Intra-articular distal tibial fractures cause a major burden to individual patients and also stresses the public health care system.

BACKGROUND AND PURPOSE: Intra-articular distal tibial fractures are most commonly caused by high-energy trauma. Additional difficulties are related to accompanying soft-tissue injuries. The purpose of this study was to evaluate the consequences of different types of distal tibial fractures to the individual patient and to the public health care system. PATIENTS AND METHODS: 126 patients with operatively treated intra-articular distal tibial fracture were identified between 2012 and 2016. Thirty-one (25%) were open fractures. Acute treatment, timing of definitive surgery, total number of surgical procedures, complications, need for soft-tissue reconstructions, hospital stay, and number of follow-up visits were recorded related to AO/OTA fracture types. RESULTS: 112 patients (89%) were treated with a staged treatment protocol. Of these patients, 74 first received an external fixation device. The definitive fracture fixation was performed on average 8 days after the trauma. Soft-tissue flap reconstruction was needed in 19 patients (15%). Additionally, 7 patients required split-thickness skin grafting. Total hospital stay ranged from 2 to 87 days (median 14 days). The median ward treatment period was 12 days in B2-3 group, 13 days in C1-2 group, and 18 days in C3 group. The median of 2 (range 1-13) surgical procedures were performed. INTERPRETATION: Intra-articular distal tibial fractures cause a major burden to individual patients and stresses the public health care system due to a frequent need for several surgical procedures because of soft-tissue injuries and complications. AO/OTA type C3 fractures had the greatest burden, as patients required several consecutive operations and prolonged hospital stays.

Functional outcome of routine versus on-demand removal of the syndesmotic screw: a multicentre randomized controlled trial.

AIMS: The aim of this study was to investigate whether on-demand removal (ODR) is noninferior to routine removal (RR) of syndesmotic screws regarding functional outcome. METHODS: Adult patients (aged above 17 years) with traumatic syndesmotic injury, surgically treated within 14 days of trauma using one or two syndesmotic screws, were eligible (n = 490) for inclusion in this randomized controlled noninferiority trial. A total of 197 patients were randomized for either ODR (retaining the syndesmotic screw unless there were complaints warranting removal) or RR (screw removed at eight to 12 weeks after syndesmotic fixation), of whom 152 completed the study. The primary outcome was functional outcome at 12 months after screw placement, measured by the Olerud-Molander Ankle Score (OMAS). RESULTS: There were 152 patients included in final analysis (RR = 73; ODR = 79). Of these, 59.2% were male (n = 90), and the mean age was 46.9 years (SD 14.6). Median OMAS at 12 months after syndesmotic fixation was 85 (interquartile range (IQR) 60 to 95) for RR and 80 (IQR 65 to 100) for ODR. The noninferiority test indicated that the observed effect size was significantly within the equivalent bounds of -10 and 10 scale points (p < 0.001) for both the intention-to-treat and per-protocol, meaning that ODR was not inferior to RR. There were significantly more complications in the RR group (12/73) than in the ODR group (1/79) (p = 0.007). CONCLUSION: ODR of the syndesmotic screw is not inferior to routine removal when it comes to functional outcome. Combined with the high complication rate of screw removal, this offers a strong argument to adopt on demand removal as standard practice of care after syndesmotic screw fixation. Cite this article: Bone Joint J 2021;103-B(11):1709-1716.

Fibular head avulsion fractures accompanying operative treated medial tibial plateau fractures.

OBJECTIVE: The aims of this work are to determine how frequently medial tibial plateau fractures are accompanied by fibular head avulsion fractures and evaluate the sensitivity of radiographs detecting them, and also to assess if the presence of fibular fracture is correlated with long-term functional outcome and peroneal nerve damage. MATERIALS AND METHODS: A retrospective chart review of operated patients with medial tibial plateau fractures at level I trauma center during 2002-2008 was performed. From 63 patients imaged preoperatively, 59 had CT and radiographs, three had only CT, and one only radiograph. The presence and fragment size of fibular fracture were retrospectively evaluated. Body mass index (BMI) and functional outcome measurements (the Modified Lysholm knee score and WOMAC) were available for 46 patients. RESULTS: Fourteen out of 63 patients (22.2%) had fibular fractures. Of the 59 patients with both CT and radiographs, 12 had fibular fractures, and of these, nine were seen with both modalities and three only in CT. Functional scores were available for ten patients with fibular fracture. Patients with fibular fracture seen on radiographs had a significantly higher score on WOMAC function (26 vs. 7; p = 0.027). The patients with fibular fractures had also higher BMI (p = 0.035). Of the six patients with peroneal nerve damage, 50% had fibular fracture. CONCLUSIONS: In patients with operatively treated medial tibial plateau fracture, the fibular fractures are relatively common. Detecting it is important, as it may be associated with worse functional scores and peroneal nerve paresis. Some fibular fractures may remain undetected on radiographs, hence preoperative CT is recommended.

