. At follow-up, both patients had radiographic evidence of reconstitution of the lateral column of the distal humerus and were able to return to heavy manual labor. [Orthopedics. 2022;45(3):e162-e167.].

Risk Factors for Infection in Patients Undergoing Osteosynthesis for Tibial Plateau Fracture in a University Hospital

Schatzker types IV to VI tibial plane fractures compromise the two tibial plateaus. Most cases involve joint deviation and require anatomic reduction and rigid fixation. Dual access and prolonged surgical time are factors that exert an influence on the occurrence of infection of the surgical wound and, consequently, the clinical outcome. The reason why these fractures have a greater incidence of infection compared to others remains unclear. The aim of the present study was to investigate risk factors for infection in patients undergoing osteosynthesis for tibial plateau fracture considering demographic, clinical, and operative factors.

A retrospective study was conducted with data on patients with Schatzker types IV, V, and VI tibial plateau fracture submitted to surgical treatment at a tertiary university hospital affiliated with the public healthcare system. The following data were extracted from the patient files: age; type of fracture; mechanisms of trauma; exposure of fracture; use of external fixator prior to osteosynthesis considering the time of fixator use, distance between Schanz screws, and location of the fracture; presence of compartment syndrome; number of surgical accesses; surgical time; number of participants in surgery and smoking; and comparing groups with and without infection at the surgical site in the immediate postoperative period (up to three weeks). Among the 44 patients studied, mean age was 48.5±15.1 years, 72.7% patients were male, 11.4% were diabetic, 56.8% had Schatzker type V tibial fracture, 88.6% had fractures caused by high-impact trauma, 95.5% of the fractures were closed, 100% used an external fixator prior to definitive osteosynthesis, 54.5% had a single lateral surgical access, and infection at the surgical site occurred in 25% of patients. In the comparison of patients with and without infection, a significant difference was found regarding the distance between the Schanz screws and location of the fracture (p=0.0286), which was shorter in patients with infection at the surgical site. The analysis of potential risk factors for infection revealed that open fracture was the only risk factor in patients with proximal tibial fracture, with a 1.22-fold increase in the likelihood of infection (odds ratios {OR}: 1.22; 95% confidence intervals {CI}: 0.93-1.62; p=0.012). In conclusion, open fracture, greater proximity between the Schanz screws of the external fixator, and the location of the fracture were considered risk factors for infection at the surgical site in patients undergoing osteosynthesis for tibial plateau fracture.

A clinico-radiological study of bicondylar tibial plateau fractures managed with dual locking plates

BACKGROUND

Treatment of bicondylar intra-articular tibial plateau fractures due to high energy trauma is complex and highly prone to complications due to fracture patterns and extensive soft tissue damage.

AIM

The study's objective was to evaluate the clinical, radiological and functional outcome, including the complications in closed Schatzker type V and VI tibial plateau fractures managed with dual locking plates using less extensile approaches and indirect reduction techniques.

MATERIALS AND METHODS

Thirty-four patients of closed Schatzker Type V and VI treated with pre-contoured locking plates were evaluated clinically and radiologically. Dual plating was done using a less extensile anterolateral approach for lateral plate and medial/open posteromedial approach for medial plate. Functional results were evaluated using the Knee Society Score (KSS) and radiological results by the Modified Rasmussen score (MRS) for radiological assessment.

RESULTS

The mean age of patients in our study was 45 years (range = 26-60 years) with a male predominance of 84.4%. The average time difference between trauma and surgery was 7.6 days (range = 5-14 days) with an average length of hospital stay of 8.5 days (range = 7-18 days). Autologous bone grafting from the iliac crest was done in 10 patients (29.4%) with a sizeable metaphyseal void. The study has a mean follow-up period of 22.6 months. The complete union was seen at an average of 17.4 weeks. The average knee ROM at the last follow-up was 110.75°. Three patients had complications, 2 with wound dehiscence and 1 with deep infection.

CONCLUSION

Internal fixation with dual locking plates is biomechanically strong and stable and gives excellent to good functional outcomes. However, the timing of internal fixation is essential in such complex injuries to prevent soft tissue complications and failure. The use of rigid fixation by less extensile approaches and indirect reduction techniques helps prevent wound healing problems and allows early knee mobilization.

The prevalence of soft tissue injuries in operative Schatzker type IV tibial plateau fractures

BACKGROUND

To describe the incidence of soft-tissue injuries in patients with surgically treated Schatzker type IV tibial plateau fractures.

METHODS

All tibial plateau fractures in skeletally mature patients treated operatively between January 2013 and August 2018 were retrospectively reviewed using a clinical medical record system. All fractures were categorized according to the AO/OTA classifications. Twenty-seven patients with Schatzker type IV tibial plateau fractures were further classified based on the Wahlquist classification. Associated soft-tissue injuries, which consisted of cruciate ligament injuries, and meniscal and collateral ligament injuries, were diagnosed through operation notes and magnetic resonance imaging (MRI) data. The categorical variables were tested by the chi-square test or Fisher's exact test.

RESULTS

The incidence of lateral meniscus tears and medial meniscus tears was 63% and 44.4% in Schatzker type IV tibial plateau fractures, respectively. Twenty-five (92.6%) patients had sustained anterior cruciate ligament (ACL) injuries, and 19 (70.4%) patients had an incomplete injury of the posterior cruciate ligament (PCL). There were 17 (63%) lateral collateral ligament (LCL) injuries, and 8 (29.6%) medial collateral ligament (MCL) injuries. Using the Wahlquist classification, these fractures were categorized as follows: type A, one patient; type B, six patients; type C, twenty patients. There was no significant difference between the type of fracture and the location of soft tissue injuries.

CONCLUSIONS

This study found that operative Schatzker type IV tibial plateau fractures represented a high incidence of soft-tissue injuries, especially LCL injuries, ACL injuries, and meniscus tears. Based on our data, we believe that soft-tissue injuries in operative Schatzker type IV tibial plateau fractures deserve more attention.

The Cambridge Experience With Tibial Plateau Fractures in Older Adults: A Case Series

Complex tibial plateau fractures (TPFs) represent a significant treatment challenge for any Orthopaedic surgeon. Current literature suggests that significantly displaced TPFs in the elderly require operative fixation, an operation that is associated with serious complications including septic and post-operative arthritis. As a result, these patients are five times more likely to require a total knee replacement (TKR). We present a case series of five elderly patients with complex TPFs who made serendipitous recoveries while awaiting operations. Their fractures were deemed so severe that they were being considered for TKR instead of fixation. We discovered their surprising functional improvements while they were being reviewed pre-operatively and decided to delay operating. We are currently unaware of any cases in the literature that have reported such findings. In total, five patients presented in 2019 with closed, varus/valgus stable fractures. They were managed non-operatively in hinged-knee braces, progressively weight-bearing with a minimum follow-up of 10 months. Oxford Knee Scores (OKS) were recorded at zero and four months after their injury. All patients were female with an average age of 69 years. Average fracture depression - 8.48mm, average fracture split - 8.66mm, average OKS reduction - 19%. All patients were able to mobilise independently at four months follow-up. Our results suggest that non-operative management can be considered as primary management in elderly patients with significantly displaced TPFs. Should this fail, or they develop arthritis, a TKR can be performed. This carries two benefits: the patient avoids the significant complications associated with fixation and should a TKR be required, it can more easily be performed in a patient without metalwork in-situ. We feel that the results from this case series might offer insight into a new treatment strategy and continue to closely follow these patients.

