Revision strategy for malunited tibial plateau fracture caused by failure of initial treatment

Intra-articular elevating osteotomy for tibial plateau fracture malunion with intra-articular depression: Surgical technique and review

Open reduction with internal fixation is the gold standard treatment for tibial plateau fractures. However, some complications can be observed despite a well-established procedure. Apart from stiffness, malunion is the most frequent complication of tibial plateau fractures. These malunions may be intra-articular or extra-articular or combined. Intra-articular or extra-articular osteotomy is a good option to treat malunion in young and active patients without significant joint damage. When malunion is associated with extensive joint involvement or the initial cartilage damage has resulted in knee osteoarthritis, the surgical option is a total replacement of the knee joint with arthroplasty. We report the case of a patient with a tibial plateau fracture treated initially at a traditional bonesetter complicated at the end of the treatment with the persistent of the knee pain and limping.

Rate and factors associated with surgical site infection following aseptic revision fixation of orthopaedic trauma injuries

PURPOSE

The primary aim of this study was to define the rate of infection following revision of fixation for aseptic failure. The secondary aims were to identify factors associated with an infection following revision and patient morbidity following deep infection.

METHODS

A retrospective study was undertaken to identify patients who underwent aseptic revision surgery during a 3-year period (2017-2019). Regression analysis was used to identify independent factors associated with SSI.

RESULTS

Eighty-six patients were identified that met the inclusion criteria, with a mean age of 53 (range 14-95) years and 48 (55.8%) were female. There were 15 (17%) patients with an SSI post revision surgery (n = 15/86). Ten percent (n = 9) of all revisions acquired a 'deep infection', which carried a high morbidity with a total of 23 operations, including initial revision, being undertaken for these patients as salvage procedures and three progressed to an amputation. Alcohol excess (odds ratio (OR) 1.61, 95% CI 1.01-6.36, p = 0.046) and chronic obstructive pulmonary disease (OR 11.1, 95% CI 1.00-133.3, p = 0.050) were independently associated with an increased risk of SSI.

CONCLUSION

Aseptic revision surgery had a high rate of SSI (17%) and deep infection (10%). All deep infections occurred in the lower limb with the majority of these seen in ankle fractures. Alcohol excess and COPD were independent risk factors associated with an SSI and patients with a history of these should be counselled accordingly.

LEVEL OF EVIDENCE

Retrospective Case Series, Level IV.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Open reduction and internal fixation is the gold standard treatment for tibial plateau fractures. However, the procedure is not free of complications such as knee stiffness, acute infection, chronic infection (osteomyelitis), malunion, non-union, and post-traumatic osteoarthritis. The treatment options for knee stiffness are mobilisation under anaesthesia (MUA) when the duration is less than 3 months, arthroscopic release when the duration is between 3 and 6 months, and open release for refractory cases or cases lasting more than 6 months. Early arthroscopic release can be associated with MUA. Regarding treatment of acute infection, if the fracture has healed, the hardware can be removed, and lavage and debridement can be performed along with antibiotic therapy. If the fracture has not healed, the hardware is retained, and lavage, debridement, and antibiotic therapy are performed (sometimes more than once until the fracture heals). Fracture stability is important not only for healing but also for resolving the infection. In cases of osteomyelitis, treatment should be performed in stages: aggressive debridement of devitalised tissue and bone, antibiotic spacing and temporary external fixation until the infection is resolved (first stage), followed by definitive surgery with grafting or soft tissue coverage depending on the bone defect (second stage). Intra-articular or extra-articular osteotomy is a good option to correct malunion in young, active patients without significant joint damage. When malunion is associated with extensive joint involvement or the initial cartilage damage has resulted in knee osteoarthritis, the surgical option is total knee arthroplasty.

Conversion Total Knee Arthroplasty After Tibial Plateau Fixation Is Associated With Lower Reimbursement, Greater Complication Rates, and Similar Opioid Use

Objective

Total knee replacement after previous open reduction and internal fixation for tibial plateau fracture (conversion total knee) increases the complexity of the procedure and the complication rate. However, very little research exists to report on opioid use and cost associated with total knee arthroplasty (TKA) following tibial plateau fracture fixation as compared to primary TKA patients with no history of tibial plateau fracture. The aim of this study is to compare the differences in opioid use, reimbursements, and complication rates between patients with and without a history of tibial plateau fracture undergoing TKA.

