Surgical fixation methods for tibial plateau fractures.

BACKGROUND: Tibial plateau fractures, which are intra-articular injuries of the knee joint, are often difficult to treat and have a high complication rate, including early-onset osteoarthritis. The most common treatment for complex tibial plateau fractures is surgical fixation. Additionally, orthopaedic surgeons often use bone defect fillers to address bone defects caused by the injury. Currently, there is no consensus on the best method of fixation and on whether bone defect fillers are necessary. OBJECTIVES: To assess the benefits and harms of different surgical interventions and bone defect fillers for treating tibial plateau fractures. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, and trial registries up to March 2023. We also searched conference proceedings and the grey literature. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs comparing surgical interventions for treating tibial plateau fractures and different types of filler for bone defects. DATA COLLECTION AND ANALYSIS: Two review authors independently screened search results, selected studies, extracted data, and assessed risk of bias. We calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, with 95% confidence intervals (CIs). Our primary outcomes (and the specific measures we considered most relevant) were generic quality of life (general health score in the 36-item Short-Form Health Survey (SF-36)), patient-reported lower limb function (Hospital for Special Surgery (HSS) score), and adverse events (frequency of unplanned reoperation). We used GRADE to assess the certainty of evidence. MAIN RESULTS: We included 15 trials in the review, with a total of 948 adult participants. Nine trials compared different types of fixation, and six trials evaluated different types of bone graft substitutes. All 15 trials were small and at high risk of bias. We considered most available evidence to be of very low certainty, meaning we have very little confidence in the results. Only limited pooling was possible. One trial compared circular fixation combined with insertion of percutaneous screws (hybrid fixation) versus standard open reduction and internal fixation (ORIF) in 82 people with open or closed Schatzker types V or VI tibial plateau fractures. At 24 months' follow-up, hybrid fixation compared with ORIF may have little or no effect on SF-36 general health score (MD 6 points higher, 95% CI 7.7 points lower to 19.7 points higher; 66 participants), patient-reported lower limb function according to the HSS score (MD 7 points higher, 95% CI 2.4 points lower to 16.4 points higher; 66 participants), or frequency of unplanned reoperation (RR 0.78, 95% CI 0.45 to 1.32; 83 fractures (82 participants)). However, the evidence for all three outcomes is very uncertain. Three trials (with 242 participants) compared single-plating ORIF versus double-plating ORIF. There may be little to know difference in patient-reported lower limb function (HSS score) at 24 months' follow-up in people who undergo single-plating ORIF compared with those who undergo double-plating ORIF (MD 0.2 points higher, 95% CI 2.12 points lower to 2.52 points higher; 1 study, 84 participants), but the evidence is very uncertain. There were no data for quality of life or unplanned reoperation at 24 months' follow-up. Six trials (including 368 participants) compared bone substitute versus autologous bone graft (autograft) for managing bone defects. No trials reported SF-36 general health score, HSS score, or frequency of unplanned reoperation at 24 months' follow-up. AUTHORS' CONCLUSIONS: There is insufficient evidence to ascertain the best method of fixation or the best method of addressing bone defects during surgery in people with tibial plateau fractures. Further well-designed RCTs with larger sample sizes are warranted.

The trochlear isometric point is different in patients with recurrent patellar instability compared to controls: a radiographical study.

PURPOSE: The purpose of the study was to investigate the theoretical isometric point based of the curve of the femoral groove and relating it to the origin of the MPFL femoral tunnel on lateral radiograph by comparing a patellar instability cohort with a control cohort. METHODS: From a Patellar Instability database the radiographs of 40 consecutive patients were analysed to define Schöttle's point, and the arc of the circle of the trochlear groove. A comparison population of 20 radiographs from comparable patients with tibiofemoral joint disorders was used as a control. The distance from Schöttle's point to the most anterior part of the groove (extension) was also compared to the distance to the distal end of the roof of the notch (flexion). RESULTS: The trochlea was circular in the controls but not the Patellofemoral Instability cohort where trochlear dysplasia is usually present. The difference between the extension and flexion length was a mean of - 2.0 ± 0.5 mm in the controls and + 6.0 ± 0.5 mm in the patellofemoral cohort. In neither cohort did the centre of the circle correspond to Schöttle's point. The extension distance correlated with the boss height. CONCLUSIONS: The dysplastic trochlea is not circular and the centre of the best matched circle was different to the control trochleae which were circular. The circle centres did not correlate with Schöttle's point for either cohort, and was more proximal in the Patellofemoral Instability cohort. CLINICAL RELEVANCE: For the MPFL to have equal tension throughout flexion within the groove, the length should not change. In normal knees the MPFL does not behave isometrically. The change in length, as measured from Schöttle's point to the trochlea, was greater for patellofemoral instability patients explaining why an isolated MPFL reconstruction in the presence of severe trochlear dysplasia risks poor outcomes. Level of evidence III.