Predictors of osteoarthritis following operative treatment of medial tibial plateau fractures.

PURPOSE: To determine factors influencing the development of posttraumatic osteoarthritis (OA) following medial tibial plateau fractures and to evaluate concomitant injuries associated with these fractures. MATERIALS AND METHODS: A chart review of patients with operatively treated medial tibial plateau fractures admitted to our Level I trauma centre from 2002 to 2008 was performed. Of 63 patients, 41 participated in a clinical and radiographic examination. The mean age was 47 years (range 16-78) and the mean follow-up time was 7.6 (range 4.7-11.7) years. All patients had preoperative computed tomography (CT) scans and postoperative radiographs. At the end of follow-up, standing radiographs, mechanical axis, and CT scans were evaluated. RESULTS: Of the 41 patients, 24 had no or mild (Kellgren-Lawrence grade 0-2) OA and 17 had severe (grade 3-4) OA. Initial articular depression measured from preoperative CT scans was a significant predictor of OA (median 1.8mm vs 4.5mm, p=0.009). Fracture line extension to the lateral plateau (p=0.68) or fracture comminution (p=0.21) had no effect on the development of posttraumatic OA, nor did articular depression at the end of follow-up (p=0.68) measured from CT scans. Mechanical axis >4° of varus and ≥2mm articular depression or step-off were associated with worse WOMAC pain scores, but did not affect other functional outcome scores. Six patients (10%) had permanent peroneal nerve dysfunction. Ten patients (16%) required LCL reconstruction and nine (14%) ACL avulsions were treated at the time of fracture stabilisation. CONCLUSIONS: The amount of articular depression measured from preoperative CT scans seems to predict the development of posttraumatic OA, probably reflecting the severity of chondral injury at the time of fracture. Restoration of mechanical axis and articular congruence are important in achieving a good clinical outcome.

Risk Factors for Deep Infection Following Plate Fixation of Proximal Tibial Fractures.

BACKGROUND: The risk factors are unclear for deep surgical site infection after plate fixation of proximal tibial fractures. The objective of this study was to identify the patient and surgical procedure-related risk factors for infection using established criteria for deep surgical site infection. METHODS: A total of 655 proximal tibial fractures were treated with open reduction and plate fixation at our center between 2004 and 2013. We identified 34 patients with deep surgical site infection. A control group of 136 patients was randomly selected from the non-infected cohort. Potential risk factors for deep surgical site infection were identified by reviewing surgical, medical, and radiographic records. Independent risk factors for infection were identified from multivariable logistic regression analysis using a stepwise procedure. RESULTS: The prevalence of deep surgical site infection was 5.2%, the mean age of affected patients was 55 years (range, 16 to 84 years), and 35% of patients were female. Twenty-eight of 34 deep infections were diagnosed within 2 months (acute onset), and only 6 infections were diagnosed >6 months after the index surgical procedure. Nine of the 28 acute-onset infections were treated with antibiotic therapy and debridement. Seventeen patients (50%) required muscle flap coverage, and 5 patients (15%) eventually required above-the-knee amputation. In the multivariable logistic regression analysis with odds ratios (ORs) and 95% confidence intervals (95% CIs), independent predictors of infection were patient age of ≥50 years (OR, 3.6 [95% CI, 1.3 to 10.1]); obesity, defined as a body mass index of ≥30 kg/m(2) (OR, 6.5 [95% CI, 2.2 to 18.9]); alcohol abuse (OR, 6.7 [95% CI, 2.4 to 19.2]); OTA/AO-type-C fracture (OR, 2.8 [95% CI, 1.1 to 7.5]); use of a temporary spanning external fixator (OR, 3.9 [95% CI, 1.4 to 11.1]); and a 4-compartment fasciotomy (OR, 4.5 [95% CI, 1.3 to 15.7]). CONCLUSIONS: There is high morbidity associated with deep surgical site infection in plated proximal tibial fractures. Patients who are ≥50 years of age, obese patients, those with a history of alcohol abuse, or those with an OTA/AO-type-C fracture are at high risk for infection. Performing a fasciotomy also increases the risk of deep infection and should be implemented with meticulous technique when deemed necessary. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.