Patient-Reported Outcomes following Tibial Plateau Fractures: Mid- to Short-Term Implications for Knee Function and Activity Level.

Background: Patients with complex proximal tibial plateau fractures (TPFs) tend to overestimate the prognosis of their injury, potentially due to factors such as a limited understanding, optimism, and the influence of the pain intensity. Understanding the reasons behind this misperception is crucial for healthcare providers to effectively communicate with patients and establish realistic expectations for treatment outcomes. The purpose of this study was to analyze the outcomes of TPFs, with a particular focus on patient-reported outcome measures concerning functional recovery, pain levels, and overall satisfaction with treatment. The authors aim to provide valuable insights into the realistic expectations and potential limitations that patients may encounter during their recovery journey. Methods: In this retrospective single-center study, all surgically treated TPFs between January 2014 and December 2019 with a minimum follow-up of 12 months were included. Several patient-reported outcome measures were obtained, including the International Knee documentation Committee Score (IKDC), Lyholm score, Tegner score, and visual analog scale (VAS) for pain. Fractures were classified according to Schatzker, and then subgrouped into simple (Schatzker I-III) and complex (Schatzker IV-VI) fractures. Results: A total of 54 patients (mean age 51.1 ± 11.9 years, 59.3% female) with a mean follow-up time of 3.9 years were included. Schatzker II fractures were present in 48% (n = 26) of the cases, with Schatzker III in 6% (n = 3), Schatzker IV fractures in 6% (n = 3), and Schatker VI fractures in 41% (n = 22) of the cases. All outcome scores showed a significant improvement between the first year after surgery and the last follow-up (mean: 3.9 years). Simple fractures showed significantly lower patient-reported outcomes when compared to the preinjury state; however, good to excellent results were observed. Patient-reported outcomes of complex fractures showed no significant changes in the study period with good to excellent results. When it comes to the Lysholm score, there were no significant differences in the outcome between simple and complex fractures. Furthermore, there was a return-to-sports rate of 100%, with high rates of changing sporting activity in 25% (simple fractures) and 45% in complex fractures. Conclusions: The data from this study showed that both simple and complex tibial plateau fractures show favorable outcomes at the midterm follow-up, and that injury severity does not correlate with worse results. While patients may tend to overestimate the recovery speed, this research highlights the importance of long-term follow-up, demonstrating a substantial improvement between one year post-surgery and the final evaluation. Return-to-sports rates were high, with adjustments needed for certain activities. However, patients should recognize the need to shift to lower-impact sports and the lengthy recovery process.

Mismatch between Clinical-Functional and Radiological Outcome in Tibial Plateau Fractures: A Retrospective Study.

BACKGROUND: The evaluation of tibial plateau fractures (TPF) encompasses the assessment of clinical-functional and radiological parameters. In this study, the authors aimed to investigate the potential correlation between these parameters by utilizing both the clinical-functional and the modified radiological Rasmussen score. METHODS: In this retrospective monocentric study conducted at a level-I trauma center, patients who underwent surgery between January 2014 and December 2019 due to a TPF were included. The clinical-functional Rasmussen score prior to the injury, at 1-year postoperatively, and during the last follow-up (minimum 18 months) was assessed using a standardized questionnaire. Additionally, the modified radiological Rasmussen score was determined at the 1-year postoperative mark using conventional radiographs in two planes. RESULTS: A total of 50 patients were included in this study, comprising 40% (n = 20) men, and 60% (n = 30) women, with an average age of 47 ± 11.8 years (range 26-73 years old). Among them, 52% (n = 26) had simple fractures (classified according to Schatzker I-III), while 48% (n = 24; according to Schatzker IV-VI) had complex fractures. The mean follow-up was 3.9 ± 1.6 years (range 1.6-7.5 years). The functional Rasmussen score assessed before the injury and at follow-up showed an "excellent" average result. However, there was a significant difference in the values of complex fractures compared to before the injury. One year postoperatively, both the clinical-functional score and the modified radiological score demonstrated a "good" average result. The "excellent" category was more frequently observed in the functional score, while the "fair" category was more common in the radiological score. There was no agreement between the categories in both scores in 66% of the cases. CONCLUSIONS: The data from this retrospective study demonstrated that patients with TPF are able to achieve a nearly equivalent functional level in the medium-term after a prolonged recovery period, comparable to their pre-injury state. However, it is important to note that the correlation between clinical-functional and radiological parameters is limited. Consequently, in order to create prospective outcome scores, it becomes crucial to objectively assess the multifaceted nature of TPF injuries in more detail, both clinically and radiologically.

