Correlation of preoperative CT imaging shift parameters of the lateral plateau with lateral meniscal injury in Schatzker IV-C tibial plateau fractures

BACKGROUND

Schatzker IV-C is a high-energy tibial plateau fracture often accompanied by lateral meniscus injuries. While imaging examinations are routine preoperative measurements, the correlation between CT imaging shift parameters of the lateral plateau and lateral meniscal injury in Schatzker IV-C fractures remains uncovered.

METHODS

This retrospective study enrolled a total of 60 patients with Schatzker IV-C tibial plateau fractures at the First People's Hospital of Hefei. Prior to surgery, CT imaging was used to measure the numerical values of lateral plateau depression (LPD) and lateral plateau widening (LPW). The degree of lateral meniscus injury was confirmed based on intraoperative direct vision, with patients being classified into meniscus injury and non-meniscus injury groups. Dichotomous logistic regression was employed to evaluate the correlation between LPD, LPW, and lateral meniscus injury, while the optimal cut-off points for predicting lateral meniscal injury with LPD and LPW were determined using receiver operator characteristic (ROC) curves.

RESULTS

The meniscus injury group exhibited a mean LPD of 15.3 ± 3.5 mm, which was significantly higher than the non-meniscus injury group's mean LPD of 8.4 ± 3.4 mm (P < 0.05). Similarly, the meniscus injury group had a larger mean LPW of 9.4 ± 1.8 mm compared to the non-meniscus injury group's mean LPW of 6.9 ± 0.9 mm (P < 0.05). The optimal cut-off points for predicting lateral meniscal injury were determined to be 8.40 mm for LPD (with a sensitivity of 95%, specificity of 85%, and AUC of 0.898) and 7.90 mm for LPW (with a sensitivity of 75%, specificity of 90%, and AUC of 0.897).

CONCLUSIONS

Patients with Schatzker IV-C tibial plateau fractures are at a significantly higher risk of lateral meniscal injury when the LPD exceeds 8.40 mm and/or the LPW exceeds 7.90 mm. Our results may provide novel reference metrics for the early diagnosis of lateral meniscal injury in Schatzker IV-C tibial plateau fracture patients when the MRI examination is not available.

Do associated proximal fibula fractures help predict the severity of tibial plateau fractures?

PURPOSE

Proximal fibula fractures are often associated with tibial plateau fractures, but their relationship is poorly characterized. The purpose of this study was to better define the relationship between tibial plateau injury severity and presence of associated soft tissue injuries.

METHODS

A retrospective review was performed on all operatively treated tibial plateau fractures at a Level 1 trauma center over a 5-year period. Patient demographics, injury radiographs, CT scans, operative reports and follow-up were reviewed.

RESULTS

Queried tibial plateau fractures from 2014 to 2019 totaled 217 fractures in 215 patients. Fifty-two percent were classified as AO/OTA 41B and 48% were AO/OTA 41C. Thirty-nine percent had an associated proximal fibula fracture. The presence of a proximal fibula fracture had significant correlation with AO/OTA 41C fractures, as compared with AO/OTA 41B fractures (chi-square, p < 0.001). Of the patients with a lateral split depression type tibial plateau fracture, the presence of a proximal fibula fracture was associated with more articular comminution, measured by number of articular fragments (mean = 4.0 vs. 2.9 articular fragments, p = 0.004). There was also a higher rate of meniscal injury in patients with proximal fibula fractures (37% vs. 20%, p = 0.003).

CONCLUSIONS

There was a significant relationship between the higher energy tibial plateau fracture type (AO/OTA 41C) and the presence of an associated proximal fibula fracture. The presence of a proximal fibula fracture with a tibial plateau fracture is an indicator of a higher energy injury and a higher likelihood of meniscal injury.

Prediction model for tibial plateau fracture combined with meniscus injury

Purpose

To investigate a prediction model of meniscus injury in patients with tibial plateau fracture.

Methods

This retrospective study enrolled patients with tibial plateau fractures who were treated in the Third Hospital of Hebei Medical University from January 1, 2015, to June 30, 2022. Patients were divided into a development cohort and a validation cohort based on the time-lapse validation method. Patients in each cohort were divided into a group with meniscus injury and a group without meniscus injury. Statistical analysis with Student's t-test for continuous variables and chi square test for categorical variables was performed for patients with and without meniscus injury in the development cohort. Multivariate logistic regression analysis was used to screen the risk factors of tibial plateau combined with meniscal injury, and a clinical prediction model was constructed. Model performance was measured by examining discrimination (Harrell's C-index), calibration (calibration plots), and utility [decision analysis curves (DCA)]. The model was validated internally using bootstrapping and externally by calculating their performance in a validation cohort.

Results

Five hundred patients (313 [62.6%] males, 187 [37.4%] females) with a mean age of 47.7 ± 13.8 years were eligible and were divided into development (n = 262) and validation (n = 238) cohorts. A total of 284 patients had meniscus injury, including 136 in the development cohort and 148 in the validation cohort We identified high-energy injuries as a risk factor (OR = 1.969, 95%CI 1.131-3.427). Compared with blood type A, patients with blood type B were more likely to experience tibial plateau fracture with meniscus injury (OR = 2.967, 95%CI 1.531-5.748), and office work was a protective factor (OR = 0.279, 95%CI 0.126-0.618). The C-index of the overall survival model was 0.687 (95% CI, 0.623-0.751). Similar C-indices were obtained for external validation [0.700(0.631-0.768)] and internal validation [0.639 (0.638-0.643)]. The model was adequately calibrated and its predictions correlated with the observed outcomes. The DCA curve showed that the model had the best clinical validity when the threshold probability was 0.40 and 0.82.

