(iii) Minimal invasive techniques in the management of tibial plateau fractures

Intra-articular fractures of the proximal tibia present a wide spectrum of injury patterns with associated soft tissue injury. The last two decades have seen the techniques of management evolve from extensive open reduction and rigid internal fixation to arthroscopy-assisted minimal invasive surgery (MIS) and biologically benign internal fixation. The ultimate aim is to prevent the occurrence of late degenerative arthritis. This could be achieved in selected patients using minimal invasive surgery, which offers the advantages of better visualisation and management of intra-articular soft tissue injuries, confirmation of fracture reduction viewed from the joint surface, faster rehabilitation and fewer wound complications.     

Characteristics,Treatments, and Outcomes of Tibial Plateau Nonunions: A Systematic Review

BackgroundDue to the rare incidence of tibial plateau nonunions, current studies are limited to small sample sizes and patient demographics. The aim of this systematic review is to quantify and report patient and fracture traits, possible risk factors, and treatment outcomes of tibial plateau nonunions.MethodsPubMed, Clinical Key, and MEDLINE were searched for articles published prior to August 2020 in accordance to the preferred reporting items for systematic reviews and meta-analyses (PRISMA). The authors used varying combinations of the following terms to identify relevant articles: “tibial,” “plateau,” “nonunion,” “non-union.” Studies were assessed for patient demographics, pre-revision nonunion characteristics, treatment, and post-revision outcomes.ResultsEight studies were included, yielding 31 tibial plateau nonunions (21 males, 10 females). The majority of nonunions were associated with high energy trauma (52.2%) and were Schatzker class VI (54.8%). Schatzker class I and II nonunions were not attributed to neglect, contradicting previous suggestions. Time to union was 4.0 months, the most common treatments being autologous bone grafting (76.7%) and revision plating (63.3%).ConclusionThis study demonstrates the effectiveness of autologous bone grafts and revision plating for tibial plateau nonunions. Physicians may use these findings to guide decision making in the event of high energy plateau nonunions. Lastly, various limitations exist within the current literature, emphasizing the need for standardized reporting measures.     

The pivotal role of the coronal fracture line for a new three-dimensional CT-based fracture classification of bicondylar proximal tibial fractures

IntroductionClassical fracture classifications (AO/OTA, Schatzker) are commonly used to characterize bicondylar proximal tibial fractures. However, none of these classifications allows for a treatment algorithm. The aim of our study was to use 3D appearance of these fractures in CT imaging to improve the clinical value of the classification.Materials and methods3D appearance of 81 CT scans of bicondylar proximal tibial fractures were systematically analyzed and were classified in 3 subtypes, based on the fracture lines orientation. The novel classification was compared for reliability and for clinical relevance with AO and Schatzker classification.ResultsA total of 159 fracture lines were identified which were most frequently oriented in sagittal (89/159), and in coronal (41/159) direction. Based on the orientation of the major fracture lines three fracture types were defined. A special emphasis was drawn to the coronal fracture line of the medial plateau leading to a surgical treatment algorithm. Interobserver reliability was analyzed for all 81 patients resulting in an excellent reliability of К = 0.936 for the 3D classification scheme compared to К = 0.720 for the AO/OTA, К = 0.785 for the Schatzker classification. Correlations with clinical parameters were only observed for the 3D classification.DiscussionThe presented classification scheme based on the 3D geometry of bicondylar proximal tibial fractures demonstrates a good reliability of clinical relevance.     

涉及后柱胫骨平台骨折的不同治疗策略

目的探讨涉及后柱胫骨平台骨折的治疗策略。方法自2009-07—2014-10收集206例胫骨平台骨折的临床资料,研究涉及后柱的胫骨平台骨折的发病率。采用Schatzker法及罗从风三柱法分别对骨折进行分类,后柱再分为后内侧柱和后外侧柱,筛选出涉及后柱的胫骨平台病历。根据后柱骨折的类型,选择合适的手术方案。结果 206例获得随访平均15.6(12~36)个月。150例骨折涉及后柱,其中130例涉及后外侧柱,97例涉及后内侧柱。206例无一例出现血管、神经损伤、内固定物松动及断裂,术后12个月复查骨折均获得骨性愈合。术后1年复位不良者3例。结论涉及后柱的胫骨平台骨折发病率高,应根据骨折类型,采用合适的切口、内固定方式等,以获得良好治疗效果。     

