Bicondylar Fractures Research Articles

Assessment of Functional Outcome of Bicolumnar Dual Plating for Bicondylar Fractures of Tibial Plateau

Introduction: Operative treatment of bicondylar fractures of tibial plateau is challenging and controversial.
 Aims: The aim of this study is to reveal the functional outcome of it by using bicolumnar dual plates and screws.
 Methods: This is a prospective hospital based interventional study carried out in the department of Orthopaedics of Nepalgunj Medical College Teaching Hospital. Thirty two Schatzker type V or AO (Association of Osteosynthesis) type 41 C1 & C2 fractures were treated between January 2016 and December 2019 with bicolumnar dual plating. The functional clinical outcomes were analyzed and evaluated using modified Rasmussen score.
 Results: Thirty two patients were included in the study. Out of which twenty four were male and eight were female. Average age was 32.21 years, eighteen were right sided and fourteen were left sided. Duration of surgery was 106 mins (range 90-120 mins) and the average duration of hospitalization was 7.81 days (range 4-14 days). Five patients of impending compartment syndrome and three patients with common peroneal nerve palsy were managed conservatively and also were included in the study. Two patients with superficial wound infection needed minimal debridement. One patient had varus angulation of 100 at third follow up after he fell from bed but surgical intervention were not needed. All fractures united. The average time for fracture healing was 21.5 weeks (range 16-32 weeks). At the Eighteen months follow up, the average knee range of motion was 1310(range 1100-1400). The functional outcome were evaluated using modified Rasmussen scoring system, which was 27.34 (range 22-30).
 Conclusion: Bicolumnar dual plating for bicondylar fractures of tibial plateau can provide excellent and stable fixation allowing early range of motion and gives excellent to good functional outcome.

Intra-articular bicondylar tibial plateau fractures managed surgically by dual plate osteosynthesis: A clinico-radiological and functional outcome evaluation

Background: The management of bicondylar fracture of proximal tibia is a challenging task and the objective of treatment is to achieve stable, painless and mobile joint and also to prevent the secondary degeneration of the joint. Dual plating in such fractures is beneficial to address fracture fragments in different planes and also to achieve anatomical reduction under direct vision. The aim of the study was to evaluate the functional results in patients with tibial plateau bicondylar fracture treated by open reduction and internal fixation using dual plate osteosynthesis. Materials and Methods: Patients who underwent dual plate fixation for post-traumatic bicondylar tibial plateau fracture were included in the study. This was a prospective study conducted at a Tertiary care Private Hospital in Kolkata, between August 2017 to May 2020. All patients were followed up at an interval of 2 weeks, 6 weeks, 12 weeks, 6 months, 9 months, 1 year and 1.5 year. Radiological and functional results were classified in four categories as per Rasmussen’s criteria. Results: Outcome at final follow-up was assessed with Rasmussen’s functional grading system. In a total of 40 patients, 24 (60%) patients showed Excellent and 11 (27.5%) patients had Good results whereas 4 (10%) patients had Fair outcome and 1 (2.5%) patient demonstrated Poor surgical result at the final follow-up. Rasmussen’s radiological assessment showed 7 (17.5%) Excellent, 25 (62.5%) Good, 5 (12.5%) Fair and 3 (7.5%) patients with Poor result. At the end of 1.5 year, the average Rasmussen’s functional knee score for 40 patients was 25.85 ± 4.83. Conclusion: Dual plate fixation of intra-articular bicondylar tibial plateau fractures is a safe and effective treatment option as it provides good surgical exposure, less soft tissue injury, rigid fixation, acceptable alignment of articular congruity, reasonable time to union and allows early weight bearing and range of motion of knee with good functional outcome.

