1
|
Dreizin D, Edmond T, Zhang T, Sarkar N, Turan O, Nascone J. CT of Periarticular Adult Knee Fractures: Classification and Management Implications. Radiographics 2024; 44:e240014. [PMID: 39146203 DOI: 10.1148/rg.240014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
Periarticular knee fractures, which include fractures of the distal femur, tibial plateau, and patella, account for 5%-10% of musculoskeletal injuries encountered in trauma centers and emergency rooms. These injuries are frequently complex, with articular surface involvement. Surgical principles center on reconstruction of the articular surface as well as restoration of limb length, alignment, and rotation to reestablish functional knee biomechanics. Fixation principles are guided by fracture morphology, and thus, CT with multiplanar reformats and volume rendering is routinely used to help plan surgical intervention. Fractures involving the distal femur, tibial plateau, and patella have distinct management considerations. This comprehensive CT primer of periarticular knee fractures promotes succinct and clinically relevant reporting as well as optimized communication with orthopedic trauma surgeon colleagues by tying fracture type and key CT findings with surgical decision making. Fracture patterns are presented within commonly employed fracture classification systems, rooted in specific biomechanical principles. Fracture typing of distal femur fractures and patellar fractures is performed using Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) classification schemes. Tibial plateau fractures are graded using the Schatzker system, informed by a newer explicitly CT-based three-column concept. For each anatomic region, the fracture pattern helps determine the surgical access required, whether bone grafting is warranted, and the choice of hardware that achieves suitable functional outcomes while minimizing the risk of articular collapse and accelerated osteoarthritis. Emphasis is also placed on recognizing bony avulsive patterns that suggest ligament injury to help guide stress testing in the early acute period. ©RSNA, 2024 Supplemental material is available for this article.
Collapse
Affiliation(s)
- David Dreizin
- From the Department of Diagnostic Radiology and Nuclear Medicine (D.D., N.S., O.T.) and Division of Orthopaedic Traumatology (T.E., T.Z., J.N.), R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 655 W Baltimore St, Baltimore, MD 21201
| | - Tyler Edmond
- From the Department of Diagnostic Radiology and Nuclear Medicine (D.D., N.S., O.T.) and Division of Orthopaedic Traumatology (T.E., T.Z., J.N.), R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 655 W Baltimore St, Baltimore, MD 21201
| | - Tina Zhang
- From the Department of Diagnostic Radiology and Nuclear Medicine (D.D., N.S., O.T.) and Division of Orthopaedic Traumatology (T.E., T.Z., J.N.), R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 655 W Baltimore St, Baltimore, MD 21201
| | - Nathan Sarkar
- From the Department of Diagnostic Radiology and Nuclear Medicine (D.D., N.S., O.T.) and Division of Orthopaedic Traumatology (T.E., T.Z., J.N.), R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 655 W Baltimore St, Baltimore, MD 21201
| | - Ozerk Turan
- From the Department of Diagnostic Radiology and Nuclear Medicine (D.D., N.S., O.T.) and Division of Orthopaedic Traumatology (T.E., T.Z., J.N.), R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 655 W Baltimore St, Baltimore, MD 21201
| | - Jason Nascone
- From the Department of Diagnostic Radiology and Nuclear Medicine (D.D., N.S., O.T.) and Division of Orthopaedic Traumatology (T.E., T.Z., J.N.), R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 655 W Baltimore St, Baltimore, MD 21201
| |
Collapse
|
2
|
Boluda-Mengod J, Olías-López B, Forcada-Calvet P, Martín-Herrero A, Herrera-Pérez M, Álvarez-De-La-Cruz J, Herrera-Rodríguez A, Pais-Brito JL. Modified Oblique Lobenhoffer (MOL) approach for posterolateral and posteromedial column access in tibial plateau fractures: a detailed cadaveric anatomical study. J Orthop Traumatol 2024; 25:27. [PMID: 38769283 PMCID: PMC11106229 DOI: 10.1186/s10195-024-00769-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 05/08/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Tibial plateau fractures involving posteromedial (PM) and posterolateral (PL) columns are complex injuries that require an appropriate approach. The management of the PL column in these cases can be controversial, and limitations using deep posteromedial interval approaches have been referenced. In this paper, a modification of the Lobenhoffer approach, designed to optimize the access to the PL column, is described in detail. The aim of this study was to assess the feasibility of this approach in a cadaveric anatomical study. MATERIALS AND METHODS In total, five fresh-frozen cadaveric specimens were used for detailed anatomical study surrounding the approach. Relationships with cutaneous and deep neurovascular structures were evaluated. The exposure area of the PL and PM columns using this approach was assessed. RESULTS The cadaveric study showed safe and adequate exposure. Oblique skin and fascia incision just medial to the posterior midline was safe to protect the medial sural cutaneous nerve and the small saphenous vein. Elevation of the popliteus and tibialis posterior muscles offered safe protection of the anterior tibial artery and popliteal neurovascular bundle during retractor placement. Adequate full proximal exposure of the PM and PL columns, including the posterolateral lateral (PLL) and posterolateral central (PLC) segments, was obtained in all specimens. CONCLUSIONS The Modified Oblique Lobenhoffer (MOL) approach can be a feasible option to access PL and PM columns in tibial plateau fractures. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Juan Boluda-Mengod
- Orthopaedic Trauma Unit, Department of Orthopaedics, Hospital Universitario Canarias (HUC), Carretera Ofra S/N, 38320, La Laguna, Tenerife, Spain.
- Department of Orthopaedics, Hospital Universitario Canarias (HUC), Carretera Ofra S/N, 38320, La Laguna, Tenerife, Spain.
