Effect of O-arm on reduction quality and functional recovery of acetabular dome impaction fractures: a retrospective clinical study.

BACKGROUND: Acetabular dome impaction fractures (ADIF) are difficult to reduce and have a high failure rate. Consistency between the acetabulum and the femoral head is usually assessed using intraoperative X-ray fluoroscopy to evaluate the quality of fracture reduction. This study examines the effects of intraoperative mobile 2D/3DX imaging system (O-arm) on the reduction quality and functional recovery of ADIF. METHODS: We retrospectively analysed the data of 48 patients with ADIF treated at Honghui Hospital between October 2018 and October 2021.The patients were divided into the X-ray and O-arm groups. The residual step-off and gap displacements in the acetabular dome region were measured, and fracture reduction quality was evaluated. Hip function was evaluated using the modified Merle d'Aubigné and Postel scoring systems. RESULTS: There were no significant intergroup differences in the preoperative general data (p > 0.05). The mean residual average step displacement in the acetabular dome region was 3.48 ± 2.43 mm and 1.61 ± 1.16 mm (p < 0.05), while the mean gap displacement was 6.72 ± 3.69 mm and 3.83 ± 1.67 mm (p < 0.05) in the X-ray and the O-arm groups, respectively. In the X-ray group, according to the fracture reduction criteria described by Verbeek and Moed et al., one case was excellent, 13 cases were good, 11 cases were poor; 56% were excellent or good. In the O-arm group, seven cases were excellent, 12 cases were good, and four cases were poor; overall in this group, 82.6% were excellent or good (p < 0.05). A total of 46 patients achieved fracture healing at the last follow-up. In the X-ray group, according to the modified Merle d'Aubigné and Postel function score, three cases were excellent,12 cases were good, six cases were middle, three cases were poor; 62.5% were excellent or good, In the O-arm group, 15 cases were excellent, four cases were good, two cases were middle, one case was poor; 86.4% were excellent or good (p < 0.05). CONCLUSIONS: The application of O-arm in ADIF can improve fracture reduction quality and functional recovery.

The influence of brace immobilization on the remodeling potential of thoracolumbar impaction fractures in children and adolescents.

PURPOSE: Different treatment methods including immediate mobilization with or without brace, bed rest or immobilization using thoracolumbosacral orthosis have been applied for stable compression fractures of the pediatric spine. The aim of this study was to evaluate the influence of bracing on the remodeling capacity of pediatric thoracolumbar type A 1.2 impaction fractures. Additionally, the prevalence of pain and functional disabilities were assessed. METHODS: All children treated conservatively between 2000 and 2011 with impaction fractures of the thoracolumbar spine (A 1.2) were included and re-invited for a clinical [including VAS 0-100, Oswestry disability index (ODI)] and radiological follow-up examination. Changes of the sagittal index (SI) at the time of the accident, the latest control visit and at the follow-up examination were analyzed. RESULTS: Seventy-two patients with a mean age of 12 years (1.8-18 years) and a total number of 133 fractured vertebrae were included. The mean SI at the time of injury was 0.76 (range 0.45-0.94, SD 0.08); 34 patients with 67 fractured vertebrae were included in the follow-up examination after a mean of 7.9 years (2.4-13.1 years). The mean SI of the 67 affected vertebrae at follow-up significantly increased to 0.92 (range 0.74-1, SD 0.06). The initial treatment regimen (brace vs no brace) did not influence the remodeling capacity. More than half of the patients (n = 18, 53 %) complained about occasional back-related pain which was not associated with the remodeling process. The mean ODI was 5.8 (range 0-26, SD 6.6) and the mean VAS of the re-evaluated patients was 87 (range 53-100, SD 14). CONCLUSIONS: A significant remodeling capacity of thoracolumbar vertebral impaction fractures sustained in childhood is demonstrated. Bracing does not seem to influence the long-term outcome of these injuries. More studies have to be performed to define the role of bracing in these fractures.

