Complications in the management of closed high-energy proximal tibial plateau fractures

The efficacy of arthroscopy-assisted versus stand-alone open reduction and internal fixation for treating tibial plateau fracture: a systematic review and meta-analysis

BACKGROUND

The optimal surgical technique for treating tibial plateau fractures remains controversial. This study aimed to compare the outcomes of arthroscopy-assisted reduction and internal fixation (ARIF) to those of open reduction and internal fixation (ORIF) in treating tibial plateau fractures.

METHODS

This systematic review and meta-analysis were conducted to compare surgical outcomes between ARIF versus ORIF for patients with tibial plateau fractures. Relevant studies, comprising randomized controlled trials (RCTs) and non-RCTs, were identified through searches in Cochrane CENTRAL, PubMed, and Embase databases. Risk of bias assessments were conducted using the revised Cochrane risk-of-bias tool for RCTs (RoB 2.0), Newcastle Ottawa scales for non-RCTs, and Joanna Briggs Institute Critical Appraisal Checklist for case series studies. Data synthesis utilized a random-effects model meta-analysis. The primary outcome assessed was functional outcomes, with complications considered as secondary outcomes.

RESULTS

There were fifteen studies (one RCT and fourteen non-RCTs) included in this study, comprising a total of 969 participants (548 in the ARIF group and 421 in the ORIF group). Although patients in the ARIF group showed a trend towards better functional outcomes compared to the ORIF group, the difference was not statistically significant (Hospital for special surgery score, mean difference (MD) = 5.13, 95% confidence interval (CI)=-1.67 to 11.92, I²=83%; Knee society score, MD = 5.84, 95% CI=-1.18 to 12.86, I²=74%). No significant differences were noted in infection, stiffness, DVT, and overall complications between two groups. The ARIF group included ten case series studies with a total of 302 patients. The pooled mean Rasmussen Radiological Score was 16.59 (95% CI, 15.72 to 17.50), and the pooled mean Rasmussen Clinical Score was 27.38 (95% CI, 26.45 to 28.33).

CONCLUSION

The findings of this study reveal no significant difference in clinical outcomes and complication rates between ARIF and ORIF. Additionally, this study found that the complication rate for patients undergoing ARIF falls within previously reported ranges. This suggests that ARIF is a reliable and effective surgical option for treating tibial plateau fractures, even in cases involving high-energy trauma.

Bicondylar Tibial Plateau Fracture in Below-Knee Amputation: A Rare Injury Case Report

Introduction

With current prostheses, below-knee amputees have sufficient mobility to perform activities with a risk of trauma and therefore fracture. However, bicondylar fractures of the tibial plateau are rare in this population and we found no recent literature or consensus regarding the management of these fractures. The aim of this study is to report a case with its surgical management, post-operative follow-up, and the specificities inherent in transtibial amputees.

Case Report

This is a case of 33-year-old below-the-knee amputee male who sustained an ipsilateral tibial plateau fracture after an electric scooter accident. The patient underwent open reduction and internal fixation with posteromedial and anterolateral plate using dual incision. We followed the patient for 1 year with good clinical and functional outcomes.

Conclusion

Bicondylar fractures of the proximal tibia in below-knee amputees are rare injuries with potentially severe consequences. Nevertheless, appropriate surgical management and multidisciplinary collaboration with physiotherapists and orthopedic technicians allow the patient to regain mobility and autonomy without compromising prosthesis fitting in the long term.

Comparison Between Conventional and Variable-Angle Locking Compression Plates in Complex Proximal Tibia Fractures

BACKGROUND

Proximal tibial fractures, particularly those involving the tibial plateau, are complex injuries that require careful management to restore knee function and prevent long-term disability. Recent advancements have introduced variable-angle locking compression plates (VALCP) as a potential alternative to the widely used fixed-angle locking plating techniques. These plates allow for more precise screw placement, potentially improving fixation and clinical outcomes. The goal of this study was to find out how well conventional locking plates and VALCP treat Schatzker's type I, II, and III tibial plateau fractures in terms of clinical, functional, and radiological outcomes. We evaluated the outcomes using the Rasmussen functional and radiological grading systems, as well as the Oxford Knee Score (OKS).

