INDIVIDUAL APPROACH TO TREATING A PATIENT WITH A CLOSED INTRAARTICULAR FRACTURE OF THE PROXIMAL TIBIA IN A COMBINATION WITH THE INJURY TO SOFT-TISSUE KNEE JOINT STRUCTURES Mikhaylov I.N., Balzhinimaev D.B.
Irkutsk Scientific Centre of Surgery and Traumatology,
Irkutsk, Russia
A simultaneous injury to the anterior cruciate ligament (ACL) of the knee joint, and an intraarticular fracture of the proximal tibial epimetadiaphysis are relatively rare now. Intraarticular proximal tibial fractures are complex, and their treatment are difficult for surgeons. Since this category of fractures is high energetic, concurrent injuries to capsule and ligament apparatus and meniscus of the knee are often identified [1, 2]. Also this type of an injury is often combined with knee joint subluxation, which is complicated by multiple injuries to knee ligaments [3]. Even in case of identification of ALC at the first stage of treatment and in full recovery of anatomy and stable fixation of a fracture, there are no general recommendations and the surgeons' uniform opinion on time intervals and techniques for concurrent injuries to knee ligaments. There are only scarce literature findings, which are mostly presented by brief clinical cases and examples, without detailed reviews of clinical cases and treatment techniques for such injuries with complete laceration of the anterior cruciate ligament.
Objective − to show the result of an individual approach to surgical treatment of a patient with a closed intraarticular fracture of the proximal tibial epimetadiaphysis with displacement of bone fragments in combination with complete rupture of the anterior cruciate ligament, flap rupture of the lateral and medial menisci of the right knee joint.
The study corresponds to the ethical standards and regulations of RF. The patient signed the informed consent for publication of the clinical case.
CLINICAL CASE
The patient Zh., female, age of 25, was admitted to the clinic. The diagnosis was: "A closed intraarticular fracture of proximal epimetadiaphysis of the right tibial bone with displacement of bone fragments. A combined contracture of the right knee joint. Pain syndrome. Right knee hemarthrosis". Concurrent diagnosis: "United fracture of the upper one-third of right fibular diaphysis. United fracture of proximal metadiaphysis of right femur. Intramedullary metal construct".
After admission, the patient complained of intense pain in the right knee joint during movement (VAS - 80 mm). Pain could be corrected with administration of NSAIDs, but she could not use the right lower extremity adequately.
The disease anamnesis: an injury happened 10 days ago as result of a road traffic accident. The ambulance car delivered her to the Central Regional Hospital according to her place of residence. A closed intraarticular fracture of the proximal epimetadiaphysis of the right tibial bone with displaced fragments, and right knee hemarthrosis were identified. The patient refused from a surgery in the Central Regional Hospital. The posterior splint was applied from the upper one-third of the hip to the ankle joint. The patient was transferred to the clinic of Irkutsk Scientific Centre of Surgery and Traumatology. She was admitted to the traumatology and orthopedics unit.
The objective examination showed that the right lower extremity was immobilized with the posterior splint from the upper one-third of the hip to the ankle joint. The splint was removed for examination of the skin surface. The skin of the right lower extremity was of usual color, without injuries. The contours of the right knee joint were smoothed. The floating patella symptom was positive. The puncture of the knee joint was performed in the dressing room. About 50 ml of hemorrhagic content was evacuated. Edema of soft tissues of the right leg was noted: about 1 cm along its length, and about 0.5 cm in the right ankle joint. Axial load to the right lower extremity was painful. Sharp pain appeared in the region of the condyle of the right tibial bone when palpated. The movements in the right knee joint were limited as result of pain syndrome. There were not any vascular and motional disorders in the toes of the right foot.
X-ray images of the right knee joint showed a disorder of integrity of the proximal tibial bone, an intraarticular fracture of the proximal epimetadiaphysis of the right tibia with displacement of fragments (Fig. 1).
