Classification systems for tibial plateau fractures suffer from poor interobserver agreement, and their value in preoperative assessment to guide surgical fixation strategies is limited. For tibial plateau fractures four major characteristics are identified: lateral split fragment, posteromedial fragment, anterior tubercle fragment, and central zone of comminution. These fracture characteristics support preoperative assessment of fractures and guide surgical decision-making as each specific component requires a respective fixation strategy. We aimed to evaluate the additional value of 3D-printed models for the identification of tibial plateau fracture characteristics in terms of the interobserver agreement on different fracture characteristics. Preoperative images of 40 patients were randomly selected. Nine trauma surgeons, eight senior and eight junior registrars indicated the presence or absence of four fracture characteristics with and without 3D-printed models. The Fleiss kappa was used to determine interobserver agreement for fracture classification and for interpretation, the Landis and Koch criteria were used. 3D-printed models lead to a categorical improvement in interobserver agreement for three of four fracture characteristics: lateral split (Kconv = 0.445 versus K3Dprint = 0.620; P < 0.001), anterior tubercle fragment (Kconv = 0.288 versus K3Dprint = 0.449; P < 0.001) and zone of comminution (Kconv = 0.535 versus K3Dprint = 0.652; P < 0.001). The overall interobserver agreement improved for three of four fracture characteristics after the addition of 3D printed models. For two fracture characteristics, lateral split and zone of comminution, a substantial interobserver agreement was achieved. Fracture characteristics seem to be a more reliable way to assess tibial plateau fractures and one should consider including these in the preoperative assessment of tibial plateau fractures compared to the commonly used classification systems

Tibial plateau fracture reduction involves restoration of alignment and articular congruity. Restorations of sagittal alignment (tibial slope) of medial and lateral condyles of the tibial plateau are independent of each other in the fracture setting. Limited independent assessment of medial and lateral tibial plateau sagittal alignment has been performed to date. Our objective was to characterize medial and lateral tibial slopes using fluoroscopy and to correlate X-ray and CT findings. Phase One: Eight cadaveric knees were mounted in extension. C-arm fluoroscopy was used to acquire an AP image and the C-arm was adjusted in the sagittal plane from 15° of cephalad tilt to 15 ° of caudad tilt with images captured at 0.5° increments. The “perfect AP” angle, defined as the angle that most accurately profiled the articular surface, was determined for medial and lateral condyles of each tibia by five surgeons. Given that it was agreed across surgeons that more than one angle provided an adequate profile of each compartment, a range of AP angles corresponding to adequate images was recorded. Phase Two: Perfect AP angles from Phase One were projected onto sagittal CT images in Horos software in the mid-medial compartment and mid-lateral compartment to determine the precise tangent subchondral anatomic structures seen on CT to serve as dominant bony landmarks in a protocol generated for calculating medial and lateral tibial slopes on CT. Phase Three: 46 additional cadaveric knees were imaged with CT. Tibial slopes were determined in all 54 specimens. Phase One: Based on the perfect AP angle on X-ray, the mean medial slope was 4.2°+/-2.6° posterior and mean lateral slope was 5.0°+/-3.8° posterior in eight knees. A range of AP angles was noted to adequately profile each compartment in all specimens and was noted to be wider in the lateral (3.9°+/-3.8°) than medial compartment (1.8°+/-0.7° p=0.002). Phase Two: In plateaus with a concave shape, the perfect AP angle on X-ray corresponded with a line between the superiormost edges of the anterior and posterior lips of the plateau on CT. In plateaus with a flat or convex shape, the perfect AP angle aligned with a tangent to the subchondral surface extending from center to posterior plateau on CT. Phase Three: Based on the CT protocol created in Phase Two, mean medial slope (5.2°+/-2.3° posterior) was significantly less than lateral slope (7.5°+/-3.0° posterior) in 54 knees (p<0.001). In individual specimens, the difference between medial and lateral slopes was variable, ranging from 6.8° more laterally to 3.1° more medially. In a paired comparison of right and left knees from the same cadaver, no differences were noted between sides (medial p=0.43; lateral p=0.62). On average there is slightly more tibial slope in the lateral plateau than medial plateau (2° greater). However, individual patients may have substantially more lateral slope (up to 6.8°) or even more medial slope (up to 3.1°). Since tibial slope was similar between contralateral limbs, evaluating slope on the uninjured side provides a template for sagittal plane reduction of tibial plateau fractures

