A biomechanical evaluation of different fixation strategies for posterolateral fragments in tibial plateau fractures and introduction of the 'magic screw'

Biomechanical analysis of tibial plateau posterolateral fracture fragment fixation and introduction of a lateral tibia plateau hook plate system

BACKGROUND

Fixing the posterolateral fragments of tibial plateau fractures has been challenging owing to potential neurovascular injuries and fibular head blocks. Several surgical approaches and fixation techniques have been reported, with distinct limitations. We propose a novel lateral tibia plateau hook plate system and compare its biomechanical stability with other fixation methods.

METHODS

Twenty-four synthetic tibia models were simulated to present posterolateral tibial plateau fractures. These models were randomly assigned to three groups. Group A models were fixed with the lateral tibia plateau hook plate system, Group B with variable-angle anterolateral locking compression plates, and Group C with direct posterior buttress plates. The models' biomechanical stability was evaluated using static (gradually increased axial compressive loads) and fatigue (cyclically loaded from 100 to 600 N for 2000 cycles each) tests.

RESULTS

Groups A and C models exhibited comparable axial stiffness, subsidence load, failure load, and displacement in the static test. Group A model exhibited higher subsidence and failure loads than Group B model. Groups A and C models exhibited comparable displacement at 100 N cyclic loading in the fatigue test. Group C model was more stable at higher loads. Group C model endured the highest subsidence cycle numbers, followed by Groups A and B models.

CONCLUSIONS

The lateral tibia plateau hook plate system provided similar static biomechanical stability as the direct posterior buttress plates and comparable dynamic stability under limited axial loading. This system is a potential posterolateral treatment choice owing to its convenience and safety, in treating tibia plateau fractures.

Effectiveness of bone grafting versus cannulated screw fixation in the treatment of posterolateral tibial plateau compression fractures with concomitant ACL injury: a comparative study

BACKGROUND

Posterolateral tibial plateau compression fractures (PTPCF) are one of the significant factors leading to knee instability and anterior cruciate ligament (ACL) reconstruction failure. The effectiveness of fixation for such cases without the use of metal implants remains inconclusive. The aim of this study is to investigate whether the fixation with isolated bone grafting is stable enough for the treatment of PTPCF with concomitant ACL injuries.

METHODS

This retrospective study analyzed patients treated for concomitant ACL injuries and PTPCF in authors' institution. A total of 53 patients (21 males and 32 females) with an average age of 47.43 ± 14.71 years were included. Patient data were collected, including factors leading to injury, affected side, height, weight, and basic medical history. The posterior inclination angle and the lateral tibial plateau lateral inclination angle were measured to evaluate the fixation stability. Rasmussen functional score and HSS score were used to assess the knee functional recovery.

RESULTS

The bone grafting group achieved satisfactory levels of Rasmussen score (28.22 ± 0.85) and HSS knee joint function scores (95.57 ± 1.97). The cannulated screw fixation group had a Rasmussen knee joint function score of 28.70 ± 0.92 and a HSS knee joint function score of 96.07 ± 1.93. No statistically significant difference was found (P > 0.05). The cannulated screw fixation group had a mean posterior inclination angle reduction loss of 0.20° ± 1.11°, while the bone grafting group had a reduction loss of 0.18° ± 1.01°, with no statistically significant difference (P > 0.05). The cannulated screw fixation group had a lateral inclination angle reduction loss of 0.01° ± 0.37°, and the bone grafting group had a reduction loss of 0.03° ± 0.43°, with no statistically significant difference (P > 0.05).

CONCLUSION

The use of bone grafting for fixation of PTPCF with accompanying ACL injuries demonstrated no substantial disparities in knee joint function. In cases of simple PTPCF, filling and compacting the bone defect underneath the tibial plateau fracture fragment can yield satisfactory fixation, obviating the necessity for supplementary cannulate screw fixation.