Proximal tibia fracture dislocations: Management and outcomes of a severe and under-recognized injury

IntroductionProximal tibia fracture dislocations (PTFDs) are a subset of plateau fractures with little in the literature since description by Hohl (1967) and classification by Moore (1981). We sought to evaluate reliability in diagnosis of fracture-dislocations by traumatologists and to compare their outcomes with bicondylar tibial plateau fractures (BTPFs). MethodsThis was a retrospective cohort study at 14 level 1 trauma centers throughout North America. In all, 4771 proximal tibia fractures were reviewed by all sites and 278 possible PTFDs were identified using the Moore classification. These were reviewed by an adjudication board of three traumatologists to obtain consensus. Outcomes included inter-rater reliability of PTFD diagnosis, wound complications, malunion, range of motion (ROM), and knee pain limiting function. These were compared to BTPF data from a previous study. ResultsOf 278 submitted cases, 187 were deemed PTFDs representing 4% of all proximal tibia fractures reviewed and 67% of those submitted. Inter-rater agreement by the adjudication board was good (83%). Sixty-one PTFDs (33%) were unicondylar. Eleven (6%) had ligamentous repair and 72 (39%) had meniscal repair. Two required vascular repair. Infection was more common among PTFDs than BTPFs (14% vs 9%, p = 0.038). Malunion occurred in 25% of PTFDs. ROM was worse among PTFDs, although likely not clinically significant. Knee pain limited function at final follow-up in 24% of both cohorts. ConclusionsPTFDs represent 4% of proximal tibia fractures. They are often unicondylar and may go unrecognized. Malunion is common, and PTFD outcomes may be worse than bicondylar fractures.

Анализ отдаленных результатов оперативного лечения пациентов с переломами проксимального отдела большеберцовой кости аппаратом Илизарова

Introduction Fractures of the tibial plateau are classified by the location of the fracture line, associated capsular ligamentous injuries to the knee and can result from different types of high – or low-energy mechanisms of injury in patients of any age with different bone quality. These factors are responsible for different long-term functional outcomes and the lack of a generally accepted algorithm for diagnosis and treatment. The objective of the study was to analyze the long-term functional outcomes in patients with tibial plateau fractures treated with the Ilizarov external fixation. Material and methods The review included long-term outcomes of 59 patients with tibial plateau fractures treated with the Ilizarov external fixator. Long-term results were evaluated in 53 patients out of 59 (89.83 %) using a subjective and objective clinical assessment system.The follow-up period ranged from 2 to 4 years. Patients were requested to complete the Oxford Knee Score questionnaire used in subjective outcome. Results Knee joint function of patients with tibial plateau fractures treated with the Ilizarov external fixation were rated as satisfactory (n = 34; 64.15 %); 16 (30.19 %) and 3 (5.66 %) patients were diagnosed with mild and moderate gonarthrosis, respectively. No infection that would affect the outcome was recorded in the study group. The mean Oxford Knee Score was 43.06 ± 3.44 (SD) in Schatzker type I split fractures of the lateral femoral condyle; 40.50 ± 5.57 (SD) in Schatzker type II split fractures combined with lateral articular surface depression; 40.71 ± 4.27 (SD) in Schatzker type III depression fractures; 42.33 ± 4.22 (SD) in Schatzker type IV medial condylar fractures; 38.50 ± 7.19 (SD) in Schatzker type V bicondylar fractures and 37.50 ± 5.17 (SD) in Schatzker type VI bicondylar fractures with dissociation of the metaphysis and diaphysis. Conclusions Tibial plateau fractures can be treated with the Ilizarov external fixation and also with the use of screws at any point of time that allows closed or open reduction of the fracture to ensure the early function of the operated limb, stable bone fixation, control of the fixation stiffness at any stage of treatment facilitating good and excellent functional outcomes.

CPD article: Fractures of the femur

Femoral fractures occur commonly in dogs and cats, accounting for 45% of all long bone fractures. Femoral fractures are classified based on anatomic locational and include fractures of the proximal epiphysis, proximal physeal fractures, subcapital fractures, fractures of the femoral neck, trochanteric fractures, subtrochanteric fractures, fractures of the femoral shaft, supracondylar fractures, distal physeal fractures, unicondylar fractures, bicondylar fractures and fractures affecting the femoral trochlea. In general, femoral fractures are not amenable to treatment with external coaptation, so surgical stabilisation or a salvage procedure is required. Selection of an implant system will depend on fracture configuration and location, and requires a thorough understanding of the forces to which the implant system will be subjected. Complications associated with stabilisation may include premature physeal closure, resorption of the femoral head or neck, malunion, non-union, altered coxofemoral development, implant failure, sciatic neurapraxia, quadriceps contracture, patellar luxation and infection. The complication rate can be substantially reduced by the use of meticulous surgical technique and appropriate implant selection with the prognosis for complete functional recovery remaining good to excellent, providing that an optimal healing environment is preserved.