Prevalence of femoral condyle injuries in the setting of tibial plateau fractures.

BACKGROUND: Tibial plateau fracture patterns are influenced by the direction and energy of the impact, and the bone quality. Associated articular femoral injuries can result from the same impact but are insufficiently studied. This study quantifies the prevalence of three distinct articular femoral condyle injuries: (1) impaction fractures, (2) contusions, and (3) condyle fractures. For impaction fractures we assessed the depth, width, length, and surface area. METHODS: We retrospectively reviewed patients who had undergone surgery for a tibial plateau fracture in a tertiary trauma center. Two fellowship-trained radiologists analyzed preoperative CT scans for associated femoral condyle injuries. We defined (1) impaction fractures (depressions ≥ 1.5 mm) with a sclerotic band, a fracture line, or both; (2) contusions (depressions < 1.5 mm) with a sclerotic band; and (3) condyle fractures as sub- or osteochondral fractures. RESULTS: We identified 149 patients (62 male) with a tibial plateau fracture with a CT scan available. The overall prevalence of articular femoral condyle injuries was 26% (n = 39). The prevalence of impaction fractures was 9.4% (n = 14), of contusions 14% (n = 21), and of condylar fractures 3.0% (n = 4). Factors associated with a higher prevalence of femoral condyle injury were younger age (p = 0.029), male sex (p = 0.014), and absence of comorbidity (p = 0.005). The mean depth of impaction fractures was 2.3 mm (SD: 0.78; range 1.6 to 4). CONCLUSION: Concomitant articular femoral condyle injuries occur in one out of four patients with a tibial plateau fracture. Although most femoral injuries were subtle, and none underwent surgical treatment, they might harbor information regarding the likelihood of future joint degeneration and knee instability. LEVEL OF EVIDENCE: IV.

Intra- and interobserver reliability of two classification systems for posterolateral tibial plateau fractures in the setting of an ACL rupture.

Background: Posterolateral tibial plateau impaction fractures occur frequently associated with anterior cruciate ligament (ACL) tears. Some authors advocate operative treatment of high-grade impaction fractures, which has led to the development of classification systems. Our study aims (1) to describe and compare the intra- and interobserver reliability of the two most used classifications and (2) to assess correlations between the grade of bony posterolateral tibial injury, patient characteristics and short-to mid-term revision rate after ACL reconstruction. Materials and methods: In a retrospective series of 163 patients who underwent ACL reconstruction, two reviewers independently evaluated the preoperative MRI scans. Conform the Menzdorf and Bernholt classification the presence and grade of an associated posterolateral impaction fracture were assessed. Statistical analyses were performed to test for both study hypotheses. Results: 171 primary ACL cases were evaluated. Mean follow-up time was 41 months (range 12-154, SD = 17.1). Mean age was 32 years (range 13-59, SD = 12). Posterolateral impaction fractures were present in 111 (64.9 %) and 120 (70.0 %) cases, according to the Menzdorf and Bernholt classification. A Segond fracture was present in 19 (11.1 %) cases. Kappa value was 0.47 for intra- and 0.52 for the interobserver reliability for the Menzdorf classification (moderate reliability). For the Bernholt classification kappa values were 0.66 and 0.61, respectively (good reliability). A Segond fracture correlated significantly with the presence of a posterolateral impaction fracture (p < 0.05). A significant association was present between patients necessitating ACL revision surgery and patients for whom operative intervention for the posterolateral impression was advised following the Menzdorf classification (p < 0.001). Conclusion: Inter- and intraobserver reliability testing for classifying posterolateral tibial fractures resulted in moderate to good reliability. High-grade posterolateral tibial fractures should be identified, selective treatment should be considered as they are associated with higher revision rates after ACL reconstruction if left untreated.

Impaction Fractures of the Lateral Femoral Condyle Related to Anterior Cruciate Ligament Injury: A Scoping Review Concerning Diagnosis, Prevalence, Clinical Importance, and Management.

