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Risitano S, Giustra F, Bosco F, Rea A, Cacciola G, Rizzolo R, Sabatini L, Capella M, Massè A. Tibial plateau fractures are associated with ligamentous and meniscal injuries. Preoperative evaluation of magnetic resonance imaging influences surgical treatment. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02581-0. [PMID: 38926170 DOI: 10.1007/s00068-024-02581-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Tibial plateau fractures (TPFs) are usually associated with ligamentous or meniscal injuries that could remain misdiagnosed. An appropriate and early recognition may change the surgical management of these soft tissue injuries (STIs) that could be addressed concomitantly with TPF treatment. Magnetic resonance imaging (MRI) is an efficient diagnostic test to identify all associated STIs in TPFs. This study aims to analyze the MRI impact in identifying and guiding the STIs treatment in TPFs. MATERIAL/METHODS This retrospective study included a consecutive series of 57 patients with TPFs treated between January 1st, 2022, and December 31st, 2022. All fracture patterns were classified according to the AO/OTA and Schatzker classification. The prevalence of STIs, including medial meniscus (MM), lateral meniscus (LM), anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), and lateral collateral ligament (LCL) injuries, was assessed through the MRI evaluation. RESULTS A statistical significance was found regarding the MRI detection of LM, ACL, PCL and MCL injuries that led to additional surgical procedures at the same time as the TPFs treatment (p < 0.05). In contrast, the amount of additional MM and LCL injuries identified by MRI, which resulted in other surgical procedures, was not statistically significant (p > 0.05). CONCLUSIONS Preoperative MRI has been demonstrated to be an effective procedure for diagnosing STIs in TPFs, significantly influencing and changing the surgical treatment. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Salvatore Risitano
- Department of Orthopaedic Surgery and Traumatology, "Città Della Salute E Della Scienza" - CTO Hospital of Turin, 10126, Turin, Italy
| | - Fortunato Giustra
- Department of Orthopaedics and Traumatology, Ospedale San Giovanni Bosco - ASL Città di Torino, Piazza del Donatore di Sangue, 3, 10154, Turin, Italy
| | - Francesco Bosco
- Department of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), University of Palermo, 90133, Palermo, Italy.
- Department of Orthopaedics and Traumatology, G.F. Ingrassia Hospital Unit, ASP 6, 90131, Palermo, Italy.
| | - Antonio Rea
- Department of Orthopaedic Surgery and Traumatology, "Città Della Salute E Della Scienza" - CTO Hospital of Turin, 10126, Turin, Italy
| | - Giorgio Cacciola
- Department of Orthopaedic Surgery and Traumatology, "Città Della Salute E Della Scienza" - CTO Hospital of Turin, 10126, Turin, Italy
| | - Raffaella Rizzolo
- Department of Orthopaedics, Traumatology and Rehabilitation, University of Turin, CTO, Via Zuretti 29, 10126, Turin, Italy
| | - Luigi Sabatini
- Department of Orthopaedics and Traumatology, Humanitas Gradenigo Hospital, Turin, Italy
| | - Marcello Capella
- Department of Orthopaedic Surgery and Traumatology, "Città Della Salute E Della Scienza" - CTO Hospital of Turin, 10126, Turin, Italy
| | - Alessandro Massè
- Department of Orthopaedic Surgery and Traumatology, "Città Della Salute E Della Scienza" - CTO Hospital of Turin, 10126, Turin, Italy
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Wang B, Zhu Y, Zhang B, Wang Y, Yan L, Xie X, Luo C. Incidence and Characteristics of Knee Ligament and Meniscal Injuries in Patients With Posterolateral Tibial Plateau Fractures. Orthop J Sports Med 2024; 12:23259671241238023. [PMID: 38601191 PMCID: PMC11005506 DOI: 10.1177/23259671241238023] [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: 09/09/2023] [Accepted: 09/18/2023] [Indexed: 04/12/2024] Open
Abstract
Background Anterior cruciate ligament (ACL) tears are commonly seen with concomitant injuries to the posterolateral tibial plateau, while the occurrence of ACL injuries in posterolateral tibial plateau fractures (PTPFs) remains unclear. Purpose To (1) explore the incidence of knee ligament (anterior or posterior cruciate ligament, medial or lateral collateral ligament) and medial or lateral meniscus injuries in patients with PTPF and (2) find reliable PTPF-related parameters to predict the risk of knee ligament and meniscal injuries. Study Design Cross-sectional study; Level of evidence, 3. Methods Patients diagnosed with PTPF who had computed tomography and magnetic resonance imaging (MRI) data were identified. Morphological parameters of the PTPF were measured on sagittal computed tomography images. Knee ligament and meniscal injuries were assessed using MRI. The association of ACL injuries with meniscal injuries was analyzed. Receiver operating characteristic (ROC) analysis was used to determine the value and cutoff point of the PTPF morphological parameters for diagnosing complete in-substance ACL tears. Results Overall, 113 patients with PTPF were included. ACL injuries were present in 94 (83.2%) patients, including 43 (38.1%) avulsion fractures and 28 (24.8%) complete in-substance tears. Patients with in-substance ACL tears had a higher incidence of lateral meniscus posterior horn tears compared with the other patients (PBonferroni < .001). ROC analysis revealed that both the fracture depression angle (cutoff point, 25.5°) and the posterior articular surface loss percentage (cutoff point, 37.5%) had a sensitivity >90% and a specificity >80% for the diagnosis of complete in-substance ACL tears. Conclusion ACL injuries were seen in 83.2% of the study patients. Complete in-substance ACL tears were associated with an increased incidence of lateral meniscus posterior horn tears. Among PTPF parameters, fracture depression angle and posterior articular surface loss percentage showed a high predictive value for the presence of complete in-substance ACL tears, thereby reducing delays in diagnosis and treatment.
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Affiliation(s)
- Binghao Wang
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi Zhu
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Binbin Zhang
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yukai Wang
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lifeng Yan
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xuetao Xie
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Congfeng Luo
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Shimizu K, Takegami Y, Tokutake K, Naruse K, Sudo Y, Matsubara Y, Imagama S. What factors are associated with loss of alignment after open reduction and internal fixation for tibial plateau fractures? A retrospective multicenter (TRON group) study. J Orthop Sci 2024; 29:286-291. [PMID: 36575098 DOI: 10.1016/j.jos.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/20/2022] [Accepted: 12/12/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Tibial plateau fractures (TPFs) are one of the most challenging intra-articular fractures to treat. Along with reconstruction of the articular surfaces, appropriate alignment of the knee joints must be obtained and maintained after open reduction and internal fixation (ORIF) for TPFs because loss of alignment (LA) is associated with worse clinical outcomes. We aimed to investigate and clarify the risk factors related to LA after ORIF for TPFs. METHODS This multicenter, retrospective cohort study used data of hospitals of the Trauma Research Group (TRON group) from January 1, 2011, to December 31, 2020. Among 293 TPFs extracted from the database, we evaluated the alignment of the articular surface to the anatomical axis of the tibia in the immediate postoperative and last follow-up radiographs. We defined a change of alignment from the immediate postoperative radiograph as LA. We evaluated the risk factors of LA using univariate and multiple logistic regression analyses. RESULTS LA was observed in 27 fractures (9.2%). In multiple logistic regression analyses, preoperative articular step-off and postoperative condylar widening were statistically associated with LA (OR = 1.1, 95% CI: 1.02-1.19 and P = 0.012; OR = 1.04, 95% CI: 1.00-1.08, P = 0.045, respectively). We calculated the threshold by drawing a receiver operating characteristic curve using the final regression model. The threshold of postoperative widening was 8.2 mm. We divided the 293 TPFs into two groups according to this threshold and determined differences between the two groups using Fisher's exact test. The two groups were statistically significantly different (P = 0.00502). CONCLUSIONS Preoperative articular step-off and postoperative condylar widening could be associated with LA after ORIF for TPFs. We suggest that intraoperative restoration of condylar widening is important for the prevention of malalignment following ORIF for TPF.
