Partial proximal tibia fractures

Interfragmentary compression force and fixation stability of lateral tibial plateau fractures in normal and osteoporotic bones

Lateral platform collapse in fixations of lateral tibial plateau fractures (TPFs) using either double-lag screws fixation (DSF) or locking-plate fixation (LPF) is not rare. This study aimed to explore the effect of enhancing the interfragmentary compression force (IFCF) on fixation stability in lateral TPFs in normal and osteoporotic bones using finite element analysis. Finite element models of DSF in normal bone and LPF in normal and osteoporotic bones were established to simulate the fixations of lateral TPF. After model validation, axial compressive forces of 500, 1000, 1500, and 2500 N to the tibial plateau along with an IFCF of 0, 100, 200, and 300 N were applied. The maximum axial micromotion of the lateral fragment (MAM-LF), maximal translational micromotion of the lateral fragment (MTM-LF), peak von Mises stress (VMS), and peak equivalent elastic strain of the lateral fragment (EES-LF) were evaluated. The MAM-LF showed a decreasing trend as the IFCF increased in all models. For DSF models, the peak VMS of implants increased as the IFCF increased when the axial loads were 500 and 1000 N. The peak EES-LF decreased as the IFCF increased under axial loads of 1000, 1500, and 2500 N. For the normal and osteoporotic LPF models, the peak VMS of the implants decreased as the IFCF increased. Peak EES-LF decreased as IFCF increased. In conclusion, enhancing IFCF was beneficial in improving the fixation stability of lateral TPF. The optimal IFCF for DSF and LPF should be as high as reasonably feasible.

The Effectiveness of Physiotherapy Rehabilitation in an Adult With Multiple Joint Fractures - A Case Report

This case report details the rehabilitation procedure for a 35-year-old man involved in a vehicle accident that resulted in multiple joint fractures. The patient had fractures to the proximal tibia, left bimalleolar, posterior malleolus, fourth and fifth metacarpal heads, and second and third proximal phalanges. After open reduction and internal fixation surgery, an 8-12 week physical treatment regimen was put into place. Exercises for both passive and active range of motion, isometric and progressive resistance training, and gait training were provided. The rehabilitation goals were pain relief, increased range of motion, muscle strength, flexibility, endurance, and functional independence. Pain levels, range of motion, muscle strength, and general function all significantly improved between pre- and post-rehabilitation evaluations. Early mobilization and structured physical therapy were crucial in achieving these outcomes, highlighting the importance of tailored rehabilitation protocols for post-operative recovery.

German S2e-Guideline "Knee Dislocation"

Knee dislocation is a devastating form of multiligament injury of the knee. Due to its high complexity, there is a large number of different diagnostic and treatment strategies. With the aim of providing evidence-based treatment recommendations, the S2e guideline on knee dislocation is aimed at all professional groups involved in diagnostics and therapy (orthopaedic and trauma surgeons, physiotherapists, outpatient/inpatient surgeons, sports physicians, etc.) as well as those affected (patients with knee dislocation) and service providers (health insurance companies, pension insurance companies). In addition to the presentation of conceptual differences between the injury entities, this includes the special features of diagnostic testing, options for conservative and surgical therapy as well as aspects of follow-up treatment - against the background of the interdisciplinary treatment approach to a severe knee injury.

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

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

[Intra-articular proximal tibia fractures]

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

BIOMECHANICAL STUDY OF MINIMALLY INVASIVE TECHNIQUES IN SURGICAL TREATMENT OF THE TIBIA PROXIMAL EPIMETAPHYSIS FRACTURES

OBJECTIVE

The aim: Improving efficiency of the tibia proximal epimetaphysis fractures treatment by introducing minimally invasive techniques using the up-to-date metallic constructions.

PATIENTS AND METHODS

Materials and methods: The study is based on the results of examination and treatment of 119 patients, using arthroscopic technique. The results were evaluated regarding the P. Rasmussen scheme, post-traumatic arthrosis -Kellgren - Lawrence, life quality - «SF-36 Health Status Survey».