- Faculty of Medicine, Universidad de La Laguna (ULL), Campus de Ofra, S/N, 38071, La Laguna, Tenerife, Spain.
| | - Beatriz Olías-López
- Orthopaedic Trauma Unit, Department of Orthopaedics, Hospital Universitario Canarias (HUC), Carretera Ofra S/N, 38320, La Laguna, Tenerife, Spain
- Department of Orthopaedics, Hospital Universitario Canarias (HUC), Carretera Ofra S/N, 38320, La Laguna, Tenerife, Spain
| | - Pau Forcada-Calvet
- Department of Anatomy, Faculty of Medicine, Universitat de Lleida (UdL), Avinguda de L'Alcalde Rovira Roure, 80, 25198, Lleida, Spain
| | - Azucena Martín-Herrero
- Orthopaedic Trauma Unit, Department of Orthopaedics, Hospital Universitario Canarias (HUC), Carretera Ofra S/N, 38320, La Laguna, Tenerife, Spain
- Department of Orthopaedics, Hospital Universitario Canarias (HUC), Carretera Ofra S/N, 38320, La Laguna, Tenerife, Spain
| | - Mario Herrera-Pérez
- Department of Orthopaedics, Hospital Universitario Canarias (HUC), Carretera Ofra S/N, 38320, La Laguna, Tenerife, Spain
- Faculty of Medicine, Universidad de La Laguna (ULL), Campus de Ofra, S/N, 38071, La Laguna, Tenerife, Spain
| | - Javier Álvarez-De-La-Cruz
- Department of Orthopaedics, Hospital Universitario Canarias (HUC), Carretera Ofra S/N, 38320, La Laguna, Tenerife, Spain
| | - Alejandro Herrera-Rodríguez
- Department of Orthopaedics, Hospital Universitario Canarias (HUC), Carretera Ofra S/N, 38320, La Laguna, Tenerife, Spain
| | - José Luis Pais-Brito
- Department of Orthopaedics, Hospital Universitario Canarias (HUC), Carretera Ofra S/N, 38320, La Laguna, Tenerife, Spain
- Faculty of Medicine, Universidad de La Laguna (ULL), Campus de Ofra, S/N, 38071, La Laguna, Tenerife, Spain
| |
Collapse
|
3
|
den Berg JV, Reul M, Vinckier O, Derksen RJ, Nijs S, Verhofstad M, Hoekstra H. Posterior tibial plateau fracture treatment with the new WAVE posterior proximal tibia plate: feasibility and first results. Eur J Trauma Emerg Surg 2021; 48:1285-1294. [PMID: 33710401 DOI: 10.1007/s00068-021-01639-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 03/03/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Operative management of posterior tibial plateau fractures (PTPF) remains challenging. The treatment goal is to restore the alignment and articular congruence, and providing sufficient stability which allows early mobilization. The purpose of this study was to assess the feasibility and safety of the newly developed WAVE posterior proximal tibia plate. METHODS Between Oct 2017 and Jun 2020, 30 adult patients with a tibial plateau fracture and posterior involvement were selected for treatment with a WAVE posterior proximal tibia plate. Patient reported outcome was assessed using the Knee injury and Osteoarthritis Outcome Score (KOOS) at time of injury (pre-injury) and at 1-year follow-up. Radiological outcome was evaluated with CT-imaging. RESULTS Twenty-eight patients were eligible for treatment with the new implant (3 'one-column', 10 'two column' and 15 'three-column' fractures), whereas in 2 patients anatomical fit was insufficient. KOOS results showed fair outcome scores at 1 year, with a large negative impact compared to pre-injury levels; however, a trend towards better results compared to a previous PTPF reference cohort. Radiological follow-up showed insufficient posterolateral buttress in two cases and residual articular step-off (> 2 mm) in seven patients, of which five were classified as three column fractures. CONCLUSION Management of PTPF using the WAVE posterior proximal tibia plate is feasible and safe with satisfactory clinical and radiological results after 1 year. Nevertheless, there is a learning curve regarding optimal implant positioning to achieve the maximum benefit of the implant. LEVEL OF EVIDENCE 4.
Collapse
Affiliation(s)
| | - Maike Reul
- Department of Orthopedics and Traumatology, VU Brussel-Free University of Brussels, Brussels, Belgium
| | - Olivier Vinckier
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Stefaan Nijs
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven-University of Leuven, Leuven, Belgium
| | - Michiel Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Harm Hoekstra
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium. .,Department of Development and Regeneration, KU Leuven-University of Leuven, Leuven, Belgium.
| |
Collapse
|
4
|
Van den Berg JD, Quintens L, Zhan Y, Hoekstra H. Why address posterior tibial plateau fractures? Injury 2020; 51:2779-2785. [PMID: 32958346 DOI: 10.1016/j.injury.2020.09.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/15/2020] [Indexed: 02/02/2023]
Abstract
Management of posterior tibial plateau fractures has gained much interest over the past few years. Fracture morphology, trauma mechanism, and soft-tissue injury have been identified as the key factors determining the treatment strategy and outcome. We provide a rationale for the operative management of posterior tibial plateau fractures by discussing the interplay between fracture morphology, trauma mechanism, and soft-tissue injury. The trauma mechanism has proven to be an important tool, not only to understand fracture morphology, but also to assess concomitant soft-tissue (i.e. ligamentous) injury. Subsequently, soft-tissue injury might play a role in future classification and diagnostic work-up of tibial plateau fractures, particularly in fractures with posterior involvement. Plate osteosynthesis using a posterior approach is safe and should be considered routinely in coronal fractures of the posterior tibial plateau, as illustrated.
Collapse
Affiliation(s)
- J D Van den Berg
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium
| | - L Quintens
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium
| | - Y Zhan
- Department of Orthopaedic Surgery, Shanghai Jiaotong University, affiliated Shanghai 6th People's Hospital, Shanghai, China
| | - H Hoekstra
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium; KU Leuven - University of Leuven, Department of Development and Regeneration, B-3000 Leuven, Belgium.
