Use of bone graft substitutes in the management of tibial plateau fractures

Effect of structural support size and position on depressed tibial plateau fractures: A finite element analysis

Objective

Structural support for depressed tibial plateau fractures is receiving increasing attention. Currently, there has been little biomechanical evaluation of structural support. This work aimed to investigate the effect of structural support size and position on fracture fixation stability.

Methods

A split-depressed tibial plateau fracture model was created according to the fracture map. Cortical screws combined with structural filler were used for fracture fixation. The filler diameter was set to small, medium and large, and the filler position was set to the center and offset by 1, 2 and 3 mm to study the effect of position and size on stability.

Results

The maximum stress on the implant in all scenarios occurs at the lower contact surface between the anterior screw and the filler. Increased support size resulted in increased mean maximum screw stress, depressed fragment axial displacement and separated fragment transverse displacement (screw stress: 266.6 ± 37.7 MPa vs. 266.7 ± 51.0 MPa vs. 273.8 ± 41.5 MPa; depressed displacement: 0.123 ± 0.036 mm vs. 0.133 ± 0.049 mm vs. 0.158 ± 0.050 mm; separated displacement: 0.402 ± 0.031 mm VS 0.412 ± 0.047 mm VS 0.437 ± 0.049 mm). The larger the offset of the support position was, the larger the peak screw stress and the larger the reduction loss of depressed and separated fragment reduction, regardless of the support size. The medium support combined with the central position presented the minimum of peak stress and reduction loss. Cortical bone was below 2 % and trabecular strain was below 10 % for all scenarios.

Conclusion

Central placement of structural support provides superior stability for the treatment of depressed tibial plateau fractures compared to the eccentric placement. When a support is placed centrally, optimal stability is achieved when the diameter matches the diameter of the depressed region. Thus, the utilization of equal-diameter fillers to provide central support appears to be an ideal selection for depressed tibial plateau fractures.

Tibial Plateau Fracture With Use of Tibia Strut and Bone Filler in a 37-Year-Old Male: A Case Report

Tibial plateau fractures (TPFs) are orthopedic challenges with multiple injury modalities and clinical presentations. TPFs are often classified using the Schatzker classification system, which can dictate management. In our case, a 37-year-old male presented at an orthopedic specialty hospital with right knee pain after a fall from a truck ramp. X-rays and CT imaging demonstrated a comminuted bicondylar TPF in the emergency room with metaphyseal dissociation. The patient was placed in a knee immobilizer, made non-weight bearing, and scheduled for outpatient follow-up with a local orthopedic surgeon. The patient was lost to follow-up and referred to our clinic six months after the fall with the chief complaint of inability to ambulate with severe pain and instability in the knee. X-rays demonstrated a malunion of the bicondylar tibial plateau with fracture deformities of the medial femoral condyle and lateral tibial plateau. The patient's deformity was corrected with a medial opening wedge proximal tibial osteotomy with a fibula strut allograft and filled with beta-tricalcium bone filler. At the first month follow-up, the patient's pain was well controlled, fragments and the knee were appropriately aligned, and no significant soft tissue or joint effusion was appreciated on imaging. After failing nonoperative treatment, this patient with comminuted bicondylar TPF has received definitive treatment with open reduction and internal fixation. Higher rates of unacceptable results from nonoperative treatment are in line with the Schatzker series, in which operative treatment resulted in more acceptable outcomes. Because the fracture in this patient is consistent with a Schatzker VI classification with intra-articular depression, the patient should have initially been treated with an external fixator and not been sent home in a knee immobilizer. This led to a malunion that necessitated corrective surgery. Therefore, correctly classifying fracture severity is important for selecting the best treatment course and minimizing complications.

A feasibility study of robot-assisted percutaneous reduction and fixation technique for treating posterolateral depression tibial plateau fractures

Posterolateral (PL)-depression fractures of the tibial plateau are difficult to manage. The aim of this study was: (1) to present our experience with a novel technique of robot-assisted percutaneous reduction and fixation and (2) to compare it with the traditional percutaneous screw osteosynthesis (PSO) technique for the treatment of PL-depression tibial plateau fractures. The clinical data of patients with PL-depression tibial plateau fractures treated by robot-assisted percutaneous reduction and fixation technique and traditional PSO technique from January 2017 to January 2021 were retrospectively analyzed. Among them, there were 18 cases in the robot-assisted group (RA group) and 23 cases in the PSO group. All fractures were unilateral, closed and fresh PL-depression fractures of the tibial plateau. Patients in the RA group were treated by robot assisted reduction and minimally invasive absorbable screw fixation. The PSO group was treated by closed reduction and percutaneous absorbable screw osteosynthesis. The incision length, operation time, intraoperative blood loss, fluoroscopic times, inpatient time, weight training time and postoperative complications of the two groups were statistically analyzed. The Rasmussen radiological score was used to assess the reduction quality after operation while the Rasmussen functional score was used to evaluate knee joint functions at one year postoperatively. All patients were followed for at least one year. There was no significant difference in demographic information between the two groups (p > 0.05). Compared with the PSO group, the RA group showed less fluoroscopic times and better Rasmussen radiological and functional scores (p < 0.05). Besides, there was no significant difference in the incidence of postoperative complications between the two groups (p > 0.05). The novel robot-assisted percutaneous reduction and fixation technique had the characteristics of less radiation, accurate reduction and fixation. It could accelerate the rehabilitation of patients with PL-depression fractures of the tibial plateau and enable patients to obtain good joint functions.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSIONS

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

S2k Guideline for Tibial Plateau Fractures - Classification, Diagnosis, and Treatment

Tibial plateau fractures are mostly complex and surgically demanding joint fractures, which require a comprehensive understanding of the fracture morphology, ligamentous and neurovascular injuries, as well as the diagnostic and therapeutic options for an optimal clinical outcome. Therefore, a standardised and structured approach is required. The success of the treatment of tibial plateau fractures relies on the interdisciplinary cooperation between surgical and conservative physicians in an outpatient and inpatient setting, physical therapists, patients and service providers (health insurance companies, statutory accident insurance, pension providers). On behalf of the German Society for Orthopaedics and Trauma Surgery (DGOU), the German Trauma Society (DGU) and the Society for Arthroscopy and Joint Surgery (AGA), under the leadership of the Fracture Committee of the German Knee Society (DKG), a guideline for tibial plateau fractures was created, which was developed in several voting rounds as part of a Delphi process. Based on the current literature, this guideline is intended to make clear recommendations and outline the most important treatment steps in diagnostics, therapy and follow-up treatment. Additionally, 25 statements were revised by the authors in several survey rounds using the Likert scale in order to reach a final consensus.

A, Ajoy SM. Fresh Fractures: A New Indication for Use of Bone Allografts-A 10-Year Data Analysis

Background

Tissue banking includes the process starting from procurement to the distribution and usage of allograft tissues. The use of bone bank in orthopaedics is not widely seen. Our objective is to describe the 10-year allograft donor and recipient data from a fully functioning tissue bank in India, analyse the types of grafts used, indications and demand for various grafts. This will show the need for a tissue bank in a tertiary care orthopaedic setup.

Methods

Analysis of donor and recipient data for allografts of a tissue bank in an Indian tertiary care setup was done from 2012 to 2022. The number of grafts procured and used were analysed. The recipient and donor sites were also analysed.

Results

In 10 years, the tissue bank provided 2776 grafts and received 1962 donations. Slices procured after total knee replacements were the most commonly used allografts (28.03%). Acute fracture with bone loss or severe comminution (23.11%) being the most common indication of bone grafting was a major result of our study. Among these, proximal tibia (27.79%) was the most frequent recipient site. Tissue bank has also served patients in neurosurgery, ophthalmology, oromaxillofacial surgery, otorhinolaryngology, urology and wound care.

