Modified hybrid fixator for high-energy Schatzker V and VI tibial plateau fractures

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Optimizing Outcomes after Operative Treatment Bicondylar Tibial Plateau Fractures - Time for Innovation?

Bicondylar tibial plateau fractures are technically demanding fractures that have a high complication rate. We sought to review the recent literature with the aim to summarize the development of new classification systems that may enhance the surgeon's understanding of the fracture pattern and injury. We highlight the best methods for infection control and touch on new innovative solutions using 3D printer models and augmented mixed reality to provide potentially personalized solutions for each specific fracture configuration.

Comparison of Arthroscopic-Assisted Percutaneous Internal Fixation With a Modified Reducer Versus Open Reduction and Internal Fixation for Schatzker Type II and III Tibial Plateau Fractures

Background

Tibial plateau fractures require anatomical reduction and stable fixation to achieve satisfactory results. In addition, addressing any related injuries is of paramount importance. Arthroscopic reduction and internal fixation (ARIF) has been promoted as a possible technique to treat tibial plateau fractures.

Purpose

To compare the effectiveness of ARIF with this modified reducer and open reduction and internal fixation (ORIF) for Schatzker types II and III tibial plateau fractures.

Study Design

Cohort study; Level of evidence, 3.

Methods

We retrospectively reviewed 68 patients who were treated for Schatzker type II or III tibial plateau fractures between August 1, 2014, and October 31, 2018. Patients were categorized into the ARIF (n = 33) and ORIF groups (n = 35). The groups were compared regarding intra-articular injuries, duration of hospital stay, complications, and clinical outcomes-including the International Knee Documentation Committee (IKDC) score, the Hospital for Special Surgery (HSS) score, and range of motion (ROM). The paired t test was used to compare preoperative and postoperative data, and the chi-square test was used to compare the IKDC and HSS scores.

Results

The median follow-up period was 36 months (26-40 months). Additional intra-articular lesions were found in 29 patients-21 in the ARIF group and 8 in the ORIF group (P = .02). A significant difference was observed in the duration of hospital stay-3.58 ± 1.46 days for the ARIF group and 4.57 ± 1.12 days for the ORIF group (t = -3.169; P = .002). All fractures healed within 3 months after surgery. The complication rate for all patients was 11%, with no significant difference between the ARIF and ORIF groups (t = 1.244; P = .265). At the final follow-up, there were no significant differences between the 2 groups in the IKDC score, HSS score, and ROM (P > .05 for all).

Conclusion

ARIF with a modified reducer was found to be an effective, reliable, and safe procedure for the treatment of Schatzker types II and III tibial plateau fractures. Both ARIF and ORIF provided equally good results, while ARIF offered a more precise evaluation and reduced the duration of hospital stay.

Importance of CT Scan in Predicting the Outcomes of Tibial Plateau Fractures: A Retrospective Study of 216 Patients over 10 Years' Time

BACKGROUND

The primary aim of this retrospective study was to assess the postoperative clinical, functional, and radiographic outcomes of patients with closed tibial plateau fractures (TPFs) surgically treated with proximal tibial locking compression plate (LCP) system with a focus on the use of preoperative CT scan.

METHODS

Two hundred and sixteen patients with TPFs who underwent surgical treatment in our department between January 2010 and December 2019 were enrolled in this study. Ninety-five patients of 216 (44.0%) had preoperative CT examination in addition to plain radiographs to better evaluate the pattern of fracture and displacement of fragments. Clinical and functional outcomes were assessed using VAS, SF-36, Knee Society Score (KSS) and WOMAC score. Radiographic outcomes were evaluated according to the Kellgreen- Lawrence classification of the pre- and postoperative grades of valgus knee, articular displacement and gonarthrosis.

RESULTS

Patients with preoperative CT showed better clinical results than the X-ray group for the VAS, KSS, WOMAC and SF-36 score. Moreover, we found that the X-ray group had worse results than the CT group in the rate of varus-valgus alignment and step-off worsening, while the posterior tibial slope showed no significant changes between the two groups at the final follow-up. Finally, the group of patients who received preoperative CT scans displayed a better immediate postoperative reduction and less long-term arthritis.

