CERAMENT treatment of fracture defects (CERTiFy): protocol for a prospective, multicenter, randomized study investigating the use of CERAMENT™ BONE VOID FILLER in tibial plateau fractures

Treatment of Spinal Aneurysmal Bone Cyst with Percutaneous Injection of Hydroxyapatite Osteoconductive Cement

PURPOSE

The aim of this study was to evaluate treatment efficacy of percutaneous injection of hydroxyapatite-osteoconductive-cement in patients with spinal aneurysmal bone cysts.

MATERIALS AND METHODS

The study was designed as a retrospective observational clinical study. We included patients who were diagnosed with of spinal aneurysmal bone cyst, at our institution between 2013 and 2020, and treated with percutaneous injection of osteoconductive cement: "Cerament"® (BONESUPPORT AB, Lund, Sweden). Typical clinical and radiological features of the ABCs treatment and follow-up were investigated.

RESULTS

Our study included nine patients, two children and seven adults. Three different types of approaches were applied: (single pedicle approach in 3 patients; double pedicle approach in 2 patients; while in the remaining cases, a multiple access approach was used. VAS score decreased from 8.5 ± 0.5 before treatment to 4.1 ± 0.9 at 6-months-follow up. All of the patients reacted well to treatment, with none neurological complications, complete loss of pain and achieved osteosclerosis as radiological marker of treatment success.

CONCLUSION

Treatment of symptomatic spinal ABC's with hydroxyapatite cement is effective to achieve complete pain reduction and sclerosis.

A Pre-clinical Standard Operating Procedure for Evaluating Orthobiologics in an In Vivo Rat Spinal Fusion Model

The rat animal model is a cost effective and reliable model used in spinal pre-clinical research. Complications from various surgical procedures in humans often arise that were based on these pre-clinical animal models. Therefore safe and efficacious pre-clinical animal models are needed to establish continuity into clinical trials. A Standard Operating Procedure (SOP) is a validated method that allows researchers to safely and carefully replicate previously successful surgical techniques. Thus, the aim of this study is to describe in detail the procedures involved in a common rat bilateral posterolateral intertransverse spinal fusion SOP used to test the efficacy and safety different orthobiologics using a collagen-soaked sponge as an orthobiologic carrier. Only two orthobiologics are currently FDA approved for spinal fusion surgery which include recombinant bone morphogenetic protein 2 (rhBMP-2), and I-FACTOR. While there are many additional orthobiologics currently being tested, one way to show their safety profile and gain FDA approval, is to use well established pre-clinical animal models. A preoperative, intraoperative, and postoperative surgical setup including specific anesthesia and euthanasia protocols are outlined. Furthermore, we describe different postoperative methods used to validate the spinal fusion SOP, which include μCT analysis, histopathology, biomechanical testing, and blood analysis. This SOP can help increase validity, transparency, efficacy, and reproducibly in future rat spinal fusion surgery procedures.

Bone Tissue Engineering in the Treatment of Bone Defects

Bones play an important role in maintaining exercise and protecting organs. Bone defect, as a common orthopedic disease in clinics, can cause tremendous damage with long treatment cycles. Therefore, the treatment of bone defect remains as one of the main challenges in clinical practice. Today, with increased incidence of bone disease in the aging population, demand for bone repair material is high. At present, the method of clinical treatment for bone defects including non-invasive therapy and invasive therapy. Surgical treatment is the most effective way to treat bone defects, such as using bone grafts, Masquelet technique, Ilizarov technique etc. In recent years, the rapid development of tissue engineering technology provides a new treatment strategy for bone repair. This review paper introduces the current situation and challenges of clinical treatment of bone defect repair in detail. The advantages and disadvantages of bone tissue engineering scaffolds are comprehensively discussed from the aspect of material, preparation technology, and function of bone tissue engineering scaffolds. This paper also summarizes the 3D printing technology based on computer technology, aiming at designing personalized artificial scaffolds that can accurately fit bone defects.

