Repair of Tibial Plateau Fracture (Schatzker II)

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

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

Tibial plateau fractures in the elderly have clinical outcomes similar to those in younger patients

BACKGROUND

The purpose of this study was to compare outcomes following surgical treatment of tibial plateau fractures in an elderly (≥ 65y) and non-elderly (< 65) population.

METHODS

Patients with tibial plateau fractures were prospectively followed. Patients were included if they were operatively treated, had an Injury Severity Score of < 16, and had follow-up through 12 months. Clinical, radiographic, and functional outcomes were evaluated at the 3, 6, and 12-month follow-up points.

RESULTS

Mean time to radiographic fracture union was by 4.68 and 5.26 months in young and elderly patients, respectively (p = 0.25). There was no difference in self-reported baseline SMFA (p = 0.617). SMFA scores were better in younger patients at 3 months (p = 0.031), however this did not hold when multivariate modeling controlled for other factors. There was no difference at 6 and 12 months (p = 0.475, 0.392). There was no difference in range of knee motion at 3 months. At 6 and 12 months, young patients had statistically but not clinically better range of knee motion (p = 0.045, 0.007). There were no differences in overall reoperation rates, conversion arthroplasty, post-traumatic osteoarthritis or wound complications.

CONCLUSIONS

Age greater than 65 does not appear to portend poorer outcomes after surgical repair of a tibial plateau fracture. The complication profiles are similar. Elderly and younger patients had similar function at 12 months compared to their baseline. These data suggest that age should not be a disqualifying factor when considering whether a patient with a tibial plateau fracture should be treated operatively.

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

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

Stresses and deformations of an osteosynthesis plate in a lateral tibia plateau fracture

This study has the aim to investigate the strain and stress in an anterolateral locking plate applied for the fixation of a lateral split fracture. To simulate a complex fracture situation, three segments were separated. With a FEM analysis, representative places for strain and stress measurement were determined. A locked osteosynthesis plate was instrumented with strain gauges and tested on a fractured and a non-fractured Saw Bone model. To simulate different loading situations, four different points of force application, from the center of the condyles to a 15 mm posterior position, were used with a medial-lateral load distribution of 60:40. The simulations as well as the biomechanical tests demonstrated that two deformations dominate the load on the plate: a bending into posterior direction and a bulging of the plate head. Shifting the point of application to the posterior direction resulted in increasing maximum stress, from 1.16 to 6.32 MPa (FEM analysis) and from 3.04 to 7.00 MPa (biomechanical study), respectively. Furthermore, the comparison of the non-fractured and fractured models showed an increase in maximum stress by the factor 2.06-2.2 (biomechanical investigation) and 1.5-3.3 (FEM analysis), respectively.

Radiological Outcome Measures Indicate Advantages of Precontoured Locking Compression Plates in Elderly Patients With Split-Depression Fractures to the Lateral Tibial Plateau (AO41B3)

Background

Split-depression fractures to the lateral tibial plateau (AO41B3) often feature severe joint surface destructions. Precontoured locking compression plates (LCPs) are designed for optimum support of the reduced joint surface and have especially been emphasized in reduced bone quality. A lack of evidence still inhibits their broad utilization in elderly patients. Thus, aim of the present study was to investigate the implant-specific radiological outcomes of AO41B3-fractures in young versus elderly patients.

Methods

The hospital’s database was screened for isolated AO41B3-factures, open reduction and internal fixation (ORIF), and radiological follow-up ≥12 months. CT-scans, radiographs, and patients’ records were analyzed. Patients were attributed as young (18–49) or elderly (≥50 years). Additional subgrouping was carried out into precontoured LCP and conventional implants. The Rasmussen Radiological Score (RRS) after 12 months was set as primary outcome parameter. The RRS postoperatively and the medial proximal tibial angle (MPTA) postoperatively and after 12 months were secondary outcome parameters.

Results

Fifty nine consecutive patients were included (26 young, 38.2 ± 7.8 years; 33 elderly, 61.3 ± 9.4 years). There were no significant differences regarding mean size and depression depth of the lateral joint surface fragments. Prior to implant-specific subgrouping, the radiological outcome measures revealed no significant differences between young (RRS = 7.7 ± 1.7; MPTA = 90.3 ± 2.3°) and elderly (RRS = 7.2 ± 1.7; MPTA = 90.5 ± 3.3°). After implant-specific subgrouping, the radiological outcome revealed significantly impaired results in young patients with conventional implants (RRS_(C) = 6.9 ± 1.6, RRS_(LCP) = 8.5 ± 1.5, P = .015; MPTA_(C) = 91.5 ± 1.9°, MPTA_(LCP) = 89.1 ± 2.1°, P = .01). The effect was even more pronounced in elderly patients, with highly significant deterioration of the radiological outcome measures for conventional implants compared to precontoured LCP (RRS_(C) = 5.7 ± 1.6, RRS_(LCP) = 8.2 ± .8, P < .001; MPTA_(C) = 92.6 ± 4.2°, MPTA_(LCP) = 89.2 ± 1.4°, P = .002).

Conclusion

Utilizing precontoured LCP in the treatment of AO41B3-fractures is associated with improved radiological outcomes. This effect is significant in young but even more pronounced in elderly patients. Consequently, precontoured LCP should closely be considered in any AO41B3-fracture, but especially in elderly patients.

