Outcomes of Schatzker II tibial plateau fracture open reduction internal fixation using structural bone allograft

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.

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.

Current concepts of bone grafting in trauma surgery

Bone graft in trauma surgery is commonly used in managing bone defects, non-union, fracture related infections, arthrodesis or to provide structural support in fractures. A variety of bone grafts are made available to the treating physician, which includes autograft, allograft and bone graft substitutes. The future of bone grafting in trauma surgery is exciting with the incorporation of technological advancement such as gene therapy, 3D-printing and tissue engineering. Regardless, there are still limitations to what we understand regarding current bone grafting techniques with conflicting literature on their clinical utility and indication. The aim of this review article therefore is to take a step back and critically evaluate the current concepts of bone grafting in trauma surgery, with special emphasis made on reviewing the types of bone graft, biology of bone graft incorporation and indication for its use in various clinical scenarios.

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.

Unilateral locking plate versus unilateral locking plate combined with compression bolt for Schatzker I-IV tibial plateau fractures: a comparative study

BACKGROUND

The quality and durability of fracture reduction play an important role in the functional prognosis of articulation. The purpose of this study was to investigate the radiological and clinical effects of compression bolts in the treatment of Schatzker I-IV tibial plateau fractures (TPFs).

METHODS

Between May 2015 and April 2018, a total of 96 consecutive adult patients with operatively treated Schatzker I-IV TPFs were included and divided into two groups according to the internal fixations: Group 1 (unilateral locking plate) and Group 2 (unilateral locking plate combined with compression bolt). Data on demographic and fracture characteristics, postoperative follow-up imaging, intraoperative indicators, postoperative reduction quality and durability, clinical outcomes, and complications were retrospectively collected and compared between the two groups.

RESULTS

There were no significant intergroup differences in preoperative baseline data, duration of operation, intra-operative blood loss, days in hospital, rate of immediate post-operative reduction loss, or complications. The time of fracture healing, the rate of secondary reduction loss, and the mean WOMAC score were significantly reduced compared with those in Group 1 (P = 0.024, 0.015, and 0.024, respectively). There were significant intergroup differences in the mean HSS score (89.0 ± 11.4 vs. 94.4 ± 6.7, P = 0.042), the mean Lysholm score (83.8 ± 9.6 vs. 88.4 ± 5.2, P = 0.027), and the mean SF-36 score (82.8 ± 12.5 vs. 90.5 ± 7.6, P = 0.001). Additionally, there were similar significant differences in subgroup analysis (only included patients with Schatzker II-III), except for WOMAC score.

CONCLUSION

Compared with unilateral locking plate fixation, unilateral locking plate combined with compressing bolt fixation can reduce the rate of secondary reduction loss, accelerate fracture healing, and show better clinical outcomes for patients with Schatzker I-IV TPFs.

Arthroscopic-assisted reduction and fixation of proximal tibial fractures: personal surgical technique

Purpose:

The purpose of this study was to describe the authors’ arthroscopic-assisted reduction and fixation (ARIF) technique in the treatment of type Schatzker I-III tibial plateau fractures, with the use of instruments commonly used in anterior cruciate ligament reconstruction, evaluating clinical and radiological outcomes on four patients at short-term follow-up.

Methods:

A retrospective analysis was performed in our Institution considering 4 patients who underwent ARIF procedure between 2018 and 2020 at minimum 3 months of follow-up. All patients were evaluated clinically (Rasmussen Score, VAS and Crosby-Insall Grading) and radiographically (after surgery and at 6 weeks).

Results:

Mean follow-up was 9 months (range 6-12 months). Rasmussen score and VAS were respectively 26 (Excellent) and 1 at the last follow-up. According to the Crosby-Insall Grading System, all patients reported excellent results. At final control the mean range of motion in the injured knee was 125°(range 100°-140°). Mean hospitalization was 2 days (range 1-4 days). No adverse events were reported.

