Comparison of radiographs and CT features between posterior Pilon fracture and posterior malleolus fracture: a retrospective cohort study

OBJECTIVES

This study explored the morphological differences between posterior Pilon fracture and posterior malleolus fracture from radiographs and CT to provide detail for diagnosis and treatment of them.

METHODS

Radiographs and CT imaging data of 174 patients with distal posterior tibial fractures who were treated from January 2013 to January 2019 were retrospectively analyzed. Based on the operation and imaging examination, the fractures were classified into posterior Pilon fractures and posterior malleolus fractures. Radiographic parameters including the width, height, depth, α angle, β angle, γ angle, fragment area ratio 1 (FAR1), δ angle and fragment area ratio 2 (FAR2) of ankle mortise were measured.

RESULTS

There were 96 posterior Pilon fractures (Type I: 30, Type II: 22 and Type III: 44) and 78 posterior malleolus fractures (Type I: 40 and Type II: 38). The ankle depth, α angle, γ angle, FAR1 and FAR2 of posterior Pilon fractures were larger than these of posterior malleolus fractures (p < 0.05). In addition, FAR1 and FAR2 of Type II and Type III posterior Pilon fractures were significantly larger than these of Type I (p < 0.05). FAR1 and FAR2 of Type I posterior malleolus fractures were significantly smaller than these of Type II (p < 0.05).

CONCLUSION

Radiographs combined with CT analysis is an effective method to accurately distinguish morphological features between posterior Pilon fracture and posterior malleolus fracture.

ADVANCES IN KNOWLEDGE

Radiographs combined with CT distinguished the fracture of posterior malleolus and posterior Pilon rapidly and accurately, instead of operation.

Epidemiological Study of Tibial Plateau Fractures Combined with Intercondylar Eminence Fractures

OBJECTIVE

To investigate the epidemiological characteristics of tibial plateau fractures combined with intercondylar eminence fractures and identify the risk factors.

METHODS

This retrospective study enrolled patients with tibial plateau fractures who were treated in the third hospital of Hebei Medical University from January 2015 to December 2018; 1020 patients (693 [68%] men and 327 [32%] women) meeting the inclusion and exclusion criteria had a mean age of 45.2 ± 13.8 years. In total, 506 (50%) cases were left injuries, 495 (48%) were right injuries, and 19 (2%) were bilateral injuries. Among them, 458 (44.9%) with a mean age of 47.0 ± 13.9 years had intercondylar eminence fractures, including 324 men and 134 women. A total of 562 (55.1%) patients were identified without intercondylar eminence fractures, including 369 (65.7%) men and 193 (34.3%) women with an average age of 43.8 ± 13.6 years. The distribution characteristics of tibial plateau fractures with intercondylar eminence involved were identified. The potential associations among fractures and various other factors, such as age, gender, occupation, and mechanism of injury, were explored.

RESULTS

The highest proportion age group of tibial plateau fractures included the ages 35-54 years, with more men than women for both age groups. For males, the highest proportion age group was 35-44 years, and for females, it was 55-64 years (χ 2 = 71.336, P < 0.01). According to Schatzker classification, type IV tibial plateau fractures had the highest risk of intercondylar eminence being involved (70.6%) without significance with type V (69.5%) and VI (68.2%) but with greater significance with types I (11.9%), II (39.2%), and III (9.4%, χ 2 = 280.187, P < 0.01). Multiple analysis showed that simple fractures, including types I, II, and III (OR 0.108, 95% CI: 0.080-0.145), were less likely to involve intercondylar eminence fractures than complex fractures, including types IV, V, and VI. Patients aged >74 years were more likely to have intercondylar eminence fractures compared with other age groups. Retired patients (OR 4.332, 95% CI: 1.147-16.362) were more likely to have fractured intercondylar eminence.

CONCLUSION

The current study revealed the characteristics of tibial plateau fractures, especially those involving intercondylar eminence fractures, as well as their proportion, distribution, and risk factors, which can be used as reference data for clinical assessment and surgical protocol selection.

Reconstruction of Gustilo Type IIIC Injuries of the Lower Extremity

BACKGROUND

Gustilo type IIIC open tibia fractures are characterized by an ischemic limb requiring immediate arterial repair. In this patient population, the decision between primary amputation and limb salvage can be challenging. This study aims to evaluate the reconstructive outcomes of patients with Gustilo type IIIC injuries.

METHODS

A single-center retrospective review of 806 lower extremity free flaps from 1976 to 2016 was performed. Flap loss and salvage rates for patients with Gustilo type IIIC injuries were determined. To determine the utility of performing salvage in this group, outcomes of the IIIC reconstructions were compared to those of similar patients with Gustilo I type IIB injuries with only a single patent vessel.

RESULTS

A total of 32 patients with Gustilo type IIIC injuries underwent reconstruction after traumatic injury. Ten patients (31.3 percent) experienced a perioperative complication, including seven unplanned returns to the operating room (21.9 percent), three partial flap losses (9.4 percent), and five complete flap losses (15.6 percent). When type IIIC injuries were compared with single-vessel Gustilo type IIIB injuries, no statistically significant differences were noted with respect to major perioperative complications (p = 0.527), unplanned return to the operating room (p = 0.06), partial flap loss (p = 0.209), complete flap loss (p = 0.596), or salvage rate (p = 0.368). Although this result was not statistically significant, Gustilo type IIIC injuries trended toward lower take-back rates and higher salvage rates compared with single-vessel Gustilo type IIIB injuries.

CONCLUSION

Patients with Gustilo type IIIC open tibia fractures should be considered candidates for limb salvage, as flap loss and reconstruction of these injuries are comparable to those of the routinely reconstructed single-vessel runoff type IIIB injuries.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Comparative evaluation of minimally invasive 'tibial tuberoplasty' surgical technique versus conventional open surgery for Schatzker II-III tibial plateau fractures: design of a multicentre, randomised, controlled and blinded trial (TUBERIMPACT study)

INTRODUCTION

Fractures of the tibial plateau are in constant progression. They affect an elderly population suffering from a number of comorbidities, but also a young population increasingly practicing high-risk sports. The conventional open surgical technique used for tibial plateau fractures has several pitfalls: bone and skin devascularisation, increased risks of infection and functional rehabilitation difficulties. Since 2011, Poitiers University Hospital is offering to its patients a new minimally invasive technique for the reduction and stabilisation of tibial plateau fractures, named 'tibial tuberoplasty'. This technique involves expansion of the tibial plateau through inflation using a kyphoplasty balloon, filling of the fracture cavity with cement and percutaneous screw fixation. We designed a study to evaluate the quality of fracture reduction offered by percutaneous tuberoplasty versus conventional open surgery for tibial plateau fracture and its impact on clinical outcome.

METHODS AND ANALYSIS

This is a multicentre randomised controlled trial comparing two surgical techniques in the treatment of tibial plateau fractures. 140 patients with a Schatzker II or III tibial plateau fracture will be recruited in France. They will be randomised either in tibial tuberoplasty arm or in conventional surgery arm. The primary outcome is the postoperative radiological step-off reduction blindly measured on CT scan (within 48 hours post-op). Additional outcomes include other radiological endpoints, pain, functional abilities, quality of life assessment and health-economic endpoints. Outcomes assessment will be performed at baseline (before surgery), at day 0 (surgery), at 2, 21, 45 days, 3, 6, 12 and 24 months postsurgery.

ETHICS AND DISSEMINATION

This study has been approved by the ethics committee Ile-De-France X and will be conducted in accordance with current Good Clinical Practice (GCP) guidelines, Declaration of Helsinki and standard operating procedures. The results will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Clinicaltrial.gov:NCT03444779.

