Clinical results after surgical treatment of posterolateral tibial plateau fractures ("apple bite fracture") in combination with ACL injuries.

PURPOSE: The anterior cruciate ligament (ACL)-tear is a common injury in orthopaedic trauma. Depending on the energy of impact fractures of the posterolateral tibial plateau are often associated. Different morphologic variants of posterolateral tibial plateau impaction fractures have been described in the setting of an ACL-tear. Up to now an algorithm of treatment for a combined injury of a posterolateral tibial head fracture and an injury to the anterior cruciate ligament is missing. METHODS: We present a retrospective study with clinical and radiological analysis of posterolateral fractures in combination with ACL-tear. Impressions with a depth of more than 2 mm and/or a width that outreaches more than half of the posterior horn of the lateral meniscus with additional 3. degree positive pivot-shift-test indicated surgical treatment of the fracture with additional ACL repair or reconstruction. Clinical evaluation included follow-up examination, Visual Analog Scale (VAS), International Knee Documentation Committee Score (IKDC), functional and radiological Rasmussen score. RESULTS: 20 patients were included with a mean age of 43.6 ± 12.4 years. Mean follow-up was 18,2 ± 13,5 months. The fracture was arthroscopically reduced and percutaneously fixed with a screw osteosynthesis (Group 1), reduced via a dorsal approach without (Group 2) or with an autologous bone graft (Group 3). Subjective IKDC score was 79,15 ± 6,07. Functional Rasmussen scores ranged from 27 to 30 (mean 28 ± 2.71). Radiological Rasmussen scores ranged from 16 to 18 points (mean 16.75 ± 1.33). According to IKDC score (p = 0.60), functional Rasmussen score (p = 0.829) and radiological Rasmussen score (p = 0.679) no significant discrepancy between the groups were seen. There was no failure of the ACL graft recorded. CONCLUSIONS: Posterolateral tibial plateau fractures in combination with an ACL-tear, can cause persistent instability and increase rotational instability. Indication for treatment of these fractures is still under debate. From the biomechanical aspect the lack of more than 50% of the posterior horn of the lateral meniscus and dislocation/depression of more than 2 mm results in an increased rotational instability of the ACL deficient knee. Combined surgical treatment with ACL repair or reconstruction is a safe procedure that results in good, short-term clinical outcome, if our algorithm is followed. In addition this study shows, that majority of posterolateral tibial plateau fractures can be treated arthroscopically.

Excellent results of lesser tuberosity transfer in acute locked posterior shoulder dislocation.

PURPOSE: The aim of the present study was to evaluate the clinical and radiological results of lesser tuberosity transfer in acute locked posterior shoulder dislocation with a humeral head defect between 25 and 45 %. METHODS: Clinical and radiological results of seven patients with locked posterior shoulder dislocation with a humeral head defect between 25 and 45 % which were managed with a modification of the McLaughlin procedure within 14 days after injury were evaluated retrospectively after a mean follow-up of 41 months. RESULTS: All shoulders remained stable. The results were good in one and excellent in six patients with a median absolute Constant score of 92 (range 80-98). Mean active pain-free abduction was 171.4° (SD 6.4), mean flexion was 175.7° (SD 4.9), and mean external rotation was 54.3° (SD 17.6). Internal rotation was restricted in all patients. There were no radiological signs of osteoarthritis. CONCLUSIONS: Lesser tuberosity transfer shows excellent clinical and radiographic mid-term results in acute cases of locked posterior shoulder dislocation with a reverse Hill-Sachs lesion between 25 and 45 %.