Fractures & Osteotomy

Tibial plateau fractures and realignment procedures, including HTO and DFO for unicompartmental arthritis and malalignment.

Overview

Corrective osteotomy aims to restore anatomic axes and improve clinical outcomes, with both open-wedge high tibial osteotomy and tibial condylar valgus osteotomy demonstrating improved short-term results postoperatively [1]. Properly performed proximal tibial osteotomy yields satisfactory clinical results when patient selection is appropriate [105]. The age of the patient does not have to be taken into consideration for the indication of high tibial osteotomy [16]. New osteotomy concepts have survived early development and are popular in many European countries, but further research is needed to achieve global acceptance and higher levels of evidence [3].

In pediatric populations, non-operative treatments for lower-extremity rotational problems are usually ineffective [6]. Rotational osteotomies are effective for these problems but are associated with significant complication rates [6]. Corrective osteotomy at both levels is advisable to restore all anatomic axes and avoid future problems following epiphyseal injury around the knee joint [5]. Proximal femoral osteotomies have different indications and treatment strategies in adolescents [17].

Internal fixation remains an effective option in select clinical circumstances for orthopaedic trauma, with successful healing and avoidance of complications largely determined by surgical technique [100]. Definitive internal fixation of both bones yields the best results for ipsilateral femoral and tibial fractures (floating knee) in almost all series [104]. Subjects undergoing autologous chondrocyte implantation (ACI) combined with patellofemoral osteotomy showed significantly greater improvements in multiple clinical outcomes compared to those undergoing isolated ACI [8]. Surgeons must understand common fracture types, evaluation methods, treatment options, and expected complications to avoid adverse outcomes [2].

The main indication for fixation of osteochondral fractures and loose bodies following traumatic patellar dislocation is large fragments [106]. Smaller and poor-quality fragments following traumatic patellar dislocation are excised rather than fixed [106].

Anatomy & Pathophysiology

Kinematics and Alignment

Knee kinematics are influenced by both intraarticular and extra-articular parameters, exhibiting significant interindividual variability [20]. The functional knee phenotype concept better represents the variability of coronal knee alignment than the conventional system of valgus, varus, and neutral [22]. Inverse kinematic alignment accommodates a greater proportion (93%) of native limb alignment compared to adjusted mechanical alignment and restricted kinematic alignment, which require more adjustments to bring outlier knees within target zones [33]. Conversely, a systematic use of the simulated measured resection mechanical alignment technique for total knee arthroplasty leads to many cases with gap modifications and imbalances [38]. Comparative anatomical studies suggest that understanding shared kinematic principles can improve the design of external bracing systems and total knee replacements [23].

Osseous and Biomechanical Factors

Realignment osteotomy around the knee is primarily used to correct biomechanical abnormalities and asymmetric loading across the knee joint due to malalignment [21]. High tibial osteotomy (HTO) resulted in normalisation of several dynamic knee function parameters such as walking speed, knee flexion and external knee flexion moment [24]. Kinematic changes resulting from open and closed high tibial osteotomy should be considered when selecting the surgical technique for patients with medial osteoarthritis [31]. Kinematic changes following biplanar medial open-wedge high tibial osteotomy correlate with poorer postoperative functional results, so that in patients with preexisting pathological patellar height a modification of the classical osteotomy technique should be discussed [35]. Decreasing tibial length relative to femoral length may alter lower extremity biomechanics in such a manner that places the anterior cruciate ligament (ACL) at risk for injury [27]. Increasing posterior tibial slope (PTS) in a native knee with intact cruciate ligaments affected 6 degrees of freedom (DOF) knee kinematics and decreased resultant forces in the medial and lateral meniscus by up to 35% in response to combined rotatory loads [34]. Mechanical axis realignment and sagittal plane correction are fundamental considerations in the management of complex knee instability presenting as a symptomatic thrust [28].

Ligamentous and Soft Tissue Structures

Posterior Kaplan fibers (PKF) and distal Kaplan fibers (DKF) are distinct and constant anatomical structures of the lateral compartment of the knee, whose anatomical characteristics and their tensioning in internal rotation presume a function of controlling rotational knee stability [42]. By adhering to the principles of anatomic anterior cruciate ligament reconstruction (ACLR), surgeons can produce an appropriately sized and located graft for the individual patient, thereby best restoring native knee kinematics and maximizing function [39]. A biomechanical study is required to verify the function of the posterior cruciate ligament (PCL) against an extension-distraction force in the knee [25]. There is no evidence that the stability of the knee can be derived from its radiographic surface geometry [37].

Patellofemoral and Joint Environment

The finite element model reliably simulates patellofemoral kinematics and contact pressures [43]. Knee stiffness is the main complication of new femoral derotation techniques based on guided growth in children, but it resolves with time [29]. In addition to biomechanical changes, the biological environment of the joint can be improved after arthroscopic knee osteotomy (AKO) [26]. A noninvasive device provides additional objective information on knee kinematics in a simple, reproducible manner to investigate preoperative and postoperative influences on tibiofemoral rotation [36].

Classification

Understanding common fracture types is critical for surgeons to avoid adverse outcomes [2].

Periprosthetic Femur Fracture (TKA): A new classification system considers fracture location and implant type, is easy to use, shows good interobserver reliability, and allows conclusions to be drawn on treatment recommendations [63]. Based on fracture location, treatment guidance includes intramedullary nails for proximal fractures, fixed-angle devices for fractures originating at the component, and revision arthroplasty for very distal fractures or those with implant loosening [4].

Tibial Plateau Fracture: Frequently used systems for classification of tibial plateau fractures display moderate intra and inter-observer reliability [49].

Giant Cell Tumour Around the Knee: The classification of 'simple fracture' and 'complex fracture' could guide decisions regarding the best surgical method for lesions in patients who have giant cell tumour around the knee with different degrees of fracture [71].

Posterior Fracture Line: The 10-segment classification might help to understand and quantify the posterior fracture line in order to balance pros and cons for different posterior surgical approaches to achieve the best result for the patient [64].

