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Arthrographic Evaluation of Problems with United Tibial Plateau Fractures 1
Diagnostic Radiology
Philip W. Anderson, M.D., John D. Harley, M.D., and Phillis U. Maslin, R.T. Double-contrast arthrotomography gives nonoperative demonstration of the intra-articular structure of the knee in patients with problems following recovery from tibial plateau fractures. INDEX TERMS:
Joints, wounds and injuries. Knee, arthrography
Radiology 119:75-78, April 1976
most patients recover from tibial plateau fracture without difficulty, early or late problems develop in some. Deformity of the joint resulting from the healed fracture may complicate the clinical interpretation, while radiographs which display the osseous structure do not define the soft-tissue surfaces. When symptoms suggest a meniscus injury, standard arthrography will usually demonstrate the meniscus lesions (1, 3, 4, 8). When clinical findings are of more vague pain or effusion, or instability, demonstration of the internal surfaces of the joint as well as the menisci may facilitate an accurate diagnostic evaluation and appropriate treatment planning. Arthroscopy permits visualization of the internal structure of the knee but requires an operating room and anesthesia (5, 7, 9). Application of tomography during double-contrast opacified arthrography permits excellent display of the
synovial and cartilaginous surfaces as well as the menisci (2). As with all arthrograms, the examination can be performed in the x-ray department without anesthesia. The following cases are typical of our experience with the use of this technique. The examination in each case contributed significantly to the patient's care.
ALTHOUGH
1-\
MATERIALS AND METHODS
A total of 307 knee arthrotomograms have been obtained. Ten tibial plateau fractures of patients 19-69 years old have been examined. There were 8 men and 2 women. The arthrotomographic examinations occurred within 1 month to 40 years after the fracture. Four patients had had operative repair of their fractures antedating the arthrotomograms. The examinations were performed by injection of
Fig. 1. Depressed lateral tibial plateau fracture 4 years after injury. A. Lateral roentgenogram shows anterior depression of tibial plateau (arrow). Band C. Lateral (B) and anteroposterior (C) arthrotomograms show the anterior lateral meniscus (vertical arrows) fixed by fibrous bands to a defect in the tibial plateau (horizontal arrows). 1 From the Departments of Radiology (P. W. A., Instructor, P. U. M., Radiologic Technician), University of Washington School of Medicine, elk and (J. D. H., Chief of Radiology), VA Hospital, Seattle, Washington. Accepted for publication in November 1975.
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April 1976
Fig. 2. A and B. Depressed medial tibial plateau fracture 40 years after injury. Anteroposterior (A) and lateral (B) roentgenograms show depression of the medial tibial plateau (arrows) and degenerative joint disease. C. Lateral arthrotomogram shows a step-off of the tibial plateau (arrow) and cysts of osteoarthritis. Notice the absence of cartilage on the femur and tibia.
positive contrast material and air, as is done for doublecontrast meniscus arthrography (1, 3, 4, 8). Stress was applied to distract the femoral condyle from the tibial plateau and tomographic exposures were made in the lateral projection. Supplementary frontal tomograms were sometimes included. Details of this technique have been reported previously (2).
plateau (Fig. 1, A). Arthrograms revealed a fibrous band joining the base of the tibial plateau fracture and the undersurface of the anterior horn of the lateral meniscus (Fig. 1, B and C). There was some fragmentation of the anterior horn of the meniscus adjacent to the fibrous band and extending to the capsule. Since the meniscus filled and smoothed the tibial defect and was adherent to it in a manner not suspected prior to the examination, meniscectomy was not performed in spite of the fragmentation of a portion of its capsular attachment. The arthrotomographic findings ruled out arthrotomy.