Tibial tubercle avulsion fracture according to different mechanisms of injury in adolescents: Tibial tubercle avulsion fracture

Tibial tubercle avulsion fracture caused by knee extensor is very rare; furthermore, non-traumatic fractures during running or bilateral fractures have been reported. The purpose of this study was to evaluate any differences according to the mechanisms of injury in adolescents with tibial tubercle avulsion fracture.Thirty patients with tibial tubercle avulsion fractures were reviewed and the average age was 13 years 1 month. Seven patients (low-stress group) had a spontaneous fracture during running without definite trauma. Twenty-three patients (high-stress group) experienced pain during jumping and landing, or definite trauma. The mechanisms of injury, age, height, weight, body mass index (BMI), BMI percentile, fracture type, as well as any complication, such as limitation of motion and deformity related to the physeal arrest, were compared between groups.There was no definite difference in age, fracture type, and surgical outcomes between groups. There was no patient with significant early physeal arrest in both groups. The weight (P = .02), BMI (P = .03) and BMI percentile (P = .01) in low-stress group were higher than those in high-stress group. In low-stress group, 6 patients' BMIs were in the 97th percentile, and 1 patient's BMI was in the 5th percentile.Extreme BMI may be a risk factor for tibial tubercle avulsion fractures in adolescents during running without definite trauma. However, there was no difference in the final outcome according to injury mechanisms.

Arthroscopic-Assisted Reduction of Tibial Plateau Fractures

Arthroscopic reduction of tibial plateau fractures have been gaining in popularity. Advantages include accurate diagnosis and treatment of joint pathology, minimally invasive soft tissue dissection, quicker recovery of joint motion, and anatomic reduction of joint surface. Success depends on accurate fracture selection. With arthroscopic-assisted reduction of tibial plateau fractures, patient set-up is similar to standard knee arthroscopy, but the C-arm is used to aid with fracture reduction and fixation. Outcomes are comparable or even improved when compared with standard procedures, and morbidity with arthroscopic reduction can often be lower with decreased rates of infection, wound complications, and thromboembolism.

Tibial pilon fractures treated with hybrid external fixator: analysis of 75 cases

INTRODUCTION

The treatment of tibial pilon fractures is a surgical challenge due to the particular anatomical and vascular characteristics of this area, and the severity of the injury that can compromise soft tissues. Nowadays there is no gold-standard treatment for these fractures.

MATERIALS AND METHODS

We reviewed 75 patients with tibial pilon fracture type C (AO classification) treated with hybrid external fixation (Stryker TenXor^®). The surgical technique was reported. We evaluated clinical (Tornetta's score, VAS score, range of motion) and radiographic outcomes.

RESULTS

In 71 cases, the first surgical treatment was definitive. Instead, in four cases, it was necessary a second surgical procedure to achieve fracture healing. We obtained 44% excellent, 40% good, 7% discrete, and 9% bad results. We found a 30% of superficial infections of the pin site, resolved with oral antibiotic treatment (amoxicillin and clavulanic acid). We never had deep infections, no neurovascular injury, and no cases of secondary amputation. Although not statistically significant, we noticed a correlation between longer recovery times and trauma severity, with slower recovery in open or grade III fractures or when associated with other fractures.

CONCLUSIONS

According to the recent literature, we think that the best treatment for non-articular fracture is the internal osteosynthesis within 6 h or after 6 days from trauma. In articular fractures, the elective treatment is the two-step management. In complicated articular fractures (Tscherne > 2, open, comminuted type III) is highly indicated the external fixation combined with minimal internal synthesis.

A new, MRI-based classification system for tibial spine fractures changes clinical treatment recommendations when compared to Myers and Mckeever

PURPOSE

Tibial spine fractures (TSFs) are graded according to the Meyers and McKever (MM) classification system, which is based on a qualitative evaluation of plain radiographs. However, although MRI images can provide important information about these fractures, there is no MRI-based classification system. This study aims to (1) establish the intra- and inter-rater reliability of the MM system for use with radiographs, (2) propose a quantitative, MRI-based system and compare its reliability to the MM system, and (3) assess how often using the MRI-based system changes the classification and potential treatment plan as previously determined using MM.

METHODS

The MRI-based system was designed with three grades based on quantitative displacement patterns of the fractured fragment and tissue entrapment. Four raters from a tertiary care center evaluated 20 fractures according to the MM and MRI-based systems. Observers graded images at two time points at least 2 weeks apart, after which we compared the intra- and inter-rater reliability of each system (using Fleiss' kappa and weighted kappa, respectively) and assessed how often using the MRI-based system changed the fracture grade.

RESULTS

Both the MM and MRI-based systems exhibit fair to moderate intra- and inter-rater reliability (average kappa values ranged from 0.38 to 0.66). Use of the MRI-based system changed the fracture grade and as a result modified the treatment recommendations in 32.5% of cases: 6.9% were previously unnoticed fractures, 13.1% underwent a raise in grade, and 12.5% were graded as lower than before.

CONCLUSION

The MRI-based system is as reliable as the MM system and provides specific, quantitative criteria for classifying fractures according to fragment displacement and tissue entrapment. The new MRI-based system potentially clarifies treatment indications for TSFs.

LEVEL OF EVIDENCE

Diagnostic Study, Level II.

Characteristics and proposed classification system of posterior pilon fractures

Posterior pilon fractures involve the medial malleolus (MM). Our purpose was to define the characteristics of posterior pilon fractures, and propose a classification system based on fracture morphology and type of management.The records of patients with posterior pilon fractures treated from 2011 to 2015 were retrospectively reviewed. The injury mechanism, fracture morphology, surgical approach, and follow-up results were reviewed and analyzed. This study was approved by the Institutional Review Board of PLA Army General Hospital.Thirty-six patients, 18 males and 18 females (mean age: 48.9 years) were included in the study. Four characteristics were used to define posterior pilon fractures. A simple posterolateral approach or a combined posterolateral and posteromedial approach was used for reduction and fixation in all patients. The mean follow-up time was 28.2 months, and at the end of follow-up, the mean American Orthopedic Foot and Ankle Society Score (AOFAS) was 82.5 points (range: 35-100 points). Based on injury mechanism and fracture morphology, we classified posterior pilon fractures into 3 types that suggest the optimal surgical approach: type I, a single complete fracture fragment; type II, a posterior malleolus fracture with 2 subtypes; type III, a posterior malleolus fracture associated with complete MM fracture with 2 subtypes.The proposed classification system based on injury mechanism and fracture morphology can guide the surgical approach to maximize outcomes.

Extra-articular Lateral Hinge Fracture Does Not Affect the Outcomes in Medial Open-Wedge High Tibial Osteotomy Using a Locked Plate System

PURPOSE

To compare the radiologic and clinical outcomes in patients with and without lateral hinge fractures (LHFs) during medial open-wedge high tibial osteotomy (MOWHTO) using a locked plate system, as well as to assess whether LHFs could affect the midterm outcomes.

METHODS

From May 2008 to November 2015, 164 knees underwent MOWHTO using a locked plate system for the treatment of knee osteoarthritis. LHFs were recognized by radiographs during or after the high tibial osteotomy and were not additionally treated. In all patients, we applied the same rehabilitation protocol that allowed full weight bearing at 6 weeks. Patients were divided into LHF (types I and II) and nonfracture groups. Radiologically, we compared any serial changes in the hip-knee-ankle angle, femorotibial angle, medial proximal tibial angle, and posterior tibial slope angle from the immediate postoperative radiographs to the final radiographs. The union process of the osteotomy site among the groups was also evaluated. Clinically, the postoperative American Knee Society Score and knee range of motion at latest follow-up were compared. Postoperative complications were also evaluated.