Background: During pivot-shift anterior cruciate ligament (ACL) injury, bone bruises or impaction fractures of the lateral femoral condyle (LFC-IF) may occur due to impaction between the posterior part of the lateral tibial plateau and anterocentral part of the LFC. The purpose of the study was to systematically review the literature concerning the diagnosis, prevalence, clinical importance, and management of LFC-IF occurring during ACL injuries. Methods: Included were studies concerning impaction fractures of the anterocentral part of the LFC occurring during ACL injuries. Studies concerning only bone bruises or cartilage lesions, without subchondral bone impaction, were not included. A search was performed in Medline and Scopus databases, with final search in May 2022. A secondary search was conducted within the bibliographies of included articles and using "Cited In" option. Two authors independently extracted data in three domains: study design, LFC-IF characteristics, and LFC-IF importance and management. Results: A total of 35 studies were included for review with several studies reporting on multiple domains. Summarily, 31 studies were on the diagnosis and prevalence, 19 studies reported on the clinical importance, and 4 studies reported on the management of LFC-IF. Conclusions: A LFC-IF occurs due to the pivot-shift mechanism of ACL injury. Its radiological feature is defined as an impaction of terminal sulcus deeper than 1 mm and is present in up to 52% of patients with a torn ACL. An LFC-IF causes injury to the cartilage, probably leads to its progressive degeneration, and is significantly associated with an increased risk of a lateral meniscus injury. A large LFC-IF might be associated with greater rotational knee instability. Although several techniques of LFC-IF treatment were proposed, none of them has been evaluated on a large cohort of patients to date.

Clinical Implications of Bone Bruise Patterns Accompanying Anterior Cruciate Ligament Tears.

BACKGROUND: Anterior cruciate ligament (ACL) tears are common injuries; they are often associated with concomitant injuries to other structures in the knee, including bone bruises. While there is limited evidence that bone bruises are associated with slightly worse clinical outcomes, the implications of bone bruises for the articular cartilage and the risk of developing osteoarthritis (OA) in the knee are less clear. Recent studies suggest that the bone bruise pattern may be helpful in predicting the presence of meniscal ramp lesions. EVIDENCE ACQUISITION: A literature review was performed in EMBASE using the keyword search phrase (acl OR (anterior AND cruciate AND ligament)) AND ((bone AND bruise) OR (bone AND contusion) OR (bone AND marrow AND edema) OR (bone AND marrow AND lesion) OR (subchondral AND edema)). STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 4. RESULTS: The literature search returned 93 articles of which 25 were ultimately included in this review. Most studies identified a high prevalence of bone bruises in the setting of acute ACL injury. Individual studies have found relationships between bone bruise volume and functional outcomes; however, these results were not supported by systematic review. Similarly, the literature has contradictory findings on the relationship between bone bruises and the progression of OA after ACL reconstruction. Investigations into concomitant injury found anterolateral ligament and meniscal ramp lesions to be associated with bone bruise presence on magnetic resonance imaging. CONCLUSION: Despite the ample literature identifying the prevalence of bone bruises in association with ACL injury, there is little evidence to correlate bone bruises to functional outcomes or progression of OA. Bone bruises may best be used as a marker for concomitant injury such as medial meniscal ramp lesions that are not always well visualized on magnetic resonance imaging. Further research is required to establish the longitudinal effects of bone bruises on ACL tear recovery. STRENGTH OF RECOMMENDATION TAXONOMY: 2.

Articular disimpaction in acetabular fractures.

