Agadzhanyan V.V., Tuzovsky A.A.

Kuzbass Clinical Center of Miners' Health Protection named after The Holy Great Martyr Barbara, Leninsk-Kuznetsky, Russia,
Kurbatov Novokuznetsk Clinical Hospital No. 1, Novokuznetsk, Russia,

Tsivyan Novosibirsk Research Institute of Traumatology and Orthopedics, Novosibirsk, Russia

The urgency of the problem of treating patients with fractures of the proximal tibia is determined not only by their high prevalence, but also by the high frequency of unsatisfactory outcomes (from 10 to 54 %), the most common cause of which is the incorrect union of fragments, leading to the formation of contractures in knee joint and the development of deforming arthrosis [15]. Instability of the knee joint develops in 5.8-28 % of cases [9, 10, 40]. Unfortunately, this leads to a high proportion of patients with permanent disability (5.9-9.1 %) [15].
According to numerous authors, intra-articular fractures in the knee joint range from 1.5 to 6.9 % of all skeletal fractures and 10-12.2 % of all intra-articular fractures. Fractures of the tibial condyles, related to severe intra-articular injuries, account for about 7 % of all fractures of the musculoskeletal system [3, 4].

The mechanogenesis of injury is determined by the position in which the knee joint is located at the time of injury, and the direction of the injuring force. R. S. Robert, C. S. Scott and J. K. Steven subdivide fractures according to the force of action: due to high-energy injury, in which falls from a height are 20 %, traffic accidents − 50 %, and low-energy injury − axis load and rotation, and as well as falls from the height of one's own height − 30 %, and elderly patients with osteoporosis are at risk. The age group with injuries to the proximal epimetaphysis is people of working age from 30 to 60 years [27].

An important place in studies is occupied by the problem of diagnosing impression fractures using modern research methods, such as arthroscopy and spiral computed tomography (SCT) [19]. So, A.Yu. Vaza showed in his work that arthroscopy reveals impression fractures in 100 % of cases, while with CT-study, the detection of depression in the articular surface is 92.3 %, and with conventional radiograph, only 68.2 %. In the absence of SCT and magnetic resonance imaging (MRI), it is proposed to use linear tomography of the knee joint to determine the volume of the impression defect zone.

N. S. Fedorova points out that MRI studies of impression fractures of the tibial condyles revealed a damage to the anterior cruciate ligament in 38.5 % of cases, damage to the tibial collateral ligament − in 62.5 %, and damage to the internal and external menisci − in 40 % of cases [27] . Ultrasound examination before surgery helps to identify the pathology of the soft tissues of the knee joint and allows you to determine the plan of the volume of surgical intervention.

In recent years, the frequency of severe intra-articular fractures of the condyles of the proximal tibial metaepiphysis (TBI), which form the "tibial plateau", is constantly increasing and, according to some authors, reaches 60 % of such injuries to all large joints, and in general structure of damage to the skeleton − 2-5 %. At the same time, isolated fractures of the lateral tibial condyle occur in 55-70 % of all fractures of this localization, and damage to the medial or both tibial condyles is observed only in 10-30 %. It should also be noted that unfavorable long-term results of treatment of such fractures range from 6 to 39 %, which often leads to permanent disability.

To date, all authors are unanimous that in the surgical treatment of patients with fractures of the tibial condyles, regardless of their location, it is necessary to achieve anatomical reposition of the articular surface fragments [7].

Classifications of intra-articular fractures of the condyles of the tibia

The classifications of J. Schatzker (1978) and AO (2002) in the treatment of patients with fractures of the tibial plateau are in the greatest demand in our country.
The J. Schatzker classification divides all fractures of this localization into 6 types:

I - a split of the lateral condyle of the tibial without articular surface impression;
II - a split of the lateral condyle with the impression of the articular platform;
III - focal impression of the articular area without a split of the lateral condyle;

IV - fracture of the medial condyle with or without a fragment of the intercondylar eminence, the lateral condyle is intact;

V - fracture of both condyles; the central section of the plateau is interested or intact;

VI - fragmentary fracture of both condyles with the presence of transverse fracture lines in the metaphysis of the tibia.