Does a staged treatment of high energy tibial plateau fractures affect functional results and bony union? A case series

PURPOSE

Tibial plateau fracture (TPF) is a devastating injury as it shatters lower articular surface of the largest joint. Apart from bony injury, TPF can lead to great soft tissue envelope compromise which affects the treatment plan and outcome. In the present study, clinical results were assessed in cases of high energy TPFs treated in staged manner.

METHODS

Twenty-three (20 males and 3 females) patients of high energy communited TPFs (Schatzker type V and VI) were consecutively treated.¹ All the patient had compromise of overlying skin conditions. They were all successively scheduled for staged treatment plan which comprised of application of bridging knee external fixator on the first day of admission and definitive internal fixation after skin and soft tissue overlying the fracture were healed. Schatzker type I, II, III and IV were excluded from the study. Primary survey was done and patient who had head injury, chest and abdominal injury, pelvic injury and contralateral limb injury and open fractures were excluded from the study. The patients were also evaluated in terms of wound complications, axial and rotary alignment of limb, fixation failure, articular congruity and range of motion of the knees and post injury employment. Statistical analysis was done using SPSS software.

RESULTS

Maximum follow-up period was 13 months. All the fractures were united at final follow-up. Clinical evaluation was done with the Tegner Lysholm knee scoring scale.² Excellent results were found in 78% cases and good and fair results in 22% cases. There was significant correlation between range of motion and the Tegner Lysholm knee score (p < 0.001, Pearson correlation coefficient = 0.741). The correlation between the score and the radiographical union duration was significant (p = 0.006, Pearson correlation coefficient = -0.554).

CONCLUSION

A staged treatment plan allows healing of soft tissue envelope, with avoidance of dreadful complications such as compartment syndrome and chronic infection. In addition, a staged treatment strategy does not hamper the fracture reduction, bony union and the functional results.

The accuracy of diagnostic Imaging techniques in patients with a suspected Fracture-related Infection (IFI) trial: study protocol for a prospective multicenter cohort study

INTRODUCTION

The optimal diagnostic imaging strategy for fracture-related infection (FRI) remains to be established. In this prospective study, the three commonly used advanced imaging techniques for diagnosing FRI will be compared. Primary endpoints are (1) determining the overall diagnostic performances of white blood cell (WBC) scintigraphy, fluorodeoxyglucose positron emission tomography (FDG-PET) and magnetic resonance imaging (MRI) in patients with suspected FRI and (2) establishing the most accurate imaging strategy for diagnosing FRI.

METHODS AND ANALYSIS

This study is a non-randomised, partially blinded, prospective cohort study involving two level 1 trauma centres in The Netherlands. All adult patients who require advanced medical imaging for suspected FRI are eligible for inclusion. Patients will undergo all three investigational imaging procedures (WBC scintigraphy, FDG-PET and MRI) within a time frame of 14 days after inclusion. The reference standard will be the result of at least five intraoperative sampled microbiology cultures, or, in case of no surgery, the clinical presence or absence of infection at 1 year follow-up. Initially, the results of all three imaging modalities will be available to the treating team as per local protocol. At a later time point, all scans will be centrally reassessed by nuclear medicine physicians and radiologists who are blinded for the identity of the patients and their clinical outcome. The discriminative ability of the imaging modalities will be quantified by several measures of diagnostic accuracy.

ETHICS AND DISSEMINATION

Approval of the study by the Institutional Review Board has been obtained prior to the start of this study. The results of this trial will be disseminated by publication of peer-reviewed manuscripts, presentation in abstract form at scientific meetings and data sharing with other investigators through academically established means.

TRIAL REGISTRATION NUMBER

The IFI trial is registered in the Netherlands Trial Register (NTR7490).

Complex Tibial Plateau Fractures: Primary Fixation Using the Ilizarov External Fixator. A Two-year Study at Civil Hospital Karachi, Pakistan

Background

The proximal tibia with the meta-diaphysis junction is a critical weight-bearing area. An injury around this region may be restricted to the tibia or associated with a significant soft-tissue injury. The objective of the present study is to assess the results of closed reduction and Ilizarov external fixation in the management of complex tibial plateau fractures.

Patients and methods

The study included 26 patients with high-energy tibial plateau fractures (Schatzker types V and VI). The ages ranged from 23 to 60 years, with an average of 35 years. The trauma was a road traffic accident in 19 cases and a fall from a height in eight cases. The fractures were closed in 18 cases and open in five. The open fractures were Gustilo-Anderson type I in three cases and type II in five cases. Soft-tissue injuries associated with closed fractures were classified according to the Tscherne system. The follow-up period averaged 24 months. The average time of surgery was 85 mins (range: 60-120 min). The mean time to union was 12 weeks. At the final follow-up, the average total range of knee flexion was 120° (range: 0-170°).

Results

Results were satisfactory in 22 cases and unsatisfactory in four cases according to Rasmussen's knee functional score. Complications included pin-tract infection in 10 cases, an extension lag in three cases and varus deformity of about 17° in one case.

Conclusion

Hybrid external fixation is a good method for the treatment of comminuted tibial plateau fractures. It allows for early joint movement and reduces the risk of serious complications.

Prevalence of Deep Surgical Site Infection After Repair of Periarticular Knee Fractures: A Systematic Review and Meta-analysis

IMPORTANCE

Surgical management of periarticular knee fractures can be challenging, and adverse outcomes may be severe. Recent literature indicates that the rate of periarticular knee surgical site infection (SSI) may range from 2% to 88% depending on the fracture site.

OBJECTIVE

To examine the prevalence of deep SSI and the rate of septic arthritis after surgical repair of fractures around the knee.

DATA SOURCES

The electronic databases MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from their inception to July 1, 2018.

STUDY SELECTION

Eligible studies had to specifically report deep SSI rates and include fractures in the distal femur, patella, tibial plateau, or proximal tibia. Risk factors that were associated with increased the risk of deep SSI were also examined.

DATA EXTRACTION AND SYNTHESIS

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Data were extracted by multiple investigators. Comprehensive Meta-Analysis software was used for the pooling of data, using either random-effects or fixed-effects models, with respect to the degree of statistical heterogeneity present. Data analyses were conducted in October 2019.

MAIN OUTCOMES AND MEASURES

The primary outcome was overall prevalence of deep SSI after periarticular knee fracture repair. The secondary outcomes were the overall prevalence of septic arthritis, risk factors associated with deep SSI, and the most commonly cultured bacteria specimens found periarticular knee infections.

RESULTS

Of 6928 articles screened, 117 articles met inclusion criteria and were included in analysis. Among 11 432 patients included in analysis, 653 patients (5.7%) experienced deep SSIs, most commonly among patients with proximal tibia fractures (56 of 872 patients [6.4%]). Among studies that included information on septic arthritis, 38 of 1567 patients (2.4%) experienced septic arthritis. The 2 most commonly reported bacteria were methicillin-resistant Staphylococcus aureus, found in 67 SSIs, and methicillin-susceptible S aureus, found in 53 SSIs. Sixty-two studies (53.0%) in the sample received a Coleman Methodological Score of poor (<50 points).

