Comparison of the clinical and radiological outcomes between an isolated tibial component revision and total revision knee arthroplasty in aseptic loosening of an isolated tibial component

BackgroundAn isolated tibial component revision could be a treatment option for isolated tibial side loosening; however, few studies have proved its efficacy. This study aimed to compare the clinical and radiological outcomes between isolated (tibial component) and total (femoral and tibial component) revision total knee arthroplasty (TKA).MethodsBetween January 2008 and February 2017, 31 patients underwent revision TKA for isolated tibial side loosening; 14 underwent an isolated tibial component revision (isolated group) and 17 underwent total (both femoral and tibial components) revision surgery (total group). The postoperative range of motion (ROM), Western Ontario and McMaster Universities osteoarthritis (WOMAC) index, Knee Society knee score (KSKS), Knee Society function score (KSFS), and mechanical axis (MA) were compared between the two groups. The intraoperative tourniquet time and amount of blood drainage were also compared.ResultsThe mean follow-up durations in the isolated and total groups were 40.7 and 56.1 months, respectively. Both groups had similar postoperative ROM, WOMAC index, KSKS, KSFS, and MA; however, significantly shorter tourniquet time (105.2 vs. 154.6 min, P < 0.001) and less blood drainage (417.2 vs. 968.1 ml, P < 0.001) were noted in the isolated group than in the total group.ConclusionIsolated tibial component revision TKA for tibial component loosening showed comparable clinical and radiological outcomes to those of total revision TKA. The advantages of the isolated tibial component revision surgery were short operation time and small blood loss.Study designLevel III, Retrospective comparative study.     

Use of Osteochondral and Meniscal Allografts from Bone Cuts of Total Knee Arthroplasty for the Treatment of Tibial Plateau Malunions: A Case Series of Four Patients Showing Early Results

PurposeIntra-articular malunion of tibial plateau fracture is a complex problem to treat. We are presenting outcomes of our series of patients of malunited tibial plateau fractures treated with osteo-chondro-meniscal allograft from lateral tibial plateau harvested from patients undergoing total knee arthroplasty (TKA).MethodsThe technique was used in four patients. Preoperative computed tomography (CT) scan was used to match donor and recipient graft dimensions and to measure any malalignment. Patients were evaluated for Visual analogue Scale (VAS) for pain (scale 1–10 cm), WOMAC (Western Ontario McMaster Osteo-Arthritis Index) score, knee range of motion, and limb alignment.ResultsThere were three medial tibial plateau malunions and one lateral tibial plateau malunion. Articular comminution with depression was seen in all of them. One patient underwent concurrent high tibial osteotomy for the elevation of the medial tibial plateau and posterior cruciate ligament reconstruction was performed concurrently in one patient. All patients showed improvement in knee range of motion, WOMAC score, and VAS score for knee pain. Limb alignment improved in all cases. Radiologically there was consolidation of the allograft in all the cases at 6 months. The mean follow-up was 15.2 months (range 12–18 months).ConclusionOsteochondral allograft can be a good choice for reconstructing large articular cartilage defects in tibial plateau malunions. Osteo-chondro-meniscal grafts obtained during TKA can be a viable alternative for reconstructing such defects with excellent early clinical, functional, and radiological outcomes.Level of EvidenceIV.     

Revision strategy for malunited tibial plateau fracture caused by failure of initial treatment