Multifocal Fractures: A simple classification of multifocal fractures helps surgeons choose the most suitable type of synthesis for surgical treatment [10].

Other Considerations: A classification system based on injury mechanism and morphological characteristics has instructive significance for preoperative evaluation of fracture features and soft tissue problems, and guides clinical management for better functional outcomes [51]. When a fracture of the lateral portion of the distal tibial epiphysis is recognized and the fragment is replaced, a good anatomical and functional result may be expected [7]. The accuracy of classification of tibia fractures in the Swedish Fracture Register is high, showing substantial agreement for AO/OTA type and moderate agreement for AO/OTA group, demonstrating the high reliability of the data for scientific analysis [72].

Clinical Presentation

History and Mechanism: A high index of suspicion is required for fractures of the capitate, which are diagnosed and reported with undeserved rarity [12]. Similarly, diagnosis of sleeve fractures of the superior pole of the patella may be missed unless there is a high index of suspicion due to the small size of fracture fragments in growing children [62]. Femoral stress fractures require prompt diagnosis to prevent progression to complete or displaced fractures that necessitate aggressive treatment and carry a higher risk of chronic morbidity [58].

Evaluation and Classification: Understanding recurrent features of tibial plateau fractures aids surgeons during diagnosis, preoperative planning, and execution of surgical strategies [14]. A simple classification of multifocal humeral fractures helps surgeons choose the most suitable type of synthesis for surgical treatment [10]. Classification of periprosthetic femoral fractures by location guides treatment selection [4]. Surgeons must understand common fracture types, evaluation methods, treatment options, and expected complications to avoid adverse outcomes [2].

Physical Examination and Imaging: Recognition of the pattern between oblique fractures of the medial malleolus and concomitant fractures of the anterolateral aspect of the tibial plafond is necessary for successful treatment, as the tibial plafond fracture may be hidden on routine radiographs [59]. Diagnosis of distal tibia fracture union based on radiographs 3 months after injury is only moderately reliable and accurate but has a high negative predictive value [15].

Special Considerations in Pediatrics: Non-operative treatments for lower-extremity rotational problems in children are usually ineffective [6]. Treatment selection for pediatric femoral shaft fractures depends on age, fracture pattern, associated injuries, and family factors to minimize complications and optimize outcomes [61].

Red-Flag Patterns and Complications: Careful analysis of patient and fracture variables helps determine the causes of fracture plate fixation failure and maximize the success of subsequent interventions [50]. Careful observation of proximal fibular fractures following conservative treatment or in the post-operative period is important to avoid complaints that may arise at a later stage [53]. The clinical performance of locked plates in orthopaedic trauma has generally been good, but several unique complications have been noted [55].

Investigations

Plain radiography: Classification of periprosthetic femoral fractures based on fracture location helps guide treatment [4]. Diagnosis of union based on radiographs 3 months after distal tibia fracture injury is only moderately reliable and accurate [15], though it has a high negative predictive value [15]. Focusing on bone morphology allows surgeons to easily perform visual assessment using preoperative radiographs for the effect of tibia plateau bone morphology on joint line convergence angle in medial open wedge high tibial osteotomy [102]. A variety of reliable skeletal maturity estimation systems using routine knee radiographs and MRI are described for planning surgeries about the knee [110]. Orthopaedic surgeons can use skeletal maturity estimation systems using routine knee radiographs and MRI to inform preoperative workups without requiring additional hand radiographs [110]. The presence of residual radiolucency is an important contraindication to removing compression plates after forearm bone refracture [115].

MRI: Over two-thirds of patients who sustained a tibial spine fracture had concomitant pathology noted on MRI [99]. 56.7% of injuries seen on MRI in tibial spine fractures correlated to what was seen at the time of surgery [99]. MRI is recommended for earlier diagnosis of avulsion of the anterior cruciate ligament from the femoral condyle as plain radiographs may not visualize osteochondral fragments in skeletally immature patients [101]. Magnetic resonance imaging parameters of a healed osteochondral fragment and patients with satisfactory functional results correspond with arthroscopic evidence of fragment stability in osteochondritis dissecans of the knee [111]. Orthopaedic treatment for acute minimally displaced cartilaginous tibial eminence fractures in children is only indicated under strict MRI control [118].

CT: Preoperative CT scans may improve surgical planning for patellar fractures by identifying secondary fracture lines poorly visualized on radiographs [85]. Computed tomography permits a more adequate assessment of the size of the fracture gap and the rotatory alignment of fracture fragments in spiral tibia fractures compared with plain radiography [108]. CT scanning provided useful information for the planning of fixation with a tibial tuberosity fracture with a proximal triplane extension [114].

Other Considerations: Understanding recurrent features of tibial plateau fractures aids surgeons during diagnosis, preoperative planning, and execution of surgical strategies [14]. ARIF led to better radiological results than ORIF in the treatment of tibial plateau fractures [109]. Fractures of the capitate are diagnosed and reported with undeserved rarity, and a higher index of suspicion would lead to the recognition and treatment of more of these fractures [12]. In questionable cases of traumatic separation of the upper femoral epiphysis in a newborn infant, arthrography will allow diagnosis before healing has progressed to the point of fixed deformity [112]. Double level osteotomy for medial osteoarthritis and bifocal varus malalignment has excellent short-term results while maintaining physiologic radiographic joint parameters [113]. Non-union is defined as a fracture where reparative processes have ceased [117]. Clinical, roentgenographic, and histological criteria are outlined for the diagnosis of non-union [117].

Treatment

Non-Operative Management

Non-operative procedures are safer and less expensive than operative management for many fractures [73]. Physiologically induced motion at the fracture site enhances osteogenesis [73]. Conservative management can be utilized for non-displaced ankle fractures in children [57]. Nondisplaced pediatric tibial eminence fractures are amenable to nonsurgical management [56]. Routine operative management of tibial condyle fractures is not recommended, though fixation is paramount to allow early motion [124]. Non-operative treatments for lower-extremity rotational problems in children are usually ineffective [6].