CONCLUSIONS AND RELEVANCE

Deep SSIs occurred in nearly 6% of periarticular knee fracture repairs, and 2.4% of SSIs were associated with septic arthritis. Surgeons managing these injuries should be vigilant when wounds are not pristine. Efforts should be made to elevate the quality of research conducted not only in this subject but also in orthopedic surgery as a whole.

CT based management of high energy tibial plateau fractures: A retrospective review of 53 cases

OBJECTIVES

The management of high energy tibial plateau fractures is a surgical challenge. Recently described Luo's classification is based on CT scans and is more objective with a better inter-observer agreement as compare to Schatzker and AO/OTA classifications. We describe the functional results of a series of 53 cases classified and managed according to the Luo's column concept.

METHODS

A retrospective review of 53 high energy tibial plateau fractures, operated between January 2012 and March 2015 at a Level I trauma center, was performed. CT scans were used to classify these injuries based on the number of columns involved. Plating configuration and surgical approach were chosen based on the number of independent articular fragments on axial sections at the level of fibular head.

RESULTS

1 one-column, 51 two-column and 1 three-column fractures were studied. Triple plating was done in 5 patients. Mean follow-up was 2.7 years and mean Insall Knee score was 95.42. Four patients had varus malalignment and 1 had joint depression in the post-operative period. These were due to imperfect reduction during the surgery itself, and no case of late collapse was detected.

CONCLUSION

Utilizing Luo's classification for treating these complex injuries will assist in better understanding of fracture pattern and hence help in achieving a better functional outcome. Each fractured column needs to be independently addressed.

Fixation of Posterior Tibial Plateau Fracture with Additional Posterior Plating Improves Early Rehabilitation and Patient Satisfaction

INTRODUCTION

Posterior tibial plateau fractures (PTPF) are difficult to manage because of options of multiple approaches, paucity of implants, and lack of ideal construct for fixation. We investigated the benefits of using posterior approach and buttress plate for fixation of the posterior tibial condylar fractures in terms of the fracture healing rate, clinico-radiological, perioperative morbidity, and patient-related outcomes and compared them in those who achieved acceptable reduction without posterior stabilization.

PATIENTS AND METHODS

Seventy two patients with posterior tibial plateau fractures were prospectively followed after random allocation into two Groups A and B. Thirty eight patients of Group A (dual plating) were managed with stabilization of posterior fragment with Lobenhoffer approach in addition to anterolateral plating. Thirty four patients of Group B (single plate) were managed with isolated anterolateral plating after reducing the PTPF. Twelve patients lost to follow-up and sixty patients were available (thirty in either group) for final assessment. Followup was done by clinical examination, radiographs and computed tomography scan, fracture union, articular continuity, and deformities around the knee. Subjective outcome assessment was done with the International Knee Documentation Committee (IKDC) 2000 and Knee Society Score (KSS).

RESULTS

At 1-year followup, the two groups did not differ in time of fracture union. IKDC and KSS were significantly better in dual-plating group (P < 0.001). Mean operative time and blood loss were more in dual-plating group (A). The mean hospital stay and complications did not show significant differences.

CONCLUSION

Addition of posterior approach for stabilization of the posterior fragment in posterior tibial plateau fractures achieves early and improved knee functions, good range of movements, minimal deformities, and pain scores by the time fracture unites. However, peri-operative morbidity, Extra implant costs and increased operative time are its disadvantages.

The use of bidirectional rapid reductor in minimally invasive treatment of bicondylar tibial plateau fractures: preliminary radiographic and clinical results

BACKGROUND

Minimally invasive treatment of complex tibial plateau fracture represents one of the most challenging problems in orthopedic surgery. We intended to describe the percutaneous surgery involving an originally designed traction device which might facilitate the closed reduction for bicondylar tibial plateau fractures. Further, to assess the clinical outcomes of this minimally invasive technique.

METHODS

Between December 2015 and July 2016, Twenty-one patients, mean age 43.71 ± 13.80 years, suffering from a bicondylar tibial plateau fracture (AO/OTA 41-type C) were included. All fractures were firstly reduced by skeletal traction with the aid of bidirectional rapid reductor, and residual depressed fragments were treated with minimally invasive bone tamp reduction. We then evaluated at a minimum follow-up of one year: (1) the rate of complications, (2) the radiographic outcomes (the amount of depression, tibial plateau widening, tibial plateau angle and posterior slope angle) and (3) the clinical outcome (Rasmussen scoring system).

RESULTS

All patients had their fractures healed without secondary displacement. No instrument-related complications occurred during operation. Post-operatively, superficial infection was found in two patients and donor-site morbidity was found in one patient. We observed a < 5 mm step-off in 100% of patients and a < 5 mm plateau widening in 95.5% of patients. Three patients were considered indicative of malalignment with TPA > 90° or PSA > 15°. At last evaluation, the Rasmussen clinical score was excellent in 11 patients (52.3%), good in 9 (42.9%) and fair in 1 (4.8%), and the radiological score was excellent in seven patients (33.3%), good in 14 (66.7%).

CONCLUSIONS

The bidirectional rapid reductor facilitates the minimally invasive treatment of bicondylar tibial plateau fracture. The patients exhibited excellent functional recovery. These results should be validated with a larger group of patients and longer period results.

TRIAL REGISTRATION

ChiCTR-OPC-16008011 .

Treatment of fractures of the tibial plateau (Schatzker VI) with external fixators versus plate osteosynthesis

INTRODUCTION

The purpose of this study was to determine the effectiveness of circular external fixation (CEF) as a definitive treatment option for patients with complex tibial plateau fractures (Schatzker VI) compared with the outcomes of a fixed angle locking plates' group.

METHODS

Level III evidence. Retrospective, comparative study in a Level I Trauma Center. Fourteen patients treated with CEF (Group A) were compared to fourteen patients treated with minimal invasive angle locking plates (Group B). The mean time from fractures to surgery was 19 days for Group A with a mean ISS of 24 and 7 days for Group B with a mean ISS of 14. The main outcome measures were clinical and radiographic.

RESULTS

Complete union was obtained in Group A at an average of 22 weeks and at 17 weeks in Group B. Two patients developed non-union, one in each group. Normal alignment was observed in both groups, no statistical differences were observed in Paley's anatomical posterior proximal tibial angle (aPPTA) and mechanical medial proximal tibial angle (mMPTA) between two groups. Results based on the Association for the Study and Application of the Method of Ilizarov criteria for Group A: 71% excellent and 29% good as far as bone outcomes are concerned and as 57% excellent, 37% good, and 7% fair for functional outcomes.

CONCLUSIONS

Definitive fixation with circular external fixator is effective in complex Schatzker VI tibial plateau fractures. Advantages include maintaining the frame till union, reduced risk of infection, early mobilization, restoration of the normal lower extremity alignment, versatility, and improved union rate in patients with multiple traumatic injuries, infection, and soft tissue injuries.

