The morphological features of different Schatzker types of tibial plateau fractures: a three-dimensional computed tomography study

Schatzker IV tibial plateau fractures involving the posterolateral column: Higher incidence of lateral meniscus and anterior cruciate ligament injuries with suboptimal postoperative outcomes

BACKGROUND

Current literature offers scant insights into Schatzker IV tibial plateau fractures (TPFs) that affect the posterolateral (PL) column. This study seeks to elucidate the prevalence of meniscal and ligamentous injuries in the knee, as well as the clinical outcomes, in Schatzker IV TPF cases, both with and without PL column involvement.

METHODS

We conducted a retrospective analysis of clinical and imaging data from patients with Schatzker IV TPFs who received surgical treatment at our institution between January 2018 and January 2022. Patient demographics and surgical details were meticulously documented. The study participants were categorized into two groups based on the involvement of the PL column in the Schatzker IV TPF. Group A comprised patients without PL column fractures, whereas Group B included those with such fractures. We compared soft tissue injuries affecting knee stability, namely meniscal and ligamentous injuries, between two groups using Magnetic Resonance Imaging (MRI) and surgical records. Further, Group B was divided into subgroups based on the presence or absence of knee subluxation. Within Group B, we measured the lateral plateau depression (LPD) and lateral plateau widening (LPW). Additionally, we investigated the frequency of meniscus entrapment in patients with PL column fractures. Clinical outcomes were assessed using The American Hospital for Special Surgery (HSS) and Rasmussen scores.

RESULTS

The study comprised 66 patients with Schatzker IV TPFs. Of these, 12 patients had no PL column fracture, while 54 had a PL column fracture. Group B demonstrated a 57.4 % and 64.8 % incidence of lateral meniscus (LM) and anterior cruciate ligament (ACL) injuries, respectively, significantly higher than that in Group A (25 %, 8.3 %) (p = 0.044, p < 0.001). Within Group B, those with knee subluxation showed a marked increase in LPD (14.5 ± 5.3 mm) and LPW (9.3 ± 4.9 mm), correlating with a higher rate of meniscus entrapment (76.0 %) (p < 0.001). Patients in Group B had lower HSS and Rasmussen scores compared to Group A (p = 0.048, p = 0.006).

CONCLUSION

This investigation reveals that Schatzker IV TPFs involving the PL column are highly associated with increased rates of LM and ACL injuries. Additionally, these fractures correlate with a greater likelihood of knee subluxation and meniscus entrapment, ultimately leading to poorer prognostic outcomes.

Outcomes of isolated medial tibial plateau fractures by fracture morphology

PURPOSE

To identify a cohort of isolated medial tibial plateau fractures treated with surgical fixation and to categorize them by Moore and Wahlquist classifications in order to determine the rate of complications with each fracture morphology and the predictive value of each classification system. We hypothesized there would be high rates of neurovascular injury, compartment syndrome, and complications overall with a higher incidence of neurovascular injury in Moore type III rim avulsion fractures and Wahlquist type C fractures that enter the plateau lateral to the tibial spines.

METHODS

Patients who presented to six Level I trauma centers between 2010 and 2021 who underwent surgical fixation for isolated medial tibial plateau fractures were retrospectively reviewed. Data including demographics, radiographs, complications, and functional outcomes were collected.

RESULTS

One hundred and fifty isolated medial tibial plateau fractures were included. All patients were classified by the Wahlquist classification of medial tibial plateau fractures, and 139 patients were classifiable by the Moore classification of tibial plateau fracture-dislocations. Nine percent of fractures presented with neurovascular injury: 5 % with isolated vascular injury and 6 % with isolated nerve injury. There were no significant differences in neurovascular injury by fracture type (Wahlquist p = 0.16, Moore p = 0.33). Compartment syndrome developed in two patients (1.3 %). The average final range of motion was 0.8-122° with no difference by Wahlquist or Moore classifications (p = 0.11, p = 0.52). The overall complication rate was 32 % without differences by fracture morphology. The overall rate of return to the operating room (OR) was 25 %.

CONCLUSIONS

Isolated medial tibial plateau fractures often represent fracture-dislocations of the knee and should receive a meticulous neurovascular exam on presentation with a high suspicion for neurovascular injury. No specific fracture pattern was found to be predictive of neurovascular injuries, complications, or final knee range of motion. Patients should be counseled pre-operatively regarding high rates of return to the OR after the index surgery.

