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Laurent Tsai SH, Lin CR, Lin YR, Liu YC, Tischler EH, Tang HC, Chen CH, Su CY, Chan YS. Comparative Analysis of Posterior Approach Versus Anterior Approach for Posterior Tibial Plateau Fractures: A Systematic Review and Meta-analysis. JBJS Rev 2023; 11:01874474-202307000-00002. [PMID: 37433013 PMCID: PMC10337318 DOI: 10.2106/jbjs.rvw.23.00030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
BACKGROUND Posterior tibial plateau fractures can lead to significant posttraumatic instability if not treated properly. It remains unclear which surgical approach achieves better patient outcomes. The objective of this systematic review and meta-analysis was to assess postoperative outcomes in patients undergoing anterior, posterior, or combined approach for posterior tibial plateau fractures. METHODS The PubMed, Embase, Web of Science, The Cochrane Library, and Scopus were searched for studies published before October 26, 2022, comparing anterior, posterior, or combined approaches for posterior tibial plateau fractures. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Outcomes included complications, infections, range of motion (ROM), operation time, union rates, and functional scores. Significance was set at p < 0.05. Meta-analysis was conducted with STATA software. RESULTS In total, 29 studies with a total of 747 patients were included for quantitative and qualitative analysis. Compared with other approaches, the posterior approach for posterior tibial plateau fractures was associated with a better ROM and shorter operative time. The complication rates, infection rates, union time, and hospital for special surgery (HSS) scores were not significantly different between surgical approaches. CONCLUSIONS The posterior approach for posterior tibial plateau fractures offers advantages such as improved ROM and shorter operative time. However, there are concerns regarding prone positioning in patients with medical or pulmonary comorbidities and indications in polytrauma cases. Further prospective studies are needed to determine the optimal approach for these fractures. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sung Huang Laurent Tsai
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung Branch, Bone and Joint Research Center, and Chang Gung University, Keelung, Taiwan
| | - Chun Ru Lin
- Chang Gung Memorial Hospital, Linkou Branch, Taoyuan City, Taiwan
| | - You-Rui Lin
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung Branch, Bone and Joint Research Center, and Chang Gung University, Keelung, Taiwan
| | - Yi-Chen Liu
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung Branch, Bone and Joint Research Center, and Chang Gung University, Keelung, Taiwan
| | - Eric H Tischler
- Department of Orthopaedic Surgery and Rehabilitation Medicine, Downstate Medical Center, State University of New York, New York, New York
| | - Hao-Che Tang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung Branch, Bone and Joint Research Center, and Chang Gung University, Keelung, Taiwan
| | - Chien-Hao Chen
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung Branch, Bone and Joint Research Center, and Chang Gung University, Keelung, Taiwan
| | - Chun-Yi Su
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung Branch, Bone and Joint Research Center, and Chang Gung University, Keelung, Taiwan
| | - Yi-Sheng Chan
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung Branch, Bone and Joint Research Center, and Chang Gung University, Keelung, Taiwan
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Overman KL, Jabara JT, Gannon NP, Edwards KE, Kahat DH, Tatman LM, Agel J, Swiontkowski MF, Nguyen MP. Comparison of clinical and radiographic outcomes of arthroscopic-assisted percutaneous fixation versus open reduction internal fixation of lateral tibial plateau fractures. INTERNATIONAL ORTHOPAEDICS 2023; 47:1583-1590. [PMID: 36939872 DOI: 10.1007/s00264-023-05777-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/12/2023] [Indexed: 03/21/2023]
Abstract
PURPOSE Treatment for tibial plateau fractures continues to evolve but maintains primary objectives of anatomic reduction of the joint line and a rapid recovery course. Arthroscopic-assisted percutaneous fixation (AAPF) has been introduced as an alternative to traditional open reduction internal fixation (ORIF). The purpose of the study is to compare clinical and radiographic outcomes in patients with low-energy Schatzker type I-III tibial plateau fractures treated with AAPF versus ORIF. METHODS A retrospective chart review was performed at a level 1 trauma centre to compare outcomes of 120 patients (57 AAPF, 63 ORIF) with low-energy lateral Schatzker type I-III tibial plateau fractures who underwent tibial plateau fixation between 2009 and 2018. Demographic information, injury characteristics, and surgical treatment were recorded. The main outcome measurements included reduction step-off, joint space narrowing, time to weight bearing, and implant removal. RESULTS There was no difference in age, gender distribution, BMI, ASA, Schatzker classification distribution, initial displacement, blood loss, and reduction step-off between the two groups (p > 0.05). Shorter tourniquet time (74.1 ± 21.7 vs 100.0 ± 21.0 min; p < 0.001), shorter time to full weight bearing (47.8 ± 15.2 vs. 69.1 ± 17.2 days; p < 0.001), and lower rate of joint space narrowing (3.5% vs. 28.6% with more than 1 mm, p < 0.001) were associated with the AAPF cohort, with no difference in pain, knee range of motion, or implant removal rate between the two cohorts. CONCLUSION AAPF may be a viable alternative to ORIF for the management of low-energy tibial plateau fractures with outcomes not inferior compared to the traditional ORIF method.