RESULTS

The average age at operation was 56.0 years (range, 42-67 years), and the average follow-up period was 62.2 months (range, 24-120 months). LHFs were observed in 37 knees (22.6%) and were divided into the type I (16 knees) and type II (21 knees) groups. All groups showed no significant changes in serial evaluations of the postoperative hip-knee-ankle angle, femorotibial angle, medial proximal tibial angle, and posterior tibial slope angle. The improvements in the American Knee Society Score and knee range of motion were not significantly different among the groups. No patients showed correction loss or union problems.

CONCLUSIONS

Type I and II LHFs in MOWHTO using a medial locked plate system and relatively conservative rehabilitation protocol with full weight-bearing walking commenced at 6 weeks postoperatively showed no radiologic changes or functional deterioration during midterm follow-up.

LEVEL OF EVIDENCE

Level IV, case series.

Epidemiology and incidence of tibia fractures in the Swedish Fracture Register

INTRODUCTION

There is a lack of epidemiological studies of fractures in all segments of the tibia classified by orthopaedic surgeons according to the AO/OTA classification. Since 2011, the Swedish Fracture Register (SFR) has provided prospectively collected, population-based data on fractures of all types, treated both surgically and non-surgically. The aim of this study was to describe the epidemiology and incidence of fractures in all segments of the tibia in a cohort of consecutive tibia fractures over a period of five years at Sahlgrenska University Hospital, Gothenburg, Sweden.

METHODS

Information on age, gender, date and mechanism of injury, fracture classification according to AO/OTA, affected side and high- or low-energy trauma was extracted from the SFR for all patients, aged 16 years and above, with tibia fractures treated at Sahlgrenska University Hospital, Gothenburg, during the five-year period 1 January 2011 to 31 December 2015.

RESULTS

1325 patients sustained 1371 tibia fractures. There were 712 proximal tibia fractures, 417 tibial shaft fractures and 242 distal tibia fractures. Patients with proximal tibia fractures had a higher mean age (54.3) and 58% were women, whereas patients with shaft and distal fractures had a slightly lower mean age (47.0 and 48.7 respectively) and a dominance of men (59% and 54% respectively). The overall incidence of tibia fractures was 51.7 per 100,000 and year. The incidence of proximal, diaphyseal and distal tibia fractures was 26.9, 15.7 and 9.1 respectively per 100,000 and year. Among women, tibia fractures showed an increasing incidence with age in all segments, whereas men had a fairly flat incidence curve, except for tibial shaft fractures, which displayed a peak among young males. The incidence of tibia fractures and graphs for age-specific incidence for each segment of the tibia are presented.

CONCLUSIONS

This study describes the epidemiology and incidence of fractures in the whole of the tibia classified by orthopaedic surgeons according to the AO/OTA classification.

A review of the management of tibial plateau fractures

Tibial plateau fractures form a wide spectrum of injuries presenting varying challenges to the trauma surgeon. The prognosis of this injury spectrum is largely dependent on the management of each particular configuration, and the literature is as a result littered with a number of management strategies with limited consensus. The aim of this review is to provide a concise guide to the trauma surgeon based on newer and classical peer-reviewed publications in international orthopaedic journals. A PubMed search was conducted to identify peer-reviewed publications within the last 10 years and expanded to identify classic papers pertaining to the Schatzker classification. The focus was on articles based on management techniques, controversies and recent developments. The management of specific injury patterns is based on the Schatzker classification which is a widely accepted traditional classification system. Whilst there is a general consensus on the ultimate goal of a stable anatomic reduction in this subset of fractures, there continues to be a number of controversies surrounding issues including pre-operative imaging, initial assessment and definitive management of specific injury patterns, some of which do not conform to the original Schatzker classification. The majority of fractures will require operative management, and with whatever management strategy employed, the main emphasis is on respecting the soft tissue envelope. There remains a paucity of prospective randomised controlled trials comparing the different available operative techniques.

[Not Available]

Zusammenfassung. Unterschenkelfrakturen gehören zu den häufigsten Schaftfrakturen bei Kindern und werden mehrheitlich konservativ behandelt. Die Analyse der Frakturmorphologie und Kenntnis des Remodeling-Potenzials des kindlichen Skeletts sind wichtige Voraussetzungen zur Einleitung der korrekten Therapie. Die konservative Therapie besteht aus einer Gipstherapie über drei bis sechs Wochen je nach Alter des Kindes. Zudem besteht die Möglichkeit, über eine Gipskeilung das Repositionsresultat günstig zu beeinflussen. Die Indikation für eine operative Therapie beschränkt sich auf stark dislozierte oder instabile sowie offene Frakturen. Im Rahmen der Nachkontrollen werden sekundäre Dislokationen sowie Wachstumsstörungen erkannt und behandelt.

[Suprapatellar Nailing of Tibial Fractures - Evaluation of Clinical and Radiological Results]

PURPOSE OF THE STUDY The locked nailing of diaphyseal fractures of the tibia currently represents a method of choice for treating the closed diaphyseal fractures, some of the tibial metaphyseal fractures and open tibial diaphyseal fractures classified as grade I and II according to Gustilo-Anderson (GA) classification. The suprapatellar (SP) approach is an alternative technique of insertion of the nail in semi-extension of the lower extremity with easier reduction, namely of multiple fractures and proximal diaphyseal fractures of the tibia in particular. This study aims to evaluate the group of patients in whom the suprapatellar approach was used and who were followed up for the period of at least 12 months. MATERIAL AND METHODS The prospective study included 55 cases of osteosynthesis of diaphyseal fractures of the tibia with the surgery performed in the period from January 2013 to June 2015, of which in 53 patients (17 women and 36 men) with the mean age of 49.6± 16.7 years the ETN nail by DePuy Synthes ® was inserted through a suprapatellar approach. In 38 cases (70.1%) an isolated trauma was involved, 15 patients (29.9%) were treated for multiple injuries or polytrauma. In nine cases (17%) it was an open fracture (2times - GA grade I, 7times - GA grade II). A multiple fracture or a fracture of the proximal third was recorded in 19 cases (34.5%). The functional and radiological results of the treatment were assessed prospectively at 12 months after the surgery using the Lysholm (LS) score. RESULTS The final functional results were successfully assessed in 49 performed osteosyntheses (89.1%). The mean duration of surgery was 72.7± 19.57 min (40-140 min, median 65 min). A total of 48 (98%) fractures healed by primary intention. In five cases (10.2%) a delayed healing occurred and in one case (2 %) non-union was reported, requiring a revision surgery. In three cases (6.1%) complete implant was removed (twice by SP and once by IP approach). The mean Lysholm score was 93.4 ± 8.39 points (59-100 points, median score of 95 points). An excellent or a good result was observed in 45 patients (91.8%), a satisfactory result in three patients (6.2%), and a poor result in one patient (2%). A statistically significant correlation (p = 0.006) between the LS score values and the age of the patients was confirmed. In patients up to 60 years of age the LS score was 96.2 ± 4.51 points (89-100, median 96), at the age of more than 60 years it was 86.9 ± 11.46 (59-100, median 89). CONCLUSIONS The suprapatellar approach in treating the tibial diaphyseal fractures represents a safe alternative nail insertion technique. If an appropriate surgical technique is applied, the risks inherent in this approach are negligible. The approach allows for an easy reduction of challenging fractures of the proximal third diaphyseal fracture of the tibia and multiple fractures of the tibia and facilitates an easy check of the axial position of the extremity. The functional results of the knee joint are comparable to those achieved with the infrapatellar nailing technique. The final LS score correlates with the age of the patients. Key words:tibial fractures, suprapatellar approach, intramedullary nailing, knee pain.