Surgical fixation of tibial plateau fractures in elderly patients with open reduction and internal fixation (ORIF) provides inferior outcomes compared to younger patients. Primary total knee arthroplasty (TKA) may be of benefit in patients with pre-existing arthritis, marked osteopenia, or severe fracture comminution. Rationale for primary TKA includes allowing early mobility in hopes of reducing associated complications such as deconditioning, postoperative pneumonia, or venous thromboembolism, and reducing post-traumatic arthritis which occurs in 25% to 45% of patients and requires revision TKA in up to 15%. Subsequent revision TKA has been shown to have significantly worse outcomes than TKA for primary osteoarthritis. This systematic review sought to elicit the clinical outcomes and peri-operative complication rates following primary TKA for tibial plateau fractures. A comprehensive search of MEDLINE, Embase, and PubMed databases from inception through March 2018 was performed in accordance with PRISMA guidelines. Two reviewers independently screened papers for inclusion and identified studies featuring perioperative complications and clinical outcomes following primary TKA for tibial plateau fractures. Studies were included for final data analysis if they met the following criteria: (1) studies investigating TKA as the initial treatment for tibial plateau fractures, (2) patients must be ≥ 18 years old, (3) have a minimum ≥ 24-month follow-up, and (4) must be published in the English language. Case series, cohort, case-control, and randomized-control trials were included. Weighted means and standard deviations are presented for each outcome. Seven articles (105 patients) were eligible for inclusion. The mean age was 73 years and average follow-up was 39 months. All-cause mortality was 4.75% ± 4.85. The total complication rate was 15.2% ± 17.3% and a total of eight patients required revision surgery. Regarding functional outcomes, the Knee Society score was most commonly reported. The average score on the knee subsection was 85.6 ± 5.5 while the average function subscore was 64.6 ± 13.7. Average range of motion at final follow-up was 107.5° ± 10°. Total knee arthroplasty for the treatment of acute tibial plateau fractures is enticing to allow early mobility and weightbearing. However, complication rates remain high. Functional outcomes are similar to patients treated with ORIF or delayed arthroplasty. Given these findings, surgeons should be highly selective in performing TKA for the immediate treatment of tibial plateau fractures

Abstract. Background. Anterior cruciate ligament (ACL) injuries with coinciding posterolateral tibial plateau (PLTP) depression fractures are rare. According to the most up to date literature, addressing the PLTP is crucial in preventing failure of the ACL. However, the surgical management of these injuries pose a great challenge to orthopaedic surgeons, given the anatomical location of the depressed PTP fragment. We report a case of a 17-year-old patient presenting to our department with this injury and describe a novel fixation method, that has not been described in the literature. Surgical Technique. A standard 2-portal arthroscopy is used to visualise the fractures. The PLTP is addressed first. With the combined use of arthroscopy and fluoroscopy, a guide pin is triangulated from the anteromedial aspect of the tibia, towards the depressed plateau fragment. Once the guide pin is approximately 1cm from the centre of the fragment, it is over-drilled with a cannulated drill, and simultaneously bluntly punched up to its original anatomical location. Bone graft is then used to fill the void, supported by two subchondral screws. Both fluoroscopy and arthroscopy are used to confirm adequacy of fixation. Finally, the tibial spine avulsion fracture is repaired arthroscopically using the standard suture bridging technique. Conclusion. We describe a novel, one-stage, minimally invasive approach that addresses both the ACL injury and PLTP fracture. We highlight the advantages of utilising this approach and functional outcomes

Tibial plateau fractures are common injuries. Displaced fractures are treated with open reduction and internal fixation (ORIF). Goals of treatment include restoration of extremity axial alignment, joint stability and congruity, allowing for early motion and prevention of osteoarthritis. Short term results of surgical fixation of tibial plateau fractures are good, however, longer term outcomes have demonstrated a higher risk of end-stage arthritis and total knee arthroplasty. Despite the vast literature around tibial plateau fractures, to our knowledge there are no series examining post-operative reductions using axial imaging. It is our goal to define the incidence of articular malreductions following surgical fixation of tibial plateau fractures, to identify patient or surgeon factors associated with malreductions, and to define any regional patterns of malreduction location. De-identified post operative computed tomography (CT) scans were reviewed to identify tibial plateau malreductions with a step or gap greater than 2 mm, or condylar width greater than 5 mm. Three independent assessors reviewed the scans meeting criteria using Osirix DICOM software. Steps and gaps were mapped onto the axial sequence at the level of the joint line. Images were then matched to side and overlaid as best fit in Photoshop software to create a map of malreductions. A grid was created to divide the medial and lateral plateaus into quadrants to identify the density of malreductions by location. A multi-variate regression model was used to assess risk factors for malreduction. Sixty five post-operative CT scans were reviewed. Twenty one reductions had a step or gap more than 2 mm for a malreduction incidence of 32.3%. The incidence in patients undergoing submeniscal arthrotomy or fluoroscopic assisted reduction was 16.6% and 41.4%, respectively (p <0.001). Side of injury, age, BMI, AO fracture type, and use of locking plates were not predictive of malreduction. Malreductions were heavily weighted to the posterior lateral tibial plateau. The incidence of articular malreductions was high at 32.3%. Fluoroscopic reduction alone was a predictor for articular malreduction with most malreductions located in the posterior lateral quadrants of the plateau

