A prospective observational study of 56 patients treated with ring fixator after a complex tibial fracture

Physiotherapy assessment and treatment of patients with tibial external fixator: a systematic scoping review

PURPOSE

To map evidence regarding physiotherapy assessment and treatment of patients with tibial external fixator (EF), and to point out literature gaps for further research.

METHODS

Systematic scoping review conducted in four databases. We included both experimental and non-experimental studies involving patients with tibial EF and outcomes of interest. We recorded study design, population, sample size, sample age, reason for EF use, type of surgery, type of EF used, instruments used for assessing function, pain, quality of life, satisfaction, psychosocial aspects, and physiotherapy treatment descriptions from included studies. We categorised data accordingly to outcomes assessed and physiotherapy treatments description.

RESULTS

Eighty-six studies were included involving 3070 patients. Causes of fixator use were traumatic conditions, acquired and congenital deformities, and non-traumatic conditions, like compartmental osteoarthritis. Function was assessed in about three-quarters of included studies, though other outcomes were not presented in most studies. Only one study described satisfactorily the physiotherapy treatment. Almost half of the studies did not provide any description of the rehabilitation process.

CONCLUSIONS

There is little evidence about the assessment of function, pain, quality of life, satisfaction, psychosocial aspects, and other outcomes in tibial EF patients. Physiotherapy treatment in these patients is poorly reported.Protocol registration: Open Science Framework: doi:10.17605/OSF.IO/UT2DA.

Fixação externa do anel de Ilizarov para fraturas complexas do platô tibial

Objetivo Analisar os resultados clínicos, radiológicos e funcionais da fratura do planalto tibial (Schatzker Tipo V, VI) tratada com fixador externo do anel Illizarov com ou sem abertura mínima.

Métodos Um total de 52 fraturas do planalto tibial dos tipos V e VI foram tratadas com fixador externo do anel Ilizarov com ou sem fixação interna mínima. A avaliação do desfecho funcional foi feita utilizando-se o escore da American Knee Society (AKS, na sigla em inglês) com consolidação clínica, radiológica e complicações encontradas.

Resultados Foram 37 (71,15%) pacientes do sexo masculino e 15 (28,84%) do sexo feminino, com idade média de 39,07 ± 12,58 anos. Acidentes de trânsito (ATs) foram a principal causa das fraturas, contabilizando 32 casos (61,53%), seguidos por lesão por queda, com 16 casos (30,76%), e impacto direto, com 4 casos (7,69%). Foram 21 (40,38%) casos de fraturas tipo V, 31 (59,61%) casos do tipo VI e 24 (46,15%) casos de fratura exposta. Os escores médios da AKS para as fraturas tipo V e VI foram de 82,8 e 80,70, respectivamente, mas não foi estatisticamente significativo em p <0,05. O escore médio da AKS para fraturas fechadas e abertas também não foi estatisticamente significativo em p <0,05.

Conclusões Para a fratura do planalto tibial complexa dos tipos V e VI de Schatzker, a fixação externa de Ilizarov é um método de tratamento seguro, econômico e eficiente que resulta em resultados satisfatórios.

Avaliação da qualidade de vida dos pacientes em uso de fixador externo circular em um hospital de trauma

Objetivo Avaliar a qualidade de vida dos pacientes em uso do fixador externo do tipo Ilizarov para tratamento de fraturas complexas e de suas sequelas

Método Trata-se de um estudo observacional e transversal, em que foi aplicado o questionário 36-item short form survey (SF-36) (traduzido para a língua portuguesa) durante as consultas ambulatoriais em 2 períodos, nos meses de julho de 2018 e janeiro de 2019. Os pacientes que participaram do estudo realizaram seus procedimentos cirúrgicos no período de janeiro a junho de 2018.

Resultados Foram avaliados 36 pacientes em uso de fixador externo do tipo Ilizarov. Foi observado predomínio do sexo masculino e idade média de 37,9 anos. As fraturas de ossos da perna e suas complicações representaram metade da amostra. Foi observada melhora na capacidade funcional e nos aspectos emocionais dos pacientes ao longo do tratamento.

Conclusão O uso do fixador externo circular constitui um método importante e eficaz para o tratamento cirúrgico de fraturas complexas e de suas sequelas. Este trabalho permitiu concluir que, após o tratamento, os pacientes alcançaram retorno funcional às atividades diárias com adequada qualidade de vida.

Delayed but favourable outcome of lateral tibial plateau fracture after screw fixation: A 3-year prospective cohort study of 56 patients

BACKGROUND

Although a large number of studies aimed to investigate the outcome following lateral tibial plateau fractures, the literature includes limited information on mid- to long-term follow up. The primary objective of the present study was to investigate the 3-year development in Knee Injury and Osteoarthritis Outcome Score (KOOS₅) of patients with surgically managed lateral tibial plateau fractures.