The AO classification for intraarticular fractures of the tibial plateau has a general coding of anatomical localization (41), and also includes 3 groups in the type of incomplete articular fractures (41B) and 3 groups in the type of complete articular fractures (41C):
41B1 - a split of the lateral condyle of the tibia;

41B2 - pure impression of the articular site without a split of the lateral condyle;

41B3 - a split of the lateral condyle of the tibia with the impression of the articular platform;

41C1 - simple articular, simple metaphyseal fracture;

1C2 - simple articular, comminuted metaphyseal fracture;
41C3 - comminuted articular, simple or comminuted metaphyseal fracture.

Thus, each of the two types includes 3 groups of intra-articular fractures, specifying the details of the position of bone fragments.
However, both of these classifications do not give an idea of which parts of the tibial condyles are damaged.

Along with the generally accepted classifications of tibial plateau fractures, a classification based on the division of the articular surface of the tibia into three [38] or four columns [30] is now increasingly used. The feasibility of this approach is confirmed by the fact that G. Yang et al. (2013) changed surgical tactics in 28.8 % of 525 clinical cases after the introduction of the three-column classification [46]. Y. Zhu et al. (2012) in 5 % of 278 cases could not satisfactorily classify the tibial plateau fracture according to J. Schatzker and AO [35], while Q. Zhai et al. (2013) revealed significant posterior bone fragments in 33.5 % of 140 cases, and fractures of the posterolateral and central sections of the tibial plateau were diagnosed in 10.7 % [41].

It is obvious that the division of the tibial plateau into 3 or 4 columns is arbitrary, since anatomically it is quite difficult to mark the border between the “anterior” and “posterior” columns of each of the condyles. However, in 2010, C.F. Luo et al. (2010) objectified this division as much as possible. On the diagram of a horizontal (transverse) CT-section, these authors identified three columns, separating them with lines between certain points [2].

Fractures of the condyles of the tibia account for more than 60 % of all intra-articular fractures of the knee joint area, while such injuries are more often in the form of multi-comminuted impression-compression fractures [21, 22]. With a modern approach to the treatment of severe compression-impression fractures of the tibial condyles, it is necessary to take into account the type and nature of the fracture, a degree of intra-articular destruction of the tibia plateau, and the possibility of concomitant damage to the ligamentous apparatus of the knee joint.

Treatment of such fractures is often associated with significant difficulties. A specific feature of impression-compression fractures is the formation of a defect in the substance of the proximal metaphysis of the tibia, which is primary at the time of injury. In this case, it is necessary not only to fully restore the congruence of the articular surfaces of the bones that make up the knee joint, but also to replenish the defect in the metaphyseal part of the condyle formed at the time of injury.

According to existing classifications, fractures of the proximal articular part of the tibia are divided into fractures from splitting and fractures from impression of fragments (impression-compression fractures). At the same time, fractures from splitting are not accompanied by the formation of a defect in the condyle and are extremely rarely combined with damage to the ligaments of the knee joint. Restoring the congruence of the articular surfaces, as a rule, does not present any particular difficulties. Taking this into account, it is possible to successfully apply both closed transosseous osteosynthesis (CTO) with external fixation devices, and open reduction of the fracture, osteosynthesis with modern submersible structures (plates with angular stability of screws).

In case of polyfragmentary impression-compression fractures, a special approach is required to ensure the most accurate comparison of fragments of the damaged condyle (condyles) with the restoration of the articular surface of the tibial plateau. The absence of an accurate reposition of the fragments, as a rule, leads to the growth of excess tissue of the regenerate around each of them, which is a condition for the development of severe deforming arthrosis and persistent contractures of the knee joint. Uncorrected post-traumatic defects of the metaphyseal part of the condyles often lead to gross deformation of the articular surface of the tibia plateau and also contribute to the development of deforming arthrosis of the joint.

Despite the correct treatment of fractures of the condyles of the tibia (by conservative or surgical methods), in the immediate postoperative period in 56.5 % of cases, impression changes and deformities of the limb axis occur. Prevention of development in the postoperative period of impression changes in fractures of the condyles of the knee joint is the use of bone grafting [24].

