Influence of reduction quality on functional outcome and quality of life in treatment of tibial plafond fractures: a retrospective cohort study.

BACKGROUND: The aim of the study was to evaluate the impact of reduction quality, using intraoperative 3D imaging, on quality of life and functional outcome in the operative treatment of tibial plafond fractures. METHODS: A group of patients with tibial plafond fractures was re-examined. The operative treatment was performed between September 2001 and October 2011. The follow-up examination was at least 2 years after the final surgical procedure. Final reduction result was assessed intraoperatively using a mobile 3D C-arm. A categorization with regard to descriptive parameters as well as type and size of joint surface irregularities was performed. Follow-up results were evaluated using: Olerud and Molander (O & M) score, Short-Form-36 (SF-36) score, movement deficit, Kellgren and Lawrence grade of osteoarthritis, and pain intensity. RESULTS: 34 patients with operatively treated tibial plafond fracture could be re-examined. Reduction quality had the greatest influence on functional result measured by the O & M score (p = 0.001) and the PCS domain of the SF-36 score (p = 0.018). Significant differences with regard to O & M score (p = 0.000), SF-36 score (p = 0.001 to p = 0.02; without MCS domain), movement deficit (p = 0.001), grade of osteoarthritis (p = 0.005) and pain (p = 0.001) could be verified under consideration of the reduction quality. The group with the anatomically more accurate reduction also showed a better result for clinical follow-up and quality of life. Furthermore, it is not the type of joint surface irregularity that is always decisive, but rather the size. CONCLUSIONS: Despite other relevant factors, it appears that reduction quality -which can be analyzed with intraoperative 3D imaging- plays the most important role in postoperative quality of life and functional outcome. Corrections should therefore be performed on joint surface irregularities with a size above 2 mm.

Impact of Intraoperative Cone Beam Computed Tomography on Reduction Quality and Implant Position in Treatment of Tibial Plafond Fractures.

BACKGROUND: The intraoperative assessment of the articular surface in displaced intra-articular distal tibia fractures can be challenging using conventional fluoroscopy. The aim of the study was to determine the frequency and the method of intraoperative corrections of fracture reductions or implant placements during open reduction, internal fixation by using cone beam computed tomography (CT) after conventional fluoroscopy. METHODS: Displaced intra-articular distal tibia fractures were retrospectively analyzed from August 2001 until December 2011. The fractures were classified according to the standards of the AO/OTA as type B or C and treated with open reduction and internal plate fixation. After primary reduction using conventional fluoroscopy, an additional cone beam CT scan was used to determine the alignment of the joint line and the implant position. The number of intraoperative revisions of the primary reduction due to the use of cone beam CT was analyzed. RESULTS: A total of 143 patients with an intra-articular tibial plafond fracture were included in the analysis. In 43 patients (30%), an intraoperative correction was performed after the cone beam CT scan. In 34 (24%) of these cases, intraoperative correction was required because of inadequate joint line reduction. Nine (6%) corrections were required as a result of a malposition of the implant. The revision rate did not differ by fracture classification. CONCLUSION: Despite its acceptance as the standard method of imaging, intraoperative conventional fluoroscopy for the assessment of implant positioning and fracture reduction of tibial plafond fractures is limited. The intraoperative utilization of cone beam CT provided additional information for the surgeon to detect insufficient reduction or implant malposition. LEVEL OF EVIDENCE: Level III, retrospective comparative series.