Conclusions:

ARIF is a reliable technique for tibial plateau fracture (Schatzker I-III). The technique described is very cheap and reproducible in any hospital. This procedure allows to well understand the pattern of fracture and to obtain an anatomical reduction with a great tissue sparing and a faster recovery of knee function. (www.actabiomedica.it)

Evaluation and management of atypical femoral fractures: an update of current knowledge

Atypical femoral fractures are often attributed to the use of anti-resorptive medications such as bisphosphonates (BP). Whilst they have proven effects on fragility fracture prevention, clinical and laboratory evidence is evolving linking BP-related suppression of bone remodelling to the development of atypical stress-related sub-trochanteric fractures (Shane et al. in JBMR 29:1-23, 2014; Odvina et al. in JCEM 90:1294-301, 2005; Durchschlag et al. in JBMR 21(10):1581-1590, 2006; Donnelly et al. in JBMR 27:672-678, 2012; Mashiba et al. in Bone 28(5):524-531, 2001; Dell et al. in JBMR 27(12):2544-2550, 2012; Black et al. in Lancet 348:1535-1541, 1996; Black et al. in NEJM 356:1809-1822, 2007; Black et al. in JAMA 296:2927-2938, 2006; Schwartz et al. in JBMR 25:976-82, 2010). Injuries may present asymptomatically or with prodromal thigh pain and most can be successfully managed with cephalomedullary nailing and discontinuation of BP therapy. Such injuries exhibit a prolonged time to fracture union with high rates of non-union and metal-work failure when compared to typical subtrochanteric osteoporotic femoral fractures. Despite emerging literature on AFFs, their management continues to pose a challenge to the orthopaedic and extended multi-disciplinary team. The purpose of this review includes evaluation of the current evidence supporting the management of AFFs, clinical and radiological features associated with their presentation and a review of reported surgical strategies to treat and prevent these devastating injures.

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.

Periosteum Mimetic Coating on Structural Bone Allografts via Electrospray Deposition Enhances Repair and Reconstruction of Segmental Defects

Structural bone allograft transplantation remains one of the common strategies for repair and reconstruction of large bone defects. Due to the loss of periosteum that covers the outer surface of the cortical bone, the healing and incorporation of allografts is extremely slow and limited. To enhance the biological performance of allografts, herein, we report a novel and simple approach for engineering a periosteum mimetic coating on the surface of structural bone allografts via polymer-mediated electrospray deposition. This approach enables the coating on allografts with precisely controlled composition and thickness. In addition, the periosteum mimetic coating can be tailored to achieve desired drug release profiles by making use of an appropriate biodegradable polymer or polymer blend. The efficacy study in a murine segmental femoral bone defect model demonstrates that the allograft coating composed of poly(lactic-co-glycolic acid) and bone morphogenetic protein-2 mimicking peptide significantly improves allograft healing as evidenced by decreased fibrotic tissue formation, increased periosteal bone formation, and enhanced osseointegration. Taken together, this study provides a platform technology for engineering a periosteum mimetic coating which can greatly promote bone allograft healing. This technology could eventually result in an off-the-shelf and multifunctional structural bone allograft for highly effective repair and reconstruction of large segmental bone defects. The technology can also be used to ameliorate the performance of other medical implants by modifying their surfaces.

Schatzker II tibial plateau fractures: Anatomically precontoured locking compression plates seem to improve radiological and clinical outcomes

INTRODUCTION

The design of anatomically precontoured locking compression plates (LCP) allows the placement of angular stable screws right underneath the reduced joint surface fragments. To date, there is a lack of evidence supporting the broad utilization of these implants in split depression fractures to the lateral tibial plateau. Thus, aim of the present matched pair retrospective cohort study was to investigate the radiological and clinical outcomes of anatomically precontoured LCP compared to conventional plate and screw osteosynthesis in Schatzker II fractures.

MATERIAL AND METHODS

The institutional databank was searched for Schatzker II fractures from 2010 to 2016. Patients that underwent open reduction and internal fixation with anatomically precontoured 3.5 mm LCP or conventional 4.5 mm l-shaped plates and screws were included. CT scans and radiographs were analyzed. Details of the operative procedures and secondary events were collected. A matched pair analyses was conducted in a best fit manner. The primary outcome parameter was the Rasmussen Radiological Score approximately one year postoperatively. Secondary outcome parameters were the medial proximal tibial angle (MPTA), the Rasmussen Clinical Score and the WOMAC Score after a follow up of at least three years.