Radiological Analysis of Gentamicin Eluting Synthetic Bone Graft Substitute Used in the Management of Patients With Traumatic Bone Voids

Background

Management of traumatic bone voids has always been challenging. Gentamicin eluting synthetic bone graft substitute (Cerament-G) showed encouraging results in achieving good bone healing with a satisfactory degree of resorption when utilised as a void filler. This study aims to assess the radiological signs of Cerament-G remodelling when used for patients with traumatic bone voids.

Methods

Retrospective data analysis of all patients admitted to our unit between 2015 and 2021 with traumatic bone voids who had Cerament-G applied intraoperatively as a void filler. Postoperative radiographic images of the fracture site at six weeks, three months, six months, and at the final follow-up were reviewed. The radiological signs of Cerament-G integration, percent of void healing at the final follow-up were assessed.

Results

A total of 51 patients (52 fractures) were included in the study. Among them 10 were female and 41 were male with a mean age of 42.7 (11 - 90) years. The mean void size was 6.58 cm³. Mean follow-up duration was 9.73 months. Primary fracture union was achieved in 44 (86.3%) patients. Delayed union was reported in six (11.7%) patients, while one (1.9%) patient had non-union. Twenty-seven (52%) patients had >90% of void healing with normal trabecular bone. Twenty (38.5%) patients had 50-90% void healing with normal bone. Whereas only five (9.5%) patients had less than 50% of void healing.

Conclusion

Cerament-G used as a void filler for patients with traumatic bone void has resulted 98% fracture union rate with good signs of radiological remodelling into a trabecular bone. More than 50% void filling with new trabecular bone was reported in more than 90% of patients. Non-union was reported in only one patient.

Structural Bicortical Autologous Iliac Crest Bone Graft Combined with the Tunnel Bone Tamping Method for the Depressed Tibial Plateau Fractures

BACKGROUND

Clinically, autologous iliac crest bone grafts (ICBG) and bone tamping methods are often applied to manage depressed tibial plateau fractures (DTPFs). The purpose of this study was to describe and evaluate the technique of using structural bicortical autologous ICBG combined with the tunnel bone tamping method (TBTM) for treating DTPFs.

METHODS

All patients with DTPFs who underwent structural bicortical autologous ICBG combined with TBTM from January 2016 to February 2018 were prospectively analysed. Demographics, injury, surgery, postoperative complications, and clinical outcomes were recorded. All patients were followed up for more than 30 months. Postoperative radiography and CT were employed to assess fracture healing and the reduction quality.

RESULTS

Forty-three of the included patients completed the follow-up. No malreduction was observed. Based on the immediate postoperative imaging, the intra-articular step-off was significantly reduced (8.19 mm preoperatively vs. 1.30 mm immediate postoperatively, P < 0.001). From the immediate operation to the latest follow-up, the reduction was maintained significantly well, with a nonnegligible absolute difference (0.18 mm, P = 0.108). A remarkable secondary loss of reduction (intra-articular step off > 3 mm) was found in two elderly patients (2/43, 4.65%). The incidence of complications related to the bone-graft donor and bone-graft site was 2.33% and 4.65%, respectively. At the final follow-up, the mean Hospital for Special Surgery (HSS) score of the knee was 98.19 ± 2.89, and the mean 36-Item Short-Form Health Survey (SF-36) score was 95.65 ± 4.59.

CONCLUSION

Structural bicortical autologous ICBG combined with TBTM is radiologically effective and stable in terms of complications for the DTPFs.

Treatment of tibial plateau fractures with a novel fenestrated screw system for delivery of bone graft substitute

PURPOSE

The purpose of this study was to describe the incidence of subsidence in patients with AO/OTA 41 (tibial plateau) fractures which were repaired with a novel fenestrated screw system to used to deliver CaPO4 bone substitute material to fill the subchondral void and support the articular reduction.

