Intra-articular Proximal Tibial Fractures Research Articles

A study of management of fracture proximal tibia by different modalities

The knee joint is one of the three major weight bearing joint in the lower extremity. Fractures that involve proximal tibia affect knee function and stability. These fractures can either be intra-articular or Extra-articular. Intra-articular fractures of proximal tibia are difficult to treat. Age, skin conditions, osteoporosis further increase the obstacles in the healing process. Various modalities of treatment are available but no ideal treatment has yet evolved. At the Chicago Orthopedic society in 1956 Manson Hole has rightly mentioned that “these fractures are tough” Complex kinematics of its weight bearing position and complex ligamentous stability and articular congruency are the main reason why these fractures are of concern to surgeon and cause disability to the patients. The mobility and stability of the lower limbs mostly depends upon a stable and functional knee joint. In most instances, intramedullary nailing has become the method of choice for the fixation of diaphyseal tibial fractures and has been extended to the treatment of proximal fractures. Reports have shown a high incidence of malalignment and loss of fixation associated with intramedullary nailing of proximal metaphyseal fractures.7Minimally invasive plate osteosynthesis techniques have recently been applied to fractures of proximal and distal tibia. Recently, the use of plate fixation utilizing minimally invasive techniques has been put forward as one way maintaining alignment in proximal tibial fractures. The purpose of this study is to study the available modalities of treatment of proximal tibia fracture in this institute and observe their functional result.

Prevention of post-traumatic osteoarthritis after intra-articular knee fractures using hyaluronic acid: a randomized prospective pilot study.

Based on the irreversible destruction of hyaline cartilage, post-traumatic osteoarthritis (PTOA) is a notorious sequelae after intra-articular knee fractures. This study evaluates the clinical efficacy and applicability of immediate post-operative intra-articular injection of hyaluronic acid (IA HA) into the knee joint with an intra-articular fracture. Prospective randomized case-control study involving 40 patients (20 in each group) with intra-articular knee fracture with an average follow-up of 23months (range 18-24months). Twenty patients with intra-articular distal femoral or intra-articular proximal tibial fractures who met our inclusion criteria received three intra-articular hyaluronic acid injections weekly starting immediately after ORIF. Another 20 patients serving as a control group received no injection after ORIF. Patients were assessed functionally with Knee injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee (IKDC) score. Plain X-rays and when indicated CT scans were used to assess radiological union. The results showed patients treated with intra-articular hyaluronic acid injection after fixation had significantly less pain (KOOS) (p = 0.01). No significant difference was found between both groups in other KOOS-related outcome measures, complications, functional outcome, or quality of life. These preliminary results support a direct role for hyaluronic acid in the acute phase of the inflammatory process that follows articular injury and provides initial evidence for the efficacy of IA HA.

Management of Chronic Infected Intra-Articular Fractures of the Proximal Tibia with Ilizarov Ring Fixation.

Infected nonunion and malunion of tibial plateau are rare injuries with no standardized protocols for treatment. This study assessed the outcome of chronic infected intra-articular proximal tibial fractures with and without metaphyseal bone loss managed with the Ilizarov ring fixator. A series of six patients of intra-articular infected nonunion of the tibial plateau and two patients with malunited plateau with metaphyseal nonunion were treated in a tertiary care hospital. Three of these eight patients had a metaphyseal bone loss or bone gap after debridement and underwent internal transport with distal corticotomy to obtain the bone length. The remaining five patients underwent static ring fixation after correction of the articular deformity. Clinical evaluation was done by Knee Society Score, Rasmussen radiological and Association for the Study and Application of Methods of Ilizarov scores. All patients but one achieved union with the ring fixator. The average follow-up was 33 months (range, 12-120 months). Average time to achieve union was 11.5 months (range, 3-30). The scores were good in four patients and poor in the rest four, out of which three had undergone internal transport. Proximal tibia intra-articular infected nonunion and malunion with or without metaphyseal bone loss can be treated successfully with the Ilizarov fixator. Malunion of the tibial plateau has to be addressed in cases with varus alignment of the limb or articular step-off of ≥ 5mm between the two tibial surfaces. Patients with associated metaphyseal bone loss tend to have complications and take a longer duration to heal. Single-stage treatment avoids intra-articular malunion and loss of limb alignment.

