Transverse Incision for Minimally Invasive Plate Osteosynthesis of Osteoporotic Tibial Plateau Fractures

Fractures of the tibial plateau frequently require surgical intervention. Open approaches are increasingly being replaced by minimally invasive techniques. Plate fixation may be uni- or bicondylar, and surgical incisions are traditionally orientated in the longitudinal plane. We describe osteoporotic fragility tibial plateau fractures managed with plate fixation applied through minimally invasive transverse incisions. All cases achieved acceptable fracture reduction, restoration of alignment, and timely bone union without infection or wound complications. This technique reduces the risk of wound complications at later arthroplasty, along with the established benefits of current minimally invasive techniques. This is the first report in the literature of the use of transverse incisions for minimally invasive plate fixation of the tibial plateau

Failure of knee osteotomy in a case of neuropathic arthropathy of the knee

Neuropathic arthropathy (Charcot’s joint) is a degenerative process that affects peripheral or vertebral joints as a consequence of a disturbance in proprioception and pain perception. The knee is one of the most frequently affected joints, but even when the diagnosis is made at an early stage there is no consensus on the best treatment options. An early diagnosis of neurosyphilis was made in a 55-year-old woman presenting a delayed union of an asymptomatic Schatzker type IV fracture of the proximal tibia. A medial opening wedge tibial osteotomy was performed to achieve fracture healing, to correct the medial depression of the articular surface, and possibly to avoid an early arthritis typical of the disease. To our knowledge, a knee osteotomy has never been reported at an early stage of neuropathic arthropathy. Even though the clinical and radiographic evaluation performed at 4 months follow-up showed a good stage of healing of the osteotomy and no typical features of neuropathic joint degeneration, at 8 months follow-up the knee was markedly deranged

LCP external fixation - External application of an internal fixator: two cases and a review of the literature

The locking compression plate (LCP) is an angle-stable fixator intended for intracorporeal application. In selected cases, it can be applied externally in an extracorporeal location to function as a monolateral external fixator. We describe one patient with Schatzker V tibial plateau fracture and one patient with Gustillo IIIB open tibia shaft fracture treated initially with traditional external fixation for whom exchange fixation with externally applied LCPs was performed. The first case went on to bony union while the second case required bone grafting for delayed union. Both patients found that the LCP external fixators facilitated mobilization and were more manageable and aesthetically acceptable than traditional bar-Schanz pin fixators

External versus internal fixation for bicondylar tibial plateau fractures: systematic review and meta-analysis.

BACKGROUND: It is uncertain whether external fixation or open reduction internal fixation (ORIF) is optimal for patients with bicondylar tibial plateau fractures. MATERIALS AND METHODS: A systematic review using Ovid MEDLINE, Embase Classic, Embase, AMED, the Cochrane Library, Open Grey, Orthopaedic Proceedings, WHO International Clinical Trials Registry Platform, Current Controlled Trials, US National Institute for Health Trials Registry, and the Cochrane Central Register of Controlled Trials. The search was conducted on 3rd October 2014 and no language limits were applied. Inclusion criteria were all clinical study designs comparing external fixation with open reduction internal fixation of bicondylar tibial plateau fractures. Studies of only one treatment modality were excluded, as were those that included unicondylar tibial plateau fractures. Treatment effects from studies reporting dichotomous outcomes were summarised using odds ratios. Continuous outcomes were converted to standardized mean differences to assess the treatment effect, and inverse variance methods used to combine data. A fixed effect model was used for meta-analyses. RESULTS: Patients undergoing external fixation were more likely to have returned to preinjury activities by six and twelve months (P = 0.030) but not at 24 months follow-up. However, external fixation was complicated by a greater number of infections (OR 2.59, 95 % CI 1.25-5.36, P = 0.01). There were no statistically significant differences in the rates of deep infection, venous thromboembolism, compartment syndrome, or need for re-operation between the two groups. CONCLUSION: Although external fixation and ORIF are associated with different complication profiles, both are acceptable strategies for managing bicondylar tibial plateau fractures

The accuracy and precision of radiostereometric analysis in monitoring tibial plateau fractures