METHODS

This prospective study was undertaken by a tertiary care medical institute from January 2020 to August 2021. The study included a total of 60 patients with Schatzker's type I, II, and III tibial plateau fractures. These patients were randomly assigned to two groups, with each group consisting of 30 patients. Conventional locking compression plates (CLCP) treated one group, while VALCP treated the other. Clinical, functional, and radiological outcomes of patients were evaluated using the OKS, Rasmussen's functional grading system, and Rasmussen's radiological grading system. Additionally, the study documented and examined the duration of the surgical procedure, the stability of the fixation, and any complications that occurred in the postoperative phase over a span of six months.

RESULTS

The study included 52 males and eight females, aged 19 to 65 years. The mean age was 42.66 years for the conventional LCP group and 35.6 years for the VALCP group. Road traffic accidents were the most common cause of injury, with 86.67% in the VALCP group and 70% in the conventional group. In both groups, the majority of fractures were Schatzker type II. At the six-month follow-up, 60% of VALCP patients had excellent functional outcomes compared to 50% in the conventional group. Radiologically, 80% of VALCP patients had excellent results versus 73.33% in the conventional group. The OKS showed that 86.67% of VALCP patients had excellent results, compared to 73.33% in the conventional group. While VALCP showed slightly better outcomes, the differences were not statistically significant. Complications were minimal, with 90% of VALCP and 86.67% of conventional LCP patients experiencing no complications.

CONCLUSION

The small number of patients, short-term study, and heterogeneity of fractures constitute a limitation of this study. VALCP plating in tibial plateau fractures is a good treatment modality because it seems to improve fixation, provides early mobilization, and has excellent to good functional and radiological outcomes. However, no significant difference in functional and radiological outcomes was found between the conventional and VALCP groups.

Treatment of Tibial Plateau Fractures with a Circular External Fixator: A Comparative Analysis of Two Assembly Methods

Objective  To compare the functional outcomes of two circular external fixation techniques to treat complex fractures of the proximal end of the tibia. Materials and Methods  The present is a retrospective cohort study with 51 patients who underwent surgical treatment for complex fractures of the tibial plateau with a circular external fixator. There were two groups of patients: 12 subjects underwent treatment with the classic assembly technique, and 39 subjects underwent treatment with the simplified technique. The variables analyzed included age, sex, injury mechanism, trauma energy, associated injuries, fixator type, time of fixator use, and clinical-radiographic outcomes. The classic technique mainly uses transfixing Kirschner wires, while the simplified one replaces the Kirschner wires with Schanz pins in the distal block of the circular external fixator. Result  There were no statistically significant differences ( p  > 0.05) between the two groups concerning the clinical-radiographic outcomes, including fracture consolidation, quality of joint fracture reduction, range of motion, lower limbs residual discrepancy, and postoperative pain. Conclusion  We suggest that the simplified technique, using Schanz pins instead of Kirschner wires, can be a viable and effective alternative to treat complex fractures of the proximal end of the tibia with a circular external fixator. This simplified approach can offer benefits, such as a lower infection rate and greater patient comfort, without compromising clinical and radiographic outcomes, thus justifying its use.

Bilateral Gastrocnemius Muscle Flap for Bilateral Defects of Knee Joint in Schatzker Type V & VI Proximal Tibial Condyle Fractures

Bilateral defects around the knee joint following fracture of the proximal tibia (Schatzker type V & VI) are difficult to reconstruct because of the unavailability of local tissue. A bicondylar proximal tibial fracture requires a bilateral approach and dual plates for fracture fixation. Because of extensive dissection during plating and extended zone of trauma, the suture lines occasionally dehisce resulting in soft tissue defects on both sides of the proximal tibia. Because of its bilateral nature, the defect requires 2 flaps. We are reporting 2 cases of suture dehiscence after fixation of bicondylar fracture of the proximal tibia which required reconstruction with bilateral gastrocnemius flaps. This reconstruction is a simple option that helps in providing stable coverage. The first case was followed up for a period of 5 years and the second case was followed up for a minimum period of 6 months. Both cases demonstrated well-healed flaps, united bone and no donor side morbidity. Bilateral gastrocnemius muscle flaps can be used simultaneously for 2 separate defects on both sides of the knee without significant donor site morbidly. This reconstructive option provides stable coverage, reduces the infection and promotes bony union thus helping in early ambulation.