RESULTS

Results: The offered treatment method provided for the following: good outcomes in BI- 94.1%, satisfactory ones - 5.9%; respectively in BII - 91.7%, 8.3%; ВIII - 92.9%, 7.1%; СI- 87.5%,12.5%; СII - 91.7%, 8.3%; СIII -88.9%, 7.4%, unsatisfactory outcomes - 3.7.

CONCLUSION

Conclusions: The tibia proximal epimetaphysis fractures make up from 8.9% to 11% of all lower leg fractures and up to 87% of the knee joint fractures. Such fractures are accompanied with the knee joint soft tissue injuries in up to 56% of cases. The meniscus injury is diagnosed in 50-94% of the patients; collateral ligament injury: 20% - 83%; anterior cruciate ligament injury : 20% - 69%, femoral muscle ligament injury- up to 47%, joint capsule ruptures - up to 75%, fibular nerve injury - 3% of cases. The treatment fails in 24.2-50% of cases. Operative treatment of such injuries using arthroscopic method provides for mini-invasive intervention character, visualizing and splint reposition control; the opposite compression screw provides for strong fixation.

[Change in the treatment of tibial plateau fractures]

BACKGROUND

The treatment of tibial plateau fractures has experienced a number of very different conceptual developments in recent years, not only with respect to technical innovations but also against the background of changing fracture patterns and the growing requirements of patients.

OBJECTIVE

What developments in recent years have had a significant impact on current treatment strategies for tibial plateau fractures?

METHODS

Narrative review of publications listed in PubMed on the topic of treatment of complex tibial plateau fractures.

RESULTS

While the two-dimensional classifications are becoming less important, computed tomography (CT)-based three-dimensional assessment of fracture progression and an access strategy based on it are coming to the fore. Direct dorsal approaches have been shown to be superior, particularly in the case of relevant posteromedial and/or posterolateral fracture involvement. The step-by-step approach extension via specific osteotomies of ligamentous attachments also enables a needs-dependent and fracture-dependent complete joint visualization and reduction control. In the treatment of geriatric tibial plateau fractures, primary treatment with endoprostheses is becoming increasingly more important to enable early mobilization under full load bearing with significantly shorter rehabilitation times.

CONCLUSION

Modern developments in the context of fracture treatment around the tibial plateau have led to a relevant reduction of infections and improved surgical outcomes; however, the high demands and the improved understanding of fractures still underline the great challenge in the treatment of complex fracture patterns.

A lateral fracture step-off of 2mm increases intra-articular pressure following tibial plateau fracture

INTRODUCTION

The aim of this study was to evaluate the effects of increasing posttraumatic step-offs after lateral tibial plateau fracture reduction on the intra-articular pressure.

MATERIALS AND METHODS

In eight fresh-frozen human cadaveric knees with intact menisci, a standardized sagittal osteotomy of the lateral tibial condyle was performed as an OTA/AO type 41-B1 fracture-model. The fragment was fixed by a customized sled including an angular stable tibia plate to evaluate step-offs from 0 mm to 8 mm in 1mm increments. In a servo-hydraulic testing machine, an axial force was applied to the tibial plateau in 0° (700N), 15° (700N), 30° (700N), 60° (350N), and 90 ° (350N) of flexion while the joint pressure was recorded by two pressure sensors.

RESULTS

A 1mm step-off did not result in an increased joint pressure. At 60° of flexion a 2mm step-off increased the lateral joint pressure by 61.84kPa (P = 0.0027). In 30° of flexion, a 3mm step raised the lateral joint pressure by 66.80kPa (p = 0.0017), whereas in 0°, 15° and 90° of flexion, a 4mm step increased the pressure by >50kPa (P < 0.05). Concomitant medial joint pressure increments were lower than those in the lateral plateau. A significant increase of 19-24kPa in the medial joint pressure was detected in 90° of flexion with a 1mm lateral step (P = 0.0075), in 15° and 60° of flexion with a 2mm step (P < 0.05), in 0° of flexion with a 4mm step (P = 0.0215) and in 30° of flexion with a 7mm step (P = 0.0487).

