Complications and outcomes of the transfibular approach for posterolateral fractures of the tibial plateau

ObjectiveEvaluate complication rates and functional outcomes of fibular neck osteotomy for posterolateral tibial plateau fractures.DesignRetrospective case series.SettingUniversity hospital.PatientsFrom January 2013 to October 2014, 11 patients underwent transfibular approach for posterolateral fractures of the tibial plateau and were enrolled in the study. All patients who underwent transfibular approach were invited the return to the hospital for another clinical and imaging evaluation.InterventionTransfibular approach (fibular neck osteotomy) with open reduction and internal fixation for posterolateral fractures of the tibial plateau.Main outcome measurementsComplications exclusively related to the transfibular approach: peroneal nerve palsy; knee instability; loss of reduction; nonunion and malunion of fibular osteotomy; and functional outcomes related to knee function.ResultsTwo patients failed to follow-up and were excluded from the study. Of the 9 patients included in the study, no patients demonstrated evidence of a peroneal nerve palsy. One patient presented loss of fracture reduction and fixation of the fibular neck osteotomy, requiring revision screw fixation. There were no malunions of the fibular osteotomy. None of the patients demonstrated clinically detectable posterolateral instability of the knee following surgery. American Knee Society Score was good in 7 patients (77.8%), fair in 1 (11.1%), and poor in 1 (11.1%). American Knee Society Score/Function showed 80 points average (60–100, S.D:11).ConclusionThe transfibular approach for posterolateral fractures is safe and useful for visualizing posterolateral articular injury. The surgeon must gently protect the peroneal nerve during the entire procedure and fix the osteotomy with long screws to prevent loss of reduction.Level of evidenceTherapeutic level IV.     

Reinforcement strategy for lateral rafting plate fixation in posterolateral column fractures of the tibial plateau: The magic screw technique

BackgroundA posterolateral column fracture of the tibial plateau (PLCF) is not uncommon, especially lateral and bicondylar tibial plateau fractures. Currently, there is no consensus on the methods of surgical treatment for PLCF, including the surgical approach or the fixation strategy. Though various posterior approaches have been explored and can allow posterior buttress plate fixation, the necessity of a posterior approach with fixation for PLCFs is increasingly questioned. Meanwhile, there is no literature to analyse the morphological features of PLCFs. None of the available surgical techniques can solve all of the problems of PLCFs.MethodsFrom February 2016 to June 2016, an inconsecutive series of 16 patients who suffered Schatzker type II tibial plateau fractures involving the posterolateral column were selected based on an analysis of the morphological characteristics of PLCFs. The patients were all treated by lateral rafting plate fixation with magic screw implantation through the extended lateral approach.ResultsAccording to PLCF morphology, 4 patients had mild slope-type depression fractures (MSDF) of the articular surface, and the other 12 patients had block-type splitting fractures (BSF). After a 12-month follow-up period, there were no complications related to the fixation technique and no significant changes in limb alignment. At the final follow-up, the average range of motion (ROM) of the affected knees was 2.3°−125°, and the average HSS score was 94.2.ConclusionsThe selected patients who suffered Schatzker type II fractures involving the posterolateral column could be successfully treated via lateral rafting plate fixation with the magic screw technique. For PLCF treatment, magic screw fixation is a valuable technique that may reduce the utilization of posterior approaches and posterior fixations.     

An anterolateral approach for the flexion-valgus type unicondylar tibial plateau depression fracture pattern a technical note

ObjectiveThe approach to pure depression fractures (PDF) of the posterolateral tibial plateau (PTP) is classically a posterior approach via a metaphyseal osteotomy window with elevation of the depressed articular fragment. Other posterolateral approaches have been described but have been criticized for affecting reduction quality, and risks to the common peroneal nerve.MethodsIn this case series, we describe a standard anterolateral approach with a window osteotomy through the metaphysis. Elevation of the PTP fracture is done through the osteotomy site.ResultsThe standard anterolateral approach avoids limitations of posterior or posterolateral approaches. Adequate reduction and good fixation of PDF of the PTP is attained.ConclusionThe anterolateral approach with osteotomy of the lateral condyle is reproducible and familiar. This avoids the need for a fibula osteotomy and the risks of neurovascular injury, while allowing adequate visualisation and fracture reduction.Level of evidenceIV.     

