tibial plateau fractures

We found that for 50 patients an X-ray would have been indicated if PKRs had been followed. Even though TPFs can be difficult to identify on standard X-ray im- ages, most of these fractures would likely have been dis- covered at the first medical contact, if the principles of the PKRs had been followed (and radiographs been ob- tained) in addition to the clinical examination in the ER setting. Figures from the Danish National Patient Regis- ter (extracted from the register’s website) show that be- tween 2005 and 2013 a total of 8797 patients were discharged with a fracture of the proximal tibiae. Of these, 1489 were coded as tibial plateau fractures, and of the 7308 fractures that did not have a detailed coding, we estimate that half were TPFs. This entails that about 5000 TPFs occurred in Denmark during these 9 years. A study on the epidemiology of TPFs from Aalborg Uni- versity hospital in Denmark supports this conclusion as it evaluated the incidence of TPFs to be 10.3 per 100,000 citizens annually [2]. The dark number (patients who have not claimed a case at DCPA) is unknown, but it is assessed that only 15 – 85% of all patients eligible for compensation, claim their case [15]. Overlooking a frac- ture is regarded as a grave mistake among patients, and

Results: In the load-to-failure testing, the jail technique showed a significantly higher mean maximum load (2275.9 N) in comparison to the conventional reconstruction (1796.5 N, p < 0.001). The trend for better outcomes for the novel technique in terms of stiffness and yield load did not reach statistical significance (p > 0.05). In cyclic testing, the jail technique also showed better trends in displacement that were not statistically significant. Failure modes showed a tendency of screws cutting through the bone (cut-out) in the conventional reconstruction. No cut-out but a bending of the lag screws at the site of the additional third screw was observed in the jail technique. Conclusions: The results of this study indicate that the jail and the conventional technique have seemingly similar biomechanical properties. This suggests that the jail technique may be a feasible alternative to conventional screw osteosynthesis in the minimally invasive reconstruction of lateral tibial plateau fractures. A potential advantage of the jail technique is the prevention of screw cut-outs through the cancellous bone.

Type VI Schatzker tibial plateau fractures are very complex intra-articular fractures that often occur after high-energy trauma, as the fracture pattern involves joint and metaphyseal-diaphyseal region [1,2]. It is common sense that the more complex the fracture type, the more difficult the choice of treatment about the ideal type of fixation. The common standard treatment is dual-plate fixation through two incisions; however, the skin complication and infection rate are relatively high [3-6]. The aim of the present study was to report the treatment of type VI Schatzker tibial plateau fractures with a newly proposed technique, through supra-patellar approach utilizing intramedullary nailing and hollow screws.

The items exhibiting a statistically significant difference were identified, for example, operation time and complica- tion of hardware impingement, and all are listed in Table 4. Post-hoc tests with the Scheffe method were applied to identify which groups differed. The result demonstrated the following: (1) There was a significantly different ratio for Schatzker classification type V or VI between group II (CDP) and group III (HDP). (2) In some cases of open frac- ture or obvious swelling of soft tissue and impending com- partment syndrome, staged treatment, initially external skeletal fixation then shifted to an internal fixator, was ar- ranged. Group III (HDP) had a markedly higher percentage of these cases than group I (ULP) or group II (CDP). (3) In group II, the average operation time was 101.4 ± 18.23 min and the hospitalization period was 15.6 ± 8.71 days. This is a longer operation time and a longer hospitalization period than for group I and group III. (4) Five people in group II felt discomfort over the lateral aspect of Table 2 Perioperative parameters and postoperative functional scores in each group of bicondylar tibial plateau fractures (total N = 45)

The knee joint is one of the strongest and impor- tant joints of the body and is directly affected by plate- au fractures. As these fractures are intra-articular in na- ture, they affect the alignment, stability, and movement of the joint. In addition, as the knee is a complex joint with dense soft tissues,its related injuries are classified as complex injuries. The mechanism of fracture is ma- inly due to axial compressive forces with varus or val- gus stress and these fractures are produced by high-en- ergy traumas (1). The Schatzker classification, which was developed in 1979 based on the anteroposterior (AP) radiographs of a series of 94 patients, has been still widely used by orthopedic surgeons. This system classify tibial plateau fractures into six types and late- ral plateau fractures typically present with depression, while medial plateau fractures typically present with split (2). In addition, these fractures usually lead to ar- throsis of the knee joint and total knee arthroplasty is a usually performed procedure following the arthrosis after tibial plateau fractures (3, 4).