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Affiliation(s)
- Kelsey L Overman
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Justin T Jabara
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Nicholas P Gannon
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Kelly E Edwards
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - David H Kahat
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Lauren M Tatman
- Department of Orthopaedic Surgery, Washington University in Saint Louis, Saint Louis, MO, USA
| | - Julie Agel
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Marc F Swiontkowski
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Mai P Nguyen
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA.
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Nguyen MP, Gannon NP, Paull TZ, Bakker C, Bzovsky S, Sprague S, Swiontkowski MF. Outcomes of arthroscopic-assisted lateral tibial plateau fixation: a systematic review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03339-3. [PMID: 35867167 DOI: 10.1007/s00590-022-03339-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/05/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE The purpose of this study is to evaluate and summarize the current literature on outcomes of arthroscopic-assisted tibial plateau fixation (AATPF) when applied for only lateral tibial plateau fractures. METHODS A comprehensive search of nine databases was conducted: ClinicalTrials.gov, Cochrane Library via Wiley, Embase and MEDLINE via Ovid, Global Index Medicus, PubMed, Scopus, SPORTDiscus via EBSCO, and Web of Science Core Collection. The study was performed in concordance with PRISMA guidelines. Studies eligible for inclusions included Schatzker I-III lateral tibial plateau fractures with a minimum of 6-month follow-up. Data extraction was performed by two authors independently using a predesigned form. RESULTS A total of 17 studies, 7 prospective and 10 retrospective, including 565 patients (age 15-82 years old) treated with AATPF were included in this review with follow-up ranging from 6 to 138 months. All 10 studies that used categorical functional outcomes demonstrated excellent/very good or good outcomes in > 90% of patients. When compared to patients managed with the traditional open reduction internal fixation (ORIF), patients treated with AATPF had statistically significantly better range of motion mean difference [5.21° (95% CI - 2.50 to 12.92, p < 0.0001)], lower blood loss [66.19 mL (95% confidence interval (CI) 32.54-99.84 mL, p < 0.0001)], shorter hospital stay [- 1.41 days (95% CI - 3.39 to 0.58 days, p < 0.0001)], better Hospital Special Surgery score [11.31 (95% CI 6.49-16.12, p < 0.0001)], and higher Rasmussen radiographic score [1.26 (95% CI - 0.72 to 3.23, p < 0.0001)]. CONCLUSION AATPF is a promising treatment of lateral tibial plateau fractures with some advantages over the traditional ORIF. LEVEL OF EVIDENCE Therapeutic Level III.
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Affiliation(s)
- Mai P Nguyen
- Regions Hospital, 640 Jackson Street, Saint Paul, MN, 55101, USA.
- University of Minnesota, 2450 Riverside Ave, Suite R200, Minneapolis, MN, 55455, USA.