CONCLUSION

CT has proved to be a good examination in preoperative planning of TPFs: it can influence postoperative results thanks to an improvement in the surgical approach, a better evaluation of the morphology of fracture lines and the involvement of the Luo's three columns in axial CT scans.

Biomechanical Analysis of the Behaviour at the Metaphyseal-Diaphyseal Junction of Complex Tibial Plateau Fractures Using Two Circular Fixator Configurations

Background

High-energy tibial plateau fractures are challenges in treatment with controversy over operative stabilisation, especially for fractures with metaphyseal–diaphyseal dissociation. Treatment with percutaneous or minimally invasive direct reduction techniques, usually associated with circular external fixation, has generated interest although there is no consensus regarding the type of external fixation to be used.

Aim

This study aims to compare the two hybrid circular external fixation mountings used to treat the high-energy tibial plateau fractures.

Methods

Two different groups of hybrid circular external fixation frame mountings were assembled using composite tibiae with proximal metaphyseal osteotomies simulating tibial plateau fractures with metaphyseal–diaphyseal dissociation. The standard all-wire frame mounting was assembled, and the comparison frame mounting had the distal K-wires replaced with half-pins. Both groups were tested through cyclic loading between 300 and 1000 N for 10,000 cycles. Interfragmentary linear and rotational displacements were analysed.

Results

The standard frame mounting behaved similarly to a classic Ilizarov frame, allowing greater axial movement (mean, 3.76 ± 0.26 mm in the standard group and 3.02 ± 0.23 mm in the test group) and smaller mediolateral displacement compared with the test frame (mean, 0.17 ± 0.16 mm compared to 0.56 ± 0.12 mm). The test frame behaved more similarly to a linear external fixator and provided greater axial stability, similar anteroposterior displacement, and lower mediolateral stability. Despite these differences, in both groups the axial displacement was greater than the prejudicial nonaxial movements.

Conclusion

Increasing the number of half-pins and decreasing the number of K-wires in hybrid circular external fixation generate frames that tend to behave more similarly to the linear external fixators.

How to cite this article

Cardoso GS, Amorim R, Penha FM, et al. Biomechanical Analysis of the Behaviour at the Metaphyseal–Diaphyseal Junction of Complex Tibial Plateau Fractures Using Two Circular Fixator Configurations. Strategies Trauma Limb Reconstr 2020;15(3):138–145.

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

IMPORTANCE

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

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION AND SYNTHESIS

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

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

Preoperative Plan with 3D Printing in Internal and External Fixation for Complex Tibial Plateau Fractures

OBJECTIVE

To compare short-term treatment effects of internal and external fixation in the treatment of complicated tibial plateau fractures by preoperative planning with 3D printing.

METHODS

Sixty-nine patients with tibial plateau fractures were examined. 3D printing was used to establish the model in all patients before the operation. Thirty-four patients were treated with an external fixator (9-Schatzker Type V, 25-Schatzker Type VI) and 35 patients were treated with internal fixation (12-Schatzker Type V, 23-Schatzker Type VI). The time span of the study was 2 years after the operation. All patients were followed up in the clinic of the attending physician who recorded patient follow-up information at the same time. Finally, the Rasmussen functional score, radiographic parameters, complication rates, hospital days and operative parameters of the two groups were analyzed.

RESULTS

The short-term (within 2 years) Rasmussen score in the external fixation group was close to that of the internal fixation group; the differences were not significant (P > 0.05). The fractures were reduced adequately using both forms of surgical treatment. There is no significant difference between internal and external fixation in terms of radiographic parameters after 2 years (Mann-Whitney U-tests, P > 0.05). Thrombosis was detected in 7 cases (2 external fixation, 5 internal fixation). Superficial infection was detected in 3 cases (1 external fixation, 2 internal fixation). Deep infection was detected in 3 cases (0 external fixation, 3 internal fixation). Knee stiffness was detected in 4 cases (2 external fixation, 2 internal fixation); 1 (2.7%) case of screw pullout occurred in the internal fixation group. The external fixation group had shorter operation times (172.94 ± 50.00 min vs 253.86 ± 64.59 min), less bleeding volume (395.88 ± 121.10 mL vs 864.29 ± 238.12 mL), and fewer days (17.03 ± 5.03 days vs 30.17 ± 8.64 days) of hospitalization compared to the internal fixation (t-test, P = 0.00); subgroup analysis of all patients with complex tibial plateau fractures revealed that for patients with tibial plateau fracture type VI, the functional score of external fixation (26.79 ± 2.04) is better than that (25.54 ± 1.69) of internal fixation (t- test, P = 0.026) and the overall infection rate of external fixation is lower than that of internal fixation (χ² - test, P = 0.047).