ObjectiveThe aim of this study was to evaluate our treatment algorithm and results in revision surgery of malunited tibial plateau fracture after failure of initial treatment.MethodsOur revision strategy was as follows: First, we determined the presence of any infection. Second, we determined whether the patient required total knee arthroplasty (TKA). Third, based on the characteristics of the tibial plateau fracture malunion, patients underwent one of the following surgical methods to achieve reduction: original fracture line osteotomy, tibial tubercle + original fracture line osteotomy, fibula head + original fracture line osteotomy, and metaphyseal open window reduction rod technique. The results was assessed with healing time, Rasmussen score, knee range of motion and complication rates.ResultsA total of 25 patients 16 men and 9 women; Mean age: 47.4 years (range: 35–63 years) underwent tibial plateau fracture revision operation. The time interval between the two surgeries was 2–24 months. The follow-up time was 12–30 months, and the operation time was 120–300 min. All patients received bone union at the last follow-up. The healing time was 3–6 months. The postoperative Rasmussen score was 19–29 (mean 23.8) compared with 14.4 points before the operation (p < 0.05). The postoperative knee joint activity was 60–110° (mean 95.0°), compared with 57.8° before the operation (p < 0.05). Six patients still had a 2-mm collapse on the articular surface, and 4 patients still had slight valgus (<5°). Except for 2 TKA cases, fracture reduction was excellent in 15 cases and good in 8 cases, with a good rate of 100%. Superficial wound infections occurred in 3 patients.ConclusionBecause revision of tibial plateau fracture malunion caused by failure of initial treatment is difficult, it is necessary to create a detailed surgical plan before the operation. Satisfactory clinical effects can be obtained if the correct revision strategy is used. The key to success is adopting a proper revision strategy according to the unique characteristics of the patient's tibial plateau fracture malunion.Level of EvidenceLevel IV, Therapeutic Study.     

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.     

Valgus Subsidence of the Tibial Component Caused by Tibial Component Malpositioning in Cementless Oxford Mobile-Bearing Unicompartmental Knee Arthroplasty

BackgroundValgus subsidence (VS) of the tibial component is a rare complication of unicompartmental knee arthroplasty (UKA), and surgeons might consider revision surgery. The present study aimed to identify the factors related to VS of the tibial component after cementless Oxford mobile-bearing UKA.MethodsThe study included 120 patients who underwent Oxford mobile-bearing UKA using a cementless tibial component in our center between September 2015 and September 2016. Six showed VS of >2° after surgery. Patients were stratified into 2 groups according to the occurrence of VS of the tibial component (VS group, n = 6; no-subsidence group, n = 114). Postoperative radiographic evaluations were conducted to assess the varus/valgus alignment, rotation, and mediolateral position of the tibial and femoral components. The Oxford Knee Score (OKS) was assessed at 3, 6, and 12 months postoperatively. Positional parameters and sequential change in OKS were compared between the two groups using unpaired t-test (P < .05, statistically significant).ResultsAt 3 months postoperatively, an average VS of 3.4° in the VS group was observed, with a significant decrease in OKS. VS was associated with a significantly more medial position and external rotation of the tibial component. After 3 months, VS stopped, and the OKS gradually improved without revision surgery.ConclusionsVS might be caused by the malpositioning of the tibial component. VS of the tibial component after UKA appears to stop, with simultaneous pain relief, even without revision after 3 months postoperatively.     

Tibial tubercle osteotomy to improve exposure in complex knee fractures: A cadaveric study and case series

Adequate exposure is fundamental to safely and correctly perform open procedures around the knee. Tibial tubercle osteotomy (TTO) has previously been described as a method to improve exposure, particularly in complex primary elective knee arthroplasty or revision surgery. We describe a tibial tubercle osteotomy technique to improve exposure in complex knee fractures and a cadaveric study and trauma case series.MethodsA cadaveric study using 8 knee specimens was conducted using a lateral subvastus approach to the knee. Standardised pictures were taken of the exposure, the tibial tubercle osteotomy was performed and pictures were taken of the new exposed area. These images were compared using a computer program that calculated the area of exposure before and after tibial tubercle osteotomy and the results analysed. The technique was then used in a case series of 6 different complex knee fractures including three distal femoral, one periprosthetic distal femur and two tibial plateau fractures. The outcomes of these patients were followed clinically and radiologically.ResultsAll specimens in the cadaveric study demonstrated an increase in area of exposure after the TTO with a mean increase of 148%. All tibial tubercle osteotomies performed in the trauma case series were united by 6 months without complication.ConclusionsTibial tubercle osteotomy is a recognised technique for improving exposure to the knee. This has been demonstrated in a cadaveric study and in a case series of six complex fractures around the knee. If performed properly, this technique can be extended to appropriate trauma cases with good results.     

