外侧胫骨平台骨折合并软组织伤的关节镜诊治

目的探讨膝关节镜在外侧胫骨平台骨折伴随软组织损伤中的诊治作用,统计各种软组织损伤的发生率。方法自2007年3月至2012年4月采用关节镜辅助内固定术治疗外侧胫骨平台骨折38例。使用膝关节镜仔细探查合并的软组织损伤,根据不同损伤类型做出相应处理,并统计各类软组织损伤的发生率。结果在本组38例患者中,合并软组织损伤24例（63．2％）,其中复合软组织损伤7例（18．4％）。半月板损伤为最常见的软组织损伤,共18例（47．4％）．前交叉韧带损伤7例16例（18．4％）,后交叉韧带损伤1例（2．6％）,外侧副韧带2例（5．3％）,内侧副韧带损伤3例（7．9％）,腓总神经损伤2例（5．3％）。结论外侧胫骨平台骨折常伴随不同类型的软组织损伤,使用膝关节镜检查可以对各类伴随的软组织损伤作出正确诊断,并及时采取针对性的治疗。     

胫骨平台骨折发生合并损伤的临床分析

目的分析胫骨平台骨折伴随合并损伤的情况。方法回顾分析224例胫骨平台骨折患者的临床资料,对骨折进行分类,统计患者发生合并损伤的情况。结果胫骨平台骨折伴有的合并损伤包括:血管损伤(5.8%),骨筋膜室综合征(7.58%),内侧半月板损伤(10.26%),外侧半月板损伤(4.91%),内侧副韧带损伤(5.8%),前交叉韧带损伤(10.26%)。结论胫骨平台骨折常伴有合并损伤,临床工作中要重视,并在早期做出全面诊断以提高治疗效果。     

胫骨平台骨折后漏诊的膝关节韧带损伤的诊治

目的提高对胫骨平台骨折伴膝关节韧带损伤的认识,从而降低漏诊率。方法回顾性分析2001年1月～2004年12月手术治疗的126例胫骨平台骨折患者中伴膝关节韧带损伤的15例患者。通过术后随访、临床表现、手术和MRI检查,明确是否伴有膝关节韧带损伤及膝关节明显不稳。证实存在膝关节韧带损伤者行手术治疗,内侧副韧带损伤患者行修补或“鹅足”转移成形术,前交叉韧带(ACL)损伤患者行Jones改良骨-韧带-骨重建术,后交叉韧带(PCL)损伤患者行Augustine术。结果术后患者获6～14个月(平均10个月)随访。15例胫骨平台骨折患者均伴有膝关节韧带损伤,行相应手术治疗后功能满意者12例,3例出现上、下楼梯困难,并且退变加重。结论胫骨平台骨折常伴膝关节韧带损伤,术前认识不足、术中探查不力、术后随访不到位是漏诊并遗留关节功能障碍的主要原因。     

Segond骨折与前交叉韧带损伤相关性的临床研究

Segond骨折是指胫骨平台外侧的撕脱骨折，也称外侧关节囊征，经常出现在新鲜的膝关节损伤中，几乎都伴随着前交叉韧带的损伤，现对我院收治的41例前交叉韧带损伤合并Segond骨折的患者的诊断及手术治疗经验进行总结。     

CT特征关节凹陷预测AO41B胫骨平台外侧骨折合并软组织损伤的价值研究

目的 评估CT特征关节凹陷程度预测AO41B外侧胫骨平台骨折合并软组织损伤的价值。方法 回顾性分析就诊于本院的AO41B外侧胫骨平台骨折患者90例，收集患者临床资料，并提取损伤后X线检查、MRI和CT扫描的结果。通过MRI评估半月板、交叉韧带和侧副韧带的损伤情况，通过数字成像软件测量CT图像上关节凹陷和胫骨平台外移程度，统计分析与软组织损伤之间的关系。结果 90名患者中，67名（74%）为男性，23名（26%）为女性。当关节凹陷超过12 mm时，外侧半月板损伤增加（P<0.05）；关节凹陷<5.9 mm与内侧半月板损伤相关（P<0.05）。结论 在AO41B外侧胫骨平台骨折中，关节凹陷增加会增加外侧半月板桶柄状撕裂的风险，而关节凹陷减少会增加内侧半月板损伤的风险。     