Biomechanics and finite element analysis comparing posterior T-plates with LCP for fixation of posterolateral tibial plate fractures

Objective: The treatment for posterolateral tibial plateau fractures (PTPF) have been subjects of controversy. We conducted a study to improve the fixation of PTPF through a lateral approach. Methods: We utilized 40 synthetic tibias and categorized the fracture models into five groups based on the locking compression plate (LCP) and T-distal radius plate (TPP) via various forms of fixation with screws through the posterolateral (PL) fracture fragments. I: Two-screw fixation using two locking screws (LPTL). Ⅱ: Two-screw fixation with both variable angle locking screws (LPTV). Ⅲ: One-screw fixation with one locking screw (LPOL). Ⅳ: One-screw fixation with one locking screw and two anteroposterior lag screws (LPOLTL). Ⅴ: a distal radius plate with three locking screws (TPP). Biomechanical tests were conducted to observe the axial compression displacement of the PL fracture fragments at force levels of 250 N, 500 N, and 750 N, as well as to determine the failure load and the axial stiffness for each respective group. Results: Under a 750 N load condition, the displacements within the five experimental groups exhibited the following trend: Ⅴ < Ⅱ < Ⅰ< Ⅳ < Ⅲ. However, there were no significant differences between Group V and Group II, Group I and Group IV (p > 0.05), and only Group Ⅲ demonstrated a displacement exceeding 3 mm. The failure load and the axial stiffness exhibited the same trend. Conversely, statistical significance was identified among the remaining group compared with Group Ⅲ (p < 0.05). Regarding the finite element analysis, the maximum displacements for the five models under the load of 750 N exhibited the following trend: Ⅴ < Ⅱ < Ⅰ< Ⅳ < Ⅲ. The following trends were observed in maximum von Mises stresses for these models under the load of 750 N: Ⅴ < Ⅱ < Ⅳ< Ⅰ < Ⅲ. Conclusion: It is crucial to address the inadequate mechanical strength associated with single screw fixation of LCP for fixing PL fractures in a clinical setting. The biomechanical strength of two-screw fixation surpasses that of single-screw fixation. Introducing variable-angle screws can further enhance the fixation range. Furthermore, the addition of two lag screws threaded from anterior to posterior can compensate the mechanical stability, when PL fracture is fixed with single screw in clinic.

[Application of a new universal locking anatomical plate in treatment of tibial plateau posterolateral column fractures]

OBJECTIVE

To investigate the effectiveness of a new tibial plateau posterolateral column universal locking anatomical plate (hereinafter referred to as "new universal locking anatomical plate") in the treatment of tibial plateau posterolateral column fractures.

METHODS

Between October 2020 and December 2021, 14 patients with tibial plateau posterolateral column fracture were treated with a new universal locking anatomical plate. There were 7 males and 7 females with an average age of 59 years ranging from 29 to 75 years. There were 5 cases on the left side and 9 cases on the right side. The causes of injury included falling from height in 5 cases, traffic accident in 7 cases, and other injuries in 2 cases. The time from injury to operation ranged from 3 to 10 days, with an average of 6 days. According to Schatzker classification, there were 4 cases of type Ⅱ, 8 cases of type Ⅴ, and 2 cases of type Ⅵ. All fractures involved the posterolateral tibial plateau. Three column classification: two columns (anterolateral column+posterior column) in 4 cases, three columns in 10 cases. The operation time, intraoperative blood loss, fracture healing, and complications were recorded. The reduction of tibial plateau fracture was evaluated by Rasmussen radiographic score, and the recovery of knee function was evaluated by Hospital for Special Surgery (HSS) score.

RESULTS

All 14 cases completed the operation successfully. The operation time was 95-180 minutes, with an average of 154 minutes, and the intraoperative blood loss was 100-480 mL, with an average of 260 mL. All patients were followed up 6-19 months, with an average of 12.5 months. All fractures healed, and the healing time was 15-24 weeks, with an average of 18.7 weeks. During the follow-up, there was 1 case of common peroneal nerve palsy and 1 case of traumatic osteoarthritis. There was no other complication such as vascular injury, incision infection, deep venous thrombosis of lower limbs, heterotopic ossification, bone nonunion, and failure of internal fixation. The reduction of tibial plateau fractures was good immediately after operation, and the Rasmussen radiological score was 10-18, with an average of 15.7; 3 cases were excellent, 10 cases were good, and 1 case was fair, with an excellent and good rate of 92.9%. The scores and grades of HSS at 3 months after operation and at last follow-up significantly improved when compared with those before operation ( P<0.05). There was no significant difference between 3 months after operation and last follow-up ( P>0.05).

CONCLUSION

For the fractures involving the posterolateral column of the tibial plateau, the new universal locking anatomical plate can provide strong fixation, satisfactory postoperative fracture reduction, and good recovery of knee function.

[Treatment of posterolateral tibial plateau fractures with a novel lateral tibial plateau annular plate via fibular neck osteotomy approach]

Objective

To investigate the effectiveness of a novel lateral tibial plateau annular plate (hereinafter referred to as the novel plate) fixation via fibular neck osteotomy approach for posterolateral tibial plateau fractures.