Anterior cruciate ligament (ACL) injuries are frequent among athletes and a leading cause of time away from competition. Stability of the knee involves the ACL for limiting anterior tibial translation and the ALL (anterolateral ligament) to restrain internal rotation of the tibia. Present indications for treatment with a combined ACL-ALL reconstruction remain unclear and mostly subjective. We mathematically modeled the tibial plateau geometry to try and identify patients at risk of ACL injury, and develop an objective trigger point for the decision to proceed with additional surgery to optimize rotational stability in these higher risk patients. We hypothesized that an increased convexity and steepness of the posterior aspect of the lateral plateau would subject knees to higher rotational torques leading to potentially a higher risk of ACL injury. The study design was a case-control study involving ACL reconstruction cases (n=68) and matched controls (n=68) between 2008–2015 at our institution. We used a two-dimensional approach, evaluating sagittal MRI images of the knee to model the posterior convexity of the lateral tibial plateau. Points were selected along the articular surface, and a least-squares regression was used to curve-fit a power function (y = a xn). In the equation, larger coefficient a and n represented steeper slopes. The cases and controls were compared using a Mann-Whitney-U test, and the statistical significance was set at α < 0.05. A subgroup analysis for females and males was also performed for the curve-fit coefficients. We observed a significant difference in the tibial surface geometry between our ACL reconstruction cases and matched controls (Figure 1). The modeled power equation for our ACL cases had larger coefficients compared to controls for all groups. For all pooled subjects, coefficient a (ACL recon cases = 0.90 vs controls = 0.68, p < 0.0001) and coefficient n (ACL recon cases = 0.34 vs controls = 0.30, p = 0.07) (Table 1). For the statistically significant coefficient a, we found it had a sensitivity of 78.9% and specificity of 77.5% for the statistically significant coefficient a, we found it had a sensitivity of 78.9% and specificity of 77.5% for predicting injury, using a cut off coefficient of a = 0.78. The odds ratio was 12.6 [5.5 – 29]. The posterolateral cartilaginous slope of the tibial plateau was mathematically modeled in patients with ACL injury. Patients with ACL injury demonstrated abnormally steep and fast slopes compared to controls that may play predispose to ACL injury by increasing anterior translation forces and internal rotation torques sustained by their knee joint. A steeper slope may also explain high-grade pivot shifts on physical exam that are thought to be a relative indication for adding an associated ALL reconstruction. Our findings are promising for adding more objectivity to surgical decision-making, especially with identifying high-risk patients that may be candidates for combined ACL-ALL reconstructions. For any figures or tables, please contact the authors directly

Abstract. Background. This study aims to estimate the risk of acquiring a medical complication or death from COVID-19 infection in patients who were admitted for orthopaedic trauma surgery during the peak and plateau of pandemic. Unlike other recently published studies, where patient-cohort includes a more morbid group and cancer surgeries, we report on a group more akin to those having routine elective orthopaedic surgery. Methods. The study included 214 patients who underwent orthopaedic trauma surgeries in the hospital between 12th March and 12th May 2020 when the COVID-19 pandemic was on the rise in the United Kingdom. Data was collected on demographic profile including comorbidities, ASA grade, COVID-19 test results, type of procedures and any readmissions, complications or mortality due to COVID-19. Results. There were 7.9% readmissions and 52.9% of it was for respiratory complications. Only one patient had positive COVID-19 test during readmission. 30-day mortality for trauma surgeries was 0% if hip fractures were excluded and 2.8% in all patients. All the mortalities were for neck of femur fracture surgeries and between ASA Grade 3 and 4 or in patients above the age of 70 years. Conclusion. This study suggests that presence of COVID-19 virus in the community and hospital did not adversely affect the outcome of orthopaedic trauma surgeries or lead to excess mortality or readmissions in patients undergoing limb trauma surgery. The findings also support resumption of elective orthopaedic surgeries with appropriate risk stratification, patient optimization and with adequate infrastructural support amidst the recovery phase of the pandemic