Introduction of 3D-classification and its derived surgical sequence of Schatzker type IV tibial plateau fractures

INTRODUCTION

Schatzker IV tibial plateau fractures usually have a worse prognosis due to their high variability and the accompanied bony and soft tissue injuries. This study aimed to introduce an injury mechanism-based new classification of Schatzker IV tibial plateau fractures and evaluate its reliability. Additionally, this study aimed to evaluate the outcomes of operative Schatzker IV tibial plateau fractures treated according to the surgical sequences determined by the new classification.

MATERIALS AND METHODS

A total of 63 cases of operative Schatzker IV tibial plateau fractures that were treated following the new surgical sequences were enrolled in our study. The CT images of these patients were reviewed and classified twice according to the new 3D classification by 4 independent observers. The reliability of the classification was calculated through kappa analysis. The classification-determined surgical sequence was evaluated by observing the postoperative efficacy during the follow-up.

RESULTS

Both the intra-observer (the mean k = 0.897, CI 0.806-0.971) and inter-observer (the mean k = 0.883, CI 0.786-0.961) reliability of 3D-classification showed excellent agreement according to Landis and Koch. All the patients were followed up for 6-28 months (average 12.8 months). As for the evaluation of the postoperative efficacy, according to KSS, 53 cases were rated as excellent, 8 cases as good, and 2 cases as fair results.

CONCLUSIONS

The new proposed classification showed high intra-observer and inter-observer reliability in our study. The surgical sequence determined by the classification can help surgeons to acquire good reduction and rigid internal fixation. Therefore the new classification of Schatzker IV tibial plateau fractures and the derived surgical sequences are worthy of further popularization and application in clinical trials.

Comparison of Arthroscopic-Assisted Percutaneous Internal Fixation With a Modified Reducer Versus Open Reduction and Internal Fixation for Schatzker Type II and III Tibial Plateau Fractures

Background

Tibial plateau fractures require anatomical reduction and stable fixation to achieve satisfactory results. In addition, addressing any related injuries is of paramount importance. Arthroscopic reduction and internal fixation (ARIF) has been promoted as a possible technique to treat tibial plateau fractures.

Purpose

To compare the effectiveness of ARIF with this modified reducer and open reduction and internal fixation (ORIF) for Schatzker types II and III tibial plateau fractures.

Study Design

Cohort study; Level of evidence, 3.

Methods

We retrospectively reviewed 68 patients who were treated for Schatzker type II or III tibial plateau fractures between August 1, 2014, and October 31, 2018. Patients were categorized into the ARIF (n = 33) and ORIF groups (n = 35). The groups were compared regarding intra-articular injuries, duration of hospital stay, complications, and clinical outcomes-including the International Knee Documentation Committee (IKDC) score, the Hospital for Special Surgery (HSS) score, and range of motion (ROM). The paired t test was used to compare preoperative and postoperative data, and the chi-square test was used to compare the IKDC and HSS scores.

Results

The median follow-up period was 36 months (26-40 months). Additional intra-articular lesions were found in 29 patients-21 in the ARIF group and 8 in the ORIF group (P = .02). A significant difference was observed in the duration of hospital stay-3.58 ± 1.46 days for the ARIF group and 4.57 ± 1.12 days for the ORIF group (t = -3.169; P = .002). All fractures healed within 3 months after surgery. The complication rate for all patients was 11%, with no significant difference between the ARIF and ORIF groups (t = 1.244; P = .265). At the final follow-up, there were no significant differences between the 2 groups in the IKDC score, HSS score, and ROM (P > .05 for all).

Conclusion

ARIF with a modified reducer was found to be an effective, reliable, and safe procedure for the treatment of Schatzker types II and III tibial plateau fractures. Both ARIF and ORIF provided equally good results, while ARIF offered a more precise evaluation and reduced the duration of hospital stay.