Conclusion

A tissue bank is a useful setup in tertiary care orthopaedic hospitals. Allografts were most widely used for acute trauma management. Allografts provide large graft quantity and reduce surgical time. Hence a tissue bank is not only an asset to the establishment but also to the surrounding hospitals, to which the grafts can be supplied.

Management of tibial plateau fractures: a fresh review

Tibial plateau fractures are complex injuries which carry significant morbidity and economic burden. They can present complex geometry depending upon the direction of the force and position of the limb and are often associated with significant soft-tissue injury. While the goals of adequate reduction, stable fixation, and early mobilization remain unchanged, the management of these injuries can be challenging even to experienced orthopaedic surgeons. Lacking consensus, this review aims to provide a summary of current state of orthopaedic practice in the face of tibial plateau fractures. A PubMed search for relevant recent articles as well as a reading of classical articles on tibial plateau fractures was carried out. The focus remained on articles concerned with management modalities and recent advances. A review of some classification systems was also done and included. A great majority of these fractures need operative fixation while respecting the soft tissues. Numerous methods have been reported in the literature including but not limited to plates, screws, external fixators, arthroscopy assisted methods, balloon-cement tibioplasty, or a combination thereof. There is a shortage of randomized controlled trials comparing various operative methods. This article provides a review of various techniques and latest advances made in the management of tibial plateau fractures. The key to achieving optimal functional outcome is using a tailored approach to the individual patient accounting for factors related to the injury pattern, type of host, surgical skills and experience, and local availability of implant devices while taking care of soft tissue. While there is no gold standard, a staged procedure is recommended with early spanning and definitive fixation at later stage by any appropriate methods while respecting the soft tissue, achieving anatomical reduction and adequate fixation and, early rehabilitation.

Bone Grafts in Dental Medicine: An Overview of Autografts, Allografts and Synthetic Materials

This review provides an overview of various materials used in dentistry and oral and maxillofacial surgeries to replace or repair bone defects. The choice of material depends on factors such as tissue viability, size, shape, and defect volume. While small bone defects can regenerate naturally, extensive defects or loss or pathological fractures require surgical intervention and the use of substitute bones. Autologous bone, taken from the patient's own body, is the gold standard for bone grafting but has drawbacks such as uncertain prognosis, surgery at the donor site, and limited availability. Other alternatives for medium and small-sized defects include allografts (from human donors), xenografts (from animals), and synthetic materials with osteoconductive properties. Allografts are carefully selected and processed human bone materials, while xenografts are derived from animals and possess similar chemical composition to human bone. Synthetic materials such as ceramics and bioactive glasses are used for small defects but may lack osteoinductivity and moldability. Calcium-phosphate-based ceramics, particularly hydroxyapatite, are extensively studied and commonly used due to their compositional similarity to natural bone. Additional components, such as growth factors, autogenous bone, and therapeutic elements, can be incorporated into synthetic or xenogeneic scaffolds to enhance their osteogenic properties. This review aims to provide a comprehensive analysis of grafting materials in dentistry, discussing their properties, advantages, and disadvantages. It also highlights the challenges of analyzing in vivo and clinical studies to select the most suitable option for specific situations.

Osteoregenerative efficacy of a novel synthetic, resorbable Ca/P/S-based bone graft substitute in intra- and peri-articular fractures: a brief medical image-based report

Background

When a fracture goes into or around a joint, it usually damages the cartilage at the ends of bones and other joint tissue. As a result, the affected joints are prone to traumatic arthritis, leading to stiffness. Repairing bone damage, maintaining joint integrity, and avoiding subchondral and metaphyseal defects caused by comminuted fractures is often a great challenge for orthopedic surgeons. Tissue engineering of synthetic bone substitutes has proven beneficial to the attachment and proliferation of bone cells, promoting the formation of mature tissues with sufficient mechanical strength and has become a promising alternative to autograft methods. The purpose of this study is to retrospectively evaluate the clinical outcome and efficacy of a novel synthetic, highly biocompatible, and fully resorbable Ca/P/S-based bone substitute based on medical image findings.

Materials and methods

A synthetic, inorganic and highly porous Ca/P/S-based bone-substituting material (Ezechbone® Granule, CBS-400) has been developed by National Cheng-Kung University. We collected fourteen cases of complex intra- and peri-articular fractures with Ezechbone® Granule bone grafting between 2019/11 and 2021/11. We studied the evidence of bone healing by reviewing, interpreting and analyzing the medical image recordings.

Results

In the present study, CBS-400 was observed to quickly integrate into surrounding bone within three weeks after grafting during the initial callus formation of the early stage of repair. All of these cases healed entirely within three months. In addition, the patient may return to daily life function after 3.5 months of follow-up and rehabilitation treatment.

Conclusions

Ezechbone® Granule CBS-400 was proved capable of promoting bone healing and early rehabilitation to prevent soft tissue adhesions and joint contractures. Moreover, it has a high potential for avoiding ectopic bone formation or abnormal synostosis.

Trial registration

The Institutional Review Board at National Cheng Kung University Hospital (NCKUH) approved the study protocol (A-ER-109-031, 3-13-2020).

Stability of internal fixation systems based on different subtypes of Schatzker II fracture of the tibial plateau: A finite element analysis

Background: Schaztker II fracture is the most common type of the tibial plateau fractures (TPF). There has been a large number of cadaveric biomechanical studies and finite element simulation studies to explore the most stable fixation methods for this type of fracture, which were based on a single fracture morphology. But differences among fracture morphologies could directly affect the stability of internal fixation systems. In this sense, we verified the stability of existing internal fixation modalities by simulating Schatzker II fractures with different fracture morphologies.

Objectives: To compare the stability of different filler types combined with locked compression plate/screw in different subtypes of Schatzker II TPF.

Methods: Four subtypes of Schatzker II were created based on 3D map of TPF. Each of the subtypes was fixed with LCP/screw or LCP/screw combined with different fill types. Stress distribution, displacement distribution, and the load sharing capacity of the filler were assessed by applying the maximum load during gait. In addition, repeated fracture risks of depressed fragment were evaluated regarding to the ultimate strain of bone.

Results: The stress concentration of the implant in each scenario was located on the screw at the contact site between the plate and the screw, and the filler of the defect site significantly reduced the stress concentration of the implant (Subtype A: Blank group 402.0 MPa vs. Experimental group 315.2 ± 5.5 MPa; Subtype C: Blank group 385.0 MPa vs. Experimental group 322.7 ± 12.1 MPa). Displacement field analysis showed that filler significantly reduced the reduction loss of the depressed fragment (Subtype A: Blank group 0.1949 mm vs. Experimental group 0.174 ± 0.001 mm; Subtype C: 0.264 mm vs. 0.253 ± 0.002 mm). Maximum strain was in subtype C with the value of 2.3% ± 0.1% indicating the greatest possibility of failure risk. And with the increase of its modulus, the bearing capacity of filler increased.

Conclusion: The existence of filler at the defect site can effectively reduce the stress concentration of the implant and the reduction loss of the collapsed block, thus providing good stability for Schatzker II fracture. In subtype A fracture, the modulus of filler presented the slightest influence on the stability, followed by subtype C, while the stability of subtype B was most influenced by the modulus of filler. Therefore, it is necessary to evaluate the preoperative patient imaging data adequately to select the appropriate stiffness of the filler.

Radiographic and clinical outcome of tibial plateau fractures treated with bone allograft

BACKGROUND

To determine the clinical outcome of patients who had been treated with bone allografts during open reduction and internal fixation (ORIF) of tibial head fractures.

METHODS

Patients who suffered a medial, lateral, or bicondylar fracture of the tibial plateau and underwent surgical treatment by open reduction and internal fixation (ORIF) using human femoral head bone allografts were included. Patients were invited to provide information for the following: Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), EuroQol Five Dimension score (EQ-5D), Lower Extremity Functional Scale (LEFS) and Parker Mobility Score. Bone mineral density (BMD) of the allograft area and the healthy human bone tissue were measured by quantitative computed tomography.