Introduction. Schatzker V & VI tibial plateau fractures are serious life-changing injuries often resulting in significant complications including post-traumatic arthritis. Reported incidence of secondary TKA following ORIF of all tibial plateau fractures is 7.3% and 13% for Schatzker V & VI tibial. This study reports a 15-year single centre experience of CEF of Schatzker V & VI fractures including PROMs and incidence of secondary TKA. This study was approved by the local Institutional board. Materials & Methods. All patients from 2007 – 2022 with Schatzker V or VI fractures treated with CEF were identified from a departmental limb reconstruction registry and included in this retrospective study. Patients’ demographics were collected from electronic institutional patient system. Further data was collected for secondary intervention, adverse events, and alignment at discharge. All deceased patients at the time of the study were excluded. Each participant completed a questionnaire about secondary intervention, EQ-5D-3L and Oxford Knee Score (OKS). Results. 90 patients (from 130 eligible) with an average age of 58.3 years completed the questionnaire. At an average follow up of 7.4 years (SD=3.8) the incidence of secondary TKA was 7.8%. There was no significant correlation between articular incongruity and the incidence of secondary TKA. The mean OKS score was 31.7 (SD=13.3). The mean EQ-VAS was 69.3 (SD=23.3) and the mean EQ-5D Index was 0.595 (SD=0.395), both were significantly lower than UK normal population means. Conclusions. This study is probably one of the largest and with the longest follow-up reporting the outcomes of Schatzker V and VI fractures treated with CEF. It appears that articular incongruity has no significant correlation with secondary TKA. Patients reported EQ-5D-3L scores were significantly lower than those for the normal UK population, and the average EQ-VAS has deteriorated with time. This study would be relevant in counselling and consenting patients with this severe injury

Open reduction and internal fixation of tibial plateau fractures is traditionally performed through an anterior, anterolateral or an anteromedial approach and more recently a posteromedial approach. These approaches allow satisfactory access to the majority of fracture patterns with the exception of posterolateral tibial plateau fractures. To improve access to posterolateral tibial plateau fractures, we developed a posterolateral transfibular neck approach that exposes the tibial plateau between the posterior margin of the iliotibial band and the PCL. The approach can be combined with a posteromedial and/or an anteromedial approach to the tibial plateau. Since April 2007, we have used this approach to treat nine posterolateral tibial plateau fractures. All cases were followed up prospectively. Fracture reduction was assessed on radiographs, CT scans and arthroscopicaly. Maintenance of fracture reduction was assessed with radiostereometric analysis. Clinical outcomes were measured using Lysholm and KOOS scores. Anatomic or near anatomic reduction was achieved in all cases. All fractures healed uneventfully and no loss of osteotomy or tibial plateau fracture reduction was identified on postoperative plain X-rays. In the cases monitored with radiostereometric analysis, the fracture fragments displaced less than 2 mm during the course of healing. All osteotomies healed either at the same rate or quicker than the tibial plateau fractures. There were no signs and no symptoms of lateral or posterolateral instability of the knee during or after the healing of the osteotomy. There were no complications related to the surgical approach, including the fibular head osteotomy. All wounds healed uneventfully and there were no symptoms related to the CPN. The patient reported outcomes recorded for this group at six months, using the Lysholm score (mean 71, median 77, range 42–95), compared favourably to the entire cohort of 33 patients treated operatively at our institution for a tibial plateau fracture and followed up prospectively during the same time period (mean 64, median 74, range 20–100). The posterolateral transfibular approach for lateral tibial plateau fractures is an approach that should be considered for a certain specific pattern of fractures of the lateral tibial plateau. Our preliminary results demonstrated no complications through the learning curve of the development of this technique

Background. Surgical planning of long bone surgery often takes place using outdated 2D axes on 2D images such as long leg standing X-rays. This leads to errors and great variation between intra- and inter- observers due to differing frames of reference. With the advent of 3D planning software, researchers developed 3D axes of the knee such as the Flexion Facet Axis (FFAx) and Trochlear Axis (TrAx), and these proved easy to derive and reliable. Unlike 2D axes, clinicians and scientists can use a single 3D axis to obtain measurements relative to other 3D axes, in all three planes Deriving a 3D axis also does not require an initial frame of reference, such as in trying to derive the 2D Posterior Condylar Axis (PCAx), whereby a slight change in slice orientation will affect its position. However, there is no 3D axis derived for the tibial plateau yet. Measurements of tibial joint line obliquity are with a 2D axis drawn on AP long leg standing X-rays. The same applies to tibial plateau rotation, as measured by 2D axes drawn on axial CT/MRI slices. this study aimed to to develop a novel new 3D axis for the tibial plateau to quantify both tibial plateau joint line obliquity and axial rotation. Methods. Materialise software version 8.0 (Materialise Inc., Belgium) handled segmentation of CT data and for analysis of bony morphology. A line joining the centroids of the medial and lateral tibial plateaus formed the TCAx (Fig1). A line joining the middle coordinate of the TCAx, to the centre of the best-fit sphere between the medial and lateral malleolus formed the Tibial Mechanical Axis (TMAx). A standard frame of reference aligned 72 tibias with the TCAx horizontal in the axial view, and the TMAx aligned parallel to the global reference coordinate system vertical axis. Tibial joint line obliquity was the angle between the TCAx and TMAx on the medial side, also known as the Medial Tibial Plateau Angle (MPTA)(Fig2). The authors compared reliability and accuracy of the TCAx against three other rotational axes of the tibia as described in the literature. Results. Our methods showed excellent reproducibility using Bland-Altman analysis between intra- and inter-observers. The tibial joint line as defined by the TCAx is oblique (varus) in the majority of knees (MPTA = 85 ± 2°), and becomes perpendicular (MPTA = 90 ± 2°) in constitutional valgus. The TCAx is also parallel to the Anatomical Tibial Axis (ATAx), (SD = 2°), which is currently the gold standard and most reliable axis in defining tibial axial rotation. Conclusions. The TCAx is a reliable axis for referencing both coronal and rotational alignment of the tibial plateau. it can be used for planning and postoperative analysis of knee replacement. (Fig 3). The variable obliqueness of the joint line suggests that neutral alignment in knee arthroplasty may not be suitable for all knees

