Prevalence of femoral condyle injuries in the setting of tibial plateau fractures

BACKGROUND

Tibial plateau fracture patterns are influenced by the direction and energy of the impact, and the bone quality. Associated articular femoral injuries can result from the same impact but are insufficiently studied. This study quantifies the prevalence of three distinct articular femoral condyle injuries: (1) impaction fractures, (2) contusions, and (3) condyle fractures. For impaction fractures we assessed the depth, width, length, and surface area.

METHODS

We retrospectively reviewed patients who had undergone surgery for a tibial plateau fracture in a tertiary trauma center. Two fellowship-trained radiologists analyzed preoperative CT scans for associated femoral condyle injuries. We defined (1) impaction fractures (depressions ≥ 1.5 mm) with a sclerotic band, a fracture line, or both; (2) contusions (depressions < 1.5 mm) with a sclerotic band; and (3) condyle fractures as sub- or osteochondral fractures.

RESULTS

We identified 149 patients (62 male) with a tibial plateau fracture with a CT scan available. The overall prevalence of articular femoral condyle injuries was 26% (n = 39). The prevalence of impaction fractures was 9.4% (n = 14), of contusions 14% (n = 21), and of condylar fractures 3.0% (n = 4). Factors associated with a higher prevalence of femoral condyle injury were younger age (p = 0.029), male sex (p = 0.014), and absence of comorbidity (p = 0.005). The mean depth of impaction fractures was 2.3 mm (SD: 0.78; range 1.6 to 4).

CONCLUSION

Concomitant articular femoral condyle injuries occur in one out of four patients with a tibial plateau fracture. Although most femoral injuries were subtle, and none underwent surgical treatment, they might harbor information regarding the likelihood of future joint degeneration and knee instability.

LEVEL OF EVIDENCE

IV.

What Is the Patient-reported Outcome and Complication Incidence After Operative Versus Nonoperative Treatment of Minimally Displaced Tibial Plateau Fractures?

BACKGROUND

Much controversy remains about whether minimally displaced tibial plateau fractures should be treated operatively or nonoperatively. It is generally accepted that gaps and stepoffs up to 2 mm can be tolerated, but this assumption is based on older studies using plain radiographs instead of CT to assess the degree of initial fracture displacement. Knowledge regarding the relationship between the degree of fracture displacement and expected functional outcome is crucial for patient counseling and shared decision-making, specifically in terms of whether to perform surgery.

QUESTIONS/PURPOSES

(1) Is operative treatment associated with improved patient-reported outcomes compared with nonoperative treatment in minimally displaced tibial plateau fractures (fractures with up to 4 mm of displacement)? (2) What is the difference in the risk of complications after operative versus nonoperative treatment in minimally displaced tibial plateau fractures?

METHODS

A multicenter, cross-sectional study was performed in patients treated for tibial plateau fractures between 2003 and 2019 at six hospitals. Between January 2003 and December 2019, a total of 2241 patients were treated for tibial plateau fractures at six different trauma centers. During that time, the general indication for open reduction and internal fixation (ORIF) was intra-articular displacement of > 2 mm. Patients treated with ORIF and those treated nonoperatively were potentially eligible; 0.2% (4) were excluded because they were treated with amputation because of severe soft tissue damage, whereas 4% (89) were excluded because of coexisting conditions that complicated outcome measurement including Parkinson disease, cerebrovascular accident, or paralysis (conditions causing an inability to walk). A further 2.7% (60) were excluded because their address was unknown, and 1.4% (31) were excluded because they spoke a language other than Dutch. Based on that, 1328 patients were potentially eligible for analysis in the operative group and 729 were potentially eligible in the nonoperative group. At least 1 year after injury, all patients were approached and asked to complete the Knee injury and Osteoarthritis Outcome Scale (KOOS) questionnaire. A total of 813 operatively treated patients (response percentage: 61%) and 345 nonoperatively treated patients (response percentage: 47%) responded to the questionnaire. Patient characteristics including age, gender, BMI, smoking, and diabetes were retrieved from electronic patient records, and imaging data were shared with the initiating center. Displacement (gap and stepoff) was measured for all participating patients, and all patients with minimally displaced fractures (gap or stepoff ≤ 4 mm) were included, leaving 195 and 300 in the operative and nonoperative groups, respectively, for analysis here. Multivariate linear regression was performed to assess the association of treatment choice (nonoperative or operative) with patient-reported outcomes in minimally displaced fractures. In the multivariate analysis, we accounted for nine potential confounders (age, gender, BMI, smoking, diabetes, gap, stepoff, AO/OTA classification, and number of involved segments). In addition, differences in complications after operative and nonoperative treatment were assessed. The minimum clinically important differences for the five subscales of the KOOS are 11 for symptoms, 17 for pain, 18 for activities of daily living, 13 for sports, and 16 for quality of life.

RESULTS

After controlling for potentially confounding variables such as age, gender, BMI, and AO/OTA classification, we found that operative treatment was not associated with an improvement in patient-reported outcomes. Operative treatment resulted in poorer KOOS in terms of pain (-4.7 points; p = 0.03), sports (-7.6 points; p = 0.04), and quality of life (-7.8 points; p = 0.01) compared with nonoperative treatment, but those differences were small enough that they were likely not clinically important. Patients treated operatively had more complications (4% [7 of 195] versus 0% [0 of 300]; p = 0.01) and reoperations (39% [76 of 195] versus 6% [18 of 300]; p < 0.001) than patients treated nonoperatively. After operative treatment, most reoperations (36% [70 of 195]) consisted of elective removal of osteosynthesis material.

CONCLUSION

No differences in patient-reported outcomes were observed at midterm follow-up between patients treated surgically and those treated nonsurgically for tibial plateau fractures with displacement up to 4 mm. Therefore, nonoperative treatment should be the preferred treatment option in minimally displaced fractures. Patients who opt for nonoperative treatment should be told that complications are rare, and only 6% of patients might undergo surgery by midterm follow-up. Patients who opt for surgery of a minimally displaced tibial plateau fracture should be told that complications may occur in up to 4% of patients, and 39% of patients may undergo a secondary intervention (most of which are elective implant removal).

LEVEL OF EVIDENCE

Level III, therapeutic study.

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.

Total knee arthroplasty following surgical treatment of tibial plateau fractures - A retrospective cohort study

BACKGROUND

Previous studies have shown the risk of post-traumatic osteoarthritis to be high following tibial plateau fracture surgery. Several investigations have examined the risk of total knee arthroplasty (TKA) following tibial plateau fracture treatment, but the risk of TKA in relation to the general population in Sweden has not previously been explored.

AIM

To determine the incidence of TKA following surgical treatment of tibial plateau fractures and compare it with that of an age-matched population in Sweden.

METHODS

A total of 349 tibial plateau fractures treated with open reduction internal fixation between 2002 and 2010 were identified from local hospital registers using diagnosis and surgical codes. The cohort was cross-matched with the Swedish Knee Arthroplasty Register to determine which patients had been treated with TKA within 10 years of fracture surgery. The incidence of primary TKA in the age-matched population in Sweden was obtained from the National Patient Register for comparison.

RESULTS

Mortality-adjusted prevalence of TKA at 10 years following fracture surgery was 6.7% (relative risk (RR) = 5.5) and peaked during the second postoperative year (RR=19.3). High age was independently associated with increased risk of TKA (P=0.004); no other examined patient factors were significantly associated with TKA.

CONCLUSION

The overall prevalence of TKA at 10 years following tibial plateau fracture surgery is low at 6.7%, however the risk is many times greater than that of the age-matched population in Sweden. The majority of patients require TKA within a few years of fracture treatment, hence post-traumatic osteoarthritis may arguably have not been the reason for TKA as this would have taken longer to develop.

Clinical and radiological outcome of extended lateral approach via epicondyle osteotomy in complex lateral tibia plateau fractures involving the central and postero-lateral segments

INTRODUCTION

The purpose of this study was to evaluate the clinical and radiological results of complex lateral tibial plateau fractures involving the central segments of the lateral tibial plateau. It was hypothesized that an extended lateral approach by using the lateral epicondyle osteotomy improves the rate of malreduction and yields to good and excellent clinical results at a mid-term follow-up.

METHODS

This retrospective case series conducted at two centers evaluated complex lateral tibial plateau fractures treated with an extended lateral approach by lateral epicondyle osteotomy. Fractures were classified according to the AO/OTA and 10-segment classification, with only B/C type fractures involving the antero-latero-central (ALC) and postero-latero-central (PLC)/postero-latero-lateral (PLL) segments. Postoperative computer tomography scans were used to assess the quality of reduction. Clinical outcomes and postoperative complications were evaluated with a minimum follow-up of 2 years.

RESULTS

Sixty-five patients (mean age: 47.7 ± 11.5 years) were included, with an average follow-up of 51.9 ± 3.6 months. Radiological outcomes revealed a postoperative fracture step at the ALC/PLC crossing of 0.8 ± 1.1 mm, at the PLC/PLL crossing of 0.4 ± 1.1 mm, and a fracture gap of 1.8 ± 4.0 mm, yielding a Rasmussen Score of 15.1 ± 3.2. No significant differences among type B and C fractures were identified. No case of nonunion of the lateral epicondyle osteotomy was recorded. The mean Knee injury and Osteoarthritis Outcome Score was 80.4 ± 16.2 (type B 85.6 ± 11.9 vs. type C 76.1 ± 18.4, p < 0.05), Lysholm score was 83.4 ± 17.1 (B 89 ± 11.3 vs. C 78.7 ± 20.1, p < 0.05) and International Knee Documentation Committee score was 69.9 ± 18.8 (type B 76.5 ± 15.7 vs. type C 64.3 ± 20.1, p < 0.05). Early complication rate requiring surgical revision due to malreduction or infection were 7 %. None of the patients reported about subjective lateral knee instability at the time of clinical follow-up.