| |
Collapse
|
5
|
Chen C, Huang L, Zheng H, Liu L, Chen Y, Xie X, Wang Y. Combined Direct Posterior Split-Gastrocnemius Approach for the Posterolateral Tibial Plateau Involved Fractures. Ther Clin Risk Manag 2020; 15:1461-1467. [PMID: 31908466 PMCID: PMC6927585 DOI: 10.2147/tcrm.s220307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 12/02/2019] [Indexed: 11/26/2022] Open
Abstract
Background Several approaches of fracture reduction and fixation are employed in complex tibial plateau fractures. However, there is a lack of consensus regarding reduction and fixation for fractures to the posterolateral part of the tibial plateau. Hypothesis The combined direct posterior split-gastrocnemius approach may be a choice of the posterior part involved comminuted tibial plateau fractures. Patients and methods We review cases of 216 patients with tibial plateau fracture and subsequent operation from 2012/1/1 to 2017/1/1. Fifty-six cases involved posterolateral plateau damage. For these 56 patients, we use anteromedial and direct posterior split-gastrocnemius approaches or anterolateral and direct posterior split-gastrocnemius approaches to fix the posterolateral and medial or lateral segments. Results From the radiography films, all patients (56/56) achieved a good reduction of the articular surface after surgery (31 patients were anatomic reduction, 25 patients were acceptable reduction). After 12 months follow up, only 2 patients showed poor reduction and no significant difference between <3 days after surgery and 12 months follow up. All patients acquired good knee functions at 12 months’ time-point of the fracture surgery. These patients have less pain and other related symptoms in daily living according to the Knee Injury and Osteoarthritis Scores. Conclusion The direct posterior split-gastrocnemius approach provides efficient and less invasive access to the posterolateral tibial plateau, which is suitable for direct reduction and rigid fixation to the fragments of posterolateral tibial fractures. It is a valuable choice when mapping a surgical approach to tibial plateau fracture reduction involving the posterior tibial plateau and its implementation may offer better post-operative functionality relative to alternative approaches.
Collapse
Affiliation(s)
- Changhong Chen
- Department of Orthopedics, Affiliated Zhongda Hospital of Southeast University, Nanjing, Jiangsu 210009, People's Republic of China.,Department of Orthopedics, Jiangyin Affiliated Hospital of Nanjing University of Chinese Medicine, Wuxi City, Jiangsu Province 214400, People's Republic of China
| | - Lei Huang
- Department of Orthopedics, Jiangyin Affiliated Hospital of Nanjing University of Chinese Medicine, Wuxi City, Jiangsu Province 214400, People's Republic of China
| | - Huaqing Zheng
- Department of Orthopedics, Jiangyin Affiliated Hospital of Nanjing University of Chinese Medicine, Wuxi City, Jiangsu Province 214400, People's Republic of China
| | - Lin Liu
- Department of Orthopedics, Jiangyin Affiliated Hospital of Nanjing University of Chinese Medicine, Wuxi City, Jiangsu Province 214400, People's Republic of China
| | - Yaofei Chen
- Department of Orthopedics, Affiliated Zhongda Hospital of Southeast University, Nanjing, Jiangsu 210009, People's Republic of China
| | - Xinhui Xie
- Department of Orthopedics, Affiliated Zhongda Hospital of Southeast University, Nanjing, Jiangsu 210009, People's Republic of China
| | - Yuntao Wang
- Department of Orthopedics, Affiliated Zhongda Hospital of Southeast University, Nanjing, Jiangsu 210009, People's Republic of China
| |
Collapse
|
6
|
Krause M, Krüger S, Müller G, Püschel K, Frosch KH. How can the articular surface of the tibial plateau be best exposed? A comparison of specific surgical approaches. Arch Orthop Trauma Surg 2019; 139:1369-1377. [PMID: 31101980 DOI: 10.1007/s00402-019-03200-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The correct choice of a fracture-specific surgical approach with an articular accessibility in complex tibial plateau fractures to facilitate durable fracture fixation of the anatomic articular reconstruction is under debate, as the most important risk factor for malreduction in complex tibial plateau fractures is an impaired visualization of the articular surface. MATERIALS AND METHODS Six established surgical approaches were simulated on 12 cadaver knees. The visible articular surface was labeled with an electrocautery device for each approach and subsequently analyzed with ImageJ. Areas of each hemiplateau were compared using the Student's t test. RESULTS In the lateral tibial plateau, the dorsal 19.0 ± 5.8% of the articular surface could be exposed via the postero-lateral approach. Via the antero-lateral arthrotomy, 36.6 ± 9.4% of the anterior articular surface was visible. The additional osteotomy of the lateral femoral epicondyle significantly increased the exposure to 65.6 ± 7.7% (p < 0.001). In the medial tibial plateau, the osteotomy of the medial femoral epicondyle significantly improved visualization of the medial articular surface (62.3 ± 8.6%) compared to the postero-medial approach (14.0 ± 7.3%) and the antero-medial approach (36.9 ± 9.2%) of the articular (p < 0.001). CONCLUSIONS Visualization of the tibial articular surface is limited through specific surgical approaches. Extension by osteotomy of the femoral epicondyle led to a significant improvement in the articular exposure without, however, obtaining sufficient visibility of the posterior joint segments, which should be included in the preoperative strategy. The proposed surgical approach-specific map of the tibial plateau may constitute an important instrument in the toolbox of an experienced surgeon to treat complex tibial plateau fractures at the highest level. LEVEL OF EVIDENCE Level IV.
Collapse
Affiliation(s)
- Matthias Krause
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sebastian Krüger
- Department of Trauma and Reconstructive Surgery, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Gunnar Müller
- Department of Trauma and Reconstructive Surgery, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Klaus Püschel
- Department of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| |
Collapse
|
7
|
Li YS, Lin KC, Chen CY, Tarng YW, Chang WN. Popliteal artery occlusion concomitant with a tibial plateau fracture and posterior cruciate ligament avulsion fracture. J Int Med Res 2019; 48:300060519869073. [PMID: 31510833 PMCID: PMC7593672 DOI: 10.1177/0300060519869073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
In acute trauma, posterior cruciate ligament (PCL) injury may occur concomitantly with a
bony fracture and be easily overlooked. A popliteal artery injury associated with a tibial
plateau fracture and PCL avulsion fracture is rare. Missed or delayed diagnosis of this
condition leads to a high amputation rate. Therefore, close attention is required with
this type of injury. The limb can be saved though early detection and immediate
reconstruction of the injured artery, followed by fasciotomy. We report here a rare case
of popliteal artery occlusion proximal to the surgical zone, which was diagnosed after
fixation of a medial tibial plateau fracture and posterior cruciate avulsion injury. In
dashboard injuries without knee dislocation, the arterial intima may be injured and become
vulnerable, even with an initial ankle brachial index greater than 0.9. This can cause
concomitant occlusion of the popliteal artery due to iatrogenic retraction during surgery.
