Plateau Fractures Research Articles

Treatment of complex tibial plateau and distal tibial fractures with Taylor spatial frame: experience in a district general hospital

Complex tibial fractures especially intraarticular pilon and plateau fractures are difficult to manage. Literature shows poor results in the treatment of these fractures due to complexity of the fracture and involvement of articular surface. Taylor spatial frame (TSF) is a hybrid, multiplanar, external fixator, which uses the slow correction principles of Ilizarov system. Specialised centres around the world use these frames to treat various long bone fractures and to correct deformities. Very few district general hospitals and hospitals of similar set-up deal with these injuries. TSF was used to treat 26 complex intraarticular fracture of tibial plateau (Schatzkar type IV–VI) and pilon fractures (Rudi III) in a district general hospital. Seventeen were pilon and nine were plateau fractures. There were 21 male and 5 female patients. Average length of time patients had the frames on was 191 days. The average follow up was 14 months. The average operative time was 2 h 13 min for pilon fractures, 2 h 37 min for tibial plateau fractures. Fourteen patients did not have any complications. Twelve had 1–3 pin-site infection. Four had chronic pain. Two pilon fractures had delayed union and one had nonunion. One patient had foot compartment syndrome and underwent decompression. No cases of osteomyelitis, broken pins or nerve palsy occurred. With proper training, preoperative and postoperative care, TSF can be used in a district general hospital safely. The procedures can be planned well in advance. Referral to specialist centre, possible complications during transfer and a second procedure at the referral centre could be avoided.

Management of posttraumatic extensive bone loss and osteomyelitis using a customized articulating knee spacer

The combination of infection and extensive bone loss presents a challenging reconstructive situation for surgeons performing total knee arthroplasty (TKA). We describe the case of a patient that suffered a grade III open fracture of the tibial plateau and developed a recurrent infection which resulted in loss of the proximal 15 cm of the tibia. Our solution was interim use of custom-made articulating, antibiotic-impregnated spacers followed by a structural tibial allograft and hinged TKA. At 2-year follow-up the patient is infection-free and is able to ambulate without the use of support.

The effect of hyaluric acid sodium injection and functional exercises on patients with comminuted fracture of tibia plateau after reposition

Objective To investigate the clinical effect of hyaluric acid sodium injection and functional exercises on patients with comminuted fracture of tibia plateau after reposition. Methods 134 patients with comminuted fracture of tibia plateau after reposition were randomized into the observation group and the control group with 67 cases in each group. The observation group received 2ml of hyaluric acidsodium injection into the knee joint cavity with 1％ lidocaine once a week and 3 times totally. At the same time active and passive functional exercises were applied. The control group was only given routine nursing. The knee function was evaluated by Lysholm Scale 4 months after operation and the results were compared. Results The score of the observation group was higher than that of the control group(P＜0.01).Conclusion The hyaluric acid sodium injection and functional exercises could improve the healing of joint cartilage and contribute to the rehabilitation of joint function in patients with comminuted fracture of tibia plateau after reposition. Key words: Fracture of tibia plateau; Hyaluric acid sodium; Lidocaine; Functional exercise

Mechanische Belastung und biomechanische Probleme des kompletten Gelenkflächenersatzes beim Tibiaplateau

Recent reports of fractures of the tibial component of total knee prostheses have raised the question of their long term endurance. The mechanical load for the tibial plateau consists of the two forces deriving from the condyles of the femur. As the collateral and crucial ligaments always allow a little play for the femoral and tibial components, the location of the load of the condyles on the tibial plateau is either on the medial or lateral side depending on minor disturbances during gait. For a tibial plateau with only little medullary anchorage this load pattern means an alternating induction of compression and tensile stresses for the underlying bone. This alternating stress pattern is discussed as a possible mechanism of aseptic loosening of such tibial components. For two cases of such aseptic loosening and consecutive fracture of the tibial plateau of a metal backed unconstrained sledge knee prosthesis the radiologic findings are demonstrated and correlated to the biomechanical mechanisms described. It is demonstrated that the structural endurance of the tibial plateau does not withstand the mechanical stresses of such a situation of aseptic loosening. In these cases further loosening or fracture of the tibial plateau results.

