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[Knee joint prosthesis implantation after fractures of the head of the tibia. Intermediate term results of a cohort analysis]
Abstract
A significant number of patients with operated tibial plateau fractures develop osteoarthritis and require total knee arthroplasty. In cases of primary osteoarthritis the results are generally good. However, it is not known whether patients with post-traumatic osteoarthritis obtain comparably favorable results. In a retrospective study we analyzed 72 patients who had undergone a self-aligning (SAL) total knee arthroplasty. Ten patients received arthroplasty due to sequelae of a tibial head fracture (group I). The median time to follow-up in this group was 30 months. Clinical and radiological evaluation was based on the Knee Society Clinical Rating System. The score comprises pain, range of motion, stability, and function. We defined the axis and possible loosening by radiological examination. For comparative descriptive statistics, a cohort of patients was chosen who had received an arthroplasty because of primary gonarthrosis (group II, 76 arthroplasties in 62 patients). The median time to follow-up in this group was 46.5 months. Three patients in group I underwent revision surgery, four patients displayed severe functional deficits and pain, and one patient had a varus deformity with good clinical function. This corresponded to an early complication rate of 27% and a late complication rate of 36%; a relevant instability or loosening of the components did not occur in this group. In group II the incidence of early complications was 10%. The patients in group I reached a mean value of 153 points using the rating system vs 167 points in group II. Analyzing the clinical parameters of the score, we found that patients in group I experienced significantly more pain, thereby affecting functions of daily living, such as walking and climbing stairs. Because of the small number of patients in group I, conclusions can only be drawn to a limited extent. However, we saw that these patients displayed a higher incidence of complications and performed less well. This has to be taken into consideration and discussed prior to surgery.
... K nee injuries often result in posttraumatic osteoarthritis (PTOA). [1][2][3][4][5][6][7][8][9] Potential triggers of PTOA are fractures with or without malalignment, ligament tears, meniscal tears, and cartilage defects. [1][2][3][4][5] The accuracy of primary reconstruction (anatomic reposition with <2 mm step in joint line) and practice stable osteosynthesis are crucial to prevent PTOA. ...
... [1][2][3][4][5][6][7][8][9] Potential triggers of PTOA are fractures with or without malalignment, ligament tears, meniscal tears, and cartilage defects. [1][2][3][4][5] The accuracy of primary reconstruction (anatomic reposition with <2 mm step in joint line) and practice stable osteosynthesis are crucial to prevent PTOA. Furthermore, missed accompanying ligamental and/or meniscal injuries predispose patients for PTOA. ...
... Furthermore, high complication rates (36% to 63%) and less favorable functional outcome compared with TKA in primary osteoarthritis underscores the clinical challenge. [2][3][4][5]15 The purpose of this study was to evaluate necessary surgical resources for TKA in PTOA compared to standard TKA in osteoarthritis. ...
The purpose of this study was to evaluate the surgical effort of total knee arthroplasty (TKA) for posttraumatic osteoarthritis (PTOA) compared with primary osteoarthritis (OA). A total of 1841 TKAs were analyzed, including 170 patients with PTOA, that resulted from soft tissue trauma in 83 patients and fractures in 87 patients. Results showed that patients were significantly younger at the time of surgery in the posttraumatic group (62 vs 71 years; P<.001). Furthermore, fracture was associated with 3.7 years earlier need of TKA compared with soft tissue trauma. Operation time was significantly longer for both of the posttraumatic groups compared with OA (P<.001). Patients undergoing TKA after knee injuries are younger and surgical treatment is more challenging compared with TKA for OA. Extended operation time and implant systems with higher constraint and modular options are required. [Orthopedics. 2016; 39(3):S36–S40.]
... Additionally, tibial plateau fracture fixation, in older patients, is more likely to require TKR [7]. Only a few literatures reported that surgical challenges and outcomes of TKR in PTOA patients were lower compared to TKR in primary OA [8][9][10][11][12]. However, not much data investigated the patient's comorbidities, functional outcome, and complication between TKR after PTOA (fracture around the knee and ligamentous injury of the knee) and TKR after primary knee OA. ...
... Previous studies demonstrated that TKR after PTOA had lower functional outcomes than TKR in primary OA [8][9][10][11][12]. However, not much data described the patient's comorbidities, functional outcome, and complication between PTOA (fracture around the knee and ligamentous injury of the knee) and primary OA of the knee. ...
Background
A few literatures reported that the outcomes of total knee replacement (TKR) in posttraumatic osteoarthritis (PTOA) were lower compared to TKR in primary osteoarthritis (primary OA). The study’s purpose was to compare the comorbidity and outcome of TKR among fracture PTOA, ligamentous PTOA, and primary OA. The secondary aim was to identify the effect of postoperatively lower limb mechanical axis on an 8-year survivorship after TKR between PTOA and primary OA.
Methods
Seven hundred sixteen patients with primary OA, 32 patients with PTOA (knee fracture subgroup), and 104 PTOA (knee ligamentous injury subgroup) were recruited. Demography, comorbidities, Charlson Comorbidity Index (CCI), operative parameters, mechanical axis, functional outcome assessed by WOMAC, and complications were compared among the three groups.
