Tibiakopf: Repositions- und Osteosynthesetechniken

Zusammenfassung

Während die Versorgung einfacher Tibiakopffrakturen selten Probleme verursacht, stellen komplexe Luxationsfrakturen eine Herausforderung dar. Die Behandlung ist aufwendig und erfordert viel Erfahrung, da häufig nicht nur der Knochen betroffen ist, sondern auch die Weichteile. Trümmerzonen, die eine anatomische Reposition unmöglich machen, anatomische Areale der Gelenkfläche, die schwer erreichbar sind und das hohe Komplikationsrisiko führen dazu, dass diese Frakturen von erfahrenen Operateuren versorgt werden sollten. Die Kombination aus einer exzellenten präoperativen Bildgebung, einer sich aus dieser ergebenden Frakturanalyse und OP-Planung und das Wissen um aktuelle OP-Verfahren ist der Schlüssel zu einer guten Versorgung von Tibiakopffrakturen. Zur Prädiktion des langfristigen Outcomes sind 2 Faktoren entscheidend. Zum einen die Frakturschwere [1], [28], insbesondere das Ausmaß der Gelenkbeteiligung [29]; zum Zweiten die exakte intraoperative anatomische Reposition [30], [31]. Zusammenfassend müssen jedoch gemäß aktueller Literatur für B3-/C3-Frakturen die schlechtesten Ergebnisse für die klinischen Scores erwartet werden [3], [6].

Abstract

Complex tibial plateau fractures remain a challenge, even for the experienced surgeon. While the soft tissue damage dictates the timing for definitive osteosynthesis, severely comminuted fracture zones sometimes make an anatomic reduction of the articular surface impossible. Fracture zones close to the tibial spine are hard to reach and difficult to reduce. An experienced surgeon, advanced radiographic imaging – including CT scan and three-dimensional reconstruction –, and meticulous preoperative planning are mandatory for a successful treatment strategy. However, two factors seem predictive for the outcome of tibial plateau fractures. The fracture severity, especially the extent of comminution of the articular surface, and the degree of anatomic reduction influence the long-term outcome. Hence, AO type B3.3 and C3 fractures have the poorest outcome.