RESULTS

A total of 22 patients with a mean follow-up time of 2.88 ± 2.46 years were included in our study. The most common fractures observed in this study were classified as Schatzker II (11 patients, 50.0%) or AO/OTA 41.B3 (12 patients, 54.5%) fractures. Postoperative WOMAC total was 13.0 (IQR = 16.3, range 0-33). Median quality of life (EQ-5D) score was 0.887 ± 0.121 (range 0.361-1.000). Median Lower Extremity Functional Scale (LEFS) score was 57.5 ± 19.0 (range 33-79). Mean Parker Mobility Score was 9 (range 6-9). Median bone mineral density (BMD) for the whole group was 300.04 ± 226.02 mg/cm³ (range - 88.68 to 555.06 mg/cm³) for region of interest (ROI 5) (central), 214.80 ± 167.45 mg/cm³ (range - 7.16 to 597.21 mg/cm³) for ROI 1-4 (marginal zones: medial, lateral, ventral, dorsal) and 168.14 ± 65.54 mg/cm³ (range 17.47-208.97 mg/cm³) for healthy bone tissue (femur and tibia).

CONCLUSION

Based on WOMAC scores, LEFS, ambulatory status, and quality of life findings, it can be concluded that following tibial head ORIF with allograft bone patients has promising results.

[Cement augmentation and bone graft substitutes-Materials and biomechanics]

BACKGROUND

Materials with different characteristics are used for cement augmentation and as bone graft substitutes.

OBJECTIVE

Cement augmentation and bone graft substitutes are the subject of current research. The evaluation of new knowledge allows its specific application.

MATERIAL AND METHODS

Selective literature search and outline of experimental research results on cement augmentation and bone graft substitutes.

RESULTS

Augmentation and bone graft substitutes are essential components of current trauma surgical procedures. Despite intensive research all materials have specific disadvantages. Cement augmentation of implants enhances not only the anchorage but also influences the failure mode.

CONCLUSION

Cement augmentation has large potential especially in osteoporotic bone. In load-bearing regions acrylic-based cements remain the standard of choice. Ceramic cements are preferred in non-load-bearing areas. Their combination with resorbable metals offers still largely unexplored potential. Virtual biomechanics can help improve the targeted application of cement augmentation.

Autologous versus synthetic bone grafts for the surgical management of tibial plateau fractures: a systematic review and meta-analysis of randomized controlled trials

Aims

Our objective was to conduct a systematic review and meta-analysis, to establish whether differences arise in clinical outcomes between autologous and synthetic bone grafts in the operative management of tibial plateau fractures.

Methods

A structured search of MEDLINE, EMBASE, the online archives of Bone & Joint Publishing, and CENTRAL databases from inception until 28 July 2021 was performed. Randomized, controlled, clinical trials that compared autologous and synthetic bone grafts in tibial plateau fractures were included. Preclinical studies, clinical studies in paediatric patients, pathological fractures, fracture nonunion, or chondral defects were excluded. Outcome data were assessed using the Risk of Bias 2 (ROB2) framework and synthesized in random-effect meta-analysis. The Preferred Reported Items for Systematic Review and Meta-Analyses guidance was followed throughout.

Results

Six studies involving 353 fractures were identified from 3,078 records. Following ROB2 assessment, five studies (representing 338 fractures) were appropriate for meta-analysis. Primary outcomes showed non-significant reductions in articular depression at immediate postoperative (mean difference -0.45 mm, p = 0.25, 95%confidence interval (CI) -1.21 to 0.31, I² = 0%) and long-term (> six months, standard mean difference -0.56, p = 0.09, 95% CI -1.20 to 0.08, I² = 73%) follow-up in synthetic bone grafts. Secondary outcomes included mechanical alignment, limb functionality, and defect site pain at long-term follow-up, perioperative blood loss, duration of surgery, occurrence of surgical site infections, and secondary surgery. Mean blood loss was lower (90.08 ml, p < 0.001, 95% CI 41.49 to 138.67) and surgery was shorter (16.17 minutes, p = 0.04, 95% CI 0.39 to 31.94) in synthetic treatment groups. All other secondary measures were statistically comparable.

Conclusion

All studies reported similar methodologies and patient populations; however, imprecision may have arisen through performance variation. These findings supersede previous literature and indicate that, despite perceived biological advantages, autologous bone grafting does not demonstrate superiority to synthetic grafts. When selecting a void filler, surgeons should consider patient comorbidity, environmental and societal factors in provision, and perioperative and postoperative care provision.

Cite this article: Bone Jt Open 2022;3(3):218–228.

Does Time to Theatre Affect the Ability to Achieve Fracture Reduction in Tibial Plateau Fractures?

Surgical management of displaced tibial plateau fracture (TPF) is often delayed due to accompanying soft tissue injuries sustained at the time of injury. The primary aim of this study was to assess the effect of time to surgery on fracture reduction in cases of TPF. The secondary aim was to assess the effect of preoperative demographics and residual articular step on Lysholm Scores and Knee Injury and Osteoarthritis Outcome Scores (KOOS) following fixation. Patients between 2006 and 2017, managed by a single surgeon, were prospectively enrolled in the study. Reduction of articular step, defined as <2 mm, was assessed by a single blinded examiner. A total of 117 patients were enrolled, 52 with Schatzker II, 4 with Schatzker IV, and 61 with Schatzker VI fractures. Patients were followed up to a mean of 3.9 years. Analysis showed that the ability to achieve fracture reduction was negatively influenced by time to theatre, with the odds of achieving reduction decreasing 17% with each subsequent day post injury (p = 0.002). Furthermore, an increased time to theatre was associated with a reduced Lysholm score at one year (p = 0.01). The ability to achieve fracture reduction did not influence PROMs within the study period. We conclude that delay in surgical fixation negatively affects fracture reduction in TPF and may delay recovery. However, residual articular step does not necessarily influence PROMs over the mid-term.

The choice between allograft or demineralized bone matrix is not unambiguous in trauma surgery

In fracture surgery, large bone defects and non-unions often require bone transplantation, and alternatives to autograft bone substitutes in the form of allografts from bone banks and the derivate demineralised bone matrix (DBM) are widely used. With a focus on efficacy, clinical evidence, safety, cost, and patient acceptance, this review evaluated the difference between allogeneic allograft or DBM as a bone substitute in trauma surgery. The efficacy in supporting bone healing from allograft and DBM is highly influenced by donor characteristics and graft processing. Mechanical stability is achieved from a structural graft. Based on the existing literature it is difficult to identify where DBM is useful in trauma surgery, and the level of evidence for the relevant use of allograft bone in trauma is low. The risk of transmitting diseases is negligible, and the lowest risk is from DBM due to the extensive processing procedures. A cost comparison showed that DBM is significantly more expensive. The experiences of dental patients have shown that many patients do not want to receive allografts as a bone substitute. It is not possible to definitively conclude whether it makes a difference if allograft or DBM is used in trauma surgery. It is ultimately the surgeon's individual choice, but this article may be useful in providing considerations before a decision is made.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

IV.

Arthroscopy-assisted surgery: The management of posterolateral tibial plateau depression fracture accompanying ligament injury: A case series and review of the literature

Tibial plateau fractures are multiple fracture patterns associated with soft-tissue injuries. Among which, the combined existence of posterolateral tibial plateau depression fracture with anterior cruciate ligament (ACL) rupture has been reported rarely. Meanwhile, surgical method for the treatment of depression fracture is fairly complex. The aim of this article is to show a case series of this unusual injury pattern and the therapy of posterolateral tibial plateau depression fracture accompanying ACL rupture. In our treatment, arthroscopy assisted reduction of depression fracture and ACL reconstruction reduces surgical trauma and leads to good functional recovery. We also review the current literature.

Elution properties of a resorbable magnesium phosphate cement

OBJECTIVE

This study tests the elution capabilities of a magnesium phosphate cement (MPC). Study objectives were to quantify the passive release of magnesium ions from MPC and to assess the effects of antibiotic-loaded MPC on bacterial growth and osteoblast viability.

