1
|
Hörmandinger C, Bitschi D, Berthold DP, Neidlein C, Schroeder L, Watrinet J, Pätzold R, Böcker W, Holzapfel BM, Fürmetz J, Bormann M. Lack of standardisation in the management of complex tibial plateau fractures: a multicentre experience. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02616-6. [PMID: 39095621 DOI: 10.1007/s00068-024-02616-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Accepted: 07/17/2024] [Indexed: 08/04/2024]
Abstract
OBJECTIVE In recent years, the trauma mechanisms and fracture types in tibial plateau fractures (TPF) have changed. At the same time, treatment strategies have expanded with the establishment of new classification systems, extension of diagnostics and surgical strategies. Evidence-based recommendations for treatment strategies are rare. The aim of this study is to assess the extent of standardization in the treatment of complex TPF. MATERIAL AND METHODS For the study, specialists in trauma surgery/orthopaedics were presented thin-slice CT data sets of three complex TPFs including 3D reconstructions. A standardized questionnaire on fracture morphology and planned treatment strategy was then completed. RESULTS A total of 23 surgeons from 7 hospitals (Trauma center levels I-III) were included. All three fractures were most frequently classified as Schatzker type V (fracture I: 52.2%, II: 56.5%, III: 60%). Averaged over all three fractures, 55% of the respondents chose the same patient positioning. The combination of a posteromedial and anterolateral approach was the most frequently chosen approach at 42.7%. Double plating was favored for the surgical treatment of all fractures (70.7%). Preoperative MRI, extended approaches and intraoperative fraturoscopy were significantly more common in level I trauma centres. CONCLUSION There are major differences in the management of complex TPF. 360° treatment is carried out in all departments regardless of the level of care, but without further standardization in terms of preoperative imaging, classification, initial treatment, approach, fixation and intraoperative imaging. There are major differences within the departments with different level of care.
Collapse
Affiliation(s)
- Christina Hörmandinger
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - David Bitschi
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Daniel P Berthold
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Claas Neidlein
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Lennart Schroeder
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Julius Watrinet
- Department of Trauma Surgery, Trauma Center Murnau, Murnau am Staffelsee, Germany
| | - Robert Pätzold
- Department of Trauma Surgery, Trauma Center Murnau, Murnau am Staffelsee, Germany
| | - Wolfgang Böcker
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Boris Michael Holzapfel
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Julian Fürmetz
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
- Department of Trauma Surgery, Trauma Center Murnau, Murnau am Staffelsee, Germany
| | - Markus Bormann
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.
| |
Collapse
|
2
|
Berninger MT, Schüttrumpf JP, Barzen S, Domnick C, Eggeling L, Fehske K, Frosch KH, Herbst E, Hoffmann R, Izadpanah K, Kösters C, Neumann-Langen M, Raschke M, Zellner J, Krause M. S2k Guideline for Tibial Plateau Fractures - Classification, Diagnosis, and Treatment. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2023. [PMID: 37673084 DOI: 10.1055/a-2121-6538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
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.
Collapse
Affiliation(s)
- Markus Thomas Berninger
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | | | - Stefan Barzen
- Unfallchirurgie und operative Orthopädie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Deutschland
| | - Christoph Domnick
- Klinik für Unfall- und Handchirurgie, Orthopädie, Euregio Klinik, Nordhorn, Deutschland
| | - Lena Eggeling
- Abteilung für Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Hamburg, Hamburg, Deutschland
| | - Kai Fehske
- Klinik und Poliklinik für Unfall-, Hand-, Plastische und Wiederherstellungschirurgie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Karl-Heinz Frosch
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
- Abteilung für Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Hamburg, Hamburg, Deutschland
| | - Elmar Herbst
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Munster, Deutschland
| | - Reinhard Hoffmann
- Unfallchirurgie und operative Orthopädie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Deutschland
| | - Kaywan Izadpanah
- Department für Orthopädie und Traumatologie, Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - Clemens Kösters
- Klinik für Orthopädie, Unfall- und Handchirurgie, Maria-Josef-Hospital Greven, Greven, Deutschland
| | - Mirjam Neumann-Langen
- Klinik für Unfallchirurgie, Handchirurgie und Orthopädie, Klinikum Konstanz, Konstanz, Deutschland
| | - Michael Raschke
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Munster, Deutschland
| | - Johannes Zellner
- Orthopädie und Sportmedizin, Sporthopaedicum Regensburg, Regensburg, Deutschland
| | - Matthias Krause
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| |
Collapse
|
3
|
Dust T, Hartel MJ, Henneberg JE, Korthaus A, Ballhause TM, Keller J, Ohlmeier M, Maas KJ, Frosch KH, Krause M. The influence of 3D printing on inter- and intrarater reliability on the classification of tibial plateau fractures. Eur J Trauma Emerg Surg 2023; 49:189-199. [PMID: 35941251 PMCID: PMC9925517 DOI: 10.1007/s00068-022-02055-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 07/03/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Tibial plateau fractures continue to be a challenging task in clinical practice and current outcomes seem to provide the potential for further improvement. Especially presurgical understanding of the orientation of fracture lines and fracture severity is an essential key to sufficient surgical treatment. The object of this study was to evaluate the reliability of modern axial CT-based classification systems for tibial plateau fractures. In addition, the diagnostic-added value of 3D printing on the classification systems was investigated. METHODS 22 raters were asked to classify 22 tibial plateau fractures (11 AO B- and 11 AO C-fractures) with the AO, the 10-Segment and the Revisited Schatzker classification in a three-step evaluation: first only using CT scans, second with 3D volumetric reconstructions and last with 3D-printed fracture models. Inter- and intraobserver agreement and the subjective certainty were analyzed. Statistics were done using kappa values, percentage match and a univariant one-way analysis of variance. RESULTS The AO classifications interobserver percentage match and kappa values improved for all raters and recorded an overall value of 0.34, respectively, 43% for the 3D print. The 10-Segment classification interobserver agreement also improved with the 3D-printed models and scored an overall kappa value of 0.18 and a percentage match of 79%. Equally the Revisited Schatzker classification increased its values to 0.31 and 35%. The intraobserver agreement showed a moderate agreement for the AO (0.44) and Revisited Schatzker classification (0.42) whereas the 10-Segment classification showed a fair agreement (0.27). Additionally, the raters changed their classification in 36% of the cases after evaluating the fracture with the 3D-printed models and the subjective certainty regarding the decisions improved as categories of self-reliant diagnostic choices were selected 18% (p < 0.05) more often after using the 3D-printed models. CONCLUSION Based on the measured outcomes it was concluded that the new classification systems show an overall slight to fair reliability and the use of 3D printing proved to be beneficial for the preoperative diagnostics of tibial plateau fractures. The 10-Segment classification system showed the highest percentage match evaluation of all classification systems demonstrating its high clinical value across all levels of user experience.