RESULTS

A total of 50 patients was included. Patient age, gender distribution, size and depression depth of the lateral joint surface fragments, frequency of utilizing bone grafts or substitutes and lateral meniscus repair as well as subsequent implant removal were comparable across the groups. Immediately postoperatively, the Rasmussen Radiological Score revealed no differences. After a mean of 64.2 weeks, the radiological outcome was significantly better in the LCP 3.5 group (RRS 8.2 vs. 6.3 points, p<0.001; MPTA 89.5 vs. 92.0°, p = 0.001). After a mean clinical follow-up of 4.5 years, the Rasmussen Clinical Score (22.9 vs. 27.8 points, p<0.001) and the WOMAC score (24.3 vs. 16.0 points, p = 0.04) revealed significantly impaired results in the conventional group.

CONCLUSION

Anatomically precontoured LCP prevent the subsidence of the reduced joint surface fragments more sufficiently and allow for improved patient outcomes compared to conventional plates and screws. The utilization of anatomically precontoured LCP should therefore closely be considered for internal fixation of any split depression fractures to the lateral tibial plateau.

Comparison of cannulated lag screws and lateral locking plate in the treatment of Schatzker type II tibial plateau fractures

Objectives

This study aims to compare the clinical and radiological outcomes of the two fixation methods frequently used in the treatment of Schatzker type II fractures: lag screw fixation and lateral anatomic plate fixation.

Patients and methods

This retrospective study, which was conducted between January 2005 and December 2014, included 61 patients (41 males, 20 females; mean age 43.4±13.1 years; range, 20 to 76 years) with Schatzker type II (Orthopaedic Trauma Association (OTA)/Arbeitsgemeinschaft für Osteosynthesefragen (AO) 41-B3) fractures. Patients were divided into two groups according to the type of surgery as cannulated lag screw fixation group (group 1, n=24, 39.4%) and lateral locking plate fixation group (group 2, n=37, 60.6%). Intraoperative mediolateral and anteroposterior instability were measured. Final knee flexion- extention range of motion (ROM), single-leg hop test, Knee Society Score (KSS), Hospital for Special Surgery (HSS) and short form 36 (SF36) scores were obtained at the last follow-up.

Results

The mean age of patients was 42.1±13.8 years in group 2 and 45.5±12.2 years in group 1. The mean follow-up period was 34±4 months. Minimal or no arthritis was detected in 75% (n=18) of patients in group 1 and 78% (n=29) of patients in group 2 (p=0.27). Single leg-hop test results (p=0.55), final follow-up knee ROM (p=0.40), KSS (p=0.21), HSS (p=0.15), and SF36 scores of group 1 were similar to group 2. In group 1, the duration of surgery was shorter (p<0.001) and the cost of treatment was lower (p<0.001).

Conclusion

Treatment of Schatzker type II tibial plateau fractures with lag screws seems to provide less invasive, cheaper, and faster surgical treatment as compared with lateral locking plate fixation. In addition, patients who underwent internal fixation with lag screws had similar clinical and radiological outcomes with those who underwent lateral locking plate fixation.

Failed Proximal Humerus Osteosynthesis Using Intramedullary Fibular Strut Allograft Conversion to Reverse Shoulder Arthroplasty

Comminuted proximal humerus fractures are more frequently being treated utilizing an intramedullary fibular strut allograft to assist with open reduction internal fixation. Although this technique has led to improved outcomes, avascular necrosis, rotator cuff failure, and/or prominent hardware may still occur necessitating conversion to reverse shoulder arthroplasty. The presence of an intramedullary strut allograft makes this conversion technically demanding and creates certain potential complications unique to this group. This manuscript details the conversion of a proximal humerus open reduction internal fixation with a fibular strut allograft to reverse shoulder arthroplasty including presurgical workup, surgical techniques, and pitfalls for undertaking this increasingly common scenario.

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.

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.