Medial compartment knee osteoarthritis: age-stratified cost-effectiveness of total knee arthroplasty, unicompartmental knee arthroplasty, and high tibial osteotomy.

PURPOSE: To compare the age-based cost-effectiveness of total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA), and high tibial osteotomy (HTO) for the treatment of medial compartment knee osteoarthritis (MCOA). METHODS: A Markov model was used to simulate theoretical cohorts of patients 40, 50, 60, and 70 years of age undergoing primary TKA, UKA, or HTO. Costs and outcomes associated with initial and subsequent interventions were estimated by following these virtual cohorts over a 10-year period. Revision and mortality rates, costs, and functional outcome data were estimated from a systematic review of the literature. Probabilistic analysis was conducted to accommodate these parameters' inherent uncertainty, and both discrete and probabilistic sensitivity analyses were utilized to assess the robustness of the model's outputs to changes in key variables. RESULTS: HTO was most likely to be cost-effective in cohorts under 60, and UKA most likely in those 60 and over. Probabilistic results did not indicate one intervention to be significantly more cost-effective than another. The model was exquisitely sensitive to changes in utility (functional outcome), somewhat sensitive to changes in cost, and least sensitive to changes in 10-year revision risk. CONCLUSIONS: HTO may be the most cost-effective option when treating MCOA in younger patients, while UKA may be preferred in older patients. Functional utility is the primary driver of the cost-effectiveness of these interventions. For the clinician, this study supports HTO as a competitive treatment option in young patient populations. It also validates each one of the three interventions considered as potentially optimal, depending heavily on patient preferences and functional utility derived over time.

Surgical fixation methods for tibial plateau fractures.

BACKGROUND: Fractures of the tibial plateau, which are intra-articular injuries of the knee joint, are often difficult to treat and have a high complication rate, including early-onset osteoarthritis. Surgical fixation is usually used for more complex tibial plateau fractures. Additionally, bone void fillers are often used to address bone defects caused by the injury. Currently there is no consensus on either the best method of fixation or bone void filler. OBJECTIVES: To assess the effects (benefits and harms) of different surgical interventions, and the use of bone void fillers, for treating tibial plateau fractures. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (12 September 2014), the Cochrane Central Register of Controlled Trials (2014 Issue 8), MEDLINE (1946 to September Week 1 2014), EMBASE (1974 to 2014 Week 36), trial registries (4 July 2014), conference proceedings and grey literature (4 July 2014). SELECTION CRITERIA: We included randomised and quasi-randomised controlled clinical trials comparing surgical interventions for treating tibial plateau fractures and the different types of filler for filling bone defects. DATA COLLECTION AND ANALYSIS: Two review authors independently screened search results, selected studies, extracted data and assessed risk of bias. We calculated risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CIs). Only very limited pooling, using the fixed-effect model, was possible. Our primary outcomes were quality of life measures, patient-reported outcome measures of lower limb function and serious adverse events. MAIN RESULTS: We included six trials in the review, with a total of 429 adult participants, the majority of whom were male (63%). Three trials evaluated different types of fixation and three analysed different types of bone graft substitutes. All six trials were small and at substantial risk of bias. We judged the quality of most of the available evidence to be very low, meaning that we are very uncertain about these results.One trial compared the use of a circular fixator combined with insertion of percutaneous screws (hybrid fixation) versus standard open reduction and internal fixation (ORIF) in people with open or closed Schatzker types V or VI tibial plateau fractures. Results (66 participants) for quality of life scores using the 36-item Short Form Health Survey (SF-36)), Hospital for Special Surgery (HSS) scores and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function scores tended to favour hybrid fixation, but a benefit of ORIF could not be ruled out. Participants in the hybrid fixation group had a lower risk for an unplanned reoperation (351 per 1000 people compared with 450 in the ORIF group; 95% CI 197 fewer to 144 more) and were more likely to have returned to their pre-injury activity level (303 per 1000 people, compared with 121 in the ORIF group; 95% CI 15 fewer to 748 more). Results of the two groups were comparable for the WOMAC pain subscale and stiffness scores, but mean knee range of motion values were higher in the hybrid group.Another trial compared the use of a minimally invasive plate (LISS system) versus double-plating ORIF in 84 people who had open or closed bicondylar tibial plateau fractures. Nearly twice as many participants (22 versus 12) in the ORIF group had a bone graft. Quality of life, pain, knee range of motion and return to pre-injury activity were not reported. The trial provided no evidence of differences in HSS knee scores, complications or reoperation entailing implant removal or revision fixation. A quasi-randomised trial comparing arthroscopically-assisted percutaneous reduction and internal fixation versus standard ORIF reported results at 14 months in 58 people with closed Schatzker types II or III tibial plateau fracture. Quality of life, pain and return to pre-injury activity were not reported. There was very low quality evidence of higher HSS knee scores and higher knee range of motion values in the arthroscopically assisted group. No reoperations were reported.Three trials compared different types of bone substitute versus autologous bone graft (autograft) for managing bone defects. Quality of life, pain and return to pre-injury activity were not reported. Only one trial (25 participants) reported on lower limb function, finding good or excellent results in both groups for walking, climbing stairs, squatting and jumping at 12 months. The incidences of individual complications were similar between groups in all three trials. One trial found no cases of inflammatory response in the 20 participants receiving bone substitute, and two found no complications associated with the donor site in the autograft group (58 participants). However, all 38 participants in the autologous iliac bone graft group of one trial reported prolonged pain from the harvest site. Two trials reported similar range of motion results in the two groups, whereas the third trial favoured the bone substitute group. AUTHORS' CONCLUSIONS: Currently, there is insufficient evidence to ascertain the best method of fixation or the best method of addressing bone defects during surgery. However, the evidence does not contradict approaches aiming to limit soft-tissue dissection and damage or to avoid autograft donor site complications through using bone substitutes. Further well-designed, larger randomised trials are warranted.