Reconstruction of a Neglected Tibial Plateau Fracture Malunion with an Open-Book Osteotomy: A Case Report

CASE

Surgical management of tibial plateau fractures can be challenging, and complications can be devastating. We report the case of a lateral tibial plateau fracture malunion with an associated intra-articular depression, which we treated with an open-book osteotomy, obviating the need for an early corrective osteotomy or knee arthroplasty.

CONCLUSION

A tibial plateau fracture malunion can be reconstructed. The surgical team should give priority to salvage options, which can obviate or delay the need for and the implications of an early total knee arthroplasty, especially in a young and active patient.

Costs and Complications of Single-Stage Fixation Versus 2-Stage Treatment of Select Bicondylar Tibial Plateau Fractures

OBJECTIVES

To determine the differences in costs and complications in patients with bicondylar tibial plateau (BTP) fractures treated with 1-stage definitive fixation compared with 2-stage fixation after initial spanning external fixation.

DESIGN

Retrospective cohort study.

SETTING

Level 1 Trauma Center.

PATIENTS/PARTICIPANTS

Patients with OTA/AO 41-C (Schatzker 6) BTP fractures treated with open reduction internal fixation.

INTERVENTION

Definitive treatment with open reduction internal fixation either acutely (1 stage) or delayed after initial spanning external fixation (2 stage).

MAIN OUTCOME MEASURES

Wound healing complications, implant costs, hospital charges, Patient-Reported Outcomes Measurement Information System (PROMIS), reoperation, nonunion and infection.

RESULTS

One hundred five patients were identified over a three-year period, of whom 52 met the inclusion criteria. There were 28 patients in the 1-stage group and 24 patients in the 2-stage group. Mean follow-up was 21.8 months, and 87% of patients had at least 12 months of follow-up. The mean number of days to definitive fixation was 1.2 in the 1-stage group and 7.8 in the 2-stage group. There were no differences between groups with respect to wound healing or any other surgery-related complications. Functional outcomes PROMIS were similar between groups. Mean implant cost in the 2-stage group was $10,821 greater than the 1-stage group, mostly because of the costs of external fixation. Median hospital inpatient charges in the 2-stage group exceeded the 1-stage group by more than $68,000 for all BTP fractures and by $61,000 for isolated BTP fractures.

CONCLUSIONS

Early single-stage treatment of BTP fractures is cost-effective and is not associated with a higher complication rate than 2-stage treatment in appropriately selected patients.

LEVEL OF EVIDENCE

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

Biomechanical analysis of walking gait when simulating the use of an Ilizarov external fixator

The Ilizarov frame is an external fixation device, primarily used for the treatment of complex fractures. The authors postulate that the size and weight of the frame may lead to biomechanical adaptations to gait, independent to any injury. Temporospatial characteristics, kinetics and kinematics were assessed when simulating the use of an Ilizarov frame. Fifteen healthy participants performed walking trials, with and without the simulated frame. Significant changes to temporospatial characteristics were identified, with a decreased mean walking speed (with: 1.24 m s–1; without: 1.29 m s–1) and increased mean step width (with: 0.14 m; without: 0.11 m). The push-off phase of gait differed significantly between test conditions with mean increases in ankle dorsiflexion angles (with: 90.4°; without: 89.0°) and extension moments (proportional to body weight or P BWT) at the knee and ankle (knee with: 0.8 P BWT·m; without: 0.7 P BWT·m; ankle with: 1.6 P BWT·m; without: 1.6 P BWT·m). Although changes were small and likely to be clinically insignificant, the size and weight of the frame led to adaptations which may be magnified for patient groups with associated injury and pain at the lower limb. Results provide an argument for the potential redesign of the frame.

RETRACTED: Comparison of arthroscopic reduction and percutaneous fixation and open reduction and internal fixation for tibial plateau fractures

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the Editor-in-Chief. The authors purportedly reviewed seven randomised trials. However, on reviewing the included studies, it became clear that most (if not all, as some were not able to be retrieved or translated) were not randomised trials. The authors included observational studies as randomised trials and also included information (apparently extracted independently by two authors) that did not exist (e.g., the method of randomisation and the presence of allocation concealment) or was clearly false (e.g., assessor blinding). The Publisher would like to apologise to any readers who were misled by information contained in this article.

Results of ring (Ilizarov) fixator in high energy Schatzker type VI fractures of proximal tibia

BACKGROUND

High-energy fractures of proximal tibia (Schatzker VI) are associated with severe articular depression, separation of both condyles, diaphyseal comminution & dissociation with loss of integrity of the soft-tissue envelope. Complications of plating are well known since last 50years in these difficult fractures. An alternative method was proposed by Ilizarov (ring fixator) and was adopted for the treatment of these complex injuries.

AIM OF STUDY

To analyse the results of patients who had ring fixator for the management of high-energy fractures (Schatzker VI) of the proximal tibia.Material & Methods: Fifteen patients (mean age of 36years) with high-energy fractures of the proximal tibia (Schatzker VI) by the Ilizarov fixator and transfixion wires. Nine fractures were open and six patients had severe soft tissue injuries. Thirteen were treated by ligamentotaxis and percutaneous fixation. All were followed for a mean of 19.4 months. Using the criteria established by Honkonen & Jarvinen (1992), the outcome was analysed.

RESULTS

Fourteen fractures united, with an average time to healing of 14.6 weeks and one took six months. 12 patients achieved full extension and 8 patients regained more than 110° of flexion. All knees were stable with one patient uniting in mild varus deformity. Normal walking was observed in nine patients and four had a mild limp. All but one knee had an articular step-off of less than 4 mm and all had normal axial alignment except one. The outcome suggested that seven knees were excellent, seven good and one as fair. There were no cases of postoperative skin infection or septic arthritis, but three cases had pin tract infection who were treated successfully.

CONCLUSION

The technique is well suited for the management of complex fractures of the proximal tibia (Schatzker VI) when extensive comminution at the fracture site and compromise of the soft tissue is present.

Characteristics of postoperative weight bearing and management protocols for tibial plateau fractures: Findings from a scoping review

OBJECTIVE

To identify and describe the characteristics of existing practices for postoperative weight bearing and management of tibial plateau fractures (TPFs), identify gaps in the literature, and inform the design of future research.

METHODS

Seven electronic databases and clinical trial registers were searched from inception until November 17th 2016. Studies were included if they reported on the surgical management of TPFs, had a mean follow-up time of ≥1year and provided data on postoperative management protocols. Data were extracted and synthesized according to study demographics, patient characteristics and postoperative management (weight bearing regimes, immobilisation devices, exercises and complications).

RESULTS

124 studies were included involving 5156 patients with TPFs. The mean age across studies was 45.1 years (range 20.8-72; 60% male), with a mean follow-up of 34.9 months (range 12-264). The most frequent fracture types were AO/OTA classification 41-B3 (29.5%) and C3 (25%). The most commonly reported non-weight bearing time after surgery was 4-6 weeks (39% of studies), with a further 4-6 weeks of partial weight bearing (51% of studies), resulting in 9-12 weeks before full weight bearing status was recommended (55% of studies). Loading recommendations for initial weight bearing were most commonly toe-touch/<10kg (28%), 10kg-20kg (33%) and progressive (39%). Time to full weight bearing was positively correlated with the proportion of fractures of AO/OTA type C (r=0.465, p=0.029) and Schatzker type IV-VI (r=0.614, p<0.001). Similar rates of rigid (47%) and hinged braces were reported (58%), most frequently for 3-6 weeks (43% of studies). Complication rates averaged 2% of patients (range 0-26%) for abnormal varus/valgus and 1% (range 0-22%) for non-union or delayed union.