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Affiliation(s)
- Keita Shimizu
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuhiko Takegami
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Katsuhiro Tokutake
- Department of Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Keita Naruse
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshito Sudo
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuji Matsubara
- Department of Orthopedic Surgery, Kariya TOYOTA General Hospital, Toyota, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Liu Y, Fang R, Tu B, Zhu Z, Zhang C, Ning R. Correlation of preoperative CT imaging shift parameters of the lateral plateau with lateral meniscal injury in Schatzker IV-C tibial plateau fractures. BMC Musculoskelet Disord 2023; 24:793. [PMID: 37803358 PMCID: PMC10557321 DOI: 10.1186/s12891-023-06924-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 09/26/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND Schatzker IV-C is a high-energy tibial plateau fracture often accompanied by lateral meniscus injuries. While imaging examinations are routine preoperative measurements, the correlation between CT imaging shift parameters of the lateral plateau and lateral meniscal injury in Schatzker IV-C fractures remains uncovered. METHODS This retrospective study enrolled a total of 60 patients with Schatzker IV-C tibial plateau fractures at the First People's Hospital of Hefei. Prior to surgery, CT imaging was used to measure the numerical values of lateral plateau depression (LPD) and lateral plateau widening (LPW). The degree of lateral meniscus injury was confirmed based on intraoperative direct vision, with patients being classified into meniscus injury and non-meniscus injury groups. Dichotomous logistic regression was employed to evaluate the correlation between LPD, LPW, and lateral meniscus injury, while the optimal cut-off points for predicting lateral meniscal injury with LPD and LPW were determined using receiver operator characteristic (ROC) curves. RESULTS The meniscus injury group exhibited a mean LPD of 15.3 ± 3.5 mm, which was significantly higher than the non-meniscus injury group's mean LPD of 8.4 ± 3.4 mm (P < 0.05). Similarly, the meniscus injury group had a larger mean LPW of 9.4 ± 1.8 mm compared to the non-meniscus injury group's mean LPW of 6.9 ± 0.9 mm (P < 0.05). The optimal cut-off points for predicting lateral meniscal injury were determined to be 8.40 mm for LPD (with a sensitivity of 95%, specificity of 85%, and AUC of 0.898) and 7.90 mm for LPW (with a sensitivity of 75%, specificity of 90%, and AUC of 0.897). CONCLUSIONS Patients with Schatzker IV-C tibial plateau fractures are at a significantly higher risk of lateral meniscal injury when the LPD exceeds 8.40 mm and/or the LPW exceeds 7.90 mm. Our results may provide novel reference metrics for the early diagnosis of lateral meniscal injury in Schatzker IV-C tibial plateau fracture patients when the MRI examination is not available.
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Affiliation(s)
- Yulong Liu
- Department of Orthopedics, The Third Affiliated Hospital of Anhui Medical University, The First People's Hospital of Hefei, 390 Huaihe Road, Hefei, 230061, Anhui, China
| | - Run Fang
- Department of Orthopedics, The Third Affiliated Hospital of Anhui Medical University, The First People's Hospital of Hefei, 390 Huaihe Road, Hefei, 230061, Anhui, China
| | - Bizhi Tu
- Department of Orthopedics, The Third Affiliated Hospital of Anhui Medical University, The First People's Hospital of Hefei, 390 Huaihe Road, Hefei, 230061, Anhui, China
| | - Zheng Zhu
- Department of Orthopedics, The Third Affiliated Hospital of Anhui Medical University, The First People's Hospital of Hefei, 390 Huaihe Road, Hefei, 230061, Anhui, China
| | - Chengnan Zhang
- Department of Orthopedics, The Third Affiliated Hospital of Anhui Medical University, The First People's Hospital of Hefei, 390 Huaihe Road, Hefei, 230061, Anhui, China
| | - Rende Ning
- Department of Orthopedics, The Third Affiliated Hospital of Anhui Medical University, The First People's Hospital of Hefei, 390 Huaihe Road, Hefei, 230061, Anhui, China.
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Rönnerfalk M, Velin L, Palm L, Meunier A, Schilcher J. Autologous Bone Graft From the Ipsilateral Distal Femur in Tibial Condyle Fractures. J Orthop Trauma 2023; 37:e377-e381. [PMID: 36729647 DOI: 10.1097/bot.0000000000002539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2022] [Indexed: 02/03/2023]
Abstract
SUMMARY Fractures of the proximal tibia often require void filling to support articular fragments in combination with internal fixation. The most common techniques are iliac autograft, allograft, or synthetic bone graft substitutes.The distal femur and its large volume condyles are a source of cancellous bone graft within the surgical site of an open reduction and internal fixation procedure. We have used a minimally invasive technique to harvest bone graft from the distal femur, using a bone graft drill. We performed this investigation to determine whether our technique of using distal femoral autograft to fill bone voids when treating proximal tibial fractures with open reduction and internal fixation is effective and safe. We also sought to determine the degree to which the bone graft incorporates into the tibia during fracture healing, the degree to which the harvest site heals, and the degree of secondary joint line depression.In all 12 patients, the bone graft had sufficient volume to fill the subchondral void in the proximal tibia, all fractures had healed at follow-up, and fracture reduction was maintained in most cases. We found no pain at the harvest site during follow-up, and there were no signs of drill penetration in articular or cortical structures. Drill holes at the harvest site showed sparse amounts of newly formed bone on CT in most of its circumference in all patients.There were no pathological changes in the femoral condyles with relation to the bone grafting procedure, and 5 patients showed radiographic signs of osteoarthritis in one or more joint compartments of the knee. The results showed this technique to provide similar success as reported alternatives without major complications and we continue to use this technique of harvesting distal femoral autograft to supplement open reduction and internal fixation of selected proximal tibial fractures.
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Affiliation(s)
- Mattias Rönnerfalk
- Department of Orthopedics and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Naruse K, Takegami Y, Tokutake K, Shimizu K, Sudo Y, Shinohara T, Imagama S. What is the Radiographic Factor Associated with Meniscus Injury in Tibial Plateau Factures? Multicenter Retrospective (TRON) Study. Indian J Orthop 2023; 57:1076-1082. [PMID: 37384016 PMCID: PMC10293136 DOI: 10.1007/s43465-023-00888-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 04/01/2023] [Indexed: 06/30/2023]
Abstract
Purpose Tibial plateau fracture (TPF) is a complex intra-articular injury involving comminution and depression of the joint, which can be accompanied by meniscal tears. The aims of this study were (1) to demonstrate the rate at which surgical treatment for lateral meniscal injury and (2) to clarify the explanatory radiographic factors associated with meniscal injury in patients with TPF. Methods We extracted the patients who received surgical treatment for TPF from our multicenter database (named TRON) included from 2011 to 2020. We analyzed 79 patients who were received surgical treatment for TPF with Schatzker type II and III and evaluation for meniscal injury on arthroscopy. We investigated the rate at which surgical treatment of the lateral meniscus was required in patients with TPF and the explanatory radiographic factors associated with meniscal injury. Radiographs and CT scans were evaluated to measure the following parameters: tibial plateau slope, distance from lateral edge of the articular surface to fracture line (DLE), articular step, and width of articular bone fragment (WDT). Meniscus tears were classified according to whether surgery was necessary. The results were analyzed by multivariate Logistic analyses. Results We showed that 27.7% (22/79) of cases of TPF with Schatzker type II and III had lateral meniscal injury that required repair. WDT ≥ 10 mm (odds ratio 10.9; p = 0.005) and DLE ≥ 5 mm (odds ratio 5.7; p = 0.05) were independent explanatory factors for meniscal injury with TPF. Conclusion Bone fragment size and the location of fracture line on radiographs in patients with TPF are associated with meniscus injuries requiring surgery. Supplementary Information The online version contains supplementary material available at 10.1007/s43465-023-00888-5.
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Affiliation(s)
- Keita Naruse
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550 Japan
| | - Yasuhiko Takegami
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550 Japan
| | - Katsuhiro Tokutake
- Department of Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Keita Shimizu
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550 Japan
| | - Yoshito Sudo
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550 Japan
| | | | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550 Japan
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The value of magnetic resonance imaging in the preoperative diagnosis of tibial plateau fractures: a systematic literature review. Eur J Trauma Emerg Surg 2022; 49:661-679. [PMID: 36307588 PMCID: PMC10175408 DOI: 10.1007/s00068-022-02127-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 10/02/2022] [Indexed: 11/03/2022]
Abstract
Abstract
Purpose
The outcome of a tibial plateau fracture (TPF) depends on the fracture reduction achieved and the extent of soft-tissue lesions, including lesions in the ligaments, cartilage, and menisci. Sub-optimal treatment can result in poor knee function and osteoarthritis. Preoperative planning is primarily based on conventional X-ray and computed tomography (CT), which are unsuitable for diagnosing soft-tissue lesions. Magnetic resonance imaging (MRI) is not routinely performed. To date, no literature exists that clearly states the indications for preoperative MRI. This systematic review aimed to determine the frequency of soft-tissue lesions in TPFs, the association between fracture type and soft-tissue lesions, and the types of cases for which MRI is indicated.
Methods
A systematic review of the literature was based on articles located in PubMed/MEDLINE and the Cochrane Central Register of Controlled Trials (CENTRAL), supplemented by searching the included articles’ reference lists and the ePublication lists of leading orthopedic and trauma journals.
Results
A total of 1138 studies were retrieved. Of these, 18 met the eligibility criteria and included a total of 877 patients. The proportion of total soft-tissue lesions was 93.0%. The proportions of soft-tissue lesions were as follows: medial collateral ligament 20.7%, lateral collateral ligament 22.9%, anterior cruciate ligament 36.8%, posterior cruciate ligament 14.8%, lateral meniscus 48.9%, and medial meniscus 24.5%. A weak association was found between increasing frequency of LCL and ACL lesions and an increase in fracture type according to Schatzker's classification. No standard algorithm for MRI scans of TPFs was found.