Results
PTOA group was significantly younger (p<0.0001) with a higher proportion of men (p=0.001) while the primary OA group had higher comorbidities than the PTOA group, including anticoagulant usage (p=0.0002), ASA class ≥3 (p<0.0001), number of diseases ≥ 4 (p<0.0001), and CCI (p<0.0001). Both the fracture PTOA group (p<0.0001) and ligamentous PTOA group (p = 0.009) had a significantly longer operative time than the primary OA group. The fracture PTOA group had significantly lower pain components and stiffness components than the primary OA group. There was no significant difference in the rate of an aligned group, outlier group, and an 8-year survivorship in both groups.
Conclusion
The outcome following TKR in the fracture PTOA was poorer compared to primary knee OA in the midterm follow-up. However, no difference was detected between the ligamentous PTOA and primary knee OA. The mechanical axis alignment within the neutral axis did not affect the 8-year survivorship after TKR in both groups.
Level of evidence
Level III; retrospective cohort study
... Twenty-four percent of all intra-articular proximal tibia fractures occur in older persons and constitute 8% of all fractures in patients over 65 years. A future increase in the incidence of proximal tibia fractures can be assumed [2][3][4]. ...
... The majority (63%) of the patients were female, as in most of the published series. Most fractures were caused by low-energy trauma, typically as a result of falling from standing height, as also previously reported [2,3]. ...
Purpose
Proximal tibial fractures are typically treated with osteosynthesis. In older patients, this method has been reported to be associated with a high complication rate, risk of post-traumatic osteoarthritis, and long partial or non-weight bearing during the recovery phase. To avoid these problems, primary total knee replacement (TKR) has become an increasingly common treatment option.
Methods
Twenty-two patients (mean age 74 years, SD 12) underwent primary TKR due to tibial plateau fracture. Follow-up data were available for a mean of 19 (SD 16) months. Trauma mechanism, fracture classification, type of prosthesis used, complications, and re-operations during the follow-up were recorded. The Knee Society Score (KSS), Oxford Knee Score (OKS), range of flexion, and patient satisfaction were evaluated.
Results
13/22 of the fractures were due to a low-energy trauma. At final follow-up, mean KSS was 160 (SD 39) and mean OKS 27 (SD 11) points. Mean flexion was 109° (SD 16°). 14/17 of the patients were satisfied or highly satisfied with their post-operative knee and 11/17 reported their knee to be same or better than pre-trauma. 2/22 of the patients had complications requiring revision surgery.
Conclusion
TKR as a primary definitive method seems to be a useful alternative to osteosynthesis, enabling immediate full weight bearing and rapid mobilization of patients. The risk of complications associated with primary TKR is higher than those reported after TKR due to primary osteoarthritis but lower than those reported after TKR due to secondary osteoarthritis.
... Abb. 1). Dabei scheint die Primärendoprothetik nach Trauma zunehmend an Bedeutung zu gewinnen [7,31]. ...
... Häufig wird nach vorheriger ORIF die Indikation zu einer sekundären Knieprothese bei posttraumatischer Arthrose nach Trauma gestellt. Leider zeigt die sekundäre im Vergleich zur elektiven Knieprothese schlechtere Langzeitergebnisse und eine höhere Komplikationsrate hinsichtlich der Häufigkeit septischer und aseptischer Lockerungen [7,9,19,23,32]. ...
The aim of open reduction and internal fixation (ORIF) of fractures around the knee joint is the exact anatomic reconstruction of joint surfaces in order to achieve an early and load stable bone situation. Primary endoprosthetics as the initial treatment can represent an alternative treatment option for a closely selected number of geriatric patients.
The chances and risks of primary endoprosthetics in comparison to ORIF as the gold standard for initial treatment of fractures close to the knee joint in the elderly are presented MATERIAL AND METHODS: A selective search of the literature was carried out in consideration of national recommendations and own experience gained as head of a center for geriatric traumatology.
If the soft tissue coverage is not damaged by the injury, primary endoprosthetics can offer advantages compared to ORIF when a load stable joint is indispensable due to poor compliance, pre-existing arthritis and advanced age.
The risk of postoperative loss of correction is minimized by the prosthesis but the revision possibilities are very limited due to voluminous prostheses with a high degree of coupling. The indications for primary prosthesis implantation for acute treatment of fractures close to the knee should therefore be closely controlled because this should be the first and last intervention for fracture treatment in geriatric patients.
... Saleh et al. [5] focused their review exclusively on sequelae of surgically managed tibial plateau fractures, with 15 cases and a mean 6.2 years' follow-up. Gerich et al. [6] reported a retrospective comparison of results for TKR in osteoarthritis secondary to longstanding tibial plateau fracture vs. TKR in primary osteoarthritis of the knee, reviewing 72 TKRs at 30 months' follow-up. The unanimous conclusion drawn from these studies is that TKR for post-traumatic osteoarthritis secondary to malunion is associated with an elevated rate of complications and poorer functional results than in primary osteoarthritis of the knee. ...