CONCLUSIONS

Postoperative rehabilitation for TPFs most commonly involves significant non-weight bearing time before full weight bearing is recommended at 9-12 weeks. Partial weight bearing protocols and brace use were varied. Type of rehabilitation may be an important factor influencing recovery, with future high quality prospective studies required to determine the impact of different protocols on clinical and radiological outcomes.

Infection following fractures of the proximal tibia - a systematic review of incidence and outcome

Background

To systematically review all available studies of operatively treated proximal tibia fractures and to report the incidence of superficial or deep infection and subsequent outcomes.

Methods

A systematic review of the literature in Medline, Cochrane, Embase and GoogleScholar was conducted to identify studies with cohorts of patients with infection after surgical treatment of proximal tibia fractures. Studies were included according to predefined inclusion and exclusion criteria. The studies were analysed for methodological deficiencies and quality of outcome reporting based on the Level of Evidence (LOE) and Coleman Methodology Scoring (CMS.)

Results

In total 32 studies were included. There was heterogeneity between the studies, in terms of subject of the studies, outcome criteria, fracture type and classification, surgical techniques and length of follow-up. Therefore, no meta-analysis could be performed. The average CMS was 54.2 (range 36–75). The included studies were 25 case series (LOE IV), 6 were prospective cohort studies (LOE III) and one was a prospective randomized trial (LOE I). 203 (12.3%, range: 2.6–45.0%) infections occurred in the overall population (n = 2063). Those were divided into 129 deep infections and 74 superficial infections. Revision due to infection was reported in 29 studies, microbiological results in 6, respectively. 72 (55,8%) of 129 cases reporting outcome after deep infection had an unsatisfactory outcome with substantial limitations of the affected joint and leg.

Conclusions

Postoperative infections are a challenge, sometimes requiring several revisions and often with a worse outcome. Further studies with structured study protocols should be performed for a better understanding of risk factors to improve treatment outcomes.

Complications and unplanned outcomes following operative treatment of tibial plateau fractures

INTRODUCTION

The operative management of tibial plateau fractures is challenging and post-operative complications do occur. The purpose of this study was three-fold. 1). To report complications and unplanned outcomes in patients who had sustained tibial plateau fractures and were operatively managed 2). To report predictors of these post-operative events 3). To report if differences in clinical outcomes exist in patients who sustained a post-operative event.

METHODS

Over 11 years, all tibial plateau fractures were prospectively followed. Clinical outcomes were assessed using the validated Short Musculoskeletal Functional Assessment (SMFA) score. Demographics, initial injury characteristics, surgical details and post-operative events were prospectively recorded. Student's t-tests were used for continuous variables and chi-squared analysis was used for categorical variables. Binary logistic regression and multivariate linear regression were conducted for independent predictors of post-operative events and complications and functional outcomes, respectively.

RESULTS

275 patients with 279 tibial plateau fractures were included in our analysis. Ten patients (3.6%) sustained a deep infection. Six patients (2.2%) developed a superficial infection. One patient (0.4%) presented with early implant failure. Two patients (0.7%) developed a fracture nonunion. Eight patients (2.9%) developed a venous thromboembolism. Seventeen patients (6.2%) went on to re-operation for symptomatic implant removal. Nine patients (3.3%) underwent a lysis of adhesions procedure. Univariate analysis demonstrated bicondylar tibial plateau fractures (P<0.001), Moore fracture-dislocations (P=0.005), open fractures (P=0.022), and compartment syndrome (P=0.001) to be associated with post-operative complications and unplanned outcomes. Long-term functional outcomes were worse among patients who developed a post-operative complication or unplanned outcome (P=0.031).

CONCLUSION

Orthopaedic trauma surgeons should be aware of complications and unplanned outcomes following operatively managed tibial plateau fractures, along with having the knowledge of factors that are associated with development of post-operative events.

Outcome evaluation of staged treatment for bicondylar tibial plateau fractures

BACKGROUND

The universal accepted strategy for treating high-energy tibial plateau fractures remains a topic of ongoing debate. The challenge for the practicing orthopaedic trauma surgeon is to provide anatomical articular fracture reduction, with successfully managing the complex soft-tissue injury that is commonly present at patient admission. The primary aim of the actual study was to evaluate the results of a staged protocol for the treatment of high-energy bicondylar tibial plateau fractures. The secondary aim was to describe the technique used for the definitive fixation of this complex fracture pattern.

METHODS

Thirty patients with unstable high-energy closed bicondylar tibial plateau fractures (17 Schatzker V and 13 Schatzker VI) were managed. There were 24 men (80%) and six women (20%). All of them were skeletally mature with their age ranging from 19 to 67 years (mean of 33.1±3.4 years). Treatment involved a two-stage procedure with appropriate emergency care, preoperative planning, and definitive fixation. Initial treatment, named 'damage control on complex articular fracture elements', consisted on temporary bridging external fixation. Definitive treatment was delayed in a mean of 10 days (ranging from seven to 13 days) and was performed when the soft-tissue conditioning demonstrated either complete or almost complete remission of the inflammatory reaction due to the 'first hit'. Conventional implants were used in the 30 patients. All patients were evaluated clinically and radiographically.

RESULTS

Twenty-six (86.7%) patients had a moderate level of activity, three (10%) patients had a very light level of activity, and one (3.3%) patient was unable to have any kind of work activity and is currently supported by the Brazilian Welfare. Using the visual analog scale mean pain score was 30 (ranging from 10 to 60); even the patient with the workers' compensation had no severe pain. All patients except three have no difficulty with stairs, giving way, locking, swelling, and squatting, but were unable to run. Three (10%) patients had problems with stairs and could not bend the operated knee more than 90^°. One of them had a varus knee but no instability. Ninety percent of the patients were either very satisfied or somewhat satisfied with their outcome. The three dissatisfied patients suffered postoperative complications, most commonly wound infections. Four (13.4%) patients with former anatomical reduction had a residual articular step-off or diastasis of less than 3mm after fracture healing. All patients had no or mild arthrosis at the time of the last outpatient consultation.

CONCLUSIONS

The two-staged procedure presented herein showed to be an effective strategy for managing bycondilar tibial plateau fractures. The protocol used for these complex traumatic injuries follows very well defined steps, which means acute stabilization with a linear bridging external fixation, adequate soft tissue handling, preoperative planning, and definitive surgical fixation after seven to 14 days. The model presents a more biological approach to optimizing functional outcome with an acceptable complication rate and minimal risk of loss of reduction in these high-energy tibial plateau fractures.

