Factors influencing the outcome after surgical reconstruction of OTA type B and C tibial plateau fractures: how crucial is the restoration of articular congruity?

INTRODUCTION: Only few and inconsistent data about the impact of articular congruity and tolerable residual intraarticular steps and gaps of the joint surface after tibial plateau fractures exist. Therefore, aim of this study was to investigate the correlation between OTA type B and C tibial plateau fracture outcomes and postoperative articular congruity using computed tomography (CT) data. MATERIALS AND METHODS: Fifty-five patients with a mean age of 45.5 ± 12.5 years and treated for 27 type B and 28 C tibial plateau fractures with pre- and postsurgical CT data were included. Primary outcome measure was the correlation of postoperative intraarticular step and gap sizes, articular comminution area, the postoperative medial proximal tibial angle (MPTA), and the Lysholm and IKDC score. Receiver-operating characteristic (ROC) curves were used to determine threshold values for step and gap heights according to the following outcome scores: IKDC > 70; Lysholm > 80. Secondary outcome measures were the correlation of fracture severity, the number of complications and surgical revisions and the outcome scores, as well as the Tegner activity score before injury and at final follow-up. RESULTS: After a mean follow-up of 42.4 ± 18.9 months, the mean Lysholm score was 80.7 ± 13.3, and the mean IKDC score was 62.7 ± 17.6. The median Tegner activity score was 5 before the injury and 4 at final follow-up (p < 0.05). The intraarticular step height, gap size, comminution area and MPTA deviation were significantly negatively correlated with the IKDC and Lysholm scores. The cutoff values for step height were 2.6 and 2.9 mm. The gap size threshold was 6.6 mm. In total, an average of 0.5 ± 0.8 (range 0-3) complications occurred, and on average, 0.5 ± 1.1 (range 0-7) surgical revisions had to be performed. The number of complications and surgical revisions also had negative impacts on the outcome. Neither fracture severity nor BMI or patient's age was significantly correlated with the IKDC or Lysholm score. CONCLUSIONS: Tibial plateau fractures are severe injuries, which lead to a subsequent reduced level of patient activity. Precise reconstruction of the articular surface with regard to intraarticular step and gap size, residual comminution area and joint angle is decisive for the final outcome. Complications and surgical revisions also worsen it. LEVEL OF EVIDENCE: III.

Instability and results after non-operative treatment of large anterior glenoid rim fractures: is there a correlation between fragment size or displacement and recurrence?

INTRODUCTION: There is little data available on non-operative treatment of anterior glenoid rim fractures (GRF). Nothing is known about fracture size and displacement in comparison to clinical outcomes and instability in a mainly middle-aged patient population. The aim of this study was to demonstrate the results of non-operative treatment in anterior glenoid rim fractures with the special focus on potential instability/recurrence. METHODS: The inclusion criteria were non-operatively treated anterior GRF of at least ≥ 5 mm width using the age- and gender-matched Constant/Murley score (a.-/g.-CMS) and the Western Ontario Instability Index (WOSI). Radiographic parameters (fracture morphology, displacement, major tuberosity fractures and Hill-Sachs lesion using initial CT and radiographs) and the proportion of the fractured glenoid were detected (2D-CT-circle-method) and osteoarthritis (A.P. and axial radiographs) was classified according to Samilson/Prieto. Proportion of fractured glenoid and medial displacement were correlated with the recurrence rate and the clinical scores. RESULTS: N = 36 patients could be followed-up after a mean of 4.4 years [12-140 month, average age: 58 (± 13, 33-86) years]. The a.-/g.-CMS was 93 (± 11, 61-100) points, and the WOSI was 81% (± 22%, 35-100%) on average. The mean intraarticular displacement was 4 mm (± 3 mm; 0-14 mm). The 2D-circle-method showed a mean glenoid fracture involvement of 21% (± 11, 10-52%). Two cases of frozen shoulders and one case with biceps pathology were associated with the trauma. Within the followed-up patient group re-instability has occurred in n = 2 patients (6%) within the first two weeks after trauma. Osteoarthritis was found in n = 11 cases. There was no correlation between the scores and the fracture size/displacement [(a.-/g.-CMS vs. displacement: r = - 0.08; p = 0.6; vs. size: r = - 0.29; p = 0.2); (WOSI vs. displacement: r = - 0.14; p = 0.4; vs. size: r = - 0.37; p = 0.06)], but very large (≥ 21%) fractures with displacement ≥ 4 mm showed slightly worse results without significant difference (a.-/g.-CMS p = 0.2; WOSI p = 0.2). The apprehension test was negative in all patients at final follow-up. CONCLUSION: Non-operative treatment of anterior GRF was associated with overall good results within a mainly middle-aged larger patient group. Re-instability is rare and is not associated with fragment size but can occur in the first weeks after trauma. Size and dislocation of the fracture is not a criterion for the prognosis of potential instability. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Incidence and risk factors for heterotopic ossification following periprosthetic joint infection of the hip.