Operative Management: General Principles

Indications: Surgeons must understand common fracture types, evaluation methods, treatment options, and expected complications to avoid adverse outcomes [2]. Only fractures recalcitrant to closed reduction and immobilization or fractures in non-compliant patients should be considered for operative treatment with Ender nailing of acute humerus fractures [54]. The indication for fibula plating in distal lower-leg fractures with tibial nailing should be made individually [76].

Surgical Approach / Technique: Invasive primary treatment of pediatric both-bone diaphyseal forearm fractures prevents re-displacement and reduces the need for re-operation in severe fractures compared to non-invasive treatment [80]. A set goal of definitive internal fixation should be established at the time of initial external fixation when using staged internal plate fixation for severe lower extremity fractures [94]. Union of an ununited long-bone fracture is achieved surgically in four basic steps: host bone preparation, bone-graft application, fixation, and postoperative care [87].

Implant Selection: The incidence of non-union can be decreased by accurate reduction, accurately placed adequate internal fixation, and carefully supervised postoperative care [83]. Non-union often results from a combination of adverse situations, and its prevention depends on the application of well-established sound principles of fracture management [82].

Operative Management: Osteotomies

Surgical Approach / Technique: Both open-wedge high tibial osteotomy and tibial condylar valgus osteotomy improve short-term clinical outcomes postoperatively [1]. The age of the patient does not influence the clinical outcome after high tibial osteotomy and should not be considered for the indication [16]. Corrective osteotomy at both levels is advisable to restore all anatomic axes and avoid future problems following epiphyseal injury around the knee joint [5]. Rotational osteotomies are effective for lower-extremity rotational problems in children but are associated with significant complication rates [6]. An individualized osteotomy approach is recommended to achieve careful preoperative planning that considers the location of the deformity and the resultant joint line, as deformity in valgus knee malalignment can be in the femur, tibia, or both [45]. The indication for concomitant tibial tubercle osteotomy in the treatment of recurrent patellar dislocation with derotational distal femoral osteotomy and medial patellofemoral ligament reconstruction should be individualized according to each patient's specific anatomical and clinical characteristics [65]. The performance of an innominate osteotomy allowed open reduction of a central acetabular fracture to be accomplished with ease and with little added risk of morbidity [32].

Implant Selection: Enhanced surgical knowledge of anatomical structures at potential risk during medial open-wedge high tibial osteotomy or plate fixation helps avoid possible injuries [30]. Directing the plane of the osteotomy toward the 'safe zone' significantly reduces the risk of lateral cortex fracture compared to an osteotomy directed at a lower level in medial open-wedge high tibia osteotomy [41]. The new fixation device (TomoFix) allows stable fixation of the osteotomy without bone grafting [79]. Using a long and rigid plate fixator makes the osteotomy as stable after breakage of the lateral cortex as with an unharmed hinge, illustrating the need for a reliable and strong implant such as an internal plate fixator [90]. A stepped staple was designed to allow both fragments to be fully engaged by the staple, addressing the discrepancy in continuity of the cortex created by wedge osteotomy [46]. Simple transverse osteotomy and threaded-pin fixation for controlled correction of torsion deformities of the tibia avoids the postoperative fixation problems of simple transverse osteotomy and the difficulties of the Z-type operation [40].

Other Considerations: New osteotomy concepts have survived early development and are popular in many European countries, but further research is needed to achieve global acceptance and higher levels of evidence [3].

Operative Management: Fracture Fixation Techniques

Implant Selection: Intramedimary nails are best for proximal periprosthetic femoral fractures above total knee replacements [4]. Fixed-angle devices are best for periprosthetic femoral fractures originating at the component [4]. Revision arthroplasty is indicated for very distal periprosthetic femoral fractures or those with implant loosening [4]. Stable osteosynthesis achieved by the right approach and correct surgical technique allows supracondylar-condylar fractures of the femur to heal in most cases without loss of joint function [11]. Plate on plate osteosynthesis is a novel method for periplate fracture fixation that may prove valuable due to the increasing population age and unique types of fractures [9]. Dual plating is indicated for certain cases, particularly old ununited fractures where intramedullary nailing is difficult, but is contraindicated in severely comminuted fractures requiring extensive dissection [67]. A fluted intramedullary rod for subtrochanteric fractures achieved union in all instances with no failure of the implant [18]. Transarticular fixation is highly successful in achieving union, stability, and relief of pain in all patients with one operation for non-union of supracondylar fractures of the femur [92]. Patella fractures treated with suture tension band fixation is a safe and promising alternative to traditional metallic fixation methods [96]. Both plate and nail fixation present unique benefits and pitfalls for treating periprosthetic fractures about a well-fixed prosthesis [97]. Augmented percutaneous cementoplasty does not seem to improve pain relief, fracture incidence, and operative time when compared with non-augmented percutaneous cementoplasty for metastatic impending fractures of the proximal femur [98]. Pain relief was obtained in all cases postoperatively [122].

Operative Management: Pediatric and Specific Fractures

Indications: Spontaneous reduction of fractures through epiphyseal plates without residual roentgenographic evidence probably occurs at other joints and will be diagnosed only by manipulation under anesthesia [129]. Surgery should be considered for ankle fractures in children involving substantial physeal or joint displacement [57]. Displaced pediatric tibial eminence fractures are managed with arthroscopic reduction and fixation [56].

Operative Management: Revision and Complex Cases

Revision: Most revisions of total knee arthroplasty require a combined approach to fixation and a multi-zone strategy should be adopted [44]. The aim of proximal femoral osteotomies in adolescence is to show different ways of performing them and their indications [17].

Complications

Surgeons must understand expected complications to avoid adverse outcomes in fracture and osteotomy treatment [2].