Preoperative Mixed-Reality Visualization of Complex Tibial Plateau Fractures and Its Benefit Compared to CT and 3D Printing.

BACKGROUND: Various studies have shown the benefit of three-dimensional (3D) computed tomography (CT) reconstruction and especially 3D printing in the treatment of tibial plateau fractures (TPFs). This study aimed to investigate whether mixed-reality visualization (MRV) using mixed-reality glasses can provide a benefit for CT and/or 3D printing in planning treatment strategies for complex TPFs. METHODS: Three complex TPFs were selected for the study and processed for 3D imaging. Subsequently, the fractures were presented to specialists in trauma surgery using CT (including 3D CT reconstruction), MRV (hardware: Microsoft HoloLens 2; software: mediCAD MIXED REALITY) and 3D prints. A standardized questionnaire on fracture morphology and treatment strategy was completed after each imaging session. RESULTS: 23 surgeons from 7 hospitals were interviewed. A total of 69.6% (n = 16) of those had treated at least 50 TPFs. A change in fracture classification according to Schatzker was recorded in 7.1% of the cases and in 78.6% an adjustment of the ten-segment classification was observed after MRV. In addition, the intended patient positioning changed in 16.1% of the cases, the surgical approach in 33.9% and osteosynthesis in 39.3%. A total of 82.1% of the participants rated MRV as beneficial compared to CT regarding fracture morphology and treatment planning. An additional benefit of 3D printing was reported in 57.1% of the cases (five-point Likert scale). CONCLUSIONS: Preoperative MRV of complex TPFs leads to improved fracture understanding, better treatment strategies and a higher detection rate of fractures in posterior segments, and it thus has the potential to improve patient care and outcomes.

Recovery of gait and function during the first six months after tibial shaft fractures.

BACKGROUND: Tibial shaft fractures require surgical stabilization preferably by intramedullary nailing. Recovery is often unsatisfactory due to limited knee function and pain, resulting in reduced quality of life. The extent of these functional limitations with respect to gait deficits has not been sufficiently recognized. RESEARCH QUESTION: Are there functional limitations during gait and squat performance during the first six months after surgically treated tibial shaft fractures? METHODS: Twenty-three patients (BMI: 24 ± 3, Age:39 ± 15) with tibial shaft fractures and 23 healthy, matched controls (BMI: 24 ± 3, Age: 40 ± 14) were assessed using instrumented motion analysis two, three and six months after surgery. Kinematic and kinetic data of the lower extremities were collected during level walking and squat performance. Data were compared among follow-up time intervals and between groups. RESULTS: Significant improvements were found for all spatiotemporal parameters and most kinetic parameters. Even six months after surgery functional deficits persisted when compared to healthy controls. There were only slight improvements in sagittal knee and ankle kinematics as well as knee moments and power within the follow-up period. A significant difference compared to the healthy controls can still be observed in these parameters. SIGNIFICANCE: Although patients with tibia fractures demonstrated functional improvements over the early course of healing, some residual deficits in lower extremity movement biomechanics were identified at six months post surgery. In particular knee kinematics in squatting as well as knee kinematics and kinetics during walking only recovered incompletely. This result can help explain the often-reported functional limitations. CLINICAL TRIAL REGISTRATION NUMBER: German register for clinical trials (DRKS00023790).

Biomechanical Comparison of 2 Double Plating Methods in a Coronal Fracture Model of Bicondylar Tibial Plateau Fractures.

