1
|
Heiman E, Menken LG, Tang A, Vialonga M, Jankowski JM, Liporace FA, Yoon RS. Early versus Standard Weight Bearing Following Operative Treatment of Tibial Plateau Fractures: Do We Really Have to Wait So Long? J Knee Surg 2024; 37:402-408. [PMID: 37586405 DOI: 10.1055/s-0043-1772232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Postoperative management of tibial plateau fractures classically involves a prolonged period between 10 and 12 weeks of nonweight bearing or partial weight bearing. In recent years, there has been some support for earlier weight-bearing protocols although this remains controversial. The goal of this study was to investigate the difference in outcomes between early weight-bearing (EWB) and traditional weight-bearing (TWB) protocols. This investigation is a retrospective review of 92 patients treated with open reduction and internal fixation of tibial plateau fractures at a single institution, from August 2018 to September 2020. Subjects were divided into EWB (< 10 weeks) and traditional nonweight bearing groups (≥ 10 weeks). Key outcome measures collected include injury classification, mechanism of injury, surgical fixation method, bone grafting, time to full weight bearing, radiographic time to union, range-of-motion, all-cause complications, and subsidence at an average follow-up time of 1 year. The EWB group had an earlier average time to weight bearing versus the TWB group (6.5 ± 1.4 vs. 11.8 ± 2.3 weeks, p < 0.0001). There was no difference in the classification of fractures treated between the two groups, with Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association B3 fractures the most common in the EWB group, and C3 fractures the most common in the TWB group. Radiographic time to union was no different between the two groups (93.5 ± 53.7 days for EWB vs. 103.7 ± 77.6 days for TWB, p = 0.49). There was no significant difference in complication rates or subsidence. Following operative treatment of tibial plateau fractures, patients who underwent a weight-bearing protocol earlier than 10 weeks were able to recover faster with similar outcomes and complications compared with patients who started weight bearing after 10 weeks or more. LEVEL OF EVIDENCE: III.
Collapse
Affiliation(s)
- Erick Heiman
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center - RWJBarnabas Health, Jersey City, New Jersey
| | - Luke G Menken
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center - RWJBarnabas Health, Jersey City, New Jersey
| | - Alex Tang
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center - RWJBarnabas Health, Jersey City, New Jersey
| | - Mason Vialonga
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center - RWJBarnabas Health, Jersey City, New Jersey
| | - Jaclyn M Jankowski
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center - RWJBarnabas Health, Jersey City, New Jersey
| | - Frank A Liporace
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center - RWJBarnabas Health, Jersey City, New Jersey
| | - Richard S Yoon
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center - RWJBarnabas Health, Jersey City, New Jersey
| |
Collapse
|
2
|
Sato EH, Treu EA, Froerer DL, Zhang C, O'Neill DC, Cizik AM, Haller JM. Establishing the Patient Acceptable Symptom State Thresholds for Patient-Reported Outcomes after Operatively Treated Tibial Plateau Fractures. J Orthop Trauma 2024; 38:121-128. [PMID: 38117573 DOI: 10.1097/bot.0000000000002750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2023] [Indexed: 12/22/2023]
Abstract
OBJECTIVES Define patient-acceptable symptom state (PASS) thresholds and factors affecting PASS thresholds for Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Knee Injury and Osteoarthritis Outcome Score (KOOS) following operatively treated tibial plateau fractures. METHODS DESIGN Retrospective cohort. SETTING Single Level I academic trauma center. PATIENT SELECTION CRITERIA All patients (n = 159) who underwent fixation of a tibial plateau fracture from 2016 to 2021 and completed patient-reported outcome measures (PROMs) at minimum 1-year follow-up were enrolled for the study. OUTCOME MEASURES AND COMPARISONS PASS thresholds for global outcome (PASS-Global), pain (PASS-Pain), and function (PASS-Function) were determined using anchor-based questions such as "How satisfied are you today with your injured lower extremity?" with answer choices of very satisfied, satisfied, neutral, unsatisfied, and very unsatisfied. PASS thresholds for each PROM were calculated using 3 methods: (1) 80% specificity, (2) 75th percentile, and (3) Youden Index. RESULTS Sixty percent of patients were satisfied with their global outcome and 53% with function. Using 80% specificity, 75th percentile, and Youden Index, PASS-Global thresholds were 48.5, 44.5, and 47.9 for PROMIS-PF and 56.3, 56.2, and 56.3 for KOOS-QOL, respectively. PASS-Pain threshold for KOOS-Pain was 84.4, 80.6, and 80.6, respectively. PASS-Function thresholds were 48.9, 46.8, and 48 for PROMIS-PF and 94.1, 90.2, and 86.8 for KOOS-ADL, respectively. Younger patients and those with bicondylar fractures or infections were associated with significantly lower PASS-Pain thresholds. Schatzker II fractures, lateral column involvement, or isolated lateral approach resulted in significantly higher PASS-Global and PASS-Function thresholds. CONCLUSIONS This study defines global, functional, and pain PASS thresholds for tibial plateau fractures. Patients with bicondylar fractures, infections, and medial column involvement were more often unsatisfied. These thresholds are valuable references to identify patients who have attained satisfactory outcomes and to counsel patients with risk factors for unsatisfactory outcomes following tibial plateau fractures. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Eleanor H Sato
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT
| | | | | | | | | | | | | |
Collapse
|
3
|
Craig A, Barron E, Sharma H, Moulder E. Do Patients Achieve "Full Weight-bearing" Immediately Following Application of Circular Frame Fixation of the Lower Limb? Strategies Trauma Limb Reconstr 2024; 19:40-44. [PMID: 38752187 PMCID: PMC11091893 DOI: 10.5005/jp-journals-10080-1605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/10/2024] [Indexed: 05/18/2024] Open
Abstract