Does pes anserinus tenotomy affect surgical site infection rate in operative tibial plateau fractures?

PURPOSE

To assess if pes anserinus tenotomy (PAT) during definitive open reduction and internal fixation (ORIF) of tibial plateau fractures is associated with a decreased risk of surgical site infection (SSI) and other postoperative complications.

METHODS

A retrospective review of all adults who underwent ORIF for tibial plateau fractures from April 2005 to February 2022 at single level 1 trauma center was performed. Patients who had a medial approach to the plateau with minimum three-month follow-up were required for inclusion. All patients with fasciotomy for compartment syndrome or with traumatically avulsed or damaged pes anserinus prior to ORIF were excluded. Two groups were created: those who received a pes anserinus tenotomy with repair (PAT group) and those whose pes anserinus were spared and left intact (control group). Patient demographics, injury and operative characteristics, and surgical outcomes were compared. The primary outcomes were rates of deep and superficial SSI.

RESULTS

The PAT group had significantly lower rates of deep SSI (9.2% vs. 19.7%, P = 0.009), superficial SSI (14.2% vs. 26.5%), P = 0.007), and any SSI (15.8% vs. 28.9%, P = 0.005). Multiple logistic regression showed that heart failure (aOR = 7.215, 95% CI 2.291-22.719, P < 0.001), and presence of open fracture (aOR = 4.046, 95% CI 2.074-7.895, P < 0.001) were independently associated with increased odds of deep SSI, while PAT was associated with a decreased odds of deep SSI (aOR = 0.481, 95% CI 0.231-0.992, P = 0.048). PAT had significantly lower rates of unplanned return to the operating room (20.8% vs. 33.7%, P = 0.010) and implant removal (10.0% vs. 18.0%, P = 0.042).

CONCLUSION

While these data do not allow for discussion of functional recovery or strength, pes anserinus tenotomy was independently associated with significantly lower rates of infection, unplanned operation, and implant removal.

LEVEL OF EVIDENCE

Level III.

Introduction of 3D-classification and its derived surgical sequence of Schatzker type IV tibial plateau fractures

INTRODUCTION

Schatzker IV tibial plateau fractures usually have a worse prognosis due to their high variability and the accompanied bony and soft tissue injuries. This study aimed to introduce an injury mechanism-based new classification of Schatzker IV tibial plateau fractures and evaluate its reliability. Additionally, this study aimed to evaluate the outcomes of operative Schatzker IV tibial plateau fractures treated according to the surgical sequences determined by the new classification.

MATERIALS AND METHODS

A total of 63 cases of operative Schatzker IV tibial plateau fractures that were treated following the new surgical sequences were enrolled in our study. The CT images of these patients were reviewed and classified twice according to the new 3D classification by 4 independent observers. The reliability of the classification was calculated through kappa analysis. The classification-determined surgical sequence was evaluated by observing the postoperative efficacy during the follow-up.

RESULTS

Both the intra-observer (the mean k = 0.897, CI 0.806-0.971) and inter-observer (the mean k = 0.883, CI 0.786-0.961) reliability of 3D-classification showed excellent agreement according to Landis and Koch. All the patients were followed up for 6-28 months (average 12.8 months). As for the evaluation of the postoperative efficacy, according to KSS, 53 cases were rated as excellent, 8 cases as good, and 2 cases as fair results.

CONCLUSIONS

The new proposed classification showed high intra-observer and inter-observer reliability in our study. The surgical sequence determined by the classification can help surgeons to acquire good reduction and rigid internal fixation. Therefore the new classification of Schatzker IV tibial plateau fractures and the derived surgical sequences are worthy of further popularization and application in clinical trials.

Efficacy of Cal-Cemex as bone substitute for tibial plateau fractures

BACKGROUND

Various factors influence treatment and outcomes in tibial plateau fractures. Bone defects are among them. Many materials have been proposed to address this problem: allograft, bone-cements and various bone substitutes (BSM). Cal-Cemex (β-tricalciophosphate and polymethylmethacrylate) is a new hybrid bi-component BSM. A retrospective multicenter study was conducted based on the clinical experience of three European Hospitals, to demonstrate its clinical effectiveness, versatility and safety.

