TRA and CABG vs. non-CABG populations.
\r\n\tThe study of populations and plant communities in their different aspects; ecological, structural, functional and dynamic, it is essential to establish a posteriori models of forest and agricultural management.
\r\n\r\n\tFor this, the methodological approaches on the type of sampling are considered essential, since there are differences between the purely ecological and the phytosociological methods, despite the fact that both pursue the same objective.
\r\n\tAlthough the ecological method for the knowledge of the vegetation is widely extended, the phytosociological one is no less so, since in the European Union it has been developed as a consequence of policies on sustainability, through which regulations have been issued, such as the habitats directive.
\r\n\tOn the other hand, research on plant dynamics and knowledge of the landscape in an integral way, have multiplied in the last 30 years, which has favored a deep knowledge of the floristic and phytocenotic wealth, which is fundamental for agricultural management, livestock and forestry.
",isbn:"978-1-83969-386-1",printIsbn:"978-1-83969-385-4",pdfIsbn:"978-1-83969-387-8",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,hash:"0abf2a59ee63fc1ba4fb64d77c9b1be7",bookSignature:"Dr. Eusebio Cano Carmona, Dr. Ricardo Quinto Canas, Dr. Ana Cano Ortiz and Dr. Carmelo Maria Musarella",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/9662.jpg",keywords:"Climatic Factors, Bioclimate, Thermotype, Flora, Conservation, Phytocenosis, Plant Dynamics, Landscape, Cartography, Vegetation Series, Crops, Reforestation",numberOfDownloads:54,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfDimensionsCitations:0,numberOfTotalCitations:0,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"November 23rd 2020",dateEndSecondStepPublish:"January 25th 2021",dateEndThirdStepPublish:"March 26th 2021",dateEndFourthStepPublish:"June 14th 2021",dateEndFifthStepPublish:"August 13th 2021",remainingDaysToSecondStep:"3 months",secondStepPassed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"Dr. Cano Carmona and colleagues have directed 12 doctoral theses and more than 200 publications among articles, books, and book chapters. He has participated in national and international congresses with about 250 papers. He has held a number of different academic positions, including Dean of the Faculty of Experimental Sciences at the University of Jaen, Spain, and founder and director of the International Seminar on Management and Conservation of Biodiversity.",coeditorOneBiosketch:"Ricardo Jorge Quinto Canas is currently an Invited Assistant Professor in the Faculty of Sciences and Technology at the University of Algarve – Portugal, and a member of the Centre of Marine Sciences (CCMAR), University of Algarve. His current research projects focus on Botany, Vegetation Science (Geobotany), Biogeography, Plant Ecology, and Biology Conservation, aiming to support Nature Conservation.",coeditorTwoBiosketch:"Ana Cano Ortiz's fundamental line of research is related to botanical bioindicators. She has worked in Spain, Italy, Portugal, and Central America. It presents more than one hundred works published in various national and international journals, as well as books and book chapters; and has presented a hundred papers to national and international congresses.",coeditorThreeBiosketch:"Carmelo Maria Musarella is a biologist, specialized in Plant Biology. He is a member of the permanent scientific committee of the International Seminar on “Biodiversity Conservation and Management” guested by several European universities. He has participated in several international and national congresses, seminars, and workshops and presented oral communications and posters.",coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"87846",title:"Dr.",name:"Eusebio",middleName:null,surname:"Cano Carmona",slug:"eusebio-cano-carmona",fullName:"Eusebio Cano Carmona",profilePictureURL:"https://mts.intechopen.com/storage/users/87846/images/system/87846.png",biography:"Eusebio Cano Carmona obtained a PhD in Sciences from the\nUniversity of Granada, Spain. He is Professor of Botany at the\nUniversity of Jaén, Spain. His focus is flora and vegetation and he\nhas conducted research in Spain, Italy, Portugal, Palestine, the\nCaribbean islands and Mexico. As a result of these investigations,\nDr. Cano Carmona and colleagues have directed 12 doctoral theses\nand more than 200 publications among articles, books and book\nchapters. He has participated in national and international congresses with about\n250 papers/communications. He has held a number of different academic positions,\nincluding Dean of the Faculty of Experimental Sciences at the University of Jaen,\nSpain and founder and director of the International Seminar on Management and\nConservation of Biodiversity, a position he has held for 13 years. He is also a member of the Spanish, Portuguese and Italian societies of Geobotany.",institutionString:"University of Jaén",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"5",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"University of Jaén",institutionURL:null,country:{name:"Spain"}}}],coeditorOne:{id:"216982",title:"Dr.",name:"Ricardo Quinto",middleName:null,surname:"Canas",slug:"ricardo-quinto-canas",fullName:"Ricardo Quinto Canas",profilePictureURL:"https://mts.intechopen.com/storage/users/216982/images/system/216982.JPG",biography:"Ricardo Quinto Canas, Phd in Analysis and Management of Ecosystems, is currently an Invited Assistant Professor in the Faculty\nof Sciences and Technology at the University of Algarve, Portugal, and member of the Centre of Marine Sciences (CCMAR),\nUniversity of Algarve. He is also the Head of Division of Environmental Impact Assessment - Algarve Regional Coordination\nand Development Commission (CCDR - Algarve). His current\nresearch projects focus on Botany, Vegetation Science (Geobotany), Biogeography,\nPlant Ecology and Biology Conservation, aiming to support Nature Conservation.\nDr. Quinto Canas has co-authored many cited journal publication, conference articles and book chapters in above-mentioned topics.",institutionString:"University of Algarve",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"3",totalChapterViews:"0",totalEditedBooks:"0",institution:null},coeditorTwo:{id:"203697",title:"Dr.",name:"Ana",middleName:null,surname:"Cano Ortiz",slug:"ana-cano-ortiz",fullName:"Ana Cano Ortiz",profilePictureURL:"https://mts.intechopen.com/storage/users/203697/images/system/203697.png",biography:"Ana Cano Ortiz holds a PhD in Botany from the University of\nJaén, Spain. She has worked in private enterprise, in university\nand in secondary education. She is co-director of four doctoral\ntheses. Her research focus is related to botanical bioindicators.\nDr. Ortiz has worked in Spain, Italy, Portugal and Central America. She has published more than 100 works in various national\nand international journals, as well as books and book chapters.\nShe has also presented a great number of papers/communications to national and\ninternational congresses.",institutionString:"University of Jaén",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"6",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"University of Jaén",institutionURL:null,country:{name:"Spain"}}},coeditorThree:{id:"276295",title:"Dr.",name:"Carmelo Maria",middleName:null,surname:"Musarella",slug:"carmelo-maria-musarella",fullName:"Carmelo Maria Musarella",profilePictureURL:"https://mts.intechopen.com/storage/users/276295/images/system/276295.jpg",biography:"Carmelo Maria Musarella, PhD (Reggio Calabria, Italy –\n23/01/1975) is a biologist, specializing in plant biology. He\nstudied and worked in several European Universities: Messina,\nCatania, Reggio Calabria, Rome (Italy), Valencia, Jaén, Almeria\n(Spain), and Evora (Portugal). He was the Adjunct Professor\nof Plant Biology at the “Mediterranea” University of Reggio\nCalabria (Italy). His research topics are: floristic, vegetation,\nhabitat, biogeography, taxonomy, ethnobotany, endemisms, alien species, and\nbiodiversity conservation. He has authored many research articles published in\nindexed journals and books. He has been the guest editor for Plant Biosystems and a\nreferee for this same journal and others. He is a member of the permanent scientific\ncommittee of International Seminar on “Biodiversity Conservation and Management”, which includes several European universities. He has participated in several\ninternational and national congresses, seminars, workshops, and presentations of\noral communications and posters.",institutionString:'"Mediterranea" University of Reggio Calabria',position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"6",totalChapterViews:"0",totalEditedBooks:"1",institution:null},coeditorFour:null,coeditorFive:null,topics:[{id:"5",title:"Agricultural and Biological Sciences",slug:"agricultural-and-biological-sciences"}],chapters:[{id:"75595",title:"Assessment of the State of Forest Plant Communities of Scots Pine (Pinus sylvestris L.) in the Conditions of Urban Ecosystems",slug:"assessment-of-the-state-of-forest-plant-communities-of-scots-pine-pinus-sylvestris-l-in-the-conditio",totalDownloads:31,totalCrossrefCites:0,authors:[null]},{id:"76010",title:"Predictive Models for Reforestation and Agricultural Reclamation: A Clearfield County, Pennsylvania Case Study",slug:"predictive-models-for-reforestation-and-agricultural-reclamation-a-clearfield-county-pennsylvania-ca",totalDownloads:24,totalCrossrefCites:0,authors:[null]}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"247865",firstName:"Jasna",lastName:"Bozic",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/247865/images/7225_n.jpg",email:"jasna.b@intechopen.com",biography:"As an Author Service Manager, my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. Whether that be identifying an exceptional author and proposing an editorship collaboration, or contacting researchers who would like the opportunity to work with IntechOpen, I establish and help manage author and editor acquisition and contact."}},relatedBooks:[{type:"book",id:"6893",title:"Endemic Species",subtitle:null,isOpenForSubmission:!1,hash:"3290be83fff5bc015f5bd3d78ae9c6c7",slug:"endemic-species",bookSignature:"Eusebio Cano Carmona, Carmelo Maria Musarella and Ana Cano Ortiz",coverURL:"https://cdn.intechopen.com/books/images_new/6893.jpg",editedByType:"Edited by",editors:[{id:"87846",title:"Dr.",name:"Eusebio",surname:"Cano Carmona",slug:"eusebio-cano-carmona",fullName:"Eusebio Cano Carmona"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6418",title:"Hyperspectral Imaging in Agriculture, Food and Environment",subtitle:null,isOpenForSubmission:!1,hash:"9005c36534a5dc065577a011aea13d4d",slug:"hyperspectral-imaging-in-agriculture-food-and-environment",bookSignature:"Alejandro Isabel Luna Maldonado, Humberto Rodríguez Fuentes and Juan Antonio Vidales Contreras",coverURL:"https://cdn.intechopen.com/books/images_new/6418.jpg",editedByType:"Edited by",editors:[{id:"105774",title:"Prof.",name:"Alejandro Isabel",surname:"Luna Maldonado",slug:"alejandro-isabel-luna-maldonado",fullName:"Alejandro Isabel Luna Maldonado"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1591",title:"Infrared Spectroscopy",subtitle:"Materials Science, Engineering and Technology",isOpenForSubmission:!1,hash:"99b4b7b71a8caeb693ed762b40b017f4",slug:"infrared-spectroscopy-materials-science-engineering-and-technology",bookSignature:"Theophile Theophanides",coverURL:"https://cdn.intechopen.com/books/images_new/1591.jpg",editedByType:"Edited by",editors:[{id:"37194",title:"Dr.",name:"Theophanides",surname:"Theophile",slug:"theophanides-theophile",fullName:"Theophanides Theophile"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3161",title:"Frontiers in Guided Wave Optics and Optoelectronics",subtitle:null,isOpenForSubmission:!1,hash:"deb44e9c99f82bbce1083abea743146c",slug:"frontiers-in-guided-wave-optics-and-optoelectronics",bookSignature:"Bishnu Pal",coverURL:"https://cdn.intechopen.com/books/images_new/3161.jpg",editedByType:"Edited by",editors:[{id:"4782",title:"Prof.",name:"Bishnu",surname:"Pal",slug:"bishnu-pal",fullName:"Bishnu Pal"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3092",title:"Anopheles mosquitoes",subtitle:"New insights into malaria vectors",isOpenForSubmission:!1,hash:"c9e622485316d5e296288bf24d2b0d64",slug:"anopheles-mosquitoes-new-insights-into-malaria-vectors",bookSignature:"Sylvie Manguin",coverURL:"https://cdn.intechopen.com/books/images_new/3092.jpg",editedByType:"Edited by",editors:[{id:"50017",title:"Prof.",name:"Sylvie",surname:"Manguin",slug:"sylvie-manguin",fullName:"Sylvie Manguin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"371",title:"Abiotic Stress in Plants",subtitle:"Mechanisms and Adaptations",isOpenForSubmission:!1,hash:"588466f487e307619849d72389178a74",slug:"abiotic-stress-in-plants-mechanisms-and-adaptations",bookSignature:"Arun Shanker and B. Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"314",title:"Regenerative Medicine and Tissue Engineering",subtitle:"Cells and Biomaterials",isOpenForSubmission:!1,hash:"bb67e80e480c86bb8315458012d65686",slug:"regenerative-medicine-and-tissue-engineering-cells-and-biomaterials",bookSignature:"Daniel Eberli",coverURL:"https://cdn.intechopen.com/books/images_new/314.jpg",editedByType:"Edited by",editors:[{id:"6495",title:"Dr.",name:"Daniel",surname:"Eberli",slug:"daniel-eberli",fullName:"Daniel Eberli"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"57",title:"Physics and Applications of Graphene",subtitle:"Experiments",isOpenForSubmission:!1,hash:"0e6622a71cf4f02f45bfdd5691e1189a",slug:"physics-and-applications-of-graphene-experiments",bookSignature:"Sergey Mikhailov",coverURL:"https://cdn.intechopen.com/books/images_new/57.jpg",editedByType:"Edited by",editors:[{id:"16042",title:"Dr.",name:"Sergey",surname:"Mikhailov",slug:"sergey-mikhailov",fullName:"Sergey Mikhailov"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1373",title:"Ionic Liquids",subtitle:"Applications and Perspectives",isOpenForSubmission:!1,hash:"5e9ae5ae9167cde4b344e499a792c41c",slug:"ionic-liquids-applications-and-perspectives",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/1373.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"72475",title:"Tibial Plateau Fracture",doi:"10.5772/intechopen.92684",slug:"tibial-plateau-fracture",body:'Fractures involving the tibial articular surface account for a little over 1% of all long bone fractures, 56.9% of all proximal tibia fractures/dislocations, and 8% of all fractures in the elderly [1, 2, 3, 4]. They have an annual incidence of 10.3 per 100,000 [5]. The combined incidence of a patient having a tibial plateau fracture with associated polytrauma on admission has been estimated at 16–40% [6, 7, 8]. The age distribution is bimodal for both males and females which is similar to what is seen in other periarticular injuries [1]. The majority of fractures occur in males (70%) with men aged 40–44 years being the most affected patient population overall [4, 5]. Comminuted fractures are more common in males [3]. The highest incidence for tibial plateau fractures in females occurs between age 55 and 59 [4]. There is a shift of incidence between males and females that occurs after the age of 60 with females predominating (61%) [4, 9]. With an increase in life expectancy as well as a large aging population in many developed countries it is expected that the incidence of low-energy tibial plateau fractures will continue to increase.
