The cast brace and tibial plateau fractures

Three hundred six tibial plateau fractures treated at the authors' institutions and in private practice were analyzed in relation to the use of a cast brace or fracture brace. One hundred forty-one of these patients had had a cast brace or fracture brace as part of their treatment program, either as the primary fracture treatment or after open reduction or traction. The aims of this study were (1) to determine if cast bracing could maintain alignment, fracture position, and range of motion and (2) to compare its results with those of other major long-term studies of similar fractures. There were 85 lateral, 24 medial, and 32 bicondylar fractures. Cast bracing was used for one to 17 weeks, with a mean of eight weeks. Ninety-nine of the 141 patients were followed for at least one year. Eighty-two of the patients maintained alignment with less than 5 degrees of deformity, and fracture position was maintained in 85% of cases, with only 15% having 4-8 mm of loss of position. Medial plateau and subcondylar fractures had an increased incidence of fracture position loss. Ninety-seven percent of patients had greater than 90 degrees of flexion, and 90% had full extension, i.e., less than 5 degrees of contracture. Pain was minimal or absent after heavy exercise in 90% of patients using cast bracing. Arthritic changes on roentgenographic analysis were absent or mild in 93.5% and moderate or severe in 6.5% of patients. Complications, including phlebitis, pulmonary emboli, wound infection, hardware slippage, and skin slough, occurred in nine patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Closed reduction of tibial plateau fractures. A comparison of functional and roentgenographic end results

One hundred tibial plateau fractures in 96 patients were treated at three teaching hospitals. Seventy-three fractures were treated by closed reduction and early mobilization of the knee using a cast brace. Twelve fractures in this group also had percutaneous pin fixation under fluoroscopic control. The end results were graded by clinical functional criteria and by roentgenographic criteria. Eighty-nine percent of the patients treated by closed reduction methods had good to excellent functional results with a low complication rate (12%). Observations based on long-term roentgenographic examinations did not correlate with the functional end results. Many patients with less than satisfactory roentgenographic results had good to excellent functional long-term results. The indications for operative stabilization of these fractures should be based on testing for knee stability in full extension, rather than on any arbitrary roentgenographic criteria. For unstable fractures, closed reduction using ligamentotaxis and percutaneous fixation supplemented by cast brace support proved effective and relatively free of complications.     

Tibial Plateau Fractures: Evaluation and Treatment

The goal of tibial plateau fracture management is a stable, well-aligned, congruent joint, with a painless range of motion and function. Minimally displaced stable fractures should be treated with protected mobilization. The treatment of displaced tibial plateau fractures, however, remains controversial. Surgical reduction and stabilization of displaced tibial plateau fractures, when indicated, requires careful evaluation of both the "personality" of the fracture and the soft-tissue envelope. The timing of surgery and the handling of the soft tissue in this region are critical to treatment success. After restoration of a congruent joint surface, bone grafting and buttress plating are usually needed to allow early range of motion and optimize treatment outcome.     

Long-term results of total arthroplasty in adolescents with debilitating polyarthropathy.

The authors retrospectively reviewed 29 hip and 13 knee arthroplasties performed in 17 adolescents and young adults from 1973 through 1979. Most patients had severe multiple joint involvement; 16 had juvenile rheumatoid arthritis. Clinical and roentgenographic evaluations were performed before operation and at routine intervals for up to 11 years after operation. The average final follow-up evaluation was at ten years seven months. The modified Harris rating improved from 17 before operation to 68 at final evaluation. A dramatic improvement was noted in the ambulatory ability of 13 patients in whom increased joint motion and reduced deformity was observed at follow-up evaluation. At the 11-year roentgenographic review, 32% of hips had gross loosening, and an additional 39% had radiolucent lines greater than 2 mm in thickness in more than two radiographic zones. No lucency greater than 2 mm was noted in any of the knee replacements. Complications included one immediate collapse of the medial tibial plateau, four femoral fractures, one hip dislocation, and one case of arthrofibrosis. Despite untoward roentgenographic results and the high incidence of complications, total arthroplasty has dramatically improved the quality of life for these patients with multiple joint pathology. For this reason, the authors continue to recommend joint replacement in these individuals and the use of new prosthetic designs and surgical techniques.     