OBJECTIVES: Because management of bicondylar tibial plateau fractures are complicated even for expert surgeons, with using a coronal fracture model, we aimed to compare 2 kinds of double locked plating techniques that consisted of the lateral locking plate and the medial locking plate inserted medial anteriorly (MA-ly) or medial posteriorly (MP-ly). METHODS: Fourteen fresh-frozen tibias stabilized with the MA or MP methods were allocated into 2 groups with similar bone mineral density values. Implanted samples were tested under incremental fatigue loading conditions using a customized load applicator. An optical motion tracking system was used to assess relative displacements and rotations of fracture fragments during loading. Static and dynamic global stiffness, failure load, failure cycles, as well as movements of fracture fragments were measured. RESULTS: There were no significant differences between the 2 fixation methods regarding global stiffness, failure load, or failure cycles (P = 0.67-0.98, depending on the parameter). The kinematic evaluations, however, revealed that different positions of the medial locking plates altered the directions of movements for the medial-anterior or medial-posterior fracture segments. CONCLUSIONS: The mechanical stability of tibia-implant constructs fixed with the double plating methods was not remarkably affected by the location of the medial locking plate. Depending on clinical conditions and surgeons' preferences, bicondylar tibial plateau fractures can be managed with either MA or MP methods.

Finite element analysis of Bi-condylar Tibial Plateau fractures to assess the effect of coronal splits.

Bi-condylar tibial plateau fractures are demanding to treat due to the complex geometry and the articular comminution. The presence of a coronal fracture line plays a crucial role in the fixation strategy. Disregarding this fracture line in previous biomechanical studies and established fracture classifications resulted in a lack of detailed knowledge regarding the influence of medial-posterior fragments on implant load sharings. This study aimed to evaluate the effects of coronal splits on stress distributions within the implants using the finite element analysis (FEA). FE models with (Fracture C) and without the coronal split (Fracture H) were developed and validated in order to assess stress distributions within the implant components. Comparing FE outcomes with biomechanical experiments indicated that both fracture models were well validated. FE evaluations demonstrated that the coronal split caused destabilization of the medial tibia, as well as a shift in the peak-stress areas from the middle part of the plate to the proximal section, and a 61% increase in the maximum stress of the kick-stand screw. Therefore, FE models based on clinically-relevant fracture morphologies can provide a reliable tool to assess implant failures as well as to compare different fracture fixation techniques.

The effect of coronal splits on the structural stability of bi-condylar tibial plateau fractures: a biomechanical investigation.

INTRODUCTION: Surgical treatment of bi-condylar tibial plateau fractures is still challenging due to the complexity of the fracture and the difficult surgical approach. Coronal fracture lines are associated with a high risk of fixation failure. However, previous biomechanical studies and fracture classifications have disregarded coronal fracture lines. MATERIALS AND METHODS: This study aimed to develop a clinically relevant fracture model (Fracture C) and compare its mechanical behavior with the traditional Horwitz model (Fracture H). Twelve samples of fourth-generation tibia Sawbones were utilized to realize two fracture models with (Fracture C) or without (Fracture H) a coronal fracture line and both fixed with lateral locking plates. Loading of the tibial plateau was introduced through artificial femur condyles to cyclically load the fracture constructs until failure. Stiffness, fracture gap movements, failure loads as well as relative displacements and rotations of fracture fragments were measured. RESULTS: The presence of a coronal fracture line reduced fracture construct stiffness by 43% (p = 0.013) and decreased the failure load by 38% from 593 ± 159 to 368 ± 63 N (p = 0.016). Largest displacements were observed at the medial aspect between the tibial plateau and the tibial shaft in the longitudinal direction. Again, the presence of the coronal fracture line reduced the stability of the fragments and created increased joint incongruities. CONCLUSIONS: Coronal articular fracture lines substantially affect the mechanical response of tibia implant structures specifically on the medial side. With this in mind, utilizing a clinically relevant fracture model for biomechanical evaluations regarding bi-condylar tibial plateau fractures is strongly recommended.

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

INTRODUCTION: Classical 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 METHODS: 3D 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. RESULTS: A 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. DISCUSSION: The presented classification scheme based on the 3D geometry of bicondylar proximal tibial fractures demonstrates a good reliability of clinical relevance.

