| Tibial plateau fracture is the most common intraarticular fracture in knee joint trauma.Fractures of this part are caused by violence,commonly seen in traffic accidents or falling from a high altitude,causing the knee to suffer from axial violence or varus violence caused by such injuries.Fractures are often accompanied by damage to the soft tissues around the knee joint.Varus or hyperextension and flexion can even cause damage to the meniscus or ligaments of the knee joint.Among them,the tibial plateau bicondylar fracture is the most complex type of tibial plateau fracture(Schatzker Ⅴ-Ⅵ),which is more common in high-energy violent injuries,not only because of the complex and diverse fracture displacement methods,but also the joint accessory structures such as meniscus and ligament injuries.If not handled properly,it will cause a variety of adverse postoperative complications.The surgical treatment of this type of fracture has always been tricky for orthopedic surgeons.The goal of surgical treatment is to restore the line of force of the lower limbs,and the most important thing is to achieve an accurate intraarticular reduction to restore knee function.Anatomical reduction,firm internal fixation and bone graft fixation of collapsed site are considered to be the three elements of surgical treatment of tibial plateau.However,the rate of loss of reduction and failure of internal fixation is always high.The relationship between the degree of fracture reduction and the strength of internal fixation has not been studied.In order to clarify this problem,we designed to measure the change of biomechanical strength of the fixation site of the proximal tibial locking compression plate under different reduction degrees,so as to clarify the biomechanical change of the fixation strength of the internal fixator under different reduction degrees of the tibial plateau.For tibial plateau bicondylar fracture surgery,it is also important to firmly fix the tibial plateau after anatomical reduction,especially how to prevent postoperative tibial plateau widening.In response to this problem,our team originally designed a slot-designed compression bolt(SCB)to assist the minimally invasive treatment of tibial plateau fractures with bilateral locking compression plates at the proximal tibia.Through biomechanical research,compare the biomechanical characteristics of two different fixation methods of tibial plateau bicondylar fractures with compression self-breaking bolts and ordinary locking screws assisted by double plates,and provide the clinical application of slot-designed compression bolts in tibial plateau intraarticular fracture biomechanical basis.Among the common complications after tibial plateau fractures,surgical site infection(SSI)is one of the challenges faced by most orthopedic surgeons.How to better prevent the occurrence of postoperative infection is far more important than the treatment of postoperative infection.In order to more accurately predict postoperative infection and find out the relevant predictive factors of postoperative infection,we prospectively studied the epidemiological characteristics and related predictive factors of SSI after tibial plateau fracture open reduction and internal fixation.Provide data support for the prevention of infection after tibial plateau fracture.Part One Analysis of biomechanical stability of locking plate and screw internal fixation system with different reduction degrees of tibial plateau bicondylar fracturesObjective: The influence of different reduction degrees of tibial plateau bicondylar fractures(Schatzker Ⅴ-Ⅵ)on the biomechanical stability of the locking plate and screw internal fixation system.Methods: 1.Thirty-six adult male knee specimens treated with formalin were used to establish a bicondylar fracture model of tibial plateau.When the displacement spacing of tibial plateau fracture separation was 0mm,1mm,2mm,and 3mm respectively,the medial and lateral proximal tibial compression locking plates and locking screws were used to fix the fractures.The axial ballast test,horizontal torsion test and cyclic axial load test were carried out on the four models.2.The pressure load range of the biomechanical machine was 0-1000 N,and the axial displacements of each group were recorded when the axial ballast load was 400 N,700 N,and 1000 N.The torsion stiffness of each group was measured when the horizontal torsion was 5°.The axial displacements of each group were recorded when the cyclic axial loads were100-400 N,100-700 N,and 100-1000 N.Each specimen was measured in 10 cycles at a time.3.SPSS 25.0 software was used for data processing.First,Shapiro-Wilk test was used to determine whether the data were in line with the normal distribution.For the data in line with the normal distribution and homogeneity of variance,the mean ± standard deviation(x ± s)was expressed.One-way ANOVA was used for the measurement data of four groups,and the Tukey method was used for pair comparison between each group.Results: In the axial ballast test,the axial displacement difference between the reduction gap of 0 mm group and the reduction gap of 1 mm group was not statistically significant.The axial displacements of 2 mm and 3mm