Methods and materials

This is a retrospective large database review study. The study included patients across the country and in various clinical settings including, but not limited to, institutions, primary and tertiary care centers, and private practice. The PearlDiver database was reviewed for patients undergoing TKA between 2010 and 2019. Patients who underwent TKA following surgical repair of a tibial plateau fracture were identified using Common Procedural Terminology (CPT) codes and the appropriate International Classification of Diseases Ninth and Tenth Revision (ICD-9, ICD-10) codes. This group was then matched by age, gender, Charleston Comorbidity Index (CCI) score, Elixhauser Comorbidity Index (ECI) score, obesity, tobacco use, and diabetes to a group of similar patients who underwent TKA with no history of tibial plateau fracture. Opioid use over the episode of care, evaluated by morphine milligram equivalents (MME), and 30-day reimbursed cost were compared between groups using an unequal variance t-test. Complication rates at 30 days, 90 days, and one year postoperatively, and revision rates at one and two years postoperatively were compared using the odd’s ratio (OR) with 95% confidence intervals (95%CI).

Results

The episode of care cost for TKA was significantly lower for patients with a history of tibial plateau fracture ($11,615 ± $15,704) than it was for patients without a history of tibial plateau fracture ($16,088 ± $18,573) (p = 3.56E-14). At 30 days after knee arthroplasty, patients with a history of tibial plateau fracture had significantly more episodes of dehiscence (OR 2.665 [95% CI 1.327-5.351]; p = 0.006) and surgical site infection (SSI) (OR 1.698 [95% CI 1.058-2.724]; p = 0.028), which was significant at 90 days postop for both dehiscence (OR 1.358 [95% CI 0.723-2.551]; p = 0.001) and SSI (OR 1.634 [95% CI 1.100-1.802]; p = 0.015), as well as mechanical complications of the implant device (OR 2.420 [95% CI 1.154-5.076]; p = 0.019). There was no significant difference in the number of opioids prescribed postoperatively to patients with a history of tibial plateau fracture (2218 ± 3255 MME) compared to those without prior tibial plateau fracture (2400 ± 4843 MME) (p = 0.258). However, there was a small but statistically significant increase in the number of days postoperatively patients with a history of tibial plateau fracture were prescribed opioids (11.99 ± 7.73 days) compared to non-tibial plateau fracture patients (11.15 ± 7.18 days) (p = 0.004).

Conclusion

Patients with a history of tibial plateau fracture who then underwent conversion TKA have a lower reimbursed cost of TKA but a higher postoperative risk for dehiscence, mechanical complications, and surgical site infections. There is no significant difference in postoperative opioid use between the two groups.

Reconstruction of Tibial Plateau Fracture Malunion in the Setting of a Large Cartilage Defect in an Adolescent: A Case Report

CASE

An 18-year-old adolescent boy presented with knee pain and stiffness secondary to tibial plateau valgus malunion and osteochondral defect, 8 months after initial injury/fixation. We opted for a novel technique that reconstructs the convex lateral tibial plateau by using osteotomy and an osteochondral autograft harvested from the lateral aspect of the ipsilateral femoral condyle.

CONCLUSION

The reported novel reconstruction technique is inexpensive, achievable with routine techniques, and demonstrated a favorable short-term outcome. At 3 years of follow-up, the patient had excellent, asymptomatic, left knee mobility and function with radiographic evidence of mild posttraumatic arthritis despite normal knee alignment.

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

Purpose

Malunions are a common complication after tibial plateau fractures (TPF), leading to stiffness, pseudo-instability and posttraumatic osteoarthritis. The purpose of this study was to analyse the clinical outcome after intraarticular osteotomy of malunited TPF and to perform a failure analysis.

Methods

Between 2013 and 2018, 23 patients (11 males, 12 females; 43.8 ± 12.8 years) with intraarticular osteotomy after malunited TPF were included in the retrospective study. Clinical examination and postoperative scores were collected with a minimum follow-up of 24 months. Malunion was measured on pre- and postoperative CT scans and localized according to the 10-segment classification while the leg axis in the frontal plane was measured pre- and postoperatively on long leg standing radiographs.

Results

Excellent and good clinical outcome was achieved in 73.9% (n = 17) of the cases and patient related outcome improved significantly (Tegner 3.3 ± 1.6–5 ± 1.8, p < 0.001; clinical Rasmussen 14.6 ± 3.8–24.9 ± 4.4, p < 0.001). Radiological parameters also improved as an intraarticular step-off was reduced from 9 ± 3.8 to 0.6 ± 0.8 mm (p < 0.001) and a lower limb malalignment from 7.2 ± 4.8° to 1.5 ± 1.9° (p = 0.003). Failure analysis showed that an impaired clinical result correlated with a postoperative extension (n = 3, p < 0.001) and flexion deficit (n = 4, p = 0.035).

Conclusion

Intraarticular osteotomy of malunited TPF lead to good clinical results with significant clinical and radiological improvement in most cases while an impaired patient outcome correlated with a limited range of motion. This study is the first failure analysis of intraarticular osteotomy after malunited TPF published up to now.