Therefore, a neurovascular examination should be repeated to prevent delayed-onset
thrombosis. To the best of our knowledge, this is the first case of popliteal artery
injury concomitant with a tibial plateau fracture and PCL avulsion owing to initial
dashboard injury-related arterial intima injury, which can present with a normal ankle
brachial index.
Collapse
Affiliation(s)
- Yi-Syuan Li
- Department of Orthopaedics, Kaohsiung Veterans General Hospital, Kaohsiung City
| | - Kai-Cheng Lin
- Department of Orthopaedics, Kaohsiung Veterans General Hospital, Kaohsiung City
| | - Chun-Yu Chen
- Department of Orthopaedics, Kaohsiung Veterans General Hospital, Kaohsiung City
| | - Yih-Wen Tarng
- Department of Orthopaedics, Kaohsiung Veterans General Hospital, Kaohsiung City
| | - Wei-Ning Chang
- Department of Orthopaedics, Kaohsiung Veterans General Hospital, Kaohsiung City
| |
Collapse
|
8
|
Treatment of AO/OTA 43-C3 Pilon Fracture: Be Aware of Posterior Column Malreduction. BIOMED RESEARCH INTERNATIONAL 2019; 2019:4265782. [PMID: 31111053 PMCID: PMC6487132 DOI: 10.1155/2019/4265782] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 03/26/2019] [Indexed: 11/17/2022]
Abstract
Treatment of pilon fractures remains challenging due to the difficulty of fracture reduction and associated soft tissue complications. The aim of this study was to evaluate the pitfalls and strategies of posterior column reduction in the treatment of complex tibial pilon fractures (AO/OTA 43-C3). Thirteen AO/OTA classification 43-C3 type pilon fractures treated between January 2013 and January 2016 were retrospectively analyzed. Nine cases were treated by external fixation within 26 hours (range, 6–56 hours) after injury. The definitive open reduction and internal fixation (ORIF) was performed after the wound was healed without infection and soft tissue swelling had subsided. During the delayed/second-stage operation, the articular surface of the distal tibial plafond was reduced through the posterolateral and anterior approaches. X-ray and CT scans were performed pre- or postoperatively. The reduction quality was evaluated using Burwell–Charnley's radiographic criteria. The follow-up was performed routinely and all complications were recorded. Ankle function was evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score. During the delayed/second-stage operation, primary reduction of the posterior column was performed entirely through posterolateral approaches. However, poor posterior column reduction was revealed by fluoroscopy in four cases, three of which were readjusted through the posterolateral and anterior approaches, and the fourth was adjusted directly through the anterior approach. Postoperative CT scan revealed that the step-off of the articular surface was less than 2 mm in 12 cases, and in only one case the step-off was greater than 2 mm but less than 5 mm. The satisfactory rate was 92.3% according to Burwell–Charnley's reduction criteria. Eleven patients were followed up regularly; superficial infections occurred in two cases but healed after wound care treatment in 3 and 5 weeks, respectively. All eleven fractures were healed within an average of 3.6 months (range, 2.6–5 months). The average range of ankle motion was 19° of dorsiflexion and 28° of plantar-flexion. The mean AOFAS ankle-hindfoot score was 82 (range, 61–92). In our opinion, we suggest that the reduction of the articular surface should be performed through combined posterolateral and anterior approaches in a delayed operation, with flexible fixation of the posterior column. If the posterior column is poorly reduced, the articular surface can easily be manipulated through anterior approaches. According to this strategy, satisfactory outcomes of AO/OTA C3 pilon fractures would be anticipated.
Collapse
|
9
|
Patient-reported quality of life and pain after permissive weight bearing in surgically treated trauma patients with tibial plateau fractures: a retrospective cohort study. Arch Orthop Trauma Surg 2019; 139:483-488. [PMID: 30523446 PMCID: PMC6420896 DOI: 10.1007/s00402-018-3088-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Indexed: 11/13/2022]
Abstract
INTRODUCTION A Dutch survey among orthopedic surgeons and trauma surgeons showed that almost 90% of the surgeons do not follow protocols regarding the weight bearing aftercare for tibial plateau fractures. Clinical studies comparing permissive weight bearing (PWB) versus restricted weight bearing (RWB) after surgically treated tibial plateau fractures are not available. The aim of this study was to inventory potential differences in quality of life and pain, and number of complications in patients with surgically treated tibial plateau fractures who followed a PWB regime, relative to those that followed a RWB regime. MATERIALS AND METHODS This retrospective cohort study included surgically treated trauma patients with tibial plateau fractures, who underwent rehabilitation according to PWB or RWB between 2005 and 2015. Data such as demographics, patient-reported quality of life and pain, and patient outcome were collected. RESULTS This cohort study included 91 patients with a tibial plateau fracture (31 and 60 patients in the PWB and RWB groups respectively). No significant between-group differences in either age or gender were found. However, a significant difference in fracture type was found between groups, (p = 0.04). No significant differences were found in either patient-reported SF-12 or VAS scores between the PWB group and RWB group. Time to full weight bearing was significantly shorter in the PWB than in the RWB group, i.e., 14.7 versus 20.7 weeks, (p = 0.02). No significant differences were found regarding postoperative complications between the PWB and the RWB groups, i.e., 6.5% versus 10.0%, respectively. CONCLUSION PWB after surgically treated tibial plateau fractures is safe and is related to a significantly reduced time to full weight bearing with no significant differences in patient-reported quality of life and pain or complication rates.