Schlüsselwörter

Repositions-Tipps - Tibiakopf - Ballonosteoplastie - Osteosynthese

Key words

reductions-tips - tibial plateau fracture - balloonosteoplasty - osteosynthesis

• Literatur

• 1 Berkson EM, Virkus WW. High-energy tibial plateau fractures. J Am Acad Orthop Surg 2006; 14: 20-31
• 2 Müller D, Sandmann GH, Martetschläger F. et al. [Tibial plateau fractures in alpine skiing–return to the slopes or career end?]. Sportverletz Sportschaden 2014; 28: 24-30
• 3 Loibl M, Bäumlein M, Massen F. et al. Sports activity after surgical treatment of intra-articular tibial plateau fractures in skiers. Am J Sports Med 2013; 41: 1340-1347
• 4 Meisinger C, Wildner M, Stieber J. et al. [Epidemiology of limb fractures]. Orthopade 2002; 31: 92-99
• 5 Mardian S, Schwabe P, Schaser KD. [Fractures of the tibial shaft]. Z Orthop Unfall 2015; 153: 99-119
• 6 Kraus TM, Martetschläger F, Müller D. et al. Return to sports activity after tibial plateau fractures: 89 cases with minimum 24-month follow-up. Am J Sports Med 2012; 40: 2845-2852
• 7 Gill TJ, Moezzi DM, Oates KM. et al. Arthroscopic reduction and internal fixation of tibial plateau fractures in skiing. Clin Orthop Relat Res 2001; (383) 243-249
• 8 Stuby F. Arthroskopisch assistierte Osteosynthese bei Tibiakopffrakturen. Trauma Berufskrankheit 2008; 10 (Suppl. 03) 3366-3369
• 9 Frosch KH, Balcarek P, Walde T. et al. [A modified posterolateral approach for the treatment of tibial plateau fractures]. Oper Orthop Traumatol 2010; 22: 107-119
• 10 Acklin YP, Potocnik P, Sommer C. Extended medial approach in posteromedial proximal tibia fracture dislocation. Oper Orthop Traumatol 2014; 27: 183-190
• 11 Stevens DG, Beharry R, McKee MD. et al. The long-term functional outcome of operatively treated tibial plateau fractures. J Orthop Trauma 2001; 15: 312-320
• 12 Reul M, Hoekstra H. [Combined posteromedial and anterolateral approach in the “floating position” – two column fracture of the tibia head]. Z Orthop Unfall 2017; 155: 661-669
• 13 Cho JW, Kim J, Cho WT. et al. Approaches and fixation of the posterolateral fracture fragment in tibial plateau fractures: a review with an emphasis on rim plating via modified anterolateral approach. Int Orthop 2017; 41: 1887-1897
• 14 Luo CF, Sun H, Zhang B. et al. Three-column fixation for complex tibial plateau fractures. J Orthop Trauma 2010; 24: 683-692
• 15 Cho JW, Samal P, Jeon YS. et al. Rim plating of posterolateral fracture fragments (PLFs) through a modified anterolateral approach in tibial plateau fractures. J Orthop Trauma 2016; 30: e362-e368
• 16 Lobenhoffer P, Gerich T, Bertram T. et al. [Particular posteromedial and posterolateral approaches for the treatment of tibial head fractures]. Unfallchirurg 1997; 100: 957-967
• 17 Galla M, Riemer C, Lobenhoffer P. [Direct posterior approach for the treatment of posteromedial tibial head fractures]. Oper Orthop Traumatol 2009; 21: 51-64
• 18 Carlson DA. Posterior bicondylar tibial plateau fractures. J Orthop Trauma 2005; 19: 73-78
• 19 Sun DH, Zhao Y, Zhang JT. et al. Anterolateral tibial plateau osteotomy as a new approach for the treatment of posterolateral tibial plateau fracture: a case report. Medicine (Baltimore) 2018; 97: e9669
• 20 Krause M, Preiss A, Müller G. et al. Intra-articular tibial plateau fracture characteristics according to the “Ten segment classification”. Injury 2016; 47: 2551-2557
• 21 Wang Y, Luo C, Zhu Y. et al. Updated Three-Column Concept in surgical treatment for tibial plateau fractures – a prospective cohort study of 287 patients. Injury 2016; 47: 1488-1496
• 22 Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto experience 1968 – 1975. Clin Orthop Relat Res 1979; (138) 94-104
• 23 Ahrens P, Sandmann G, Bauer J. et al. Balloon osteoplasty – a new technique for reduction and stabilisation of impression fractures in the tibial plateau: a cadaver study and first clinical application. Int Orthop 2012; 36: 1937-1940
• 24 Mauffrey C, Fader R, Hammerberg EM. et al. Incidence and pattern of technical complications in balloon-guided osteoplasty for depressed tibial plateau fractures: a pilot study in 20 consecutive patients. Patient Saf Surg 2013; 7: 8
• 25 Pizanis A, Garcia P, Pohlemann T. et al. Balloon tibioplasty: a useful tool for reduction of tibial plateau depression fractures. J Orthop Trauma 2012; 26: e88-e93
• 26 Hahnhaussen J, Hak DJ, Weckbach S. et al. Percutaneous inflation osteoplasty for indirect reduction of depressed tibial plateau fractures. Orthopedics 2012; 35: 768-772
• 27 Werner CM, Scheyerer MJ, Schmitt J. et al. [Minimally invasive balloon-assisted reduction and internal fixation of tibial plateau fractures]. Unfallchirurg 2012; 115: 1126-1132
• 28 Barei DP, Nork SE, Mills WJ. et al. Functional outcomes of severe bicondylar tibial plateau fractures treated with dual incisions and medial and lateral plates. J Bone Joint Surg Am 2006; 88: 1713-1721
• 29 Markhardt BK, Gross JM, Monu JU. Schatzker classification of tibial plateau fractures: use of CT and MR imaging improves assessment. Radiographics 2009; 29: 585-597
• 30 Manidakis N, Dosani A, Dimitriou R. et al. Tibial plateau fractures: functional outcome and incidence of osteoarthritis in 125 cases. Int Orthop 2010; 34: 565-570
• 31 Tscherne H, Lobenhoffer P. Tibial plateau fractures. Management and expected results. Clin Orthop Relat Res 1993; (292) 87-100