Autograft, Allograft, and Bone Graft Substitutes: Clinical Evidence and Indications for Use in the Setting of Orthopaedic Trauma Surgery

Bone grafts are the second most common tissue transplanted in the United States, and they are an essential treatment tool in the field of acute and reconstructive traumatic orthopaedic surgery. Available in cancellous, cortical, or bone marrow aspirate form, autogenous bone graft is regarded as the gold standard in the treatment of posttraumatic conditions such as fracture, delayed union, and nonunion. However, drawbacks including donor-site morbidity and limited quantity of graft available for harvest make autograft a less-than-ideal option for certain patient populations. Advancements in allograft and bone graft substitutes in the past decade have created viable alternatives that circumvent some of the weak points of autografts. Allograft is a favorable alternative for its convenience, abundance, and lack of procurement-related patient morbidity. Options include structural, particulate, and demineralized bone matrix form. Commonly used bone graft substitutes include calcium phosphate and calcium sulfate synthetics-these grafts provide their own benefits in structural support and availability. In addition, different growth factors including bone morphogenic proteins can augment the healing process of bony defects treated with grafts. Autograft, allograft, and bone graft substitutes all possess their own varying degrees of osteogenic, osteoconductive, and osteoinductive properties that make them better suited for different procedures. It is the purpose of this review to characterize these properties and present clinical evidence supporting their indications for use in the hopes of better elucidating treatment options for patients requiring bone grafting in an orthopaedic trauma setting.

Novel Treatment Options for the Surgical Management of Young Femoral Neck Fractures

In physiologically young patients with displaced femoral neck fractures, surgical treatment is aimed at achieving fracture union while preserving native hip anatomy and biomechanics. The intracapsular environment, tenuous vascular supply, and unfavorable hip biomechanics contribute to the high complication rates seen after osteosynthesis of these fractures. Conventional fixation methods for osteosynthesis of femoral neck fractures include multiple cancellous screws, fixed-angle dynamic implants, and fixed-angle length-stable constructs. Despite several biomechanical and clinical studies evaluating various surgical options, the optimal fixation construct to allow healing and prevent nonunion of displaced femoral neck fractures is not known. This article will review the clinical data regarding conventional fixation constructs and describe the technique and rationale behind 2 novel alternative treatment options for these challenging fractures. The surgical technique and clinical examples for constructs involving multiple cannulated screws/Pauwels screw augmented with a fibular strut graft, as well as a novel fixed-angle locking plate with controlled dynamic compression, are presented.

Orthobiologics for Bone Healing

Orthobiologics are a group of biological materials and substrates that promote bone, ligament, muscle, and tendon healing. These substances include bone autograft, bone allograft, demineralized bone matrix, bone graft substitutes, bone marrow aspirate concentrate, platelet-rich plasma, bone morphogenetic proteins, platelet-derived growth factor, parathyroid hormone, and vitamin D and calcium. Properties of orthobiologics in bone healing include osteoconduction, osteoinduction, and osteogenesis. This article discusses the important properties of orthobiologics in bone healing, many of the orthobiologics currently available for bone healing, the related literature, their current clinical uses in sports medicine, and systemic factors that inhibit bone healing.

The Use of Fibular Allograft in Complex Periarticular Fractures Around the Knee

Although the use of fibular strut allografts in proximal humerus fractures has gained popularity, their use in other types of fractures is less well described. Fibular allografts have recently been used in the repair of complex periarticular fractures of the proximal tibia and distal femur. Fibular allografts can be inserted in a variety of manners to achieve goals specific to each individual fracture pattern. In the proximal tibia, insertion through a fracture line or cortical window facilitates joint surface elevation, prevents subsidence and enhances overall construct stability. In distal femoral fractures, including complex periarticular fractures, insertion through the fracture or cortical window permits indirect reduction of the medial cortex and provides necessary medial column support. An additional option in distal femur fractures includes fibula insertion as an intramedullary nail, allowing enhanced fixation in short distal fracture segments. In all cases, the use of a fibular allograft augments poor bone stock and provides improved screw purchase and construct stability when combined with conventional plating methods. Here we present a series of cases at our institution illustrating an array of novel techniques utilizing endosteal fibular allografts in the fixation of complex periarticular fractures about the knee.

No Difference Between Bracing and No Bracing After Open Reduction and Internal Fixation of Tibial Plateau Fractures

INTRODUCTION

The use of a postoperative brace may be beneficial after open reduction and internal fixation of tibial plateau fractures. However, bracing has potential drawbacks related to cost, fitting, wound complications, and compliance. We hypothesized that no difference will be found between patients with and without bracing after open reduction and internal fixation of tibial plateau fractures.