根据改良的Schatzker分型治疗复杂胫骨平台骨折

目的探讨改良的Schatzker分型对复杂胫骨平台骨折制定术前计划的指导作用,使术前计划更充分,减少术中误判。方法 2006年3月至2013年10月,对58例需要切开复位及内固定的常规SchatzkerⅤ型、Ⅵ型胫骨平台骨折,随机分成对照组及实验组,每组29例,对照组进行Schatzker分型,实验组进行改良的Schatzker分型,并分别确定手术入路、内固定物放置位置及数量,比较两种分型对手术进路、内固定物放置位置及数量的正确率,比较两种分型对指导治疗方案的满意度。结果根据改良的Schatzker分型,对SchatzkerⅤ型、Ⅵ型骨折患者进行手术入路选择,确定内固定物放置位置及数量,进行术前计划和术中观察,对关节面的复位及主要问题骨的显露和直接固定的正确率为100%,而根据常规Schatzker分型,对SchatzkerⅤ型、Ⅵ型胫骨平台骨折选择手术入路、内固定物放置位置及数量,正确率为86.36%,差异有统计学意义。结论根据改良的Schatzker分型,对需要切开复位及内固定的复杂胫骨平台骨折,选择手术入路及内固定物放置位置及数量更准确,使术前计划更充分,减少术中误判,术中证明对关节面及主要问题骨的复位更好,对主要问题骨的固定更直接,更准确。     

Schatzker Ⅳ 型胫骨平台骨折手术疗效分析

目的探讨根据骨折类型及形态特征制定不同手术方案治疗 Schatzker Ⅳ 型胫骨平台骨折的疗效。方法回顾分析 2012 年 3 月—2016 年 4 月收治的 18 例 Schatzker Ⅳ 型胫骨平台骨折切开复位内固定患者临床资料。男 6 例，女 12 例；年龄 36～74 岁，平均 45 岁。致伤原因：交通事故伤 2 例，摔伤 14 例，撞伤 1 例，重物压伤 1 例。均为新鲜闭合性骨折，无神经、血管损伤。根据 Wahlquist 胫骨平台 Ⅳ 型骨折亚分型：A 型 1 例，B 型 5 例，C 型 12 例。受伤至手术时间 6～16 d，平均 9.5 d。将胫骨内侧平台远端骨折线尖端所在部位确定为手术入路所在部位。根据 DeCoster 等分级标准评价胫骨平台骨折复位情况，采用肌肉骨骼功能评分表（SMFA）和美国特种外科医院（HSS）评分系统对膝关节功能进行评估。结果患者术后切口均 Ⅰ 期愈合，无手术相关早期并发症发生。不同入路均获得满意的术中显露；根据 DeCoster 等分级标准评价胫骨平台关节面复位达优 13 例、可 5 例。18 例患者均获随访，随访时间 12～30 个月，平均 18 个月。X 线片示骨折均于术后 10～16 周，平均 12 周达临床愈合；随访期间无钢板移位、螺钉松动等并发症发生。末次随访时 SMFA 评分为 15～48 分，平均 28.5 分。HSS 膝关节评分为 52～94 分，平均 81.1 分；其中优 10 例，良 5 例，可 2 例，差 l 例，优良率 83.3%；评分为差者主要表现为重度创伤性骨关节炎症状。结论根据骨折类型及形态特征制订不同手术方案治疗 Schatzker Ⅳ 型胫骨平台骨折，可取得较满意的临床效果。     

锁定钢板内固定术治疗复杂胫骨平台骨折的疗效及技巧探讨

目的探讨锁定钢板内固定治疗复杂胫骨平台骨折的效果及技巧分析。方法 98例复杂性胫骨平台骨折随机分为A组和B组,各49例,A组采用锁定钢板内固定治疗,B组采用双切口双钢板内固定术式,记录2组患者手术耗时、切口长度、术中出血量、骨折愈合时间及术后膝关节功能恢复的优良率。结果 98例患者术后随访平均(5.1±0.5)个月,A组患者骨折愈合时间显著短于B组(P<0.05),且A组下地负重锻炼的时间显著早于B组(P<0.05),A组患者膝关节功能恢复的优良率为87.8%(43/49),略高于B组的83.8%(41/49),但差异无统计学意义(P>0.05)。结论相比于双切口双钢板内固定术式,在治疗复杂胫骨平台骨折时锁定钢板内固定更利于骨折端的愈合,缩短骨折愈合时间,在实际操作中需把握好手术时机及螺钉的放置方法。     