Five-Year Risk of Conversion to Total Knee Arthroplasty After Operatively Treated Periarticular Knee Fractures in Patients Over 40 Years of Age

BackgroundPeriarticular knee fractures present a significant challenge to minimize post-traumatic osteoarthritis. The purpose of this study is to compare the rates of conversion to total knee arthroplasty (TKA) for different periarticular knee fractures, investigate the rate of knee injections as a more rapid assessment of knee symptoms, and identify risk factors that lead to conversion to TKA following periarticular fractures.MethodsA comprehensive retrospective review of the Humana administrative claims database was performed. A total of 2813 patients greater than 40 years of age with diagnosis code for tibial plateau fracture or distal femur fracture linked to a Current Procedural Terminology code of open reduction internal fixation between 2007 and 2011 were evaluated. The rates of TKA and knee injections within 5 years were compared. Cox proportional hazards model was used to evaluate risk factors for conversion.ResultsOf 2813 periarticular fractures, the 5-year rate of conversion to TKA was 3.3%. The rate of conversion for tibial plateau fractures was significantly higher at 4.5% compared to 2.3% for distal femur fractures (P = .001). Tibial plateau fracture, obesity, and female gender were risk factors found to portend an increased risk of conversion to TKA with hazard ratios of 1.77, 1.69, and 1.88, respectively. The overall rate of knee injections was 12.8% with an average time to injection of 18.2 months after open reduction internal fixation.ConclusionThe rate of conversion to TKA for periarticular knee fractures overall was 3.3%, while the rate of knee injections within 5 years of surgery was 12.8%, suggesting a not insignificant minority of patients require treatment for symptomatic knee pain.Level of EvidenceTherapeutic Level III.     

Shear's role in non-union. Measuring mean angle of long bone multi-fragmentary non-unions

IntroductionBoth mechanical and biological theories have been proposed in the development of non-union. The mechanical theory suggests that a high strain environment in a fracture will predispose it to non-union. While in simple fractures and wedge fractures there are only one and two primary fracture planes respectively, in multi-fragmentary fractures there are many and a non-union may form along any of the original fracture lines, however the plane which experiences the highest strain is at 45^O – the shear plane. We hypothesise that in multi-fragmentary fractures the initial fracture line that most often fails to unite will tend towards the plane with the highest strain.Objectives1) Define the mean non-union angle in a cohort of multi-fragmentary tibial and femoral fractures.2) In wedge-like fractures within the cohort, define and compare the mean angle of initial fracture planes which go on to form a non-union to those that unite3) In comminuted fractures within the cohort, define the mean non-union angleDesignRetrospective cohort studySettingLevel-1 trauma centreMethodologyFractures were categorised into wedge-like and comminuted. A published technique was utilised to measure fracture and non-union angles. In wedge-like fractures, united and non-united initial planes were compared. In comminuted fractures only the mean non-union angle was defined. Demographic patient data was also collected.Results183 non-unions were screened, 68 patients were included. The mean non-union angle was 56°(SD 18) across all fractures. In wedge-like fractures the mean non-union angle was 59°(SD 18). In comminuted fractures the mean non-union angle was 50°(SD 19). Non-united initial fracture planes in wedge-like fractures showed a peaked distribution about a mean of 58° while united fracture planes were distributed at the extremities of the range.ConclusionsIn patients with multi-fragmentary fractures resulting in non-union, the mean tibial non-union angle was 52° while the mean femoral non-union angle was 65°. In wedge-like fractures, non-unions occurred more commonly than appropriate union in fractures between 41°-80°. The non-union angle is closer to 45° in comminuted fractures than in wedge-like fractures. These results support the mechanical theory that strain from the shear plane is an important factor in the formation of non-unions.Level of EvidencePrognostic level 3.     