Conclusions

Patients with blood type B and high-energy injuries are more likely to have meniscal injury. This may help in clinical trial design and individual clinical decision-making.

"Flipped Lid" Fracture of the Lateral Tibial Plateau with Dislocated Lateral Meniscus: A Case Report

CASE

We present a rare "flipped lid" type of fracture of the lateral tibial plateau with dislocation of the lateral meniscus into the notch with intact roots. This was fixed using headless screws through arthrotomy and peripheral suturing of the meniscus. At the 1-year follow-up, although there was terminal restriction of 10° flexion with redislocation of the lateral meniscus, the patient was able to perform all daily activities and declined further surgery.

CONCLUSION

Flipped lid-type fracture is rare and results in good outcome when fixed early. Meniscal dislocation repair requires close monitoring to detect failure.

The value of magnetic resonance imaging in the preoperative diagnosis of tibial plateau fractures: a systematic literature review

Purpose

The outcome of a tibial plateau fracture (TPF) depends on the fracture reduction achieved and the extent of soft-tissue lesions, including lesions in the ligaments, cartilage, and menisci. Sub-optimal treatment can result in poor knee function and osteoarthritis. Preoperative planning is primarily based on conventional X-ray and computed tomography (CT), which are unsuitable for diagnosing soft-tissue lesions. Magnetic resonance imaging (MRI) is not routinely performed. To date, no literature exists that clearly states the indications for preoperative MRI. This systematic review aimed to determine the frequency of soft-tissue lesions in TPFs, the association between fracture type and soft-tissue lesions, and the types of cases for which MRI is indicated.

Methods

A systematic review of the literature was based on articles located in PubMed/MEDLINE and the Cochrane Central Register of Controlled Trials (CENTRAL), supplemented by searching the included articles’ reference lists and the ePublication lists of leading orthopedic and trauma journals.

Results

A total of 1138 studies were retrieved. Of these, 18 met the eligibility criteria and included a total of 877 patients. The proportion of total soft-tissue lesions was 93.0%. The proportions of soft-tissue lesions were as follows: medial collateral ligament 20.7%, lateral collateral ligament 22.9%, anterior cruciate ligament 36.8%, posterior cruciate ligament 14.8%, lateral meniscus 48.9%, and medial meniscus 24.5%. A weak association was found between increasing frequency of LCL and ACL lesions and an increase in fracture type according to Schatzker's classification. No standard algorithm for MRI scans of TPFs was found.

Conclusion

At least one ligament or meniscal lesion is present in 93.0% of TPF cases. More studies with higher levels of evidence are needed to find out in which particular cases MRI adds value. However, MRI is recommended, at least in young patients and cases of high-energy trauma.

The pivot fracture: an unusual tibial plateau fracture found in association with acute ACL injury

Tibial plateau fractures are common fractures which are often associated with concurrent soft tissue injury and for which accurate preoperative diagnosis is important for development of an appropriate treatment plan and outcome prediction. Here, we present an extreme manifestation of the pivot shift phenomenon with an unusual tibial plateau fracture with flipped component not described by any existing tibial plateau fracture classification system and never reported previously in conjunction with an anterior cruciate ligament injury. We describe the utilization of advanced imaging not typically utilized in the management of tibial plateau fractures in combination with clinical suspicion to diagnose the associated soft tissue injuries and develop an appropriate management plan.

Is It Necessary To Add Soft Tissue Injury to the Classification in Tibial Plateau Fracture Management?

Background

A gold standard classification for the treatment of tibial plateau fractures with soft tissue injury has not been established yet.This study aimed to evaluate the usability of a novel modified classification that can provide preoperative information to the surgeon about soft tissue injuries in tibial plateau fractures.

Methodology

A total of 36 patients with tibial plateau fractures were included in the study. Patients’ age, gender, and affected sides were recorded. Injuries to the medial meniscus, lateral meniscus, anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament, and lateral collateral ligament were examined with preoperative magnetic resonance imaging. Soft tissue injuries were arranged according to the novel modified classification based on the Schatzker classification.

Results

The mean age of the study participants was 45 (19-76) years; 72% of the patients were men and 28% were women. Moreover, 44% and 56% of the patients had broken the right and left tibial plateaus, respectively. At least one soft tissue injury was detected in 29 (81%) patients. In 14 (39%) patients, two or more soft tissue injuries were observed. All patients were arranged according to the novel modified classification regarding ligament and meniscus injuries.

Conclusions

With this novel modified classification system, we think that having better information about the preoperative condition of the soft tissue injuries can change the surgical strategy in patients with tibial plateau fractures.

Clinical and radiographic results after arthroscopic repair of lateral meniscus tear in lateral-depression tibial plateau fracture

INTRODUCTION

To evaluate the clinical and radiographic results of AR/IF and meniscus repair for treating lateral meniscus (LM) tears associated with lateral tibial plateau fractures and to identify the factors associated with LM tear.

