An efficacy analysis of surgical timing and procedures for high-energy complex tibial plateau fractures

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.

Treatment of Schatzker Type VI Tibia Fractures Using Circular External Fixation: State of the Art, Surgical Technique and Results

BACKGROUND

Schatzker type VI tibia fractures are usually associated with infection and surgical wound-related problems. Circular external fixation (CEF) has been shown to minimize such complications.

METHODS

We pose a retrospective study of patients with Schatzker type VI fractures treated with CEF.

RESULTS

Twenty-two (22) patients were included (11M/11F) with a mean age of 60.1 ± 14.9 years. According to the AO/OTA classification, two fractures (9.1%) were A2, three (13.6%) were A3, and seventeen (77.3%) were C3. Three (13.6%) of them were open. The tissue damage observed in the nineteen (86.4%) closed fractures was classified according to Tscherne (four grade I, twelve grade II, and three grade III). The mean ex-fix time was 24.1 ± 5.1 weeks. None of the patients experienced deep infections, nonunion, or malunion. The mean ROM was 111.4 ± 17.8 degrees. Although stability was achieved in all cases, 50% of them suffered osteoarthritic degeneration. Four knees required TKR at a mean of 8.77 ± 5.58 years from trauma. The mean HHS knee score was 84.2 ± 10.3 points (excellent in fifteen (68.2%) cases, good in four (18.2%), and acceptable in three (13.6%)). The mean Rasmussen radiological score was 13.3 ± 3.5 (excellent in three (13.6%) cases, good in fifteen (68.2%), and acceptable in four (18.2%)). The mean SF-12 score was 35.1 ± 10.4 points on the physical scale and 53.0 ± 10.6 points on the mental scale.

CONCLUSIONS

CEF has shown itself to be a valid treatment for patients with Schatzker type VI fractures, particularly for those where the fracture is comminuted, severely displaced, open, or associated with severe soft tissue damage.

What factors are associated with loss of alignment after open reduction and internal fixation for tibial plateau fractures? A retrospective multicenter (TRON group) study

BACKGROUND

Tibial plateau fractures (TPFs) are one of the most challenging intra-articular fractures to treat. Along with reconstruction of the articular surfaces, appropriate alignment of the knee joints must be obtained and maintained after open reduction and internal fixation (ORIF) for TPFs because loss of alignment (LA) is associated with worse clinical outcomes. We aimed to investigate and clarify the risk factors related to LA after ORIF for TPFs.

METHODS

This multicenter, retrospective cohort study used data of hospitals of the Trauma Research Group (TRON group) from January 1, 2011, to December 31, 2020. Among 293 TPFs extracted from the database, we evaluated the alignment of the articular surface to the anatomical axis of the tibia in the immediate postoperative and last follow-up radiographs. We defined a change of alignment from the immediate postoperative radiograph as LA. We evaluated the risk factors of LA using univariate and multiple logistic regression analyses.

RESULTS

LA was observed in 27 fractures (9.2%). In multiple logistic regression analyses, preoperative articular step-off and postoperative condylar widening were statistically associated with LA (OR = 1.1, 95% CI: 1.02-1.19 and P = 0.012; OR = 1.04, 95% CI: 1.00-1.08, P = 0.045, respectively). We calculated the threshold by drawing a receiver operating characteristic curve using the final regression model. The threshold of postoperative widening was 8.2 mm. We divided the 293 TPFs into two groups according to this threshold and determined differences between the two groups using Fisher's exact test. The two groups were statistically significantly different (P = 0.00502).

CONCLUSIONS

Preoperative articular step-off and postoperative condylar widening could be associated with LA after ORIF for TPFs. We suggest that intraoperative restoration of condylar widening is important for the prevention of malalignment following ORIF for TPF.

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

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

[Intra-articular proximal tibia fractures]

The incidence of proximal intra-articular tibial fractures is continuously increasing. In addition to high-energy trauma in young patients, osteoporotic fractures occur more frequently in geriatric patients. After a thorough clinical examination including X‑ray and computed tomography (CT) imaging, consolidation of the soft tissue is followed by surgical treatment to achieve the best possible anatomic reconstruction of the articular surface. Nonanatomic reduction with articular gaps >2.5 mm leads to a significantly increased risk of osteoarthritis. Selection of the surgical approach and planning of the osteosynthesis are based on the fracture morphology and the existing soft tissue damage. In addition to arthroscopically assisted percutaneous procedures, sophisticated osteosynthesis is often necessary, which requires several surgical approaches. In this context, posterior surgical approaches are becoming increasingly more important. Primary knee arthroplasty can also play a role, particularly in older patients.

