Acute Tibial Plateau Fractures Research Articles

Total Knee Replacement as Primary Management in Comminuted Tibial Plateau Fracture in Elderly Patients: A Systematic Review and Meta-Analysis

Abstract Background Fracture of the tibial plateau represents approximately 8% of fractures in elderly patients. These injuries occur with an estimated incidence of 13.3 per 100,000 adults annually, with nearly a quarter of these occurring in elderly patients with concomitant osteoporosis. In young patients, the mainstay treatment for displaced tibial plateau fracture is open reduction and internal fixation (ORIF). However, in elderly patients with periarticular fracture, the combination of poor bone quality, metaphyseal bone comminution, and friable soft tissue envelope creates unique challenges to traditional ORIF. Aim of the Work To evaluate the perioperative complication rates and clinical outcomes in patients following TKA for primary treatment of tibial plateau fracture and to establish whether TKA can be considered a reliable primary treatment option in selected individuals. Patients and Methods The present systematic review will be performed in accordance with the preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search for all level I–IV evidence published articles using the online databases MEDLINE, Embase, and PubMed will be performed. The purpose of this search is to identify all eligible studies featuring perioperative complications or clinical outcomes in patients following TKA for primary treatment of tibial plateau fracture. Results The immediate management of acute tibial plateau fracture in elderly patients continues to be controversial. Although there is emerging evidence showing positive results for primary TKA for tibial plateau fracture, it is paramount to appreciate that performing TKA in the context of acute tibial plateau fracture is not a straightforward attempt. Many of these patients have notable loss of the articular surface, which disrupts normal anatomic references, and compromised soft tissue due to possible coexisting ligamentous injury. Conclusion Total knee arthroplasty for treatment of acute tibial plateau fracture is an enticing alternative to ORIF to allow early weight bearing, especially in elderly patients with poor bone quality and a friable soft tissue envelope. Our systematic review shows that functional scores are only average.

The Relationship Between Intra-articular Fracture Energy and a Patient's Inflammatory Response.

Prior studies have demonstrated elevated inflammatory cytokine concentrations in the synovial fluid of articular fracture patients postinjury. Similarly, CT-based fracture energy measurements have been correlated with posttraumatic osteoarthritis risk after pilon fracture. The purpose of this study was to determine the associations between synovial fluid cytokine levels, fracture energy, and overall trauma to the body in articular fracture patients. Acute tibial plateau, tibial plafond, and rotational ankle fracture patients were prospectively enrolled from December 2011 through January 1, 2019. Synovial fluid concentrations of interleukin-1 beta, interleukin-1 receptor antagonist, IL-6, IL-8, IL-10, matrix metallopeptidase-1, MMP-3, and MMP-13 were quantified. Patient CT scans were used to calculate fracture energy. The Injury Severity Score (ISS) was used to relate cytokine levels to whole-body injury severity. Spearman rho correlation coefficients were calculated to assess the relationship between injury severity metrics and synovial fluid cytokine, chemokine, and matrix metallopeptidase concentrations. Eighty-seven patients were enrolled with 42 had a tibial plateau fractures (OTA/AO 41B1-2, 41B2-14, 41B3-3, 41C1-3, 41C2-4, 41C3-16), 24 patients had a tibial plafond fracture (OTA/AO 43B1-2, 43B2-4, 43B3-5, 43C1-2, 43C2-3, 43C3-8), and 21 had a rotational ankle fracture (OTA/AO 44B1-3, 44B2-3, 44B3-6, 44C1-4, 44C2-5). Fracture energy significantly differed between fracture patterns, with ankle fractures involving substantially less fracture energy (median = 2.92 J) than plafond (10.85 J, P < 0.001) and plateau fractures (13.05 J, P < 0.001). After adjustment for multiple comparisons, MMP-3 was significantly correlated with transformed fracture energy (r = 0.41, 95% confidence interval [CI], 0.22-0.58, P < 0.001), while IL-1β was significantly correlated with the Injury Severity Score (Spearman ρ = 0.31, 95% CI, 0.08-0.49, P = 0.004). Synovial fluid MMP-3 concentration was significantly correlated with CT-quantified fracture energy in intra-articular fracture patients. Given that in clinical practice fracture energy tends to correlate with posttraumatic osteoarthritis risk, MMP-3 may warrant further investigation for its role in posttraumatic osteoarthritis development after articular fracture. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Total knee arthroplasty for acute tibial plateau fractures: a survey amongst 68 Dutch orthopaedic surgeons.