CONCLUSION

Lateral fracture step-offs of 2mm or larger should be reduced intraoperatively to avoid large increases in lateral joint pressure.

Weightbearing after combined medial and lateral plate fixation of AO/OTA 41-C2 bicondylar tibial plateau fractures: a biomechanical study

Background

Combined medial and lateral plate fixation is recommended for complex tibial plateau fractures with medial fragments or no cortical bone contact. Although such fixation is adequate to resist forces during range of motion, it may be insufficient to support immediate postoperative weightbearing. Here, we analyzed displacement, stiffness, and fixation failure during simulated full weightbearing of bicondylar tibial plateau fractures treated with combined medial and lateral locking plate fixation.

Methods

We used 10 fresh-frozen adult human cadaveric tibias and mated femurs. Osteotomies were performed with an oscillating saw and cutting template to simulate an AO Foundation and Orthopaedic Trauma Association (AO/OTA) 41-C2 fracture (simple articular, multifragmentary metaphyseal fracture). Specimens were anatomically reduced and stabilized with combined medial and lateral locking plates (AxSOS, Stryker, Mahwah, NJ). Specimens were loaded axially to simulate 4 weeks of walking in a person weighing 70 kg. The specimens were cyclically loaded from 200 N to a maximum of 2800 N. Then, if no failure, loading continued for 200,000 cycles. We measured displacement of each bone fragment and defined fixation failure as ≥5 mm of displacement. Construct stiffness and load at failure were calculated. Categorical and continuous data were analyzed using Chi-squared and unpaired t-tests, respectively.

Results

Mean total displacement values after 10,000 loading cycles were as follows: lateral, 0.4 ± 0.8 mm; proximal medial, 0.3 ± 0.7 mm; distal medial, 0.3 ± 0.6 mm; and central 0.4 ± 0.5 mm. Mean stiffness of the construct was 562 ± 164 N/mm. Fixation failure occurred in 6 of 10 specimens that reached 5 mm of plastic deformation before test completion. In the failure group, the mean load at failure was 2467 ± 532 N, and the mean number of cycles before failure was 53,155. After test completion, the greatest displacement was found at the distal medial fracture site (2.3 ± 1.4 mm) and lateral fracture site (2.2 ± 1.7 mm).

Conclusions

Although combined medial and lateral plate fixation of complex tibial plateau fractures provides adequate stability to allow early range of motion, immediate full weightbearing is not recommended.

Highly impacted bone allograft may allow immediate weight bearing in tibial plateau fractures: A case report

Introduction

Proximal tibial fractures are common with an incidence of 10.2/100.000. Those displaced and involving the articular surface will often require surgical treatment. However, no consensus exists on whether to allow the patient early weight bearing or not. We developed a technique using structural bone chips, highly impacted under the articular surface, to permit immediate weight bearing after surgery.

Patient

The patient was a 44-year old male who suffered a lateral tibial plateau fracture (AO type 41B2).

Intervention

We used an anterolateral approach with an S-shaped incision. A small window in the tibia was made using an awl, and the articular surface was reduced under radiographic imaging. The bone allograft was prepared by splitting the frozen femoral head in quarters and then taking large pieces of bone with a bone rongeur forceps avoiding the cartilage. The large pieces of bone were gathered in a small tray and thereafter compressed into the drill guide insert. The drill guide filled with bone graft was then inserted into the tibia window and directed in the appropriate position guided by radiography. Hereafter, the bone graft was impacted under the articular surface with force using the appropriate trocar and a hammer, and the fracture was finally reduced. Finally, the fracture was fixated utilizing an angular stable plate.

Outcome

The patient was followed up one year postoperatively and allowed immediate weight bearing after surgery. No subsequent articular collapse occurred.

Discussion

In this case, we present a proximal tibial fracture with articular depression, which was surgically treated with a highly impacted bone allograft of large pieces and a locking plate. The patient was allowed immediate weight bearing and no subsequent articular collapse occurred.