The injury mechanism seen in tibial plateau fractures is largely age-dependent. The majority of tibial plateau fractures in the elderly are due to low energy falls. With an aging population and associated osteoporosis, the incidence of this injury is increasing. Osteopenia and osteoporosis play a large role in the fracture mechanisms and patterns observed. In the elderly, lateral fracture patterns are seen more commonly than medial. The forces acting on the bone in conjunction with the bone quality determine the resulting fracture patterns [10]. Bone quality influences fracture patterns with low bone density decreasing the force necessary for injury. A higher incidence of compression fracture patterns tends to be seen in such cases despite lower energy injury mechanisms. In the younger population, high energy mechanisms predominate. Male gender is more common. The injury mechanism can involve motor vehicles, sports, and falls from height. The most common mechanism of injury overall is pedestrian struck by motorized vehicles (30%) and the second most common is low energy falls (22%) [11].
The magnitude and direction of the force of injury many times will influence the fracture pattern. Angular, axial, and compression forces can all lead to failure of the condyles. Axial load is usually a predominant component of the injury mechanism and produces higher energy at failure than angular forces. In general, greater axial load results in more severe fractures with increased comminution, fragment displacement, and associated soft tissue injury. In a cadaver study [12] that looked at mechanisms of injury it was found that pure valgus forces resulted in the typical lateral split fractures, axial forces resulted in joint compression fractures, and a combination of axial and valgus forces resulted in split depression fractures. The same study also concluded that an intact MCL is required for an isolated lateral plateau fracture to occur because the MCL acts as the pivot point causing the lateral femoral condyle to impact the lateral tibial plateau. The proximal tibia is more readily subject to valgus force because of an anatomic predisposition with 5–7° of knee valgus in normal anatomic alignment and due to lateral side impacts being a more common injury mechanism.
The superior tibia widens from the diaphysis proximally (Figure 1). The proximal anterior tibia forms the tibial tubercle and provides the attachment of the patellar tendon. Lateral to the tibial tubercle is Gerdy’s tubercle which serves as the insertion site of the distal iliotibial band. The lateral proximal tibia forms the lateral tibial condyle and the inferior aspect of this serves as the attachment site of the anterior compartment muscles of the leg. The origin of the anterior muscles must be elevated in order to place an anterolateral plate. Medially and proximal to the tibial tubercle is the medial condyle. The medial condyle is less often involved in failure than the lateral condyle. The palpable fibular head (which is extra-articular to the knee joint) is found posterolateral and serves as the attachment site of the fibular collateral ligament and the biceps femoris tendon. The peroneal nerve wraps from posterior to anterior around the neck of the fibula. Even though the fibula does not participate in the knee joint articulation it does act as a buttress for the lateral tibial plateau. Because of this, associated proximal fibular fractures can result in greater valgus instability.
Proximal tibia anatomy (A) and normal plain radiographs of the tibial plateau anterior-posterior (AP) view (B) and lateral view (C) (Drawing and radiographs: courtesy of John Riehl MD &
The medial and lateral tibial plateaus articulate directly with the medial and lateral condyles of the femur. The tibial articular width is slightly wider than the femoral articular width (tibia:femur articular width ratio was found to be 1.01 ± 0.04 in one study of healthy knees) [13]. With this in mind it might be useful to use the femur as a reference to judge pathologic tibial plateau widening and adequacy of intraoperative reductions [13, 14]. The lateral plateau is more proximal and slightly convex whereas the medial plateau is more concave and slightly distal to the lateral plateau. The medial plateau bears around 60% of the total load borne across the knee. Relative to the tibial diaphysis, the plateau is slightly varus due to the proximal nature of the lateral tibial condyle [15]. The concavity of the medial plateau allows for greater congruity of the medial tibia with the femoral condyle compared to the lateral. The tibial plateau slopes about 15° posteroinferiorly making the anterior plateau proximal and posterior plateau more distal [16]. The medial plateau’s posterior tibial slope is greater than the lateral plateau’s posterior slope [17]. Variations to an individual’s normal coronal and sagittal alignment can be crucial for surgical planning, so side by side knee radiographs can be useful in assessing each patient’s anatomical variation [15]. The tibial plateau surfaces are covered by articular hyaline cartilage and partially by menisci composed of fibrocartilage. The lateral plateau is more covered by its meniscus than the medial plateau is. The intercondylar eminence consists of two spines, one medial and one lateral. The intercondylar eminence is non-articular and splits the proximal tibia into the lateral and medial plateaus. The medial spine serves as the attachment site of the anterior cruciate ligament and the posterior cruciate ligament attaches posteriorly on the proximal tibia.
Fracture classifications are widely used in clinical practice in order to help communicate and plan treatment as well as to aid in prognosis and to provide standards for clinical research. Commonly used classifications include the Schatzker, Hohl-Moore, Luo, and Orthopedic Trauma Association classifications.
The Schatzker Classification (Figure 2) was first published in 1979 and is one of the most commonly used tibial plateau fracture classifications still today [18]. The system divides tibial plateau fractures into six types designated from I to VI. The main limitation of this classification system is its failure to account for many important tibial plateau fracture patterns [19, 20, 21, 22, 23]. The Schatzker classification was based on the use of AP plain radiographs of the knee and because of this it is primarily beneficial in analysis of sagittal fracture lines on the medial and lateral plateaus leaving out fractures in the coronal plane.
Schatzker classification of tibial plateau fractures (Drawings created by
Type I fractures are pure split fractures. The lateral femoral condyle is driven into the lateral tibial plateau resulting in a sagittal fracture line that splits the lateral tibial plateau with a fracture line running laterally and inferiorly creating a wedge-shaped fragment. There is no associated articular depression or crush. These fractures are most commonly seen in young patients with healthy bone. Percutaneous screw fixation and lateral buttress plate fixation are two surgical treatments commonly employed for these fractures.
Type II fractures are split fractures combined with articular depression. These are similar to type I fractures with a lateral split except there is also lateral articular surface depression. The injury mechanism in type II fractures is typically either high energy, low energy with poor bone quality, or both high energy and poor bone quality. Treatment is dictated by the degree of joint depression, width of condylar split, and knee stability. Many Schatzker type II fractures are treated surgically with the elevation of the articular depression with some sort of bone grafting or graft substitute. The fracture is then often stabilized with articular surface compression and lateral buttress plating. Newer locking plates have shown promise in maintaining articular reduction following compression, especially in patients with poor bone quality.
Type III fractures are pure depression fractures. They do not have a lateral split as seen in type I and II. This is most commonly seen in elderly patients with poor subchondral bone quality from osteopenia or osteoporosis. The femoral condyle presses into the lateral tibial plateau resulting in depression of the articular surface rather than a split because of the underlying poor bone quality. The surgical treatment of these fractures involves elevating and supporting the articular surface.
Type IV fractures are medial condylar fractures (Figure 3). Schatzker describes these with two subtypes. In these subtypes, the medial plateau is either split off as a wedge fragment or depressed and comminuted. Either of these subtypes can also include fractures of the tibial spine. Pure medial tibial plateau fractures are rare. Fracture lines usually include the tibial spine and on occasion the lateral plateau. This fracture is more commonly associated with a higher energy mechanism of injury and results in a loss of medial buttressing. Non-operative management will often result in varus deformity. Medial tibial plateau fracture types are considered to be variants of knee dislocations. The ACL and MCL are intact but the lateral plateau and tibial shaft shift laterally away from the medial fragment. This puts patients at higher risk for neurovascular injury and compartment syndrome [24, 25]. The incidence of compartment syndrome may be as high as 53% in this fracture pattern [25].
Patient with multitrauma and a Schatzker IV fracture seen on plain radiographs (A and B) and CT scan (C and D) fixed with compression screws (E and F) (Radiographs and intraoperative imaging courtesy of John Riehl MD).
Type V fractures are bicondylar fractures. In this fracture pattern, both medial and lateral tibial plateaus are fractured. A portion of the metaphysis and diaphysis remain continuous, however, differentiating it from a type VI pattern. Schatzker IV-VI fractures are most often the result of a high energy mechanism of injury. Surgical treatment (when indicated) for type V fractures includes reduction and fixation of both condyles in order to reestablish stability, which is often done with dual approaches and dual plating, but may be done occasionally through a single approach with locked plating depending on the fracture pattern and displacement.
Type VI fractures are tibial plateau fractures with dissociation of the metaphysis and diaphysis. The hallmark of these fractures is either a horizontal or oblique fracture line that separates the diaphysis from the joint segment. These fractures are very unstable. Reduction and fixation of both plateaus is often necessary. These patients are at increased risk for neurovascular and soft tissue compromise [26, 27, 28]. The literature reports an incidence of 17–34% of compartment syndrome in this fracture pattern [25, 26, 29].