Surgical treatment of complex tibial plateau fractures by closed reduction and external fixation. A review of 32 consecutive cases operated

Abstract Complex tibial plateau fractures are a challenge in trauma surgery. In these fractures it is necessary to anatomically reduce the articular part of the fracture and to obtain stable fixation. The aim of this study is to review the results of a surgical technique consisting of fluoroscopic closed reduction and combined percutaneous internal and external fixation. Thirty-two complex tibial plateau fractures in 32 patients were included. Twenty-one fractures were closed, 4 were open Gustilo grade I, 3 were Gustilo grade II and 4 were Gustilo grade III. The mean age was 37.8 years (range 21–64 years). Surgery was performed with patients in transcalcaneal traction and the knee flexed at 30° was used. Through a 1-cm incision centred over the tibial metaphysis of the tibia, a 3.2-mm hole was drilled in the antero-medial tibial aspect. The tibial plateau fracture fragments were elevated using either 1 or 2 curved Kirschner wires under fluoroscopy to control the reduction. Then the fragments were fixed with 2 cannulated AO screws inserted through small incisions into the medial aspect of the tibial plateau. Knee rehabilitation started postoperatively. Weight bearing started after 8–12 weeks depending upon the radiographic appearance. All external fixators were removed in outpatient facilities. All patients were clinically and radiographically evaluated at a mean follow-up of 48 months (range 38–57 months). Clinical results were evaluated according to the Knee Society clinical score. Average healing time was 24 weeks (range 18–29 weeks). In 1 patient a non-union occurred. This patient was treated with open reduction and plate fixation. In 2 patients a varus knee deformity occurred and a surgical correction was performed. There were no surgical complications. Mean knee range of motion was 105° (range 75–125°) and mean Knee Society clinical score was 89. Twenty-five results were scored as excellent, 4 good, 2 fair and 1 poor. Using this technique there is limited soft tissue damage and virtually no periosteum damage to the fracture fragments. However anatomical reconstruction of the joint can be obtained. Furthermore knee rehabilitation can be started immediately after surgery. We think that these factors were responsible for the optimal clinical long-term results.     

Updated Three-Column Concept in surgical treatment for tibial plateau fractures – A prospective cohort study of 287 patients

PurposeThis study introduces an updated Three-Column Concept for the classification and treatment of complex tibial plateau fractures. A combined preoperative assessment of fracture morphology and injury mechanism is utilized to determine surgical approach, implant placement and fixation sequence. The effectiveness of this updated concept is demonstrated through evaluation of both clinical and radiographic outcome measures.Patients and methodsFrom 2008 to 2012, 355 tibial plateau fractures were treated using the updated Three-Column Concept. Standard radiographic and computed tomography imaging are used to systematically assess and classify fracture patterns as follows: (1) identify column(s) injured and locate associated articular depression or comminution, (2) determine injury mechanism including varus/valgus and flexion/extension forces, and (3) determine surgical approach(es) as well as the location and function of applied fixation. Quality and maintenance of reduction and alignment, fracture healing, complications, and functional outcomes were assessed.Results287 treated fractures were followed up for a mean period of 44.5 months (range: 22–96). The mean time to radiographic bony union and full weight-bearing was 13.5 weeks (range: 10–28) and 14.8 weeks (range: 10–26) respectively. The average functional Knee Society Score was 93.0 (range: 80–95). The average range of motion of the affected knees was 1.5–121.5°. No significant difference was found in knee alignment between immediate and 18-month post-operative measurements. Additionally, no significant difference was found in functional scores and range of motion between one, two and three-column fracture groups. Twelve patients suffered superficial infection, one had limited skin necrosis and two had wound dehiscence, that healed with nonoperative management. Intraoperative vascular injury occurred in two patients. Fixation of failure was not observed in any of the fractures treated.ConclusionAn updated Three-Column Concept assessing fracture morphology and injury mechanism in tandem can be used to guide surgical treatment of tibial plateau fractures. Limited results demonstrate successful application of biologically friendly fixation constructs while avoiding fixation failure and associated complications of both simple and complex tibial plateau fractures.Level of evidenceLevel II, prospective cohort study.     

