Department of Trauma and Reconstructive Surgery, Asklepios Clinic St. Georg, Lohmühlenstraße 5, 20099, Hamburg, Germany.
Department of Trauma and Orthopaedic Surgery Sportstraumatology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany.
Eur J Trauma Emerg Surg. 2020 Dec;46(6):1239-1248. doi: 10.1007/s00068-020-01509-8. Epub 2020 Sep 26.
The anterior cruciate ligament (ACL)-tear is a common injury in orthopaedic trauma. Depending on the energy of impact fractures of the posterolateral tibial plateau are often associated. Different morphologic variants of posterolateral tibial plateau impaction fractures have been described in the setting of an ACL-tear. Up to now an algorithm of treatment for a combined injury of a posterolateral tibial head fracture and an injury to the anterior cruciate ligament is missing.
We present a retrospective study with clinical and radiological analysis of posterolateral fractures in combination with ACL-tear. Impressions with a depth of more than 2 mm and/or a width that outreaches more than half of the posterior horn of the lateral meniscus with additional 3. degree positive pivot-shift-test indicated surgical treatment of the fracture with additional ACL repair or reconstruction. Clinical evaluation included follow-up examination, Visual Analog Scale (VAS), International Knee Documentation Committee Score (IKDC), functional and radiological Rasmussen score.
20 patients were included with a mean age of 43.6 ± 12.4 years. Mean follow-up was 18,2 ± 13,5 months. The fracture was arthroscopically reduced and percutaneously fixed with a screw osteosynthesis (Group 1), reduced via a dorsal approach without (Group 2) or with an autologous bone graft (Group 3). Subjective IKDC score was 79,15 ± 6,07. Functional Rasmussen scores ranged from 27 to 30 (mean 28 ± 2.71). Radiological Rasmussen scores ranged from 16 to 18 points (mean 16.75 ± 1.33). According to IKDC score (p = 0.60), functional Rasmussen score (p = 0.829) and radiological Rasmussen score (p = 0.679) no significant discrepancy between the groups were seen. There was no failure of the ACL graft recorded.
Posterolateral tibial plateau fractures in combination with an ACL-tear, can cause persistent instability and increase rotational instability. Indication for treatment of these fractures is still under debate. From the biomechanical aspect the lack of more than 50% of the posterior horn of the lateral meniscus and dislocation/depression of more than 2 mm results in an increased rotational instability of the ACL deficient knee. Combined surgical treatment with ACL repair or reconstruction is a safe procedure that results in good, short-term clinical outcome, if our algorithm is followed. In addition this study shows, that majority of posterolateral tibial plateau fractures can be treated arthroscopically.
前交叉韧带（ACL）撕裂是矫形创伤中的常见损伤。根据撞击能量的不同，常伴有胫骨后外侧平台的骨折。在 ACL 撕裂的情况下，已经描述了胫骨后外侧平台挤压骨折的不同形态变异。目前，对于胫骨后外侧头骨折和前交叉韧带损伤的联合损伤，尚无治疗算法。
我们进行了一项回顾性研究，对 ACL 撕裂合并后外侧胫骨平台骨折进行了临床和影像学分析。深度大于 2mm 和/或宽度超过外侧半月板后角的一半以上，且伴有 3 度阳性枢轴转移试验的压痕表明需要手术治疗骨折，同时进行 ACL 修复或重建。临床评估包括随访检查、视觉模拟量表（VAS）、国际膝关节文献委员会评分（IKDC）、功能和影像学 Ras mussen 评分。
共纳入 20 例患者，平均年龄 43.6±12.4 岁。平均随访时间为 18.2±13.5 个月。骨折采用关节镜下复位和经皮螺钉固定（1 组）、经背侧入路复位（2 组）或经背侧入路复位加自体骨移植（3 组）。主观 IKDC 评分为 79.15±6.07。功能 Ras mussen 评分为 27 至 30 分（平均 28±2.71）。影像学 Ras mussen 评分为 16 至 18 分（平均 16.75±1.33）。根据 IKDC 评分（p=0.60）、功能 Ras mussen 评分（p=0.829）和影像学 Ras mussen 评分（p=0.679），各组之间无显著差异。未记录到 ACL 移植物失效。
ACL 撕裂合并胫骨后外侧平台骨折可导致持续性不稳定和旋转不稳定增加。这些骨折的治疗指征仍存在争议。从生物力学角度来看，外侧半月板后角缺失超过 50%和脱位/凹陷超过 2mm会导致 ACL 缺失膝关节的旋转不稳定增加。如果遵循我们的算法，联合手术治疗 ACL 修复或重建是一种安全的方法，可获得良好的短期临床效果。此外，本研究表明，大多数胫骨后外侧平台骨折可通过关节镜治疗。
