Biomechanical evaluation of different medial column fixation patterns for valgus pilon fractures.

BACKGROUND: The purpose of this study was to perform a biomechanical analysis to compare different medial column fixation patterns for valgus pilon fractures in a case-based model. METHODS: Based on the fracture mapping, 48 valgus pilon fracture models were produced and assigned into four groups with different medial column fixation patterns: no fixation (NF), K-wires (KW), intramedullary screws (IS), and locking compression plate (LCP). Each group contained wedge-in and wedge-out subgroups. After fixing each specimen on the machine, gradually increased axial compressive loads were applied with a load speed of one millimeter per minute. The maximum peak force was set at 1500 N. Load-displacement curves were generated and the axial stiffness was calculated. Five different loads of 200 N, 400 N, 600 N, 800 N, 1000 N were selected for analysis. The specimen failure was defined as resultant loading displacement over 3 mm. RESULTS: For the wedge-out models, Group-IS showed less displacement (p < 0.001), higher axial stiffness (p < 0.01), and higher load to failure (p < 0.001) than Group-NF. Group-KW showed comparable displacement under loads of 200 N, 400 N and 600 N with both Group-IS and Group-LCP. For the wedge-in models, no statistical differences in displacement, axial stiffness, or load to failure were observed among the four groups. Overall, wedge-out models exhibited less axial stiffness than wedge-in models (all p < 0.01). CONCLUSIONS: Functional reduction with stable fixation of the medial column is essential for the biomechanical stability of valgus pilon fractures and medial column fixation provides the enough biomechanical stability for this kind of fracture in the combination of anterolateral fixation. In detail, the K-wires can provide a provisional stability at an early stage. Intramedullary screws are strong enough to provide the medial column stability as a definitive fixation. In future, this technique can be recommended for medial column fixation as a complement for holistic stability in high-energy valgus pilon fractures.

Biomechanical study of a new rim plate fixation strategy for two kinds of posterolateral depression patterns of tibial plateau fractures: a finite element analysis.

PURPOSE: The biomechanical capacity of "Barrel Hoop Plate (BHP)" in the treatment of the posterolateral tibial plateau (PL) depression fractures remains unknown. In this study, two kinds of posterolateral tibial plateau depression models involving mild slope-type depression fracture (MSDF) and local sink hole-type depression fracture (LSDF) were created to test and compare the biomechanical capacities of BHP with the other two conventional fixations (Anterolateral Plate and Posterolateral Plate, ALP and PLP) by finite element analysis. METHODS: The 3D models of three kinds of plate-screw systems and the two kinds of PL-depression models (MSDF and LSDF) were created. An axial force of 400N was applied from the distal femur to the tibial plateau. The maximal displacements of the posterolateral fractures (PLFs), the distribution on the PLFs articular surface and key points displacements were measured. Stresses in the fixation complex including the maximal Equivalent (von-Mises) Stress of implants, the max shear stress of PLFs and stiffness of the fixation were calculated. RESULTS: The maximal displacement of MSDF was least in Group BHP. The maximal displacement of LSDF was least in Group ALP. In MSDF, BHP showed the best rim fix effect in MSDF, but unsatisfactory results in LSDF. In both MSDF and LSDF, the greatest max Equivalent Stress of the plate and the screw occurred in the PLP system. ALP and BHP showed a comparable stiffness in MSDF and ALP had the strongest stiffness in the fixation of LSDF. CONCLUSIONS: In MSDF, the BHP has the best biomechanical capacity, especially in displacements of key points such as the PL rim, fracture line, and depression center. In LSDF, the ALP system shows the best biomechanical effect. Although the PLP has the best fixation effect on the posterior wall, it is not suitable for PL-depression fracture fixation.

Clinical outcomes and affecting factors of ipsilateral femoral neck and shaft fractures - Multination, multicenter analysis.

