Clinical instability of the knee and functional differences following tibial plateau fractures versus distal femoral fractures

Gait biomechanics in patients with intra-articular tibial plateau fractures - gait analysis at three months compared with age- and gender-matched healthy subjects

INTRODUCTION

Tibial plateau fractures involve the knee joint, one of the most weight-bearing joints in the body. Studies have shown that gait asymmetries exist several years after injury. Instrumental gait analysis, generating both kinematic and kinetic data from patients with tibial plateau fractures, is uncommon.

AIM

To examine walking ability and knee range of motion in patients suffering intra-articular tibial plateau fractures.

METHOD

Twenty participants, eight males and 12 females, aged 44 years (range 26-60), with unilateral isolated tibial plateau fractures, were examined 12 weeks (range 7-20) after injury. The investigation consisted of passive range of motion (ROM) using a goniometer, six-minute walking test (6 MW), pain estimation using the visual analogue scale (VAS), the "Knee injury and Osteoarthritis Outcome Score" (KOOS) self-assessment questionnaire and instrumental 3-dimensional gait analysis (3DGA). 3DGA included spatiotemporal variables (speed, relative stance time, step length), kinematic variables (knee flexion, knee extension, ankle dorsiflexion) and kinetic variables (generating knee power (extension) and ankle power (plantarflexion)). A skin marker model with twenty reflective markers was used. Non-parametric tests were used for comparisons of the injured leg, the uninjured leg and a reference group.

RESULT

The participants walked more slowly compared with healthy references (p < 0.001). Stance time and step length was shorter for the injured side compared with the uninjured side (p < 0.014). Step length was shorter compared with the reference group (p = 0.001). The maximum knee extension in the single stance phase was worse in the injured side compared with the uninjured side and the reference group (p < 0.001) respectively. The maximum ankle dorsiflexion during stance phase was higher in the injured leg compared with the uninjured side and the reference group (p < 0.012). Maximum generated power in the knee was lower in the injured side compared with the uninjured side and the reference group (p < 0.001 respectively). The same was true of maximum power generated in the ankle (p < 0.023). The median KOOS value was lower in the study group (p < 0.001). ROM showed decreased flexion and extension in the knee joint and decreased dorsiflexion in the ankle joint compared with the uninjured side (p < 0.006). The average distance in the six-minute walking test was shorter in the study group (p < 0.001).

CONCLUSION

Patients who have sustained tibial plateau fractures generally display a limitation in their walking pattern 3 months after injury. These limitations are mainly related to the inability to extend the knee.

Clinical Management of Arthrofibrosis: State of the Art and Therapeutic Outlook

* Arthrofibrosis is a pathologic condition that is characterized by excessive periarticular scar-tissue formation. Arthrofibrosis may occur secondary to injury, surgical trauma, hemarthrosis, or infection, or it may occur idiopathically.* The pathogenesis of arthrofibrosis is incompletely understood but involves the dysregulation of normal reparative pathways, with transforming growth factor-beta (TGF-[beta]) as a principal mediator.* Current treatment options for arthrofibrosis primarily involve physiotherapy, operative manipulation, and surgical debridement, all with imperfect results.* Currently, there are no pharmacologic treatment options for arthrofibrosis. This has prompted increased investigational interest in the development of antifibrotic intra-articular therapies.

Why tibial plateau fractures are overlooked

BACKGROUND

Tibial plateau fractures (TPFs) are sometimes overlooked in the emergency room (ER). Using a national register covering 18 years we aimed to find out why and to evaluate if use of a specific radiographic decision rule, Pittsburgh Knee Rules (PKRs), could have reduced the number of overlooked TPFs.

METHODS

Medical records for 137 patients, prospectively registered during 18 years by the Danish Patient Compensation Association (DPCA) (a national register), were studied. The inclusion criterion was a delayed diagnosis of a fracture in the knee following a trauma. Case records, legal assessments, and evaluations by specialist doctors were reviewed, and the consequences of the delayed diagnosis for outcome and treatment were registered.

RESULTS

Only 58 patients (42%) had been evaluated according to PKRs. In 53 patient cases, the fracture was not diagnosed on radiographs obtained at the first medical contact. However, in 84% of these cases, the fracture was visible or was suspected by retrospective evaluation. 50 out of 79 patients, for whom X-rays were not obtained, were candidates for radiographs according to PKRs, 17 cases lacked information to evaluate by PKRs and 12 cases were not candidates. In 53% of all cases, it was evaluated that the fracture position had worsened at the time of diagnosis. A significant disability compensation was granted in 36% of cases due to the delayed identification of fractures, totaling 841,000 EUR.

CONCLUSIONS

The major reasons for overlooking TPFs were 1) difficulty in recognizing the fractures on X-rays and 2) that X-ray decision rules were not employed. Two thirds of the patients, for whom a radiograph had not been prescribed, would have had an X-ray, if the PKRs had been used. Overlooking TPFs significantly increased patient disability in one third of cases. We recommend that healthcare professionals in the ER use X-ray decision rules in addition to clinical examination to avoid overlooking TPFs. When standard radiographs are evaluated as normal in patients that are clinically suspect of a TPF, oblique X-rays, magnetic resonance imaging (MRI) or Computed Tomography (CT)-scan should be considered.

Expert Tibial Nails for Treating Distal Tibial Fractures With Soft Tissue Damage: A Patient Series

Distal tibial fractures with soft tissue damage are relatively difficult to treat. We assessed the outcomes of patients with these fractures treated with the Expert Tibial Nail^® (DePuy Synthes, Raynham, MA) from March 2012 to December 2014. At 6 months postoperatively, the general health quality of patients was assessed using operative time, interval to return to work, American Orthopaedic Foot and Ankle Society ankle scale score, pain measured using a visual analog scale, and short-form health outcomes 36-item survey physical functioning and mental health dimension scores. Of 11 cases, 7 (63.6%) were open fractures (3 [27.3%] Gustilo-Anderson type II, 3 [27.3%] type IIIA, and 1 [9.1%] type IIIB) and 4 (36.4%) were closed fractures with Tscherne-Oestern type II tissue damage. Their mean age was 52.2 (range 28 to 66) years. The mean operative time was 83 (range 65 to 105) minutes. The mean follow-up period was 16.3 (range 14 to 18) months. The median short-form 36-item survey scores were 79.1 (range 68.9 to 89.0) for the physical function dimension and 77.0 (range 64.3 to 90.0) for the mental health dimension. The mean postoperative ankle score was 88.6 (range 84 to 94). The mean pain score was 1.6 (range 0 to 4) mm. The mean interval to return to work was 14 (range 11 to 17) months. No patient showed evidence of neurovascular damage, malunion, nonunion, or shortening of the tibia. Taken together, we have confirmed that Expert Tibial Nails can effectively treat distal tibial fractures with soft tissue damage.