Surgical treatment of tibial plateau fracture in elderly patients

This retrospective study involves 22 patients with displaced tibial plateau fractures who were treated surgically from July 1993 to April 1996. All the patients were over 60 years old (mean 66.3 years old, range 61– 80 years). All of the patients were treated by open reduction and internal fixation with AO/ASIF buttress plates (Synthes, Bochum, Switzerland). Additional small fragment plate or inter-fragmental screws were used in some of them as indicated. Two patients died during follow-up of causes unrelated to the fractures. The average follow-up time was 49.8 months (range 36–68 months). The other 20 patients were interviewed at the outpatient clinic, and radiographs of bilateral standing knees were taken. By comparison with the uninjured side on radiographs, condylar joint space depression was noted in 6 patients. However, joint depression greater than 4 mm was not found. Malalignment with varus or valgus greater than 5 deg was not demonstrated in any case. Their range of motion was restored in all patients, with more than 120 deg of flexion and without extension lag except for the one who suffered a superficial wound infection. No complication required further surgical management. During the period of follow-up, no accelerated degenerative change in the operated knee joint resulted in total knee arthroplasty. Two patients needed occasional medical treatment for residual knee joint pain. Only two patients needed canes for assistance during walking due to old age and minor stroke. The results justify surgical treatment for displaced tibial plateau fractures in elderly patients. Received: 11 August 1999     

A new method of closed reduction using the spring action of Kirschner wires for fractures of the tibial plateau--a preliminary report

The treatment of fractures of the lateral tibial plateau is still a subject of controversy. Many authors have emphasized the importance of early mobilization of the knee joint following fractures of the tibial plateau. However, local depression fractures of the tibial plateau occur quite frequently in elderly patients and have presented many difficult problems in management. In 1982, the authors developed a new method of closed reduction using the spring action of Kirschner wires for severely displaced local depression fractures of the tibial plateau. The principle of this procedure is to apply continuous positive pressure to the depressed fragment for its reduction and retention. By re-establishing stability in the fracture, active knee mobilization can be allowed from the beginning. Seven patients were treated with this procedure, and the results of short-term follow-up, ranging from three to 26 months, were promising as to the range of motion, stability and relief of pain.     

An injectable calcium phosphate cement as a bone-graft substitute in the treatment of displaced lateral tibial plateau fractures

In the treatment of displaced tibial plateau fractures, filling the resultant metaphyseal defect is essential for maintaining reduction. This study reports on 14 patients with an average age of 53 (range 34-63) years who sustained such a fracture and whose tibial defect was augmented with an injectable calcium phosphate cement under arthroscopic and fluoroscopic control. Eight fractures were treated with subcortical percutaneous screw fixation, plates were used in four cases and two fractures were treated with bone cement only. Full weight-bearing was allowed after 6-12 weeks. At the last follow-up which averaged 28 (range 18-47) months, the reduction achieved at the index operation was not altered in any of the patients except one. Most patients recorded little or no pain with an average VAS score of 1.2 (0-3.4). Ten patients had no limitation of their walking distance. Patient satisfaction was good or excellent in 12 cases. Flexion averaged 140 degrees (range 130-150 degrees ) and extension was unlimited in 13 patients. The Lysholm knee score averaged 80 and the Knee Society score 180 (range 127-195). In our opinion the injectable calcium phosphate cement used here is a promising alternative for filling metaphyseal defects in the treatment of displaced tibial plateau fractures.     

Operative treatment of tibial plateau fractures in patients older than 55 years

Surgical treatment of tibial plateau fractures in the older patient poses an additional challenge because of the underlying condition of the bone and articular surface. We sought to identify risk factors for poorer outcomes in the operative treatment of displaced tibial plateau fractures in older patients. Thirty-nine displaced tibial plateau fractures in patients 55 years and older were treated operatively. Patients were evaluated objectively with Rasmussen clinical and radiologic scoring techniques, and the Short Musculoskeletal Function Assessment and the Short-Form 36 self-assessment instruments. The Rasmussen clinical and radiologic scoring systems, used on average 2.54 years postoperatively, found acceptable results in 87.2% and 82.1% of patients, respectively. The fracture classification of Schatzker was not predictive of results. External fixation was associated with significantly poorer results. Increasing age was associated with poorer clinical and self-assessment scores, although preexisting degenerative joint disease was not. The results from the Short-Form 36 indices were not significantly worse for our study patients. The average Short Musculoskeletal Function Assessment score of our study patients indicated poorer function for mobility than a normative group. Operative treatment of this injury in this population can result in favorable outcomes as evaluated by clinical, radiographic, and self-assessment criteria.     