CONCLUSION

Using 3D printed models in combination with external fixation has more advantages for short-term treatment of complex tibial plateau fractures. In particular, relatively better functional recovery and lower rates of infection can be achieved for Schatzker type VI fractures. The external fixation treatment was preferred in cases of Schatzker VI tibial plateau fractures.

Chronic Osteomyelitis Revisited: A Case Report

Chronic osteomyelitis treatment is always a challenge to orthopaedic surgeons which requires great dedication and perseverance. We report a successful limb salvage case of a 46-year-old man who suffered from a left tibia chronic osteomyelitis with soft tissue defect. The treatment approach was a thorough wound debridement of devitalized tissues and necrotized bone, commencement of culture-directed antibiotics, reconstruction with vascularized osteomyocutaneous fibula flap, and skeletal stabilization with internal fixation. As compared to below knee amputation, the result we obtained in this case is more promising with regard to mobility and function.

Lateral Locked Plating or Dual Plating: A Comparison of Two Methods in Simple Bicondylar Tibial Plateau Fractures

Background

In this study, our aim was to compare the results of the dual locking plate fixation technique and lateral locking plate fixation technique for tibial bicondylar plateau fractures without posteromedial fragment.

Methods

We evaluated 20 patients who underwent surgical treatment due to bicondylar tibial plateau fracture between 2010 and 2015. Ten patients were included in group 1, in which a dual locking plate was employed, whereas 10 patients were included in group 2, in which a lateral locking plate was used. In both groups, functional and clinical outcomes after treatment were rated according to the Knee Society Knee Scoring System, Rasmussen functional score, and Rasmussen radiological score.

Results

The mean follow-up time was 24 months. There were no significant differences between the groups with respect to functional and radiographic outcomes at the final follow-up.

Conclusions

In bicondylar tibial plateau fractures without posteromedial fragment, the lateral locking plate fixation technique showed the similar clinical and radiological outcomes as the dual locking plate fixation technique.

Establishment of Classification of Tibial Plateau Fracture Associated with Proximal Fibular Fracture

OBJECTIVE

The purpose of this retrospective study was to determine the incidence of fibular fractures as an associated injury in tibial plateau fractures according to CT scan. We also attempt to introduce a new morphological sub-classification on this associated injury and to analyze the correlation between this classification and tibial plateau fractures.

METHODS

We selected cases with fibular fractures from all the tibial plateau fracture patients. The cases were further divided into 2 groups: unicondylar group and bicondylar group. On the basis of our new classification system of fibular fracture, all the included cases were divided into 5 subgroups.

RESULTS

Finally, a total of 150 cases associated with fibular fractures in 502 tibial plateau fracture cases were identified from our institution database. The incidence of fibular head fracture in tibial plateau fractures was 29.88% (150/502). Seventy-one cases (47.3%) were involved one condyle, and 79 cases (52.7%) involved both. It shows significant difference in the subgroup of avulsion fracture with horizontal fracture line (Type A) which is ratio of 16.9% in unicondylar group and 1.27% in bicondylar group.

CONCLUSION

A new classification of this associated injury describing the morphology of the fracture fragments may improve operative planning.

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

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

Angle Stable Interlocking Intramedullary Nails for Tibial Plateau Fractures

OBJECTIVE

Angle stable interlocking intramedullary nail (ASIN), a novel technique, has rarely been used for treatment of tibial plateau fractures (TPF). This retrospective study was designed to introduce this novel technique, ASIN, as well as to describe the initial experience and verify the effectiveness when ASIN was used for the management for TPF.