Characterization of the proximal metaepiphysis of the tibia

The intramedullary canal of the tibia, like that of the femur, in longitudinal section resembles an hourglass in shape. The wide parts are located in the metaepiphyses, a narrow (isthmal) zone falls in the middle or is located on the border of the middle and lower thirds of the diaphysis [1].
A group of authors from the Canadian University established the influence of the shape of the intraosseous canal of the tibia on the stability of the intramedullary locking nail. They analyzed 20 tibial cadaveric bones (cross-sectional area and cortical layer, canal width) using MRI and CT. Quantitative characteristics of the area of  the cortical layer on transverse sections of the tibia were determined: at a distance of 1-4 cm from the edge of the tibial plateau - from 2 to 2.5 mm; 4-6 cm - from 2.5 to 3.0 mm; 10 cm -from 3.5 to 4.0 mm.

Similar results were obtained by other researchers of the architectonics of intramedullary canals.

Modern guidelines for the treatment of reparative osteogenesis disorders (ROD) suggest the following principles of surgical interventions:

- strong fixation of fragments;

- minimal traumatization of bone and soft tissue structures of the damaged segment;

- maximum restoration of the axis and length of the segment;

- early function of the injured limb.

In this case, various methods of surgical treatment are used, which can be divided into three groups:
1. Extrafocal transosseous osteosynthesis (ETO) with external fixation devices with or without bone grafting.

2. Submersible stable osteosynthesis (plates, rods, special devices) with or without bone grafting.

3. Combined osteosynthesis: internal osteosynthesis in combination with an external fixation device with or without bone grafting.

The recent introduction of hybrid-type external fixation devices has significantly reduced the number of problems associated with the use of the classic Ilizarov apparatus, against the background of its indisputable advantages, such as low invasiveness and respect for surrounding soft tissues, stability of fixation, the possibility of deformity correction and early axial load. At the same time, while estimating the achieved anatomical and functional results of restoring the integrity of the limb in patients with false joints of long bones, some authors consider the long period of their use to be the only but significant drawback of the methods of fixing fragments with extrafocal transosseous osteosynthesis devices (pin, rod and combined). In this case, the device is in the external environment, which creates inconvenience for the patient and increases the risk of secondary infection of the bone and soft tissues.
Taking into account these circumstances, as well as the need to standardize the treatment process and reduce its time, in modern practice of treating the consequences of fractures, technologies for submerged fixation of fragments have become widely used: external and locking intramedullary osteosynthesis (LIO).

In traumatology and orthopedics, these methods of fixation are called as the gold standard [5, 18].
  Those who support transosseous osteosynthesis also use this term.

The goal of treatment is to obtain good results - to preserve the function of the joint, to restore the anatomical and functional features of the injured limb. Accurate reposition, strong fixation of fragments and early onset of movements in the knee joint lead to a positive outcome, which implies a faster restoration of joint function.

A large number of surgical techniques have been proposed for the treatment of fractures of the proximal tibia. When analyzing the literature on indications for surgical treatment of fractures of the proximal tibia, there is a lack of consensus on the tactics and methods of treatment.

According to A.K. Grigoryan (2008), fractures 41B2, 41B3, 41C1, 41C2, 41C3 according to the AO/ASIF classification, as well as displacement of the articular surface by more than 2 mm, are direct indications for surgical treatment. The use of submersible AO structures provides fixation, which makes it possible to begin early development of movements in the joint. The range of motion was restored to 87 % of the full range of motion of the joint. The disadvantage of the plates is the need for their modeling during the operation.

The advantage of minimally invasive bone osteosynthesis is low traumatization, but there is no control over the state of fragments. The shape of the support plate in this method can be T- and L-shaped with a double bend or be a dynamic compression plate with limited contact.

LCP (Locking Compression Plate) is often used. With this osteosynthesis, the fixation of bone fragments is stable. A common disadvantage of this method is the difficulty in visual control of reposition, which, in turn, leads to the possible occurrence of rotational deformities and axial deviations. As a result of incomplete fit of the fixator to the anatomical surface of the bone, in some cases there is a general deformation of the fracture.

D. P. Barei and S. E. Nork (2006) suggested using a short anti-slip plate along the medial surface for fractures of both tibial condyles. Osteosynthesis is performed from the anterolateral and posteromedial approaches. The use of two plates gives greater stability, but is accompanied by an increase in the frequency of purulent complications due to an increase in the number of surgical approaches and their trauma [10].

