Risk Factors for Knee Stiffness Surgery After Tibial Plateau Fracture Fixation

Surgically treated acute knee dislocations with knee stiffness perform equally as well as non-stiff knees when treated with arthroscopic arthrolysis

PURPOSE

Postoperative knee stiffness is a common issue in multiligament knee injuries (MLKIs). This study aims to compare outcomes between MLKI patients who underwent postoperative arthroscopic lysis of arthrofibrosis (LOA) for limited range of motion (ROM) and those who did not.

METHODS

Thirty-one patients (10 IIIM, nine IIIL and 12 IV) were included in this retrospective clinical study with acute type III or IV knee dislocations, while two patients were lost to follow up. Thirteen patients underwent LOA at a mean of 18.7 ± 8.4 weeks (Group A), while 18 did not require this intervention (Group B). Patient-reported outcome measures (IKDC, Lysholm, VAS) and ROM were evaluated.

RESULTS

The average follow up period was 31.0 ± 10.2 months. The mean time to LOA was 19.4 ± 7.6 weeks and a significant increase in ROM was observed after LOA (flexion: before LOA: 83.8° ± 19.2, after LOA: 119.6° ± 9.9; P < 0.0001). There were no significant differences between groups regarding clinical scores (Lysholm: Group A 85.0 ± 13.4, Group B 84.6 ± 14.5; IKDC: Group A 74.3 ± 10.8, Group B 76.7 ± 14.7) and ROM (flexion: Group A 118.6° ± 9.8, Group B 124.3° ± 12.8). There were no complications regarding LOA.

CONCLUSIONS

Patients, whether undergoing LOA or not, performed equally well in terms of ROM and clinical scores at final follow up, while timing of LOA appears less critical. LOA is a simple, durable and safe method of treating ROM deficits in patients treated for acute knee dislocation, with very good results.

Staged Management for Distal Femur Fractures: Impacts on Reoperation, Stiffness, and Overall Outcomes

OBJECTIVES

To evaluate the outcomes of staged management with external fixation (ex-fix) before definitive fixation of distal femur fractures.

METHODS

DESIGN

Retrospective cohort.

SETTING

Single Level I Trauma Center.

PATIENT SELECTION CRITERIA

Adults treated operatively between 2004 and 2019 for distal femur fractures (OTA/AO 33A/33C) were identified using Current Procedural Terminology codes. Excluded cases were those with screw only fixation, acute distal femur replacement, 33B fracture pattern, no radiographs available, or did not have 6-months of follow-up.

OUTCOME MEASURES AND COMPARISONS

Postoperative complication rates including surgical site infection [SSI], reoperation to promote bone healing, final knee arc of motion <90 degrees, heterotopic ossification formation, and reoperation for stiffness were compared between patients treated with ex-fix before definitive fixation and those not requiring ex-fix.

RESULTS

A total of 407 patients were included with a mean follow-up of 27 months [median (IQR) of 12 (7.33) months] (range 6-192 months). Most patients were male (52%) with an average age of 48 (range: 18-92) years. Ex-fix was utilized in 150 (37%) cases and 257 (63%) cases underwent primary definitive fixation. There was no difference in SSI rates ( P = 0.12), final knee arc of motion <90 degrees ( P = 0.51), and reoperation for stiffness ( P = 0.41) between the ex-fix and no ex-fix groups. The 150 patients requiring ex-fix spent an average of 4.2 days (SD 3.3) in the ex-fix before definitive fixation. These patients were further analyzed by comparing the duration of time spent in ex-fix, <4 days (n = 82) and ≥4 days (n = 68). Despite longer time spent in ex-fix before definitive fixation, there was again no significant difference in any of the complication and reoperation rates when comparing the 2 groups, including final knee arc of motion <90 degrees ( P = 0.63), reoperation for stiffness ( P = 1.00), and SSI ( P = 0.79).

CONCLUSION

Ex-fix of distal femur fractures as a means of temporary stabilization before definitive open reduction internal fixation does not increase the risk of complications such as SSI, final knee arc of motion <90 degrees, or reoperations for bone healing or stiffness when compared with single-stage open reduction internal fixation of distal femur fractures.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Is Staged Surgery Always Necessary for Schatzker Type IV-VI Tibial Plateau Fractures? A Comparison Study

AIMS

This study aims to compare the outcomes of immediate (followed by closed-incision negative-pressure therapy use) versus delayed ORIF in patients with Schatzker type IV-VI TPFs.