关节镜辅助分期手术治疗膝关节多韧带损伤合并胫骨平台骨折的疗效观察

目的观察关节镜辅助分期手术治疗膝关节多韧带损伤合并胫骨平台骨折的临床疗效。方法回顾性分析自2012-10—2016-11采用关节镜辅助分期手术治疗的9例膝关节多韧带损伤合并胫骨平台骨折,一期手术在关节镜下行胫骨平台骨折有限切开复位内固定、半月板撕裂成形、软骨修复、侧副韧带修复,3~5个月后二期手术进行前交叉韧带和(或)后交叉韧带重建。结果 9例均获得随访,随访时间平均37(22~58)个月。术后所有患者胫骨平台骨折均愈合,未出现骨筋膜室综合征、血管神经损伤、感染等并发症。术后仅1例前抽屉试验及Lachman试验呈弱阳性。末次随访时膝关节功能Lysholm评分为(90.6±2.6)分,较术前(51.3±4.0)分明显提高。末次随访时膝关节功能IKDC评分为(91.2±3.0)分,较术前(50.1±3.7)分明显提高。结论关节镜辅助分期手术治疗膝关节多韧带损伤合并胫骨平台骨折疗效肯定,具有关节面解剖复位满意、胫骨平台骨折固定可靠、膝关节稳定性恢复良好、并发症少等优点。     

胫骨平台骨折的诊治进展

胫骨平台骨折是一类常见骨折,可分为低能量损伤和高能量损伤,后者常伴有较高的并发症发生率且预后较差.常用分类方法为Schatzker分型,其被广泛用于指导治疗方法的选择.但迄今在胫骨平台骨折的诊断、治疗及预后方面,仍存在一些尚未解决的问题.本文回顾性分析近十几年来的相关文献,针对以下6个问题作一综述. 一、胫骨平台骨折合并软组织损伤的发生情况 当暴力作用于膝关节导致胫骨平台骨折时,作为膝关节重要附属结构的半月板和韧带往往一同遭受损伤.关于胫骨平台骨折伴发半月板与韧带损伤的发生率,文献报道差异较大,主要与所采用的检查方法不同有关.早期文献[1-3]报道以术前体检和术中探查作为主要检查方法,发现的半月板与韧带损伤的发生率为20％ ～ 30％.     

胫骨平台骨折中严重软组织损伤的诊断与治疗

目的:探讨胫骨平台骨折中韧带、半月板、血管和神经等损伤的诊断与治疗。方法:治疗伴发严重软组织损伤的胫骨平台骨折19例,17例在骨折切开复位时即得到修复,2例晚期进行重建。结果:随访1年8个月～6年,优良率76.5％。结论:对胫骨平台骨折中严重的软组织损伤应早期诊断,早期修复。     

胫骨平台骨折合并血管神经和其他软组织损伤的治疗体会

目的总结胫骨平台骨折合并血管神经及其他软组织损伤的处理方法。方法 42例胫骨平台骨折合并重要软组织损伤患者,均接受复位内固定手术治疗,同时对腓总神经、韧带及半月板损伤实施相应处理。结果 11例(26.1%)伴动脉损伤患者,行血管修补后血液循环得以重建。10例(23.8%)"骨筋膜室综合症"患者,给予切开减张,术后未发生肢体坏死、切口感染、皮肤坏死等早期并发症。7例(16.6%)腓总神经损伤患者,实施"神经探查"均获康复。42例患者均获随访12~36个月,骨折均于12周内愈合,无关节不稳、强直和内、外翻畸形。结论对胫骨平台骨折患者,应全面检查确定合并症的损伤程度,制定并实施精确完整的治疗计划和手段,提高治愈率。     