Thromboembolism: Deep venous thrombosis (DVT) incidence after surgical treatment of isolated patella fractures is substantial [95]. The overall incidence of DVT after osteotomy around the knee is 13.8%, even with prophylactic anticoagulant use [107]. High-risk factors for preoperative lower extremity DVT in tibial fracture patients include age > 40.5 years, systemic immune-inflammation index (SII) > 858.5, and D-dimer > 1.36 mg/L [127]. Distal femur osteotomy (DFO) shows relatively low overall mean rates of VTE regardless of early or delayed post-operative weightbearing protocols [123]. Breast cancer patients have a two-fold increased risk of complications after total hip arthroplasty (THA), including venous thromboembolism (VTE) [130].

Infection: Treatment of open tibial fractures with the Lottes nail results in a 6% infection rate [139].

Nonunion / Delayed Union: Distal femur osteotomy (DFO) shows relatively low overall mean rates of delayed union and nonunion regardless of early or delayed post-operative weightbearing protocols [123]. Treatment of open tibial fractures with the Lottes nail results in a 16% delayed union rate [139]. Plating of periprosthetic greater trochanter (GT) fractures has a nonunion rate of 39% [161]. Total tibial pilon fractures have a high complication rate, with neither internal plating nor definitive external fixation proving more effective overall [163].

Malunion / Deformity: Distal femur osteotomy (DFO) shows relatively low overall mean rates of loss of deformity correction regardless of early or delayed post-operative weightbearing protocols [123]. Treatment of open tibial fractures with the Lottes nail results in a 4% malunion rate [139].

Hardware Failure / Reoperation: Plating of periprosthetic greater trochanter (GT) fractures has a high incidence of reoperation (20%) within two years and a hardware failure rate of 28% [161]. Tibial tubercle osteotomy for patella alta has a mean postoperative complication rate of 7.6% and a reoperation incidence of 14.3%, primarily due to hardware removal [159].

Periprosthetic Fracture: Breast cancer patients have a two-fold increased risk of complications after total hip arthroplasty (THA), including intraoperative fracture [130]. Revision total knee arthroplasty (TKA) for periprosthetic fractures is associated with decreased implant survivorship, particularly when stemmed or augmented components are used [151].

Other Considerations: Osteotomies around the knee carry an elevated risk of vascular injury [134]. Patient weight, age, and deformity genesis do not influence complication rates in lower limb corrective osteotomies [134]. Unicompartmental knee arthroplasty (UKA) has lower complication rates than periarticular knee osteotomy, which has an overall surgical complication rate of 23.7% [158]. TKA performed after distal femoral osteotomy has a high complication rate secondary to knee balancing problems, despite 95% 10-year survivorship free from aseptic loosening [141]. Intra-medullary nailing for tibial shaft fractures has a high complication burden, but specific patient or fracture characteristics predicting individual risk remain difficult to identify [138]. The Deyerle treatment for femoral neck fractures increases morbidity [156]. External fixation for femoral shaft fractures carries inherent risks, though no disastrous complications occurred in one series [154].

Recovery

Light activity (weeks): Timely surgery, optimized perioperative care, and evidence-based activity resumption advice are necessary to improve return-to-sport and work outcomes after knee osteotomy [91]. For medial open-wedge high tibial osteotomy using a locked plate system, conservative rehabilitation protocols permit full weight-bearing at 6 weeks [75]. In patients with Type I and II lateral hinge fractures, this protocol shows no radiologic changes or functional deterioration during midterm follow-up [75]. Closed intramedullary nailing of femoral shaft fractures using the Küntscher technique facilitates early weight-bearing and rapid hospital discharge [66].

Full activity (months): Primary and revision medial patellofemoral ligament reconstruction with concomitant tibial tubercle osteotomy result in high return-to-sport rates [19]. Adult tibial eminence fractures treated with arthroscopic K-wire folded fixation allow return to pre-injury sports levels [84]. Screw fixation for certain phalangeal and metacarpal fractures allows early range-of-motion exercises and full recovery of motion [69]. The "candy box" technique for inferior pole patellar fractures incorporates early functional exercise to enhance prognosis [74]. Rehabilitation programs and functional assessments are important for patients operated on for avulsion fractures of the tibial tuberosity following Osgood-Schlatter disease [77].

Complete recovery / outcome plateau (months): Open-wedge high tibial osteotomy and tibial condylar valgus osteotomy both improve short-term clinical outcomes postoperatively [1]. High tibial osteotomy provides satisfactory pain relief and functional outcomes for selected patients with high activity demands, though it carries a higher risk of revision in total knee arthroplasty [126]. Femoral osteotomy leads to significant improvements in quality of life and functional capabilities, although physical recovery requires an extended duration [137]. Single-stage acute osseous correction with femoral shortening for neglected congenital dislocation allows correction of osseous deformity without soft-tissue lengthening, enabling return to work and improving functional and psychological state [136]. Stable osteosynthesis via correct surgical approach and technique allows supracondylar-condylar femur fractures to heal in most cases without loss of joint function [11]. Intramedullary nailing for long bone fractures in polytrauma patients yields good clinical results when damage control principles are applied, complications are prevented through proper reduction and firm fixation, and early soft tissue reconstruction and rehabilitation are performed [70]. Ipsilateral femoral neck and shaft fractures treated with a specific protocol result in excellent outcomes with all fractures uniting and good long-term functional outcomes [132]. Appropriate reduction of fracture fragments is key to achieving a good functional result in displaced four-part proximal humerus fractures treated with intramedullary nailing [68].

Rehabilitation protocol: Patients have high expectations for surgical treatment of proximal tibial fractures, particularly regarding unrestricted return to sport, work, and painlessness [81]. Tibial plateau fractures are associated with poor functional outcomes compared to the contralateral side and preoperative condition, with bicondylar fractures linked to worse functional outcomes [133]. Older patients and those with more severe tibial plateau fractures are more likely to require total knee arthroplasty after fracture repair [116]. Total knee arthroplasty is a promising primary treatment for tibial plateau fractures in older persons with osteoporotic bone, offering immediate stability, early mobilization, and decreased reoperation rates [120]. Posterolateral sheared tibial plateau fractures can be reset and fixed sufficiently to achieve excellent long-term postoperative recovery [119]. Non-displaced spontaneous osteonecrosis of the tibial plateau lesions often heal spontaneously with protected weight-bearing, but arthroplasty may be indicated if collapse or fracture occurs [131].