Flexion-valgus unicondylar tibial plateau depression fracture pattern: Classification and treatment

PurposeThe authors have identified a subset of unicondylar tibial plateau depression fracture patterns caused by a flexion-valgus force. The purpose of this study was to describe this fracture pattern and suggest a modified lateral approach that may allow for improved reduction and stabilization.MethodsThe preoperative radiographs and CT scans of 102 patients who sustained unicondylar tibial plateau fractures (OTA 41B) were reviewed. Twenty-six fracture patients had posterolateral (PL) tibial plateau depression fractures. By medical record review and telephone follow-up, the injury mechanism of the 22 unicondylar tibial plateau fractures was confirmed as a flexion-valgus force. The radiographic features of those cases were analyzed and measured. To address this specific fracture pattern, a modified approach combined with a novel intra-articular osteotomy was applied.ResultsAccording to the morphological characteristics, this tibial plateau fracture pattern could be divided into two subtypes: type A was a confined, basin-like articular surface depression fracture located in the PL quadrant, and type B was a cancellous fracture involving the PL tibial plateau resulting in a decrease in the posterior slope. One radiographic hallmark of this fracture pattern is an anatomically or a mechanically intact posterior column wall. The novel approach was applied to both types. The postoperative radiographic measurements revealed excellent reduction quality. On axial scans, the distance between the most posterior rafting screw and the tangent line of the tibial plateau rim was 3.0 ± 2.07 mm (from −1.9 to 4.3), and the angulation between them was 8.9 ± 3.02° (from −7.3 to 15.6). These results indicated excellent PL quadrant coverage from the rafting screws.ConclusionFlexion-valgus force-induced unicondylar tibial plateau depression fracture is a unique injury pattern. We suggest a novel surgical approach to address this injury’s key features, which may facilitate exposure and enhance fixation strength.     

Treatment of isolated posterior coronal fracture of the lateral tibial plateau through posterolateral approach for direct exposure and buttress plate fixation

Purpose  To present a case series of patients with isolated posterior coronal fractures of lateral tibial plateau treated by direct exposure and buttress plate fixation through posterolateral approach. Methods  Between May 2007 and April of 2008, eight middle aged patients were identified that had isolated posterior coronal fractures of the lateral tibial plateau. All eight patients underwent direct fracture exposure, reduction under visualization, and buttress plate fixation through posterolateral approach. Results  There were 1 case of split, two cases of pure depression and five cases of split-depression fractures. Four were associated fibular head split fractures without common peroneal nerve injuries. Five patients were injured from a simple fall on riding electrical bicycle while the knee was relaxed in 90° position The articular displacement (8 cases) measured in CT scan was 10.5 mm in average (range 8–15 mm). The cortical split length (from the articular rim to the distal tip, 6 cases) was 2.8 cm in average (range 2.4–3.5 cm). The articular reduction was perfect in seven (absolutely no step-off) and imperfect in 1(<2 mm step-off) as measured by X-ray. With a mean follow-up of 10 months (6 cases > 12 months), the average range of motion arc was 119°, four patients have flexion lag 10°–20°. The average SMFA dysfunction score was 15.8, and average HSS score was 98. All eight patients stated they were highly satisfied. Conclusions  Direct posterolateral approach by dividing lateral border of soleus muscle, provides excellent fracture reduction under visualization and internal buttress plate fixation for posterior coronal fracture of the lateral tibial plateau. Good functional results and recovery can be expected.     

The anterolateral supra-fibular-head approach for plating posterolateral tibial plateau fractures: A novel surgical technique