METHODS

MPC constructs were created and incubated in fetal bovine serum (FBS). At 2, 4, and 17 weeks, a sample was collected for magnesium ion concentration analysis. Control and vancomycin-loaded (vanc) MPC beads were also created. Zone of inhibition was measured after incubating beads on Staphylococcus aureus agar plates for 24 h. Osteoblasts were seeded onto control and vanc beads and cultured for 9 days. Metabolic activity was measured via a resazurin assay. ANOVA with Tukey HSD post-hoc tests and t-tests were performed.

RESULTS

Magnesium ions were eluted at 2 and 4-week time points without significant difference, but demonstrated a significant spike at the 17-week time point. Zones of inhibition for the bacterial species was observed for Vanc-MPC beads, but not control beads. No cytotoxic effects on osteoblasts were noted.

CONCLUSION

MPC has potential to improve bone regeneration based on its ability to passively elute magnesium. Additionally, antibiotic-loaded MPC inhibits bacterial growth while avoiding osteoblast cytotoxicity.

Lateral tibial plateau fractures-functional outcomes and complications after open reduction and internal fixation

PURPOSE

Tibial plateau fractures are severe intra-articular injuries; their treatment is accompanied by numerous complications and requires extensive surgical experience. In this manuscript, we compared our experiences with data from the literature.

METHODS

Retrospectively, we analyzed 41 patients with closed lateral tibial plateau fracture (Schatzker's I-III). All fractures were treated surgically with open reduction and internal plate fixation. Post-operative complications and final outcomes were monitored according to the Tegner Lysholm Knee Scoring System. The average follow-up was 5.7 years (2-10).

RESULTS

We analyzed 41 patients (Schatzker I-III), average age 46.7 ± 13.0 years. Traumatic lesion of the lateral meniscus was present in 15 (36.58%) patients. Post-traumatic knee osteoarthritis was present in all (100%) patients after lateral meniscectomy and in 20% of patients it occurred after meniscus repair (p = 0.007). Post-traumatic knee osteoarthritis was present in 12 (29.68%) patients. Infection occurred in five (12.19%) patients, DVT in three (7.3%) patients, and we had one (2.43%) case of non-lethal PE. Final functional outcomes were excellent in 13 (31.7%), good in 21 (51.21%), moderate in five (12.19%), and poor in two (4.87%) patients.

CONCLUSION

Lateral tibial plateau fractures are severe intra-articular injuries which can leave lasting consequences, regardless of the restoring of the articular surface and stable internal fixation. Local skin condition and associated soft tissue injuries, comminution, degree of dislocation, and depression can significantly affect the development of post-traumatic osteoarthritis and poor outcomes.

Highly impacted bone allograft may allow immediate weight bearing in tibial plateau fractures: A case report

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.

A review of calcium phosphate cements and acrylic bone cements as injectable materials for bone repair and implant fixation

Treatment of bone defects caused by trauma or disease is a major burden on human healthcare systems. Although autologous bone grafts are considered as the gold standard, they are limited in availability and are associated with post-operative complications. Minimally invasive alternatives using injectable bone cements are currently used in certain clinical procedures, such as vertebroplasty and balloon kyphoplasty. Nevertheless, given the high incidence of fractures and pathologies that result in bone voids, there is an unmet need for injectable materials with desired properties for minimally invasive procedures. This paper provides an overview of the most common injectable bone cement materials for clinical use. The emphasis has been placed on calcium phosphate cements and acrylic bone cements, while enabling the readers to compare the opportunities and challenges for these two classes of bone cements. This paper also briefly reviews antibiotic-loaded bone cements used in bone repair and implant fixation, including their efficacy and cost for healthcare systems. A summary of the current challenges and recommendations for future directions has been brought in the concluding section of this paper.

Fixation augmentation using titanium cage packing with xenograft in the treatment of tibial plateau fractures

OBJECTIVES

To evaluate a new surgical technique concerning titanium cage packing with xenograft demineralized bone matrix bovine augmentation in the management of subchondral bone defects associated with tibial plateau fractures.

METHODS

All patients underwent plate fixation augmentation using titanium cage packing with xenograft, with the help of digital medical software of Mimics and 3-matic preoperatively. Duration of the surgical procedure, intraoperative bleeding volume, bone union time, quality of reduction and alignment, fracture healing, complications, and functional outcomes based on Oxford knee outcome score were recorded.

RESULTS

A total of 18 patients were followed for average 18.1 months (range, 12-24 months). The average radiographic bony union time was 12.8 weeks (range, 11-17 weeks) and full weight bearing time was 13.4 weeks (range, 11-16 weeks) respectively. At one-year follow-up, the mean degrees of knee extension were 2.7° (range, 0-6) and the mean degrees of knee flexion were 122.0° (range, 112-134). The articular step-off was unchanged from 0.9 ± 0.6 mm (range, 0-1.8 mm) to 1.0 ± 0.6 mm (0-1.9 mm) (P = 0.512). All the cases had satisfactory reduction. No secondary loss of reduction was found over the time period studied. Superficial infection was found in one case, and resolved with closed treatment. No implant failures were noted. The average Oxford knee score was 19.9 ± 5.4 (range, 12-30) at the final follow-up.

CONCLUSION

Fixation augmentation using titanium cage packing with xenograft augmentation is a safe and effective way to treat the depressed tibial plateau fractures.

Bone Xenografts in Trauma and Orthopaedics (Analytical Review)

Purpose of the analytical review — to evaluate the application experience of bone xenografts in trauma and orthopaedics surgery. Methods. Data search was performed in the electronic databases of PubMed and eLIBRARY with depth of 20 years. Results. The authors identified 13 papers which described the application experience of bone xenografts in trauma surgery and orthopaedics. The highest efficiency (from 92 to 100%) was reported for cases of xenografts use to replace defects in intraarticular fractures and revision arthroplasty. Unsatisfactory outcomes were related to cases with no integration and graft rejection. The least efficiency (from 41,9 to 46,1%) was reported in reconstructive foot surgery. No effect of bone xenografts was observed for replacement of defects in cases of pseudoarthrosis. The most frequent complication was graft material infection. The summarized literature data provided the calculated share of complications following xenograft use of 7,53% (18 out of 239 cases, CI 5-95%, 4,53-11,21). Two areas were identified for improvement of technical and biological properties of bone xenografts: 1. Modification of original xeno-matrix (enhancement of purification technique, alteration of structure of chemical composition of the bone matrix); 2. Augmentation of matrix volume by additional elements (biologically active agents, stem cells). It’s noted that demand for xenografts in traumatology and orthopaedics can increase after refining and expanding the indications for clinical use. Conclusion. Bone xenografts used in the modern trauma surgery and orthopaedics to replace bone defects in revision arthroplasty as well as in certain fracture types. Such material is relatively safe and its ability to be modified allows to improve its biological properties.

Augmented Fixation for Fractures of the Appendicular Skeleton

Despite advances in technology such as locked plating, osteoporotic bone and bone defects remain challenging complications for orthopaedic surgeons. The concept of augmented fixation is useful in these settings. Augmented fixation can be described as improving construct strength and stability by enhancing the surrounding environment. By understanding and using the techniques of alternative fixation strategies, endosteal or medullary support, structural grafting, or the use of bone graft substitutes in combination with standard or integrated fixation, surgeons can improve the chances of success when treating difficult fractures. The purpose of this article is to introduce the reader to the concept of augmented fixation, review strategies for its application, and review applicable published results.