... Within these limitations, however, it represents one of the largest series in the literature, confirming the conclusions initially reported. TKR in this indication remains justified by the significant improvement obtained in knee and function scores, but failed to match that obtained in more classical etiologies of osteoarthritis of the knee associated with constitutional deformity, as demonstrated by Gerich et al. [6]. The complications rate over 20% was also higher than found in classical etiologies, in agreement with former reports. ...
Introduction
Peu de données sont disponibles concernant la prise en charge des gonarthroses sur cal vicieux intra-articulaire. Le but de ce travail était d’analyser et de rapporter les résultats des prothèses de genou dans cette indication ainsi que les complications et leurs particularités techniques.
Hypothèse
Les arthroplasties pour gonarthrose après cal vicieux articulaire sont exposées à un taux élevé de complications et à un résultat fonctionnel limité.
Objectifs
Tester cette hypothèse sur une série rétrospective de 74 gonarthroses sur cal vicieux articulaire.
Patients et méthodes
Dans une série rétrospective multicentrique, nous avons colligé les dossiers de 74 patients d’âge moyen 63 ± 14 ans opérés d’une prothèse totale de genou (PTG) entre 2000 et 2008 pour gonarthrose post-traumatique sur cal vicieux intra-articulaire. Le délai moyen entre le traumatisme initial et la prothèse était de 21,8 ± 19 ans (un à 56 ans). Les patients ont été évalués cliniquement et radiographiquement au dernier recul sur la base du score de la Knee Society modifié selon la Société orthopédique de l’Ouest (SOO).
Résultats
Avec un recul moyen global de 4 ± 3 ans (un à neuf ans), le score genou a été amélioré passant de 25 ± 12 à 85 ± 7 au dernier recul (p < 0,001) ainsi que le score fonction, passant de 52 ± 13 à 66 ± 10 (p = 0,004). Le gain de flexion moyen était de 6° avec une flexion moyenne préopératoire de 104° ± 28° (10° à 150°) et de 110° ± 19° (20° à 130°) au dernier recul. Dix-neuf patients (26 %) ont présenté une complication dont 13 graves, susceptibles d’altérer le résultat fonctionnel : trois avulsions de l’appareil extenseur (tendon patellaire), quatre infections, cinq raideurs et un cas d’instabilité.
Discussion et conclusions
Ces résultats mettent en évidence un taux de complications élevé et des résultats cliniques inférieurs à ceux des prothèses pour gonarthrose sur déformation constitutionnelle. Le traumatisme initial avec l’hémarthrose, et les chirurgies parfois itératives pour réduire et fixer la fracture initiale, induisent une fibrose et des adhérences synoviales à l’origine de raideurs et de difficultés d’exposition. Il est nécessaire d’en informer le patient en le prévenant d’une amplitude de flexion postopératoire améliorée mais nécessairement limitée surtout en cas de raideur initiale.
Niveau d’évidence
Niveau IV : étude rétrospective non comparative.
... Saleh et al. [5] focused their review exclusively on sequelae of surgically managed tibial plateau fractures, with 15 cases and a mean 6.2 years' follow-up. Gerich et al. [6] reported a retrospective comparison of results for TKR in osteoarthritis secondary to longstanding tibial plateau fracture vs. TKR in primary osteoarthritis of the knee, reviewing 72 TKRs at 30 months' follow-up. The unanimous conclusion drawn from these studies is that TKR for post-traumatic osteoarthritis secondary to malunion is associated with an elevated rate of complications and poorer functional results than in primary osteoarthritis of the knee. ...
... Within these limitations, however , it represents one of the largest series in the literature, confirming the conclusions initially reported. TKR in this indication remains justified by the significant improvement obtained in knee and function scores, but failed to match that obtained in more classical etiologies of osteoarthritis of the knee associated with constitutional deformity, as demonstrated by Gerich et al. [6]. The complications rate over 20% was also higher than found in classical etiologies, in agreement with former reports. ...
There is a lack of data on the management of osteoarthritis of the knee associated with intra-articular malunion. The present study sought to analyze and report results of total knee replacement (TKR) in this indication, including complications and technical specificities.
TKR for osteoarthritis of the knee associated with intra-articular malunion entails an elevated risk of complication, with impaired functional results.
To test this hypothesis in a retrospective series of 74 cases of osteoarthritis of the knee associated with intra-articular malunion.
A multicenter retrospective series collated the records of 74 patients (mean age, 63 ± 14 years) who underwent TKR for post-traumatic osteoarthritis of the knee associated with intra-articular malunion between 2000 and 2008. Mean trauma-to-TKR interval was 21.8 ± 19 years (range 1 to 56 years). Patients were assessed clinically and radiologically at last follow-up, using the Knee Society score as modified by the Western France Orthopedic Society (Société orthopédique de l'Ouest).
At a mean overall follow-up of 4 ± 3 years (range 1 to 9 years), mean knee score improved from 25 ± 12 to 85 ± 7 (P<0.001) and mean functional score from 52 ± 13 to 66 ± 10 (P=0.004). Mean flexion gain was 6°: mean preoperative flexion, 104° ± 28° (10° to 150°), vs. 110° ± 19° (20° to 130°) at follow-up. Nineteen patients (26%) had complications, 13 of which were severe and liable to affect the functional result: three extensor system avulsions, four infections, five cases of stiffness and one of instability.