Evaluation of medial open wedge high tibial osteotomy in patients with varus mal-union after fractures of proximal tibia

Background: Aim of our study was to assess the functional outcome of Medial Open Wedge High Tibial Osteotomy performed in patients of varus mal-union after intra-articular fractures of proximal tibia. Methods: This study included prospective analysis of 16 patients of varus mal-union of tibia after intra-articular fractures of proximal tibia treated at our institute between June 2011 to January 2018. All patients were operated under spinal anaesthesia. Patients were called every 2 weeks for follow up examination till 3 months, every month till 6 months, every 2 months till one year and yearly thereafter. Radiographs were taken at 6th and 12th week. Knee Society Scoring system was used to evaluate Functional Outcome.Results: 16 patients diagnosed as varus mal-union of tibia presenting after minimum of 6 months after the treatment for intra-articular fractures of proximal tibia were included in the study. There were 14 male patients and 2 female patients, with the mean age of 47 years (range, 26–55 years). Mean duration of follow-up from the time of Medial Open Wedge High Tibial Osteotomy was 3.2 years. (Range 2 – 4.5 years). All patients achieved clinical and radiological union from 3.5 to 6 months with mean interval of 4.2 months. Medial Proximal Tibial Angle was corrected from mean 750 (range 700-850) to mean 870 (range 830-900) (P

Plating as an operative management of intra articular fractures of the upper end of tibia: a prospective clinical study

<p class="abstract"><strong>Background:</strong> <span lang="EN-IN">Tibial plateau fracture management is challenging because of the severe displacement of the bony fragments, the concomitant depression and impaction of the cancellous subchondral bone, and the inevitable associated cartilage injury.</span></p><p class="abstract"><strong>Methods:</strong> <span lang="EN-IN">A prospective cohort study of 25 patients who suffered high energy intra-articular fractures of proximal tibia was done and they were diagnosed and classified according to Schatzker’s classification. The study was done to study the outcomes of surgical management of high energy tibial plateau fractures with buttress plate, to achieve anatomical reduction and absolute stable internal fixation to prevent malunion, to achieve early mobilisation, to prevent post-operative knee stiffness and also to determine timing of operation after trauma and sequence of fixation of bicondylar fractures. All patients were treated with open reduction and internal fixation with a buttress plate either a lateral, medial or bicondylar plating</span>.<strong></strong></p><p class="abstract"><strong>Results:</strong> <span lang="EN-IN">Average radio-graphic bony union time was 12 weeks. Average full weight bearing time was 13 weeks. Knee stiffness improved with physiotherapy and full range was achieved on an average in 8 weeks, mean range of movement 0-124.5º was achieved. 4 patients (16%) developed infection. </span></p><p class="abstract"><strong>Conclusions:</strong> <span lang="EN-IN">Fractures of upper end of tibia can be treated with the plating technique, to achieve anatomical reduction and stable internal fixation with 82% good functional outcome. The plating technique facilitates early mobilisation of injured joint and attains good range of movements. Minimal mal reduction does not seem to vitiate the results. The infection rate of 16% is of concern with this procedure, but responds well to antibiotics and surgical debridement.</span></p>

Assessment of results of different modalities of treatments in fractures of Tibial plateau

Introduction: The knee joint is complex joint and is the commonly injured joint now a day because of increased vehicular trauma and sports related injuries. Being superficial joint and more exposed to external forces, this joint easily gets injured5. Intra-articular fractures of proximal tibia are difficult to treat. Age, skin conditions, osteoporosis further increase the obstacles in the healing process. Material and method: The criterion for selection of the cases was a radiologically demonstrable fracture of the tibial condyle with the fracture line extending into the articular surface of the knee joint. Patients with polytrauma and multiple fractures were excluded from the study. The fractures were classified using the method of Schatzker‟s classification Computerized Tomographic evaluation was done in cases which had more comminution and when x-ray was inconclusive. All of the cases in this study were treated operatively as articular surface reconstruction was the main consideration. Patients were evaluated for one year, with serial x-rays at 1,2,3,6 and 12 months. The results were evaluated using the functional grading of Rasmussen et al. Observations: The RTA is the most common mode of injury present between the age group 22 yrs to 75 yrs with almost equal distribution in males and females. Type II fracture pattern (44.4%) is most common type of fracture followed by type VI (22.2%) then type V (14.8%). The treatment modality varies from CCS fixation, ORIF with fragment elevation with or without bone grafting and unilateral or dual buttress plating according to varying nature of the fracture pattern. Results of surgery are acceptable (92.6%) for the varying type of fractures except complication developed due to infection in terms of decreased ROM and stiffness which lead to poor results (7.4%). It is mandatory to delay the surgical procedure till the soft tissue condition improves. This may decrease the chances of complications like wound dehiscence and infection.Conclusion: In our series type II is the most common type of fracture pattern. CT scan with three dimensional reconstructions gives accurate idea of fracture geometry for preoperative planning for osteosynthesis. Result of various types surgeries are good for various patterns of fracture pattern except when complications developed in elderly patient with type VI fracture pattern in the form infection and stiffness which led to an unacceptable outcome Medial side buttress plating is always desirable in bicondylar fracture pattern with unstable medial condyle as otherwise it collapses into varus.