Improved cerebrovascular reactivity following low flow EC/IC bypass in patients with occlusive carotid disease.

Patients with major cerebral artery occlusive disease can suffer cerebral hypoperfusion and be at an increased risk of future strokes. EC/IC bypass has been shown to reduce this risk. Patients with cerebral hypoperfusion, and who are at risk of haemodynamic ischaemia, can be identified by the use of xenon computerised tomography (XeCT) to demonstrate severe impairment of the cerebrovascular reserve (CVR). We report our series on the effect of low flow EC/IC bypass on CVR in patients with symptomatic cerebral haemodynamic ischaemia. Thirteen patients with clinical and radiological features of cerebral hypoperfusion were assessed with acetazolamide activated XeCT. Pre- and postoperative regional cerebral blood flow (rCBF) and CVR were assessed. The change in CVR from pre- to post surgery was calculated (%CVR). Values were compared using ANOVA and Student's paired t-test. Unless otherwise stated, values are given as mean +/- standard error of the mean. Statistical significance was taken at p < 0.05. Pre-operative symptomatic hemisphere CBF was 38 +/- 2 mls/100g/min compared to 40 +/- 3.2 mls/100 g/min in the asymptomatic hemisphere, with the greatest difference observed in the MCA territory (38.6 +/- 2 cf 45.4 +/- 3.2 mls/100g/min). Baseline CBF was not significantly improved post EC/IC bypass. However CVR was significantly improved in the symptomatic hemisphere post-operatively (p = 0.015), with the greatest increase (28%) seen in the MCA territory (p = 0.0105). First, 85% of patients had either an improvement in symptoms or no further symptoms. There was a 93% graft patency and no operative mortality. Low flow EC/IC bypass can improve CVR in patients with symptomatic cerebral ischaemia in the presence of occlusive carotid disease. However, therapy must be individualised, with careful patient selection and minimal surgical morbidity.

Impaction bone grafting in revision hip surgery: past, present and future.

Joint replacement surgery can have excellent clinical results. However, as the number of patients undergoing surgery increases, the number of failed joint replacements is set to rise. One of the greatest challenges for the revision surgeon is the restoration of bone stock. This article focuses upon revision hip surgery, with particular reference to the scope of the problem; historical and current solutions to bone loss in the femur and acetabulum; the clinical results following revision surgery; and the basic science behind impaction bone grafting, before ending with possible future directions for improving the restoration of bone stock.

Stiffness post-total knee replacement: A proof of principle study investigating the effect of gene expression analysis of markers of fibrosis.

