Mastering Orthopedic Techniques: Intra-articular Fractures Rajesh Malhotra
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Intra-articular Fractures: What Have We Learnt?1

Bhavuk Garg, Rajesh Malhotra
 
Introduction
Life is movement, Movement is life. This sentence has always been cited as the steering principle of fracture care.1 This principle is more than vital in the management of intra-articular fractures: fractures that extend or involve the articular cartilage. It is an irony that junior most orthopedic surgeons operate most of the intra-articular fractures like patellar fractures, malleolar fractures, neck femur fractures, olecranon fractures, etc. (Fig. 1.1).
Intra-articular fractures, if not properly treated, inevitably lead to stiffness, pain or osteoarthritis (post-traumatic). In his famous book on conservative management of fractures entitled, “The Closed Treatment of Common Fractures”, Sir John Charnley advocated nonoperative management of intra-articular fractures.2
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Figure 1.1: Common intra-articular fractures, which are usually managed by junior most orthopedic surgeons
2Several other authors including Neer et al3 and Stewart et al4 also advocated the same. The main reason for this favor for conservative management was unavailability of proper internal fixation devices as well as lack of proper understanding of orthopedic surgical principles.
After foundation of AO group in 1958 at Biel, Switzerland, a lot of improvements in orthopedic internal fixation devices as well as an improved understanding of orthopedic surgical principles prevailed. AO/ASIF group reported better outcome of intra-articular fractures with open reduction and internal fixation.5 Several other authors echoed similar results.6,7 It was also observed that intra-articular fractures that underwent ORIF as well as immobilization had much more stiffness and worse outcome than fractures, which were either, treated with ORIF and early motion, or, immobilization alone.8 AO group also advocated that intra-articular fractures behave in a different biological and functional manner as compared to diaphyseal fractures.
 
Principles of Intra-articular Fracture Management
Müeller et al1 enunciated the AO principles of intra-articular fracture care that anatomical reduction as well as absolute stability is vital to the optimum healing of articular fractures. These factors also enable the patient for early motion, leading to best outcome for intra-articular fractures. Mitchell and Shepard9 reported that articular cartilage regenerate after intraarticular fractures provided anatomical reduction and absolute stability. Salter et al10 showed that continuous passive motion stimulates articular cartilage healing as well as regeneration. Schatzker et al11 pointed out following principles of intra-articular fracture treatment:
  1. Immobilization of intra-articular fractures leads to stiffness of joint.
  2. Immobilization combined with ORIF of intra-articular fractures causes much more stiffness.
  3. Depressed and impacted articular fragments will not reduce by closed manipulation or ligamentotaxis.
  4. Big articular defects do not fill by fibrocartilage, resulting in instability due to their displacement.
  5. Anatomical reduction and as well as absolute stability is vital to the optimum healing of articular fractures (Fig. 1.2).
  6. Metaphyseal voids should be bone grafted (Fig. 1.3) (however, with use of current locking plates, this has become controversial).
  7. Any metaphyseal and diaphyseal displacements should be reduced to prevent extra load on the joint (This reduction need not to be anatomical).
  8. It is extremely important to restore the joint congruity as well as axial alignment.
  9. Early motion is essential for optimal healing of articular cartilage and best outcome. Stable internal fixation is a must for this.
 
Basic Sciences Facts about Intra-articular Fractures
Articular cartilage is an aneural structure with no blood or lymphatic supply and is dependent upon diffusion from surrounding tissues for nutrition. The cartilage matrix has got hypoxic environment and depends on anaerobic glycolysis and mainly consists of type-2 collagen and proteoglycans important for the joint. This structure makes articular cartilage very sensitive to injury and confers to it poor reparative potential.
Relationship between articular cartilage injury and subsequent development of osteoarthritis is a complex phenomenon. Articular cartilage healing leads to formation of fibrocartilage, however it does not restore the structural and mechanical properties of a normal articular cartilage.12 Larger the defect, larger is the alteration of mechanical properties; larger is the risk of progression to osteoarthritis.123
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Figure 1.2: A depressed intra-articular fracture of proximal tibia managed by anatomical reduction, stable fixation and early motion. Patient had excellent functional result
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Figure 1.3: Bone grafting should be done in cases of metaphyseal voids, particularly in osteoporotic bones
4Severity of articular cartilage injury has also been linked to the outcome of intra-articular fractures. Marsh et al13 reported that development of post-traumatic osteoarthritis correlate with the severity of articular damage. Several other authors have also reported the same findings.14,15
Effect of step-off defects and development of post-traumatic osteoarthritis has also been studied in detail. The thickness of articular cartilage varies from joint to joint and is also variable at different sites in a single joint16 (Ankle 1.0–1.62 mm, Knee 1.69–2.55 mm, Patella 1.76–2.59 mm). Articular cartilage step-offs do remodel but have limited capability.17 Articular step-offs that exceeds the full thickness of articular cartilage usually do not remodel completely. These step offs lead to localized and altered mechanical peak pressures, leading to rapid progression of osteoarthritis.18 Usually a step-off of less than 2 mm is acceptable.12 Extra-articular deformities also affect the development of osteoarthritis after intra-articular fractures by virtue of altered mechanical axis and eccentric joint loading.19 Management of soft tissue surrounding joint is also very important in determining the optimal outcome following intraarticular fractures.20,21 Joint immobilization causes raised joint pressure leading to loss of nutrition and chondrocyte death. There is also liberation of several enzymes like proteases, which lead to articular surface degeneration. Motion promotes healing of full thickness articular cartilage defects with hyaline articular “cartilage like” material.
 