Conclusion
At least one ligament or meniscal lesion is present in 93.0% of TPF cases. More studies with higher levels of evidence are needed to find out in which particular cases MRI adds value. However, MRI is recommended, at least in young patients and cases of high-energy trauma.
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Giordano V, Pires RE, Pimenta FS, Campos TVDO, Andrade MAPD, Giannoudis PV. Posterolateral Fractures of the Tibial Plateau Revisited: A Simplified Treatment Algorithm. J Knee Surg 2022; 35:959-970. [PMID: 33167054 DOI: 10.1055/s-0040-1721026] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
High-energy fractures of the proximal tibia with extensive fragmentation of the posterolateral (PL) quadrant of the tibial plateau are challenging to manage. Herein, we present a review of the literature on the patterns and options of approach and fixation of the PL fragment of the tibial plateau to optimize the treatment of this specific injury pattern. We searched PubMed (1980-May 2020) to identify and summarize the most relevant articles evaluating both the morphology and treatment recommendations, including the choice of approach and fixation strategy, for the PL tibial plateau fracture. We found PL fragment can present in several patterns as a pure split, split depression, contained pure depression, and noncontained depression (rim crush), which are mostly determined by the position of the knee and the force magnitude applied during the course of the accident. Based on previous concepts described by Schatzker and Kfuri, we suggest a simplified treatment algorithm highlighting the two concepts (buttressing and containment) used for plating the PL tibial plateau fragments. Based on the available current evidence, we propose an algorithm for these two morphological types of PL tibial plateau fracture. Shear-type fractures need buttressing (the "rule of thumb"), whereas noncontained peripheral rim-type fractures need peripheral repair and containment. Contained pure depression fractures are not frequent and need percutaneous-assisted elevation and subchondral rafting, either controlled by fluoroscopy or arthroscopically. It is believed that such an approach would simplify their assessment and preoperative planning and would assist the clinicians to appreciate and manage more consistently these complex injuries.
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Affiliation(s)
- Vincenzo Giordano
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro, RJ, Brazil.,Clínica São Vicente, Rede D'or São Luiz, Rio de Janeiro, RJ, Brazil
| | - Robinson Esteves Pires
- Departamento de Ortopedia, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | | | | | | | - Peter V Giannoudis
- Academic Department of Trauma & Orthopaedic Surgery, School of Medicine, University of Leeds, Leeds, United Kingdom
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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.
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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
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A radiographic zone-based approach to predict meniscus injury in lateral tibial plateau fracture. Injury 2021; 52:1539-1543. [PMID: 33046254 DOI: 10.1016/j.injury.2020.10.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 08/24/2020] [Accepted: 10/05/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES There is limited data regarding meniscal injury and it's association to fracture location and articular impaction/displacement (AID) in tibial plateau fractures. The purpose of this study was to predict lateral meniscal injury in tibial plateau fractures, based on location and extent of AID as visualized on pre op CT images. DESIGN Retrospective review study. SETTING Level I academic trauma center. PATIENTS We retrospectively reviewed lateral tibia plateau fracture patients that were treated operatively using CPT codes 27535 and 27536. Two hundred patients were identified. Inclusion criteria were lateral tibia plateau fracture, age of 18 years or older, and documented direct examination of lateral meniscus integrity intraoperatively. Seventy patients met inclusion criteria. INTERVENTION The injured lateral tibial plateau was divided into four quadrants on pre-operative CT and maximum AID was measured. The zone of fracture was defined as the location of largest AID (Image-1). All patients had an arthrotomy at the time of surgery to evaluate the integrity of the meniscus. Intra operative data regarding meniscal integrity and preoperative CT data were analyzed. Logistic regression was used to estimate what effect zone and amount of AID had on predicting the meniscal injury. Receiver operating characteristic (ROC) analysis was performed to determine cut off points for high sensitivity/specificity. MAIN OUTCOME MEASUREMENTS Amount and area of depression in the lateral tibial plateau as relates to meniscal injury. RESULTS Mean age was (45.1 ± 12.9) years. Twelve had Schatzker type I and 58 had type II fractures. Twenty-two patients had meniscus injury (MI) and forty-eight patients did not have a meniscus injury (NMI). Mean AID for MI was 12.48 mm ± 7.17 mm and 6.4 mm ± 4.3 mm for NMI (p<0.01). In MI group, largest AID was in Posterolateral (PL) zone(17.58 mm ± 8.9 mm) followed by Anteromedial (AM) zone (13.3 mm ± 7.2 mm) and Anterolateral (AL) zone (9.4 mm ± 5.8 mm). In NMI group largest AID was in AL zone (8.52 mm ± 2.6 mm) followed by AM zone (8.04 mm ± 5.4 mm) and PL zone (7.75 mm ± 2.35 mm). Patients with PL zone involvement had a lower meniscus tear rate compare to other zones. Logistic regression revealed that for every 1 mm increase in AID there is a 21% increase chance of meniscus tear (p<0.01). Comparison of the zones indicated that for the same AID, AL and AM zone fractures have 7.3 and 5.6 times increase risk of meniscus tear, respectively, as compared to PL zone (p<0.05). ROC analysis revealed that AID of 4.3 mm as a cut off point provides 100% sensitivity for diagnosis of meniscus tear. CONCLUSION With 1 mm increase in AID there is a 21% increase in chance of meniscal tear. With the same AID, AL and AM zone fractures have a significantly higher chance of having a meniscal tear. AID of 4.3 mm provides 100% sensitivity to predict meniscal tear in lateral tibia plateau fracture. These values are useful in predicting pre op meniscal tear without MRI.
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The degree of fracture displacement does not affect the risk for concomitant proximal fibular fractures in tibial plateau fractures. INTERNATIONAL ORTHOPAEDICS 2021; 45:2963-2971. [PMID: 33825001 DOI: 10.1007/s00264-021-05034-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The proximal fibula plays an important role in the knee joint; however, it has not been given enough attention by surgeons. This study aimed to investigate the risk factors for concomitant proximal fibular fractures in patients with tibial plateau fractures through computed tomography (CT) imaging. MATERIALS AND METHODS From January 2016 to November 2017, patients who underwent percutaneous reduction and internal fixation (PRIF) for tibial plateau fractures at a level 1 trauma centre institute were included in this retrospective study. Full materials of CT imaging were obtained for measurements. Schatzker's and a newly proposed classification system were used for the fracture of the tibial plateau and proximal fibula, respectively. Several clinical and radiological characteristics were recorded, and the impact of those variables on fibular fractures was assessed with univariate and multivariate analyses. RESULTS In total, 174 patients were enrolled in the study with mean age of 45.6±13.1 years. The incidence of combined proximal fibular fracture was 38.3%. Schatzker type VI fracture had the highest rate of fibular fracture (77.4%). High-energy-pattern tibial plateau fractures (p=0.029) and posterolateral joint facet (PJF) involvements (p=0.002) are risk factors for proximal fibular fracture on multivariate analysis. Neither posterolateral column (PLC) involvements nor fracture displacement correlated with proximal fibular fractures. CONCLUSIONS Proximal fibular fractures were commonly seen among patients who sustained tibial plateau fractures. Schatzker type VI fractures had the highest rate of fibular fractures than other fracture types. High-energy fractures and PJF involvements correlated with a higher risk of proximal fibular fractures. A better understanding and awareness of the risk factors for proximal fibular fractures will provide surgeons with comprehensive understanding of tibial plateau fractures.
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Chen YD, Chen SX, Liu HG, Zhao XS, Ou WH, Li HX, Huang HX. Is traumatic meniscal lesion associated with acute fracture morphology changes of tibia plateau? A series of arthroscopic analysis of 67 patients. World J Clin Cases 2021; 9:81-90. [PMID: 33511174 PMCID: PMC7809655 DOI: 10.12998/wjcc.v9.i1.81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/10/2020] [Accepted: 11/14/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Computed tomography (CT) has become a routine preoperative examination for tibial plateau fractures (TPFs). Assessing the location of the fragment and intercondylar eminence fracture can provide clinicians with valuable information; however, the evaluation of traumatic meniscal lesion (TML) and arthroscopic management are controversial.
AIM To predict TML by three-dimensional skeletal anatomy changes in unilateral TPF and bilateral TPF on preoperative thin layer CT.
METHODS Acute fracture of tibial plateau patients undergoing arthroscopic surgery between December 2017 and December 2019 were included in this retrospective study. The type, zone, and location of TMLs were diagnosed based on the operation records and/or arthroscopic videos. Measurement of three-dimensional fracture morphology included the following: Frontal fragment width of plateau, sagittal fragment subsiding distance (FSD), sagittal fracture line distance, sagittal posterior tibial slope, and transversal area ratio of fragment area) on preoperative CT three-dimensional plane. The correlation of TML with skeletal values was calculated according to unicondylar TPFs and bicondylar TPFs.