Acetabular impaction fractures when not adequately addressed leads to early arthritis. Dome impaction injuries and marginal impaction injuries have to be properly planned pre-operatively with respect to surgical approach, disimpaction techniques and fixation strategies. CT scan is the best modality to analyse the site, extent of impaction and plan strategies to reduce. Emphasis of early mobilisation should not drive the surgeon towards the motive of rigid fixation of columns alone, as the inadequate reduction of acetabular impaction leads to loss of mechanical support on weight bearing and thereby cause loss of reduction. Bone grafting either by auto or allograft or graft substitutes in the void after disimpaction helps in reducing anatomically and provide mechanical support adequately. In cases of severe comminution, reconstruction of the wall defect with autologous graft is a better treatment option. In this article we reviewed the characteristics of impaction injuries of acetabulum exploring surgical procedures, approaches and techniques for achieving open reduction and internal fixation.

High-Grade Posterolateral Tibial Plateau Impaction Fractures in the Setting of a Primary Anterior Cruciate Ligament Tear Are Correlated With an Increased Preoperative Pivot Shift and Inferior Postoperative Outcomes After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Impaction fractures of the posterolateral tibial plateau have been previously described to occur in association with anterior cruciate ligament (ACL) tears; however, the effect of these injuries on patient-reported outcomes (PROs) after ACL reconstruction (ACLR) is not well known. PURPOSE: (1) To assess the effect of posterolateral tibial plateau impaction fractures on preoperative clinical knee stability assessed by the Lachman and pivot-shift examinations and (2) to assess the effect of impaction fractures on PROs after ACLR. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients undergoing ACLR for primary ACL tears with available magnetic resonance imaging (MRI) scans were included in this study. MRI scans were reviewed for the presence of posterolateral tibial plateau impaction fractures, which were classified according to the morphological variant. Associations with clinical laxity determined by an examination under anesthesia were assessed using binary logistic regression. Also, 2-year postoperative PROs (12-Item Short Form Health Survey [SF-12] Mental Component Scale and Physical Component Scale [PCS], Lysholm, Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Tegner scores) were modeled using multiple ordinal logistic regression to assess the effect of posterolateral tibial plateau impaction fracture classification while adjusting for other covariates. Pearson correlation coefficients (PCCs) were used to assess for correlations between postoperative PROs and the amount of tibial plateau bone loss present. RESULTS: Displaced posterolateral tibial plateau impaction fractures were present in 407 (49.3%) of 825 total knees included in this study. Knees with type IIIB impaction fractures had an increased likelihood of having a high-grade pivot shift (odds ratio, 2.3; P = .047), with no other impaction fracture types showing a significant association. There were no significant associations between posterolateral tibial plateau impaction fracture type and a higher Lachman grade. Of the 599 eligible knees with 2-year follow-up, postoperative information was obtained for 419 (70.0%). Patients improved in all PROs at a mean of 3.0 years after ACLR (P < .001). Multiple ordinal logistic regression demonstrated a posterolateral tibial plateau impaction fracture as an independent predictor of the postoperative Lysholm score, with higher grade impaction fractures showing decreased Lysholm scores. Pearson correlation testing demonstrated weak but statistically significant correlations between sagittal bone loss of posterolateral tibial plateau impaction fractures and SF-12 PCS (PCC = -0.156; P = .023), WOMAC total (PCC = 0.159; P = .02), Lysholm (PCC = -0.203; P = .003), and Tegner scores (PCC = -0.151; P = .032). CONCLUSION: When classified into distinct morphological subtypes, high-grade posterolateral tibial plateau impaction fractures were independently associated with decreased postoperative outcomes after ACLR when controlling for other demographic or clinical variables. Patients with large depression-type posterolateral tibial plateau impaction fractures (type IIIB) had an increased likelihood of having high-grade pivot-shift laxity on clinical examination under anesthesia.

Incidence of Displaced Posterolateral Tibial Plateau and Lateral Femoral Condyle Impaction Fractures in the Setting of Primary Anterior Cruciate Ligament Tear.