Collapse
Affiliation(s)
- Tobias Dust
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Maximilian J Hartel
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
| | - Julian-Elias Henneberg
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Alexander Korthaus
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Tobias Malte Ballhause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Johannes Keller
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Malte Ohlmeier
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Kai-Jonathan Maas
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
| | - Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| |
Collapse
|
4
|
Behrendt P, Berninger MT, Thürig G, Dehoust J, Christensen JH, Frosch KH, Krause M, Hartel MJ. Anterolateral versus modified posterolateral approach for tibial plateau fractures with involvement of the posterior column: a cadaveric study. Eur J Trauma Emerg Surg 2023; 49:201-207. [PMID: 36171336 PMCID: PMC9925589 DOI: 10.1007/s00068-022-02113-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 09/17/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The aim of this study was to compare the reduction quality of the anterolateral (AL) and modified posterolateral approach (PL) in lateral tibial plateau fractures involving the posterior column and central segments. METHODS Matched pairs of pre-fractured cadaveric tibial plateau fractures were treated by either AL approach (supine position) or PL approach (prone position). Reduction was controlled by fluoroscopy and evaluated as satisfying or unacceptable. Afterwards, the reduction was examined by 3D scan. RESULTS 10 specimens (3 pairs 41B3.1, 2 pairs 41C3.3) were evaluated. PL approach achieved significantly (p 0.00472) better fracture reduction results (0.4 ± 0.7 mm) of the posterior column compared to the AL group (2.1 ± 1.4 mm). Fracture steps involving the central area of the lateral plateau were insufficiently reduced after fluoroscopy using both approaches. CONCLUSION Optimal reduction of displaced tibial plateau fractures involving the posterolateral column necessitates a posterior approach, which can be conducted in prone or lateral positioning. The anterolateral approach is indicated in fractures with minor displacement of the posterolateral rim but fracture extension in the latero-central segments. In these cases, an additional video-assisted reduction or extended approaches are helpful.
Collapse
Affiliation(s)
- Peter Behrendt
- Department of Trauma Surgery, Orthopedics and Sports Orthopedics, Asklepios St. Georg, Hamburg, Germany.
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
- Department of Anatomy, Christian-Albrechts-University, Kiel, Germany.
| | - Markus T Berninger
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Grégoire Thürig
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Orthopedics and Traumatology, Cantonal Hospital Fribourg, Fribourg, Switzerland
| | - Julius Dehoust
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
| | - Jan H Christensen
- Department of Orthopedics and Traumatology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
| | - Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian J Hartel
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
| |
Collapse
|
5
|
Behrendt P, Berninger MT, Thürig G, Dehoust J, Christensen J, Frosch KH, Krause M, Hartel MJ. Nanoscopy and an extended lateral approach can improve the management of latero-central segments in tibial plateau fractures: a cadaveric study. Eur J Trauma Emerg Surg 2022; 49:1433-1439. [DOI: 10.1007/s00068-022-02188-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/24/2022] [Indexed: 12/13/2022]
Abstract
Abstract
Introduction
The objective of this investigation was to compare different techniques to improve visualization and reduction in tibial plateau fractures involving the central lateral segments.
Methods
Matched pairs of pre-fractured cadaveric tibial plateau fractures that include the central lateral segments were treated by either an anterolateral approach (supine) or PL approach (prone). Reduction was stepwise extended by additional fracturoscopy (FS), nanoscopy (NS) and lastly by epicondyle osteotomy (ECO). Reduction was analyzed by 3D scan and visualization of the lateral plateau was quantified.
Results
Ten specimens (3 pairs 41B3.1, 2 pairs 41C3.3) were analyzed. Fracture steps involving the antero-latero-central (ALC) segment were insufficiently reduced after fluoroscopy using both approaches (AL 2.2 ± 1.2 mm vs PL 2.2 ± 1.0 mm, p 0.95). Additional NS and ECO achieved optimized fracture reduction in the ALC segment (NS AL 1.6 ± 1.3 mm vs PL 0.8 ± 0.9 mm, p 0.32). NS provided visualization of the entire lateral plateau (PL 102.9% ± 7.4, AL 108.8 ± 19.2%), while fracturoscopy only allowed visualization of the ALL segment and partially of PLL and ALC segments (PL 22.0 ± 23.4%, AL 29.7 ± 18.3%).
Conclusion
Optimized reduction of tibial head fractures with involvement of latero-central segments requires additional video-assisted reduction or extended approaches. Nanoscopy helps visualizing of the entire lateral plateau, when compared to fracturoscopy and may become a valuable reduction aid.