In older patients with highly comminuted intra- articular tibial plateau fractures (TPFs), primary total knee arthroplasty (TKA) may be a treatment option. Our aim was to report and rank decisional factors considered by Dutch orthopaedic trauma and knee surgeons that may lead to the decision for TKA as treatment for TPFs. A survey was distributed among 141 experts on traumatology and arthroplasty of the knee. The survey assessed the likelihood of TKA surgery after TPF in various patient and radiological characteristics. The level of experience with this of each responder was also noted. Descriptive statistics were calculated for all items. 141 participants were approached and 68 responded (48.2%). Responders were not more likely to proceed with TKA based on fracture types, impaired mobility, multiple incisions for ORIF, body mass index and ASA classification. However, in patients with pre-existing osteoarthritis (OA) and age ≥ 80 a majority would be more likely to proceed with TKA, with respectively 69.1% and 50.0%. The most strongly considered factors were the presence of pre-existing OA, the age of the patient and the type of fracture, with respectively 55.9%, 51.4% and 42.6% of responders ranking it in their top three most important factors. The study showed that the presence of pre-existing symptomatic OA and age of the patient were valued highest and increased the probability of a TKA in acute TPFs.

No false elevation in ankle brachial index in patients with tibial plateau fractures and vascular risk factors

ObjectivesThe ankle brachial index (ABI) is a useful tool in detection of lower extremity vascular injury. However, diabetes mellitus (DM), chronic kidney disease (CKD), and peripheral vascular disease (PVD) may affect extremity perfusion leading to possible false elevation of the ABI value. If true in trauma patients, this can affect initial evaluation, diagnostics, and management. We therefore explored mean ABI values in tibial plateau fractures of patients with vascular risk factors to help determine whether there is a difference. DesignThis is a retrospective chart review of patients sustaining tibial plateau fractures with a specific ABI value recorded in the medical record. Patients were identified as either having vascular risk factors or not and data analysis performed to determine if their ABI differed and whether they were more likely to have a vascular injury. Results282 acute tibial plateau injuries with specific ABI values were identified, 46 of which carried the risk factors in question. The average risk factor group ABI was 0.95 ± 0.15 versus those without risk factors 1.0 ± 0.15 (p = 0.057). No patient with risk factors required a vascular intervention or four-compartment fasciotomy. ConclusionsThis study shows no statistical significance between the presenting ABI of patients with risk factors such as DM, CKD, or PVD and those without those risk factors who sustained acute tibial plateau fractures. Therefore, in general the ABI still holds as a useful screening tool for evaluation of vascular insult in the setting of acute lower extremity trauma.

Value of quantitative assessment using Multidetector CT in predicting ligamentous and meniscal injuries in acute tibial plateau fractures

PurposeTo assess the ability of MDCT to predict ligamentous and meniscal injuries in acute tibial plateau fractures compared to MR images. Patients and methodsForty patients with acute tibial plateau fracture and 15 control subjects were subjected to MDCT and MR images. Lateral plateau depression (LPD) and lateral plateau widening (LPW) were measured in coronal MDCT images. Meniscal, cruciate, and collateral ligaments injuries were evaluated in MR images. ResultsSoft tissue injuries incidence was not related to Schatzker type (P > 0.05). LBD and LBW were different significantly between patients and control subjects ((P value < 0.001∗). LPD was correlated to meniscal, cruciate, and collateral ligaments injuries (P < 0.05). LPW was correlated to cruciate and collateral ligaments tears (P < 0.05) but not meniscal lesions (P > 0.05). LPD > 6 mm or LPW > 7 mm increased possibility of Soft tissue injuries. Multiple soft tissue injuries were not related to Schatzker types (P > 0.05). LPD and LPW were correlated with number of soft tissue injuries. ConclusionMDCT measurements of LPD and LPW are correlated with incidence and number of ligamentous and meniscal injuries. MDCT can predict ligamentous and meniscal injuries without waiting for MRI in acute tibial plateau fractures.