METHODS

Patients with unicondylar and bicondylar tibial plateau fractures were treated according to the usual technique of two surgeons. After fixation, the Zimmer Biomet N-Force Fixation System®, a fenestrated screw that allows for the injection of bone substitute was placed and used for injection of the proprietary calcium phosphate bone graft substitute into the subchondral void. For all included patients, demographic information, operative data, radiographs, and clinic notes were reviewed. Patients were considered to have articular subsidence if one or more of two observations were made when comparing post-operative to their most recent clinic radiographs: > 2 mm change in the distance between the screw and the lowest point of the tibial plateau, > 2 mm change in the distance between the screw and the most superior aspect of the plate. Data were analyzed to determine if there were any identifiable risk factors for complication, reoperation, or subsidence using logistic regression. Statistical significance was set at p < 0.05.

RESULTS

34 patients were included with an average follow-up of 32.03 ± 22.52 weeks. There were no overall differences between height relative to the medial plateau or the plate. Two patients (5.9%) had articular subsidence. Six patients (15.2%) underwent reoperation, two (6%) for manipulations under anaesthesia due to arthrofibrosis, and four (12%) due to infections. There were 6 (19%) total infections as 2 were superficial and required solely antibiotics. One patient had early failure.

CONCLUSION

Use of a novel fenestrated screw system for the delivery of CaPO4 BSM results in articular subsidence and complication rates similar to previously published values and appears to be a viable option for addressing subchondral defects in tibial plateau fractures.

LEVEL OF EVIDENCE

IV.

Autologous Iliac Bone Graft Compared with Biphasic Hydroxyapatite and Calcium Sulfate Cement for the Treatment of Bone Defects in Tibial Plateau Fractures: A Prospective, Randomized, Open-Label, Multicenter Study

BACKGROUND

Bone-graft substitutes are commonly used for the augmentation of traumatic bone defects in tibial plateau fractures. However, their clinical performance compared with that of autologous bone-grafting, the gold standard in bone defect reconstruction, still remains under debate. This study investigates the differences in quality of life, pain, and radiographic outcomes in the treatment of tibial plateau fracture-associated bone defects with either autologous bone grafts or a bioresorbable hydroxyapatite and calcium sulfate cement (CERAMENT BONE VOID FILLER [CBVF]; BONESUPPORT).

METHODS

In this study, 135 patients with acute depression and split-depression fractures of the proximal part of the tibia (OTA/AO types 41-B2 and 41-B3) were enrolled in a prospective, controlled, randomized, multicenter trial including 20 hospitals in Germany. Patients were randomized to receive either autologous iliac bone graft or CBVF for reconstruction of the bone defect. The primary outcome measures were the Short Form (SF)-12 version 2 Physical Component Summary (PCS) score at week 26 (the study was designed to show noninferiority of the CBVF with regard to the PCS with a prespecified margin of -5 points) and the pain level at 26 weeks postoperatively measured by a visual analog scale (VAS). The secondary outcomes were the SF-12 version 2 Mental Component Summary (MCS) and SF-12 PCS scores at weeks 1, 6, and 12 and bone-healing on radiographs.

RESULTS

Age, sex, fixation methods, and fracture pattern were comparable in both groups. There were no significant differences (p > 0.05) in the SF-12 PCS or VAS scores at postoperative week 26. There was a significant reduction of blood loss (p = 0.007) and pain levels (p = 0.008) at postoperative day 1 in the CBVF group. The rates of fracture-healing, defect remodeling, and articular subsidence were not significantly different (p > 0.05) in both groups.

CONCLUSIONS

Bioresorbable CBVF was noninferior to autologous bone graft with regard to both patient-reported and radiographic outcomes in tibial plateau fractures of OTA/AO types 41-B2 and 41-B3.