ObjectiveThe posterolateral (PL) tibial plateau quadrant is laterally covered by the fibular head and posteriorly covered by a mass of muscle ligament and important neurovascular structures. There are several limitations in exposing and fixing the PL tibial plateau fractures using a posterior approach. The aim of this study is to present a novel anterolateral supra-fibular-head approach for plating PL tibial plateau fractures.MethodsFive fresh and ten preserved knee specimens were dissected to measure the following parameters:1) the vertical distance from the apex of the fibular head to the lateral plateau surface, 2) the transverse distance between the PL platform and fibula collateral ligament (FCL), and 3) the tension of the FCL in different knee flexion positions. Clinically, isolated PL quadrant tibial plateau fractures were treated via an anterolateral supra-fibular-head approach and lateral rafting plate fixation. The outcome of the patients was assessed after a short to medium follow-up period.ResultsThe distance from the apex of the fibular head to the lateral condylar surface was 12.2 ± 1.6 mm on average. With the knee extended and the FCL tensioned, the transverse distance between the PL platform and the FCL was 6.7 ± 1.1 mm. With the knee flexed to 60° and the FCL was in the most relaxed position, the distance increased to 21.1 ± 3.0 mm. Clinically, a series of 7 cases of PL tibial plateau fractures were treated via this anterolateral supra-fibular-head approach. The patient was placed in a lateral decubitus position with the knee flexed to approximately 60 degrees. After the posterior retraction of the FCL, the plate was placed more posteriorly to provide a raft or horizontal belt fixation of the PL tibial plateau fragment. After an average of 14.3 months of follow up, the knee range of motion(ROM) was 121.4°±8.8° (range: 105°-135°), the HSS score was 96.7 ± 2.6 (range: 90-100), and the SMFA dysfunction score was 22.4 ± 3.8 (range: 16-28) points.ConclusionThe anterolateral supra-fibular-head approach can provide direct visualization of the posterolateral tibial plateau quadrant and put the plate more posteriorly to provide a raft for the fragments such that good clinical outcomes can be anticipated.     

Correlation of parameters on preoperative CT images with intra-articular soft-tissue injuries in acute tibial plateau fractures: A review of 132 patients receiving ARIF

IntroductionTibial plateau fractures often occur in conjunction with soft-tissue injuries of knees. The hypothesis of this study is that parameters of CT imaging can predict intra-articular soft-tissue injuries.Patients and methodsPatients who underwent arthroscopically assisted reduction and internal fixation (ARIF) for acute tibial plateau fractures performed by a single orthopedic surgeon between 2005 and 2015 were included in this retrospective study. Patients with concomitant ipsilateral femoral fractures, who had received revision surgery or who had undergone index surgery more than 30 days from the event were excluded. We measured lateral plateau depression and widening, medial plateau depression and displacement, and column involvement observed on preoperative CT scans. Intra-articular soft-tissue injuries were diagnosed based on findings from knee arthroscopy. The correlation of imaging parameters with soft-tissue injuries was analyzed by the area under a receiver operating characteristic (AUROC) curve and multivariate logistic regression.ResultsOne-hundred and thirty-two patients were enrolled in the study. The average age was 45.7 ± 13.1 years (range: 18–75 years). Lateral tibial plateau depressions >11 mm were significantly associated with increased risk of lateral meniscus tears (p = 0.001). However, there was no significant threshold of lateral tibial plateau widening that could be used to predict lateral meniscus tear. Greater risk of anterior cruciate ligament (ACL) avulsion fracture was observed in younger patients, patients with high-energy-pattern tibial plateau fractures, patients with fractures involving anteromedial or posterolateral columns, and patients with medial tibial plateau displacement >3 mm (p < 0.05).ConclusionMeasuring lateral tibial plateau depression and column involvement on preoperative CT scans can help predict a higher risk of lateral meniscus tear and ACL avulsion fracture respectively in patients with acute tibial plateau fractures.     

Posterolateral and anterolateral approaches to unicondylar posterolateral tibial plateau fractures: A comparative study

Background

Lateral tibial plateau fractures that are located posterolaterally are difficult to reduce through an anterolateral surgical approach because of the lack of direct visualisation of the fracture. This study compared the results of unicondylar posterolateral tibial plateau fractures in two patient cohorts: one treated through a posterolateral direct approach and the other through an anterolateral indirect approach.

Patients and methods

All nine patients admitted to our hospital, a tertiary care, urban, public hospital in Australia, from 2007 to 2010 with unicondylar posterolateral tibial plateau fractures were treated through a direct posterolateral transfibular approach and prospectively studied. All eight patients admitted from 2004 to 2007 with unicondylar posterolateral tibial plateau fractures were treated through an indirect anterolateral approach and retrospectively reviewed. Fracture reduction and maintenance of reduction were assessed radiographically over 2 years. Knee function was assessed clinically and using the Lysholm score.

Results

Fractures managed through a direct posterolateral transfibular approach were reduced with no measurable articular step on standard radiography and had no loss of reduction over time. By contrast, fractures treated through an indirect anterolateral approach had a median postoperative articular step of 5.5 mm (interquartile range = 4.5). These displacements worsened over time in six of the eight patients. At 2 years, patients treated through a direct approach had significantly better Lysholm scores than those treated through an indirect approach.

Conclusion

This study suggests that a direct posterolateral transfibular approach to unicondylar posterolateral tibial plateau fractures results in improved reduction, stabilisation and functional outcomes at early follow-up compared to an indirect anterolateral approach.     