The present results highlight an elevated rate of complications, with poorer clinical results than those found with osteoarthritis of the knee secondary to constitutional deformity. The initial trauma, with associated hemarthrosis, and sometimes iterative surgery to reduce and fix the initial fracture, induce fibrosis and synovial attachments, leading to stiffness and hindering exposure. The patient should be informed, and warned that postoperative flexion amplitude may be improved but is bound to remain limited, especially in case of initial stiffness.
Level IV: non-comparative retrospective study.
... Also, it could be used as a guideline for shared decision-making regarding treatment options taken into account these risks. This is especially true in the patients with a high risk on a TKA, since conversion to a TKA secondary to a tibial plateau fracture is associated with a higher rate of complications than TKA for primary osteoarthritis due to previous scars, bone loss and poor knee alignment [20][21][22]. Primary or early treatment with a TKA was found to be a suitable alternative in elderly patients with a complex fracture [20], and could be considered in these high-risk patients. ...
Purpose
Currently used classification systems and measurement methods are insufficient to assess fracture displacement. In this study, a novel 3D measure for fracture displacement is introduced and associated with risk on conversion to total knee arthroplasty (TKA).
Methods
A multicenter cross-sectional study was performed including 997 patients treated for a tibial plateau fracture between 2003 and 2018. All patients were contacted for follow-up and 534 (54%) responded. For all patients, the 3D gap area was determined in order to quantify the degree of initial fracture displacement. A cut-off value was determined using ROC curves. Multivariate analysis was performed to assess the association of 3D gap area with conversion to TKA. Subgroups with increasing levels of 3D gap area were identified, and Kaplan–Meier survival curves were plotted to assess survivorship of the knee free from conversion to TKA.
Results
A total of 58 (11%) patients underwent conversation to TKA. An initial 3D gap area ≥ 550 mm ² was independently associated with conversion to TKA (HR 8.4; p = 0.001). Four prognostic groups with different ranges of the 3D gap area were identified: excellent (0–150 mm ² ), good (151–550 mm ² ), moderate (551–1000 mm ² ), and poor (> 1000 mm ² ). Native knee survival at 10-years follow-up was 96%, 95%, 76%, and 59%, respectively, in the excellent, good, moderate, and poor group.
Conclusion
A novel 3D measurement method was developed to quantify initial fracture displacement of tibial plateau fractures. 3D fracture assessment adds to current classification methods, identifies patients at risk for conversion to TKA at follow-up, and could be used for patient counselling about prognosis.
Level of evidence
Prognostic Level III.
... complications in such cases [2][3][4]. To the best of our knowledge, literature is scarce for such cases that were managed by MAKO. ...
... Of all intra-articular proximal tibia fractures, 24% occur in older persons and account for 8% of all fractures in patients over age 65 years [6]. The incidence of tibial plateau fractures will increase in the future [6][7][8]. ...
Introduction
Tibial plateau fractures are typically treated with osteosynthesis. In older patients, osteosynthesis is associated with some complications, risk of post-traumatic osteoarthritis and long partial, or non-weight bearing during the recovery phase. To avoid these problems, primary total knee replacement (TKR) has become an increasingly common treatment option. The aim of this study was to evaluate all the relevant literature and summarize the current evidence-based knowledge on the treatment of tibial plateau fractures with primary TKR in older patients.
Materials and methods
A systematic literature search of studies on total knee replacement (TKR) as primary treatment for acute traumatic tibial plateau fracture was conducted using OVID Medline, Scopus, and Cochrane databases from 1946 to 18 November 2019. We included all studies without restrictions regarding total knee replacement (TKR) as primary treatment for acute traumatic tibial plateau fracture.
Results
Of the 640 reviewed articles, 16 studies with a total of 197 patients met the inclusion criteria. No controlled trials were available, and the overall quality of the literature was low. The results, using different clinical scoring systems, were good or fair. Four-year follow-up complication (6.1%) and revision (3.6%) rates after primary TKR appeared to be lower than after secondary TKR (complication rate 20–48%, revision rate 8–20%) but higher than after elective primary TKR.
Conclusion
Based on low-quality evidence, TKR appears to be a useful treatment option for tibial plateau fractures in older patients. Controlled trials are mandatory to determine the relative superiority of these two options as primary treatment of tibial plateau fractures in older patients.
... Based on the poor outcomes following the treatment )303( of tibial plateau fractures, high rate of complications in TKA for post-traumatic OA and the short time-interval between primary treatment of the fracture and required TKA, it has been advocated limitedly to perform acute primary TKA (PTKA) in older patients with osteoporosis or knee degenerative changes (15)(16)(17)(18)(19). Satisfactory outcomes in previous reports and limited data regarding this treatment method suggest the evaluation of acute PTKA outcomes in elderly patients with tibial plateau fractures. ...
Background:
Proximal tibial fractures in elderly patients with osteoporosis or knee osteoarthritis (OA) are challenging cases. In the current study, we present our experience with uncommon acute primary total knee arthroplasty (PTKA) in this patient population.
Methods:
PTKAs were performed following proximal tibial fractures in 30 consecutive patients over 60 years of age with osteoporosis or knee OA between 2005 and 2009. Three constrained condylar knees (CCK) and no hinged knee prosthesis were used. Patients were followed up for 4.5±1.1 years.