LEVEL OF EVIDENCE

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

Effect of antibiotic infused calcium sulfate/hydroxyapatite (CAS/HA) insets on implant-associated osteitis in a femur fracture model in mice

Cerament (Bonesupport Holding, Lund, Sweden) is a bioresorbable synthetic bone substitute consisting of calcium sulfate and hydroxyapatite which is successfully used as a bone graft in bone defects or in delayed and non-unions after fractures. Besides, calcium sulfate/ hydroxyapatite (CAS/HA) could have, attributed to its composition and osteoinductive properties, have great importance in the treatment of bone infections with critical size defects (CSD). Aim of the study was to evaluate the effects of antibiotic infused CAS/HA on inflammation and bone healing in an implant-associated osteitis mice model. In a standardized murine model, the left femur of 72 BALB/c mice were osteotomized, generating a CSD (2,5 mm) with stabilization through a 6-hole titanium locking plate. Osteitis has been induced through inoculation of Staphylococcus aureus (SA) into the fracture gap. To analyze the effect of CAS/HA, following groups were generated with either CAS/HA, CAS/HA with gentamycin (CAS/ HA-G) or CAS/HA with vancomycin (CAS/HA-V) insets placed into the osteotomy. Debridément and lavages were progressed on day 7 and 42 to determine the local bacterial growth and the immune reaction. Fracture healing was quantified on day 7 and 42 by x-ray and bone healing markers from blood samples. Progression of infection was assessed by estimation of colony-forming units (CFU) and immune response was analyzed by determination of Interleukin (IL)– 6 and polymorphonuclear neutrophils (PMN) in lavage samples. Osteitis induced higher IL-6 and PMN-levels in the lavage samples on day 7. Both parameters showed a reduction in all groups on day 42. CAS/HA-V revealed a significant reduction of CFU and PMNs in lavage samples on day 42. A positive effect on bone healing could only be shown in non-infected mice. Whereas, application of mere CAS/HA in infected mice did show tendencies of bone destruction and lysis, independent of impregnation with antibiotics or not. Thus, application of CAS/HA in acute implant-associated infections is not recommended. In non-infectious environments or after infect-convalescence CAS/HA could albeit serve as a suggestive tool in trauma and orthopedic surgery.

Use of a biphasic cement bone substitute in the management of metaphyseal fractures

OBJECTIVES

In recent years, the increase in utilisation of bone substitutes in the reconstruction of bone defects has been fuelled by donor site complications associated with autologous bone harvesting. However the ability of bone substitute to stimulate bone union while maintaining fracture reduction has been a topic of debate. Cerament Bone Void Filler (CBVF) is a novel biphasic and injectable ceramic bone substitute that has high compressive strength and the ability to promote cancellous bone healing.

MATERIALS AND METHOD

This is a retrospective study to evaluate the surgical outcome of utilising CBVF in the treatment of depressed metaphyseal bone fractures over a two year period. The patients were followed up for at least six months after surgery and clinical parameters such as wound site complications were collated. Radiographic imaging was evaluated to determine loss of fracture reduction and rate of cement resorption.

RESULTS

Thirteen patients with depressed metaphyseal fractures were enrolled, which included: (i) one proximal humerus fracture; (ii) three tibial plateau fractures; and (iii) nine calcaneal fractures. None of the patients showed significant collapse in fracture reduction after six months of follow up. Cement resorption was noted in one patient as early as three weeks after surgery. There were no cases of cement leak or wound site complications.

CONCLUSION

Cerament Bone Void Filler (CBVF) is a promising bone graft substitute in the management of depressed metaphyseal bone fractures, with the ability to maintain fracture reduction despite cement resorption.