PATIENTS AND METHODS

A prospective study of patients undergoing ORIF between January 2018 and December 2019 was performed. The inclusion criteria were patients (>18 years) with a closed fracture sent to the emergency room (ER) within 24 h of injury. All the patients underwent preoperative image evaluation. Two senior orthopedic trauma surgeons evaluated the soft tissue condition in the ER by 5P's of the compartment syndrome, judging the timing of the operation of definitive ORIF. Group 1 (n = 16) received delayed ORIF. Group 2 (n = 16) received immediate ORIF and ciNPT use. Patient follow-up occurred after 2 and 6 weeks and 3, 6, and 12 months after surgery. The assessments included the time to definitive fixation, the length of hospital stay, the time to bone union, surgical site complications, and reoperation within 12 months. A universal goniometer was used to measure the postoperative 3 m, 6 m, and 12 m ROM.

RESULTS

The patient demographics were similar between the groups (p > 0.05). Group 2 displayed significantly a shorter time to definitive fixation (5.94 ± 2.02 vs. 0.61 ± 0.28, p < 0.0001) and hospital stay (14.90 ± 8/78 vs. 10.30 ± 6.78, p = 0.0016). No significant difference was observed in the time to bone union, surgical site complication incidence, and reoperation rates (p > 0.05). Flexion and flexion-extension knee ROM were demonstrated to be significantly improved in Group 2, 3, 6, and 12 months postoperatively (p < 0.0001).

CONCLUSIONS

In this study, early ORIF and ciNPT use resulted in a shorter hospital length of stay, a reduced time to early active motion of the knee, and improved knee ROM. These results suggest that early ORIF with ciNPT for Schatzker type IV-VI TPFs is safe and effective in some patients. However, further research to confirm these findings across larger and more diverse populations is needed.

Minimally Invasive Quadricepsplasty Using the Adolphson-Cerqueira Technique: A Retrospective Study after 1-Year of Follow-up

Aim

Knee stiffness limits activities of daily living with treatment having no gold standard technique currently. We present follow-up data 1-year after quadricepsplasty using the Adolphson-Cerqueira technique for the treatment of knee stiffness in a Brazilian population sample.

Materials and methods

This retrospective study included patients who underwent a quadricepsplasty using the Adolphson-Cerqueira technique between January 2006 and March 2023 at our institution. The inclusion criteria were: (1) Knee stiffness with a range of motion <70°; (2) Patellar excursion ≥2 mm on physical examination; (3) Available knee radiography in the anteroposterior and lateral views; and (4) A follow-up at 1 year postoperatively. The Judet Classification was used to assess the outcome of the quadricepsplasty.

Results

Sixty-seven patients were included. The results were 6% poor, 31.3% fair, 44.8% good, and 17.9% excellent according to the Judet Classification. A correlation was observed between age and the gain in range of motion at the 1-year postoperative follow-up, and between the gain in range of motion intraoperatively and that at the 1-year follow-up. There were five cases of complications (7.46%): one of patellar fracture, three of quadriceps tendon rupture, and one of avulsion fracture in the superior pole of the patella.

Conclusion

Quadricepsplasty using the Adolphson-Cerqueira technique produced satisfactory results overall for improving knee joint stiffness and had a complication rate comparable with other currently used techniques.

Clinical significance

Loss of knee range of motion remains a difficult problem without there being a clear gold standard in treatment. Many different options are described in the literature. We provide a further option with follow-up results.

How to cite this article

Cerqueira FS, Silva L, Kropf LL, et al. Minimally Invasive Quadricepsplasty Using the Adolphson-Cerqueira Technique: A Retrospective Study after 1-Year of Follow-up. Strategies Trauma Limb Reconstr 2024;19(2):87-93.

Arthroscopic Arthrolysis of Knee: Timing, Technique and Results

Aim

To evaluate the functional outcomes of patients undergoing arthroscopic arthrolysis of the knee and find the ideal timing for arthrolysis to achieve maximum range of motion (ROM) of the knee.

Methods

All patients who underwent arthroscopic arthrolysis for post-operative joint stiffness following surgery for injuries around knee joint at a tertiary care centre from 2009 to 2023 were included in this study. The patients' details such as primary injury, time interval between the index surgery and arthrolysis, improvement in knee range of ROM and Lysholm score from prior to arthrolysis to last follow-up post arthrolysis were retrieved from hospital database and analysed.