MATERIALS AND METHODS

Forty-two patients with lateral plateau fractures (Schatzker types II and III) treated by AR/IF were included retrospectively. Radiographic evaluations using the Rasmussen system and computerized tomography (CT) were performed. Clinical evaluations were also conducted at final follow-up. Second-look arthroscopy was applied during metal removal.

RESULTS

All fractures were healed after 46.3 months of follow-up. The mean Tegner activity level was not decreased significantly, going from 7.1 ± 2.1 pre-injury to 6.6 ± 2.3 at final follow-up (p = 0.301). However, the amount of depression noted on CT imaging was significantly decreased from 8.9 mm ± 4.4 to 1.2 mm ± 1.3 (p = 0.000). The mean Rasmussen radiologic score at final follow-up was 14.5 ± 5.3 points. Osteoarthritis was progressed in six patients (14.3%). Twenty-five patients had concomitant LM tear, with 18 cases treated by repair and the remaining ones treated by partial meniscectomy. Preoperative joint depression (> 11 mm) was significantly associated with the risk of LM tear (p = 0.024; odds ratio (OR): 9.0, 95% confidence interval (CI): 1.018-79.545) and most of those lesions could be repaired (p = 0.001). Postoperatively, 16 repaired patients were evaluated by second-look arthroscopy; 15 had healed completely and one had healed partially.

CONCLUSION

LM tears are frequently combined with lateral tibial plateau fracture, especially in correlation with more than 11 mm of joint depression, though most of those lesions can be repaired at the time of fracture fixation. AR/IF with arthroscopic meniscus repair could achieve good clinical and radiographic outcomes when treating Schatzker types II and III tibial plateau fractures.

STUDY DESIGN

Level IV retrospective cohort study.

Arthroscopic evaluation for tibial plateau fractures on the incidence and types of cruciate ligamentous injuries following closed reduction and internal fixation

PURPOSE

To evaluate the overall incidence and types of anterior cruciate ligament (ACL) injuries and posterior cruciate ligament (PCL) injuries associated with tibial plateau fractures (TPFs) following closed reduction and internal fixation (CRIF), and to identify the relationship between the incidence and types of cruciate ligamentous injuries with Schatzker classification and "three-column" classification.

METHODS

From January 2016 to January 2018, 185 patients with closed TPFs who underwent CRIF were included in this retrospective study. All patients were performed with arthroscopic examination after CRIF, and then, the incidence and types of cruciate ligamentous injuries were recorded and evaluated.

RESULTS

The overall incidence rates of cruciate ligamentous injuries associated with TPFs were 37.3% with 21.6% of these being ACL injuries and 15.7% had PCL injuries. Importantly, patients with fractures in "two-column" fractures have a significantly higher incidence rate of ACL avulsion fracture and PCL complete tears (P < 0.05) than other fracture types, especially involving anteromedial and posterior column fractures. In addition, the incidence of PCL partial tears in patients with three-column involvement was 11.8%, which was higher than other fracture patterns based on three-column classification system (P < 0.05). In the current study, Schatzker IV was most commonly associated with ACL injuries, occurring in 48.1% of our series. Furthermore, PCL injuries occurred at a significantly higher incidence in Schatzker VI with 34.5% than other fracture types (P < 0.05). Statistical analysis revealed that there was a significant difference between Schatzker classification and incidence of injury to the ACL (P < 0.05) and PCL (P < 0.05). Of note, avulsion fracture was the most common types of ACL injuries which was observed in 45% ACL injuries, while partial tear was the most common types of PCL injuries. However, no significant relationship was identified between the types of cruciate ligamentous injuries and Schatzker classification (P > 0.05).

CONCLUSIONS

In the recognition of concomitant cruciate ligamentous injuries associated with TPFs based on Schatzker classification and three-column classification, orthopaedic trauma surgeons may better guide optimal surgical protocols for patients.

Knee and Leg Injuries

Knee and leg injuries are extremely common presentations to the emergency department. Understanding the anatomy of the knee, particularly the vasculature and ligamentous structures, can help emergency physicians (EPs) diagnose and manage these injuries. Use of musculoskeletal ultrasonography can further aid EPs through the diagnostic process. Proper use of knee immobilizers can also improve long-term patient outcomes.

Combined autologous chondrocyte implantation and meniscus reconstruction for large chondral defect in the lateral compartment due to discoid lateral meniscus tear: A case report

Discoid lateral meniscus tear leads to large chondral defect in the lateral compartment of the knee joint. There are few effective treatments for large chondral defect in both the tibial and femoral sides with severe degenerative lateral meniscus. We have developed a combined autologous chondrocyte implantation and meniscus reconstruction technique using hamstring tendon. This technique allows biological reconstruction and avoids knee arthroplasty.

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Discoid lateral meniscus tear leads to large chondral defect.

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A combination of autologous chondrocyte implantation and meniscus reconstruction technique using hamstring tendon is introduced.

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This novel method allows biological reconstruction.