Fracture stabilization of proximal tibial fractures with the proximal tibial LISS: early experience in Birmingham, Alabama (USA)

This study is a prospective evaluation of the Less Invasive Stabilization System (LTSS) for the treatment of high-energy tibial plateau and proximal tibial fractures treated between November, 1998 and June, 2000. Thirty-two patients sustained thirty-five acute fractures of the tibial plateau (25) or proximal tibia (10). These patients were injured primarily in blunt trauma accidents, with eighteen having multiple fractures, fifteen having ipsilateral extremity fractures, and eleven having major knee ligament injuries. Seventeen patients had open fractures. Thirty-four patients healed their fractures, with one developing a nonunion. Two patients developed infections, both following Type III open fractures. Final range of motion averaged 2 to 116 degrees. Alignment was well maintained, with no patient losing the alignment that was obtained in the operating room. The tibial LISS system worked well at stabilizing difficult fractures of the tibial plateau and proximal tibia with a low incidence of complications in this preliminary study with short-term follow-up.     

Contact stress aberrations following imprecise reduction of simple tibial plateau fractures

Despite the well-recognized association between poorly reduced intraarticular fractures and late degenerative changes, current guidelines regarding the reduction precision necessary to avoid excessive cartilage pressures are based largely on anecdotal clinical observations. To gain a quantitative appreciation of the relation between local pressure elevations and fracture reduction imprecision, a simplified laboratory cadaver model of minimally displaced tibial plateau fractures was developed. Cartilage contact stress distributions were measured as a function of depressed fragment malreduction in seven knees, using high-resolution (100 pixels/mm2) digital image scans of Fuji-film stain patterns. The contact stress data showed a general trend of increases of peak local pressure with increasing fracture site incongruity, and in a few isolated instances the effect was very pronounced. Across the whole series, however, statistically significant departures from anatomic pressure levels did not occur until the fragment stepoff was greater than 1.5 mm. Even at the 3-mm stepoff level, for which the depressed fragment usually no longer made contact with the femoral condyle, the peak local pressure values on the intact side of the fracture line averaged only approximately 75% greater than those prevailing anatomically. Given the successful clinical outcomes normally achieved for conservatively managed simple tibial plateau fractures having stepoff magnitudes (5-10 mm) clearly sufficient to insure fragment articular noncontact, the present laboratory results suggest that nominally factor-of-two peak local pressure elevations, provided that they occur over only small portions of the cartilage surface, are probably within the long-term overall tolerance range of an articular joint.     

The significance of early motion in the treatment of tibial plateau fractures

Although the trend in management of tibial plateau fractures has been toward early motion, the period of immobilization that can be tolerated safely is open to question. In the present study, 160 acute tibial plateau fractures were reviewed in an effort to answer this question. The 112 fractures that were suitable for analysis were divided into undisplaced fractures, displaced fractures treated nonoperatively, and displaced fractures treated operatively. Among these groups, results were compared based on the period after injury that the knee was immobilized. Undisplaced fractures and displaced fractures that were treated nonoperatively regained full knee motion when immobilized up to six weeks. Fractures treated operatively tended to develop knee stiffness with only two weeks of immobilization. Loss of fracture reduction tended to occur in patients who were immobilized for relatively short periods. Immediate knee motion was correlated with prolonged hospitalization. Based on these results, knee mobilization following tibial plateau fractures is determined by the degree of fracture displacement, method of treatment, and quality of aftercare.     