MATERIALS AND METHODS

From December 2016 to March 2022, 45 displaced tibial plateau fractures were treated with internal fixation and augmentation using Cal-Cemex. The average age was 55.9 years. According to Schatzker classification, we included 13 type II, 24 type III, 3 type V and 4 type VI fractures. The postoperative follow-up (FU) consisted of clinical and radiological examinations at 6 and 12 weeks and 1 year after surgery. A CT scan was performed preoperatively and 1 year after surgery. Full weight bearing was permitted after less than 6 weeks. Clinical data were collected from patient charts, while functional data were evaluated using the Rasmussen knee function score, the KOOS score and the Hospital for Special Surgery knee rating score (HSS), to evaluate the range of motion, axis and functionality of the knee.

RESULTS

The average FU was 42.8 months. CT scans taken at 1 year demonstrated a good surface osteointegration without radiolucent lines or osteolysis with good evidence of interdigitation and even bone ingrowth. At 1-year FU, the mean Rasmussen score was 24.7, the mean KOOS score was 90.7 and the mean HSS was 89.9 and the average full weight-bearing period 34.9. No patients had hardware failure or fracture secondary displacement.

DISCUSSION

Cal-Cemex combines biological features and good mechanical performances. It guarantees biocompatibility and osteoconductivity, although it is not fully reabsorbable; β-tricalciophosphate component gives macro- and microporosity that allow fluids to penetrate inside the material, to stimulate bone ingrowth.

CONCLUSIONS

The study suggests that Cal-Cemex is an option for tibial plateau fractures, where augmentation and support are necessary for early full weight bearing. The absence of major complications, ease of application, the possibility to cut and perforate this material support its extensive use in bone augmentation for trauma cases.

Correlation of preoperative CT imaging shift parameters of the lateral plateau with lateral meniscal injury in Schatzker IV-C tibial plateau fractures

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.

Degree of articular injury as measured by CT cross sectional area is associated with physical function following the treatment of bicondylar tibial plateau fractures

BACKGROUND

Bicondylar tibial plateau fractures are complex injuries that commonly require surgical repair. Long-term clinical outcome has been associated with discrepancies in leg alignment, instability and condylar width abnormalities. While intuitive, the degree of articular damage at time of injury has not been linked to outcomes in patients with bicondylar tibial plateau fractures. The aim of this study was to quantify percentage of articular surface cross sectional area disruption and assess for correlation between the degree of articular injury and patient reported physical function.

METHODS

Retrospective cohort study at two level 1 trauma centers. 57 consecutive patients undergoing surgical repair for bicondylar tibial plateau fractures between 2013 and 2016.

MAIN OUTCOME MEASURE

Preoperative CT scans were reviewed, and the percentage of articular surface disruption cross sectional area was calculated. PROMIS® scores were collected from patients at a minimum of 2 years.

RESULTS

57 patients with an average age of 58 ± 14.3 years were included. The average PROMIS® score was 45.5. There was a correlation between percentage of articular surface disruption and total PROMIS® scores (0.4, CI: 0.2-0.5, p = .007) and the physical function of the PROMIS® score (0.4, CI: 0.2-0.6, p < .001).

CONCLUSION

Our method for calculating articular surface disruption on CT is a simple, reproducible and accurate method for assessing the degree of articular damage in patients with bicondylar tibial plateau fractures. We found that the percentage of cross-sectional articular surface disruption correlates with patient reported outcomes and physical function.

Reamed compared with unreamed nailing of tibial shaft fractures: Does the initial method of nail insertion influence outcome in patients requiring reoperations?

BACKGROUND

Patients with a tibial shaft fracture experiencing their first postoperative complication following treatment with intramedullary nails may be at greater risk of subsequent complications than the whole population. We aimed to determine whether the initial method of nail insertion influences outcome in patients with a tibial shaft fracture requiring multiple reoperations.

METHODS

Using the Study to Prospectively Evaluate Reamed Intramedullary Nails in Tibial Shaft Fractures trial data, we categorized patients as those not requiring reoperation, those requiring a single reoperation and those requiring multiple reoperations, and we compared them by nail insertion technique (reamed v. unreamed) and fracture type (open v. closed). We then determined the number of patients whose first reoperation was in response to infection, and we compared other clinical outcomes between the reamed and unreamed groups.