Incidence and Radiological Predictors of Concomitant Meniscal and Cruciate Ligament Injuries in Operative Tibial Plateau Fractures: A Prospective Diagnostic Study

The aim of this prospective study was to determine the incidence of meniscal and cruciate ligament injuries in operative tibial plateau fractures detected using knee arthroscopy, and to identify the radiological predictors observed on CT images. From January 2016 to February 2017, a total of 102 closed tibial plateau fractures were enrolled in this prospective protocol. Each patient underwent arthroscopic examination following the tibial plateau internal fixation. Univariate analysis and multivariable logistic regression were used to assess the association between imaging parameters and soft-tissue injuries. The menisci were traumatically injured in 52.9% of subjects (54 of 102) and the cruciate ligaments injured in 22.5% (23 of 102). Significantly higher injury rates for bucket-handle meniscal tears were observed in Schatzker type VI fractures (P = 0.04). Greater risk of lateral meniscus injury was observed in patients with >6.3 mm of lateral joint depression. Greater risk of ACL injury when the volumetric lateral joint depression was ≤209.5 mm2 and/or with >5.7 mm lateral joint widening. Associated meniscal and ligament injuries were commonly seen among operative tibial plateau fractures. Preoperative CT measurements might help predict a higher risk of meniscus and ACL injury, providing guidance to the surgeon to look for and to be prepared to treat such injuries.

Prediction of Meniscal and Ligamentous Injuries in Lateral Tibial Plateau Fractures Based on Measurements of Lateral Plateau Widening on Multidetector Computed Tomography Scans

Background

The influence of increasing lateral plateau widening on the frequency of meniscal and ligamentous lesions in lateral tibial plateau fractures has been examined in very few studies using plain radiographs. Because the amount of this parameter cannot be measured accurately on plain radiographs, the purpose of this survey was to look for a possible correlation between the extent of lateral plateau widening, as measured on multidetector CT (MDCT) scans, and different soft-tissue injuries determined from magnetic resonance imaging (MRI).

Materials and Methods

55 patients with a lateral tibial plateau fracture were included in this retrospective case series. Patient age averaged 52.6 years (SD = 18.0). The degree of lateral plateau widening was measured on CT images. MRIs were screened for meniscal and ligamentous injuries.

Results

We found a significant effect of increasing lateral plateau widening on the incidence of lateral meniscus lesions (P = 0.021), lateral collateral ligament tears (P = 0.047), and the overall quantity of meniscal and ligamentous lesions (P = 0.001).

Discussion

MRIs are not widely used as a diagnostic tool in lateral plateau fractures of the tibia. Reasons might be the costs and the fact that it is a time-consuming examination. The results of this study may help to estimate the probability of specific soft-tissue lesions in lateral tibial plateau fractures based on measurements of lateral plateau widening on MDCT scans, and they may guide the decision for additional MRI and/or arthroscopically assisted repair.

What Is Important Besides Getting the Bone to Heal? Impact on Tissue Injury Other Than the Fracture

Fracture surgeons do a great job of managing bone issues, but they may overlook the associated soft tissue injuries that play a significant role in the final outcome after musculoskeletal injury. The soft tissue reconstruction ladder can help guide reconstructive procedures based on the least complex procedure that allows the best chance of fracture healing. Muscle injury, volume loss, and deconditioning occur with traumatic injury and during the recovery phase. Neuromuscular stimulation, nutrition, and strength training are potential ways to aid in recovery. Complex periarticular knee injuries have a high rate of associated soft tissue injuries that may affect outcome if associated with knee instability. Identifying and addressing these injuries can increase the likelihood of a good outcome. Articular cartilage loss can make articular reconstruction impossible. Large fresh osteoarticular allografts can be a reconstructive option. Addressing all the damaged structures involved with a fracture may be the next step in improving patient outcomes.

The Effect of Soft Tissue Injuries on Clinical Outcomes After Tibial Plateau Fracture Fixation

OBJECTIVE

To determine if ligamentous and meniscal injuries as determined by initial magnetic resonance imaging altered clinical outcomes after the fixation of tibial plateau fractures.

DESIGN

Comparative cohort study.

SETTING

Academic level I trauma center.

PATIENTS/PARTICIPANTS

Eighty-two patients from a prospective database of operatively treated tibial plateau fractures met the inclusion criteria, which consisted of injury radiographs, preoperative knee magnetic resonance imaging (MRI), and a minimum of 12 months of clinical outcomes.

INTERVENTION

In addition to radiographs and computed tomography scans for fracture assessment, an MRI was performed to detect tears in the medial and lateral menisci and complete ruptures of the cruciate ligaments (anterior cruciate ligament and posterior cruciate ligament) and collateral ligaments [lateral collateral ligament and medial collateral ligament (MCL)]. Surgical fixation of tibial plateau fractures was performed by a single surgeon based on injury patterns.

MAIN OUTCOME MEASUREMENTS

Clinical outcomes included the Knee Outcome Survey Activities of Daily Living Scale, the Lower Extremity Functional Scale, the Short-Form 36, and knee range of motion. Secondary soft tissue surgeries and conversion to arthroplasty were also noted.

RESULTS

On injury MRI, 60 patients (73%) had injuries to at least one soft tissue structure. At final follow-up, 2 patients (2%) had a secondary soft tissue surgery and 1 patient (1%) underwent total knee arthroplasty. Patient-reported outcomes and range of motion assessments were not significantly different in patients with and without medial meniscal tears, lateral meniscal tears, and complete MCL ruptures.