Collapse
|
6
|
Kohn L, Rauch A. [Fractures of tibial shaft and tibial head in winter sports]. ORTHOPADIE (HEIDELBERG, GERMANY) 2022; 51:882-890. [PMID: 36224282 DOI: 10.1007/s00132-022-04312-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/13/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Injuries in alpine skiing often affect the lower extremities, in particular the knee joint and lower leg. In addition to conventional radiological diagnostics, CT and, in the case of fractures of the knee joint area, MRI also play an important role. In the case of tibial head fractures, especially if there has been a dislocation mechanism, there is an increased risk of vascular and nerve injuries. Lower leg fractures are predestined for the development of a compartment syndrome. For these reasons, an exact survey of the vascular-nerve status and a monitoring of the soft tissues should be carried out. THERAPY In the further therapy, whether conservative or surgical, the soft tissue situation must also be included in the planning. In the case of tibial head fractures in particular, the choice of the right approach is essential for a good result in surgical therapy. Angle-stable plate osteosynthesis and screw osteosynthesis play the most important role as osteosynthesis methods in the knee joint area. In the case of fractures in the shaft area, medullary nail osteosynthesis or angle-stable plate systems are primarily used. In the case of severely compromised soft tissue or unstable situations, it may be necessary to apply an external fixator first. The initiated therapy should enable functional follow-up treatment as early as possible. PREVENTION Good physical fitness, driving-specific training, but also good core stabilization have a preventative effect against injuries. In addition, the correct material coordination between ski boot, binding and ski is important for accident prevention.
Collapse
Affiliation(s)
- L Kohn
- Klinik für Unfallchirurgie und Orthopädie, Krankenhaus Landshut-Achdorf, Achdorfer Weg 3, 84036, Landshut, Deutschland.
| | - A Rauch
- ECOM - Praxis für Orthopädie, Sportmedizin & Unfallchirurgie, München, Deutschland
- Sporttraumatologie und Kniechirurgie, ATOS-Klinik München, München, Deutschland
| |
Collapse
|
7
|
Moufid A, Bokam P, Harika-Germaneau G, Severyns M, Caillé L, Valle V, Vendeuvre T, Germaneau A. Study of Mechanical Behavior in Epiphyseal Fracture Treated by Reduction and Cement Injection: No Immediate Post-Operative Weight-Bearing but Only Passive and Active Mobilization Should be Advised. Front Bioeng Biotechnol 2022; 10:891940. [PMID: 35860325 PMCID: PMC9289102 DOI: 10.3389/fbioe.2022.891940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/25/2022] [Indexed: 11/16/2022] Open
Abstract
The development of new percutaneous treatment techniques using a balloon for the reduction and cement for the stabilization for tibial plateau fractures (TPF) are promising. The biomechanical changes brought by the cement in the periarticular fracture are unknown. The objective of this study was to provide elements of understanding of the bone behavior in an epiphyseal fracture treated with cementoplasty and to define the modifications brought about by the presence of this cement in the bone from both an architectural and biomechanical point of view. In vitro animal experimentation was conducted. Bones samples were prepared with a cavity created with or without cancellous compaction, aided by balloon expansion following the same protocol as in the treatment of TPF. A uniaxial compression test was performed with various speeds and by using Heaviside Digital Image Correlation to measure mechanical fields. Preliminary finite element models were constructed with various boundary conditions to be compared to our experimental results. The analysis of the images permits us to obtain a representative load vs. time response, the displacement fields, and the strain distribution for crack initiation for each sample. Microcracks and discontinuity began very early at the interface bone/cement. Even when the global behavior was linear, microcracks already happened. There was no strain inside the cement. The finite element model that matched our experiments had no link between the two materials. In this work, the use of a novel correlation process highlighted the biomechanical role of the cement inside the bone. This demonstrated that there is no load transfer between bone and cement. After the surgery, the cement behaves like a rigid body inside the cancellous bone (same as a screw or plate). The cement provides good reduction and primary stabilization (mini-invasive approach and good stress distribution), permitting the patient to undergo rehabilitation with active and passive mobilization, but no weight-bearing should be authorized while the cortical bone is not consolidated or stabilized.
Collapse
Affiliation(s)
- A. Moufid
- Department of Orthopaedic Surgery and Traumatology, University Hospital, Poitiers, France
- Institut Pprime UPR 3346, CNRS—Université de Poitiers—ISAE-ENSMA, Poitiers, France
| | - P. Bokam
- Institut Pprime UPR 3346, CNRS—Université de Poitiers—ISAE-ENSMA, Poitiers, France
- Unité de Recherche Clinique Pierre Deniker, Centre Hospitalier Henri Laborit, Poitiers, France
| | - G. Harika-Germaneau
- Unité de Recherche Clinique Pierre Deniker, Centre Hospitalier Henri Laborit, Poitiers, France
- CERCA UMR 7295, CNRS—Université de Poitiers, Poitiers, France
| | - M. Severyns
- Institut Pprime UPR 3346, CNRS—Université de Poitiers—ISAE-ENSMA, Poitiers, France
| | - L. Caillé
- Institut Pprime UPR 3346, CNRS—Université de Poitiers—ISAE-ENSMA, Poitiers, France
| | - V. Valle
- Institut Pprime UPR 3346, CNRS—Université de Poitiers—ISAE-ENSMA, Poitiers, France
| | - T. Vendeuvre
- Department of Orthopaedic Surgery and Traumatology, University Hospital, Poitiers, France
- Institut Pprime UPR 3346, CNRS—Université de Poitiers—ISAE-ENSMA, Poitiers, France
| | - A. Germaneau
- Institut Pprime UPR 3346, CNRS—Université de Poitiers—ISAE-ENSMA, Poitiers, France
- *Correspondence: A. Germaneau,
| |
Collapse
|
8
|
Krause M, Frosch KH. [Change in the treatment of tibial plateau fractures]. Unfallchirurg 2022; 125:527-534. [PMID: 35380266 DOI: 10.1007/s00113-022-01165-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The treatment of tibial plateau fractures has experienced a number of very different conceptual developments in recent years, not only with respect to technical innovations but also against the background of changing fracture patterns and the growing requirements of patients. OBJECTIVE What developments in recent years have had a significant impact on current treatment strategies for tibial plateau fractures? METHODS Narrative review of publications listed in PubMed on the topic of treatment of complex tibial plateau fractures. RESULTS While the two-dimensional classifications are becoming less important, computed tomography (CT)-based three-dimensional assessment of fracture progression and an access strategy based on it are coming to the fore. Direct dorsal approaches have been shown to be superior, particularly in the case of relevant posteromedial and/or posterolateral fracture involvement. The step-by-step approach extension via specific osteotomies of ligamentous attachments also enables a needs-dependent and fracture-dependent complete joint visualization and reduction control. In the treatment of geriatric tibial plateau fractures, primary treatment with endoprostheses is becoming increasingly more important to enable early mobilization under full load bearing with significantly shorter rehabilitation times. CONCLUSION Modern developments in the context of fracture treatment around the tibial plateau have led to a relevant reduction of infections and improved surgical outcomes; however, the high demands and the improved understanding of fractures still underline the great challenge in the treatment of complex fracture patterns.
