Treatment of tibial plateau fractures by modified posterior medial approach

doi:10.21203/rs.3.rs-1887259/v1

Purpose

To report the effect of posterior medial approach preserving pes anserinus in the treatment of tibial plateau fracture.

Method

Patients who underwent surgery in a large hospital due to tibial plateau fractures from December 2013 to January 2021 were retrospectively analyzed.These patients underwent a posteromedial approach preserving the pes anserinus and a traditional posteromedial approach.The general information, fracture classification, preoperative and postoperative conditions of the patients were recorded and compared. HSS score and VAS score were used to evaluate knee function and pain respectively.

Result

All patients were followed for more than 1 year.In general, there were no statistically significant differences to the baseline demographic factors between the two groups.The patients in the observation group had longer operation time, more intraoperative bleeding and intraoperative fluoroscopy times, the difference was statistically significant.The observation group had lower VAS scores, either on day 1, day 3 or day 14 after surgery.The observation group had a better HSS score 3 months after operation, and the difference was statistically significant. However, there was no significant difference in HSS score between the two groups one year after operation.Similarly, the patients in the observation group had better knee range of motion 3 months after operation, and the difference was statistically significant. However, there was no significant difference in HSS score between the two groups one year after operation.

Conclusion

In conclusion, compared with the traditional posteromedial approach, the modified posteromedial approach with pes anserinu preserved can significantly reduce soft tissue injury in the operative area, relieve early postoperative pain, and improve early knee range of motion.

Tibial plateau fracture is a very common fracture. Severe displaced tibial plateau fractures often require surgical intervention.Because the articular surface is often involved, these fractures need to be perfectly reduced.The posteromedial approach is often used for the treatment of medial tibial plateau fractures.During surgery, sometimes the pes anserinus needs to be cut off in order to make the fracture more visible.The pes anserinus is located on the inner side of the proximal tibia and plays a certain role in maintaining the stability of the knee joint[1].At present, there are few reports on whether the preservation of pes anserinus will affect the function of knee joint.The author tries to preserve and record pes anserinus in recent years.And the effect of goose foot retention on postoperative function was recorded.

Study design and patients

We conducted a retrospective study between December 2013 and January 2021. A total of 123 patients with patellar fractures who underwent open reduction at our hospital were enrolled for the study.Patients who conform to the inclusion criteria (age, >18 years old) were included in the study. Schatzker classification was used to classify fractures.The inclusion and exclusion criteria were presented in Table 1. The choice of operation method is random.Our study was approved by the Hospital Ethics Committee.

The general data and imaging data of patients are obtained through the electronic medical record system.Fracture classification was performed by two orthopaedic attending physicians. They don't know each other's typing results. If there is a difference in the typing results between the two, a chief orthopaedic physician will type.123 patients were included in the study, including 65 cases in the observation group and 58 cases in the control group.

Surgical techniques

The operation was completed by a chief orthopaedic physician who had worked for more

than 20 years.Both groups underwent surgery in supine position. The lower part of the patient's

knee joint is padded with soft cloth, so that the patient's knee joint will also flex slightly.The

surgical incision is on the posteromedial side of the knee joint.The incision starts about 5 cm

above the joint. It was cut longitudinally along the medial and posterior margin of tibia, with a

length of 8 ~ 10 cm.The pes anserinus of the patients in the control group were removed along the

incision direction.The fracture was fully exposed, reduced and fixed.

The pes anserinus of the patients in the observation group were preserved. Periosteal stripping ions were used to blunt separate the pes anserinust from the bone surfaceThe stop of the goose's foot is still preserved.When the fracture line at the knee needs to be exposed, the pes anserinus is pulled to the distal end of the limb. When the fracture line of the upper tibia needs to be exposed, the pes anserinus is pulled to the proximal end of the limb.Kirschner wire is used for temporary fixation of fractures.When the fracture is confirmed to be well reduced under intraoperative X-ray fluoroscopy, the locking plate is used for fracture fixation.