CONCLUSION

The extended lateral approach with lateral epicondyle osteotomy demonstrated excellent radiological alignment and favorable mid-term clinical outcomes. An overall low complication rate was recorded. Notably, long-term revisions due to lateral instability were absent, indicating the safety and efficacy of lateral epicondyle osteotomy as an operative technique.

Biomechanical analysis of the effect of postero-latero-central tibial plateau fractures in the knee joint: Can posterior soft tissues prevent instability? A finite element study

BACKGROUND

Almost 86 % of all tibial plateau fractures involves the failure of the postero-latero-central region of the tibial plateau. Surgical treatment of this region is technically demanding and in case of limited depression, it's occasionally chosen to leave them untreated. The aim of the study is to numerically check to what extent this choice can be accepted avoiding inferior outcomes (i.e. joint instability), and to analyze posterior soft tissues role in presence of this fractures.

METHODS

Starting from a previous validated finite element model with baseline structures, several configurations were developed by inserting posterior soft tissues and postero-latero-central fracture, with different articular depressions. Squat motion was numerically simulated and tibio-femoral kinematics were compared among configurations.

FINDINGS

An increasing step-off led to a progressive joint instability, especially in the first 35°-40° of flexion. Posterior soft tissues showed to be beneficial in initial stabilization and early flexion. Tibial Axial Rotation didn't show any restorative effect of posterior soft tissues on knee kinematics. Tibial Antero-Posterior Translation is the most significant biomechanical parameter, showing posterior soft tissues restoring native antero-posterior translation, completely for 1-mm step-off fracture, only partially for 2-mm step-off fracture, and not sufficiently for 3-mm step-off fracture, at least in the first 30° of flexion.

INTERPRETATION

The results suggest that postero-latero-central fractures with step-off ≥2 mm should be treated to restore articular kinematic, whereas fractures with step-off <2 mm need a broad evaluation to assess the effective need of surgery. These information can be valuable for surgeons, to aid their decision to surgically operate or not.

Subchondral rafting wires reduce tibial plateau fracture subsidence

PURPOSE

To determine if subchondral rafting wires retained as adjunctive tibial plateau fracture fixation affect postoperative articular subsidence.

METHODS

A retrospective cohort study was conducted at one Level 1 trauma center and one academic university hospital. Consecutive adults with closed, displaced OTA/AO 41B/C tibial plateau fractures treated between 2018 and 2023 with open reduction internal fixation were included. Patients who were not ambulatory, with contralateral injuries limiting weight bearing, and without follow-up radiographs of the injured extremity were excluded. The intervention was retention of subchondral rafting wires as definitive fixation. The primary outcome was linear articular surface subsidence between postoperative and follow-up AP knee radiographs. Linear subsidence was compared between groups using Welch's two sample t test. Associations of linear subsidence with patient, injury, and treatment characteristics were assessed by multivariable linear regression.

RESULTS

We identified 179 patients of a mean age of 44 ± 14 years, of whom 15 (8.4%) received subchondral rafting wires. Median follow-up was 121 days. No patients who received rafting wires as definitive implants experienced linear subsidence ≥ 2 mm, while 22 patients (13.4%) who did not receive rafting wires experienced linear subsidence ≥ 2 mm (p = 0.130). Subchondral rafting wires were associated with less linear subsidence (0.3 mm [95% confidence interval - 0.3-0.9 mm] vsersus 1.0 mm [- 0.9-2.9 mm], p < 0.001). The depth of linear subsidence was significantly associated on multivariable regression with male sex, depressed plateau area, active smoking, and retained rafting wires.

CONCLUSION

Subchondral rafting wires were associated with a small reduction in articular subsidence after internal fixation of tibial plateau fractures. Routine rafting wires may be useful for patients and fractures at high risk of articular subsidence.

Fragment size of lateral Hoffa fractures determines screw fixation trajectory: a human cadaveric cohort study

BACKGROUND AND PURPOSE

Recommendations regarding fragment-size-dependent screw fixation trajectory for coronal plane fractures of the posterior femoral condyles (Hoffa fractures) are lacking. The aim of this study was to compare the biomechanical properties of anteroposterior (AP) and crossed posteroanterior (PA) screw fixations across differently sized Hoffa fractures on human cadaveric femora.

PATIENTS AND METHODS

4 different sizes of lateral Hoffa fractures (n = 12 x 4) were created in 48 distal human femora according to the Letenneur classification: (i) type I, (ii) type IIa, (ii) type IIb, and (iv) type IIc. Based on bone mineral density (BMD), specimens were assigned to the 4 fracture clusters and each cluster was further assigned to fixation with either AP (n = 6) or crossed PA screws (n = 6) to ensure homogeneity of BMD values and comparability between the different test conditions. All specimens were biomechanically tested under progressively increasing cyclic loading until failure, capturing the interfragmentary movements via motion tracking.

RESULTS

For Letenneur type I fractures, kilocycles to failure (mean difference [∆] 2.1, 95% confidence interval [CI] -1.3 to 5.5), failure load (∆ 105 N, CI -83 to 293), axial displacement (∆ 0.3 mm, CI -0.8 to 1.3), and fragment rotation (∆ 0.5°, CI -3.2 to 2.1) over 5.0 kilocycles did not differ significantly between the 2 screw trajectories. For each separate subtype of Letenneur type II fractures, fixation with crossed PA screws resulted in significantly higher kilocycles to failure (∆ 6.7, CI 3.3-10.1 to ∆ 8.9, CI 5.5-12.3) and failure load (∆ 275 N, CI 87-463 to ∆ 438, CI 250-626), as well as, less axial displacement from 3.0 kilocycles onwards (∆ 0.4°, CI 0.03-0.7 to ∆ 0.5°, CI 0.01-0.9) compared with AP screw fixation.

CONCLUSION

Irrespective of the size of Letenneur type II fractures, crossed PA screw fixation provided greater biomechanical stability than AP-configured screws, whereas both screw fixation techniques demonstrated comparable biomechanical competence for Letenneur type I fractures. Fragment-size-dependent treatment strategies might be helpful to determine not only the screw configuration but also the surgical approach.

Biomechanics and finite element analysis comparing posterior T-plates with LCP for fixation of posterolateral tibial plate fractures

Objective: The treatment for posterolateral tibial plateau fractures (PTPF) have been subjects of controversy. We conducted a study to improve the fixation of PTPF through a lateral approach. Methods: We utilized 40 synthetic tibias and categorized the fracture models into five groups based on the locking compression plate (LCP) and T-distal radius plate (TPP) via various forms of fixation with screws through the posterolateral (PL) fracture fragments. I: Two-screw fixation using two locking screws (LPTL). Ⅱ: Two-screw fixation with both variable angle locking screws (LPTV). Ⅲ: One-screw fixation with one locking screw (LPOL). Ⅳ: One-screw fixation with one locking screw and two anteroposterior lag screws (LPOLTL). Ⅴ: a distal radius plate with three locking screws (TPP). Biomechanical tests were conducted to observe the axial compression displacement of the PL fracture fragments at force levels of 250 N, 500 N, and 750 N, as well as to determine the failure load and the axial stiffness for each respective group. Results: Under a 750 N load condition, the displacements within the five experimental groups exhibited the following trend: Ⅴ < Ⅱ < Ⅰ< Ⅳ < Ⅲ. However, there were no significant differences between Group V and Group II, Group I and Group IV (p > 0.05), and only Group Ⅲ demonstrated a displacement exceeding 3 mm. The failure load and the axial stiffness exhibited the same trend. Conversely, statistical significance was identified among the remaining group compared with Group Ⅲ (p < 0.05). Regarding the finite element analysis, the maximum displacements for the five models under the load of 750 N exhibited the following trend: Ⅴ < Ⅱ < Ⅰ< Ⅳ < Ⅲ. The following trends were observed in maximum von Mises stresses for these models under the load of 750 N: Ⅴ < Ⅱ < Ⅳ< Ⅰ < Ⅲ. Conclusion: It is crucial to address the inadequate mechanical strength associated with single screw fixation of LCP for fixing PL fractures in a clinical setting. The biomechanical strength of two-screw fixation surpasses that of single-screw fixation. Introducing variable-angle screws can further enhance the fixation range. Furthermore, the addition of two lag screws threaded from anterior to posterior can compensate the mechanical stability, when PL fracture is fixed with single screw in clinic.

Initial and Residual 3D Fracture Displacement Is Predictive for Patient-Reported Functional Outcome at Mid-Term Follow-Up in Surgically Treated Tibial Plateau Fractures

BACKGROUND

Conventional measures of fracture displacement have low interobserver reliability. This study introduced a novel 3D method to measure tibial plateau fracture displacement and its impact on functional outcome.

METHODS

A multicentre study was conducted on patients who had tibial plateau fracture surgery between 2003 and 2018. Eligible patients had a preoperative CT scan (slice thickness ≤ 1 mm) and received a Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire. A total of 362 patients responded (57%), and assessment of initial and residual fracture displacement was performed via measurement using the 3D gap area (mm2). Patients were divided into four groups based on the 3D gap area size. Differences in functional outcome between these groups were assessed using analysis of variance (ANOVA). Multiple linear regression was used to determine the association between fracture displacement and patient-reported outcome.