Multifunctional scaffolds for facile implantation, spontaneous fixation, and accelerated long bone regeneration in rodents

Graft-guided regenerative repair of critical long bone defects achieving facile surgical delivery, stable graft fixation, and timely restoration of biomechanical integrity without excessive biotherapeutics remains challenging. Here, we engineered hydration-induced swelling/stiffening and thermal-responsive shape-memory properties into scalable, three-dimensional–printed amphiphilic degradable polymer-osteoconductive mineral composites as macroporous, non–load-bearing, resorbable synthetic grafts. The distinct physical properties of the grafts enabled straightforward surgical insertion into critical-size rat femoral segmental defects. Grafts rapidly recovered their precompressed shape, stiffening and swelling upon warm saline rinse to result in 100% stable graft fixation. The osteoconductive macroporous grafts guided bone formation throughout the defect as early as 4 weeks after implantation; new bone remodeling correlated with rates of scaffold composition-dependent degradation. A single dose of 400-ng recombinant human bone morphogenetic protein-2/7 heterodimer delivered via the graft accelerated bone regeneration bridging throughout the entire defect by 4 weeks after delivery. Full restoration of torsional integrity and complete scaffold resorption were achieved by 12 to 16 weeks after surgery. This biomaterial platform enables personalized bone regeneration with improved surgical handling, in vivo efficacy and safety.

Composite Xenohybrid Bovine Bone-Derived Scaffold as Bone Substitute for the Treatment of Tibial Plateau Fractures

Introduction: Tibial plateau fractures represent a common challenge for orthopaedic surgeons, sometimes representing complex cases to manage, where augmentation using bone grafts is required for stabilisation. Autologous iliac bone graft (AIBG) is the current gold standard for bone grafting. In order to overcome limitations related to the procedure, alternative strategies, like allogenic and xenogeneic bone substitutes have been investigated. Here, within the framework of an observational clinical study, we report clinical and radiological outcomes of patients treated for tibial plateau fractures with a composite xenohybrid bone graft, aiming at assessing clinical and radiological outcomes. Materials and Methods: We performed a cohort retrospective study of patients treated for tibial plateau fractures from May 2017 to January 2018. Thirty-four patients, i.e. 100% of those having received the bone graft under investigation for tibial plateaux fracture treatment, met the inclusion criteria and were enrolled in the study. Patients were assessed at 2 weeks, and then at a 1-, 3-, and 6-months, and 1-year follow-up. At each evaluation patients filled a visual analogue scale (VAS) for the level of pain during the day life activities and underwent physical exam and anteroposterior and lateral projection radiographs of the knee. At 1 year the Tegner Lysholm Scoring Scale, International Knee Document Committee 2000 (IKDC 2000), and Short Form (36) Health Survey (SF-36) were administered. Results: At 1-year, mean VAS decreased from 6.33 ± 1.40 to 1 ± 0.79 (P < 0.0001); Tegner Lysholm Scoring Scale was 89 ± 4.10 and mean IKDC 2000 was 78.67 ± 3.31. No infections, neurovascular complications or adverse effects related to implants were reported during the clinical exams at follow-up. Mean ROM was 124 ± 6°. Radiographs did not show defects of consolidation or progressive post-surgical subsidence and demonstrated a good grade of integration of the implant. Conclusions: Clinical and radiological outcomes, and scores of questionnaires, were good. The xenograft has demonstrated to be a safe biomaterial, with satisfactory mechanical and biological performances in the mid-term period. It also showed a high grade of osteointegration and remodelling.

Screen-enrich-combine circulating system to prepare MSC/β-TCP for bone repair in fractures with depressed tibial plateau

Aim: To evaluate the clinical efficacy of mesenchymal stem cell/β-tricalcium phosphate composites (MSC/β-TCP) prepared with a screen-enrich-combine circulating system (SECCS) in patients with depressed tibial plateau fractures. Materials & methods: Bone defects in depressed tibial plateaus were filled with MSC/β-TCP (n = 16) or with β-TCP only (n = 23). Enrichment efficiency and effect of enrichment on cell viability were evaluated. Clinical results were assessed by imaging examination and Lysholm score. Results: SECCS effectively integrated MSCs with β-TCP. At 18 months postimplantation, new bone ratio was significantly higher in patients treated with MSC/β-TCP than in those treated with β-TCP only (p = 0.000). Patients with MSC/β-TCP implants had better functional recovery (p = 0.028). Conclusion: MSC/β-TCP prepared by SECCS were effective in the treatment of bone defects in patients with depressed tibial plateau fractures, promoted bone regeneration and improved joint function recovery.

[Biomechanical study on nickel-titanium three-dimensional memory alloy mesh combined with autologous bone for living model of canine tibial plateau collapse fracture]

Objective

To evaluate the effect of nickel-titanium three-dimensional memory alloy mesh combined with autologous bone for living model of canine tibial plateau collapse fracture by biomechanical testing.

Methods

Sixteen healthy 12-month-old Beagle dogs were randomly divided into 4 group, 4 dogs in each group. The dogs were used to establish the tibial plateau collapse fracture model in groups A, B, and C. Then, the nickel-titanium three-dimensional memory alloy mesh combined with autologous bone (the fibula cortical bone particles), the artificial bone (nano-hydroxyapatite), and autologous fibula cortical bone particles were implanted to repair the bone defects within 4 hours after modeling in groups A, B, and C, respectively; and the plate and screws were fixed outside the bone defects. The dogs were not treated in group D, as normal control. At 5 months after operation, all animals were sacrificed and the tibial specimens were harvested and observed visually. The destructive axial compression experiments were carried out by the biomechanical testing machine. The displacement and the maximum failure load were recorded and the axial stiffness was calculated.

Results

All animals stayed alive after operation, and all incisions healed. After 1-3 days of operation, the animals could stand and move, and no obvious limb deformity was found. The articular surfaces of the tibial plateau specimens were completely smooth at 5 months after operation. No obvious articular surface collapse was observed. The displacement and maximum failure load of specimens in groups A and D were significantly higher than those in groups B and C ( P<0.05). But no significant difference was found between groups A and D and between groups B and C ( P>0.05).

Conclusion

The nickel-titanium three-dimensional memory alloy mesh combined with autologous bone for subarticular bone defect of tibial plateau in dogs has good biomechanical properties at 5 months after operation, and has better axial stiffness when compared with the artificial bone and autologous bone graft.

Novel injectable strontium-hardystonite phosphate cement for cancellous bone filling applications

Injectable bone cement (IBC) such as those based on methacrylates and hydraulic calcium phosphate and calcium sulfate-based cements have been used extensively for filling bone defects with acceptable clinical outcomes. There is a need however for novel IBC materials that can address some of the inherent limitations of currently available formulations to widen the clinical application of IBC. In this study, we characterized a novel hydraulic IBC formulation consisting of bioactive strontium-doped hardystonite (Sr-HT) ceramic microparticles and sodium dihydrogen phosphate, herein named Sr-HT phosphate cement (SPC). The resultant cement is comprised of two distinct amorphous phases with embedded partially reacted crystalline reactants. The novel SPC formulation possesses a unique combination of physicochemical properties suitable for use as an IBC, and demonstrates in vitro cytocompatibility when seeded with primary human osteoblasts. In vivo injection of SPC into rabbit sinus defects show minor new bone formation at the SPC periphery, similar to those exhibited in sinus defects filled with a clinically available calcium phosphate cement. The current SPC formulation presented in this paper shows promise as a clinically applicable IBC which can be further enhanced with additives.