The Hohl-Moore classification (Figure 4) was developed in 1981 and reevaluated in 1987 based on 988 tibial plateau fractures seen at University of Southern California from 1970 to 1979 [2, 30]. It has been used to classify fracture-dislocations not described completely by the Schatzker classification which accounts for around 10% of all tibial plateau fractures. These fracture patterns more commonly involve the lateral plateau (79%) and are more associated with instability, soft tissue injury, vascular compromise, and compartment syndrome [2].
Hohl-Moore classification of tibial plateau fractures (Drawings created by
Type I fractures are coronal split fractures. These are found in 37% of tibial plateau fracture-dislocation [30]. These injuries are more clearly seen on lateral radiographs. They usually involve the medial plateau and the oblique fracture runs in a coronal-transverse plane. Common associations include avulsion fractures of the fibula or Gerdy’s tubercle and capsular disruptions. Treatment of this fracture ranges from nonoperative casting to percutaneous screw fixation or ORIF with plate fixation. Treatment depends on the stability of the knee and the extent of the tibial plateau the fracture involves.
Type II fractures are entire condylar fractures. Either the entire medial or more commonly the lateral condyle is fractured. The fracture line extends beyond the tibial spine into the opposite plateau differentiating it from a traditional Schatzker I or IV. Soft tissue injury occurs in many of these patients. Opposite compartment collateral ligament injury occurs in up to 50% of patients and neurovascular injury in 12% [30]. Treatments range again depending on stability and extent of articular involvement.
Type III are rim avulsion fractures. The lateral plateau is involved 93% of the time but the medial plateau can be involved as well [2]. Tearing of the ACL or PCL or both is commonly seen. Neurovascular injury is common in this fracture pattern occurring up to 30% of the time [30]. Instability is generally present and usually requires fixation. Soft tissue repair or reconstruction is considered.
Type IV are rim compression fractures. This fracture accounts for 12% of all tibial plateau fracture-dislocations [30]. The lateral plateau is much more commonly involved [2]. Collateral ligament injury of the unfractured condyle commonly occurs and cruciate ligament injury occurs in more than 75% of cases [30].
Type V are four-part fractures. These account for 10% of all fracture dislocations [30]. The medial and lateral condyles of the tibia are fractured as well as the intercondylar eminence. These fractures are highly unstable due to loss of the stabilizing effects of the collateral and cruciate ligaments. Neurovascular injury occurs as high as 50% of the time [30]. With their severe instability, these fractures will usually require surgical management.
The AO/OTA classification system is a more comprehensive classification system that was first published in 1996 with the intent of bringing uniformity to all fracture classification [31]. This fracture classification uses two main components, fracture location and morphology. Localization defines the specific bone and the segment of bone involved (proximal, distal, shaft). Morphology classifies the fracture type, group, and subgroup delineating articular involvement and simple vs. multifragmentary patterns. With tibial plateau fractures the localization number is 41 (4 is for the tibia and 1 is for the proximal segment). Morphology types include extra-articular, partial articular and complete articular fractures which are labeled A, B, and C respectively and then fractures are further grouped and subgrouped using numbers 1–3 and 0.1–0.3 further specifying the fractures specific morphology. The AO/OTA system subcategories by degree of comminution of the metaphysis and articular surface making it more comprehensive than the Schatzker Classification and able to distinguish ranges of severity of high-energy patterns.
The Luo Three-Column Classification (Figure 5) was published in 2010 based on 3D conceptualization of the tibial plateau and is useful in describing multiplanar complex tibial plateau fractures [19, 20, 21]. Traditionally the treatment and classification of tibial plateau fractures was based on two-dimensional classification systems like Moore and Schatzker that used plain radiographs whereas Luo uses axial CT scan images. Luo divides the tibial plateau using three intersecting lines dividing the plateau into three columns (medial, lateral, and posterior). The meeting point is the middle of the two tibial spines. The anterior line connects the midpoint of the plateau to the tibial tuberosity. The medial line travels from the midpoint to the posteromedial ridge and the lateral line is drawn from the midpoint to just anterior to the fibular head. Fractures can be defined as zero, one, two, or three column fractures. With this classification a column is considered fractured only if a cortical split is present in the column, thus a pure depression fracture (Schatzker III) is considered a zero column fracture. This classification system is useful in preoperative planning especially when there is posterior involvement. The posterior segment has been shown to be more prevalent than previously recognized and failure to identify and manage it has been associated with misalignment and functional instability [22, 32, 33].
Luo Three Column Classification (Radiograph courtesy of John Riehl MD).
It is important to obtain a thorough history in all tibial plateau fractures. The mechanism of injury should be assessed to give an idea of the severity of the injury and the need for urgent or emergent management. Low energy falls or twisting injuries are more likely to have a lower risk of neurovascular injury or compartment syndrome whereas falls from a height, motor vehicle accidents, and pedestrians struck by a vehicle are more likely to be higher risk and may necessitate more urgent or emergent management. Although knowing the mechanism of injury can be helpful, the fracture pattern is also extremely important in determining the treatment approach and risk for complications. Location and severity of pain, the timing of the injury, associated injuries, and any treatments administered are helpful pieces of information. Past medical history should be assessed for tobacco use, prior knee problems, ambulatory status prior to injury, and medical comorbidities (such as pulmonary disease, diabetes, vascular disease, cancers, renal disease, nutritional deficiencies, previous poor DEXA scan results, as well as use of immunosuppressive medicines). Medical comorbidities and certain medications can affect bone quality, increase risk for postoperative infection, and inhibit wound healing. The patient’s activity level, social support, mental condition, and employment status should be known in order to make an appropriate surgical and rehabilitation plan.
As a part of the initial assessment of tibial plateau fractures, the physical exam should attempt to rule out soft tissue compromise, open fractures, compartment syndrome, and neurovascular injury. A circumferential assessment of the overlying skin and a neurovascular baseline status should be conducted. Circumferential skin and soft tissue inspection and palpation should be done to assess for open injury and severity of soft tissue injury. The severity of soft tissue injury may be further defined based on size, character, and location of swelling, contusions, and fracture blisters. Soft tissue assessment is key to determining surgical approaches and timing.
A non-compressible, firm extremity and pain with passive stretching are suggestive of compartment syndrome. Compartment syndrome should be monitored for throughout the patient’s stay since this can develop days after injury or surgery. Measurement of compartment pressures in high energy fracture patterns or unresponsive patients may be beneficial on presentation and may need to be repeated based on clinical assessment. If the diagnosis is made in conjunction with elevated compartment pressures or if the diagnosis is clear on the physical exam, a fasciotomy will need to be performed.
For high-energy injuries especially (such as fracture-dislocations and metaphyseal-diaphyseal dissociation patterns) it is imperative to obtain a thorough neurovascular assessment. Vascular injury is rare overall but delays >8 h in diagnosis and surgical intervention can result in lower extremity amputation rates as high as 86% [34, 35, 36]. Neurovascular assessment should include testing for sensation patterns in the distribution of tibial, superficial peroneal, saphenous, and sural nerves as well as extremity color and temperature, capillary refill, and distal pulses including the posterior tibial and dorsalis pedis. Results should be compared with the contralateral side. Any differences in pulses or sensation can be further investigated with an ankle-brachial index (ABI) measurement. For some high-energy fractures, consideration may be given to obtain ABI regardless. An ABI > 0.8 has a remarkably high negative predictive value, approaching 100%. With ABI <0.9 further vascular assessment with a CT arteriogram and/or a vascular surgery consultation should be obtained [34].
Varus and valgus stress testing may be necessary to assess for instability if this is unclear based on radiographic assessment. Valgus instability is important in determining indications for surgical management, especially in lateral tibial plateau fractures. If instability is present it may not resolve without surgical fracture reduction and fixation [37, 38].
Imaging is a large part of the surgical planning process. The imaging modalities used range from plain radiographs to CT with 3D reconstruction and MRI.
The diagnosis of a tibial plateau fractures is usually made initially by plain radiographs. For some simple fractures, this may be the only imaging modality necessary. Typically anteroposterior (AP) and lateral views of the knee are obtained for plain radiograph assessment. An additional view, the caudal view (also known as the “tibial plateau view”) is shot 10–15° caudally from a typical 90° AP view and is used to provide a view in line with the plane of the plateau. This is done to account for the 15° posteroinferior slope of the plateau surface. In this view, the proximal articular surface can be viewed as a single radiodense line which allows better assessment than lateral and AP views of articular depression [16]. Radiographs of the entire tibia should be obtained as well. Oblique views have also been used to assess the fracture lines and degree of displacement, however, they are not routine now that computed tomography (CT) scans have largely filled the need that was once provided by additional views. Of note, it has been shown that plain radiographs alone can miss insufficiency fractures in osteopenic patients [39].
Traction radiographs are helpful when there is substantial displacement to better assess the fracture anatomy in both plain radiographs and CT scans. This can be obtained by manual traction or spanning external fixators.
Contralateral radiographs may be helpful in severely comminuted fractures to serve as a template for reduction, condylar width, coronal alignment, and the posterior slope of the plateau in the sagittal plane.
Computed tomography (CT) scans have become a routine part of the assessment of tibial plateau fractures (Figure 6). Axial CT cuts are especially helpful in visualizing posteromedial fracture lines (Figure 7). Axial CT and reconstructions provide important insight into fracture anatomy as well as serving as an aid in preoperative planning. It has been demonstrated in numerous studies that the use of CT scans allows surgeons to more reliably classify fractures which aids in providing the most appropriate treatment formulation [40, 41, 42, 43, 44, 45, 46]. CT allows accurate visualization of articular displacement and comminution more readily than what is observed with plain radiographs [46]. CT also allows for better assessment of location and orientation of fracture lines as well as the degree of depression and size of articular segments, which provides important information in preoperative planning.
CT of a normal tibial plateau axial view (A), coronal view (B), and Sagittal view (C) (Images courtesy of John Riehl MD).
CT allows for better visualization and more accurate classification compared with plain radiographs (A,B) of this bicondylar tibial plateau fracture more clearly seen in the axial view (C), sagittal view (D), and coronal view (E) (Images courtesy of John Riehl MD).
Magnetic resonance imaging (MRI) continues to gain wider acceptance in use for evaluation of tibial plateau fractures. Some argue it is indicated to adequately assess and treat soft tissue injuries especially in fractures due to high energy mechanisms which have a high percentage of ligamentous and meniscal pathology [47]. MRI is more sensitive than CT in detecting ligamentous and meniscal injuries which are both common occurrences in tibial plateau fractures [48]. MRI is the gold standard when it comes to detecting occult fractures not seen on plain radiograph.
Compartment syndrome (CS) is a serious complication of trauma and other conditions that cause bleeding, edema or vascular compromise. Progressive swelling of a limb increases mass within the myofascial compartment due to accumulation of blood or fluid as well as inflammation. The inelasticity of the muscle fascia and connective tissue results in increased pressure in the compartment compressing thin-walled veins leading to venous hypertension and tissue ischemia. Compartment pressure increases further once cellular death accelerates and lysis of cells releases osmotically active fluid into the interstitial space. Myonecrosis may occur within 2 h of injury [49] and after 6–8 h irreversible nerve damage occurs.
