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

[Lateral open wedge tibial osteotomy for posttraumatic deformity]

OBJECTIVE

Correction of pseudoinstability and tibial malalignment by re-establishment of the pretraumatic tibial axis.

INDICATIONS

Posttraumatic valgus malalignment accompanied by pseudoinstability.

CONTRAINDICATIONS

Infections, significant inhibition of movement and multidirectional ligament instability.

SURGICAL TECHNIQUE

Standard anterolateral approach to the proximal tibial head. Lateral open wedge high tibial osteotomy above (supra) the tibiofibular joint and opening until the pseudoinstability of the lateral collateral ligament is levelled.

POSTOPERATIVE MANAGEMENT

Partial weight bearing for 4 weeks, after radiological control full body weight loading is allowed. Implant removal after full bony consolidation.

RESULTS

There is limited evidence in the current literature but the available results show good results in 70% of the cases in long-term follow-up.

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.

S2k Guideline for Tibial Plateau Fractures - Classification, Diagnosis, and Treatment

Tibial plateau fractures are mostly complex and surgically demanding joint fractures, which require a comprehensive understanding of the fracture morphology, ligamentous and neurovascular injuries, as well as the diagnostic and therapeutic options for an optimal clinical outcome. Therefore, a standardised and structured approach is required. The success of the treatment of tibial plateau fractures relies on the interdisciplinary cooperation between surgical and conservative physicians in an outpatient and inpatient setting, physical therapists, patients and service providers (health insurance companies, statutory accident insurance, pension providers). On behalf of the German Society for Orthopaedics and Trauma Surgery (DGOU), the German Trauma Society (DGU) and the Society for Arthroscopy and Joint Surgery (AGA), under the leadership of the Fracture Committee of the German Knee Society (DKG), a guideline for tibial plateau fractures was created, which was developed in several voting rounds as part of a Delphi process. Based on the current literature, this guideline is intended to make clear recommendations and outline the most important treatment steps in diagnostics, therapy and follow-up treatment. Additionally, 25 statements were revised by the authors in several survey rounds using the Likert scale in order to reach a final consensus.

The Efficacy of 3D Printing Model in the Intraarticular Osteotomy in the Treatment of Malunion of Tibial Plateau Fracture

OBJECTIVES

Three-dimensional (3D) printing technology has shown potential advantages in accurate and efficient tibial plateau fracture (TPF) treatment. This technology can provide structural morphology to repair fracture fragments. Here, we summarize our experience with the use of 3D printing technology during intraarticular osteotomy in the treatment of the malunion of TPF.

METHODS

The patients who were treated with malunion of TPF in our hospital between January 2015 and December 2018 were retrospectively analyzed. These patients were divided into two groups: the conventional group without 3D-printed model application and the 3D printing group with 3D-printed model application. All patients received the intraarticular osteotomy during operation, and we compared the operation time (min), fracture healing time (months), postoperative knee Rasmussen scores (0-30 points), knee mobility range (0-140°) (the independent t-test), fracture reduction evaluation (Biggi's method) (the chi-square test: Fisher's exact test), and postoperative complications of each group.

RESULTS

Twenty-six patients aged 18-65 years who underwent TPF revision operation were included in this study, including 18 patients in the conventional group, and eight patients in the 3D printing group. The follow-up time was 24-48 months, and the operation time was 185 min in the conventional group and 180 min in the 3D printing group. All patients received a bone union at the last follow-up. The healing time was 4.2 months in the conventional group and 3.75 months in the 3D printing group (p > 0.05). The respective postoperative Rasmussen scores were 24.6 and 26.2, and postoperative knee mobility was 103.5° and 118.5° in the conventional group and 3D printing group, respectively. Both the Rasmussen scores and degrees of mobility were significantly improved after surgery (p < 0.05), and the postoperative knee mobility was significantly better in the 3D printing group versus the conventional group (p < 0.05). Four patients still had a 2-mm collapse on the articular surface, and two patients still had slight valgus (<5°) in the conventional group. Only one case in the 3D printing group suffered from an articular surface collapse. Superficial wound infections occurred in two patients in the conventional group.

CONCLUSION

The results show that 3D printing technology is an effective preoperative preparation in the treatment of TPF malunion. This technology can facilitate accurate preoperative planning to select the optimal surgical approach, plan the implant placement, visualize the screw trajectory, and anticipate possible intraoperative difficulties.

Complications of the surgical treatment of fractures of the tibial plateau: prevalence, causes, and management

Open reduction and internal fixation is the gold standard treatment for tibial plateau fractures. However, the procedure is not free of complications such as knee stiffness, acute infection, chronic infection (osteomyelitis), malunion, non-union, and post-traumatic osteoarthritis. The treatment options for knee stiffness are mobilisation under anaesthesia (MUA) when the duration is less than 3 months, arthroscopic release when the duration is between 3 and 6 months, and open release for refractory cases or cases lasting more than 6 months. Early arthroscopic release can be associated with MUA. Regarding treatment of acute infection, if the fracture has healed, the hardware can be removed, and lavage and debridement can be performed along with antibiotic therapy. If the fracture has not healed, the hardware is retained, and lavage, debridement, and antibiotic therapy are performed (sometimes more than once until the fracture heals). Fracture stability is important not only for healing but also for resolving the infection. In cases of osteomyelitis, treatment should be performed in stages: aggressive debridement of devitalised tissue and bone, antibiotic spacing and temporary external fixation until the infection is resolved (first stage), followed by definitive surgery with grafting or soft tissue coverage depending on the bone defect (second stage). Intra-articular or extra-articular osteotomy is a good option to correct malunion in young, 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 total knee arthroplasty.