经膝外侧腓骨截骨入路治疗胫骨平台后外侧骨折

目的探讨经膝外侧腓骨截骨入路治疗胫骨平台后外侧骨折的手术方法和临床疗效。方法2011年1月至2013年1月,收治胫骨平台后外侧骨折患者18例,男13例,女5例。年龄23.0-62.0岁,平均40.6岁。按AO分型：B3型8例,C3型10例。CT扫描和三维重建示后外侧平台劈裂塌陷,8例合并腓骨头或上端骨折。B3型骨折采用膝外侧腓骨截骨入路,C3型骨折采用联合入路（外侧＋后内侧入路）,直视下撬拨后外侧塌陷骨块并行植骨及支撑钢板内固定。对于骨折复位情况采用DeCoster评定标准,对于膝关节功能采用HSS膝关节评分标准。结果术后X线片按DeCoster评定标准评定,达到解剖复位12例,良好4例,一般2例;18例患者均获得6.0-24.0个月随访,平均12.2个月。术后3.0个月,复查X线片显示骨折均已愈合,高度未见丢失,HSS评分为84.0-95.0分,平均88.9分。2例腓总神经麻痹,2个月后自行恢复,1例术后伤口感染经清创后愈合。结论外侧腓骨近端截骨入路能充分暴露后外侧平台,直视下对后外侧劈裂骨折进行复位和内固定,值得临床推广应用。     

A combined approach for the treatment of lateral and posterolateral tibial plateau fractures

IntroductionThe treatment of tibial plateau fractures involving the lateral and posterolateral column is a demanding and fine surgical challenge. The purpose of this study was to evaluate the safety and clinical efficacy of combined approach for the treatment of lateral and posterolateral tibial plateau fractures.MethodsA prospective study was performed in 17 patients with lateral and posterolateral tibial plateau fractures between January 2009 and December 2012. There were 12 males and 5 females with a mean age of 40 years. All of them received dual-plate fixation through the combined approach, with the patients in a floating position. The combined approaches included a conventional anterolateral approach and an inverted L-shaped posterolateral approach. Operation time, intraoperative blood loss, fracture healing time, Hospital for Special Surgery (HSS) knee score, knee flexion and extension range of motion, and complications were recorded to evaluate treatment effects.ResultsThere were no intraoperative complications related to this technology. Mean operation time was 144 min with a mean intraoperative blood loss volume of 233 mL. The mean follow-up was 23 months. All 17 patients had good postoperative fracture healing. Mean union time was 12 weeks. At the final follow-up, the average HSS score was 92.5, with the average knee flexion of 125° and an average knee extension of 2°. Two patients had complications in postoperative incisions with aseptic fat liquefaction. After thorough debridement, second-stage wounds healing were achieved. No neurovascular injury occurred. No collapse of reduced articular surface was detected.ConclusionsThe combined approach with dual-plate offers direct and complete surgical exposure and provide an effective method for the treatment of lateral and posterolateral tibial plateau fractures.     

经腓骨截骨入路治疗胫骨平台后外侧骨折的疗效观察

 目的 探讨经腓骨截骨入路治疗胫骨平台后外侧骨折的疗效。方法 自2009年8月至2011年8月,采用经腓骨截骨入路治疗17例胫骨平台后外侧骨折患者,男12例,女5例;年龄24～76岁,平均37.8岁。按Schatzker胫骨平台骨折分类法：Ⅱ型骨折8例,Ⅲ型骨折3例,Ⅴ型骨折6例。所有患者随访中摄X线片评估骨折愈合情况,记录随访过程中出现的并发症,并采用Rasmussen放射评分标准对患者膝关节的X线表现进行评估,根据末次随访结果采用Rasmussen评分标准评定膝关节功能。结果 17例患者均获得随访,随访时间为9～35个月,平均18个月。骨折愈合时间为10～18周,平均13．5周。随访期间未见高度丢失,术后1例出现腓总神经损伤症状,小腿远端外侧、足背出现局部感觉减退,术后2周恢复。Rasmussen放射评分14．0～18．0分,平均17．5分。膝关节活动度-5°-0°-135°,平均活动范围123．5°。膝关节功能按照Rasmussen评分为22~30分,平均26.9分。结论 经腓骨截骨治疗胫骨平台后外侧骨折暴露充分,复位及固定满意,不会出现血管神经损伤及膝关节屈曲挛缩畸形,术后膝关节稳定性及功能恢复良好。     