Correlation of parameters on preoperative CT images with intra-articular soft-tissue injuries in acute tibial plateau fractures: A review of 132 patients receiving ARIF

IntroductionTibial plateau fractures often occur in conjunction with soft-tissue injuries of knees. The hypothesis of this study is that parameters of CT imaging can predict intra-articular soft-tissue injuries. Patients and methodsPatients who underwent arthroscopically assisted reduction and internal fixation (ARIF) for acute tibial plateau fractures performed by a single orthopedic surgeon between 2005 and 2015 were included in this retrospective study. Patients with concomitant ipsilateral femoral fractures, who had received revision surgery or who had undergone index surgery more than 30days from the event were excluded. We measured lateral plateau depression and widening, medial plateau depression and displacement, and column involvement observed on preoperative CT scans. Intra-articular soft-tissue injuries were diagnosed based on findings from knee arthroscopy. The correlation of imaging parameters with soft-tissue injuries was analyzed by the area under a receiver operating characteristic (AUROC) curve and multivariate logistic regression. ResultsOne-hundred and thirty-two patients were enrolled in the study. The average age was 45.7±13.1 years (range: 18–75 years). Lateral tibial plateau depressions >11mm were significantly associated with increased risk of lateral meniscus tears (p=0.001). However, there was no significant threshold of lateral tibial plateau widening that could be used to predict lateral meniscus tear. Greater risk of anterior cruciate ligament (ACL) avulsion fracture was observed in younger patients, patients with high-energy-pattern tibial plateau fractures, patients with fractures involving anteromedial or posterolateral columns, and patients with medial tibial plateau displacement >3mm (p<0.05). ConclusionMeasuring lateral tibial plateau depression and column involvement on preoperative CT scans can help predict a higher risk of lateral meniscus tear and ACL avulsion fracture respectively in patients with acute tibial plateau fractures.

Nature’s wrath—The effect of weather on pain following orthopaedic trauma

BackgroundDespite frequent complaints by orthopaedic trauma patients, to our knowledge there is no data regarding weather’s effect on pain and function following acute and chronic fracture. The aim of our study was to investigate the influence of daily weather conditions on patient reported pain and functional status. MethodsWe retrospectively examined prospectively collected data from 2369 separate outpatient visits of patients recovering from operative management of acute tibial plateau fractures, acute distal radius fractures, and chronic fracture nonunions. Pain and functional status were assessed using a visual analogue scale (VAS) and the DASH and SMFA functional indexes. For each visit date, the mean temperature, difference between mean temperature and expected temperature, dew point, mean humidity, amount of rain, amount of snow, and barometric pressure were recorded. Statistical analysis was run to search for associations between weather data and patient reported pain and function. ResultsLow barometric pressure was associated with increased pain across all patient visits (p=0.007) and for patients at 1-year follow-up only (p=0.005). At 1-year follow-up, high temperature (p=0.021) and high humidity (p=0.030) were also associated with increased pain. No significant association was noted between weather data and patient reported functional status at any follow-up interval. ConclusionsPatient complaints of weather influencing pain after orthopaedic trauma are valid. While pain in the immediate postoperative period is most likely dominated by incisional and soft tissue injuries, as time progresses barometric pressure, temperature, and humidity impact patient pain levels. Affirming and counseling that pain may vary based on changing weather conditions can help manage patient expectations and improve satisfaction.

Sexual Function Is Impaired After Common Orthopaedic Nonpelvic Trauma.

The purpose of this study was to investigate the prevalence and longitudinal improvement of patient reported sexual dysfunction after 5 common nonpelvic orthopaedic traumatic conditions. Retrospective analysis of prospectively collected data. Academic Medical Center. The functional status of 1324 patients with acute proximal humerus fractures (n = 104), acute distal radius fractures (n = 396), acute tibial plateau fractures (n = 118), acute ankle fractures (n = 434), and chronic long bone fracture nonunions (n = 272) was prospectively assessed at baseline, 3, 6, and 12 months of posttreatment. Patient reported sexual dysfunction, acquired from validated functional outcomes surveys, was compared with overall patient reported functional outcome for each follow-up visit. Men and women were analyzed separately. Sexual dysfunction at the 3-month follow-up was reported in 31% of proximal humerus fracture patients, 32% of distal radius fracture patients, 47% of tibial plateau patients, 11% of ankle fracture patients, and 42% of long bone nonunions. By 1-year follow-up, greater than 80% of patients with all fracture types reported mild or no sexual dysfunction. Women reported a significantly higher degree of sexual dysfunction than men at 6 months (P = 0.003) and 12 months of follow-up (P = 0.031). After treatment of acute and chronic orthopaedic trauma conditions, a considerable number of patients experience sexual dysfunction, with women reporting more dysfunction than men. The results of this study should allow orthopaedic trauma surgeons to counsel patients regarding expectations of sexual function after traumatic orthopaedic conditions. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Intraarticular Matrix Metalloproteinases and Aggrecan Degradation Are Elevated After Articular Fracture.