groups were significantly higher than those of 0 mm and 1 mm groups under three kinds of loads,and the difference of axial displacements was statistically significant compared with that of 0mm and 1mm groups in pairwise comparison.In the horizontal torsion test,when the clockwise torsion was 5°,the torsional stiffness of the system gradually decreased with the increase of the reduction gap,and the differences of torsional stiffness among the reduction groups were statistically significant.In the process of cyclic axial load test,there was no statistically significant difference in the cyclic axial displacement between the 0 mm group and the 1 mm group at the three cycle levels of 100-400,100-700 and 100-1000.The cyclic axial displacements of 2 mm and 3 mm groups under three kinds of loads were significantly higher than those of 0 mm and 1 mm groups,and the difference of cyclic axial displacements was statistically significant compared with that of 0 mm and 1mm groups.Conclusions: The degree of reduction of the fracture of the tibial plateau bicondylar fracture affected the biomechanical stability around the tibial plateau.The increase of the gap between fracture lines after reduction resulted in the decrease of the vertical stiffness and torsional stiffness of the internal fixation system with medial and lateral plate screws of the tibial plateau.Anatomical repositioning for double condyle fracture of tibial plateau,was the best way to restore the physiological state,when the fracture separation shift was 0 to 1 mm,which was not greater than 1 mm,strong internal fixation system could make the tibia platform around the internal fixation stiffness stability,when separation fracture displacement was greater than 2 mm,could make around the internal fixation of tibial plateau system stiffness significantly reduced.Part Two Biomechanical comparison study of slot-designed compression bolts and locking screws assisted bone plates for fixation of tibial plateau bicondylar fracturesObjective: The biomechanical characteristics and stability of slot-designed compression bolts assisted locking plates and screw assisted locking plates for fixation of tibial plateau bicondylar fractures(SchatzkerⅤ-Ⅵ).Methods: 36 preservative specimens of adult male femur were used to establish a tibial plateau bicondylar fracture model.When the pressure load was 400,600,800 and 1000 N,the data changed of axial displacement,system torsional stiffness and cyclic load displacement of two different fixed methods were analyzed.1.Thirty-six adult male knee joint specimens treated with formalin preservative,and tibial plateau bicondylar fracture model.According to the random number table,the fracture models were divided into 2 groups,and the bilateral locking compression plate combined with the locking screw group and the bilateral locking compression plate combined with the slot-designed compression bolt were used for fixation.Perform vertical ballast test,horizontal torsion test and cyclic axial load test on the two models.2.The pressure load range of the biomechanical machine was 0-1000 N,and the axial displacement of each group when the axial ballast load was 400,600,800 and 1000 N was recorded;the torsional stiffness of each group when the horizontal torsion was 5°was tested;the circulation axis was recorded.The axial displacement of each group when the load was 100-400 N,100-600 N,100-800 and 100-1000 N.Each specimen was measured in 10 cycles at a time.3.Use SPSS 25.0 software for data processing.The measurement data first used the Shapiro-Wilk test to determine whether the data conformed to the normal distribution.For the data conforming to the normal distribution and homogeneity of variance,it was expressed as the mean ± standard deviation(x± s),and the four groups of measurement data use single-factor analysis of variance One-Way ANOVA method,the pairwise comparison between each group adopts the Tukey method.Results: In the axial load test,when the axial load was 400 N,there was no statistically significant difference in the axial stiffness between the slot-designed compression bolt group and the locking screw group(p>0.05).When the axial load increased to 600,800,1000 N,the axial stiffness of the slot-designed compression bolt assisted the locking steel plate group was significantly higher than that of the locking screw assisted the locking steel plate group,and the difference was statistically significant.In the horizontal torsional load test,there was no significant difference in the torsional stiffness between slot-designed compression bolt assisted the locking plate group and the locking screw assisted the locking plate group at a counterclockwise twist of 5°.In the cyclic axial load test,the compression displacement of slot-designed compression bolt-assisted locking steel plate group was significantly lower than that of the common locking screw assisted locking steel plate group at the four cycle intervals of 100-400,100-600,100-800 and100-1000 N,and the difference between the two groups was statistically significant.Conclusions: Compared with ordinary locking screws,the slot-designed compression bolts assisted bilateral locking compression plates to fix tibial plateau