METHODS

A cohort of 19 cases with closed TPF aged from 18-70 years with at least 23 months follow-up from November 2008 to September 2013 was analyzed retrospectively. All patients underwent the ASIN procedure, which was performed by the same group of surgeons. Perioperative and postoperative parameters like the measurement of radiographic pictures, surgical data, and clinical function were recorded including the changes in treatment. A modified Hohl-Luck radiological and functional score combined with the Hospital for Special Surgery (HSS) score were applied to evaluate the final results and to provide reliable data through the whole procedure when applying the ASIN procedure.

RESULTS

The patients were followed up regularly for an average of 26.3 (range, 23-34) months. All patients achieved a bony union at an average of 15.1 weeks with no incidences of malunion, nonunion, or infection. Anatomical reduction of the articular surface was obtained in 16 patients. No secondary failure of fixation occurred. The mean postoperative knee flexion was 122.9°. The modified Hohl-Luck radiological and functional score was excellent and good, respectively, in 16 patients. The mean HSS score was 89.4.

CONCLUSION

The angle stable interlocking intramedullary nail system turned out to be a viable alternative protocol in the treatment of tibia plateau fractures and provided satisfactory results, with good fracture reduction, biomechanical fixation, low rates of complications, and passable postoperative knee function.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Complex tibial plateau fractures: a retrospective study and proposal of treatment algorithm

INTRODUCTION

Complex tibial plateau fractures are characterized by compression and sinking of one or both the articular surfaces. In this study, we evaluated clinical and radiological outcomes in patients with 41.C1,41.C2,41.C3 fractures according to AO classification. We also provide a specific therapeutic algorithm for each type of fracture.

MATERIAL AND METHODS

The study was conducted in 43 patients who underwent surgical treatment for complex tibial plateau fractures and were followed for a minimum of 12 months. Outcome measures included: range of motion (ROM) recovery, Short Form 36 Health Survey (SF36), Knee injury and Osteoarthritis Outcome Score (KOOS), tibial plateau angle (TPA), and posterior angle (PA).

RESULTS

Analyses were performed in 38 patients after excluding 5 cases because of missing imaging evaluations at follow-up. All patients showed good quality of life in all areas considered by SF36 and KOOS as well as satisfactory recovery of ROM. Average TPA and PA values were 87.9° and 0.6°, respectively.

DISCUSSION

In complex tibial plateau fractures, surgical treatment is instrumental to obtain full restoration of the joint surface and fast functional recovery. Results are highly related to the type of treatment adopted for different kinds of fracture. In our case series, the best results were obtained when 41.C1 fractures were treated with a single plate. In 41.C2 fractures, clinical and imaging outcomes were independent of the number of plates used. In contrast, in 41.C3 fractures, optimal results were achieved with double plates.

CONCLUSIONS

Based on our findings, as also supported by the literature, 41.C1 fractures should be treated with single plate, which reduces the surgical time, soft tissue damage and infection risk. On the other hand, 41.C3 fractures have best outcomes in stability, consolidation and recovery time when treated with double plate.

Advantages of external hybrid fixators for treating Schatzker V-VI tibial plateau fractures: A retrospective study of 40 cases

INTRODUCTION

Proximal tibia fractures make up 1% of all fractures in adults. The fractures classified as Schatzker V and VI fractures can compromise knee structure and function. They are challenging to treat and often have complications. While plate fixation is the gold standard, the resulting infection rate has led us to favor external hybrid fixation. The aims of this study were to assess the radiographic and functional outcomes along with the complication rate when using this method and to compare them to historical plate fixation data.

MATERIAL AND METHODS

This was a retrospective study of 40 patients. The complications, quality of reduction, IKS, Lysholm and Rasmussen functional scores at the latest follow-up and factors affecting the functional outcome were evaluated. These parameters were compared to published results from plate fixation studies.

RESULTS

The deep infection rate was 2.5%. The union rate was 80%. Satisfactory reduction was obtained in 70% of cases; however, 52% of patients had malunion. The mean IKS score was 73.74, the mean Rasmussen score was 22.85 and the mean Lysholm score was 75.53. Age, reduction at latest follow-up, mechanical axis and anteroposterior laxity had a significant effect on the functional outcome.

DISCUSSION

Despite the malunion rate being higher than other studies, the functional outcomes were nearly identical based on the variables measured. There are several advantages associated with using a hybrid external fixator: shorter operative time, less bleeding, shorter hospital stays and lower infection rate.