Collapse
|
10
|
Sinha S, Singh M, Saraf SK, Rastogi A, Rai AK, Singh TB. Fixation of Posterior Tibial Plateau Fracture with Additional Posterior Plating Improves Early Rehabilitation and Patient Satisfaction. Indian J Orthop 2019; 53:472-478. [PMID: 31080290 PMCID: PMC6501631 DOI: 10.4103/ortho.ijortho_295_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Posterior tibial plateau fractures (PTPF) are difficult to manage because of options of multiple approaches, paucity of implants, and lack of ideal construct for fixation. We investigated the benefits of using posterior approach and buttress plate for fixation of the posterior tibial condylar fractures in terms of the fracture healing rate, clinico-radiological, perioperative morbidity, and patient-related outcomes and compared them in those who achieved acceptable reduction without posterior stabilization. PATIENTS AND METHODS Seventy two patients with posterior tibial plateau fractures were prospectively followed after random allocation into two Groups A and B. Thirty eight patients of Group A (dual plating) were managed with stabilization of posterior fragment with Lobenhoffer approach in addition to anterolateral plating. Thirty four patients of Group B (single plate) were managed with isolated anterolateral plating after reducing the PTPF. Twelve patients lost to follow-up and sixty patients were available (thirty in either group) for final assessment. Followup was done by clinical examination, radiographs and computed tomography scan, fracture union, articular continuity, and deformities around the knee. Subjective outcome assessment was done with the International Knee Documentation Committee (IKDC) 2000 and Knee Society Score (KSS). RESULTS At 1-year followup, the two groups did not differ in time of fracture union. IKDC and KSS were significantly better in dual-plating group (P < 0.001). Mean operative time and blood loss were more in dual-plating group (A). The mean hospital stay and complications did not show significant differences. CONCLUSION Addition of posterior approach for stabilization of the posterior fragment in posterior tibial plateau fractures achieves early and improved knee functions, good range of movements, minimal deformities, and pain scores by the time fracture unites. However, peri-operative morbidity, Extra implant costs and increased operative time are its disadvantages.
Collapse
Affiliation(s)
- Shivam Sinha
- Department of Orthopaedics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India,Fellow Paediatric Orthopaedics and Limb Lengthening, KUMC, Seoul, South Korea,Fellow Arthroscopy and Arthroplasty, SIOR, Pune, Maharashtra, India,Address for correspondence: Dr. Shivam Sinha, Department of Orthopaedics, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh, India. E-mail:
| | - Mahipat Singh
- Department of Orthopaedics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Shyam K Saraf
- Department of Orthopaedics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Amit Rastogi
- Department of Orthopaedics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Alok K Rai
- Department of Orthopaedics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Tej Bali Singh
- Department of Biostatistics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| |
Collapse
|
11
|
Sun H, He QF, Zhang BB, Zhu Y, Zhang W, Chai YM. A biomechanical evaluation of different fixation strategies for posterolateral fragments in tibial plateau fractures and introduction of the 'magic screw'. Knee 2018; 25:417-426. [PMID: 29678367 DOI: 10.1016/j.knee.2018.03.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 02/28/2018] [Accepted: 03/26/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Posterior plate fixation is biomechanically the strongest fixation method for posterolateral column fracture (PLCF) of the tibial plateau; however, there are inherent deficiencies and risks of a posterior approach. Thus, the 'magic screw' was proposed to enhance fixation stability of the lateral rafting plate used for PLCF. The purpose of this study was to re-examine and compare the stability of different fixation methods for PLCF. METHODS Synthetic tibiae models were used to simulate posterolateral split fractures. The fracture models were randomly assigned into three groups: Group A, fixed with posterolateral buttress plates; Group B, with lateral locking compression plates (LCP); and Group C fixed with lateral LCPs and one 'magic screw'. Gradually increased axial compressive loads were applied to each specimen. RESULTS There was a mean subsidence hierarchy of the posterolateral fragment at different load levels: Group A had the least subsidence, followed by Group C, and Group B had the most. There were no significant differences in the mean loads at different displacements between Group A and Group C. Group A had the highest axial stiffness. Additionally, there was a significant difference in axial stiffness between Group B and Group C. CONCLUSION Biomechanical stability of the combined fixation of the posteriorly positioned lateral rafting plate with the 'magic screw' was much closer to that of posterior plate fixation for split-type PLCF. The necessity of posterior fixation through a posterior approach may be reduced for selected patients.
Collapse
Affiliation(s)
- Hui Sun
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Qi-Fang He
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Bin-Bin Zhang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yi Zhu
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Wei Zhang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
| | - Yi-Min Chai
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
| |
Collapse
|
12
|
Sun DH, Zhao Y, Zhang JT, Zhu D, Qi BC. Anterolateral tibial plateau osteotomy as a new approach for the treatment of posterolateral tibial plateau fracture: A case report. Medicine (Baltimore) 2018; 97:e9669. [PMID: 29505010 PMCID: PMC5779779 DOI: 10.1097/md.0000000000009669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
RATIONALE It is challenging to visualize and reduce a posterolateral tibial plateau fracture through an anterolateral approach as the tibial plateau fragments are often covered by the fibular head and ligamentous structures. PATIENT CONCERNS In this case report, we describe a patient with a depression fracture of the posterolateral quadrant combined with a split fracture of the posteromedial quadrant and an avulsion fracture of the tibial intercondylar eminence. DIAGNOSES Tibial plateau fracture(AO type 41-B3). INTERVENTIONS A posteromedial approach combined with an anterolateral approach and an osteotomy involving the proximal tibiofibular joint of the tibial plateau was used to expose, reduce, and fix the fracture. OUTCOMES There was no risk of injury to the common peroneal nerve or ligaments. The patient is recovering well and is satisfied with the function of the injured knee. LESSONS We recommend anterolateral tibial plateau osteotomy for the treatment of posterolateral tibial plateau fractures in clinical practice.