Objective: To investigate the value of 3D printing techniques in the treat- ment of complex tibial plateau fractures. Methods: From September 2016 to September 2018, 28 patients with complex tibial plateau fractures were treated in our hospital. According to the odevity of hospitalized order, the patients were divided into two groups. Group A used 3D reconstruction, virtually reduction, 3D printing and demonstration of individual fracture model before operation while group B only received conventional process by use X-rays or CT image. Comparison between the two groups was made in operation time, operative blood loss, radiation frequency, surgery in- strument cost and knee function score. Results: The follow-up was 14.4 months on average (ranged 6 to 22 months). There was no statistical dif- ference of the surgery instrument cost between the 2 groups (P > 0.05). The operation time of group A was significantly shorter than that of group B (P < 0.05). Group A also performed better than group B in comparison of operative blood loss and radiation frequency. The excellent good rate of HSS score in group A was 92.86%; it was higher than that 85.71% in group B. There was no statistical difference between the 2 groups ( χ 2 = 0.373, P =

used for classifying tibial plateau fractures in clinical practice, bicondylar including Schatzker, AO/OTA, and Three-Column classifications [7–9]. Based on X-ray plain radiographs, Schatzker and AO classifications de- scribe the location and general pattern of fracture with- out consideration of the fracture line orientation, which usually determines the right position of the bone plate. They were also lacking in adequate details of depression morphological characteristics. However, identification of depression morphological characterization would facili- tate surgical plan and therapeutic effect postoperatively [10]. Failure to accomplish the reduction of depression is associated with residual pain, post-traumatic arthritis, and deformity [10–12].

A well-aligned limb is important to the eventual outcome of patients with tibial plateau fractures. The eventual alignment of the knee after fracture healing is determined by a combination of the presence or absence of extra-articular fracture deformity, residual articular depression, and knee instability. Initial assessments of limb alignment are frequently made based on the appearances of the fracture on radiographs, but deformity may be apparent on inspection. In lateral tibial plateau fractures assessing for valgus instability of the knee may provide a guide to the need for surgical treatment. If instability is present it is likely caused by fracture displacement and will not resolve without reducing the fracture. However, pain from the injury often makes it difficult to examine the knee for coronal instability, limiting the value of this assessment.

Cho et al. [3] reported a novel technique of 2.7-mm rim plating in tibial plateau fractures to address these problems. Rim plates function as positional plates (named “Hugging plates”) rather than buttress plates. The rim plate maintains the posterolateral tibial fracture reduction with the collinear clamp used for a rigid maneuver reduc- tion throughout the fixation procedure. This rim plating technique can be easily applied to isolated posterolateral fracture fragments. However, it is difficult to use in pa- tients with posterolateral tibial comminution and pos- terolateral corner depression. Moreover,both anterior and posterior stripping to obtain an adequate operative field, together with less antiskid ability, limits its use.

After receiving approval from our Institutional Review Board, we retrospectively examined a consecutive series of 33 patients (33 bicondylar tibial plateau fractures (Schatzker type V, VI) admitted at our level I trauma centre between 2002 and 2006. Fractures were identified through our trauma database and were cross-matched with operating room records. Median ISS was 14.3, ran- ging from 9 to 33. Inclusion criteria were the presence of a bicondylar tibial plateau fracture Schatzker type V- VI, patients’ age over 18 years and the ability to walk without assistance before injury. Polytrauma patients with tibial plateau fractures requiring prolonged ICU care (AIS>3 for head and chest) and patients with bilat- eral plateau fractures, were excluded from the study. All patients were followed according to a protocol. All frac- tures were treated with either closed reduction and hybrid external fixation (14 fxs/36.6%) or with minimal open reduction and a hybrid system (19 fxs/63.4%). The study group was consisted of 20 males (60.6%) and 13 females (39.4%) with an average age for males of 40.3 years (range 30 - 62 years) and for females 49 years (range 17 - 86 years). In 27 patients (81.8%) the mechanism of injury was high energy trauma (motor vehicle accident or fall from height greater than 3 m). All patients had anteroposterior and lateral radiographs as well as a CT-scan for proper preoperative evaluation of their fracture.

Depression type lateral tibial plateau fractures are usually low-velocity injuries that result from axial and bending forces across the knee. Articular surface depression is more frequently seen in elderly patients because of a progressive weakness in the subchondral cancellous bone secondary to osteoporosis [6]. The goal of treating these fractures is to restore the congruity of the articular surface. This is commonly done by elevating and realigning the depressed articular surfaces, placing a graft material into the metaphyseal defect and supporting this reconstruction with internal fixation [1]. The "gold standard" in bone grafting is autograft cancellous bone. The major problems with autologous bone grafts are donor site morbidity and poor compressive strength. Its inability to provide signifi- cant support to the articular fragments has lead to a high incidence of loss of correction and malunion [1].