METHODS

Prospective cohort study. The study includes all patients treated surgically following a lateral tibial plateau fracture (AO-41B) in the period December 2013 to November 2016. The primary outcome measurement was the patient-reported KOOS₅ score. Secondary outcome measurements were quality of life, knee osteoarthritis, muscle strength, pain reactions, and gait function.

RESULTS

Fifty-six patients were included. Thirty-nine patients were eligible for the 3-year follow up (70%). The mean age at the time of the 3-year follow up was 58.3 years with a range of 25-89. The 3-year postoperative mean KOOS₅ scores were 75.5 (95% confidence interval: 68.6-82.3). Compared with the KOOS₅ score at 12-month follow up (61.3), a significant increase was observed (P > 0.001). In comparison with the established KOOS reference population, the study population showed statistically worse KOOS outcomes only for the subscale sport.

CONCLUSIONS

Patient-reported outcome (KOOS₅) among patients with a fracture of the lateral tibial plateau increased significantly between the 1-year and 3-year follow ups. In contrast to the 1-year follow up, patients at the 3-year follow up reported results comparable to those of a healthy reference population, excluding the Sport subscale. Guiding the patients in anticipation of a prolonged recovery period is highly important in everyday clinical practice.

Physiotherapy after tibial plateau fracture fixation: A systematic review of the literature

Background

Tibial plateau fractures are frequent injuries that orthopaedic surgeons face. It has been reported that they have a significant negative impact on the patients' lives, decreasing their quality of live, keeping them of work for long periods of time and reducing their activity levels.

Aim

Interestingly, there is not enough focus in the literature about the post-operative rehabilitation of these patients. The aim of the present review is to investigate this field of the literature and try to give answers in four main questions: the range of motion exercises post-surgery, the immobilisation, the weight-bearing status and the ongoing rehabilitation.

Materials and Methods

A literature search was conducted using the PubMed and the Google Scholar search engines. A total of 39 articles met the criteria to be included in the study.

Results

The literature about this subject is scarce and controversial. Early range of motion exercises should be encouraged as soon as possible after the procedure. The immobilisation after plate fixation does not seem to be correlated with any benefits to the patients. The weight-bearing status of the patients was the most controversial in the literature with the early weight-bearing gaining ground at the most recent studies. Tibia plateau fractures can have significant impact on the patients' lives, so ongoing rehabilitation with focus on quadriceps strengthening and proprioception exercises is recommended.

Conclusion

The present literature review illuminates the controversy that exists in the literature about the physiotherapy following tibia plateau fracture fixation. Early range of motion exercises and early weight bearing should be encouraged. Immobilisation does not seem to provide any benefit. Ongoing rehabilitation should be considered with the view of better clinical outcomes.

Taylor Spatial Frame or Reamed Intramedullary Nailing for Closed Fractures of the Tibial Shaft: A Randomized Controlled Trial

OBJECTIVES

To compare a modern ring fixator [Taylor Spatial Frame (TSF)] and reamed intramedullary nailing (IMN) for the treatment of closed tibial shaft fractures.

DESIGN

Randomized controlled trial.

SETTING

Two university hospitals.

PATIENTS

Patients between 18 and 70 years of age surgically treated for an acute tibial shaft fracture.

INTERVENTION

TSF (n = 31) versus a reamed intramedullary nail (n = 32). The patients were followed up for 2 years.

MAIN OUTCOME MEASUREMENTS

The physical component summary of Short Form 36 (SF-36) at 2 years was the primary outcome measure. Secondary outcomes included the other components of the SF-36, pain assessed by a visual analogue scale (VAS), complications, and resource consumption.

RESULTS

The mean age was 43 years (SD 14.0), and 42 (67%) were men. The physical component summary at 2 years was 52.4 (SD 6.3) in the TSF group and 53.3 (SD 8.0) in the IMN group (P = 0.35). There were modest differences in the other SF-36 scores during the follow-up period. Up to and including 12 months, the TSF group had less knee pain [at 12 months: VAS 0.5 (SD 1.2) vs. VAS 2.4 (SD 2.2; P < 0.001)], but this was not statistically significant at 24 months [VAS 0.7 (SD 1.4) vs. VAS 1.5 (SD 2.0; P = 0.11)]. Superficial skin infections were more frequent in the TSF group [22 (71%) vs. 4 (13%); P < 0.001]. The number of other complications was similar between the groups.

