Articular coronal fracture angle of posteromedial tibial plateau fragments: A computed tomography fracture mapping study

Objectives: The purpose of this study is to analyze posteromedial fragment morphology using two-dimensional computed tomography fracture mapping and to compare posteromedial fragment morphology in various Schatzker type tibial plateau fractures. Materials & methods: One hundred twenty-seven consecutive AO/OTA B- and C-type tibial plateau fractures were retrospectively analyzed using 2DCT fracture mapping. The posteromedial articular fracture angle and articular surface areas of all fractures with posteromedial fragments were calculated. Based on biomechanical studies, posteromedial fragments with coronal fracture angles >68° were considered amenable for anterolateral stabilization with standardized plating. Kruskall-Wallis non-parametric test was used for statistical comparison of morphological features of posteromedial fragments between the various Schatzker types. Results: Forty-seven out of 127 tibial plateau fractures included a posteromedial fragment. The mean posteromedial articular fracture angle was 44° (range: 2°-90o standard deviation: 23°). Forty fragments (85%) had a fracture angle of <68° increasing the risk for insufficient stabilization with standardized anterolateral plating. The mean articular surface area was 34% of the entire tibial plateau (range: 7%–53%, SD: 12%). There were no significant differences in posteromedial fragment morphology between Schatzker type IV, V, and VI fractures. Discussion and conclusion: Posteromedial fragments commonly occur not only in Schatzker type V and VI, but also in Schatzker type IV tibial plateau fractures. Eighty-five percent of tibial plateau fractures with a posteromedial fragment may benefit from non-standard customized lateral plating, or may require an additional medial or posterior surgical approach for fracture-specific fixation to optimize screw purchase and biomechanical stability

Tibial Plateau Fracture Characteristics: Computed Tomography Mapping of Lateral, Medial, and Bicondylar Fractures

Background: Computed tomography (CT) is seen as a useful diagnostic modality in preoperative planning for tibial plateau fractures. The purpose of this study was to characterize patterns of tibial plateau fractures with use of CT mapping. We hypothesized that CT mapping of fractures of the tibial plateau would reveal recurrent patterns of fragments and fracture lines, including patterns that do not fit into Schatzker's original classification. Methods: One hundred and twenty-seven tibial plateau fractures were retrospectively included in this study. Fracture lines and zones of comminution were graphically superimposed onto an axial template of an intact subarticular tibial plateau to identify major patterns of fracture and comminution. This fracture map of the tibial plateau was subsequently divided into lateral (Schatzker types I, II, and III), medial (Schatzker type IV), and bicondylar (Schatzker types V and VI) fracture maps. Results: This study included seventy-three female and fifty-four male patients (average age, forty-seven years [range, seventeen to ninety-one years]) with a tibial plateau fracture. Sixty-four of the fractures were Schatzker type I, II, or III; fifteen were Schatzker type IV; and forty-eight were Schatzker type V or VI. Analysis of the fracture maps suggested patterns in the Schatzker type-IV, V, and VI fractures beyond those described in Schatzker's original classification. The maps of the 127 fractures revealed four recurrent major fracture features: the lateral split fragment (A), found in 75%; the posteromedial fragment (B), seen in 43%; the tibial tubercle fragment (C), seen in 16%; and a zone of comminution that included the tibial spine and frequently extended to the lateral condyle (D), seen in 28%. Conclusions: Tibial plateau fracture maps show recurrent patterns of fracture lines, revealing four major fracture characteristics. An understanding of these recurrent features of tibial plateau fractures can aid surgeons during diagnosis, preoperative planning, and execution of surgical strategie

The pathoanatomy of the anterior bundle of the medial ulnar collateral ligament

Background: The purpose of this study was to increase our understanding of the pathoanatomy of the ulnar collateral ligament (UCL) by performing a descriptive analysis of the surgical inspection of the anterior bundle in patients undergoing reconstruction. Methods: A single-surgeon series of 163 patients who underwent UCL reconstruction between 2009 and 2017 was retrospectively analyzed. Descriptions of the pathoanatomy of injury were obtained from the operative reports. Magnetic resonance imaging data were reviewed to assess whether the presence and location of tissue disruptions were accurately recognized. Demographic and clinical characteristics were obtained from medical records and correlated to observed pathoanatomy. Results: Injuries to the anterior bundle were characterized by a single tissue disruption (65%), tissue disruptions at more than 1 location (23%), or injuries without distinct fiber tissue disruptions (12%). The presence and location of tissue disruptions matched magnetic resonance imaging findings in 124 of 153 patients (81%). Partial tears more frequently affected the anterior band of the anterior bundle distally as opposed to the posterior band of the anterior bundle proximally (P = .012). Patients with single tissue disruptions more frequently reported a popping sensation than patients with non-tear insufficiency (P = .030). Conclusions: This study shows the heterogeneity of anterior bundle injuries in patients undergoing UCL reconstruction. A variety of injury configurations and chronic attritional damage to the anterior bundle were observed, as well as distinct tear patterns at the distal and proximal attachment sites. Future research may elucidate the diagnostic value of a pop sign for UCL injury