Preliminary Results of Highly Injectable Bi-Phasic Bone Substitute (CERAMENT) in the Treatment of Benign Bone Tumors and Tumor-like Lesions

Background: CERAMENT™|BONE VOID FILLER is an injectable and moldable ceramic bone substitute material intended for bone voids. The material consists of hydroxyapatite and calcium sulfate hemihydrate. The aim of this study is to present the first long-term results following open curettage of benign bone tumors and tumor-like lesions and void filling with this novel injectable and synthetic bone graft. Methods: Thirty three patients were enrolled into the study between June 2013 and October 2014 .Totally, we treated 24 women and 9 men with a median age of 47 years (range: 22-74). All patients suffered from primary musculoskeletal system disorders (enchondroma 63,6%, giant cell tumor 18%, aneurysmal bone cyst 9%, fibrous dysplasia 9%, Gaucher disease 3%). We performed curettage of pathological lesions, then the bone substitute was administered by means of needle to the void. Results: The average follow-up was 13 months (range: 2-13 months, median 10 months). No metastasis or recurrence had been detected. We received significant clinical improvement relating to VAS, MSTS, and oncological results. Conclusions: The results of our study report that CERAMENT can be successfully used as a bone substitute in patients with various bone diseases, as well as benign bone tumors. CERAMENT can provide an effective and long-term solution for reconstructive procedures following curettage of bone tumors and tumor like lesions.

Kirschner Wire and Bone Cement is a Viable Alternative to Reconstruction of Large Iliac Bone Defects After Strut Bone Graft Harvesting

STUDY DESIGN

A retrospective study.

OBJECTIVE

To assess the safety and efficacy of iliac crest defect reconstruction using Kirschner wire (K-wire)/polymethylmethacrylate (PMMA) versus traditional autologous rib graft reconstruction.

SUMMARY OF BACKGROUND DATA

The iliac crest has been the preferred donor site for strut bone graft for various spinal fusion surgeries.

METHODS

Seventy-three patients (44 males and 29 females; average age: 57.2 y) were divided into 2 groups: the rib group (35 patients) and the K-wire/PMMA group (38 patients). All operations involved anterior spinal interbody fusion. Patients were followed-up, on average, for 34.2 months using plain radiographs and both pain and cosmesis visual analog scales (VAS) to assess the clinical results after surgery.

RESULTS

Almost all patients had pain VAS scores of ≤1 and grade 1 cosmesis VAS scores with no significant difference between the 2 groups in terms of either pain or cosmesis (P=1.00 and 0.505, respectively). In addition, few complications were noted in both groups. Radiographic complications in the rib group and the K-wire group numbered 4 (11%) and 2 (5%), respectively; however, did not significantly differ between the 2 groups (P=0.418). One case required intraoperative revision of the length of the K-wire and 1 case needed reoperation for iliac ring fracture and K-wire migration. An additional case required revision due to a bad fall.

CONCLUSIONS

K-wire and bone cement reconstruction is an effective and safe alternative method for large iliac bone defect repair when autologous rib graft is not available.

The Use of Bone Graft Substitute in Hand Surgery: A Prospective Observational Study

Bone defects are a very common problem in hand surgery, occurring in bone tumor surgery, in complicated fractures, and in wrist surgery. Bone substitutes may be used instead of autologous bone graft to avoid donor site morbidity. In this article, we will review our experience with the use of Cerament bone void filler (Bonesupport, Lund, Sweden) in elective and trauma hand surgery. A prospective clinical study was conducted with 16 patients treated with this bone graft substitute in our department over a period of 3.5 years. Twelve patients (2 female, 10 male; with an average age of 42.42 years) with monostoic enchondroma of the phalanges were treated and 4 patients (1 female, 3 male; with an average age of 55.25 years) with complicated metacarpal fractures with bone defect. Data such as postoperative course with rating of pain, postoperative complications, functional outcome assessment at 1, 2, 3, 6 months, time to complete remodeling were registered. Postoperative redness and swelling after bone graft substitute use was noticed in 7 patients with enchondroma surgery due to the thin soft-tissue envelope of the fingers. Excellent total active motion of the involved digit was noticed in 10 of 12 enchondroma patients and in all 4 fracture patients at 2-month follow-up. In summary, satisfying results are described, making the use of injectable bone graft substitute in the surgical treatment of enchondromas, as well as in trauma hand surgery a good choice.