A study on surgical management of Bicondylar fracture tibia

Background: The knee joint is complex joint and being superficial joint is more exposed to external forces. It is the commonly injured joint now a day because of increased vehicular trauma and sports related injuries. Bicondylar tibial plateau fractures usually occur in a bimodal age distribution. The most important factor in deciding the timing and modality of definitive management is the status of local soft tissue. Adequate fixation and early achievement of post-operative range of motion are important for a good prognosis and adequate postoperative functioning. Surgical fixation of Bicondylar tibial plateau fractures is challenging because of geographic complexity and compromise of the soft tissue envelope. In this small study, our aim is to outline the various principles of surgical management of Bicondylar fracture tibia as practiced in our institution and to evaluate the results while having an insight into contemporary literature related to the topic.Materials and Methods: A prospective, observational study conducted on 34 patients satisfying the inclusion criteria from June 2016 to June 2018 to study different methods of surgical management of bicondylar fracture tibia.Result: According to Modified Rasmussen Scoring System, clinically we had 06(17.65%) excellent, 23(67.65%) good, 4(11.76%) fair and 01(2.94%) poor results and radiologically 10(29.41%) excellent, 16(47.06%) good, 08(23.53%) fair and none poor results. We also used Oxford Knee Score in our study where we had 8(23.52%) excellent results, 19(55.88%) good results, 7(20.58%) fair results and 00(00%) poor results.Conclusion: Pre-op planning is must. CT scan gives exact anatomy of fracture pattern and helps in deciding type of implant and also guides about the surgical approach to be used. To reduce skin related problems and to achieve reasonable alignment, spanning external fixator should be applied at early stage and kept till acute phase is over. Bicondylar tibial plateau fractures having bone defects must be filled with iliac crest autograft / bone substitutes after reduction of articular fragments. Medial side buttress plating is always desirable in bicondylar fracture pattern with unstable medial condyle to prevent delayed medial collapse and undesirable varus deformity. Early mobilization not only gives good knee ROM but also restores patient’s confidence resulting in better compliance.

A prospective evaluation of posteromedial buttress plate as a tool for management of bicondylar fracture of tibia

Background: Tibial plateau is important component of knee joint and bicondylar fracture of tibial plateau is a complex fracture and challenges to orthopaedic surgeon. The lateral locking plate alone may not be sufficient to hold this fragment, because of the morphology and position of postero-medial fragment, leading to late varus collapse. To counter this problem, a separate posteromedial buttress plateis now been used by surgeons.Method: This is a prospective study that included 36 patients with closed posteromedial tibial plateau fractures who had undergone open reduction and internal fixation through a posteromedial approach by plate and screws between August 2017 and December 2020. Open reduction was done for all patients with anterolateral and open posteromedial approach internal fixation was done with lateral and posteromedial buttress plate.Result: As per Rasmussen’s functional scoring 26(72.23%) patients have excellent outcome, in 8 (22.23%) patients and in two patients (5.56%) outcome was fair.Discussion and Conclusion: Bicondylar fracture is more common in younger population with female predominance. Road traffic accident is more common than then fall and schatzker type 5 fracture was common than schatzker type 6 fracture. Rasmussen’s functional scoring patients have excellent in more than 70 % patients. Posteromedial buttress plate is a good tool for management of bicondylar fracture of tibia.