CS can be quite common in certain patterns of tibial plateau fractures, and has been found to be as high as 53% in Schatzker type IV fractures [25]. Overall the reported incidence of CS following tibial plateau fracture ranges from 0.7 to 12% [26, 29, 50, 51, 52, 53]. Although a somewhat controversial topic with conflicting findings in the literature, acute compartment syndrome requiring fasciotomy has been reported in some studies to significantly increase the rate of non-unions [27] and infections [27, 54, 55, 56]. On the other hand, Ruffalo et al. [57] found no increase in the association of nonunion and infection. In medial plateau fractures, one study found a 67% CS rate when the fracture entered the joint line lateral to the tibial spine and exited through the medial metaphysis, 33% CS rate when the fracture is within the spine and 14% when the fracture is medial to the intercondylar spine [24]. CS was found to have a higher incidence in Schatzker type IV (53%) compared with type VI (18%) fracture patterns [25]. However, this result was not consistent throughout the literature, and another group reported compartment syndrome to be relatively rare in type IV and only type VI patterns were significantly more likely to develop it [26]. CS was least common in Schatzker type I and II fractures [26]. The two biggest radiographic predictors of CS were fracture length and fibular head fracture [26, 28].
Early diagnosis of CS is crucial for avoiding the substantial morbidity caused by its late sequelae. A clinical diagnosis of CS can be difficult to make even when the generally accepted clinical signs of CS are present, which include worsening pain that is out of proportion to the clinical situation, pain with passive stretch, and paresthesia/hypoesthesia. These clinical signs and symptoms have been shown to have low sensitivity [58, 59]. Also, clinical findings can be difficult to obtain in polytrauma patients and impossible to assess in sedated patients. Late diagnosis can be diminished by frequent or continuous measurement of intramuscular pressure (IMP). When to initiate IMP monitoring is still controversial but whenever clinical examination is unreliable in an at-risk patient measurement of IMP could be considered. When using IMP, diastolic differential pressure (delta p) <30 mm Hg has been used as a threshold for compartment syndrome requiring fasciotomy. Prayson et al. [60] warn against using a single measurement <30 mm Hg alone as this may not be clinically significant. In their series they found that this can occur transiently in patients without evidence of compartment syndrome. About 84% of their lower extremity fracture patients had at least one delta p < 30 mm Hg and 58% had a delta p < 20 mm Hg. Instead, McQueen et al. [61] suggest a threshold for fasciotomy of an IMP<30 mm Hg for two consecutive hours or more, which had a sensitivity for diagnosis of CS of 94%.
One of the potential pitfalls of using pressure measurements is that intraoperative diastolic blood pressure measurements have been shown by Tornetta et al. [62] to give spuriously low delta p values and lead to unnecessary fasciotomies. The authors of this study recommend use of preoperative blood pressure values when calculating delta p in patients under general anesthesia unless the patient is to remain under anesthesia for numerous hours. IMP values also vary with proximity to the fracture site and muscular depth. Pressures are highest when measuring within 5 cm of the fracture [63] and centrally in the muscle [64]. Most recommend obtaining the measurement within 5 cm of the fracture site but the standarizability of this is still controversial.
Soft tissue injuries occur commonly in tibial plateau fractures. Overall soft tissue injury incidence has been estimated between 73 and 99% from MRI studies [65, 66, 67]. In an MRI analysis of 103 operative tibial plateau fracture patients, Gardner et al. [65] only found 1 patient who had complete absence of soft tissue injury. Collateral or cruciate injuries were sustained in 77% of patients and lateral and medial meniscus pathology was seen in 91% and 44%, respectively. Similar results were seen in a study on nonoperative tibial plateau fracture patients with 90% having significant soft tissue injuries, 80% with meniscal tears and 40% with ligament disruptions [66].
Overall ligamentous injury incidence has been estimated by MRI studies to be between 40 and 77% [47, 65, 66]. MRI studies in the literature estimate that complete anterior cruciate ligament (ACL) tears have an incidence of 11–44%, posterior cruciate ligament (PCL) 8–40%, lateral collateral ligament (LCL) 29%, medial collateral ligament (MCL) 32%, and posterolateral corner (PLC) injuries 45–68% [47, 65]. Higher energy fracture (type IV–VI) patterns have higher incidences of ligamentous injuries.
The incidence of meniscal injury associated with tibial plateau fractures based on preoperative MRI has been reported from 49 to 91% [47, 65, 66, 67, 68]. Degree of lateral articular depression and condylar widening has been shown to directly correlate with frequency of soft tissue injuries in many studies [69, 70, 71]. Gardner et al. [72] in their MRI study on lateral split depression fractures found that articular depression >6 mm and condylar widening >5 mm was associated with a lateral meniscal injury 83% of the time. Stahl et al. [73] in their 661 patient intraoperative visualization study found that the most common Schatzker pattern associated with a lateral meniscus tear was the split depression fracture (45%) and the most common associated meniscal tear for this fracture pattern is peripheral rim avulsions (83%). 86% of Schatzker IV fractures had an associated medial meniscus tear [65].
Diagnosis of soft tissue injury based on physical exam findings is difficult due to the pain, swelling, and instability that is frequently present with these fractures. Recent studies have utilized preoperative MRI or operative arthroscopy to evaluate the extent of soft tissue damage. Treatment and pre-operative imaging protocols of ligamentous and meniscal pathology are controversial. Some authors advocate for MRI screening and surgical repair [47, 74, 75] whereas others have shown good results with no surgical intervention and advocate against MRI screening [67, 76, 77, 78]. Others argue against the use of pre-operative MRI because it overstates the true incidence of meniscal tears that require operative management, and instead they recommend direct visualization for lateral split depression fractures because the incidence of meniscal injury is sufficiently high enough to warrant this [73]. The clinical impact of identification of ligament and meniscal injuries is not clear from the current studies in the literature. Determining the functional impact would require a study that randomizes ligament treatment into surgical and nonsurgical groups. The literature does provide us with a clearer indication for nonoperative management on specific ligamentous injuries like MCL tears which can heal with nonoperative care with excellent functional outcomes. It remains controversial whether ACL or PCL surgical reattachment is indicated in the setting of tibial plateau fractures.
Nonsurgical management is an option for certain fractures and specific clinical circumstances. Immediate passive range of motion with non-weight bearing for anywhere from 6 to 12 weeks in hinged bracing is currently preferred because it allows for mobility while maintaining coronal support. Indications for nonsurgical treatment include undisplaced or minimally displaced fractures, less than 5° of varus/valgus instability, delayed presentation, significant medical comorbidities precluding patients from operation, nonambulatory patients, and elderly patients with low functional status where deformities would be tolerated. Key to selecting patients for nonsurgical management is the ability to predict the post-treatment risk for deformity, malalignment, and instability. Angular malalignment is not well tolerated by patients and will cause cosmetic issues, articular cartilage overload, and increased likelihood of knee instability which can cause patients to be unbalanced and have an increased risk for falls. Risk for instability can be further assessed with a knowledge of the patient’s demographics, activity level, comorbidities, and limb alignment. Imaging assessments that are helpful in assessing risk for instability include bone quality, fracture type, condylar width, degree of articular depression, and extent of fracture comminution.
Looking at the fracture pattern can further help your decision making. Larger lateral split depression fractures and all medial plateau fractures have a much higher propensity to collapse into valgus and varus deformity respectively whereas smaller fragment Schatzker II fractures can be amenable to nonsurgical management. Nearly all unicondylar medial tibial plateau fractures with displacement and displaced bicondylar fractures should be operated on [79].
Surgical treatment is commonly utilized in order to assure accurate limb alignment, gain early mobility, and achieve a better reduction. However, it behooves the clinician to remember that nonsurgical treatments can achieve excellent outcomes for patients unable or unwilling to undergo surgery despite articular incongruities and displacements [80].
Until the 1950s tibial plateau fractures were mostly treated nonoperatively with cast immobilization, however, operative treatment is currently the standard of care in the majority of tibial plateau fractures overall. The goals of surgical treatment of a tibial plateau fracture are to restore articular congruity, axial alignment, joint stability, and knee functionality. Fixation must be able to maintain stability postoperatively while allowing for early motion and minimizing complications.
Operative management is indicated for tibial plateau fractures where near-anatomic alignment cannot predictably be achieved based on fracture pattern, physical exam findings, and radiographic measurements. In young active patients without comorbidities, fracture patterns that necessitate operative management include bicondylar plateau fractures and shaft dissociation patterns. Also, the majority of medial and lateral plateau fractures require surgical management unless they are minimally displaced and normal tibial/knee alignment can be achieved without fixation.
Another proposed indication for surgery is based on the amount of articular depression. This indication is more heavily debated and different cutoffs are found throughout the literature. Cutoffs for articular depression that result in poor outcomes if not operatively managed range from >2.5 to >10 mm [37, 38, 79, 81, 82, 83, 84, 85]. Unfortunately, the accuracy and reliability of measuring degree of articular depression is questionable. Martin et al. found that independent observers make articular depression measurements that differ by 12 mm or more 10% of the time [86]. Having a greater degree of articular depression than a predetermined cutoff should not be the sole basis for proceeding or not proceeding with surgery.
Poor functional outcomes and a high incidence of meniscal pathology have led many authors to suggest a condylar width increase of >5 mm and varus/valgus instability >5° as an indication for surgery [38, 72, 79]. However, Wang et al. [87] were unable to predict soft tissue injury based on tibial plateau widening. Johannsen et al. [14] suggest that discrepancies in the literature on condylar widening can be reconciled by instead using a ratio of the articular widths of the femur and tibia in order to minimize problems in measurement with magnification and calibration.
In the elderly, inactive or less active, or patients with comorbidities that place them at higher surgical risk, the decision whether to proceed with operative management needs to be more carefully assessed. A risk benefit analysis for each individual patient needs to be weighed in order to decide appropriate management. Elderly and the less active will be less affected by minor deformity if their functional demands are less.
External fixation use has continued to evolve in the temporary and definitive management of these injuries. External fixation is commonly used as a temporary treatment by spanning the knee. This technique realigns and restores length allowing for soft tissue recovery prior to definitive treatment with internal fixation. Egol et al. [88] demonstrated the effectiveness of this technique with relatively low rates of complications in patients with high-energy tibial plateau fractures. With minimal soft tissue complications, the group recommended staged fixation for all high-energy fractures of the proximal tibia. Temporary external fixation not only provides skeletal stabilization to maintain length, alignment, and rotation, but also allows for easy access for wound and blister management. Studies have been performed, however, that show immediate fixation of most high energy tibial plateau fractures is safe and effective [89, 90, 91].
Definitive external fixation typically uses a fine wire external fixator to compress against the fracture segments in conjunction with limited-access internal fixation which allows for minimal soft tissue disruption and permits early range of motion compared to ORIF with similar stabilization. Indications for definitive external fixation include severe open fractures and highly comminuted fractures where internal fixation is not possible. External fixation can also be used in conjunction with minimal internal fixation such as lag screws providing compression to the articular fragments. Multiple studies report equivocal rates of infections and complications when comparing ORIF and external fixation [76, 92, 93]. On the contrary, Krupp et al. [94] conducted a study comparing external fixation and open reduction of bicondylar tibial plateau fractures and they report significantly higher rates of malunion (7% vs. 40%), infections (7% vs. 13%), knee stiffness (4% vs. 13%) and overall complications (27% vs. 48%) of external fixation compared to ORIF. Shao et al. [56] also report significantly higher surgical site infection rates with external fixation.
Pin site placement and its importance varies between surgeons and in the literature. Classically, it is recommended that pins should be placed outside the zone of future plate placement and at least 14 mm distal to the joint line to avoid penetration into the joint [95]. However, there is new conflicting data on whether this has any effect at all on infection rate. Labile et al. [96] found no increased infection rate whereas Shah et al. [97] found the opposite. However, until we have a larger study to give us a definitive answer the recommendation is to place pin sites outside of the zone of injury in the case of temporary external fixation, and outside of the knee capsular reflection when placing wires for definitive treatment. With that being said, these recommendations should not outweigh the goal of achieving restoration of length, alignment, and stability of the fracture regardless of plans for future surgery.