BACKGROUND: Bone bruising of the posterolateral tibial plateau and the lateral femoral condyle sulcus terminalis has a well-established association with anterior cruciate ligament (ACL) tears. Impaction fractures of the femur and tibia may occur in these locations; however, there is a paucity of literature describing these fractures. PURPOSE: The primary objective was to quantify the incidence, size, and location of impaction fractures of the posterolateral tibial plateau and lateral femoral condyle in patients with primary ACL tears. The secondary objective was to investigate the association between impaction fractures and concomitant meniscal and ligamentous injuries. STUDY DESIGN: Case series; Level of evidence 4. METHODS: Patients with available magnetic resonance imaging (MRI) scans who were treated for primary ACL tear by a single surgeon were identified. MRI scans were reviewed with denotation of posterolateral tibial and femoral condylar contusions and displaced impaction fractures. Measurements of the lateral tibial plateau were taken in all patients with displaced lateral tibial plateau fractures and in a subset of control patients without tibial plateau fracture present to characterize the size and location of the bony lesion. Associations of impaction fractures with concomitant meniscal or ligamentous injuries were evaluated through use of chi-square testing. RESULTS: There were 825 knees identified with available MRI scans. Lateral tibial plateau bone bruising was present in 634 knees (76.8%), and lateral femoral condyle bone bruising was present in 407 knees (49.3%). Posterolateral tibial plateau impaction fractures were present in 407 knees (49.3%), and lateral femoral condylar impaction fractures were present in 214 knees (25.9%). Patients with posterolateral tibial plateau impaction fractures were older than patients without these fractures (42.6 vs 32.7 years; P < .001), whereas patients with lateral femoral condylar impaction fractures were younger (23.8 vs 32.7 years; P < .001). There were 71 knees (8.6%) with a posterolateral tibial plateau impaction fracture with greater than 10% loss of lateral tibial plateau depth, and this group had an increased incidence of lateral meniscus posterior root tears (22.1% vs 12.0%; P = .02). CONCLUSION: Posterolateral tibial plateau impaction fractures occurred with a high incidence (49.3%) in patients with primary ACL tears and demonstrated an increased association with lateral meniscus posterior horn root tears as their size increased. Lateral femoral condylar impaction fractures occurred in 25.9% of patients with primary ACL tears and entailed an increased incidence of lateral meniscal tears and medial meniscal ramp lesions.

Morphologic Variants of Posterolateral Tibial Plateau Impaction Fractures in the Setting of Primary Anterior Cruciate Ligament Tear.

BACKGROUND: Impaction fractures of the posterolateral tibial plateau commonly occur in the setting of anterior cruciate ligament (ACL) tears, with considerable variability found in fracture size and morphologic features. PURPOSE: The primary objective was to characterize different morphologic variants of posterolateral tibial plateau impaction fractures. The secondary objective was to investigate the association between these impaction fracture variants and concomitant meniscal and ligamentous injuries. STUDY DESIGN: Cross-sectional study; Level of evidence 3. METHODS: Patients treated for primary ACL tears and having magnetic resonance imaging available were included in this study, and magnetic resonance images were reviewed with denotation of displaced posterolateral tibial impaction fractures. A classification system was created based on morphologic variants of impaction fractures; associations were evaluated through use of independent chi-square testing. RESULTS: There were 825 knees meeting the inclusion criteria, with displaced posterolateral tibial plateau impaction fractures present in 407 knees (49.3%). We observed 3 distinct morphologic variants of lateral tibial plateau impaction fractures: (I) posterior cortical buckle not involving the articular surface; (II) posterior impaction fracture involving the articular surface, with subtypes based on (A) tibial plateau depth bone loss <10% and (B) bone loss >10%; and (III) displaced osteochondral fragment, with subtypes for (A) shear or (B) depressed fragment. Type IIIA impaction fractures were associated with an increased incidence of lateral meniscus posterior root tears (33.3% vs 12.4%; P = .009) and an increased incidence of lateral meniscal tears (83.3% vs 56.7%; P = .024) compared with all knees without type IIIA impaction fracture. An increased incidence of medial collateral ligament (MCL) tears was noted in patients with type IIIA impaction fractures compared with those who had no fracture or had another fracture type (61.1% vs 20.1%; P < .001). Type IIIB impaction fractures were associated with an increased incidence of lateral meniscal tears (80.0% vs 56.2%; P = .005). CONCLUSION: A high prevalence of displaced posterolateral tibial plateau impaction fractures occur in the setting of ACL tears, and they can be classified into distinct morphologic subtypes. Posterolateral tibial plateau impaction fractures with displaced depressed or shear fragments were both associated with an increased incidence of lateral meniscal tears, whereas impaction fractures with a shear fragment were associated with an increased incidence of lateral meniscus posterior root tears and MCL tears.