Methods

Between January 2015 and December 2018, 22 patients with posterolateral tibial plateau fractures were treated. There were 10 males and 12 females with an average age of 39.0 years (range, 25-56 years). Seven fractures were caused by falls, 10 by traffic accidents, and 5 by falling from height. The time from injury to hospitalization ranged from 3 to 12 days, with an average of 7.0 days. All patients were closed fractures. According to Schatzker classification, the fractures were classified as type Ⅱ in 8 cases, type Ⅲ in 9 cases, type Ⅴ in 1 case, and type Ⅵ in 4 cases. The fractures were fixed with the novel plates after reduction via fibular neck osteotomy approach. The fracture reduction and healing were observed by X-ray film after operation. The range of motion of the knee joint was recorded and the function was evaluated by modified American Hospital for Special Surgery (HSS) score.

Results

All operations were completed successfully. The operation time was 60-95 minutes (mean, 77.6 minutes). The intraoperative blood loss was 100-520 mL (mean, 214.5 mL). There was 1 case of common peroneal nerve injury during operation and 2 cases of fat liquefaction of incision after operation. All patients were followed up 13-32 months (mean, 19.4 months). Postoperative X-ray films showed that the fracture reduction was good in 17 cases and moderate in 5 cases, and all fractures healed with a healing time of 10-18 weeks (mean, 13.0 weeks). At last follow-up, the range of motion of the knee joint ranged from 100° to 145° in flexion (mean, 125.5°) and from 0° to 4° in extension (mean, 1.2°). The modified HSS score was 82-95 (mean, 86.3). There was no complications such as plate deformation, screw fracture, fracture reduction loss, skin necrosis, and so on.

Conclusion

For posterolateral tibial plateau fractures, the novel plate fixation via fibular neck osteotomy approach has the advantages of clear intraoperative field, firm fracture fixation, and less postoperative complications, which is beneficial to the recovery of knee joint function.

Lateral locking plate plus antero-posterior lag screws techniques for the management of posterolateral tibial plateau fracture: preliminary clinical results and biomechanical study

INTRODUCTION

To date, there is no consensus on the optimal surgical strategy for the treatment of posterolateral tibial plateau fracture (PLF). This study introduced a novel, simple technique for treating PLF with a lateral locking plate plus antero-posterior lag screws (LPpLS).

METHODS

We conducted a retrospective case series of 42 patients (Female/Male 19/23) with PLF treated with LPpLS between 1 July 2016 and 30 June 2019. Several pre- and postoperative outcomes were recorded, including operative time, intraoperative blood loss, CT findings, HSS, and ROM. For biomechanical studies, seventy synthetic tibiae with a simulated posterolateral split fracture were divided into seven groups. The biomechanical evaluation included displacement measurement at axial compression and fatigue testing.

RESULTS

Forty-two eligible patients were followed up for an average of 18 months (range 14-21 months). Postoperative radiographs and CT showed good positioning of plates and screws, no fracture fragment loss, and normal articular surfaces in all 42 cases. The biomechanical study showed that the axial stiffness of LPpLS was in the same fashion as the posterior buttress plate and better than the other fixation methods (P < 0.05). Additionally, the LPpLS group had a smaller displacement of fracture fragments along the X-axis (medial to lateral direction) than the BP group (P < 0.01).

CONCLUSIONS

The LPpLS technique could implement good reconstruction of the PLF, showing satisfactory therapeutic effect. The biomechanical evaluation demonstrated that the LPpLS had better stability in three-dimensional directions for PLF than other fixation strategies.

Anterior Tibial Artery and Its Clinical Importance in the Posterolateral Approach to the Tibial Plateau: An Angiographic Study on 219 Lower Limbs