胫骨平台骨折合并周围韧带损伤治疗探讨

目的 分析胫骨平台骨折术后随访病例膝关节稳定性的变化，探讨胫骨平台骨折合并周围韧带损伤的发生率及早期诊断和处理措施。方法 对2000年1月～2003年6月期间在我院治疗的不同类型胫骨平台骨折进行回顾，对有随访的57例良好复位的平台骨折病例膝关节稳定度进行分析。结果 随访6个月～2.5年，平均15个月，未见明显膝关节不稳现象，总结出本组病例膝关节稳定性良好的原因：①胫骨平台骨折合并周围韧带损伤发生率低；②胫骨平台骨折合并韧带损伤程度轻；③解剖复位及坚强内固定；④术后良好制动及正确的康复训练指导。结论 胫骨平台骨折合并周围韧带完全断裂的发生率较低，韧带不全损伤非手术治疗可获得良好疗效。     

Soft tissue injury of the knee after tibial plateau fractures

The purpose of this study was to document the pattern of ligament and meniscal injuries that occur during high-energy tibial plateau fractures. One hundred three patients with fractures due to high-energy mechanisms were evaluated with knee magnetic resonance imaging (MRI). All studies were read by a single musculoskeletal radiologist who was blinded to surgical and physical exam findings. Pertinent demographic information was obtained. There were 66 patients with AO/OTA type 41C fractures and 37 patients with AO/OTA type 41B fractures. Seventy-three (71%) patients tore at least one major ligament group, and 55 (53%) patients tore multiple ligaments. There were 53 torn ligaments in AO/OTA type 41C fractures (80%) compared with 20 torn ligaments in AO/OTA type 41B fractures (54%) (p < 0.001, Fisher's exact test). Using Schatzker's classification, we found the following correlation: type I, 13 fractures with 6 ligaments (46%); type II, 11 fractures with 5 ligaments (45%); type IV, 13 fractures with 9 ligaments (69%); type V, 13 fractures with 11 ligaments (85%); and type VI, 53 fractures with 42 ligaments (79%). A significant difference exists between the groups regarding the incidence of ligament injuries (p < 0.05) and also regarding high-energy (type IV, V, VI) versus low-energy (type I, II, III) fracture patterns. The incidence of knee dislocation was 32% for AO/OTA type 41B fractures and 23% for AO/OTA type 41C fractures. Knee dislocations (dislocated on presentation, bicruciate injury, or at least three ligament groups torn with a dislocatable knee) were most common in Schatzker type IV fractures (46%). Fifty patients sustained meniscus tears (49%), with 25 medial menisci and 35 lateral menisci injuries. Tibial plateau fractures frequently have important soft tissue injuries that are difficult to diagnose on physical examination. High-energy fracture patterns (AO/OTA type 41C or Schatzker type IV, V, VI) clearly have a significantly higher incidence of ligament injury, and these patients should be carefully evaluated to rule out a spontaneously reduced knee dislocation. We believe MRI scanning should be considered for tibial plateau fractures due to high-energy mechanism, allowing identification and treatment of associated soft tissue injuries.     

The incidence of soft tissue injury in operative tibial plateau fractures: a magnetic resonance imaging analysis of 103 patients

OBJECTIVES: The goal of this study was to determine the incidence of injury to soft tissue structures of the knee in tibial plateau fractures scheduled for surgery. DESIGN: Prospective cohort. SETTING: Level I academic medical center. PATIENTS/PARTICIPANTS: One hundred three consecutive patients with acute tibial plateau fractures indicated for operative intervention. INTERVENTION: Standard x-ray examinations, including anteroposterior, lateral, and oblique views, were performed in the emergency department. Subsequently all patients had magnetic resonance imaging performed. The Schatzker and AO/OTA classifications were used to classify each fracture pattern based solely on the x-rays. Soft tissue injuries were assessed by magnetic resonance imaging. MAIN OUTCOME MEASUREMENTS: Fifteen categories of injury were determined as positive or negative on each magnetic resonance imaging, which included tears of the cruciates, collateral ligaments, menisci, and posterolateral corner. RESULTS: The overall incidence of injury to soft tissues was higher than previously reported. Only 1 patient (1%) in the series had complete absence of any soft tissue injury. Seventy-nine patients (77%) sustained a complete tear or avulsion of 1 or more cruciate or collateral ligaments. Ninety-four patients (91%) had evidence of lateral meniscus pathology. Forty-five patients (44%) had medial meniscus tears. Seventy patients (68%) had tears of 1 or more of the posterolateral corner structures of the knee. The most frequent fracture pattern was a lateral plateau split-depression (Schatzker II) (60%). No pure depression injuries (Schatzker III, AO/OTA 41-B2) were seen. CONCLUSIONS: The incidence of complete ligamentous or meniscal disruption associated with operative tibial plateau fractures was higher than previously reported. Though the clinical importance of injury to each of these structures is unknown, the treating surgeon should be aware that a variety of soft tissue injuries are common in these fractures. In addition, all fractures had at least 1 cortical split visible on magnetic resonance imaging, implying that pure depression patterns are very rare or may not exist.     