Introduction The decision to use circular frame fixation for lower limb trauma, or elective deformity correction, often accompanies the assertion that the patient will be able to fully weight-bear through the limb immediately following surgery. Materials and methods About 53 patients underwent retrospective review. Included in the study were current attendees of adult specialist physiotherapy, following circular frame application to the lower leg at our Institution between August 2018 and January 2020. Cases with incomplete data, cases given postoperative status of non-weight-bearing, those with physiotherapy follow-up conducted elsewhere, or cases of polytrauma were excluded from the study.Weight-bearing assessment and rehabilitation supervision were at the discretion of the physiotherapy team. The clinical concept of 'full weight-bearing' is poorly defined, but was documented in the context of displaying a stable gait using elbow crutches and subsequently without walking aids. Comparative data was analysed using an unpaired, two-tailed Welch's t-test. Results Mean postoperative time to full weight-bearing using crutches was 28.3 days (0-159) (n = 40).Mean postoperative time to independent full weight-bearing with no walking aids was 230.6 days (35-393), or 7.1 months (0-12) (n= 34).No significant differences were seen between:Frames for open injuries (n= 5) vs closed injuries (n = 17; p > 0.4).Joint-spanning constructs (n= 18) vs non-spanning constructs (n = 21; p > 0.6), orTreatment of intra-articular injuries (n = 14) vs extra-articular injuries (n = 17; p > 0.2).Interpretation of these results should be made with caution due to sample size. Conclusion The ability to permit patients to fully weight-bear immediately after surgery is often a distinct advantage of the circular frame over other fixation modalities, for a variety of indications. However, it does not follow that patients are capable of doing so; there is a long dependency on walking aids. This would appear to be the case irrespective of open/closed injuries, intra-/extra-articular injuries, or the use of a spanning construct across the knee or ankle. How to cite this article Craig A, Barron E, Sharma H, et al. Do Patients Achieve "Full Weight-bearing" Immediately Following Application of Circular Frame Fixation of the Lower Limb? Strategies Trauma Limb Reconstr 2024;19(1):40-44.
Collapse
Affiliation(s)
- Andy Craig
- Department of Trauma and Orthopaedics, Hull Royal Infirmary, Hull, England, United Kingdom
| | - Elizabeth Barron
- Department of Physiotherapy, Hull Royal Infirmary, Hull, England, United Kingdom
| | - Hemant Sharma
- Department of Trauma and Orthopaedics, Hull Royal Infirmary, Hull, England, United Kingdom
| | - Elizabeth Moulder
- Department of Trauma and Orthopaedics, Hull Royal Infirmary, Hull, England, United Kingdom
| |
Collapse
|
4
|
Dong W, Lisitano LSJ, Marchand LS, Reider LM, Haller JM. Weight-bearing Guidelines for Common Geriatric Upper and Lower Extremity Fractures. Curr Osteoporos Rep 2023; 21:698-709. [PMID: 37973761 DOI: 10.1007/s11914-023-00834-2] [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] [Accepted: 11/03/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review paper is to summarize current weight-bearing guidelines for common geriatric fractures, around weight-bearing joints, of the upper and lower extremities. RECENT FINDINGS There is an increasing amount of literature investigating the safety and efficacy of early weight-bearing in geriatric fractures, particularly of the lower extremity. Many recent studies, although limited, suggest that early weight-bearing may be safe for geriatric distal femur and ankle fractures. Given the limited data pertaining to early weight-bearing in geriatric fractures, it is difficult to establish concrete weight-bearing guidelines in this population. However, in the literature available, early weight-bearing appears to be safe and effective across most injuries. The degree and time to weight-bearing vary significantly based on fracture type and treatment method. Future studies investigating postoperative weight-bearing protocols should focus on the growing geriatric population and identify methods to address specific barriers to early weight-bearing in these patients such as cognitive impairment, dependence on caregivers, and variations in post-acute disposition.
Collapse
Affiliation(s)
- Willie Dong
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Leonard S J Lisitano
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Lucas S Marchand
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Lisa M Reider
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Justin M Haller
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA.
| |
Collapse
|
5
|
Wei G, Niu X, Li Y, Chang T, Zhang J, Wang H, Li X, He Y, Wang R, Tian F, Xu Y. Biomechanical analysis of internal fixation system stability for tibial plateau fractures. Front Bioeng Biotechnol 2023; 11:1199944. [PMID: 37388773 PMCID: PMC10303893 DOI: 10.3389/fbioe.2023.1199944] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/06/2023] [Indexed: 07/01/2023] Open
Abstract
Background: Complex bone plateau fractures have been treated with bilateral plate fixation, but previous research has overemphasized evaluating the effects of internal fixation design, plate position, and screw orientation on fracture fixation stability, neglecting the internal fixation system's biomechanical properties in postoperative rehabilitation exercises. This study aimed to investigate the mechanical properties of tibial plateau fractures after internal fixation, explore the biomechanical mechanism of the interaction between internal fixation and bone, and make suggestions for early postoperative rehabilitation and postoperative weight-bearing rehabilitation. Methods: By establishing the postoperative tibia model, the standing, walking and running conditions were simulated under three axial loads of 500 N, 1000 N, and 1500 N. Accordingly, finite element analysis (FEA) was performed to analyze the model stiffness, displacement of fractured bone fragments, titanium alloy plate, screw stress distribution, and fatigue properties of the tibia and the internal fixation system under various conditions. Results: The stiffness of the model increased significantly after internal fixation. The anteromedial plate was the most stressed, followed by the posteromedial plate. The screws at the distal end of the lateral plate, the screws at the anteromedial plate platform and the screws at the distal end of the posteromedial plate are under greater stress, but at a safe stress level. The relative displacement of the two medial condylar fracture fragments varied from 0.002-0.072 mm. Fatigue damage does not occur in the internal fixation system. Fatigue injuries develop in the tibia when subjected to cyclic loading, especially when running. Conclusion: The results of this study indicate that the internal fixation system tolerates some of the body's typical actions and may sustain all or part of the weight early in the postoperative period. In other words, early rehabilitative exercise is recommended, but avoid strenuous exercise such as running.