BACKGROUND: This study aimed to evaluate the clinical outcomes of ipsilateral femoral neck and shaft fractures and identify the risk factors associated with missed diagnosis of femoral neck fractures and clinical outcomes of this fracture. METHODS: The ipsilateral femoral neck and shaft fractures from seven centers were retrospectively reviewed. Data on injury mechanism, fracture pattern, and fracture classification; surgical factors including fixation method; and timing of detection of femoral neck fracture were analyzed. The clinical outcomes, complications, and the incidence of avascular necrosis of the femoral head (AVNFH) were reviewed. Risk factors for missed femoral neck fracture and complications were analyzed. RESULTS: In total, 74 patients with an average age of 43.6 years were included. Of the femoral shaft fractures, 56.8% were type A, 21.6% were type B, and 21.6% were type C. Sixteen patients had an open fracture of the femoral shaft. Femoral neck fracture was initially missed in 27% patients and the timing of delayed diagnosis was at an average of 11.1 days after injury. For detecting femoral neck fractures, minimal displacement of the femoral neck fracture was a risk factor, whereas computed tomography (CT) was a protective factor. The incidence of AVNFH was 6.8% at an average of 36.8 months after injury. The AVNFH group had more displaced femoral neck fractures at the time of surgery, but there was no difference in the timing of diagnosis compared to non-AVNFH group. The femoral shaft showed considerable healing problems, with an average union time of 29.7 weeks and a 20.2% nonunion rate. CONCLUSION: Ipsilateral femoral neck and shaft fractures had a high rate of missed diagnosis, especially in minimally displaced fractures; however, CT was a protective factor. AVNFH occurred in 6.8% and was related to femoral neck fracture displacement, but not delayed diagnosis. The femur nonunion rate was high, which warrants attention.

Novel Rim Plating Technique for Treatment of the Inferior Pole Fracture of the Patella.

To aim of the present paper was to introduce a novel fixation technique for the treatment of inferior pole fracture of the patella. We performed a prospective observational study of consecutive cases of inferior pole fracture of the patella that were treated at our institution between January 2018 and June 2019. The patients include three men and one woman, with an average age of 47 years (range: 42-59 years). All patients were treated with the novel rim plating fixation technique for preserving the inferior pole of the patella. During the surgery, a 2.4 mm straight locking compression plate was contoured to adapt to the arc of the lower half of the patella as the rim plate. After reduction of the fracture, the rim plate was fixed to the proximal fragment of the patella through multiple locking screws, against the continuous pull of the patellar tendon. The rim plate encircles and constricts the inferior pole fragments, functioning as a compression and blocking construct. If necessary, an additional anterior tension band or mini locking plate can be used to further prevent anterior displacement of the inferior pole fragments. Under this rigid fixation, motion of the knee and full weight-bearing were encouraged postoperatively. The patients were followed up monthly until 12 months after surgery. The time to achieve 90°pain-free, full range of motion of the knee, and fracture healing, were recorded. Related complications were monitored, including infection, loss of reduction, fixation failure, anterior knee pain, and soft-tissue irritation. The modified Cincinnati knee rating system was used for knee function assessment. The average operative time was 58.8 min (range: 52-63 min). The average blood loss was 59.8 mL (range: 45-71 mL). For all patients, pain-free 90° range of motion was restored in 2-4 weeks, and the full range of motion was restored in 8-11 weeks. All patients achieved bone union in 6-9 weeks with no displacement of the fragments or breakage of the implant. No patient complained of anterior knee pain or soft-tissue irritation. The modified Cincinnati score at 12-month follow up demonstrated excellent outcomes in all four patients. The rim plating technique may be a feasible option for the treatment of the inferior pole fracture of the patella.

Patient expectations predict outcomes following distal radius fracture: a prospective cohort study using the TEFTOM questionnaire.

INTRODUCTION: The relationship between patient expectations and clinical outcomes has recently been of increasing interest in the field of orthopaedics. The objective of this study was to evaluate the relationships between (1) patient pre-treatment expectations and post-treatment clinical outcomes, and (2) fulfillment of expectations and patient satisfaction, following distal radius fracture. METHODS: This was a prospective multicenter cohort study conducted across three hospitals. A total of 133 patients admitted to hospital between 2016 and 2018 with a distal radius fracture were recruited. Patients were administered the Trauma Expectation Factor (TEF) at baseline to measure expectations of pain and functioning at one-year post-injury. Patients were followed up at 6 and 12 months post-injury and outcomes were measured using the Trauma Outcome Measure (TOM), Shortened Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire, and Short-Form 12-item (SF-12) health survey. Fulfillment of expectations was measured as TEF score minus TOM score at each time point. Patient satisfaction was also measured using the Patient Satisfaction Questionnaire Short Form (PSQ-18). Multivariate regression models were created to evaluate the effect of expectations on outcomes. RESULTS: Patient expectations correlated moderately with outcomes at 6 and 12 months post-injury. In the multivariate analysis, patient expectations were predictive of better outcomes at 6 and 12 months. Injury severity, age, mechanism of injury, and whether the injury occurred on duty also contributed significantly to one or more regression models. Patient satisfaction correlated weakly with fulfillment of expectations at 6 months, but moderately with all outcome scores. At 12 months, satisfaction did not correlate significantly with expectations fulfillment but correlated moderately to highly with all outcome scores. CONCLUSION: Patient expectations independently predicted outcomes at 6 and 12 months post-injury. Standardized assessment and management of patient expectations may be relevant to future clinical practice and research to best quantify and optimize patient outcomes.