The role of external fixation in trauma

External fixation is a method of immobilization that uses percutaneous pins placed in bone and linked with external connectors to maintain the fracture segments in a desired spatial relationship. It is a valuable clinical treatment option, providing surgeons with the ability to affect the spatial relationship of tissues, both statically and dynamically, via minimally invasive techniques. The ease and speed of application, adjustability of the frame, and minimization of blood loss with preservation of blood supply at the cutaneous and osseous levels are advantages of the external fixation technique. Care of the trauma patient remains one of the major applications for external fixation. Open fractures with severe soft tissue injuries and/or massive contamination are ideally suited to this technique. External fixation is also a versatile salvage technique for the complications arising from extremity trauma. The management of residual fracture deformity, bone loss, infections, and complex post-traumatic arthritis are often facilitated by external fixation.

Indications and anatomic landmarks for the application of lower extremity traction: a review

PURPOSE

Fractures of the lower extremity, particularly of the femur and acetabulum, may be difficult to immobilize with splinting alone. These injuries may be best stabilized with the application of various types of skeletal traction. Often, traction is applied percutaneously in an emergent setting, making the knowledge of both superficial and deep anatomy crucial to successful placement.

METHODS

Review was performed via PubMed search as well as referencing the Orthopaedic literature. Relevant articles to the anatomy of the knee, ankle and calcaneus as they pertain to traction placement were referenced in compiling the optimal recommendations for traction placement.

CONCLUSION

By palpating and marking superficial landmarks and observing specific anatomic relationships, safe application of traction pins can be performed while minimizing iatrogenic injury to vital anatomic structures, and avoiding intra-articular placement which could potentially lead to joint infection.

Ilizarov management of Schatzker IV to VI fractures of the tibial plateau

This study aimed to determine the long-term functional, clinical and radiological outcomes in patients with Schatzker IV to VI fractures of the tibial plateau treated with an Ilizarov frame. Clinical, functional and radiological assessment was carried out at a minimum of one year post-operatively. A cohort of 105 patients (62 men, 43 women) with a mean age of 49 years (15 to 87) and a mean follow-up of 7.8 years (1 to 19) were reviewed. There were 18 type IV, 10 type V and 77 type VI fractures. All fractures united with a mean time to union of 20.1 weeks (10.6 to 42.3). No patient developed a deep infection. The median range of movement (ROM) of the knee was 110o and the median Iowa score was 85.

Our study demonstrates good long-term functional outcome with no deep infection; spanning the knee had no detrimental effect on the ROM or functional outcome.

High-energy fractures of the tibial plateau may be treated effectively with a fine wire Ilizarov fixator.

Cite this article: Bone Joint J 2015;97-B:1693–7.

Low Complication Rates Associated With the Application of Lower Extremity Traction Pins

OBJECTIVE

To quantify the infection risks of temporary lower extremity traction pins and compare these rates to nationwide and institution-specific surgical site infection rates. Additionally, to qualitatively describe pin site infections and to analyze the impact of traction pins on infection risks at associated open reduction internal fixation (ORIF) surgical sites.

DESIGN

A retrospective case-control study.

SETTING

Level I Urban University Trauma Center.

PATIENTS

One hundred sixty-nine cases of traction pin application occurring in 157 unique patients extracted from a trauma patient database.

INTERVENTION

Bedside application of a traction pin in the femur or tibia.

MAIN OUTCOME MEASUREMENTS

Rates of 90-day and 1-year minor and major infections at pin insertion locations and at ORIF wounds associated with traction pins.

RESULTS

A single infection, a septic knee, was reported. There were no superficial infections or osteomyelitis cases observed. The 90-day and 1-year rates of infection were identical with a per pin infection rate of 0.6% [95% confidence interval (CI), 0.1%-3.4%], a minor infection rate of 0.0% (95% CI, 0.0%-2.3%), and a major infection rate of 0.6% (95% CI, 0.1%-3.4%). Observed rates were lower than, but statistically similar to, nationwide infection rates for open reduction procedures and similar to institution-specific infection rates for arthroplasty procedures. Infection rates at associated ORIF wounds were not increased in comparison with nationwide controls. Pin placement played a definitive role in the infection observed.

CONCLUSIONS

Temporary lower extremity traction pins have low infection rates and can be safely placed at the bedside. Careful pin placement and review of postinsertion radiographs is necessary to avoid iatrogenic infection.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Posttraumatic stress disorder associated with orthopaedic trauma: a study in patients with extremity fractures

OBJECTIVE

The aims of this prospective study were to determine the prevalence of posttraumatic stress disorder (PTSD) in a population of young male military conscripts who experienced an extremity long-bone fracture, and to evaluate whether injury-related variables are associated with the development of PTSD.

DESIGN

Prospective, nonrandomized comparative study.

SETTING

Level 1 trauma center.

PATIENTS AND METHODS

A total of 148 men (age older than 18 years) who had 1 or more acute long-bone extremity fractures within 12 months and were seen at the Seoul Regional Military Manpower Center for examination of military conscripts from March 2013 to March 2014, were enrolled. The Korean version of the posttraumatic disorder scale was used to identify aspects of PTSD. The injury-related variables assessed included injury mechanism, fracture location and multiplicity, fracture severity, and the occurrence of joint ankylosis and secondary osteoarthritis.

RESULTS

Of the 148 participants, 40 (27.0%) met the criteria for the diagnosis of PTSD. Multivariate logistic linear analysis confirmed that lower extremity fracture, multiple fractures, and a higher pain visual analog scale score were significantly (P = 0.042, P = 0.043 and P < 0.001, respectively) related to the occurrence of PTSD.

CONCLUSIONS

Lower extremity fracture, multiple extremity fractures, and higher pain visual analog scale scores were significantly related to the occurrence of PTSD. To achieve an optimal recovery after orthopaedic injury, clinicians must address both physical and psychologic needs of their patients.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Cadaveric analysis of capsular attachments of the distal femur related to pin and wire placement

OBJECTIVES

Septic arthritis following intra-capsular penetration of the knee by external fixation devices is a complication of traction/fixation devices inserted in the lower extremity [1,2]. The authors were unable to find reference to or exact measurements of the capsular attachments relating to the distal femur documented in the current literature. This study aimed to demonstrate the capsular attachments and reflections of the distal femur to determine safe placements of wires or traction devices.

METHODS

The attachments of the capsule to the distal femur were measured in 10 unembalmed cadaveric knees. Capsular attachments were measured anteriorly at the maximal extension of the supra-patella pouch. Medially and laterally measurements were expressed as percentages related to the maximal AP diameter of the distal femur.

RESULTS

Mean distance from the centre of the anterior part of the notch to the superior fold was 79.5mm (Range 48.1-120.7 mm). The medial capsular reflections measured in a plane from the adductor tubercle to the anterior edge of the medial femoral condyle demonstrated the capsular reflection was attached an average of 57% back from the anterior edge (Range 41-74%). Laterally the capsular reflections on a line drawn from the maximal diameter in the sagittal plane were attached an average of 48% from the anterior reference point (Range 33-57%). Measuring the reflections at 45 degrees to the long axis of the femur in the sagittal plane the attachment was an average of 51% from the anterior reference point.