CONCLUSION

Hybrid external fixation is a reliable fracture fixation method that leads to satisfactory functional outcomes, while reducing the infection rate and allowing arthroplasty to be performed in the future if needed.

Retrospective review of tibial plateau fractures treated by two methods without staging

INTRODUCTION

Management of complex tibial plateau fractures can be challenging for orthopaedic surgeons. Wide disagreement still remains about the best surgical technique to use in these fractures. The purpose of this study was to compare the results of complex tibial plateau fractures treated by an open reduction and internal fixation (ORIF) versus hybrid external fixation (EF) in term of clinical and functional outcomes.

MATERIALS AND METHODS

We retrospectively examined a series of 79 patients affected by tibial plateau fractures admitted at our Department between January 2006 and November 2011. Forty-one patients were treated using a hybrid EF; in 38 cases, ORIF technique was used. Clinical evaluation was performed using the method of Rasmussen; functional assessment was made using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire. Residual pain was detected using a Numeric Rating Scale (NRS).

RESULTS

The average time to union in the plate group was 17.2 weeks (9.1-45 weeks), while in the EF one 15.9 (7.5-32). The mean overall hospital stay was 14.2 days for the ORIF group and 7.8 for the EF group. At the last follow-up, the mean Rasmussen score was 24.9 (good) in the patients treated with ORIF and 25 (good) in those who received EF. The WOMAC index disclosed a relatively higher score in the EF group (80.5 ORIF-84.2 EF). Pain evaluation revealed no differences between the groups. In terms of complications, deep infection occurred in four (10.5%) patients belonging to the ORIF group and 2 (4.9%) to EF one. Signs of osteoarthritis (OA) were observed in 4 (10.5%) knees that had open reduction and in 11 (26.9%) that had a hybrid external fixator.

CONCLUSIONS

Either ORIF or hybrid EF represents a valid treatment option in complex tibial plateau fractures. However, hybrid external fixation has shown relative better functional outcome results, relative lower rate of infection and decreased hospital stays. These aspects make of EF our best choice in case of high-energy complex tibial fractures.

External versus internal fixation for bicondylar tibial plateau fractures: systematic review and meta-analysis

Background

It is uncertain whether external fixation or open reduction internal fixation (ORIF) is optimal for patients with bicondylar tibial plateau fractures.

Materials and methods

A systematic review using Ovid MEDLINE, Embase Classic, Embase, AMED, the Cochrane Library, Open Grey, Orthopaedic Proceedings, WHO International Clinical Trials Registry Platform, Current Controlled Trials, US National Institute for Health Trials Registry, and the Cochrane Central Register of Controlled Trials. The search was conducted on 3rd October 2014 and no language limits were applied. Inclusion criteria were all clinical study designs comparing external fixation with open reduction internal fixation of bicondylar tibial plateau fractures. Studies of only one treatment modality were excluded, as were those that included unicondylar tibial plateau fractures. Treatment effects from studies reporting dichotomous outcomes were summarised using odds ratios. Continuous outcomes were converted to standardized mean differences to assess the treatment effect, and inverse variance methods used to combine data. A fixed effect model was used for meta-analyses.

Results

Patients undergoing external fixation were more likely to have returned to preinjury activities by six and twelve months (P = 0.030) but not at 24 months follow-up. However, external fixation was complicated by a greater number of infections (OR 2.59, 95 % CI 1.25–5.36, P = 0.01). There were no statistically significant differences in the rates of deep infection, venous thromboembolism, compartment syndrome, or need for re-operation between the two groups.

Conclusion

Although external fixation and ORIF are associated with different complication profiles, both are acceptable strategies for managing bicondylar tibial plateau fractures.

Level of evidence

II.

A comparison of lateral fixation versus dual plating for simple bicondylar fractures

BACKGROUND

The best fixation method for bicondylar tibial plateau fracture is debated. The aim of this study was to compare the effect of a lateral locking plate with that of dual plates in the treatment of tibial plateau fracture with a relatively intact medial condyle fragment.