Results:
Patients were discharged after 4.6±1.2 days. The postoperative Tegner activity scale (3.5±1.3) was improved significantly compared to the preoperative scale (2.5±1.2) (P<0.001). The knee flexion range was significantly greater in the operated side (106±13 degrees) compared to the uninjured knee (120±8 degrees) (P<0.001). The two sections of knee society knee score (knee and function section) averaged 90.7±6.5 and 69.6±8.8, respectively. All patients returned to their previous activities. Based on the visual analogue scale, the patients' satisfaction and pain at final visit were scored 8.1±1 and 1.5±1.2, respectively. No infection, thromboembolic events and loosening were observed.
Conclusion:
PTKA following a proximal tibial fracture in elderly patients with osteoporosis or knee degeneration can be considered as a safe alternative for open reduction and internal fixation. PTKA resulted in immediate weight-bearing, improved functional status and patients' satisfaction. However, functional outcomes were dependent on the general condition of 24 the patient. Also, constrained knee prostheses were not necessary for a vast majority of the patients.
... A significant number of patients, even if operated on, develop OA and require a total knee arthroplasty. 5 To achieve good results, the aims of the treatment should be anatomic reduction and stabilization of the articular surface, restoration and maintenance of the mechanical axis of the leg, preservation of the soft tissue envelope of the proximal tibia, and restoration of a functional range of motion (ROM). 6 In the management of complex tibial plateau fractures, therefore, no single treatment modality can be applied; the optimal treatment should be a multiple approach restoring all the morphological and functional characteristics, with prevention of posttraumatic joint deformity, axial misalignment, and possibly OA development. ...
Complex fractures of the tibial plateau are difficult to treat and present a high complication rate. The goal of this report is to describe a combined biological and mechanical approach to restore all morphological and functional knee properties.
We treated a 50-year-old woman, who was affected by a posttraumatic osteochondral lesion and depression of the lateral tibial plateau with knee valgus deviation. The mechanical axis was corrected with a lateral tibial plateau elevation osteotomy, the damaged joint surface was replaced by a recently developed biomimetic osteochondral scaffold, and a hinged dynamic external fixator was applied to protect the graft and at the same time to allow postoperative joint mobilization.
A marked clinical improvement was documented at 12 months and further improved up to 5 years, with pain-free full range of motion and return to previous activities. The MRI evaluation at 12 and 24 months showed that the implant remained in site with a hyaline-like signal and restoration of the articular surface.
This case report describes a combined surgical approach for complex knee lesions that could represent a treatment option to avoid or at least delay posttraumatic osteoarthritis and more invasive procedures.
... Weiss et al. [35] confirm these observations in a series of 63 ancient fractures of the tibial plateau secondarily managed by arthroplasty (three infections, five loosenings) resulting in a revision rate of more than 20%. Based on the results of shorter series, Gerich et al. [36] and Saleh et al. [37] came to the same conclusions. ...
Over the past few years the use of arthroplasty was broadened to treating complex epiphyseal fractures at the shoulder and elbow joints. Similar trends to treat this type of fractures at the knee are less documented. Based on a multicenter retrospective series study, the aims of this work is to evaluate the short term clinical results of total knee prostheses in the management of comminuted epiphyseal fractures around the knee, to identify the technical issues and fine tune the indications.
Following the initiative of the French Hip and Knee Society (SFHG) and the Traumatology Study Group (GETRAUM), 26 charts from eight different centers in France were included in this multicenter retrospective series. Inclusion criteria were: primary total knee arthroplasty (TKA) in the management of complex articular fractures involving the proximal end of the tibia or distal end of the femur. Surgical features were identified and complications were analyzed. The assessment protocol at last follow-up was standardized and included patient demographic data, analysis of the Parker and IKS scores.
During the immediate postoperative period, six patients (23%) reported a general complication and four patients (15%) a local arthroplasty-related complication. At last follow-up (mean 16.2 months), the overall final Parker score was 6.3 (a mean decrease of 1.7) and the mean IKS knee score was 82 points for a mean function score of 54 points.
Primary TKA is a suitable management option for complex fractures in autonomous elderly patients suffering from knee osteoarthritis. The key technical details of this procedure should be respected and meticulously planned to achieve optimal results and limit the risk of complications. This risk in these acute complex fractures remains higher than after conventional TKA but comparable to that observed after TKA for post-traumatic arthritis.
IV; retrospective cohort study.
Background The treatment of fractures of the tibial plateau or distal femur often represents a severe problem in geriatric patients. In particular, complex fracture types and concomitant severe osteoporosis are confronted with inferior results following internal fixation. Therefore, primary arthroplasty is increasingly propagated for such particular cases.
Patients, Materials and Methods In 16 patients suffering from fractures of the distal femur or tibial plateau were treated either by internal fixation (n = 8) or primary arthroplasty (n = 8). The outcome of each case was retrospectively analysed according to clinical and economic criteria.
Results In the investigated geriatric patients, primary arthroplasty was significantly superior to internal fixation regarding mobilisation and range of motion without being inferior in cost-effectiveness.
