Treatment Of Postoperative Infection Of Tibial Plateau Fractures In Adults With Induced Membrane Technique

Backgroud:As the most important load structure of the knee joint,the tibial plateau is prone to cause intra-articular fractures after trauma.Due to the different degrees of injury mechanism,fracture morphology and soft tissue damage,it has caused great trouble to orthopedic surgeons.In the early stage of improper treatment,it is easy to cause infection,soft tissue necrosis,loss of reset,internal fixation failure,vascular injury and other complications.Late stage is prone to infection,malunion,delayed nonunion,nonunion,joint stiffness,traumatic arthritis and other complications.Among the many complications,infection remains a serious complication.According to relevant literature analysis,compared with the infection rate(1-3%)after open reduction and internal fixation,the higher infection rate(2.6-45%)after tibial plateau fracture brings great challenge to the orthopedic surgeon.Traditional treatments include repeated debridement,lavage drainage,removal or retention of internal fixation,flap or muscle flap coverage,systemic sensitive antibiotics,and local antibiotic bead chain.However,due to the long treatment period and poor therapeutic effect,the knee joint function has a great influence.Some patients can only choose amputation above the knee joint as the final outcome.Since 2000,membrane induced technique have been reported successfully in treating many long bone defects.The technique is divided into two stages: one-stage thorough debridement,external fixation,bone stablization,polymethyl methacrylate(PMMA)bone cement filling bone defect.After the formation of a bioactive membrane during the second stage,the bone cement is removed and fully grafted the bone in the membrane.Considering the existence of bacterial biofilms,internal fixation is considered as a contraindication,and external fixation has always been the gold standard for fixation in infection cases.However,external fixators have their limitations,including loose nails,nail infections,uncomfortable wearing,poor tolerance,especially long term cross-articular fixation can lead to joint contracture and rigidity.In recent years,good clinical outcome of antibiotic bone cement-coated locking plate have been reported as a temporary internal fixation in dealing with long bone infection.So we further extend it to the postoperative infection treatment of the fracture around the joint.Objective:1.To explore membrane induced technique for the treatment of postoperative infections in adult tibial plateau fractures and assess clinical outcomes.2.To summarize and analyze the preconditions,clinical features and treatment related factors of membrane induced technique in the treatment of postoperative infection of adult tibial plateau fractures..Methods:From April 2013 to May 2017,21 cases of tibial plateau fracture were treated with membrane induced technique.There were 19 men and 2 women,aged from 19 to 60 years old(average 44).The initial fracture was classified according to Schatzker classification: 1 cases of type IV,14 cases of type V,6 cases of type VI.According to the classification of infection time,there were 3 cases of early infection,12 cases of delayed infection and 6 cases of late infection.Patients were followed at least 12 months.Clinical efficacy was evaluated by infection control rate,bone healing time,maximum activity,and knee function scores collected at outpatient visits.A retrospective review of all patient imaging and clinical outcomes was performed by complete follow-up.Infection time,maximum knee mobility,and knee function score(HSS)were statistically analyzed.Results:All 21 patients were followed up for 12~62 months(average 23.5 months).Clinical bone healing was obtained in all patients,and the imaging healing was achieved in 4-6 months(average 4.5 months)after the operation.In these cases,2 patients were treated with local transfer flap after debridement,and 4 cases received more than two times of debridement surgery.There were 2 cases treated with knee arthrodesis.The results of the last follow-up confirmed that the maximum activity of the knee joint was significantly improved in early and delayed infection patients(early infection t =7.7520,delayed infection t =3.5260,P <0.01).The maximum dynamic degree of knee joint was not significantly improved(t =0.0465,P >0.05)in patients with late infection(t =0.0465,P >0.05).The HSS score of patients with infection was significantly higher than preoperative evaluation(t =7.1398,P <0.01)in early infection,delayed infection and late stage infection groupConclusion:Membrane induced technique combined with locking plate and antibiotic bone cement can achieve satisfactory clinical efficacy in the treatment of adult tibial plateau fractures infection.Early intervention and active functional exercise could improved knee function significantly.