Minimally Invasive Technologies in the Treatment of Proximal Tibial Epimetaphyseal Fractures

Abstract

Proximal tibial epimetaphyseal fractures account for 8.9–11% of cases among the fractures of the tibia bones and up to 87% among fractures in the knee joint. Lateral condyle fractures are determined in 52–80% of cases, medial condyle fractures – up to 7%, and multifragmentary fractures – in 41% of patients. The main mechanism of injury is varus or valgus loading with or without axial overload. The implementation of modern surgical treatment tactics is based on the concept of minimally invasive surgery, which is currently used in traumatology and orthopedics, namely: minimally invasive osteosynthesis with plates and screws. The objective: to improve the results of treatment of patients with proximal tibial epimetaphyseal fractures by a differential approach using minimally invasive technologies depending on the type of fracture. Materials and methods. During the research we used our own experience in diagnosis and treatment of 437 patients with proximal tibial epimetaphyseal fractures from 2004 to the present. The inclusion criteria for the study were proximal tibial epimetaphyseal fractures of type B and C according to the AO/ASIF classification and the presence of informed patient’s consent. The study did not include patients with proximal tibial epimetaphyseal fractures of type B, severe knee joint pathology in the terminal stages of dystrophic-degenerative or inflammatory processes, severe somatic pathology of various genesis, and those who did not provide informed consent. Results. During the study, a statistically significant difference was found in the accuracy diagnosis by computed tomography (CT) and X-ray examination. In the cases of non-displaced fractures, the frequency of accuracy diagnosis was higher with CT (92.9%) compared to X-ray examination (57.1%). In cases of displaced fractures, the difference in the rate of diagnostic accuracy was also statistically significant – by CT (98.5%) compared to X-ray examination (57.1%). Due to the high accuracy of fracture diagnosis using CT, this method can be considered the gold standard for the diagnosis of fractures of this part of human’s organism. Preoperative planning plays a crucial role in ensuring positive outcomes, the purpose of which is to establish the type of fracture according to the AO/ASIF classification; to choose a rational surgical approach; to determine the optimal fixation devices or their combination; to determine the need, extend and method of bone grafting. 3D modeling is a significant help in solving these problems. The treatment management of proximal tibial epimetaphyseal fractures for choose of a fixation device was determined individually and depended not only on the type of the fracture, but also on the degree of soft tissue damage. Conclusions. The use of a differentiated approach to the treatment of patients with proximal tibial epimetaphyseal fractures resulted in excellent outcomes. The analysis of the treatment results shows that for type BI fractures the excellent outcomes were determined in 51.3% of patients, good results – in 43.6%, and satisfactory results – in 5.1%; for type BII fractures – 54.5%, 38.2%, and 7.3%; for BIII fractures – 46.9%, 40.6%, and 12.5%; for CI fractures – 50.0%, 38.9%, and 11.1%; for CII fractures – 51.8%, 33.9%, and 14.3%; for type CIII fractures excellent outcomes were found in 46.8% of patients, good outcomes – in 32.3%, and satisfactory ones – in 16.1%; and poor outcomes – in 4.8%. Poor treatment outcomes in patients with type CIII fractures were attributed to the severity of damage to the bone, cartilage, and soft tissue structures of the knee joint.

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