METHODS

Eighty-six patients diagnosed with a bicondylar tibial plateau fracture with a relatively intact medial condyle were assigned to groups treated with either dual buttress plates (DP group) or a lateral locking plate (LP group). Preoperative characteristics, surgical details, and postoperative complications were recorded and compared between groups. Hospital for Special Surgery Knee Scoring System score was used to evaluate clinical outcome.

RESULTS

Both groups displayed satisfactory clinical and radiographic results. There were no significant differences in associated preoperative conditions between the DP and LP groups. Durations of hospital stay and operation were significantly shorter, and blood loss significantly less, in the LP group than in the DP group (P=0.045;0.038;0.031). The rate of delayed-union was significantly lower in the LP group than in the DP group (P=0.023).

CONCLUSION

Both dual-plate and lateral locking-plate fixation can provide satisfactory treatment of bicondylar tibial plateau fractures if properly used. When the medial tibial condyle is relatively intact, a lateral locking plate can provide stability similar to that of dual plate while decreasing operative duration and soft-tissue complications, which can assist fracture healing and shorten hospital stay.

LEVEL OF EVIDENCE

I - Randomized controlled trial.

Comparison of outcome of unilateral locking plate and dual plating in the treatment of bicondylar tibial plateau fractures

BACKGROUND

Tibial plateau fracture (TPF) includes different fracture patterns with varied degrees of articular depression and displacement. Many kinds of fixators, including newly designed plate with locking screws, were applied to treat these complicated fractures. We intended to follow up the surgical outcomes of (1) unilateral locking plate, (2) classic dual plates, or (3) hybrid dual plates for TPF.

MATERIALS AND METHODS

We retrospectively reviewed 76 patients with TPF, Schatzker types V and VI, who we operated from June 2006 to May 2009 in our institute. Excluding patients who expired due to other medical conditions and without complete follow-up, 45 patients were sorted out in this series. The scheme of surgical intervention was designed by visiting staff, and 15 patients, as group I, were treated with unilateral locking plate. The other 19 patients, as group II, were treated with classic dual plates. The residual 11 patients, as group III, were treated with hybrid dual plates (one lateral approach locking compression plate (LCP) + medial anti-gliding plate). All patients were under periodic F/U at about 6 weeks interval for at least 18 months postoperatively.

RESULTS

In group I, 13 cases achieved solid bony union without obvious traumatic OA change, limitation of ROM, or malalignment. In groups II and III, 15 and 10 patients reached the same goal, respectively. By analysis of the recorded parameters with statistical software (SPSS 12.0), there were five parameters with significant difference, including Schatzker classification, operation time, staged treatment or not, hospitalization period, and hardware impingement.

CONCLUSIONS

There was no significant statistical difference of union rate between these three groups in our series. Based on our clinical follow-up, several key points were emphasized: (1) Soft tissue problems should be kept in mind, and usage of locking plate can reduce the discomfort of hardware impingement effectively. (2) The single lateral approach technique for TPF with locking plate results in less operation time and shorter hospitalization period. (3) If the medial buttress cannot be established by reduction of the lateral fracture, then open reduction of the medial side is necessary and buttresses the medial fragment by dual plates.

An efficacy analysis of surgical timing and procedures for high-energy complex tibial plateau fractures

OBJECTIVE

To identify the most effective treatment for application to high-energy complex plateau fractures.

METHODS

125 patients with closed high-energy complex tibial plateau fractures who had been surgically treated between 2003 and 2010 were reviewed retrospectively. Five procedure methods were studied (e.g. four open reduction and internal fixations, and close reduction via a minimal incision with hybrid external fixation) in five surgical timings, with a control group. The incidence of wound complications after operative treatment in the five surgical timings and the clinical effects of the five surgical procedure options were evaluated statistically. A postoperative follow-up ranging 26-110 months (mean, 36.5 months) was performed.

RESULTS

Among the various groups, the respective overall wound complication incidences were 20.0%, 41.6%, 33.3%, 2.5%, and 16.7% within 4 hours, 4 hours to 3 days, 3-5 days, 5-8 days, and more than 8 days after injury. Failed fixation was clearly observed in Group 1 (23.1%, 6/26) and Group 5 (21.7%, 5/23) (P < 0.05). Significant differences were also found among Group 2 (92.6%), Group 3 (93.3%), and Group 5 (69.6%), in terms of the good and excellent rate of joint function according to the Rasmussen score (P < 0.05).