RESULTS

Among 1226 patients included in this analysis, 175 (14.27%) experienced a single reoperation and 44 patients (3.59%) underwent multiple reoperations. Nail insertion techniques (reamed v. unreamed) did not play a role in the need to perform multiple reoperations. Seventy-five percent of patients requiring multiple reoperations had open tibial shaft fractures. An equal number of these were reamed and unreamed insertions. The majority of patients had their course complicated by infection and almost 50% of patients whose first reoperation was for infection required more than 2 reoperations for management. The rest required multiple procedures for nonunion or bone loss.

CONCLUSION

Our findings corroborate those of other studies, in which open fracture type rather than nail insertion technique was found to be the cause of morbidity following intramedullary nailing of tibial fractures.

CLINICAL TRIAL REGISTRATION

www.

CLINICALTRIALS

gov, no. NCT00038129.

Dealing with soft tissue compromised in tibial plateau fractures by using a hybrid external fixation

INTRODUCTION AND IMPORTANCE

Tibial plateau fractures are often accompanied by soft tissue compromise, especially in Schatzker 5 and 6, caused by high-energy trauma. In this situation, more careful consideration is needed. A rush decision will result in morbidity, bad postoperative wounds, and infections resulting in dehiscence.

CASE PRESENTATION

We have three patients with the tibial plateau. In the first case, ORIF was still performed on the fracture with soft tissue compromised. The patient was found to have wound dehiscence resulting in an implant-exposed bone. In the subsequent two cases, Patients with tibial plateau Schatzker 6 fractures also showed blisters around their injured knees. We performed hybrid external fixation. Screwing fixation was performed to obtain compression. Kirschner wire 2.2 formed a raft configuration attached to the semicircular frame and uniplanar external fixation to support the tibial plateau.

CLINICAL DISCUSSION

A hybrid external fixation is an excellent option for treating tibia plateau fractures with compromised soft tissue. It can achieve early fracture fixation while avoiding soft tissue problems; thus, the patients can start early rehabilitation.

CONCLUSION

A hybrid external fixation can be applied to tibial plateau fractures with soft tissue compromised without waiting for subsiding and has satisfactory clinical and radiological outcomes. The author also explains this case report's hybrid external fixation technique.

Post-operative complications of tibial plateau fractures treated with screws or hybrid external fixation

PURPOSE

To assess the complications and second surgeries rates at 1 year follow-up in a group of patients underwent minimally invasive fixation with screws or hybrid external fixation (HEF) for tibial plateau fractures (TPF). The hypothesis was that low Schatzker (I-IV) TPF would have shown a lower complication rate with respect to high Schatzker (V-VI) TPF.

METHODS

148 patients who underwent minimally invasive surgery with screws or HEF for TPF were included and pooled in two groups: mono-condylar (Schatzker I-IV) and bi-condylar (Schatzker V-VI). The rate of second surgeries and complications, such as stiffness, infection, wound dehiscence and malunion occurred within 1 year, were reported.

RESULTS

Statistically significant difference between mono-condylar and bi-condylar groups was found in terms of stiffness (18% vs. 37%, p = 0.01), malunion (4% vs 21%, p = 0.004) and second surgeries (32% vs. 48%, p = 0.049). Associated procedures performed during TPF fixation increased risk of second surgeries (OR 2.1, p < 0.001). No differences in terms of second surgeries and complications were found in bi-condylar group treated with screws and HEF.

CONCLUSION

Bi-condylar TPF treated with minimally invasive surgery developed a significantly higher rates of stiffness, malunion and second surgeries within 1 year compared to mono-condylar fractures. Moreover, when an associated procedure was performed, the risk of a reoperation was nearly doubled. Trial registration number PG 0012506 CE AVEC 620/2018/Oss/IOR.

Characteristics, Treatments, and Outcomes of Tibial Plateau Nonunions: A Systematic Review

BACKGROUND

Due to the rare incidence of tibial plateau nonunions, current studies are limited to small sample sizes and patient demographics. The aim of this systematic review is to quantify and report patient and fracture traits, possible risk factors, and treatment outcomes of tibial plateau nonunions.

