Clinical and radiological risk factors associated with the occurrence of acute compartment syndrome in tibial fractures: a systematic review of the literature

Introduction

Acute compartment syndrome (ACS) is an orthopedic emergency that may lead to devastating sequelae. Diagnosis may be difficult. The aim of this systematic review is to identify clinical and radiological risk factors for ACS occurrence in tibial fractures.

Methods

PubMed® database was searched in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Additional articles were found by a manual research of selected references and authors' known articles.

Results

The identification process individualized 2758 via database and 30 via other methods. After screening and eligibility assessment, 29 articles were included. Age, gender, occupation, comorbidities, medications, habits, polytrauma, multiple injuries, mechanism, sports, site, open vs closed, contiguous lesion, classification, and pattern were found to be related to ACS occurrence.

Conclusions

Younger age and male gender are strong independent risk factors in tibial plateau and shaft fractures. High-energy fractures, polytrauma, more proximal fractures and fractures with contiguous skeletal lesions are aggravating risk factors; higher AO/OTA and Schatzker classification types, increased displacement of the tibia relative to the femur, and increased tibial joint surface width are associated risk factors in tibial plateau fractures; higher AO Foundation/Orthopaedic Trauma Association classification types and subgroups and more proximal fractures within the diaphysis are associated risk factors in tibial shaft fracture. Open fractures do not prevent ACS occurrence. Increased fracture length is the only factor suggesting a higher risk of ACS in tibial pilon fractures. The presence of each independent predictor may have a cumulative effect increasing the risk of ACS occurrence.

Biomechanical comparison of intramedullary nail and plate osteosynthesis for extra-articular proximal tibial fractures with segmental bone defect

Purpose: Proximal tibial fractures are common, but the current available internal fixation strategies remain debatable, especially for comminuted fractures. This study aimed to compare the biomechanical stability of three internal fixation strategies for extra-articular comminuted proximal tibial fractures. Methods: A total of 90 synthetic tibiae models of simulated proximal tibial fractures with segmental bone defects were randomly divided into three groups: Single lateral plating (LP), double plating (DP) and intramedullary nailing (IN). Based on the different number of fixed screws, the above three groups were further divided into nine subgroups and subjected to axial compression, cyclic loading and static torsional testing. Results: The subgroup of intramedullary nailing with five proximal interlocking screws showed the highest axial stiffness of 384.36 ± 35.00 N/mm. The LP group obtained the lowest axial stiffness performance with a value of 96.59 ± 16.14 N/mm. As expected, the DP group offered significantly greater biomechanical stability than the LP group, with mean static axial stiffness and mean torque increasing by approximately 200% and 50%, respectively. According to static torsional experiments, the maximum torque of the DP subgroup was 3,308.32 ± 286.21 N mm, which outperformed all other groups in terms of torsional characteristics. Conclusion: Utilizing more than four distal screws did not provide improved biomechanical stability in the LP or DP groups, while a substantial increase in the biomechanical stability of DP was obtained when an additional medial plate was used. For the intramedullary nailing group, increasing the number of proximal interlocking screws could significantly improve biomechanical stability, and the intramedullary nailing with three proximal interlocking screws had similar static and cyclic stiffness as the DP group. The intramedullary nailing with five proximal screws had better axial stability, whereas DP had better torsional stability.

Long-Term Incidence of Total Knee Arthroplasty after Open Reduction and Internal Fixation of Proximal Tibial and Distal Femoral Fractures: A Nationwide Cohort Study

Knee fractures often require open reduction internal fixation (ORIF) for knee function recovery. More than one fifth of patients with knee fractures subsequently develop posttraumatic arthritis, and over 5% of them need total knee arthroplasty (TKA). We conducted this nationwide retrospective cohort study using the data of 2,000,000 people in the general population who received TKA and were followed up in the 17-year period 2001-2017, through random sampling of the Taiwan National Health Insurance Research Database. We matched the ORIF and non-fracture groups by a propensity score, based on age, sex, index date of surgery, and comorbidities enrolled in CCI calculated at a 1:1 ratio. The average proportion of subjects receiving TKA after ORIF for distal femoral or proximal tibial fractures was 2.0 per 1000 person-years, which was significantly higher than that in the non-fracture group. Patients aged 20-65 years and males represented a significantly higher proportion of subjects receiving TKA after ORIF than that in the non-fracture group. The proportion of subjects receiving TKA for the 20-65-year subgroup of the ORIF group was 4%, and that for the male subgroup was 1.5%; both rates increased over the 17-year follow-up period. More aggressive intraoperative and postoperative adjuvant therapies may be necessary for these subgroups.