CASE REPORTS
CASE II (L.H.): A 69-year-old woman sustained an intra-articular fracture of her left knee 40 years before examination. She did well for 25 years after initial nonsurgical treatment but presented with 15 years of increasing knee pain, most marked for 6 months. Ambulation was limited by pain to four blocks and climbing stairs was particularly painful. She could dress herself, drive her car, and had minimal night pain. She had been injected with local steroids on three occasions. Physical examination revealed no effusion. She obtained 90° flexion and full extension. The medial, lateral, and cruciate ligaments were competent, but there was medial joint-line tenderness, mild quadriceps atrophy, and 10° varus angulation while standing. Radiographs showed a depressed medial tibial plateau, complete loss of medial joint-space height, and osteophytes of osteoarthritis (Fig. 2, A-B). Arthrotomograms revealed a step-off of the medial tibial plateau, full-thickness loss of the articular cartilage from the medial femoral condyle and tibial plateau, and cystic erosions of the tibial plateau (Fig. 2, C). A large popliteal cyst and cartilage loss from the lateral femoral condyle and tibial plateau were demonstrated. Both menisci were extensively degenerated. Since the ex-
CASE I (R.K.): A 19-year-old man was injured 4 years before examination. A fall on a glacier resulted in a depressed fracture of the left lateral tibial plateau. He continued to walk with the fracture, and after 3 days sought medical care and was treated with 3 days of skin traction. The leg was then encased in a long, leg plaster cast for 8 weeks followed by 4 weeks with active range-of-motion exercise and no cast. During this entire 12 weeks the leg was not allowed to bear weight. Childhood poliomyelitis caused a shortened contralateral right leg. A left distal femoral epiphysiodesis equalized leg length in early adolescence. Four years after injury he complained of lateral knee pain with prolonged standing. He had no locking or effusions. Physical examination revealed Grade II lateral instability. Internal rotation of the tibia with the knee in full extension produced lateral joint-line pain. The clinical diagnosis was detachment of the lateral meniscus resulting in lateral joint-line symptoms. Radiographs showed an anterior depression of the lateral tibial
Vol. 119
77
UNITED TIBIAL PLATEAU FRACTURES
Diagnostic Radiology
Fig. 3. Bone-grafted posterior lateral tibial plateau. A. Lateral roentgenogram shows nonunion 5 years after graft placement. Band C. Lateral (B) and anteroposterior (C) arthrotomograms show that the bone graft and covering reparative soft tissues provide excellent support for the posterior lateral joint (arrows) in spite of the osseous nonunion.
tent of degeneration of the joint was worse than anticipated, a total knee prosthesis placement was performed instead of a debridement. The arthrotomographic findings were confirmed at arthro-
tomy. CASE III. (D.S.): A 32-year-old man sustained a direct blow to his left knee producing effusion and pain 5 years before examination. Recovery was complete. Five months later he fell 15 ft. and landed on his feet. He exhibited sudden left knee pain and swelling. Radiographs revealed an osteochondral fragment in the anterior portion of the joint and a torn medial meniscus, which were removed. The fragment was found to be from the posterior lateral tibial plateau. After rehabilitation, fluoroscopy showed the posterior lateral joint to be unstable, allowing the femoral condyle to move posteriorly off the defect in the tibial plateau. A second arthrotomy 2 months after the first permitted lateral meniscectomy and placement of a fibular bone graft in the posterior tibial defect. The graft was held by two K-wires and a screw. The K-wires were removed without incident 2 Y2 years later. He returned 5 years after injury and surgery, with a varus stress injury to the knee which produced pain and swelling. Radiographs and fluoroscopy indicated nonunion of the grafted tibial plateau, which suggested inadequacy of the articular surface (Fig. 3, A). Arthrotomography revealed a smooth articulation of the femoral condyle with the grafted bone and soft tissue, which had invested and covered the graft. The result was reconstitution of the posterior tibial plateau giving adequate support to the posterolateral joint in spite of failure of osseous union of the graft (Fig. 3, B and C). The extent to which the healing process had reconstructed the plateau was not appreciated until the arthrotomographic examination. There were no further manipulations and the patient has not returned with complaints.