Biomechanical comparison of anatomical plating systems for comminuted distal humeral fractures.

PURPOSE: Six different mono-axial and poly-axial distal humeral plating systems with an anatomical plate design were compared. The aim of the biomechanical tests was to examine differences regarding system stiffness, median fatigue limit, and failure mechanisms. METHODS: Different configurations of two double plate fixation systems by two manufacturers for the treatment of complex distal humeral fractures (AO/OTA type C2.3) were biomechanically tested in a physiologically relevant setup. RESULTS: The 180° Stryker configuration presented itself as the system with the highest stiffness, being significantly stiffer (p < 0.001) than every system other than the poly-axial 180° aap system (p = 0.378). For the median fatigue limit the 180° Stryker and poly-axial aap systems were ranked first and second. The failure mechanism for all 90° systems was a fatigue breakage of the posterolateral plate. The 180° aap systems demonstrated breakage of the most distal screws of the lateral plate. The 180° Stryker system demonstrated screw breakage on both the medial and lateral plates. DISCUSSION: Breakage of the posterolateral plate as a failure mechanism for the 90° systems was expected. The 180° systems demonstrated a higher stiffness compared to the 90° constructs for the axial loading. In conclusion, both poly-axial anatomical plating systems provide sufficient stability in this scenario, and the 180° configurations demonstrated superior stiffness.

The influence of distraction force on the intradiscal pressure gradient in the bridged lumbar spine: a biomechanical investigation using a calf model.

STUDY DESIGN: A biomechanical calf cadaver study. OBJECTIVE: The purpose of this study was to determine the intradiscal pressure gradient of bridged healthy intervertebral segments in correlation with intraoperative distraction force. SUMMARY OF BACKGROUND DATA: Bisegmental dorsal stabilization and anatomic reduction is a common treatment option for incomplete burst fractures of the lumbar spine. However, it remains unknown to what extent bridging and intraoperative distraction compromises an intact intervertebral disc. METHODS: The L2-L3 intervertebral disc level was evaluated in 6 freshly frozen calf cadaver spines. Pressure measurements were obtained with the spine uninstrumented, after dorsal segmental instrumentation from L1 to L3, and after distraction with 400 N and 800 N. Pressure gradient measurements were accomplished with a balloon pressure sensor placed within the nucleus pulposus of the L2-L3 intervertebral disc. Pressure data were recorded by computer data acquisition. Flexion, extension, and lateral bending moments were applied continuously by a testing machine up to a load moment of 7.5 N·m. The pressure gradients were compared with respect to the effects of added instrumentation and distraction. RESULTS: After segmental bridging the mean pressure gradients were significantly reduced in all movement directions (P < 0.001). However, after dorsal stabilization a continuously rising intervertebral disc pressure was recordable. In contrast, no relevant additional reduction of the intradiscal pressure gradient was detectable after applying distraction forces of 400 N or 800 N. CONCLUSION: In a calf model, a distraction force of up to 800 N leads to no additional reduction of the pressure gradient of bridged healthy lumbar segments under flexion and extension moments.

Clinical course, complication rate and outcome of segmental resection and distraction osteogenesis after chronic tibial osteitis.

INTRODUCTION: Radical segmental resection and subsequent distraction osteogenesis are considered the gold standard in the treatment of chronic tibial osteitis. We investigated the clinical course of treatment, particularly with respect to patients' quality of life, and the complication rate associated with this technique. METHODS: In this prospective case series, 25 patients (22 men, 3 women, average age: 46 years) with chronic post-traumatic tibial osteitis were managed operatively from 2006 to 2009. Standardised treatment included bacterial eradication by segmental resection, bone transport using Ilizarov apparatus, and docking manoeuvre. The follow-up rates during bacterial eradication, bone transport, post docking, and complete osseous consolidation were 100% while follow-up two years after completed consolidation was 76%. The main outcome measurements consisted of the quality of life (Medical Outcomes Study 36-Item Short Form Health Survey (SF-36 score)) and the virtual analogue scale (VAS) of pain during the five stages of therapy. Additionally, all complications and difficulties were documented. RESULTS: The average defect size was 5.3 cm (range: 3-13). The healing index was 57 days per cm transport (range: 18-172). The overall treatment time averaged 93 weeks (range: 38-183). Patients suffered 22 minor and 13 major complications including one amputation. The average complication rate per patient consisted of 0.88 minor and 0.52 major complications. After the period of bone transport, the physical and mental component summary scores increased continuously. After completed consolidation, the average mental summary score was comparable to a normal collective. CONCLUSIONS: Distraction osteogenesis is challenging for both the patient and the surgeon. The arduous and demanding nature of the clinical course subjects the patient to considerable mental and physical stress. Thankfully, the average physical and mental status of health continues to improve during the clinical course of treatment. The 2-year success rate of the distraction osteogenesis in an infected tibia is 96%.