RESULTS

Functional outcome appeared significantly worse when initial or residual fracture displacement increased. Multivariate linear regression showed that initial 3D gap area (per 100 mm2) was significantly negatively associated with all KOOS subscales: symptoms (-0.9, p < 0.001), pain (-0.0, p < 0.001), ADL (-0.8, p = 0.002), sport (-1.4, p < 0.001), and QoL (-1.1, p < 0.001). In addition, residual gap area was significantly negatively associated with the subscales symptoms (-2.2, p = 0.011), ADL (-2.2, p = 0.014), sport (-2.6, p = 0.033), and QoL (-2.4, p = 0.023).

CONCLUSION

A novel 3D measurement method was applied to quantify initial and residual displacement. This is the first study which can reliably classify the degree of displacement and indicates that increasing displacement results in poorer patient-reported functional outcomes.

Radiographic Predictors of Conversion to Total Knee Arthroplasty After Tibial Plateau Fracture Surgery: Results in a Large Multicenter Cohort

BACKGROUND

Radiographic measurements of initial displacement of tibial plateau fractures and of postoperative reduction are used to determine treatment strategy and prognosis. We assessed the association between radiographic measurements and the risk of conversion to total knee arthroplasty (TKA) at the time of follow-up.

METHODS

A total of 862 patients surgically treated for tibial plateau fractures between 2003 and 2018 were eligible for this multicenter cross-sectional study. Patients were approached for follow-up, and 477 (55%) responded. The initial gap and step-off were measured on the preoperative computed tomography (CT) scans of the responders. Condylar widening, residual incongruity, and coronal and sagittal alignment were measured on postoperative radiographs. Critical cutoff values for gap and step-off were determined using receiver operating characteristic curves. Postoperative reduction measurements were categorized as adequate or inadequate on the basis of cutoff values in international guidelines. Multivariable analysis was performed to assess the association between each radiographic measurement and conversion to TKA.

RESULTS

Sixty-seven (14%) of the patients had conversion to TKA after a mean follow-up of 6.5 ± 4.1 years. Assessment of the preoperative CT scans revealed that a gap of >8.5 mm (hazard ratio [HR] = 2.6, p < 0.001) and step-off of >6.0 mm (HR = 3.0, p < 0.001) were independently associated with conversion to TKA. Assessment of the postoperative radiographs demonstrated that residual incongruity of 2 to 4 mm was not associated with increased risk of TKA compared with adequate fracture reduction of <2 mm (HR = 0.6, p = 0.176). Articular incongruity of >4 mm resulted in increased risk of TKA. Coronal (HR = 1.6, p = 0.05) and sagittal malalignment (HR = 3.7 p < 0.001) of the tibia were strongly associated with conversion to TKA.

CONCLUSIONS

Substantial preoperative fracture displacement was a strong predictor of conversion to TKA. Postoperative gaps or step-offs of >4 mm as well as inadequate alignment of the tibia were strongly associated with an increased risk of TKA.

LEVEL OF EVIDENCE

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

Effect of Schatzker type VI tibial plateau fractures combined with a proximal fibular and/or posterolateral joint facet fracture on early postoperative functional recovery

PURPOSE

The objective of this study was to investigate the effect of proximal fibular and/or posterolateral joint facet (PJF) fractures on early functional recovery after Schatzker type VI tibial plateau fractures (TPFs).

METHODS

Seventy-nine patients with Schatzker type VI TPFs sustained from November 2016 to February 2021 were divided into three groups according to the integrity of the proximal fibula and PJF (groups A, B, and C). Details including demographics, duration of surgery, and complications were recorded. The Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) score, Hospital for Special Surgery (HSS) score, lateral knee pain and lateral hamstring tightness were ascertained at the final follow-up. The HSS and WOMAC scores have high reliability in evaluating knee function and osteoarthritis.

RESULTS

There was a significant difference in the HSS score between groups A and C (P < 0.001) and between groups B and C (P = 0.036). The hospital stay was significantly different between groups A and C (P = 0.038) and between groups B and C (P = 0.013). There was a significant difference in lateral knee pain and lateral hamstring tightness between groups A and C (P < 0.001) and between groups B and C (P < 0.001).

CONCLUSION

Our study demonstrates that proximal fibular and PJF fractures do not increase the time from injury to surgery, the incidence of complications, or the duration of surgery for Schatzker type VI TPFs. However, fractures of the proximal fibula significantly increase the hospital stay, reduce knee function, and cause lateral knee pain and lateral hamstring tightness. Combined proximal fibular fracture is more decisive than PJF involvement for prognosis.

Factors influencing the outcome after surgical reconstruction of OTA type B and C tibial plateau fractures: how crucial is the restoration of articular congruity?

INTRODUCTION

Only few and inconsistent data about the impact of articular congruity and tolerable residual intraarticular steps and gaps of the joint surface after tibial plateau fractures exist. Therefore, aim of this study was to investigate the correlation between OTA type B and C tibial plateau fracture outcomes and postoperative articular congruity using computed tomography (CT) data.

MATERIALS AND METHODS

Fifty-five patients with a mean age of 45.5 ± 12.5 years and treated for 27 type B and 28 C tibial plateau fractures with pre- and postsurgical CT data were included. Primary outcome measure was the correlation of postoperative intraarticular step and gap sizes, articular comminution area, the postoperative medial proximal tibial angle (MPTA), and the Lysholm and IKDC score. Receiver-operating characteristic (ROC) curves were used to determine threshold values for step and gap heights according to the following outcome scores: IKDC > 70; Lysholm > 80. Secondary outcome measures were the correlation of fracture severity, the number of complications and surgical revisions and the outcome scores, as well as the Tegner activity score before injury and at final follow-up.

RESULTS

After a mean follow-up of 42.4 ± 18.9 months, the mean Lysholm score was 80.7 ± 13.3, and the mean IKDC score was 62.7 ± 17.6. The median Tegner activity score was 5 before the injury and 4 at final follow-up (p < 0.05). The intraarticular step height, gap size, comminution area and MPTA deviation were significantly negatively correlated with the IKDC and Lysholm scores. The cutoff values for step height were 2.6 and 2.9 mm. The gap size threshold was 6.6 mm. In total, an average of 0.5 ± 0.8 (range 0-3) complications occurred, and on average, 0.5 ± 1.1 (range 0-7) surgical revisions had to be performed. The number of complications and surgical revisions also had negative impacts on the outcome. Neither fracture severity nor BMI or patient's age was significantly correlated with the IKDC or Lysholm score.

CONCLUSIONS

Tibial plateau fractures are severe injuries, which lead to a subsequent reduced level of patient activity. Precise reconstruction of the articular surface with regard to intraarticular step and gap size, residual comminution area and joint angle is decisive for the final outcome. Complications and surgical revisions also worsen it.

LEVEL OF EVIDENCE

III.

Clinical Outcomes of Fixation of Depressed Posterolateral Tibial Plateau Fractures Using a Direct Lateral Approach

Introduction

Fixation of plateau posterolateral fracture (PLF) is challenging because the fracture site is mostly covered by vital neurovascular structures. We operated on 15 cases of PLF using a direct lateral approach. This study aims to report on clinical results.

Material and methods

Between 2017 and 2019, 15 cases of PLFs were fixed with a direct lateral approach and a tricortical autologous bone graft from the iliac crest. A depression of more than 2 mm was indicated for the surgical treatment. Clinical evaluation included Lysholm score, International Knee Documentation Committee Score (IKDC) score, and Tegner activity scale after two years follow-up.

Results

The last follow-up was at 24 months after the operation. The mean postoperative Tegner activity scale did not change significantly compared to before the injury (6.5 (6-7) vs. 7 (6-8, p = 0.5)). The postoperative IKDC and Lysholm scores improved significantly compared to before the operation (p < 0.001). The full range of motion was seen in all patients except one who was manipulated after three months.

Conclusions

Surgical treatment using a direct lateral approach is a safe procedure for PLFs that results in good, short-term clinical and radiologic outcomes without fibular osteotomy or compromising the important neurovascular structures.

Level of evidence

IV.

Clinical outcomes of Schatzker type II tibial plateau fractures using joint depression morphology: A cross-sectional study

Tibial plateau fracture is a common intra-articular fracture caused by axial compression and Varus or Valgus force. This study aimed at the relationship between Luo classification morphology of tibial plateau fractures with clinical outcomes and surgical complications. The cross-sectional study was conducted on patients with Schatzker type II tibial plateau fracture who underwent surgery between May 2018 and January 2021. Clinical outcomes were measured by the AKSS, VAS, Lysholm score, alignment, and ROM. A total of 65 patients with a mean age of 36.38 years were enrolled. There was a significant difference in AKSS (p=0.001), VAS score (p=0.011), and mechanical axis alignment (p=0.037) between the groups by pre-operative joint depression depth below and above 10 millimeters. The higher pre-operative or post- operative size of joint depression depth in patients with Schatzker type II tibial plateau fractures was associated with poor outcomes, more pain, and malalignment. A higher surface area of joint depression was associated with a lower clinical outcome score and more pain.

Influence of articular step-off on contact mechanics in fractures of the posterolateral-central tibial plateau - a biomechanical study

BACKGROUND

The posterior quadrants of the tibial plateau are frequently involved in OTA type C tibial plateau fractures. The biomechanical influence of a residual articular step-off of the posterolateral-central (PLC) segment, which is difficult to visualize intraoperatively, remains unclear. Therefore, aim of this study was to investigate the contact area and stress of the tibial plateau in cases of different articular step-offs of the PLC segment.