Surgical therapy in osteoarthritis

OBJECTIVE

To provide an evidence-based overview of the different surgical procedures in osteoarthritis (OA).

DESIGN

This narrative review reports on surgical therapies (1) for severe, end stage OA and (2) of surgical options aiming to possibly reduce OA development earlier in the course of the disease.

RESULTS

Surgical practice guidelines provide evidence-based recommendations to assist in the clinical decision-making. Total joint arthroplasty represents the only valuable, established surgical option for severe, end stage OA. For hip and knee OA, it is by far the most common surgical procedure and provides considerable pain relief, functional restoration, and improved quality of life. Surgical therapy aiming to postpone OA essentially addresses extra- or intraarticular pre-osteoarthritic deformities, defined as congenital or acquired disturbances of the joint structure that adversely affect its function. Approaches in this category include osteotomies and different cartilage repair procedures such as osteochondral autograft and allograft transfer, marrow stimulation techniques, and autologous chondrocyte implantation. However, they are not only less commonly performed than arthroplasty, but the scientific clinical evidence in favour of this type of surgery to reduce the long-term risk of developing OA is considerably reduced.

CONCLUSION

Total knee and hip arthroplasty are two of the most successful procedures in all of medicine. As the progression of this insidious disease is often asymptomatic and slow, it is imperative to judge reparative procedures at their potential to reduce OA development at long-term, besides their primary clinical outcomes. Evidence-based guidelines provide a valuable tool for high-quality surgical decision making in OA.

Clinical results after very early, early and late arthroscopic arthrolysis of the knee

Purpose

Impaired patient outcome can be directly related to a loss of motion of the knee following surgical procedures. If conservative therapy fails, arthroscopic arthrolysis is an effective procedure to improve range of motion (ROM). The purpose of this study was to evaluate the outcome of patients undergoing very early (< 3 months), early (3 to 6 months), and late (> 6 months) arthroscopic arthrolysis of the knee.

Methods

With a follow-up on average at 35.1 ± 15.2 (mean ± SD, 24 to 87) months, 123 patients with post-operative motion loss (> 10° extension deficit/ < 90° of flexion) were included between 2013 and 2018 in the retrospective study, while eight patients were lost to follow-up. A total of 115 patients were examined with a minimum follow-up of two years. Twenty percent (n = 23) of patients of this study population had a post-operative motion loss after distal femoral fracture, 10.4% (n = 12) after tibial head fracture, 57.4% (n = 66) after anterior/posterior cruciate ligament (ACL/PCL) reconstruction, 8.7% (n = 10) after infection of the knee, and 3.4% (n = 4) after patella fracture. Thirty-seven patients received very early (< 3 months, mean 1.8 months) arthroscopic arthrolysis, and 37 had early (3 to 6 months, mean 4.3 months) and 41 late (> 6 months, mean 9.8 months) arthroscopic arthrolysis after primary surgery.

Results

The average ROM increased from 73.9° before to 131.4° after arthroscopic arthrolysis (p < 0.001). In the group of very early (< 3 months) arthroscopic arthrolysis 76% (n = 28) of the patients had a normal ROM (extension/flexion 0/140°), in the group of early (3–6 months) arthrolysis 68% (n = 25) of the patients and in the group of late arthrolysis 41.5% (n = 17) of the patients showed a normal ROM after surgery (p = 0.005). The total ROM after arthrolysis was also significantly increased in the group of very early and early arthrolysis (136.5° and 135.3° vs. 123.7°, p < 0.001). A post-operative flexion deficit occurred significantly less in the group of very early and early arthroscopic arthrolysis compared to the late arthroscopic arthrolysis (3.9° and 4.2° vs. 16.6°, p < 0.001). Patients treated with very early (< 3 months) and early (3 to 6 months) showed a significantly increased post-operative Tegner score of 4.8 ± 1 and 4.7 ± 1.1 compared to 3.8 ± 1.1 in the group of late arthroscopic arthrolysis (> 6 months, p < 0.001).

Conclusions

An arthroscopic arthrolysis is highly effective and leads to good to excellent mid-term results. An early arthroscopic arthrolysis within 6 months after primary surgery leads to significantly improved ROM and functional scores compared to the late arthrolysis (> 6 months).

Post-operative complications of tibial plateau fractures treated with screws or hybrid external fixation

PURPOSE

To assess the complications and second surgeries rates at 1 year follow-up in a group of patients underwent minimally invasive fixation with screws or hybrid external fixation (HEF) for tibial plateau fractures (TPF). The hypothesis was that low Schatzker (I-IV) TPF would have shown a lower complication rate with respect to high Schatzker (V-VI) TPF.

METHODS

148 patients who underwent minimally invasive surgery with screws or HEF for TPF were included and pooled in two groups: mono-condylar (Schatzker I-IV) and bi-condylar (Schatzker V-VI). The rate of second surgeries and complications, such as stiffness, infection, wound dehiscence and malunion occurred within 1 year, were reported.

RESULTS

Statistically significant difference between mono-condylar and bi-condylar groups was found in terms of stiffness (18% vs. 37%, p = 0.01), malunion (4% vs 21%, p = 0.004) and second surgeries (32% vs. 48%, p = 0.049). Associated procedures performed during TPF fixation increased risk of second surgeries (OR 2.1, p < 0.001). No differences in terms of second surgeries and complications were found in bi-condylar group treated with screws and HEF.

CONCLUSION

Bi-condylar TPF treated with minimally invasive surgery developed a significantly higher rates of stiffness, malunion and second surgeries within 1 year compared to mono-condylar fractures. Moreover, when an associated procedure was performed, the risk of a reoperation was nearly doubled. Trial registration number PG 0012506 CE AVEC 620/2018/Oss/IOR.