Collapse
Affiliation(s)
- Matthias Krause
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | - Karl-Heinz Frosch
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.,Abteilung für Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Hamburg, Hamburg, Deutschland
| |
Collapse
|
9
|
Guttowski D, Krause M, Püschel K, Kolb JP, Hartel M, Frosch KH. Improved Visualization by Central Subluxation of the Lateral Meniscus in Comminuted Lateral Tibial Plateau Fractures. J Knee Surg 2021; 34:1408-1412. [PMID: 32413932 DOI: 10.1055/s-0040-1709518] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The goal of surgical reconstruction of comminuted tibial plateau fractures is an anatomical reconstruction and stable fixation of the articular surface. This can be difficult due to poor visualization of the posterolateral and central segments of the articular surface of the proximal tibia. To improve visualization, the lateral approach can be extended with an osteotomy of the femoral epicondyle. In most cases, use of the extended lateral approach allows the whole lateral plateau to be visualized. Nevertheless, in some cases, an osteotomy alone is not enough to expose the entire fracture, especially the central segments of the tibial plateau. For these specific cases, we developed an additional technical trick that significantly improves articular visualization; the lateral meniscocapsular fibers are dissected allowing for central subluxation of the lateral meniscus, while leaving the anterior and posterior roots intact. With central subluxation of the lateral meniscus in comminuted tibial plateau fractures, the joint surface can be completely visualized, allowing an anatomical reduction even in highly complex fractures.
Collapse
Affiliation(s)
- Dario Guttowski
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Krause
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Klaus Püschel
- Department of Forensic Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Philipp Kolb
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian Hartel
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
10
|
Chen YF, Ren D, Geng LD, Yao SQ, Song ZH, Guang L, Wang TC, Wang PC. Treatment of posterolateral tibial plateau fractures with a rotational support plate and special pressurizer: technical note and retrospective case series. J Orthop Surg Res 2021; 16:407. [PMID: 34162413 PMCID: PMC8220735 DOI: 10.1186/s13018-021-02544-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/08/2021] [Indexed: 11/24/2022] Open
Abstract
Background In tibial plateau fractures, the posterolateral segment of the tibia plateau is frequently affected and challenging to treat. Although there are many surgical approaches and fixation methods for the treatment of these fractures, all of these methods have limitations. We designed a new rotational support plate (RSP) and a special pressurizer that can fix the fracture directly via the anterolateral approach. This method is advantageous because it leads to little trauma, involves a simple operation, and has a reliable fixation effect. This study details the technique of treating these fractures with the RSP and special pressurizer and provides the outcomes. Methods From May 2016 to January 2019, the data of 12 patients with posterolateral tibial plateau fractures treated with the RSP and special pressurizer in our hospital were retrospectively analyzed. Postoperative rehabilitation was advised, knee X-rays were taken at follow-ups, and fracture healing, complications, and knee range of motion were assessed. The Hospital for Special Surgery (HSS) knee score and Knee Injury and Osteoarthritis Outcome Score (KOOS) were used to evaluate knee function at the last follow-up. Results The average follow-up time of all patients was 16.5 months (range, 12–25 months). The average bony union time was 3.2 months (range, 3–4.5 months). At the last follow-up, the average knee range of motion was 138° (range, 107–145°). The average HSS score was 91 (range, 64–98). The average KOOS Symptoms score was 90 (range, 75–96). The average KOOS Pain score was 91 (range, 72–97). The average KOOS ADL score was 91 (range, 74–97). The average KOOS sport/recreation score was 83 (range, 70–90). The average KOOS QOL score was 88 (range, 69–93). Skin necrosis, incision infections, and fixation failure did not occur during the follow-up period. Conclusions With our newly designed RSP and special pressurizer, posterolateral tibial plateau fractures can be easily and effectively reduced and fixed through the anterolateral approach, which serves as a novel treatment for posterolateral tibial plateau fractures. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-021-02544-w.
Collapse
Affiliation(s)
- Yu-Feng Chen
- Orthopaedic Trauma Service Center, Major Laboratory of Orthopaedic Biomechanics in Hebei Province, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Dong Ren
- Orthopaedic Trauma Service Center, Major Laboratory of Orthopaedic Biomechanics in Hebei Province, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Lin-Dan Geng
- Orthopaedic Trauma Service Center, Major Laboratory of Orthopaedic Biomechanics in Hebei Province, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Shuang-Quan Yao
- Orthopaedic Trauma Service Center, Major Laboratory of Orthopaedic Biomechanics in Hebei Province, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Zhao-Hui Song
- Orthopaedic Trauma Service Center, Major Laboratory of Orthopaedic Biomechanics in Hebei Province, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Liang Guang
- Orthopaedic Trauma Service Center, Major Laboratory of Orthopaedic Biomechanics in Hebei Province, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Tian-Ci Wang
- Orthopaedic Trauma Service Center, Major Laboratory of Orthopaedic Biomechanics in Hebei Province, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Peng-Cheng Wang
- Orthopaedic Trauma Service Center, Major Laboratory of Orthopaedic Biomechanics in Hebei Province, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China.