Results

Total of 42 patients who underwent arthroscopic arthrolysis of knee from 2009 to 2023 were included in this study. Follow-up range was 6 months to 6 years. ROM after arthrolysis significantly improved in the early and delayed arthrolysis groups as compared to late arthrolysis groups (mean 126.25 and 115.62 vs 106.3, p < 0.05). Patients treated with early arthroscopic arthrolysis (within 3 months) showed significant increase in post operative Lysholm score compared to other groups (p < 0.05). ROM of 120° and beyond was achieved in 75% of cases in early arthrolysis group compared to 62.8% and 39% in delayed and late arthrolysis group (p < 0.05).

Conclusions

Arthroscopic arthrolysis done within 6 months (with maximum effect when done within 3 months) after the primary surgery leads to significant improvement in ROM and functional scores as compared to those with late arthrolysis group.

Patient preferences for physical therapy programs after a lower extremity fracture: a discrete choice experiment

OBJECTIVE

To quantify patients' preferences for physical therapy programmes after a lower extremity fracture and determine patient factors associated with preference variation.

DESIGN

Discrete choice experiment.

SETTING

Level I trauma centre.

PARTICIPANTS

One hundred fifty-one adult (≥18 years old) patients with lower extremity fractures treated operatively.

INTERVENTION

Patients were given hypothetical scenarios and asked to select their preferred therapy course when comparing cost, mobility, long-term pain, session duration, and treatment setting.

MAIN OUTCOME MEASURES

A multinomial logit model was used to determine the relative importance and willingness to pay for each attribute.

RESULTS

Mobility was of greatest relative importance (45%, 95% CI: 40% to 49%), more than cost (23%, 95% CI: 19% to 27%), long-term pain (19%, 95% CI: 16% to 23%), therapy session duration (12%, 95% CI: 9% to 5%) or setting (1%, 95% CI: 0.2% to 2%). Patients were willing to pay US$142 more per session to return to their preinjury mobility level (95% CI: US$103 to US$182). Willingness to pay for improved mobility was higher for women, patients aged 70 years and older, those with bachelor's degrees or higher and those living in less-deprived areas. Patients were willing to pay US$72 (95% CI: US$50 to US$93) more per session to reduce pain from severe to mild. Patients were indifferent between formal and independent home therapy (willingness to pay: -US$12, 95% CI: -US$33 to US$9).

CONCLUSIONS

Patients with lower extremity fractures highly value recovering mobility and are willing to pay more for postoperative physical therapy programmes that facilitate returning to their pre-injury mobility level. These patient preferences might be useful when prescribing and designing new techniques for postoperative therapy.

Risk factors for failure of manipulation under anesthesia in posttraumatic knee stiffness

OBJECTIVES

To determine the proportion of patients who fail manipulation under anesthesia (MUA) as a treatment for posttraumatic knee stiffness and determine the risk factors for MUA failure.

METHODS

A retrospective cohort study was performed at a level I trauma center. We identified 213 knees in 199 patients with arthrofibrosis treated by MUA within 1 year of injury from 2007 to 2020. The primary outcome was MUA failure as defined by need for repeat MUA or surgical release after MUA. Multivariable logistic regression was used to determine the association between MUA failure and potential risk factors.

RESULTS

Overall, 111 knees (52%) failed treatment with MUA. An association was demonstrated between MUA failure and delay in treatment >90 days after injury (OR 3.6, p < 0.01), neurologic injury (OR 2.2, p = 0.02), and pre-procedure knee flexion <45° (OR 1.9, p < 0.01). The rate of failure for knees with no risk factors was 0% (0 of 14), 37% for knees with one risk factor (27 of 73), and 67% (84 of 126) for knees with two or more risk factors.

CONCLUSION

For patients whose MUA is delayed beyond 90 days postinjury, pre-manipulation knee flexion is <45°, or those with associated neurologic injury; odds of MUA failing to correct posttraumatic arthrofibrosis are significantly increased. The likelihood of obtaining adequate range of motion (ROM) with MUA alone is lower than reported in other populations, with a higher likelihood of being treated with surgical release or additional MUA to attempt to obtain adequate ROM.