METHODS

PubMed, Clinical Key, and MEDLINE were searched for articles published prior to August 2020 in accordance to the preferred reporting items for systematic reviews and meta-analyses (PRISMA). The authors used varying combinations of the following terms to identify relevant articles: "tibial," "plateau," "nonunion," "non-union." Studies were assessed for patient demographics, pre-revision nonunion characteristics, treatment, and post-revision outcomes.

RESULTS

Eight studies were included, yielding 31 tibial plateau nonunions (21 males, 10 females). The majority of nonunions were associated with high energy trauma (52.2%) and were Schatzker class VI (54.8%). Schatzker class I and II nonunions were not attributed to neglect, contradicting previous suggestions. Time to union was 4.0 months, the most common treatments being autologous bone grafting (76.7%) and revision plating (63.3%).

CONCLUSION

This study demonstrates the effectiveness of autologous bone grafts and revision plating for tibial plateau nonunions. Physicians may use these findings to guide decision making in the event of high energy plateau nonunions. Lastly, various limitations exist within the current literature, emphasizing the need for standardized reporting measures.

Treatment of tibial plateau fractures with a novel fenestrated screw system for delivery of bone graft substitute

PURPOSE

The purpose of this study was to describe the incidence of subsidence in patients with AO/OTA 41 (tibial plateau) fractures which were repaired with a novel fenestrated screw system to used to deliver CaPO4 bone substitute material to fill the subchondral void and support the articular reduction.

METHODS

Patients with unicondylar and bicondylar tibial plateau fractures were treated according to the usual technique of two surgeons. After fixation, the Zimmer Biomet N-Force Fixation System®, a fenestrated screw that allows for the injection of bone substitute was placed and used for injection of the proprietary calcium phosphate bone graft substitute into the subchondral void. For all included patients, demographic information, operative data, radiographs, and clinic notes were reviewed. Patients were considered to have articular subsidence if one or more of two observations were made when comparing post-operative to their most recent clinic radiographs: > 2 mm change in the distance between the screw and the lowest point of the tibial plateau, > 2 mm change in the distance between the screw and the most superior aspect of the plate. Data were analyzed to determine if there were any identifiable risk factors for complication, reoperation, or subsidence using logistic regression. Statistical significance was set at p < 0.05.

RESULTS

34 patients were included with an average follow-up of 32.03 ± 22.52 weeks. There were no overall differences between height relative to the medial plateau or the plate. Two patients (5.9%) had articular subsidence. Six patients (15.2%) underwent reoperation, two (6%) for manipulations under anaesthesia due to arthrofibrosis, and four (12%) due to infections. There were 6 (19%) total infections as 2 were superficial and required solely antibiotics. One patient had early failure.

CONCLUSION

Use of a novel fenestrated screw system for the delivery of CaPO4 BSM results in articular subsidence and complication rates similar to previously published values and appears to be a viable option for addressing subchondral defects in tibial plateau fractures.

LEVEL OF EVIDENCE

IV.

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.

Incidence and risks for surgical site infection after closed tibial plateau fractures in adults treated by open reduction and internal fixation: a prospective study

Background

Surgical site infection (SSI) was the most common complication of tibial plateau fracture after open reduction and internal fixation (ORIF). Severe infections even required repeat surgeries, which would cause serious psychological harm to patients and increased the economic burden of treatment. In order to identify the characteristics of the SSI and to avoid the occurrence of SSI, we conducted a prospective study to investigate the incidence and independent risk factors of SSI after ORIF for closed tibial plateau fractures in adults.

Methods

This study was performed at a first-level trauma center. From October 2014 to December 2018, the study subjects were adult patients with closed fractures of the tibial plateau, all of whom underwent open reduction and internal fixation (ORIF) treatment. Finally, a total of 1108 patients were followed up. We collected patient demographics information, surgery-related variables, and indexes from preoperative laboratory examinations. Univariate and multivariate logistic analysis models were used to investigate the potential risk factors.

Results

Twenty-five patients (2.3%, 25/1108) developed SSI. A total of 15 of 25 infections (60.0%) were due to Staphylococcus aureus and 3 (12.0%) were due to MRSA. Independent risk factors of SSI identified by multivariate logistic analysis model were bone grafting: autograft (OR 6.38; 95% CI 2.155–18.886; p = 0.001) and allograft (OR 3.215; 95% CI 1.009–10.247; p = 0.048), fracture type (Schartzker V–VI) (OR 8.129; 95% CI 2.961–22.319; p < 0.001), aspartate aminotransferase (>40 U/L) (OR 5.500; 95% CI 2.191–13.807; p < 0.001), white blood cell (>10*10⁹/L) (OR 2.498; 95% CI 1.025–6.092; p = 0.044), and anion gap (>16 mmol/L) (OR 8.194; 95% CI 1.101–60.980).

