Maarten V. Rademakers

Operative treatment of 109 tibial plateau fractures: five- to 27-year follow-up results

Objective: To analyze the long-term (5-27 years) functional and radiologic results of surgically treated fractures of the tibial plateau. Design: Retrospective study. Setting: University hospital. Patients and Methods: Two hundred two consecutive tibial plateau fractures were included in this study. All fractures were classified according to both the AO and the Schatzker classification. There were 112 men and 90 women. The mean age at injury was 46 years (16 to 88). One hundred sixty-three patients had isolated fractures and 39 had multiple fractures. A 1 year follow-up was done in all 202 patients. One hundred nine of these patients also had an additional long-term follow-up visit. Functional results of these 109 patients were graded with the Neer- and HSS-knee scores. Radiologic results were graded with the Ahlbäck score. Statistical analysis was performed by means of the SPSS data analysis program. Results: An uneventful union was present at the 1 year follow-up in 95% of the patients, along with a mean knee ROM of 130 degrees (range, 10-145 degrees). One hundred nine patients had a long-term follow-up visit after a mean period of 14 years (range, 5-27 years). The mean ROM at this time was 135 degrees (range, 0-145 degrees). Functional results showed a mean Neer score of 88.6 points (range, 56-100 points) and a mean HSS score of 84.8 points (range, 19-100 points). Monocondylar fractures showed statistically significant better functional results compared to bicondylar fractures. In 31% of the patients, secondary osteoarthritis had developed but was well tolerated in most (64% of the patients). Patients with a malalignment of more then 5 degrees developed a moderate to severe grade of osteoarthritis statistically significant more often (27% of the patients) compared to patients with an anatomic knee axis (9.2%; MWU, P = 0.02). Age did not appear to have any influence on the results. Conclusion: Long-term results after open reduction and internal fixation for tibial plateau fractures are excellent, independent of the patients age.

Intra-articular fractures of the distal femur - A long-term follow-up study of surgically treated patients

Objective To analyze the long-term (5–25 years) functional and radiologic results of surgically treated intra-articular fractures of the distal femur. Design Retrospective study. Setting University hospital. Patients and Methods Sixty-seven surgically treated consecutive patients with 67 intra-articular distal femoral fractures were included in this study. All fractures were classified according to the AO classification. There were 36 men and 31 women. The mean age at time of accident was 45 years (range 16–94 years). There were 38 patients with isolated fractures and 29 with multiple fractures. Median hospital stay was 23 days (range 12–330 days). A 1-year follow-up was done in all 67 patients. Thirty-two of these patients were also seen for an additional long-term follow-up visit. Functional results of these 32 patients were graded using the Neer and HSS knee scores. Radiologic results were graded using the Ahlbäck score. Statistical analysis was performed by means of the SPSS data analysis program. Results At 1-year follow-up in 40 of 65 patients (62%), the fracture was fully healed, in 22 patients (34%) a fixation callus still existed, and 1 patient had a nonunion. In 2 patients, an arthrodesis was performed. The mean knee range of motion was 111° (range 10–145°). After a mean follow-up of 14 years (range 5–25 years), the mean knee range of motion was 118° (range 10–145°). The Neer score showed good to excellent results in 84% of the patients, and the HSS knee score showed good to excellent results in 75% of the patients. Patients with isolated fractures scored significantly better functionally (Neer/HSS 90 points) compared with those with multiple fractures. The Ahlbäck score showed a moderate to severe development of secondary osteoarthritis in 36% of all patients. Seventy-two percent of these patients still scored a good to excellent functional result. Seven patients (10%) had local complications in the form of a deep wound infection. Five of these patients were treated successfully, whereas 2 had a chronic infection that subsequently led to an arthrodesis. Conclusion Surgical treatment of monocondylar and bicondylar femoral fractures shows good long-term results after open reduction and internal fixation. Knee function increases through time, though the range of motion does not increase after 1 year. The presence of secondary osteoarthritis does not mean less favorable functional results in most patients.