Collapse
Affiliation(s)
- Guoqiang Wei
- Department of Rehabilitation Medicine, Changzhi Medical College Affiliated Changzhi People’s Hospital, Changzhi, China
| | - Xiaofen Niu
- Department of Rehabilitation Medicine, Changzhi Medical College Affiliated Changzhi People’s Hospital, Changzhi, China
| | - Yuan Li
- Department of Orthopedics, Changzhi Medical College Affiliated Peace Hospital, Changzhi, China
| | - Tingjie Chang
- Department of Orthopedics, Changzhi Medical College Affiliated Peace Hospital, Changzhi, China
| | - Jianfang Zhang
- Department of Rehabilitation Medicine, Changzhi Medical College Affiliated Changzhi People’s Hospital, Changzhi, China
| | - Haiyan Wang
- Department of Anatomy, School of Basic Medical Sciences, Inner Mongolia Medical University, Hohhot, China
| | - Xiaohe Li
- Department of Anatomy, School of Basic Medical Sciences, Inner Mongolia Medical University, Hohhot, China
| | - Yujie He
- Department of Anatomy, School of Basic Medical Sciences, Inner Mongolia Medical University, Hohhot, China
| | - Ruijiang Wang
- Department of Orthopedics, Changzhi Second People’s Hospital, Changzhi, China
| | - Fei Tian
- Department of Health Management, Changzhi Medical College, Changzhi, China
- Department of Rehabilitation Medicine, Changzhi Medical College Affiliated Peace Hospital, Changzhi, China
| | - Yangyang Xu
- Beijing Key Laboratory for Design and Evaluation Technology of Advanced Implantable and Interventional Medical Devices, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| |
Collapse
|
6
|
Bennett KJ, Callary SA, Atkins GJ, Martelli S, Perilli E, Bogdan Solomon L, Thewlis D. Ex vivo assessment of surgically repaired tibial plateau fracture displacement under axial load using large-volume micro-CT. J Biomech 2022; 144:111275. [DOI: 10.1016/j.jbiomech.2022.111275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 07/27/2022] [Accepted: 08/23/2022] [Indexed: 10/31/2022]
|
7
|
Canton G, Sborgia A, Dussi M, Rasio N, Murena L. Early weight bearing in tibial plateau fractures treated with ORIF: a systematic review of literature. J Orthop Surg Res 2022; 17:261. [PMID: 35549974 PMCID: PMC9097122 DOI: 10.1186/s13018-022-03156-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To review the current clinical evidence on advantages and risks of early weight bearing (EWB) after internal fixation for tibial plateau fracture. METHODS Data source: PubMed and Google Scholar from inception of database to 20 August 2021, using PRISMA guidelines. The included studies were randomized controlled trials, prospective and retrospective observational studies, case reports. Data extraction was performed independently by 2 reviewers. Collected data were compared to verify agreement. Statistical analysis was not performed in this study. RESULTS The literature search produced 174 papers from PubMed and 186 from Google Scholar, with a total amount of 360 papers. The two reviewers excluded 301 papers by title or duplicates. Of the 59 remaining, 33 were excluded after reading the abstract, and 17 by reading the full text. Thus, 9 papers were finally included in the review. CONCLUSIONS EWB can be considered safe and effective in selected cases after internal fixation for tibial plateau fractures. Level of evidence Therapeutic Level III.
Collapse
Affiliation(s)
- Gianluca Canton
- Orthopaedics and Traumatology Unit, Department of Medical, Surgical and Life Sciences, Cattinara Hospital, Trieste University, Strada di Fiume 447, 34149, Trieste, Italy
| | - Andrea Sborgia
- Orthopaedics and Traumatology Unit, Department of Medical, Surgical and Life Sciences, Cattinara Hospital, Trieste University, Strada di Fiume 447, 34149, Trieste, Italy.