Management of tibial plateau fractures: a fresh review

Tibial plateau fractures are complex injuries which carry significant morbidity and economic burden. They can present complex geometry depending upon the direction of the force and position of the limb and are often associated with significant soft-tissue injury. While the goals of adequate reduction, stable fixation, and early mobilization remain unchanged, the management of these injuries can be challenging even to experienced orthopaedic surgeons. Lacking consensus, this review aims to provide a summary of current state of orthopaedic practice in the face of tibial plateau fractures. A PubMed search for relevant recent articles as well as a reading of classical articles on tibial plateau fractures was carried out. The focus remained on articles concerned with management modalities and recent advances. A review of some classification systems was also done and included. A great majority of these fractures need operative fixation while respecting the soft tissues. Numerous methods have been reported in the literature including but not limited to plates, screws, external fixators, arthroscopy assisted methods, balloon-cement tibioplasty, or a combination thereof. There is a shortage of randomized controlled trials comparing various operative methods. This article provides a review of various techniques and latest advances made in the management of tibial plateau fractures. The key to achieving optimal functional outcome is using a tailored approach to the individual patient accounting for factors related to the injury pattern, type of host, surgical skills and experience, and local availability of implant devices while taking care of soft tissue. While there is no gold standard, a staged procedure is recommended with early spanning and definitive fixation at later stage by any appropriate methods while respecting the soft tissue, achieving anatomical reduction and adequate fixation and, early rehabilitation.

Statistical Morphology and Fragment Mapping of Complex Proximal Humeral Fractures

Background and Objectives: Proximal humerus fractures (PHFs) are common in the elderly, but the treatment results are often poor. A clear understanding of fracture morphology and distribution of cortical bone loss is important for improved surgical decision making, operative considerations, and new implant designs. The aim of this study was to develop a 3D segmentation fracture mapping technique to create a statistical description of the spatial pattern and cortical bone loss of complex PHFs. Materials and Methods: Fifty clinical computed tomography (CT) scans of complex PHFs and their contralateral intact shoulders were collected. In-house software was developed for semi-automated segmentation and fracture line detection and was combined with manual fracture reduction to the contralateral template in a commercial software. A statistical mean model of these cases was built and used to describe probability maps of the fracture lines and cortical fragments. Results: The fracture lines predominantly passed through the surgical neck and between the tuberosities and tendon insertions. The superior aspects of the tuberosities were constant fragments where comminution was less likely. Some fracture lines passed through the bicipital sulcus, but predominantly at its edges and curving around the tuberosities proximally and distally. Conclusions: A comprehensive and systematic approach was developed for processing clinical CT images of complex fractures into fracture morphology and fragment probability maps and applied on PHFs. This information creates an important basis for better understanding of fracture morphology that could be utilized in future studies for surgical training and implant design.

The automized fracture edge detection and generation of three-dimensional fracture probability heat maps

With proven impact of statistical fracture analysis on fracture classifications, it is desirable to minimize the manual work and to maximize repeatability of this approach. We address this with an algorithm that reduces the manual effort to segmentation, fragment identification and reduction. The fracture edge detection and heat map generation are performed automatically. With the same input, the algorithm always delivers the same output. The tool transforms one intact template consecutively onto each fractured specimen by linear least square optimization, detects the fragment edges in the template and then superimposes them to generate a fracture probability heat map. We hypothesized that the algorithm runs faster than the manual evaluation and with low (< 5 mm) deviation. We tested the hypothesis in 10 fractured proximal humeri and found that it performs with good accuracy (2.5 mm ± 2.4 mm averaged Euclidean distance) and speed (23 times faster). When applied to a distal humerus, a tibia plateau, and a scaphoid fracture, the run times were low (1-2 min), and the detected edges correct by visual judgement. In the geometrically complex acetabulum, at a run time of 78 min some outliers were considered acceptable. An automatically generated fracture probability heat map based on 50 proximal humerus fractures matches the areas of high risk of fracture reported in medical literature. Such automation of the fracture analysis method is advantageous and could be extended to reduce the manual effort even further.

A preliminary study of the surgical approach for posterior tibial plateau fractures: Based on posterior fragment segment classification

PURPOSE

The optimal surgical approach for the posterior tibial plateau fractures (PTPFs) remains controversial. This study aims to establish a method for posterior fragment segment classification to guide the choice of surgical approach and to reveal the outcome of their early reduction and health status.

METHODS

The medical records of 42 PTPFs patients treated with the strategy were collected retrospectively from December 2017 to December 2021. The posterior cortex of the tibial plateau was classified into postero-medial (PM), postero-central (PC), and postero-lateral (PL) segments. A posteromedial inverted L-shaped approach was adopted when the fractures involved the PM segment in the presence or absence of PC. The Frosch approach was performed when the PL segment was concerned. Fractures containing both PM and PL segments were treated by combined approaches. Four factors were measured to evaluate the reduction effect, including medial proximal tibial angle (MPTA), lateral posterior slope angle (LPSA), medial posterior slope angle (MPSA), and articular step-off. The Short Form 36 (SF-36) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were completed at the last follow-up to assess health status and the degree of osteoarthritis.