INTRODUCTION: Heterotopic ossifications (HOs) commonly occur following total hip arthroplasty. Data regarding the appearance of HO after periprosthetic joint infection (PJI) of the hip are rare. Therefore, the aim of this study was to analyze the incidence and potential risk factors for the development of HO in patients with PJI of the hip. MATERIALS AND METHODS: We performed a single-center, retrospective study including patients treated with a two- or multistage operation and patients undergoing salvage procedure in cases of PJI of the hip with a minimum follow-up of 6 months. A total of 150 patients were included in the analysis. The Brooker-scale was used to classify HO. Patients were divided in three groups: (1) No HO, (2) HO Brooker type 1-4, and (3) high-grade HO (HO Brooker type 3 and 4). In each group, we checked possible risk factors for the development of HO for statistical significance. RESULTS: Patients included in our study had a mean age of 70.4 ± 12.1 years. Of all patients, 75 were women (50%). HOs could be found in 70 patients (46.7%). Twenty-seven patients showed HO Brooker type 1, 23 type 2, 15 type 3 and 5 type 4. Male gender [odds ratio (OR) 2.14; p = 0.022], smoking (OR 5.75; p = 0.025) were significant risk factors for HO. A chronic infection (OR 3.54; p = 0.029) and a higher number of procedures (p = 0.009) were significant risk factors for the development of high-grade HO. CONCLUSIONS: HOs often occur following surgical care of PJI. Male gender, smoking, a chronic infection and high number of operations are risk factors for developing HO after PJI.

Ilizarov bone transport using an intramedullary cable transportation system in the treatment of tibial bone defects.

INTRODUCTION: Segmental tibia defects remain challenging for orthopedic surgeons to treat. The aim of this study was to demonstrate bone-related and functional outcomes after treatment of complex tibial bone defects using Ilizarov bone transport with a modified intramedullary cable transportation system (CTS). PATIENTS AND METHODS: We conducted a single-center, retrospective study including all 42 patients treated for tibial bone loss via Ilizarov bone transport with CTS between 2005 and 2018. Bone-related and functional results were evaluated according to the Association for the Study and Application of Methods of Ilizarov (ASAMI) scoring system. Complication and failure rates were determined by the patients' medical files. RESULTS: Patients had a mean age of 45.5 ± 15.1 years. The mean bone defect size was 7.7 ± 3.4 cm, the average nonunion scoring system (NUSS) score was 59 ± 9.5 points, and the mean follow-up was 40.8 ± 24.4 months (range, 13-139 months). Complete bone and soft tissue healing occurred in 32/42 patients (76.2%). These patients had excellent (10), good (17), fair (2), and poor (3) results based on the ASAMI functional score. Regarding bone stock, 19 patients had excellent, 10 good, and 3 fair results. In total, 37 minor complications and 62 major complications occurred during the study. In 7 patients, bone and soft tissue healing occurred after CTS failure with either an induced membrane technique or classic bone transport; 3 patients underwent lower leg amputation. Patients with treatment failure were significantly older (57.6 vs. 41.8 years; p = 0.003). Charlson score and treatment failure had a positive correlation (Spearman's rho 0.43; p = 0.004). CONCLUSION: Bone transport using both intramedullary CTS and Ilizarov ring fixation is viable for treating patients with bone loss of the tibia and complex infection or soft tissue conditions. However, a high number of complications and surgical revisions are associated with the treatment of this severe clinical entity and should be taken into account.