Collapse
|
13
|
Are there four tibial plateau columns? Yes there are, as illustrated by a postero-lateral apple-bite fracture. Response to a letter-to-the-editor. INTERNATIONAL ORTHOPAEDICS 2017; 42:443-446. [DOI: 10.1007/s00264-017-3686-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 10/30/2017] [Indexed: 01/12/2023]
|
14
|
Sun H, Zhu Y, He QF, Shu LY, Zhang W, Chai YM. Reinforcement strategy for lateral rafting plate fixation in posterolateral column fractures of the tibial plateau: The magic screw technique. Injury 2017; 48:2814-2826. [PMID: 29096929 DOI: 10.1016/j.injury.2017.10.033] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 10/22/2017] [Accepted: 10/25/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND A posterolateral column fracture of the tibial plateau (PLCF) is not uncommon, especially lateral and bicondylar tibial plateau fractures. Currently, there is no consensus on the methods of surgical treatment for PLCF, including the surgical approach or the fixation strategy. Though various posterior approaches have been explored and can allow posterior buttress plate fixation, the necessity of a posterior approach with fixation for PLCFs is increasingly questioned. Meanwhile, there is no literature to analyse the morphological features of PLCFs. None of the available surgical techniques can solve all of the problems of PLCFs. METHODS From February 2016 to June 2016, an inconsecutive series of 16 patients who suffered Schatzker type II tibial plateau fractures involving the posterolateral column were selected based on an analysis of the morphological characteristics of PLCFs. The patients were all treated by lateral rafting plate fixation with magic screw implantation through the extended lateral approach. RESULTS According to PLCF morphology, 4 patients had mild slope-type depression fractures (MSDF) of the articular surface, and the other 12 patients had block-type splitting fractures (BSF). After a 12-month follow-up period, there were no complications related to the fixation technique and no significant changes in limb alignment. At the final follow-up, the average range of motion (ROM) of the affected knees was 2.3°-125°, and the average HSS score was 94.2. CONCLUSIONS The selected patients who suffered Schatzker type II fractures involving the posterolateral column could be successfully treated via lateral rafting plate fixation with the magic screw technique. For PLCF treatment, magic screw fixation is a valuable technique that may reduce the utilization of posterior approaches and posterior fixations.
Collapse
Affiliation(s)
- Hui Sun
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, 600 YiShan Road, Shanghai, 200233, China.
| | - Yi Zhu
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, 600 YiShan Road, Shanghai, 200233, China.
| | - Qi-Fang He
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, 600 YiShan Road, Shanghai, 200233, China.
| | - Lin-Yuan Shu
- Department of Emergency, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, 600 YiShan Road, Shanghai, 200233, China.
| | - Wei Zhang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, 600 YiShan Road, Shanghai, 200233, China.
| | - Yi-Min Chai
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, 600 YiShan Road, Shanghai, 200233, China.
| |
Collapse
|
15
|
Arnold JB, Tu CG, Phan TM, Rickman M, Varghese VD, Thewlis D, Solomon LB. Characteristics of postoperative weight bearing and management protocols for tibial plateau fractures: Findings from a scoping review. Injury 2017; 48:2634-2642. [PMID: 29102370 DOI: 10.1016/j.injury.2017.10.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 10/10/2017] [Accepted: 10/28/2017] [Indexed: 02/02/2023]
Abstract
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.
Collapse
Affiliation(s)
- John B Arnold
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Sansom Institute for Health Research, School of Health Sciences, University of South Australia, Adelaide, Australia
| | - Chen Gang Tu
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Port Road, Adelaide, SA, Australia
| | - Tri M Phan
- Hospital for Trauma and Orthopaedics, Ho Chi Minh, Vietnam
| | - Mark Rickman
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Port Road, Adelaide, SA, Australia; Centre for Orthopaedic and Trauma Research, Discipline of Orthopaedics and Trauma, University of Adelaide, Adelaide, Australia
| | - Viju Daniel Varghese
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Port Road, Adelaide, SA, Australia
| | - Dominic Thewlis
- Centre for Orthopaedic and Trauma Research, Discipline of Orthopaedics and Trauma, University of Adelaide, Adelaide, Australia
| | - Lucian B Solomon
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Port Road, Adelaide, SA, Australia; Centre for Orthopaedic and Trauma Research, Discipline of Orthopaedics and Trauma, University of Adelaide, Adelaide, Australia.
| |
Collapse
|
16
|
Zhang P, Lian K, Luo D, Huang Z, Li T, Lin D. A combined approach for the treatment of lateral and posterolateral tibial plateau fractures. Injury 2016; 47:2326-2330. [PMID: 27440528 DOI: 10.1016/j.injury.2016.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 07/03/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The treatment of tibial plateau fractures involving the lateral and posterolateral column is a demanding and fine surgical challenge. The purpose of this study was to evaluate the safety and clinical efficacy of combined approach for the treatment of lateral and posterolateral tibial plateau fractures. METHODS A prospective study was performed in 17 patients with lateral and posterolateral tibial plateau fractures between January 2009 and December 2012. There were 12 males and 5 females with a mean age of 40 years. All of them received dual-plate fixation through the combined approach, with the patients in a floating position. The combined approaches included a conventional anterolateral approach and an inverted L-shaped posterolateral approach. Operation time, intraoperative blood loss, fracture healing time, Hospital for Special Surgery (HSS) knee score, knee flexion and extension range of motion, and complications were recorded to evaluate treatment effects. RESULTS There were no intraoperative complications related to this technology. Mean operation time was 144min with a mean intraoperative blood loss volume of 233mL. The mean follow-up was 23 months. All 17 patients had good postoperative fracture healing. Mean union time was 12 weeks. At the final follow-up, the average HSS score was 92.5, with the average knee flexion of 125° and an average knee extension of 2°. Two patients had complications in postoperative incisions with aseptic fat liquefaction. After thorough debridement, second-stage wounds healing were achieved. No neurovascular injury occurred. No collapse of reduced articular surface was detected. CONCLUSIONS The combined approach with dual-plate offers direct and complete surgical exposure and provide an effective method for the treatment of lateral and posterolateral tibial plateau fractures.