Postoperative care

The first day after surgery, the patients underwent a routine blood test to estimate the blood loss. Patients received the same analgesic regimen after surgery, which was mainly composed of non steroidal anti-inflammatory drugs.After surgery, patients could begin quadriceps contraction exercises and ankle pump training under the guidance of a physician. If the patient's condition permits, the patient can sit up. On the second day after surgery, the patient received wound cleaning and X-ray examination. They received continuous followed at 4weeks, 8weeks, 12 weeks, 6months and 12 months. Patients were followed up for X-ray examination to see if the fracture were healed. If there is no sign of fracture healing at 12 week, the patient will be followed up every 3 weeks. Patients could walk with the assist of crutches with no load.After X-ray identification of fracture healing, the patients would get the permission of full activities and weight-bearing.

Contrast index

Visual analogue scale (VAS) was used to evaluate postoperative pain. Hospital for special surgery (HSS) score was used to evaluate the knee function of patients.Two orthopedic physicians evaluated the postoperative imaging data of patients, and they did not know the evaluation results estimated by each other. If the results of the two evaluations are different, a chief orthopaedic physician will conduct the final evaluation .The patient's knee range of motion was also recorded.The patient's operation was retrieved through the electronic medical record system. The follow-up of patients was obtained through outpatient medical records. Some patients were followed up through telematics software. These patients often live far away from the hospital. They had an imaging review at the local hospital and then communicated with the orthopedic doctor with the help of video chat software.

Statistical analysis

Statistical assessment was performed using SPSS V19 software. Consecutive data were summarized as mean and standard deviation (SD), or median and range; whereas categorical data were summarized as frequencies and percentage. Comparison amongcategorical variables was performed using Chi-Square test; for continuous data, independent t-test was used if variables were normally distributed, otherwise Mann-Whitney test was employed.

All patients were followed for more than 1 year.As mentioned above,123 patients were included in the study, including 65 cases in the observation group and 58 cases in the control group. In general, there were no statistically significant differences to the baseline demographic factors between the two groups（See in Table 2）.

The patients in the observation group had longer operation time, more intraoperative bleeding and intraoperative fluoroscopy times, the difference was statistically significant.The observation group had lower VAS scores, either on day 1, day 3 or day 14 after surgery.The observation group had a better HSS score 3 months after operation, and the difference was statistically significant. However, there was no significant difference in HSS score between the two groups one year after operation.Similarly, the patients in the observation group had better knee range of motion 3 months after operation, and the difference was statistically significant. However, there was no significant difference in HSS score between the two groups one year after operation.

The fracture line of tibial plateau fracture often involves the articular surface of knee joint.Good reduction and reliable fixation are very important in the treatment of this fracture[4].However, even if the fracture is well reduced, some patients will still have sequelae such as traumatic arthritis[5].Soft tissue injury is considered to be closely related to the prognosis of tibial plateau fracture[6].In the author's study, the pes anserinus of the patients in the observation group were preserved during the operation as an important part of the soft tissue.Under the same analgesic regimen, these patients had less pain. And these patients achieved better knee function in the early stage, although the improvement of knee function became no longer obvious with the extension of time.

On the other hand, the retention of pes anserinus will prolong the operation time and increase intraoperative bleeding.Pes anserinus is a joint tendon structure similar to goose foot, which is formed by overlapping the tendon ends of sartorius muscle, gracilis muscle and semitendinosus muscle on the inner side of the upper end of tibia[7].This results in a lot of times, th pes anserinus is attached to the fracture.For a long time, partial excision of pes anserinus has been a very common and effective method.In the author's study, the pes anserinus was stripped from the bone surface, but its stop was still retained.The author exposed the fracture line by pulling thpes anserinus up and down.The operation time was also prolonged. The number of intraoperative bleeding and fluoroscopy also increased.

In our study, pain relief and increased knee motion were also associated with the retention of pes anserinus.On the one hand, in the control group, the removal of the anseris foot resulted in an aggravation of soft tissue injury, which may lead to postoperative pain. The goose foot, on the other hand, needs to be sutured after the plate is placed. The presence of the plate increases the tension of the pes anserinus, and so does the tension at the suture. This may also have something to do with the onset of pain.