High Prevalence of Persistent Measurable Postoperative Knee Joint Laxity in Patients with Tibial Plateau Fractures Treated by Open Reduction and Internal Fixation (ORIF)

The development of post-traumatic osteoarthrosis after tibial plateau fracture (TPF) is multifactorial and can only be partially influenced by surgical treatment. There is no standardized method for assessing pre- and postoperative knee joint laxity. Data on the incidence of postoperative laxity after TPF are limited. The purpose of this study was to quantify postoperative laxity of the knee joint after TPF. Fifty-four patients (mean age 51 ± 11.9 years) were included in this study. There was a significant increase in anterior-posterior translation in 78.0% and internal rotation in 78.9% in the injured knee when compared to the healthy knee. Simple fractures showed no significant difference in laxity compared to complex fractures. When preoperative ligament damage and/or meniscal lesions were present and surgically treated by refixation and/or bracing, patients showed higher instability when compared to patients without preoperative ligament and/or meniscal damage. Patients with surgically treated TPF demonstrate measurable knee joint laxity at a minimum of 1 year postoperatively. Fracture types have no influence on postoperative laxity. This emphasizes the importance of recognizing TPF as a multifaceted injury involving both complex fractures and damage to multiple ligaments and soft tissue structures, which may require further surgical intervention after osteosynthesis.

Maintenance of an Intraoperative External Fixator Is Associated With Decreased Postoperative Stiffness After Definitive Management of High-Energy Tibial Plateau Fractures

Introduction Postoperative stiffness is a common complication after high-energy tibial plateau fractures. Investigation into reported surgical techniques for the prevention of postoperative stiffness is limited. The purpose of this study was to compare the rates of postoperative stiffness after second-stage definitive surgery for high-energy tibial plateau fractures between groups of patients who had the external fixator prepped into the surgical field and those who did not. Methods Two hundred forty-four patients met the inclusion criteria between the two academic Level I trauma centers, representing the retrospective observational cohort. Patients were separated based on prepping of the external fixator into the surgical field during second-stage definitive open reduction and internal fixation. One hundred sixty-two patients were in the prepped group and 82 were in the non-prepped group. Post-operative stiffness was determined by the need to return to the operating room for subsequent procedures. Results At the final follow-up (mean = 14.6 months), patients in the non-prepped group had an increased rate of stiffness post-operatively (18.3% non-prepped versus 6.8% prepped; p = 0.006). No other investigated variables were associated with increased post-operative stiffness, including the number of days spent in the fixator and operative time. The relative risk for post-operative stiffness associated with complete fixator removal was 2.54 (95% CI 1.26-4.41; p = 0.008 on binary logistic regression; absolute risk reduction 11.5%). Conclusion At the final follow-up, maintenance of an intraoperative external fixator as a reduction aid was associated with a clinically significant decrease in post-operative stiffness after definitive management of high-energy tibial plateau fractures, when compared with complete removal prior to prepping.

Effect of Ultrasound Image-Guided Nerve Block on the Postoperative Recovery Quality of Patients with Tibial Fractures Using the Concept of Enhanced Recovery after Surgery

This study was aimed at investigating the clinical effect of ultrasound-guided nerve block based on the concept of enhanced recovery after surgery (ERAS) for postoperative anesthesia in patients with tibial fractures. The noise-reduction processing was introduced in ultrasound images to adjust the ultrasound clarity of the patient. A total of 177 patients with tibial fractures in our hospital were retrospectively analyzed and divided into OG group (general anesthesia combined with nerve block, 78 cases), C1 group (simple general anesthesia, 27 cases), C2 group (ultrasound-guided nerve block combined with general anesthesia, 10 cases), and C3 group (62 cases of spinal-epidural anesthesia). The effect of anesthesia and postoperative recovery time of patients in each group were analyzed. The wake-up time of the OG group was significantly shorter than that of the other three groups (P < 0.05). The doses of propofol and remifentanil in the OG group were much lower than those in the other groups (P < 0.05). After the ultrasound image was processed with noise reduction, the image showed the lesion more clearly. The excellent and good rates of OG group, C1 group, C2 group, and C3 group were 89.86%, 62.73%, 75.37%, and 61.07%, respectively. The Ramsay sedation score and anesthesia satisfaction in the OG group were obviously higher than those in the other groups, but there was no significant difference (P > 0.05). The visual analogue scale (VAS) scores of the OG group at 12 h, 24 h, and 36 h after the surgery were 4.52 ± 0.41, 4.72 ± 0.24, and 4.81 ± 0.74, respectively, which were significantly higher than those of the other three groups (P < 0.05). On the basis of ERAS, ultrasound-guided nerve block combined with general anesthesia can improve the perioperative pain in patients with tibial fractures and significantly shorten the time for the wake-up time. In addition, it was safe and reliable, so it was worthy of clinical promotion.