CONCLUSIONS

In this cohort of patients with operative tibial plateau fractures, sutured lateral meniscal tears, untreated medial meniscus tears, and complete MCL ruptures did not significantly affect clinical outcomes. In addition, these data suggest that obtaining a preoperative MRI in patients with tibial plateau fractures to diagnose soft tissue injuries may not alter the surgical treatment or alter patient prognosis for midterm outcomes.

LEVEL OF EVIDENCE

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

The Efficacy of Meniscal Treatment Associated with Lateral Tibial Plateau Fractures

Purpose

The purpose of this study was to examine the incidence of lateral meniscal tears associated with lateral tibial plateau fractures and report the clinical outcomes of meniscal treatment with internal fixation of fractures.

Materials and Methods

All lateral tibial plateau fractures (Schatzker types II and III) in skeletally mature patients treated operatively at our institution between January 2010 and February 2016 were included. All patients underwent open reduction and internal fixation using a buttress plate or cancellous screws. All meniscal tears were initially considered for repair using an all-inside technique.

Results

The incidence of lateral meniscal tears with lateral tibial plateau fractures was 64%. Ten patients underwent meniscal repair. In second-look arthroscopy, normal healing was observed in all of the repaired lateral menisci. At the last follow-up, none of the 10 patients had clinical symptoms related to meniscal injuries. One of the 4 patients who had not undergone meniscal treatment although a lateral tear was suspected based on magnetic resonance imaging achieved stable bony union; however, due to the complaint of persisting knee pain, lateral meniscectomy was performed.

Conclusions

Treatment of meniscal lesions associated with lateral tibial plateau fractures showed good clinical and second-look arthroscopic results. Therefore, we believe that recognition and treatment of a meniscal injury at the time of surgical fixation can improve clinical outcome.

Accuracy of 64-section MDCT in the diagnosis of cruciate ligament tears

AIM

To evaluate the accuracy of non-arthrographic 64-section multidetector computed tomography (CT) in the assessment of cruciate ligament tears. A secondary goal was to determine its accuracy in the diagnosis of additional soft-tissue injuries around the knee.

MATERIALS AND METHODS

Forty consecutive outpatients underwent same-day magnetic resonance imaging (MRI) and 64-slice multidetector CT (MDCT) of the knee in this prospective study. MDCT images were independently evaluated for integrity of the anterior (ACL) and posterior cruciate ligaments (PCL), medial and lateral menisci, and medial and lateral collateral ligaments. Recognised secondary signs of ACL tears were also documented. MRI images were subsequently assessed by two radiologists and a consensus reached.

RESULTS

The sensitivity of MDCT for ACL tears was 87.5-100%, with a specificity of 100%. The presence of one or more secondary signs of ACL tears on MDCT had a sensitivity of 50-87.5% with a specificity of 100%. The sensitivity of MDCT for PCL tears was 0-25% with a specificity of 100%. The sensitivity for meniscal tears was 9.1-23.1% with a specificity of 96.3-100%.

CONCLUSION

64-section MDCT has very high sensitivity and specificity for ACL tears and, as on MRI, secondary signs, such as buckling of the PCL, are also useful in their diagnosis. MDCT has a low sensitivity for other soft-tissue injuries at the knee; however, its high specificity indicates that apparent PCL, meniscal, and collateral ligament tears can reliably be treated as true-positive findings.

Evolution of Intrameniscal Signal-Intensity Alterations Detected on MRI Over 24 Months in Patients With Traumatic Anterior Cruciate Ligament Tear

OBJECTIVE

The objective of our study was to assess the prevalence and evolution of intrameniscal signal-intensity alteration in subjects with an anterior cruciate ligament (ACL) tear over 24 months and compare clinical outcome and changes of cartilage between subjects with and those without this meniscal abnormality.

MATERIALS AND METHODS

Fifty-seven subjects with an ACL tear were screened for intrameniscal signal-intensity alteration. Morphologic and compositional MRI was performed before ACL reconstruction and 12 and 24 months after ACL reconstruction. Twelve subjects with an intrameniscal signal-intensity alteration and 12 subjects without any meniscal abnormality on MRI were identified. Clinical outcome was measured using the Knee Injury and Osteoarthritis Outcome Score (KOOS), and T1ρ and T2 maps of the cartilage were obtained.

RESULTS

In 10 of 12 subjects (83%) the meniscal signal-intensity abnormality identified on baseline MRI was located at the posterior horn of the medial meniscus. None of these subjects presented with a meniscal tear over 24 months of follow-up. At 12 months after the ACL tear, the intrameniscal signal-intensity alteration detected on baseline MRI had completely resolved in seven of 12 subjects (58%), showed a signal-intensity decrease in four (33%), and remained stable in one subject (8%). Of the 10 subjects who underwent MRI at 24 months, the meniscal signal-intensity alteration had completely resolved in eight (80%), and the signal intensity had decreased in the other two subjects. Changes in the KOOS and cartilage T1ρ and T2 values from baseline and 24 months did not differ significantly between subjects with and those without intrameniscal signal-intensity alteration (p > 0.05).

CONCLUSION

High intrameniscal signal-intensity alterations are a common finding in subjects with an ACL tear and have a benign course over 24 months after surgical repair of the ACL tear.