Population-Based Epidemiology of Tibial Plateau Fractures

Although epidemiologic studies of tibial plateau fractures have been conducted, none have included geographically defined populations or a validated fracture classification based on computed tomography (CT). The goals of this study were to provide up-to-date information on the incidence and basic epidemiology of tibial plateau fractures in a large unselected patient population and to report the mechanisms of injury involved and the distribution of fractures according to a validated CT-based fracture classification. The authors conducted a population-based epidemiologic study of all patients treated for tibial plateau fracture over a 6-year period from 2005 to 2010. The study was based on an average background population of 576,364 citizens. A retrospective review of hospital records was performed. During this time, a total of 355 patients were treated for tibial plateau fracture. This group included 166 men and 189 women, and mean age was 52.6 years (SD, 18.3). The most common fracture type was AO type 41-B3, representing 35% of all tibial plateau fractures. The second most common fracture type was AO type 41-C3, representing 17% of all tibial plateau fractures. The incidence of tibial plateau fractures was 10.3 per 100,000 annually. Compared with women, men younger than 50 years had a higher incidence of fractures. The incidence of fractures increased markedly in women older than 50 years but decreased in men older than 50 years. In both sexes, the highest frequency was between the ages of 40 and 60 years.

Morphologic study of posterior articular depression in Schatzker IV fractures

The Schatzker classification of tibial plateau fractures is widely accepted. Type IV fractures are medial tibial plateau fractures that are either split off as a wedge fragment or depressed and comminuted. Posterior articular surface depression in Schatzker type IV tibial plateau fractures can be seen as a unique variant that increases the difficulty of reduction of the articular surface. Its morphologic characteristics have not been fully studied, and the incidence is sometimes underestimated. The goal of this study was to evaluate the morphologic characteristics of posterior articular depression in Schatzker type IV fractures based on computed tomography measurements. From January 2009 to December 2011, the medical records, including digital radiologic data, of all patients treated for tibial plateau fracture at the authors' institution were retrospectively analyzed. Articular surface depression deeper than 5 mm was the criterion for study inclusion. The depression depth, precise location of the articular depression center, surface area percentage, and distance of the fracture gap to the depression center were calculated. One hundred fifteen cases of Schatzker type IV fracture were retrieved, and a total of 47.83% (55 of 115) cases had posterior articular surface depression. The average depth of the depressed articular surface was 12.41 mm, the surface area percentage was 20.15% of the entire tibial plateau, and the gap distance from the medial direction was 41.40 mm, 2.8 times longer than that from the posterior direction, which was 14.91 mm. Posterior articular surface depression occurs in nearly half of Schatzker type IV fractures, and the posterior approach provides more direct access to the depression than the medial approach.

Validation of the Non-Union Scoring System in 300 long bone non-unions

INTRODUCTION

Non-union of long bones is a significant consequence of fracture treatment. The ideal classification for non-union of long bones would give sufficient significant information to the orthopaedic surgeon to enable good management of the treatment required and to facilitate the creation of comparable study groups for research purposes. The Non-Union Scoring System (NUSS) is a new scoring system to assist surgeons in the choice of the correct treatment in non-union surgery. The aim of this study was to determine the evidence supporting the use of the NUSS classification in the treatment of non-unions of long bones and to validate the treatment algorithm suggested by this scoring system.

MATERIALS AND METHODS

A total of 300 patients with non-union of the long bones were included in the clinical study.

RESULTS

A radiographic and clinical healing was reached in 60 of 69 non-unions (86%) in group 1 (0-25 points), in 102 of 117 non-unions (87%) in group 2 (26-50 points), and in 69 of 84 (82%) in group 3 (51-75 points). The mean time to clinical healing was 7.17 ± 1.85 months in group 1, 7.30 ± 1.72 months in group 2 and 7.60 ± 1.49 months in group 3. The mean time to radiographic healing was 8.78 ± 2.04 months in group 1, 9.02 ± 1.84 months in group 2 and 9.53 ± 1.40 months in group 3.

DISCUSSION

There are few articles in the scientific literature that examine the classification systems for non-union.

CONCLUSIONS

A statistical analysis of the first results we have obtained with the use of NUSS showed significant rates of union in all the evaluated groups. This indicates that NUSS could be an appropriate scoring system to classify and stratify non-unions and to enable the surgeon to choose the correct treatment.

Schatzker type IV medial tibial plateau fractures: a computed tomography-based morphological subclassification

Schatzker type IV medial tibial plateau fractures have an unfavorable prognosis, likely due to the mechanism of injury (fracture-dislocation/subluxation type) and possibly due to the involvement of the posterolateral plateau, which is different from previously thought. The aim of this study was to propose a new subclassification of Schatzker type IV fracture patterns based on 2-dimensional (2-D) computed tomography and three-dimensional (3-D) reconstruction. The authors defined Schatzker type IV medial tibial plateau fractures as AO/OTA 41 type B fractures (partial articular), with partial or total medial plateau involvement, leaving at least the anterolateral quadrant intact. The images of 42 fractures (42 patients) were evaluated. The fractures were further anatomically divided into 2 groups: Group 1 were classic medial unicondylar fractures and Group 2 were more complicated variants involving both condyles, characterized by medial condyle fractures with lateral plateau extension, usually with articular impaction of the centroposterior lateral plateau. Twelve (29%) cases involved only the medial condyle, and 30 (71%) involved both the medial and lateral condyles. Twenty-nine (69%) cases demonstrated posterior coronal fractures. The most common patterns were bicondylar posteromedial plateau fractures with posterolateral quadrant depression (bicondylar posterior fractures: 14 cases, 33%) and total/subtotal medial condyle fractures with posterolateral quadrant depression (13 cases, 31%). The isolated unicondylar posteromedial split fracture was uncommon (2 cases, 5%). Computed tomography-based reconstruction enhances the understanding of fracture anatomy and the relationships between fracture fragments. In Schatzker type IV medial tibial plateau fractures, the involvement of posterolateral quadrants is common.

Plating of open pediatric tibia fractures

This study is a single center retrospective chart and radiographic review of patients with open tibia fractures under the age of 16 years of age over past 10 years. The purpose of this study is to investigate the treatment of open pediatric tibia fractures with plating in regards to time to ambulation, time to union, and deformity in comparison to other treatment options. We found that plating open pediatric tibia fractures is a safe treatment option that can lead to excellent results with low risk of complications.

Tibial eminentia avulsion fracture in children - a systematic review of the current literature

INTRODUCTION

Tibial eminentia avulsion fracture is the paediatric equivalent to a midsubstance anterior cruciate ligament injury. It is most common between the ages of 8 and 19 years of age. The incidence is three per 100,000 per year. We explored the clinical evaluation and classification of the fracture, indications for and methods of surgery and the possible sequelae.

METHODS

We performed a systematic search in the PubMed database and retrieved 127 articles. A total of 16 articles met the defined inclusion criteria and were reviewed. Only studies on adolescents were included.