Collapse
Affiliation(s)
- Peng Zhang
- Department of Orthopaedic Surgery, The Affiliated Southeast Hospital of Xiamen University, Zhangzhou, China
| | - Kejian Lian
- Department of Orthopaedic Surgery, The Affiliated Southeast Hospital of Xiamen University, Zhangzhou, China
| | - Deqing Luo
- Department of Orthopaedic Surgery, The Affiliated Southeast Hospital of Xiamen University, Zhangzhou, China
| | - Zunxian Huang
- Department of Orthopaedic Surgery, The Affiliated Southeast Hospital of Xiamen University, Zhangzhou, China
| | - Teng Li
- Department of Orthopaedic Surgery, The Affiliated Southeast Hospital of Xiamen University, Zhangzhou, China
| | - Dasheng Lin
- Department of Orthopaedic Surgery, The Affiliated Southeast Hospital of Xiamen University, Zhangzhou, China; Experimental Surgery and Regenerative Medicine, Department of Surgery, Ludwig Maximilians University, Munich, Germany.
| |
Collapse
|
17
|
Tomás-Hernández J, Monyart JM, Serra JT, Vinaixa MR, Farfan EG, García VM, Feliu EC. Large fracture of the anteromedial tibial plateau with isolated posterolateral knee corner injury: case series of an often missed unusual injury pattern. Injury 2016; 47 Suppl 3:S35-S40. [PMID: 27692105 DOI: 10.1016/s0020-1383(16)30604-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Tibial plateau fractures are a heterogeneous group of lesions with multiple fracture patterns. They are often associated with soft tissue injuries, the lateral meniscus and the anterior cruciate ligament (ACL) being the most common structures affected. The purpose of this article is to present a case series of an often missed unusual injury pattern that consists on the association of a large anteromedial tibial plateau fracture with a posterolateral (PL) knee corner injury without involvement of the cruciate ligaments. The diagnosis of PL complex injury may go unrecognized in a considerable number of cases and delay on the treatment decreases the success rate of soft tissue repairing. The importance of a high index of suspicion and a proper early diagnosis with an MRI is of paramount importance. We also describe the current surgical management used by the authors and review of the current literature.
Collapse
Affiliation(s)
- Jordi Tomás-Hernández
- Department of Orthopaedic and Trauma Surgery, Trauma Unit, Hospital Vall d'Hebron - Universitat Autonoma de Barcelona (UAB), Passeig Vall d'Hebron, Barcelona, Spain.
| | - Joan Minguell Monyart
- Department of Orthopaedic and Trauma Surgery, Knee Unit, Hospital Vall d'Hebron - Universitat Autonoma de Barcelona (UAB), Passeig Vall d'Hebron, Barcelona, Spain
| | - Jordi Teixidor Serra
- Department of Orthopaedic and Trauma Surgery, Trauma Unit, Hospital Vall d'Hebron - Universitat Autonoma de Barcelona (UAB), Passeig Vall d'Hebron, Barcelona, Spain
| | - Merce Reverté Vinaixa
- Department of Orthopaedic and Trauma Surgery, Knee Unit, Hospital Vall d'Hebron - Universitat Autonoma de Barcelona (UAB), Passeig Vall d'Hebron, Barcelona, Spain
| | - Ernesto Guerra Farfan
- Department of Orthopaedic and Trauma Surgery, Trauma Unit, Hospital Vall d'Hebron - Universitat Autonoma de Barcelona (UAB), Passeig Vall d'Hebron, Barcelona, Spain
| | - Vicente Molero García
- Department of Orthopaedic and Trauma Surgery, Trauma Unit, Hospital Vall d'Hebron - Universitat Autonoma de Barcelona (UAB), Passeig Vall d'Hebron, Barcelona, Spain
| | - Enric Castellet Feliu
- Department of Orthopaedic and Trauma Surgery, Knee Unit, Hospital Vall d'Hebron - Universitat Autonoma de Barcelona (UAB), Passeig Vall d'Hebron, Barcelona, Spain
| |
Collapse
|
18
|
Updated Three-Column Concept in surgical treatment for tibial plateau fractures - A prospective cohort study of 287 patients. Injury 2016; 47:1488-96. [PMID: 27211226 DOI: 10.1016/j.injury.2016.04.026] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 04/12/2016] [Accepted: 04/19/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE This study introduces an updated Three-Column Concept for the classification and treatment of complex tibial plateau fractures. A combined preoperative assessment of fracture morphology and injury mechanism is utilized to determine surgical approach, implant placement and fixation sequence. The effectiveness of this updated concept is demonstrated through evaluation of both clinical and radiographic outcome measures. PATIENTS AND METHODS From 2008 to 2012, 355 tibial plateau fractures were treated using the updated Three-Column Concept. Standard radiographic and computed tomography imaging are used to systematically assess and classify fracture patterns as follows: (1) identify column(s) injured and locate associated articular depression or comminution, (2) determine injury mechanism including varus/valgus and flexion/extension forces, and (3) determine surgical approach(es) as well as the location and function of applied fixation. Quality and maintenance of reduction and alignment, fracture healing, complications, and functional outcomes were assessed. RESULTS 287 treated fractures were followed up for a mean period of 44.5 months (range: 22-96). The mean time to radiographic bony union and full weight-bearing was 13.5 weeks (range: 10-28) and 14.8 weeks (range: 10-26) respectively. The average functional Knee Society Score was 93.0 (range: 80-95). The average range of motion of the affected knees was 1.5-121.5°. No significant difference was found in knee alignment between immediate and 18-month post-operative measurements. Additionally, no significant difference was found in functional scores and range of motion between one, two and three-column fracture groups. Twelve patients suffered superficial infection, one had limited skin necrosis and two had wound dehiscence, that healed with nonoperative management. Intraoperative vascular injury occurred in two patients. Fixation of failure was not observed in any of the fractures treated. CONCLUSION An updated Three-Column Concept assessing fracture morphology and injury mechanism in tandem can be used to guide surgical treatment of tibial plateau fractures. Limited results demonstrate successful application of biologically friendly fixation constructs while avoiding fixation failure and associated complications of both simple and complex tibial plateau fractures. LEVEL OF EVIDENCE Level II, prospective cohort study.