| |
Collapse
|
11
|
Völk D, Neumaier M, Einhellig H, Biberthaler P, Hanschen M. Outcome after polyaxial locking plate osteosynthesis in proximal tibia fractures: a prospective clinical trial. BMC Musculoskelet Disord 2021; 22:286. [PMID: 33736638 PMCID: PMC7976713 DOI: 10.1186/s12891-021-04158-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/08/2021] [Indexed: 11/10/2022] Open
Abstract
Background The aim of this study was to evaluate the clinical and/or radiologic outcome using different polyaxial locking plates for the treatment of proximal tibia fractures, the Non-Contact-Briding plate (NCB-PT®) by Zimmer or the Variable Angle Locking Compression Plate (VA-LCP®) by Synthes. Methods This study enrolled 28 patients with proximal tibia fractures (AO/ OTA 41 B-C) and indication for locking plate osteosynthesis. All patients were treated with a polyaxial locking plate system. Depending on the fracture morphology, patients were either treated with a NCB-PT® or VA-LCP®. The implant was chosen according to the surgeon’s experience and preference, in case of a higher degree of comminution the tendency was observed to use the NCB-PT® plate. After a time interval of 12 months postoperative we conducted clinical (e.g. range of motion, the Rasmussen score) and radiological (e.g. primary/secondary loss of reduction) follow-ups. Results Patients provided with the NCB-PT® (9 patients) showed longer operation time, use of longer implants, longer interval from injury to surgery and lower clinical scores after the 12 months follow-up compared with the VA-LCP® group (19 patients). Interestingly, the results showed no significant differences regarding the clinical and radiologic outcome. Conclusions The small number of patients as well as the heterogeneity of fractures constitute a limitation of this study. Nevertheless, the differentiated use of implants is associated with comparable clinical and radiological outcomes. This trial emphasizes the need for further prospective randomised trials with higher patient numbers. Trial registration Retrospectively registered 21.12.2020. Registration number NCT04680247.
Collapse
Affiliation(s)
- Dominik Völk
- Department of Trauma Surgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Markus Neumaier
- Department of Trauma and Orthopaedic Surgery, Klinikum Freising, Freising, Germany
| | - Heike Einhellig
- Department of Radiology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Peter Biberthaler
- Department of Trauma Surgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Marc Hanschen
- Department of Trauma Surgery, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675, Munich, Germany.
| |
Collapse
|
12
|
Krause M, Alm L, Berninger M, Domnick C, Fehske K, Frosch KH, Herbst E, Korthaus A, Raschke M, Hoffmann R. Bone metabolism is a key factor for clinical outcome of tibial plateau fractures. Eur J Trauma Emerg Surg 2020; 46:1227-1237. [PMID: 33151357 PMCID: PMC7691299 DOI: 10.1007/s00068-020-01537-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 10/28/2020] [Indexed: 11/10/2022]
Abstract
Purpose Given that tibial plateau fractures (TPF) are rare, they may pose a challenge to the treating surgeon due to their variety of complex fracture patterns. Numerous studies have identified potential fracture-specific, surgery-related, and patient-related risk factors for impaired patient outcomes. However, reports on the influence of bone metabolism on functional outcomes are missing. Methods In a retrospective multicenter cohort study, 122 TPF of 121 patients were analyzed with respect to radiological and clinical outcomes (Rasmussen) with a mean follow-up of 35.7 ± 24.9 months. The risk factor assessment included bone metabolism-affecting comorbidities and medication.
Results The findings showed that 95.9% of the patients reported a good-to-excellent clinical outcome, and 97.4% reported a good-to-excellent radiological outcome. Logistic regression revealed that potentially impaired bone metabolism (IBM) was an independent risk factor for the clinical (p = 0.016) but not the radiological outcome (Table 4). Patients with 41-type B fractures and a potential IBM had a seven times higher risk to present a fair-to-poor clinical outcome [OR 7.45, 95 CI (4.30, 12.92)]. The most common objective impairment was a limited range of motion in 16.4% of the patients, especially in 41-type C fractures (p = 0.06). The individual failure analysis additionally identified surgery-related options for improvement. Conclusion This study demonstrated that potential IBM was an independent risk factor for a poor-to-fair clinical outcome.
Collapse
Affiliation(s)
- Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martini Str. 52, 20246, Hamburg, Germany.
| | - Lena Alm
- BG Trauma Hospital Hamburg, Hamburg, Germany
| | - Markus Berninger
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martini Str. 52, 20246, Hamburg, Germany
| | - Christoph Domnick
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Kai Fehske
- Department of Orthopaedic Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martini Str. 52, 20246, Hamburg, Germany
| | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Alexander Korthaus
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martini Str. 52, 20246, Hamburg, Germany
| | - Michael Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Reinhard Hoffmann
- Department of Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt Am Main, Frankfurt am Main, Germany
| | | |
Collapse
|
13
|
Mutschler W, Herterich V. [29/m-all-terrain vehicle accident with knee involvement : Preparation for the medical specialist examination-Part 14]. Unfallchirurg 2020; 124:32-37. [PMID: 33006633 DOI: 10.1007/s00113-020-00875-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Wolf Mutschler
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Klinikum der Universität München, Nussbaumstr. 20, 80336, München, Deutschland.
| | - Viktoria Herterich
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Klinikum der Universität München, Nussbaumstr. 20, 80336, München, Deutschland
| |
Collapse
|
14
|
Extended approach to the lateral tibial plateau with central meniscal subluxation in fracture repair: feasibility and first clinical and radiographic results. Eur J Trauma Emerg Surg 2020; 46:1221-1226. [PMID: 32865596 PMCID: PMC7691302 DOI: 10.1007/s00068-020-01467-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/18/2020] [Indexed: 11/11/2022]
Abstract
Purpose Anatomic reduction in tibial plateau fractures remains to be demanding. For further visualisation of and approach to the joint surface an extended lateral approach using a lateral femoral epicondyle osteotomy and subluxation of the lateral meniscus was recently described. First clinical and radiographic mid-term results of this technique are presented in this feasibility study. Method Ten complex tibial plateau fractures treated with extended lateral approach and lateral meniscal subluxation were prospectively analysed. Clinical and radiographic results were objectified according to the Rasmussen scores. Results After a median follow-up of 8.6 (IQR 4.3) months good to excellent clinical and radiographic results were noted. The clinical Rasmussen Score showed a median of 25 (IQR 2.8) and radiographic a median of 17 (IQR 2.0) points. Conclusion Good to excellent clinical and radiological scores were obtained after using an extended lateral approach with lateral femoral epicondyle osteotomy and central meniscus subluxation. No approach specific complications could be observed. Electronic supplementary material The online version of this article (10.1007/s00068-020-01467-1) contains supplementary material, which is available to authorized users.