The difference in knee range of motion may also be related to the retention of anseropod.The patients' pain was reduced by the retention of anthera anthera, and the reduction of pain degree made it easier for patients to carry out functional exercises of knee joint. Knee motion and functional scores improved as a result.The pes anserinus is a structure that maintains the stability of the knee joint[8], and its role may be underestimated.In addition to knee pain, patients with pes anserinus injury are often accompanied by poor knee function[9].For a long time, some scholars have realized that pes anserinus plays an important role in strengthening the rotation function of knee joint[10].Our study indirectly confirmed the important role of pes anserinus.Scar formation may be the reason why there is no significant difference in knee function between the two groups one year after operation.

The present study has a few limitations. First, the sample size in this study is small. Second, the study does not compare the proposed technology with other technologies in the field. Therefore, future studies should address the present limitations to validate the findings and obtain more comprehensive results.

In conclusion, compared with the traditional posteromedial approach, the modified posteromedial approach with pes anserinu preserved can significantly reduce soft tissue injury in the operative area, relieve early postoperative pain, and improve early knee range of motion.

Tibial plateau fracture is a very common fracture. Severe displaced tibial plateau fractures often require surgical intervention.Because the articular surface is often involved, these fractures need to be perfectly reduced.The posteromedial approach is often used for the treatment of medial tibial plateau fractures.During surgery, sometimes the pes anserinus needs to be cut off in order to make the fracture more visible.The pes anserinus is located on the inner side of the proximal tibia and plays a certain role in maintaining the stability of the knee joint[1].At present, there are few reports on whether the preservation of pes anserinus will affect the function of knee joint.The author tries to preserve and record pes anserinus in recent years.And the effect of goose foot retention on postoperative function was recorded.

Acknowledgements

Not applicable.

Funding

Not applicable.

Author information

Authors and Affiliations

Department of Orthopaedic Surgery, Quanzhou First Hospital, Quanzhou,Fujian,

Contributions

ZYS developed the design and analysis of the study. SWJ contributed to data collection, All authors read and approved the final manuscript.

Ethics declarations

Ethics approval and consent to participate

The experimental protocol was approved by Quanzhou First Hospital.

Competing interests

The authors declare that they have no competing interests.

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Table 1 is available in the Supplementary Files section

Table 2 Baseline demographic characteristics of study patients

Variables	Observation group(n=65)	control group(n=58)	P value
Age(years)	51.26±13.27 42/23	53.72±11.56 33/25	0.28 0.33
Sex(Male/Female)	51.26±13.27 42/23	53.72±11.56 33/25	0.28 0.33
Fracture classification(schatzker classification)			0.52
IV V VI	23 25 17	18 25 15

Table 3 Summarized depiction of perioperative data and results

Parameters	Observation group	control group	P value
The operation time(minute)	93.23±13.63	75.77±11.55	＜0.01
Blood loss(ml) Number of intraoperative X-ray fluoroscopy VAS scores on the first day after surgery	153.36±37.29 10.56±1.72 4.72±0.95	111.27±26.39 7.63±3.33 6.15±1.23	＜0.01 ＜0.01 ＜0.01
VAS scores on the third day after surgery	3.55±0.62 1.35±0.76 70.15±6.35 83.33±7.33 98.33±6.73 112.35±17.33 3	3.93±0.68 1.69±0.55 66.73±5.25 81.17±10.23 93.37±5.13 110.65±7.55 2	＜0.01 0.02 ＜0.01 0.18 ＜0.01 0.49 0.74
VAS scores on the 14th day after surgery HSS score at 3 months after surgery HSS score at 1 year after surgery Knee motion 3 months after surgery(°) Knee range of motion 1 year after surgery(°) Number of cases with unhealed fractures 3 months after surgery			＜0.01 0.02 ＜0.01 0.18 ＜0.01 0.49 0.74

No competing interests reported.

Table1.docx

Treatment of tibial plateau fractures by modified posterior medial approach

Status:

Version 1

Abstract

Introduction

Materials And Methods

Results

Discussion

Conclusion

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1