Knee Surg Sports Traumatol Arthrosc (2009) 17:1406–1411 DOI 10.1007/s00167-009-0726-z
KNEE
The use of b-TCP in the surgical treatment of tibial plateau fractures Chao Shen Æ Jie Ma Æ Xiao-Dong Chen Æ Li-Yang Dai
Received: 31 August 2008 / Accepted: 16 January 2009 / Published online: 24 February 2009 Ó Springer-Verlag 2009
Abstract The objective of this study was to evaluate the outcome of using b-TCP in the treatment of depression tibial plateau fractures. A total of 124 patients with depression tibial fractures were included in this study and followed for a minimum of 12 months. All the cases were treated with open reduction and internal fixation, and grafted with b-TCP ceramic. The clinical and radiological outcomes were assessed using Hospital for Special Surgery (HSS) score of knee and Rasmussen score during the follow-up. No obvious redisplacement was found at the follow-up assessment. Most of the patients had excellent HSS score and Rasmussen clinical score. Bone healing was noted in all fractures and Schatzker II-type fractures had the best functional outcome. The results suggested that using b-TCP combined with open reduction and rigid internal fixation was an effective treatment for depression fractures of the tibial plateau. Keywords Tibial plateau fractures Bone substitutes b-TCP Operative treatment Outcome
C. Shen J. Ma Department of Orthopaedic Surgery, Shanghai Jiaotong Universtiy School of Medicine, Shanghai, China X.-D. Chen (&) L.-Y. Dai (&) Xinhua Hospital, 1665 Kongjiang Road, 200092 Shanghai, China e-mail:
[email protected] L.-Y. Dai e-mail:
[email protected]
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Introduction Since fractures of the tibial plateau involve a major weightbearing joint, it would be an optimal choice to restore joint congruity and therefore to preserve normal function of the knee. However, depression tibial plateau fractures always pose a challenge to orthopedic surgeons because the fractures are often associated with the loss of intact joint surface, which will lead to late osteoarthritis and therefore significant disability [9]. In a prospective study by Rasmussen et al. [26], osteoarthritis was noted in 17% of the patients who had been managed with open reduction and internal fixation. Autograft or allograft has been widely used to fill the bone defect and to maintain joint stability in clinical practice since the last century [13]. Now autograft is accepted as the golden standard for surgical treatment of depression tibial plateau fractures [20, 28]. Schatzker et al. [27] reported a series of 70 tibial plateau fractures treated nonoperatively or operatively with an average follow-up of 28 months. As much as 78% of acceptable results were achieved in 41 operative patients of whom 35 received bone grafting as compared with 58% in the non-operative group. Segal et al. [28] noted satisfactory outcomes after using bone grafting augmented with internal fixation in severe depression tibial plateau fractures. However, autograft or allograft may be associated with donor site morbidity or infection, thus resulting in the investigation of new bone substitutes. Recently, biocompatible bone substitutes have been used as the alternative to bone grafting for treating depression tibial plateau fractures [12, 32]. Tricalcium phosphate (TCP) is believed to be reliably osteoconductive and resorbable as it works as the carrier of growth factors or scaffold for the mesenchymal stem cells when used for bone regeneration [19]. This property of
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TCP has been proved in spine fusion surgery [5]. Some authors [3, 7, 11] reported satisfactory results of using b-TCP to repair bone defect in reconstructive surgery of orthopedic trauma, but few reports have documented the use of TCP in the treatment of tibial plateau fractures. The objective of the present study was to evaluate prospectively the clinical and radiological outcomes of using b-TCP in the treatment of depression tibial plateau fractures.
expose the medial joint surface. The depressed fragments were elevated with the aid of fluoroscopy until the articular surface was reduced anatomically and temporarily maintained by K-wires [2]. After cleaning the debris and blood clots, the commercially available b-TCP ceramic granules (BioLu) were grafted into the area of cancellous defect and impacted. Internal fixation was achieved by a standard proximal tibial plate (n = 47) or a buttress plate (n = 77; Synthes, Philadelphia). The wound was closed with a drainage, which was removed within the following 48 h.