METHODS

In this prospective, comparative trial, patients were randomized to 6 weeks of bracing or no bracing after open reduction and internal fixation of tibial plateau fractures. Functional, subjective, and radiographic outcomes were recorded. Patients with an open physis, unstable ligamentous injuries, extensor mechanism disruption, and/or <6 months of prospective outcome data were excluded.

RESULTS

The 24 patients with bracing (average age, 50 ± 16 years; 14 women and 10 men) were compared with the 25 patients without bracing (average age, 51 ± 12 years [P = 0.74]; 9 women and 16 men). No statistically significant differences were found in most of the functional, subjective, and radiographic outcomes, including fracture characteristics, complications, postoperative range of motion, Medical Outcomes Study 36-Item Short Form scores, and union rates. In the nonbraced group, one patient had late joint collapse with valgus malalignment (>10°). Two wound complications occurred in the braced group and four wound complications occurred in the nonbraced group, but this difference was not statistically significant.

DISCUSSION

Improvements in conventional and locking plate technology have allowed more reliable rigid internal fixation of tibial plateau fractures. However, the use of a brace for postoperative rehabilitation after open reduction and internal fixation of tibial plateau fractures continues to be debated.

CONCLUSION

Our prospective study showed no statistically significant difference between bracing and no bracing after open reduction and internal fixation of tibial plateau fractures in terms of functional, subjective, and radiographic outcomes.

LEVEL OF EVIDENCE

Therapeutic level II.

The Effect of Soft Tissue Injuries on Clinical Outcomes After Tibial Plateau Fracture Fixation

OBJECTIVE

To determine if ligamentous and meniscal injuries as determined by initial magnetic resonance imaging altered clinical outcomes after the fixation of tibial plateau fractures.

DESIGN

Comparative cohort study.

SETTING

Academic level I trauma center.

PATIENTS/PARTICIPANTS

Eighty-two patients from a prospective database of operatively treated tibial plateau fractures met the inclusion criteria, which consisted of injury radiographs, preoperative knee magnetic resonance imaging (MRI), and a minimum of 12 months of clinical outcomes.

INTERVENTION

In addition to radiographs and computed tomography scans for fracture assessment, an MRI was performed to detect tears in the medial and lateral menisci and complete ruptures of the cruciate ligaments (anterior cruciate ligament and posterior cruciate ligament) and collateral ligaments [lateral collateral ligament and medial collateral ligament (MCL)]. Surgical fixation of tibial plateau fractures was performed by a single surgeon based on injury patterns.

MAIN OUTCOME MEASUREMENTS

Clinical outcomes included the Knee Outcome Survey Activities of Daily Living Scale, the Lower Extremity Functional Scale, the Short-Form 36, and knee range of motion. Secondary soft tissue surgeries and conversion to arthroplasty were also noted.

RESULTS

On injury MRI, 60 patients (73%) had injuries to at least one soft tissue structure. At final follow-up, 2 patients (2%) had a secondary soft tissue surgery and 1 patient (1%) underwent total knee arthroplasty. Patient-reported outcomes and range of motion assessments were not significantly different in patients with and without medial meniscal tears, lateral meniscal tears, and complete MCL ruptures.

CONCLUSIONS

In this cohort of patients with operative tibial plateau fractures, sutured lateral meniscal tears, untreated medial meniscus tears, and complete MCL ruptures did not significantly affect clinical outcomes. In addition, these data suggest that obtaining a preoperative MRI in patients with tibial plateau fractures to diagnose soft tissue injuries may not alter the surgical treatment or alter patient prognosis for midterm outcomes.

LEVEL OF EVIDENCE

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

Characteristics of postoperative weight bearing and management protocols for tibial plateau fractures: Findings from a scoping review

OBJECTIVE

To identify and describe the characteristics of existing practices for postoperative weight bearing and management of tibial plateau fractures (TPFs), identify gaps in the literature, and inform the design of future research.