SINGLE LATERAL PLATE VERSUS DOUBLE PLATING OF COMMINUTED SUPRACONDYLAR FEMORAL FRACTURES

Background: Fractures of the distal femur are rare and severe. For an extra-articular fracture, all therapeutic options are possible and mini-invasive surgery can be performed. In case of an intra-articular fracture, open reduction and internal plate fixation should be performed. Objective: To evaluate the functional and radiological outcomes of 20 patients with comminuted supracondylar fractures managed by either single or double plating. Patients and Methods: A prospective randomized clinical study was done in the period between November 2019 and September 2020 involving 20 cases with distal femoral fractures. All patients were operated at Al-Azhar University Hospitals and Al-Helal Hospital. Patients were divided into two groups/ preoperatively. The patients were randomly allocated for treatment with either: Group I managed by single lateral plate ,or group II managed by double plating. Results: There were insignificant differences between the two groups regarding range of movement, pain, knee society score and complications. Conclusion: Although both lateral and double plating fixation using dual approach for type C2 and C3 distal femoral fractures were efficient and safe methods of management, double plating recommended in these cases, i.e. medial supracondylar bone loss, low transcondylar bicondylar fracture, medial Hoffa fracture, per prosthetic distal femur fractures, nonunion after failed fixation with single lateral plate, poor bone quality and comminuted distal femur fractures C3.

A comparative study based on surgical and functional outcome of proximal tibia fractures between unicondylar and bicondylar fractures

Background: Tibia plateau fractures constitute 1%of all fractures. Bicondylar fractures account for 10-30%, whereas isolated medial and lateral condyle fractures constitute the remaining injuries. Although only 3% of these fractures are open injuries, many of them have closed degloving, deep abrasions or severe soft tissue injuries which require careful consideration in deciding the timing and the nature of surgery. Proximal tibia fractures may be difficult to treat even in experienced hands due to intraarticular extension, comminution, cartilage damage and soft tissue injuries of the cruciate ligaments and menisci. Aim: To compare the functional and surgical outcomes of operative treatment of unicondylar and bicondylar fractures. Materials and Methods: It was a prospective and comparative study of Surgical and functional outcome of proximal tibial fractures in the department of orthopaedics from July 2019 to December 2019. Clearance was obtained from the hospital ethical committee. Fifty patients were taken into consideration for the study. All patients are selected on the basis of history, clinical examination and radiography. The Schatzker’s classification was used to classify these fractures. The patients were followed up for an average period of 6 to 12 months. The patients were divided into two groups. Twenty-five patients in the unicondylar fracture group 1and 25 patients in the bicondylar fracture group 2. Results: The mean age of group 1 patients was 45.7210.85 years, and that of group 2 patients was 46.408.602 years (p>0.05). In group 1 there were 18 (72%) males and 7 (28%) females, in group 2 there were 21 (84%) males and 4 (16%) females. In group 1, the mean union time was 3.04 0.351 and in group 2 was 3.1 0.433(p>0.05). In group 1, the mean follow-up time was 12.81 2.09 and in group 2 was 13.04 2.28 (p>0.05). The mean functional score of group 1 was 91.212.27, and in group 2, it was 8718.2 (p>0.050). In group1 mean WOMAC score was

Functional outcome of tibial condylar fractures (Schatzker type V, VI) managed surgically with mippo technique

Introduction: Fractures involving proximal tibia & extending into the knee joint, are known as tibial plateau fractures. They comprise of 1% of all fractures and 8% of the fractures in elderly. Lateral condyle fractures are most common (55-70%). Medial condyle fractures (10 to 23%), bicondylar fractures (10-30%). Most common mechanism of injury is direct axial compression, with a valgus or varus moment and indirect sheer forces. AIM: This study was conducted to observe the functional outcome of surgical management in schatzker type V, VI tibial plateau fractures with proximal locking compression plate. Materials and Methods: 30 cases of Schatzker type V and VI Tibial plateau fractures were taken up for this prospective study. Patients were followed up for a minimum period of 6 months. First follow up was at 6th week, and second follow up was done at 3 months. Both radiological and clinical evaluation was done at both the times. The anatomic and functional evaluation was done using the modified Rasmussen clinical and radiological criteria. Results: In our study, we found that most cases were between 5th-6th decade. Males were affected more than females (80% & 20%). Majority of the patients showed involvement of right tibia (21/30), as compared to left (9/30). RTA was the most common mode of injury, accounting to 77% of the cases followed by self-fall-23%. Conclusion: MIPPO (minimally invasive percutaneous plate osteosynthesis) technique minimizes the size of the surgical incision and avoids soft tissue injury, in turn reducing post-operative complications, leading to better wound healing.