CONCLUSIONS

Capsular reflections varied among specimens. Medially the capsule attachment was up to 74% of diameter of distal femur at the level of the adductor tubercle. Therefore, the insertion of distal femoral traction pins or similar should be placed proximal to the adductor tubercle and no further than 25% of the distance to the anterior cortex. Care is also needed to ensure pins do not travel to exit too anteriorly on the lateral side as capsular attachments were found to be up to a distance 48% of the diameter of the femur from anterior reference point. Distal condylar extra-articular fixation with Schanz screws is feasible if orientated in the oblique plane.

Complications of high-energy bicondylar tibial plateau fractures treated with dual plating through 2 incisions

OBJECTIVES

To characterize the rate of complications after operative fixation of bicondylar (OTA/AO 41-C) tibial plateau fractures and to evaluate the contribution of common risk factors.

DESIGN

Retrospective review.

SETTING

Level 1 regional trauma center.

PATIENTS/PARTICIPANTS

One hundred thirty-eight patients older than 18 years with 140 bicondylar tibial plateau fractures were participated in this study.

INTERVENTION

Open reduction and internal fixation using medial and lateral plate construct through 2 incisions.

MAIN OUTCOME MEASUREMENTS

Development of a deep infection or a nonunion.

RESULTS

The overall major complication rate was 27.9%: 23.6% deep infection and 10.0% nonunion. Open fractures were associated with a higher rate of infection: 43.8% versus 21.0% for closed injuries (odds ratio = 2.96, P = 0.05). Fasciotomy closure before definitive fixation was associated with significantly fewer deep infections compared with internal fixation with open fasciotomy wounds: 11.8% versus 50.0% (odds ratio = 7.5, P = 0.05). The presence of compartment syndrome, tobacco use, diabetes, and timing of surgery had no statistically significant association on the rate of infection or nonunion.

CONCLUSIONS

Nonunion and deep infections occur commonly after staged open reduction and internal fixation of high-energy tibial plateau fractures. Open fractures and open fasciotomy wounds at the time of internal fixation are associated with higher rates of infection.

LEVEL OF EVIDENCE

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

Outcome of angular stable locking plate fixation of tibial plateau fractures Midterm results in 101 patients

BACKGROUND

Articular reconstruction and stable fixation of tibial plateau fractures and its various subtypes continue to represent a surgical challenge. Only few trials have studied results following angular stable plate fixation. The present study aimed to investigate the clinical, radiological, functional and quality of life results following tibial plateau fractures using angular stable plate fixation.

MATERIALS AND METHODS

101 patients were retrospectively studied using functional (ROM; KSS; VAS), radiographic (osteoarthritis score, loss of reduction) and quality of life (WOMAC; Lysholm) scores. There were 46 males and 55 females. The average of patients was 51 years (range 22-77 years). Study groups were assigned according to the AO fracture classification.

RESULTS

Mean followup was 57 ± 30 months. Fracture type distribution revealed a significantly (P < 0.001) increased number of type B- (62.4%) compared to C-fractures. Functional assessment showed a significantly better total KSS (84.1 ± 15.6 vs. 74.7 ± 18.0; P = 0.01) as well as ROM (active: 124°±17° vs. 116°±15°, P = 0.014; passive: 126°±18° vs. 118 ± 14°, P = 0.017) in the B-fracture group. VAS was found to be markedly higher (P = 0.0039) following type C-fractures. Rating osteoarthritis secondary to a tibial plateau fracture as a function of injury severity (r = 0.485; P < 0.001) and relating the loss of reduction to the grade of evolving osteoarthritis (r = 0.643; P < 0.001) a positive correlation was found. Quality of life showed significantly improved results for Lysholm score (P = 0.004) following B-fractures with low overall values for the WOMAC score.

CONCLUSION

Presented data provide sufficient evidence that anatomic restoration of tibial plateau fractures with angular stable plate fixation result in decreased loss of reduction and declined incidence of posttraumatic osteoarthritis, thereby providing acceptable mid to long term outcome.

Evaluation of tibial condyle fractures treated with Ilizarov fixation, a prospective study

BACKGROUND

Tibial plateau fractures are associated with significant soft tissue injuries which increases the risks of complications and must be considered when managing tibial plateau fractures. Various modalities of treatment are available for treatment of these fractures but Ilizarov fixation has a special advantage over others. Review of literature shows many studies of Ilizarov fixation in the treatment of tibial plateau fractures with variable results. Aim of our study was to evaluate tibial condyle fractures treated by Ilizarov fixation.

MATERIALS AND METHODS

Study included 43 patients with Schatzker type II and above tibial plateau fractures treated by ilizarov fixation. Standard trauma evaluation, a meticulous musculoskeletal and neurologic examination was carried out. All patients underwent Ilizarov fixation by same team of surgeons. Clinicoradilogical assessment of the patients carried out at regular intervals.

RESULTS

Our study included 43 cases of tibial plateau of various types except type I. Mean time for radiological union was 24.51 wk (range 15 to 32 wk). Mean fixator period was 26.6 wk( 16-34 wk). The functional results were measured by Lyshom's and Hohl and Luck score. The mean Lyshom's score was at the end of one year was 82.16. At end of one year by Hohl and Luck grading 11 patients had fair, 23 had good and 9 had excellent results.

CONCLUSION

High energy tibial plateau fractures can be definitively treated with Ilizarov external fixation. Treatment with this method gives good union rates and less risk of infection. Closed reduction, minimal soft tissue damage and early mobilization are the key to low complications.

Principles of tibial fracture management with circular external fixation

There is a growing mass of literature to suggest that circular external fixation for high-energy tibial fractures has advantages over traditional internal fixation, with potential improved rates of union, decreased incidence of posttraumatic osteomyelitis, and decreased soft tissue problems. To further advance our understanding of the role of circular external fixation in the management of these tibial fractures, randomized controlled trials should be implemented. In addition to complication rates and radiographic outcomes, validated functional outcome tools and cost analysis of this method should be compared with open reduction with internal fixation.

Locking plate as a definitive external fixator for treating tibial fractures with compromised soft tissue envelop

INTRODUCTION

Tibial fractures with compromised soft tissue envelop may lead to significant complications. The optimal management of these injuries remains controversial. Recently, locking plate used as a definitive external fixator is attractive because it not only minimizes trauma to the soft tissues, but also overcomes the shortcomings of standard external fixators. The objective of this study was to evaluate the outcome of using locking plate as a definitive external fixator for treating tibial fractures with compromised soft tissue envelop.

PATIENTS AND METHODS

A prospective series of 12 consecutive tibial fractures with compromised soft tissue envelop were treated using locking plate as a definitive external fixator. Of these patients, six were Gustilo and Anderson type IIIA, three were type II and three were closed fractures (AO/ASIF soft tissue injury classification IC4: 2, IC5: 1). Time to union, nonunion, malunion, leg shortening, range of motion and function for the knee and ankle, deep infection, pin tract infections were evaluated.

RESULTS

The mean bone healing time was 37.8 weeks (range 20-56 weeks). Eventually, all of the fractures united. Most of the fractures healed in acceptable positions. There were no cases of deep infection. Pin tract infection was seen in 1 (8.3 %) patient, no loosening or failure of the external fixator was seen. At the most recent follow-up, the mean range of motion at the knee was extension 0° to flexion 135°, and the mean ankle range of motion was dorsi flexion 12° to plantar flexion 32°. All patients had excellent or good functional results and were fully weight bearing with a well-healed tibia at the final follow-up.