The radiographic soft tissue thickness is associated with wound complications after open reduction and internal fixation of patella fractures

Background

Displaced patella fracture is commonly treated with open reduction and internal fixation (ORIF). Wound complications after surgery often lead to prolonged hospitalization and dissatisfaction of patients. Periarticular adiposity and swelling may be associated with wound complications. The purpose of this study is to determine the relationship between periarticular soft tissue thickness and wound complications after ORIF of patella fractures.

Methods

We retrospectively studied 237 patients undergoing ORIF for patella fractures from June 2017 to February 2021 at our institution. We established periarticular soft tissue thickness ratio (PSTTR) to evaluate soft tissue status on lateral knee X-ray radiographs. Univariate analysis was performed to identify the association between PSTTR and postoperative wound complication. A receiver-operating characteristic (ROC) curve analysis was performed to evaluate the predictive value of PSTTR.

Results

The incidence of postoperative wound complication was 10.5%. Minor wound complication occurred in 24 patients, and major wound complication occurred in one patient. The average femoral PSTTR (fPSTTR) was 0.94 ± 0.17 and the average tibial PSTTR (tPSTTR) was 0.66 ± 0.16. fPSTTR proved to be associated with postoperative wound complication. In the ROC analysis of fPSTTR predicting postoperative wound complication, the area under curve (AUC) was 0.676, which indicated a moderate predictive value.

Conclusions

PSTTR was a feasible method to assess periarticular soft tissue. The increased fPSTTR was associated with wound complications after ORIF of patella fractures.

[Change in the treatment of tibial plateau fractures]

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.

Internal fixation of delayed union of fracture with chronic osteomyelitis due to Staphylococcus epidermidis: A case report

INTRODUCTION

The most feared and challenging complication in treating patients with musculoskeletal trauma is infection after fracture fixation, which can delay healing and, in turn, result in permanent functional loss of limbs or even amputation.

CASE PRESENTATION

Here, we describe a case in which a patient presented with stage 4 chronic osteomyelitis on the right tibia and fibula. To treat the late infection by eradicating or reducing the infection, it was recommended to replace the internal fixation with surgical debridement for 6 weeks and antibiotics for 6-12 weeks until the internal fixation device could be removed.

CONCLUSION

Delayed union and chronic osteomyelitis are possible complications of IAFF.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Epidemiological Study of Tibial Plateau Fractures Combined with Intercondylar Eminence Fractures

OBJECTIVE

To investigate the epidemiological characteristics of tibial plateau fractures combined with intercondylar eminence fractures and identify the risk factors.

METHODS

This retrospective study enrolled patients with tibial plateau fractures who were treated in the third hospital of Hebei Medical University from January 2015 to December 2018; 1020 patients (693 [68%] men and 327 [32%] women) meeting the inclusion and exclusion criteria had a mean age of 45.2 ± 13.8 years. In total, 506 (50%) cases were left injuries, 495 (48%) were right injuries, and 19 (2%) were bilateral injuries. Among them, 458 (44.9%) with a mean age of 47.0 ± 13.9 years had intercondylar eminence fractures, including 324 men and 134 women. A total of 562 (55.1%) patients were identified without intercondylar eminence fractures, including 369 (65.7%) men and 193 (34.3%) women with an average age of 43.8 ± 13.6 years. The distribution characteristics of tibial plateau fractures with intercondylar eminence involved were identified. The potential associations among fractures and various other factors, such as age, gender, occupation, and mechanism of injury, were explored.

RESULTS

The highest proportion age group of tibial plateau fractures included the ages 35-54 years, with more men than women for both age groups. For males, the highest proportion age group was 35-44 years, and for females, it was 55-64 years (χ 2 = 71.336, P < 0.01). According to Schatzker classification, type IV tibial plateau fractures had the highest risk of intercondylar eminence being involved (70.6%) without significance with type V (69.5%) and VI (68.2%) but with greater significance with types I (11.9%), II (39.2%), and III (9.4%, χ 2 = 280.187, P < 0.01). Multiple analysis showed that simple fractures, including types I, II, and III (OR 0.108, 95% CI: 0.080-0.145), were less likely to involve intercondylar eminence fractures than complex fractures, including types IV, V, and VI. Patients aged >74 years were more likely to have intercondylar eminence fractures compared with other age groups. Retired patients (OR 4.332, 95% CI: 1.147-16.362) were more likely to have fractured intercondylar eminence.

CONCLUSION

The current study revealed the characteristics of tibial plateau fractures, especially those involving intercondylar eminence fractures, as well as their proportion, distribution, and risk factors, which can be used as reference data for clinical assessment and surgical protocol selection.

