Optimizing Outcomes after Operative Treatment Bicondylar Tibial Plateau Fractures - Time for Innovation?

Bicondylar tibial plateau fractures are technically demanding fractures that have a high complication rate. We sought to review the recent literature with the aim to summarize the development of new classification systems that may enhance the surgeon's understanding of the fracture pattern and injury. We highlight the best methods for infection control and touch on new innovative solutions using 3D printer models and augmented mixed reality to provide potentially personalized solutions for each specific fracture configuration.

Staged treatment of bicondylar tibial plateau fractures: influence of frame configuration and quality of reduction on outcomes

PURPOSE

Despite evolving treatment, the surgical management of high-energy tibial plateau fractures (TPF) remains challenging, associating high rates of complications. In recent decades, staged management has emerged as an encouraging option. The main goal of our study was to evaluate the influence of bridging external fixation (EF) frame configuration and the resultant quality of reduction (QOR) on outcomes after staged-treatment of bicondylar TPF.

METHODS

A retrospective review was conducted of patients with bicondylar TPF treated at our level-I trauma center using a staged-treatment protocol from January 2010 to January 2020. Data on baseline characteristics, injuries, treatments, and clinical/radiological results were collected. The QOR was evaluated on CT images after EF and on plain films after ORIF.

RESULTS

Sixty-eight patients were eligible for analysis. By our criteria, QOR was good in 57.4% and 70.6% after EF and ORIF, respectively. A squared EF configuration was associated with superior EF QOR (p = 0.032), while better EF QOR was linked to improved ORIF QOR (p = 0.016). No relationship between ORIF delay and ORIF QOR was identified. Postoperative complications were documented in 19 patients. Average ROM at one-year follow-up was 114.9 ± 12.6°, and non-influenced by anterior femoral pin placement.

CONCLUSIONS

Staged management of bicondylar TPF resulted in a reasonable rate of complications. A direct relationship between QORs obtained with EF and after ORIF was found. Squared frames were associated with faster and better reductions, regardless of the surgeon's background. Considering our results, we advocate for the wider use of squared EF configurations in these patients.

Outcomes after ORIF of Bicondylar Schatzker VI (AO type C) Tibial Plateau Fractures in an Elderly Population

BACKGROUND

The surgical management of bicondylar tibial plateau (BTP) fractures in elderly patients aims to restore knee stability while minimizing soft tissue complications. The purpose of this study was to compare injury characteristics and surgical outcomes after ORIF of BTP fractures (AO/OTA 41-C (Schatzker VI)) in young (< 50 years) versus elderly (> 65 years) patients.

METHODS

A retrospective cohort study was conducted using data from two American College of Surgeons (ACS) level I trauma centers. Inclusion criteria were: (1) age 18 years or older, (2) bicondylar tibial plateau fracture (AO/OTA 41-C or Schatzker VI), (3) treatment with ORIF, and (4) minimum of 6 months follow-up. Patients between 50 and 65 years of age were excluded. Data collection was performed by reviewing electronic medical records, operative reports, and radiology reports.

RESULTS

We identified 323 patients (61% male) with 327 BTP fractures and a median follow-up of 685 days. There were 230 young patients (71%) < 50 years and 93 elderly patients (29%) >6 5 years at time of presentation. Elderly patients were significantly more likely to have a low energy mechanism of injury (44.6 vs. 16.2%, p < 0.001), and present with diabetes (19.4 vs. 4.4%, p < 0.001) or coronary artery disease (12.9 vs. 1.3%, p < 0.001). Elderly patients were also significantly less likely to undergo staged management with initial knee-spanning external fixation followed by delayed ORIF (19.2 vs. 33.9%, p = 0.008). Elderly patients had a lower arc of motion at final follow-up (105 vs. 113°, p < 0.001) and reduced PROMIS-10 function scores (43.8 vs. 49.8, p = 0.013). No differences were observed in rates of superficial infection, deep infection, reoperation, or EQ-5D scores between age groups.

CONCLUSIONS

This is the largest study to compare injury characteristics and outcomes after ORIF of BTP fractures according to age. Elderly patients (age > 65 years) sustained BTP fractures by lower energy mechanisms than their younger counterparts with similar fracture patterns and were often managed with ORIF. The results of this study suggest that ORIF of BTP fractures in elderly patients is associated with similar complication rates and outcomes as in younger patients despite higher comorbidities and poorer bone quality in the elderly population.

Modified anterior midline approach to treat hyperextension bicondylar tibial plateau fractures: Surgical technique and clinical experience with 18 cases

BACKGROUND

We evaluated the modified anterior midline approach and its efficacy for hyperextension bicondylar tibial plateau (HEBTP) fractures.