Open Reduction internal fixation (ORIF) is the most commonly used operative treatment for tibial plateau fractures. Multiple surgical approaches have been described in the surgical treatment of tibial plateau fractures. Anterolateral and posteromedial are the two surgical approaches that are most commonly used to reduce and internally fix tibial plateau fractures. They are used either together or in isolation depending on the fracture pattern. Dual incision approach is as effective in obtaining reduction and much safer than extensile approaches with no significant increase in infection rates seen [54, 98]. There are also multiple other posterior approaches described in the literature that have become popular. The fracture pattern is the main determinant of the approach and fixation technique. Direct anterior approaches can be helpful in conjunction with parapatellar arthrotomy in order to gain direct visualization and access to a greater area of the articular surface, especially centrally. It is important to note that when a direct anterior approach is used, soft tissue dissection should only proceed in one direction, medial or lateral from the incision. Anterior midline approaches with large dissection medial and lateral on the plateau are not recommended due to the devascularization caused to the plateau itself.
Plates and screws are the most common implants used in the fixation of tibial plateau fractures. Manufacturers have available pre-contoured periarticular plates as well as locking plates that are designed to fit against the proximal tibial surface. The plates can serve different functions depending on the anatomic placement and fracture pattern. Anterolateral plate placement in split depression fractures allows the plate to act as a buttress of the lateral tibial condyle supporting the weakened lateral cortex. On the other hand posteromedial plate placement functions as an antiglide device that resists shearing forces. Precontoured medial plates are also available from some manufacturers. Recently, plates have become thinner and both lateral and medial plates are most commonly 3.5 mm instead of the previous 4.5 mm. This allows the plates to fit closer to the bone and the corresponding 3.5 mm screws can be placed closer to the articular surface to better support reduced fragments. The plates also allow for subchondral screws to be placed parallel to the articular surface through the head of the plate, termed “rafting” (Figure 8), to significantly minimize postoperative articular depression [99]. Medially, plate position is more important than screw placement. The plate position must be closely intimate to the apex of the fracture and a screw near the apex of the fracture will help to ensure close apposition of the plate in this critical area.
AP radiograph of a medial tibial plateau fracture treated by ORIF with a medial buttress plate (Radiograph courtesy of John Riehl MD).
Lateral plates alone can occasionally be used for bicondylar and Schatzker type VI fractures (Figure 9). These plates must resist axial, rotational, and bending force. The addition of locking screws to the plate has been a major advance in moving away from dual plating in some instances. Bending forces tend to create a varus deformity, however, and this must be considered if planning on using a single lateral plate in a bicondylar fracture pattern. Decreasing this varus collapse with fixed angle devices has decreased the need for dual plating in some instances, but this alone may be insufficient for providing adequate support for an unstable medial column. Although locking technology is available for most tibial plateau specific implants, its use in unicondylar fractures for buttress or antiglide plates is of unknown significance.
AP radiograph of a Schatzker VI tibial plateau fracture treated by ORIF with a lateral plate and three independent lag screws (Radiograph courtesy of John Riehl MD).
A special consideration must be taken for posterior plateau fragments which may not be adequately buttressed by medial or lateral plating. Involvement of the posterior segment has been shown to be more prevalent than previously recognized and failure to identify and manage it has been associated with misalignment and functional instability [22, 32, 100]. This could also be one of the reasons for failure in some fractures that still collapse secondarily after fixation [98, 101]. The use of the three column concept [19, 20, 21] may help in adequately addressing these fractures.
Articular depression fractures (i.e., Schatzker II and III) result in a loss of cancellous bone volume due to the compression of cancellous trabeculae (Figure 10A). As a result of this, reduction of depressed tibial plateau articular fragments leads to an area void of bone underneath the reduced fragment (Figure 10B and C).These fragments in turn need to be adequately supported in order to reduce the risk of redisplacement. Metaphyseal void filling in these fracture patterns can be done to reduce this risk and to increase stability (Figure 10D).
Preoperative AP (A) X-ray of a Schatzker II split depression fracture. Intraoperative fluoroscopy shows elevation of the articular segment with a Cobb elevator (B), provisionally stabilized with K-wires creating a metaphyseal void (C). Final intraoperative imaging shows the reduced fracture with a lateral plate and calcium phosphate void filling cement (D) (Radiographs courtesy of John Riehl MD).
A wide range of options for materials to fill these voids are available. Autograft bone can be used, but supply is limited, extra surgical time is required, and there is associated morbidity at donor sites. Complications range from temporary pain or numbness, superficial infections, seromas, and minor hematomas to chronic pain, herniation of abdominal contents through donor sites at the pelvis, vascular injuries, deep infections, neurologic injuries, deep hematomas and iliac wing fractures.
Allografts have the advantage of no donor site morbidity and increased quantity available from bone banks. Osteogenesis, osteoinduction and osteoconduction are benefits and properties of autografts whereas only osteoconduction and poorer osteoinduction are provided by most allografts. As a result, the healing of allografts is often slower than the healing that occurs with autograft. The possibility of donor disease transmission exists but this risk is significantly reduced with donor screening and tissue testing. Segur et al. [102] found no complication secondary to the allograft transplantation in their short term follow up study (non-union, infection, fracture, resorption and transmission of disease).
Several commercially available graft substitutes are now used in the treatment of tibial plateau fractures. Most recently, phase-changing cements have shown promising results with better mechanical properties to autologous and allogenic bone grafts. Calcium phosphate cement was significantly stiffer and displayed significantly less displacement at 1000 N when compared to cancellous bone in a split depression fracture cadaver model study [103]. Lobenhoffer et al. [104] noted improved radiographic outcomes and earlier weight bearing due to its high mechanical strength. Russell et al. [105] noted a significantly higher rate of articular subsidence during the 3- to 12-month follow-up period in the autogenous bone graft group compared with the calcium phosphate group in their 119-patient study that included all six Schatzker patterns. Welch et al. [106] found similar results in their study comparing autologous bone graft with calcium phosphate in lateral articular depression fractures in goats. They found the autograft did not maintain anatomic reductions and calcium phosphate had significantly reduced fracture subsidence compared to the autograft at all time points. Recently, the use of calcium phosphate has also shown improved results in complex tibial plateau fractures (Figure 11) with significantly lower rates of articular step-off [107].
AP and lateral X-ray showing reduction and fixation of a bicondylar tibial plateau fracture with posteromedial buttress plating, lateral lag screws, and quickset calcium phosphate (Radiographs courtesy of John Riehl MD).
Another option that has been recently studied is beta-tricalciumphosphate which is a synthetic bone substitute that is biocompatible, biomechanically stable, and osteoconductive. Rolvien et al. [33] studied the long term results in tibial plateau depression fractures that used beta-tricalciumphosphate. They found no non-union or loss of reduction at a mean of 36 months of follow up. About 83% of patients achieved excellent reduction with <2 mm residual incongruity and 82% of patients achieved excellent functional outcomes. Histologic analysis of 7 of the patients demonstrated incorporation of bone around the graft but complete resorption was not observed. They concluded that beta-tricalciumphosphate represents an effective and safe treatment for these fractures, but its biological degradation and replacement is less pronounced in humans compared with previous animal studies.
Calcium sulfate has also been used as a void filler. Yu et al. [108] followed 28 patients for a mean of 14.6 months after using calcium sulfate as a void filler and found that 67% of the graft material was incorporated at 8 weeks and full incorporation was seen at 12 weeks. Fractures healed in all patients, and no nonunion or infection occurred. Wound exudations were observed in two cases, and the wound healed in 2–3 weeks with wound dressing. However, Goff et al. [109] showed possible reason for caution with the use of calcium sulfate in their more recent meta-analysis including 672 patients, comparing multiple void filling substitutes. They reported secondary collapse of the knee joint surface ≥2 mm in 8.6% in the biological substitutes (allograft, demineralized bone matrix, and xenograft), 5.4% in the hydroxyapatite, 3.7% in the calcium phosphate cement, and 11.1% in the calcium sulfate cases. It should be noted that the sample size of the calcium sulfate cases in this study was <40.
Biphasic bone grafts that include calcium sulfate may give better results than calcium sulfate alone. A 2020 prospective, randomized control, multicenter study was conducted by Hofmann et al. [110] comparing autologous iliac bone graft to biphasic hydroxyapatite and calcium sulfate cement (60% calcium sulfate and 40% hydroxyapatite) in tibial plateau fractures. They concluded that the bioresorbable cement used was noninferior in both patient reported and radiographic outcomes to autologous bone graft in tibial plateau fractures.
MIPO is a plating technique that enables indirect fracture reduction and percutaneous submuscular implant placement which improves healing rate due to its minimal disruption of soft tissues, including the periosteum and its vascularity [111, 112, 113]. Farouk et al. performed a cadaver study comparing post-procedure bone blood supplies in conventional plate osteosynthesis versus MIPO. Perforating and nutrient arteries remained intact and better periosteal and medullary perfusion was observed in the MIPO group compared to conventional plating [113]. ORIF allows for direct visualization, reduction, and fixation, but it is at the cost of substantial soft tissue dissection, increased risk of wound breakdown, stiffness, and deep infections [114]. Surgical techniques can provide benefits of both ORIF and MIPO techniques with the utilization of a small incision near the joint line with direct visualization and fixation of the joint while simultaneously performing percutaneous minimally invasive techniques in placement and securing the shaft portion of a plate. While some surgeons prefer to place percutaneous screws with use of fluoroscopy and feel, percutaneous guides can assist in efficient and accurate placement of shaft screws in these plates.
Intramedullary nailing (IMN) has many advantages for fracture fixation. These include minimally invasive exposure, biologically friendly implant insertion, longer implants to span more complex fractures, and load sharing fixation that allows for earlier weight bearing. With previous implants, concern for malreduction with intra-articular fractures was due to the nails inherent design flaws that failed to align properly with metaphyseal and epiphyseal segments. Recent advances in the implants have placed multiplanar interlocking screws clustered near the ends of nails to facilitate greater purchase in proximal segments and the ability to lock the interlocking screws to the nail creating a fixed angle construct which theoretically improves stability [115]. With these new improvements intramedullary nailing can be safely used to stabilize proximal intra-articular tibial fractures in which a stable articular block can be created. Often, this is performed by placement of independent lag screws proximally and outside of the intended path for the nail, or with buttress plating used with techniques compatible with nailing (Figure 12). Intramedullary nailing can especially be considered in tibial fracture patterns with diaphyseal extension, segmental injuries, or patients with increased risk for wound complications [115, 116]. Patients at increased risk for wound complications include patients with morbid obesity, diabetes, peripheral vascular disease, thin skin and compromised soft tissues. Prior to nailing, fractures should be converted from C-type articular fractures to A-type fractures by obtaining anatomic reduction and stable fixation of the articular surface. Contraindications to nailing may include tibial tubercle involvement in the fracture pattern and inability to reconstruct the articular surface outside of the planned nail trajectory. Fractures with tibial tuberosity fragments are poor candidates because the nail can cause a substantial anteriorly directed deforming force [115].
Tibial plateau fracture with diaphyseal extension treated with a combination of lateral buttress plating and a tibial nail (Radiograph courtesy of John Riehl MD).
Intramedullary nailing reliably leads to excellent outcomes when performed for appropriate indications. In a multi-center case series Yoon et al. [117] found excellent outcomes with the use of adjunct plate fixation prior to IMN for complex tibial plateau fractures with 93% (25/27) achieving bony union and no late fracture displacement reported. Jia et al. [118] had similar excellent outcomes in their cohort with no incidences of malunion, nonunion, or infection. Meena et al. [119] randomized proximal metaphyseal tibia fractures to lateral percutaneous locked plating versus IMN. The IMN group had significantly shorter average hospital stay, time to fracture union, and time to full weight bearing. No significant difference was found for infection rate, range of motion of the knee or degrees of malunion and nonunion.