Settable polymer/ceramic composite bone grafts stabilize weight-bearing tibial plateau slot defects and integrate with host bone in an ovine model

Bone fractures at weight-bearing sites are challenging to treat due to the difficulty in maintaining articular congruency. An ideal biomaterial for fracture repair near articulating joints sets rapidly after implantation, stabilizes the fracture with minimal rigid implants, stimulates new bone formation, and remodels at a rate that maintains osseous integrity. Consequently, the design of biomaterials that mechanically stabilize fractures while remodeling to form new bone is an unmet challenge in bone tissue engineering. In this study, we investigated remodeling of resorbable bone cements in a stringent model of mechanically loaded tibial plateau defects in sheep. Nanocrystalline hydroxyapatite-poly(ester urethane) (nHA-PEUR) hybrid polymers were augmented with either ceramic granules (85% β-tricalcium phosphate/15% hydroxyapatite, CG) or a blend of CG and bioactive glass (BG) particles to form a settable bone cement. The initial compressive strength and fatigue properties of the cements were comparable to those of non-resorbable poly(methyl methacrylate) bone cement. In animals that tolerated the initial few weeks of early weight-bearing, CG/nHA-PEUR cements mechanically stabilized the tibial plateau defects and remodeled to form new bone at 16 weeks. In contrast, cements incorporating BG particles resorbed with fibrous tissue filling the defect. Furthermore, CG/nHA-PEUR cements remodeled significantly faster at the full weight-bearing tibial plateau site compared to the mechanically protected femoral condyle site in the same animal. These findings are the first to report a settable bone cement that remodels to form new bone while providing mechanical stability in a stringent large animal model of weight-bearing bone defects near an articulating joint.

Utility of cement injection to stabilize split-depression tibial plateau fracture by minimally invasive methods: A finite element analysis

BACKGROUND

Treatment for fractures of the tibial plateau is in most cases carried out by stable fixation in order to allow early mobilization. Minimally invasive technologies such as tibioplasty or stabilization by locking plate, bone augmentation and cement filling (CF) have recently been used to treat this type of fracture. The aim of this paper was to determine the mechanical behavior of the tibial plateau by numerically modeling and by quantifying the mechanical effects on the tibia mechanical properties from injury healing.

METHODS

A personalized Finite Element (FE) model of the tibial plateau from a clinical case has been developed to analyze stress distribution in the tibial plateau stabilized by balloon osteoplasty and to determine the influence of the cement injected. Stress analysis was performed for different stages after surgery.

FINDINGS

Just after surgery, the maximum von Mises stresses obtained for the fractured tibia treated with and without CF were 134.9 MPa and 289.9 MPa respectively on the plate. Stress distribution showed an increase of values in the trabecular bone in the treated model with locking plate and CF and stress reduction in the cortical bone in the model treated with locking plate only.

INTERPRETATION

The computed results of stresses or displacements of the fractured models show that the cement filling of the tibial depression fracture may increase implant stability, and decrease the loss of depression reduction, while the presence of the cement in the healed model renders the load distribution uniform.

Minimally invasive opening wedge tibia outpatient osteotomy, using screw-to-plate locking technique and a calcium phosphate cement

Medial knee osteoarthritis on angular varus deformity of a lower limb is very common. Open-wedge high tibial osteotomy is a treatment of choice if cartilage is not excessively worn (Allback 1 or 2). The technique based on a plate fixation and the bone defect filled with calcium phosphate cement is thoroughly described. Data at 1, 3, 6 months and 1 year of a 19 cases continuous and prospective series are collected and analysed. Mean age at the time of operation was 55 years. The average preoperative varus deformity was 5° and corrected to an average postoperative valgus of 4° (range 3°-6°). Each control includes the collection of eventual complications, the measurement of health status (quality of life and functional scores) and antero-posterior and lateral X-rays. All osteotomies were considered healed at 6 weeks without any correction loss except one, probably result of a technical error. There was no difference in clinical and functional results between the group and the literature, but the final result occurred earlier in the treatment when the bone defect was filled with either calcium phosphate cement. Faster recovery involved no specific complication and enabled outpatient treatment in a majority of patients.

Complex Tibial Plateau Fractures Treated by Hybrid External Fixation System: A correlation of followup computed tomography derived quality of reduction with clinical results

BACKGROUND

Tibial plateau fractures are common due to high energy injuries. The principles of treatment include respect for the soft tissues, restoring the congruity of the articular surface and reduction of the anatomic alignment of the lower limb to enable early movement of the knee joint. There are various surgical fixation methods that can achieve these principles of treatment. Recognition of the particular fracture pattern is important, as this guides the surgical approach required in order to adequately stabilize the fracture. This study evaluates the results of the combined treatment of external fixator and limited internal fixation along with the advantages using postoperative computed tomography (CT) scan after implant removal. Materials and.

METHODS

55 patients with a mean age of 42 years (range 17-65 years) with tibial plateau fracture, were managed in our institution between October 2010 and September 2013., Twenty fractures were classified as Schatzker VI and 35 as Schatzker V. There were 8 open fractures (2 Gustilo Anderson 3A and 6 Gustilo Anderson 2). All fractures were treated with closed reduction and hybrid external fixation (n = 21/38.2%) or with minimal open reduction internal fixation and a hybrid system (n = 34/61.8%). After the removal of the fixators, CT-scan was programmed for all the cases, for correlation with the results. At final followup, the American Knee Society Score (AKSS) was administered.

RESULTS

All patients were evaluated with a minimum of 12 months (range 12-21 months) followup. Average time to union was 15.5 weeks (range 13-19 weeks). The postoperative joint congruity as evaluated in the postoperative CT-scan was <2 mm of articular step-off in 8 patients (14.5%), between 2 and 4 mm in 18 patients (32.7%) and over 4 mm in 29 (52.7%). The injured limb mechanical axis was restored within 5° compared to the contralateral limb in 36 cases (65%) and with an angulation >5° in 19 cases (35%). Patients with residual joint depression <3.5 mm had a 95% chance of having excellent AKSS knee score results and 80% chance of having excellent AKSS function scores. On the other hand, residual joint depression of >4.5 mm displayed a 100% chance of getting poor-fair scores both in AKSS knee and AKSS function score. The association of a postoperative mechanical axis within 5° of the contralateral limb and improved knee scores was statistically significant for the AKSS function and total scores but not for the AKSS knee score. The AKSS was negatively correlated with postoperative joint depression magnitude which was statistically significant. Only the amount of joint collapse was verified as a prognostic factor in a multivariate logistic regression analysis.

CONCLUSIONS

The postoperative CT-scan shows important information about bone healing, and an exact image of the reduction and the shaft alignment. Postoperative radiographs may have led to an underestimation of the degree of residual displacement. On the contrary, CT-scan demonstrates the exact grade of articular displacement and depending on CT-scan results one can better manage the postoperative rehabilitation.

Long-term radiographic appearance of calcium-phosphate synthetic bone grafts after surgical treatment of tibial plateau fractures

OBJECTIVES

Synthetic bone grafts (SBGs) are widely used to fill bone defects after fracture reduction. This study assessed the long-term resorption of two different calcium phosphate products (A=ChronOS™ inject and B=Norian^® SRS^®; both DePuy Synthes, Oberdorf, Switzerland) used in the surgical treatment of tibial plateau fractures.

DESIGN

Long-term clinical and radiologic follow-up of 52 patients after surgical treatment of intraarticular tibial plateau fractures augmented with SBGs.

SETTING

The study was performed at a level 3 trauma center.

PATIENTS

Between January 2000 and December 2006 a total of 52 patients with intraarticular tibial plateau fractures were operatively treated and augmented with SBGs consisting of a Brushite matix with β-TCP granules (SBG A) or hydroxylapatite with 4-6% carbonate content (SBG B). 46 patients could be contacted and 38 were included in the study. Half of the patients received SBG A and the other half SBG B.

MAIN OUTCOME MEASUREMENTS

Loss of reduction and SBG resorption was investigated by comparison of follow-up X-ray images to pre- and postoperative X-ray images. Furthermore, pain, activity level and knee function were evaluated by means of questionnaires and clinical examination.

RESULTS

The mean age of patients was 59.7±12.5years. The follow-up was 8.6±0.9years for SBG A and 11.6±1.4years for SBG B (p<0.001). In most cases SBG A was completely resorbed in a homogenous pattern, while SBG B was still visible on the X-ray images revealing a peripheral resorption pattern. A loss of reduction (>2mm) could be observed in two patients with SBG A and two patients with SBG B, although only one of them had an impaired knee function.