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

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

Knee Arthrofibrosis following Tibial Plateau Fracture Treated with Arthroscopic Lysis of Adhesions with Manipulation

Posttraumatic arthrofibrosis is a common problem encountered in the orthopaedic setting for which there is no agreement on the optimal management strategy. The literature does not optimally describe the efficacy of arthroscopic lysis of adhesions for arthrofibrosis following tibial plateau fracture. The purpose of this study is to quantify the efficacy of arthroscopic lysis of adhesions with manipulation for the treatment of arthrofibrosis of the knee in patients who previously underwent surgical management of tibial plateau fracture. All patients who underwent arthroscopic lysis of adhesions from a single surgeon since 1999 were retrospectively reviewed. Clinical outcomes were evaluated by flexion, extension, and range of motion (ROM) preoperatively, intraoperatively, and postoperatively at intervals of 1, 4, 8, and 12 weeks, and any additional long-term follow-up. A total of 28 patients who had developed arthrofibrosis following surgical management of a tibial plateau fracture and failed nonsurgical management of knee stiffness were included in this study. There were significant improvements in total ROM following intervention at all time points compared with preoperative values (p < 0.001), with mean improvements of 59.3 degrees intraoperatively, 32.9 degrees (1 week), 37.1 degrees (4 weeks), 41.5 degrees (8 weeks), and 47.6 degrees (12 weeks). There were significant improvements in degrees of knee flexion following intervention at all time points compared with preoperative values (p < 0.001), with mean improvements of 50.8 degrees intraoperatively, 27.3 degrees (1 week), 36.0 degrees (4 weeks), 38.3 degrees (8 weeks), and 43.9 degrees (12 weeks). There were significant increases in degrees of knee extension intraoperatively (8.5 degrees) and at 1 week postoperatively (5.9 degrees) compared with preoperative values (p <0.01). At 12 weeks postoperatively, those who had previously undergone external fixation had significantly greater increases in ROM (p = 0.048). Arthroscopic lysis of adhesions for knee arthrofibrosis following surgical management of tibial plateau fracture significantly improves knee ROM.

Conversion Total Knee Arthroplasty After Tibial Plateau Fixation Is Associated With Lower Reimbursement, Greater Complication Rates, and Similar Opioid Use

Objective

Total knee replacement after previous open reduction and internal fixation for tibial plateau fracture (conversion total knee) increases the complexity of the procedure and the complication rate. However, very little research exists to report on opioid use and cost associated with total knee arthroplasty (TKA) following tibial plateau fracture fixation as compared to primary TKA patients with no history of tibial plateau fracture. The aim of this study is to compare the differences in opioid use, reimbursements, and complication rates between patients with and without a history of tibial plateau fracture undergoing TKA.

Methods and materials

This is a retrospective large database review study. The study included patients across the country and in various clinical settings including, but not limited to, institutions, primary and tertiary care centers, and private practice. The PearlDiver database was reviewed for patients undergoing TKA between 2010 and 2019. Patients who underwent TKA following surgical repair of a tibial plateau fracture were identified using Common Procedural Terminology (CPT) codes and the appropriate International Classification of Diseases Ninth and Tenth Revision (ICD-9, ICD-10) codes. This group was then matched by age, gender, Charleston Comorbidity Index (CCI) score, Elixhauser Comorbidity Index (ECI) score, obesity, tobacco use, and diabetes to a group of similar patients who underwent TKA with no history of tibial plateau fracture. Opioid use over the episode of care, evaluated by morphine milligram equivalents (MME), and 30-day reimbursed cost were compared between groups using an unequal variance t-test. Complication rates at 30 days, 90 days, and one year postoperatively, and revision rates at one and two years postoperatively were compared using the odd’s ratio (OR) with 95% confidence intervals (95%CI).