Other Considerations: Routine postoperative radiographs after tibial plateau fixation have minimal impact on patient care and result in minimal management changes [121]. Native distal femur fractures (NDFF) type 33 C are at greater risk of unexpected return to the operating room compared to periprosthetic fractures [93]. Overlooking tibial plateau fractures significantly increases patient disability in one-third of cases [103].

Key Evidence

• [L3] Both osteotomy procedures improved short-term clinical outcomes postoperatively. (10.1186/s12891-024-07205-7)
• [L5] New osteotomy concepts have survived early development and are popular in many European countries, but further research is needed to achieve global acceptance and higher levels of evidence. (10.1007/s00167-012-2175-3)
• [L4] Classification based on fracture location can help guide treatment, with intramedullary nails best for proximal fractures, fixed-angle devices for fractures originating at the component, and revision arthroplasty for very distal fractures or those with implant loosening. (10.5435/00124635-200401000-00003)
• [L4] Corrective osteotomy at both levels is advisable to restore all anatomic axes and avoid future problems. (10.1007/s001670050022)
• [L4] Non-operative treatments are usually ineffective, and while rotational osteotomies are effective, they are associated with significant complication rates. (10.2106/00004623-198567050-00027)
• [L4] When the fracture is recognized and the fragment is replaced a good anatomical and functional result may be expected. (10.2106/00004623-196446010-00003)
• [L4] When individual studies compared these 2 groups, significantly greater improvements in multiple clinical outcomes in subjects undergoing ACI combined with osteotomy were observed. (10.1016/j.arthro.2012.10.008)
• [L4] Plate on plate osteosynthesis is a novel method that may prove valuable due to the increasing population age and unique types of fractures. (10.1177/2325967120s00043)
• [Paper] A simple classification of multifocal fractures is suggested to help the surgeon choose the most suitable type of synthesis for surgical treatment. (10.1016/j.injury.2013.10.010)
• [L4] The injury has been diagnosed and reported with undeserved rarity, and a higher index of suspicion would lead to the recognition and treatment of more of these fractures. (10.2106/00004623-196244080-00003)
• [L4] The role of varus osteotomy remains poorly defined. (10.1007/s00167-012-2180-6)
• [L4] An understanding of these recurrent features of tibial plateau fractures can aid surgeons during diagnosis, preoperative planning, and execution of surgical strategies. (10.2106/jbjs.n.00866)
• [Paper] Diagnosis of union based on radiographs 3 months after injury is only moderately reliable and accurate but has a high negative predictive value. (10.1016/j.injury.2012.10.034)
• [L3] As a consequence, the age of the patient does not have to be taken into consideration for the indication of high tibial osteotomy. (10.1007/s00167-012-2016-4)
• [L4] The aim of this review is to show the different ways of proximal femoral osteotomies and their indications after having done a selective literature research. (10.1055/a-1023-4679)
• [L4] Union was achieved in all instances and no failure of the implant occurred. (10.2106/00004623-197961050-00014)
• [L3] Patients who had primary and revision surgery reported clinical and statistical improvements in nearly all PROMs over time, with low recurrent instability and high RTS rates in both groups. (10.1177/03635465251409151)
• [L5] Knee kinematics is influenced by both intraarticular and extra-articular parameters, showing significant interindividual variability. (10.1016/j.arth.2016.02.049)
• [L5] Realignment osteotomy around the knee is primarily used to correct biomechanical abnormalities and asymmetric loading across the knee joint due to malalignment. (10.1016/j.arth.2024.10.065)
• [L4] The functional knee phenotype concept better represents the variability of the coronal knee alignment than the conventional system of valgus, varus and neutral. (10.1177/2325967120s00301)
• [L5] Comparative anatomical studies suggest that understanding these shared kinematic principles can improve the design of external bracing systems and total knee replacements. (10.2106/00004623-198769070-00004)
• [L3] HTO resulted in normalisation of several dynamic knee function parameters such as walking speed, knee flexion and external knee flexion moment. (10.1007/s00167-011-1496-y)
• [Case_report] A biomechanical study is required to verify this function of the PCL against an extension-distraction force in the knee. (10.1186/1749-799x-5-67)
• [L4] In addition to biomechanical changes, the biological environment of the joint can be improved after AKO. (10.1016/j.arthro.2023.07.008)
• [L3] It is possible that decreasing tibial length relative to femoral length alters lower extremity biomechanics in such a manner that places the ACL at risk for injury. (10.1177/23259671251343811)
• [L4] Mechanical axis realignment and sagittal plane correction are fundamental considerations in the management of complex knee instability presenting as a symptomatic thrust. (10.1177/0363546503258907)
• [Paper] Knee stiffness is the main complication but resolves with time. (10.1016/j.otsr.2019.06.005)
• [L5] Enhanced surgical knowledge of anatomical structures that are at a potential risk during the different steps of osteotomy or plate fixation will help to avoid possible injuries. (10.1007/s00167-016-4181-3)
• [L5] These kinematic changes should be considered when selecting the surgical technique for patients with medial osteoarthritis. (10.1007/s00167-007-0305-0)
• [L4] Inverse kinematic alignment accommodates a greater proportion (93%) of native limb alignment compared to adjusted mechanical alignment and restricted kinematic alignment, which require more adjustments to bring outlier knees within target zones. (10.1007/s00167-023-07326-x)
• [L5] Increasing PTS in a native knee with intact cruciate ligaments affected 6 DOF knee kinematics and decreased resultant forces in the medial and lateral meniscus by up to 35% in response to combined rotatory loads. (10.1002/ksa.12577)
• [L3] These kinematic changes correlate with poorer postoperative functional results, so that in patients with preexisting pathological patellar height a modification of the classical osteotomy technique should be discussed. (10.1177/2325967116s00039)
• [Letter] The authors conclude that while the introduced noninvasive device has limitations, it is a useful and valuable tool to investigate preoperative and postoperative influences on tibiofemoral rotation and provides additional objective information on knee kinematics in a simple, reproducible manner. (10.1177/0363546510376622)