Conclusion Compared to internal fixation, primary arthroplasty represents an efficient and cost-effective therapeutical option for the treatment of complex fractures of the distal femur or tibial plateau of the elderly patient.
The surgical management of tibial plateau fractures can be technically demanding. In younger patients, the mainstay is fixation with cartilage preservation. In older patients with osteoporotic bone, this method has higher rates of fixation failure; in addition, it requires prolonged bed rest or protected weight bearing, which are major challenges in this group. In contrast, total knee arthroplasty performed acutely for primary treatment of tibial plateau fractures has potential advantages for elderly patients, such as immediate stability, early mobilization, and positive functional outcomes with decreased rates of reoperation. Additionally, arthroplasty can be technically challenging in younger patients with previous tibial plateau fractures in whom debilitating posttraumatic arthritis develops. In these patients, old wounds, retained metalwork, bony deficiency, and instability can lead to poorer outcomes and higher complication rates than in routine knee arthroplasty. In both cases, we recommend surgery be performed by experienced arthroplasty surgeons with ample access to a range of implants with varying constraints and the option of stems and augments.
Gegenstand dieser Studie ist die Untersuchung von unterschiedlichen Osteosynthesemöglichkeiten bei Tibiakopfimpressionsfrakturen am Kunstknochen. Dafür wurde ein Kunstknochenmodell ausgesucht, das in seinen mechanischen Eigenschaften einem humanen, osteoporotischen Knochen nahe kommt. Nachdem die Knochen in neun Gruppen aufgeteilt wurden, wurde eine Impressionsfraktur des lateralen Tibiaplateaus generiert, um diese anschließend mit verschiedenen Osteosynthesetechniken zu versorgen. Zur biomechanischen Testung der Stabilität wurden die Knochen über 3000 Zyklen mit 250 N belastet. Abschließend erfolgte in einer Load-to-failure-Testung die Prüfung der maximalen Belastbarkeit. Der erste Teil dieser Studie konnte zeigen, dass es in Bezug auf das initiale Einsinken des Frakturfragmentes und die Steifigkeit der Osteosynthesetechnik von entscheidender Bedeutung ist, den Knochendefekt bis direkt unter das Impressionsfragment mit Kalziumphosphatzement aufzufüllen. Das ist nur möglich, wenn der Zement gebohrt werden kann und somit die Auffüllung vor der Schraubenosteosynthese möglich ist. Andernfalls behindern die Schrauben die optimale Unterfütterung des Defektes. Auf die maximale Belastbarkeit hat die Auffülltechnik keinen Einfluss. Die Ergebnisse des zweiten Studienteils zeigen, dass die alleinige Versorgung der Fraktur mit chronOs Inject® keine ausreichende Stabilität bietet. In der Gesamtschau der Messergebnisse und dem Verhalten der Knochen während der Load-to-failure-Phase schneidet die Versorgung mit der Jail-Technik und chronOs Inject® (Gruppe 7) am besten ab. Bei dem Vergleich der mechanischen Eigenschaften der beiden verwendeten Kalziumphosphatzemente Norian Drillable® und chronOs Inject® in Ziel 3 der Studie schneidet der nicht bohrbare Zement chronOs Inject® im Displacement und der Steifigkeit besser ab. Dabei muss bedacht werden, dass Norian Drillable® als bohrbarer Knochenzement seine entscheidende Fähigkeit nicht ausspielen konnte. Grundsätzlich ist zu sagen, dass die optimale Behandlung einer Tibiakopfimpressionsfraktur zwei Bedingungen erfüllen muss. Einerseits muss sie der vom Patienten einzuhaltenden Teilbelastung in der postoperativen Phase standhalten (zyklische Belastung), andererseits muss sie auch stabil genug sein, um bei einer maximalen Belastung nicht zu versagen (Load-to-failure-Testung). Zur Vermeidung eines Repositionsverlustes ist es bedeutsam, den entstandenen Knochendefekt mit einem Knochenersatzmaterial aufzufüllen. Entscheidend dabei ist es, dass das Material auch tatsächlich bis unterhalb des Fragmentes gefüllt wird. Ist das nicht der Fall, verfällt der positive Effekt auf das Displacement. Wird der Knochen mit einer maximalen Kraft belastet, ist es für das Ergebnis ausschlaggebend, dass die Fraktur verplattet oder verschraubt ist. Die Studienergebnisse weisen die Verschraubung der Fraktur in der Jail-Technik in Kombination mit dem bohrbaren Kalziumphosphatzement Norian Drillable® als momentan beste Versorgungstechnik für Tibiakopfimpressionsfrakturen aus. Limitiert wird die Studie durch die Verwendung von Kunstknochen und den Versuchsaufbau, da die tatsächlichen Verhältnisse im biologischen System nicht widergespiegelt werden. Aber es lässt sich zeigen, dass sich zum Zweck von biomechanischen Analysen der Tibiakopfimpressionsfraktur dieser Frakturtyp standardisiert hervorrufen lässt. Auch das Kriterium der Reproduzierbarkeit kann erfüllt werden.