Comparison of outcome of unilateral plating and dual plating in treatment of bicondylar tibia plateau fractures

Introduction: Fractures of the proximal tibia, particularly those that extend into the knee joint are termed as tibial plateau or tibial condylar fractures. It results from indirect coronal or direct axial compressive forces. Overall worldwide, it comprises of 1% of all fractures & 8% of the fractures in elderly. In the past two decades, with improvements in surgical techniques and implants, there has been a growing trend towards surgical management of these injuries. Thus we have advanced from the conservative approach to internal fixation in fractures as an acceptable mode of treatment. No proven uniform successful method of treatment. Nevertheless, tibial plateau fractures remain challenging because of their number, variety and complexity.Aim: To study the surgical management in terms of unilateral and dual plating for bicondylar intraarticular fractures of proximal tibia to obtain a stable, pain free, mobile joint, to prevent the development of osteoarthritis and to correlate the radiological findings with the type of fracture and the functional end result. Materials and Methods: This was a prospective study of 44 cases. All patients included in this study sustained tibial plateau fracture grade V and VI according to Schatzker Classification. We used Rasmussen’s functional and radiological scoring system for the comparison of outcome of plating. In the surgical group 20 patients were treated by unilateral plating and 24 patients were with dual plating. These patients were followed up for an average period of 13 months. Results and discussion: In our study according to Rasmussens functional scoring4, we have achieved excellent outcome in 43%, good in 50%, fair in 7%, which is comparable to the standard studies. These studies suggest that while isolated lateral locked plating may offer a more biological approach to bicondylar fractures, and may provide a viable alternative for open fractures with a medial wound or fractures with tenous soft tissues, classical dual plating remains the most rigid construct. Conclusion: The surgical management of tibial bicoondylar fracture is challenging and dual plating gives excellent anatomical reduction and rigid fixation to restore articular congruity, facilitate early knee motion by reducing post-traumatic osteoarthritis and thus achieving optimal knee function.

A prospective study of operative results of intra-articular fractures of proximal tibia

A prospective study of operative results of intra-articular fractures of proximal tibia

A comparative biomechanical study for complex tibial plateau fractures: Nailing and compression bolts versus modern and traditional plating

AimTo compare the biomechanical properties of a newly proposed technique, utilizing intramedullary nailing and compression bolts, for the osteosynthesis of intra-articular proximal tibial fractures with meta–diaphyseal comminution, with modern and conventional plating techniques. MethodsFifteen left tibia 4th generation composite Sawbones models (in 3 groups of 5 for each technique) with identically reproduced type VI Schatzker tibial plateau fractures, including meta–diaphyseal dissociation, were used. Three different techniques of osteosynthesis were tested: (a) a new technique that combines intramedullary nailing and compression bolts, (b) internal fixation with a single lateral locking plate and (c) internal fixation with dual buttress plating technique. The model-device constructs were successively subjected to 500N, 1000N and 1500N load levels with five cycles applied at each level on both articular compartments and a final load cycle to failure. Four parameters were recorded for each technique: the average reversible or irreversible displacement in vertical subsidence, the horizontal diastasis of the intra-articular fracture, the average passive construct stiffness and the load to failure. ResultsThe new intramedullary nailing technique provided rigid intra-articular osteosynthesis being statistically similar to dual buttress plating for subsidence at medium and higher load levels. At the same time the proposed technique provided statistically equivalent stiffness values to the single lateral locking plate incarnating the rational of biologic fixation. Average load to failure was 1611N for single lateral locking plates, 2197N for intramedullary nailing and 4579N for dual buttress plating. The single lateral locking plate technique had the worse results in interfragmentary displacement while dual buttress plating was superior in stiffness from the other 2 techniques. The mode of failure differed between techniques, with collapse of medial plateau occurring exclusively in the single lateral locking plates group. ConclusionThe proposed new technique of intramedullary nailing and compression bolts demonstrates a flexural behaviour similar to single lateral locking plates, which complies with the terms and benefits of biological fixation, while at the same time maintains a rigid intra-articular stability similar to the stiff dual buttressing plating technique.