Bracing postoperatively is common practice with rigid braces holding the knee in extension, or more commonly hinged braces used for 3–6 weeks [120]. However, a recent prospective trial conducted by Chauhan et al. [121] found no significant difference between 6 weeks of bracing and no bracing at all after ORIF of tibial plateau fractures for union rates, postoperative range of motion, and Medical Outcomes Study 36-Item Short Form scores.
Full weight-bearing is commonly delayed for 9–12 weeks with 4–6 weeks of non-weight bearing followed by 4–6 weeks of partial weight-bearing [120]. Two recent retrospective articles with sample sizes of 17 and 90 have challenged this notion with excellent results with immediate full weight bearing as tolerated [122, 123]. Basic science evidence supports a period of protected weight bearing followed by progressive loading due to evidence that gentle compressive loading may positively impact articular cartilage healing by improving chondrocyte survival, but excessive shearing may be detrimental [124]. More robust research is likely needed before major changes in weight-bearing protocols are implemented.
A 2019 meta-analysis including 7925 patients found the incidence of superficial and deep surgical site infections after tibial plateau fracture repairs to be 4.2% and 5.9%, respectively [55]. Risk factors that have been found to be associated with surgical site infections include open fractures [54, 55, 56, 125], compartment syndrome [27, 54, 55, 56], smoking [55, 56, 125], alcohol intake [126], definitive external fixation [56, 94] and intraoperative duration approaching 3 h [54, 56, 125]. A recent article found a strong correlation between a significantly higher peak of C-reactive protein (CRP) >100 μg/mL on postoperative day 3 and the development of surgical site infections in tibial plateau patients [127]. This finding might be an indication for more close surveillance in these patients regardless of CRP normalization over the following days, especially if the patient is at increased risk for noncompliance (e.g., Dementia).
The incidence of knee osteoarthritis following tibial plateau fractures reported in the literature has a wide range from 13 to 83% [6, 37, 38, 83, 84, 128, 129, 130, 131, 132, 133, 134]. Associated risk factors of early onset knee arthritis include degree of comminution, bicondylar fractures, meniscectomy, axial malalignment, joint instability, and older age [83, 85, 135, 136]. Wasserstein et al. [136], reporting on 8426 tibial plateau fractures, found that 7.3% of patients underwent total knee arthroplasty (TKA) 10 years after surgical management of tibial plateau fractures compared to only 1.8% in their control group. However, only adult patients treated by open reduction internal fixation (ORIF) were included and young patients and patients managed by conservative means or external fixation were excluded. Elsoe et al. [137] studied 7950 tibial plateau fracture patients in a matched cohort study and found the rate of TKA after tibial plateau fracture was 5.7% compared to 2% in their reference group.
Tibial plateau fractures comprise a wide range of fracture patterns, injury severity, and can exist with the presence or absence of significant associated injuries. History, physical exam, and imaging modalities can help to determine management of this complex category of injuries. Surgical and nonsurgical treatments can be employed to achieve healing and satisfactory long term results. Emerging technologies and implants continue to provide the promise of improved patient outcomes.
Transradial access (TRA) is now well established as the safest route for percutaneous coronary intervention (PCI) and must be attempted at first whenever possible. In real world, too many cases today are still performed though transfemoral access (TFA). In a case-to-case confrontation, “believers” in the radial way [1] would easily refute common arguments still actually developed by TFA proponents to skip the TRA attempt (or to dash the attempt off): planned intervention better managed/proceeded through femoral access (angiography for a patient with previous coronary artery bypass graft (CABG) surgery being a frequent one), planned interventions requiring large materials/catheters, anticipated lack of support during intervention (a true but often hidden fear for several operators), poor/small/not palpable radial artery, previous attempt failure(s), lack of time (“urgency”), “fast” intervention required for a frailty patient, negative Allen test (it is the most hilarious reason for a radial believer), and finally a failed but often too short attempt.
What is the truth in the background of this resistance? The truth is TRA is not and will never be an easy way to perform cardiac catheterization, the learning curve is long (and never ends), and TRA requires from the operator a true personal investment. Hopefully—and it has to be written somewhere—the return on investments in the TRA technique is large, and succeeding in a difficult case is usually even more gratifying for the physician and his patient when the procedure involved only TRA.
“TRA for everybody” is a personal crusade, and it lets the author to succeed a “non-femoral” vascular route for 1019 of his last 1023 procedures (from mid-March 2017 to mid-November 2018). The 1023 procedures included primary PCI for 152 ST elevation myocardial infarct (STEMI) patients—femoral access for 2 of them—coronary angiography (and ad hoc PCI when requested) for 108 post-CABG patients, and a total of 568 PCI were performed (73% with 5 Fr guide catheters).
Common challenges associated with a “TRA for everybody” strategy and possible solutions must be considered. Subjects being discussed will be:
The vascular access.
Some patient populations “at risk” to be catheterized by TFA:
The CABG population.
Myocardial infarct (MI) patients in unstable condition.
Frailty and small body-sized ill patients.
The radial artery occlusion problem.
Cannulation failure, which is the main cause of TRA failure, is disgracefully received by the majority of interventional cardiologists and stays subsequently hidden. And yet it is not a shame to fail the radial artery cannulation: it is a difficult task and so for many reasons. First, the artery is usually small-sized, its diameter being around 2–3 mm [2] depending of the individual body height as demonstrated in one recent study [3]. The arterial wall may be difficult to go through; the vessel may flee away the tip of the needle or may simply “disappear” when a so frequently—and wrongly—invoked “spasm” occurs after a first unsuccessful stick (see discussion below). Although permeable and functional, a radial artery may be unpalpable due to a thick arterial wall or a low flow state. As any other arterial bed, the radial artery is not spared by the inverse remodeling process associated with diabetes, arteritis, and aging. Finally, the patient may be hypotensive with a more difficult vascular access.
So, the first step to optimize the TRA success rate and therefore “TRA for everybody” is investing in solving the problem of the puncture/cannulation of the radial artery.
Data clarifying the causes of TRA failure will now be presented, and secondly, some clues helping in the problem’s resolution will be explored.
A prospective study about the TRA, conducted by two TRA “believers” and with two major objectives in mind, started in 2015 [4]: firstly, defining the rate of conversion to transfemoral access when the operator must first attempt (and fail) both radial arteries before converting to transfemoral and secondly, the study was designed to record daily and on a case-by-case basis the causes/location of radial artery attempt failure and to define their relative occurrences. The protocol also required grading (1) the ease for cannulation (before catheterization, as assessed at the bedside), (2) the real ease for the attempt, and (3) the ease for the catheterization itself (catheter manipulation).
By protocol, every single consecutive left heart cardiac catheterization, diagnostic or interventional, elective or urgent, has to be first attempted by TRA (right or left or both). Only non-palpable radial artery (on both sides) or abnormal Allen test (Barbeau type D on both sides) and patient refusal were excluded. Let us say immediately that the two operators never encountered a patient with a Barbeau type D present on both sides and that non-palpable radial artery may be permeable and functional as easily assessed with a Doppler probe. Thus, basically, no patient was excluded from the study for such reasons: “TRA for everybody” is feasible at the level of the initial assessment for an arterial access.
As designed by the protocol, all sorts of patient populations were attempted by radial artery, including post-CABG surgery patients, even patients grafted with both left and right internal mammary artery. Some local surgeons also used the gastroepiploïc artery as graft (and not as free graft). Such patients were also included.
Even shock patients were included in the study.
From January 2005 to June 2007, both operators successively and prospectively proceeded to catheterize 1826 patients, starting from right or left TRA, at the operator discretion. PCI accounted for 40% of the procedures. The study was published as an original contribution in the Journal of Invasive Cardiology in September 2010 [4].
The first and major contribution of the study was to offer strong data for the cornerstone of an effective politic of “TRA for everybody”: to have to attempt both radial arteries before converting to a femoral access. The study succeeded in offering a “TRA only” procedure for 98.8% of the study population (Figure 1). This high success rate was obtained after attempting the second radial artery for the 6.2% missed first radial artery, 4.4% when excluding the patients with previous CABG surgery. Attempting the second radial artery was successful in about 80% of the cases.
TRA success rate for 1826 consecutive procedures.
As illustrated in Figure 1, the study did not identify a special population who will not benefit from TRA. It also dismisses some apprehensions regarding TRA: rate of truly difficult cannulation was half less than anticipated, and difficult catheterizations were 50% less frequent than anticipated (and this rate stays stable at 6%), Figure 2.
TRA: Real versus anticipated difficulties.
Multivariate analysis (GEE, RMGEE program, K.Y. Liang and S.I. Zeger, Longitudinal data analysis using generalized linear models, Biometrika 73, 1986) strongly proved the learning curve existence and identified some of the major factors playing in the TRA world, namely, the artery size and a diffusely diseased arterial bed (peripheral artery disease). Four predictive variables for a first radial attempt failure emerged in the study:
Year of the procedure, variable related to the learning curve, and operators getting better and better with time, OR 0.6, 95% C.I. 0.4–0.8, p < 0.001.
Presence of peripheral artery disease, OR 1.8, 95% CI 1.1–2.8, p 0.016.
Pre-procedure clinical evaluation for a difficult access, OR 2.5, 95% C.I. 1.3–4.9, p 0.006.
Small radial artery size as assessed clinically before catheterization, OR 2.6, 95% C.I. 1.4–5.0, p 0.003.
The second major contribution was to reveal that the main cause of TRA failure was not at all related to difficult anatomies as commonly reported and taught (Figure 3). At the start of a TRA business, the radial artery cannulation is accounting for about 75% as the main cause to fail. It accounts for 90% of attempt failures when operator had gained more experience. There are several ways to fail an artery cannulation, reflecting the three steps involved: (1) the puncture itself, (2) wiring the needle or the plastic cannula when they sit in the lumen vessel, and (3) after needle/cannula removal, pushing the sheath over the wire.
Causes of TRA failure at first attempt.
When analyzing the three different steps, the far most prevalent problem arises at the wiring step: operator reaches the lumen artery, usually with a good blood’s backflow, but he cannot forward the wire. Identifying this problem lets to develop better strategies and material (see below).
Thereafter 2007, enrollment in the study protocol was extended, allowing the creation of a large radial access database. With time and experience, more expertise arose [5], and looking at the same data in 2010, failures related to anatomical consideration were actually avoided: failure to cannulate the artery emerged as the cause for 92% of failed attempts (again mainly because of the wiring problem). Crossover to femoral access declined to 0.9% (2010) and is now 0.4% (2017–2018).
Let us talk about sticking the artery, first. Two techniques for radial artery cannulation are at works in the cardiac catheterization world and both gets around 50% of the actual “market.”
The first one is derived from the femoral world and is the Seldinger technique. It uses a bore metal needle (usually a 21 Gauge) wired with a short metallic 0.021″ straight or J wire. Its advantage is a sharper bevel, more able to penetrate a stiff arterial wall and a better echogenicity when puncturing with ultrasound guidance. Using the needle with a small body length is recommended: backflow at the hub, signing the puncture success, will happen quicker with a short needle like the Cook® needle 3.5 cm 21 G.
There is a major drawback with the bore metal needle technique: when the standard wire does not progress (either at the needle’s entry in the vessel or further away within the artery), the choice for an alternative wire is limited, and particularly all kind of hydrophilic or angioplasty wires may not be used (possible “peeling” of the coating). When you know that more than 75% of artery cannulation is missed because of the wiring problem, it is annoying to lose this possibility.