RESULTS

No prospective studies were found. The Meyers & McKeever and Zaricznyj classifications were commonly used, also when evaluating fractures for surgery. X-ray in three views is often sufficient to establish a diagnosis, but computed topographies can be necessary to further evaluate the type of fracture. There is disagreement as to whether a type II-fracture needs surgery. The method of fixation varies greatly between different kinds of suture techniques and screw fixations, but arthroscopic surgery is preferred in the most recent literature. Whether to cross the physis when fixating the fracture is also a matter of dis-agreement, but there is a lack of literature on the subject. All authors describe low rates of subjective sequelae.

CONCLUSION

Arthroscopic surgery is less invasive and allows for earlier mobilisation than other techniques. Pull-out suture seems to be a recommendable technique. There is a lack of literature on transphyseal fixation and a need for prospective studies evaluating the many different surgical techniques described and the indications for surgery.

Surgical approach in difficult tibial pilon fractures

AIM

The aim of the present study is to emphasize the optimal moment and approach for tibial pilon complex fractures and their complications.

MATERIAL AND METHODS

We have investigated and treated 7 patients with complex fractures of the tibial pilon with tendencies to complications. According to AO classification,we have recorded 4 fractures type 43C2 AO, 2 fractures type 43C3 AO (with one open fracture type IIIA Gustilo) and 1 fracture type 43B3 AO. According to soft tissue status, surgical treatment was performed by a one-step or two-step approach.

RESULTS

All fractures healed after an interval of 13.6 weeks(range 8-28 weeks) with one delayed consolidation. The open fracture was complicated by posttraumatic arthrosis. No infections or implant failures were recorded. According toOvadia score, objective and subjective evolution showed good results in 5 cases, one excellent result and one poor result.

CONCLUSIONS

Fracture type and the soft tissue status are crucial for the results of operated fractures. These arguments determine the application of one-step or two-step surgical procedure as well as optimal implant choice.

Distal tibial fractures and pilon fractures

Fractures of the distal tibia are often very severe injuries that generally occur in the context of high-energy trauma and present with significant concomitant soft tissue involvement. Open fractures and extensive destruction of the articular surfaces are important challenges to the treating surgeon. In consequence the outcome for distal meta- and epiphyseal tibial fractures depends largely on the severity of the soft tissue injury and its management. Conventionally, tibial pilon fractures require surgical intervention. Conservative treatment would only be considered in some exceptional cases, for example, inoperability of the patient. Controversial discussion of optimal surgical technique and optimal timing of surgery is ongoing. There is broad consensus that soft tissue consolidation must have first priority as this is the basis for both fracture healing and good long-term outcomes. Surgical intervention can be managed as a one-stage or multi-stage procedure to achieve internal or external fracture fixation.

Single long midline incision versus two small incision techniques in treatment of Schatzker type V and type VI tibial plateau fractures--a comparative study

Tibial plateau fractures had been treated with single long midline incision technique traditionally. But recently two-incision technique is becoming popular Tibial plateau fractures are generally classified according to the method developed by Schatzker. Schatzker types V and VI fractures are high-energy fractures often accompanied by other injuries and complications, such as postoperative inflammation, wound problems and infections. It was a prospective randomised study where 56 patients with Schatzker types V and VI were included in the study group. Alternatively all were allocated in the two groups ie, two small incision and one midline incision. Two incision was better than single midline incision in terms of posteromedial collapse, postoperative infection, skin necrosis. Operative fixation of complex fractures of the tibial plateau remains quite difficult and is associated with postoperative functional limitations in a large percentage of patients. Dual plating through an anterolateral and posteromedial approach is recommended in fractures complicated by a significantly displaced posteromedial fragment or depression of the medial articular surface.

[Establishment of Schatzker classification digital models of tibial plateau fractures and its application on virtual surgery]

OBJECTIVE

To explore the establishment of Schatzker classification digital model of tibial plateau fractures and its application in virtual surgery.

METHODS

Proximal tibial of one healthy male volunteer was examined with 64-slice spiral computed tomography (CT). The data were processed by software Mimics 10.01 and a model of proximal tibia was reconstructed. According to the Schatzker classification criteria of tibial plateau fractures, each type of fracture model was simulated.Screen-captures of fracture model were saved from different directions.Each type of fracture model was exported as video mode.Fracture model was imported into FreeForm modeling system.With a force feedback device, a surgeon could conduct virtual fracture operation simulation.Utilizing the GHOST of FreeForm modeling system, the software of virtual cutting, fracture reduction and fixation was developed.With a force feedback device PHANTOM, a surgeon could manipulate virtual surgical instruments and fracture classification model and simulate surgical actions such as assembly of surgical instruments, drilling, implantation of screw, reduction of fracture, bone grafting and fracture fixation, etc.

RESULTS

The digital fracture model was intuitive, three-dimensional and realistic and it had excellent visual effect.Fracture could be observed and charted from optional direction and angle.Fracture model could rotate 360 ° in the corresponding video mode. The virtual surgical environment had a strong sense of reality, immersion and telepresence as well as good interaction and force feedback function in the FreeForm modeling system. The user could make the corresponding decisions about surgical method and choice of internal fixation according to the specific type of tibial plateau fracture as well as repeated operational practice in virtual surgery system.

CONCLUSION

The digital fracture model of Schatzker classification is intuitive, three-dimensional, realistic and dynamic. The virtual surgery systems of Schatzker classifications make the virtual surgery training more normalized, programmed and standardized.In addition, virtual surgery system can serve as a new tool for preoperative planning and surgeon-patient interactions.

[Our experience with orthopedic damage control in high-energy tibial pylon fractures]

High-energy tibial pylon fractures represent some of the most severe injuries of the ankle joint and currently represent a challenge for the orthopedic surgeon. These are usually polytraumatized patients and before admitting them into the traumatology unit, spinal cord, pelvic or thoracoabdominal injuries should be ruled out. Due to the special anatomy of the area, its thin skin cover and subcutaneous location, soft tissues are usually severely affected and this is key when choosing the time for a surgical intervention. Although the definitive treatment of these injuries is controversial, the so called two-stage treatment seems to predominate in order to minimize soft tissue iatrogenic injuries applying the concept of orthopedic damage control of the limb. We present the preliminary results of 10 patients operated with this method at our center.

Contemporary internal fixation techniques for periprosthetic fractures of the hip and knee

The volume of total hip and knee arthroplasties continues to increase as the US population ages. The number of prosthetic complications, specifically those involving periprosthetic fractures, is also increasing. Periprosthetic fractures can be difficult to manage. Reduction and fixation of these fractures is a complex undertaking, primarily because the preexisting implants can obstruct the reduction and placement of fixation devices. It is crucial to consider the fracture location, implant stability, and bone quality when determining a treatment plan. Expertise in both fracture management and joint reconstruction is often necessary to provide the best care and outcomes for patients. Although periprosthetic fractures are challenging, advancements in surgical techniques and available implants offer the surgeon tools to provide good outcomes and patient satisfaction.

[Redintegration of articular surface and alignment with tibia type III Pilon fracture]

OBJECTIVE

To explore an improved method of surgical operation for redintegration of the articular surface and alignment with type III Pilon fractures.

METHODS

Between August 2005 and August 2010, 31 patiens with closed type III Pilon fracture (Rüedi-Allgöwer type III) were treated. There were 25 males and 6 females, aged 36.8 years on average (range, 16-60 years). The injury was caused by falling from height in 18 patients, by traffic accident in 10 patients, and by other reasons in 3 patients. The average time between injury and operation was 10 days (range, 6-14 days). Temporary external fixation was used for adjustment and maintenance of limb length and power lines; application of fibular flip combined with anteromedial approach was used for the repair of articular surface; and bone grafting and fixation were performed.