| | - Micol Dussi
- Orthopaedics and Traumatology Unit, Department of Medical, Surgical and Life Sciences, Cattinara Hospital, Trieste University, Strada di Fiume 447, 34149, Trieste, Italy
| | - Nicholas Rasio
- Orthopaedics and Traumatology Unit, Department of Medical, Surgical and Life Sciences, Cattinara Hospital, Trieste University, Strada di Fiume 447, 34149, Trieste, Italy
| | - Luigi Murena
- Orthopaedics and Traumatology Unit, Department of Medical, Surgical and Life Sciences, Cattinara Hospital, Trieste University, Strada di Fiume 447, 34149, Trieste, Italy
| |
Collapse
|
8
|
Thamyongkit S, Abbasi P, Parks BG, Shafiq B, Hasenboehler EA. Weightbearing after combined medial and lateral plate fixation of AO/OTA 41-C2 bicondylar tibial plateau fractures: a biomechanical study. BMC Musculoskelet Disord 2022; 23:86. [PMID: 35078451 PMCID: PMC8790864 DOI: 10.1186/s12891-022-05024-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 09/01/2021] [Indexed: 11/25/2022] Open
Abstract
Background Combined medial and lateral plate fixation is recommended for complex tibial plateau fractures with medial fragments or no cortical bone contact. Although such fixation is adequate to resist forces during range of motion, it may be insufficient to support immediate postoperative weightbearing. Here, we analyzed displacement, stiffness, and fixation failure during simulated full weightbearing of bicondylar tibial plateau fractures treated with combined medial and lateral locking plate fixation. Methods We used 10 fresh-frozen adult human cadaveric tibias and mated femurs. Osteotomies were performed with an oscillating saw and cutting template to simulate an AO Foundation and Orthopaedic Trauma Association (AO/OTA) 41-C2 fracture (simple articular, multifragmentary metaphyseal fracture). Specimens were anatomically reduced and stabilized with combined medial and lateral locking plates (AxSOS, Stryker, Mahwah, NJ). Specimens were loaded axially to simulate 4 weeks of walking in a person weighing 70 kg. The specimens were cyclically loaded from 200 N to a maximum of 2800 N. Then, if no failure, loading continued for 200,000 cycles. We measured displacement of each bone fragment and defined fixation failure as ≥5 mm of displacement. Construct stiffness and load at failure were calculated. Categorical and continuous data were analyzed using Chi-squared and unpaired t-tests, respectively. Results Mean total displacement values after 10,000 loading cycles were as follows: lateral, 0.4 ± 0.8 mm; proximal medial, 0.3 ± 0.7 mm; distal medial, 0.3 ± 0.6 mm; and central 0.4 ± 0.5 mm. Mean stiffness of the construct was 562 ± 164 N/mm. Fixation failure occurred in 6 of 10 specimens that reached 5 mm of plastic deformation before test completion. In the failure group, the mean load at failure was 2467 ± 532 N, and the mean number of cycles before failure was 53,155. After test completion, the greatest displacement was found at the distal medial fracture site (2.3 ± 1.4 mm) and lateral fracture site (2.2 ± 1.7 mm). Conclusions Although combined medial and lateral plate fixation of complex tibial plateau fractures provides adequate stability to allow early range of motion, immediate full weightbearing is not recommended.
Collapse
Affiliation(s)
- Sorawut Thamyongkit
- Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., #A667, Baltimore, MD, 21224-2780, USA.,Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand
| | - Pooyan Abbasi
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Brent G Parks
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Babar Shafiq
- Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., #A667, Baltimore, MD, 21224-2780, USA
| | - Erik A Hasenboehler
- Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., #A667, Baltimore, MD, 21224-2780, USA.
| |
Collapse
|
9
|
Palke L, Schneider S, Karich B, Mende M, Josten C, Böhme J, Henkelmann R. Anti-gravity treadmill rehabilitation improves gait and muscle atrophy in patients with surgically treated ankle and tibial plateau fractures after one year: A randomised clinical trial. Clin Rehabil 2021; 36:87-98. [PMID: 34355605 DOI: 10.1177/02692155211037148] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To compare the one-year postoperative outcomes of anti-gravity treadmill rehabilitation with those of standard rehabilitation in patients with ankle or tibial plateau fractures. DESIGN An open-label prospective randomised study. SETTING Three trauma centres. SUBJECTS Patients were randomised into the intervention (anti-gravity treadmill) or control (standard protocol) rehabilitation group. MAIN MEASURES The primary endpoint was changes in the Foot and Ankle Outcome Score for ankle fractures and Knee Injury and Osteoarthritis Outcome Score for tibial plateau fractures from baseline to 12 months after operation. Secondary endpoints were the subscores of these scores, muscle atrophy (leg circumference at 20 cm above and 10 cm below the knee joint) and the Dynamic Gait Index. RESULTS Initially, 73 patients (37 vs 36) underwent randomisation. After 12 months, 29 patients in the intervention group and 24 patients in the control group could be analysed. No significant difference was noted in the Foot and Ankle Outcome Score (80.8 ± 18.4 and 78.4 ± 21.1) and Knee Injury and Osteoarthritis Outcome Score (84.8 ± 15.2 and 81.7 ± 17.0). The change in the Dynamic Gait Index from 12 weeks to 12 months differed significantly between the groups (P = 0.04). Patients with tibial plateau fractures had a 3 cm wider thigh circumference in the intervention group than those in the control group (95% confidence interval: -0.2 to 6.3 cm, P = 0.08). CONCLUSION One year after surgery, patients who had undergone anti-gravity treadmill rehabilitation showed better gait than patients in the control group, and those with tibial plateau fractures had less muscle atrophy.