RESULTS

A posteromedial inverted L-shaped approach was adopted in 16 PTPFs patients, a Frosch approach was adopted in 14 PTPFs patients, and a combined approach was adopted in 12 PTPFs patients. Immediate radiographic results indicated a promising fixation performance with this treatment strategy. The results of SF-36 and WOMAC scores reported good health status in all patients with a mean follow-up time of 34.50 (23-50) months. Two patients developed superficial wound infections, and one patient had liquefaction necrosis in adipose tissue. Although skin numbness occurred in 4 patients, they recovered within 6 months.

CONCLUSION

PTPFs patients treated under the guidance of posterior fragment segment classification achieved encouraging levels of immediate fixation and health status.

Tibial plateau fractures: three dimensional fracture mapping and morphologic measurements

Purpose

The injury mechanisms and classifications of tibial plateau fractures (TPFs) are still controversial. The aim of this study is to show 3D fracture mapping of different types of tibial plateau fractures. Moreover, combined with Schatzker and ten-segment classification, we aimed to analyze the injury frequency and characteristics of different segments.

Methods

In total, 346 patients with TPFs treated at level I trauma centres from 2017 to 2021 were reviewed. The CT files of the included cases were typed and categorized. 3D reconstruction of TPFs patients’ CT files were performed using software. All fracture lines were superimposed on the standard model by the software to create TPFs 3D fracture mapping.

Results

This study included 204 male and 142 female patients (average age, 47 years [range, 18 to 83 years]) with a tibial plateau fracture. Using the Schatzker classification, we found 39 type I (11.27%), 103 type II (29.77%), nine type III (2.60%), 71 type IV (20.52%), 52 type V (15.03%), 59 type VI (17.05%) fractures, and 13 others (3.76%). The density areas of fracture lines are mainly located in the ALC and PLC segments (74.3%, 69.1%). In different views, fracture lines of different Schatzker types showed distinct distribution characteristics.

Conclusions

Schatzker classification combined with 3D fracture mapping provides a new presentation of tibial plateau fracture morphology. According to the 3D fracture mapping, different types of TPFs have distinctly different distribution characteristics of fracture lines. There are significant differences between different types of fracture injury segments.

Intra- and inter-observer reliability assessment of widely used classifications and the "Ten-segment classification" of tibial plateau fractures

BACKGROUND

Ten-segment classification provides a different approach to the evaluation of tibial plateau fractures. The purpose of this study was to assess the intra- and inter-observer reliability of three widely used classification systems (Schatzker, Arbeitsgemeinschaft für Osteosynthesefragen (AO/OTA), and the updated three-column concept (uTCC)) with ten-segment classification in two-dimensional computed tomography (2D-CT) and three-dimensional computed tomography (3D-CT).

METHOD

Ninety 2D-CT and 3D-CT scans of patients with tibial plateau fractures were included in this retrospective cohort study. The included data were independently classified by six observers of different years of seniority and were independently observed and classified again after eight weeks. Inter-observer and intra-observer reliability of the four fracture classifications made by the six observers was analyzed using the kappa statistic. Kappa values were interpreted according to the categorical rating by Landis and Koch.

RESULTS

When the inter-observer reliability was based on 2D-CT/3D-CT analysis, the mean Kappa values for the Schatzker, AO/OTA, uTCC, and ten-segment classification were 0.64/0.66, 0.56/0.59, 0.53/0.65, and 0.60/0.73, respectively. When intra-observer reliability was based on 2D-CT/3D-CT, the mean Kappa values for the Schatzker, AO/OTA, uTCC, and ten-segment classification were 0.68/0.83, 0.69/0.83, 0.74/0.85, and 0.80/0.91, respectively.

CONCLUSIONS

The use of 3D-CT is important for the reliable diagnosis and recognition of tibial plateau fracture features compared to 2D-CT. When using 3D-CT, ten-segment classification showed high intra- and inter-observer agreement.