RESULTS

No extensive necrosis or deep infection were observed. Superficial skin infection of incision and wound edge necrosis occurred in 2 cases respectively, and were cured after dressing change. All patients were followed up 26 months on average (range, 9-79 months). According to the Burwell et al. judging standards of radiology evaluating, the anatomical reduction was found in 25 cases (80.6%), satisfactory reduction in 4 cases (12.9%), and unsatisfactory reduction in 2 cases (6.5%). The X-ray films showed bony healing was achieved in all cases with an average fracture healing time of 16 weeks (range, 12-25 weeks). According to the Mazur et al. criterion for ankle joint function, excellent result was obtained in 11 cases, good in 13, fair in 5, and poor in 2; the excellent and good rate was 77.4%.

CONCLUSION

Good exposure and fixation of articular surface or accurate adjustments and maintenance of the limb alignment are key factors of successful operation to treat type III Pilon fractures.

Pilon fractures: a new classification and therapeutic strategies

BACKGROUND

Operative decision-making of Pilon fractures are of great challenges until now. The aim of this study was to investigate the guidance of the four-column theory in decision-making therapeutic strategies for Pilon fractures and its result.

METHODS

One hundred and ten cases (107 patients) of Pilon fractures classified by the four-column theory and treated by ORIF, were reviewed. According to the four-column classification scheme, lateral column of 85 cases, posterior column of 66 cases, medial column of 77 cases, and anterior column of 61 cases are involved. Among all the 110 cases, single column of 14 cases, two columns of 46 cases, three columns of 17 cases, and all of four columns of 33 cases are involved.

RESULTS

One hundred and eight cases have been followed up. The average follow up time is 14.7 months, varying between 7 and 52 months. The average healing time is 3.6 months, ranging from 2.5 to 8.0 months. Reduction of 86.1% reviewed Pilon cases are good or acceptable according to Burwell and Charley's Radiology Evaluation System. Ankle function of 87.1% cases are excellent or good according to the AOFAS evaluation system.

CONCLUSION

As a simple and comprehensive classification, the four-column classification can contribute to reasonable operation decision-making and good prognosis of Pilon fracture.

Comparison of low, multidirectional locked nailing and plating in the treatment of distal tibial metadiaphyseal fractures

PURPOSE

The aim of this study was to compare the results of a new technique for low, multidirectional locked nailing with closed reduction and minimally invasive plating in the treatment of distal tibial metadiaphyseal fractures.

METHODS

Forty-six matched patients were divided according to age, gender, Injury Severity Score, and fracture pattern into group A (expert tibial nailing) and group B (minimally invasive plating). Then, the patients were followed up, and the clinical and radiographic results were retrospectively analysed.

RESULTS

The mean followed-up was 24.7±2.7 months in group A and 25.8±2.8 months in group B. No patient had nonunion, shortening, hardware breakdown, or deep-seated infection. Patients in group A had a significantly shorter mean operating time, hospital stay, full weight-bearing time and union time (76±16.6 vs. 90±20.3 minutes, p=0.000; 5.8±2.1 vs. 8.9±3.1 days, p=0.000; 9.0±1.4 vs. 11.1±1.7 weeks, p=0.000; and 21.3±3.5 vs. 23.1±3.6 weeks, p=0.047, respectively). Three patients in group A and one patient in group B presented with malalignment (p=0.608). The mean Olerud-Molander Ankle score was 89.0±7.1 in group A and 87.6±8.4 in group B (p=0.478).

CONCLUSIONS

Distal tibia metadiaphyseal fractures may be treated successfully with low, multidirectional locked nails or plates. However, low, multidirectional locked nailing may represent a superior surgical option, since it offers advantages in terms of mean operating time, hospital stay, full weight-bearing time and union time.

Fuzzy approach for reducing subjectivity in estimating occupational accident severity

Quantifying or, more generally, estimating the severity of the possible consequences of occupational accidents is a decisive step in any occupational risk assessment process. Because of the lack of historic information (accident data collection and recording are incipient and insufficient, particularly in construction) and the lack of practical tools in the construction industry, the estimation/quantification of occupational accident severity is a notably arbitrary process rather than a systematic and rigorous assessment. This work proposes several severity functions (based on a safety risk assessment) to represent biomechanical knowledge with the aim of determining the severity level of occupational accidents in the construction industry and, consequently, improving occupational risk assessment quality. We follow a fuzzy approach because it makes it possible to capture and represent imprecise knowledge in a simple and understandable way for users and specialists.

Staged treatment and associated complications of pilon fractures

Historically, the treatment and outcomes related to pilon fractures have been variable despite anatomic reduction and fixation. Early results with treatment via early primary open reduction and internal fixation yielded mixed clinical outcomes, especially suboptimal complication rates, including infection, malunion, and nonunion. Treatment with external fixation also exhibited similar outcomes with mixed support reported in the literature. Despite continued controversy, the advent of newer implant technologies, improved surgical techniques, and management with a staged protocol have resulted in encouraging clinical outcomes with minimization of postoperative complications. Crucial decisions made during treatment can help to maximize outcomes while minimizing complication rates. Particular attention to the fracture pattern with radiographic guidance can help direct surgical decision making with appropriate care given to optimize soft-tissue status. A variety of available incisions can facilitate proper bony and articular reduction. During the late and failed stages of fracture management, additional treatment options include external ring fixation, arthrodesis, and arthroplasty. As complications arise, meticulous, prompt care can help to achieve the best possible outcomes.

Clinical study of a new design multifunction dynamic external fixator system for open tibial fracture

BACKGROUND

The tibial shaft is one of the most common sites of open fracture. External fixators emerged as the treatment of choice for high energy open tibial fractures because they were easy to apply, allow sufficient access for wound care and provide sufficient mechanical fixation for patient mobilization and bone healing. Based on the advantages of dynamization in increased union rate and the simplicity of monolateral frame, a new design dynamic external fixator system was developed for definite treatment in open tibial fracture.

OBJECTIVE

To evaluate the clinical results of open tibial fractures treated with a new design dynamic external fixator system until healing.

MATERIAL AND METHOD

The case series of 60 patients with open tibial fracture treated with the new design dynamic external fixator system for acute and definitive-treatment frame between 2005 and 2009. According to the system of Gustilo and Anderson, 14 fractures were classified as type II, 43 as type IIIA, and three as type IIIB. Partial weight bearing with crutches was instructed when tolerable for dynamization. When there were evidences of fracture healing in both clinical and radiographic, external fixator was removed.

RESULTS

All fractures united. The median union time was 12 weeks (range, 10-15) in type 11, 16 weeks (range, 10-24) in type IIIA, and 20 weeks (range, 20-21) in type IIIB. Iliac bone grafting was performed in six cases at a mean time of 3.8 weeks to enhance bone union. Seven cases (12%) developed pintract infections. No deep infection was found in the present study. Ninety-five percent of fractures united with less than 10 degrees angulation in any plane. No instrument failure was found. The external fixator frame could be reused.

CONCLUSION

The new design dynamic external fixator system successfully treated open tibial fractures with a good result and low complication rate. It is simple, safe, and easy to use.

[Tillaux fracture and fracture of the lateral malleolus with no medial soreness]

Tillaux fracture is a fracture of the anterolateral tibial epiphysis most often seen in children between 11 and 16 years of age. The fracture occurs when the medial and central part of the distal tibial epiphysis is closed and the lateral part remains open. We present a case with a combination of a Tillaux fracture and an ipsilateral fracture of the lateral malleolus in a 16 year-old boy and discuss the fracture mechanism using the Lauge-Hansen ankle fracture classification system.