Displaced intra-articular calcaneal fracture treated surgically with limited posterior incision

The incidence of calcaneal fracture has been slowly increasing; however, the ideal treatment for displaced intra-articular fracture is not available yet, even though the fracture brings frequent complication and disability. Between April 1991 and March 1998, we treated 103 displaced intra-articular calcaneal fractures of 92 patients surgically with limited posterior incision, modified Gallie approach. There were thirty-seven tongue-type fractures, fifteen tongue-type fractures with moderate comminution, nineteen joint-depression fractures, twenty-nine joint-depression fractures with moderate comminution, and three extensively comminuted fractures. The fracture fragments were fixed mainly with partly threaded small cancellous screws or Steinmann pins without any bone graft. Ankle and subtalar motion was permitted immediately if fixation were stable enough. Otherwise, a short period of cast immobilization was utilized. With a mean follow-up of 28 months (range, 12 to 66 months), eighty six percent of feet had no pain or only occasional pain not requiring medication. Using American Orthopedic Foot and Ankle Society hindfoot score system for assessment, ninety percent of feet rated as good to excellent. We used "Circle draw test" for evaluation of subtalar motion during follow-up visitation and found eight-seven percent of feet showed good to excellent correlation with the functional recovery. We recommend a limited posterior incision for reduction and internal fixation of displaced intra-articular calcaneal fractures. For displaced intra-articular fractures with three or four large fragments without further comminution and without a displaced fracture of the calcaneal cuboid joint, this method is particularly useful. We also recommend a Circle draw test for evaluation of subtalar joint motion as well as an indicator of functional recovery after displaced calcaneal fractures.     

Balloon tibioplasty: a useful tool for reduction of tibial plateau depression fractures

Reduction of the articular surface in displaced tibial plateau fractures is still challenging and may result in joint incongruence, leading to posttraumatic arthrosis. Conventional techniques use bone tamps and similar instruments, which can increase the surgical trauma due to their size. "Balloon tibioplasty" is a novel minimally invasive technique for the reduction of depressed tibial plateau fractures. We successfully applied an inflatable balloon, commercially available from kyphoplasty, to elevate the depressed articular fragments. This technique allowed for reduction of the depressed tibial plateau fragment without classic fenestration of the tibia, thereby minimizing surgical trauma. Furthermore, under fluoroscopic control, optimal centering of the expanding tibioplasty balloon allows a widespread and continuously increasing reduction force to the fracture area. After fluoroscopy or arthroscopic confirmation of reduction of the articular surface, the cavity resulting from tibioplasty was filled with ceramic bone cement through small incisions and fractures were fixed with a small fragment locking T-plate (3.5 mm). Balloon tibioplasty was applied in 5 patients with displaced tibial plateau fractures (OTA type B2/3). No intra- or postoperative complications were observed. This new technique may be a useful tool to facilitate the reduction of select depressed tibial fractures in the future.     

The prevalence of soft tissue injuries in nonoperative tibial plateau fractures as determined by magnetic resonance imaging

OBJECTIVE: To determine the incidence of meniscus tears and complete ligament disruption in nondisplaced and minimally displaced tibial plateau fractures, which are otherwise amenable to nonoperative management. DESIGN: Prospective clinical study. SETTING: Level I urban trauma center. INTERVENTION: Magnetic resonance imaging of 20 consecutive nonoperative tibial plateau fractures. RESULTS: Magnetic resonance imaging was performed on 20 consecutive nonoperative (nondisplaced or minimally displaced) tibial plateau fractures to determine the frequency of significant soft tissue injuries. Ninety percent (18 of 20) had magnetic resonance imaging-diagnosed significant injuries to the soft tissues, including 80% (16 of 20) with meniscal tears, and 40% (8 of 20) with complete ligament disruptions. CONCLUSIONS: This study found a high prevalence of soft tissue injuries with nondisplaced fractures of the tibial plateau and cautions the physician and patient with respect to future knee function and possible arthrosis.     

Arthroscopic management of tibial plateau fractures.

Ten tibial plateau fractures treated arthroscopically are reported. In eight cases, closed internal fixation was performed under arthroscopic control while in another two patients, arthroscopic washout alone was undertaken. Only one case required external splintage (a cast brace), the remainder being mobilized non-weight-bearing without plaster immediately after the operation. The results were good. We suggest that the arthroscope is a useful tool in the treatment of these fractures and provides information not otherwise available. There is a low morbidity, inpatient stay is short and early joint movement can be encouraged.     