Biomechanical analysis of "Barrel hoop plate" technique for the posterolateral fragments of tibial plateau fractures with different displacement tendency.

OBJECTIVES: The purpose of our study is to evaluate the three-dimensional biomechanical properties of "Barrel Hoop plate" in two kinds of artificial posterolateral tibial plateau fracture fragment (PLF) by using of synthetic models, each of which has an initial amplifying displacement tendency. MATERIAL AND METHODS: Thirty-six tibiae models were randomly assigned into two groups with different displacement tendencies: posterior displacement (PD) and lateral displacement (LD). Each model was then fixed with three patterns: Anterolateral plate (AP), Posterolateral plate (PP), and "Barrel Hoop plate" (BHP). Displacement in three axes of vertical, sagittal and horizontal axis was captured by Optotrak Certus motion analysis system. Bluehill 2 software was used for load control and data collection. RESULTS: In Model-PD, when the load was over 1000 N, the posterior displacement of Group-PP and Group-BHP were less than Group-AP (P<0.01). The inferior displacement in the vertical axis of Group-PP was larger than both Group-AP and Group-BHP in all the loading set (P<0.01). In Model-LD, both of the lateral displacement in Group-AP and Group-BHP was less than that of Group-PP when the load was over 1000 N (P<0.01). The inferior displacement of Group-AP was less than that of Group-PP in the load of 1500 N (P<0.01). Both of the posterior displacement of Group-AP and Group-BHP was less than that of Group-PP when the loading was 1500 N (P<0.01). The stiffness of Group PP was less than that of Group AP (P<0.01). CONCLUSIONS: The results demonstrated that the 2.7 mm "Barrel Hoop plate" had a greater capacity of anti-three-dimension axes displacement of PLF. The 3.5 mm Anterolateral plate had the advantage in anti-lateral displacement and anti-inferior displacement but was weak at anti-posterior displacement of PLF. The 2.7 mm Posterolateral plate was stronger in anti-posterior, however, weak in anti-inferior displacement capacity.

Evaluation of an expectation and outcome measurement questionnaire in ankle fracture patients: The Trauma Expectation Factor Trauma Outcomes Measure (TEFTOM) Eurasia study.

BACKGROUND: The Trauma Expectation Factor Trauma Outcomes Measure (TEFTOM) questionnaire is a self-administered, patient-rated outcome measurement questionnaire designed to measure both 'expectation' and 'outcome' in orthopaedic trauma patients using two subsets of 10 items. We aimed to validate this instrument in a culturally diverse cohort of patients recruited from Asian and European regions. METHODS: A total of 193 adult patients with surgically treated AO Foundation/Orthopaedic Trauma Association types 43 and 44 ankle malleolar and distal tibia fractures were recruited with 158 followed up till 1 year. Expectations were assessed prior to surgery, at 2 weeks and after 6 months using the trauma expectation factor (TEF) score. Outcomes were evaluated at 2 weeks, 6 and 12 months using the trauma outcome measure (TOM), American Academy of Orthopaedic Surgeons (AAOS), foot and ankle outcome score (FAOS) and short form-36 (SF-36) questionnaires. Psychometric properties of TEFTOM were assessed. RESULTS: TEF and TOM demonstrated good internal consistency (Cronbach's α > 0.87) and reliability at all time points (intra-class correlation coefficients > 0.90). TOM showed strong correlations (R2 ≥ 0.60) with the AAOS foot and ankle score, all FAOS subscales, except 'symptoms' and SF-36 physical functioning, role physical, bodily pain, social functioning and the physical component summary at 6 and 12 months. Effect sizes for TOM were 2.30 and 0.74 from 2 weeks to 6 months and from 6 months to 12 months, respectively. The baseline patient TEF was predictive for the 1-year TOM score. CONCLUSIONS: TEFTOM demonstrated good psychometric properties in this cohort of patients with ankle fractures. The TEF 'expectation' score was predictive of the TOM 'outcome' score. We recommend researchers and clinicians to utilize TEFTOM when patient expectation measurement is concerned for orthopaedic trauma patients.