Conclusions

We should pay enough attention to patients who carried one or more of these factors at admission and adopt more reasonable treatment strategies to reduce or avoid the occurrence of SSI.

Combined lateral peripatellar and posteromedial approaches for Schatzker type IV tibial plateau fractures involving posteromedial plane: a prospective study

Background

The objective of this study to evaluate prospectively the effectiveness of Schatzker type IV tibial plateau fractures involving posteromedial plane managed by combined lateral peripatellar and posteromedial approaches.

Methods

We analyzed 18 patients with Schatzker type IV tibial plateau fractures involving posteromedial plane. There were 12 males and 6 females with an average of 38.5 years (range, 25–60 years). The mechanism of injury included traffic accident in 15 patients and falling in 3 patients. The injured lower limbs were right in 11 patients and left in 7 patients. The mean time from injury to surgery was 6.78 days (range, 5–9 days). There were 8 patients with meniscus injuries in our study.

Results

The mean operation time was 3.41 h (range, 3–4 h). The mean blood loss was 352.78 ml (range, 300–410 ml). All the injured meniscuses were repaired. All patients were followed up, and the average time of follow up was 16.61 months (range, 14–22 months). Bone union was achieved at a mean of 12 weeks (range, 10–14 weeks). The mean degree of knee extension was 1.11° (range, 0–5°), and the mean degree of knee flexion was 120.56° (range, 110–130°). The mean points of KSS were 83 (range, 74–89 points). According to the criteria of KSS, 14 patients had clinical outcomes rated as excellent and 4 patients were rated as good.

Conclusion

Our results suggested that Combined lateral peripatellar and posteromedial approaches in the treatment of Schatzker type IV tibial plateau fractures involving posteromedial plane acquired satisfying outcomes. It was good for repairing the injured meniscus through our approaches.

Walking impairments after severe tibia plateau fractures. A gait pattern analysis

PURPOSE

Tibia plateau fractures are severe knee injuries which have a great impact on the patients' lives, but in what extend is not clear yet in the literature. The purpose of this study was to investigate the short-term gait alternations after severe tibia plateau fractures treated with circular Ilizarov frame.

MATERIALS & METHODS

Gait pattern evaluation was performed to patients who were treated with circular Ilizarov frame after severe tibia plateau fractures (Schatzker IV-VI), three to six months after the frame removal. Gait evaluation performed by using a force plate in a walking platform at self selected speeds. Data collected from two walking tasks for each limb. Demographic, clinical, radiological and quality of life questionnaire (SF-12v2) and COST data were also collected.

RESULTS

The gait pattern of sixteen patients (aged 48.8 ± 13.3 years), following treatment with circular Ilizarov frame for severe tibia plateau fractures (Schatzker IV-VI) was analysed. The tests were performed at an average of 10.4 months after the initial treatment. SF-12v2 Mental scores have returned to normal (mean 55.8 ± 11.9) but physical scores remained impaired (mean 40.6 ± 11.3). COST scores reached average levels (mean 54.1 ± 19.8). A one-way repeated measures ANOVA was conducted to compare the GRFs and gait timing data of the affected limb with the normal one. Single limb support interval was significantly reduced to the affected limb (p < 0.001) and terminal stance phase was prolonged for the normal limb (p = 0.05). The rest of the GRF and gait timing data did not reach significant differences.

CONCLUSIONS

During the early stages of rehabilitation following severe tibia plateau fractures treated with circular Ilizarov frame, the gait pattern returns to normal curve morphology, but with reduced single limb support and terminal stance phases at the affected knee. Mental status returns to normal but symptoms and function remain impaired.

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.

Outcome of complex tibial plateau fractures with Ilizarov external fixation with or without minimal internal fixation

PURPOSE

To evaluate the clinico-radiological outcome of complex tibial plateau fractures treated with Ilizarov external fixation with or without minimal internal fixation.