bicondylar fractures were stronger and more reliable,and had higher system rigidity.Compared with ordinary locking screws,the slot-designed compression bolt had the effect of intra-articular compression in fixing the fracture,so that the fracture reduction was more stable.Part Three Postoperative imaging and efficacy analysis of minimally invasive treatment of tibial plateau bicondylar fracture by double reverse traction versus open reduction and internal fixationObjective: To compare the use of double reverse drawing restorer closed reduction and minimally invasive treatment of double condyle fracture of tibial plateau(Schatzker Ⅴ-Ⅵ)with conventional open reduction and internal fixation(ORIF)imaging results and the analysis of the clinical outcomes.Methods: We retrospectively analyzed the clinical data of 78 patients with bicondylar fractures of the tibial plateau(Schatzker Ⅴ-Ⅵ)who were treated from October 2014 to December 2019.Among them,40 patients were treated with conventional open reduction and internal fixation,and 38 patients were treated with closed reduction and minimally invasive treatment with double reverse traction reductors.The surgery related indexes were collected from computer imaging system and electronic medical record system.Knee function score(HSS score system)after one year follow-up;Radiographic findings at one-year follow-up included medial proximal tibial angle(MPTA),tibial plateau posterior inclination(PSA),tibial plateau compression,and tibial plateau widening and loss of reduction.The differences between the two groups were statistically analyzed.Results: Dual reverse traction closed reduction and minimally invasive surgery group was used in the operation time(153.55±51.82 min vs192.25±58.67 min,P=0.002)and intraoperative blood loss(313.95±195.94 ml vs 473.75±171.34 ml,P<0.001)were better than those in the open reduction and internal fixation group.At the one-year postoperative follow-up,imaging findings included loss of compression reduction of the tibial plateau(1.17±0.64 mm vs.1.45±0.57 mm,P<0.001),tibial plateau widening and loss of reduction(1.14±0.58 mm vs 1.51±0.45 mm,P<0.001)and the posterior Angle of the tibial plateau(8.76±0.53 mm vs.9.12±0.81 mm,P=0.025).The closed reduction and minimally invasive surgery group with double reverse traction was superior to the conventional open reduction and internal fixation group.The HSS score of the closed reduction and minimally invasive treatment group(86.08±8.06 vs 83.31±8.70,P=0.014)was better than that of the open reduction and internal fixation group.There was no significant difference in other surgical data and variables at the last follow-up(P>0.05).Conclusions: Compared with the conventional open reduction and internal fixation,the closed reduction and minimally invasive treatment of bicondylar fracture of tibial plateau with double reverse traction has the advantages of less bleeding and shorter operation time.The clinical effect and imaging results were also better than the conventional open reduction and internal fixation group,and the incidence of adverse complications was reduced.Part Four Incidence and risk factors of surgical site infection in adults with closed tibial plateau fracture treated with open reduction and internal fixation: a prospective cohort studyObjective: Surgical site infection is one of the common complications in the open reduction treatment of tibial plateau fracture,which can lead to serious consequences such as lifelong disability and amputation.The purpose of this study was to investigate the incidence and risk factors of surgical site infection in the treatment of adult closed tibial plateau fracture with open reduction and internal fixation,and to provide a theoretical basis for the prevention of surgical site infection of tibial plateau fracture.Methods: This study was performed at a first-level trauma center.From October 2014 to December 2018,the study subjects were adult patients with closed fractures of the tibial plateau,all of whom underwent open reduction and internal fixation(ORIF)treatment.Finally,a total of 1108 patients were followed up.We collected patient demographics information,surgery-related variables and indexes from pre-operative laboratory examinations.Univariate and multivariate logistic analysis models were used to investigate the potential risk factors.Results: Twenty-five patients(2.3%,25/1108)developed SSI.A total of15 of 25 infections(60.0%)were due to Staphylococcus aureus and 3(12.0%)were due to MRSA.Independent risk factors of SSI identified by multivariate logistic analysis model were bone grafting: autograft(OR,6.38;95% CI,2.155-18.886;P=0.001)and allograft(OR,3.215;95% CI,1.009-10.247;P=0.048),fracture type(Schartzker Ⅴ-Ⅵ)(OR,8.129;95% CI,2.961-22.319;P<0.001),aspartate aminotransferase(>40 U/L)(OR,5.500;95% CI,2.191-13.807;P<0.001),white blood cell(>10*109/L)(OR,2.498;95% CI,1.025-6.092;P=0.044),and anion gap(>16mmol/L)(OR,8.194;95% CI,1.101-60.980).Conclusions: We should pay enough attention to patients who carried one or more of these factors at admission and adopt more reasonable treatment strategies to reduce or avoid the occurrence of SSI. |
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