Collapse
|
15
|
[Intra-articular osteotomy for malunion of the tibial plateau]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2020; 32:367-384. [PMID: 32725290 DOI: 10.1007/s00064-020-00671-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 03/23/2020] [Accepted: 04/18/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Restoration of anatomy of the joint surface of the tibial plateau in posttraumatic deformity. INDICATIONS Malunions of the tibial plateau with significant intra-articular depression and/or steps. CONTRAINDICATIONS Local or systemic infection, critical soft tissues in the area of planned incisions; advanced osteoarthritis of the knee; loss of meniscus in the involved compartment; motoric or neurophysiological impairment hindering normal knee function. SURGICAL TECHNIQUE Malunion after posteromedial split fracture: posterior approach in prone position, osteotomy of the former fragment following the fracture lines, anatomical reduction of the fragment in extended position of the knee using the implant as reduction tool, fixation by posterior plate. Malunion after lateral and posterolateral split/depression fracture: Lateral approach with fibula head osteotomy in lateral decubitus position, intra-articular osteotomy of depressed fragments, autologous bone graft, lateral or posterolateral plate osteosynthesis. Osteosynthesis of fibula head with small fragment lag screw or tension-band. POSTOPERATIVE MANAGEMENT Walking with crutches starting from day 1 after surgery. Partial weight-bearing until radiographic healing of the osteotomies, usually 4-6 weeks. No limitation of range-of-motion. RESULTS A series of 23 patients had lateral corrective osteotomy after lateral tibial plateau fracture. Mean follow-up was 13 years (range 2-26 years). Two patients had early poor results. In all, 17 patients (74%) scored excellent in the Lysholm/Gillquist score, 3 patients good, 1 patient average and 2 patients poor.
Collapse
|
16
|
Alm L, Frings J, Krause M, Frosch KH. Intraarticular osteotomy of malunited tibial plateau fractures: an analysis of clinical results with a mean follow-up after 4 years. Eur J Trauma Emerg Surg 2020; 46:1203-1209. [PMID: 32712774 PMCID: PMC7691306 DOI: 10.1007/s00068-020-01440-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/13/2020] [Indexed: 11/25/2022]
Abstract
Purpose Malunions are a common complication after tibial plateau fractures (TPF), leading to stiffness, pseudo-instability and posttraumatic osteoarthritis. The purpose of this study was to analyse the clinical outcome after intraarticular osteotomy of malunited TPF and to perform a failure analysis. Methods Between 2013 and 2018, 23 patients (11 males, 12 females; 43.8 ± 12.8 years) with intraarticular osteotomy after malunited TPF were included in the retrospective study. Clinical examination and postoperative scores were collected with a minimum follow-up of 24 months. Malunion was measured on pre- and postoperative CT scans and localized according to the 10-segment classification while the leg axis in the frontal plane was measured pre- and postoperatively on long leg standing radiographs. Results Excellent and good clinical outcome was achieved in 73.9% (n = 17) of the cases and patient related outcome improved significantly (Tegner 3.3 ± 1.6–5 ± 1.8, p < 0.001; clinical Rasmussen 14.6 ± 3.8–24.9 ± 4.4, p < 0.001). Radiological parameters also improved as an intraarticular step-off was reduced from 9 ± 3.8 to 0.6 ± 0.8 mm (p < 0.001) and a lower limb malalignment from 7.2 ± 4.8° to 1.5 ± 1.9° (p = 0.003). Failure analysis showed that an impaired clinical result correlated with a postoperative extension (n = 3, p < 0.001) and flexion deficit (n = 4, p = 0.035). Conclusion Intraarticular osteotomy of malunited TPF lead to good clinical results with significant clinical and radiological improvement in most cases while an impaired patient outcome correlated with a limited range of motion. This study is the first failure analysis of intraarticular osteotomy after malunited TPF published up to now.
Collapse
Affiliation(s)
- Lena Alm
- Department of Trauma and Orthopaedic Surgery, Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
| | - Jannik Frings
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| |
Collapse
|
17
|
Abstract
BACKGROUND A confident diagnosis and classification of proximal femoral and tibia fractures are crucial to determine further therapeutic procedures. MATERIALS AND METHODS In this article the current standards regarding diagnostic imaging of proximal femoral and tibia fractures are presented and the different classification systems are discussed. CONCLUSIONS Plain radiography in two planes remains the initial investigation of choice for suspected osseous injury. While this is usually sufficient to determine further procedures for injuries of the proximal femur, cross-sectional imaging is normally necessary in the diagnosis of proximal tibia fractures.