Injured vs. uninjured elbow opening on clinical stress radiographs and its relationship to ulnar collateral ligament injury severity in throwers

Background: Stress radiography measures medial joint space opening of the elbow, but its value in the management of throwing athletes is unclear. The purpose of this study was to analyze the relationship between medial joint opening (gapping and excess opening) and ulnar collateral ligament (UCL) injury severity on magnetic resonance imaging, as well as to explore factors related to the unexpected finding of a greater opening of the uninjured elbow compared with the injured elbow (negative excess opening) with valgus stress radiography. Methods: Medial joint space measurements were independently performed by 2 raters in a clinical series of 74 patients evaluated with standardized valgus stress radiography as part of their clinical workup for throwing-related medial elbow pain. Demographic data were collected by chart review, and UCL injury severity was classified based on available imaging into intact UCLs, partial-thickness tears of the anterior bundle, or full-thickness tears of the anterior bundle. Results: Joint gapping was related to UCL injury severity (P = .003), and group-level comparison showed a difference among tear severity groups (P = .050). Excess opening was not significantly related to UCL injury severity (P = .109). A negative excess opening was observed in 22% of patients, but no factors corroborating guarding or a mechanical explanation were significant for a decreased medial joint opening of the injured elbow compared with the uninjured elbow. Conclusions: Medial joint gapping was correlated to UCL injury severity in throwing athletes with medial elbow pain and a clinical suggestion of UCL injury, but no association between injury severity and excess opening was observed in this clinical series, which may limit the usefulness of stress radiography in the clinical workup of throwing athletes

Tibial Plateau Fracture Characteristics: Reliability and Diagnostic Accuracy

The purpose of this study was to assess the interobserver reliability and diagnostic accuracy for 2-dimensional (2D) and 3-dimensional (3D) computed tomography (CT)-based evaluation of tibial plateau fracture characteristics. We hypothesized that recognition of specific tibial plateau fracture characteristics is equally reliable and accurate in 2DCT and 2D- and 3DCT. Eighty-one orthopedic trauma surgeons and residents were randomized to either 2DCT or 2D- and 3DCT evaluation of 15 complex tibial plateau fractures using web-based platforms to recognize 4 tibial plateau fracture characteristics: (1) a posteromedial component, (2) a lateral component, (3) a tibial tubercle component, and (4) a tibial spine (central) component. Interobserver reliability was evaluated by Siegel and Castellan's multirater kappa measure and kappa values were interpreted according to the categorical rating by Landis and Koch. Diagnostic accuracy was calculated according to standard formulas. Interobserver reliability of tibial plateau fracture characteristics ranged from "fair" to "substantial". The addition of 3DCT reconstructions did not improve agreement between observers or diagnostic accuracy, because kappa values and diagnostic accuracy were significantly better for evaluation of tibial plateau fractures using 2DCT alone. Diagnostic accuracy of fracture characteristics ranged from 70% to 89% and was better for more frequently encountered components (ie, the posteromedial and lateral component). The recognition of tibial plateau fracture characteristics prove accurate and reliable on CT-based evaluation in this study and may be useful besides current classification systems, which do not account for all fracture components, in daily practice to help clinical decision making. Further research is needed to evaluate whether the use of distinct fracture components helps preoperative planning of surgical approach and specific fixation technique

Evaluation of Hip Preservation-related Patient Education Materials from Leading Orthopaedic Academic Centers in the United States and Description of a Novel Video Assessment Tool