Materials and methods Postoperative management A total of 130 consecutive patients who sustained depression tibial plateau fractures between January 2002 and June 2006 were included in this study. During the follow-up, no patient was lost and all the patients were followed for no less than 12 months (mean 18.2 ± 6 months, range, 12– 37 months). There were 41 female and 83 male patients. The mean age of the patients was 47 (range, 15–85) years. The diagnosis was made based on the results of plain radiographs in the anteroposterior and lateral views as well as computed tomographic scan, according to Schatzker classification [27]. Any case that was associated with open fracture, cruciate ligament injury or primary knee joint disease, or underwent previous knee joint surgery was excluded from the study (six patients were excluded from the current study, four for open fractures and two for dislocation of the knee joint). Thus, there were 73 patients with Schatzker type II fractures (58.87%), 34 with type V fractures (27.42%) and 17 with type VI fractures (13.71%) in the series (Table 1). The study was approved by the Institutional Ethical Review Committee and informed consent was obtained from all patients. Before surgery, all patients underwent the same medical care, which included elevation of the affected extremities with temporary fixation, soft tissue care and analgesia.
Evaluation Rasmussen radiological score (Table 2) [26] was measured after the surgery. All the patients were followed up clinically and radiologically 1, 3, 6 and 12 months after the surgery, and annually thereafter. Functional outcome was assessed by the Hospital of Special Surgery (HSS) score of knee (Table 3) [25] and Rasmussen clinical score (Table 4) [26] during the follow-up. The integrity of articular surface was determined by using standard anteroposterior and
Table 2 Criteria for radiologic assessment of Rasmussen scoring system Parameter
Points
Depression
Surgical technique All patients underwent open reduction and internal fixation within 1 week of injury. The fractures were approached with an anterolateral incision. In Schatzker type V or VI fractures, an additional medial incision was needed to
Table 1 Demography of the patients included Fracture type
All patients underwent postoperative continuous passive motion during hospitalization. Weight-bearing was forbidden until 6 weeks after surgery. Then the patients were allowed limited weight-bearing with the use of crutches or walkers only after fracture healing was confirmed radiologically.
None
6
\6 mm
4
6–10 mm
2
[10 mm
0
Condylar widening None \6 mm
6 4
6–10 mm
2
[10 mm
0
Number of cases
Mean age (years)
Gender (M/F)
Angulation (valgus/varus)
Schatzker type II
73
45.3 ± 16.1
47/26
\10°
4
Schatzker type V
34
49.5 ± 15.6
21/13
10°–20°
2
Schatzker type VI
17
49.5 ± 10.7
15/2
[20°
0
None
Excellent
Good
Fair
Poor
6
4
2
0
6
4
2
0
6
4
2
0
6
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Table 3 HSS score of knee Subject
Score
Clinical parameter
Pain, 30 points No pain at any time
30
No pain on walking
15
Mild pain on walking
10
Moderate pain on walking Severe pain on walking No pain at rest Mild pain at rest Moderate pain at rest Severe pain at rest
5 0 15 10 5 0