Collapse
|
18
|
Shen Q, Zhang J, Xing G, Liu Z, Li E, Zhao B, Zheng Y, Cao Q, Zhang T. Surgical Treatment of Lateral Tibial Plateau Fractures Involving the Posterolateral Column. Orthop Surg 2019; 11:1029-1038. [PMID: 31693310 PMCID: PMC6904677 DOI: 10.1111/os.12544] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 08/25/2019] [Accepted: 08/28/2019] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To summarize the indications and the clinical effects of a transfibular neck osteotomy approach and a combined anterolateral and posterolateral approach in the treatment of fractures of the lateral tibial plateau involving the posterolateral column. METHODS Eleven patients with lateral tibial plateau fractures were included in the present study. The fractures were Schatzker type II or lateral platform fractures involving posterolateral column. The anterolateral combined posterolateral approach (lateral + posterolateral locking plate fixation) was applied in 7 patients and 4 patients underwent transfibular neck osteotomy (lateral + posterolateral locking plate fixation + 1/4 tubular plate edge fixation, fibular osteotomy with Kirschner wire tension band fixation, and hollow nail fixation for upper tibiofibular joint). All cases were followed up for 12-24 months, with an average follow-up of 17.5 ± 5.0 months. At the last followup, the Rasmussen radiological criteria were used to evaluate the effect of fracture reduction and fixation. The knee joint function was evaluated using the knee function evaluation criteria of the Hospital for Special Surgery (HSS). The Lachman test and the pivot-shift test were used to evaluate the anterior and posterior and rotational stability of the knee joint. The range of knee motion was recorded. RESULTS Bone healing was achieved in all patients with fractures treated with a transfibular neck osteotomy approach and a combined anterolateral and posterolateral approach. At the last follow-up, both the Lachman test and the pivot-shift test results were negative. All patients had complete knee extension. For the combined anterolateral and posterolateral approach, the knee flexion angle was 110°-130°, with an average of 122.86° ± 7.56°. For the transfibular neck osteotomy approach, the knee flexion angle was 115°-130°, with an average of 120.00° ± 7.07°. For the patients in which the combined anterolateral and posterolateral approach was used, the Rasmussen score was 12-18 points, with an average of 16.00 ± 2.56 points. The results were excellent in 4 cases and good in 3 cases; therefore, 100% of results were excellent or good. For patients in which the transfibular neck osteotomy approach was used, the Rasmussen score was 10-18 points, with an average of 15.25 ± 3.77 points. The results were excellent in 2 cases, good in 1 case, and acceptable in 1 case; therefore, 75% of results were excellent or good. The HSS score for the combined anterolateral and posterolateral approach was 76-98 points, with an average of 88.43 ± 7.55 points. The results were excellent in 5 cases and good in 2 cases; therefore, 100% of results were excellent or good. The HSS score for the transfibular neck osteotomy approach was 74-96 points, with an average of 87.25 ± 9.43 points. The results were excellent in 3 cases and good in 1 case; therefore, 100% of results were excellent or good. There were no significant differences in operation time, surgical blood loss, fracture healing time, postoperative imaging score, and knee function evaluation between the two approaches. One patient who underwent transfibular neck osteotomy had a 3-mm step that gradually appeared, but no significant abnormalities were found in the width of the platform and the lower limb force line. One patient in whom the combined anterolateral and posterolateral approach was used showed numbness in the common peroneal nerve. No common peroneal nerve injury occurred through the transfibular neck osteotomy approach. CONCLUSIONS The anterolateral combined posterolateral approach and the transfibular neck osteotomy approach are effective in the surgical treatment of lateral tibial plateau fractures involving the posterolateral column. However, the transfibular neck osteotomy approach is more suitable for the posterolateral plateau articular surface damaged with bone separation and displacement, deep collapse, cases involving a large range of the posterolateral column, especially fractures of the lateral tibial plateau in the upper tibiofibular syndesmosis area of the line connecting the anterior and posterior margin of the fibular head to the midpoint of the plateau.
Collapse
Affiliation(s)
- Qi‐jie Shen
- Department of OrthopaedicsTianjin HospitalTianjinChina
| | - Jin‐li Zhang
- Department of OrthopaedicsTianjin HospitalTianjinChina
| | - Guo‐sheng Xing
- Tianjin Institute of Orthopedics of Integrated Traditional Chinese and Western MedicineTianjin HospitalTianjinChina
| | - Zhong‐yu Liu
- Department of OrthopaedicsTianjin HospitalTianjinChina
| | - En‐qi Li
- Department of OrthopaedicsTianjin HospitalTianjinChina
| | | | - Yu‐chen Zheng
- Department of OrthopaedicsTianjin HospitalTianjinChina
| | - Qing Cao
- Department of OrthopaedicsTianjin HospitalTianjinChina
| | - Tao Zhang
- Department of OrthopaedicsTianjin HospitalTianjinChina
| |
Collapse
|
19
|
Krause M, Krüger S, Müller G, Püschel K, Frosch KH. How can the articular surface of the tibial plateau be best exposed? A comparison of specific surgical approaches. Arch Orthop Trauma Surg 2019; 139:1369-1377. [PMID: 31101980 DOI: 10.1007/s00402-019-03200-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The correct choice of a fracture-specific surgical approach with an articular accessibility in complex tibial plateau fractures to facilitate durable fracture fixation of the anatomic articular reconstruction is under debate, as the most important risk factor for malreduction in complex tibial plateau fractures is an impaired visualization of the articular surface. MATERIALS AND METHODS Six established surgical approaches were simulated on 12 cadaver knees. The visible articular surface was labeled with an electrocautery device for each approach and subsequently analyzed with ImageJ. Areas of each hemiplateau were compared using the Student's t test. RESULTS In the lateral tibial plateau, the dorsal 19.0 ± 5.8% of the articular surface could be exposed via the postero-lateral approach. Via the antero-lateral arthrotomy, 36.6 ± 9.4% of the anterior articular surface was visible. The additional osteotomy of the lateral femoral epicondyle significantly increased the exposure to 65.6 ± 7.7% (p < 0.001). In the medial tibial plateau, the osteotomy of the medial femoral epicondyle significantly improved visualization of the medial articular surface (62.3 ± 8.6%) compared to the postero-medial approach (14.0 ± 7.3%) and the antero-medial approach (36.9 ± 9.2%) of the articular (p < 0.001). CONCLUSIONS Visualization of the tibial articular surface is limited through specific surgical approaches. Extension by osteotomy of the femoral epicondyle led to a significant improvement in the articular exposure without, however, obtaining sufficient visibility of the posterior joint segments, which should be included in the preoperative strategy. The proposed surgical approach-specific map of the tibial plateau may constitute an important instrument in the toolbox of an experienced surgeon to treat complex tibial plateau fractures at the highest level. LEVEL OF EVIDENCE Level IV.