胫骨平台外后壁骨折的治疗

目的 探讨胫骨平台外后壁骨折的手术治疗方法。方法 采用延长的外侧途径并腓骨颈截骨显露骨折，应用异形钢板松质骨螺丝钉联合固定治疗13例胫骨平台外后壁骨折。结果 13例均获得随访，平均随访26个月，患膝关节功能评价按Hohl评分标准：优10例，良3例。结论 以延长的外侧途径及腓骨颈截骨为入路可充分显露胫骨平台外后壁骨折端，完成骨折的解剖复位，获得良好的治疗效果，值得临床推广使用。     

Moore I postero-medial articular tibial fracture in alpine skiers: Surgical management and return to sports activity

PurposeOver the past 10 years, like many authors, we observed an increasing number of Moore I tibial plateau fractures related to alpine skiing for which the surgeon may face difficult choices regarding surgical approach and fixation means. Some authors have recently been suggesting a posterior approach associated to open reduction and osteosynthesis by a buttress plate. But in our knowledge there is no specific study on sports activity recovery after Moore I tibial fractures. The aim of this work was to assess sports activities and clinical outcomes after surgically treated Moore I tibial plateau fractures in an athletic population of skiers.MethodsWe conducted a prospective case series between 2012 and 2014. This included fifteen patients aged 39.6 ± 7 years whom presented with a Moore I tibial plateau fracture during a skiing accident. 12 cases (80%) presented with an associated tibial spine fracture. Treatment consisted of a standard antero-medial approach, with a medial para patellar arthrotomy to allow direct visualisation of articular reduction and spinal fixation. Two or three 6.5 mm long cancellous bone screws were placed antero-posteriorly so as to ensure perfect compression of the fracture site. Radiological and functional results were assessed by an independent observer (Lysholm-Tegner, UCLA, KOOS scores) at the longest follow-up.ResultsMean follow-up was 18.2 ± 6 months (12–28). An immediate postoperative anatomical reduction was achieved in all cases and remained stable in time. At last follow-up Lysholm mean score was 85 ± 14 points (59–100), UCLA score was 7.3 ± 1.6 (4–10) and Tegner score was 4.6 ± 1.3 (3–6). Mean KOOS score was 77 ± 15 (54–97). 87% of patients had resumed their skiing activity and 93% were satisfied or very satisfied from their post-operative surgical outcome. We observed no pseudarthrosis or secondary varus displacement.ConclusionIn our series 87% of patients had resumed back to their sporting activities. Surgical management of Moore I tibial plateau fractures by isolated antero-posterior screwing provides excellent clinical and radiological results. The anteromedial incision has a dual advantage of anatomical reduction, tibial spine fixation (in 80% of our cases) and posteromedial fragment reduction.     

经后外侧入路治疗胫骨外侧平台单纯后侧、后外侧骨折的初步报告

目的 探讨胫骨外侧平台单纯后侧、后外侧骨折的损伤机制及介绍采用自行设计的后外侧入路进行治疗的经验.方法 自2007年5月至2007年10月,采用自行设计的后外侧人路治疗少见的胫骨外侧平台单纯后侧、后外侧骨折的患者6例.根据AO分型:41-B-2.2.4型即胫骨外侧平台后侧塌陷性骨折2例,41-B-3.1.2型即胫骨外侧平台后外侧塌陷劈裂性骨折4例.采用T型支撑钢板治疗4例,L型支撑钢板治疗2例. 结果 术后X线片检查示所有患者均达到解剖复位,6例术后随访15～37周,平均26.3周.随访3个月时X线片示骨折均已愈合,未见高度丢失,Rasmussen放射评分16～18分,平均17.3分.膝关节总伸屈度100°～135°,平均120°.膝关节功能HSS评分为85～95分,平均89.3分. 结论 胫骨外侧平台后侧、后外侧髁骨折是膝关节屈曲且在不同程度外翻状态下受到轴向暴力所致,而后外侧入路是治疗这种类型骨折较为理想的手术入路,具有暴露清楚、内崮定安放方便、创伤小以及临床疗效好等优点.     