CASE IV (D.A.): A 30-year-old man sustained an intra-articular left tibial fracture 1 year before examination. The fracture was inflicted by an automobile as a direct lateral blow while he was riding a bicycle. The intercondylar tibial spines were avulsed and a fracture line extended through the weight-bearing portion of the lateral tibial plateau. He was treated initially with a cylinder cast and then with early motion. One year later, having recovered full activity, he complained of medial and lateral joint-line pain with exertion. Physical examination was normal. Radiographs showed a central depression in the lateral tibial plateau adjacent to the tibial spine (Fig. 4, A and B). Arthrotomography revealed that the cartilage and fibrous healing of the tibial plateau defect was such that the articular surface was completely smooth and unlikely to be the source of symptoms (Fig. 4, C and D). The medial meniscus was torn and the lateral meniscus was normal. Arthrotomy confirmed the arthrotomographic findings and permitted excision of the medial meniscus. The patient is currently rehabilitating from surgery.
DISCUSSION
Our experience with arthrotomography applied to problems resulting from tibial plateau fractures indicates that it yields better delineation of the articular surfaces than any other currently available nonoperative techniques. Although not all of our patients were found to have surgically correctable problems, the decisions concerning patient treatment were made with a maximum amount of anatomical information. In most cases a careful examination of the menisci
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Fig. 4. A and B. Healed tibial plateau fracture. Anteroposterior (A) and lateral (B) radiographs show sclerotic bone along the healed plateau fracture (arrows). C and D. Anteroposterior (C) and lateral (D) arthrotomograms show a defect in the tibial plateau (arrows) with smooth covering cartilage. Notice the normal lateral meniscus (arrowheads).
accompanies and complements the tomographic examination. The usual intra-articular positive contrast material and air-injection technique (1, 3, 4, 8) is adequate for both examinations. The meniscus exposures are made first, since they are more dependent on positivecontrast enhancement of surfaces than are the tomograms. Addition of epinephrine to the injection to prolong edge enhancement, as recently advocated (6), has not been necessary, since the tomograms primarily display the interfaces of the air with the synovium and cartilage. No complications of double-contrast arthrography have been reported, although we have observed < 1 % incidence of sterile synovitis following arthrography. No problems were encountered with these patients examined following tibial plateau fracture. Department of Radiology University of Washington School of Medicine Seattle, Wash. 98195
REFERENCES 1. Angell FL: Fluoroscopic technique of double contrast thrography of the knee. Radiol Clin North Am 9:85-98, Apr 1971 2. Anderson PW, Maslin PU: Tomography applied to knee thrography. Radiology 110:271-275, Feb 1974 3. Andren L, Wehlin L: Double-contrast arthrography of knee with horizontal roentgen ray beam. Acta Orthop Scand
ararthe
29:
307-314, 1960 4. Butt WP, Mcintyre JL: Double-contrast arthrography of the knee. Radiology 92:487-499, Mar 1969 5. Casscells SW: Arthroscopy of the knee joint. J Bone Joint Surg [Am] 53:287-298, Mar 1971 6. Hall FM: Epinephrine-enhanced knee arthrography. Radiology 111:215-217, Apr 1974 7. Jackson RW, Abe I: The role of arthroscopy in the management of disorders of the knee: An analysis of 200 consecutive examinations. J Bone Joint Surg [Br] 54:310-322, May 1972 8. Nicholas JA, Freiberger RH, Killoran PJ: Double-contrast arthrography of the knee: Its value in the management of two hundred and twenty-five knee derangements. J Bone Joint Surg [Am] 52: 203-220, Mar 1970 9. O'Connor RL: Arthroscopy in the diagnosis and treatment of acute ligamentous injuries of the knee. J Bone Joint Surg [Am] 56: 333-337, Mar 1974