Outcome of revision surgery for bisphosphonate related subtrochanteric fracture non-union following failed intramedullary nailing

BackgroundBisphosphonates use is a recognised cause of atypical femur fractures. Intramedullary nailing is the first line of treatment for these fractures, but failure is a common problem due to altered biology, resulting in a non-union and a challenging problem.PurposeThere is lack of evidence in the literature on revision surgery for the management of non-union after failed nailing in atypical femur fracture. We present our experience of treating this complex problem.Patient and MethodsA retrospective review of all consecutive cases of revision surgery for non-union of bisphosphonate related subtrochanteric fractures was undertaken. All procedures were performed between 2012 and 2017 by a single surgeon. Revision surgery included removal of failed metalwork, resection of non-union, bone grafting and double plating with a lateral DCS plate and anterior locking compression plate.ResultsTen patients (9 females, 1 male) were included with a mean age of 71.5 years and mean BMI of 34 at the time of revision. All patients received previous Bisphosphonate treatment on average for 6.2 years. One patient was lost to follow up. Mean time for non-weight bearing (NWB) mobilization was 7 months and mean time for union was 14 months.ConclusionsFracture healing can be achieved with bone grafting and compression plating in all patients. However, a prolonged time to achieve union and a long follow-up duration should be expected.     

Outcome of Revision Surgery for the Idiopathic Stiff Total Knee Arthroplasty

BackgroundIdiopathic stiff total knee arthroplasty (TKA) represents one of the most challenging subsets of the stiff TKA, as the etiology is unknown and there is no consensus on the most appropriate surgical treatment modality. Therefore, the aim of this study is to report on postoperative outcomes of revision surgery for idiopathic stiff TKA.MethodsWe retrospectively reviewed 189 consecutive patients (202 knees) who underwent revision TKA for stiffness: (1) 101 knees in the idiopathic stiffness cohort and (2) 88 in the non-idiopathic stiffness cohort. In the idiopathic stiffness cohort, 42 knees underwent isolated tibial insert exchange and 59 knees underwent component revision. Perioperative knee range of movement and complications were analyzed.ResultsThe overall revision surgery outcomes of the idiopathic stiffness cohort were worse than those of the non-idiopathic stiffness cohort with regard to maximum flexion (91.7° vs 100.1°, P = .02) and flexion range of motion (ROM) (87.6° vs 97.1°, P = .01). In the idiopathic stiffness cohort, isolated tibial insert exchange demonstrated greater maximum flexion (96.8° vs 88.4°, P = .06) and flexion ROM (93.2° vs 83.9°, P = .07). In terms of re-revision rates, the isolated tibial insert exchange idiopathic stiffness cohort demonstrated lower re-revision rates compared to the component revision idiopathic stiffness cohort (16.7% vs 31.0%, P = .01).ConclusionThis study demonstrates that the overall revision surgery outcome of idiopathic stiff TKA is worse than non-idiopathic TKA stiffness. In idiopathic stiffness cohorts, isolated tibial insert exchange was associated with lower re-revision rates than component revision, with similar efficacy in improving ROM, suggesting that isolated tibial insert exchange may be a preferred surgical treatment option in TKA patients with idiopathic stiffness.     

