Long-term outcome after surgical treatment of intra-articular tibial plateau fractures in skiers.

INTRODUCTION: Tibial plateau fractures occur frequently during downhill skiing. There is a lack of information about the outcome and development of posttraumatic osteoarthritis after internal fixation of such fractures at long-term follow-up in skiers. MATERIALS AND METHODS: A population of 83 skiers was followed up in a case series after internal fixation of intra-articular tibial plateau fractures AO-OTA 41 B1-B3 and C1-C3. Functional outcomes Visual Analog Scale, Tegner Activity Scale, Modified Lysholm Score, Hospital for Special Surgery (HSS) Knee Score and X-ray images of the affected knees (preoperative, postoperative and at time of follow-up) were obtained. Radiological evaluation focused on severity of osteoarthritis according to the Kellgren and Lawrence score of the lateral, medial and retropatellar knee compartments separately. Subgroup analyses for fracture type and age were performed separately. RESULTS: Patients age was 49.8 ± 12.9 years (range 19-74 years) at the time of surgery, with a mean follow-up period of 10.3 ± 1.9 years (range 6-14 years). All tibial plateau fractures affected the lateral compartment, while the medial compartment was affected in addition as part of bicondylar fractures in two cases. Both the Tegener Activity Scale and Lysholm Score decreased significantly during the follow-up period and their median values dropped from 6 (range 3-7) to 5 (range 2-7) and from 100 (range 90-100) to 95 (range 58-100), respectively (both p < .01). The median clinical knee function at the time of follow-up revealed an HSS Knee Score of 96.5 points (range 74-100). Among the whole patient population, the radiological evaluation at follow-up revealed a significantly higher grade of osteoarthritis in all compartments of the knee joint compared to the time of the operation (p < .01). The grade of osteoarthritis in the lateral compartment was significantly higher than that in the medial and retropatellar compartments (p < .01). CONCLUSIONS: In addition to physiologic aging, progression of radiologic signs of osteoarthritis following internal fixation of intra-articular tibial plateau fractures in an athletic population of skiers is most severe in the lateral knee compartment corresponding to fracture location. However, the long-term functional outcomes seem to be very satisfactory.

Long-term radiographic appearance of calcium-phosphate synthetic bone grafts after surgical treatment of tibial plateau fractures.

OBJECTIVES: Synthetic bone grafts (SBGs) are widely used to fill bone defects after fracture reduction. This study assessed the long-term resorption of two different calcium phosphate products (A=ChronOS™ inject and B=Norian® SRS®; both DePuy Synthes, Oberdorf, Switzerland) used in the surgical treatment of tibial plateau fractures. DESIGN: Long-term clinical and radiologic follow-up of 52 patients after surgical treatment of intraarticular tibial plateau fractures augmented with SBGs. SETTING: The study was performed at a level 3 trauma center. PATIENTS: Between January 2000 and December 2006 a total of 52 patients with intraarticular tibial plateau fractures were operatively treated and augmented with SBGs consisting of a Brushite matix with ß-TCP granules (SBG A) or hydroxylapatite with 4-6% carbonate content (SBG B). 46 patients could be contacted and 38 were included in the study. Half of the patients received SBG A and the other half SBG B. MAIN OUTCOME MEASUREMENTS: Loss of reduction and SBG resorption was investigated by comparison of follow-up X-ray images to pre- and postoperative X-ray images. Furthermore, pain, activity level and knee function were evaluated by means of questionnaires and clinical examination. RESULTS: The mean age of patients was 59.7±12.5years. The follow-up was 8.6±0.9years for SBG A and 11.6±1.4years for SBG B (p<0.001). In most cases SBG A was completely resorbed in a homogenous pattern, while SBG B was still visible on the X-ray images revealing a peripheral resorption pattern. A loss of reduction (>2mm) could be observed in two patients with SBG A and two patients with SBG B, although only one of them had an impaired knee function. CONCLUSIONS: The composite SBG A reveals a comprehensive long-term resorption in comparison to SBG B. Nevertheless, both provided suitable mechanical support as part of the surgical treatment of tibial plateau fractures. LEVEL OF EVIDENCE: Case series, Level IV.

Sports activity after surgical treatment of intra-articular tibial plateau fractures in skiers.