Clinical radiological & functional outcome of Tibial Bi-Condylar fractures treated surgically

Objectives: With the advancement in surgical, approaches, technique and newer fixation devices the treatment outcome of bicondylar proximal tibial fractures have improved. Therefore it is paramount to identify the appropriate treatment techniques for better functional outcomes in terms of better stability and early weight bearing without pain. Hence this study was carried out to study the functional outcomes of Intra-articular bicondylar tibial fractures, treated with operative management using contoured locking plate over both the condyles. Material and Methods: This study was carried out as a prospective study. Fifty (50 fractures) patients with acute, displaced Intra-Articular bicondylar tibial aged above 18 years, were enrolled in the study. Open fractures and fractures older than two weeks were excluded. The functional outcome was assessed every 4 weeks. Assessment included OA change, limitation of ROM, or malalignment. Results: Of the 50 patients, all were males. 35 patients had left sided fractures, while 15 had right sided fractures. Post operatively all 50 patients had swelling, 20 patients had persisting pain, 5 had superficial infections and 2 had deep infection. Superficial infections healed with antibiotics and dressings, while the patient with deep infection had persistent pain and difficulty in walking with discharge from surgical wound site. Both of them underwent implant removal and debridement after a year. Of the 50, 32 had OA changes, 14 had fair limited ROM and 4 had malalignment. Hence we conclude from the above findings that dual plate fixation helps in improving the functional outcome of the patients in view of their physical and radiological findings. Soft tissue problems should be kept in mind, and usage of locking plate can reduce the discomfort of hardware impingement effectively. Conclusion: A relatively better functional outcome was observed in displaced and comminuted fractures in dual plating, provided that the intra-articular congruity was restored. The technique of dual plate fixation is good with regards to fracture union and functional outcome.

Predictors of functional outcome of surgical management in proximal tibia fractures

Background: Tibia plateau fractures constitute about 1% of all fractures and complex bicondylar fractures constitute 30% of all Tibial plateau fractures. These fractures pose an inherent difficulty in treatment due to the extent of soft tissue damage, fracture comminution, instability, displacement of articular fragments and increased risk of compartment syndrome. Present study was carried to find out functional outcome in different fracture management technique. Material and methods: A total 25 cases of tibial plateau fracture treated with different implants from April 2019 to September 2019 in Santokba Durlabhji Memorial Hospital were followed for minimum of 6months. Patients less than 18 years and more than 60 years of age, Compound trauma and fractures due to pathological conditions were excluded. Functional outcome was measured using Rasmussen’s grading system at 6month follow up. Results: Maximum study subjects (36%) were in age group of 31-40yrs, 80% had road traffic accidents as a mode of injury. 32% were of type V Schatzker fracture classification. 48% subjects were operated by ORIF with LCP Plating, 24% subjects were operated by LCP Plating plus CC screw, 20% were operated by bicondylar plating, 8% were operated by CC screw. Most of the subjects with plates had either excellent or good outcome. Conclusion: ORIF with plating gives excellent to good functional outcome with minimal soft tissue complications.