CONCLUSIONS

The composite SBG A reveals a comprehensive long-term resorption in comparison to SBG B. Nevertheless, both provided suitable mechanical support as part of the surgical treatment of tibial plateau fractures.

LEVEL OF EVIDENCE

Case series, Level IV.

GIT1 gene deletion delays chondrocyte differentiation and healing of tibial plateau fracture through suppressing proliferation and apoptosis of chondrocyte

Background

Although tibial plateau fracture is an uncommon injury, its regulation is challenging and there are some influencing factors, including the effects of severe bone displacement, depression and cancellous bone cartilage, and inevitable cartilage damage. And GIT1 plays an important role in bone mass and 78 osteoblast cell migration.

Methods

The study used 72 C57/BL6 mice. A tibial plateau fracture model was established by using mice with the same number of GIT1 gene deletions (the experimental group) and their wild-type littermates (the control group). Joint and bone callus recovery were evaluated by X-ray and CT thin layer scans. Micro CT assay and histomorphometry were conducted in order to evaluate the volume of newly formed blood vessels. Type II collagen expression in tibial tissues after tibial plateau fracture were detected by immunohistochemistry after 7, 14 and 21 days. The number of proliferating cell nuclear antigen (PCNA) positive cells after tibial plateau fracture was tested by immunohistochemistry after 14 and 21 days. The terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling (TUNEL) staining was conducted after 14 and 21 days in order to test chondrocyte apoptosis in tibial tissues after tibial plateau fracture.

Results

The GIT1 gene deletion group mice spent less time on the rotating rod than the control group mice (P < 0.05). Compared with the control group, postoperative recovery was retarded, because GIT1 gene deletion slowed down neovascularization after tibial plateau fracture (P < 0.05). Compared with the control group, mouse type II collagen expression significantly decreased in the GIT1 gene deletion group, and the proportion of PCNA positive cells significantly decreased (P < 0.05). The TUNEL results indicate that GIT1 gene deletion led to reduced chondrocyte apoptosis.

Conclusion

GIT1 gene deletion can inhibit chondrocyte proliferation and apoptosis during the recovery of tibial plateau fracture, so as to delay chondrocyte differentiation and tibial plateau fracture healing.

Partial proximal tibia fractures

Partial tibial plateau fractures may occur as a consequence of either valgus or varus trauma combined with a rotational and axial compression component.

High-energy trauma may result in a more complex and multi-fragmented fracture pattern, which occurs predominantly in young people. Conversely, a low-energy mechanism may lead to a pure depression fracture in the older population with weaker bone density.

Pre-operative classification of these fractures, by Müller AO, Schatzker or novel CT-based methods, helps to understand the fracture pattern and choose the surgical approach and treatment strategy in accordance with estimated bone mineral density and the individual history of each patient.

Non-operative treatment may be considered for non-displaced intra-articular fractures of the lateral tibial condyle. Intra-articular joint displacement ⩾ 2 mm, open fractures or fractures of the medial condyle should be reduced and fixed operatively. Autologous, allogenic and synthetic bone substitutes can be used to fill bone defects.

A variety of minimally invasive approaches, temporary osteotomies and novel techniques (e.g. arthroscopically assisted reduction or ‘jail-type’ screw osteosynthesis) offer a range of choices for the individual and are potentially less invasive treatments.

Rehabilitation protocols should be carefully planned according to the degree of stability achieved by internal fixation, bone mineral density and other patient-specific factors (age, compliance, mobility). To avoid stiffness, early functional mobilisation plays a major role in rehabilitation. In the elderly, low-energy trauma and impression fractures are indicators for the further screening and treatment of osteoporosis.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160067. Originally published online at www.efortopenreviews.org

Biomechanical comparison of acute Hill-Sachs reduction with remplissage to treat complex anterior instability

BACKGROUND

Acute Hill-Sachs reduction represents a potential alternative method to remplissage for the treatment of an engaging Hill-Sachs lesion. This study biomechanically compared the stabilizing effects of an acute Hill-Sachs reduction technique and remplissage.

METHODS

Six cadaveric shoulders were tested. For the acute Hill-Sachs lesion, a unique model was used to create a 30% defect, compressing the subchondral bone while preserving the articular surface. Five scenarios were tested: intact specimen, bipolar lesion, Bankart repair, remplissage with Bankart repair, and Hill-Sachs reduction technique with Bankart repair. The Hill-Sachs lesion was reduced through a lateral cortical window with a bone tamp, and the subchondral void was filled with bone cement.

RESULTS

At 90° of abduction and external rotation (ER), total translation was 11.6 ± 0.9 mm for the bipolar lesion. This was significantly reduced after remplissage (5.9 ± 1.1 mm; P < .001) and after Hill-Sachs reduction (4.7 ± 0.4 mm; P < .001). Compared with an isolated Bankart repair, the average ER loss after remplissage was 4° ± 4° (P = .65), and the average ER loss after Hill-Sachs reduction was 1° ± 3° (P = .99). Similar joint stability was conferred after both procedures, with minimal change in range of motion.

CONCLUSIONS

Remplissage may still be the best way to address chronic Hill-Sachs lesions; however, the reduction technique is a more anatomic alternative and may be a potential option for treating an acutely engaging Hill-Sachs lesion.

Articular impaction injuries in the lower limb

The effective management of articular impacted fractures requires the successful elevation of the osteochondral fragment to eliminate joint incongruency and the stable fixation of the fragments providing structural support to the articular surface.The anatomical restoration of the joint can be performed either with elevation through a cortical window, through balloon-guided osteoplasty or direct visualisation of the articular surface.Structural support of the void created in the subchondral area can be achieved through the use of bone graft materials (autologous tricortical bone), or synthetic bone graft substitutes.In the present study, we describe the available techniques and materials that can be used in treating impacted osteochondral fragments with special consideration of their epidemiology and treatment options. Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160072. Originally published online at www.efortopenreviews.org.

Treatment strategy for tibial plateau fractures: an update

Tibial plateau fractures are complex injuries produced by high- or low-energy trauma. They principally affect young adults or the 'third age' population.These fractures usually have associated soft-tissue lesions that will affect their treatment. Sequential (staged) treatment (external fixation followed by definitive osteosynthesis) is recommended in more complex fracture patterns. But one should remember that any type of tibial plateau fracture can present with soft-tissue complications.Typically the Schatzker or AO/OTA classification is used, but the concept of the proximal tibia as a three-column structure and the detailed study of the posteromedial and posterolateral fragment morphology has changed its treatment strategy.Limb alignment and articular surface restoration, allowing early knee motion, are the main goals of surgical treatment. Partially articular factures can be treated by minimally-invasive methods and arthroscopy is useful to assist and control the fracture reduction and to treat intra-articular soft-tissue injuries.Open reduction and internal fixation (ORIF) is the gold standard treatment for these fractures. Complex articular fractures can be treated by ring external fixators and minimally-invasive osteosynthesis (EFMO) or by ORIF. EFMO can be related to suboptimal articular reduction; however, outcome analysis shows results that are equal to, or even superior to, ORIF. The ORIF strategy should also include the optimal reduction of the articular surface.Anterolateral and anteromedial surgical approaches do not permit adequate reduction and fixation of posterolateral and posteromedial fragments. To achieve this, it is necessary to reduce and fix them through specific posterolateral or posteromedial approaches that allow optimal reduction and plate/screw placement.Some authors have also suggested that primary total knee arthroplasty could be an option in specific patients and with specific fracture patterns. Cite this article: Prat-Fabregat S, Camacho-Carrasco P. Treatment strategy for tibial plateau fractures: an update. EFORT Open Rev 2016;1:225-232. DOI: 10.1302/2058-5241.1.000031.

Autograft versus allograft reconstruction of acute tibial plateau fractures: a comparative study of complications and outcome

BACKGROUND

There is no consensus regarding the use of filling agent in the re-elevation of depressed tibial plateau fracture (TPF). Although autograft is considered as the gold standard approach of such reconstructions, its limitation has led to a recent attraction toward allograft substitution. In this study, we compare the complications and outcome of autograft and allograft in TPF reconstruction, in order to address the existing controversy.