Results

The episode of care cost for TKA was significantly lower for patients with a history of tibial plateau fracture ($11,615 ± $15,704) than it was for patients without a history of tibial plateau fracture ($16,088 ± $18,573) (p = 3.56E-14). At 30 days after knee arthroplasty, patients with a history of tibial plateau fracture had significantly more episodes of dehiscence (OR 2.665 [95% CI 1.327-5.351]; p = 0.006) and surgical site infection (SSI) (OR 1.698 [95% CI 1.058-2.724]; p = 0.028), which was significant at 90 days postop for both dehiscence (OR 1.358 [95% CI 0.723-2.551]; p = 0.001) and SSI (OR 1.634 [95% CI 1.100-1.802]; p = 0.015), as well as mechanical complications of the implant device (OR 2.420 [95% CI 1.154-5.076]; p = 0.019). There was no significant difference in the number of opioids prescribed postoperatively to patients with a history of tibial plateau fracture (2218 ± 3255 MME) compared to those without prior tibial plateau fracture (2400 ± 4843 MME) (p = 0.258). However, there was a small but statistically significant increase in the number of days postoperatively patients with a history of tibial plateau fracture were prescribed opioids (11.99 ± 7.73 days) compared to non-tibial plateau fracture patients (11.15 ± 7.18 days) (p = 0.004).

Conclusion

Patients with a history of tibial plateau fracture who then underwent conversion TKA have a lower reimbursed cost of TKA but a higher postoperative risk for dehiscence, mechanical complications, and surgical site infections. There is no significant difference in postoperative opioid use between the two groups.

Incidence and risk factors for decreased range of motion of the knee joint after surgery for closed tibial plateau fracture in adults

Purpose

The aim of this study was to quantify the incidence of and identify independent risk factors for decreased range of motion (ROM) of the knee joint after surgery for closed tibial plateau fractures in adults.

Methods

This retrospective study was performed at the trauma centre in our hospital from January 2018 to December 2019. Data from adult patients with tibial plateau fractures treated by surgery were extracted from the electronic medical records. A total of 220 tibial plateau fracture patients were enrolled. We extracted the patients’ demographic characteristics, fracture characteristics, and surgery-related variables. Univariate and multivariate logistic regression models were used to investigate the potential independent risk factors.

Results

Fifty-seven patients developed decreased ROM of the knee joint at the 1-year follow-up in this study. The overall incidence was 25.9%. The independent predictors of decreased ROM after surgery, as identified in the multivariate analysis, were orthopedic polytrauma (odds ratio = 3.23; 95% CI = 1.68–6.20; p = 0.000), fracture type (Schatzker V-VI) (odds ratio = 2.52; 95% CI = 1.16–5.47; p = 0.019), and an open reduction and internal fixation approach (odds ratio = 2.10; 95% CI = 1.07–4.12; p = 0.031).

Conclusions

The study confirmed that patients with orthopaedic polytrauma, more complex fractures and those treated with open reduction and internal fixation (ORIF) surgery were more likely to suffer decreased ROM of the knee joint 1 year after surgery.

Clinical results after very early, early and late arthroscopic arthrolysis of the knee

Purpose

Impaired patient outcome can be directly related to a loss of motion of the knee following surgical procedures. If conservative therapy fails, arthroscopic arthrolysis is an effective procedure to improve range of motion (ROM). The purpose of this study was to evaluate the outcome of patients undergoing very early (< 3 months), early (3 to 6 months), and late (> 6 months) arthroscopic arthrolysis of the knee.

Methods

With a follow-up on average at 35.1 ± 15.2 (mean ± SD, 24 to 87) months, 123 patients with post-operative motion loss (> 10° extension deficit/ < 90° of flexion) were included between 2013 and 2018 in the retrospective study, while eight patients were lost to follow-up. A total of 115 patients were examined with a minimum follow-up of two years. Twenty percent (n = 23) of patients of this study population had a post-operative motion loss after distal femoral fracture, 10.4% (n = 12) after tibial head fracture, 57.4% (n = 66) after anterior/posterior cruciate ligament (ACL/PCL) reconstruction, 8.7% (n = 10) after infection of the knee, and 3.4% (n = 4) after patella fracture. Thirty-seven patients received very early (< 3 months, mean 1.8 months) arthroscopic arthrolysis, and 37 had early (3 to 6 months, mean 4.3 months) and 41 late (> 6 months, mean 9.8 months) arthroscopic arthrolysis after primary surgery.

Results

The average ROM increased from 73.9° before to 131.4° after arthroscopic arthrolysis (p < 0.001). In the group of very early (< 3 months) arthroscopic arthrolysis 76% (n = 28) of the patients had a normal ROM (extension/flexion 0/140°), in the group of early (3–6 months) arthrolysis 68% (n = 25) of the patients and in the group of late arthrolysis 41.5% (n = 17) of the patients showed a normal ROM after surgery (p = 0.005). The total ROM after arthrolysis was also significantly increased in the group of very early and early arthrolysis (136.5° and 135.3° vs. 123.7°, p < 0.001). A post-operative flexion deficit occurred significantly less in the group of very early and early arthroscopic arthrolysis compared to the late arthroscopic arthrolysis (3.9° and 4.2° vs. 16.6°, p < 0.001). Patients treated with very early (< 3 months) and early (3 to 6 months) showed a significantly increased post-operative Tegner score of 4.8 ± 1 and 4.7 ± 1.1 compared to 3.8 ± 1.1 in the group of late arthroscopic arthrolysis (> 6 months, p < 0.001).