Epidemiological data about tibial plateau and associated intra-articular proximal tibial fractures provides clinicians with an understanding of the range, variety, and patterns of injury. There are relatively few studies examining this injury group as a whole. We prospectively recorded all tibial plateau and intra-articular proximal tibial fractures occurring in our regional population of 545,000 adults (aged 15 years or older) in 2007–2008. We then compared our results with previous research from our institution in 2000. There were 173 fractures around the knee, 65 of these involved the tibial plateau. Median age was 59 years (IQR, 36.5–77.5 yrs). Tibial plateau fractures were more common in women (58.5%vs 41.5%). The median age of men was 37 years (IQr, 29–52 yrs) compared to women, 73 years (IQR, 57–82 yrs). Tibial plateau fractures accounted for 0.9% overall and 2.5% of lower limb fractures. Incidence was 1.2/10,000/yr (95% CI, 0.9–1.5). We have prospectively identified and described the epidemiological characteristics of tibial plateau fractures in adults from our region. We have identified a change to the epidemiology of these fractures over a relatively short time frame as the patients at risk age

Introduction:. Tibial component fit, specifically significant overhang of tibial plateau or underhang of cortical bone, can lead to pain, loosening and subsidence. The purpose was to utilize morphometric data to compare size, match, and fit between patient specific and incrementally sized standard unicompartmental knee arthroplasty (UKA) implants. Methods:. CT images of 20 medial UKA knees and 10 lateral UKA knees were retrospectively reviewed. Standard and patient-specific implants were modeled in CAD, utilizing sizing templates and patient-specific CAD Designs. Virtual surgery maximized coverage of tibial plateau while minimizing implant overhang. Tibial plateau implant coverage was evaluated for fit and incidence of overhang/undercoverage. RESULTS:. Patient specific implants provided significantly greater cortical rim coverage versus incrementally sized standard implants, 77% v. 43% (range 41–46%) respectively medially (p < 0.0001) and 60% v. 37% (range 29–41%) laterally (p < 0.0001). Patient-specific and standard implants' arc length were evaluated for percent of implant edge on cortical bone, 84% v. 55% (range 48–59%) medially (p < 0.0001) and 79% v. 57% (range 53–60%) laterally (p < 0.0001). Average amount of overhang/undercoverage of cortical rim area differed in patient-specific and standard implants: 0.24 mm v. 0.46 mm maximum overhang, (p = 0.043); 0.87 mm vs. 3.01 mm maximum undercoverage medially (p < 0.0001); 0.14 mm vs. 0.59 mm maximum overhang, (p = 0.05); 1.19 mm vs. 2.26 mm maximum undercoverage laterally (p = 0.017). Anterior overhang yielded 25 −75% and 30–80% of medial and lateral implants respectively in standard implant group; no overhang in patient-specific implant group. Conclusions:. Tibial plateau anatomy variability produces difficulty optimizing coverage and preventing significant implant overhang/undercoverage with standard unicompartmental implants. Using virtual implantation, standard implants were undersized to avoid overhang. However, we encountered significantly more overhang in standard implants versus patient specific cohort. This study removed variability matching tibial tray and femoral standard group implant placement. Patient-specific implants provide superior cortical bone coverage and fit while minimizing issues of overhang and undercoverage seen in standard implants