RESULTS A total of 67 patients were enrolled in this study, among which 30 patients had TMLs, lateral/medial (23/7). FSD was a particularly positive factor to predict TML, with odds ratio of 2.31 (1.26-5.63). On sagittal view of CT, FSD degree of 8 mm and posterior tibial slope exceeding 11.74° implied enhanced risk of TML in bicondylar TPFs. On coronal view, once fragment width of plateau surpassed 3 cm, incidence of TML reached 100%. On transverse view, area ratio of fragment as enhanced risk of 5.5% and FSD > 4.3 mm for predicting TML were observed in unicondylar TPFs.
CONCLUSION TML can be predicted by different parameters on preoperative CT views according to unicondylar fractures and bicondylar TPFs.
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Affiliation(s)
- Yan-Dong Chen
- 3rd Institute of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou 510000, Guangdong Province, China
- Department of Joint Trauma, Jiangmen Wuyi Hospital of Traditional Chinese Medicine, Affiliated Jiangmen Traditional Chinese Medicine Hospital of Jinan University, Jiangmen 529031, Guangdong Province, China
| | - Shu-Xiang Chen
- Department of Joint Trauma, Jiangmen Wuyi Hospital of Traditional Chinese Medicine, Affiliated Jiangmen Traditional Chinese Medicine Hospital of Jinan University, Jiangmen 529031, Guangdong Province, China
| | - Hong-Guang Liu
- Department of Joint Trauma, Jiangmen Wuyi Hospital of Traditional Chinese Medicine, Affiliated Jiangmen Traditional Chinese Medicine Hospital of Jinan University, Jiangmen 529031, Guangdong Province, China
| | - Xiang-Sheng Zhao
- Department of Radiology, Jiangmen Wuyi Hospital of Traditional Chinese Medicine, Jiangmen 529031, Guangdong Province, China
| | - Wen-Huan Ou
- Department of Joint Trauma, Jiangmen Wuyi Hospital of Traditional Chinese Medicine, Affiliated Jiangmen Traditional Chinese Medicine Hospital of Jinan University, Jiangmen 529031, Guangdong Province, China
| | - Huan-Xi Li
- Department of Joint Trauma, Jiangmen Wuyi Hospital of Traditional Chinese Medicine, Affiliated Jiangmen Traditional Chinese Medicine Hospital of Jinan University, Jiangmen 529031, Guangdong Province, China
| | - Hong-Xing Huang
- Science and Education Section, The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510378, Guangdong Province, China
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Van den Berg JD, Quintens L, Zhan Y, Hoekstra H. Why address posterior tibial plateau fractures? Injury 2020; 51:2779-2785. [PMID: 32958346 DOI: 10.1016/j.injury.2020.09.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/15/2020] [Indexed: 02/02/2023]
Abstract
Management of posterior tibial plateau fractures has gained much interest over the past few years. Fracture morphology, trauma mechanism, and soft-tissue injury have been identified as the key factors determining the treatment strategy and outcome. We provide a rationale for the operative management of posterior tibial plateau fractures by discussing the interplay between fracture morphology, trauma mechanism, and soft-tissue injury. The trauma mechanism has proven to be an important tool, not only to understand fracture morphology, but also to assess concomitant soft-tissue (i.e. ligamentous) injury. Subsequently, soft-tissue injury might play a role in future classification and diagnostic work-up of tibial plateau fractures, particularly in fractures with posterior involvement. Plate osteosynthesis using a posterior approach is safe and should be considered routinely in coronal fractures of the posterior tibial plateau, as illustrated.
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Affiliation(s)
- J D Van den Berg
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium
| | - L Quintens
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium
| | - Y Zhan
- Department of Orthopaedic Surgery, Shanghai Jiaotong University, affiliated Shanghai 6th People's Hospital, Shanghai, China
| | - H Hoekstra
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium; KU Leuven - University of Leuven, Department of Development and Regeneration, B-3000 Leuven, Belgium.
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14
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Deng X, Chen W, Shao D, Hu H, Zhu J, Ye Z, Zhang Y. Arthroscopic evaluation for tibial plateau fractures on the incidence and types of cruciate ligamentous injuries following closed reduction and internal fixation. INTERNATIONAL ORTHOPAEDICS 2020; 45:1287-1298. [PMID: 33123747 DOI: 10.1007/s00264-020-04864-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/23/2020] [Indexed: 01/08/2023]
Abstract
PURPOSE To evaluate the overall incidence and types of anterior cruciate ligament (ACL) injuries and posterior cruciate ligament (PCL) injuries associated with tibial plateau fractures (TPFs) following closed reduction and internal fixation (CRIF), and to identify the relationship between the incidence and types of cruciate ligamentous injuries with Schatzker classification and "three-column" classification. METHODS From January 2016 to January 2018, 185 patients with closed TPFs who underwent CRIF were included in this retrospective study. All patients were performed with arthroscopic examination after CRIF, and then, the incidence and types of cruciate ligamentous injuries were recorded and evaluated. RESULTS The overall incidence rates of cruciate ligamentous injuries associated with TPFs were 37.3% with 21.6% of these being ACL injuries and 15.7% had PCL injuries. Importantly, patients with fractures in "two-column" fractures have a significantly higher incidence rate of ACL avulsion fracture and PCL complete tears (P < 0.05) than other fracture types, especially involving anteromedial and posterior column fractures. In addition, the incidence of PCL partial tears in patients with three-column involvement was 11.8%, which was higher than other fracture patterns based on three-column classification system (P < 0.05). In the current study, Schatzker IV was most commonly associated with ACL injuries, occurring in 48.1% of our series. Furthermore, PCL injuries occurred at a significantly higher incidence in Schatzker VI with 34.5% than other fracture types (P < 0.05). Statistical analysis revealed that there was a significant difference between Schatzker classification and incidence of injury to the ACL (P < 0.05) and PCL (P < 0.05). Of note, avulsion fracture was the most common types of ACL injuries which was observed in 45% ACL injuries, while partial tear was the most common types of PCL injuries. However, no significant relationship was identified between the types of cruciate ligamentous injuries and Schatzker classification (P > 0.05). CONCLUSIONS In the recognition of concomitant cruciate ligamentous injuries associated with TPFs based on Schatzker classification and three-column classification, orthopaedic trauma surgeons may better guide optimal surgical protocols for patients.
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Affiliation(s)
- Xiangtian Deng
- School of Medicine, Nankai University, Tianjin, 300071, People's Republic of China.,Department of Orthopaedic Surgery of Hebei Province, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Wei Chen
- Department of Orthopaedic Surgery of Hebei Province, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Decheng Shao
- Department of Orthopaedic Surgery of Hebei Province, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Hongzhi Hu
- Department of Orthopaedic Surgery of Hebei Province, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China.,Department of Orthopedics, Union Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, 430022, People's Republic of China
| | - Jian Zhu
- School of Medicine, Nankai University, Tianjin, 300071, People's Republic of China.,Department of Orthopaedic Surgery of Hebei Province, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - ZhiPeng Ye
- School of Medicine, Nankai University, Tianjin, 300071, People's Republic of China.,Department of Orthopaedic Surgery of Hebei Province, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Yingze Zhang
- School of Medicine, Nankai University, Tianjin, 300071, People's Republic of China. .,Department of Orthopaedic Surgery of Hebei Province, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China.
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15
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Adams JDJ, Loeffler MF. Soft Tissue Injury Considerations in the Treatment of Tibial Plateau Fractures. Orthop Clin North Am 2020; 51:471-479. [PMID: 32950216 DOI: 10.1016/j.ocl.2020.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Tibial plateau fractures represent a highly variable spectrum of injury that requires a multifaceted diagnostic and therapeutic approach in order to adequately treat. Constant vigilance is required to consider all the injured structures and avoid focusing only on the bony aspect of the injury. Management of the soft tissue envelope and repair/reconstruction of critical stabilizing structures of the knee should be at the forefront of the thought process when approaching these complex injuries. This article aims to emphasize the high incidence of injury to associated soft tissue structures and provide general approach considerations to these complex injuries.