Combined Intra-Articular and Varus Opening Wedge Osteotomy for Lateral Depression and Valgus Malunion of the Proximal Part of the Tibia

BACKGROUND Reconstructive surgical measures for treatment of posttraumatic deformities of the lateral tibial plateau are seldom reported on in the literature. We report the long-term follow-up results of a consecutive series of reconstructive osteotomies performed to treat depression and valgus malunions of the proximal part of the tibia. METHODS From 1977 through 1998, a combination of an intra-articular elevation and a lateral opening wedge varus osteotomy of the proximal part of the tibia was performed in twenty-three consecutive patients. The patients were assessed clinically and radiographically at a minimum of five years postoperatively. RESULTS A correction of the intra-articular depression and the valgus malalignment was achieved and the anatomic lower-extremity axis was restored in all patients. The clinical results were evaluated at a mean of thirteen years (range, two to twenty-six years) after the reconstructive osteotomy. Two patients had an early failure and were considered to have had a poor result. Two other patients had severe progression of osteoarthritis after the osteotomy, four had slight progression, and fifteen had no progression. There were no nonunions. There were two superficial wound infections, which were treated successfully without surgical intervention. According to the scale of Lysholm and Gillquist, the subjective result was excellent for seventeen patients (74%), good for three, fair for one, and poor for two. CONCLUSIONS A knee-joint-preserving osteotomy can provide satisfactory results in active patients with painful posttraumatic lateral depression and valgus malunion of the proximal part of the tibia.

Correction of lateral tibial plateau depression and valgus malunion of the proximal tibia.

ZusammenfassungOperationszielVerbesserung der Gelenkkongruenz bei fehlverheilten Frakturen des lateralen Tibiaplateaus, Schmerzreduktion, Vorbeugung einer Arthrose.IndikationenValgusfehlstellung der proximalen Tibia und damit verbundene intraartikuläre Impression des TibiaplateausKontraindikationenPatienten in schlechtem Allgemeinzustand.Hochgradiges Defizit der Kniegelenkfunktion.Patientenalter > 65 Jahre.Chronische Infektion.Weichteilprobleme.Unfähigkeit des Patienten, die Extremität nach der Operation abrollend zu belasten.OperationstechnikTangentiale Osteotomie des mittlerer Fibuladrittels. Gerader lateraler oder parapatellarer Zugang zur lateralen proximalen Tibia. Laterale Arthrotomie des Kniegelenks. Proximale keilförmige öffnende („open wedge‘ Osteotomie der Tibia. Intraartikuläre Korrektur der Impression des lateralen Tibiakondylus durch subchondrales Einstößeln von Spongiosa. Beurteilung der Achsenverhältnisse des Beins. Interposition kortikospongiöser Knochentransplantate zur Stützung der öffnenden Osteotomie. Bei Bedarf interne Fixation.WeiterbehandlungKontinuierliche passive Bewegung bis 90° Flexion ab dem 1. postoperativen Tag. Nach Anlage einer stabilisierenden Schiene dürfen die Patienten 8 Wochen abrollend mobilisieren. Nach radiologischer Knochenheilung schrittweiser Aufbau der Belastung. ErgebnisseZwischen 1977 und 1998 wurden 23 Patienten operiert. Zwei Fehlschläge waren zu verzeichnen, wovon einer in einer Arthrodese und der andere in einem totalen Gelenkersatz mündete. Nach durchschnittlich 14 Jahren (5–6 Jahre) wurden 21 Patienten nachuntersucht. Zwei Patienten litten unter einer signifikanten Verschlechterung der Arthrose, vier Patienten wiesen eine leicht progrediente Knorpeldegeneration auf, und bei 15 Patienten war das Ausmaß des Gelenkverschleißes unverändert. Durchschnittlich konnten der tibiofemorale Winkel um 8,6° (13–14,4°), die Tibiakopfimpression um 6 mm (4–9 mm) und der Bewegungsumfang um 12° (0–20°) verbessert werden. Pseudarthrosen fanden sich nicht.AbstractObjectiveImprovement of joint congruency in malunited lateral tibial plateau fractures, reduction of pain, prevention of osteoarthritis.IndicationsValgus malalignment of the proximal tibia combined with intraarticular depression of the tibial plateau.ContraindicationsPatients in poor general condition.Severe loss of knee functionElderly patients (> 65 years).Chronic infection.Soft-tissue problems,Inability to perform non-weight bearing after the operationSurgical TechniqueOblique osteotomy of the middle third of the fibula. Straight lateral or parapatellar approach to the lateral proximal tibia. Lateral arthrotomy of the knee joint. Proximal open wedge osteotomy of the tibia. Intraarticular correction of the depressed lateral tibial plateau through subchondral impaction of cancellous bone grafts. Evaluation of leg alignment. Interposition of bicorticocancellous bone grafts to maintain the open wedge osteotomy. Internal fixation, if necessary.Postoperative ManagementContinuous passive motion to 90° of flexion from the 1st postoperative day. After application of a stabilizing brace, patients are allowed toe-touch weight bearing for 8 weeks. After radiologic bony healing has occurred, patients are allowed to increase weight bearing stepwise.ResultsBetween 1977 and 1998, 23 patients were operated on. There were two failures resulting in one arthrodesis and one total knee arthroplasty. After an average of 14 years (5–6 years) 21 patients were followed up. Two patients suffered from severe progression of osteoarthritis after the osteotomy, four had some progression of cartilage degeneration, and 15 presented without changes in osteoarthritis. Mean difference in pre- and postoperative tibiofemoral angle was 8.6° (range 13–4.4°), mean difference in pre- and postoperative depression 6 mm (range 4–9 mm), and mean difference in pre- and postoperative range of motion 12° (range 0–20°). There were no nonunions.