Conclusions

An arthroscopic arthrolysis is highly effective and leads to good to excellent mid-term results. An early arthroscopic arthrolysis within 6 months after primary surgery leads to significantly improved ROM and functional scores compared to the late arthrolysis (> 6 months).

Increased Articular Exposure of the Lateral Tibial Plateau with a Midline Lateral Parapatellar Arthrotomy Compared to an Anterolateral Submeniscal Arthrotomy: a Cadaveric Study

PURPOSE

To quantitatively compare the articular exposure of the proximal tibia with a lateral parapatellar arthrotomy through a straight midline incision (ML) versus a lateral submeniscal arthrotomy through a curvilinear anterolateral incision (AL).

METHODS

Eight surgical approaches (4 ML and 4 AL) were performed on 4 fresh cadavers. Access to key articular landmarks was assessed, including divisions of the lateral meniscus, lateral tibial spine, and anterior cruciate ligament. The boundary of the exposed articular surface of the tibia was marked, and the proximal tibias were then stripped of soft tissues. A calibrated digital image was taken of each proximal tibia, and exposed articular surface area was calculated with ImageJ software (NIH, Bethesda, MD). Statistical analysis was performed using a two-sample t-test.

RESULTS

Average articular surface area exposed was 2.2 times greater through the midline approach compared with the anterolateral approach (11.2 vs 5.1 cm², p = 0.010). All key anatomic landmarks were directly visualized through the midline approach in each specimen. Complete visualization of the lateral meniscus posterior horn, lateral tibial spine, and anterior cruciate ligament was not accomplished through the anterolateral approach in any specimen.

CONCLUSIONS

The midline approach provides more extensive articular exposure of the lateral tibial plateau compared with the anterolateral approach. This improved exposure may offer an advantage when treating fractures not amenable to arthroscopic or minimally invasive techniques. It may be of most use when treating fractures with extension into the posteromedial quadrant of the lateral plateau, fractures with extensive comminution of the lateral plateau, or fractures with complex lateral meniscus tears and fractures with tibial spine involvement.

Impact of surgical site infection on patients' outcome after fixation of tibial plateau fractures: a retrospective multicenter study

Background

Surgical site infection (SSI) occurs in 3–10 % of patients with surgically treated tibial plateau fractures. This study aimed to evaluate the impact of SSI on patients’ outcome after fixation of tibial plateau fractures.

Methods

We conducted a retrospective multicenter study in seven participating level I trauma centers between January 2005 and December 2014. All participating centers followed up with patients with SSI. In addition, three centers followed up with patients without SSI as a reference group. Descriptive data and follow-up data with patient-reported outcome scores (Knee Injury and Osteoarthritis Outcome Score [KOOS] and Lysholm knee scoring scale score) were evaluated.

Results

In summary, 287 patients (41 with SSI and 246 without SSI; average 50.7 years) with an average follow-up of 75.9 ± 35.9 months were included in this study. Patients with SSI had a significantly poorer overall KOOS (KOOS5) (48.7 ± 23.2 versus [vs.] 71.5 ± 23.5; p < 0.001) and Lysholm knee scoring scale score (51.4 ± 24.0 vs. 71.4 ± 23.5; p < 0.001) than patients without SSI. This significant difference was also evident in the KOOS subscores for pain, symptoms, activities of daily living (ADL), and quality of life (QoL). SSI remained an important factor in multivariable models after adjusting for potential confounders. Clinically relevant differences in the KOOS5 and KOOS subscores for symptoms, pain, and ADL were found between those with SSI and without SSI even after adjustment. Furthermore, the number of previous diseases, Arbeitsgemeinschaft für Osteosynthesefragen Foundation (AO) C fractures, and compartment syndrome were found to be additional factors related to poor outcome.

Conclusions

Compared to previous studies, validated patient-reported outcome scores demonstrated that the impact of SSI in patients with surgically treated tibial plateau fractures is dramatic, in terms of not only pain and symptoms but also in ADL and QoL, compared to that in patients without SSI.