Arthroscopic management of proximal tibial fractures: technical note and case series presentation

Background and aims

The purpose of this article is to describe a new surgical method of arthroscopy assisted treatment of intraarticular proximal tibial fractures (ARIF – arthroscopic reduction and internal fixation), analyzing its efficiency and safety on a series of patients. Tibial plateau fractures affect the proximal tibial metaphyseal and articular surface, representing 1.2% of all fractures and up to 8% of all fractures in elderly.

Patients and method

Our case series consists of 6 patients with Schatzker types I-III tibial plateau fractures, treated in the Orthopedic and Traumatology Clinic of Cluj-Napoca from July 2012 to August 2014. Patients included in the study presented Schatzker type I-III tibial plateau fracture.

Results

The results obtained with the arthroscopic method were excellent in 5 cases (mean Rasmussen score 27.60 points) and good in 1 case (mean score 23.75). The radiological consolidation appeared after a mean of 12 weeks. No major complication was noted.

Conclusions

Diagnosis and treatment of associated lesions, shortening of hospitalization length and postoperative rehabilitation, but also the lower rate of complications, can make arthroscopic reduction and internal fixation the method of choice for the operative treatment of selected Schatzker I-III types of proximal tibial fractures.

Arthroscopy-assisted surgery for tibial plateau fractures

PURPOSE

This study aimed to summarize the recent clinical outcomes of patients undergoing arthroscopy-assisted reduction and internal fixation (ARIF) for tibial plateau fractures.

METHODS

A systematic electronic search of the PubMed and Cochrane databases was performed in January 2014. All English-language clinical studies on tibial plateau fractures treated with ARIF that were published after January 1, 2000 were eligible for inclusion. Basic information related to the surgery was collected.

RESULTS

The search criteria initially identified 141 articles, and 19 studies were included in this systematic review. There were 2 retrospective comparative studies, 16 case series studies, and one clinical series based on a technique note. There were a total of 609 patients in this systematic review, with a mean follow-up time of 52.5 months. The most common fracture types were Schatzker types II and III. Concomitant injuries were common: 42.2% of the patients had meniscal injuries, and 21.3% had anterior cruciate ligament (ACL) injuries. In addition, the status of 90.5% of the patients was classified as good or excellent according to the clinical Rasmussen scoring system, and 90.9% of the patients were satisfied with the treatment. Only 6 severe complications were reported, including one case of compartment syndrome.

CONCLUSIONS

ARIF is a reliable, effective, and safe method for the treatment of tibial plateau fractures, especially when they present with concomitant injuries.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and Level IV studies.

The usefulness of MRI and arthroscopy in the diagnosis and treatment of soft-tissue injuries associated with split-depression fractures of the lateral tibial condyle

The role of arthroscopy in the treatment of soft-tissue injuries associated with proximal tibial fractures remains debatable. Our hypothesis was that MRI over-diagnoses clinically relevant associated soft-tissue injuries. This prospective study involved 50 consecutive patients who underwent surgical treatment for a split-depression fracture of the lateral tibial condyle (AO/OTA type B3.1). The mean age of patients was 50 years (23 to 86) and 27 (54%) were female. All patients had MRI and arthroscopy. Arthroscopy identified 12 tears of the lateral meniscus, including eight bucket-handle tears that were sutured and four that were resected, as well as six tears of the medial meniscus, of which five were resected. Lateral meniscal injuries were diagnosed on MRI in four of 12 patients, yielding an overall sensitivity of 33% (95% confidence interval (CI) 11 to 65). Specificity was 76% (95% CI 59 to 88), with nine tears diagnosed among 38 menisci that did not contain a tear. MRI identified medial meniscal injuries in four of six patients, yielding an overall sensitivity of 67% (95% CI 24 to 94). Specificity was 66% (95% CI 50 to 79), with 15 tears diagnosed in 44 menisci that did not contain tears.

MRI appears to offer only a marginal benefit as the specificity and sensitivity for diagnosing meniscal injuries are poor in patients with a fracture. There were fewer arthroscopically-confirmed associated lesions than reported previously in MRI studies.

Cite this article: Bone Joint J 2014;96-B:1631–6.

Lateral meniscocapsular separation in patients with tibial plateau fractures: detection with magnetic resonance imaging

OBJECTIVE

This study aimed to retrospectively evaluate magnetic resonance imaging findings for the detection of lateral meniscocapsular separation (LMCS) in patients with tibial plateau fractures. We hypothesize that patients with LMCS have greater perimeniscal abnormal signal or greater distance between the lateral meniscus (LM) and the lateral collateral ligament (LCL) than patients without LMCS.

METHODS

The study group included 16 patients with LMCS and 11 patients with normal LMCS who underwent surgery due to tibial plateau fracture. Magnetic resonance images were assessed for the width of perimeniscal abnormal signals on 3 orthogonal planes. The distance between LM and LCL was measured on coronal images. Nonparametric tests were performed.