[Surgical approaches to tibial plateau fractures]

Intra-articular tibial plateau fractures can present a surgical challenge due to complex injury patterns and compromised soft tissue. The treatment goal is to spare the soft tissue and an anatomical reconstruction of the tibial articular surface. Depending on the course of the fracture, a fracture-specific access strategy is recommended to provide correct positioning of the plate osteosynthesis. While the anterolateral approach is used in the majority of lateral tibial plateau fractures, only one third of the joint surface is visible; however, posterolateral fragments require an individual approach, e. g. posterolateral or posteromedial. If necessary, osteotomy of the femoral epicondyles can improve joint access for reduction control. Injuries to the posterior columns should be anatomically reconstructed and biomechanically correctly addressed via posterior approaches. Bony posterior cruciate ligament tears can be refixed via a minimally invasive posteromedial approach.

Prevalence of Deep Surgical Site Infection After Repair of Periarticular Knee Fractures: A Systematic Review and Meta-analysis

IMPORTANCE

Surgical management of periarticular knee fractures can be challenging, and adverse outcomes may be severe. Recent literature indicates that the rate of periarticular knee surgical site infection (SSI) may range from 2% to 88% depending on the fracture site.

OBJECTIVE

To examine the prevalence of deep SSI and the rate of septic arthritis after surgical repair of fractures around the knee.

DATA SOURCES

The electronic databases MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from their inception to July 1, 2018.

STUDY SELECTION

Eligible studies had to specifically report deep SSI rates and include fractures in the distal femur, patella, tibial plateau, or proximal tibia. Risk factors that were associated with increased the risk of deep SSI were also examined.

DATA EXTRACTION AND SYNTHESIS

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Data were extracted by multiple investigators. Comprehensive Meta-Analysis software was used for the pooling of data, using either random-effects or fixed-effects models, with respect to the degree of statistical heterogeneity present. Data analyses were conducted in October 2019.

MAIN OUTCOMES AND MEASURES

The primary outcome was overall prevalence of deep SSI after periarticular knee fracture repair. The secondary outcomes were the overall prevalence of septic arthritis, risk factors associated with deep SSI, and the most commonly cultured bacteria specimens found periarticular knee infections.

RESULTS

Of 6928 articles screened, 117 articles met inclusion criteria and were included in analysis. Among 11 432 patients included in analysis, 653 patients (5.7%) experienced deep SSIs, most commonly among patients with proximal tibia fractures (56 of 872 patients [6.4%]). Among studies that included information on septic arthritis, 38 of 1567 patients (2.4%) experienced septic arthritis. The 2 most commonly reported bacteria were methicillin-resistant Staphylococcus aureus, found in 67 SSIs, and methicillin-susceptible S aureus, found in 53 SSIs. Sixty-two studies (53.0%) in the sample received a Coleman Methodological Score of poor (<50 points).

CONCLUSIONS AND RELEVANCE

Deep SSIs occurred in nearly 6% of periarticular knee fracture repairs, and 2.4% of SSIs were associated with septic arthritis. Surgeons managing these injuries should be vigilant when wounds are not pristine. Efforts should be made to elevate the quality of research conducted not only in this subject but also in orthopedic surgery as a whole.

Is "Early Total Care" a Safe and Effective Alternative to "Staged Protocol" for the Treatment of Schatzker IV-VI Tibial Plateau Fractures in Patients Older Than 50 Years?

OBJECTIVES

To compare "Early Total Care" (ETC) with "Staged Protocol" (SP) for the treatment of Schatzker IV-VI tibial plateau fractures in patients older than 50 years regarding safety and effectiveness.

DESIGN

Retrospective cohort study.

SETTING

An academic level 1 US trauma center.

PATIENTS/PARTICIPANTS

Eighty-one patients older than 50 years with Schatzker grade IV-VI tibial plateau fractures were included.

INTERVENTION

Fifty-three patients were treated under SP with immediate external fixation followed by definitive internal fixation. Twenty-eight patients were treated under ETC with immediate internal fixation.

MAIN OUTCOME MEASUREMENTS

Comparison of perioperative findings, time to bony and clinical union, soft-tissue and bony complications, radiological outcome, and secondary procedures.

RESULTS

The 2 groups were comparable without significant difference regarding age, sex, side of involvement, body mass index, smoking status, American Society of Anesthesiologist classification, associated injuries, comorbidities, follow-up duration, and fracture classification. No statistically significant difference was found regarding the perioperative complications, quality of reduction, time to union, Rasmussen score at union or at the final follow-up, soft-tissue/bony complications, and the rate of the secondary procedures.

CONCLUSION

ETC seems to be a safe, efficacious, and effective alternative to the SP for the treatment of some Schatzker IV-VI fractures in patients older than 50 years.