Minimally invasive percutaneous plate osteosynthesis for closed proximal tibia fractures: A study of 30 cases

Tibial plateau fractures comprises about one percent of all fractures and complex bicondylar fractures comprise of 30% of all Tibial plateau fractures. Minimally invasive percutaneous plate osteosynthesis [MIPPO] is a method of biological fixation where a plate is percutaneously inserted and fixed at a distance proximally and distally from the site of fracture. By minimal exposure, this aids in the protection of the essential fracture hematoma, minimal soft tissue dissection, avoidance of periosteal stripping and providing a sufficient fixation. So the need for the study is to assess the effectiveness of the technique in achieving fracture union, functional outcome and to know the rate of complications associated with MIPPO. The purpose of this study was to assess the results and the efficacy of MIPPO for of the proximal tibia fracture. This is a prospective study of 30 patients with tibial condylar fractures treated by minimally invasive percutaneous plate osteosynthesis at Karpaga vinayaga institute of medical sciences and research center, Chengalpattu, Tamil Nadu. These patients were followed both clinically and radiologically after surgical fixation. A total of 30 patients with tibial condylar fracture were included in the study. The mean age of the participants was 38.70±14.14 years, with 21 (70%) males and 9 (30%) females. In our study containing 30 patients operated by MIPPO, we had 66.67% had excellent result, 20% had good results, 6.67% had fair results and remaining 6.67% had poor results. In our study it was found that high velocity injuries (type IV – VI) have poorer outcome than low velocity injuries (type I-III). In this way cautious patient selection, careful preoperative planning, delicate and reasonable soft tissue and bone handling, precise contouring of plates and vigorous postoperative rehabilitation and patient education appears to be the key to success of the procedure.

Predictors of Symptomatic Implant Removal After Open Reduction and Internal Fixation of Tibial Plateau Fractures: A Retrospective Case-Control Study.

A retrospective case-control study was conducted at a level I trauma center to assess whether radiographic details of tibial plateau fixation can predict symptomatic implant removal. Nine hundred fifty-one tibial plateau fractures were treated with open reduction and internal fixation from 2007 to 2016. Eighty-two (9%) were treated with implant removal for localized pain over the implant. A control group was selected from the remaining patients using cumulative sampling. Records and radiographs were reviewed for predictors hypothesized to be associated with implant removal. Based on the authors' multivariable model, implant removal was associated with each additional protruding screw (adjusted odds ratio, 1.32; 95% confidence interval, 1.13-1.55; P<.001), bicondylar fractures (adjusted odds ratio, 2.13; 95% confidence interval, 1.11-4.11; P=.02), and lower body mass index (P=.05). Associations that approached significance were observed with decreased age (adjusted odds ratio, 0.82 per 10 years; 95% confidence interval, 0.66-1.01; P=.06) and closed fractures (adjusted odds ratio, 0.34; 95% confidence interval, 0.10-1.19; P=.09). The model discriminated fractures requiring implant removal with moderate accuracy (area under the curve=0.71). Each additional screw that radiographically protrudes beyond the far cortex increases the odds of symptomatic implant removal by 32%. Bicondylar fractures and lower body mass index are also associated with symptomatic implant removal. These findings might help inform patients and guide fixation techniques to reduce the likelihood of symptomatic implant removal. [Orthopedics. 2020;43(3):161-167.].

Bilateral Gastrocnemius Flap For Harlequin Defects Around The Knee

&#x0D; &#x0D; &#x0D; &#x0D; Background : Tibial plateau fractures (especially bicondylar Schatzker type 5 and type 6) are a result of high energy trauma. Along with bony component, soft tissue injury is a major determinant in the treatment and final outcome. Bicondylar fractures needs bicolumnar fixation and as such require separate approaches: postero-medial and lateral incisions. The soft tissue of the proximal tibia swells significantly after the injury, coupled with extensive soft tissue dissection during fixation this can lead to subsequent wound breakdown and infection along either side of the proximal tibia which resembles “harlequin eyes”. This study describes outcome of management of post operative soft tissue complications following bicolumnar fixation of proximal tibia with medial and lateral gastrocnemius flap.&#x0D; Method : Three patients who had bilateral soft tissue necrosis at surgical incision sites treated with debridement and bilateral gastrocnemius flaps between January 2016 and December 2017 were included in this study. The mean age was 38 years (range 18–50 years) and the mean duration of follow-up was 10 months. Outcome assessments included the condition of the flap and fracture healing time.&#x0D; Result : All fractures united after surgery. There were no soft tissue complications and all flaps healed well. The mean bony union time was 6 months.&#x0D; Conclusion: Our technique of covering soft tissue loss at surgical site on medial and lateral side of proximal tibia with bilateral gastrocnemius flap in the same setting is a reliable and safe surgical method for these conditions.&#x0D; &#x0D; &#x0D; &#x0D;

Dual Plating of the Distal Femur: Indications and Surgical Techniques.