Medial sided articular impaction in tibial plateau fractures

INTRODUCTION

Tibial plateau fractures are a heterogenous group of injuries with a variable amount of articular injury and are commonly associated with lateral sided articular impaction. Previous work has focused on describing the morphology of tibial plateau fractures, but has neglected description of medial sided articular impaction. The aim of this investigation was to assess the morphology of medial sided articular impaction in tibial plateau fractures, with specific attention directed toward the frequency, location, size, and associated fracture patterns.

METHODS

Skeletally mature patients presenting to a Level I trauma center from 2008-2018 with a tibial plateau fracture (AO/OTA 41B-C) were identified retrospectively. Fractures were classified by AO/OTA and Schatzker type. Radiographs and computed tomography (CT) scans were reviewed to identify and localize medial sided articular impaction. The location and surface area of impaction was characterized by creating frequency diagram heat maps from axial CT scans. Descriptive statistics were performed using standard measures.

RESULTS

Of the 1032 tibial plateau fractures included, 82 (7.9%) were noted to have medial sided articular impaction. Rate of impaction varied by fracture type (p = 0.03): Schatzker II, 2% (7 of 381); Schatzker IV, 21% (19 of 96); and Schatzker VI, 11% (56 of 524). Average total surface area of impaction was 9% of the total and 19% of the medial plateau area. Area of impaction varied by fracture type (p = 0.004): Schatzker II, 6% (95% confidence interval [CI], 4%-7%); Schatzker IV, 11% (95% CI, 9%-13%), and Schatzker VI, 9% (95% CI, 7%-11%). The area of impaction occurred primarily along the lateral aspect of the medial plateau in Schatzker II fractures, in the anteromedial quadrant of Schatzker IV fractures, and was evenly distributed across the medial plateau in Schatzker VI fractures.

CONCLUSIONS

Surgeons should be aware that medial articular impaction is present in approximately 8% of tibial plateau fractures. Schatzker IV fractures are most likely to have medial impaction and a larger proportion of the joint surface involved in these injuries.

3D mapping and classification of tibial plateau fractures

Aims

Tibial plateau fractures (TPFs) are complex injuries around the knee caused by high- or low-energy trauma. In the present study, we aimed to define the distribution and frequency of TPF lines using a 3D mapping technique and analyze the rationalization of divisions employed by frequently used classifications.

Methods

In total, 759 adult patients with 766 affected knees were retrospectively reviewed. The TPF fragments on CT were multiplanar reconstructed, and virtually reduced to match a 3D model of the proximal tibia. 3D heat mapping was subsequently created by graphically superimposing all fracture lines onto a tibia template.

Results

The cohort included 405 (53.4%) cases with left knee injuries, 347 (45.7%) cases with right knee injuries, and seven (0.9%) cases with bilateral injuries. On mapping, the hot zones of the fracture lines were mainly concentrated around the anterior cruciate ligament insertion, posterior cruciate ligament insertion, and the inner part of the lateral condyle that extended to the junctional zone between Gerdy’s tubercle and the tibial tubercle. Moreover, the cold zones were scattered in the posteromedial fragment, superior tibiofibular syndesmosis, Gerdy’s tubercle, and tibial tubercle. TPFs with different Orthopaedic Trauma Association/AO Foundation (OTA/AO) subtypes showed peculiar characteristics.

Conclusion

TPFs occurred more frequently in the lateral and intermedial column than in the medial column. Fracture lines of tibial plateau occur frequently in the transition zone with marked changes in cortical thickness. According to 3D mapping, the four-column and nine-segment classification had a high degree of matching as compared to the frequently used classifications.

Cite this article: Bone Joint Res 2020;9(6):258–267.

Plate-screw and screw-washer stability in a Schatzker type-I lateral tibial plateau fracture: a comparative biomechanical study