This article will analyse the critical issues in the surgical technique peculiar of knee prostheses after fracture: previous scars, intra- or extra-articular deformity, bone defects, ligament balance, stiffness and laxity, with a comparison between our outcomes and the results of the literature.
Introduction
Les indications d’arthroplasties pour des fractures complexes épiphysaires se sont multipliées ces dernières années au coude et à l’épaule, mais les indications restent peu documentées au genou. En se fondant sur l’étude d’une série rétrospective multicentrique, les buts de ce travail étaient d’évaluer les résultats cliniques à court terme des prothèses totales de genou (PTG) pour fracture épiphysaire comminutive du genou, d’identifier les problèmes techniques et de préciser les indications.
Matériel et méthodes
À l’initiative de la Société française de chirurgie du la hanche et du genou (SFHG) et du groupe d’étude en traumatologie (GETRAUM), 26 observations provenant de huit centres en France ont été incluses dans cette série multicentrique rétrospective. Les critères d’inclusion étaient : PTG de première intention posée pour fracture articulaire complexe de l’extrémité proximale du tibia ou de l’extrémité distale du fémur. Les caractéristiques chirurgicales étaient précisées et les complications analysées. Le protocole d’évaluation au dernier recul était standardisé et comprenait les données démographiques du patient, une évaluation du score de Parker et du score IKS.
Résultats
En postopératoire immédiat six patients (23 %) ont présenté une complication générale et quatre patients (15 %) une complication locale directement liée à l’arthroplastie. Au dernier recul (en moyenne 16,2 mois), le score de Parker global final était de 6,3 (chute moyenne de 1,7) et le score IKS genou moyen était de 82 points et le score IKS fonction moyen de 54 points.
Discussion
Il y a une place pour la PTG en première intention dans les fractures complexes du sujet âgé autonome souffrant de gonarthrose. Cette chirurgie comporte des points techniques clés qui doivent être respectés et planifiés afin d’optimiser les résultats et de limiter les complications dont le nombre reste supérieur à celui obtenu après PTG conventionnelle mais comparable à celui observé après PTG post-traumatique.
Niveau de preuve
Niveau IV, étude rétrospective de cohorte.
Purpose of the studyBone comminution, serious cartilage damage, and the poor mechanical quality of osteoporotic bone create a difficult challenge for osteosynthesis of joint fractures in the elderly subject. Poor results with certain hip, elbow and shoulder fractures have lead certain authors to propose emergency arthroplasty in selected cases. We report our experience with four knee arthroplasties implanted for recent severe fracture of the proximal tibial epiphysis in elderly subjects.Material and methodsFour independent patients aged over 75 years presented a severe comminutive fracture of the proximal epiphysis of the tibia (Three Schatzker 5, one Schatzker 4). After obtaining the patients’ informed consent, early knee arthroplasty was performed. A long-stem cemented tibial piece was used on which the epiphysis was reconstructed. Implants providing support for ligament deficits were used in all cases. Immediate weight-bearing was authorized.ResultsFollow-up ranged from two to seven years. The IKS function score (15, 60, 100, 100) depended on the patient's general status. The IKS knee score was excellent for three knees (90, 95, 95), and fair in one (45). Re-operations were not needed in any of the patients. All x-rays showed bone healing with correctly aligned limbs (less than 2̊ deformation). There were no lucent lines at last follow-up.DiscussionEarly arthroplasty for complex fractures of the proximal epiphysis of the tibia is a realistic option. Using a cemented long-stem tibial piece ensures primary stability sufficient for early weight-bearing before bone healing. Use of a constrained prosthesis, or better a hinged prosthesis, can be questioned but avoids the difficulty of ligament balance on an osteoporotic knee with a destroyed joint surface. None of the patients required reoperation and the results in terms of pain were excellent. The overall outcome depends on the general status of the patient.
In contrast to younger patients, tibial head fractures of the elderly usually result from minor trauma. In these patients, fractures of the tibial plateau are frequently seen and classified according to the Tscherne classification. In addition to plain radiographs which consist of an a.p. and a lateral view, a CT-scan is an obligatory part of the preoperative diagnostic. The therapeutic management is strongly depending on the psychic and physical condition of the patient, the fracture morphology, the decreased bone mineralization and the soft tissue damage. Low bone density requires rigid implants to provide a stable osteosynthesis. Metaphyseal defects have to be augmented with synthetic bone substitutes to avoid secondary loss of reduction. Early mobilization should be achieved to decrease the risk of serious complications.
Complex intra-articular fractures of the proximal tibia are difficult to treat, especially in the elderly osteoporotic patient. Pre-existing osteoarthritis, cartilage damage during trauma, suboptimal reduction and fixation due to poor bone stock and/or secondary displacement frequently lead to poor outcome. After osteosynthesis rehabilitation is cumbersome as patients have been non-weight bearing for long periods of time and secondary total knee arthroplasty can be challenging. For these reasons, we investigated the possibility to perform a total knee arthroplasty with or without adjuvant osteosynthesis as a primary treatment in elderly and/or osteoarthritic patients with complex tibial plateau fractures. Between 2002 and 2009, 12 patients (mean age: 73 years (58-81)) with an AO-41 fracture type B1 (1), B3 (8) and C3 (3) were treated with a primary total knee arthroplasty within three weeks from their trauma. Most patients (7/12) were allowed early full-weight bearing. One patient died due to an unrelated cause; the remaining eleven were reviewed at a mean follow-up period of 31 months (5 w-81 m). At final follow-up the median knee score was 78 (50-100) and the function score 58 (0-100): 7/11 patients had an excellent result, while 1/11 had a fair and 3/11 a poor result. Fair and poor results were mostly related to pre-existing poor general condition and/or concomitant disease. Most patients were satisfied and only minor short- and long-term complications were noted. There was no need for revision surgery. Our limited series of well-selected elderly and/or osteoarthritic patients with a complex tibial plateau fracture treated with primary total knee arthroplasty yielded encouraging results.