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Affiliation(s)
- John D Jd Adams
- Department of Orthopedic Surgery, Division of Orthopedic Trauma, Prisma Health, Greenville Memorial Medical Hospital, 701 Grove Road, 2nd Floor Support Tower, Greenville, SC 29605, USA.
| | - Markus F Loeffler
- Department of Orthopedic Surgery, Prisma Health, Greenville Memorial Medical Hospital, 701 Grove Road, 2nd Floor Support Tower, Greenville, SC 29605, USA
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16
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Clinical features and treatment of "Non-dislocated hyperextension tibial plateau fracture". J Orthop Surg Res 2020; 15:289. [PMID: 32727505 PMCID: PMC7391511 DOI: 10.1186/s13018-020-01806-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/16/2020] [Indexed: 12/14/2022] Open
Abstract
Background To explore the epidemiological characteristics, clinical characteristics, treatment strategies, and clinical results of non-dislocated hyperextension tibial plateau fracture. Method A total of 25 cases of non-dislocated hyperextension tibial plateau fracture patients were collected (12 males and 13 females), aged 27–79 years. Preoperative tibial plateau posterior slope angle was − 10~0° (average − 5.2°). Preoperative MRI showed 5 cases of MCL injury, 3 cases of PLC complex injury, and 2 cases of PLC + PCL injury. The change of tibial plateau posterior slope angle was more than 10° in patients with ligament injury, and the patients with a tibial plateau posterior slope angle change less than 10° had no ligament injury; 6 patients with simple column fracture had a ligament injury, 2 patients with bilateral column fracture had a ligament injury, and 2 patients with three column fracture had a ligament injury. Results Patients were followed up for 12–24 months (average 16.4 months). The operative time was 65–180 min (average 124 min), and the blood loss was 20–200 ml (average 106 ml). The plate was placed on the anterior part of tibial plateau. Evaluation of postoperative fracture reduction was as follows: 20 cases reached anatomic reduction, 5 cases reached good reduction (between 2 and 5 mm articular surface collapse), and the excellent rate of fracture reduction was 100%. The fracture healing time was 3–6 months (average 3.3 months). The postoperative knee Rasmussen score was 18–29 (average 24.9), and the postoperative knee joint mobility was 90–130° (average 118°). Two patients suffered superficial infection. Conclusions The main imaging characteristic of “non-dislocated hyperextension tibial plateau fracture” is the change of tibial plateau posterior slope angle. The injury of single anteromedial column/anterolateral column fracture is easy to combine with “diagonal” injury, and when the tPSA changes more than 10°, it is easy to be combined with ligament injury. By reducing the joint articular surface and lower limb force line, repairing the soft tissue structure, and reconstructing the knee joint stability, we can get satisfactory results. Trial registration It was a retrospective study. This study was consistent with the ethical standards of the Second Affiliated Hospital of Zhejiang University Medical College and was approved by the hospital ethics committee and the trial registration number of our hospital was 20180145.
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17
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Taljanovic MS, Chang EY, Ha AS, Bartolotta RJ, Bucknor M, Chen KC, Gorbachova T, Khurana B, Klitzke AK, Lee KS, Mooar PA, Nguyen JC, Ross AB, Shih RD, Singer AD, Smith SE, Thomas JM, Yost WJ, Kransdorf MJ. ACR Appropriateness Criteria® Acute Trauma to the Knee. J Am Coll Radiol 2020; 17:S12-S25. [PMID: 32370956 DOI: 10.1016/j.jacr.2020.01.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 01/27/2020] [Indexed: 11/20/2022]
Abstract
Acute trauma to the knee is a common presentation seen in the emergency department. After a routine clinical examination, imaging is frequently performed to facilitate the diagnosis and almost always starts with radiographs. If clinically indicated, advanced cross-sectional imaging may then be performed for further evaluation. CT is often performed for preoperative planning of the complex tibial plateau and distal femur fractures. Currently, MRI is the study of choice for evaluation of bone marrow, internal derangements, and other soft-tissue injuries about the knee joint. In patients with knee dislocations, MR angiography may be performed simultaneously with MRI for evaluation of internal derangements and vascular injuries with less morbidity compared to conventional angiography. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Eric Y Chang
- Panel Chair, VA San Diego Healthcare System, San Diego, California
| | - Alice S Ha
- Panel Vice-Chair, University of Washington, Seattle, Washington
| | | | - Matthew Bucknor
- University of California San Francisco, San Francisco, California
| | - Karen C Chen
- VA San Diego Healthcare System, San Diego, California
| | | | | | - Alan K Klitzke
- Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Kenneth S Lee
- University of Wisconsin Hospital & Clinics, Madison, Wisconsin
| | - Pekka A Mooar
- Temple University Hospital, Philadelphia, Pennsylvania; American Academy of Orthopaedic Surgeons
| | - Jie C Nguyen
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Andrew B Ross
- University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin
| | - Richard D Shih
- Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida; American College of Emergency Physicians
| | - Adam D Singer
- Emory University School of Medicine, Atlanta, Georgia
| | - Stacy E Smith
- Brigham & Women's Hospital & Harvard Medical School, Boston, Massachusetts
| | - Jonelle M Thomas
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - William J Yost
- UnityPoint Health, Des Moines, Iowa; American College of Physicians
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18
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Elsoe R, Motahar I, Mahdi F, Larsen P. Presence of magnetic resonance imaging verified soft tissue injuries did not significantly affect the patient-reported outcome 12 months following a lateral tibial plateau fracture: A 12-month prospective cohort study of 56 patients. Knee 2020; 27:420-427. [PMID: 32035704 DOI: 10.1016/j.knee.2020.01.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 10/26/2019] [Accepted: 01/21/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Soft tissue injuries following lateral tibial plateau fracture affect more than half of patients. Regardless of the type of soft tissue injured, it is still unclear how different treatment strategies influence postoperative outcome. The aim of this study was to report the 12-month Knee Injury and Osteoarthritis Outcome Score (KOOS5) of patients with surgically managed lateral tibial plateau fractures divided into groups with and without conservatively managed magnetic resonance imaging (MRI)-verified soft tissue injuries. METHODS Prospective cohort study. Patients treated surgically following a lateral tibial plateau fracture (AO-41B) between December 2013 and November 2016 were included. Soft tissue injuries were evaluated with preoperative MRI scans. The primary outcome score was the 12-month KOOS5 score divided into groups with and without soft tissue injuries. RESULTS A total of 56 patients were included. Average patient age was 56 years (range 22-86). Thirty-three patients (59%) were female. Fifty percent of patients presented with MRI-verified soft tissue injuries. At 12 months postoperatively, the mean KOOS5 score for patients with soft tissue injuries was 53.5 (95% confidence interval (CI): 44.8-62.1) and the KOOS5 score for patients without soft tissue injuries was 59.6 (95% CI: 50.7-68.6). No significant difference in the KOOS5 score between patients with and without soft tissue injuries was observed (P = .31). CONCLUSIONS At 12-month follow-up the presence of MRI-verified soft tissue injuries did not significantly affect the patient-reported KOOS5 score. More research is needed to investigate the effects of surgical vs. non-surgical treatment strategies of associated soft tissue injuries following lateral tibial plateau fractures.
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Affiliation(s)
- Rasmus Elsoe
- Department of Orthopaedic Surgery, Aalborg University Hospital, Hobrovej 18, 9000 Aalborg, Denmark.
| | - Isa Motahar
- Department of Radiology, Aalborg University Hospital, Hobrovej 18, 9000 Aalborg, Denmark
| | - Firaz Mahdi
- Department of Radiology, Aalborg University Hospital, Hobrovej 18, 9000 Aalborg, Denmark
| | - Peter Larsen
- Department of Orthopaedic Surgery, Aalborg University Hospital, Hobrovej 18, 9000 Aalborg, Denmark; Department of Occupational Therapy and Physiotherapy, Aalborg University Hospital, Hobrovej 18, 9000 Aalborg, Denmark
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19
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Widening is a predictive factor of bucket handle tear in tibial plateau fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 30:695-699. [PMID: 31912239 DOI: 10.1007/s00590-019-02606-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 12/13/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND It is well known that tibial plateau fractures have an association with soft tissue injuries. However, as far as the authors are aware, there has been no literature specifically on the incidence of bucket handle meniscal tears in patients with tibial plateau fractures. Bucket handle tears are often symptomatic and amenable to repair if detected early. Our objective was therefore to determine the incidence of bucket handle tears specifically in tibial plateau fractures and identify radiographic features which are suggestive of bucket handle tears. METHOD Data for 88 consecutive patients with tibial plateau fractures in a major trauma centre over a two-year period were analysed. Clinical records were reviewed to identify injuries with an associated bucket handle tear. Pre-operative computerised tomography was reviewed. Monovariant and multivariant analyses were conducted to identify radiographic predictive features. RESULTS The results showed a 20% incidence of soft tissue injuries in concurrence with the existing literature. In addition, there was found to be a 10% incidence of meniscal bucket handle tears. Articular widening of > 8 mm was found to be a unique significant predictor of bucket handle tears. CONCLUSION It is essential to bear in mind the association with soft tissue injuries in tibial plateau fractures and the incidence of bucket handle tears in particular. The radiographic feature of articular widening should alert the clinician to the possibility of this injury. This will enable appropriate investigations and surgical planning to be carried out in order to improve patient management and outcomes.