Collapse
Affiliation(s)
- Lisa Palke
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany
| | - Sebastian Schneider
- Hospital St. Georg GmbH, Clinic of Trauma, Orthopaedic and Septic Surgery, Leipzig, Germany; Ambulantes Reha Centrum Leipzig GmbH, Leipzig, Germany
| | - Bernhard Karich
- Department of Trauma and Physical Medicine, Heinrich-Braun-Klinikum GmbH, Zwickau, Germany
| | - Meinhard Mende
- Centre for Clinical Trials and Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Leipzig, Germany
| | - Christoph Josten
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany
| | - Jörg Böhme
- Hospital St. Georg GmbH, Clinic of Trauma, Orthopaedic and Septic Surgery, Leipzig, Germany; Ambulantes Reha Centrum Leipzig GmbH, Leipzig, Germany
| | - Ralf Henkelmann
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany
| |
Collapse
|
10
|
Bennett KJ, Millar SC, Fraysse F, Arnold JB, Atkins GJ, Solomon LB, Martelli S, Thewlis D. Postoperative lower limb joint kinematics following tibial plateau fracture: A 2-year longitudinal study. Gait Posture 2021; 83:20-25. [PMID: 33069125 DOI: 10.1016/j.gaitpost.2020.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 08/30/2020] [Accepted: 10/04/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND The goal of postoperative tibial plateau fracture (TPF) management is to ensure surgical fixation is maintained while returning patients to normal function as soon as possible, allowing patients to resume their normal activities of daily living. The aim of this study was to investigate longitudinal changes in lower limb joint kinematics following TPF and determine how these kinematics relate to self-reported function. METHODS Patients presenting with a TPF were recruited (n = 18) and undertook gait analysis at six postoperative time points (two weeks, six weeks, three months, six months, one and two years). Lower limb joint kinematics were assessed at each time point based on gait data. Statistical parametric mapping (SPM) was undertaken to investigate the change in joint kinematic traces with time. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was assessed at each time point to obtain self-reported outcomes. A healthy reference was also analyzed and used for qualitative comparison of joint kinematics. RESULTS AND SIGNIFICANCE Knee kinematics showed improvements with time, however only minor changes were noted after six weeks at the hip, and six months at the knee and ankle relative to two weeks postoperative. SPM identified significant improvements with time in hip (p < 0.001) and knee (p = 0.003) flexion. No significant changes were observed with time at the ankle however, when compared to the healthy reference, participants showed reduced plantarflexion at two years. Lower limb joint ROM showed significant weak to moderate correlation with the ADL sub-scale of the KOOS (hip r = 0.442, knee r = 0.303, ankle r = 0.367). The lack of significant changes with time and overall reduced plantarflexion at the ankle potentially reduces propulsive capacity during gait up to two years postoperative. In this study, we see a deficiency in joint kinematics in TPF patients up to two years when compared to a healthy reference, especially at the ankle.
Collapse
Affiliation(s)
- Kieran J Bennett
- Centre for Orthopaedic and Trauma Research, The University of Adelaide, SA, Australia.
| | - Stuart C Millar
- Centre for Orthopaedic and Trauma Research, The University of Adelaide, SA, Australia; Alliance for Research in Exercise, Nutrition and Activity (AREAN), Sansom Institute for Health Research, University of South Australia, SA, Australia
| | - Francois Fraysse
- Alliance for Research in Exercise, Nutrition and Activity (AREAN), Sansom Institute for Health Research, University of South Australia, SA, Australia
| | - John B Arnold
- Innovation, Implementation and Clinical Translation in Health (IIMPACT), University of South Australia, Adelaide, Australia
| | - Gerald J Atkins
- Centre for Orthopaedic and Trauma Research, The University of Adelaide, SA, Australia
| | - L Bogdan Solomon
- Centre for Orthopaedic and Trauma Research, The University of Adelaide, SA, Australia; Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Saulo Martelli
- College of Science and Engineering, Flinders University, Adelaide, SA, Australia
| | - Dominic Thewlis
- Centre for Orthopaedic and Trauma Research, The University of Adelaide, SA, Australia
| |
Collapse
|
11
|
Iliopoulos E, Galanis N. Physiotherapy after tibial plateau fracture fixation: A systematic review of the literature. SAGE Open Med 2020; 8:2050312120965316. [PMID: 33133602 PMCID: PMC7576901 DOI: 10.1177/2050312120965316] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 09/18/2020] [Indexed: 11/16/2022] Open
Abstract
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.
Collapse
Affiliation(s)
| | - Nikiforos Galanis
- Division of Sports Medicine, Department of Orthopaedics, Papageorgiou General Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| |
Collapse
|
12
|
Hare KB, Brand E, Bloch T. Highly impacted bone allograft may allow immediate weight bearing in tibial plateau fractures: A case report. Trauma Case Rep 2020; 29:100331. [PMID: 32715076 PMCID: PMC7378690 DOI: 10.1016/j.tcr.2020.100331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2020] [Indexed: 10/25/2022] Open
Abstract
Introduction Proximal tibial fractures are common with an incidence of 10.2/100.000. Those displaced and involving the articular surface will often require surgical treatment. However, no consensus exists on whether to allow the patient early weight bearing or not. We developed a technique using structural bone chips, highly impacted under the articular surface, to permit immediate weight bearing after surgery. Patient The patient was a 44-year old male who suffered a lateral tibial plateau fracture (AO type 41B2). Intervention We used an anterolateral approach with an S-shaped incision. A small window in the tibia was made using an awl, and the articular surface was reduced under radiographic imaging. The bone allograft was prepared by splitting the frozen femoral head in quarters and then taking large pieces of bone with a bone rongeur forceps avoiding the cartilage. The large pieces of bone were gathered in a small tray and thereafter compressed into the drill guide insert. The drill guide filled with bone graft was then inserted into the tibia window and directed in the appropriate position guided by radiography. Hereafter, the bone graft was impacted under the articular surface with force using the appropriate trocar and a hammer, and the fracture was finally reduced. Finally, the fracture was fixated utilizing an angular stable plate. Outcome The patient was followed up one year postoperatively and allowed immediate weight bearing after surgery. No subsequent articular collapse occurred. Discussion In this case, we present a proximal tibial fracture with articular depression, which was surgically treated with a highly impacted bone allograft of large pieces and a locking plate. The patient was allowed immediate weight bearing and no subsequent articular collapse occurred.