Medial Open-wedge Osteotomy with Double-plate Fixation for Varus Malunion of the Distal Femur.

OBJECTIVE: To present our clinical experience of treating varus malunion of the distal femur through a medial open-wedge osteotomy with double-plate fixation. METHODS: A prospective cohort study was performed. From January 2005 to February 2015, 15 consecutive patients with varus malunion following distal femur fractures were surgically treated at a single level I trauma center. The coronal and sagittal deformity were corrected by a medial open-wedge osteotomy of the distal femur. A medial buttress plate was used to maintain the realignment. A lateral locking plate was additionally used as a protection plate. The mean age of patients at the time of the surgery was 35.5 years (range, 22-58 years). The radiographical evaluation included the mechanical femorotibial angle, the mechanical lateral distal femoral angle, the anatomic posterior distal femoral angle, and the leg length discrepancy. Clinical outcome evaluation consisted of the range of motion (ROM) and Hospital for Special Surgery (HSS) score. RESULTS: Mean follow-up was 7.4 years (range, 4-11.5 years). Varus and flexion malalignment and limb discrepancy were adequately corrected in all patients. The mechanical femorotibial angle, the mechanical lateral distal femoral angle, and the anatomic posterior distal femoral angle were restored from 17.5° (range, 13°-25°) to 2.3° (range, - 2°-7°), 102.3° (range, 95°-112°) to 85.2° (range, 81°-92°), and 77.1° (range, 65°-87°) to 82.7° (range, 76°-88°), respectively. The leg length discrepancy was diminished from 3.4 cm (range, 2.4-4.5 cm) to 0.8 cm (range, 0-1.7 cm). The average bone healing time was 4.1 months (range, 2.5-6 months). The average ROM of the affected knees at 24-month follow-up was 3.4°-112.55°. The score of HSS at 4-years follow-up was 76.1 (range, 64-88). No internal fixation failure or secondary operation was noted until the last follow-up. CONCLUSION: Medial open-wedge osteotomy can adequately correct the posttraumatic varus malunion of the distal femur. With fixation of the double plate, non-displaced bone healing and good functional outcome are expected.

Interlocking Intramedullary Nailing Versus Locked Dual-Plating Fixation for Femoral Shaft Fractures in Patients with Multiple Injuries: A Retrospective Comparative Study.

PURPOSE: Intramedullary nailing (IMN) is a popular method in the management of femoral shaft fractures (FSFs). However, whether the association of IMN with pulmonary fat emboli can compromise the pulmonary and nervous systems is debatable. The purpose of this study is to compare IMN with the locked dual plating (LDP) method by assessing the clinical outcomes of FSF patients with head or chest injury. METHOD: A total of 126 FSF patients were included in this study between January 2010 and July 2016 and divided into LDP and IMN groups. Patient demographic characteristics, operative time, blood loss, Harris Hip Score, Lysholm Knee Score, radiological outcomes, and systemic complications were collected and compared between the two treatment groups. Patients were followed up for at least 12 months. RESULTS: The LDP group performed better than IMN in terms of operative time, estimated blood loss amount, and malunion rate. Differences in function scores, fracture union rate, overall pulmonary complication rate, and in-hospital mortality between the two groups were not significant. Average radiographic union time was significantly longer in the LDP group (36.3 weeks) than in the IMN group (32.5 weeks). One case of fixation failure occurred postoperatively in the LDP group, whereas one case of fracture nonunion took place in the IMN group. CONCLUSION: Our findings suggest that dual-plating fixation is a promising method for FSFs with multiple injuries. However, the retrospective nature of this study necessitates high-quality trials to be performed to assess the clinical efficiency of dual plating.

Tibial plateau fractures in elderly people: an institutional retrospective study.