The value of a CT scan compared to plain radiographs for the classification and treatment plan in tibial plateau fractures

This study aimed to evaluate the intra- and interobserver agreement for both fracture classification according to Schatzker and treatment plan of tibial plateau fractures using plain radiographs alone and with computed tomography (CT) scans. The study was carried out prospectively to assess the impact of an advanced radiographic study on the agreement of treatment plan and fracture classification of tibial plateau fractures. Eight experienced observers (six surgeons and two radiologists) classified 15 tibial plateau fractures with plain radiographs and CT scans and set up a treatment plan. Agreement was measured using kappa coefficients. Using plain radiographs alone, the mean interobserver kappa coefficient for classification was 0.47, which decreased to 0.46 after addition of CT scans. Using plain films alone for formulating a treatment plan, the mean interobserver kappa coefficient was 0.40, which decreased to 0.30 after addition of CT scans. The mean intraobserver kappa coefficient for fracture classification using plain radiographs was 0.60, which decreased to 0.57 with addition of CT scans. The mean intraobserver kappa coefficient for treatment plan based on plain radiographs alone was 0.53, which decreased to 0.45 after addition of CT scans. In contrast with other recent publications, there is no increase in inter- and intra-agreement of a CT scan compared to plain radiographs for the classification and treatment plan in tibial plateau fractures. Routine CT scanning of the knee for tibial plateau fractures is not supported by this study.

[Classification of pilon fractures by computed tomography and its guide to clinical treatment]

OBJECTIVE

To introduce a method of three-column classifications for Pilon fractures and observe clinical utility on column fixation.

METHODS

From June 2007 to March 2010,a total of 27 patients (29 ankles, 26 males and 1 female,ranging in age from 23 to 59 years, with an average of 33.1 years) with Pilon fractures were treated through column fixation by using semitubular plates or screws with anteromedial, anterior, posterolateral,posteromedial approach. And postoperative follow up were carried out.

RESULTS

The mean follow up was 17.5 months(ranged,5 to 33 months). According to the Mazur ankle grading system, the outcome was excellent in 20, good in 4 and fair in 5 ankles. Patients in this group did not have complications of wound dehiscence, deep infection, osteomyelitis, nonunion, ankylosis, and joint instability.

CONCLUSION

Based on the three-column classification, the clinical results for the treatment of Pilon fractures demonstrate the rationality and efficiency of this method.

A decision analysis of amputation versus reconstruction for severe open tibial fracture from the physician and patient perspectives

Although reconstruction is often the primary choice of surgeons after an open tibial fracture, there is no evidence to support the long-term effectiveness of flap reconstruction over below-knee amputation. The aim of this study was to perform a decision analysis to evaluate treatment preferences for type IIIB and IIIC tibial fractures. Reconstructive microsurgeons, physical medicine physicians, and patients with lower extremity trauma completed a Web-based standard gamble utility survey to generate quality-adjusted life years (QALYs). Physicians assigned quite high utility values, and there was a slight preference for reconstruction over amputation, with a gain of only 0.55 QALY. Patients assigned significantly lower utility values and also favored reconstruction over amputation, but with a larger gain of 5.54 QALYs. The disparate utilities assigned by the physicians and the patients highlight the necessity of realistic discussion of outcomes, regardless of the management methods.

[Computed tomographic classification of posterior condylar tibial plateau fractures]

OBJECTIVE

To study the new computed tomographic (CT) classification, surgical approaches and clinical efficacy of posterior condylar tibial plateau fractures.

METHODS

From January 2006 to July 2009, a total of 39 patients of posterior condylar tibial plateau fractures were treated by posteromedial and posterolateral knee approaches. There were 23 males and 16 females. The mean age was 41.6 years old (range: 28 - 68). Among all patients, the causes were traffic accidents (n = 26), falls (n = 9) and other injuries (n = 4). By CT classification, there were type I with posteromedial condylar tibial plateau split fracture (n = 7), type II with posterolateral condylar tibial plateau split fracture (n = 5), type III with posterolateral condylar tibial plateau depression fracture (n = 11), type IV with posterolateral condylar tibial plateau split depression fracture (n = 2) and type V with posteromedial split and posterolateral condylar tibial plateau depression fracture (n = 14).

RESULTS

The mean follow-up period was 18.1 months (range: 12 - 30). The radiographic bony union time was 11 - 16 weeks (mean: 15.2) and the full weight-bearing time 12 - 20 weeks (mean: 15.6). No infection, knee varus/valgus, nerve injury or screw loosening/breakage was found. Bony union was achieved in all cases. According to the Rasmussen functional scoring, the results were excellent in 20, good in 14 and fair in 5. And the excellent and good rate was 87.2%. The radiological results were graded with the Rasmussen score to evaluate the reduction of fracture. The outcome was excellent in 28, good in 8 and fair in 3. And the excellent and good rate was 92.3%.

CONCLUSION

This new CT classification scheme of posterior condylar tibial plateau fractures can significantly improve the reliability, guide the clinicians to select appropriate treatment plans and design an ideal regimen of operative approach and internal fixation.

Tibial plateau fractures: internal fixation with locking plates and the MIPO technique

Proximal tibial fractures are difficult lesions to treat because of the involvement of the articular surface, the often occurring comminution, and the precarious condition of the soft tissues, especially following high-energy trauma. Aim of the treatment is to restore the congruence of the articular surface supporting the tibial plateau cartilage which is usually depressed; to fix the fracture with a stable device; to allow early rehabilitation. We present our treatment strategy, utilising closed or open reduction and internal fixation, angle-stable polyaxial plates, immediate osteointegration, when necessary, with autologous bone graft or other osteoconductive material augmented with autologous platelet gel. Surgery is soft-tissue dependent in terms of timing, and it is usually performed directly or under supervision of an experienced surgeon utilising, whenever possible, a tissue sparing technique. A cohort of 58 proximal tibial fractures, surgically treated, from January 2004 to June 2007, was retrospectively reviewed. Fractures were classified according the OTA/AO classification. The assessment of the functional outcome with the use of the Rasmussen score identified good to excellent results in 78% of the cohort 12 months post-surgery. Internal fixation with locking plates, following the principles of MIPO (Minimally Invasive Percutaneous Osteosynthesis), provides satisfactory fracture reduction with good results regarding the mid-term clinical outcome.

[Results of treatment of the intercondylar eminence of tibia in children]

Fracture of the tibial eminence in children is a condition in which there is no widely accepted and approved therapeutic scheme. The greatest divergence of treatment options concerns type II according to Mayers and McKeever classification. Described therapeutic options range from cast immobilisation of the lower extremity without attempt of closed reduction to open reduction with internal fixation. Paper shows the results of treatment of tibial emienence fractures in children treated at our institution. Cohort of patients consists of 21 children at age 7 to 16 years of age (mean 12.2 years). There were three cases of type I, five cases of type II and thirteen cases of type III fracture according to Mayers and McKeever classification. Operatively 16 patients were treated with type II and III fracture, and the rest of them were treated nonoperatively. Open reduction and internal fixation was performed according to modified technique described in 1937 by H. Lee. The results were evaluated by X-ray, clinical examination of stability and range of motion of the affected knee and by subjective clinical outcome with use of modified Lysholm knee scale. All patients treated operatively presented very good and good clinical outcome. Nonoperatively treated patients was a small and no homogenous group. Results of treatment ranged from very good to poor. Worse outcomes were associated with additional injuries to the affected knee (poor result in patient with type II fracture) and qualification for the conservative treatment in patient with type III fracture.