Arthrographic Evaluation of Problems with United Tibial Plateau Fractures 1
Diagnostic Radiology
Philip W. Anderson, M.D., John D. Harley, M.D., and Phillis U. Maslin, R.T. Double-contrast arthrotomography gives nonoperative demonstration of the intra-articular structure of the knee in patients with problems following recovery from tibial plateau fractures. INDEX TERMS:
Joints, wounds and injuries. Knee, arthrography
Radiology 119:75-78, April 1976
most patients recover from tibial plateau fracture without difficulty, early or late problems develop in some. Deformity of the joint resulting from the healed fracture may complicate the clinical interpretation, while radiographs which display the osseous structure do not define the soft-tissue surfaces. When symptoms suggest a meniscus injury, standard arthrography will usually demonstrate the meniscus lesions (1, 3, 4, 8). When clinical findings are of more vague pain or effusion, or instability, demonstration of the internal surfaces of the joint as well as the menisci may facilitate an accurate diagnostic evaluation and appropriate treatment planning. Arthroscopy permits visualization of the internal structure of the knee but requires an operating room and anesthesia (5, 7, 9). Application of tomography during double-contrast opacified arthrography permits excellent display of the
synovial and cartilaginous surfaces as well as the menisci (2). As with all arthrograms, the examination can be performed in the x-ray department without anesthesia. The following cases are typical of our experience with the use of this technique. The examination in each case contributed significantly to the patient's care.
ALTHOUGH
1-\
MATERIALS AND METHODS
A total of 307 knee arthrotomograms have been obtained. Ten tibial plateau fractures of patients 19-69 years old have been examined. There were 8 men and 2 women. The arthrotomographic examinations occurred within 1 month to 40 years after the fracture. Four patients had had operative repair of their fractures antedating the arthrotomograms. The examinations were performed by injection of
Fig. 1. Depressed lateral tibial plateau fracture 4 years after injury. A. Lateral roentgenogram shows anterior depression of tibial plateau (arrow). Band C. Lateral (B) and anteroposterior (C) arthrotomograms show the anterior lateral meniscus (vertical arrows) fixed by fibrous bands to a defect in the tibial plateau (horizontal arrows). 1 From the Departments of Radiology (P. W. A., Instructor, P. U. M., Radiologic Technician), University of Washington School of Medicine, elk and (J. D. H., Chief of Radiology), VA Hospital, Seattle, Washington. Accepted for publication in November 1975.
75
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PHILIP ANDERSON AND OTHERS
April 1976
Fig. 2. A and B. Depressed medial tibial plateau fracture 40 years after injury. Anteroposterior (A) and lateral (B) roentgenograms show depression of the medial tibial plateau (arrows) and degenerative joint disease. C. Lateral arthrotomogram shows a step-off of the tibial plateau (arrow) and cysts of osteoarthritis. Notice the absence of cartilage on the femur and tibia.
positive contrast material and air, as is done for doublecontrast meniscus arthrography (1, 3, 4, 8). Stress was applied to distract the femoral condyle from the tibial plateau and tomographic exposures were made in the lateral projection. Supplementary frontal tomograms were sometimes included. Details of this technique have been reported previously (2).
plateau (Fig. 1, A). Arthrograms revealed a fibrous band joining the base of the tibial plateau fracture and the undersurface of the anterior horn of the lateral meniscus (Fig. 1, B and C). There was some fragmentation of the anterior horn of the meniscus adjacent to the fibrous band and extending to the capsule. Since the meniscus filled and smoothed the tibial defect and was adherent to it in a manner not suspected prior to the examination, meniscectomy was not performed in spite of the fragmentation of a portion of its capsular attachment. The arthrotomographic findings ruled out arthrotomy.
