Upon admission, all patients completed relevant examinations, had their affected limbs raised, and underwent dehydration treatment to prevent deep vein thrombosis. External fixation or traction of the calcaneal tuberosity was performed to stabilize the fracture. This allowed for soft tissue recovery by restoring fracture length and alignment. Emergency incision and decompression was instantly performed in order to prevent compartment syndrome, and the cross-articular external fixation was placed with the nail channel as far away as possible from the position of the second surgical incision. The resulting wound was sutured one week after the incision decompression. The internal fixation was performed within 16 days post injury after the skin swelling had subsided. In all patients, blisters appeared 24 hours after the injury, and reached a peak at 7 days after the injury. The blisters were continuously washed with a Revnauer-infused gauze, and larger blisters were suctioned with a sterile syringe. Among the 18 patients examined in this study, 5 were treated with emergency incision decompression.
Either epidural anesthesia or general anesthesia was applied before the surgery. The affected limb was tied with a tourniquet. To begin the operation, a combined medial and lateral double incision was performed[9-11]. The lateral incision was initiated from the upper edge of the lateral tibial condyle and extended inwardly and downwardly to below the tibial tubercle. This incision was about 15 cm long. Next, an arcuate incision was performed on the inner and posterior edge of the knee extending about 10 cm long. Care was taken to maintain a skin bridge width >8 cm between the two incisions. Subsequently, the skin was cut sequentially beginning with the subcutaneous layer and continuing with the deep fascia, and the fracture ends were exposed through double incisions. The medial incision was used to fix the inner posterior and medial columns, and the lateral incision was used to fix the lateral columns.The surgical sequence was to first reset the posterior medial and medial cortical bone before resetting the lateral region. To that end, the collapsed cortical bone was opened and lifted. Quantitative measurement of bone defects using a Kirschner wire .A horizontal cut was introduced to the collapsed articular surface at 1.0 cm below the cartilage with a wide osteotomy until it was flat and leveled with the contralateral articular surface. Next, the iliac bone measuring 3X2X1 cm was fixed to the contralateral side of the affected limb. This was followed by horizontally inserting a large medial plate of the iliac bone facing the joint upward to lift the articular surface, which is equivalent to reconstructing the subchondral cortical bone of the tibial plateau.The lateral plate of the iliac bone was then removed, and the exposed cancellous bone was molded into a bone strip to tightly fill the condyle. Following this, the iliac bone column was used to vertically support the condyle, thereby reconstructing the lateral column. Cancellous bone was again used to compactly pack the surrounding space. Special attention was given to the double incisions linkage during the reduction, and the point-type reduction forceps was used to fix the medial column and lateral column as a whole. Additionally, the width of the platform was maintained as close as possible to the anatomy. On occasion when resetting was difficult, the area was examined for broken bones or meniscus jams. The posterior medial side was fixed and supported with a 3.5 system limited contact pressure steel plate and a T-shaped steel plate. Alternately, the lateral side was fixed with an L-shaped locking steel plate. In case of cruciate ligament avulsion fractures, one-stage steel wire fixation was performed simultaneously. In order to prevent severe lateral column crushing, either a large amount of iliac or Kirschner needles resembling bamboo raft-like fixed support was used for firm fixation. All patients discussed in this study received autologous iliac bone grafts instead of allogeneic bone or artificial bone.
Injury to the medial and lateral collateral ligaments were treated in stages, however, the meniscus rupture was repaired by in-situ suture instantly. Tibial plateau fractures, being intra-articular fractures, were anatomical reduced as much as possible during the operation. X-rays were taken during the operation next to a standard, with special attention given to maintaining articular surface flatness and height recovery. This study was aware that non-standard fluoroscopy can easily cause the illusion of a good reduction. Therefore, post fixation, the knee joint lateral stress test was performed to evaluate the stability of the joint before the wound was washed and drained using the internal and external incisions, the joint capsule was repaired, and the wound was closed. The operation, on average, was completed within 90 minutes of the tourniquet placement. The intraoperative surgical fixation parameters are shown in Table 2 (above), and images from a typical case (case 2) are presented in Figure 1 and Figure 2. (below).
Antibiotic cefuroxime was routinely provided after the operation, 2 g/time, 2 times/day, NSAID Sanalgesics was administered intravenously, low-molecular-weight heparin calcium was applied for anticoagulation treatment continuously for 3 weeks post surgery, and the wound dressing was changed aseptically once every 3 days depending on exudation. On the second day after the operation, the patients were encouraged to perform ankle pump and quadriceps exercises along with knee flexion and extension exercises, under the guidance of an attending doctor. The range of active flexion and extension was 100°-0°.The stitches were removed 2 weeks after the surgery. The patients walked with crutches without weight on the affected leg within 6 weeks, and were gradually able to place weight on the affected leg after 3 months. The postoperative follow-up time was between 8-40 months, with an average time of 23.44 months. The average HSS knee score was 86.72. All patients achieved complete bone healing, as evidenced by X-ray, 6 months after surgery. This study had 2 cases of traumatic osteoarthritis and 3 cases of quadriceps atrophy. The postoperative score and bone healing judgment were completed in cohort by 2 rehabilitation physicians and 1 orthopedic physician.