METHODS

Seven human cadaveric knees were used to simulate articular impressions of the PLC segment with step-offs of 1 mm, 3 mm, and 5 mm. The knees were axially loaded up to 150 N during a total of 25 dynamic cycles of knee flexion up to 90°. Pressure mapping sensors were inserted into the medial and lateral joint compartments beneath the menisci to measure articular contact area and stress.

RESULTS

Between 60° and 90° of knee flexion, increasing PLC segment impressions of the tibial plateau led to increasing contact stress and a significantly reduced contact area. The largest decrease in the contact area was 30 %, with an articular step-off of 5 mm (0.003). An increase in contact stress, especially from a 3-mm step-off, was measured, with a doubling of the mean contact stress at 3-mm and 5-mm step-offs and 90° knee flexion (p = 0.06/0.05).

CONCLUSION

From a biomechanical point of view, posterior impressions of the PLC segment greater than a 1-mm step-off should be addressed as anatomically as possible, especially in active patients with the need for higher knee flexion angles.

Area of the plateau depression and higher age predict post-operative subsidence in split-depression lateral tibial fracture

INTRODUCTION

The aim of this study was to determine factors that affect post-operative subsidence in split-depression lateral plateau tibial fracture (OTA/AO 41B3.1) which was treated with raft construct through a locking plate.

PATIENTS AND METHODS

The retrospective study evaluated all split-depression lateral plateau tibial fracture cases treated with raft construct through a locking plate between 01/2015 and 04/2020 with a minimum of 12-month follow-up. Data on the patients' age, sex, time from injury to surgery, type of plate, and use of subchondral bone defect filler were retrieved from the hospital database. The measurements of total plateau area (TPA), depressed lateral plateau area (DPA), and maximal plateau depression (MPD) were performed on the patients' pre-operative CT scans. The percentage of DPA to TPA (%DPA) was calculated. Post-operative radiographs were used for the evaluation of plateau subsidence. A subsidence greater than 2 mm was considered a failure.

RESULTS

There were 41 consecutive cases of split-depression lateral plateau tibial fracture in the reviewed period. Five cases were excluded, three of them were lost to follow up, 1 patient had no pre-operative CT scan and 1 had a history of cancer. A failure was identified in 11 (31%) cases. Patients in the failure group were older (61.0 vs 50.7 years, p = 0.01), and had a higher incidence of fractures extending into intercondylar eminence (100% vs 56%, p = 0.02). Multiple logistic regression identified DPA (OR = 3.6; 95%CI 1.4-9.5, p < 0.01) and age (OR = 1.2; 95% CI 1.0-1.4, p = 0.02) as predictive factors for plateau subsidence. DPA cut-off value for predicting subsidence greater than 2 mm was 5.8 cm² [Area Under the ROC Curve 0.89 (95% CI 0.74-0.97), sensitivity 91%, specificity 80%, p < 0.01)].

CONCLUSION

Age and depressed lateral plateau area (DPA) in split-depression lateral plateau tibial fracture treated with raft construct through a locking plate are risk factors for post-operative subsidence greater than 2 mm.

Anterolateral versus modified posterolateral approach for tibial plateau fractures with involvement of the posterior column: a cadaveric study

INTRODUCTION

The aim of this study was to compare the reduction quality of the anterolateral (AL) and modified posterolateral approach (PL) in lateral tibial plateau fractures involving the posterior column and central segments.

METHODS

Matched pairs of pre-fractured cadaveric tibial plateau fractures were treated by either AL approach (supine position) or PL approach (prone position). Reduction was controlled by fluoroscopy and evaluated as satisfying or unacceptable. Afterwards, the reduction was examined by 3D scan.

RESULTS

10 specimens (3 pairs 41B3.1, 2 pairs 41C3.3) were evaluated. PL approach achieved significantly (p 0.00472) better fracture reduction results (0.4 ± 0.7 mm) of the posterior column compared to the AL group (2.1 ± 1.4 mm). Fracture steps involving the central area of the lateral plateau were insufficiently reduced after fluoroscopy using both approaches.

CONCLUSION

Optimal reduction of displaced tibial plateau fractures involving the posterolateral column necessitates a posterior approach, which can be conducted in prone or lateral positioning. The anterolateral approach is indicated in fractures with minor displacement of the posterolateral rim but fracture extension in the latero-central segments. In these cases, an additional video-assisted reduction or extended approaches are helpful.

Nanoscopy and an extended lateral approach can improve the management of latero-central segments in tibial plateau fractures: a cadaveric study

Introduction

The objective of this investigation was to compare different techniques to improve visualization and reduction in tibial plateau fractures involving the central lateral segments.

Methods

Matched pairs of pre-fractured cadaveric tibial plateau fractures that include the central lateral segments were treated by either an anterolateral approach (supine) or PL approach (prone). Reduction was stepwise extended by additional fracturoscopy (FS), nanoscopy (NS) and lastly by epicondyle osteotomy (ECO). Reduction was analyzed by 3D scan and visualization of the lateral plateau was quantified.

Results

Ten specimens (3 pairs 41B3.1, 2 pairs 41C3.3) were analyzed. Fracture steps involving the antero-latero-central (ALC) segment were insufficiently reduced after fluoroscopy using both approaches (AL 2.2 ± 1.2 mm vs PL 2.2 ± 1.0 mm, p 0.95). Additional NS and ECO achieved optimized fracture reduction in the ALC segment (NS AL 1.6 ± 1.3 mm vs PL 0.8 ± 0.9 mm, p 0.32). NS provided visualization of the entire lateral plateau (PL 102.9% ± 7.4, AL 108.8 ± 19.2%), while fracturoscopy only allowed visualization of the ALL segment and partially of PLL and ALC segments (PL 22.0 ± 23.4%, AL 29.7 ± 18.3%).

Conclusion

Optimized reduction of tibial head fractures with involvement of latero-central segments requires additional video-assisted reduction or extended approaches. Nanoscopy helps visualizing of the entire lateral plateau, when compared to fracturoscopy and may become a valuable reduction aid.

A review of Risk Factors for Post-traumatic hip and knee osteoarthritis following musculoskeletal injuries other than anterior cruciate ligament rupture

Post-traumatic osteoarthritis (PTOA) is a common form of osteoarthritis that might occur after any joint trauma. Most PTOA publications mainly focus on anterior cruciate ligament (ACL) injuries. However, many other traumatic injuries are associated with PTOA, not only for the knee but also for the hip joint. We aim to identify and summarize the existing literature on the musculoskeletal injuries associated with knee and hip PTOA and their risk factors in determining those with a worse prognosis, excluding ACL injuries. Despite the narrative nature of this review, a systematic search for published studies in the last twenty years regarding the most relevant injuries associated with a higher risk of PTOA and associated risk factors for OA was conducted. This review identified the six more relevant injuries associated with knee or hip PTOA. We describe the incidence, risk factors for the injury and risk factors for PTOA of each. Meniscal injury, proximal tibial fracture, patellar dislocation, acetabular, femoral fractures and hip dislocations are all discussed in this review.

Feasibility of the modified inverted L-shaped approach for posterolateral tibial plateau fracture: A retrospective study

Approaches for treating posterolateral tibial plateau fractures vary among surgeons, and the inverted L-shaped approach is a known option. This article aims to introduce a new modified posterolateral inverted L-shaped approach for isolated posterolateral tibial plateau fractures and study its feasibility. Medical records of patients with posterolateral tibial plateau fractures were reviewed. Plain radiographs were obtained during the follow-up period, and the hospital for special surgery (HSS) score was used to assess the function of the injured limb. Perioperative complications were recorded and followed-up. In total, 32 patients with posterolateral tibial plateau fractures were treated using a modified posterolateral approach. The mean age of the patients was 44 ± 11 years (28-64 years). All patients successfully underwent surgery and were followed-up for a mean duration of 13 ± 2 months (10-16 months). On plain radiographs, fracture lines were fuzzy 3 months after surgery and disappeared 12 months after surgery. No perioperative complications occurred during the follow-up period. The HSS score was evaluated 12 months after surgery, and the mean score was 91 ± 5 points (81-97 points), including 25 excellent cases and 7 good cases. The modified posterolateral inverted L-shaped approach has the advantages of small soft tissue dissection, fracture reduction under direct vision, easy internal fixation, and a lower risk of neurovascular injury. This approach is feasible for the treatment of isolated posterolateral tibial plateau fractures, and further high-quality randomized control trials are required to confirm its clinical efficacy.

Comparison of tibial plateau fracture surgical outcomes between young and elderly patients: are outcomes really poorer in the elderly?

INTRODUCTION

Several studies have reported that total knee arthroplasty (TKA) is a suitable solution to treat elderly patients with complex tibial plateau fractures. The purpose of the present study was to compare surgical treatment outcomes after open reduction internal fixation (ORIF) between elderly and younger patients.

MATERIALS AND METHODS

We reviewed patients with plateau fracture (OTA/AO classification types 41B and 41C) who underwent ORIF at two academic trauma centers between November 2006 and October 2019. Of the 341 patients, 76 were ultimately included in the younger group (< 60 years old) and 77 in the elderly group (≥ 60 years). The average follow-up was 24 months (range 12-96 months). The primary outcome was any common complication of plateau fracture, namely post-traumatic arthritis and alignment change. Conversion to TKA, Reduction loss, coronal malalignment, non-union, union time, infection, and limb length discrepancy (LLD) were also assessed.