The anterior tibial artery (ATA) is the most critical anatomical structure at risk at the distal border of the posterolateral approach to the tibial plateau. This study aimed to use available lower extremity digital subtraction angiography (DSA) images to determine the distal safe limit of this approach by measuring the distance from the tibial joint line to the ATA where it pierces the interosseous membrane. Tibial plateau mediolateral width (TP-ML-W) and the perpendicular distances from the ATA to the tibial joint line and fibular head were measured on DSA images in 219 lower extremities. To normalize the distances according to the tibial dimensions, each distance was divided by the TP-ML-W, and a ratio was obtained. Popliteal artery branching pattern was categorized according to the classification proposed by Kim et al. Comparative analysis between right and left extremities, genders, and anatomical variations were performed. There were 102 male and 26 female subjects with a mean age of 60.7 ± 15.7 years (range, 17-92 years). Ninety-one subjects had bilateral lower extremity DSA; thus, a total of 219 extremities were analyzed. The TP-ML-W was wider in male (78.3 ± 7.0) than female (70.5 ± 7.3) subjects (p = 0.001). The ATA coursed through the interosseous membrane at 50.9 ± 6.9 mm (range, 37.4-70.2 mm) distal to the tibial plateau joint line, and it was 66.5 ± 7.2% of the TP-ML-W. The ATA coursed through the interosseous membrane at 36.5 ± 6.0 mm (range, 21.9-53.8 mm) distal to the fibular head, and it was 47.7 ± 6.6% of the TP-ML-W. All measured variables were similar between the regular branching pattern of the popliteal artery (type 1A) and other observed variations among male subjects. The safe length of dissection in the posterolateral approach is average 66.5% (range, 45.7-86.7%) of the TP-ML-W. This ratio is valid for both genders. The use of a ratio instead of a distance, which is subject to personal variations, seems to be more logical and practical for planning this surgery, but the wide range should still not be ignored.

The Study of Biomechanics and Clinical Anatomy on a Novel Plate Designed for Posterolateral Tibial Plateau Fractures via Anterolateral Approach

There is no consensus about the optimal internal fixation selection for treatment of posterolateral tibial plateau fracture. This study described a novel plate through an anterolateral approach for posterolateral tibial plateau fractures (PTPFs). We evaluated the biomechanical performance of a novel plate and two conventional internal implants and investigated the anatomic feasibility of the novel plate. The fracture models were randomly assigned into six groups: Groups A–C were the model groups of posterolateral split fracture, fixed with the posterior buttress plate, the lateral locking plate, and the novel plate, respectively. Groups D–E were the model groups of posterolateral depression fracture, fixed with the posterior buttress plate, the lateral locking plate, and the novel plate, respectively. We evaluated the biomechanical performance of six model groups by the biomechanical testing and finite element analysis. Progressively increasing axial compressive loads were applied to each synthetic fracture model by using a customized indentor under 250–750 N loads. Meanwhile, we dissected 12 fresh frozen knee specimens and fixed them with the novel plate through the anterolateral approach. We recorded the adjacency of the novel plate to important anatomic structures. Biomechanical testing showed that the novel plate had the least displacement, followed by the posterior buttress plate, and the lateral plate had the most displacement in posterolateral split fracture. There was no significant difference in the displacement between the novel plate and the lateral plate at different loads in posterolateral depression fractures. And the posterior buttress plate showed the most displacement. In the finite element analysis, the maximum stress values of Groups A, B, and C were 383.76, 414.63, and 305.07 MPa under the load of 750 N, respectively. The maximum stress values of Groups D, E, and F were 474.28, 436.31, and 413.4 MPa under the load of 750 N, respectively. In the anatomic study, the placement of the novel plate had a low risk of damage to the important anatomic structures of knee posterolateral corner. The novel plate could be a great choice for the treatment of PTPFs due to better biomechanical performance and easy manipulation.

The treatment of posterolateral tibial plateau fracture with a newly designed anatomical plate via the trans-supra-fibular head approach: preliminary outcomes

BACKGROUND

There are no ideal plates or approaches for anatomical restoration and rigid fixation of posterolateral tibial plateau fractures. This study aimed to evaluate the short-term preliminary outcomes of our novel anatomical plate placed via the trans-supra-fibular approach to treat posterolateral tibial plateau fractures.

METHODS

From May 2016 to May 2018, 23 consecutive patients with posterolateral tibial quadrant fractures underwent open reduction with internal fixation via the trans-supra-fibular-head approach with our newly developed plate. The tibial plateau-tibial shaft angle (TPTSA), lateral posterior tibial slope angle (LPSTA), step-off, and condylar widening were measured on radiological images pre-operatively, 3 days post-operatively, 3 months post-operatively, and at the final follow-up examination. The radiological Rasmussen score was calculated, and the Hospital for Special Surgery (HSS) knee score was assessed to evaluate the functional outcomes.

RESULTS

The LTPSA, TPTSA, step-off, and condylar widening at 3 days post-operatively, 3 months post-operatively, and at the final follow-up were significantly different (p = 0.001) compared with those pre-operatively, as was the radiological Rasmussen score (p = 0.001). The HSS score at the final follow-up was 89.10 ± 5.94 (range, 78-98), which was significantly higher than that at the 3-month follow-up 84.36 ± 6.76 (range, 74-96); p = 0.001).