The purpose of this study was to review the long term functional results of patients undergoing treatment for high energy tibial plateau fractures. Between January 1994 and June 2013 our unit managed 105 high energy tibial plateau fractures (Schatzker IV-VI) with an Ilizarov frame. All cases were treated via ligamentotaxis and percutaneous fine wire fixation or with a limited open reduction of the joint surface. A retrospective analysis of all patients that have undergone Ilizarov fixation of a tibial plateau fracture was performed with radiological and clinical functional outcome measurements. We analysed 105 patients with a mean follow up of 93.5 months (range 5–200). The patient group had an average age of 49 years (range 15–87) with 62 patients being male. Fracture pattern was analysed with Schatzker's classification showing 18 type IV, 10 type V and 77 type VI tibial plateau fractures. All fractures had an average time to union of 145 days. Patients had and average range of movement of 117 degrees. Patients undergoing Ilizarov treatment for high energy tibial plateau fractures achieve successful results long term. Definitive treatment should be decided with respect to fracture pattern and the soft tissue envelope. The management aim should be to achieve anatomical reduction and stable fixation to enable early mobilization. Our study confirms the good functional outcomes and low morbidity that can be achieved in high energy fractures treated with Ilizarov fixation

The outcome of 77 high energy tibial plateau fractures treated by locking or conventional plating was reviewed. The aim of the study was to determine if there was any advantage of locking plates in reducing the complication rates associated with fixation of these injuries. All patients had a high energy injury pattern (medial or bicondylar plateau fractures). There were 32 locked plates and 45 non-locking plates used. Compartment syndrome complicated 5 patients (16%) in the locked plate group and 3 (7%) in the non-locked group (p = 0.198). Superficial infection occurred in 4 (13%) patients with locked plates and 7 (16%) patients with non-locked plates. Thromboembolic complications occurred in 3 (7%) patients treated with non-locked plates. There were no thrombembolic complications in the locked plate group (p = 0.135). Overall, malunion of the plateau occurred in 10 (22%) patients treated with non-locked plates compared to 7 (22%) patients who received locked plates. This was due to residual malreduction in 4 (13%) patients in the locked plate group and 6 (13%) patients in the non-locked plate group at the time of surgery. In the remaining cases loss of reduction after fixation occurred in 4 (9%) patients who received non-locked plates and in 3 (9%) patients who were treated with locked plates. No statistically significant difference was noted in the treatment outcomes of patients managed with locked plates or non-locked plates, regardless of fracture severity. We concluded that there is no definite advantage associated with the use of locked plating for high energy tibial plateau fractures

Introduction. Design evolution of total knee arthroplasty (TKA) has improved implant durability and clinical outcomes. However, it has been reported that some patients have limited satisfaction with their operated knees [1]. In view of better patient satisfaction, there have been growing interests in anatomically aligned TKA. The anatomically aligned TKA technique aims to replicate natural joint line of the patients [2][3]. However, restoration of natural joint line may be difficult for the knees with severe deformity, as their joint alignment with respect to bony landmarks at a time of surgery may be critically different from their pre-diseased state. The purpose of this study is to investigate alignment of the tibial growth plate with respect to tibial anatomical landmarks for possible application in estimation of pre-diseased joint alignment. Methods. Three-dimensional tibial models were created from CT scans of 22 healthy Japanese knees (M7:F15, Age 31.0±12.6 years) using Mimics (Materialise NV, Leuven, Belgium). The mid-sagittal plane of the tibia was defined by medial margin of the tibial tuberosity, origin of the PCL and center of the foot joint. The tibial plateau (or joint line plane) was determined by following three points; a dwell point of aligned femur on lateral tibial articular surface, and two points at anterior and posterior rim of medial tibial articular surface defined within sagittal plane that coincide with dwell point of femur on medial tibia. All measurements were made with respect to the mid-sagittal plane. The shape of the tibial growth plate (GP) was extracted using Livewire function and mask editing tools of Mimics. To determine 3D orientation of the GP, moment of inertia axes were calculated for the 3D model. The inertia axes were also determined for medial and lateral half of the GP (Figure 1). Results. Tibial plateau (TP) had 2.38±1.78 degrees of varus and 11.37±3.76 degrees of posterior inclination. In coronal view, the GP axis was in varus alignment to the normal axis of the TP by 3.29±1.45 degrees. The shape of the GP is found to be different for medial and lateral half. The posterior inclination of the medial half tends to follow the TP, while the lateral half is twisted anteriorly (Figure 2). The GP medial half was in 5.03±2.89 degrees valgus and 1.62±2.37 degrees anteriorly inclined relative to the TP. The GP lateral half was in 10.38±2.62 degrees varus and 18.11±3.79 degrees anteriorly inclined relative to the TP. Discussion. The results from 22 healthy knees suggested that the tibial growth plate is aligned to tibial plateau in varus orientations with relatively small deviations. Distinctive shape difference for medial and lateral half of the growth plate was also observed. Limitation of this study is a number of subjects available for the analysis. Future study should consider inclusion of arthritic knees with various levels of deformities. For figures/tables, please contact authors directly.