RESULTS

The elderly group had a significantly higher prevalence of diabetes, but there were no other significant differences between the groups in terms of patient demographics, fracture characteristics, and operation characteristics. We detected no differences between the groups in terms of post-traumatic arthritis (p = 0.216), alignment change (p = 0.093), conversion to TKA (p = 0.681), reduction loss (p = 0.079), coronal malalignment (p = 0.484), non-union rate (p = 0.719), infection (p = 0.063), LLD (p = 0.154), or time to union (p = 0.513). Logistic regression analysis revealed that age > 60 years was not associated with treatment failure, defined as either post-traumatic arthritis greater than grade II or non-union (p = 0.468). OTA/AO classification type 41C2 (p = 0.019), type 41C3 (p = 0.008), and malreduction (p = 0.050) were significant risk factors for failure.

CONCLUSION

Age ≥ 60 years is not an independent risk factor of poor radiographic outcome and high complication rate in tibial plateau fractures. This indicates that ORIF is still a good solution to treat elderly patients, similar to their younger counterparts.

Treatment of tibial plateau fractures: A comparison of two different operation strategies with medium-term follow up

Background

The objective of this study was to compare the clinical and radiological outcomes of two surgical methods for tibial plateau fractures (TPFs): minimally invasive surgery (MIS) using a double reverse traction repositor and traditional open reduction internal fixation (ORIF).

Methods

From our prospectively collated database, 187 consecutive adult patients with 189 operatively treated TPFs in our level I trauma center were included from January 2015 to March 2018 who had a minimum of three years’ follow-up. All cases were performed by the senior surgeon using either MIS (group 1, 84 patients with 84 TPFs) or ORIF (group 2, 103 patients with 105 TPFs). Details of the demographics, injury mechanism, pre- and postoperative follow-up imaging, operative procedures and complications were collected. The final results from the 36-Item Short-Form Health Survey (SF-36), Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) and Hospital for Special Surgery (HSS) were obtained at the final follow-up.

Results

Clinically, significant differences were observed in the WOMAC (pain, P ​= ​0.001; stiffness, P ​< ​0.001), HSS (P ​= ​0.003) and SF-36 (P ​= ​0.001). Radiologically, significant intergroup differences were observed in the loss of immediate postoperative reduction rates, secondary loss of reduction rates and signs of osteoarthritis (Kellgren–Lawrence). Two and ten superficial infections in group 1 (2.4%) and group 2 (9.5%), respectively, and 6 lateral popliteal nerve palsy cases occurred (0 MIS, 6 ORIF), with significant intergroup differences.

Conclusion

Our study shows that the MIS using a double reverse traction repositor is promising and safe technique for the TPFs when used for the correct indications.

The translational potential of this article

The current status of using a minimally invasive surgery for the treatment of TPFs have been analyzed and a new method of using a double reverse traction repositor for the treatment of TPFs have been proposed in this study, which updated treatment concept of TPFs.

Percutaneous surgery with balloon for tibial plateau fractures, results with a minimum of 5 years of follow-up

Tibial plateau fracture is a frequent entity for which surgical management is difficult both surgically and postoperatively, with multiple complications and often delayed recovery. The challenge lies in the anatomical reduction of the joint, the limitation of complications and the rapid functional recovery. Tuberoplasty appears to be an innovative technique that meets current expectations. The objective is to evaluate the reliability of tuberoplasty in reducing surgical risks and improving postoperative clinical results. This single-centre retrospective study included 30 patients with depressed tibial plateau fractures who underwent tuberoplasty from September 2011 to March 2014. Reduction analysis was performed by comparing pre-operative and post-operative depression from computed tomography (CT) data. Clinical outcomes were assessed by measuring flexion joint ranges, time to weight-bearing, KOOS questionnaire and a pangonogram. The mean depression was 7.4mm pre-operatively and 2.6mm [0;9] post-operatively, with 47% (14/30) having a residual depression of 2mm or less. Mean flexion at 6 weeks was 103° [30; 130]. Partial and total weight-bearing were allowed on day 47 [3; 150] and day 58 [20; 150], respectively. The mean KOOS score was 25.43 [1.15; 62.30] at a minimum of 5 years after surgery and the mean axis was 176.54° [172; 180]. There was one case of thrombophlebitis and one sensory-motor deficit in the common fibular nerve territory. The reduction of the tibial plateau observed in our study from tuberoplasty is in line with the literature results obtained from a conventional approach. Our results indicate that tuberoplasty is stable in the long term, has good functional results and early recovery with few complications. This preliminary study presents results that need to be investigated in a prospective randomised double-blind study.

Does 3D-assisted surgery of tibial plateau fractures improve surgical and patient outcome? A systematic review of 1074 patients

PURPOSE

The aim of this systematic review was to provide an overview of current applications of 3D technologies in surgical management of tibial plateau fractures and to assess whether 3D-assisted surgery results in improved clinical outcome as compared to surgery based on conventional imaging modalities.

METHODS

A literature search was performed in Pubmed and Embase for articles reporting on the use of 3D techniques in operative management of tibial plateau fractures. This systematic review was performed in concordance with the PRISMA-guidelines. Methodological quality and risk of bias was assessed according to the guidelines of the McMaster Critical Appraisal. Differences in terms of operation time, blood loss, fluoroscopy frequency, intra-operative revision rates and patient-reported outcomes between 3D-assisted and conventional surgery were assessed. Data were pooled using the inverse variance weighting method in RevMan.

RESULTS

Twenty articles evaluating 948 patients treated with 3D-assisted surgery and 126 patients with conventional surgery were included. Five different concepts of 3D-assisted surgery were identified: '3D virtual visualization', '3D printed hand-held fracture models', 'Pre-contouring of osteosynthesis plates', '3D printed surgical guides', and 'Intra-operative 3D imaging'. 3D-assisted surgery resulted in reduced operation time (104.7 vs. 126.4 min; P < 0.01), less blood loss (241 ml vs. 306 ml; P < 0.01), decreased frequency of fluoroscopy (5.8 vs. 9.1 times; P < 0.01). No differences in functional outcome was found (Hospital for Special Surgery Knee-Rating Scale: 88.6 vs. 82.8; P = 0.23).

CONCLUSIONS

Five concepts of 3D-assisted surgical management of tibial plateau fractures emerged over the last decade. These include 3D virtual fracture visualization, 3D-printed hand-held fracture models for surgical planning, 3D-printed models for pre-contouring of osteosynthesis plates, 3D-printed surgical guides, and intra-operative 3D imaging. 3D-assisted surgery may have a positive effect on operation time, blood loss, and fluoroscopy frequency.

Comparison Between Treatment of Bicondylar Tibial Plateau Fractures With or Without Posterolateral Fragments Using Posteromedial and Anterolateral Approaches

BACKGROUND

The best surgical approach for treating posterolateral fragments in tibial plateau fractures remains controversial. This study compared the radiological and functional outcomes of bicondylar tibial plateau fractures, with or without posterolateral fragments, treated using the same posteromedial and anterolateral approaches.

METHODS

Twenty-six patients with 27 bicondylar tibial plateau fractures were surgically treated between June 2006 and February 2020. The patients were divided into two groups: with posterolateral fragments (PL group) and without posterolateral fragments (non-PL group). All patients were treated with the combined posteromedial and anterolateral approach. Knee function was assessed using the Lysholm score and by measuring the range of motion (ROM). Fracture reduction was assessed using Rasmussen radiological scores.

RESULTS

Fifteen bicondylar fractures were classified in the PL group and 12 in the non-PL group. No significant difference was found in the ROM and Lysholm scores between the groups. No significant difference was noted in Rasmussen radiological scores between the groups.

CONCLUSION

Using the combined posteromedial and anterolateral approach, bicondylar tibial plateau fractures with posterolateral fragments achieved reasonable functional and radiological outcomes compared to those without a posterolateral fragment. This combined approach enabled an adequate visualization and reduction of posterolateral fragments. These standard approaches may be adequate for most bicondylar tibial plateau fractures with posterolateral fragments.

Two-level fixation with headless compression screws for tibial plateau fractures

PURPOSE

Reduction and fixation of tibial plateau fractures associated with small, "floating" intra-articular fragments proposes a challenge. We use fully threaded headless compression screws for (interfragmentary) fixation of such fragments before final plate fixation when standard fixation of intra-articular fragments with k-wires or lag screws is deemed insufficient. Our aim is to describe our technique and clinical experience of this two-level fixation.

METHODS

Between 2006 and 2021, 29 patients with a comminuted tibial plateau fracture were treated with this two-level fixation in this retrospective case series. Clinical baseline and surgical variables were collected for all patients. Clinical outcome variables were available for 28 patients with a median follow-up of 16.5 months (IQR 5-24). Functional outcomes were measured with the Knee Injury and Osteoarthritis Outcome Score (KOOS) and reported by 22 patients at a median of 5.2 years (IQR 3.5-9.8).

RESULTS

Reduction was anatomic or good in 82% of cases, fair in 14%, and a malreduction in 4%. Arthrosis was graded as grade 0 in 25% of cases, 1 in 39%, 2 in 21%, and 3 in 14%. Flexion was 110 degrees (IQR 100-130). Five patients had an extension deficit of 5 to 10 degrees. Median KOOS for symptoms and stiffness was 69 points (IQR 45-78), for pain 71 (IQR 45-88), for ADL 85 (IQR 52-95), for sports 30 (IQR 11-55), and for quality of life 34 (IQR 19-56).