• [Paper] Based on the results, there is no evidence that the stability of the knee can be derived from its radiographic surface geometry. (10.1007/s00402-011-1345-y)
• [L4] A systematic use of the simulated measured resection mechanical alignment technique for total knee arthroplasty leads to many cases with imbalance. (10.1007/s00167-019-05562-8)
• [L5] By adhering to the principles of anatomic ACLR, surgeons can produce an appropriately sized and located graft for the individual patient, thereby best restoring native knee kinematics and maximizing function. (10.1016/j.arthro.2023.03.004)
• [L4] The procedure avoids the postoperative fixation problems of the simple transverse osteotomy and the difficulties of the Z-type operation. (10.2106/00004623-195537010-00022)
• [L5] Directing the plane of the osteotomy toward the 'safe zone' significantly reduces the risk of lateral cortex fracture compared to an osteotomy directed at a lower level. (10.1007/s00167-011-1706-7)
• [L5] PKF and DKF are distinct and constant anatomical structures of the lateral compartment of the knee, whose anatomical characteristics and their tensioning in IR presume a function of controlling rotational knee stability. (10.1007/s00402-020-03718-7)
• [L5] The finite element model reliably simulates patellofemoral kinematics and contact pressures. (10.1016/j.arthro.2021.08.008)
• [L5] Most revisions require a combined approach to fixation and a multi-zone strategy should be adopted. (10.1302/0301-620x.97b2.34144)
• [L4] An individualised osteotomy approach would be recommended to achieve careful preoperative planning that considers the location of the deformity and the resultant joint line. (10.1002/ksa.12141)
• [L4] A stepped staple was designed to allow both fragments to be fully engaged by the staple, addressing the discrepancy in continuity of the cortex created by wedge osteotomy. (10.2106/00004623-196951050-00022)
• [L4] Early excision of the fragment is usually not necessary or advisable; correct initial diagnosis and treatment are important, particularly if the fracture fragment is large. (10.2106/00004623-198264040-00006)
• [L1] Frequently used systems for classification of tibial plateau fractures display moderate intra and inter-observer reliability. (10.1016/j.injury.2018.01.025)
• [L5] Careful analysis of all patient and fracture variables is helpful in determining the causes of fixation failure and maximizing the success of subsequent interventions. (10.5435/00124635-200910000-00007)
• [L4] The proposed classification system based on injury mechanism and morphological characteristics has instructive significance for preoperative evaluation of fracture features and soft tissue problems, and guides clinical management for better functional outcomes. (10.1186/s13018-019-1321-8)
• [L4] Careful observation of proximal fibular fractures following conservative treatment or in the post-operative period is important to avoid complaints that may arise at a later stage. (10.1007/s00167-004-0525-5)
• [L3] However, only fractures that are recalcitrant to closed reduction and immobilization or fractures in the non-compliant patient should be considered for this form of operative treatment. (10.2106/00004623-198769040-00013)
• [L5] The clinical performance of locked plates generally has been good, but several unique complications have been noted. (10.5435/00124635-200806000-00007)
• [L5] Nondisplaced fractures are amenable to nonsurgical management, while displaced fractures are managed with arthroscopic reduction and fixation. (10.5435/00124635-201007000-00002)
• [L5] Conservative management can be utilized for non-displaced fractures, but surgery should be considered for fractures involving substantial physeal or joint displacement. (10.1302/2058-5241.6.200042)
• [Paper] Femoral stress fractures require prompt diagnosis to prevent progression to complete or displaced fractures that necessitate aggressive treatment and carry a higher risk of chronic morbidity. (10.1016/j.csm.2005.08.003)
• [L4] Recognition of this pattern is necessary for successful treatment, as the tibial plafond fracture may be hidden on routine radiographs. (10.2106/00004623-198769030-00009)
• [L4] No complications were seen in type I fractures, while type II fractures resulted in delayed unions with correction loss in some cases. (10.1016/j.arthro.2011.06.034)
• [L5] Treatment selection depends on age, fracture pattern, associated injuries, and family factors to minimize complications and optimize outcomes. (10.5435/jaaos-d-22-00415)
• [Case_report] The diagnosis may be missed unless there is a high index of suspicion due to the small size of fracture fragments in growing children. (10.1007/s00167-004-0514-8)
• [L4] The new classification system for PPF of the femur following TKA considers fracture location and implant type, is easy to use, shows good interobserver reliability, and allows conclusions to be drawn on treatment recommendations. (10.1186/s12891-017-1855-z)
• [L4] The 10-segment classification might help to understand and quantify the posterior fracture line in order to balance pros and cons for different posterior surgical approaches to achieve the best result for the patient. (10.1007/s00264-017-3686-9)
• [L4] The indication for concomitant tibial tubercle osteotomy should be individualized according to each patient's specific anatomical and clinical characteristics. (10.1186/s13018-025-06646-7)
• [L4] Primary union was achieved in all patients with excellent clinical results regarding early joint movement, early weight-bearing, and rapid hospital discharge. (10.2106/00004623-198163080-00015)
• [L4] Dual plating is still indicated for certain cases, particularly old ununited fractures where intramedullary nailing is difficult, but is contraindicated in severely comminuted fractures requiring extensive dissection. (10.2106/00004623-196345020-00026)
• [Paper] Appropriate reduction of fracture fragments is the key for a good functional result. (10.1016/j.injury.2019.06.029)
• [L4] The technique allows early range-of-motion exercises and full recovery of motion, though traditional methods are preferred for most other fractures. (10.2106/00004623-197658040-00010)
• [Paper] Good clinical results can be expected in patients with long bone fractures if the principles of damage control are applied and complications are prevented through proper reduction, firm fixation, early soft tissue reconstruction, and early rehabilitation. (10.1016/j.injury.2017.04.016)