The use of calcium carbonate beads containing gentamicin in the second stage septic revision of total knee arthroplasty reduces reinfection rate

BACKGROUND

The aim of the study was to analyze effectiveness and safety of packing the medullary canal of the tibia and femur with Herafill (Heraeus Medical GmbH, Wehrheim, Germany), a void filler and antibiotic carrier, during second stage revision total knee arthroplasty (TKA) for periprosthetic joint infection (PJI).

METHODS

Two groups were formed of 28 consecutive patients during second stage revision TKA, comparable for gender and age. The study group received Herafill, while the control group did not. The average follow-up was 52 months (minimum 36 months).

RESULTS

No reinfections were observed in the study group, while five were seen in the control group. No other differences were observed between the study and control groups, including mean clinical KSS (Knee Society score) (67.4 and 68.4 points, respectively) and functional score (72.5 and 70.5 points respectively). No side effects related to the use of Herafill beads were noted.

CONCLUSIONS

Herafill packed into the tibial and femoral intramedullary canal during second stage of septic revision TKA is a reliable bone substitute, may reduce recurrence of infection and incorporates well with host bone. However, results after PJI treatment are less than optimal measured by KSSs as compared to patients who do not require revision.

Clinical trial and in-vitro study comparing the efficacy of treating bony lesions with allografts versus synthetic or highly-processed xenogeneic bone grafts

Background

Our study aim was to compare allogeneic cancellous bone (ACB) and synthetic or highly-processed xenogeneic bone substitutes (SBS) in the treatment of skeletal defects in orthopedic surgery.

Methods

232 patients treated for bony lesions with ACB (n = 116) or SBS (n = 116) within a 10-year time period were included in this case–control study. Furthermore, both materials were seeded with human osteoblasts (hOB, n = 10) and analyzed by histology, for viability (AlamarBlue®) and protein expression activity (Luminex®).

Results

The complication rate was 14.2 %, proportion of defects without bony healing 3.6 %; neither outcome parameter differed comparing the intervention groups. Failed consolidation correlated with an increase in complications (p < 0.03). The rate of complications was further highly significant in association with the location of use (p < 0.001), but did not depend on age, ASA risk classification, BMI, smoking behavior or type of insurance. However, those factors did significantly influence the bony healing rate (p < 0.02). Complication and consolidation rates were independent of gender and the filling substances employed within the different locations. Histological examination revealed similar bone structures, whereas cell remnants were apparent only in the allografts. Both materials were biocompatible in-vitro, and seeded with human osteoblasts. The cells remained vital over the 3-week culture period and produced microscopically typical bone matrix. We observed initially increased expression of osteocalcin, osteopontin, and osteoprotegerin as well as leptin and adiponectin secretion declining after 1 week, especially in the ACB group.

Conclusion

Although both investigated materials appeared to be similarly suitable for the treatment of skeletal lesions in-vivo and in-vitro, outcome was decisively influenced by other factors such as the site of use or epidemiological parameters.

Surgical fixation methods for tibial plateau fractures

BACKGROUND

Fractures of the tibial plateau, which are intra-articular injuries of the knee joint, are often difficult to treat and have a high complication rate, including early-onset osteoarthritis. Surgical fixation is usually used for more complex tibial plateau fractures. Additionally, bone void fillers are often used to address bone defects caused by the injury. Currently there is no consensus on either the best method of fixation or bone void filler.

OBJECTIVES

To assess the effects (benefits and harms) of different surgical interventions, and the use of bone void fillers, for treating tibial plateau fractures.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (12 September 2014), the Cochrane Central Register of Controlled Trials (2014 Issue 8), MEDLINE (1946 to September Week 1 2014), EMBASE (1974 to 2014 Week 36), trial registries (4 July 2014), conference proceedings and grey literature (4 July 2014).

SELECTION CRITERIA

We included randomised and quasi-randomised controlled clinical trials comparing surgical interventions for treating tibial plateau fractures and the different types of filler for filling bone defects.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, selected studies, extracted data and assessed risk of bias. We calculated risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CIs). Only very limited pooling, using the fixed-effect model, was possible. Our primary outcomes were quality of life measures, patient-reported outcome measures of lower limb function and serious adverse events.