Collapse
Affiliation(s)
- Kristoffer B Hare
- Department of Orthopedics, Næstved-Slagelse-Ringsted Hospitals, Region Zealand, Denmark.,Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Region Zealand, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Eske Brand
- Department of Orthopedics, Næstved-Slagelse-Ringsted Hospitals, Region Zealand, Denmark
| | - Thomas Bloch
- Department of Orthopedics, Næstved-Slagelse-Ringsted Hospitals, Region Zealand, Denmark
| |
Collapse
|
13
|
Millar SC, Bennett K, Fraysse F, Arnold JB, Solomon LB, Thewlis D. Longitudinal changes in lower limb joint loading up to two years following tibial plateau fracture. Gait Posture 2020; 78:72-79. [PMID: 32272398 DOI: 10.1016/j.gaitpost.2020.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 02/17/2020] [Accepted: 03/10/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Tibial plateau fractures are one of the most common intra-articular fractures resulting from high or low energy impact trauma. Few studies have assessed postoperative outcomes of these fractures with respect to changes in knee joint loading post-surgery. This gait analysis study compared lower limb joint loading up to two years post-surgery. METHODS Twenty patients (range 27-67 years; 9:11(male:female)) were treated with open reduction internal fixation and instructed to weight bear as tolerated immediately following surgery. Joint loading at the hip, knee and ankle were assessed at six time points post-operatively up to two years. Gait analyses were performed at each time point and a musculoskeletal model was used to compute external joint moments for the lower limb. RESULTS Hip flexion and extension (P = <0.001, P = <0.001), knee flexion (P = 0.014) and ankle plantarflexion moments (P = <0.001) showed significant increases with time. The hip flexion moment increased between six months and one year (mean difference = 0.16 Nm/kg) but did not increase thereafter (mean difference = 0.01 Nm/kg). Knee flexion and extension, and ankle plantarflexion moments increased up to six months (mean difference = 0.22 Nm/kg, 0.14 Nm/kg, 0.80 Nm/kg, respectively), but no further differences were seen with time from six months postoperative. DISCUSSION The greatest changes in joint loads were observed at the hip and ankle within the first six months, likely a result of mechanical adaptations attempting to account for limited motion at the knee. Knee joint loading plateaued beyond six months suggesting functional outcomes are largely reliant on postoperative management within the initial three months while the bone is healing.
Collapse
Affiliation(s)
- Stuart C Millar
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Sansom Institute for Health Research, University of South Australia, Adelaide, SA, 5000, Australia; Centre for Orthopaedic and Trauma Research, University of Adelaide, Adelaide, SA, 5000, Australia.
| | - Kieran Bennett
- Centre for Orthopaedic and Trauma Research, University of Adelaide, Adelaide, SA, 5000, Australia
| | - François Fraysse
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Sansom Institute for Health Research, University of South Australia, Adelaide, SA, 5000, Australia
| | - John B Arnold
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Sansom Institute for Health Research, University of South Australia, Adelaide, SA, 5000, Australia
| | - Lucian B Solomon
- Centre for Orthopaedic and Trauma Research, University of Adelaide, Adelaide, SA, 5000, Australia; Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA, 5000, Australia
| | - Dominic Thewlis
- Centre for Orthopaedic and Trauma Research, University of Adelaide, Adelaide, SA, 5000, Australia
| |
Collapse
|
14
|
Donohoe E, Roberts HJ, Miclau T, Kreder H. Management of Lower Extremity Fractures in the Elderly: A Focus on Post-Operative Rehabilitation. Injury 2020; 51 Suppl 2:S118-S122. [PMID: 32448467 DOI: 10.1016/j.injury.2020.04.050] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 04/22/2020] [Accepted: 04/25/2020] [Indexed: 02/02/2023]
Abstract
Fractures in the elderly population are increasing in incidence and represent a rising burden of disease. It is difficult for the elderly population to adhere to restricted weight bearing, and immobility poses significant risks and increased morbidity. Therefore, a primary goal of fracture management in the elderly population is early post-operative weight bearing. This review examines published literature regarding lower extremity fracture management in the elderly, with a focus on post-operative rehabilitation. While extensive literature supports early weight bearing after hip fractures in the elderly, further research is warranted to provide guidelines for management of other lower extremity fractures in this population.
Collapse
Affiliation(s)
- Erin Donohoe
- Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Heather J Roberts
- Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Theodore Miclau
- Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Hans Kreder
- Sunnybrook Health Sciences Centre, Division of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada.
| |
Collapse
|
15
|
Wu F, Yin P, Yu X, Zheng W. Several issues on the article: 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; 139:1479-1480. [PMID: 31485727 DOI: 10.1007/s00402-019-03274-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Fei Wu
- Department of Trauma and Joint Surgery, The Fifth Affiliated Hospital of Sun Yat-Sen University, No. 52, Meihua East Road, Xiangzhou District, Zhuhai, Guangdong Province, China
| | - Peng Yin
- Department of Orthopaedic Surgery, The Second Hospital of Dalian Medical University, No. 467, Zhongshan Road, Shahekou District, Dalian, Liaoning Province, China
| | - Xuefeng Yu
- Department of Orthopaedic Surgery, The Second Hospital of Dalian Medical University, No. 467, Zhongshan Road, Shahekou District, Dalian, Liaoning Province, China
| | - Weihao Zheng
- Department of Orthopaedic Surgery, The Second Hospital of Dalian Medical University, No. 467, Zhongshan Road, Shahekou District, Dalian, Liaoning Province, China.