The second method is derived from the nursing world: it uses an over-the-needle cannula system (needles designed for puncturing veins and intravenous cannula insertion). Insertion of the small cannula within the first mm of the radial artery greatly facilitates the radial wiring and subsequent sheath insertion. Exchange for any hydrophilic or coronary dedicated angioplasty wires is possible and may help and saves many attempts failing with standard wires. The technique is in the author’s mind more successful addressing radial arteries of small diameter. Using a 22 gauge system, the vessel injury at the tip of the needle is minimal and allows a through-and-through puncture. The technique is easy to standardize and thus to teach: beginners are instructed to push more deeply the over-the-needle cannula system once the needle reaches the artery lumen (backflow at the hub): doing so, the bevel of the needle is now lying beyond the arterial’s posterior wall. Keeping firmly the cannula in place, the metallic part of the system is removed. Then the plastic cannula is gently and mm per mm withdrawn until the blood flows again: the cannula is now perfectly lying in the arterial lumen, and wiring is easier (with the standard or optional wires). For wiring attempts, it is easier to secure in position a plastic cannula than a bore metallic needle. The drawback of the technique is quite minimal: the bevel of the needle is usually not well sharpened for crossing an arterial wall (stiffer and thicker than a venous one); the echogenicity is less than the bore metallic needle (smaller size); some plastics are not well supportive for the standard metallic wire when it has to enter the arterial lumen (all brands of intravenous cannula are not equivalent for that purpose).
Investing in the over-the-needle cannula system, a needle dedicated for the radial access was designed, several prototypes were successfully tested, and the needle is now patented in the USA and Japan and patent pending in the EU [6, 7]. The invention lies in a small distal aperture near the metallic needle tip combined with at least one reinforcing shoulder at the inner surface of the overlying plastic cannula: the system allows a very fast visualization of the tip needle entering the vessel lumen, faster than when you have to wait until the blood flow reaches the more distant needle hub: with the invention, the operator sees first the blood entering the needle’s body and then reaching the hub. This feature helps for the first step of sticking the vessel, shortens the cannulation time, and enhances the success rate (no need to re-puncture, less chance to have “spasm” after a first unsuccessful stick). The needle is waiting investors/manufacturers to get in production.
So, the first recommendation for resolution of the cannulation problem is to invest in the over-the-needle cannula technique for puncturing, giving attention to the choice of the puncture material and to the alternative wires.
The radial artery is a quite superficial structure easily assessed by ultrasound. The technique requires only a small-sized probe, and setup is easy and fast: puncturing while viewing the artery is obviously easier, and in the most recent author’s practice, its use allowed to succeed when blinded attempt had failed. Since its introduction in January 2018 as a bailout technique, and for 439 consecutive procedures, the ultrasound-guided puncture accounted for 43 patients. The visualization of an artery just attempted blindly offered the explanation for the probably most frequent mechanism in play when reattempting unsuccessfully to re-puncture or rewire the vessel: hematoma arising around and within the wall of the vessel, reducing further its lumen (and the pulse). So the “spasm” frequently invoked is in reality hematoma compression/expansion: it explains why the artery is no more palpable and more difficult to re-stick. Furthermore, the ultrasound guidance lets the operator decides to stick at another position or to skip to the ulnar or the contralateral radial/ulnar artery. The ultrasound-guided puncture allows the operator to stick more successfully the artery, but it does not resolve the problem of wiring.
Since many years, as soon as a Doppler signaled the presence of an arterial flow, cannulation of unpalpable radial arteries was attempted. With the ultrasound guidance, it is now far easier to perform this task (and to confirm that the operator may attempt the cannulation, the views allowing the diagnosis of an occluded artery). With the help of ultrasound, the operator may also decide to attempt a less disease or a larger vessel (ulnar or contralateral).
Clearly, the use of ultrasound-guided puncture has a major role to play in a modern strategy of “transradial (or transulnar) access for everybody,” and it is the second recommendation for solving the cannulation problem.
You may be an excellent PCI operator and be quite “ordinary” regarding the puncture task (and some hate this fundamental step). On another hand, in every catheterization laboratory, there are individuals very efficient for sticking vessels, and there are individuals well trained for surface ultrasound. A few years ago, nurses interested in the cannulation task were trained for radial artery puncture. The over-the-needle cannula technique was taught, nurses being well customized with this kind of needle and technique. The fundamental difference between their usual way of working with an over-the-needle cannula and for intravenous cannulation is that they absolutely need to go through and through the vessel for a successful radial artery cannulation. They also have to learn the use of the different wires at (good) works. Recently, the same teaching program was successfully offered to technicians in radiology working in the catheterization laboratory: it provided the advantage of adding peoples trained for ultrasound techniques. Actually, the trained nurses and technologists perform 70% of the author’s artery cannulations without any undesired crossover to a femoral access.
So, the next recommendation is to train willing and well-skilled nurses and technologists to perform the cannulation task.
The ulnar artery has been shown to be a safe alternative route for left heart catheterization [8]. It is anyway a safer route than the femoral access and is sometimes larger than the radial artery. It seats deeper and a sensitive nerve is present along the vessel at the puncture level. Hemostasis is easily performed with the material dedicated for the radial artery compression. So, when a radial attempt fails, the ulnar artery cannulation may be a good alternative even at the same wrist. Of course, ultrasound-guided puncture is also an excellent way to optimize the success cannulation rate. Left distal radial TRA is actually in evaluation as a possible way to further improve operator and mainly patient comfort and safety, at least when starting from the left hand. Large series looking at the ease and effectiveness of the hemostasis together with vessel patency and avoidance of ischemic/sensitive problems are mandatory.
The last recommendation will be to become familiar with ulnar artery cannulation, and ultrasound-guided puncture should be a must.
Patients with previous CABG surgery are difficult to angiography by comparison with non-CABG surgery patients. They are older and have advanced coronary artery disease for many years. Peripheral artery disease and other comorbid conditions such as some degree of chronic kidney failure and chronic obstructive pulmonary disease are frequently found. Graft assessment is an additional task after coronary angiogram and may be tricky due to nonstandard vein graft’s ostial location and unavailable dedicated efficient pre-shaped catheters. Arterial grafts are also uneasy to reach: both mammary arteries are originating at a sharp angle from their subclavicular arteries that are to be engaged: the right subclavicular artery may particularly be tricky to reach, except when starting from the right upper extremity. Finally, the gastroepiploic artery, a branch of the coeliac trunk artery, used by some surgeons to graft the right posterior descending artery, may also be difficult to adequately angiography. The additional task of graft angiography and the higher-risk profile of these patients let to more catheters use, more manipulations, and therefore a greater risk of neurological complications [9].
Due to the anticipated complexity of this procedure and concerns about possible greater X-ray exposition, TRA—and its associated clinical benefits—is often denied to this population.
Louvard et al. [10] and Yabe et al. [11] reported in 1998 the feasibility of graft angiography and particularly left internal mammary artery (LIMA) angiography through a right radial artery approach. Kim [12] and Kwang [13] described bilateral selective internal mammary artery angiography via the right radial approach as early as 2001. Sanmartin et al. published in 2006 their feasibility analysis and comparison with transfemoral approach [14]. They concluded that there is no excessive delay or greater radiation exposure and that the TRA appears at least as safe as TFA. Their study was retrospective, excluded patients with bilateral mammary grafted, and the left radial access was predominant (133 of the 151 TRA compared to the 154 TFA). They reported four failures of cannulation, one puncture failure, one LIMA, and one saphenous vein graft (SVG) not reached. Only 15% of ad hoc PCI were carried out. In 2008, Burzotta [15] and experienced TRA operators described tips and tricks available for addressing post-CABG patients and already pointed out the right radial access as the best first option in case of bilateral mammary artery grafts.
In 2009, Rathore et al. [16] reported a similar technical TRA success rate for SVG-PCI compared to TFA. Periprocedural MI, access-site bleeding-related complications, and large hematomas were higher in the TFA group. They reported a 5.8% crossover to the femoral route. The Transradial Committee of the SCAI in a 2011 publication concluded that TRA for CABG patients might safely be integrated into routine practice as experience increases [17].
The published 2010 prospective study of 1826 consecutive procedures [4] looking at the conversion rate from TRA to TFA when both radial arteries have to be attempted before the crossover to femoral included 187 patients with previous CABG surgery. The study was extended for the CABG population until 2012, and results were presented at the 2012 ACC meeting [18].
The study differs from the previously reported series: it prospectively addressed patients with previous CABG surgery; the choice of the radial artery to be attempted at first, right versus left, was free, but both radial arteries had to be attempted before converting to femoral access. Patients grafted with both mammary arteries were not excluded, and the study also included patients with gastroepiploïc arteries used as graft. Ad hoc and elective PCI were performed. Importantly, all causes of failed attempts were analyzed and classified.
This study reinforces the previous conclusions about TRA feasibility. When considering angiography for the CABG population, particularly when only one mammary artery is grafted, TRA performs as well as for the general population. A success rate above 98% was obtained with a very low requirement for a second artery access (7.2%) in case of only one internal mammary artery (IMA) grafted. Of course, the radial artery to be attempted at first must be ipsilateral to the utilized IMA, and it is better to start with in hand the description of the performed surgery. In case of bilateral IMA, the strategy of attempting the right radial artery at first enhances the chance of completing the procedure through one arterial access (actual chance of success is around 60%). To be noted, in the published series, about 35.5% of procedures included angioplasty and stenting (mainly ad hoc). Tables 1
Population | Any previous CABG surgery | Previous CABG surgery | p | Previous CABG surgery ≤1 IMA | p (vs. no previous CABGs) | Previous CABG surgery 2 IMA | p (vs. no previous CABGs) |
---|---|---|---|---|---|---|---|
N | 1639 | 507 | 320 | 187 | |||
Age | 65 ± 11 | 71 ± 9 | <0.001 | 72 ± 10 | <0.001 | 70 ± 9 | <0.001 |
Female (%) | 31% | 18% | <0.001 | 20% | <0.001 | 14% | <0.001 |
Diabetes (%) | 17% | 29% | <0.001 | 28% | <0.001 | 32% | <0.001 |
HTN (%) | 44% | 56% | <0.001 | 54% | 0.001 | 58% | <0.001 |
Peripheral vascular disease (%) | 21% | 41% | <0.001 | 43% | <0.001 | 38% | <0.001 |
Weight (kg) | 79.0 ± 16 | 81.6 ± 15 | 0.001 | 80.8 ± 15 | 0.037 | 83.0 ± 16 | 0.001 |
Height (cm) | 168 ± 9 | 169 ± 8 | 0.26 | 168 ± 9 | 0.82 | 170 ± 8 | 0.021 |
BMI | 27.8 ± 5 | 28.6 ± 9 | 0.001 | 28.6 ± 6 | 0.009 | 28.6 ± 5 | 0.017 |
BMI ≤ 22 (%) | 10.5% | 4.3% | <0.001 | 4.1% | <0.001 | 4.8% | 0.014 |
Radial artery looks not easy to puncture | 13.9% | 12.6% | 0.46 | 13.8% | 0.94 | 10.7% | 0.224 |
Volume of contrast (ml) | 156 ± 78 | 226 ± 92 | <0.001 | 218 ± 87 | <0.0001 | 239 ± 97 | <0.0001 |
Percutaneous coronary Intervention (ad hoc + elective) | 40.5% | 35.5% | 0.04 | 41% | 0.8 | 26% | <0.001 |
TRA and CABG vs. non-CABG populations.