Comparison of X-Ray Imaging and Computed Tomography Scan in the Evaluation of Knee Trauma

Background and objectives: The aim of the study was to compare the accuracy of X-ray (XR) imaging according to computed tomography (CT) scanning in the diagnosis of knee bone fractures, and in the determination of fracture characteristics, and to identify CT scan indications in patients with knee trauma. Materials and methods: The patients who presented to the emergency department (ED) due to knee trauma between January 2017 and December 2018 and who underwent XR imaging and CT scans were included in the study. XR images were reinterpreted by an emergency physician. The official reports, which had been interpreted by a radiologist in the hospital automation system for CT images, were considered valid. Results: Five hundred and forty-eight patients were included in the study. Of the patients, 200 (36.5%) had fractures in XR imaging and 208 (38.0%) had fractures in CT scans. Compared to CT scanning, XR imaging was found to have 89% sensitivity, 95% specificity, 92% positive predictive value, and 92% negative predictive value in identifying the fracture. The sensitivity of XR imaging in identifying growth plate fracture, angulation, stepping off, and extension of the fracture into the joint space was determined as 78% and less. According to the kappa value, there was determined a perfect concordance between the XR imaging and CT scans in angulation, stepping off, and extension of the fracture into the joint space. This concordance was moderate in growth plate fractures. Conclusions: XR imaging has a low sensitivity in identifying knee fractures. There is a moderate concordance between XR imaging and CT scanning in identifying growth plate fractures. Therefore, CT scanning should be performed in patients whose fracture type and fracture characteristics are not able to be determined exactly with XR imaging in knee injury.

[Surgical approaches to tibial plateau fractures]

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

Non-hip/non-vertebral fractures - How to treat best?

Fractures of the extremities in the elderly constitute more than two-thirds of all fragility fractures befalling frail, osteoporotic and sarcopenic patients. Although treatment controversies abound, consensus exists. Upper extremity fractures hinder activities of daily living and are debilitating. Open fractures or displaced fractures will need surgical intervention. Wrist fractures treated operatively allow early use of the hand. Most pelvic fractures are treated conservatively. In the lower extremities, fractures of the long bones, tibia and femur need surgical intervention. Non-displaced fractures around the foot may be treated with immobilisation and avoidance of full weight-bearing. As a rule, fractures take four months for consolidation. Individually tailored solutions are needed for frail patients with comorbidities. Maintaining joint mobility and muscle strength preserves mobility and autonomy. Caring for extremities trauma is team work, involving family and health care providers. Prevention efforts are mandatory.

Preliminary application of three-dimension printing technology in surgical management of bicondylar tibial plateau fractures

OBJECTIVE

Surgical management of bicondylar tibial plateau fractures, which is frequently associate with high wound complication rates and functional impairment, remains a challenge for orthopedic surgeons. Recently, the emergence of three-dimension(3D) printing provided orthopedic surgeons with a new technology which has revolutionary impacts on surgical planning, operative guidance and custom-made implants manufacture. The aim of this study is to explore the clinical feasibility and application value of 3D printing in the surgical management of bicondylar tibial plateau fractures.

METHOD

Data of this retrospective study was collected from 11 patients suffering bicondylar tibial plateau fracture from October 2015 to August 2016. All of them underwent surgical treatment with the assistance of 3D printing technology. Real-size solid models and screw guide templates were printed for preoperative planning, surgical simulation and intraoperative guidance. Patients' Demographics, surgery duration, intraoperative blood loss, the accuracy of preoperative planning were recorded and evaluated.

RESULT

The 3D printed models successfully provided the omni-directional exhibition of the fracture morphology. Model-based surgical simulation procedures and pre-selection of implants were generally consistent with the results of actual surgeries. There were no significant differences between the length of the osteosynthesis screws and that of actual surgeries (59.43 ± 11.13 mm vs 60.14 ± 12.05 mm). Beyond that, other parameters, such as surgical duration, intraoperative blood loss and HSS scores was satisfactory according to the surgical records and follow-up.

CONCLUSIONS

According to our experience, the assistance of 3D printing technology in the surgical management of bicondylar tibial plateau fractures provides a comprehensive understanding of fracture features, an accurate patient-specific preoperative planning and an intraoperative guidance for real surgeries, thus leading to the optimization of clinical outcomes.