Purpose: Problem: Tibia plateau fractures may lead to end-stage post-traumatic arthritis that requires reconstructive surgery. The incidence of this problem is unknown but has been estimated at 20–40% by studies that were limited by small sample sizes, potential follow-up bias, and the limitations of using radiographic arthritis as a chosen outcome (not correlated to function). The use of administrative data bases to follow the care of a large number patients for robust end points such as surgery, offers an opportunity to address these limitations. Purpose: to determine the minimum ten year incidence of post-traumatic arthritis necessitating reconstructive surgery following tibia plateau fractures.

Method: We queried our prospectively collected Orthopedic Trauma Data base to identify operatively treated patients with tibia plateau fractures. These cases were cross-referenced with the data from our Province’s administrative health database and tracked over time for the performance of reconstructive knee surgery. Each individual’s exposure/follow-up period was limited by end of health plan coverage on record or date of death from vital statistics data. The minimum follow-up was ten years.

Results: Between 1987 and 1994, 378 patients with a tibia plateau fracture were treated at our institution. The average age was 46 years (sd=18, range 14–87), while 56% of patients were males. Seventeen out-of-Province residents were excluded, along with forty-six others whose “Medical Services Plan” numbers could not be identified. Of which seven were WCB patients and one who was affiliated with the military. The study cohort therefore consisted of 311 patients with 314 tibia plateau fractures. Four individuals (1.3%) we treated tibia plateau fractures have required reconstructive knee surgery for end-stage post-traumatic knee arthritis at 10 years. Of these 3 of 4 were type VI fractures and 1 of 4 was open.

Conclusion: Patients who require surgical treatment of tibia plateau fractures may be counseled on their long-term risk of requiring reconstructive knee surgery for endstage knee arthritis based on a clinical study. Based on our findings, the proportion of those who have required a total knee surgery, ten years following their injury, is lower than previously published.

Purpose: Femoral and tibial shaft malunion may predispose to knee osteoarthritis but may also pose a problem for knee reconstruction; malposition of total knee prostheses being a known cause of early failure. Limb realignment may prove to be beneficial prior to proceeding with arthroplasty. The purpose of this study was to evaluate the outcome and effect of shaft osteotomy prior to total knee arthroplasty (TKA).

Method: A search of the trauma database between 1987 and 2006 was conducted. Twenty-two osteotomies were performed on 21 patients with femoral or tibial shaft malunion who had been considered for TKA. Mean age at osteotomy was 54 years and mean follow-up 86 months. Time intervals between surgical procedures and Knee Society scores were calculated. Patients were surveyed regarding pain relief and functional improvement.

Results: Femoral osteotomy improved mean Knee Society knee scores from 47 to 76 and function scores from 34 to 61. Tibial osteotomy improved knee scores from 53 to 82 and function scores from 28 to 50. Four osteotomies were complicated by nonunion and required further intervention. Osteotomy subjectively improved pain and function for a mean of 56 months. Femoral and tibial shaft osteotomy delayed TKA in 45% (10 cases) for a mean period of just over 6.5 years (89 and 73 months for femoral and tibial osteotomy respectively). Pre and post Knee society scores were: Femur: knee 56 to 88, function 41 to 72; Tibia: knee 65 to 85, function 25 to 57. One TKA was revised after 11 months due to valgus malalignment and was complicated by a wound infection. There were no other infections or wound complications. The procedure additionally relieved pain and improved function in the remaining 12 joints, not yet requiring arthroplasty.

Conclusion: Femoral and tibial shaft osteotomy may delay and possibly avoid TKA, relieve pain and improve function in patients who present with malunion and end-stage knee arthritis. The complication rate and clinical results of TKA following shaft osteotomy appear to be similar to primary TKA. This treatment strategy should be considered in younger patients with post traumatic osteoarthritis where significant femoral or tibial deformity is present.

Purpose: To evaluate the long-term outcomes of the early management of severe ligamentous knee injuries.

Methods: We reviewed the long-term results of patients with multiple knee ligament injuries, i.e. at least 3 ligament ruptures, including both cruciates, in patients entered prospectively onto the trauma database between 1985 and 1999. Forty patients with this injury had Lysholm scores at long term follow-up a mean of 8 years post-injury. Non-operative treatment involved a cast or spanning external fixator (2–4 weeks) followed by bracing. The mode of operative treatment fell into 3 groups: direct suture or screw fixation of avulsions (Group 1), mid-substance ruptures treated with posterior cruciate reconstruction with hamstring tendons (Group 2), or suture repairs of mid-substance ruptures (Group 3). All operative procedures were undertaken within 2 weeks of injury. Statistical analysis was performed on the Lysholm scores.

Results: The 40 patients in the study group were predominantly young males, 40% had polytrauma, 33% had isolated injuries. Thirteen patients (33%) had non-operative management, the remainder had early operative treatment of their ligament injuries, tailored to the type of ligament injuries identified.

Long term patient outcome data shows statistically significant differences (p< 0.05) between the best results, in patients with direct fixation of bony avulsions (mean = 89), followed by those who had early hamstring reconstruction (mean = 79), followed by those who underwent simple ligament repairs (mean = 65). There was a statistically significant difference (p< 0.05) between the overall scores for the operative group (mean = 80) compared with the non-operative group (mean = 50).

Conclusion: Operative treatment of multiple ligament injuries, particularly fixation of avulsions and primary reconstruction of the posterior cruciate ligament appears to yield better results than non-operative or simple repair in the long term follow-up in this group with significant knee injuries.