BACKGROUND: Tibial plateau fractures are the most common intra-articular fractures, which require careful evaluation and preoperative planning. The treatment of tibial plateau fractures in elderly patients is challenging, and the comprehension of epidemiology and morphology can be helpful. This study described the characteristics of geriatric tibial plateau fractures. METHODS: A total of 327 (23.24%) patients aged ≥60 years were reviewed in our level one trauma center over a 4-year period (from January 2013 to November 2016). The following parameters were collected and evaluated: (1) demographic data, (2) injury mechanisms and (3) fracture classifications. RESULTS: Females accounted for 60.86% in all included elderly patients. Electric-bike accidents were the cause of 32.42% of all these injuries, and 39.62% of these led to high-energy injuries. The most common type of fracture was Schatzker II (54.74%). According to the three-column classification, single lateral column fracture (28.75%) and four-quadrant fracture (involving lateral, medial, posterolateral and posteromedial fractures) (23.24%) were the two most frequent patterns. In all cases, 67.58% involved the posterior column, and the prevalence of posterolateral and posteromedial fractures were 62.69% and 37.92% respectively. Isolated posterior column fractures accounted for 12.54% of patients in total, which mostly consisted of posterolateral fracture in older females (85.37%). CONCLUSIONS: The majority of elderly patients with tibial plateau fractures are females, and Electric-bike accidents are an important cause of injury. Geriatric tibial plateau fractures have unique distribution in classification.

Plate fixation for Letenneur type I Hoffa fracture: a biomechanical study.

BACKGROUND: A coronal fracture of the posterior femoral condyle, also known as a Hoffa fracture, is an unusual injury, and there are only a handful of case reports or series exploring it. The optimal fixation method of these intraarticular fractures remains controversial; improper or unstable fixation usually lead to an unsatisfactory prognosis. The use of posterior-anterior or reversed lag screw fixation is still a popular method. Additional buttress plating is also recommended for fixation of these difficult fractures. The purpose of this study was to compare the mechanical strength of four different fixation patterns for this uncommon fracture. MATERIAL AND METHODS: Sixteen sawbone simulated models of Letenneur type I Hoffa fractures were created with one of four fixation patterns: two screws implanted in the anterior-posterior (AP) direction or posterior-anterior (PA) direction; one screw in the PA direction with a plate implanted in the posterior position of the distal femoral condyle or with a plate in the lateral position. Biomechanical testing was performed to determine the post-fixation axial stiffness, the maximum load to failure and the fragment vertical displacement for each of the four constructs. RESULTS: The plate fixation patterns whether implanted in the posterior or lateral position were shown to provide higher overall axial stiffness and load to failure, and less vertical displacement than the other two patterns of pure screw fixation. Among these constructs, the lateral plate fixation was found to provide the highest stiffness and load to failure and the least displacement for the posterior condylar fragments, followed by the posterior plate fixation. The lowest overall stiffness and load to failure and the largest vertical displacement were found in the construct with the AP direction placed screws. CONCLUSION: It was concluded that the lateral position implanted plate is biomechanically the strongest fixation method for Letenneur type I Hoffa fractures. However, this plate fixation is not recommended for all cases. The choice of internal fixation pattern depends on the surgeons.

Modified posteromedial approach for treatment of posterior pilon variant fracture.

BACKGROUND: Posterior pilon variant fracture is a recently described posterior malleolus fracture characterized by the involvement of both posterolateral and posteromedial malleolar fragment. The associated surgical approach remains controversial. The aim of this study was to present the application of modified posteromedial approach in the treatment for posterior pilon variant fracture. METHODS: Sixteen patients were identified with posterior pilon variant fractures. All fractures were operated via modified posteromedial approach. Fragment length ratio, area ratio and height were measured as morphologic assessments. The clinical outcome was evaluated with American Orthopaedic Foot & Ankle Society ankle-hind foot score and visual analogue scale. Radiological images were evaluated using osteoarthritis-score. RESULTS: According to the radiological measurements, the average fragment length ratio of posteromedial and posterolateral fragment was 25.3 and 31.5 % respectively. All fractures healed within a mean period of 13.1 weeks without malalignment or articular step-off. Fourteen patients were followed up, and all achieved good or excellent ankle function. The average score of American Orthopaedic Foot & Ankle Society and visual analogue scale at rest, motion and weight bearing walking was 85.6 and 0.25, 0.81, 1.31 respectively. CONCLUSION: Modified posteromedial approach provides an alternative surgical treatment for posterior pilon variant fractures, and the short-term outcome was good.