Posttraumatic osteoarthritis (OA) is a variant of OA that can develop after articular injury. Although the mechanism(s) of posttraumatic OA are uncertain, the presence and impact of postinjury proteolytic enzymes on articular cartilage remain unknown. To our knowledge, there are no studies that evaluate the presence of matrix metalloproteinases (MMPs) or aggrecan degradation after articular fracture. (1) Are MMP concentrations and aggrecan degradation elevated after intraarticular fracture? (2) Are MMP concentrations and aggrecan degradation greater in high-energy injuries compared with low-energy injuries? (3) Do the concentrations of these biomarkers remain elevated at a secondary aspiration? Between December 2011 and June 2013, we prospectively enrolled patients older than 18 years of age with acute tibial plateau fracture. Exclusion criteria included age older than 60 years, preexisting knee OA, injury greater than 24 hours before evaluation, contralateral knee injury, history of autoimmune disease, open fracture, and non-English-speaking patients. During the enrollment period, we enrolled 45 of the 91 (49%) tibial plateau fractures treated at our facility. Knee synovial fluid aspirations were obtained from both the injured and uninjured knees; two patients received aspirations in the emergency department and the remaining patients received aspirations in the operating room. Twenty patients who underwent spanning external fixator followed by definitive fixation were aspirated during both surgical procedures. MMP-1, -2, -3, -7, -9, -10, -12, and -13 concentrations were quantified using multiplex assays. Aggrecan degradation was quantified using sandwich enzyme-linked immunosorbent assay. There were higher concentrations of MMP-1 (3.89 ng/mL [95% confidence interval {CI}, 2.37-6.37] versus 0.37 ng/mL [95% CI, 0.23-0.61], p < 0.001), MMP-3 (457.35 ng/mL [95% CI, 274.5-762.01] versus 129.17 ng/mL [95% CI, 77.01-216.66], p < 0.001), MMP-9 (6.52 ng/mL [95% CI, 3.86-11.03] versus 0.96 ng/mL [95% CI, 0.56-1.64], p < 0.001), MMP-10 (0.52 ng/mL [95% CI, 0.40-0.69] versus 0.23 ng/mL [95% CI, 0.17-0.30], p < 0.001), and MMP-12 (0.18 ng/mL [95% CI, 0.14-0.23] versus 0.10 ng/mL [95% CI, 0.0.081-0.14], p = 0.005) in injured knees compared with uninjured knees. There was not a detectable difference in MMP concentrations or aggrecan degradation between high- and low-energy injuries. MMP-1 (53.25 versus 3.89 ng/mL, p < 0.001), MMP-2 (76.04 versus 0.37 ng/mL, p < 0.001), MMP-3 (1250.62 versus 457.35 ng/mL, p = 0.002), MMP-12 (1.37 versus 0.18, p < 0.001), MMP-13 (0.98 versus 0.032 ng/mL, p < 0.001), and aggrecan degradation (0.58 versus 0.053, p < 0.001) were increased at the second procedure (mean, 9.5 days; range, 3-21 days) as compared with the initial procedure. Because MMPs and aggrecan degradation are elevated after articular fracture, future studies are necessary to evaluate the impact of elevated MMPs and aggrecan degradation on human articular cartilage. If further clinical followup can demonstrate a relationship between posttraumatic OA and elevated MMPs and aggrecan degradation, they may provide potential for therapeutic targets to prevent or delay the destruction of the joint. Additionally, these markers may offer prognostic information for patients.

Inflammatory cytokine response following acute tibial plateau fracture.