Imaging of Intra-articular Fractures
A detailed radiographic work-up is essential to understand the fracture anatomy of intra-articular fractures. Anteroposterior and lateral X-rays alone are usually not sufficient. Computed tomography is very useful for delineating the fracture configuration and has proved invaluable in current planning and management of intra-articular fractures (Fig. 1.4). This is more important in certain complex fractures like acetabular fractures, distal humerus fractures, distal tibia fractures, etc. CT gives detailed description of articular gap and step offs.22,23 According to a study by Tornetta,24 surgical plan changed in 64% cases after CT and additional information was available in 82% cases.
Recently intraoperative 3D fluoroscopy has been introduced, which usually provides inferior quality images than intraoperative CT but is much cheaper and has similar clinical value. Several studies26,27 have proved the usefulness of this investigation and have led the surgeons to change their implant placement during surgery.
 
Timing to Operate
Intra-articular fractures rarely require urgent ORIF except in open fractures, fractures with neurovascular complications, associated compartment syndrome and irreducible fracture dislocations. Proper management of intra-articular fractures requires appreciation of fracture anatomy as well as soft tissue injury. Usually complex intra-articular fractures are associated with significant trauma to surrounding soft tissue. Surgical approach through such traumatized soft tissue envelop, if done early, will cause additional trauma to soft tissue envelope, leading to problems related to wound healing and infection (Fig. 1.5). So it is prudent to wait for soft tissue healing before embarking upon the surgery. This can vary from days to weeks.11 In between the time, one can use bridging external fixators also known as traveling fixators (Fig. 1.6) with definitive fixation later on. Several indirect reduction techniques and biological fixation concepts have also come to reduce trauma to the soft tissue envelope.
It is also important to assess the resources of surgeon as well as of the institution and cases should be referred to higher centers if facilities are inadequate.5
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Figure 1.4: CT gives much detailed description of intraarticular fracture anatomy. Die-punch component (arrow) was easily identified on CT in this case
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Figure 1.5: Infection and wound healing problems are common if surgery is done early through traumatic soft tissue envelope
 
Surgical Principles (Figs 1.7A to E)
An atraumatic surgical approach should be used. Both minimally invasive and open approaches are available, however all articular fragments must be reduced anatomically and preferably under vision. Ligamentotaxis will only work for fragments with ligament attachment (i.e. some split fractures of the tibial plateau).
Surgical reconstruction begins with anatomical reduction of the articular surface.
Quite often the depressed fragments need to be elevated. Bone graft or bone substitute is used to support this elevated fragment if necessary.6
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Figure 1.6: Traveling temporary fixator
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Figures 1.7A to E: (A) AP and lateral X-rays of intraarticular distal humerus fracture; (B) Exposure of fracture; (C) Reduction of articular surface; (D) Provisional fixation of fracture with K wires; (E) Postoperative X-rays showing definitive fixation with plates and screws
This articular reduction is then secured with K-wires or screws and then this articular block is fixed to the metaphysis with the help of definitive implant. Nowadays, periarticular anatomical locking plates have become indispensable in the management of these fractures. All measures are taken to minimize trauma to the surrounding soft tissue.
 
Postoperative Rehabilitation
Several studies29-31 have reported beneficial effects of early motion in intra-articular fractures. Active assisted exercises are preferable, muscles and joints both are rehabilitated. Continuous passive motion (CPM) does not prevent muscle atrophy, however; it is still a useful tool in the management of intra-articular fractures. Sometimes, stability of fixation can be of concern. Some sort of additional stability can be provided with 7ROM-splints. Plaster immobilization should not be used after ORIF of intra-articular fractures as it leads to more stiffness. Patients are kept non-weight bearing until articular fracture is healed.
 
Emerging Technologies
T1-rho MRI mapping, which measure relaxation times in cartilage can assess specific components of articular cartilage biochemistry and ultra-structure. It has shown to be more sensitive to cartilage degradation than conventional MRI techniques.32-34
Recently virtual operative plan can be made preoperatively with the help of electronic templating. Electronic templating is also useful in planning of implant needs as well as positioning over the bone fragments. Superior softwares are being introduced to improve the efficacy as well as extent of application of this technology.35
Navigation is another important breakthrough which helps in the management of complex intra-articular fractures like acetabular fractures. Both CT based as well as fluoroscopy based navigations are available in today's world.36,37
New technologies are being added to orthopedics day by day. Some technologies like nanotechnology have the potential to change the current orthopedic practice completely.
References
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