METHODS

Seven electronic databases and clinical trial registers were searched from inception until November 17th 2016. Studies were included if they reported on the surgical management of TPFs, had a mean follow-up time of ≥1year and provided data on postoperative management protocols. Data were extracted and synthesized according to study demographics, patient characteristics and postoperative management (weight bearing regimes, immobilisation devices, exercises and complications).

RESULTS

124 studies were included involving 5156 patients with TPFs. The mean age across studies was 45.1 years (range 20.8-72; 60% male), with a mean follow-up of 34.9 months (range 12-264). The most frequent fracture types were AO/OTA classification 41-B3 (29.5%) and C3 (25%). The most commonly reported non-weight bearing time after surgery was 4-6 weeks (39% of studies), with a further 4-6 weeks of partial weight bearing (51% of studies), resulting in 9-12 weeks before full weight bearing status was recommended (55% of studies). Loading recommendations for initial weight bearing were most commonly toe-touch/<10kg (28%), 10kg-20kg (33%) and progressive (39%). Time to full weight bearing was positively correlated with the proportion of fractures of AO/OTA type C (r=0.465, p=0.029) and Schatzker type IV-VI (r=0.614, p<0.001). Similar rates of rigid (47%) and hinged braces were reported (58%), most frequently for 3-6 weeks (43% of studies). Complication rates averaged 2% of patients (range 0-26%) for abnormal varus/valgus and 1% (range 0-22%) for non-union or delayed union.

CONCLUSIONS

Postoperative rehabilitation for TPFs most commonly involves significant non-weight bearing time before full weight bearing is recommended at 9-12 weeks. Partial weight bearing protocols and brace use were varied. Type of rehabilitation may be an important factor influencing recovery, with future high quality prospective studies required to determine the impact of different protocols on clinical and radiological outcomes.

Do clinical outcomes correlate with bone density after open reduction and internal fixation of tibial plateau fractures

INTRODUCTION

The operative management of tibial plateau fractures in elderly patients has historically led to inconsistent results, and these clinical outcomes were thought to be associated with poor bone quality often in elderly patients. The goal of this study was to investigate the relationship between bone density and subjective clinical outcome scores after open reduction and internal fixation of tibial plateau fractures.

MATERIALS AND METHODS

This is a retrospective cohort study from a single-surgeon conducted at an Academic, Level 1 Trauma Center. A preoperative computed tomography (CT) scan was obtained for all patients. Bone density of the distal femur was quantified with Hounsfield units (HU) as measured on axial CT scans. Inter-rater reliability of HU measurements was assessed using interclass correlation coefficients. Regression models controlling for age were used to identify relationships between bone density (HU) and the following variables: articular subsidence and 1-year subjective clinical outcomes scores [Knee Outcome Survey Activities of Daily Living Scale (KOS-ADLS), and Short-Form-36 (SF-36) physical and mental component scores (PCS, MCS)].

RESULTS

Sixty-one patients with a mean age of 59.3 years (range 27-85 years) and a minimum of 12 months of clinical follow-up were included in the study. The majority of the fractures (32 of 61) were classified as Schatzker II tibial plateau fractures, and there were 13 Schatzker V fractures, 11 Schatzker VI fractures, 2 Schatzker IV fractures and 1 Schatzker 1 fracture. HU measurements demonstrated an almost perfect inter-observer reliability (ICC = 0.97). Age was negatively correlated with HU measurements (r = -0.51, p < 0.001), and using a geriatric cut-off of 65 years of age, the geriatric group had a lower mean HU compared to the non-geriatric group (78.2 versus 114.8, p = 0.018). There was no significant relationship between bone quality, as assessed by distal femoral HU, and any subjective clinical outcome score.

CONCLUSIONS

Inferior bone mineral density alone does not appear to affect clinical outcomes 1 year postoperatively when bone grafting is used to restore osseous voids. Poor bone quality should not be used as an indication for non-operative management of tibial plateau fractures.

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.

Functional and Clinical Outcomes of Nonsurgically Managed Tibial Plateau Fractures

INTRODUCTION

This study sought to assess and compare long-term functional and clinical outcomes in patients with tibial plateau fractures that are treated nonsurgically.