应用髂骨内板修复胫骨平台骨折关节面缺损

目的：探讨应用髂骨内板修复复杂胫骨平台骨折关节面缺损的可行性。方法：复杂胫骨平台骨折23例,男17例,女6例;年龄18～51岁,平均28.3岁。关节面缺损1cm×2cm～3cm×3cm,平均6.7cm^2。取带骨膜髂骨内板,修剪成和缺损区匹配的形状,并用直径1.5mm的克氏针间隔3～4mm钻孔,凹面朝上置入缺损区,其下植骨,T形或L形钢板固定。术后石膏外固定4周。结果：23例经随访8个月～3年,平均13.6个月,X线片示骨折全部愈合,关节面平整。采用Rasmussen评价标准,优11例,良8例,可3例,差1例。结论：对于复杂胫骨平台骨折关节面缺损,应用髂骨内板进行修复可恢复关节面平整,使膝关节获得满意功能,方法简单易行,很少发生供区并发症,临床实用性较强,可修复较大面积关节面缺损。     

辅助后内侧小切口阻挡钢板治疗Schantzker Ⅴ、Ⅵ型胫骨平台骨折

目的探讨辅助后内侧小切口阻挡钢板治疗SchantzkerⅤ、Ⅵ型胫骨平台骨折的手术技巧及疗效。方法对26例SchantzkerⅤ、Ⅵ型胫骨平台骨折均采用辅助后内侧小切口阻挡钢板配合外侧插入式支撑钢板内固定。观察术后骨折愈合、膝关节功能恢复程度及术后并发症,分析手术效果。结果 26例均获得随访,时间6～24个月。骨折临床愈合时间为12～18周。膝关节功能参考HSS评分标准:优18例,良8例。结论辅助后内侧小切口阻挡钢板治疗SchantzkerV、Ⅵ型胫骨平台骨折可以恢复平台高度,减少软组织损伤安全、有效,是一种理想的治疗方法。     

Tibial plateau fractures: standardized evaluation of operative results

Twenty patients with fractures of the tibial plateau were treated operatively by a single surgeon experienced in the techniques advocated by the Association for the Study of Internal Fixation (AO/ASIF). Patients were reviewed an average of 27.4 months postoperatively. Results are reported and evaluated according to standardized criteria recommended in the literature. In addition, subjective and objective evaluation parameters were integrated into a 100-point knee rating score. Thirteen patients had good or excellent results. Poor results were attributed to the severity of the fractures, associated soft tissue injuries, and postoperative complications. Results of patients treated in a similar manner and reported in the literature are reviewed. The recent emphasis on operative treatment of displaced tibial plateau fractures requires detailed uniform reporting and evaluation of results to allow comparison between series and to improve outcome.     

Fractures of the tibial plateau. Treatment by closed reduction and spica cast.

A retrospective study of sixty-one displaced fractures of the tibial plateau treated by closed manipulative reduction and immobilization for six weeks in a molded single hip-spica cast revealed that there was bone union in all cases. Weight-bearing was carefully avoided for twelve to sixteen weeks while motion of the knee was regained. Fifty-three patients were followed for six months to twenty-two years, an average of 3.8 years. Objectively, 85 per cent of the patients' results were rated good or excellent while subjectively 94 per cent of the patients were satisfied with their results.     

Flexible medullary nailing of tibial shaft fractures

Fifty-two tibial shaft fractures in 50 patients were treated with flexible medullary nails (Ender type). In 32 cases the fracture was closed and in the remaining 28 cases the fracture was open. Forty-eight of the 52 fractures united in an average time of 16.8 weeks and there were no cases of deep infection or osteomyelitis. Nonunion in four patients required a secondary procedure to obtain union. Flexible medullary nailing is an excellent method for fixation of tibial shaft fractures because it combines the benefits of closed nailing and functional bracing while minimizing the disadvantages of each. Three-point fixation within the medullary canal maintains length alignment and avoids rotational problems. Nailing is done by closed methods without reaming. The technique allows early weight-bearing in a patellar tendon bearing cast or functional brace. Dynamic controlled motion at the fracture site leads to early callus formation which is biomechanically and biologically favorable. The procedure is relatively easy to perform, short in duration, and requires little specialized equipment. Flexible medullary nailing is an alternative treatment modality for selected open and closed displaced tibial shaft fractures.