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20
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Third day laboratory follow-up: mandatory for surgical site infections of tibial plateau fractures. Eur J Trauma Emerg Surg 2019; 47:581-587. [PMID: 31535161 DOI: 10.1007/s00068-019-01232-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 09/12/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Tibial plateau fractures are common fractures in adults and can be extremely challenging for surgeons. State-of-the-art therapy is open reduction and internal fixation (ORIF), although major complications of ORIF are surgical site infections (SSIs). This is especially critical on the proximal tibia, which is only sparsely covered by soft tissue and has a close relation to the knee joint. We analyzed SSIs after ORIF to correlate established laboratory parameters to the occurrence of SSIs. METHODS A monocentric case-control study in a Level 1 Trauma Center was conducted. Data were acquired from electronic medical records from 2011 until 2016. White blood cell count (WBC) and C-reactive protein (CRP) were used as laboratory parameters and statistically analyzed. RESULTS In total, 97 patients were included, with four patients suffering from SSIs. Patients with SSIs had a significantly increased WBC count and CRP levels on the third postoperative day. Infection was diagnosed after rehospitalization, 12 ± 4 weeks after initial surgery. Furthermore, a large bony destruction through trauma coincides with a rise of WBC count with no influence on CRP level. CONCLUSION We highly recommend a laboratory analysis with WBC count and CRP on the third day after ORIF. Patients with a CRP level above 100 mg/l should be closely watched, even if laboratory parameters few days later are adequate-since a one-time increase above this landmark might be a hint regarding the development of a SSI.
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21
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Porrino J, Wang A, Kani K, Kweon CY, Gee A. Preoperative MRI for the Multiligament Knee Injury: What the Surgeon Needs to Know. Curr Probl Diagn Radiol 2019; 49:188-198. [PMID: 30824164 DOI: 10.1067/j.cpradiol.2019.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 02/06/2019] [Indexed: 01/13/2023]
Abstract
The multiligament knee injury is devastating and potentially limb threatening. Preoperative magnetic resonance imaging for the evaluation of the multiligament knee injury is an invaluable clinical tool, and when the radiologist is familiar with how certain injury patterns influence management, optimal outcomes can be achieved. We provide a detailed description of the relationship between salient imaging features of the multiligament knee injury, focusing on the preoperative magnetic resonance imaging, and their influence on clinical decision-making.
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Affiliation(s)
- Jack Porrino
- Yale Radiology and Biomedical Imaging, New Haven, CT 06520.
| | - Annie Wang
- Yale Radiology and Biomedical Imaging, New Haven, CT 06520.
| | - Kimia Kani
- Department of Radiology, University of Maryland School of Medicine, Baltimore, MD 21201.
| | - Christopher Y Kweon
- University of Washington, Department of Orthopaedics & Sports Medicine, Seattle, WA 98195.
| | - Albert Gee
- University of Washington, Department of Orthopaedics & Sports Medicine, Seattle, WA 98195.
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22
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Yao X, Xu Y, Yuan J, Lv B, Fu X, Wang L, Yang S, Meng S. Classification of tibia plateau fracture according to the "four-column and nine-segment". Injury 2018; 49:2275-2283. [PMID: 30270010 DOI: 10.1016/j.injury.2018.09.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 08/31/2018] [Accepted: 09/09/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE The existing classification systems of tibial plateau fracture (TPF) are suboptimal for clinical use and academic communication. A more comprehensive and universal classification system with the capability to analyze all patterns of TPF is urgently required to guide the clinical practice. This study aimed to analyze the incidence and fracture characteristics of TPF using a computed tomography-based "four-column and nine-segment" classification. METHODS According to the differentiated morphological characteristics, tibial plateau and proximal fibula were divided into four columns, which were subdivided into nine segments. Tibia plateau injury index (TPII) was innovatively introduced to represent the extent of injury. A total of 698 consecutive adult patients with 704 affected knees were included (377 females, 321 males, mean age 51.6 ± 12.9 years). Fracture mapping was retrospectively analyzed according to the new-style classification system based on the CT imaging. RESULTS 371 (53.2%) left knees and 321 (46.0%) right knees were injured solely and 6 (0.9%) cases sustained bilateral injuries. The rates of one-column, two-column, three-column and all-four-column injuries were 30.5%, 31.5%, 28.0% and 9.9%, respectively. On average, 2.2 ± 1.0 columns and 3.6 ± 2.1 segments were involved, the mean TPII was 5.7 ± 3.0. The rates of mild, moderate and severe comminuted fractures were 50.0%, 37.5% and 12.5%. The most frequently affected columns were lateral column (572, 81.3%) and intermedial column (524, 74.4%), and the less frequently involved columns were the medial column (219, 31.1%) and fibular column (218, 31.0%). The most frequently affected segments were the posterolateral segment (465, 66.1%), anterolateral segment (453, 64.3%) and posteromedian segment (379, 53.8%). The least frequently involved segment was tubercle segment (85, 12.1%). CONCLUSIONS The novel "four-column and nine-segment" classification will be a beneficial classification system for clinical diagnosis, statistical analysis and prognostic judgment of tibial plateau fractures.
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Affiliation(s)
- Xiang Yao
- Department of Orthopedics, The Affiliated People's Hospital with Jiangsu University, Zhenjiang, Jiangsu Province, China
| | - Yong Xu
- Department of Orthopedics, The Affiliated People's Hospital with Jiangsu University, Zhenjiang, Jiangsu Province, China
| | - Jishan Yuan
- Department of Orthopedics, The Affiliated People's Hospital with Jiangsu University, Zhenjiang, Jiangsu Province, China
| | - Bin Lv
- Department of Orthopedics, The Affiliated People's Hospital with Jiangsu University, Zhenjiang, Jiangsu Province, China
| | - Xingli Fu
- Jiangsu University Health Science Center, Zhenjiang, Jiangsu Province, China
| | - Lei Wang
- Department of Orthopedics, The Affiliated People's Hospital with Jiangsu University, Zhenjiang, Jiangsu Province, China
| | - Shengquan Yang
- Department of Orthopaedics, The No.1 People's Hospital of Yancheng, Yancheng, Jiangsu Province, China
| | - Sheng Meng
- Department of Orthopedics, The Affiliated People's Hospital with Jiangsu University, Zhenjiang, Jiangsu Province, China.
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Chang H, Zheng Z, Shao D, Yu Y, Hou Z, Zhang Y. Incidence and Radiological Predictors of Concomitant Meniscal and Cruciate Ligament Injuries in Operative Tibial Plateau Fractures: A Prospective Diagnostic Study. Sci Rep 2018; 8:13317. [PMID: 30190502 PMCID: PMC6127198 DOI: 10.1038/s41598-018-31705-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 08/09/2018] [Indexed: 11/08/2022] Open
Abstract
The aim of this prospective study was to determine the incidence of meniscal and cruciate ligament injuries in operative tibial plateau fractures detected using knee arthroscopy, and to identify the radiological predictors observed on CT images. From January 2016 to February 2017, a total of 102 closed tibial plateau fractures were enrolled in this prospective protocol. Each patient underwent arthroscopic examination following the tibial plateau internal fixation. Univariate analysis and multivariable logistic regression were used to assess the association between imaging parameters and soft-tissue injuries. The menisci were traumatically injured in 52.9% of subjects (54 of 102) and the cruciate ligaments injured in 22.5% (23 of 102). Significantly higher injury rates for bucket-handle meniscal tears were observed in Schatzker type VI fractures (P = 0.04). Greater risk of lateral meniscus injury was observed in patients with >6.3 mm of lateral joint depression. Greater risk of ACL injury when the volumetric lateral joint depression was ≤209.5 mm2 and/or with >5.7 mm lateral joint widening. Associated meniscal and ligament injuries were commonly seen among operative tibial plateau fractures. Preoperative CT measurements might help predict a higher risk of meniscus and ACL injury, providing guidance to the surgeon to look for and to be prepared to treat such injuries.
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Affiliation(s)
- Hengrui Chang
- Department of Orthopaedic Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, P.R. China
- Key laboratory of biomechanics of Hebei Province, Shijiazhuang, Hebei, 050051, P.R. China
| | - Zhanle Zheng
- Department of Orthopaedic Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, P.R. China
- Key laboratory of biomechanics of Hebei Province, Shijiazhuang, Hebei, 050051, P.R. China
| | - Decheng Shao
- Department of Orthopaedic Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, P.R. China
- Key laboratory of biomechanics of Hebei Province, Shijiazhuang, Hebei, 050051, P.R. China
| | - Yiyang Yu
- Department of Orthopaedic Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, P.R. China
- Key laboratory of biomechanics of Hebei Province, Shijiazhuang, Hebei, 050051, P.R. China
| | - Zhiyong Hou
- Department of Orthopaedic Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, P.R. China
- Key laboratory of biomechanics of Hebei Province, Shijiazhuang, Hebei, 050051, P.R. China
| | - Yingze Zhang
- Department of Orthopaedic Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, P.R. China.
- Key laboratory of biomechanics of Hebei Province, Shijiazhuang, Hebei, 050051, P.R. China.