METHODS

Over a period of 8 years, 305 consecutive tibial plateau fractures were treated by three surgeons at a single institution and followed prospectively in an Institutional Review Board-approved study. Overall, 41 patients (13%) were treated nonsurgically and 37 were available for follow-up. Indications for nonsurgical management were minimal fracture displacement or preclusion of surgery because of comorbidities. A series of univariate retrospective analyses were used to identify individual risk factors potentially predictive of Short Musculoskeletal Functional Assessment scores.

RESULTS

Thirty-seven patients were included with a mean follow-up of 21 ± 14.9 months. Overall, 59% of patients (n = 22) attained good to excellent functional outcomes. In patients for whom surgery was precluded because of comorbidities, outcome scores were significantly poorer (38.8 ± 23.0 versus 12.7 ± 14.2; P = 0.001). Surgery precluded by a factor other than minimal fracture displacement predicted poor outcome (P = 0.002).

DISCUSSION

Carefully selected patients with minimally displaced tibial plateau fractures can expect good to excellent outcomes when treated nonsurgically.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Surgical Technique of Anterolateral Approach for Tibial Plateau Fracture

A 66-year-old woman had sustained crush injury 3 hours prior to her presentation to our hospital. The diagnosis was defined as lateral tibial plateau fracture of the right knee (Schatzker III). Supine position was set up and a pad was put under the affected hip. After sterilization of the surgical field the sterilized sheets were placed beneath the leg in order to be higher than the other side. A rolled sheet was put under the knee joint so that the knee joint was flexed around 30° to 40°. After the surgical field was draped the skin was incised. Iliotibial band was incised by blade (not by electrotomy) and sharp dissection was performed in the Gerdy's tubercle. Capsulotomy was made by cutting the tibial meniscal ligament. Then the meniscus was tagged superiorly and the articular surface was clearly visualized. A window was made in the lateral cortex beneath the plateau, so the impacted fragment was elevated through the window. The metaphyseal void was filled by bone allograft. The placement of the raft-screw plate must be ensured that the raft screws passing the plate could purchase the subchondral bone. After perfect placement of the plate was defined, the femoral distractor was removed and the knee joint was relaxed. It was ensured that the alignment of the lower leg was normal, and then the other screws were inserted. Following placing drainage in the wound the iliotibial band was closed and the subcutaneous soft tissue and skin were closed in layer.

Elective removal of implants after open reduction and internal fixation of Tibial Plateau fractures improves clinical outcomes

INTRODUCTION

Tibial plateau fractures are common injuries often treated with open reduction and internal fixation. We have noted improved patient satisfaction following implant removal for these patients. The purpose of this study was to assess the effect of removal of surgical implants after union on patient reported outcomes.

MATERIALS AND METHODS

All patients at our Level 1 Trauma Center undergoing open reduction an internal fixation by the senior surgeon are offered enrollment into a prospective registry and have clinical outcomes recorded at follow-up [Knee Outcomes Survey (KOS), Lower Extremity Functional Scale (LEFS), Short Form-36 Physical and Mental Component Summary (SF-36 PCS, SF-36 MCS), and Visual analog pain scale (VAS)]. Routinely, removal of surgical implants is offered after fracture union resulting in two cohorts: those who had undergone elective removal of surgical implants and those who had not. Outcome scores were compared before and after implant removal as well as between the two study populations at final follow-up.

RESULTS

Seventy-five patients were identified as having 12 month outcome scores: 36 (48%) had retained implants; 39 (52%) had implants removed. KOS and LEFS outcomes improved significantly after implant removal (p < 0.05). Clinical outcomes (KOS, SF-36 PCS) were also significantly better in patients who had implants removed compared to those that did not at final follow-up (p < 0.05). There was no statistical difference seen in VAS pain scores.

CONCLUSIONS

The results of this study indicate that patients who have elective removal of their surgical implants after open reduction and internal fixation of a tibial plateau fracture have improved clinical outcomes after removal and also demonstrate significantly better outcomes than those who have retained implants at final follow-up. Patients who are unhappy with their clinical result should be counseled that removal of the implant may improve function, but may not improve pain.