METHODS

From 2015 to 2019, 18 patients with HEBTP fractures with just little posterior cortical displacement were treated using the modified anterior midline approach. The operative protocols are fully described in this article, and the following parameters: articular step-off height (ASH), posterior tibial slope angle (pTSA), and medial tibial plateau angle (mTPA) were measured perioperatively and at the final follow-up. We also recorded the Rasmussen score and range of motion (ROM) to assess knee joint function at the final follow-up.

RESULTS

No complications, such as percutaneous nerve damage, infection, skin necrosis, and internal fixation breakage or loosening occurred perioperatively. The mean time for bony union was 13.7 weeks, and the mean preoperative ASH of the anterior cortex was 4.49 mm; this was restored to its normal height after surgery. The mean preoperative pTSA and mTPA were - 5.89° and 81.69°, respectively, compared with 3.89° and 87.91°, respectively, postoperatively. Comparing the postoperative and final follow-up radiographs, there were no significant differences in ASH, pTSA, and mTPA (P < 0.05). The average Rasmussen score was 27.2 (range, 23-29) at the final follow-up. Excellent results were achieved in 14 (77.8%) patients and good in 4 (22.2%) patients. The mean ROM in flexion was 123.2° and 2.9° in extension at the final follow-up.

CONCLUSIONS

This study suggested that the modified anterior midline approach is a reasonable alternative for HEBTP fracture repair.

Long-term outcomes after open reduction and internal fixation of bicondylar tibial plateau fractures

INTRODUCTION

To establish normative data, long-term patient-reported functional outcome and health-related quality of life (HrQoL) after operative treatment of bicondylar tibial plateau fractures. Secondly, to identify risk factors associated with functional outcome and HrQoL.

PATIENTS AND METHODS

We performed a retrospective cohort study at two Level I trauma centers. All adult patients with AO/OTA 41-C or Schatzker V/ VI tibial plateau fractures treated between 2001 and 2016 (n = 450) by open reduction internal fixation (ORIF). The survey was completed by 214 patients (48%). Primary outcome was patient-reported functional outcome assessed with the PROMIS Physical Function (PROMIS PF). Secondary outcomes were HrQoL measured with the EuroQol 5-Dimensions 3-Levels (EQ-5D-3 L), infection rate, and total knee arthroplasty (TKA) rate.

RESULTS

Infection occurred in 26 cases (12%) and TKA was performed in 6 patients (3%). The median PROMIS PF scores was 49.8 (IQR;42-54). The median EQ-5D-3 L was 0.83 (IQR;0.78-1.0).%). The multivariable regression model revealed female gender, diabetes, and worse HrQoL were correlated with worse functional outcome. The multivariable regression model revealed smoking, diabetes, and the subsequent need for TKA to be correlated with worse HrQoL.

CONCLUSION

The PROMIS PF and EQ-5D-3L did not reach a minimum clinically important difference. The PROMIS PF items revealed patients had no difficulty in walking more than a mile or climbing a flight of stairs. However, patients were limited in doing vigorous activities and patients should be counseled about the expected long-term outcomes. This study emphasizes the correlation between injury specific functional outcome measures and general health measures.

LEVEL OF EVIDENCE

Therapeutic Level III.

Diagnosis and treatment of hyperextension bicondylar tibial plateau fractures

PURPOSE

To report the diagnosis, injury mechanisms, and imaging characteristics of hyperextension bicondylar tibial plateau fractures and examine the indications and feasibility of the modified anterior midline incision as a treatment strategy.

METHODS

We performed a retrospective analysis of 11 cases of hyperextension bicondylar tibial plateau fractures who were treated with open reduction and internal fixation, predominantly via an anterolateral and posteromedialdouble incision or a modified anterior midline incision. Radiological and functional evaluations were performed.

RESULTS

Eleven patients were followed-up for a mean period of 11.5 months (range 3-24 months). The mean time to radiographic bony union was 12.5 weeks (range 10-26 weeks). At final follow-up, the average Rasmussen functional score was 26.8 (range 24 - 29); five patients had an excellent rating, and six a good rating. The average range of motion of the affected knees was 3.4-130° postoperatively. Fixation failure was not observed in any of the treated fractures.

CONCLUSION

Hyperextension bicondylar tibial plateau fractures show a special Tiankeng-like collapse characteristic, while the changes in posterior tibial slope angle are easy to overlook. The modified anterior midline incision is a safe and effective approach for treatment of hyperextension bicondylar tibial plateau fractures with less rear displacement. Open reduction and double plating for the treatment of hyperextension bicondylar tibial plateau fractures provides excellent results.

Malreduction of tibial articular width in bicondylar tibial plateau fractures treated with circular external fixation is associated with post-traumatic osteoarthritis

Objectives

We aimed to report outcomes of Bicondylar Tibial Plateau (BTP) fractures treated using Ilizarov fixation, and identify risk factors for developing post-traumatic radiographic osteoarthritis (ROA).