MATERIALS AND METHODS

A total of 81 patients with acute TPF were included in this study. Allograft and autograft were applied in 58 and 23 cases, respectively. The mean age of the patients was 40.26 years, and the mean follow-up period of patients was 19.1 months. Clinical and radiological assessment of the outcome was conducted, employing the modified Rasmussen clinical criteria.

RESULTS

A total of three infections were observed in our patients, from which two infections occurred in allograft received patients. Articular surface collapse was seen in two cases, including one allograft and one autograft receiving patient. The mean clinical score was 18.65 and 18.55 in autograft and allograft received patients, respectively (p = 0.09). The mean radiological score was 15.65 and 15.68 in autograft and allograft received patients (p = 0.3).

CONCLUSION

With respect to the comparable complication rate, clinical and radiological outcome of allogenic versus autologous reconstruction of TPF, freeze-dried allograft could be recommended as an appropriate substitute of autograft in this treatment. Nevertheless, the longer follow-up period of the patients could further extend our understanding of the clinical outcome of each component.

The role of peptides in bone healing and regeneration: a systematic review

BACKGROUND

Bone tissue engineering and the research surrounding peptides has expanded significantly over the last few decades. Several peptides have been shown to support and stimulate the bone healing response and have been proposed as therapeutic vehicles for clinical use. The aim of this comprehensive review is to present the clinical and experimental studies analysing the potential role of peptides for bone healing and bone regeneration.

METHODS

A systematic review according to PRISMA guidelines was conducted. Articles presenting peptides capable of exerting an upregulatory effect on osteoprogenitor cells and bone healing were included in the study.

RESULTS

Based on the available literature, a significant amount of experimental in vitro and in vivo evidence exists. Several peptides were found to upregulate the bone healing response in experimental models and could act as potential candidates for future clinical applications. However, from the available peptides that reached the level of clinical trials, the presented results are limited.

CONCLUSION

Further research is desirable to shed more light into the processes governing the osteoprogenitor cellular responses. With further advances in the field of biomimetic materials and scaffolds, new treatment modalities for bone repair will emerge.

What's new in the management of complex tibial plateau fractures?

The management of complex tibial plateau fractures is ever evolving. The severity of the injury to the surrounding soft tissues influences the timing and the method of fixation. Minimal invasive techniques continue to dominate our philosophy of reduction and reconstruction whereas augmentation of depressed intra-articular fragments remains an accepted strategy to maintain reduction and prevent secondary collapse. Locking plates, conventional plates and fine wire fixators all have been used successfully with satisfactory outcomes. In this article we report on the latest advances made in the management of these complex injuries.

Efficacy of novel synthetic bone substitutes in the reconstruction of large segmental bone defects in sheep tibiae

The treatment of large bone defects, particularly those with segmental bone loss, remains a significant clinical challenge as current approaches involving surgery or bone grafting often do not yield satisfactory long-term outcomes. This study reports the evaluation of novel ceramic scaffolds applied as bone graft substitutes in a clinically relevant in vivo model. Baghdadite scaffolds, unmodified or modified with a polycaprolactone coating containing bioactive glass nanoparticles, were implanted into critical-sized segmental bone defects in sheep tibiae for 26 weeks. Radiographic, biomechanical, μ-CT and histological analyses showed that both unmodified and modified baghdadite scaffolds were able to withstand physiological loads at the defect site, and induced substantial bone formation in the absence of supplementation with cells or growth factors. Notably, all samples showed significant bridging of the critical-sized defect (average 80%) with evidence of bone infiltration and remodelling within the scaffold implant. The unmodified and modified baghdadite scaffolds achieved similar outcomes of defect repair, although the latter may have an initial mechanical advantage due to the nanocomposite coating. The baghdadite scaffolds evaluated in this study hold potential for use as purely synthetic bone graft substitutes in the treatment of large bone defects while circumventing the drawbacks of autografts and allografts.

Bone graft substitutes and bone morphogenetic proteins for osteoporotic fractures: what is the evidence?

Despite improvements in implants and surgical techniques, osteoporotic fractures remain challenging to treat. Among other major risk factors, decreased expression of morphogenetic proteins has been identified for impaired fracture healing in osteoporosis. Bone grafts or bone graft substitutes are often used for stabilizing the implant and for providing a scaffold for ingrowth of new bone. Both synthetic and naturally occurring biomaterials are available. Products generally contain hydroxyapatite, tricalcium phosphate, dicalcium phosphate, calcium phosphate cement, calcium sulfate (plaster of Paris), or combinations of the above. Products have been used for the treatment of osteoporotic fractures of the proximal humerus, distal radius, vertebra, hip, and tibia plateau. Although there is generally consensus that screw augmentation increased the biomechanical properties and implant stability, the results of using these products for void filling are not unequivocal. In osteoporotic patients, Bone Morphogenetic Proteins (BMPs) have the potential impact to improve fracture healing by augmenting the impaired molecular and cellular mechanisms. However, the clinical evidence on the use of BMPs in patients with osteoporotic fractures is poor as there are no published clinical trials, case series or case studies. Even pre-clinical literature on in vitro and in vivo data is weak as most articles focus on the beneficial role for BMPs for restoration of the underlying pathophysiological factors of osteoporosis but do not look at the specific effects on osteoporotic fracture healing. Limited data on animal experiments suggest stimulation of fracture healing in ovariectomized rats by the use of BMPs. In conclusion, there is only limited data on the clinical relevance and optimal indications for the use of bone graft substitute materials and BMPs on the treatment of osteoporotic fractures despite the clinical benefits of these materials in other clinical indications. Given the general compromised outcome in osteoporotic fractures and limited alternatives for enhancement of fracture healing, clinicians and researchers should focus on this important topic and provide more data in this field in order to enable a sound clinical use of these materials in osteoporotic fractures.

Arthroscopy Assisted Balloon Osteoplasty of a Tibia Plateau Depression Fracture: A Case Report

Context:

A clinical case of a tibia plateau fracture is presented which was treated with balloon osteoplasty and arthroscopy guidance. Balloon Tibioplasty has been shown to be a very useful method for the management of tibial plateau fractures. The use of calcium phosphate has been described in the literature for management and restoration of bone defects in tibial plateau fractures.

Case Report:

A 45-years-old Caucasian woman was presented after a fall from a ladder. The patient sustained a lateral tibia plateau fracture which was classified as Shatzker type III (AO 41-B2) with posterolateral depression of the joint surface. Surgical treatment was applied using a minimal approach which included percutaneous reduction of the fracture under arthroscopy and fluoroscopy guidance. The bone defect was filled with calcium phosphate via injection. The clinical outcome at the 6, 12 and 24 weeks was excellent with full-range of motion of the knee joint.

Conclusion:

Arthroscopy assisted balloon osteoplasty seems to be a safe and effective method for the treatment of depressed tibia plateau fractures. Further study is needed for the proper evidence based use and application of this method.

Porous titanium granules are better than autograft bone as a bone void filler in lateral tibial plateau fractures: A randomised trial

A total of 20 patients with a depressed fracture of the lateral tibial plateau (Schatzker II or III) who would undergo open reduction and internal fixation were randomised to have the metaphyseal void in the bone filled with either porous titanium granules or autograft bone. Radiographs were undertaken within one week, after six weeks, three months, six months, and after 12 months. The primary outcome measure was recurrent depression of the joint surface: a secondary outcome was the duration of surgery. The risk of recurrent depression of the joint surface was lower (p < 0.001) and the operating time less (p < 0.002) when titanium granules were used. The indication is that it is therefore beneficial to use porous titanium granules than autograft bone to fill the void created by reducing a depressed fracture of the lateral tibial plateau. There is no donor site morbidity, the operating time is shorter and the risk of recurrent depression of the articular surface is less.