Dual-plating of the distal femur is required in some cases to achieve stable fixation. The indications of a medial plate in addition to the lateral plate are medial supracondylar bone loss, low trans-condylar bicondylar fractures, medial Hoffa fracture, peri-prosthetic distal femur fractures, non-union after failed fixation with single lateral plate, poor bone quality and comminuted distal femur fractures (AO type C3). We recommend orthogonal plate configuration with locked plates by a single incision or dual incision approach as per surgeon choice.

Are Continuous Femoral Nerve Catheters Beneficial for Pain Management After Operative Fixation of Tibial Plateau Fractures? A Randomized Controlled Trial

To determine whether a continuous femoral nerve block after open reduction internal fixation of tibial plateau fractures would diminish Visual Analog Scale (VAS) scores and/or systemic narcotic intake. Randomized controlled trial. Level 1 academic trauma center. Forty-two consecutive patients with operatively treated tibial plateau fractures. Continuous femoral nerve catheter for postoperative pain management was performed in the experimental group. Both the VAS scores for pain and narcotic intake were assessed at 4, 8, 12, 24, 36, 48, and 72 hours postoperatively. Forty-two patients were enrolled in this study. There were 21 women and 21 men 21-70 years of age (avg 49) with operatively treated tibial plateau fractures. Twenty-one patients were randomized to receive a femoral nerve block with 5 crossovers for technical reasons. Accordingly, we analyzed 16 patients with femoral nerve blocks and 26 with standard care. There were no significant differences between the study groups regarding age, sex, or fracture type. There was no significant difference in VAS scores between the control and experimental group at any time point. The total systemic morphine equivalent for the femoral nerve block group and the control group was 375 and 397 respectively (P = 0.76). Across groups, patients with bicondylar fractures tended to have higher VAS than those with unicondylar fractures and to use more narcotics, although neither was statistically significant. Femoral nerve blocks for postoperative pain management in tibial plateau fractures did not demonstrate an improvement in pain relief or narcotic use. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

PO 18133 - Internal fixation of displaced intra-articular fractures of the hallux through a dorsomedial approach

Introduction: Intra-articular fractures of the hallux are usually treated nonoperatively, except when the fragments are displaced and the joint is incongruent. Displaced fractures treated nonoperatively can result in degenerative arthritis of the interphalangeal joint, causing pain and range of motion limitation. The aim of this study is to present the results of the surgical treatment of displaced interphalangeal joint (IPJ) fractures of the hallux using a dorsomedial approach. It is our understanding that this approach minimizes injury to the soft tissue envelope without the need to detach or create a tenotomy of the extensor hallucis longus tendon (EHL), allowing rigid fixation and early weight bearing and range of motion. Methods: A retrospective case series was performed of 5 patients with displaced IPJ fractures of the hallux treated with the dorsomedial approach from July 2013 to October 2017. Two patients were male and three female, with a mean age of 37,4 years and a mean follow-up of 36 months. The surgical indication for open reduction and internal fixation through a dorsomedial approach of the IPJ was displaced (&gt;2 mm) bicondylar fractures of the proximal phalanx of the hallux. The incision was performed along the medial border of the EHL tendon without the need to detach or create a tenotomy of this tendon. In the postoperative period, follow-up included clinical evaluation and radiographic exams. All patients were assessed by visual analog scale (VAS) scores for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Results: All patients presented bone consolidation and returned to their previous activities without limitations. At the final follow-up, the mean VAS score was 0, and the mean AOFAS score was 92,6. Clinical evaluation revealed preservation of approximately 50% of the range of motion of the IPJ compared with the contralateral side. Conclusion: We concluded that a dorsomedial approach should be considered in the surgical management of displaced intra-articular fractures of the hallux. It preserves soft tissue and most of the IPJ motion, preventing postoperative joint pain and stiffness.