All | Non-CABG patients | CABG patients | p | CABG ≤1 IMA | p | CABG 2 IMA | p | TRA-IMA same side | p | |
---|---|---|---|---|---|---|---|---|---|---|
N Patients | 2146 | 1639 | 507 | 320 | 187 | 298 | ||||
TRA success | 2118 | 1621 | 497 | 314 | 183 | 293 | ||||
(%) | 98.7 | 98.9 | 98 | 0.13 | 98.1 | 0.247 | 97.9 | 0.216 | 98.3 | 0.395 |
N radial attempted | 2327 | 1711 | 616 | 339 | 277 | 311 | ||||
N of radial attempts/patient | 1.084 | 1.044 | 1.215 | <0.001 | 1.059 | 0.23 | 1.481 | <0.001 | 1.047 | 0.981 |
Right radial as first attempt | 1560 | 1359 | 201 | 62 | 139 | 41 | ||||
Right radial failed at first attempt | 139 (8.9%) | 68 (5.0%) | 71 (35.3%) | <0.001 | 10 (16.1%) | <0.001 | 61 (43.9%) | <0.001 | 4(9.7%) | 0.175 |
Left radial as first attempt | 586 | 280 | 306 | 258 | 48 | 257 | ||||
Left radial failed at first attempt | 56 (9.6%) | 12 (4.3%) | 44 (14.4%) | <0.001 | 13(5.0%) | 0.678 | 31 (64.6%) | <0.001 | 12 (4.7%) | 0.83 |
All failures (first attempt) | 195 | 80 | 115 | 23 | 92 | 16 | ||||
One (first) failure/patient | 9.1% | 4.9% | 22.7% | <0.001 | 7.2% | 0.091 | 49.2% | <0.001 | 5.4% | 0.721 |
Radial artery cannulation: failures at first attempt.
Non-CABG patients | CABG patients | p | CABG patient ≤1 IMA | p (vs. no CABG) | CABG patient 2 IMA | p (vs. no CABG) | |
---|---|---|---|---|---|---|---|
N | 1639 | 507 | 320 | 187 | |||
N R ± L radial failed (% patients) | 90 (5.5%) | 119 (23.5%) | <0.001 | 25 (7.8%) | 0.106 | 94 (50.3%) | <0.001 |
N puncture/wiring failed (% total failures) | 67 (74.4%) | 14 (11.8%) | <0.001 | 12 (48%) | 0.012 | 2 (2.1%) | <0.001 |
N “route to aorta” failed (% total failures) | 12 (13.3%) | 5 (4.2%) | 0.017 | 2 (8%) | 0.471 | 3 (3.2%) | 0.012 |
N “coronary or SVG ostium” failed (% total failures) | 11 (12.2%) | 12 (10.0) | 0.625 | 5 (20%) | 0.32 | 7 (7.5%) | 0.276 |
N “IMA contra not reached” (% total failures) | 0 (0%) | 88 (74.0%) | <0.001 | 6 (24%) | <0.001 | 82 (87.2%) | <0.001 |
TRA CABG vs. non-CABG, causes of failed attempt.
To summarize the published statistics, for a general population and excluding patients with previous CABG surgery, cannulation failed in 4.9% (requiring crossover to the second radial artery or to an ulnar artery). For the CABG population when the surgeon protocol is available and when only one IMA is grafted, the ipsilateral to the IMA radial cannulation fails for 5.4% of patients and requires use of the ipsilateral ulnar artery. When both IMA are grafted, starting from the right TRA succeeds for about 60% of patients; 40% will further need cannulation of the left TRA (mainly for an adequate LIMA graft patency assessment). In terms of patient safety and avoidance of vascular access-related complications and hemorrhage, a bilateral radial cannulation is far less dangerous than one femoral access, particularly in case of coronary/graft angioplasty. By the way and as reported [19], the PCI success rate stays unaltered by the vascular access.
The TRA lifesaving benefit is directly linked to the illness severity: the STEMI and the unstable non-ST elevation myocardial infarct (NSTEMI) patients are the more likely to require a high level of several anticoagulants/antiplatelet therapies paving the road for serious hemorrhagic events mainly at the vascular (femoral) access site [20]. Vascular closure devices have not been demonstrated to be effective in reducing these vascular complications in the setting of ACS. On the contrary, hemostasis is easily obtained after TRA, even in situation of high anticoagulation level. Performing through a radial artery access in these circumstances removes the fear of “collateral damages” related to intense anti-clot treatments and allows retaining the benefits linked to their use. When the situation requires the use of intra-aortic counterpulsation, the TRA PCI saves at least this access from hemorrhage, the intra-aortic balloon being usually removed some days later, when the degree of anticoagulation is far less intense. Door-to-balloon time is only one of the important lifesaving parameters and must not serve as a pretext to skip a well-performed TRA attempt: speed may not lead to haste! Acute MI patients usually maintain initially a decent radial pulse, and cannulation may succeed as in stable condition. Particularly in the setting of acute coronary syndrome (ACS), a failed first attempt must lead to attempting the second radial artery (or the ulnar artery) before crossing over to the less safe femoral route. The author’s most recent statistics in STEMI patients will illustrate the TRA feasibility “in real world.”
Since mid-March 2017 to mid-November 2018, from a total of 1023 procedures, 152 STEMI patients were primarily addressed by PCI. A grand total of two primary PCI were performed through a femoral access: one MI patient had previously a thoracic vascular repair after a thoracic trauma (car accident): his right arm was unavailable for left heart catheterization, and cannulation of the left radial artery led to an occluded left subclavicular artery. The second femoral case was a small-sized lady, and the attempts to wire radial (and ulnar) arteries failed at both wrists. This case happened before the availability of the ultrasound technique for rescuing the failed attempts. Seven STEMI cases required simultaneous use of the femoral artery for left ventricular assistance (intra-aortic balloon pump). The hemorrhage-saving TRA feature lets to more liberal use of potent antiplatelet drugs and high heparin doses: it may lead to less distal thrombus embolism and less no-reflow post-reperfusion states. As already stated, femoral access accounted for only 4 cases of the last 1023 author’s procedures.
There is another category of patients likely to get catheterized by the femoral route: the small body-sized ill patients, particularly if a frailty condition is associated. Excuses to skip the radial access stay similar: anticipated—but not objectively assessed by ultrasound—too small radial artery, need of a large guide catheter for a quicker intervention, speed required by the degree of illness, etc. Nevertheless, this kind of patient will very badly recover from any hemorrhagic event, and their condition increases greatly the vascular risk [20]. The reader is invited to look at the way a cohort of such frailty; old and severely diseased patients were successfully TRA managed through a double radial route for addressing distal left main or proximal left coronary artery disease [21]. It allowed to position and to work simultaneously with two 5 French-sized guide catheters at no cost of vascular-related complication (Table 4).
Case 1 | Case II | Case III | Case IV | Case V | |
---|---|---|---|---|---|
Age | 81 | 70 | 86 | 87 | 89 |
M/F | M | F | M | F | F |
BMI/height (cm)/weight (kg) | 25/174/75 | 33/159/85 | 30/160/78 | 22/160/56 | 22/160/56 |
Frailty (0–3+) | 2+ | 1+ | 3+ | 3+ | 3+ |
Symptoms at presentation | New chest pain and SOB CCVS Class 3 | Progression of chest pain, SOB CCVS Class 3 | Chest pain and SOB CCVS Class 4 | Acute pulmonary edema NSTEMI VT, persistent HF | Acute pulmonary edema NSTEMI VT, persistent HF |
Associated medical conditions | Severe COPD Gold IV, permanent O2 therapy | Severe COPD Gold III Past CVA and CAD | Valvular aortic stenosis, severe (< 1 cm2), COPD, transient AV block | HBP, paroxysmal atrial fibrillation Low Ef (recent) | HBP, diabetes, low Ef (recent) |
CAD, syntax score (SS) | Distal LMCA Medina 1,1,1 Left dominance Syntax score 30 | Distal LMCA Medina 1,1,1 Syntax score 23 | distal LMCA, medina 1,1,1 occluded RCA (3VD), Syntax score 48 | LMCA equivalent, 100% RCA Syntax score 28 | Prox. and mid-LAD a. 75% CX a., 95% RCa. lesion 70%, syntax score 35 |
Addressed vessel(s) | LMCA | LMCA | LMCA | Ostial-LAD/ostial CX arteries | Prox. to distal LAD-Diag a. |
Arterial access | R TUlnA/L TRA, 5F Glidesheath | R+ L TRA, 5F Glidesheath | R+ L TRA, 5F Glidesheath | R+ L TRA, 5F Glidesheath | R+ L TRA, 5F Glidesheath |
Fluoroscopy time/volume of contrast/DAP/CPK 24 h | 44′/290 ml/228 Gy/cm2 CPK (−) | 17′/212 ml/143 Gy/cm2 CPK (−) | 20′/148 ml/114 Gy/cm2 CPK (−) | 15′/140 ml/73 Gy/cm2 CPK (−) | 20′/128 ml/173 Gy/cm2 CPK (−) |
Follow-up | Alive > 1 year, acute pneumonia at 1 month | Alive > 1 year, no angina | Alive > 1 year, aortic valve stenosis said moderate | Alive > 1 year, class 1, normalized LV function | Alive > 1 year, class 1, normalized LV function (had 2 weeks re-hosp for HF) |
TRA PCI and frailties, adapted from ACC, 18;3, 45-52.
Coronary artery disease (CAD) is a progressive disease, and many patients “enjoying” a first successful TRA PCI will require in the future one or more interventions, evenly in emergency (subacute stent thrombosis, new STEMI or new acute coronary syndrome, etc.). So, preserving a well-patent radial artery may be lifesaving later.
In 2016, 1 year before the CRASOC studies were accepted for publication in the American Journal of Cardiology [3] as the largest randomized and prospective study analyzing the hemostasis role in radial artery occlusion (RAO). Rashid et al. published a well-documented systematic review and meta-analysis [22] about the TRA-related radial artery occlusion. It is easy to summarize the problem and to understand the different ways we must follow to reduce the RAO rate. RAO is the direct consequence of the vessel injury associated with any TRA. Injury happens at three levels, and we have to minimize the trauma at each of these levels: first, the puncture; second, the sheath insertion and catheter manipulations (within the sheath); and finally, the compression/hemostasis following the catheterization. Mention for selecting the best technique and material for artery puncture and cannulation was already made. The author makes the hope that, someday, TRA operators will get the chance to handle the specifically designed and actually patented radial artery needle: it should be the best way to reduce as far as possible the puncture-related aggression. In the same way, it is obvious that reducing the size of the sheath is another excellent way to reduce the related harm against the artery wall. Not only should the size be reduced as far as possible, but also the material must be hydrophilic: non-hydrophilic sheath should be banished from a good TRA practice. The “slippery” problem of the hydrophilic sheath is the best proof of the appropriately reduced parietal stress. This problem may be easily “fixed” at the skin level: a simple “opsite” film placed over the sheath does the job. The introduction of the Terumo® “Glidesheath” family of radial introducers represents a welcomed improvement: The company cleverly worked to offer a reduced outside diameter of the sheath (what the artery” feels”) together with a normal inside diameter. It allows operators working predominantly in 5 French (including for PCI), to offer a “virtual 4F” TRA procedure for the majority of their patients.
The post-catheterization hemostasis step contributes to the global artery’s damage: as proven effective thanks to the 3616 analyzed patients in the CRASOC studies, a gentle and short hemostasis with pneumatic compression (TR Band® compression device, 10 cc of air/90 minutes) represents today the best and most elegant way to minimize the RAO rate. A TRA operator has to be reminded that the hemostasis step is his last chance to save the radial artery patency.
“TRA for everybody” is highly desirable for patient safety and comfort. This strategy is achievable, and solutions for more complex populations are provided. Ways to maintain the artery patency are described. Better-suited materials for easier TRA are already offered, and innovations will continue [23, 24]. The author still believes that in year 2018 the radial way requires a gentleman attitude (at least for the radial artery), demands a rebel inclination—to discard all the negative thinking about the TRA feasibility—and is best served by a “believer” behavior: a believer always will try to find indication rather than contraindication for TRA.
If you are associated with any of the institutions in our list below, you can apply to receive OA publication funds by following the instructions provided in the links.
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