Comparison of intramedullary nailing fixation and percutaneous locked plating fixation for the treatment of proximal tibial fractures: A meta-analysis

OBJECTIVE

This meta-analysis aimed to systematically compare the clinical outcomes of intramedullary nailing (IMN) fixation and percutaneous locked plating (PLP) fixation in the treatment of proximal tibial fractures.

METHODS

We searched PubMed, Embase, Cochrane library, China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database (VIP), and Wan Fang to select relevant articles up to March 29, 2020 without language limit. Continuous variables were estimated by weighted mean difference (WMD) with a 95% confidence interval (CI) and dichotomous outcomes were calculated by relative risk (RR) with 95% CI. Moreover, heterogeneity analysis was evaluated. Furthermore, publication bias assessment and sensitivity analysis were conducted. Stata 11.0 software was used to perform the statistical analysis.

RESULTS

Ten studies involving 667 cases (321 from IMN fixation group and 346 from PLP fixation group) were included. The type of fractures involved in the included articles was extra-articular proximal tibia fractures. IMN fixation method achieved significantly shorter union time (WMD = -2.88, 95% CI: -3.23 to -2.53, p < 0.001) and full weight-bearing time (WMD = -2.81, 95% CI: -3.64 to -1.97, p < 0.001) than PLP fixation method. Meanwhile, IMN fixation resulted in lower risks of infection (RR = 0.50, 95% CI: 0.27 to 0.91, p = 0.02) and total complications (RR = 0.36, 95% CI: 0.22 to 0.60, p < 0.001) than PLP fixation. No significant differences were found in the incidence of nonunion (p = 0.33), malunion (p = 0.38), and osteofascial compartment syndrome (OCS, p = 0.62) between the two groups.

CONCLUSIONS

Compared to PLP fixation, IMN fixation had several advantages in treating proximal tibial fractures, including the short time of union and full weight-bearing, as well as a low risk of infection and total complications.

Acute Primary Total Knee Arthroplasty for Proximal Tibial Fractures in Elderly

BACKGROUND

Proximal tibial fractures in elderly patients with osteoporosis or knee osteoarthritis (OA) are challenging cases. In the current study, we present our experience with uncommon acute primary total knee arthroplasty (PTKA) in this patient population.

METHODS

PTKAs were performed following proximal tibial fractures in 30 consecutive patients over 60 years of age with osteoporosis or knee OA between 2005 and 2009. Three constrained condylar knees (CCK) and no hinged knee prosthesis were used. Patients were followed up for 4.5±1.1 years.

RESULTS

Patients were discharged after 4.6±1.2 days. The postoperative Tegner activity scale (3.5±1.3) was improved significantly compared to the preoperative scale (2.5±1.2) (P<0.001). The knee flexion range was significantly greater in the operated side (106±13 degrees) compared to the uninjured knee (120±8 degrees) (P<0.001). The two sections of knee society knee score (knee and function section) averaged 90.7±6.5 and 69.6±8.8, respectively. All patients returned to their previous activities. Based on the visual analogue scale, the patients' satisfaction and pain at final visit were scored 8.1±1 and 1.5±1.2, respectively. No infection, thromboembolic events and loosening were observed.

CONCLUSION

PTKA following a proximal tibial fracture in elderly patients with osteoporosis or knee degeneration can be considered as a safe alternative for open reduction and internal fixation. PTKA resulted in immediate weight-bearing, improved functional status and patients' satisfaction. However, functional outcomes were dependent on the general condition of 24 the patient. Also, constrained knee prostheses were not necessary for a vast majority of the patients.