CASE REPORTS
CASE II (L.H.): A 69-year-old woman sustained an intra-articular fracture of her left knee 40 years before examination. She did well for 25 years after initial nonsurgical treatment but presented with 15 years of increasing knee pain, most marked for 6 months. Ambulation was limited by pain to four blocks and climbing stairs was particularly painful. She could dress herself, drive her car, and had minimal night pain. She had been injected with local steroids on three occasions. Physical examination revealed no effusion. She obtained 90° flexion and full extension. The medial, lateral, and cruciate ligaments were competent, but there was medial joint-line tenderness, mild quadriceps atrophy, and 10° varus angulation while standing. Radiographs showed a depressed medial tibial plateau, complete loss of medial joint-space height, and osteophytes of osteoarthritis (Fig. 2, A-B). Arthrotomograms revealed a step-off of the medial tibial plateau, full-thickness loss of the articular cartilage from the medial femoral condyle and tibial plateau, and cystic erosions of the tibial plateau (Fig. 2, C). A large popliteal cyst and cartilage loss from the lateral femoral condyle and tibial plateau were demonstrated. Both menisci were extensively degenerated. Since the ex-
CASE I (R.K.): A 19-year-old man was injured 4 years before examination. A fall on a glacier resulted in a depressed fracture of the left lateral tibial plateau. He continued to walk with the fracture, and after 3 days sought medical care and was treated with 3 days of skin traction. The leg was then encased in a long, leg plaster cast for 8 weeks followed by 4 weeks with active range-of-motion exercise and no cast. During this entire 12 weeks the leg was not allowed to bear weight. Childhood poliomyelitis caused a shortened contralateral right leg. A left distal femoral epiphysiodesis equalized leg length in early adolescence. Four years after injury he complained of lateral knee pain with prolonged standing. He had no locking or effusions. Physical examination revealed Grade II lateral instability. Internal rotation of the tibia with the knee in full extension produced lateral joint-line pain. The clinical diagnosis was detachment of the lateral meniscus resulting in lateral joint-line symptoms. Radiographs showed an anterior depression of the lateral tibial
Vol. 119
77
UNITED TIBIAL PLATEAU FRACTURES
Diagnostic Radiology
Fig. 3. Bone-grafted posterior lateral tibial plateau. A. Lateral roentgenogram shows nonunion 5 years after graft placement. Band C. Lateral (B) and anteroposterior (C) arthrotomograms show that the bone graft and covering reparative soft tissues provide excellent support for the posterior lateral joint (arrows) in spite of the osseous nonunion.
tent of degeneration of the joint was worse than anticipated, a total knee prosthesis placement was performed instead of a debridement. The arthrotomographic findings were confirmed at arthro-
tomy. CASE III. (D.S.): A 32-year-old man sustained a direct blow to his left knee producing effusion and pain 5 years before examination. Recovery was complete. Five months later he fell 15 ft. and landed on his feet. He exhibited sudden left knee pain and swelling. Radiographs revealed an osteochondral fragment in the anterior portion of the joint and a torn medial meniscus, which were removed. The fragment was found to be from the posterior lateral tibial plateau. After rehabilitation, fluoroscopy showed the posterior lateral joint to be unstable, allowing the femoral condyle to move posteriorly off the defect in the tibial plateau. A second arthrotomy 2 months after the first permitted lateral meniscectomy and placement of a fibular bone graft in the posterior tibial defect. The graft was held by two K-wires and a screw. The K-wires were removed without incident 2 Y2 years later. He returned 5 years after injury and surgery, with a varus stress injury to the knee which produced pain and swelling. Radiographs and fluoroscopy indicated nonunion of the grafted tibial plateau, which suggested inadequacy of the articular surface (Fig. 3, A). Arthrotomography revealed a smooth articulation of the femoral condyle with the grafted bone and soft tissue, which had invested and covered the graft. The result was reconstitution of the posterior tibial plateau giving adequate support to the posterolateral joint in spite of failure of osseous union of the graft (Fig. 3, B and C). The extent to which the healing process had reconstructed the plateau was not appreciated until the arthrotomographic examination. There were no further manipulations and the patient has not returned with complaints.