RESULTS

The thickness of perimeniscal abnormal signals was increased in the patient group than in control group (median, 10.00 [interquartile range, 9.00-12.70] mm vs 3.39 [2.45-3.67] mm at axial images [P < 0.001]; 8.60 [3.75-11.26] mm vs 2.73 [1.64-4.38] mm at coronal images [P = 0.015]; 13.57 [9.50-15.04] mm vs 4.65 [0-5.89] mm at sagittal images [P = 0.002], respectively). Sixteen patients in the patient group had involvement around the whole LM, whereas none of the patients in the control group had involvement around the whole LM (P < 0.001). The distance between LM and LCL was increased in the patient group than in the control group (9.00 [7.47-10.75] mm vs 5.11 [4.38-7.07] mm [P = 0.002], respectively). The cutoff value of 7 mm thickness of abnormal signal and distance between LM and LCL showed an accuracy of 96% (26/27 patients) and 85% (23/27 patients), respectively.

CONCLUSIONS

Patients with perimeniscal signal greater than 7 mm or distance between LM and LCL greater than 7 mm have high likelihood of LMCS.

Measurement of lateral plateau depression and lateral plateau widening in a Schatzker type II fracture can predict a lateral meniscal injury

PURPOSE

The purpose of this study is to determine the plain radiographic signs that can be indicative of meniscal injuries in Schatzker type II tibial plateau fractures.

METHODS

The lateral plateau depression and lateral plateau widening were measured on anteroposterior knee radiographs in 20 patients with Schatzker type II tibial plateau fracture. Meniscal injury was present in 12 patients (three, meniscal tears; nine, peripheral meniscal detachments). The lateral plateau depression and lateral plateau widening measurements were compared between those who had meniscal injury (Group 1) and those who did not (Group 2).

RESULTS

In Group 1, the median lateral plateau depression was 20 mm (IQR: 14-25) and the median lateral plateau widening was 12 mm (IQR: 10-14). In Group 2, the respective values were 10 mm (IQR: 5-17) and 6 mm (IQR: 2-10). There was a statistically significant difference in both parameters when the two groups were compared (p = 0.001).

CONCLUSIONS

A plain anteroposterior radiograph depicting a lateral plateau depression ≥14 mm and/or a lateral plateau widening ≥10 mm is associated with a significantly increased risk of meniscal injury in Schatzker type II tibial plateau fractures. These parameters can be used to predict the probable presence of lateral meniscal injury in such patients in routine clinical practice.

LEVEL OF EVIDENCE

Retrospective comparative study, level III.

Lateral compartment osteoarthritis of the knee

The lateral compartment is predominantly affected in approximately 10% of patients with osteoarthritis of the knee. The anatomy, kinematics and loading during movement differ considerably between medial and lateral compartments of the knee. This in the main explains the relative protection of the lateral compartment compared with the medial compartment in the development of osteoarthritis. The aetiology of lateral compartment osteoarthritis can be idiopathic, usually affecting the femur, or secondary to trauma commonly affecting the tibia. Surgical management of lateral compartment osteoarthritis can include osteotomy, unicompartmental knee replacement and total knee replacement. This review discusses the biomechanics, pathogenesis and development of lateral compartment osteoarthritis and its management.

Cite this article: Bone Joint J 2013;95-B:436–44.

The degree of articular depression as a predictor of soft-tissue injuries in tibial plateau fracture

PURPOSE

Magnetic resonance imaging (MRI) provides sufficient information with regard to specific soft-tissue injuries in the knee, but it is not generally used to evaluate acute tibial plateau fractures. The aim of the present study was to determine whether the amount of tibial plateau fracture depression on multi-detector computed tomography (MDCT) scans correlates with the incidence of associated soft-tissue injuries on MRI.

METHODS

A total of 54 consecutive patients with a mean age of 51.2 years (SD = 18.3) were included in this retrospective study. All patients were admitted to the emergency department of a university clinic with acute tibial plateau fracture. The amount of articular depression was assessed from MDCT scans. Magnetic resonance images were evaluated for crucial and collateral ligament injury, meniscal tears, and patellar retinaculum lesions.

RESULTS

Logistic regression revealed a significant impact of increasing tibial plateau fracture depression on the incidence of meniscus lateralis tears (P = 0.025) and anterior cruciate ligament lesions (P = 0.018). Analysis of covariance demonstrated a significant correlation between the amount of articular depression and absolute number of soft-tissue injuries (P = 0.001).

CONCLUSIONS

Articular depression is a potential predictor of specific meniscal and ligamentous injuries in acute tibial plateau fracture. Magnetic resonance imaging is generally recommended with respect to associated soft-tissue injuries, especially in cases with distinct tibial plateau fracture depression on multi-detector computed tomography scans.

LEVEL OF EVIDENCE

Case series, Level IV.

Repair of meniscal tears associated with tibial plateau fractures: a review of 15 cases

BACKGROUND

Tibial plateau fractures are frequently associated with meniscal tears. Little is known about the results of meniscal repair in this group of patients.

PURPOSE

To determine the results of repair of meniscal tears found during arthroscopically assisted reduction and internal fixation (ARIF) of tibial plateau fractures.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

In a cohort of 51 tibial plateau fractures treated with ARIF, 15 associated meniscal tears (15 knees) in 14 patients were repaired. There were 12 peripheral longitudinal tears of the lateral meniscus, 1 longitudinal peripheral tear of the medial meniscus, 1 full-thickness radial tear of the lateral meniscus, and 1 bird-beak tear of the lateral meniscus. Repairs were performed using an outside-in technique for the anterior horn and all-inside repair for the body and posterior horn lesions. Mean (SD) age at operation was 47.3 (14.0) years. Patients were followed for a mean (SD) of 4.83 (1.01) years and evaluated using the Rasmussen, Honkonen, Lysholm, Tegner, and International Knee Documentation Committee (IKDC) scores. A second-look arthroscopy was performed in 13 knees a mean (SD) of 14.2 (10.1) months after the initial surgery.