Combined intra-articular and varus opening wedge osteotomy for lateral depression and valgus malunion of the proximal part of the tibia. Surgical technique.

BACKGROUND Reconstructive surgical measures for treatment of posttraumatic deformities of the lateral tibial plateau are seldom reported on in the literature. We report the long-term follow-up results of a consecutive series of reconstructive osteotomies performed to treat depression and valgus malunions of the proximal part of the tibia. METHODS From 1977 through 1998, a combination of an intra-articular elevation and a lateral opening wedge varus osteotomy of the proximal part of the tibia was performed in twenty-three consecutive patients. The patients were assessed clinically and radiographically at a minimum of five years postoperatively. RESULTS A correction of the intra-articular depression and the valgus malalignment was achieved and the anatomic lower-extremity axis was restored in all patients. The clinical results were evaluated at a mean of thirteen years (range, two to twenty-six years) after the reconstructive osteotomy. Two patients had an early failure and were considered to have had a poor result. Two other patients had severe progression of osteoarthritis after the osteotomy, four had slight progression, and fifteen had no progression. There were no nonunions. There were two superficial wound infections, which were treated successfully without surgical intervention. According to the scale of Lysholm and Gillquist, the subjective result was excellent for seventeen patients (74%), good for three, fair for one, and poor for two. CONCLUSIONS A knee-joint-preserving osteotomy can provide satisfactory results in active patients with painful posttraumatic lateral depression and valgus malunion of the proximal part of the tibia.

Tibial spine fractures: a long-term follow-up study of open reduction and internal fixation

Objective: To analyze the long-term (5-27 years) functional and radiologic results of surgically treated tibial spine fractures. Design: Retrospective cohort study. Setting: University hospital. Patients and Methods: Forty-four surgically treated consecutive patients with 44 displaced tibial spine fractures were included in this study. All fractures were classified according to a modified Meyers and McKeever classification. There were 24 men and 20 women. The mean age at time of accident was 24 years (range 9-57 years). Sixteen patients had an open physis at the time of trauma. There were 36 patients with isolated fractures and 8 with multiple fractures. All patients were seen for a 1-year follow-up, and 37 patients (84%) were seen for a long-term follow-up visit. Functional results of these 37 patients were graded using the Lysholm, SF-36, and the Western Ontario and McMaster Universities scores. Radiologic results were graded using the Ahlbäck score. Results: At 1-year follow-up, in all 44 patients, the fracture was fully healed. One patient (3%) needed revision of the osteosynthesis due to hardware failure, and in 1 patient (3%), a deep infection (purulent arthritis) developed that was treated by surgical irrigation. The median knee range of motion (ROM) after 1 year was 125 degrees (range 110-140 degrees). The ROM did not change significantly at long term. After a mean follow-up of 16 years (range 5-27 years), the median knee ROM was 130 degrees (range 115-140 degrees). As measured with an objective testing device, no statistically significant difference of anteroposterior stability between the injured and uninjured legs was found, with a mean difference of 1 mm (range −3.9 to 6.9 mm). The Lysholm score showed good to excellent results in 86% of the patients; the Western Ontario and McMaster Universities score showed a mean of 93 (range 40.63-100) points. The mean SF-36 general health score was 77 (24-99). The Ahlbäck score showed a moderate development of secondary osteoarthritis in 2 of the 37 patients (5%). The 16 patients with an open physis at the time of the operation did not develop axial malalignment at long term. Conclusions: Surgical treatment of tibial spine fractures offers the possibility to regain full stability of the knee joint and good long-term results after open reduction and internal fixation with low infection rates. Knee function is adequately restored in most patients with a minimal risk of developing secondary osteoarthritis.