CONCLUSION

The locking plate used as a definitive external fixator provided a high rate of union. The patients experienced a comfortable clinical course, excellent knee and ankle joint motion, satisfactory functional results and an acceptable complication rate. However, the stiffness of external locked plating is not clear, therefore, clinical recommendation on its practical use to reduce the risk of implant failure still need to be determined.

Bicondylar tibial plateau fractures treated with fine-wire circular external fixation

Bicondylar tibial plateau fractures are serious injuries to a major weight-bearing joint. These injuries are often associated with severe soft tissue injuries that complicate surgical management. We reviewed 54 consecutive patients who sustained bicondylar tibial plateau fractures that were treated with limited open reduction and cannulated screw fixation combined with fine-wire circular external fixation. Forty-six patients met the inclusion criteria of this retrospective review. Eight patients were excluded because they did not complete a minimum of 1-year follow-up. Thirty-six patients had Schatzker type-VI, and ten patients had Schatzker type-V fractures. All fractures were united without loss of reduction; there were no incidences of wound complications, osteomyelitis or septic arthritis. The average Knee Society Clinical Rating Score was 81.6, translating to good clinical results. Minor pin track infection was the most common complication encountered. This review concludes that fine-wire circular external fixation, combined with limited open reduction and cannulated screw fixation, consistently produces good functional results without serious complications.

Are distal femoral traction pins intra-articular? A cadaveric study

OBJECTIVES

To examine the frequency of intra-articular placement of distal femoral traction pins and their proximity to the superficial femoral artery (SFA).

METHODS

Wires were placed in the distal femurs of 28 cadaveric knees at the adductor tubercle (ADT), the superior pole of the patella (SPP), and 2 cm proximal to SPP (SPP+2). A lateral fluoroscopic image was obtained after injection of radiopaque contrast to assess for joint penetration. Dissection was performed to confirm or refute fluoroscopic findings. The distance from each wire to the SFA was measured.

RESULTS

The percentage of intra-articular placement was higher (29%) at the ADT than the SPP+2 (0%) level. The mean (SD) distances from the ADT, SPP, and SPP+2 to the SFA were 7.4 (±1.8) cm, 5.7 (±1.7) cm, and 3.8 (±1.7) cm, respectively (P < 0.0001). None of the wires penetrated the femoral artery. The proportion of wires judged to be intra-articular was not statistically different whether judged by fluoroscopy or anatomic dissection (exact P = 1.0).

CONCLUSIONS

Wires placed at the level of the ADT are at risk for capsular penetration. Risk of major vascular injury with transmedullary placement at all levels seems to be minimal. The optimum position for distal femoral pins remains unknown, but aiming >0.7 cm proximal to the ADT may lower the risk of intra-articular placement. No difference was detected between fluoroscopic arthrography and gross dissection.

A comparative biomechanical study for complex tibial plateau fractures: nailing and compression bolts versus modern and traditional plating

AIM

To compare the biomechanical properties of a newly proposed technique, utilizing intramedullary nailing and compression bolts, for the osteosynthesis of intra-articular proximal tibial fractures with meta-diaphyseal comminution, with modern and conventional plating techniques.

METHODS

Fifteen left tibia 4th generation composite Sawbones models (in 3 groups of 5 for each technique) with identically reproduced type VI Schatzker tibial plateau fractures, including meta-diaphyseal dissociation, were used. Three different techniques of osteosynthesis were tested: (a) a new technique that combines intramedullary nailing and compression bolts, (b) internal fixation with a single lateral locking plate and (c) internal fixation with dual buttress plating technique. The model-device constructs were successively subjected to 500N, 1000N and 1500N load levels with five cycles applied at each level on both articular compartments and a final load cycle to failure. Four parameters were recorded for each technique: the average reversible or irreversible displacement in vertical subsidence, the horizontal diastasis of the intra-articular fracture, the average passive construct stiffness and the load to failure.

RESULTS

The new intramedullary nailing technique provided rigid intra-articular osteosynthesis being statistically similar to dual buttress plating for subsidence at medium and higher load levels. At the same time the proposed technique provided statistically equivalent stiffness values to the single lateral locking plate incarnating the rational of biologic fixation. Average load to failure was 1611N for single lateral locking plates, 2197N for intramedullary nailing and 4579N for dual buttress plating. The single lateral locking plate technique had the worse results in interfragmentary displacement while dual buttress plating was superior in stiffness from the other 2 techniques. The mode of failure differed between techniques, with collapse of medial plateau occurring exclusively in the single lateral locking plates group.

CONCLUSION

The proposed new technique of intramedullary nailing and compression bolts demonstrates a flexural behaviour similar to single lateral locking plates, which complies with the terms and benefits of biological fixation, while at the same time maintains a rigid intra-articular stability similar to the stiff dual buttressing plating technique.

Risk factors of infection after ORIF of bicondylar tibial plateau fractures

OBJECTIVES

This study was designed to evaluate risk factors of infection after bicondylar tibial plateau fractures. We hypothesized that open fractures and smoking would be associated with deep infection requiring reoperation.

DESIGN

We retrospectively identified all bicondylar (AO/OTA 41-C) tibial plateau fractures treated operatively over an 8-year period from 2002 to 2010.

SETTING

Single, high-volume, level 1 trauma center.

PATIENTS/PARTICIPANTS

A total of 302 patients aged 18 years and older were identified as undergoing operative fixation of bicondylar (AO/OTA 41-C) tibial plateau fractures during this time period.

INTERVENTION

Open reduction internal fixation of bicondylar (AO/OTA 41-C) tibial plateau fractures.

MAIN OUTCOME MEASUREMENTS

Bivariate and multivariable logistic regression analyses were used to assess the association between patient demographics and clinical characteristics and deep infection requiring reoperation. Variables that were significant at P < 0.05 in bivariate analyses were entered into a multivariable logistic regression model.

RESULTS

Forty-three (14.2%) of 302 patients developed deep infection requiring reoperation. Methicillin-resistant Staphylococcus aureus (MRSA) was cultured in 20 (46.5%) of 43 patients with deep infections. An external fixator was initially placed before definitive fixation in 81.4% of patients and definitive surgical treatment was delayed by an average of 17.5 days. Eighty-five (28.1%) patients required a reoperation after definitive fixation.Open fracture (OR, 3.44; P = 0.003), smoking (OR, 2.40; P = 0.02), compartment syndrome requiring fasciotomies (OR, 3.81; P = 0.01), and fractures requiring 2 incisions and 2 plates (OR, 3.19; P = 0.01) were all risk factors for deep infection requiring reoperation.

CONCLUSIONS

In spite of a staged protocol with temporizing external fixation and delayed fixation, deep infection rate remained high. A disproportionate amount of MRSA (47%) was cultured from deep infections in this population, and MRSA prophylaxis may be considered. Smoking was the only patient modifiable predictor identified of deep infection, and patients should be informed of the increased risk of deep infection associated with their choice to continue smoking.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.