Figure 1
X-ray image of the right knee joint of the patient Zh. in frontal (a) and lateral (b) planes before surgery
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The diagnosis was made after the clinical radiologic examination: "A closed intraarticular fracture of the proximal epimetadiaphysis of the right tibial bone with displacement of bone fragments. A complete rupture of the anterior cruciate ligament. Anterior instability of the knee of degree 3. Combined contracture of the right knee. Pain syndrome".
A surgery was conducted on February 11, 2016: opened reposition of the proximal epimetadiaphysis of the right tibial bone with elevation of tibial plateau; internal osteosynthesis with the locked plate. Arthrotomy showed a complete laceration of the anterior cruciate ligament (rupture from the femoral bone).
The postsurgical period was without complications. The movements in the adjacent joints were allowed from the first day after the surgery. The sutures were removed on 14th day after the surgery. The patient was discharged for outpatient treatment.
Six months later, the control X-ray images of the right knee (Fig. 2) showed a healed intraarticular fracture of the proximal epimetadiaphysis of the right tibial bone. A metal construct. Osteoarthrosis of the right knee of degree 2. It was allowed to remove the metal construct. The patient was admitted to the traumatology and orthopedics unit of Irkutsk Scientific Centre of Surgery and Traumatology.
Figure 2
X-ray image of the right knee joint of the patient Zh. in frontal (a) and lateral (b) planes after surgery
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The surgery was performed on October 16, 2016: a metal construct of the proximal tibial bone was removed (Fig. 3).
Figure 3
X-ray image of the right knee joint of the patient Zh. in frontal plane after removal of the metal construct
The patient could use her right lower extremity in daily life with limitations in view of periodical senses of instability of the knee joint. The range of movements in the knee: flexion-extension − 130°/0°/0°, deficiency of flexion −10°-15°.
One month after surgery, the patient initiated the program of active rehabilitation, which included swimming, exercise bicycle training, physical therapy, remedial gymnastics for preparation of the injured extremity for the stage 2 of the surgical management and rehabilitation.
On the stage 2 of treatment, the diagnosis was confirmed with MRI of the knee joint: some signs of old complete laceration of ACL of the right knee, MRI signs of a horizontal rupture of medial and lateral menisci (degree 3 according to Stoller).
On October 17, 2016, the patient was admitted to Irkutsk Scientific Centre of Surgery and Traumatology.
The surgery was conducted on October 18, 2016: arthroscopy of the right knee joint, autotendoplasty of the anterior cruciate ligament of the right knee with the autotendoendoprosthesis from a half of the tendon of the long fibular muscle according to all-inside technique with use of Arthrex® fixators with TightRope fixing system, modeling partial resection of the posterior horn of the medial meniscus and the body of the lateral meniscus of the right knee joint.
The arthroscope 30° was introduced into the cavity of the right knee joint through two standard parapatellary approaches under spinal analgesia in septic conditions. A complete rupture of ACL in view of its rupture from the lateral condyle of the femoral bone, a flapped rupture of the posterior horn of medial meniscus, anterior drawer sign, Lachman's test +++,positive symptoms of Steiman, Perelman, Baykov; intact posterior cruciate ligament.
Modeling partial resection of the posterior horn of the medial meniscus and the lateral meniscus body of the right knee joint was conducted.
A longitudinal incision (3.5 cm) was made along the posterior external surface of the lower one-third of the right leg. The tendon of the long fibular muscle was separated in layer-by-layer manner. An external part (a half size of thickness of the tendon of the long fibular muscle, 28 cm) was separated from the tendon (Fig. 4). The stripper was used for taking of a half of the tendon of the fibular muscle (Fig. 5). The length of the ready autograft was 6 cm, the diameter − 9 mm (Fig. 6).