Korrekturosteotomie bei lateraler Tibiakopfimpression und Valgusfehlstellung Correction of Lateral Tibial Plateau Depression and Valgus Malunion of the Proximal Tibia

ZusammenfassungOperationszielVerbesserung der Gelenkkongruenz bei fehlverheilten Frakturen des lateralen Tibiaplateaus, Schmerzreduktion, Vorbeugung einer Arthrose.IndikationenValgusfehlstellung der proximalen Tibia und damit verbundene intraartikuläre Impression des TibiaplateausKontraindikationenPatienten in schlechtem Allgemeinzustand.Hochgradiges Defizit der Kniegelenkfunktion.Patientenalter > 65 Jahre.Chronische Infektion.Weichteilprobleme.Unfähigkeit des Patienten, die Extremität nach der Operation abrollend zu belasten.OperationstechnikTangentiale Osteotomie des mittlerer Fibuladrittels. Gerader lateraler oder parapatellarer Zugang zur lateralen proximalen Tibia. Laterale Arthrotomie des Kniegelenks. Proximale keilförmige öffnende („open wedge‘ Osteotomie der Tibia. Intraartikuläre Korrektur der Impression des lateralen Tibiakondylus durch subchondrales Einstößeln von Spongiosa. Beurteilung der Achsenverhältnisse des Beins. Interposition kortikospongiöser Knochentransplantate zur Stützung der öffnenden Osteotomie. Bei Bedarf interne Fixation.WeiterbehandlungKontinuierliche passive Bewegung bis 90° Flexion ab dem 1. postoperativen Tag. Nach Anlage einer stabilisierenden Schiene dürfen die Patienten 8 Wochen abrollend mobilisieren. Nach radiologischer Knochenheilung schrittweiser Aufbau der Belastung. ErgebnisseZwischen 1977 und 1998 wurden 23 Patienten operiert. Zwei Fehlschläge waren zu verzeichnen, wovon einer in einer Arthrodese und der andere in einem totalen Gelenkersatz mündete. Nach durchschnittlich 14 Jahren (5–6 Jahre) wurden 21 Patienten nachuntersucht. Zwei Patienten litten unter einer signifikanten Verschlechterung der Arthrose, vier Patienten wiesen eine leicht progrediente Knorpeldegeneration auf, und bei 15 Patienten war das Ausmaß des Gelenkverschleißes unverändert. Durchschnittlich konnten der tibiofemorale Winkel um 8,6° (13–14,4°), die Tibiakopfimpression um 6 mm (4–9 mm) und der Bewegungsumfang um 12° (0–20°) verbessert werden. Pseudarthrosen fanden sich nicht.AbstractObjectiveImprovement of joint congruency in malunited lateral tibial plateau fractures, reduction of pain, prevention of osteoarthritis.IndicationsValgus malalignment of the proximal tibia combined with intraarticular depression of the tibial plateau.ContraindicationsPatients in poor general condition.Severe loss of knee functionElderly patients (> 65 years).Chronic infection.Soft-tissue problems,Inability to perform non-weight bearing after the operationSurgical TechniqueOblique osteotomy of the middle third of the fibula. Straight lateral or parapatellar approach to the lateral proximal tibia. Lateral arthrotomy of the knee joint. Proximal open wedge osteotomy of the tibia. Intraarticular correction of the depressed lateral tibial plateau through subchondral impaction of cancellous bone grafts. Evaluation of leg alignment. Interposition of bicorticocancellous bone grafts to maintain the open wedge osteotomy. Internal fixation, if necessary.Postoperative ManagementContinuous passive motion to 90° of flexion from the 1st postoperative day. After application of a stabilizing brace, patients are allowed toe-touch weight bearing for 8 weeks. After radiologic bony healing has occurred, patients are allowed to increase weight bearing stepwise.ResultsBetween 1977 and 1998, 23 patients were operated on. There were two failures resulting in one arthrodesis and one total knee arthroplasty. After an average of 14 years (5–6 years) 21 patients were followed up. Two patients suffered from severe progression of osteoarthritis after the osteotomy, four had some progression of cartilage degeneration, and 15 presented without changes in osteoarthritis. Mean difference in pre- and postoperative tibiofemoral angle was 8.6° (range 13–4.4°), mean difference in pre- and postoperative depression 6 mm (range 4–9 mm), and mean difference in pre- and postoperative range of motion 12° (range 0–20°). There were no nonunions.