BACKGROUND: Tibial plateau fractures occur frequently while participating in winter sports, but there is no information on whether skiers can resume sports and recreational activities after internal fixation of these fractures. HYPOTHESIS: Skiers can resume low-impact sports activity after internal fixation of tibial plateau fractures. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 103 patients were surveyed by postal questionnaires to determine their sports activities at a mean of 7.8 ± 1.8 years after internal fixation of intra-articular tibial plateau fractures. The survey also included the Lysholm score, the Tegner activity scale, and a visual analog scale (VAS) for pain. RESULTS: At the time of the survey, 88% of the patients were engaged in sports activities (rate of return to sports, 88%), and 53% continued to participate in downhill skiing. The median number of different activities declined from 5 (range, 1-17) preoperatively to 4 (range, 0-11) postoperatively (P < .01). Sports frequency and duration per week did not change: 3 (range, 1-7) preoperatively versus 3 (range, 0-7) postoperatively (P = .275) and 4 hours (range, 1-16 hours) preoperatively versus 3.5 hours (range, 0-15 hours) postoperatively (P = .217), respectively. Median values of all outcome scores declined: Lysholm score, 100 (range, 85-100) preoperatively versus 94.5 (range, 37-100) postoperatively (P < .01); VAS, 0 (range, 0-7) preoperatively versus 1 (range, 0-8) postoperatively (P < .01). Median Tegner activity scale scores declined in all age groups except for patients aged 51 to 60 years. The ability to participate in sports at the time of follow-up compared with the ability before the accident was rated as "similar" by 57 patients (62.0%) and as "worse" by 35 patients (38.0%). The more severe fracture types, B3 and C3 according to the AO classification system, were associated with poorer outcomes related to return to sports and functional scores. CONCLUSION: A large percentage of skiers with surgically treated intra-articular tibial plateau fractures cannot continue to participate in downhill skiing; however, the majority could resume an active lifestyle for several years after the trauma. Fracture type seems to be an important factor influencing physical activity and general functional outcome.

Intramedullary nailing of clavicular midshaft fractures with the titanium elastic nail: problems and complications.

BACKGROUND: Intramedullary nailing of clavicular midshaft fractures using the titanium elastic nail has been described as a technically easy, minimally invasive operation with few complications and an early return to competitive sports. HYPOTHESIS: The results reported thus far have been positive. The titanium elastic nail is associated with multiple intraoperative and postoperative problems. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: From April 2004 to March 2007, 34 patients at our institution were treated with intramedullary nailing. A standard titanium elastic nail was used in 19 cases and a titanium elastic nail with an end cap in 15 cases. The titanium elastic nail was inserted and advanced under fluoroscopic control. A short incision at the fracture site was made for open reduction if needed. Postoperatively, free range of motion was allowed. RESULTS: In 62% of patients, open reduction was necessary independent of fracture type, flattening of the titanium elastic nail, or transverse fragments. Operating time was 44 minutes (range, 10-105 minutes) and fluoroscopy time 9 minutes (range, 2-25 minutes). In 70% of patients, problems or complications occurred (7 medial perforations, 7 lateral penetrations, 1 titanium elastic nail breakage, 1 titanium elastic nail dislocation, 7 hardware irritations). The reoperation rate was 36%. Medial migration and pain were significantly reduced by using an end cap. CONCLUSION: Intramedullary nailing of clavicular midshaft fractures using the titanium elastic nail is a technically demanding operation with various complications in the postoperative phase. This study might explain why the implant has not yet achieved widespread application, despite the fact that other authors have reported good results. Amending the operative technique and postoperative treatment might improve the outcome in the future.

Snowboarder's talus fracture: treatment outcome of 20 cases after 3.5 years.

BACKGROUND: Fracture of the lateral process of the talus is a typical snowboarding injury. Basic data are limited, particularly with respect to treatment and outcome. HYPOTHESIS: As the axial-loaded dorsiflexed foot becomes externally rotated and/or everted, fracture of the lateral process of the talus occurs. Primary surgical treatment may improve the outcome of this injury, reducing the risk of secondary subtalar joint osteoarthritis. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: We recorded details of the treatment and evaluation of 20 patients (8 female and 12 male; age at trauma, 29 years [range, 17-48 years]) who sustained a lateral process of the talus fracture while snowboarding. The injury pathomechanism was documented. The patients were treated either nonsurgically or surgically based on a fracture-type treatment algorithm. The evaluation at most recent follow-up (mean, 42 months [range, 26-53 months]) included clinical and functional examination, follow-up of sport activity, and radiological assessment (radiograph, computed tomography scan). RESULTS: The injury mechanism included axial impact (100%), dorsiflexion (95%), external rotation (80%), and eversion (45%). Using the American Orthopaedic Foot and Ankle Society hindfoot score, the patients obtained a mean of 93 points; the surgically treated group (n = 14) scored higher (97 points) than did the nonoperative group (n = 6; 85 points) (P < .05). Degenerative disease of the subtalar joint was found in 3 patients (15%; operative, 1 patient; nonoperative, 2 patients). All but 4 (20%, all after nonsurgical treatment) patients reached the same sport activity level as before injury. CONCLUSION: The snowboarding-related lateral process of the talus fracture represents a complex hindfoot injury. In type II fractures, primary surgical treatment has led to achieving better outcomes, reducing sequelae, and allowing patients to regain the same sports activity level as before injury.