The aim of this study was to evaluate the biomechanical role of both a non-locking two-hole small fragment dynamic compression plate with 3.5-mm screws and a 4.5-mm cortical screw with a washer applied to a Schatzker type-I tibial plateau fracture. Sixteen right synthetic tibiae were used to create an anterolateral shear tibial plateau fracture (Schatzker type-I fracture). Eight models were fixed with a small fragment non-locked straight dynamic compression plate with one 3.5-mm bicortical screw (plate-screw construction) and eight models were fixed with a 4.5-mm cortical screw and a washer (screw-washer construction), both inserted at 1.0 mm distal to the apex of the fracture. Specimens were tested up to the onset of yielding at a constant strain rate of 5.0-mm/min. Stiffness ranged from 311.83 N/mm to 199.54 N/mm, with a mean + SD of 260.32 + 33.8 N/mm in the plate-screw construction, and from 290.34 N/mm to 99.16 N/mm, with a mean + SD of 220.46 + 63.12 N/mm in screw-washer construction. There was no significant difference (p=0.172). Use of a two-hole small-fragment non-locked plate with one 3.5-mm cortical screw or a 4.5-mm cortical screw with a washer applied at 1.0 mm distal to the apex of the fracture as buttressing present similar stiffness in terms of preventing axial displacement in synthetic tibiae models tested up to the onset of yielding.

Epidemiological Study of Tibial Plateau Fractures Combined with Intercondylar Eminence Fractures

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Comparative Analysis of Mechanism-Associated 3-Dimensional Tibial Plateau Fracture Patterns

BACKGROUND

The association between tibial plateau fracture morphology and injury force mechanism has not been well described. The aim of this study was to characterize 3-dimensional fracture patterns associated with hypothesized injury force mechanisms.

METHODS

Tibial plateau fractures treated in a large trauma center were retrospectively reviewed. Three experienced surgeons divided fractures independently into 6 groups associated with injury force mechanisms proposed from an analysis of computed tomographic (CT) imaging: flexion varus, extension varus, hyperextension varus, flexion valgus, extension valgus, and hyperextension valgus. The fracture lines and comminution zones of each fracture were graphically superimposed onto a 3-dimensional template of the proximal part of the tibia. Fracture characteristics were then summarized on the basis of the fracture maps. The association between injury force mechanism and ligament avulsions was calculated.

RESULTS

In total, 353 tibial plateau fractures were included. The flexion varus type pattern was seen in 67 fractures characterized by a primary fracture apex located posteromedially and was frequently associated with concomitant anterior cruciate ligament (ACL) avulsion (44.8%). The extension varus pattern was noted in 60 fractures with a characteristic medial fragment apex at the posteromedial crest or multiple apices symmetrically around the crest and was commonly completely articular in nature (65%). The hyperextension varus pattern was seen in 47 fractures as noted by anteromedial articular impaction, 51% with a fibular avulsion and 60% with posterior tension failure fragments. The flexion valgus pattern was observed in 51 fractures characterized by articular depression posterolaterally, often (58.9%) with severe comminution of the posterolateral cortical rim. The extension valgus patterns in 116 fractures only involved the lateral plateau, with central articular depression and/or a pure split. The hyperextension valgus pattern occurred in 12 fractures denoted by anterolateral articular depression. A moderate positive association was found between flexion varus fractures and ACL avulsions and between hyperextension varus fractures and fibular avulsions.

CONCLUSIONS

Tibial plateau fractures demonstrate distinct, mechanism-associated 3-dimensional pattern characteristics. Further research is needed to validate the classification reliability among other surgeons and to determine the potential value in the diagnosis and formulation of surgical protocols.

Reliability and repeatability of tibial plateau fracture assessment with an injury mechanism-based concept

Objectives

CT-based three-column classification (TCC) has been widely used in the treatment of tibial plateau fractures (TPFs). In its updated version (updated three-column concept, uTCC), a fracture morphology-based injury mechanism was proposed for effective treatment guidance. In this study, the injury mechanism of TPFs is further explained, and its inter- and intraobserver reliability is evaluated to perfect the uTCC.

Methods

The radiological images of 90 consecutive TPF patients were collected. A total of 47 men (52.2%) and 43 women (47.8%) with a mean age of 49.8 years (sd 12.4; 17 to 77) were enrolled in our study. Among them, 57 fractures were on the left side (63.3%) and 33 were on the right side (36.7%); no bilateral fracture existed. Four observers were chosen to classify or estimate independently these randomized cases according to the Schatzker classification, TCC, and injury mechanism. With two rounds of evaluation, the kappa values were calculated to estimate the inter- and intrareliability.

Results

The overall inter- and intraobserver agreements of the injury mechanism were substantial (κ_inter = 0.699, κ_intra = 0.749, respectively). The initial position and the force direction, which are two components of the injury mechanism, had substantial agreement for both inter-reliability or intrareliability. The inter- and intraobserver agreements were lower in high-energy fractures (Schatzker types IV to VI; κ_inter = 0.605, κ_intra = 0.721) compared with low-energy fractures (Schatzker types I to III; κ_inter = 0.81, κ_intra = 0.832). The inter- and intraobserver agreements were relatively higher in one-column fractures (κ_inter = 0.759, κ_intra = 0.801) compared with two-column and three-column fractures.