Continuous Local Infiltration Analgesia after TKA: A Meta-Analysis.

The analgesic effect of local infiltration analgesia (LIA) after total knee arthroplasty (TKA) has been reported to be less than 24 hours. The concept of continuous LIA (CLIA) has been developed to achieve prolonged analgesia by bolus injections or by pump infusion of analgesics. The purpose of this meta-analysis is to assess the effect of CLIA versus single-shot injection LIA (SLIA) and placebo on pain after TKA.A systematic search was performed in most relevant databases to identify all randomized controlled trials (RCTs) comparing intra-articular CLIA with SLIA or placebo for TKA. Primary outcome measures were visual analogue scale (VAS)-scores after 24, 48, and 72 hours at rest and during activity. Data were extracted for meta-analysis and pooled using Cochrane software. The results of comparable studies were pooled using the fixed effects model or random effects model.A total of 11 RCTs were included. Five articles were eligible for meta-analysis comparing CLIA versus placebo, involving 227 TKAs. VAS scores at rest 24 hours after surgery were in favor of CLIA with a decrease of pain scores of 46%. On the second and third postoperative day, the decrease in VAS scores was no longer significant. During activity VAS scores were also in favor of CLIA after 24 and 48 hours.Two studies were eligible for meta-analysis comparing CLIA versus SLIA. VAS scores at rest, 48 hours after surgery, were in favor of CLIA. CLIA can possibly provide a reduced pain perception for 24 hours postoperative at rest after performing a TKA. This effect may persist until 48 hours postoperative during activity. Due to the high level of heterogeneity no firm further conclusions can be drawn.

No effect of double nerve block of the lateral cutaneous nerve and subcostal nerves in total hip arthroplasty: A randomized controlled trial

Background and purpose — The use of local infiltration anesthesia (LIA) has become one of the cornerstones of rapid recovery protocols in total knee arthroplasty patients during the past decade. In total hip arthroplasty (THR), however, the study results are more variable and LIA has therefore not yet been generally accepted. There is no consensus on which structure should be infiltrated and the cutaneous nerves are generally neglected. Hence, we hypothesized a pain-reducing effect of specifically blocking these nerves. Patients and methods — We performed a single-center randomized placebo-controlled trial in 162 subjects to evaluate the infiltration of the lateral cutaneous femoral and subcostal nerve with ropivacaine in patients undergoing total hip arthroplasty via a straight lateral approach. The primary endpoint was pain at rest after 24 hours. Patients were followed up to 6 weeks postoperatively. Results — After correction for multiple testing, no statistically significant differences in pain scores were found between the ropivacaine compared with the placebo group after surgery. In addition, no differences were observed in the use of escape pain medication, complications, and the length of hospital stay. Interpretation — We found no clinically meaningful differences in pain scores between placebo and ropivacaine patients in the postoperative period after THA performed via a straight lateral approach under spinal anesthesia and a multimodal pain regimen. Moreover, our primary endpoint, pain reduction after 24 hours, was not met. Further research should focus on the composition and volume of the LIA suspension, the optimal localization of the infiltration, and should be evaluated for every surgical approach separately.

Bilateral Scapulohumeral Ankylosis after Prolonged Mechanical Ventilation

This case demonstrates a rarely reported bilateral scapulohumeral bony ankylosis. A young woman developed extensive heterotopic ossifications (HOs) in both shoulder joints after being mechanically ventilated for several months at the intensive care unit in a comatose status. She presented with a severe movement restriction of both shoulder joints. Surgical resection of the bony bridges was performed in 2 separate sessions with a significant improvement of shoulder function afterwards. No postoperative complications, pain, or recurrence of HOs were noted at 1-year follow-up. Mechanical ventilation, immobilization, neuromuscular blockage, and prolonged sedation are known risk factors for the development of HOs in the shoulder joints. Relatively early surgical resection of the HOs can be performed safely in contrary to earlier belief. Afterwards, nonsteroidal anti-inflammatory drugs and/or radiation therapy can be possible treatment modalities to prevent recurrence of HOs.