Methods

Retrospective study of 80 BTP fractures managed with Ilizarov fixation.

Results

All fractures united, with only 3 cases of deep infection. ROA was evident in 12.5% at average 13 months post-injury. Increased tibial articular-widening associated with risk of developing ROA (p = 0.02).

Conclusion

Ilizarov fixation is safe and reliable in the management of BTP fractures. Restoration of tibial articular-width at fixation associated with reduced risk of developing radiographic OA.

Staged Treatment of Bicondylar Tibial Plateau Fracture (Schatzker Type V or VI) Using Temporary External Fixator: Correlation between Clinical and Radiological Outcomes

Purpose

This study is to investigate clinical and radiological results of staged treatment using a temporary external fixator in bicondylar tibial plateau fractures (TPFs) and to evaluate correlation between prognostic factors and postoperative clinical outcomes.

Materials and Methods

Twenty-four bicondylar TPF patients were selected. All patients were operated by a temporary external fixator first and then open reduction and internal fixation with dual plating. Clinical and radiological outcomes were evaluated.

Results

The mean American Knee Society score (AKSS) was 85.3. The mean Western Ontario and McMaster Universities Osteoarthritis index was 11.2. The mean range of motion (ROM) was 123.4°. The mean medial tibial plateau angle (mTPA) was 88.3°, and the mean proximal posterior tibial angle (PPTA) was 8.4°. Compared with the uninjured limb, the mean difference of mTPA was 1.5° and that of PPTA was 4.0°. The difference of PPTA and the AKSS demonstrated negative correlation (p=0.007). Patients with normal mTPA showed better ROM than those with abnormal mTPA (p=0.041).

Conclusions

Staged treatment using a temporary external fixator in bicondylar TPFs showed good clinical and radiological outcomes. Surgeons should evaluate the reduction status intraoperatively by fluoroscopy and also refer to the uninjured limb radiologically.

Bicondylar conjoint Hoffa's fracture with patella entrapped in the fracture: A rare case report

Bicondylar Hoffa fracture involving both the femoral condyles is a rare injury. Conjoint variety with intact bone bridge between condyles in intercondylar notch area is even rare. We report a conjoint variety of bicondylar open grade III A Hoffa's fracture with patella entrapped in the fracture with quadriceps rupture in an adult which was surgically treated with initial debridement and later open reduction with fixation and quadriceps repair. The final outcome at 1 year post injury is satisfactory. To the best of our knowledge, no such case has been reported till date in English literature.

Operative Treatment of Isolated Bicondylar Hoffa Fracture With a Modified Swashbuckler Approach

Introduction:

An isolated coronal fracture of either or both femoral condyles is a rare entity and is usually associated with high-energy injury trauma. Such fractures should be meticulously fixed for a good functional outcome as they involve the articular surface of a weight bearing joint. A modified swashbuckler approach provides adequate exposure for appropriate reduction and fixation of such fractures.

Case Presentation:

A 32-year-old male sustained a bicondylar Hoffa fracture of the right femur which was treated by open reduction and internal fixation using a modified swashbuckler approach. At two years of follow-up, the patient had excellent radiological and functional outcome.

Conclusions:

In our study, we treated this rare fracture successfully using a modified swashbuckler approach and found it to be a good approach for such fractures as compared to the conventional approach.

Management of Proximal Tibia Fractures Using Wire Based Circular External Fixator

INTRODUCTION

Management of high grade proximal tibia or tibial plateau fractures is often associated with complications. The use of wire fixators for the definitive treatment of such fractures entails a minimally invasive technique of insertion that gives good fracture reduction and stability combined with minimal postoperative complications.

AIM

To assess the outcome of treatment of such fractures by the use of Joshi's external stabilization system (JESS), which is a wire based, circular external fixator system.

MATERIALS AND METHODS

A prospective, uncontrolled study was done using JESS on 20 consecutive patients of high energy fractures of the tibial plateau, classified according to the Schatzker's classification as type VI.

RESULTS

In this series, road traffic accidents accounted for most of the injuries (n=12), while pedestrian accidents (n=4), injury due to fall from height (n=3) and injury due to fall while playing (n=1) were the other modes of injury. The mean patient age was 39.4 years. The mean follow up period was 24 weeks. In this study, using Knee society score evaluation, excellent results were seen in 12 patients (60%), good results were seen in 5 patients (25%), fair in 2 patients (10%) and bad in 1 patient (5%). Complications seen were, pin tract infections in two cases (10%) which resolved with dressings and oral antibiotics and one case of non-union (5%), in which the tibial plateau fracture extended into proximal 1/3 of the tibial shaft with severe comminution. No other complication was encountered.

CONCLUSION

JESS is a simple, inexpensive and useful technique in the management of high grade tibial plateau fractures.