Free subchondral screws in tibial plateau fractures: do they hinder a total knee arthroplasty? Strategies to prevent complications.

Open reduction and internal fixation of extended lateral column tibial plateau fractures through a tibial condyle osteotomy and limited arthrotomy with the use of free subchondral locking screws is a straightforward and safe technique. However, these free subchondral screws are enclosed in the subchondral bone and therefore virtually impossible to remove after bone healing. The question arises whether these free subchondral screws might hinder a future total knee arthroplasty. In order to refute this, we retrospectively reviewed all surgically managed tibial plateau fractures in our tertiary center during one year and assessed the number, position and configuration of these in situ subchondral screws and K-wires. In addition, we performed a cadaver study, wherein we prepared 7 tibial plateaus for a total knee arthroplasty tibial component placement with free subchondral screws in situ. In this experiment, we demonstrated that free subchondral screws do not interfere with total knee arthroplasty, but they can increase operative time in some cases. We also provide recommendations to avoid difficulties and potential complications.

Trauma mechanism and patient reported outcome in tibial plateau fractures with posterior involvement.

INTRODUCTION: Posterior tibial plateau fractures (PTPF) have a high impact on functional outcome and the optimal treatment strategy is not well established. The goal of this study was to assess the relationship between trauma mechanism, fracture morphology and functional outcome in a large multicenter cohort and define possible strategies to improve the outcome. METHODS: An international retrospective cohort study was conducted in five level-1 trauma centers. All consecutive operatively treated PTPF were evaluated. Preoperative imaging was reviewed to determine the trauma mechanism. Patient reported outcome was scored using the Knee injury and Osteoarthritis Outcome Score (KOOS). RESULTS: A total of 145 tibial plateau fractures with posterior involvement were selected with a median follow-up of 32.2 months (IQR 24.1-43.2). Nine patients (6%) sustained an isolated posterior fracture. Seventy-two patients (49%) sustained a two-column fracture and three-column fractures were diagnosed in 64 (44%) patients. Varus trauma was associated with poorer outcome on the 'symptoms' (p = 0.004) and 'pain' subscales (p = 0.039). Delayed-staged surgery was associated with worse outcome scores for all subscales except 'pain'. In total, 27 patients (18%) were treated with posterior plate osteosynthesis without any significant difference in outcome. CONCLUSIONS: Fracture morphology, varus trauma mechanism and delayed-staged surgery (i.e. extensive soft-tissue injury) were identified as important prognostic factors on postoperative outcome in PTPF. In order to assess possible improvement of outcome, future studies with routine preoperative MRI to assess associated ligamentous injury in tibial plateau fractures (especially for varus trauma) are needed.

Functional outcome and economic burden of operative management of patellar fractures: the pivotal role of onerous implants.

OBJECTIVES: The complication rate following operative treatment of patellar fractures remains high and is associated with a poor functional outcome. The primary goal of this study was to evaluate our functional outcome of patellar fracture osteosynthesis and define strategies to improve the outcome. The healthcare costs and utilization were calculated. METHODS: All demographic, clinical, radiographic variables and hospital-related costs of 111 patients with 113 surgically treated patellar fractures between January 2005 and December 2014 were analyzed. Fractures were grouped as either simple or complex. Functional outcome was assessed using Knee Injury and Osteoarthritis Outcome Score (KOOS). RESULTS: There were 67 simple fractures (59.3%) and 46 complex fractures (40.7%). The overall complication rate was 48.7%, including 19.5% implant-related complications. In 69 patients (61.1%), implants were removed. The outcome was rather poor, with considerable impairment in all KOOS subscales with the knee-related quality of life rated worst (median 62.5, IQR 37.5-81.25). Poor outcome correlated significantly with complex patellar fractures and extensive tension-band constructs. CONCLUSIONS: The operative treatment of patellar fractures was associated with a high complication rate, functional impairment and reduced quality of life. Complex patellar fractures and extensive tension-band constructs were identified as the main determinants of poor outcome and increased economic burden due to higher reinterventions rates. Strategies to reduce complications and improve outcome should focus on less onerous implants.

[Open reduction and internal fixation of lateral tibial plateau fractures with free subchondral 2.7 mm screws]. / Offene Reposition und interne Fixation lateraler Tibiaplateaufrakturen mit freien subchondralen 2,7-mm-Schrauben.