The management of complex fractures of the proximal tibia with minimal intra-articular impaction in fragility patients using intramedullary nailing and compression bolts

Background Intra-articular fractures of the proximal tibia that extend to the meta-diaphyseal part of the bone represent a severe injury, especially if they occur in osteoporotic patients. Current treatment modalities include either internal fixation with traditional or modern plating techniques or external fixation with circular frames or hybrid systems. However, problems and complications related with these techniques are increasing with age and future reconstructive operations, such as arthroplasty, may be jeopardised. Method This is a prospective pilot study about a novel type of osteosynthesis for complex intra-articular proximal tibial fractures without significant articular impaction in patients over 60 years of age. Within a period of 54 months, eight patients underwent fixation of such fractures with condylar compression bolts and intramedullary nailing. Results The follow-up period was from 12 to 50 months (mean 24.7 months). There were no neurovascular complications, wound infections, delayed unions or nonunions. All patients had their fractures healed without secondary displacement or malalignment. At the final follow-up, all patients had full extension of the knee joint whilst the flexion ranged from 125 to 140°. The mean new Oxford Knee score was calculated to be 43.75 points. Conclusions The management of selected osteoporotic complex intra-articular fractures of the proximal tibia with compression bolts and intramedullary nailing offers specific advantages and, in the present pilot study, provided promising results. These results should be validated and confirmed with larger case series and comparison studies in the future.

Proximal tibial fractures: early experience using polyaxial locking-plate technology

Between 2004 and 2009, 60 patients with proximal tibial fractures were included in this prospective study. All fractures were treated with the polyaxial locked-plate fixation system (DePuy, Warsaw, IN, USA). Clinical and radiographic data, including fracture pattern, changes in alignment, local and systemic complications, hardware failure and fracture union were analysed. The mean follow-up was 14 (12-36) months. According to the Orthopaedic Trauma Association (OTA) classification, there were five 41-A, 28 41-B and 27 41-C fractures. Fractures were treated percutaneously in 30% of cases. Double-plating was used in 11 cases. All but three fractures progressed to union at a mean of 3.2 (2.5-5) months. There was no evidence of varus collapse as a result of polyaxial screw failure. No plate fractured, and no screw cut out was noted. There was one case of lateral joint collapse (>10°) in a patient with open bicondylar plateau fracture. The mean Knee Society Score at the time of final follow-up was 91 points, and the mean functional score was 89 points. The polyaxial locking-plate system provided stable fixation of extra-articular and intra-articular proximal tibial fractures and good functional outcomes with a low complication rate.

The use of condylar bolts and intramedullary nailing in the treatment of intra-articular proximal tibial fractures

The use of condylar bolts and intramedullary nailing in the treatment of intra-articular proximal tibial fractures

Biological approach to treatment of intra-articular proximal tibial fractures with double osteosynthesis

The treatment of intra-articular proximal tibial fractures is associated with complications, and much conflicting literature exists concerning the treatment of choice. In our study, an attempt has been made to develop an ideal and adequate treatment protocol for these intra-articular fractures. The principle of double osteosynthesis, i.e., lateral minimally invasive plate osteosynthesis (MIPO), was combined with a medial external fixator to treat 22 intra-articular proximal tibial fractures with soft tissue injury with a mean follow-up of 25 months. Superficial pin track infection was observed in one case, and no soft tissue breakdown was noted. Loss of articular reconstruction was reported in one case. Bridging callus was seen at 12 weeks (8 weeks-7 months). The principle of substitution or double osteosynthesis, i.e., lateral MIPO, was combined with a medial external fixator and proved to be a fairly good method of fixation in terms of results and complications.

Primary total knee arthroplasty for periarticular fractures

We present a series of 6 patients with periarticular fractures of the knee that were treated by primary total joint arthroplasty. These fractures around in 6 elderly women, three in the proximal tibia and three in the distal femoral. All the patients had osteoarthritis and osteopenia. In five patients, a hinged total knee arthroplasty was performed, and in one case an unconstrained prosthesis was performed. Cementing techniques were used in all. Postoperatively, immediate mobilization with full weight bearing was initiated. No radiographic or clinical evidence of loosening was seen, and the functional outcome was satisfying. The results suggest that another treatment option for intra-articular distal femoral or intra-articular proximal tibial fractures in elderly patients with severe osteopenia and osteoarthritis is primary total knee arthroplasty. Furthermore, this primary total knee arthroplasty may require some degree of constraint.