Background and purpose: The application of radiostereometric analysis (RSA) to monitor stability of tibial plateau fractures during healing is both limited and yet to be validated. We therefore evaluated the accuracy and precision of RSA in a tibial plateau fracture model. Methods: Combinations of 3, 6, and 9 markers in a lateral condyle fracture were evaluated with reference to 6 proximal tibial arrangements. Translation and rotation accuracy was assessed with displacement-controlled stages, while precision was assessed with dynamic double examinations. A comparison of error according to marker number and arrangement was completed with 2-way ANOVA models. Results: The results were improved using more tantalum markers in each segment. In the fracture fragment, marker scatter in all axes was achieved by a circumferential arrangement (medial, anterior, and lateral) of the tantalum markers above the fixation devices. Markers placed on either side of the tibial tuberosity and in the medial aspect of the fracture split represented the proximal tibial reference segment best. Using 6 markers with this distribution in each segment, the translation accuracy (root mean square error) was less than 37 μm in all axes. The precision (95% confidence interval) was less than ± 16 μm in all axes in vitro. Rotation, tested around the x-axis, had an accuracy of less than 0.123° and a precision of ± 0.024°. Interpretation: RSA is highly accurate and precise in the assessment of lateral tibial plateau fracture fragment movement. The validation of our center's RSA system provides evidence to support future clinical RSA fracture studies.Lucian B Solomon, Aaron W Stevenson, Stuart A Callary, Thomas R Sullivan, Donald W Howie, and Mellick J Chehad

Cannulated screw and hexapodal fixator reconstruction for compound upper tibial fractures

OBJECTIVES: The aim of the treatment of tibial plateau fractures is to obtain a pain-free and fully functional knee with closed reduction, percutaneous cannulated screw fixation and hexapodal external fixator reconstruction for high energy compound upper tibial fractures. METHODS: Patients with comminuted tibial plateau fractures underwent closed reduction, percutaneous fixation with cannulated screws, and reconstruction with hexapodal external fixator. The follow-up period was 24 months. RESULTS: The clinical and radiological results were good or excellent. The average knee flexion was 125°. CONCLUSION: Our results are successful in the initial stage, however, it should be pointed out that during the long term follow-up osteoarthritis may develop leading to worsening of the condition. Level of Evidence IV, Case Series

A surgical protocol for bicondylar four-quadrant tibial plateau fractures

Purpose Bicondylar tibial plateau fractures involving four articular quadrants are severe and complex injuries, and they remain a challenging problem in orthopaedic trauma. The aim of this study was to introduce a new treatment protocol with dual-incision and multi-plate fixation in the floating supine patient position as well as to report the preliminary clinical results. Methods From January 2006 to December 2011, 16 consecutive patients with closed bicondylar four-quadrant tibial plateau fractures (Schatzker type VI, OTA/AO 41C2/3) were treated with posteromedial inverted L-shaped and anterolateral incisions. With the posteromedial approach, three quadrants (posteromedial, anteromedial and posterolateral) can be exposed, reduced and fixed with multiple small antiglide plates and short screws in an enclosure pattern. With the anterolateral approach, after articular elevation and bone substitute grafting, a strong locking plate with long screws to the medial cortex is used to raft-buttress the reduced lateral plateau fracture, hold the entire reconstructed tibial condyles together, and contact the condyles with the tibial shaft. All patients were encouraged to exercise knee motion at an early stage. The outcome was evaluated clinically and radiologically after a minimum two-year follow-up. Results The average operation time was 98 +/- 26 minutes (range 70-128) and the average duration of hospitalization was 29 +/- 8.6 days (range 20-41). Three cases used five plates, nine cases used four plates, and four cases used three plates. All patients were followed for a mean of 28.7 +/- 6.1 months (range 26-38). Fifteen incisions healed initially, while one patient developed a medial wound dehiscence and was successfully managed by debridement. All patients achieved radiological fracture union after an average of 20.2 weeks. At the two-year follow up, the average knee range of motion (ROM) was 98A degrees aEuro parts per thousand A +/- aEuro parts per thousand 13.7 (range 88-125A degrees), with a Hospital for Special Surgery (HSS) knee score of 87.7 A +/- 10.3 (range 75-95), and SMFA score of 21.3 A +/- 8.6 (range 12-33). Conclusion For bicondylar four-quadrant tibial plateau fractures, the treatment protocol of multiple medial-posterior small plates combined with a lateral strong locking plate through dual incisions can provide stable fracture fixation to allow for early stage rehabilitation. Good clinical outcomes can be anticipated