Bilateral external fixator combined with limited internal fixation for the treatment of open fracture of tibial plateau

目的 探讨应用外固定支架结合有限内固定治疗开放性胫骨平台骨折的方法和疗效.方法 自2001年2月至2005年9月,采用双臂外固定支架治疗开放性胫骨平台骨折53例,按Schatzker分型:Ⅴ型35例,Ⅵ型18例.开放性创口按照Gustilo分型:Ⅰ型15例,Ⅱ型22例,Ⅲ型16例.结果 随访5～22个月,平均10个月,所有患者均骨性愈合.根据Merchant评分标准,优18例,良25例,可9例,优良率达83%.结论 双臂外固定支架结合有限内固定技术具有创伤小、内固定牢靠、并发症少等优点,是治疗开放性胫骨平台骨折的有效方法。

Dicke Chance – die operative Behandlung der schweren Adipositas bei posttraumatischer Osteoarthrose

In times of plentiful nutrition an environmental advantage turns into a problem - obesity. Apart from an increase in morbidity and overall mortality the development of osteoarthrosis is well documented. Pre-arthrotic conditions may arise from trauma and can lead, depending on the pattern of injury, to full-blown arthrosis. The presence of obesity can play the role of a relevant progressive factor in this setting. Here we report about the case of an obese man (BMI 53.5 kg/m(2)), who suffered a fracture of the femoral head with acetabular participation (Pipkin IV) as well as a fracture of the tibial plateau. Operative management and rehabilitation were followed by gastric bypass surgery for weight reduction. The case is discussed with regard to the present literature.

A case report of discoid fracture of tibial plateau treated with rivet internal fixation

患者 女性,30岁,因骑助动车不慎右膝撞上路旁护栏,右膝疼痛,活动障碍半天入院.查体示右膝肿胀,右膝外侧压痛阳性,膝关节活动受限,无血管神经受损体征.X线片显示为胫骨外侧平台向上撕脱性盘状骨折(图1)。

Fratura avulsão do planalto tibial medial (Segond reverso)

Descreve-se neste artigo um padrão de lesão descrito na literatura apenas duas vezes, num total de quatro casos, denominado Segond reverso por apresentar achados clínicos e radiológicos exatamente opostos aos da clássica lesão de Segond. Semelhantemente aos casos previamente descritos, apresentou fratura avulsão do planalto tibial medial, na inserção do ligamento colateral medial profundo, associada a lesão do ligamento cruzado posterior. Assim como em um dos casos prévios, foi constatada lesão do ligamento cruzado anterior. Entretanto, diferiu dos anteriormente relatados por não apresentar lesão do menisco medial.

Intraoperative cone-beam CT for image-guided tibial plateau fracture reduction

Objectives: A mobile isocentric C-arm was modified in our laboratory in collaboration with Siemens Medical Solutions to include a large-area flat-panel detector providing multi-mode fluoroscopy and cone-beam CT (CBCT) imaging. This technology is an important advance over existing intraoperative imaging (e.g., Iso-C3D), offering superior image quality, increased field of view, higher spatial resolution, and soft-tissue visibility. The aim of this study was to assess the system's performance and image quality in tibial plateau (TP) fracture reconstruction.Methods: Three TP fractures were simulated in fresh-frozen cadaveric knees through combined axial loading and lateral impact. The fractures were reduced through a lateral approach and assessed by fluoroscopy. The reconstruction was then assessed using CBCT. If necessary, further reduction and localization of remaining displaced bone fragments was performed using CBCT images for guidance. CBCT image quality was assessed with respect to projection speed, dose and filtering technique.Results: CBCT imaging provided exquisite visualization of articular details, subtle fragment detection and localization, and confirmation of reduction and implant placement. After fluoroscopic images indicated successful initial reduction, CBCT imaging revealed areas of malalignment and displaced fragments. CBCT facilitated fragment localization and improved anatomic reduction. CBCT image noise increased gradually with reduced dose, but little difference in images resulted from increased projections. High-resolution reconstruction provided better delineation of plateau depressions.Conclusion: This study demonstrated a clear advantage of intraoperative CBCT over 2D fluoroscopy and Iso-C3D in TP fracture fixation. CBCT imaging provided benefits in fracture type diagnosis, localization of fracture fragments, and intraoperative 3D confirmation of anatomic reduction.