CONCLUSIONS

Our newly designed anatomical plate placed via the trans-supra-fibular approach can effectively treat posterolateral tibial plateau fractures. We noted minor trauma, stable fixation, and satisfactory clinical results.

Biomechanical analysis of "Barrel hoop plate" technique for the posterolateral fragments of tibial plateau fractures with different displacement tendency

OBJECTIVES

The purpose of our study is to evaluate the three-dimensional biomechanical properties of "Barrel Hoop plate" in two kinds of artificial posterolateral tibial plateau fracture fragment (PLF) by using of synthetic models, each of which has an initial amplifying displacement tendency.

MATERIAL AND METHODS

Thirty-six tibiae models were randomly assigned into two groups with different displacement tendencies: posterior displacement (PD) and lateral displacement (LD). Each model was then fixed with three patterns: Anterolateral plate (AP), Posterolateral plate (PP), and "Barrel Hoop plate" (BHP). Displacement in three axes of vertical, sagittal and horizontal axis was captured by Optotrak Certus motion analysis system. Bluehill 2 software was used for load control and data collection.

RESULTS

In Model-PD, when the load was over 1000 N, the posterior displacement of Group-PP and Group-BHP were less than Group-AP (P<0.01). The inferior displacement in the vertical axis of Group-PP was larger than both Group-AP and Group-BHP in all the loading set (P<0.01). In Model-LD, both of the lateral displacement in Group-AP and Group-BHP was less than that of Group-PP when the load was over 1000 N (P<0.01). The inferior displacement of Group-AP was less than that of Group-PP in the load of 1500 N (P<0.01). Both of the posterior displacement of Group-AP and Group-BHP was less than that of Group-PP when the loading was 1500 N (P<0.01). The stiffness of Group PP was less than that of Group AP (P<0.01).

CONCLUSIONS

The results demonstrated that the 2.7 mm "Barrel Hoop plate" had a greater capacity of anti-three-dimension axes displacement of PLF. The 3.5 mm Anterolateral plate had the advantage in anti-lateral displacement and anti-inferior displacement but was weak at anti-posterior displacement of PLF. The 2.7 mm Posterolateral plate was stronger in anti-posterior, however, weak in anti-inferior displacement capacity.

Influence of the Screw Positioning on the Stability of Locking Plate for Proximal Tibial Fractures: A Numerical Approach

Tibial fractures are common injuries in people. The proper treatment of these fractures is important in order to recover complete mobility. The aim of this work was to investigate if screw positioning in plates for proximal tibial fractures can affect the stability of the system, and if it can consequently influence the patient healing time. In fact, a more stable construct could allow the reduction of the non-weight-bearing period and consequently speed up the healing process. For that purpose, virtual models of fractured bone/plate assemblies were created, and numerical simulations were performed to evaluate the reaction forces and the maximum value of the contact pressure at the screw/bone interface. A Schatzker type I tibial fracture was considered, and four different screw configurations were investigated. The obtained results demonstrated that, for this specific case study, screw orientation affected the pressure distribution at the screw/bone interface. The proposed approach could be used effectively to investigate different fracture types in order to give orthopaedists useful guidelines for the treatment of proximal tibial fractures.

Where should the pins be placed to decrease the failure rate after fixation of a Mayo IIA olecranon fracture? A biomechanical analysis

BACKGROUND

Clinically, treatment of Mayo IIA olecranon fractures (MIOF) using pins is associated with a high rate of failure. The purpose of our study was to compare the biomechanical stability and strength of four different fracture fixation configurations and to recommend the best method for the clinical treatment of MIOFs.

METHODS

Twenty synthetic ulnar models were created and equally divided into 4 different fracture fixation groups: a double cortical configuration using Kirschner (K) wires; a double cortical configuration using transcortical pins; an intramedullary pin system; and an intramedullary pin system with a 3-mm distance between the eyelet and the proximal end of the olecranon (loose fixation). The stiffness and strength of all specimens were tested under a loading rate of 2 mm/min. Between-group differences were evaluated using an independent t-test, with significance set at P < 0.05.