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Prediction of Meniscal and Ligamentous Injuries in Lateral Tibial Plateau Fractures Based on Measurements of Lateral Plateau Widening on Multidetector Computed Tomography Scans. BIOMED RESEARCH INTERNATIONAL 2018; 2018:5353820. [PMID: 30151383 PMCID: PMC6087612 DOI: 10.1155/2018/5353820] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 03/11/2018] [Accepted: 07/12/2018] [Indexed: 12/27/2022]
Abstract
Background The influence of increasing lateral plateau widening on the frequency of meniscal and ligamentous lesions in lateral tibial plateau fractures has been examined in very few studies using plain radiographs. Because the amount of this parameter cannot be measured accurately on plain radiographs, the purpose of this survey was to look for a possible correlation between the extent of lateral plateau widening, as measured on multidetector CT (MDCT) scans, and different soft-tissue injuries determined from magnetic resonance imaging (MRI). Materials and Methods 55 patients with a lateral tibial plateau fracture were included in this retrospective case series. Patient age averaged 52.6 years (SD = 18.0). The degree of lateral plateau widening was measured on CT images. MRIs were screened for meniscal and ligamentous injuries. Results We found a significant effect of increasing lateral plateau widening on the incidence of lateral meniscus lesions (P = 0.021), lateral collateral ligament tears (P = 0.047), and the overall quantity of meniscal and ligamentous lesions (P = 0.001). Discussion MRIs are not widely used as a diagnostic tool in lateral plateau fractures of the tibia. Reasons might be the costs and the fact that it is a time-consuming examination. The results of this study may help to estimate the probability of specific soft-tissue lesions in lateral tibial plateau fractures based on measurements of lateral plateau widening on MDCT scans, and they may guide the decision for additional MRI and/or arthroscopically assisted repair.
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Value of quantitative assessment using Multidetector CT in predicting ligamentous and meniscal injuries in acute tibial plateau fractures. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2018. [DOI: 10.1016/j.ejrnm.2017.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Trans-articular Kirschner wire fixation in treating complex tibial plateau fractures complicated by multiple ligaments injuries: A case report and literature review. Injury 2018; 49:382-385. [PMID: 29162269 DOI: 10.1016/j.injury.2017.11.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 11/15/2017] [Indexed: 02/02/2023]
Abstract
There is no guideline and consensus about when and how to treat accompanying multi-ligaments injuries, especially anterior and/or posterior cruciate ligaments, in tibial plateau fractures. We report one case of fracture and dislocation of tibial plateau, treated by open reduction and internal plates fixation, augmented by trans-articular Kirschner wire fixation to overcome instability and malrotation of the knee joints discovered intraoperatively. The Kirschner wire was removed about four weeks after the index operation, and the patient begun functional exercise from then on. The fracture united uneventfully, the knee joint regained full range of motion without malalignment. The patient reported excellent knee function and satisfied with the operations. We suppose that trans-articular Kirschner wires fixation combined with open reduction internal plates fixation maybe is a treatment solution in treating complex tibial plateau fractures complicated by multiple ligamentous injuries.
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Lacey M, Lamplot J, Walley KC, DeAngelis JP, Ramappa AJ. Technical note: Anterior cruciate ligament reconstruction in the presence of an intramedullary femoral nail using anteromedial drilling. World J Orthop 2017; 8:379-384. [PMID: 28567341 PMCID: PMC5434344 DOI: 10.5312/wjo.v8.i5.379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 02/03/2017] [Accepted: 03/13/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To describe an approach to anterior cruciate ligament (ACL) reconstruction using autologous hamstring by drilling via the anteromedial portal in the presence of an intramedullary (IM) femoral nail.
METHODS Once preoperative imagining has characterized the proposed location of the femoral tunnel preparations are made to remove all of the hardware (locking bolts and IM nail). A diagnostic arthroscopy is performed in the usual fashion addressing all intra-articular pathology. The ACL remnant and lateral wall soft tissues are removed from the intercondylar, to provide adequate visualization of the ACL footprint. Femoral tunnel placement is performed using a transportal ACL guide with desired offset and the knee flexed to 2.09 rad. The Beath pin is placed through the guide starting at the ACL’s anatomic footprint using arthroscopic visualization and/or fluoroscopic guidance. If resistance is met while placing the Beath pin, the arthroscopy should be discontinued and the obstructing hardware should be removed under fluoroscopic guidance. When the Beath pin is successfully placed through the lateral femur, it is overdrilled with a 4.5 mm Endobutton drill. If the Endobutton drill is obstructed, the obstructing hardware should be removed under fluoroscopic guidance. In this case, the obstruction is more likely during Endobutton drilling due to its larger diameter and increased rigidity compared to the Beath pin. The femoral tunnel is then drilled using a best approximation of the graft’s outer diameter. We recommend at least 7 mm diameter to minimize the risk of graft failure. Autologous hamstring grafts are generally between 6.8 and 8.6 mm in diameter. After reaming, the knee is flexed to 1.57 rad, the arthroscope placed through the anteromedial portal to confirm the femoral tunnel position, referencing the posterior wall and lateral cortex. For a quadrupled hamstring graft, the gracilis and semitendinosus tendons are then harvested in the standard fashion. The tendons are whip stitched, quadrupled and shaped to match the diameter of the prepared femoral tunnel. If the diameter of the patient’s autologous hamstring graft is insufficient to fill the prepared femoral tunnel, the autograft may be supplemented with an allograft. The remainder of the reconstruction is performed according to surgeon preference.
RESULTS The presence of retained hardware presents a challenge for surgeons treating patients with knee instability. In cruciate ligament reconstruction, distal femoral and proximal tibial implants hardware may confound tunnel placement, making removal of hardware necessary, unless techniques are adopted to allow for anatomic placement of the graft.
CONCLUSION This report demonstrates how the femoral tunnel can be created using the anteromedial portal instead of a transtibial approach for reconstruction of the ACL.
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Abstract
INTRODUCTION This study sought to assess and compare long-term functional and clinical outcomes in patients with tibial plateau fractures that are treated nonsurgically. METHODS Over a period of 8 years, 305 consecutive tibial plateau fractures were treated by three surgeons at a single institution and followed prospectively in an Institutional Review Board-approved study. Overall, 41 patients (13%) were treated nonsurgically and 37 were available for follow-up. Indications for nonsurgical management were minimal fracture displacement or preclusion of surgery because of comorbidities. A series of univariate retrospective analyses were used to identify individual risk factors potentially predictive of Short Musculoskeletal Functional Assessment scores. RESULTS Thirty-seven patients were included with a mean follow-up of 21 ± 14.9 months. Overall, 59% of patients (n = 22) attained good to excellent functional outcomes. In patients for whom surgery was precluded because of comorbidities, outcome scores were significantly poorer (38.8 ± 23.0 versus 12.7 ± 14.2; P = 0.001). Surgery precluded by a factor other than minimal fracture displacement predicted poor outcome (P = 0.002). DISCUSSION Carefully selected patients with minimally displaced tibial plateau fractures can expect good to excellent outcomes when treated nonsurgically. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Abstract
Tibial plateau fractures are complex injuries produced by high- or low-energy trauma. They principally affect young adults or the 'third age' population.These fractures usually have associated soft-tissue lesions that will affect their treatment. Sequential (staged) treatment (external fixation followed by definitive osteosynthesis) is recommended in more complex fracture patterns. But one should remember that any type of tibial plateau fracture can present with soft-tissue complications.Typically the Schatzker or AO/OTA classification is used, but the concept of the proximal tibia as a three-column structure and the detailed study of the posteromedial and posterolateral fragment morphology has changed its treatment strategy.Limb alignment and articular surface restoration, allowing early knee motion, are the main goals of surgical treatment. Partially articular factures can be treated by minimally-invasive methods and arthroscopy is useful to assist and control the fracture reduction and to treat intra-articular soft-tissue injuries.Open reduction and internal fixation (ORIF) is the gold standard treatment for these fractures. Complex articular fractures can be treated by ring external fixators and minimally-invasive osteosynthesis (EFMO) or by ORIF. EFMO can be related to suboptimal articular reduction; however, outcome analysis shows results that are equal to, or even superior to, ORIF. The ORIF strategy should also include the optimal reduction of the articular surface.Anterolateral and anteromedial surgical approaches do not permit adequate reduction and fixation of posterolateral and posteromedial fragments. To achieve this, it is necessary to reduce and fix them through specific posterolateral or posteromedial approaches that allow optimal reduction and plate/screw placement.Some authors have also suggested that primary total knee arthroplasty could be an option in specific patients and with specific fracture patterns. Cite this article: Prat-Fabregat S, Camacho-Carrasco P. Treatment strategy for tibial plateau fractures: an update. EFORT Open Rev 2016;1:225-232. DOI: 10.1302/2058-5241.1.000031.