Knee laxity following anterior cruciate ligament (ACL) injury is a complex phenomenon influenced by various biomechanical and anatomical factors. The contribution of soft tissue injuries – such as ligaments, menisci, and capsule – has been previously defined, but less is known about the effects of bony morphology. (Tanaka et al, KSSTA 2012) The pivot shift test is frequently employed in the clinical setting to assess the combined rotational and translational laxity of the ACL deficient knee. In order to standardise the maneuver and allow for reproducible interpretation, the quantitative pivot shift test was developed. (Hoshino et al, KSSTA 2013) The aim of this study is to employ the quantitative pivot shift test to determine the effects of bone morphology as determined by magnetic resonance imaging (MRI) on rotatory laxity of the ACL deficient knee. Fifty-three ACL injured patients scheduled for surgical reconstruction (36 males and 17 females; 26±10 years) were prospectively enrolled in the study. Preoperative magnetic resonance imaging (MRI) scans were reviewed by two blinded observers and the following parameters were measured: medial and lateral tibial slope, tibial plateau width, femoral condyle width, bicondylar width, and notch width. (Musahl et al. KSSTA 2012). Preoperatively and under anaesthesia, a quantitative pivot shift test was performed on each patient by a single experienced examiner. An image analysis technique was used to quantify the lateral compartment translation during the maneuver. Subjects were classified as “high laxity” or “low laxity” based upon the median value of lateral compartment translation. (Hoshino et al. KSSTA 2012) Independent t-tests and univariate logistic regression were used to investigate the relationship between the pivot shift grade and various features of bone morphology. Statistical significance was set at p<0.05. A high inter-rater reliability was observed in all MRI measurements of bone morphology (ICC=0.72–0.88). The median lateral compartment translation during quantitative pivot shift testing was 2.8mm. Twenty-nine subjects were classified as “low laxity” (2.8mm). The lateral tibial plateau slope was significantly increased in “high laxity” patients (9.3+/−3.4mm versus 6.1+/−3.7mm; p<0.05). No other significant difference in bone morphology was observed between the groups. This study employed an objective assessment tool – the quantitative pivot shift test – to assess the contribution of various features of bone morphology to rotatory laxity in the ACL deficient knee. Increased lateral tibial plateau slope was shown to be a significant independent predictor of high laxity. These findings could help guide treatment strategies in patients with high grade rotatory laxity. Further research into the role of tibial osteotomies in this sub-group is warranted

Introduction. Posterolateral tibial plateau fractures account for 7 % of all proximal tibial fractures. Their fixation often requires posterolateral buttress plating. Approaches for the posterolateral corner are not extensile beyond the perforation of the anterior tibial artery through the interosseous membrane. This study aims to provide accurate data about the inferior limit of dissection by providing measurements of the anterior tibial artery from the lateral joint line as it pierces the interosseous membrane. Materials and Methods. Forty unpaired adult lower limbs cadavers were used. The posterolateral approach to the proximal tibia was performed as described by Frosch et al. Perpendicular measurements were made from the posterior limit of the articular surface of the lateral tibial plateau and fibula head to the perforation of the anterior tibial artery through the interosseous membrane. Results. The anterior tibial artery coursed through the interosseous membrane at 46.3 +/− 9.0 mm (range 27–62 mm) distal to the lateral tibial plateau and 35.7 +/− 9.0 mm (range 17–50 mm) distal to the fibula head. There was no significant difference between right or left sided knees. Discussion. This cadaveric study demonstrates the safe zone (min 27 mm, mean 45mm) up to which distal exposure can be performed for fracture manipulation and safe application of a buttress plate for displaced posterorlateral tibial plateau fractures. Evidence demonstrates quality of reduction correlates with clinical outcome and the surgeon can expect to be able to use a small fragment buttress plate of up to 45mm as this is the mean

Introduction. Periprosthetic medial tibial plateau fractures (TPF) are rare but represent a serious complication in unicompartmental knee arthroplasty (UKA). Most common treatment of these fractures is osteosynthesis with canulated screws or plates. Aim. The aim of this study was to evaluate these two different treatment options of periprosthetic fractures. The hypothesis was that osteosynthetic treatment with plates show significantly higher maximum fracture loads than fixation with cannulated screws. Materials and Methods. 12 matched paired fresh frozen tibias with periprosthetic tibial plateau fractures were used for this study. In group A osteosyntheses with angle-stable plates were performed, whereas in group B cannulated screws were utilized to fixate the periprosthetic fractures. DEXA bone density measurement and standard X-rays (ap and lateral) were accomplished before loading the tibias under standardised conditions with a maximum load of up to 10.0kN. Results. In the plate group all tibias fractured with a median load of Fmax=2.64 (0.45–5.68) kN, whereas in the group with cannulated screws fractures occurred at a mean load of Fmax=1.50 (0.27–3.51) kN. The difference was statistically significant with p<0.05. Discussion. Angle-stable plates showed significantly higher fracture load resistance than fixation with cannulated screws. Therefore osteosynthesis with angle-stable plates in periprosthetic tibial plateau fractures should be recommended. MULTIPLE DISCLOSURES