Collapse
|
19
|
Kokkalis ZT, Iliopoulos ID, Pantazis C, Panagiotopoulos E. What's new in the management of complex tibial plateau fractures? Injury 2016; 47:1162-9. [PMID: 26989043 DOI: 10.1016/j.injury.2016.03.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The management of complex tibial plateau fractures is ever evolving. The severity of the injury to the surrounding soft tissues influences the timing and the method of fixation. Minimal invasive techniques continue to dominate our philosophy of reduction and reconstruction whereas augmentation of depressed intra-articular fragments remains an accepted strategy to maintain reduction and prevent secondary collapse. Locking plates, conventional plates and fine wire fixators all have been used successfully with satisfactory outcomes. In this article we report on the latest advances made in the management of these complex injuries.
Collapse
Affiliation(s)
- Zinon T Kokkalis
- University of Patras, School of Medicine, University Hospital of Patras, Department of Orthopaedics, Papanikolaou 1, 26504 Rio-Patras, Greece.
| | - Ilias D Iliopoulos
- University of Patras, School of Medicine, University Hospital of Patras, Department of Orthopaedics, Papanikolaou 1, 26504 Rio-Patras, Greece
| | - Constantinos Pantazis
- University of Patras, School of Medicine, University Hospital of Patras, Department of Orthopaedics, Papanikolaou 1, 26504 Rio-Patras, Greece
| | - Elias Panagiotopoulos
- University of Patras, School of Medicine, University Hospital of Patras, Department of Orthopaedics, Papanikolaou 1, 26504 Rio-Patras, Greece.
| |
Collapse
|
20
|
Giannotti S, Giovannelli D, Dell'Osso G, Bottai V, Bugelli G, Celli F, Citarelli C, Guido G. Angular stable plates in proximal meta-epiphyseal tibial fractures: study of joint restoration and clinical and functional evaluation. Musculoskelet Surg 2016; 100:15-18. [PMID: 26590578 DOI: 10.1007/s12306-015-0389-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 11/12/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND The tibial plateau fractures involve one of the main weight bearing joints of the human body. The goals of surgical treatment are anatomical reduction, articular surface reconstruction and high primary stability. The aim of this study was to evaluate the clinical and functional outcomes after internal plate fixation of this kind of fractures. MATERIALS AND METHODS From January 2009 to December 2012, we treated 75 cases of tibial plateau fracture with angular stable plates. We used Rasmussen Score and the Knee Society Score for the clinical and functional evaluation. Twenty-five cases that underwent hardware removal had arthroscopic and CT evaluation of the joint. RESULTS No complications occurred. The clinical and functional evaluation, performed by the KSS and Rasmussen Score, highlighted the high percentage of good-to-excellent results (over 90 %). In every case, the range of motion was good with flexion >90°. Arthroscopy showed the presence of chondral damage in 100 % of patients. In all the cases, we found that X-ray images seem better than the CT images. CONCLUSIONS Angular stable plates allow to obtain a good primary stability, permitting an early joint recovery with an excellent range of motion. Avoiding to perform a knee arthrotomy at the time of fracture reduction could prove to be an advantage in terms of functional recovery. The meniscus on the injured bone should be preserved in order to maintain good function of the joint. X-ray images remain the gold standard in checking the progression of post-traumatic osteoarthritis.
Collapse
Affiliation(s)
- S Giannotti
- IInd Orthopaedic and Traumatologic Clinic, University of Pisa, Pisa, Italy.
| | - D Giovannelli
- IInd Orthopaedic and Traumatologic Clinic, University of Pisa, Pisa, Italy
| | - G Dell'Osso
- IInd Orthopaedic and Traumatologic Clinic, University of Pisa, Pisa, Italy
| | - V Bottai
- IInd Orthopaedic and Traumatologic Clinic, University of Pisa, Pisa, Italy
| | - G Bugelli
- IInd Orthopaedic and Traumatologic Clinic, University of Pisa, Pisa, Italy
| | - F Celli
- IInd Orthopaedic and Traumatologic Clinic, University of Pisa, Pisa, Italy
| | - C Citarelli
- IInd Orthopaedic and Traumatologic Clinic, University of Pisa, Pisa, Italy
| | - G Guido
- IInd Orthopaedic and Traumatologic Clinic, University of Pisa, Pisa, Italy
| |
Collapse
|
21
|
Hoekstra H, Rosseels W, Luo CF, Nijs S. A combined posterior reversed L-shaped and anterolateral approach for two column tibial plateau fractures in Caucasians: A technical note. Injury 2015; 46:2516-9. [PMID: 26520364 DOI: 10.1016/j.injury.2015.10.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 10/08/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Open reduction and internal fixation of two column posterior and lateral tibial plateau fractures through a combined posterior reversed L-shaped and anterolateral approach in floating position in Caucasians. INDICATIONS Two column posterior and lateral tibial plateau fractures. CONTRAINDICATIONS Tibial plateau fractures that do not involve the posterior and lateral column. SURGICAL TECHNIQUE The patient is positioned in floating position, a reversed L-shaped skin incision is made, the posterior column after lateral retraction of the medial head of the gastrocnemius muscle is exposed, and the posterior fragments are reduced and fixed. Subsequently, flexion and varus stress on the knee is applied, an anterolateral skin incision is made, the lateral column is exposed, and the lateral fragments are reduced and fixed. CONCLUSION Despite a different physique as Asians, a combined posterior reversed L-shaped and anterolateral approach in a floating position for the surgical treatment of two column posterior and lateral tibial plateau fractures is technically possible in Caucasians. In our experience, this combined approach is an excellent strategy in most patients for surgical treatment of two column posterior and lateral column fractures.
Collapse
Affiliation(s)
- H Hoekstra
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium; KU Leuven - University of Leuven, Department of Development and Regeneration, B-3000 Leuven, Belgium.
| | - W Rosseels
- KU Leuven - University of Leuven, Faculty of Medicine, B-3000 Leuven, Belgium
| | - C-F Luo
- Shanghai Sixth People's Hospital, Shanghai Jiaotong University, Department of Orthopedic Surgery, 200233 Shanghai, China
| | - S Nijs
- University Hospitals Leuven, Department of Trauma Surgery, B-3000 Leuven, Belgium; KU Leuven - University of Leuven, Department of Development and Regeneration, B-3000 Leuven, Belgium
| |
Collapse
|