Surgically treated Hoffa Fractures with poor long-term functional results

IntroductionHoffa fractures are rare injuries and usually involve the lateral condyle. There are few published studies of large series of isolated coronal plane fractures of the femoral condyle. The aim of the study to determine the long-term functional outcomes and complications in surgically treated Hoffa fractures.Patients and methodsA retrospective review was made of 13 consecutive patients who were treated surgically for an isolated coronal plane fracture of the distal femur posterior condyle. The patients were evaluated with physical examination, PA and lateral radiographs and CT at the final follow-up examination. Functional outcome was evaluated with the OXFORD knee scoring system and Knee Society Score (KSS). Pain at rest and in activity was assessed using a Visual Analog Scale (VAS).ResultsThe patients comprised 11 males and 2 females with an average age at surgery of 27.5 years. The mean follow-up period was 93 months (range, 62–134 months). Mean time to fracture healing was 10 weeks (range, 8–12 weeks). The mean ROM was determined as 110°, mean KSS 78,4 and mean Oxford knee score 38,2. The mean KSS was 66,5 for medial Hoffa fracture patients and it was 83,8 for lateral Hoffa fracture patients. The mean Oxford knee score was 33,2 for medial Hoffa fracture patients and it was 40,4 for lateral Hoffa fracture patients. The mean VAS at rest and in activity was 1,1 and 2,9, respectively. Osteoarthritis was seen in 7 (54%) patients and avascular necrosis in 2 (15.4%). Varus instability was determined in 1 patient and valgus instability in 1 patient.ConclusionHoffa fractures may easily be overlooked if the radiological examination is not made carefully. Screw fixation was seen to provide enough biomechanical stability until the fracture healed. Arthrosis is a frequent long-term complication which worsens the functional results. Medial Hoffa fractures tend to have worse functional results than lateral Hoffa fractures.Level of evidence: Therapeutic Level IV retrospective case series.     

Comparative Efficacy of the Different Surgical Approaches in Total Knee Arthroplasty: A Systematic-Review and Network Meta-Analysis

BackgroundSeveral surgical approaches including midvastus, subvastus, mini-parapatellar, quadriceps-sparring (QS) and parapatellar are currently used to perform total knee arthroplasty (TKA). Since none of published study exhibited a simultaneous comparison of all of them, a network meta-analysis has been conducted to compare the most widely used knee surgical approaches regarding the improvement of functional outcomes and the range of motion (ROM).MethodsRandomised controlled trials (RCTs) comparing TKA approaches were searched in electronic databases, major orthopedics journals, and oral communications, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform until May 1st, 2020. Two reviewers independently selected trials and extracted data. The primary outcomes were functional scores at 6 months post-surgeryevaluated by KSS and WOMAC, and the ROM.ResultsSixty RCTs involving 5042 patients with 5107 TKA were included. No significant differences between different approaches were found for the KSS assessment or the WOMAC at 6 months. The mean of ROM at 6 months post-surgery were higher in the subvastus group than in all the others surgical approaches. The difference of ROM with subvastus approach was 7.3° (95% CI ?14.1 to ?0.1) with the midvastus approach, 11.1° (95% CI ?18.7 to ?2.8) with mini-parapatellar, 8.9° (95% CI ?14.2 to ?3.1) with standard parapatellar, and 9.2° (95% CI ?16.1 to ?1.8) with QS.ConclusionNo differences were found in functional outcomes over short or medium terms but subvastus seemed to increase the ROM at 6 months post-surgery. Until or unless future studies can demonstrate a long-term benefit, based on these results all studied surgical approaches to perform a TKA are equal.Level of EvidenceNetwork meta-analysis. Level 1.     