Intra-articular tibial plateau fracture characteristics according to the “Ten segment classification”

BackgroundCurrently existing classifications of tibial plateau fractures do not help to guide surgical strategy. Recently, a segment-based mapping of the tibial plateau has been introduced in order to address fractures with a fracture-specific surgical approach. The goal of the present study was to analyze incidence and fracture specifics according to a new 10-segment classification of the tibial plateau.MethodsA total of 242 patients with 246 affected knees were included (124 females, 118 males, mean age 51.9 ± 16.1 years). Fractures were classified according to the OTA/AO classification. Fracture pattern was analyzed with respect to a 10-segment classification based on CT imaging of the proximal tibial plateau 3 cm below the articular surface.Results161 Patients suffered an OTA/AO type 41-B and 85 patients an OTA/AO type 41-C tibial plateau fracture. Females had an almost seven times higher risk to suffer a fracture due to low-energy trauma (OR 6.91, 95% CI (3.52, 13.54), p < 0.001) than males. In 34% of the patients with affection of the medial tibial plateau, a fracture comminution, primarily due to low-energy trauma (p < 0.001), was observed. In type B fractures, the postero-latero-lateral (65.2%), the antero-latero-lateral (64.6%) and the antero-latero-central (60.9%) segment were most frequently affected. Every second type C fracture showed an unique fracture line and zone of comminution. The tibial spine was typically involved (89.4%). A typical fracture pattern of high-energy trauma demonstrated a zone of comminution of the lateral plateau and a split fracture in the medial plateau. The most frequently affected segments were the postero-latero-central (85.9%), postero-central (84.7%), and antero-latero-central (78.8%) segment.ConclusionPosterior segments were the most frequently affected in OTA/AO type B and C fractures. Acknowledging the restricted visibility of posterior segments, whose reduction and fixation is crucial for long-term success, our findings implicate the use of posterior approaches more often in the treatment of tibial plateau fractures. Also, low-energy trauma was identified as an important cause for tibial plateau fractures.     

Operative strategy in postero-medial fracture-dislocation of the proximal tibia

Objective

In 1981, Moore introduced a new classification for dislocation-type fractures caused by high-energy mechanisms. The most common medial Moore-type fractures are entire condyle fractures with the avulsion of the median eminence (tibial anterior cruciate ligament (ACL) insertion). They are usually associated with a posterolateral depression of the tibial plateau and an injury of the lateral menisco-tibial capsule. This uniform injury of the knee is increasingly observed in the recent years after skiing injuries due to the high-speed carving technique. This uprising technique uses shorter skis with more sidecut allowing much higher curve speeds and increases the forces on the knee joint.The aim of this study was to describe the injury pattern, our developed operative approach for reconstruction and outcome.

Methods

A total of 28 patients with 29 postero-medial fracture dislocation of the proximal tibia from 2001 until 2009 were analysed. Clinical and radiological follow-up was performed after 4 years on average (1 year in minimum). Evaluation criteria included the Lysholm score for everyday knee function and the Tegner score evaluating the activity level. All fractures were stabilised post primarily. The surgical main approach was medial. First, the exposure of the entire medial condyle fracture was performed following the fracture line to the articular border. The posterolateral impaction was addressed directly through the main fracture gap from anteromedial to posterolateral. Small plateau fragments were removed, larger fragments reduced and preliminarily fixed with separate K-wire(s). The postero-medial part of the condyle was then prepared for main reduction and application of a buttress T-plate in a postero-medial position, preserving the pes anserinus and medial collateral ligament. In addition, a parapatellar medial mini-arthrotomy through the same main medial approach was performed. Through this mini-arthrotomy, the avulsed anterior eminence with attached distal ACL is retained by a transosseous suture back to the tibia.

Results

We could evaluate 26 patients (93%); two patients were lost to follow-up due to foreign residence. Median age was 51 years (20–77 years). The fractures were treated post primarily at an average of 4 days; in 18 cases a two-staged procedure with initial knee-spanning external fixator was used. All fractures healed without secondary displacement or infection. As many as 25 patients showed none to moderate osteoarthritis after a median of 4 years. One patient showed a severe osteoarthritis after 8 years. All patients judge the clinical result as good to excellent. The Lysholm score reached 95 (75–100) of maximal 100 points and the Tegner activity score 5 (3–7) of maximal 10 points (competitive sports). The patients achieved a median flexion of 135° (100–145°).

Conclusion

In our view, it is crucial to recognise the different components of the injury in the typical postero-medial fracture dislocation of the proximal tibia. The described larger medial approach for this type of medial fracture dislocation allows repairing most of the injured aspects of the tibial head, namely the medial condyle with postero-medial buttressing, the distal insertion of the ACL and the posterolateral impaction of the plateau.     