BACKGROUND: To establish proof of principle of a link between phenotypic expression and stiffness after TKR. METHODS: From 100 patients, genetic expression of markers of fibrosis was performed for 15 synovial samples from patients categorised as 'best post-operative range of movement (ROM)' and 15 samples from patients with 'worst ROM'. These markers included Matrix Metalloproteinases (MMPs), A Disintegrin and Metalloproteinases with Thrombospondin (ADAMTS) and Tissue Inhibitors of Matrix Metalloproteinases (TIMPs). Genetic marker data were compared to Oxford Knee Scores (OKS) and Pain Catastrophizing Scores (PCS). RESULTS: Quantitative markers for gene expression demonstrated more outliers in stiff compared to non-stiff knees, suggesting a greater imbalance in pro- and anti-fibrotic markers in stiff knees. Whilst there was a significant difference in the range of post-operative knee flexion (p = 0.001) and extension (p = 0.001), there was no statistically significant difference between stiff and non-stiff knees in pre-operative or post-operative OKS (p ≥ 0.06). There was no difference in the individual components of the individual PCS score items nor the PCS total scores when stiff and non-stiff knees were compared (p > 0.05). CONCLUSION: Biological factors, namely gene expression of MMPs, TIMPs and ADAMTS, may contribute towards post-TKR stiffness. This now warrants further investigation to better understand this relationship based on larger, multi-centre, cohorts. LEVEL OF EVIDENCE: Level 3.

The delayed diagnosis of radial head fractures.

Radial head fractures are a common orthopaedic injury presenting to Emergency Departments. Most are diagnosed radiographically, either with a visible fracture or by the presence of abnormal fat pads. We present two cases of delayed radiological diagnosis of radial head fractures despite a high index of clinical suspicion of a fracture at initial consultation.

A preference-based single-item measure of quality of life following medial opening wedge high tibial osteotomy: large improvements similar to arthroplasty.

BACKGROUND: Improvements in generic and disease specific scores have been reported with medial opening wedge high tibial osteotomy (MOW HTO). However, meaningful comparisons between competing surgical interventions have been hampered by the lack of a preference based single index of health related quality of life (HRQoL). The primary aim of this study was to derive and report a single index measure of HRQoL for patients undergoing MOW HTO, preoperatively and at 12 and 24 postoperatively. Secondary aims were to evaluate changes in various additional measures of quality of life at these time points. METHODS: The impact of MOW HTO was evaluated using generic and disease specific instruments. One hundred thirty eight patients completed the Medical Outcomes Study short form health survey (SF-12) and Knee Osteoarthritis Outcomes Score (KOOS) before, 12 and 24 months after surgery. A preference-based single index measure of HRQoL was calculated and changes were evaluated. RESULTS: The mean change in the HRQoL suggested large, clinically significant improvements from 0.69 preoperatively to 0.82 (p<0.001) and 0.8 at 12 and 24 months postoperatively respectively. All dimensions of the SF-12, except role mental health, and all dimensions of the KOOS also demonstrated statistically significant improvements between pre and postoperative measurements. CONCLUSIONS: The preoperative HRQoL of young patients with mechanical varus alignment and medial compartment knee osteoarthritis is similar to older patients with knee osteoarthritis. Medial opening wedge high tibial osteomoty results in significant improvements in HRQoL, the magnitude of which is comparable to other surgical interventions for knee osteoarthristis.

A survey of post-intake orthopaedic trauma meetings in England.

INTRODUCTION: The structure of trauma meetings has been noted to vary considerably throughout our region. The aim of this study was to assess current practice of trauma meetings on a national level and to propose a structure on the basis of the survey. MATERIALS AND METHODS: A telephone survey of 120 hospitals in England was performed with a 100% response rate. The on-call duty orthopaedic surgeon at each hospital was contacted and questioned regarding trauma meetings held at that hospital. Details obtained included the frequency of meetings, the presence of medical staff and staff from other disciplines, review of radiographs and educational value. RESULTS: In total, 107 (89.2%) hospitals conducted regular trauma meetings with a mean duration of 36 min (range, 15-120 min). Teaching of junior medical staff occurred at 89 (83.2%) meetings. Postoperative radiographs were reviewed at 80 (74.8%) hospitals. A radiologist attended in 5 (4.7%) of meetings. The median number of consultants present was 3 (range, 1-10). Other attendees included trauma co-ordinators (34.6%), physiotherapists (30.8%), theatre staff (23.4%), nursing staff (20.6%) and anaesthetists (15.9%). CONCLUSIONS: Trauma meetings assist with the organisation of trauma lists, the review of results and have a valuable educational component. However, in busier orthopaedic units, additional meetings for teaching purposes may be necessary as an adjunct to routine daily trauma meetings.