Stabilization of proximal tibial fractures with the LIS-System: Early clinical experience in Berlin

The Proximal Tibia Less Invasive Stabilization System (LISS PLT) is an internal fixator for the treatment of proximal tibial fractures according to the principles of "Minimally invasive surgery". From July 1998 to August 2000 22 fractures were treated in our clinic with the new Proximal Tibia LISS and the prospective course of healing was documented. The period of follow-up was 12 months. The inclusion criteria were defined as proximal tibial shaft fractures and intraarticular proximal tibial fractures of all degrees of severity. A total of 15 proximal medial and lateral tibial plateau fractures (AO 41) and 7 metaphyseal fractures were treated (AO 42), seven of these fractures presented with open soft tissue damage. The average age of the patients treated was 42 years. With a follow-up rate of 91% (2 patients lost to follow-up), definite consolidation of the fracture was seen in 19/20 cases. In one patient, the fracture had only been partially bridged and secondary bone grafting was performed. Radiologically, there was one case of a varus malalignment of 6 degrees, in two further cases there were valgus malalignments of 5 degrees and 7 degrees at the time of surgery. The other cases all healed in correct alignment. In one case, the implant became loose on the distal shaft and was stabilized again using bicortical screws. In a case with type IIIB soft tissue damage, a soft tissue infection became manifest, but healed uneventfully after a revision operation with the implant in situ.

High-energy fractures of the tibial plateau. Knee function after longer follow-up.

Studies of the long-term outcomes of treatment of fractures of the tibial plateau have included wide mixtures of fracture types and mostly low-energy split and split-depression fractures. The long-term results of treatment of high-energy intra-articular proximal tibial fractures are unknown. The purpose of this study was to assess the function of the knee and the development of arthrosis at a minimum of five years after injury in a consecutive series of patients in whom a high-energy fracture of the tibial plateau had been treated with a uniform technique of external fixation. Between July 1988 and December 1994, thirty patients with a total of thirty-one fractures of the tibial plateau were treated with a monolateral external fixator and limited internal fixation of the articular surface. Follow-up data on twenty-four knees in twenty-three patients were obtained at a mean of ninety-eight months. Twenty patients (twenty knees) returned specifically for the study, at which time they completed an Iowa Knee Score questionnaire and a Short Form-36 (SF-36) general health survey, a physical examination was performed, and weight-bearing radiographs were made. The results of the SF-36 evaluations for fourteen patients and the Knee Scores for twelve were compared with those obtained five years previously, at two to four years after the injury. After healing, no patient required a secondary reconstructive procedure. The range of motion of the knee averaged 3 degrees of extension to 120 degrees flexion, which was an average of 87% of the total arc of the contralateral knee. The average Iowa Knee Score was 90 points (range, 72 to 100 points). For twelve patients, the Iowa Knee Score previously recorded at two to four years averaged 92 points, as did the score at the time of the latest follow-up. Thirteen patients rated their outcome as excellent; six, as good; and three, as fair. Fifteen patients were working, and ten of them were performing strenuous labor. Radiographs showed no evidence of arthrosis in fourteen knees, grade-1 arthrosis in three, grade-2 in three, and grade-3 in two. Compared with the radiographic appearance two to four years after injury, there was no evidence of progression of arthrosis in eighteen knees and one grade of progression in four. The SF-36 subscale scores were similar to those of age-matched controls. The fourteen patients who had previous SF-36 scores had no deterioration of these scores. Patients with a high-energy fracture of the tibial plateau treated with external fixation have a good prognosis for satisfactory knee function in the second five years after injury. The knee joint cartilage appears to be tolerant of both the injury and mild-to-moderate residual articular displacement, which was associated with a low rate of severe arthrosis.

Cast Brace Treatment of Plateau and Bicondylar Fractures of the Proximal Tibia

Twenty-nine patients with 30 intraarticular proximal tibial fractures were treated with early application of a cast brace. All fractures united, knee motion was excellent or good in all but one patient. The fracture fragments did not lose position after cast brace application. Varus or valgus deformities could be corrected and maintained. Ninety per cent had no pain at follow-up. Hospital stay was as short as two days and generally under two weeks.