CONCLUSION

The use of fully threaded headless compression screws is a simple and helpful addition in the treatment of comminuted tibial plateau fractures.

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.

Risk of total knee replacement after proximal tibia fracture: a register-based study of 7,841 patients

Background and purpose - Post-traumatic knee osteoarthritis following proximal tibia fracture (PTF) is a common complication that may lead to total knee replacement as secondary treatment (TKRS). We determined the risk of TKRS following PTF, whether treated nonoperatively or operatively, and compared the results with a 38-fold control group without prior PTF. Patients and methods - We identified all patients over 18 years of age in Finland with PTF treated during the period 2009-2018 from the Finnish Hospital Discharge Register (FHDR) and Finnish Arthroplasty Register (FAR). Age, sex, treatment method, follow-up time, and possible TKRS were recorded. Results - 7,701 patients were treated for PTF during the period 2009-2018. Over the 5.1-year (SD 3.1) follow-up, TKRS was performed in 340 (4.3%) patients with a prior PTF after a mean of 2.1 (SD 2.0) years post-fracture. TKRS was needed in 138 (3.7%, HR 1.8) patients in the nonoperatively treated group and in 202 (5.0%, HR 3.2) patients in the operatively treated group. Operative treatment, female sex, and high age were identified as risk factors for TKRS. The incidence of TKRS was highest during the first 2 years after fracture and remained elevated throughout the follow-up. Interpretation - Patients with a prior PTF had a 1.8- to 3.2-fold higher risk of TKRS compared with controls during the first 5 years post-fracture. Risk of TKRS was associated with an operatively treated PTF, female sex, and high age. The patients in the operative group likely sustained more complex fractures, while female sex and age may be explained by more osteoporotic bone quality.

Lateral femoral notch sign and posterolateral tibial plateau fractures and their associated injuries in the setting of an anterior cruciate ligament rupture

INTRODUCTION

ACL injury is one of the most common injuries of the knee joint in sports. As accompanying osseous injuries of the ACL rupture a femoral impression the so-called lateral femoral notch sign and a posterolateral fracture of the tibial plateau are described. However, frequency, concomitant ligament injuries and when and how to treat these combined injuries are not clear. There is still a lack of understanding with which ligamentous concomitant injuries besides the anterior cruciate ligament injury these bony injuries are associated.

MATERIALS AND METHODS

One hundred fifteen MRI scans with proven anterior cruciate ligament rupture performed at our center were retrospectively evaluated for the presence of a meniscus, collateral ligament injury, a femoral impression, or a posterolateral impression fracture. Femoral impressions were described according to their local appearance and posterolateral tibial plateau fractures were described using the classification of Menzdorf et al. RESULTS: In 29 cases a significant impression in the lateral femoral condyle was detected. There was a significantly increased number of lateral meniscal (41.4% vs. 18.6% p = 0.023) and medial ligament (41.4% vs. 22.1%; p = 0.040) injuries in the group with a lateral femoral notch sign. 104 patients showed a posterolateral bone bruise or fracture of the tibial plateau. Seven of these required an intervention according to Menzdorf et al. In the group of anterior cruciate ligament injuries with posterolateral tibial plateau fracture significantly more lateral meniscus injuries were seen (p = 0.039).

CONCLUSION

In the preoperative planning of ACL rupture accompanied with a positive femoral notch sign, attention should be paid to possible medial collateral ligament and lateral meniscus injuries. As these are more likely to occur together. A posterolateral impression fracture of the tibial plateau is associated with an increased likelihood of the presence of a lateral meniscal injury. This must be considered in surgical therapy and planning and may be the indication for necessary early surgical treatment.

Complex Tibial Plateau Fractures Treated with a Hybrid External Fixator – Long Term Results

Introduction: High energy tibial plateau fractures represent a challenge because of the combined bone and soft tissue injury. The iatrogenic impact can further increase the likelihood for crippling complications. Less invasive treatment protocols have been developed to improve the results.

Objective: We present the long-term results of limited internal fixation combined with a small wire external fixator.

Patients and Methods: Fourteen patients were followed for at least 10 years. Initial and final functional results, complications and presence of joint degeneration were registered according to validated rating scores.

Results: Of all patients included in the study, thirteen showed an excellent initial rating and one had an average result at baseline. 10 years later, eight patients still showed excellent grading results, four – good ones, one – average and one – poor results. Ten knees (71%) had osteoarthritis. Postphlebitic syndrome was diagnosed in two cases. Three knees showed medio-lateral instability, one showed a varus and one – a valgus deformity. Knee arthroplasty was performed in one case.

Conclusion: The limited internal fixation combined with a hybrid ex fix can be considered as an alternative to the ORIF, especially when the soft tissues are severely compromised. Despite the inevitable joint degeneration, the associated overall morbidity is low and the long term function is quite satisfactory.

Importance of CT Scan in Predicting the Outcomes of Tibial Plateau Fractures: A Retrospective Study of 216 Patients over 10 Years' Time

BACKGROUND

The primary aim of this retrospective study was to assess the postoperative clinical, functional, and radiographic outcomes of patients with closed tibial plateau fractures (TPFs) surgically treated with proximal tibial locking compression plate (LCP) system with a focus on the use of preoperative CT scan.

METHODS

Two hundred and sixteen patients with TPFs who underwent surgical treatment in our department between January 2010 and December 2019 were enrolled in this study. Ninety-five patients of 216 (44.0%) had preoperative CT examination in addition to plain radiographs to better evaluate the pattern of fracture and displacement of fragments. Clinical and functional outcomes were assessed using VAS, SF-36, Knee Society Score (KSS) and WOMAC score. Radiographic outcomes were evaluated according to the Kellgreen- Lawrence classification of the pre- and postoperative grades of valgus knee, articular displacement and gonarthrosis.

RESULTS

Patients with preoperative CT showed better clinical results than the X-ray group for the VAS, KSS, WOMAC and SF-36 score. Moreover, we found that the X-ray group had worse results than the CT group in the rate of varus-valgus alignment and step-off worsening, while the posterior tibial slope showed no significant changes between the two groups at the final follow-up. Finally, the group of patients who received preoperative CT scans displayed a better immediate postoperative reduction and less long-term arthritis.

CONCLUSION

CT has proved to be a good examination in preoperative planning of TPFs: it can influence postoperative results thanks to an improvement in the surgical approach, a better evaluation of the morphology of fracture lines and the involvement of the Luo's three columns in axial CT scans.

Initial displacement of the intra-articular surface after articular fracture correlates with PTA in C57BL/6 mice but not "superhealer" MRL/MpJ mice

Posttraumatic arthritis (PTA) occurs commonly after articular fracture and may arise, in part, from joint surface incongruity after injury. MRL/MpJ (MRL) "super-healer" mice are protected from PTA compared to C57BL/6 (B6) mice following articular fracture. However, the relationship between the initial displacement of the articular surface, biologic response, and susceptibility to PTA after fracture remains unclear. The objective of this study was to assess whether joint incongruity after articular fracture, as measured by in vivo micro-computed tomography (microCT), could predict pathomechanisms of PTA in mice. B6 and MRL mice (n = 12/strain) received a closed articular fracture (fx) of the left tibial plateau. Articular incongruity was quantified as bone surface deviations (BSD) for each in vivo microCT scan obtained from pre-fx to 8 weeks post-fx, followed by histologic assessment of arthritis. Serum concentrations of bone formation (PINP) and bone resorption (CTX-I) biomarkers were quantified longitudinally. Both strains showed increases in surface incongruity over time, as measured by increases in BSD. In B6 mice, acute surface incongruity was significantly correlated to the severity of PTA (R ²  = 0.988; p = .0006), but not in MRL mice (R ²  = 0.224; p = .220). PINP concentrations significantly decreased immediately post-fx in B6 mice (p = .023) but not in MRL mice, indicating higher bone synthesis in MRL mice. MRL/MpJ mice demonstrate a unique biologic response to articular fracture such that the observed articular bone surface displacement does not correlate with the severity of subsequent PTA. Clinical Relevance: Identifying therapies to enhance acute biologic repair following articular fracture may mitigate the risk of articular surface displacement for PTA.

Intraoperative 3D imaging in intraarticular tibial plateau fractures - Does it help to improve the patients' outcomes?

BACKGROUND

In tibial plateau fractures (TPF) the restoration of an anatomical joint surface as well as an exact subchondral screw position for postoperative stability is crucial for the outcome. The aim of this study was to determine whether the additional use of an intraoperative 3D imaging intensifier (3D) might help to improve the outcome of complex TPF.

METHODS

We performed a retrospective case-control study of a level 1 trauma center. Patients with AO/OTA 41 B3 and C-TPF operated on using a 3D imaging intensifier between November 2015 and December 2018 (3D group) were included. The outcomes of this patients were compared to patients operated without 3D imaging between January 2005 to December 2014 (2D group). The comparison of the groups was performed by matched pair analysis. The functional outcome of both groups was measured by KOOS and Lysholm Score after a follow-up period of at least 12 months. Operation time, infections and postoperative revisions were registered.