The objective of the present study was to evaluate human synovial fluid for inflammatory cytokine concentrations following acute tibial plateau fracture. Our hypothesis was that there would be an elevated inflammatory response following intra-articular fracture, and that the inflammatory response would be greater after high-energy compared with low-energy injuries. Between December 2011 and June 2013, we prospectively enrolled forty-five patients with an acute tibial plateau fracture. Synovial fluid aspirations were performed on the injured and uninjured knees. Twenty patients who required an external fixator followed by delayed fixation underwent aspiration at both surgical procedures. The concentrations of interferon-gamma (IFN-γ), interleukin-1 beta (IL-1β), interleukin-1 receptor antagonist (IL-1RA), IL-2, IL-4, IL-6, IL-7, IL-8, IL-10, IL-12(p70), IL-13, IL-17A, tumor necrosis factor-alpha (TNF-α), monocyte chemoattractant protein-1 (MCP-1), and macrophage inflammatory protein-1 beta (MIP-1β) were quantified with use of multiplex assays. The forty-five patients had an average age of forty-two years (range, twenty to sixty years). There were twenty-four low-energy and twenty-one high-energy tibial plateau injuries. There was a significant difference between injured and uninjured knees (p < 0.001) with regard to concentrations of IL-1β, IL-6, IL-8, IL-10, IL-1RA, and MCP-1. There was not a detectable difference in synovial fluid cytokine concentrations between high and low-energy injuries. The concentrations of IL-10 (p < 0.001), IL-1RA (p = 0.002), IL-6 (p < 0.001), IL-8 (p < 0.001), and MCP-1 (p = 0.002) were significantly greater in the injured knee than in the uninjured knee at the second aspiration, at a mean of 9.5 days (range, three to twenty-one days) after the initial injury. There was a significant local inflammatory response following acute tibial plateau fracture. There was not a detectable difference in inflammatory cytokine concentration between high and low-energy injuries. Synovial fluid concentrations of IL-10, IL-8, IL-6, IL-1RA, and MCP-1 remained elevated at the second aspiration.

Knee trauma and posttraumatic osteoarthritis-more science needed: commentary on an article by Justin M. Haller, MD, et al.: "Inflammatory cytokine response following acute tibial plateau fracture".

We do not understand posttraumatic arthritis. Preliminary research with preclinical models is under way1,2 to better understand the postinjury intra-articular cascade that leads to posttraumatic arthritis. Certainly clarification of the pathways would allow modulation of healing and perhaps identify targets in the chain for therapeutic approaches. We have had little success for many reasons: lack of a good preclinical model, paucity of research, lack of controls, failure to differentiate between systemic and local conditions, and no large clinical trials, among others. We absolutely need the information that Haller et al. sought in the clinical setting. Haller et al. evaluated inflammatory cytokine concentrations in human synovial fluid following acute tibial plateau fractures. Their hypothesis was that there would be an elevated inflammatory response following intra-articular fracture and that the inflammatory response would be greater after high-energy injuries than after low-energy injuries. Fractures heal through inflammation, and supposedly higher-energy trauma results in more inflammation. The difficulty is in specifying which marker shows up and when it appears. We are also not sure whether there are missing markers or temporal relationships between markers that may affect the cascade. The authors quantified the concentrations of interferon-gamma (IFN-γ), interleukin-1 beta (IL-1β), interleukin-1 receptor antagonist (IL-1RA), IL-2, IL-4, IL-6, IL-7, IL-8, IL-10, IL-12 (p70), IL-13, IL-17A, tumor necrosis factor-alpha (TNF-α), monocyte chemoattractant protein-1 (MCP-1), and macrophage inflammatory protein-1 beta (MIP-1β) with multiplex assays (see glossary below). They were hoping that the large grab bag of inflammatory markers would provide insight into the pathways of healing or arthritis. My initial thought was that this would be difficult without real-time values but perhaps there would be some room for interpolation of the values that could provide insight into the inflammatory cascade and/or healing following cartilage injury. Why did the authors choose all …

The distinct prediction standards for radiological assessments associated with soft tissue injuries in the acute tibial plateau fracture.

The goal of this study was to assess the incidence of soft tissue injury in the tibial plateau fracture by magnetic resonance image (MRI) and reveal the relationship between the articular widening/depression and the risk of meniscus and ligament disorder. A total of 54 patients with tibial plateau fracture were indicated for operative intervention. Soft tissue injuries were assessed by MRI. Meniscus, anterior/posterior cruciate ligaments and medial/lateral collateral ligaments injuries on MRI were evaluated. The articular widening/depression was measured in picture archiving and communication systems. Schatzker classification of fracture types was not significantly associated with soft tissue injuries. The rates of soft tissue injury in types IV and II (respectively, 85.7 and 74.1 %) were higher than those in other types. The meniscus injury was the most common soft tissue damage, and the incidence of meniscus injury was 55.6 %. When LPDCT and LPWCT were, respectively, about 7.6 mm and 10.1 mm and LPDX-ray and LPWX-ray, respectively, 5.6 and 7.4 mm, more attention should be paid on the collateral and cruciate ligament injuries in types I, II and III. Furthermore, when LPWCT and LPWX-ray were, respectively, about 10.3 and 8.6 mm, the collateral and cruciate ligaments were susceptible to injury in types IV and V. In conclusion, tibial plateau fracture can occur high morbidity of soft tissue injury, including meniscus and ligament disorder. X-ray and CT scan had different predicting standards for soft tissue injury, and the articular widening/depression in the tibial plateau was associated with meniscus and ligament injuries.