| |
Collapse
|
16
|
Kidiyoor B, Kilaru P, Rachakonda KR, Joseph VM, Subramaniam GV, Sankineani SR, Nugur A, Gurava Reddy AV. Clinical outcomes in periarticular knee fractures with flexible fixation using far cortical locking screws in locking plate: a prospective study. Musculoskelet Surg 2019; 103:149-153. [PMID: 29968233 DOI: 10.1007/s12306-018-0553-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 06/25/2018] [Indexed: 06/08/2023]
Abstract
PURPOSE Periarticular fractures around the knee joint are treated traditionally by locking plates which provide excellent stability but suppress callus formation. Far cortical locking (FCL) screws allow axial motion and enhance uniform callus formation. Our study aims to evaluate the outcomes of FCL screws in traditional locking plate in periarticular fractures of the knee. METHODS Thirty patients with periarticular fractures of the knee joint were operated with locking plate using FCL screws. All patients were evaluated clinically and radiographically using X-rays at 6, 12, 24 weeks, 1 year and with CT scan at 12-weeks follow-up. RESULTS The average time for complete union was 20 weeks in tibial fractures and 24 weeks in femur fractures. Average time to full weight bearing ambulation was 4.8 ± 0.93 weeks. One patient had delayed union in which union was complete after 9 months. CONCLUSION This study shows that FCL screws in locking plates allow uniform callus formation and fracture union with minimal complication rates.
Collapse
Affiliation(s)
- B Kidiyoor
- Department of Orthopaedics and Traumatology, Sunshine Hospitals, Secunderabad, Telangana, 500003, India
| | - P Kilaru
- Department of Orthopaedics and Traumatology, Sunshine Hospitals, Secunderabad, Telangana, 500003, India
| | - K R Rachakonda
- Department of Orthopaedics and Traumatology, Sunshine Hospitals, Secunderabad, Telangana, 500003, India
| | - V M Joseph
- Department of Orthopaedics and Traumatology, Sunshine Hospitals, Secunderabad, Telangana, 500003, India
| | - G V Subramaniam
- Department of Orthopaedics and Traumatology, Sunshine Hospitals, Secunderabad, Telangana, 500003, India
| | - S R Sankineani
- Department of Orthopaedics and Traumatology, Sunshine Hospitals, Secunderabad, Telangana, 500003, India.
| | - A Nugur
- Department of Orthopaedics and Traumatology, Sunshine Hospitals, Secunderabad, Telangana, 500003, India
| | - A V Gurava Reddy
- Department of Orthopaedics and Traumatology, Sunshine Hospitals, Secunderabad, Telangana, 500003, India
| |
Collapse
|
17
|
Consigliere P, Iliopoulos E, Ads T, Trompeter A. Early versus delayed weight bearing after surgical fixation of distal femur fractures: a non-randomized comparative study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 29:1789-1794. [PMID: 31267203 DOI: 10.1007/s00590-019-02486-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 06/27/2019] [Indexed: 01/06/2023]
Abstract
Distal femur fractures are rare injuries with a bimodal distribution (high-energy injury in young males and low-energy fragility fractures in old females). Their management can be challenging: open reduction and internal fixation (ORIF) with distal femur locking plates is a commonly performed procedure especially in comminuted fractures with articular involvement. Anxiety regarding the stability of the fixation, especially in osteoporotic bone, leads to post-operative restrictive instructions with limitations regarding the weight-bearing status. Early weight bearing (EWB), however, was shown to enhance bone healing and was not correlated with an increased risk of fracture displacement or implant failure in previous published studies, which reported the results of proximal femur, tibia and ankle fractures surgical treatment. The current study analysed the results of a series of distal femur fractures (51 patients, mean age 64.3 ± 20.7) all treated with ORIF in a level-I major trauma centre, but differently rehabilitated. Group A was, in fact, instructed not to weight bear or to touch weight bear, while group B started to weight bear soon after surgery without specific restrictions. The objective was to compare the outcome and the complication rate in the two groups at 6 and 12 weeks after surgery. The results showed no statistically significant differences in the two groups and no post-operative complications in the EWB group. Six complications were observed in the non-weight-bearing group (four fractures displacement and two implants failure at 12-week follow-up). Distal femur fractures treated with locking plates can be rehabilitated with EWB to allow early return to function. There is no evidence that EWB increases the risk of fracture displacement or implant failure in distal femur fractures treated with distal locking plates. Instead, it is possible that post-operative non-weight-bearing status delays the fracture-healing process increasing the risk of failure of the fixation.
Collapse
Affiliation(s)
- Paolo Consigliere
- St George's University Hospital NHS Foundation Trust, Blackshaw Rd, London, SW17 0QT, UK.