后方入路治疗胫骨平台后方骨折

目的:探讨后方入路治疗胫骨平台后方骨折的骨折类型、手术方法和临床疗效。方法:回顾性分析自2008年6月至2011年2月采用后方入路治疗且随访完整的8例胫骨平台后方骨折,男5例,女3例;年龄23～55岁,平均41.1岁。致伤原因:车祸伤5例,高处坠落伤3例。2例胫骨平台后方冠状面骨折伴后交叉韧带撕脱和1例后外侧平台劈裂伴塌陷骨折采用正后方"S"形入路,2例后内侧平台骨折采用后内侧倒"L"型入路,3例同时累及胫骨平台前后侧及胫骨干骺端骨折者采用后内侧倒"L"形入路联合前外侧入路行钢板螺钉内固定。关节面塌陷者采用同种异体骨或自体髂骨植骨术。结果:所有患者获得随访,时间8～39个月,平均20个月。全部病例获得影像学上的骨性愈合,愈合时间11～21周,平均14.5周。术中未出现血管、神经损伤,术后无一例出现切口感染、内固定松动及断裂。所有患者术后即刻与术后6个月胫骨平台内翻角(TPA)、内外侧平台后倾角(PA)度数均无统计学差异。术后末次随访Rasmussen膝关节功能评分为19～29分,平均25.60分,其中优4例,良3例,可1例。术后末次随访Rasmussen放射学评分14～18分,平均17.25分,其中优6例,良2例。结论:胫骨平台骨折以后侧为主时,后方入路能得到很好的骨折端暴露,有利于直视下复位固定,术后近期疗效满意。     

改良前外侧入路治疗胫骨平台后外侧塌陷骨折

目的 :探讨改良前外侧入路治疗胫骨平台后外侧塌陷骨折的疗效。方法 :2011年2月至2013年1月,共收治13例单纯的胫骨平台后外侧塌陷骨折,男8例,女5例;年龄28~59岁,平均49.2岁。随访时检查膝关节功能,摄X线片,评估骨折愈合情况,记录随访过程中出现的并发症。采用Rasmussen放射学评分标准对骨折复位情况进行评估,根据末次随诊结果采用Rasmussen功能评分标准评定膝关节功能。结果:所有患者获随访,时间6~18个月,平均13.7个月;骨折愈合时间11~17周,平均15.1周。随访期间未见复位丢失,1例出现足背麻木,足背伸力及伸趾力减弱;1例出现切口红肿,少量淡黄色渗液,经扩大创口,引流换药后治愈。Rasmussen放射学评分13~18分,平均(16.50±0.67)分;Rasmussen功能评分13~30分,平均(25.20±2.21)分;膝关节活动度0°~135°,平均运动范围(125.3±9.3)°。结论:改良前外侧入路治疗胫骨平台后外侧塌陷骨折,暴露充分,复位及固定满意,不会出现血管神经损伤,术后膝关节稳定性及功能恢复好。     

经腓骨头上入路手术治疗单纯后外侧胫骨平台骨折疗效观察

目的探讨经腓骨头上入路手术治疗单纯后外侧胫骨平台骨折的安全性与有效性。方法回顾性分析自2016-01—2019-10采用腓骨头上入路切开复位内固定治疗的34例单纯后外侧胫骨平台骨折。经腓骨头上入路的切口起自于Gerdy’s结节,向上向后经过腓骨头上缘2 cm处作一个直切口。胫骨平台高度及关节面高度恢复后,取塑形好的L形锁定钢板头部倒置于腓骨头上,位置尽量靠后,在横臂靠后处钻孔置入1枚螺钉固定,钢板长臂置于胫骨平台后外侧,置入螺钉固定。结果 34例均获得随访,随访时间6~24(13.5±6.5)个月。术后骨折愈合时间为(13.7±2.3)周,完全负重时间为(14.9±2.4)周。末次随访时膝关节屈伸活动度为(105.6±20.7)°。末次随访时膝关节功能HSS评分为(88.9±7.2)分,其中优22例,良10例,可2例,优良率94.1%。结论经腓骨头上入路手术治疗单纯后外侧胫骨平台骨折操作简便、安全,不容易损伤膝关节重要血管神经,不破坏膝关节周围骨性结构与韧带,有利于术后膝关节功能恢复。