Retrospective analysis of 514 cases of tibial plateau fractures based on morphology and injury mechanism

BackgroundTibial plateau fractures remain a clinical challenge due to the complexity of the fracture patterns which have been repeatedly categorized by many researchers. However, limitations do exist in some respects. So we aimed to reclassify tibial plateau fractures based on injury mechanism and morphological characteristics.MethodsFive hundred fourteen cases of tibial plateau fractures were enrolled. The X-rays and CT scans were analyzed.ResultsAccording to our observation and analysis, tibial plateau fractures can be categorized into the following six types: (1) Lateral condylar fractures (axial force applied while knee extending in valgus position). Two hundred fifty-one cases were included (48.83%). (2) Fracture dislocation (multiple forces especially rotational stress while knee extending). Fifty-five out of 514 cases belong to this pattern (10.70%). Correction of the subluxation remains primary and crucial during surgical procedures. (3) Simple medial condylar fractures (axial force applied while knee extending in varus position). One third of which were associated with an avulsion fracture of fibular head. Fifteen cases were included (2.92%). (4) Bicondylar fractures (axial forces applied while knee extending). One hundred twelve cases were included (21.79%). Surgical algorithm greatly depends on soft tissue conditions. (5) Posterior condylar fractures (axial stress applied while knee flexing). Sixty-five cases were seen in our study (12.65%), most of which were associated with an avulsion fracture of the intercondylar eminence (49/65, 75.38%). The fracture of posteromedial part, posterolateral part, and intercondylar eminence forms a unique pattern of injury defined as “Posterior Condylar Triad.” (6) Anterior condylar compression fractures (axial, varus, or valgus forces applied while knee overextending). Posterior structural complexes, crucial ligaments, or even popliteal arteries are prone to be damaged. Sixteen cases were identified (3.11%).ConclusionOur classification system has instructive significance in overall preoperative evaluation of fracture features and soft tissue problems as well as guiding clinical management for better functional outcomes.

Comparison of Postoperative Outcomes Between Open Reduction and Internal Fixation and Ilizarov for Schatzker Type V and Type VI Fractures.

IntroductionOpen reduction and internal fixation (ORIF), hybrid fixation, and external fixation are available treatment options for bicondylar fractures of the proximal tibia but which one is superior to the others is not yet established. Therefore, the study aimed to establish a gold standard treatment option for bicondylar fractures by comparing the clinical, functional, and radiological outcomes managed by Ilizarov and ORIF at 24 months.MethodsThis was a retrospective study conducted from 2009 to 2014 at a public sector, tertiary care, level I trauma center. Patients with Schatzker type V and type VI open and closed fractures were included. Floating knee, pathological fractures of the tibia, and patients having medical conditions were excluded from the study. Honkonen and Jarvinen (HJ) criteria for subjective, clinical, radiological, and functional outcomes were used to compare between the two groups at 24 months. Demographic data included age, gender, Schatzker type, mechanism of injury, and range of knee flexion. Chi-square was used to find the level of significance, which was 0.05.ResultsA total of 137 patients were included in this study, with 68 patients in the ORIF group and 69 in the Ilizarov group during the study period. The mean age of the patients was 45.08 ± 10.52, respectively. The male to female distribution was 107/30 (78.1% and 21.89%). According to the mechanism of injury, road traffic accidents (RTA) were the primary cause of injury: 96 (70.07%), falls were 21 (15.32%), and gunshots were 18 (13.13%). Seventy-four were Schatzker type VI (54.01%) whereas 63 (45.98) were Shcatzker V. The average knee flexion at 24 months was 115.51 ± 16.82. There were no differences in the clinical, functional, and radiological outcomes at 24 months between the two treatment groups.ConclusionNo single treatment option can be applied in all cases, and the decision depends on the complexity of the injury, the surgeon’s expertise, and host factors.