Tibial plateau fractures form a very challenging entity for the orthopedic surgeon. The increasing incidence of road traffic accidents and high energy injuries resulting therewith contribute to the rising number of complex proximal tibial fractures presenting to the healthcare provider. In addition, in elderly with osteoporotic bones, even low energy injuries such as domestic falls may lead to complex tibial plateau fractures. The optimal treatment is difficult and giving the patient a painless, mobile joint needs a very strong technical knowledge and surgical expertise.

Tibial plateau fractures are difficult to treat. Surgical management of these fracturs are challenging. Tibial plateau fractures require extensive exposure for reduction of the fractures bone which leads to risk of infection and soft tissue complications. The surgical treatment for tibial plateau fractures should inflict minimal surgical trauma, to achieve desired satisfactory outcomes. Therefore, the indirect reduction has now become the standard option in the management of these fractures. Although indirect reduction has the advantage of avoiding extensive exposures, adequacy of joint articular surf ace reduction can be difficult to evaluate under routine intra -operative fluoroscopy. (6)

In case of Split tibial plateau fractures Type I and Type IVa with little or no comminution and little central depression reduction was done using joy stick technique. 9,18,22,31,38,44,62 A kirschner wire or Steinman’ pin was introduced into fracture fragment to facilitate manipulation under fluoroscopic guidance. When an adequate reduction was achieved fixation was done using 6.5 cannulated screws of appropriate length. 9,18,22,38 In case of greater comminution and osteoporotic bones either cannulated screws were used along with washer or proximal tibial locking plate was used through small incision over fracture site. 22,31,44

Results: According 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%). Conclusion: Our 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.

experience of the surgeons regarding the diagnosis and surgical treatment of the complex tibial plateau frac- tures. Some patients were operated only with the assist- ance of X-rays, obviously causing incomplete evaluation of the fracture and further affecting the planning of the surgery. This in turn led to the failure of the first sur- gery. Surgeons need to have a correct understanding of the characteristics and types of the fractures as these are the key information for successful surgical management of complex tibial plateau fractures. As a result, we should make the full use of X-rays and CT scans to ob- tain the stereo image of the fracture and to clarify the complicated fracture lines and multiplanar displacement of the fracture fragments in order to make a more accur- ate evaluation of the fracture [4, 19].

Uniaxial locking systems have the advantage of not being able to manoeuvre locking screws around obstacles such as screws or other implants, or to target fracture fragments at different levels. This has forced research towards the development of polyaxial technology. The option of using a multi-trajectory locking screw instead of a fixed-angle one is achieved with various techniques which are widely used in clinical practice [13]. Our study suggests that single lateral locked plate can be an effective implant in providing fracture stabilization of Bicondylar tibial plateau fractures. (Table 5) illustrates comparison between our study and other studies published since 2004 with the start of era of single lateral locked plating for Bicondylar tibial plateau fractures [14-17].

when tibial plateau fractures involve the pos- terolateral and lateral columns simultaneously. Although many other approaches have been developed for posterolateral tibial plateau frac- tures, the available area for exposure and fixa- tion remains unsatisfactory [14, 15]. Chen et al [14] successfully used the extended anterolat- eral approach and lateral supporting plate to achieve anatomic reduction and fixation of pos- terolateral tibial plateau fractures. It was stated that this approach could provide excellent visu- alization of the posterolateral tibial plateau quadrant and the plate could be positioned more posteriorly as compared with that possi- ble with an anterolateral approach. Hu et al [15] obtained good clinical outcomes using a similar method of anterolateral supra-fibular-head approach. These approaches are not suitable for a significant posterior cortex rupture and posterolateral cortical wall requiring recons- truction.

Tibial plateau fractures (TPFs) account for approxi- mately 1% of all fractures (1). There is a higher incidence of TPF in males below 50 years compared to females, whereas after this age, the incidence increases in females and de- creases in males. The highest frequency has been reported in the age range of 40 - 60 years in both genders (2). Nondisplaced TPF can be treated conservatively, whereas displaced fractures are conventionally treated with open reduction and internal fixation (ORIF) (1, 3, 4).

The use of three-dimensional computed tomography has been under increasing investigation over the past several years. Few authors have investigated the impact that these reconstructions have on fracture management. All new diagnostic modalities come at a cost, and therefore should be evaluated prior to their widespread use. Our study demonstrated no significant influence on the pre- operative plans of tibial plateau fractures when 3D-CT was added to 2D-CT. Given the added cost, we question its utility when managing this particular fracture pattern. Further investigation into the use of 3D-CT with regards to other intra-articular fractures will help to identify the best use of this imaging technique.