Study of outcomes of dual plate osteosynthesis in Schatzker type 5 and 6 fractures of proximal tibia

Background: The operative treatment of complicated bicondylar fractures of the tibial plateau remains a challenge to even the most experienced surgeons. Such injuries are usually the result of high-energy trauma, and the management of such fractures is complicated by metaphyseal and articular comminution and the frequent occurrence of associated soft tissue injuries. Aims: The aim of this retrospective study was to evaluate the clinical and radiological outcomes of dual plating for treating Schatzker types 5 and 6 bicondylar tibial plateau fractures. Methods: 24 patients with bicondylar tibial plateau fractures and operatively treated in our orthopedic department with dual-plating technique between January 2006 and December 2012 were retrospectively analyzed. Inclusion criteria for this study were (1) acute and unilateral fractures and (2) displaced bicondylar tibial plateau fractures (Orthopaedic Trauma Association types C1, C2, and C3).Knee score was used for evaluation of outcome Results: At 12 months postoperatively, the knee score was 88.5 and 84.4in the double buttress plate and combination plate groups, respectively, and the difference was not significant. Out of 24 patients 19 achieved excellent knee score (>90), 4 achieved good (80-90), 1 achieved fair (70-80) and no patient had poor (<70) knee score. Mean range of knee flexion was 115 degrees for dual buttress group and 117.5 degree for combination group. Conclusion: Dual plating in Schatzker type 5 and 6 fractures results in good outcome with low complication rates.

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

Magnetic resonance imaging (MRI) provides sufficient information with regard to specific soft-tissue injuries in the knee, but it is not generally used to evaluate acute tibial plateau fractures. The aim of the present study was to determine whether the amount of tibial plateau fracture depression on multi-detector computed tomography (MDCT) scans correlates with the incidence of associated soft-tissue injuries on MRI. A total of 54 consecutive patients with a mean age of 51.2years (SD=18.3) were included in this retrospective study. All patients were admitted to the emergency department of a university clinic with acute tibial plateau fracture. The amount of articular depression was assessed from MDCT scans. Magnetic resonance images were evaluated for crucial and collateral ligament injury, meniscal tears, and patellar retinaculum lesions. Logistic regression revealed a significant impact of increasing tibial plateau fracture depression on the incidence of meniscus lateralis tears (P=0.025) and anterior cruciate ligament lesions (P=0.018). Analysis of covariance demonstrated a significant correlation between the amount of articular depression and absolute number of soft-tissue injuries (P=0.001). Articular depression is a potential predictor of specific meniscal and ligamentous injuries in acute tibial plateau fracture. Magnetic resonance imaging is generally recommended with respect to associated soft-tissue injuries, especially in cases with distinct tibial plateau fracture depression on multi-detector computed tomography scans. Case series, Level IV.

The Incidence of Soft Tissue Injury in Operative Tibial Plateau Fractures

The goal of this study was to determine the incidence of injury to soft tissue structures of the knee in tibial plateau fractures scheduled for surgery. Prospective cohort. Level I academic medical center. One hundred three consecutive patients with acute tibial plateau fractures indicated for operative intervention. Standard x-ray examinations, including anteroposterior, lateral, and oblique views, were performed in the emergency department. Subsequently all patients had magnetic resonance imaging performed. The Schatzker and AO/OTA classifications were used to classify each fracture pattern based solely on the x-rays. Soft tissue injuries were assessed by magnetic resonance imaging. Fifteen categories of injury were determined as positive or negative on each magnetic resonance imaging, which included tears of the cruciates, collateral ligaments, menisci, and posterolateral corner. The overall incidence of injury to soft tissues was higher than previously reported. Only 1 patient (1%) in the series had complete absence of any soft tissue injury. Seventy-nine patients (77%) sustained a complete tear or avulsion of 1 or more cruciate or collateral ligaments. Ninety-four patients (91%) had evidence of lateral meniscus pathology. Forty-five patients (44%) had medial meniscus tears. Seventy patients (68%) had tears of 1 or more of the posterolateral corner structures of the knee. The most frequent fracture pattern was a lateral plateau split-depression (Schatzker II) (60%). No pure depression injuries (Schatzker III, AO/OTA 41-B2) were seen. The incidence of complete ligamentous or meniscal disruption associated with operative tibial plateau fractures was higher than previously reported. Though the clinical importance of injury to each of these structures is unknown, the treating surgeon should be aware that a variety of soft tissue injuries are common in these fractures. In addition, all fractures had at least 1 cortical split visible on magnetic resonance imaging, implying that pure depression patterns are very rare or may not exist.