CONCLUSIONS

Both TSF and IMN provided good clinical results. TSF had more pin-track infections but less knee pain the first year.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Ilizarov Fixation Method of Tibia Plateau Fractures: A Prospective Observational Study

BACKGROUND

 Tibia plateau fractures are most commonly managed with open reduction and internal fixation (ORIF) technique, external fixation via minimally invasive technique are an excellent alternative. The aim of this study was to assess the results of tibia plateau fractures by using the Ilizarov external fixator. The analysis was done both clinically and radiologically.

METHODOLOGY

 Some 72 patients with isolated tibia plateau fractures were brought to ED and clinics and assessed. The fractures were classified according to Schatzker Tibia Plateau Fracture classification, only Schatzker type III to VI were included using conventional X-rays. All patients for their tibia plateau fractures underwent surgical correction using Ilizarov technique with full weight bearing and knee range of motion allowed the next day. Patient follow-up up to one year was done. KOOS and self-appraisal were used to evaluate the knee pain and function.

RESULTS

 All the fractures healed with 67 patients achieving a range of motion better than 0-100º. KOOS score shows that patients who had worse fracture patterns (Schatzker-V and VI) have worse global scores (p=0.002); still when managed with an Ilizarov it has been seen that these patients are able to maintain a moderately pain free knee (p=0.013) other aspects of the KOOS. Patients with higher BMI showed to have worsening fracture patterns with 20 out of the 30 overweight patients suffering Schatzker-V (66.67%). We experienced an extremely low rate of pin tract infections with only two debridements required.

CONCLUSION

 Ilizarov external fixation method is a valuable alternative treatment with excellent clinical outcomes and early mobilization.

Post-operative outcomes of open reduction and internal fixation versus circular external fixation in treatment of tibial plafond fractures: A systematic review and meta-analysis

INTRODUCTION

Tibial plafond fractures (TPF) are complex injuries often resulting in poor outcomes. Combination of articular impaction, metaphysealcomminution and soft-tissue injury results in a significant treatment challenge. The aim of this study was to conduct a systematic review and meta-analysis to compare post-operative complications and functional outcomes of open reduction and internal fixation (ORIF) versus circular external fixation (CEF) for treatment of TPF.

METHODS

A comprehensive search of PubMed/MEDLINE, Embase, Scopus and Cochrane library was undertaken. All studies published in English language comparing ORIF with CEF for treatment of TPF were included.

RESULTS

5 comparative studies with 239 fractures met the inclusion criteria. Meta-analysis showed no significant difference in rates of non-union, malunion, superficial infection, deep infection, and secondary arthrodesis between the two treatment groups. Significantly higher rate of unplanned metalwork removal (RR 5.68, 95% CI 1.13 to 28.55, p = 0.04) and lower rate of post-traumatic arthritis (RR 0.48, 95% CI 0.30 to 0.78, p = 0.003) were found in patients that underwent ORIF. 1 study showed significantly lower functional outcomes scores with CEF (p< 0.05), whereas 3 studies found comparable functional outcomes between the two treatment groups. Overall, there was a preference in treating more severe injuries with CEF.

CONCLUSION

CEF and ORIF are both acceptable treatment options for surgical management of TPF, with comparable post-operative complication rates and functional outcomes. This study highlights paucity of high-quality evidence regarding the optimal fixation method for TPF.

Musculoskeletal Infection in Orthopaedic Trauma: Assessment of the 2018 International Consensus Meeting on Musculoskeletal Infection

Fracture-related infections (FRIs) are among the most common complications following fracture fixation, and they have a huge economic and functional impact on patients. Because consensus guidelines with respect to prevention, diagnosis, and treatment of this major complication are scarce, delegates from different countries gathered in Philadelphia in July 2018 as part of the Second International Consensus Meeting (ICM) on Musculoskeletal Infection. This paper summarizes the discussion and recommendations from that consensus meeting, using the Delphi technique, with a focus on FRIs. A standardized definition that was based on diagnostic criteria was endorsed, which will hopefully improve reporting and research on FRIs in the future. Furthermore, this paper provides a grade of evidence (strong, moderate, limited, or consensus) for strategies and practices that prevent and treat infection. The grade of evidence is based on the quality of evidence as utilized by the American Academy of Orthopaedic Surgeons. The guidelines presented herein focus not only on the appropriate use of antibiotics, but also on practices for the timing of fracture fixation, soft-tissue coverage, and bone defect and hardware management. We hope that this summary as well as the full document by the International Consensus Group are utilized by those who are charged with musculoskeletal care internationally to optimize their management strategies for the prevention and treatment of FRIs.

Tibial plateau fractures are associated with a long-lasting increased risk of total knee arthroplasty a matched cohort study of 7,950 tibial plateau fractures

OBJECTIVE

This study aims to investigate the risk of total knee replacement (TKR) following tibia plateau fractures. Secondary the study aims to investigate the risk of knee arthroscopy following tibial plateau fractures.