Navigation of Uni knee arthroplasty (UKA) is not common. Usually the software includes navigation of the tibial as well as the femoral implant. In order to simplify the surgical procedure we thought that navigation of the tibial plateau alone could be a good option. Since 2005 we have been using a mobile bearing UKA of which the ancillary is based on dependent bone cuts. The tibial cut is made first and the femoral cut is automatically performed using cutting blocks inserted between the tibial cut and the distal end of the femur. Although we are satisfied with this procedure, it is not rare we have some difficulties getting the right under correction needed to get a good long-term result. The aim of this paper was to present our computer-assisted UKA technique and our preliminary radiological results in genu varum (17 cases) as well as genu valgum (6 cases) deformities. The series was composed of 23 patients, 10 females and 13 males, aged from 63 to 88 years old (mean age: 75 +/− 8). The mean preoperative HKA (Hip-Knee-Ankle) angle was: 172.35° +/− 2.31° (167° to 176°) for the genu vara and 186.33° +/− 2.87° (182° to 189°) for the genu valga. The goal of the navigation was to get an HKA angle of 177° +/− 2° for genu varum deformity and 183° +/− 2° for genu valgum. We used the SURGETICS® device (PRAXIM, GRENOBLE, FRANCE) in the first six cases and the ORTHOPILOT® device (B-BRAUN-AESCULAP, TUTTLINGEN, GERMANY) in the other cases. The principles are the same for both devices. The 1rst step consists in inserting percutaneously the rigid-bodies on the distal end of the femur and on the proximal end of the tibia. Then, we locate the center of the hip by a movement of circumduction, the center of the ankle by palpating the malleoli and the center of the knee by palpating intra articular anatomic landmarks to get the HKA angle in real time. This step is probably the most important because it allows checking the reducibility of the deformity in order to avoid an over correction when inserting a mobile bearing prosthesis. The 3. rd. step consists in navigation of the tibial cut such as the height of the resection, the tibial slope (3 to 5° posterior tibial slope) and the varus of the implant (2 to 3°). Once the tibial cut was done, we must use the conventional ancillary to perform the femoral bone cuts (distal and chamfer). The last step consists in inserting the trial implants and checking the HKA angle and the laxity of the medial or lateral side. We used postoperative long leg X-Rays to evaluate the accuracy of navigation and plain radiographs to evaluate the right position of the implant. As far as genu varum deformity was concerned, the mean postoperative HKA angle was 177.23° +/− 1.64° (173°–179°). The preoperative goal was reached in 94% of the cases. Moreover, this angle could be superimposed on the peroperative computer-assisted angle, which was 177° +/− 1.43° (p>0.05). For genu valgum, the mean postoperative HKA angle was 181° +/− 1.41° (179°–183°). The preoperative goal was reached in 66% of the cases but the series is too short to give any conclusion. The navigation of tibial plateau alone can be used with accuracy, provided one has the right ancillary to use dependent bone cuts. The procedure is quick and needs only one tibial cutting guide equipped with a rigid-body. Our results, especially in genu varum deformity, are quite remarkable. Regarding genu valgum, the results seem to be less accurate, but the software was designed for medial UKA and the series is short, so, it is too soon to extrapolate any conclusion. The main interest in this navigation is to avoid too much under correction and even better to avoid over correction when the deformity is over reducible. Indeed, when one uses a mobile bearing plateau, the risk is to have a dislocation of the meniscus. So, when tightening the collateral ligaments, checking the lower limb axis may persuade not to use a mobile bearing plateau but rather a fixed plateau

Tibial plateau fractures classically present in a bimodal distribution associated with high energy mechanisms in the younger population and fragility fractures in the elderly populations as a result they are well suited for looking at the effect major trauma centre status. Military trauma surgeons in training should be exposed to as much young high-energy trauma as possible to equip them for operations. Retrospective review of all tibial plateaus presenting to RVI 20 months before MTC status and 20 months following this. 61 patients pre, 66 post. Schatzker grade 1–4 were similar pre and post change. Post change there was an increase in Schatzker 5 (62%) and 6 (27%). High energy injuries were most common in younger males, cause was falls followed by RTAs. MTC status has meant an increase in high energy tibial plateaus (Schatzker 5–6) These were predominantly seen in younger males with high-energy mechanisms. As this is likely to be replicated across all injuries, we would recommend military trauma surgeons have a significant period of time training in major trauma centres to ensure adequate exposure to young high energy trauma