Collapse
Affiliation(s)
- Matthias Krause
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sebastian Krüger
- Department of Trauma and Reconstructive Surgery, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Gunnar Müller
- Department of Trauma and Reconstructive Surgery, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Klaus Püschel
- Department of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| |
Collapse
|
20
|
Gensior TJ, Mester B, Ullerich F, Colcuc S, Schoepp C. Primäre Spongiosaplastik und AMIC® bei Tibiakopffraktur. ARTHROSKOPIE 2019. [DOI: 10.1007/s00142-019-0294-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
21
|
[Extended medial and extended lateral approach for tibial plateau fractures]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2019; 31:127-142. [PMID: 30887093 DOI: 10.1007/s00064-019-0593-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 09/10/2018] [Accepted: 09/28/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Complete visualization of the articular surface in comminuted uni- or bicondylar tibial plateau fractures as a prerequisite for anatomical reconstruction to reduce the risk of posttraumatic osteoarthritis. INDICATIONS Unicondylar lateral or medial as well as bicondylar intra-articular tibial plateau fractures with central and/or dorsal fracture lines; comminuted destruction of the medial or lateral tibial plateau with dislocation of >2 mm. CONTRAINDICATIONS Critical soft tissue in the approach area, femoral condylar fracture, intraligamentous ruptures of the medial or lateral ligaments or the posterolateral corner. SURGICAL TECHNIQUE Medial: via the medial or anteromedial approach; lateral: via the antero- or posterolateral approach for open reduction and internal fixation of the tibial plateau fracture. Sharp dissection down to the medial/lateral ligamentous accompanying structures with subsequent presentation of the medial/lateral femoral epicondyle. Medial: approximately 2 × 2 cm osteotomy of the medial femoral epicondyle. Lateral: osteotomy of an approximately 1 × 1 × 0.5 cm bone block of the lateral femoral epicondyle either with protection or including the popliteus tendon running ventrally in the sulcus popliteus. In this case, a violation of the articular condyle should be avoided. POSTOPERATIVE MANAGEMENT Early functional posttreatment with full mobilization and 10-20 kg partial load bearing on forearm crutches, fracture-dependent for 6-12 weeks. RESULTS Very good visualization of the comminuted articular surface with postoperatively anatomical reconstruction of complex fracture patterns without postoperative concomitant instabilities.
Collapse
|
22
|
Ull C, Jansen O, Seybold D, Königshausen M, Schildhauer TA, Gessmann J. Differences between primary and secondary definitive osteosynthesis for fractures of the lower leg with concomitant acute compartment syndrome. Eur J Trauma Emerg Surg 2019; 46:1167-1173. [PMID: 30747274 DOI: 10.1007/s00068-019-01089-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 02/07/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE To analyze the differences in outcomes between primary and secondary definitive osteosynthesis for fractures of the lower leg with concomitant acute compartment syndrome (ACS). METHODS From our trauma database, we identified a total of 107 patients with 126 fractures of AO/OTA type 41-44 and 120 ACS from January 01, 2001 to December 31, 2015 who were treated with primary or secondary definitive osteosynthesis after concomitant fasciotomy. RESULTS Seventy-one patients with 77 fractures of AO/OTA classification type 41-44 suffering ACS received primary definitive osteosynthesis at the time of compartmental incision (POCI) and were compared to 36 patients with 49 fractures of AO/OTA type 41-44 and ACS, who received secondary definitive osteosynthesis after compartmental incision and soft tissue coverage (SOCI). Patients with POCI had a significantly shorter length of hospital stay with significantly fewer necessary surgeries to achieve definitive fracture treatment and soft tissue closure than SOCI patients (p ≤ 0.001). The overall rate of infections in both groups was 13%, without any difference between POCI and SOCI. CONCLUSIONS POCI for AO/OTA fractures type 41-44 with ACS is a safe and effective procedure without increasing the infection rate compared to a gradual treatment (SOCI). However, the possible selection bias due to the retrospective study design needs to be considered.
Collapse
Affiliation(s)
- Christopher Ull
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany.
| | - Oliver Jansen
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Dominik Seybold
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Matthias Königshausen
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Thomas Armin Schildhauer
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Jan Gessmann
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany.
| |
Collapse
|
23
|
[Osteosynthesis of bicondylar tibial plateau fracture in a prone position : Video article]. Unfallchirurg 2018; 121:1004-1010. [PMID: 30402690 DOI: 10.1007/s00113-018-0574-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The aim of the surgical treatment of intra-articular bicondylar tibial plateau fractures is the anatomical reconstruction and direct biomechanical optimal fixation of the fractured articular surface and the leg axis, taking the frequently associated soft tissue damage into account. INDICATIONS This article presents a cadaver model of a simulated complex bicondylar tibial plateau fracture 41C3 according to the AO classification with fracture involvement of all 10 segments and indications for surgery due to a posteromedial shearing fracture and lateral articular destruction with posterolaterocentral impaction. CONTRAINDICATIONS Pronounced soft tissue damage with acute or incompletely healed infections in the area of the surgical approach. SURGICAL TECHNIQUE In the presented video of the operation, which is available online, the direct treatment of an intra-articular complex tibial plateau fracture from dorsal in a prone position is shown in detail: posterolateral ca. 13 cm long skin incision immediately above the fibular head with subsequent gentle preparation of the peroneal nerve at the medial border of the biceps femoris muscle. Retraction of the lateral head of the gastrocnemius muscle medially. Proximal detachment of the soleus muscle from the fibular head and retraction of the popliteus muscle medially. Horizontal capsule incision for fracture visualization. Opening of the lateral window ventral to the lateral collateral ligament. If necessary, osteotomy of the lateral femoral epicondyle for improved posterolaterocentral fracture visualization. Angular stable osteosynthetic fixation. Posteromedial approach medial to the medial gastrocnemius head. Retraction of the medial head of the gastrocnemius muscle laterally, horizontal capsular incision with sparing of the semimembranosus muscle medially and posterior cruciate ligaments laterally, fracture reduction, fixation with posteromedial support plate, image converter control, wound closure. FOLLOW-UP Postoperative cooling and elevation of the operated limb. Depending on the fracture 6-10 weeks partial loading of maximum 20 kg. Prior to full load bearing clinical radiological follow-up checks to determine the bony consolidation and material positioning. RESULTS This is an established and safe delivery strategy for complex fracture patterns with dorsally running fractures. The risk of intraoperative malreduction is low. Postoperative reduction losses depend on fracture, operation and especially patient-specific characteristics.
Collapse
|