Extra-articular distal tibia facture (AO-43A): A retrospective study comparing modified MIPPO with IMN.

PURPOSE: We introduce a new MIPPO procedure which is simple and effective for the treatment of extra-articular distal tibia facture (AO-43A). The aim of this retrospective study was to compare our modified MIPPO with IMN. MATERIALS AND METHODS: This retrospective study included 64 patients treated with our modified MIPPO and 61 patients with IMN. The data of sex, age, operation time, blood loss, wound complications, mal-reduction, shortening and fracture healing was analyzed. RESULTS: The operation time was significantly shorter in the MIPPO group than in the IMN group (56.0min vs. 85.0min, P<0.001). There were 5 patients (8.2%) in the IMN group and 2 patients (3.1%) in the MIPPO group who had wound complications (P=0.399). Mal-reduction occurred in 17 patients (27.9%) managed with IMN and in 3 patients (4.7%) who had MIPPO (P<0.001). Furthermore, no patients had a left/right difference in the length of the tibia of >1cm and nonunion in both groups. CONCLUSIONS: Our results have shown that our modified MIPPO has enormous advantages over IMN for extra-articular distal tibia fracture (AO-43A).

Minimally invasive surgery under fluoro-navigation for anterior pelvic ring fractures.

BACKGROUND: The incidence of pelvic fractures in trauma patients is reported to be 3-8.2%, with roughly half of these fractures being caused by high energy injuries with a potential for catastrophic hemorrhage and death. Indications for internal fixation of anterior pelvic ring are controversial. Because of fears of disturbing the pelvic hematoma and causing additional hemorrhage, open reduction and internal fixation of pelvic ring disruption is routinely delayed. In contrast to conventional surgery, percutaneous screw fixation is gaining popularity in the treatment of pelvic and acetabular fractures mainly because of minimal soft tissue damage, less operative blood loss, early surgical intervention and comfortable mobilization of the patient. Fluoro-navigation is a new surgical technique in orthopedic trauma surgery. This study is to investigate clinical results of fluoro-navigation surgery in anterior pelvic ring fractures. MATERIALS AND METHODS: From January 2006 to October 2011, 23 patients with anterior pelvic ring fractures were treated with percutaneous cannulated screw under fluoro-navigation. There were 14 men and 9 women, with a mean age of 40.1 years (range 25-55). According to the AO and Orthopedic Trauma Association classification, there were seven A 2.1, two A 2.2, one A 2.3, six B 1.2, one B 2.1: 1, one B 2.2, one C 1.2, two C 1.3 and two C 2.3 types of fractures. Amongst these patients, 13 had posterior pelvic ring injuries, 8 had other injuries including urethral, lumbar vertebrae fractures and femoral fractures. All patients were operated when their general condition stabilized after emergency management. The mean time from injury to percutaneous screw fixation of the anterior pelvic ring fracture was 12 days (3-15 days). All the anterior ring fractures were fixed with cannulated screws by two senior surgeons. They were familiar with the navigation system and had gained much experience in the computer-assisted percutaneous placement of screws. RESULTS: A total of 32 screws were inserted, including 19 in the pubic ramis and 13 in the anterior acetabular columns. The average surgical time was 23.3 min/screw. The average time of X-ray exposure was 19.1 ± 2.5 s/screw. The virtual images of fluoro-navigation were compared with real-time X-rays during and after the surgery. Compared to the final position of the screw, the average deviated distance was 3.11 mm and the average trajectory difference was 2.81°. Blood loss during the operation was minimal (22.3 ml/screw). One screw (3.1%) deviated out of the fracture site during the operation. No superficial or deep infection occurred. No patient sustained recognized neurologic, vascular, or urologic injury as a result of the percutaneous screw fixation. All fractures united at the last followup. CONCLUSIONS: Fluoro-navigation technique could become a safe, accurate, and fairly quick method for the treatment of anterior pelvic ring fractures. Standardization of the operative procedure and training are mandatory for the success of this procedure.

Results of a modified posterolateral approach for the isolated posterolateral tibial plateau fracture.