RESULTS

The mean (SD) Rasmussen score was 29.1 (0.96). Thirteen of 15 patients scored good or excellent results in all Honkonen sections. The mean (SD) Lysholm score was 88.6 (12.4). The mean (SD) IKDC score was 79.3 (19.3). There was a small decrease of the activity level according to the Tegner score when compared with the preoperative situation (1.20 [1.82], P = .022). There were not any meniscal symptoms in any case. Of the 13 menisci evaluated with second-look arthroscopy, 12 had healed completely and a radial tear had healed partially in the vascular zone. In one of the cases that healed, a new tear was found in a different location.

CONCLUSION

Meniscal repair of tears associated with tibial plateau fractures has good results. All patients had good or excellent clinical results. Second-look arthroscopy confirmed complete healing in 92% of meniscal tears when performed.

Effect of combined traumatic impact and radial transection of medial meniscus on knee articular cartilage in a rabbit in vivo model

PURPOSE

The purpose of this study was to test the hypothesis that combined meniscectomy and traumatic impact accelerate early degeneration of articular cartilage in the knee versus meniscectomy alone.

METHODS

A previously published in vivo rabbit cartilage impact model was used combined with radial transection of the medial meniscus posterior horn versus meniscal transection alone. Rabbits were killed 3 months after surgery. Quantitative histologic analysis of the articular cartilage proteoglycan depth and glycosaminoglycan (GAG) fraction was performed at the site of impact on the posterior femoral condyle (PFC) and at the distal femoral condyle (DFC) overlying the meniscectomy in the surgical knee and the contralateral control knee.

RESULTS

The articular cartilage in the knees that underwent isolated meniscectomy did not differ significantly from the contralateral control knees for any measured value. The knees with a combined insult had a lower GAG fraction (P = .03) at the PFC and a greater depth of proteoglycan loss at both the PFC (P = .02) and the DFC (P = .04) versus contralateral controls. Compared with meniscectomy alone, the combined-insult knees had a greater depth of proteoglycan loss at the DFC (P = .005).

CONCLUSIONS

On the basis of early results using GAG fraction and proteoglycan depth, combined traumatic impact and meniscectomy are more damaging to articular cartilage than meniscectomy alone.

CLINICAL RELEVANCE

A knee with a combination of meniscal injury and articular cartilage impact may be at particularly high risk for early joint degeneration.

ACR appropriateness criteria(®) acute trauma to the knee

There are more than 1 million visits to the ER annually in the United States for acute knee trauma. Many of these are twisting injuries in young patients who can walk and bear weight, and emergent radiography is not required. Several clinical decision rules have been devised that can considerably reduce the number of radiographic studies ordered without missing a clinically significant fracture. Although fractures are seen on only 5% of emergency department knee radiographs, 86% of knee fractures result from blunt trauma. In patients with falls or twisting injuries who have focal tenderness, effusion, or inability to bear weight, radiography should be the first imaging study performed. If radiography shows no fracture, MRI is best for evaluating for a suspected meniscal or ligament tear or patellar dislocation. Patients with knee dislocation should undergo radiography and MRI, as well as fluoroscopic angiography, CT angiography, or MR angiography. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Bicondylar tibial fractures: Internal or external fixation?

Bicondylar fractures of the tibia, representing the Schatzker V and VI fractures represent a challenging problem. Any treatment protocol should aim at restoring articular congruity and the metaphyseo-diaphsyeal dissociation (MDD)-both of these are equally important to long-term outcome. Both internal and external fixations have their proponents, and each method of treatment is associated with its unique features and complications. We review the initial and definitive management of these injuries, and the advantages and disadvantages of each method of definitive fixation. We suggest the use of a protocol for definitive management, using either internal or external fixation as deemed appropriate. This protocol is based on the fracture configuration, local soft tissue status and patient condition. In a nutshell, if the fracture pattern and soft tissue status are amenable plate fixation (single or double) is performed, otherwise limited open reduction and articular surface reconstruction with screws and circular frame is performed.

Knee and leg injuries

The knee plays a significant role in ambulation and the activities of daily living. During the course of these activities and its role in weight bearing, the knee is susceptible to a variety of different forces and the emergency physician should be familiar with the diagnosis and treatment of the injuries that result. In addition to following basic trauma protocols, thorough neurovascular and musculoskeletal examinations should be performed and supplemented with appropriate imaging. Emergency physicians should also consider recent developments in knee anatomy and function when evaluating the patient with an acutely injured knee.

Peri-articular fractures of the knee: an update on current issues

Peri-articular fractures of the knee in the young and elderly pose several management dilemmas. Over the last decade enormous interest has been generated in various fixation modalities, none proving to be an ideal stabilisation method. The problem is compounded by a lack of well-designed studies comparing various treatment options. In this article, the issues surrounding the diagnostic and management strategies of peri-articular fractures of the knee are discussed.