Ligament injuries associated with tibial plateau fractures

Thirty-nine patients with tibial plateau fractures and concomitant ligament injury were evaluated at least one year after injury. Ligamentous injury was determined by stress roentgenograms, plain roentgenograms, operative findings, and Pelle-grini-Stieda's ossification. There were 22 isolated medial collateral, eight lateral collateral, one isolated anterior cruciate, and eight combined ligament injuries. All types of tibial plateau fractures were associated with ligamentous injury, although split compression and local compression were most common. Twenty patients (Group 1) did not have operative repair of the injured ligaments, and 19 patients (Group 2) had primary repair of the injured ligaments. Open reduction and internal fixation of the plateau fracture(s) were performed in 13 patients in Group 1 and 19 patients in Group 2. Follow-up evaluation (100-point scale), including subjective, functional, and anatomic factors, revealed 12 excellent and good, four fair, and three poor results in the 19 patients with ligamentous repair. There were ten excellent and good, two fair, and eight poor results in those without ligament repair. Ten of the 12 patients with 10 degrees or more of instability had poor results. These poor results included five unrepaired medial collateral ligaments, two unrepaired lateral collateral ligaments, and three patients with cruciate ligament injury. This study confirms the view that instability is a major cause of unacceptable results in tibial plateau fractures. Operative repair of medial and lateral collateral ligaments, with appropriate treatment of the bony plateau fracture, may reduce late instability and may improve overall morbidity in these concomitant injuries. Cruciate ligament injury associated with a tibial plateau fracture carries a poor prognosis.     

Proximal avulsion of five ligaments and revised diagonal principle in tibial plateau fractures

PurposeThe aim of the study was to analyze the incidence of proximal avulsion of the five main ligaments and to revise the diagonal tension/compression concept in tibial plateau fractures.MethodsComputed tomographic images of 1263 cases of tibial plateau fractures were retrospectively analyzed by the OTA/AO classification and four-column nine-segment classification. The correlation between proximal avulsion of five ligaments and the injury mechanism was analyzed.ResultsIn total, 1263 tibial plateau fractures in 1253 patients were included. A total of 92 cases (7.3%) associated with proximal avulsions were identified among the 1263 tibial plateau fracture cases obtained from our institution's database. The 92 avulsions occurred in 82 patients, among whom 10 patients had two different avulsions in a single knee. The incidence of proximal avulsion fracture of the medial and lateral collateral ligament was 3.6% (45/1263) and 2.1% (26/1263), respectively. The incidence of avulsion of the anterior cruciate ligament and avulsion of the posterior cruciate ligament was much lower at 0.2% (2/1263) and 0.1% (1/1263), respectively. Proximal avulsion of the patellar ligament occurred in 18 cases (incidence rate = 1.4%). Several combinations of injuries, composed of distal tibial plateau fractures and proximal avulsion of ligaments, were identified.ConclusionsAmong the patients with tibial plateau fracture, the incidence of proximal avulsion of the five ligaments was 7.3% (92/1263). The four-column and nine-segment classification is an exhaustive method for recording injuries in these ligaments. The revised diagonal injury concept is useful for understanding the injury mechanism and choosing the appropriate surgical strategy.     

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.     