BACKGROUND: There are few posterolateral approaches that do not require the common peroneal nerve (CPN) dissection. With the nerve exposure, it would pose a great challenge and sometimes iatrogenic damage over the surgical course. The purpose was to present a case series of patients with posterolateral tibial plateau fractures treated by direct exposure and plate fixation through a modified posterolateral approach without exposing the common peroneal nerve (CPN). MATERIALS AND METHODS: 9 consecutive cases of isolated posterior fractures of the posterolateral tibial plateau were operated by open reduction and plate fixation through the modified posterolateral approach without exposing the CPN between June 2009 and January 2012. Articular reduction quality was assessment according to the immediate postoperative radiographs. At 24 month followup, all patients had radiographs and were asked to complete a validated outcome measure and the modified Hospital for Special Surgery (HSS) Knee Scale. RESULTS: All patients were followedup, with a mean period of 29 months (range 25-40 months). Bony union was achieved in all patients. In six cases, the reduction was graded as best and in three cases the reduction was graded as middle according to the immediate postoperative radiographs by the rank order system. The average range of motion arc was 127° (range 110°-134°) and the mean postoperative HSS was 93 (range 85-97) at 24 months followup. None of the patients sustained neurovascular complication. CONCLUSIONS: The modified posterolateral approach through a long skin incision without exposing the CPN could help to expand the surgical options for an optimal treatment of this kind of fracture, and plating of posterolateral tibial plateau fractures would result in restoration and maintenance of alignment. This approach demands precise knowledge of the anatomic structures of this region.

SMAD7 prevents heterotopic ossification in a rat Achilles tendon injury model via regulation of endothelial-mesenchymal transition.

The endothelial-mesenchymal transition (EndMT) is known to play a central role in the pathological process of heterotopic ossification (HO). Based on the ability of SMAD7 (mothers against decapentaplegic homolog 7) to block EndMT-related processes such as myofibroblast transformation, we hypothesized that SMAD7 may be a potential therapeutic target for HO. We constructed a lentivirus overexpressing SMAD7 and tested on rat aortic endothelial cells for optimal titre and transduction efficiency. The lentivirus was then injected into a surgical rat model of Achilles tendon injury. Expression of endothelial markers and mesenchymal markers at the injury sites was subsequently quantified by qPCR and western analysis. Lentiviral delivery of SMAD7 in vivo resulted in an upregulation of endothelial markers (CD31, VE-cadherin) and a downregulation of mesenchymal markers (N-cadherin and vimentin), suggesting that EndMT is blocked due to local SMAD7 overexpression. The difference is more apparent at 10 weeks than at 6 weeks after surgery. X-ray imaging and histological staining further confirmed the absence of ossified structure in the tendon tissue injected with SMAD7-delivering lentivirus, as opposed to the control groups. Post-surgical HO may be prevented in vivo by local delivery of SMAD7 without affecting the normal wound-healing process. These data advance our understanding of the HO process at the molecular level, and provide additional avenues for the prevention and treatment of postoperative HO.

Extended anterolateral approach for treatment of posterolateral tibial plateau fractures improves operative procedure and patient prognosis.

PURPOSE: The treatment of posterolateral tibial plateau fracture remains controversial and challenging. Several approaches for this fracture have been applied for direct exposure and support plate fixation. However, several structures are to be at risk via posterior approach, which may affect exposure and plate application. To solve this problem, an extended anterolateral approach was developed and reported. METHODS: 15 patients with posterolateral tibial plateau fractures treated with this approach were reviewed. The primary outcomes, such as Rasmussen functional score, and the secondary outcomes, such as knee deformity, postoperative infection, as well as complications were evaluated. RESULTS: All 15 cases have been followed up for 12 to 30 months (19.7 months at average). Rasmussen functional score after surgeries was 25.0 ± 2.8 points. A score ≥ 27 points was considered as excellent (ten patients), a score of 20-26 points (four patients) was considered as good; and a score of 10-19 points (one patient) was considered as fair. Anatomic reductions were obtained in 14 patients, but a 3 mm gap was found in one patient. For all patients, there were no wound complications, nonunion, valgus knee deformities, plate loosening or breakages, or fracture re-displacements. No vascular or neural injuries occurred in any patient. CONCLUSION: The extended anterolateral approach provides excellent visualization, which can facilitate the internal fixation and reduction of posterolateral tibial plateau fractures, and shows encouraging results.

Combined approaches for fixation of Schatzker type II tibial plateau fractures involving the posterolateral column: a prospective observational cohort study.

