Bi-planar intra-articular deformity following malunion of a Schatzker V tibial plateau fracture: Correction with intra-articular osteotomy using patient-specific guides and arthroscopic resection of the tibial spine bone block

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Malunion of the Tibia: A Systematic Review

Background and Objectives: Tibial malunions are defined as tibial fractures that have healed in a clinically unacceptable position, resulting in deformity such as shortening, lengthening, abnormal rotation, or angulation. These deformities can have adverse effects on patients, such as pain and gait disturbance, as well as long term development of post-traumatic arthritis. This paper seeks to highlight some of the options for surgical management of malunions and detail the strategies and approaches used to manage these complicated cases. Materials and Methods: An exhaustive search was conducted on PubMed using the key search terms “Tibial” OR “Tibia” AND “Malunion” to be included in the title. Exclusions to the search included any article with patients aged < 18 years, any nonhuman subjects, and any article not published or translated into English. Results: A systematic review of the literature revealed 26 articles encompassing 242 patients who had undergone surgical correction for tibia malunion. A total of 19 patients suffered from complications. Methods of treatment included osteotomies, with plate and screws, external fixator, angled blade plate, intramedullary nails, Ilizarov fixator, Taylor Spatial Frame, Precise nail, and total knee arthroplasty. Restoring alignment and the articular surface led to overwhelmingly positive patient outcomes. Conclusions: Tibial malunions take many forms, and as such, there are many approaches to correcting deformities. The literature supports the following radiological parameters to diagnose tibial malunion: 5−10 degrees angulation, 1−2 cm shortening, 10−15 degrees internal rotation, and 10−20 degrees external rotation. Surgical plans should be customized to each individual patient, as there are many approaches to tibial malunion that have been shown to be successful in delivering excellent clinical outcomes.

Use of Osteochondral and Meniscal Allografts from Bone Cuts of Total Knee Arthroplasty for the Treatment of Tibial Plateau Malunions: A Case Series of Four Patients Showing Early Results

PURPOSE

Intra-articular malunion of tibial plateau fracture is a complex problem to treat. We are presenting outcomes of our series of patients of malunited tibial plateau fractures treated with osteo-chondro-meniscal allograft from lateral tibial plateau harvested from patients undergoing total knee arthroplasty (TKA).

METHODS

The technique was used in four patients. Preoperative computed tomography (CT) scan was used to match donor and recipient graft dimensions and to measure any malalignment. Patients were evaluated for Visual analogue Scale (VAS) for pain (scale 1-10 cm), WOMAC (Western Ontario McMaster Osteo-Arthritis Index) score, knee range of motion, and limb alignment.

RESULTS

There were three medial tibial plateau malunions and one lateral tibial plateau malunion. Articular comminution with depression was seen in all of them. One patient underwent concurrent high tibial osteotomy for the elevation of the medial tibial plateau and posterior cruciate ligament reconstruction was performed concurrently in one patient. All patients showed improvement in knee range of motion, WOMAC score, and VAS score for knee pain. Limb alignment improved in all cases. Radiologically there was consolidation of the allograft in all the cases at 6 months. The mean follow-up was 15.2 months (range 12-18 months).

CONCLUSION

Osteochondral allograft can be a good choice for reconstructing large articular cartilage defects in tibial plateau malunions. Osteo-chondro-meniscal grafts obtained during TKA can be a viable alternative for reconstructing such defects with excellent early clinical, functional, and radiological outcomes.

LEVEL OF EVIDENCE

IV.

Arthroscopy-Assisted Corrective Osteotomy, Reduction, Internal Fixation and Strut Allograft Augmentation for Tibial Plateau Malunion or Nonunion

Purpose: The purpose of this study was to present the results of arthroscopy-assisted corrective osteotomy (AACO), reduction, internal fixation, and strut allograft augmentation for tibial plateau malunion or nonunion. Methods: Fifty-eight patients, mean age 49 ± 11.9 years old, with tibial plateau malunion (n = 44) or nonunion (n = 14), were included in this study. There were 19 Schatzker type II fractures (32.7%), 2 type III fractures (3.4%), 7 type IV fractures (12%), 20 type V fractures (34.5%), and 10 type VI fractures (17.2%). The mean follow-up period was 46.2 ± 17.6 months. Clinical and radiologic outcomes were scored by the Rasmussen system. Articular depression was measured from computed tomography. Secondary osteoarthritis was diagnosed when radiographs showed a narrowed joint space in the injured knee at follow-up. Results: Mean clinical score improved from 15.4 ± 3.9 (pre-revision) to 23.2 ± 4.5 (post-revision). Mean radiologic score improved from 7.7 ± 2.5 (pre-revision) to 12.0 ± 3.9 (post-revision). Fifty-six fractures achieved successful union. The average union time was 19.6 ± 7.5 weeks. Post-revision, 81% had good or excellent clinical results and 62% had good or excellent radiological results. Secondary osteoarthritis (OA) was noted in 91% of all injured knees, where 25.8% were mild OA, 25.8 % were moderate OA, and 38% were severe OA. There were 6 cases of deep infection (10.3%) and 1 case of wound edge necrosis (1.7%). Five cases were converted to total knee replacement after the index surgery with an average period of 13.5 months (range 8–24 months). Conclusions: Arthroscopy-assisted corrective osteotomy, reduction, internal fixation, and strut allograft augmentation can restore tibial plateau malunion/nonunion with well-documented radiographic healing and good clinical outcomes.