METHODS

This retrospective review was conducted on all the cases of Schatzker types V and VI tibial plateau fractures treated by Ilizarov external fixation between July 2006 and December 2015 with the minimum follow-up duration of one year. There were 30 patients: 24 males and 6 females, mean age 43.33 years, and mean follow-up 3.6 years. Three of them were open fractures; 15 cases were Schatzkertype V fractures and the other 15 type VI. According to AO/OTA classification, there were 11 type C1, 12 C2 and 7 type C3 fractures. Outcome assessment was made with American Knee Society Score (AKSS) and Rasmussen's Radiological Score (RRS) at final follow-up.

RESULTS

Out of the 30 cases, mini-open reduction was performed in 7, bone graft in 4, minimal internal fixation in 10 and knee temporary immobilisation in 11 patients. Mean duration of external fixation was 11.8 weeks. All fractures united. Pin tract infections in 7 and common peroneal neuropathy in 2 patients were self-limiting. Two patients had axial misalignment of less than 10°. At final follow-up, the mean knee range of motion was 114.7, mean AKSS 81.5 and mean RRS 16.7. On statistical analysis, Schatzker type of fractures, use of minimal internal fixation and knee-spanning did not influence the final outcome.

CONCLUSION

Ilizarov external fixator with or without minimal internal fixation provides acceptable outcome for complex tibial plateau fractures. Care must be taken to look for minor loss of alignment, especially in Type VI Schatzker fractures after removal of the fixator. However small sample size precludes firm conclusions.

A review of the management of tibial plateau fractures

Tibial plateau fractures form a wide spectrum of injuries presenting varying challenges to the trauma surgeon. The prognosis of this injury spectrum is largely dependent on the management of each particular configuration, and the literature is as a result littered with a number of management strategies with limited consensus. The aim of this review is to provide a concise guide to the trauma surgeon based on newer and classical peer-reviewed publications in international orthopaedic journals. A PubMed search was conducted to identify peer-reviewed publications within the last 10 years and expanded to identify classic papers pertaining to the Schatzker classification. The focus was on articles based on management techniques, controversies and recent developments. The management of specific injury patterns is based on the Schatzker classification which is a widely accepted traditional classification system. Whilst there is a general consensus on the ultimate goal of a stable anatomic reduction in this subset of fractures, there continues to be a number of controversies surrounding issues including pre-operative imaging, initial assessment and definitive management of specific injury patterns, some of which do not conform to the original Schatzker classification. The majority of fractures will require operative management, and with whatever management strategy employed, the main emphasis is on respecting the soft tissue envelope. There remains a paucity of prospective randomised controlled trials comparing the different available operative techniques.

Incidence and risk factors for surgical site infection following open reduction and internal fixation of adult tibial plateau fractures

PURPOSE

The aim of this study was to identify independent risk factors for surgical site infection (SSI) and quantify the incidence of SSI in tibial plateau fractures after open reduction and internal fixation (ORIF).

METHODS

This retrospective study was performed at a level 1 trauma centre from January 2015 to June 2016. Data of adult patients with tibial plateau fractures treated by ORIF were extracted from the electronic medical records. A total of 370 patients were collected. We reviewed the patients' demographics, characteristics of fracture, treatment-related variables, and indexes of laboratory examination. Multivariate logistic analysis models were performed respectively to determine independent predictors of SSI.

RESULTS

Twenty-one patients developed SSI in this study. The overall incidence of SSI after ORIF of tibial fracture was 5.7%, with six (1.6%) for deep infection and 15 (4.1%) for superficial SSI. Independent predictors of SSI identified by multivariate analysis were open fracture (odds ratio=4.53; 95% CI=1.64-15.26; p=0.000), intra-operative duration (odds ratio=2.72; 95% CI=1.17-6.29; p=0.020), and smoking (odds ratio=4.79; 95% CI=1.46-15.73; p=0.010).

CONCLUSIONS

The SSI incidence was high (5.7%) after surgical tibial plateau fractures by ORIF and open fracture, operative time, and smoking were identified as independent related risk factors. Therefore, we recommend that a smoking cessation program is introduced immediately at the time of admission to hospital. More reasonable management strategies on open injury should be utilized to reduce the SSI rate.