Fracture of lateral tibial plateau treated through lateral approach of knee joint

目的 探讨膝关节外侧入路治疗胫骨外侧平台骨折的可行性及初步临床效果.方法 2001年9月～2004年3月采用膝关节外侧入路手术治疗43例Schatzker分型Ⅰ～Ⅲ型胫骨平台骨折患者,观察手术操作时间、术中出血量及术后功能结果.结果 41例患者获12～42个月(平均23.5个月)随访.手术时间平均为75 min,出血量平均为300 mL.2例患者术后2周拆线时出现局部皮缘浅层坏死,3例出现深静脉血栓,1例出现肺栓塞.术后膝关节外侧稳定,未见松弛.按Rasmussen疗效评分标准评定疗效:优22例,良13例,可4例,差2例,优良率为85.4%.结论 膝关节外侧入路手术操作简单、损伤小、术后功能恢复快,是SchatzkerⅠ～Ⅲ型胫骨外侧平台骨折手术治疗比较可靠的方法。

Minimally invasive internal fixation assisted by external fixators to treat high-energy fracture of tibial plateau

目的 评价外固定架辅助微创内固定治疗胫骨平台骨折的疗效.方法1999年10月～2005年2月采用微创内固定加外固定架治疗25例胫骨平台骨折患者,其中Schatzker Ⅴ型6例,Ⅵ型19例.采用Illizarov支架固定者8例,Sheffield支架固定者12例,AO外固定架固定者5例.其中13例患者采用跨膝关节外固定架固定.随访时采用Honkonen-Jarvinen评分标准进行评分.结果所有患者获12～30个月(平均18个月)随访.除1例患者出现感染性骨不连外,其他患者骨折全部愈合,骨愈合时间为10～18周,平均13周.根据Honkonen-Jarvinen标准评分,患者的影像学、客观表现、主观症状及日常功能评分的优良率分别为84%、76%、88%和72%.结论外固定架辅助微创内固定治疗复杂胫骨平台骨折能减少术后并发症的发生和降低术后感染,是一种有效的治疗方法。

Early Failure of Minimally Invasive Unicompartmental Knee Arthroplasty Is Associated with Obesity

There has been increasing use of and expanding indications for unicompartmental knee arthroplasty using minimally invasive techniques. We sought to define contraindications by examining failures. We retrospectively reviewed the early results of a consecutive series of minimally invasive medial unicompartmental knee arthroplasty using two implant designs. Seventy-nine consecutive unicompartmental knee arthroplasty cases (48 instrumented and 31 noninstrumented) with minimum 2-year followup were reviewed. Patients with radiographic involvement with or without pain referable to the lateral compartment or to the patellofemoral joint were not considered candidates. Failure was defined as revision or pending revision. The average followup was 40.2 months. There were 16 failures (six tibial loosening, three plateau fracture, four persistent medial pain, one progressive arthritis, and two sepsis). Age, gender, disease severity and implant design did not predict failure. Body mass index greater than 32 did predict failure and was associated with a reduction in survivorship by log-rank and Wilcoxon analyses. These results show reliable success if obesity is considered a contraindication and technical errors resulting in fracture are eliminated. Better defining the ideal candidate for unicompartmental knee arthroplasty, with obesity remaining a contraindication, will make this a more predictable and reliable procedure. Prognostic study, Level IV-2 (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Segond Fracture Revealed by Ultrasonography

Segond fracture is an eponym that refers to an avulsion fracture of the anterolateral margin of the proximal tibia, just below the lateral plateau. This fracture was described originally in 1879 by French surgeon Paul Ferdinand Segond (1851-1912) in cadaveric experiments. 1 On the anteroposterior view of the knee, the Segond fracture characteristically appears as a small elliptical bone fragment with its long axis oriented vertically, parallel to the proximal tibia. 2 Recognition of this fracture is important because it has a high association with other knee injuries, including anterior cruciate ligament (ACL) tears (75%-100% of cases) and meniscal tears (53%-75% of cases). 2 - 7 The Segond fracture results from excessive internal rotation and varus stress, which cause abnormal tension on the middle portion of the lateral joint capsule (ie, the lateral capsular ligament [LCL] of the knee) and therefore produce an avulsion fracture of the lateral tibial plateau. 1 - 4 The Segond fracture is usually diagnosed on anteroposterior radiographs of the knee; however, some fractures have subtle findings, and the avulsed cortical fragment may be difficult to detect on routine views. 8 At magnetic resonance (MR) imaging, focal bone marrow edema may be seen at the lateral tibial rim, but the bony fragment itself may be overlooked.4 To our knowledge, there is no report of ultrasonographic findings in Segond fracture. We present a case of Segond fracture diagnosed ultrasonographically and confirmed by radiographs and MR imaging.