Introduction:The readability, reliability, and quality of online hip preservation-related patient education materials from the top 20 orthopaedic academic centers in the United States were evaluated.Methods:The patient educational materials were evaluated with the following assessment tools: Flesch-Kincaid (FK) readability test, Flesch Reading Ease formula, LIDA instrument, and DISCERN tool. Videos were assessed using the Patient Educational Video Assessment Tool (PEVAT), an author-developed scoring system.Results:A total of 121 educational items were reviewed. Median (interquartile range) or mean ± SD of the FK level, Flesch Reading Ease, LIDA, and DISCERN scores were 11.00 (3.00), 47.32 ± 12.14, 41.00 (6.00), and 64.00 (7.00), respectively. Higher ranking was correlated with higher FK (ρ = -0.21, P value = 0.034), higher DISCERN score (ρ = -0.39, P value < 0.005), and a lower PEVAT score (r = 0.61, P value = 0.034). The PEVAT score found that 83% of videos were classified as high quality.Discussion:An analysis of the hip preservation patient education text articles found low readability. Overall, high ranking was associated with poorer readability, higher quality text content, and lower quality video content. Video content was found to be predominantly of high quality. Improving the educational accessibility and effect of hip preservation-related topics may result in improved treatment outcomes

Clinical Value of an Acute Popping Sensation in Throwing Athletes With Medial Elbow Pain for Ulnar Collateral Ligament Injury

Background: Throwing athletes sustaining an ulnar collateral ligament (UCL) injury may recall a popping sensation originating from the medial elbow at the time of injury. There are no studies available that inform clinicians how to utilize this salient anamnestic information and what amount of diagnostic weight to afford to it. Purpose: To assess the diagnostic value of a popping sensation for significant UCL injury in throwing athletes who sustained an injury causing medial elbow pain. Study Design: Cohort study (prognosis); Level of evidence, 3. Methods: A total of 207 consecutive patients with throwing-related medial elbow pain were evaluated for UCL injury by the senior author between 2011 and 2016. The presence or absence of a popping sensation was routinely reported by the senior author. Magnetic resonance imaging was evaluated for UCL injury severity and classified into intact, edema/low-grade partial-, high-grade partial-, and full-thickness tears. Results: The overall frequency of a pop was 26%. The proportion of patients who reported a pop significantly increased with UCL tear severity (P <.001), from 13% in patients with low-grade UCL injuries to 26% in patients with high-grade partial-thickness tears and 51% in patients with full-thickness tears. The positive likelihood ratio, negative likelihood ratio, and odds ratio of a popping sensation for significant UCL injury were 3.2, 0.7, and 4.4 (P <.001), respectively (P <.001). A pop was not associated with either distal or proximal UCL tears (P ≥.999). Conclusion: A popping sensation at the time of injury in throwing athletes with medial elbow pain was associated with UCL injury severity. When a throwing athlete reports a pop, this should moderately increase a clinician’s suspicion for a significant UCL injury. Conversely, absence of a pop should not substantially decrease suspicion for significant UCL injury. The findings of this study allow for the clinical interpretation of the salient anamnestic finding of a pop at the time of injury, which can be used for diagnostic purposes as well as patient counseling. This study provides reference foundation for future studies of predictive and diagnostic factors for UCL injury in throwing athletes

Interobserver reliability of the Schatzker and Luo classification systems for tibial plateau fractures

INTRODUCTION: Tibial plateau fracture classification systems have limited interobserver reliability and new systems emerge. The purpose of this study was to compare the reliability of the Luo classification and the Schatzker classification for two-dimensional computed tomography (2DCT) and to study the effect of adding three-dimensional computed tomography (3DCT). MATERIALS AND METHODS: Eighty-one observers, orthopedic surgeons and residents, were randomized to either 2DCT or 2D- and 3DCT evaluation of a spectrum of 15 complex tibial plateau fractures using web-based platforms in order to classify according to the Schatzker and according to Luo's Three Column classification. Reliability was calculated with the use of Siegel and Castellan's multirater kappa measure. Kappa values were interpreted according to the categorical rating by Landis and Koch. RESULTS: Overall interobserver reliability of the Schatzker classification was significantly better compared to the Luo classification (kSchatzker=0.32 and kLuo=0.28, P=0.021), however, 'fair' for both fracture classification systems. For the Schatzker classification observers agreed significantly better on 2DCT compared to 2D- and 3DCT (k2DCT=0.37 and k2D+3DCT=0.29, P<0.001). The addition of 3DCT did not improve the overall interobserver reliability for the Luo classification as well, as kappa values were not significantly different on 2DCT and 2D- and 3DCT (k2DCT=0.31 and k2D+3DCT=0.25, P=0.096). CONCLUSIONS: The agreement between observers was significantly better for the Schatzker classification compared to Luo's Three Column classification, however agreement was fair for both classification systems. Furthermore, the addition of 3DCT reconstructions did not improve the reliability of CT-based evaluation of tibial plateau fractures. Considering that new classification systems and 3DCT do not seem to improve agreement between surgeons, other efforts are needed that lead to more reliable diagnosis of complex tibial plateau fractures