RESULTS

In total, 18 patients were included in the 3D group (mean age: 51.0± 16.4 years; 12 females) and an equal number of matching partners from the 2D group (mean age: 50.3± 15.2 years; 11 females) were found (p=0.82; p=0.79). We found 9x B3, 2x C1, 1x C2, 6x C3 fractures according to AO/OTA for each group (p=1.00) with comparable ASA score (p=0.27). The mean operation time was 127.9± 45.9 min and 116.1± 45.7 min for the 3D and 2D group (p=0.28). The mean follow-up time was 20.9± 10.7 months for the 3D and 55.5± 34.7 months for the 2D group (p< 0.001). For the 3D group a mean Lysholm overall score of 67.4± 26.8 and KOOS overall score of 72.6± 23.5 could be assessed. In contrast, a mean Lysholm overall score of 62.0± 21.4 and KOOS overall score of 65.8± 21.6 could be measured in the 2D group (p=0.39; p=0.31). Thereby, functional outcome of the 3D group showed a significant higher KOOS Sport/Rec sub score of 54.7± 35.0 in comparison to the 2D group with 26.7± 31.6 (p= 0.01). Postoperative revisions had to be performed in 27.8% of cases in both groups (p=1.00). Due to the 3D imaging an intraoperative revision was performed in 33.3% (6/18).

CONCLUSION

In our study we could show that re-reduction of the fracture or implant re-positioning were performed in relevant numbers based on the 3D imaging. This was associated with a midterm clinical benefit in regard to better KOOS Sport/Rec scores.

TRIAL REGISTRATION

AZ 488 /20-ek.

The concept of direct approach to lateral tibial plateau fractures and stepwise extension as needed

Malreduction after tibial plateau fractures mainly occurs due to insufficient visualization of the articular surface. In 85% of all C-type fractures an involvement of the posterolateral-central segment is observed, which is the main region of malreduction. The choice of the approach is determined (1) by the articular area which needs to be visualized and (2) the positioning of the fixation material. For simple lateral plateau fractures without involvement of the posterolateral-central segment an anterolateral standard approach in supine position with a lateral plating is the treatment of choice in most cases. For complex fractures the surgeon has to consider, that the articular surface of the lateral plateau only can be completely visualized by extended approaches in supine, lateral and prone position. Anterolateral and lateral plating can also be performed in supine, lateral and prone position. A direct fixation of the posterolateral-central segment by a plate or a screw from posterior can be only achieved in prone or lateral position, not supine. The posterolateral approach includes the use of two windows for direct visualization of the fracture. If visualization is insufficient the approach can be extended by lateral epicondylar osteotomy which allows exposure of at least 83% of the lateral articular surface. Additional central subluxation of the lateral meniscus allows to expose almost 100% of the articular surface. The concept of stepwise extension of the approach is helpful and should be individually performed as needed to achieve anatomic reduction and stable fixation of tibial plateau fractures.

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.

Clinical results after surgical treatment of posterolateral tibial plateau fractures ("apple bite fracture") in combination with ACL injuries

PURPOSE

The anterior cruciate ligament (ACL)-tear is a common injury in orthopaedic trauma. Depending on the energy of impact fractures of the posterolateral tibial plateau are often associated. Different morphologic variants of posterolateral tibial plateau impaction fractures have been described in the setting of an ACL-tear. Up to now an algorithm of treatment for a combined injury of a posterolateral tibial head fracture and an injury to the anterior cruciate ligament is missing.

METHODS

We present a retrospective study with clinical and radiological analysis of posterolateral fractures in combination with ACL-tear. Impressions with a depth of more than 2 mm and/or a width that outreaches more than half of the posterior horn of the lateral meniscus with additional 3. degree positive pivot-shift-test indicated surgical treatment of the fracture with additional ACL repair or reconstruction. Clinical evaluation included follow-up examination, Visual Analog Scale (VAS), International Knee Documentation Committee Score (IKDC), functional and radiological Rasmussen score.

RESULTS

20 patients were included with a mean age of 43.6 ± 12.4 years. Mean follow-up was 18,2 ± 13,5 months. The fracture was arthroscopically reduced and percutaneously fixed with a screw osteosynthesis (Group 1), reduced via a dorsal approach without (Group 2) or with an autologous bone graft (Group 3). Subjective IKDC score was 79,15 ± 6,07. Functional Rasmussen scores ranged from 27 to 30 (mean 28 ± 2.71). Radiological Rasmussen scores ranged from 16 to 18 points (mean 16.75 ± 1.33). According to IKDC score (p = 0.60), functional Rasmussen score (p = 0.829) and radiological Rasmussen score (p = 0.679) no significant discrepancy between the groups were seen. There was no failure of the ACL graft recorded.

CONCLUSIONS

Posterolateral tibial plateau fractures in combination with an ACL-tear, can cause persistent instability and increase rotational instability. Indication for treatment of these fractures is still under debate. From the biomechanical aspect the lack of more than 50% of the posterior horn of the lateral meniscus and dislocation/depression of more than 2 mm results in an increased rotational instability of the ACL deficient knee. Combined surgical treatment with ACL repair or reconstruction is a safe procedure that results in good, short-term clinical outcome, if our algorithm is followed. In addition this study shows, that majority of posterolateral tibial plateau fractures can be treated arthroscopically.

Extended approach to the lateral tibial plateau with central meniscal subluxation in fracture repair: feasibility and first clinical and radiographic results

Purpose

Anatomic reduction in tibial plateau fractures remains to be demanding. For further visualisation of and approach to the joint surface an extended lateral approach using a lateral femoral epicondyle osteotomy and subluxation of the lateral meniscus was recently described. First clinical and radiographic mid-term results of this technique are presented in this feasibility study.

Method

Ten complex tibial plateau fractures treated with extended lateral approach and lateral meniscal subluxation were prospectively analysed. Clinical and radiographic results were objectified according to the Rasmussen scores.

Results

After a median follow-up of 8.6 (IQR 4.3) months good to excellent clinical and radiographic results were noted. The clinical Rasmussen Score showed a median of 25 (IQR 2.8) and radiographic a median of 17 (IQR 2.0) points.

Conclusion

Good to excellent clinical and radiological scores were obtained after using an extended lateral approach with lateral femoral epicondyle osteotomy and central meniscus subluxation. No approach specific complications could be observed.

Electronic supplementary material

The online version of this article (10.1007/s00068-020-01467-1) contains supplementary material, which is available to authorized users.

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.

Outcomes of lateral unicompartmental knee arthroplasty in post-traumatic osteoarthritis, a retrospective comparative study

PURPOSE

We asked whether the clinical and radiographic outcomes and survivorship after unicompartmental knee arthroplasty (UKA) for osteoarthritis (OA) consequent to lateral tibial plateau fracture were comparable with those obtained after lateral UKA for primary OA.

METHODS

A total of 13 patients receiving lateral UKA for OA secondary to tibial plateau fracture (post-traumatic UKA, P-UKA) were compared with 13 patients who underwent lateral UKA for primary OA (OA-UKA). Patients were matched for age at surgery, gender, body mass index, and follow-up length. Pre- and post-operative clinical and radiographic assessments included clinical (KSS-c) and functional (KSS-f) Knee Society Score, Hip-Knee-Ankle (HKA) angle, and signs of osteolysis.

RESULTS

Mean follow-up was similar in both groups: 9.9 ± 4.6 years for P-UKA and 9.3 ± 2.4 years for OA-UKA. The two way ANOVA procedure followed by the Bonferroni multiple comparisons test highlighted a baseline difference in KSS-c with P-UKA having greater scores than OA-UKA (+ 12; p < 0.05) and both groups showed large improvements in KSS-c (p < 0.001), KSS-f (p < 0.001), and HKA angle (p < 0.001) at follow-up. The nine year prosthesis survival rate, tested by the Kaplan-Meier methods, was 92% in both groups.

CONCLUSION

Lateral UKA for OA secondary to tibial plateau fracture was efficient in restoring joint function, improving clinical results, and correcting lower limb alignment. Clinical outcomes and nine year survivorship did not differ from lateral UKA for primary OA. Consequently, lateral UKA should be considered a valid option in treating lateral posttraumatic OA in carefully selected patients.

TRIAL REGISTRATION NUMBER

( clinicaltrials.gov ) NCT04198389.

[Diagnostic imaging and classification of proximal femoral and tibia fractures in adults]

BACKGROUND

A confident diagnosis and classification of proximal femoral and tibia fractures are crucial to determine further therapeutic procedures.

MATERIALS AND METHODS

In this article the current standards regarding diagnostic imaging of proximal femoral and tibia fractures are presented and the different classification systems are discussed.

CONCLUSIONS

Plain radiography in two planes remains the initial investigation of choice for suspected osseous injury. While this is usually sufficient to determine further procedures for injuries of the proximal femur, cross-sectional imaging is normally necessary in the diagnosis of proximal tibia fractures.

Fate of the lateral femoral notch following early anterior cruciate ligament reconstruction

BACKGROUND

The goal of this longitudinal study was to investigate the fate of the lateral femoral notch (LFN), which is frequently seen as an impaction fracture of the lateral femoral condyle in patients with anterior cruciate ligament (ACL) tears.

METHODS

Patients who underwent early ACL reconstruction between 2006 and 2010 were reviewed. If post-injury magnetic resonance images showed an LFN greater than 1.5 mm in depth, patients with untreated LFN were followed. Two blinded observers performed quantitative and qualitative imaging analysis.

RESULTS

Sixteen patients (five women, 11 men) were available for follow-up nine years (six to 10 years) post-injury. The median defect area of the LFN significantly decreased from 2.3 cm² (range: 0.9-3.8 cm²) to 1.6 cm² (range: 0.4-3.2 cm²) (P < .001). The defect depth did not significantly change from 2.3 mm (range: 2.0-3.6 mm) to 2.5 mm (range: 1.3-3.6 mm) (P > .05). The International Cartilage Repair Society (ICRS) score increased from 1.5 (range: 0-3) post-injury to 2.0 (range: 0-4) at follow-up (P < .01). The Lysholm score was 93 (72-100), the Tegner activity level was 6 (3-9) and the knee injury and osteoarthritis outcome score (KOOS) score was 97 (91-100).