MAIN RESULTS

We included six trials in the review, with a total of 429 adult participants, the majority of whom were male (63%). Three trials evaluated different types of fixation and three analysed different types of bone graft substitutes. All six trials were small and at substantial risk of bias. We judged the quality of most of the available evidence to be very low, meaning that we are very uncertain about these results.One trial compared the use of a circular fixator combined with insertion of percutaneous screws (hybrid fixation) versus standard open reduction and internal fixation (ORIF) in people with open or closed Schatzker types V or VI tibial plateau fractures. Results (66 participants) for quality of life scores using the 36-item Short Form Health Survey (SF-36)), Hospital for Special Surgery (HSS) scores and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function scores tended to favour hybrid fixation, but a benefit of ORIF could not be ruled out. Participants in the hybrid fixation group had a lower risk for an unplanned reoperation (351 per 1000 people compared with 450 in the ORIF group; 95% CI 197 fewer to 144 more) and were more likely to have returned to their pre-injury activity level (303 per 1000 people, compared with 121 in the ORIF group; 95% CI 15 fewer to 748 more). Results of the two groups were comparable for the WOMAC pain subscale and stiffness scores, but mean knee range of motion values were higher in the hybrid group.Another trial compared the use of a minimally invasive plate (LISS system) versus double-plating ORIF in 84 people who had open or closed bicondylar tibial plateau fractures. Nearly twice as many participants (22 versus 12) in the ORIF group had a bone graft. Quality of life, pain, knee range of motion and return to pre-injury activity were not reported. The trial provided no evidence of differences in HSS knee scores, complications or reoperation entailing implant removal or revision fixation. A quasi-randomised trial comparing arthroscopically-assisted percutaneous reduction and internal fixation versus standard ORIF reported results at 14 months in 58 people with closed Schatzker types II or III tibial plateau fracture. Quality of life, pain and return to pre-injury activity were not reported. There was very low quality evidence of higher HSS knee scores and higher knee range of motion values in the arthroscopically assisted group. No reoperations were reported.Three trials compared different types of bone substitute versus autologous bone graft (autograft) for managing bone defects. Quality of life, pain and return to pre-injury activity were not reported. Only one trial (25 participants) reported on lower limb function, finding good or excellent results in both groups for walking, climbing stairs, squatting and jumping at 12 months. The incidences of individual complications were similar between groups in all three trials. One trial found no cases of inflammatory response in the 20 participants receiving bone substitute, and two found no complications associated with the donor site in the autograft group (58 participants). However, all 38 participants in the autologous iliac bone graft group of one trial reported prolonged pain from the harvest site. Two trials reported similar range of motion results in the two groups, whereas the third trial favoured the bone substitute group.

AUTHORS' CONCLUSIONS

Currently, there is insufficient evidence to ascertain the best method of fixation or the best method of addressing bone defects during surgery. However, the evidence does not contradict approaches aiming to limit soft-tissue dissection and damage or to avoid autograft donor site complications through using bone substitutes. Further well-designed, larger randomised trials are warranted.

Recent progress in the diagnosis and treatment of posterior tibial plateau fractures

The posterior tibial plateau fracture is drawing increasing attention from orthopedists in recent years with the popularity of CT. However, due to the particular and severity of posterior tibial plateau fracture, there is still controversy in its classification and treatment. It is very difficult to achieve the ideal reduction and fixation by conventional techniques and approaches. The modified posterior approach is favorable for posterior tibial plateau fracture, but disadvantages remain. Recently, the lateral approach is applied by doctors. It is ideal for treatment of posterior tibial plateau fracture. Because of the complexity of local anatomical structure, the operative management of posterior tibial plateau fractures is a contentious issue as revealed in the recent surge of published literature addressing the surgical approach. This review mainly summaries the diagnosis, classification and surgery of the posterior tibial plateau fractures.