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Frosch KH, Krause M, Frings J, Drenck T, Akoto R, Müller G, Madert J. [Posttraumatic deformities of the knee joint : Intra-articular osteotomy after malreduction of tibial head fractures]. Unfallchirurg 2016; 119:859-76. [PMID: 27655027 DOI: 10.1007/s00113-016-0234-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Malreduction of tibial head fractures often leads to malalignment of the lower extremity, pain, limited range of motion and instability. The extent of the complaints and the degree of deformity requires an exact analysis and a standardized approach. True ligamentous instability should be distinguished from pseudoinstability of the joint. Also extra- and intra-articular deformities have to be differentiated. In intra-articular deformities the extent of articular surface displacement, defects and clefts must be accurately evaluated. A specific surgical approach is necessary, which allows adequate visualization, correct osteotomy and refixation of the fractured area of the tibial head. In the long-term course good clinical results are described for intra-articular osteotomies. If the joint is damaged to such an extent that it cannot be reconstructed or in cases of advanced posttraumatic osteoarthritis, total knee arthroplasty may be necessary; however, whenever possible and reasonable, anatomical reconstruction and preservation of the joint should be attempted.
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Affiliation(s)
- K-H Frosch
- Chirurgisch-Traumatologisches Zentrum, Abteilung Unfall- und Wiederherstellungschirurgie mit Sektion Knie- und Schulterchirurgie, Sporttraumatologie, Asklepios Klinik St. Georg, Lohmühlenstr. 5, 20099, Hamburg, Deutschland.
| | - M Krause
- Chirurgisch-Traumatologisches Zentrum, Abteilung Unfall- und Wiederherstellungschirurgie mit Sektion Knie- und Schulterchirurgie, Sporttraumatologie, Asklepios Klinik St. Georg, Lohmühlenstr. 5, 20099, Hamburg, Deutschland
| | - J Frings
- Chirurgisch-Traumatologisches Zentrum, Abteilung Unfall- und Wiederherstellungschirurgie mit Sektion Knie- und Schulterchirurgie, Sporttraumatologie, Asklepios Klinik St. Georg, Lohmühlenstr. 5, 20099, Hamburg, Deutschland
| | - T Drenck
- Chirurgisch-Traumatologisches Zentrum, Abteilung Unfall- und Wiederherstellungschirurgie mit Sektion Knie- und Schulterchirurgie, Sporttraumatologie, Asklepios Klinik St. Georg, Lohmühlenstr. 5, 20099, Hamburg, Deutschland
| | - R Akoto
- Chirurgisch-Traumatologisches Zentrum, Abteilung Unfall- und Wiederherstellungschirurgie mit Sektion Knie- und Schulterchirurgie, Sporttraumatologie, Asklepios Klinik St. Georg, Lohmühlenstr. 5, 20099, Hamburg, Deutschland
| | - G Müller
- Chirurgisch-Traumatologisches Zentrum, Abteilung Unfall- und Wiederherstellungschirurgie mit Sektion Knie- und Schulterchirurgie, Sporttraumatologie, Asklepios Klinik St. Georg, Lohmühlenstr. 5, 20099, Hamburg, Deutschland
| | - J Madert
- Chirurgisch-Traumatologisches Zentrum, Abteilung Unfall- und Wiederherstellungschirurgie mit Sektion Knie- und Schulterchirurgie, Sporttraumatologie, Asklepios Klinik St. Georg, Lohmühlenstr. 5, 20099, Hamburg, Deutschland
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Tuite MJ, Kransdorf MJ, Beaman FD, Adler RS, Amini B, Appel M, Bernard SA, Dempsey ME, Fries IB, Greenspan BS, Khurana B, Mosher TJ, Walker EA, Ward RJ, Wessell DE, Weissman BN. ACR Appropriateness Criteria Acute Trauma to the Knee. J Am Coll Radiol 2015; 12:1164-72. [DOI: 10.1016/j.jacr.2015.08.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 08/16/2015] [Indexed: 01/03/2023]
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Huang TW, Lee CY, Chen SY, Lin SJ, Hsu KY, Hsu RWW, Chan YS, Lee MS. Outcomes and second-look arthroscopic evaluation after combined arthroscopic treatment of tibial plateau and tibial eminence avulsion fractures: a 5-year minimal follow-up. BMC Musculoskelet Disord 2015; 16:311. [PMID: 26490156 PMCID: PMC4618521 DOI: 10.1186/s12891-015-0769-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 10/08/2015] [Indexed: 11/25/2022] Open
Abstract
Background Tibial eminence avulsion fracture often co-occurs with tibial plateau fracture, which leads to difficult concomitant management. The value of simultaneous arthroscopy-assisted treatment continues to be debated despite its theoretical advantages. We describe a simple arthroscopic suture fixation technique and hypothesize that simultaneous treatment is beneficial. Methods Patients with a tibial eminence avulsion fracture and a concurrent tibial plateau fracture who underwent simultaneous arthroscopically assisted treatment between 2005 and 2008 were enrolled in this retrospective study. Second-look arthroscopic evaluation and Rasmussen scores of clinical and radiographic parameters were used to assess simultaneous treatment. Results Forty-one patients (41 knees) met the inclusion criteria. All 41 fractures were successfully united. All patients had side-to-side differences of less than 3 mm and negative findings in Lachman and pivot-shift tests at their final follow-up. The mean postoperative Rasmussen clinical score was 27.3 (range: 19–30), and the mean radiologic score was 16.5 (range: 12–18). Clinical and radiographic outcomes in 98 % of the patients were good or excellent. There were no complications directly associated with arthroscopy in any patient. Conclusions Simultaneous arthroscopic suture fixation of associated tibial eminence avulsion fracture did not interfere with the plates and screws used to stabilize the tibial plateau fracture. It gave the knee joint adequate stability, minimal surgical morbidity, and satisfactory radiographic and clinical outcomes in a minimum follow-up of 5 years and in the arthroscopic second-look assessments.
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Affiliation(s)
- Tsan-Wen Huang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan. .,Chang Gung University, Taoyuan, Taiwan.
| | - Chien-Ying Lee
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan.
| | - Szu-Yuan Chen
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.
| | - Shih-Jie Lin
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan.
| | - Kuo-Yao Hsu
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan. .,Chang Gung University, Taoyuan, Taiwan.
| | - Robert Wen-Wei Hsu
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan. .,Chang Gung University, Taoyuan, Taiwan.
| | - Yi-Sheng Chan
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan. .,Chang Gung University, Taoyuan, Taiwan.
| | - Mel S Lee
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan. .,Chang Gung University, Taoyuan, Taiwan.
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Abstract
Tibial plateau fractures present in a wide spectrum of injury severity and pattern, each requiring a different approach and strategy to achieve good clinical outcomes. Achieving those outcomes starts with a thorough evaluation and preoperative planning period, which leads to choosing the most appropriate surgical approach and fixation strategy. Through a case-based approach, this article presents the necessary pearls, techniques, and strategies to maximize outcomes and minimize complications for some of the more commonly presenting plateau fracture patterns.
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Affiliation(s)
- Richard S Yoon
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, NYU langone medical center, 301 East 17th Street, Suite 1402, New York, NY 10003, USA
| | - Frank A Liporace
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, NYU langone medical center, 301 East 17th Street, Suite 1402, New York, NY 10003, USA
| | - Kenneth A Egol
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, NYU langone medical center, 301 East 17th Street, Suite 1402, New York, NY 10003, USA.
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The distinct prediction standards for radiological assessments associated with soft tissue injuries in the acute tibial plateau fracture. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2015; 25:913-20. [PMID: 25749752 DOI: 10.1007/s00590-015-1614-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 02/03/2015] [Indexed: 12/17/2022]
Abstract
The goal of this study was to assess the incidence of soft tissue injury in the tibial plateau fracture by magnetic resonance image (MRI) and reveal the relationship between the articular widening/depression and the risk of meniscus and ligament disorder. A total of 54 patients with tibial plateau fracture were indicated for operative intervention. Soft tissue injuries were assessed by MRI. Meniscus, anterior/posterior cruciate ligaments and medial/lateral collateral ligaments injuries on MRI were evaluated. The articular widening/depression was measured in picture archiving and communication systems. Schatzker classification of fracture types was not significantly associated with soft tissue injuries. The rates of soft tissue injury in types IV and II (respectively, 85.7 and 74.1 %) were higher than those in other types. The meniscus injury was the most common soft tissue damage, and the incidence of meniscus injury was 55.6 %. When LPDCT and LPWCT were, respectively, about 7.6 mm and 10.1 mm and LPDX-ray and LPWX-ray, respectively, 5.6 and 7.4 mm, more attention should be paid on the collateral and cruciate ligament injuries in types I, II and III. Furthermore, when LPWCT and LPWX-ray were, respectively, about 10.3 and 8.6 mm, the collateral and cruciate ligaments were susceptible to injury in types IV and V. In conclusion, tibial plateau fracture can occur high morbidity of soft tissue injury, including meniscus and ligament disorder. X-ray and CT scan had different predicting standards for soft tissue injury, and the articular widening/depression in the tibial plateau was associated with meniscus and ligament injuries.
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