• [L3] The classification of 'simple fracture' and 'complex fracture' could guide decisions regarding the best surgical method for lesions in patients who have giant cell tumour around the knee with different degrees of fracture. (10.1186/s12891-022-06005-1)
• [L4] The accuracy of classification of tibia fractures in the Swedish Fracture Register is high, showing substantial agreement for AO/OTA type and moderate agreement for AO/OTA group, demonstrating the high reliability of the data for scientific analysis. (10.1016/j.injury.2015.11.002)
• [L5] Nonoperative procedures described in the manual have proven safer and less expensive than operative management for many fractures, and physiologically induced motion at the fracture site enhances osteogenesis. (10.2106/00004623-200211000-00042)
• [L5] By incorporating early functional exercise and ensuring strong internal fixation, patient prognosis could be enhanced. (10.1186/s12891-023-06946-1)
• [L4] Type I and II lateral hinge fractures in medial open-wedge high tibial osteotomy using a medial locked plate system and relatively conservative rehabilitation protocol with full weight-bearing walking commenced at 6 weeks postoperatively showed no radiologic changes or functional deterioration during midterm followup. (10.1016/j.arthro.2018.07.022)
• [L1] The indication for fibula plating should be made individually. (10.1302/2058-5241.6.210003)
• [L4] The study highlights the importance of postoperative rehabilitation programs and functional assessments for patients operated on for avulsion fracture of the tibia. (10.1007/s00167-003-0383-6)
• [L4] The new fixation device (TomoFix) allows stable fixation of the osteotomy without bone grafting. (10.1016/j.injury.2003.09.028)
• [L3] Invasive primary treatment seemed to prevent re-displacement and the need for re-operation of severe fractures was less common in the invasive treatment group than in the non-invasive treatment group. (10.1016/j.injury.2012.08.032)
• [L4] Patients have very high expectations of the surgical treatment of proximal tibial fractures, particularly regarding unrestricted return to sport, work, and painlessness. (10.1177/2325967120s00311)
• [L5] Non-union often results from a combination of adverse situations, and its prevention depends to a great extent on the application of well-established sound principles of fracture management. (10.2106/00004623-196547010-00015)
• [L4] The incidence of non-union can be decreased and many aspects of the unsolved fracture can be resolved by accurate reduction, accurately placed adequate internal fixation, and carefully supervised postoperative care. (10.2106/00004623-196244050-00006)
• [L4] All patients achieved fracture union, returned to pre-injury sports levels, and reported high satisfaction. (10.1007/s00167-006-0284-6)
• [L5] Preoperative CT scans may improve surgical planning by identifying secondary fracture lines poorly visualized on radiographs. (10.2106/jbjs.20.01478)
• [L5] Union of an ununited long-bone fracture is achieved surgically in four basic steps: host bone preparation, bone-graft application, fixation, and postoperative care. (10.2106/00004623-196547010-00016)
• [Letter] The study illustrates the need for a reliable and strong implant such as the internal plate fixator, as using a long and rigid plate fixator the osteotomy was as stable after breakage of the lateral cortex as with unharmed hinge. (10.1007/s00167-006-0193-8)
• [L5] Timely surgery, optimized perioperative care including evidence-based advice for resumption of activities, and prospective data collection are the next steps to improve return to sport and work outcomes after knee osteotomy. (10.1016/j.arthro.2022.01.027)
• [L4] The procedure described was highly successful in achieving union of the fractured femur, stability, and relief of pain in all patients with one operation. (10.2106/00004623-197961070-00008)
• [L3] NDFF type 33 C fractures are at greater risk of unexpected return to the operating room. (10.1186/s13018-024-04796-8)
• [Paper] This procedure requires a set goal of definitive internal fixation at the time of initial external fixation. (10.1007/s00402-018-3049-z)
• [L3] Incidence of postoperative DVT in patients with isolated patella fractures is substantial. (10.1186/s13018-021-02240-9)
• [L4] The authors believe that this technique is a safe and promising alternative to traditional metallic fixation methods. (10.1186/s13018-021-02309-5)
• [L4] Both plate and nail fixation present unique benefits and pitfalls for treating periprosthetic fractures about a well-fixed prosthesis. (10.1016/j.otsr.2016.11.018)
• [L1] APC does not seem to improve pain relief, fracture incidence, and operative time when compared with PC. (10.1016/j.injury.2020.02.045)
• [L3] Over two-thirds of patients who sustained a tibial spine fracture were noted to have concomitant pathology on MRI, with 56.7% of injuries seen on MRI correlating to what was seen at the time of surgery. (10.1177/2325967123s00232)
• [L5] Internal fixation remains an effective option in select clinical circumstances, with successful healing and avoidance of complications largely determined by surgical technique. (10.5435/jaaos-d-23-01256)
• [Case_report] MRI is recommended for earlier diagnosis as plain radiographs may not visualize osteochondral fragments in skeletally immature patients. (10.1007/s00167-006-0090-1)
• [L3] Focusing on bone morphology allows surgeons to easily perform visual assessment using preoperative radiographs. (10.1186/s12891-022-05526-z)
• [L4] Overlooking these fractures significantly increased patient disability in one third of cases. (10.1186/s12891-018-2170-z)
• [L4] Definitive internal fixation of both bones yields the best results in almost all series. (10.1302/2058-5241.1.000042)
• [L5] Properly performed proximal tibial osteotomy yields satisfactory clinical results with appropriate patient selection. (10.2106/jbjs.i.00367)
• [L4] Regarding management, the main indication for fixation was large fragments, while smaller and poor-quality fragments are excised. (10.1007/s00167-022-07043-x)
• [L3] This study demonstrated that DVT occurred at a substantial rate (overall incidence of 13.8%) after osteotomy around the knee even with the use of prophylactic anticoagulant. (10.1007/s00167-020-06326-5)
• [L5] Computed tomography permits a more adequate assessment of the size of the fracture gap and the rotatory alignment of the fracture fragments as compared with plain radiography. (10.2106/00004623-198668050-00029)
• [L3] ARIF led to better radiological results than ORIF. (10.1007/s00167-016-4285-9)