Fate of the lateral femoral notch following early anterior cruciate ligament reconstruction.

BACKGROUND: The goal of this longitudinal study was to investigate the fate of the lateral femoral notch (LFN), which is frequently seen as an impaction fracture of the lateral femoral condyle in patients with anterior cruciate ligament (ACL) tears. METHODS: Patients who underwent early ACL reconstruction between 2006 and 2010 were reviewed. If post-injury magnetic resonance images showed an LFN greater than 1.5 mm in depth, patients with untreated LFN were followed. Two blinded observers performed quantitative and qualitative imaging analysis. RESULTS: Sixteen patients (five women, 11 men) were available for follow-up nine years (six to 10 years) post-injury. The median defect area of the LFN significantly decreased from 2.3 cm2 (range: 0.9-3.8 cm2) to 1.6 cm2 (range: 0.4-3.2 cm2) (P < .001). The defect depth did not significantly change from 2.3 mm (range: 2.0-3.6 mm) to 2.5 mm (range: 1.3-3.6 mm) (P > .05). The International Cartilage Repair Society (ICRS) score increased from 1.5 (range: 0-3) post-injury to 2.0 (range: 0-4) at follow-up (P < .01). The Lysholm score was 93 (72-100), the Tegner activity level was 6 (3-9) and the knee injury and osteoarthritis outcome score (KOOS) score was 97 (91-100). CONCLUSIONS: The defect area of the LFN decreased overtime, whereas the depth of the impression remained. Focal cartilage lesions were found in all except two patients post-injury and progressed during follow-up. However, patient-reported outcome scores were satisfying.

Novel Technique for Femoral Head Reconstruction using Allograft following Obturator Hip Dislocation.

INTRODUCTION: Obturator hip dislocations with an associated osteochondral fracture of the femoral head are uncommon. The treatment of these injuries is challenging and the functional outcomes are poor. Though the injury pattern has been described previously in literature, there are few published reports regarding treatment options. This case report illustrates a novel technique for fixation and stabilization for an unusual injury involving an obturator hip dislocation and an osteochondral impaction fracture of the femoral head. CASE PRESENTATION: A 30-years old African American male, involved in a motor vehicle collision, sustained an obturator dislocation of the left hip with a large posterior osteochondral fracture of the femoral head. An emergency closed reduction procedure was performed followed by a computed tomography (CT) scan of the hip joint which demonstrated a large osteochondral defect (25 x 10 mm, depth: 5 mm) of the femoral head, visualized within the weight-bearing area. Surgical intervention was planned as a fracture of the femoral head with a defect deeper than four millimeters has been shown to be a risk factor for the development of post-traumatic arthritis, often with onset of symptoms within 5 years of the date of injury. Following surgical hip dislocation, the defect of the femoral head was reconstructed with implantation of a femoral head allograft and internal fixation. At the six months follow-up, the patient could ambulate with minimal pain and without assistive devices. Radiographs demonstrated maintenance of articular congruity with no evidence of implant failure, post-traumatic arthritis or avascular necrosis. CONCLUSION: Surgical hip dislocation and reconstruction using femoral head allograft used to treat obturator hip dislocations with concomitant femoral head impaction fractures can lead to satisfactory short term functional outcomes.