CONCLUSIONS

The defect area of the LFN decreased overtime, whereas the depth of the impression remained. Focal cartilage lesions were found in all except two patients post-injury and progressed during follow-up. However, patient-reported outcome scores were satisfying.

Presence of magnetic resonance imaging verified soft tissue injuries did not significantly affect the patient-reported outcome 12 months following a lateral tibial plateau fracture: A 12-month prospective cohort study of 56 patients

BACKGROUND

Soft tissue injuries following lateral tibial plateau fracture affect more than half of patients. Regardless of the type of soft tissue injured, it is still unclear how different treatment strategies influence postoperative outcome. The aim of this study was to report the 12-month Knee Injury and Osteoarthritis Outcome Score (KOOS₅) of patients with surgically managed lateral tibial plateau fractures divided into groups with and without conservatively managed magnetic resonance imaging (MRI)-verified soft tissue injuries.

METHODS

Prospective cohort study. Patients treated surgically following a lateral tibial plateau fracture (AO-41B) between December 2013 and November 2016 were included. Soft tissue injuries were evaluated with preoperative MRI scans. The primary outcome score was the 12-month KOOS₅ score divided into groups with and without soft tissue injuries.

RESULTS

A total of 56 patients were included. Average patient age was 56 years (range 22-86). Thirty-three patients (59%) were female. Fifty percent of patients presented with MRI-verified soft tissue injuries. At 12 months postoperatively, the mean KOOS₅ score for patients with soft tissue injuries was 53.5 (95% confidence interval (CI): 44.8-62.1) and the KOOS₅ score for patients without soft tissue injuries was 59.6 (95% CI: 50.7-68.6). No significant difference in the KOOS₅ score between patients with and without soft tissue injuries was observed (P = .31).

CONCLUSIONS

At 12-month follow-up the presence of MRI-verified soft tissue injuries did not significantly affect the patient-reported KOOS₅ score. More research is needed to investigate the effects of surgical vs. non-surgical treatment strategies of associated soft tissue injuries following lateral tibial plateau fractures.

Defining the "mediolateral widening of tibial plateau" as a guide for reduction in tibial plateau fractures: An Indian perspective

PURPOSE

The primary aim in fixation of the tibial plateau fractures is the restoration of normal anatomy. Evaluation of the widening of the tibial plateau, which has been linked with adverse long term outcomes, still needs precise markers for quantification. The purpose of this study is to analyze the normal limits of tibial plateau widening in the Indian population in relation to the distal femur in a standardized manner to provide important radiological parameters for the same.

METHODS

We retrospectively analyzed electronically archived true AP radiographs of uninjured normal knee joints during one year between 2018 and 2019. We measured the mediolateral width of the articular surface and extraarticular extent of the tibial plateau and compared them with the distal femoral articular and extra-articular extents. The measurements were compared between the male and female groups.

RESULTS

Tibial plateau articular width was found to be 4% wider in relation to the distal femoral articular surface. The medial articular rim of distal femur matches closely to the medial articular rim of the tibial plateau. The lateral articular rim of distal femur lies medial to the lateral articular rim of tibial plateau with a mean distance of 3.49 mm.

CONCLUSIONS

Owing to individual variations in bony extents around the knee, the differential extent of tibial plateau relative to distal femur would be a more reliable parameter than absolute measurements. Medially the articular extent of distal femur matches closely with the articular extent of tibial plateau while the lateral extra-articular extent of distal femur matches closely with the lateral tibial articular extent. Gender-based differences do not significantly affect these two parameters.

Challenging Surgical Treatment of Displaced Articular Tibial Plateau Fractures: Do Early Knee Radiographic Features Have a Predictive Value of the Mid-Term Clinical Functional Outcomes?

Objective

To evaluate mid‐term radiographic and functional outcomes of tibial plateau fracture (TPF) patients treated with the open reduction internal fixation (ORIF) technique and to find predictive factors of clinical outcomes.

Methods

A retrospective, single‐center study was performed enrolling a consecutive series of patients with diagnosis of TPF. All subjects were treated by ORIF between January 2010 and December 2015 at our level‐1 healthcare trauma center. The inclusion criteria were: age between 18 and 75 years; ORIF technique used for articular TPF, type 41‐B and 41‐C, isolated or with associated injuries. The patients were divided in two groups, according to fracture patterns and compared. Their characteristics, radiographic and clinical outcomes were recorded. Radiographs 12 months after surgery were evaluated for reduction and alignment, and radiographs at 24 months to describe post‐traumatic osteoarthritis (PTOA). Functional outcomes were assessed using the visual analog scale (VAS), the Short Form 36 (SF‐36), the knee injury and osteoarthritis outcome score (KOOS), and the American Knee Society score (AKSS) questionnaires. Return to work and sport activities were also investigated. Univariate and multivariate analysis were performed, and the statistical significance was defined as two‐tailed P < 0.05.

Results

Forty‐five patients were included, 29 males and 16 females; the mean age was 54.5 years. The mean follow‐up was 57.18 months (range, 26–94). There were AO 41‐B fractures (partial articular fractures) in more than half of the patients (66.67%), while the remaining 15 had AO 41‐C fractures (complete articular fractures). The sub‐type AO 41‐B3 was the most common, reported in 62.22% of patients. The mean KOOS score was 69.0. Mean AKSS and SF‐36 PCS scores were 79.0 and 41.4, respectively. There were significant relationships between age and functional results (KOOS ADL, Sport, QoL, and SF‐36 PCS) and between BMI and KOOS Pain, ADL, Sport, and QoL. No differences were found between the two types of fractures regarding quality of reduction and alignment. AO 41‐C TPF tend to develop PTOA more frequently with respect to 41‐B fractures, while type AO 41‐C TPF had the worst clinical outcomes. We found that the presence of an articular step‐off and the malalignment of the tibial axis after surgery were predictive of daily pain felt by patients. PTOA was predictive of a worse AKSS. The overall complication rate was 13.33%: 1 superficial wound infection, 1 deep vein thrombosis, and 4 cases of transitory deficit of the common peroneal nerve.

Conclusion

The present study demonstrates that early radiographic features may be predictive for pain perceived by patients at mid‐term follow‐up.

Upregulation of microRNA-9-5p inhibits apoptosis of chondrocytes through downregulating Tnc in mice with osteoarthritis following tibial plateau fracture

Osteoarthritis (OA) is a common degenerative joint disease which is typically progressed with age, affecting smaller joints of hands, lower limbs, and the vertebral column. It has been reported that microRNAs could regulate the biological processes of OA. Therefore, the purpose of this study was to elucidate miR-9-5p's role in regulating cartilage remodeling of OA mice following tibial plateau fracture (TPF) through regulation of tenascin C (Tnc). Initially, we determined the expression of miR-9-5p and Tnc in mice with OA and then testified their relationship. The results displayed a high expression of Tnc, but a poor expression of miR-9-5p with high methylation in OA. Tnc was confirmed to be a target gene of miR-9-5p. Moreover, based on gain- and loss-function experiments, an increase of miR-9-5p and loss of Tnc had the potential to inhibit cell apoptosis, while facilitating cell proliferation, migration, invasion, and cartilage remodeling of mice with OA following TPF. This was further demonstrated by a higher expression of type II collagen, lower type X collagen, and protogenin expression. Subsequently, downregulation of miR-9-5p aggravated the pathological changes of mice, illustrated by an increase in the Mankin score. In conclusion, the present study proved that overexpression of miR-9-5p suppressed chondrocytes apoptosis and promoted cartilage remodeling through downregulating of Tnc in mice with OA.

Tibial plateau fractures are associated with a long-lasting increased risk of total knee arthroplasty a matched cohort study of 7,950 tibial plateau fractures

OBJECTIVE

This study aims to investigate the risk of total knee replacement (TKR) following tibia plateau fractures. Secondary the study aims to investigate the risk of knee arthroscopy following tibial plateau fractures.

METHOD

The study was designed as a matched cohort study. All patients who sustained a tibial plateau fracture in Denmark between January 1, 1996, and December 31, 2000, were included and followed until December 31, 2015. For each patient with a tibial plateau fracture, 10 matched citizens without a tibial plateau fracture were included as a reference group.

RESULTS

7,950 patients sustained a tibial plateau fracture in Denmark during the study period. The median age of patients was 52.6 (IQR: 32.4-71.5) years. The mean observational period was 13.9 years. 5.7% were treated with a TKR (N = 452), and 2.0% of patients from the reference group were treated with a TKR (N = 1,623). Patients with a tibial plateau fracture had a 3.5 (95%CI: 3.1-3.9) times higher hazard ratio (HR) compared to patients from the reference group. 7.6% of patients with a tibial plateau fracture were treated with a secondary knee arthroscopy (N = 603) and 2.0% of patients from the reference group were treated with a knee arthroscopy (N = 1,565). Patients with a tibial plateau fracture presented with a 5.0 (95%CI: 4.5-5.6)) times higher HR compared to patients in the reference group.

CONCLUSIONS

Tibial plateau fractures are associated with a 3.5 times increased risk of TKR compared with an age- and gender-matched reference group with a mean follow-up of 13.9 years.