Conclusion

The complete theory of injury mechanism of TPFs was first put forward to make the TCC consummate. It demonstrates substantial inter- and intraobserver agreement generally. Furthermore, the injury mechanism can be promoted clinically.

Cite this article: B-B. Zhang, H. Sun, Y. Zhan, Q-F. He, Y. Zhu, Y-K. Wang, C-F. Luo. Reliability and repeatability of tibial plateau fracture assessment with an injury mechanism-based concept. Bone Joint Res 2019;8:357–366. DOI: 10.1302/2046-3758.88.BJR-2018-0331.R1.

Tibial plateau fractures in elderly people: an institutional retrospective study

BACKGROUND

Tibial plateau fractures are the most common intra-articular fractures, which require careful evaluation and preoperative planning. The treatment of tibial plateau fractures in elderly patients is challenging, and the comprehension of epidemiology and morphology can be helpful. This study described the characteristics of geriatric tibial plateau fractures.

METHODS

A total of 327 (23.24%) patients aged ≥60 years were reviewed in our level one trauma center over a 4-year period (from January 2013 to November 2016). The following parameters were collected and evaluated: (1) demographic data, (2) injury mechanisms and (3) fracture classifications.

RESULTS

Females accounted for 60.86% in all included elderly patients. Electric-bike accidents were the cause of 32.42% of all these injuries, and 39.62% of these led to high-energy injuries. The most common type of fracture was Schatzker II (54.74%). According to the three-column classification, single lateral column fracture (28.75%) and four-quadrant fracture (involving lateral, medial, posterolateral and posteromedial fractures) (23.24%) were the two most frequent patterns. In all cases, 67.58% involved the posterior column, and the prevalence of posterolateral and posteromedial fractures were 62.69% and 37.92% respectively. Isolated posterior column fractures accounted for 12.54% of patients in total, which mostly consisted of posterolateral fracture in older females (85.37%).

CONCLUSIONS

The majority of elderly patients with tibial plateau fractures are females, and Electric-bike accidents are an important cause of injury. Geriatric tibial plateau fractures have unique distribution in classification.

Arthroscopic-assisted balloon tibioplasty versus open reduction internal fixation (ORIF) for treatment of Schatzker II-IV tibial plateau fractures: study protocol of a randomised controlled trial

INTRODUCTION

Arthroscopic-assisted balloon tibioplasty is an emerging technology that has shown advantages in recovering depression of the articular surface. However, studies evaluating clinical outcomes between arthroscopic-assisted balloon tibioplasty and traditional open reduction internal fixation (ORIF) are sparse. This is the first randomised study to compare arthroscopic-assisted balloon tibioplasty with ORIF, and will provide guidance for treating patients with Schatzker types II, III and IV with depression of the medial tibial plateau only.

METHODS AND ANALYSIS

A blinded randomised controlled trial will be conducted and a total of 80 participants will be randomly divided into either the arthroscopic-assisted balloon tibioplasty group or the ORIF group, at a ratio of 1:1. The primary clinical outcome measures are the knee functional scores, Rasmussen radiological evaluation scores and the quality of reduction based on postoperative CT scan. Secondary clinical outcome measures are intraoperative blood loss, surgical duration, visual analogue scale score after surgery, hospital duration after surgery, complications and 36-Item Short-Form Health Survey score.

ETHICS AND DISSEMINATION

This study has been reviewed and approved by the Institutional Review Board of the Second Affiliated Hospital of Wenzhou Medical University (batch: 2017-12). The results will be presented in peer-reviewed journals after completion of the study.

TRIAL REGISTRATION NUMBER

NCT03327337, Pre-results.