Tibial plateau fractures

The classification of tibial plateau fractures is based on morphological criteria according to AO/ASIF and Schatzker or on functional criteria according to Moore. A total of 81 acute tibial plateau fractures were operated on over a 6-year period. The patient data and the operative procedure are given (not including late results). Some 6% of ligamentous lesions were treated conservatively. Bicondylar osteosynthesis was performed in 11%, and 14% of the operations were minimally invasive procedures. In 61.7% the plateau was fixed by a buttress plate. Autologous cancellous bone from the iliac crest was implanted into the fracture, especially into depressed wedge fractures (Type AO/ASIF B3 or Moore Type IV). In 39.5% of the cases a corticocancellous wedge-shaped bone chip from the iliac crest was used. Complications were rare, and no infection was observed. Most important are the soft tissue balance, the timing of surgery, choice of longitudinal incisions directly above the lesion, and a stabilization procedure which maintains blood flow and coverage of the fracture. The operative procedures are described including tibial plateau fractures in children and the management of complications. In special situations a conservative treatment is still useful.

MR imaging of tibial plateau fractures

Magnetic resonance (MR) images of five patients with acute tibial plateau fractures are presented and correlated with both clinical examination and findings at surgical intervention. The role of MR imaging in the evaluation of both osseous and soft tissue deformity in acute trauma, specifically in patients with tibial plateau fractures is discussed. The value of MR imaging as an alternative to computed tomography and arthroscopic evaluation of these patients is emphasized.

MR findings in patients with acute tibial plateau fractures

Objective. The purpose of this study was to demonstrate the MRI findings associated with acute tibial plateau fractures. Materials and Methods. MR scans of 29 patients with acute tibial plateau fractures were analyzed retrospectively. The images were evaluated for the presence of injuries involving the menisci, cruciate and collateral ligaments. The presence of a lipohemarthrosis or a simple joint effusion was also noted. The tibial plateau fractures were classified according to the scheme devised by Schatzker. Results. Evidence of internal derangement of the knee was found in 28 (97%) patients. Tibial collateral ligament (55%) injuries and lateral meniscus (45%) tears were noted most frequently. Medial meniscus tears were seen in 21% and fibular collateral ligment injuries were diagnosed in 34%. Forty-one percent had anterior cruciate ligament injuries while the posterior cruciate ligament was injured in 28%. Twelve (41%) patients demonstrated the characteristic MRI features of a lipohemarthrosis. Simple joint effusion were found in the remaining 17 (59%) patients. Conclusion. MR imaging in patients with acute tibial plateau fractures commonly demonstrates associated ligamentous and meniscal injuries. By imaging in multiple planes, MRI can aid in the accurate characterization of tibial plateau fracture patterns and severity.

The Significance of Early Motion in the Treatment of Tibial Plateau Fractures

Although the trend in management of tibial plateau fractures has been toward early motion, the period of immobilization that can be tolerated safely is open to question. In the present study, 160 acute tibial plateau fractures were reviewed in an effort to answer this question. The 112 fractures that were suitable for analysis were divided into undisplaced fractures, displaced fractures treated nonoperatively, and displaced fractures treated operatively. Among these groups, results were compared based on the period after injury that the knee was immobilized. Undisplaced fractures and displaced fractures that were treated nonoperatively regained full knee motion when immobilized up to six weeks. Fractures treated operatively tended to develop knee stiffness with only two weeks of immobilization. Loss of fracture reduction tended to occur in patients who were immobilized for relatively short periods. Immediate knee motion was correlated with prolonged hospitalization. Based on these results, knee mobilization following tibial plateau fractures is determined by the degree of fracture displacement, method of treatment, and quality of aftercare.