Definitive fixation of tibial plateau fractures

Tibial plateau fractures present in a wide spectrum of injury severity and pattern, each requiring a different approach and strategy to achieve good clinical outcomes. Achieving those outcomes starts with a thorough evaluation and preoperative planning period, which leads to choosing the most appropriate surgical approach and fixation strategy. Through a case-based approach, this article presents the necessary pearls, techniques, and strategies to maximize outcomes and minimize complications for some of the more commonly presenting plateau fracture patterns.

Metaphyseal tibial level (MTL) screws: a modified percutaneous technique for lateral plateau depression fractures

INTRODUCTION

Lateral tibial plateau fractures are more frequent than medial fractures, and those with articular depression are particularly challenging because of high displacement risk. To prevent secondary subsidence, the gold standard is raft screws with a periarticular or anti-glide plate. Graft is used to fill the metaphyseal defect created by reduction in the depressed fragment. We present a case of Schatzker II fracture managed in a complete percutaneous fashion, with a new combined technique of raft screws and interference screw used as a support.

CASE REPORT

A 51-year-old female sustained a Schatzker II tibial plateau fracture. Based on pre-operative CT, direction of reduction force to apply was drawn on coronal and sagittal cuts.

OPERATIVE TECHNIQUE

Under fluoroscopic control, the split component of the fracture was reduced. The cortical window was then drilled in the lateral cortex, and a K wire advanced under the depressed fragment under fluoroscopic guidance. After fragment reduction with a bone impacter, internal fixation was completed by percutaneous introduction of two subchondral cortical screws. A bioabsorbable interference screw was then introduced in the impacter tunnel to support impacted bone under the reduced articular surface. Finally, a cortical screw was introduced, from anterior to posterior to prevent screw cut-out.

CONCLUSION

The combination of subchondral screws in a jail technique with a bioabsorbable interference screw that we named metaphyseal tibia level (MTL) screw technique is, to our knowledge, not described. The MTL screw promises to be a true percutaneous reduction and fixation technique for Schatzker II and III fractures in patients with reasonable bone quality.

Clinical instability of the knee and functional differences following tibial plateau fractures versus distal femoral fractures

BACKGROUND

Fractures of the knee account for about 6% of all trauma admissions. While its management is mostly focused on fracture treatment, it is not the only factor that defines the final outcome.

OBJECTIVES

This study aimed to study objective and subjective outcomes after proximal tibial versus distal femoral fractures in terms of knee instability and health-related quality of life.

PATIENTS AND METHODS

This retrospective, cross-sectional, cohort study was carried out on 80 patients with either isolated proximal tibial (n = 42) or distal femoral (n = 38) fractures, who underwent open reduction and internal fixation. All the fractures were classified based on the Schatzker and AO classification for tibial plateau and distal femoral fractures, respectively. The patients were followed and examined by an orthopedic knee surgeon for clinical assessment of knee instability. In their last follow-up visit, these patients completed a Lysholm knee score and the short-form (SF) 36 health survey.

RESULTS

Among the 42 tibial plateau fractures, 25% were classified as Schatzker type 2. Of the 38 distal femoral fractures, we did not find any type B1 or B3 fractures. The overall prevalence of anterior and posterior instability was 42% and 20%, respectively. Medial Collateral Ligament (MCL) and Lateral Collateral Ligament (LCL) injuries were detected clinically in 50% and 28%, respectively. The incidence rates of ligament injuries in tibial plateau fractures were as follows: Anterior Collateral Ligament (ACL) 26%, Posterior Collateral Ligament (PCL) 7%, MCL 24%, and LCL 14%. Medial collateral ligament injury was the most common in the Schatzker type 2 (50% of the injuries). Distal femoral fractures were associated with ACL injury in 16%, PCL in 13%, MCL in 26% and LCL in 14%. However, final knee range of motion (ROM) and function (Lysholm score) were not associated with fracture location. No statistically significant difference was observed between the two groups, except for the valgus stress test at 30°knee flexion, which was more positive in tibial fractures. All eight domains of SF-36 score in the distal femoral and proximal tibial fractures were significantly different from the normal values; however, there were no statistically significant differences between femoral and tibial fracture scores.

CONCLUSIONS

Although ROM is acceptable in knee joint fractures, instability is common. However, it seems that knee function and quality of life are not associated with the location of the fracture.