Joint line plate fixation for tibial plateau fractures caused by hyperextension varus

The present study evaluated the outcomes of internal fixation with a joint line plate in the treatment of tibial plateau fractures caused by hyperextension of the varus. The study included 25 cases (13 males and 12 females; age, 19-71 years) of tibial plateau fracture caused by hyperextension of the varus, which were treated at Puai Hospital, Tongji Medical College (Wuhan, China) between January 2015 and June 2017. Fractures were treated with internal fixations of the inner cortex with a self-clipped joint line plate made of steel. After the surgery, patients were examined immediately and at 3, 6 and 12 months. Healing was evaluated by X-ray examination. All cases were cured during follow-up. After surgery, one patient developed partial necrosis of the skin margin of the incision and recovered after a dressing change. Furthermore, one patient with a concomitant peroneal nerve injury and hypoesthesia recovered after treatment with neurotrophic drugs. No screw loosening, fractures or failure of the internal fixations occurred. According to the X-ray results, there were significant differences in the tibial plateau angle (TPA) and medial posterior slope angle (m-PSA) between the pre-operative stage and 12 months post-operatively (P<0.05). However, no significant differences in either the TPA or m-PSA were present between the immediate post-operative stage and 12 months post-operatively (P>0.05). In conclusion, internal fixation with a joint line plate is an appropriate treatment for tibial plateau fractures involving the anteromedial margin with good clinical efficacy.

Comparison between computed tomography and magnetic resonance imaging in clinical diagnosis and treatment of tibial platform fractures

BACKGROUND

Tibial plateau fracture is one of the common fracture types. It occurs mainly in teenagers and is usually caused by a fall. After the occurrence of fracture, knee swelling, pain, limited activity, etc. greatly affect the patient’s exercise habits and lifestyle. X-ray, computed tomography (CT) and magnetic resonance imaging (MRI) were used in this examination. X-rays are relatively new and easy to operate. However, there are some errors in the observation of fracture collapse and fracture displacement. In recent years, CT and MRI have been actively used to diagnose various types of clinical fractures. They have more diagnostic power than X-ray film. However, some scholars believe that CT is also prone to errors in clinical application. The volume effect leads to missed diagnosis and misdiagnosis in some cases, while the multidirection scanning of MRI technology can effectively overcome the shortcomings of CT. To facilitate the selection of clinical examination regimens, this study further observed the diagnostic ability of these two regimens in the diagnosis of tibial plateau fractures.

AIM

To explore the value of nuclear MRI and CT in the clinical diagnosis of tibial plateau fractures.

METHODS

A total of 120 patients with tibial plateau fractures admitted from September 2017 to August 2019 were included. All patients were examined by nuclear MRI and CT scanning. The results were sent to senior physicians in our hospital to complete the diagnosis.

RESULTS

Nuclear magnetic resonance showed the same effects as CT in four aspects: fracture displacement, bone defect, fracture site and fracture comminution. There was no significant difference in the score data (P > 0.05). Nuclear magnetic resonance and CT tended to be consistent in the B3, C2 and C3 fracture diagnosis coincidence rate, combined injury detection rate and fracture detection rate. The diagnostic coincidence rate of type B1, B2 and C1 fractures and the accuracy rate of overall fracture classification indicated that the MRI technique was significantly better than that of CT (P > 0.05).

CONCLUSION

MRI and CT have good diagnostic typing in the diagnosis of tibial plateau fractures, but MRI is more accurate and may be preferred.

Patient function continues to improve over the first five years following tibial plateau fracture managed by open reduction and internal fixation

Aims

Tibial plateau fractures are serious injuries about the knee that have the potential to affect patients’ long-term function. To our knowledge, this is the first study to use patient-reported outcomes (PROs) with a musculoskeletal focus to assess the long-term outcome, as compared to a short-term outcome baseline, of tibial plateau fractures treated using modern techniques.

Methods

In total, 102 patients who sustained a displaced tibial plateau fracture and underwent operative repair by one of three orthopaedic traumatologists at a large, academic medical centre and had a minimum of five-year follow-up were identified. Breakdown of patients by Schatzker classification is as follows: two (1.9%) Schatzker I, 54 (50.9%) Schatzker II, two (1.9%) Schatzker III, 13 (12.3%) Schatzker IV, nine (8.5%) Schatzker V, and 26 (24.5%) Schatzker VI. Follow-up data obtained included: Visual Analogue Scale (VAS) or Numeric Rating Scale (NRS) pain scores, Short Musculoskeletal Functional Assessment (SMFA), and knee range of movement (ROM). Data at latest follow-up were then compared to 12-month data using a paired t-test.

Results

Patient-reported functional outcomes as assessed by overall SMFA were statistically significantly improved at five years (p < 0.001) compared with one-year data from the same patients. Patients additionally reported an improvement in the Standardized Mobility Index (p < 0.001), Standardized Emotional Index (p < 0.001), as well as improvement in Standardized Bothersome Index (p = 0.003) between the first year and latest follow-up. Patient-reported pain and knee ROM were similar at five years to their one-year follow-up. In total, 15 of the patients had undergone subsequent orthopaedic surgery for their knees at the time of most recent follow-up. Of note, only one patient had undergone knee arthroplasty following plateau fixation related to post-traumatic osteoarthritis (OA).

Conclusion

Knee pain following tibial plateau fracture stabilizes at one year. However, PROs continue to improve beyond one year following tibial plateau fracture, at least in a statistical sense, if not also clinically. Patients displayed statistical improvement across nearly all SMFA index scores at their minimum five-year follow-up compared with their one-year follow-up. Cite this article: Bone Joint J 2020;102-B(5):632–637.