Percutaneous humeroplasty of posterolateral humeral head defects (Hill-Sachs) associated with anterior shoulder dislocation: a cadaveric study (SS-63)

The significance of the Hill-Sachs lesion in relation to recurrent anterior dislocations of the shoulder has been well described. While numerous procedures have been devised for the treatment of recurrent anterior shoulder dislocations associated with these defects, none are directly aimed at correcting the lesion itself. A percutaneous bone tamp has been used successfully in treating central tibial articular depressions seen in plateau fractures. We propose that the percutaneous bone tamp can be used to correct or decrease the size of large Hill-Sachs defects which we will term “humeroplasty.” The purpose of our study was to evaluate whether percutaneous humeroplasty can be used to achieve correction of a large Hill-Sachs defect. Our hypothesis is that percutaneous humeroplasty can reduce large Hill-Sachs lesions to normal. Fourteen cadaveric humeri were used for our study. The average age was 49.9 years. There were 13 males, 1 female. A reproducible, “significant” Hill-Sachs defect that was morphologically similar to in vivo lesions was created, as defined by previous studies. Defect arc depth, arc width and the length were then measured and will be used to calculate the volumetric loss from the Hill-Sachs lesion as well as volume restoration following humeroplasty. The defect was then reduced visually and under fluoroscopic guidance using our percutaneous humeroplasty technique. This technique involves a 10-mm diameter cortical window created in the mid-greater tuberosity just lateral to the bicipital groove, through which the curved bone tamp is directed to the defect and correction is obtained. The residual defect following humeroplasty was then measured and recorded. Paired t tests were used to compare the pre- to post-humeroplasty parameters including arc depth, width, length, and volume as well as comparing post-humeroplasty measurements to no defect. Significance is set at P = .05. The average arc depth, width, length, and volume of the Hill-Sachs defect measured 8.9 mm, 16.3 mm, 24.1 mm, and 1755.6 mm3, respectively. Following percutaneous humeroplasty, these defects were reduced to 1.6 mm, 6.2 mm, 10.4 mm, and 50.3 mm3, respectively. All reductions were statistically significant (P < .001). When the reduced defect arc depth, width, length, and volume were compared with no defect (0 mm or 0 mm3), there was a statistically significant difference in all parameters (P < .001). We were able to reproducibly create large Hill-Sachs deformities in vitro. While we were not able to prove our hypothesis that percutaneous humeroplasty can reduce large Hill-Sachs lesions to normal, we were able to significantly reduce these to “small” defects, as described in previous clinical studies. This reduction of the Hill-Sachs lesion to a “small” defect may prevent the increased risk of recurrence normally seen following the surgical treatment of anterior shoulder instability with large Hill-Sachs defects. Additional cadaveric research followed by clinical studies is needed to further investigate percutaneous humeroplasty as a viable technique for the treatment of anterior shoulder instability with large Hill-Sachs lesions.

Bone Transport In Chronic Infected Non-Union Using AO External Fixator

We used AO external fixator for bone transport in 4 patients with chronic osteomyelitis after trauma including 2 cases with femoral shaft fracture (type I and III A), one femoral supracondylar fracture (type III B) and one case with fracture of the proximal of tibia (plateau) type III B. The mean age of the patients was 34.7 years (24-46 years). All fractures were open because of car accident. Internal fixation had been initially carried out for the patients with femoral fracture and calcaneal pin traction for the patient with plateau fracture. The mean time between fracture and the onset of bone transport external fixation was 85 days (24-180 days). All the patients were culture-positive, identified the gram negative bacteria including Pseudomona, E-coli and Enterobacter as the causative pathogens. The mean of bone defects was 10.2 centimeters (7-14 centimeters).The mean duration of bone transport was 134 days (77-210 days). The total duration of treatment from placing AO external fixator until bringing out the device was 11-25 months (mean, 19.2 months). According to our experience when bone transport carried out by AO external fixator and with use of a five-toseven day latency period and a rate of distraction of one millimeter per day, approximately 1.9 month treatment (including time for distraction and healing) was required per each centimeter bone defect which is less than the duration of treatment using Ilizarov technique for bone transport requiring 2 to 3 months treatment per centimeter. In our experience major intercalary defects in femur and also tibia have been bridged and new bone has formed in the defect with concomitant restoration of the osseous integrity and alignment of the limb.