| | - Efthymios Iliopoulos
- St George's University Hospital NHS Foundation Trust, Blackshaw Rd, London, SW17 0QT, UK
| | - Tamer Ads
- St George's University Hospital NHS Foundation Trust, Blackshaw Rd, London, SW17 0QT, UK
| | - Alex Trompeter
- St George's University Hospital NHS Foundation Trust, Blackshaw Rd, London, SW17 0QT, UK
| |
Collapse
|
18
|
Failure analysis of primary surgery and therapeutic strategy of revision surgery for complex tibial plateau fractures. J Orthop Surg Res 2019; 14:110. [PMID: 31014377 PMCID: PMC6480809 DOI: 10.1186/s13018-019-1147-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 04/09/2019] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To analyze the cause of failure of the primary surgery for complex tibial plateau fractures and to define the therapeutic strategy of the revision surgery for the same. METHODS Twenty-one cases with failure of primary surgery for complex tibial plateau fractures were treated in our hospital from January 2012 to September 2016. There were 13 males and 8 females with an average age of 39.4 years (ranged between 27 and 58 years). Patients presented with different types of complex tibial plateau fractures like Schatzker type V (n=9), VI (n=12), type 41.C1 (n=9), type 41.C2 (n=6), and type 41.C3 (n=6). The therapeutic strategy for revision surgery in individual patients was decided following careful analysis and accurate assessment of the causes of failure of the primary surgery. All the patients were followed-up with Rasmussen radiographic scores and Hospital for Special Surgery (HSS) knee scores. RESULTS All 21 patients underwent clinical and radiological examination after a mean follow-up time of 32.6 months. The average time of fracture healing was 4.5 months (ranged between 3 and 6 months). During the last follow-up, the mean range of motion of knee extension was 2.3° and knee flexion was 123.8°. The mean radiological Rasmussen score was 15.6 points, with an overall success rate of 85.7%. The average HSS knee score was 84.3 points, with an overall success rate of 80.9%. CONCLUSION The common reasons for the failure of primary surgery of complex tibial plateau fractures were inadequate experience of the surgeon, inaccurate diagnosis and management, improper selection of implants, and poor surgical techniques. The key factors to succeed revision surgery were adequate preoperative evaluation, accurate intraoperative procedures, and proper postoperative rehabilitation. LEVEL OF EVIDENCE Level IV, case series, treatment study.
Collapse
|
19
|
Abstract
Tibial plateau fractures have a broad spectrum of presentations, depending on the mechanism and energy of the trauma. Many classification systems are currently available to describe these injuries. In 1974, Schatzker proposed a classification based on a two-dimensional representation of the fracture. His classification with the six-principles types became one of the most utilized classification systems for tibial plateau fractures. More than four decades after this original publication, we are revisiting each fracture type in the light of information made available by computed tomography, which today comprises a standard tool in assessing articular fractures. The classification we are proposing relies on the fact that the tibial plateau has two anatomical columns, lateral and medial. We are introducing a virtual equator which splits the articular surface in the coronal plane. The equator divides each column into two quadrants, the anterior (A) and the posterior (P). Unicondylar fracture types (I to IV) have now additional modifiers A (anterior) and P (posterior) to describe the exact spatial location of the primary fracture plane. Bicondylar fracture types (V and VI) have the modifiers (A and P) of the main fracture plane for each column, and lateral (L) and medial (M) to denote the column. We are introducing the concept of the main fracture plane. Recognition of the exact location of the principal fracture plane is essential for preoperative planning of patient positioning, surgical approach and for determining where to apply the hardware to achieve stable fixation. The new three-dimensional classification is based on the template of the original Schatzker classification. It covers the mechanism of the injury, the energy of the trauma, the morphologic characteristics of the fracture and its location in three dimensions.
Collapse
Affiliation(s)
- Mauricio Kfuri
- Department of Orthopedics, University of Missouri, Columbia, MO, United States; Department of Biomechanics, Medicine and Rehabilitation of the Locomotor System, School of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil.
| | - Joseph Schatzker
- Division of Orthopedics, Sunnybrook Health Sciences Center, University of Toronto, Ontario, Canada
| |
Collapse
|
20
|
Williamson M, Iliopoulos E, Jain A, Ebied W, Trompeter A. Immediate weight bearing after plate fixation of fractures of the tibial plateau. Injury 2018; 49:1886-1890. [PMID: 30017182 DOI: 10.1016/j.injury.2018.06.039] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/16/2018] [Accepted: 06/27/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Proximal articular fractures of the tibia are commonly stabilised with internal fixation using plates and screws. There is a lack of evidence and conflicting guidelines as to the most suitable post-operative rehabilitation regime including weight bearing status. There are numerous physiological and socioeconomic benefits of early weight bearing after orthopaedic surgery, but concerns remain around loss of fracture reduction. Therefore, the aim of this study is to investigate whether the weight bearing status after tibial plateau plate fixation is associated with any loss of reduction or articular collapse. METHODS We retrospectively analysed data from our prospectively collected major trauma centre database. All tibial plateau fractures that required open reduction and internal fixation with plate and screws were included. The immediate post-operative weight bearing status of these patients was recorded. Group I consisted of those patients that were either non-weight bearing or touch weight bearing for the first six post-operative weeks. Group II consisted of patients who were instructed to weight bear fully (as tolerated) immediately after the operation. Radiographs were taken on day one post-operation, at six weeks and at three months and analysed for fracture displacement and joint depression or loss of fixation. RESULTS A total of 90 patients were included in the study. Group I (non-weight bearing or touch weight bearing) consisted of 60 patients (67%). Group II (full weight bearing as tolerated) consisted of 30 patients (33%). The follow up radiographs demonstrated no failure of fixation in either study group. One patient from the weight bearing group had >1 mm joint depression (4 mm) identified at the first follow up, which did not progress. CONCLUSIONS This study shows immediate post-operative full weight bearing does not affect the fixation or cause articular collapse up to three months after surgery and thus we propose that patients should be allowed to weight bear immediately after surgical stabilisation of tibial plateau fractures. This will enable patients to benefit from the positive effects on fracture healing of early weight bearing post-surgery and avoid the complications of non-weight bearing without loss of fixation or articular collapse.
Collapse
Affiliation(s)
- M Williamson
- Trauma & Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, United Kingdom
| | - E Iliopoulos
- Trauma & Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, United Kingdom
| | - A Jain
- Trauma & Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, United Kingdom
| | - W Ebied
- Trauma & Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, United Kingdom
| | - A Trompeter
- Trauma & Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, United Kingdom
| |
Collapse
|
21
|
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
|