A review of the management of tibial plateau fractures

Tibial plateau fractures form a wide spectrum of injuries presenting varying challenges to the trauma surgeon. The prognosis of this injury spectrum is largely dependent on the management of each particular configuration, and the literature is as a result littered with a number of management strategies with limited consensus. The aim of this review is to provide a concise guide to the trauma surgeon based on newer and classical peer-reviewed publications in international orthopaedic journals. A PubMed search was conducted to identify peer-reviewed publications within the last 10 years and expanded to identify classic papers pertaining to the Schatzker classification. The focus was on articles based on management techniques, controversies and recent developments. The management of specific injury patterns is based on the Schatzker classification which is a widely accepted traditional classification system. Whilst there is a general consensus on the ultimate goal of a stable anatomic reduction in this subset of fractures, there continues to be a number of controversies surrounding issues including pre-operative imaging, initial assessment and definitive management of specific injury patterns, some of which do not conform to the original Schatzker classification. The majority of fractures will require operative management, and with whatever management strategy employed, the main emphasis is on respecting the soft tissue envelope. There remains a paucity of prospective randomised controlled trials comparing the different available operative techniques.

Tibial plateau fracture management: arthroscopically-assisted versus ORIF procedure - clinical and radiological comparison

INTRODUCTION

Tibial plateau fractures are articular injuries that may influence final functional outcome of the knee. Although these fractures comprise only 1% of all fractures, the fracture pattern is usually complex and requires anatomical reduction and absolutely stable fixation to achieve satisfactory results. The development of knee osteoarthritis is a common late complication and it can be strongly influenced by additional, underestimated cartilage defects, and meniscal and ligament tears.

MATERIALS AND METHODS

Between January 2012 and February 2015, a total of 78 patients with tibial plateau fractures (Schatzker type I-III) were enrolled in the study. Patients were divided into two groups: one group was treated with arthroscopically-assisted reduction and internal fixation (ARIF) and the other with open reduction and internal fixation (ORIF). The final number of patients was 75; 40 in the ARIF group and 35 in the ORIF group. Radiography and computed tomography were used to assess fracture pattern. An immediate postoperative radiograph was performed, and then repeated at 6 weeks, and 3,6 and 12 months after surgery. Demographic data (age and sex), additional intraarticular injuries, hospital stay and complications were noted, and clinical and radiological Rasmunssen score at 3, 6 and 12 months after surgery were evaluated.

RESULTS

Additional intraarticular lesions were found in 27 patients; 20 in the ARIF group and 7 in the ORIF group (p = 0.06). There was a statistically significant difference in average duration of hospital stay: 3.10 ± 0.63 days for the ARIF group and 5.51 ± 1.66 days for the ORIF group (p = 0.0001). All fractures healed within 3 months following surgery. The overall complication rate was 12%. There was no statistically significant difference in complication rate between the two groups (p = 0.63). Clinical and radiological scores were excellent in most patients in both groups. There was no statistically significant difference in average clinical and radiological Rasmunssen scores between the two groups.

CONCLUSIONS

Both ARIF and ORIF can provide equally good results; however, ARIF seems to offer a more precise evaluation and treatment of associated intraarticular lesions and to reduce the duration of hospital stay.

Extending the limits of the anterior tibial artery as the recipient vessel for around the knee and proximal lower extremity defect reconstruction using the free anterolateral thigh and gracilis flap

PURPOSE

The aim is to describe a technique with orthograde dissection of the anterior tibial artery (ATA) used as the recipient vessel for the end-to-end (ETE) anastomosis in defect reconstruction around the knee and for proximal/middle third leg defects with free anterolateral thigh (ALT) and gracilis flaps.

PATIENTS AND METHODS

Between March 2009 and May 2014, 22 patients undergoing lower extremity reconstruction were evaluated. Of those, 4 patients were included. The locations of injury were 3 defects around the knee and 1 defect at the proximal and middle third of the lower leg (mean defect size 18 x 8.5 cm and a range of 17-20 x 5-10 cm). There were 2 cases after trauma and 2 cases with infection. Two free gracilis and 2 free ALT flaps were performed of equal size to the defects. The mean flap pedicle length was 11 cm (range of 7-16 cm) and the mean length of the mobilized recipient vessels was 10.5 cm (range of 6-14 cm).

RESULTS

One flap loss (ALT) occurred, requiring a salvage procedure with a latissimus dorsi flap, whereas wound dehiscence at the donor site and a hematoma below the ALT flap was observed in 2 cases, requiring small revision. After a mean follow-up of 52 months (range of 38-87 months), there was stable soft tissue coverage in all patients.

CONCLUSION

By orthograde dissection of the ATA, an adequate vessel length and size may be achieved, improving arc of rotation to successfully cover more distant defects.