Figure 4
Approach to the leg, separation of ½ thickness of the tendon of the long peroneal muscle
Figure 5
½ part of the tendon of the long peroneal muscle with use of the stripper
Figure 6
The ready autograft from ½ tendon of the long peroneal muscle
The next stage was debridement with use of the ablator. The end-to-end femoral canal (diameter of 3.5 mm) was formed through the arthroscopic lateral approach along the guide with use of original Flipcutter. In retrograde manner, the blind canal (diameter of 9 mm, length of 30 mm) was formed.
With use of Flipcutter and the guide, the end-to-end tibial canal (3.5 mm) was made, and, in retrograde manner, the blind canal (diameter of 9 mm, length − 25 mm). The autograft was passed into femoral and tibial canals. TightRope was used for fixation. The range of movements in the knee joint was full. There was no conflict between the autograft and the intercondylar fossa of the femoral bone. In palpatory manner with the arthroscopic hook, the elastic tension of the autograft was determined, with correct orientation, and negative anterior drawer sign and Lachman's test. Hemostasis was conducted during surgery. The approaches were sutured in layer-by-layer manner. The knee joint was drained according to Redon. Aseptic dressing was applied. The lower extremities were dressed with elastic dressings for prevention of DVT and PE. The knee joint was fixed with the orthesis in full extension position.
On the third day after surgery, the patient complained of insignificant pain in the surgical site (VAS − 30 mm).
The hospital period was 7 days. By the moment of discharge, the patient did not have persistent pain in the site of the tendon taking and in the operated knee joint. The body temperature was normal. The supporting function of the operated lower extremity recovered in conditions of fixation with the brace in full extension position. There were no venous thrombosis (on the basis of clinical signs and ultrasonic dopplerography), synovitis and hemarthrosis of the operated knee.
The knee immobilization with the orthesis was completed after one and half of a month after surgery. Active rehabilitation was initiated in our clinic [7].
After 3 and 6 months from the surgery, the patient did not have complaints, edema, synovitis and signs of knee instability. Postsurgical scars were without signs of inflammation in the site of the left knee joint. There were no edema and morbidity. Meniscus symptoms of Baykov, Steiman and Perelman were negative. The ligament complex was stable: anterior drawer symptom and Lachman's test were negative. Posterior drawer symptom was negative. Symptom of external and internal lateral oscillation was negative. The volume of motions in the knee according to 0-passing method after 3 months: flexion/extension− 125/0/0; ankle joint: flexion/extension − 45/0/30, pronation/supination − 25/0/45. After 6 months: flexion/extension − 135/0/0, with full range of movements in the ankle joint. Pain was absent. Vascular, motional and sensory disorders were not found in distal parts of extremities.
One and a half year after surgery, the control examination did not show pain syndrome and discomfort in the operated knee joint and in the site of tendon grafting (the ankle joint site). Anterior drawer symptom, Lachman's test and Pivot-shift were negative. Hypotrophy of quadriceps muscle and gastrocneius muscle of the operated extremity were not found. Pronation and supination of the foot on the side of operated lower extremity was within the full volume. The volume of movements in the knee joint was full (Fig. 7, 8).
Figure 7
Full range of extension of knee joint
Figure 8
Full range of flexion of knee joint
CONCLUSION
This clinical case shows:
1. Recovery of integrity of bone structures at the first stage allows exclusion of possible undesirable outcomes such as formation of a false joint, bone tissue defects in the proximal tibia and incorrect orientation of canals of the planned graft. Recovery of tibial plateau at rehabilitation stage allowed recovery of range of movements in the knee joint.
2. At the second stage, reconstruction of the anterior cruciate ligament with selected techniques allowed achieving recovery of full function of the knee.
Therefore, the selected two-stage management allowed achievement of recovery of appropriate function of the knee joint and improvement in life quality.
Information on financing and conflict of interests
The study was conducted in compliance with the plan of researches at Irkutsk Scientific Centre of Surgery and Traumatology. The authors declare the absence of any clear or potential conflicts of interests relating to publication of this article.