OBJECTIVES: Exact reconstruction of the depressed articular surface and stable subchondral fixation of the lateral tibial plateau (ORIF, "open reduction and internal fixation"). INDICATIONS: Tibial plateau fractures with involvement of the lateral column and depression of the articular surface. CONTRAINDICATIONS: Critical soft tissue. Severe osteoporosis. SURGICAL TECHNIQUE: Supine position, classical anterolateral approach, lateral submeniscal arthrotomy, visualisation of the fracture, osteotomy of the lateral tibial condyle. Reconstruction of the articular surface under visual control and temporary fixation with Kirschner wires. One or more 2.7 mm locking screws are placed subchondral for permanent stable fixation of the articular surface. If needed, the metaphyseal bone defect is filled with autologous or allogenic bone graft. The lateral tibial condyle is reduced and a 3.5 mm (variable angle) locking compression plate applied. Closure of fascia and skin in layers. FOLLOW-UP MANAGEMENT: Free range of motion, in case of residual instability of the collateral ligaments varus-valgus stabilizing brace, partial weight-bearing of 10-15 kg for 8 weeks, control computed tomography (CT) scan after 3 months. RESULTS: Since February 2014, a total of 23 lateral tibial plateau fractures were treated using the described technique; 4 patients were lost to follow-up and the 3­month follow-up of 2 patients is not completed yet. After an average of 167 days, 11 patients had no complaints. At approximately 3 months postoperatively, 10 patients had full range of motion, 3 had a flexion deficit of at least 30°, and 2 patients had residual instability of the medial collateral ligament. One postoperative superficial infection was noted. At the 3 month CT, 10 of 17 patients showed successful reduction without significant articular steps or anatomical malalignment.

The use of gentamicin-coated nails in complex open tibia fracture and revision cases: A retrospective analysis of a single centre case series and review of the literature.

INTRODUCTION: Despite modern advances in fracture care, deep (implant-related) infection remains a problem in the treatment of tibia fractures. There is some evidence that antibiotic-coated implants are beneficial in the prevention of this sometimes devastating complication. In the following study we describe our results using a gentamicin-coated intramedullary tibia nail (Expert Tibia Nail (ETN) PROtect™) for the surgical treatment of complex open tibia fracture and revision cases. MATERIALS AND METHODS: We describe the outcome of patients treated between January 2012 and September 2013, using a gentamicin-coated intramedullary tibia nail. Treatment indications included acute, Gustilo grade II-III, open tibia fractures or closed tibia fractures with long-term external fixation prior to intramedullary nailing and complex tibia fracture revision cases with a mean of three prior surgical interventions. Outcome parameters in this study were deep infection and nonunion. RESULTS: In total, 16 consecutive patients with 16 tibia fractures were treated with a gentamicin-coated intramedullary nail. The overall patient population was subdivided into two groups. The first group consisted of 11 patients (68.8%) with acute fractures who were treated with a gentamicin-coated intramedullary nail. The second group consisted of 5 complex revision cases (31.2%). In our patient population no deep infections could be noted after the treatment with a gentamicin-coated tibia nail. Nonunion was diagnosed in 4 patients (25.0%), 1 of these was a revision case. CONCLUSIONS: Musculoskeletal complications place a cost burden on total healthcare expenditure. Better understanding of the epidemiology and pathogenesis is essential because this can lead to prevention rather than treatment strategies. The purpose of the study was to evaluate a gentamicin-coated tibia nail in the prevention of deep (implant-related) infection. In our patient population no deep infections occurred after placement of the gentamicin-coated nail. Following this study and literature data, antibiotic-coated implants seem a potential option for prevention of deep infection in trauma patients. In the future this statement needs to be confirmed by large randomised clinical trials.

Impaired glucocorticoid receptor function evolves in aberrant physiological responses to bacterial endotoxin.

The consequences of glucocorticoid receptor (GR) dysfunction for neuroimmunoendocrine responses to an inflammatory challenge were studied in transgenic mice expressing antisense RNA directed against the GR [GR-impaired (GR-i) mice]. Mice were implanted intraperitoneally with a biotelemetry transmitter to monitor body temperature and locomotion. GR-i mice showed decreased locomotion and body temperature during the dark phase of the diurnal cycle. Intraperitoneal administration of saline caused a rapid increase in body temperature in control mice, which was terminated within 90 min. In GR-i mice, however, body temperature remained elevated for about 6 h. Intraperitoneal injection of endotoxin (10 micrograms/mouse) produced a biphasic fever in control mice. However, in endotoxin-injected GR-i mice, body temperature was not significantly different from their saline-injected controls during the first 6 h. Body temperature then increased and remained elevated during the night period. Both strains showed hypolocomotion after endotoxin. In a second experiment, mice were injected intraperitoneally with saline or endotoxin and killed after 1, 3, 6 or 24 h. In GR-i mice, endotoxin caused an augmented rise in plasma ACTH, but not in corticosterone levels. The endotoxin-induced increase in serum levels of interleukin-1 beta and interleukin-6 was not different between the strains. However, whereas in control mice tumour necrosis factor-alpha levels were below detection at the time points studied, substantial levels of this cytokine were found in the serum of GR-i mice 1 h after endotoxin administration. It may be concluded that life-long impairment of GR evolves in aberrant physiological and humoral responses to an acute inflammatory challenge. These findings expand our understanding about the neuroendocrine and physiological disturbances associated with stress-related disorders.