Walking distance of five to ten blocks and standing ability intermittent (more than half an hour) Walking one to five blocks and standing ability up to half an hour
Points Excellent Good Fair Poor
Subjective Pain None
6
Occasional pain, needs no medication
5
Stabbing pain
4
Intense, activity related
2
Night pain, at rest
0
Walking capacity Normal
6
12
Outdoors [1 h
4
10
Outdoors \15 min
2
Indoors only
1
Wheelchair/bedridden
0
Function, 22 points A. Unlimited walking and standing
Table 4 Criteria for clinical assessment of Rasmussen scoring system
8 4
Extension
Cannot walk
0
Normal
6
B. Climb stairs
5
\10° loss
4
Climb stairs with support
2
2
Transfer activity
5
[10° loss Total range of motion
Transfer activity with support
2
[140°
6
[120°
5
[90°
4
[60°
2
[30°
1
0°
0
ROM, 18 points 1 point for each 8°of arc of motion, maximum of 18 points Muscle strength, 10 points 10
Good, can break quadriceps power
8
Fair, moves through arc of motion
4
Stability
Poor, cannot move through arc of motion
0
Normal
Flexion deformity, 10 points No deformity
Abnormal in 20° flexion
5
Instability in extension \10°
4
Few degrees
8
Instability in extension [10°
2
5–10°
5
11° or more
0
Instability, 10 points 10
Mild, 0–5°
8
Moderate, 6–15°
5
Severe, 16° or more
0
Subtract 1 point for using a cane, 2 points for one crutch and 3 points for two crutches; 2 points for 5°of extension lag, 3 points for 10° and 5 points for 15°or more. One point for 5° valgus and varus deformities
lateral views of plain radiographs, with any displacement more than 5 mm of the joint surface recorded. The resorption of the b-TCP granules was defined as the decrease in the size and density of grafting on radiographs (Fig. 1).
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2
0
6
4
2
1
6
4
2
2
5
4
2
1
5
4
2
2
6
10
No
4
Objective
Walk less than one block
Good, cannot break quadriceps power
5
Results All patients underwent surgery within 1 week of injury. The average operative time was 68 min (range 50–80 min). There were no intra-operative complications. Post-operatively, one patient suffered from superficial wound infection and the wound soon resolved with antibiotic care and local debridement. No deep infection or skin irrigation was found in all the patients. No hardware failure was noted during the follow-up. Functional outcome Clinically, the average HSS score of knee was 91.8 ± 4.0 in Schatzker type II fractures, 82.7 ± 4.8 in type V
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Fig. 1 A 48-years-old male patient with a Schatzker V type fracture. a Before surgery. b After 3 months, the fracture line disappeared and the patient began full weight-bearing. c The fracture healed and the patient had restored full range of motion without pain, 1 year after surgery
fractures and 78.2 ± 6.2 in type VI fractures. In all the 124 patients, 81 (65.3%) cases had excellent grade, 37 (29.8%) cases had good grade, and 6 (4.8%) had fair grade. The average Rasmussen clinical score was 87.4 ± 4.3 (range, 66–98) and the results were excellent in 42 cases (33.9%), good in 78 (62.9%) and fair in 4(3.2%). The results of the functional outcome are listed in Table 5.
6–12 months). No valgus deviation or obvious collapse of joint surface was present in the weight-bearing radiographs in any case, and there was no early sign of osteoarthritis in all the patients at the last follow-up.