• [L4] A variety of reliable skeletal maturity estimation systems using routine knee radiographs and MRI are described; orthopaedic surgeons can use these to inform preoperative workups without requiring additional hand radiographs. (10.5435/jaaos-d-24-00133)
• [L4] This study suggests that magnetic resonance imaging parameters of a healed osteochondral fragment and patients with satisfactory functional results correspond with arthroscopic evidence of fragment stability. (10.1177/0363546505274717)
• [L4] In questionable cases, arthrography will allow diagnosis before healing has progressed to the point of fixed deformity. (10.2106/00004623-197153080-00020)
• [L4] Double level osteotomy has excellent short-term results while maintaining physiological radiographic parameters. (10.1007/s00167-022-07247-1)
• [Case_report] CT scanning provided useful information for the planning of fixation with this complex, transitional fracture. (10.1016/j.injury.2015.02.003)
• [L4] The presence of residual radiolucency is an important contraindication to removing the plate. (10.2106/00004623-199072010-00028)
• [L2] Older patients and those with more severe fractures are also more likely to need total knee arthroplasty after repair of a tibial plateau fracture. (10.2106/jbjs.l.01691)
• [L5] The paper defines non-union as a fracture where reparative processes have ceased and outlines clinical, roentgenographic, and histological criteria for diagnosis. (10.2106/00004623-196446030-00023)
• [L4] Orthopaedic treatment for acute minimally displaced fractures is only indicated under strict MRI control, and suture fixation is the recommended strategy in other situations. (10.1007/s00167-015-3707-4)
• [L4] Posterolateral sheared tibial plateau fractures are rare but severe injuries that can be reset and fixed sufficiently to achieve excellent long-term postoperative recovery. (10.1186/s12891-021-04373-8)
• [L4] Total knee arthroplasty holds promise as a primary treatment for tibial plateau fractures in older persons with osteoporotic bone, offering immediate stability, early mobilization, and decreased reoperation rates. (10.5435/jaaos-d-16-00565)
• [Paper] Routine postoperative radiographs following tibial plateau ORIF resulted in minimal management change for patients. (10.1016/j.injury.2019.07.025)
• [L4] There were relatively low overall mean rates of delayed union, nonunion, loss of fixation or deformity correction, and VTE after DFO, regardless of an early or delayed post-operative weightbearing protocol. (10.1002/ksa.70340)
• [L1] High tibial osteotomy offers satisfactory pain relief and functional outcome in selected patients with high activity demand. (10.1186/s12891-020-3177-9)
• [L3] The incidence of DVT is relatively high in patients with tibial fractures, with Age > 40.5 years, SII > 858.5, and D-dimer > 1.36 mg/L identified as high-risk factors. (10.1186/s13018-026-06738-y)
• [L4] Spontaneous reduction of fractures through epiphyseal plates without residual roentgenographic evidence probably occur at other joints as well and will be diagnosed only by manipulation under anesthesia. (10.2106/00004623-196244080-00012)
• [L3] However, there was a two-fold increased risk of complications after THA, including intraoperative fracture and VTE. (10.1302/0301-620x.106b4.bjj-2023-0968.r1)
• [Case_report] Most lesions of spontaneous osteonecrosis of the tibial plateau will heal spontaneously with protected weight-bearing, but once there is collapse or fracture of the plateau, arthroplasty may be indicated. (10.2106/00004623-198870030-00022)
• [L4] The developed protocol produced excellent results with all fractures uniting and good long-term functional outcomes. (10.2106/00004623-198466020-00013)
• [L3] Tibial plateau fractures decrease the function of the knee when compared with the contralateral side and to the preoperative condition, with bicondylar fractures associated with worse functional outcomes. (10.1002/ksa.12153)
• [L3] The risk of vascular injury is elevated in osteotomies around the knee, while patient weight, age, and deformity genesis do not influence complication rates. (10.1007/s00167-017-4566-y)
• [L4] Single-stage acute osseous correction with femoral shortening allowed correction of the osseous deformity without the need for soft-tissue lengthening, enabling the patient to return to work and dramatically improving his functional and psychological state. (10.2106/jbjs.i.00128)
• [L3] Significant improvements in quality of life and functional capabilities can be achieved following femoral osteotomy, though physical recovery requires an extended duration. (10.1016/j.arth.2025.06.066)
• [L2] However, based on current data it remains difficult to identify specifiers and determinants of an individual patient with specific fracture characteristics at risk for complications. (10.1016/j.injury.2020.04.021)
• [L4] The rate of infection was 6 per cent, delayed union 16 per cent, and malunion 4 per cent. (10.2106/00004623-198365070-00001)
• [L3] Ten-year survivorship free from aseptic loosening was 95% with reliable improvement in clinical function, though there was a high complication rate secondary to problems with balancing the knee. (10.1302/0301-620x.101b6.bjj-2018-1334.r2)
• [L2] A previous osteotomy is associated with decreased implant survival in subsequent TKAs, especially if a TKA component with stems and/or augmentations was used. (10.1002/ksa.70013)
• [L4] The use of the multiple-pin and plate technique causes an increase in morbidity. (10.2106/00004623-197860020-00027)
• [L3] Compared with UKA, complication rates were higher after osteotomy, with an overall surgical complication rate of 23.7%. (10.1177/23259671241257818)
• [L4] A mean postoperative complication rate of 7.6% was reported with a reoperation incidence of 14.3%, related primarily to hardware removal. (10.1177/03635465211012371)
• [L4] In this large contemporary series, there was a high incidence of reoperation (20%) within the first 2 years following plating of periprosthetic GT fractures, as well as a high rate of nonunion (39%) and hardware failure (28%). (10.1016/j.arth.2022.07.012)
• [Paper] The complication rate is high and neither internal plating nor definitive external fixation has proven to be more effective overall. (10.1016/j.otsr.2013.06.016)

See Also

• Biomechanics
• Anterior Cruciate Ligament

References

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[130] Do breast cancer patients have increased risk of complications after primary total hip and total knee arthroplasty?. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b4.bjj-2023-0968.r1

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