Total knee arthroplasty after complex tibial plateau fractures

Total knee arthroplasty following complex fractures of the tibial plateau is considered a challenge for orthopaedic surgeons and clinical outcomes may vary. A total of 29 total knee replacements were performed after a tibial plateau fracture: 25 patients (16 women, 9 men; average age: 57 years; mean follow-up: 92 months) were available. We had two significative complications: one partial avulsion of the patellar tendon, conservatively treated by bracing, and one case of deep venous thromboembolism, managed with low molecular weight heparin. In two cases (8%) there was a failure of the implant; nine cases were excellent, nine good, four fair and one poor. A percentage of patients with previous complex proximal tibia fractures had an increased rate of postoperative complications due to anatomical deformity, functional deficiency and post-traumatic arthritis and required solutions similar to revision surgery. Total knee arthroplasty is a suitable solution for the treatment of these challenging cases: compared to primary knee replacement, final KSS score is generally lower, but improvement is similar due to poorer pre-operative scores.     

Epidemiology and outcomes of tibial plateau fractures in adults aged 60 and over treated in the United Kingdom

BackgroundTibial plateau fractures are common in older adults, often resulting from low-energy falls. Although lower limb fragility fracture care has evolved, the management of tibial plateau fractures in older patients remains poorly researched. This study aimed to define the epidemiology, treatment and outcomes of tibial plateau fractures in patients aged over 60 years.MethodologyPatients aged 60 years or older with a tibial plateau fracture who presented to a single trauma center between January 2008 and December 2018 were identified. Incomplete records were excluded. Epidemiological data, fracture classification, injury management, radiological outcomes, complications, and mortality were assessed via retrospective case note and radiograph review. Local ethics approval was obtained.ResultsTwo-hundred and twenty patients with a mean age of 74 years (range 60–100) were included. 73% were female and 71% of injuries were sustained following low-energy falls. Median follow up was three months. 50% of fractures involved the lateral plateau. 60% of injuries were treated non-operatively. 76% of patients had their weight-bearing restricted for the first six weeks, with little difference between operatively and non-operatively managed patients. 8% of all patients required subsequent knee replacement. All-cause mortality at 30-days and one-year were 2% and 5% respectively.ConclusionThe majority of tibial plateau fractures in the over 60s are sustained from low-energy trauma. Management is relatively conservative when compared with younger cohorts. The data reported brings up questions of whether surgical treatment is beneficial to this patient group, or whether restricted weight bearing is either possible or beneficial. Prospective, multi-center comparative trials are needed to determine whether increased operative intervention or different rehabilitation strategies purveys any patient benefit.     

A clinico-radiological study of bicondylar tibial plateau fractures managed with dual locking plates

BackgroundTreatment of bicondylar intra-articular tibial plateau fractures due to high energy trauma is complex and highly prone to complications due to fracture patterns and extensive soft tissue damage.AimThe study's objective was to evaluate the clinical, radiological and functional outcome, including the complications in closed Schatzker type V and VI tibial plateau fractures managed with dual locking plates using less extensile approaches and indirect reduction techniques.Materials and methodsThirty-four patients of closed Schatzker Type V and VI treated with pre-contoured locking plates were evaluated clinically and radiologically. Dual plating was done using a less extensile anterolateral approach for lateral plate and medial/open posteromedial approach for medial plate. Functional results were evaluated using the Knee Society Score (KSS) and radiological results by the Modified Rasmussen score (MRS) for radiological assessment.ResultsThe mean age of patients in our study was 45 years (range = 26–60 years) with a male predominance of 84.4%. The average time difference between trauma and surgery was 7.6 days (range = 5–14 days) with an average length of hospital stay of 8.5 days (range = 7–18 days). Autologous bone grafting from the iliac crest was done in 10 patients (29.4%) with a sizeable metaphyseal void. The study has a mean follow-up period of 22.6 months. The complete union was seen at an average of 17.4 weeks. The average knee ROM at the last follow-up was 110.75°. Three patients had complications, 2 with wound dehiscence and 1 with deep infection.ConclusionInternal fixation with dual locking plates is biomechanically strong and stable and gives excellent to good functional outcomes. However, the timing of internal fixation is essential in such complex injuries to prevent soft tissue complications and failure. The use of rigid fixation by less extensile approaches and indirect reduction techniques helps prevent wound healing problems and allows early knee mobilization.