| | - Nicholas P Gannon
- University of Minnesota, 2450 Riverside Ave, Suite R200, Minneapolis, MN, 55455, USA
| | - Thomas Z Paull
- Regions Hospital, 640 Jackson Street, Saint Paul, MN, 55101, USA
- University of Minnesota, 2450 Riverside Ave, Suite R200, Minneapolis, MN, 55455, USA
| | - Caitlin Bakker
- University of Minnesota, 2450 Riverside Ave, Suite R200, Minneapolis, MN, 55455, USA
| | - Sofia Bzovsky
- McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
| | - Sheila Sprague
- McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada
| | - Marc F Swiontkowski
- University of Minnesota, 2450 Riverside Ave, Suite R200, Minneapolis, MN, 55455, USA
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Krause M, Frosch KH. [Change in the treatment of tibial plateau fractures]. Unfallchirurg 2022; 125:527-534. [PMID: 35380266 DOI: 10.1007/s00113-022-01165-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The treatment of tibial plateau fractures has experienced a number of very different conceptual developments in recent years, not only with respect to technical innovations but also against the background of changing fracture patterns and the growing requirements of patients. OBJECTIVE What developments in recent years have had a significant impact on current treatment strategies for tibial plateau fractures? METHODS Narrative review of publications listed in PubMed on the topic of treatment of complex tibial plateau fractures. RESULTS While the two-dimensional classifications are becoming less important, computed tomography (CT)-based three-dimensional assessment of fracture progression and an access strategy based on it are coming to the fore. Direct dorsal approaches have been shown to be superior, particularly in the case of relevant posteromedial and/or posterolateral fracture involvement. The step-by-step approach extension via specific osteotomies of ligamentous attachments also enables a needs-dependent and fracture-dependent complete joint visualization and reduction control. In the treatment of geriatric tibial plateau fractures, primary treatment with endoprostheses is becoming increasingly more important to enable early mobilization under full load bearing with significantly shorter rehabilitation times. CONCLUSION Modern developments in the context of fracture treatment around the tibial plateau have led to a relevant reduction of infections and improved surgical outcomes; however, the high demands and the improved understanding of fractures still underline the great challenge in the treatment of complex fracture patterns.
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Affiliation(s)
- Matthias Krause
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | - Karl-Heinz Frosch
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.,Abteilung für Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Hamburg, Hamburg, Deutschland
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Frosch KH, Korthaus A, Thiesen D, Frings J, Krause M. The concept of direct approach to lateral tibial plateau fractures and stepwise extension as needed. Eur J Trauma Emerg Surg 2020; 46:1211-1219. [PMID: 32607776 PMCID: PMC7691307 DOI: 10.1007/s00068-020-01422-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/15/2020] [Indexed: 10/31/2022]
Abstract
Malreduction after tibial plateau fractures mainly occurs due to insufficient visualization of the articular surface. In 85% of all C-type fractures an involvement of the posterolateral-central segment is observed, which is the main region of malreduction. The choice of the approach is determined (1) by the articular area which needs to be visualized and (2) the positioning of the fixation material. For simple lateral plateau fractures without involvement of the posterolateral-central segment an anterolateral standard approach in supine position with a lateral plating is the treatment of choice in most cases. For complex fractures the surgeon has to consider, that the articular surface of the lateral plateau only can be completely visualized by extended approaches in supine, lateral and prone position. Anterolateral and lateral plating can also be performed in supine, lateral and prone position. A direct fixation of the posterolateral-central segment by a plate or a screw from posterior can be only achieved in prone or lateral position, not supine. The posterolateral approach includes the use of two windows for direct visualization of the fracture. If visualization is insufficient the approach can be extended by lateral epicondylar osteotomy which allows exposure of at least 83% of the lateral articular surface. Additional central subluxation of the lateral meniscus allows to expose almost 100% of the articular surface. The concept of stepwise extension of the approach is helpful and should be individually performed as needed to achieve anatomic reduction and stable fixation of tibial plateau fractures.
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Affiliation(s)
- Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Alexander Korthaus
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Darius Thiesen
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jannik Frings
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Extended approach to the lateral tibial plateau with central meniscal subluxation in fracture repair: feasibility and first clinical and radiographic results. Eur J Trauma Emerg Surg 2020; 46:1221-1226. [PMID: 32865596 PMCID: PMC7691302 DOI: 10.1007/s00068-020-01467-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/18/2020] [Indexed: 11/11/2022]
Abstract
Purpose Anatomic reduction in tibial plateau fractures remains to be demanding. For further visualisation of and approach to the joint surface an extended lateral approach using a lateral femoral epicondyle osteotomy and subluxation of the lateral meniscus was recently described. First clinical and radiographic mid-term results of this technique are presented in this feasibility study. Method Ten complex tibial plateau fractures treated with extended lateral approach and lateral meniscal subluxation were prospectively analysed. Clinical and radiographic results were objectified according to the Rasmussen scores. Results After a median follow-up of 8.6 (IQR 4.3) months good to excellent clinical and radiographic results were noted. The clinical Rasmussen Score showed a median of 25 (IQR 2.8) and radiographic a median of 17 (IQR 2.0) points. Conclusion Good to excellent clinical and radiological scores were obtained after using an extended lateral approach with lateral femoral epicondyle osteotomy and central meniscus subluxation. No approach specific complications could be observed. Electronic supplementary material The online version of this article (10.1007/s00068-020-01467-1) contains supplementary material, which is available to authorized users.
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