Knee
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Search for other papers by Salvi Prat-Fabregat in
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Tibial plateau fractures are complex injuries produced by high- or low-energy trauma. They principally affect young adults or the ‘third age’ population.
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These fractures usually have associated soft-tissue lesions that will affect their treatment. Sequential (staged) treatment (external fixation followed by definitive osteosynthesis) is recommended in more complex fracture patterns. But one should remember that any type of tibial plateau fracture can present with soft-tissue complications.
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Typically the Schatzker or AO/OTA classification is used, but the concept of the proximal tibia as a three-column structure and the detailed study of the posteromedial and posterolateral fragment morphology has changed its treatment strategy.
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Limb alignment and articular surface restoration, allowing early knee motion, are the main goals of surgical treatment. Partially articular factures can be treated by minimally-invasive methods and arthroscopy is useful to assist and control the fracture reduction and to treat intra-articular soft-tissue injuries.
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Open reduction and internal fixation (ORIF) is the gold standard treatment for these fractures. Complex articular fractures can be treated by ring external fixators and minimally-invasive osteosynthesis (EFMO) or by ORIF. EFMO can be related to suboptimal articular reduction; however, outcome analysis shows results that are equal to, or even superior to, ORIF. The ORIF strategy should also include the optimal reduction of the articular surface.
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Anterolateral and anteromedial surgical approaches do not permit adequate reduction and fixation of posterolateral and posteromedial fragments. To achieve this, it is necessary to reduce and fix them through specific posterolateral or posteromedial approaches that allow optimal reduction and plate/screw placement.
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Some authors have also suggested that primary total knee arthroplasty could be an option in specific patients and with specific fracture patterns.
Cite this article: Prat-Fabregat S, Camacho-Carrasco P. Treatment strategy for tibial plateau fractures: an update. EFORT Open Rev 2016;1:225-232. DOI: 10.1302/2058-5241.1.000031.
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Recent studies have challenged the long-held notion that neutral mechanical alignment after total knee arthroplasty leads to optimal function and survivorship.
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The ideal alignment for function and survivorship may actually be different.
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Kinematic alignment, where components are implanted to re-create the natural flexion/extension axis of the knee, may lead to improved functional results.
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Residual varus alignment may not adversely impact survivorship provided the tibial component is implanted in neutral alignment.
Cite this article: Lording T, Lustig S, Neyret P. Coronal alignment after total knee arthroplasty. EFORT Open Rev 2016;1:12-17. doi: 10.1302/2058-5241.1.000002.
Search for other papers by Jonathan G. Robin in
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Patients with unstable, malaligned knees often present a challenging management scenario, and careful attention must be paid to the clinical history and examination to determine the priorities of treatment.
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Isolated knee instability treated with ligament reconstruction and isolated knee malalignment treated with periarticular osteotomy have both been well studied in the past. More recently, the effects of high tibial osteotomy on knee instability have been studied.
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Lateral closing-wedge high tibial osteotomy tends to reduce the posterior tibial slope, which has a stabilising effect on anterior tibial instability that occurs with ACL deficiency.
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Medial opening-wedge high tibial osteotomy tends to increase the posterior tibia slope, which has a stabilising effect in posterior tibial instability that occurs with PCL deficiency.
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Overall results from recent studies indicate that there is a role for combined ligament reconstruction and periarticular knee osteotomy.
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The use of high tibial osteotomy has been able to extend the indication for ligament reconstruction which, when combined, may ultimately halt the evolution of arthritis and preserve their natural knee joint for a longer period of time.
Cite this article: Robin JG, Neyret P. High tibial osteotomy in knee laxities: Concepts review and results. EFORT Open Rev 2016;1:3-11. doi: 10.1302/2058-5241.1.000001.