Risk factors for failed two-stage procedure after chronic posttraumatic periprosthetic hip infections.

INTRODUCTION: The aim of the study was to identify risk factors of failed two-stage procedures in cases of chronic posttraumatic periprosthetic hip infections. PATIENTS AND METHODS: Between 2006 and 2008, 26 patients with chronic posttraumatic periprosthetic infections after hip arthroplasty were included. In all cases operative bacterial eradication was initiated. The therapy was carried out according to a standardized treatment protocol including the eradication of the bacterial infection and the prosthetic replacement after three negative intra-operative specimens as a two-stage procedure. Follow-up was performed at least 2 years after revision procedure. RESULTS: Twelve patients showed no signs of infectious recurrence 2 years after prosthetic hip revision therapy (46 %) and were assigned to group I. Group II is constituted by the other 14 patients (54 %). Four of them (16 %) suffered from an infectious recurrence after prosthetic hip replacement, ten patients (38 %) were characterised by a failed bacterial eradication. The spectrum of pathogens showed a significantly higher resistance pattern (p = 0.001) in group II, with a majority of methicillin-resistant Staphylococcus epidermidis (MRSE) and highly resistant Pseudomonas. In addition, patients of group II offered significantly higher American Society of Anesthesiology (ASA) scores (p = 0.015), the body mass index (BMI) was significantly elevated (p = 0.031) and received a significantly higher number of operative procedures (p = 0.016). CONCLUSIONS: A reduced general state of health, a high BMI and highly resistant pathogens are the main risk factors for a failed two-stage procedure after chronic posttraumatic periprosthetic hip infections. Therefore, different treatment strategies are required for a defined subgroup of patients.

Auxiliary locking plate improves fracture stability and healing in intertrochanteric fractures fixated by intramedullary nail.

BACKGROUND: Intertrochanteric fractures present a significant management challenge due to their low inherent stability. The objective of this study was to determine whether an auxiliary locking plate decreases interfragmentary motions and improves fracture healing in intertrochanteric fractures treated by intramedullary nail. METHODS: Biomechanical tests and a clinical retrospective study in intertrochanteric to subtrochanteric nonunions were performed. Six synthetic femurs were osteotomized intertrochanterically and fixated with a long gamma nail and an additional locking compression plate. Mechanical tests were conducted that simulated the hip joint force during gait cycle. Following the initial test, the locking compression plate (LCP) was removed from each specimen and the test was repeated. Interfragmentary motions, strains on implants and osteosynthesis stiffness were determined. For the clinical part of the study, 13 intertrochanteric to subtrochanteric nonunions were treated with revisional long gamma nail and additional locking compression plate. Complications and time to union were determined. FINDINGS: Biomechanically, interfragmentary rotation was 48% smaller (P=0.047) and interfragmentary shear movement was 42% smaller (P=0.007) with locking compression plate. Strains on the nail decreased by 20-27% (P<0.027) and the osteosynthesis stiffness increased by 23% (P=0.005) with locking compression plate. Clinically, fracture healing was achieved in eleven out of 13 patients after 9.0months (range 4 to 22months). INTERPRETATION: The findings of our study indicate that auxiliary locked plating considerably improves biomechanical performance and results in successful healing of unstable intertrochanteric to subtrochanteric femur fractures.