Fractures of the tibial plateau

The diagnosis, evaluation and management of the patient who sustains a fracture of the tibial plateau are complex. There are a small number of strategies and a large number of tactics that can be used. The underlying principle of assessment, lower limb alignment and early joint movement, is likely to produce the best results that can be achieved. The more severe the violence of the injury, the greater the likelihood of infection and/or delays in skin healing. Several less invasive techniques are now being more widely applied, and time will tell whether these will be effective in the hands of a wider range of trauma and orthopaedic surgeons.

COMMON CAUSES OF KNEE EFFUSIONS IN SPINAL CORD INJURY

Patients with spinal cord injury are predisposed to knee effusions owing to osteoporosis, heterotopic ossification, trauma, and benign hydrarthrosis. This retrospective review discusses 11 patients with spinal cord injury and knee effusions seen during two years. One objective is to correlate the initial diagnosis based on clinical findings with the final diagnosis based on synovial fluid analysis and radiographic studies. Another is to describe the variety and complexity of clinical situations that involve knee effusions in spinal cord injury. The initial diagnosis was different from the final diagnosis in all of our cases. The final diagnoses were trauma (6 cases), pseudogout (2 cases), spasticity, fracture of the tibial plateau, septic joint, and tears of the anterior cruciate and lateral collateral ligaments. Knee effusions in this unique population must be carefully investigated to avoid erroneous diagnoses based on the initial clinical presentation, which can be complicated by multiple medical problems.

Ｋｙｕｒｏ膝装具を用いた新鮮膝十字靭帯損傷の保存療法とＭＲＩ所見

We describe the results of conservative treatment using a Kyuro knee brace in 12 cases (6 males and 6 females, ranging in age from 6 to 64 years) who had fresh tears of their cruciate ligament. The treatment consisted of eary continuous passive knee motion with protective bracing for three months. The mean follow-up period after injury was 5 months. M R imaging at follow-up revealed two different modes of conjoining. Seven cases with ACL tears had successful results at 6 months. However one case with on ACL tear and plateau fracture did not achieve such successful results. Two cases with avulsion fractures of the PCL had successful results at 3 months. We believe that conservative treatment is effective for treating fresh tears of the cruciate ligament.

Posteromedial fracture of the tibial plateau is not an avulsion injury. A case report and experimental study

We report a case of an apparent avulsion fracture of the posteromedial margin of the medial plateau of the tibia. This was associated with a tear of the medial meniscus and rupture of the anterior cruciate ligament (ACL). This triad has been previously reported, and the plateau fracture was related to the insertion of the semimembranosus tendon. The detailed investigation of our case and some experiments on cadaver knees showed that the injury was not an avulsion fracture but was produced by varus and external rotation forces on a flexed knee. It was due to the anterior subluxation of the medial tibial plateau after rupture of the ACL.

High tibial osteotomy: a retrospective review of 72 cases.

Past experience has shown that the results of high tibial osteotomy are difficult to predict. The purpose of this review was to correlate preoperative findings with postoperative results to define more precisely the indications and contraindications and to improve results. Between 1970 and 1983, 72 high tibial osteotomies for osteoarthritis were done at Duke University Medical Center by one surgeon using a consistent surgical technique. Fourteen complications were identified in 72 knees. The only one causing a persistent problem was a fracture of the tibial plateau. Forty-five knees in 38 patients were available for follow-up at an average of six years (range 1.5 to 15.0 years). Results in 15 knees (33%) were classified as "good" (pain free), in 20 knees (44%) as "fair" (improved), and in ten knees (22%) as "poor" (unchanged or worse). Three patients with fair results subsequently had total knee arthroplasty at least nine years after the osteotomy, and two of those with poor results received total knee replacement within two years of the tibial osteotomy. Measurements obtained from standing roentgenograms revealed an average of 3 degrees of preoperative varus and 8 degrees of postoperative valgus, for an average correction of 11 degrees. There was no statistically significant correlation between preoperative measurements of joint space or alignment and postoperative result. This review indicates that preoperative standing films of the knee alone are not a reliable indication for patient selection.