INTRODUCTION: This study aimed to investigate the surgical techniques and the clinical efficacy of combined approaches for the treatment of Schatzker type II tibial plateau fractures involving the posterolateral column [lateral and posterolateral columns (LPCs) fractures] in a prospective cohort. MATERIALS AND METHODS: From January 2007 through December 2010, a total of 65 patients with LPCs underwent dual-plate fixation via a combined anterior and posterior approach. The anterior and posterior approaches were the conventional anterolateral approach and a posteromedial inverted L-shaped approach, respectively, with the patients in a floating position. RESULTS: Ultimately, 41 patients were followed up for a mean period of 52.5 months. All fractures healed. The mean time to radiographic bony union was 15.2 weeks and the mean time to full weight-bearing was 18.7 weeks. No parameter associated with knee alignment changed significantly between immediately postoperation and 2 years postoperation. No collapse of the reduced articular surface was detected. Two years postoperation, the mean Hospital for Special Surgery score was 92.3; the mean Short Form-36 score was 90.1, and the mean range of knee motion was 1.7°-123.6° (extension-flexion). Two patients suffered dehiscence of the anterolateral incision and another suffered partial necrosis at the margin of the posteromedial incision postoperatively. All healed in response conservative treatment. Another two patients experienced numbness in the posteromedial inferior region of the calf. No implant loosening, breakage, fixation failure, or other complication was observed during follow-up. CONCLUSIONS: LPCs are not uncommon. Careful preoperative analysis of computed tomography images and impeccable preparation are necessary to avoid neglecting a posterolateral column fracture. It is inappropriate to generalize one scenario for all Schatzker type II fractures: a single approach cannot address all subtypes of these fractures. Dual-plate fixation via a combined approach is an effective treatment for LPCs.

Percutaneous drainage of Morel-Lavallée lesions when the diagnosis is delayed.

SUMMARY: Morel-Lavallée lesions are a closed internal degloving, and open débridement can damage the only remaining blood supply to the skin. We performed percutaneous draining and débridement to treat 8 patients in whom the diagnosis of Morel-Lavallée lesions was delayed more than 1 week. Here we discuss our treatment procedures and the outcomes in these 8 patients. We consider percutaneous drainage to be an effective treatment for patients with delayed diagnosis of Morel-Lavallée lesions.

Pathoanatomy and incidence of the posterolateral fractures in bicondylar tibial plateau fractures: a clinical computed tomography-based measurement and the associated biomechanical model simulation.

OBJECTIVES: The aim of our study is to evaluate the incidence and pathoanatomy of posterolateral fragments and analyze the associated fracture mechanism in bicondylar tibial plateau fractures. METHODS: From 1.1.2008 to 3.15.2012, all patients suffering bicondylar tibial plateau fractures were identified, scanned and analyzed at the Shanghai Clinical Trauma Center. Furthermore cadaver knees were selected into three groups of 30/60/90 knee flexion to simulate the posterolateral tibial plateau fracture by an impact device. RESULTS: One hundred and sixty-four (44.32 %) bicondylar tibial plateau fractures finally satisfied our requirements. Fifty-three and ninety-four cases were measured eventually in the groups of posterolateral split and depression. The posterolateral articular fragment proportion was 15.43 %. The posterolateral articular fragment angle showed an average of 12.94°. The posterolateral fragment cortical height was on average 2.96 cm. The posterolateral sagittal fragment angle averaged at 72.06°. Ninety-four cases were measured in the posterolateral depression group. The average posterolateral articular depression proportion was 16.74 %. The average posterolateral articular depression height was 2.47 cm. In the biomechanical modeling of such kinds of fracture patterns, posterolateral split fractures in 30° and 60° flexion are significantly more than those in 90° flexion. Posterolateral splits combined with anterolateral depression fractures in 30° flexion are significantly more than those in 90° flexion. CONCLUSION: The incidence of posterolateral fractures is 44.32 % in bicondylar tibial plateau fractures. The morphology of posterolateral area can be referenced for the surgeon in the future clinical work. The information is also helpful for the design of locking plate and fracture modeling in biomechanical test. In addition, that posterolateral split and posterolateral depression might be caused by different injury mechanisms. Different angles of knee flexion under the axial impact loading are possibly the interpretations for these two fracture patterns.