Predictors of osteoarthritis following operative treatment of medial tibial plateau fractures

PurposeTo determine factors influencing the development of posttraumatic osteoarthritis (OA) following medial tibial plateau fractures and to evaluate concomitant injuries associated with these fractures.Materials and methodsA chart review of patients with operatively treated medial tibial plateau fractures admitted to our Level I trauma centre from 2002 to 2008 was performed. Of 63 patients, 41 participated in a clinical and radiographic examination. The mean age was 47 years (range 16–78) and the mean follow-up time was 7.6 (range 4.7–11.7) years. All patients had preoperative computed tomography (CT) scans and postoperative radiographs. At the end of follow-up, standing radiographs, mechanical axis, and CT scans were evaluated.ResultsOf the 41 patients, 24 had no or mild (Kellgren-Lawrence grade 0–2) OA and 17 had severe (grade 3–4) OA. Initial articular depression measured from preoperative CT scans was a significant predictor of OA (median 1.8 mm vs 4.5 mm, p = 0.009). Fracture line extension to the lateral plateau (p = 0.68) or fracture comminution (p = 0.21) had no effect on the development of posttraumatic OA, nor did articular depression at the end of follow-up (p = 0.68) measured from CT scans. Mechanical axis >4° of varus and ≥2 mm articular depression or step-off were associated with worse WOMAC pain scores, but did not affect other functional outcome scores. Six patients (10%) had permanent peroneal nerve dysfunction. Ten patients (16%) required LCL reconstruction and nine (14%) ACL avulsions were treated at the time of fracture stabilisation.ConclusionsThe amount of articular depression measured from preoperative CT scans seems to predict the development of posttraumatic OA, probably reflecting the severity of chondral injury at the time of fracture. Restoration of mechanical axis and articular congruence are important in achieving a good clinical outcome.     

Open reduction and internal fixation versus hybrid fixation for bicondylar/severe tibial plateau fractures: a systematic review of the literature

Introduction  Bicondylar/Schatzker 6 type tibial plateau fractures are a significant challenge to the trauma and orthopaedic surgeon. These injuries tend to be complex, high energy and are activated with significant morbidity. Two surgical methods are commonly in use: (1) hybrid external fixation or (2) internal fixation. We performed a systematic analysis of papers comparing these two techniques. Methods  The Medline database was used and the MeSH terms associated with bicondylar/severe tibial plateau fractures were inserted. Results  Forty-nine studies were retrieved but only five papers presented data to directly compare the two techniques as these studies actually compared the implants. Study designs and outcome measures were not consistent in all studies and therefore no direct comparison could be made between the papers. The first two studies were laboratory based and suggested that hybrid external fixation may have a benefit over internal fixation with respect to failure load and its use in compromised bone. Two further papers presented only type 4 evidence. The final paper was a multicentre randomised controlled trial and it demonstrated a marginal non-significant benefit of hybrid external fixation over internal fixation although there was suggestion of beta error [i.e. accepting the hypothesis when it is not true]. Conclusion  Bicondylar/Schatzker 6 type fractures are difficult to manage. The treatment of such fractures, need to pay specific attention to the soft tissue envelope around the knee. Hybrid external fixation has theoretical advantages in terms of the soft tissues but the benefit over internal fixation is modest at best and has not demonstrated improved outcome. Newer fixed angle screw and plate systems are increasingly in use and need comparative studies to determine their role in this complex group of fractures.     

Schatzker分型指导胫骨平台骨折治疗的应用体会

目的探讨在胫骨平台骨折的的众多分型方法中,Schatzker分型是否具有指导选择治疗方法的临床意义。方法以我院骨科2010年1月1日～2011年12月30日收治的78例胫骨平台骨折患者为研究对象,根据Schatzker分型,分别采用手术与非手术治疗,并回顾性分析患者的相关临床资料。结果全部患者得到随访,随访时间为6.3～24个月,以雍氏评级标准进行评定,总的优良率为94.9%。结论 Schatzker分型方法具有指导胫骨平台骨折患者选择治疗方法的临床实际意义,值得在临床上推广应用。