The human medial tibial plateau is concave, whereas the lateral tibial plateau is convex. In a normal knee, the convex femoral condyles roll and glide on the tibia during the standing phase of walking. The designs of most commercially available knee prostheses do not take this morphological feature into consideration. The novel design of the AEQUOS G1 knee replacement prosthesis is based on the natural anatomy of the knee joint, with a convex lateral tibia plateau and a sagittal offset of the medial and lateral compartments. Following extensive development and testing, initial clinical results of the AEQUOS G1 prosthesis in a mulitcenter study are presented. From Mai 2005 to March 2007, 158 patients in 4 clinics underwent total knee arthroplasty with the AEQUOS G1 and agreed to participate in the study. Patients were evaluated preoperatively and at 3, 6 and 12 months of follow-up using a standardized protocol that included the American Knee Society Score (AKSS), the Oxford Knee Score (OKS) and the Visual Analog Scale (VAS) for pain. After 3 months, 151 patients appeared for follow up appointments, after 6 months, 134, and after 12 months, 127. The mean range of motion preoperatively was 97.0 degrees (+/-19.9 degrees ) and 107.5 degrees (+/-15.9 degrees ) 12 months after surgery. The AKSS, as well as the modified OKS, significantly improved (p<0.0001) from preoperative scores of 98.8 (+/-35.8) and 37.3 (+/-6.9) points, respectively, to 165.8 (+/-34.1) and 21.9 (+/-7.8) points, preoperatively, and 12 months postoperatively. The VAS score significantly decreased (p<0.001) from 7.4 (+/-1.8) points preoperatively to 1.9 (+/-2.2) points 12 months postoperatively.One implant was revised because of arthrofibrosis and another due to patellar luxation. Two patients required revision because their implants revealed malalignement with ligamentous instability. No infections, aseptic loosening or other implant-specific complications were observed at this early follow-up. Good clinical results were observed at early follow-up with the AEQUOS G1 knee arthroplasty. However, longer follow-up is necessary for a general evaluation of the implant.
Posttraumatic osteochondral defects following a tibial plateau fracture are common and a serious complication that may lead to the development of posttraumatic arthrosis. Successful reconstruction of the tibial plateau must include restoration of limb alignment, repair of bone defects, restoration of the articular cartilage, and preservation of the menisci. When osteochondral defects are present, the use of bulk bone grafts to restore the original articular surface anatomy of the tibial plateau is difficult due to incongruity between the graft and the original joint surface. Recognizing this, an autologous osteochondral transplantation utilizing the mosaic technique was performed successfully on a 32-year-old male alpine skier with a posttraumatic osteochondral defect following a tibial plateau fracture. At 2 years postsurgery, the patient had regained the capacity to perform most activities of daily living and to participate in sports. Clinical examination revealed an improvement of the Lysholm score from 48 points to 72 points.
Fractures of the tibial head are severe injuries, characterized by enormous variety. Fractures can be classified into fractures of the tibial plateau, luxation fractures, and comminuted fractures. Due to the mechanism of injury luxation fractures are frequently associated with lesions of the menisci and intra- and extra-articular ligaments. Multiple factors can be etiologic for post-traumatic gonarthrosis: nonanatomic reduction of the joint surface, malalignment, and unaddressed associated injuries. Therefore in addition to diagnostic steps such as X-ray, CT scan, and MRI a sophisticated therapeutic regime is necessary. In cases with severely damaged soft tissue or unstable patients, the fracture should initially be reduced and fixed with an external fixator and the definite fixation should be performed in a second setting. Arthroscopically assisted treatment is reserved for fractures of the tibial eminence, crack fractures, and impression fractures. Comminuted and bilateral fractures can be addressed via different incisions. New locking plates with angular stability allow avoidance of bilateral plating in most situations. In specific cases such as compound fractures and for patients with low compliance, a hybrid fixator may be a well-chosen alternative.
Ten patients aged 55-85 years with a tibial head fracture AO B3 or C3 were treated primarily by implantation of an endoprosthesis. There were one unilateral, three superficial, and six revision-type prostheses. Follow-up was 6 months to 3 years; two patients were lost to follow-up. There were no intra- or postoperative complications except one deep infection which could be cured by repeated arthroscopic lavage. At last follow-up all eight patients were completely or almost pain free; the extension deficit was less than 10 degrees , and flexion was 100 degrees or more. Primary endoprosthetic replacement of the knee joint is a valuable procedure for the treatment of complex tibial head fractures in elderly patients.
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