Percutaneous Reduction and Internal Fixation for Monocondylar Fractures of Tibial Plateau: A Systematic Review

Instead of extensive dissection of soft tissue around the fracture site, percutaneous techniques have unique advantages in managing displaced fragments, including preservation of soft tissues, less blood loss, lower risk of complications, and earlier functional rehabilitation. However, there are few systematic reviews on the effects of percutaneous reduction and internal fixation (PRIF) for tibial plateau fractures. A systematic search of Cochrane, EMBASE, and MEDLINE databases was performed for all publicly available data in March 2017 regarding the use of PRIF in treating monocondylar tibial plateau fractures. Basic information of included articles, surgical information, clinical outcomes, and concomitant soft tissue injuries were collected for analysis. Finally, a total of 20 articles including 561 patients were retrieved. Traffic accident was the most common cause of injury. Percutaneous techniques using bone tamp reduction were described in all studies. The majority (≥85%) of patients were classified as excellent or good according to clinical and radiological Rasmussen scores. The overall complication rate was 6.6%, with loss of reduction the most frequent complication with an incidence of 2.4%. This systematic review indicated that PRIF was an optimal alternative that physicians should consider for the treatment of monocondylar tibial plateau fractures.     

Meniscuses and ligaments injuries in tibial plateau fractures in comparative evaluation of clinical, intraoperative and MR examination]

The diagnosis of the meniscal and ligament injuries accompanying the tibial plateau fractures is difficult and unconvincing. Thus the capsular, ligament and meniscal injuries coexisting with this kind of fractures were questioned for many years. Introducing of MR afforded for the precise evaluation of the bone as well as the soft tissue injury. This article demonstrates the results of MR images of 112 patients with the acute proximal tibia fractures. The number and the degree of the meniscal and ligament injury were estimated and intraoperative verification of MR was made in 66 patients qualified for an operative procedure. The attempt to find the correlation between the type of the fracture and the meniscal and ligament injury was made according to Schatzker classification. MR images revealed that the bone injury was accompanied by the ligament or meniscal injury in 88%. Most commonly the partial tears (77% considering ligament injuries and 70% considering meniscal injuries) occurred. The most frequent extracapsular and intracapsular injury was MCL tear (70%) and LM tear (56%) respectively. No correlation between the type of the fracture and the soft tissue injury was found.     

Reasons for failure of surgical treatment in 25 tibial plateau fractures

BackgroundThe management of tibial plateau fracture is challenging. Restoration of articular congruity and early range of motion should be the primary goal. Proper and adequate preoperative planning is essential for a good outcome.PurposeThe study was a retrospective analysis of failed surgical treatment of tibial plateau fractures.MethodsTwenty-five patients with tibial plateau fractures were referred to our hospital after having undergone surgery elsewhere. Because of functional disability, the patients received revision surgery with concomitant treatment of associated soft tissue injuries. The average age at operation was 43.5 years (range, 27–71 years). The average interval between the first treatment and the secondary operation was 10.4 months (range, 6–24 months). From the radiographs and operative findings, we analyzed the factors that cause failure of the index surgical treatments for tibial plateau fractures.ResultsSchatzker classification identified five type II, one type III, four type IV, seven type V, and eight type VI fractures. Among these 25 cases, nonunion was found in seven (28%) patients and malunion in 18 patients (72%). The causes of failed surgeries included inadequate fixation (76%), malreduction (84%), and bone defect (100%). In addition, there were associated soft tissue injuries in nine patients (36%).ConclusionsThe main elements of the surgical management of tibial plateau fractures are anatomical reduction, firm fixation, and bone grafting. Inadequate fixation, malreduction, and bone defects can lead to the failure of surgical treatment. The key to successful surgical treatment is a well-designed surgical scheme tailored on the specific fracture type and soft tissue condition; this can prevent serious complications and resultant malpractice suits.     

Percutaneous methods of tibial plateau fixation

Various methods of percutaneous fixation of tibial plateau fractures are available. The optimal method of fixation is dictated by soft tissue injury, fracture characteristics, and functional demands of the patient. Unicondylar fractures are amenable to percutaneous stabilization with screws or plates although some fractures are best approached with open techniques. Hybrid and ring external fixators are most appropriate for patients with bicondylar injuries who have severe soft tissue trauma. Use of intramedullary nails to align ipsilateral shaft fractures adjacent to percutaneously fixed plateau injuries remains controversial but may be indicated for some patients with bicondylar lesions and combined plateau and shaft fractures.