METHOD

The study was designed as a matched cohort study. All patients who sustained a tibial plateau fracture in Denmark between January 1, 1996, and December 31, 2000, were included and followed until December 31, 2015. For each patient with a tibial plateau fracture, 10 matched citizens without a tibial plateau fracture were included as a reference group.

RESULTS

7,950 patients sustained a tibial plateau fracture in Denmark during the study period. The median age of patients was 52.6 (IQR: 32.4-71.5) years. The mean observational period was 13.9 years. 5.7% were treated with a TKR (N = 452), and 2.0% of patients from the reference group were treated with a TKR (N = 1,623). Patients with a tibial plateau fracture had a 3.5 (95%CI: 3.1-3.9) times higher hazard ratio (HR) compared to patients from the reference group. 7.6% of patients with a tibial plateau fracture were treated with a secondary knee arthroscopy (N = 603) and 2.0% of patients from the reference group were treated with a knee arthroscopy (N = 1,565). Patients with a tibial plateau fracture presented with a 5.0 (95%CI: 4.5-5.6)) times higher HR compared to patients in the reference group.

CONCLUSIONS

Tibial plateau fractures are associated with a 3.5 times increased risk of TKR compared with an age- and gender-matched reference group with a mean follow-up of 13.9 years.

Medium-Long-Term Radiographic and Clinical Outcomes after Surgical Treatment of Intra-Articular Tibial Pilon Fractures by Three Different Techniques

Introduction

The goal of this retrospective, observational, case series study was to evaluate the medium-long-term clinical and radiographic results of the three most common surgical osteosynthesis techniques used for the treatment of articular tibial pilon fractures: ORIF, MIPO, and EF.

Materials and Methods

A consecutive series of patients with articular pilon fractures who underwent surgery at our institution were enrolled in this study. Fractures were classified according to the Müller AO classification system. Overall outcomes took the following into account: radiographic quality of reduction, evaluated using Ovadia and Beals' criteria; clinical assessment, evaluated using the AOFAS questionnaire; and general health, evaluated with the SF36-v2 Health Survey.

Results

A total of 94 articular pilon fractures (34 type 43-B and 60 43-C) were evaluated with a mean follow-up of 56.34 months (range 33–101). The techniques used were ORIF, MIPO, and EF in 63 (67%), 17 (18.9%), and 14 cases (14.1%), respectively. According to Ovadia and Beals' criteria, good, fair, and poor results were reported in 61 (64.89%), 26 (27.66%), and 7 (7.45%) cases, respectively. The mean AOFAS score was 82.41 for MIPO, 79.83 for ORIF, and 50.57 for EF, respectively. Thirty-nine patients (41.49%) presented early and/or late complications.

Conclusion

Satisfactory outcomes using the three different techniques were reported. In particular, the radiographic outcomes were inversely proportional to the fracture comminutions and statistically different between internal and external osteosynthesis, but comparable between ORIF and MIPO techniques. On the other hand, the clinical outcomes were closely related to the soft tissue conditions and the anatomical reconstruction of the joint.

Asymmetry in gait pattern following bicondylar tibial plateau fractures-A prospective one-year cohort study

INTRODUCTION

Despite the high number of studies evaluating outcomes following tibial plateau fractures, the literature lacks studies including the objective assessment of gait pattern. The purpose of the present study was to evaluate asymmetry in gait patterns at 12 months after frame removal following ring fixation of a tibial plateau fracture.

PATIENTS AND METHODS

The study design was a prospective cohort study. The primary outcome measurement was the gait patterns 12 months after frame removal measured with a pressure-sensitive mat. The mat registers footprints and present gait speed, cadence, as well as temporal and spatial parameters of the gait cycle. Gait patterns were compared to a healthy reference population.

RESULTS

Twenty-three patients were included with a mean age of 54.4 years (32-78 years). Patients presented with a shorter step-length of the injured leg compared to the non-injured leg (asymmetry of 11.3%). Analysis of single-support showed shorter support time of the injured leg compared to the non-injured leg (asymmetry of 8.7%). Moreover, analysis of swing-time showed increased swing-time of the injured leg (asymmetry of 8.9%). Compared to a healthy reference population, increased asymmetry in all gait patterns was observed. The association between asymmetry and health-related quality of life (HRQOL) showed moderate associations (single-support: R=0.50, P=0.03; step-length: R=0.43, P=0.07; swing-time: R=0.46, P=0.05).

CONCLUSION

Compared to a healthy reference population, gait asymmetry is common 12 months after frame removal in patients treated with external ring fixation following a tibial plateau fracture of the tibia.