CASE IV (D.A.): A 30-year-old man sustained an intra-articular left tibial fracture 1 year before examination. The fracture was inflicted by an automobile as a direct lateral blow while he was riding a bicycle. The intercondylar tibial spines were avulsed and a fracture line extended through the weight-bearing portion of the lateral tibial plateau. He was treated initially with a cylinder cast and then with early motion. One year later, having recovered full activity, he complained of medial and lateral joint-line pain with exertion. Physical examination was normal. Radiographs showed a central depression in the lateral tibial plateau adjacent to the tibial spine (Fig. 4, A and B). Arthrotomography revealed that the cartilage and fibrous healing of the tibial plateau defect was such that the articular surface was completely smooth and unlikely to be the source of symptoms (Fig. 4, C and D). The medial meniscus was torn and the lateral meniscus was normal. Arthrotomy confirmed the arthrotomographic findings and permitted excision of the medial meniscus. The patient is currently rehabilitating from surgery.
DISCUSSION
Our experience with arthrotomography applied to problems resulting from tibial plateau fractures indicates that it yields better delineation of the articular surfaces than any other currently available nonoperative techniques. Although not all of our patients were found to have surgically correctable problems, the decisions concerning patient treatment were made with a maximum amount of anatomical information. In most cases a careful examination of the menisci
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Fig. 4. A and B. Healed tibial plateau fracture. Anteroposterior (A) and lateral (B) radiographs show sclerotic bone along the healed plateau fracture (arrows). C and D. Anteroposterior (C) and lateral (D) arthrotomograms show a defect in the tibial plateau (arrows) with smooth covering cartilage. Notice the normal lateral meniscus (arrowheads).
accompanies and complements the tomographic examination. The usual intra-articular positive contrast material and air-injection technique (1, 3, 4, 8) is adequate for both examinations. The meniscus exposures are made first, since they are more dependent on positivecontrast enhancement of surfaces than are the tomograms. Addition of epinephrine to the injection to prolong edge enhancement, as recently advocated (6), has not been necessary, since the tomograms primarily display the interfaces of the air with the synovium and cartilage. No complications of double-contrast arthrography have been reported, although we have observed < 1 % incidence of sterile synovitis following arthrography. No problems were encountered with these patients examined following tibial plateau fracture. Department of Radiology University of Washington School of Medicine Seattle, Wash. 98195
REFERENCES 1. Angell FL: Fluoroscopic technique of double contrast thrography of the knee. Radiol Clin North Am 9:85-98, Apr 1971 2. Anderson PW, Maslin PU: Tomography applied to knee thrography. Radiology 110:271-275, Feb 1974 3. Andren L, Wehlin L: Double-contrast arthrography of knee with horizontal roentgen ray beam. Acta Orthop Scand
ararthe
29:
307-314, 1960 4. Butt WP, Mcintyre JL: Double-contrast arthrography of the knee. Radiology 92:487-499, Mar 1969 5. Casscells SW: Arthroscopy of the knee joint. J Bone Joint Surg [Am] 53:287-298, Mar 1971 6. Hall FM: Epinephrine-enhanced knee arthrography. Radiology 111:215-217, Apr 1974 7. Jackson RW, Abe I: The role of arthroscopy in the management of disorders of the knee: An analysis of 200 consecutive examinations. J Bone Joint Surg [Br] 54:310-322, May 1972 8. Nicholas JA, Freiberger RH, Killoran PJ: Double-contrast arthrography of the knee: Its value in the management of two hundred and twenty-five knee derangements. J Bone Joint Surg [Am] 52: 203-220, Mar 1970 9. O'Connor RL: Arthroscopy in the diagnosis and treatment of acute ligamentous injuries of the knee. J Bone Joint Surg [Am] 56: 333-337, Mar 1974