Tibial intercondylar eminence fractures in children: The long-term perspective

PURPOSE OF THE STUDY

To analyze objective and subjective results on medium-term follow-up of intercondylar fractures of the tibia in children.

MATERIAL AND METHODS

A retrospective, single-center study of 32 fractures (17 boys, 14 girls) was performed. Fractures were itemized on the Meyers and McKeever classification as modified by Zaricznyj: there were eight type-I, 17 type-II, five type-III and two type-IV fractures. Treatment was conservative for type-I and II fractures (with mild displacement) and for the others surgical. Seven patients were lost to follow-up and one had insufficient follow-up for inclusion. Thirteen patients were assessed on a KT 1000 arthrometer and a dynamometer, and on the IKDC and ARPEGE scoring systems. Ten patients chose to answer only the subjective IKDC questionnaire, by mail.

RESULTS

The mean IKDC score of subjects answering by mail was 91 and of those with clinical examination was 80. Mean ARPEGE score was 8.3. Subjective IKDC score classified four patients as A, four as B, four as C and one as D. Mean difference in tibial anterior translation between affected and unaffected knees was 0.88mm for type I fractures, 0.82mm for type II and 0.30mm for types III and IV together.

DISCUSSION

The mean difference in tibial anterior translation between affected and unaffected knees was greater in patients with conservative treatment (0.96mm for conservative vs. 0.29mm for surgical treatment). Seventy per cent of patients reported pain at follow-up. Only two had pathological knee laxity. Twelve out of thirteen had returned to sport activity, half of them at the same level as before injury.

CONCLUSION

The cases treated surgically had a better objective result than those treated conservatively. Nevertheless there was no correlation between subjective evaluation and degree of knee laxity. Overall, intercondylar fractures of the tibial eminence in children have good long-term prognosis, at least subjectively. This study shows that, in spite of a very satisfactory subjective result for most patients, results were not so good on objective measures.

LEVEL OF EVIDENCE

Level IV: retrospective study.

Tibial pilon fractures

Tibial pilon fractures are severe injuries to the distal articular surface of the tibia. Such injuries frequently result from high-energy axial impact and are often associated with extended soft tissue injury. Various treatment methods are available, depending not only on the fracture type but mostly on the extent of the soft tissue injury; one of the most frequent procedures is a two-stage surgery: the initial closed reduction of the fracture via primary placement of an ankle joint-spanning external fixator, if possible in conjunction with open reduction and internal fixation of the fractured fibula followed by a secondary procedure after soft tissue recovery by open reduction and internal fixation of the tibial plafond. By now, new types of low-profile and locking plates are available for internal fixation allowing the anatomical reconstruction of the fractured articular surface while sparing the soft tissue. Nonetheless, the treatment of tibial pilon fractures is technically demanding because of their potential for severe complications.

Staged external and internal less-invasive stabilisation system plating for open proximal tibial fractures

High-energy proximal tibial fractures are complex injuries that may lead to significant complications. Staged treatment of these injuries using a spanning external fixator across the knee joint in the acute setting decreases the incidence of complications. This article is a prospective evaluation of outcomes using a two-stage procedure for treatment of 15 patients who sustained open proximal tibial fractures between April 2006 and January 2008. In the first stage, we used low profile, less-invasive stabilisation system (LISS) plates for temporary external fixation to immobilise the fractures after anatomic reduction, followed by soft-tissue reconstruction. In the second stage, we applied LISS plates for definitive internal fixation, using minimally invasive percutaneous osteosynthesis. All fractures were monitored for a mean of 20.4 months (range, 12-32 months). All fractures united at a mean of 38.6 weeks (range, 18-66 weeks). Knee motion ranged from a mean of 1 degrees (range, 0 degrees to 5 degrees ) to 125 degrees of flexion (range, 100 degrees to 145 degrees ). The reduction was scored as good in 13 patients and fair in two patients. At follow-up, 10 patients had excellent, and five had good knee scores. The complications included minor screw-track infections in three patients. In conclusion, the two-stage technique was well suited for treating these difficult injuries, and for patients who needed longer periods of external fixation. Surgeons were able to achieve gross anatomy restoration, soft-tissue reconstruction, stable fixation and high union rates. Patients obtained good-to-excellent motion, function and comfort after treatment.

[Distant functional outcomes of treatment and physiotherapy of tibial eminence fractures in adults]

Authors of paper present distant functional outcomes of treatment and physiotherapy of tibial eminence fractures basing on clinical material covering years from 1998 to 2006, that make up 15 patients, 7 women (46.7%) and 8 men (53.3%), aged between 18 and 57 years, on average 37.5-years-old. Subject fractures ware classified basing on Meyers i McKeever criteria, however obtained outcomes basing on IKDC (International Knee Documentation Committee) system. Obtained outcomes persuade authors to standpoint, that inoperative treatment of fractures type I leads to good functional outcomes, operative treatment of fracture type II leads to good functional outcomes too and operative treatment of fracture type III and III+ leads to sufficient outcomes.

Current concepts in tibial plateau fractures

Tibial plateau fractures can range from a simple lateral split pattern to very complex bicondylar injuries that can be a sour- ce of great disability. these fractures can provide a challenge for both junior as well as for senior surgeons alike. careful evaluation of the mechanism of injury and fracture pattern plays a crucial part in the operative planning. Assessment of the soft tissues should be performed carefully and adequate imaging is mandatory to allow a more detailed evaluation of the fracture architecture and pre-operativeplanning. Timely accurate reduction and fixation is the goal. Over the last decade the surgical approach chosen has been largely determined by the fracture pattern. Internal plate osteosynthesis through antero-lateral and postero-medial incisions is the most commonly utilised technique for complex bi-condylar fractures. An early range of motion with special attention to full knee extension is essential for a successful functional outcome. Application of the principles mentioned is a pre-requisite to achieve the best result. New fixation techniques, such as locking plates, have not changed those principles but helped to apply them more reliably.

[One-stage management of open distal tibial Pilon fractures]

OBJECTIVE

To explore the operative method of open distal tibial pilon fractures, and to evaluate the outcome of ankle joint function postoperatively.

METHODS

From March 2003 to March 2007, 24 patients with open Pilon fractures were treated with one-stage open reduction and internal fixation (18 males and 6 females). The average age was 37.6 years (14-53 years). All 24 patients had open fracture, 12 of whom combined fibular fracture. According to AO comprehensive classification system, the fractures was classified as C1 in 4, C2 in 9, and C3 in 11. According to Gustilo-Anderson classification method, the fracture was classified as Type I in 3, Type II in 5, Type III A in 4, Type III B in 10, and Type III C in 2. All tibial pilon fractures were treated by radical debridement, one-stage open reduction and internal fixation. Soft tissue defection was covered by a vascularized flap and continually washed by pipes under the flap.

RESULTS

All patients were followed-up at an average of 2.3 years (1-3.8 years) after the surgery. All the fractures healed at an average of 22.3 weeks (16-54 wk) postoperatively. According to the scoring system of Conroy, 17 were excellent (62.5%), 4 good (25%), and 3 poor (12.5%), the excellence rate was 87.5%. According to the ankle score of Teeny and Wiss, there were 11 excellent (37.5%), 7 good (37.5%), 3 fair (16.7%), and 3 poor (8.3%) and the excellence rate was 75%.

CONCLUSION

One-stage management for open Pilon fracture has the advantages of fewer complications, lower infectious rate, and better ankle joint function.