Radiological results
The knee joint is the major weight-bearing joint of the body and tibial plateau fractures are frequently followed by cartilage degeneration and posttraumatic arthritis [2, 21, 23]. The reconstruction of joint surface has always been recommended for achieving good clinical outcome. Lansinger et al. [16] in a 20-year follow-up study of depression tibial plateau fractures found that good to excellent functional outcomes were obtained with a depression of less than 10 mm. Thus, autograft or allograft was frequently required to maintain the reduction during the reconstruction of the
According to Rasmussen radiological score, 42 (33.9%) patients were rated as excellent, 78 (62, 9%) as good and 4 (3.1%) as fair at final follow-up examination. Fracture healing was confirmed in all the patients at 6 months after injury. Degradation of TCP ceramic granules was observed radiologically 3 months after surgery. Resorption of TCP ceramic was observed on the radiographs in the majority of the patients at 10 months after grafting (range,
Discussion
Table 5 Functional outcome of 124 patients HSS score of knee
Rasmussen score of knee
Rasmussen reduction index
Type II (n = 73)
91.8 ± 4.0
26.7 ± 2.0
16.3 ± 1.2
Type V (n = 34)
82.7 ± 4.8
23.6 ± 2.2
13.7 ± 1.7
Type VI (n = 17)
78.2 ± 6.2
22.2 ± 2.0
12.7 ± 1.7
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integrity of the joint surface [4, 18, 33]. Despite the good outcomes, the use of autograft and allograft has been associated with some complications, such as postoperative donor site pain and infection. [1, 18, 33]. Accordingly, biocompatible bone substitutes have been used as an alternative method. Using calcium phosphate as the bone substitute, in the treatment of depression tibial plateau fractures, have been widely recommended recently [15, 17, 29–31]. Horstman et al. [10] reported the use of injectable calcium phosphate cement to treat 14 depression tibia plateau fracture cases under arthroscopic and fluoroscopic control. All patients were followed up for 28 months and the functional outcome was good or excellent in 12 cases. Lobenhoffer et al. [22] also reported the use of injectable calcium phosphate cement for treating 26 unstable depression tibial plateau fractures. Two of these cases developed partial reduction loss of the fractures between 4 and 8 weeks after surgery, and revision surgery was required in one case. The author concluded that injectable mineral bone cement with high initial mechanical strength could be used to fill bone defects in unstable tibial plateau fractures with good success. However, the degradation of calcium phosphate cement is slow, which will result in longer term integration of host bone when compared with TCP ceramic [6, 8, 15, 29, 31]. The porous scaffold structure of TCP ceramic can provide bone ingrowth environment by osteoconduction. Also, the porosity of TCP enhances the fluid flow and blood diffusion, thus improving cell-mediated resorption and local metabolic rate [8, 14]. In the current study, the clinical result was similar to or better than those from the reports of using calcium phosphate cement as the bone substitute. A reduction loss rate of 16–23% was noted in these studies [14, 29]. Two factors may attribute, we believe, to the satisfactory results of this study. One was that no weightbearing was allowed until 6 weeks after the surgery as TCP ceramic has weak stiffness when compared with calcium phosphate cement [8, 19, 29]. Early full weight-bearing would increase the risk of re-collapse of the joint surface. Another factor might be that all fractures were well reduced and rigidly fixed. Rigid fixation would provide sufficient support for the TCP granules at an early stage of fracture healing. Partial weight-bearing was encouraged 6 weeks after surgery to accelerate the resorption and osteoconduction of b-TCP as proved in an animal model [24]. In this study, calcium phosphate ceramic proved to be an effective alternative method of tibial plateau fracture treatment. During the follow-up, all fracture lines disappeared radiologically at 6 months and the density of b-TCP decreased progressively, suggesting that b-TCP could facilitate bone ingrowth with good biocompatibility. Only one patient had complications with superficial infection that was soon under control after local care and no further
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treatment was needed. No obvious redisplacement was found in any case in the study. Most of the patients (95.2%) had excellent or good results as assessed by HSS score of knee with no early osteoarthritis signs on radiographs. In general, the clinical outcome suggested that TCP showed effectiveness in the treatment of depression tibial plateau fractures with reduction and internal fixation, compared with autograft [27]. To the best of our knowledge, no report has focused on using b-TCP ceramic as the bone ceramic for treating depression tibial plateau fractures. The limitation of this study might be that although fracture healing was obtained, the time of follow-up was relatively short. However, the results are encouraging with satisfactory functional outcome and radiological evidence. In conclusion, this study proved that b-TCP, augmented with rigid internal fixation, achieved satisfactory functional outcome and reliable radiological results in depression tibial plateau fractures. Furthermore, the complications of bone harvesting site can be avoided by using b-TCP for grafting. We suggest the use of b-TCP as an alternative method for autograft in the treatment of depression tibial plateau fractures. Acknowledgments This study was supported by the Science and Technology Commission of Shanghai Municipality (No. 04419626).
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