CONCLUSION

The optimal surgical timing is within 4 hours after trauma, for which no obvious swelling was observed in the limbs. This is followed by surgical timing within 5-8 days, after which trauma showed only subsided limb swelling. Dual plating provides the best stabilization option, as it allows early joint mobilization, cartilage regeneration, and joint remodeling, thus decreasing the risk of joint stiffness. Hybrid external fixation may provide relative stability to maintain fracture alignment without the need for massive soft tissue dissection, and also minimizes blood loss and potential soft tissue complications.

Second-look arthroscopy after surgical treatment of Schatzker type II plateau fractures through the lateral submeniscal approach

MAIN PROBLEM

To evaluate cartilage healing using second-look arthroscopic examination in tibia plateau fracture patients who have undergone open reduction and internal fixation with a submeniscal approach technique.

METHODS

Between January 2007 and January 2010, we used second-look arthroscopy during 18-24-month follow-up of 20 patients with Schatzkar type II tibial plateau fractures who had undergone open reduction and internal fixation with a submeniscal approach technique. We classified patients according to step-off, knee range of motion, and Knee Society Score, and compared the results with those obtained by arthroscopy.

RESULTS

Radiologically, 16 cases (80 %) were reduced within 2 mm of step-off. In 11 of these cases, according to the Outerbridge classification, we checked for chondromalacia from grade II to III. We observed 2 mm of step-off in four cases, and each had chondromalacia of at least grade III. The Knee Society Score was associated with chondromalacia grade (p < 0.05).

CONCLUSION

Even in patients with normal joint range of motion and good clinical and radiological results, the actual condition of the articular cartilage varied significantly. Therefore, more long-term and regular follow-up is needed for proximal plateau fractures.

Return to sports activity after tibial plateau fractures: 89 cases with minimum 24-month follow-up

BACKGROUND

Tibial plateau fractures requiring surgery are severe injuries. For professionals, amateurs, and recreational athletes, tibial plateau fractures might affect leisure and professional life.

HYPOTHESIS

Athletic patients will be affected in their sporting activity after a tibial plateau fracture. Despite a long rehabilitation time and program, physical activity will change to low-impact sports.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 89 consecutive patients (age range, 14-76 years) were included in the study and were surveyed by a questionnaire. Inclusion criteria were surgical treatment of tibial plateau fractures between 2003 and 2009 with a minimum follow-up of 24 months. The sporting activity was determined at the time of injury, 1 year postoperatively, and at the time of the survey at an average of 52.8 months postoperatively. The clinical evaluation included the Lysholm score, the Tegner activity scale, the activity rating scale (ARS), and a visual analog scale (VAS) for pain perception. Fractures were classified and analyzed using both the Arbeitsgemeinschaft für Osteosynthesefragen (AO) and the Schatzker classifications.

RESULTS

At the time of injury, 88.8% of all patients were engaged in sports compared with 62.9% 1 year postoperatively and 73.0% at the time of the survey. Of the professional or competitive athletes (n = 11 at the time of injury), only 2 returned to competition at the time of the survey. The number of different sporting activities declined from 4.9 at the time of injury to 3.6 at the time of the survey (P < .001). The sports frequency and the activity duration per week, being 2.8 sessions and 4.5 hours at the time of injury, respectively, declined to 2.4 sessions and 3.8 hours (P < .001 and P = .007, respectively) at the time of the survey, respectively. The Lysholm score (98.7 points before accident) and the VAS for pain perception (0.2 before accident) illustrated significant declines to 76.6 points for the Lysholm score and 2.6 for the VAS (P < .001 and P < .001, respectively) at the time of the survey. The high-energy traumas, Schatzker IV to VI, had significant worse results in the clinical scores compared with the low-energy traumas (Lysholm, P < .001; Tegner, P = .027).

CONCLUSION

The majority of patients could not return to their previous level of activity, and for patients playing competitive sports, this injury can be a career ender. Overall, we noticed a postinjury shift toward activities with less impact. However, at the time of the survey, 73% of all patients were engaged in sports.