RESULTS

Stiffness and strength were significantly better for the K-wire than intramedullary group: stiffness, 63.467±14.063 N/mm and 36.243±5.625 N/mm, respectively (P=0.009); and strength, 624.293±148.728 N and 406.486±74.109 N, respectively (P=0.019). There was no difference in stiffness (P=0.370) or strength (P=0.929) between the use of transcortical pins and K-wires. Moreover, a 3-mm prominence of the pin at the olecranon did not have a negative effect on either stiffness (P=0.494) or strength (P=0.391).

CONCLUSIONS

Our biomechanical analysis indicated that using a double cortical pin configuration provided the best stability and strength and, thus, may lower the risk of fracture fixation failure. The use of either K-wires or pins in the double cortical configuration did not influence fixation stability. A loose double cortical configuration might decrease fracture stability, although there differences were not significant.

Arthroscopically assisted and three-dimensionally modeled minimally invasive rim plate osteosynthesis via modified anterolateral approach for posterolateral tibial plateau fractures

AIM

The aim of this study was to describe a new, closed, arthroscopically-assisted reduction of posterolateral tibial plateau fractures with minimally invasive plate osteosynthesis using a plate pre-contoured over a 3D-model based on a CT-scan of the injured tibial plateau and positioned by using a minimal anterolateral approach.

METHODS

A five to six centimeter long curvilinear incision was made over the Gerdy's tubercle. After subcutaneous dissection, the fascia was incised, the ileo-tibial band was split, and the dissection was extended posteriorly. The knee was flexed to 90° and the space between the fibular collateral ligament and the posterolateral plateau rim (para-FCL space) was created. A variable-angle locking compression plate contoured on a 3D-model was inserted flush to the tibial plateau rim. Two cortical screws were placed to ensure support under the area of depression as far posteriorly as possible. Two additional screws were implanted, and a cortical screw was used for the most anterior screw hole. The custom pre-contoured plate based on a person-specific 3D-model, associated with arthroscopy reduction, provides a supporting and containing effect to the posterolateral periarticular fragments and allows a minimally invasive plate osteosynthesis fixation to be performed. This guarantees a proper reduction and fixation without the described limitations and risks associated with the classic approaches.

CONCLUSIONS

This approach should be considered to treat fractures of the posterolateral plateau, isolated or associated with medial tibial plateau fractures, as it could improve the outcome in terms of lower associated risks, better reduction and fixation, and faster and improved patient recovery.

Investigating the biomechanical function of the plate-type external fixator in the treatment of tibial fractures: a biomechanical study

Background

The design of an external fixator with the optimal biomechanical function and the lowest profile has been highly pursued, as fracture healing is dependent on the stability and durability of fixation, and a low profile is more desired by patients. The plate-type external fixator, a novel prototype of an external tibial fixation device, is a low profile construct. However, its biomechanical properties remain unclear. The objective of this study was to investigate the stiffness and strength of the plate-type external fixator and the unilateral external fixator. We hypothesized that the plate-type external fixator could provide higher stiffness while retaining sufficient strength.

Methods

Fifty-four cadaver tibias underwent a standardized midshaft osteotomy to create a fracture gap model to simulate a comminuted diaphyseal fracture. All specimens were randomly divided into three groups of eighteen specimens each and stabilized with either a unilateral external fixator or two configurations of the plate-type external fixator. Six specimens of each configuration were tested to determine fixation stiffness in axial compression, four-point bending, and torsion, respectively. Afterwards, dynamic loading until failure was performed in each loading mode to determine the construct strength and failure mode.

Results

The plate-type external fixator provided higher stiffness and strength than the traditional unilateral external fixator. The highest biomechanics were observed for the classical plate-type external fixator, closely followed by the extended plate-type external fixator.

Conclusions

The plate-type external fixator is stiffer and stronger than the traditional unilateral external fixator under axial compression, four-point bending and torsion loading conditions.

Failure analysis of primary surgery and therapeutic strategy of revision surgery for complex tibial plateau fractures

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.

Extended lateral column tibial plateau fractures. How do we do it?

We describe the operative management of extended lateral column fractures according to the revised three-column classification approach in a step-by-step fashion. We show that direct reduction and stable fixation of extended lateral column tibial plateau fractures via a limited arthrotomy and tibia condyle osteotomy, with the use of free subchondral 2.7 mm locking screws is a reliable technique. Subsequently, diverging VA-LCP locking screws further improve the structural properties. It is a straightforward technique and the single lateral approach (Lazy-S) facilitates direct reduction of the articular surface and stable fixation of the fracture fragments under direct vision with good radiological and fair functional outcome.