LEVEL OF EVIDENCE

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

Skiers and snowboarders have improved short-term outcomes with immediate fixation of tibial plateau fractures

Background

Tibial plateau fractures (TPFs) are frequently associated with motor vehicle accidents, auto-pedestrian crashes and falls. However, hospitals near ski resorts commonly treat TPF resulting from skiing. The soft tissue envelope and original mechanism of injury are important determinants in the decision to proceed with immediate or delayed fixation of the fracture. Our objective was to assess whether immediate (≤24 hours) versus delayed (>24 hours) open reduction internal fixation (ORIF) affected in-hospital outcomes among snow sport participants.

Methods

This was a retrospective study of patients with isolated TPF who were injured while skiing or snowboarding and treated at a Level III Trauma Center that serves four major ski resorts between 2010 and 2013. Clinical characteristics and in-hospital outcomes were obtained from an existing trauma database. Imaging was reviewed to classify the fracture as high (Schatzker IV–VI) or low (Schatzker I–III) energy. Differences in clinical characteristics and outcomes between immediate and delayed ORIF patients were analyzed with χ² and Wilcoxon two-sample tests. These analyses were also performed in the high-energy and low-energy fracture populations.

Results

ORIF was performed on 119 snow sport patients, 93 (78%) immediately. Patients had a median age of 49 years (range 19–70) and were predominantly male (66%). Forty percent sustained a high-energy TPF. No differences were observed between the demographic characteristics, injury severity, Schatzker scores or time from injury to hospital arrival for patients treated immediately versus delayed treatment. Compared with delayed fixation, patients treated immediately had less compartment syndrome (3% vs 27%), needed fewer fasciotomies (6% vs 31%) and had a shorter length of stay (3 vs 6.5 days), p<0.05 for all. These results persisted in the stratified analysis of high-energy fracture patients.

Discussion

Treating patients immediately led to more favorable in-hospital outcomes compared with delayed treatment, even among the patients with a high-energy fracture.

Level of evidence

Level IV, Therapeutic/Care Management.

External fixation versus open reduction and internal fixation for tibial pilon fractures: A meta-analysis based on observational studies

PURPOSE

Tibial pilon fractures remain challenging for an orthopaedic surgeon to repair. External fixation (ExFix) and open reduction and internal fixation (ORIF) are two widely used methods for repairing tibial pilon fractures. However, conclusions of comparative studies regarding which method is superior are controversial. Our aim is to compare ORIF and ExFix and clarify which method is better in terms of reduction and union results and major complications.

METHODS

A computerized research of MEDLINE, EMBASE, Springer, and Cochrane Library (before December 2014) for studies of any design comparing ORIF and ExFix was conducted. Weighted mean difference (WMD), risk ratio (RR) and corresponding 95% confidence intervals (CI) were used for esti- mating the effects of the two methods. Statistical analyses were done using Review Manager Version 5.2.

RESULTS

Ten cohort studies and one randomized clinical trial were included in our ultimate analysis. And the analysis found no significant difference between the two methods in deep infection (p = 0.13), reduction (p = 0.11), clinical evaluation (p = 0.82), post-traumatic arthrosis (p = 0.87), and union time (p = 0.35). Besides, ExFix group was found to have a higher rate of superficial infection (p =0.001), malunion (p = 0.01) and nonunion (p = 0.02), but have a lower risk of unplanned hardware removal (p = 0.0002).

CONCLUSIONS

We suggest that ORIF has a relatively lower incidence rate of superficial infection, malunion and nonunion, but a higher rate of unplanned hardware removal. No difference was found in deep infection, reduction, clinical evaluation, post-traumatic arthrosis and union time.

A Meta-Analysis for Postoperative Complications in Tibial Plafond Fracture: Open Reduction and Internal Fixation Versus Limited Internal Fixation Combined With External Fixator

The treatment of tibial plafond fractures is challenging to foot and ankle surgeons. Open reduction and internal fixation and limited internal fixation combined with an external fixator are 2 of the most commonly used methods of tibial plafond fracture repair. However, conclusions regarding the superior choice remain controversial. The present meta-analysis aimed to quantitatively compare the postoperative complications between open reduction and internal fixation and limited internal fixation combined with an external fixator for tibial plafond fractures. Nine studies with 498 fractures in 494 patients were included in the present study. The meta-analysis found no significant differences in bone healing complications (risk ratio [RR] 1.17, 95% confidence interval [CI] 0.68 to 2.01, p = .58], nonunion (RR 1.09, 95% CI 0.51 to 2.36, p = .82), malunion or delayed union (RR 1.24, 95% CI 0.57 to 2.69, p = .59), superficial (RR 1.56, 95% CI 0.43 to 5.61, p = .50) and deep (RR 1.89, 95% CI 0.62 to 5.80) infections, arthritis symptoms (RR 1.20, 95% CI 0.92 to 1.58, p = .18), or chronic osteomyelitis (RR 0.31, 95% CI 0.05 to 1.84, p = .20) between the 2 groups.