Association Between Femoral "Spike" Size After Intramedullary Nailing and Subsequent Knee Motion Surgery

OBJECTIVES

To determine the association between displaced femoral shaft bone fragments ("spikes") seen on radiographs after intramedullary nail insertion and the need for future motion surgery.

DESIGN

Retrospective case-control study.

SETTING

Academic trauma center.

PATIENTS

We included patients with femoral shaft fractures treated with intramedullary nail insertion. Case patients (n = 22) had developed knee stiffness treated with motion surgery. The control group was a randomly selected sample (1:3 ratio).

MAIN OUTCOME MEASURES

Motion surgery to address knee stiffness. We defined a "spike distance ratio" and "spike area ratio" from initial postoperative anteroposterior and lateral radiographs. Multivariable logistic regression determined the effect of spike distance and area ratios on the likelihood of need for motion surgery, controlling for polytraumatic injuries and bilateral fractures.

RESULTS

The case group had a median femoral spike distance ratio of 1.9 [interquartile range (IQR), 1.6-2.5] compared with 1.5 (IQR, 1.2-1.8) in the control group. An increased femoral spike distance ratio was associated with increased odds of motion surgery (P < 0.01). A femoral spike distance >2 times the femoral radius had 32 times the odds (95% confidence interval, 2-752) of motion surgery compared with patients with distance ratios <1.25. Median femoral spike area ratios were similar between the case (0.2; IQR, 0.1-0.5) and control (0.2; IQR, 0.0-0.5) groups and were not associated with increased odds of motion surgery (P = 0.34).

CONCLUSIONS

A larger spike distance ratio is associated with increased odds of subsequent motion surgery.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Bone metabolism is a key factor for clinical outcome of tibial plateau fractures

Purpose

Given that tibial plateau fractures (TPF) are rare, they may pose a challenge to the treating surgeon due to their variety of complex fracture patterns. Numerous studies have identified potential fracture-specific, surgery-related, and patient-related risk factors for impaired patient outcomes. However, reports on the influence of bone metabolism on functional outcomes are missing.

Methods

In a retrospective multicenter cohort study, 122 TPF of 121 patients were analyzed with respect to radiological and clinical outcomes (Rasmussen) with a mean follow-up of 35.7 ± 24.9 months. The risk factor assessment included bone metabolism-affecting comorbidities and medication.

Results

The findings showed that 95.9% of the patients reported a good-to-excellent clinical outcome, and 97.4% reported a good-to-excellent radiological outcome. Logistic regression revealed that potentially impaired bone metabolism (IBM) was an independent risk factor for the clinical (p = 0.016) but not the radiological outcome (Table 4). Patients with 41-type B fractures and a potential IBM had a seven times higher risk to present a fair-to-poor clinical outcome [OR 7.45, 95 CI (4.30, 12.92)]. The most common objective impairment was a limited range of motion in 16.4% of the patients, especially in 41-type C fractures (p = 0.06). The individual failure analysis additionally identified surgery-related options for improvement.

Conclusion

This study demonstrated that potential IBM was an independent risk factor for a poor-to-fair clinical outcome.

Sustained Release of Levobupivacaine, Lidocaine, and Acemetacin from Electrosprayed Microparticles: In Vitro and In Vivo Studies

In this study, we explored the release characteristics of analgesics, namely levobupivacaine, lidocaine, and acemetacin, from electrosprayed poly(D,L-lactide-co-glycolide) (PLGA) microparticles. The drug-loaded particles were prepared using electrospraying techniques and evaluated for their morphology, drug release kinetics, and pain relief activity. The morphology of the produced microparticles elucidated by scanning electron microscopy revealed that the optimal parameters for electrospraying were 9 kV, 1 mL/h, and 10 cm for voltage, flow rate, and travel distance, respectively. Fourier-transform infrared spectrometry indicated that the analgesics had been successfully incorporated into the PLGA microparticles. The analgesic-loaded microparticles possessed low toxicity against human fibroblasts and were able to sustainably elute levobupivacaine, lidocaine, and acemetacin in vitro. Furthermore, electrosprayed microparticles were found to release high levels of lidocaine and acemetacin (well over the minimum therapeutic concentrations) and levobupivacaine at the fracture site of rats for more than 28 days and 12 days, respectively. Analgesic-loaded microparticles demonstrated their effectiveness and sustained performance for pain relief in fracture injuries.