A low-traumatic method is a closed, minimally invasive osteosynthesis of fractures with screws. The disadvantage of this method is the lack of stable fixation of fragments, which leads to the use of a plaster cast for additional immobilization, and this, in turn, to late rehabilitation.

In recent years, in the treatment of type B2 and B3 fractures according to the AO classification, many authors use allo- and autografts, such as hydroxyapatite preparations, porous ceramics, carbon implants, and their own menisci.

Used implants are divided into osteoinductive, or osteogenic, and osteoconductive. Osteoinductive implants include those that stimulate osteogenesis: autologous bone, bone morphogenic protein (BMP), demineralized bone matrix (DBN) and, less commonly, allocone. Osteoconductive implants do not stimulate fusion, but only fill the defect, while gradually growing into bone tissue, since they are similar to its mineral component. In cases of tibial plateau fractures, osteoconductive implants are used. Deijkers (1999), based on his research, believes that the use of allografts can be complicated by rejection even if the grafts are frozen and devoid of bone marrow. He calls the allograft "a warehouse of antigens that provides a continuous immune response for several years."

Supporters of the use of autologous plastics believe that it should be used to exclude delayed fracture consolidation − in cases with insufficient vascularization, a large bone defect, and an unsatisfactory bone and cartilage reaction.

However, many authors are now moving away from the use of bone grafting as a method of treating impression fractures of the tibial plateau, as this is associated with an increase in trauma and duration of the operation. There are also undesirable consequences when using autobone. When taking a transplant, infectious complications may occur, which amount to 8-10 %. However, Urban (2002) considers autologous bone to be the "gold standard for tibial condylar defect repair". As a defect filler, in his opinion, bioactive ceramics can be widely used. The author observed 12 patients aged 2 to 8 years with fractures B3.1, B3.2, C3.2 (according to the AO classification) of the proximal tibia. The bone defect
  after the condyle elevation was filled with BASO glass-ceramic granules in combination with 10 ml of the patient's bone marrow, then fixed with screws or a support plate under the control of an electron-optical converter. The author notes the absence of resorption, displacement, and encapsulation of the implant and rapid integration with bone tissue. During the study, the author injected bone marrow in order to stimulate bone genesis. The advantage of the method is the reduction in the duration of surgery and the number of postoperative complications, and the disadvantage is the preservation of residual impression in the postoperative period, on average, 2.0 mm.

It is worth noting the widespread use of porous ceramic hydroxyapatite “Endobon”, which has been used since 1989. Operations were performed to implant it using arthroscopy, followed by transosseous osteosynthesis with screws. "Endobon" was used to fill defects in the metaphysis of the tibia. In the postoperative period, during the control computed tomography between 6 and 12 months, partial replacement of bone tissue in the area of ​​implantation with hydroxyapatite was observed, as well as a decrease in bone density and, conversely, an increase in the density of the Endobon hydroxyapatite implant. The disadvantage of this technique is the long period of germination of the hydroxyapatite implant by the bone tissue − more than 6 months [23].

Principles of fixation of fractures of the condyles of the tibia

To date, the main types of fixation of tibial plateau fractures are various modifications of bone osteosynthesis, as well as external fixation. An external fixator as the final type of osteosynthesis is most often used when it is impossible to perform internal osteosynthesis [48]. However, in domestic and foreign literature there is a description of the successful use of extracortical hybrid devices for osteosynthesis, including in complex fractures of types V and VI according to J. Schatzker or C1-C3 types according to the AO classification [34, 43]. According to foreign experts, the use of an external or external fixator is determined not only by the ability for anatomical and reliable fixation of bone fragments, but also by the condition of soft tissues and the presence of compartment syndrome, often associated with high-energy injuries [49]. However, regardless of the chosen method of osteosynthesis, intra-articular fractures of the tibial condyles require precise (anatomical) restoration of the articular surface and the creation of interfragmentary compression in the fracture zone [7].
To fulfill these conditions, it is necessary, first of all, to ensure adequate visualization of the intra-articular fracture zone. Visualization can be improved by radiological intraoperative control. However, due to the complex anatomical configuration of the tibial condyles, the planar image of the image intensifier tube does not provide all the necessary information about the quality of bone fragment reposition [44]. Therefore, it seems promising to improve the visualization of the fracture zone with the help of arthroscopic assistance. This technique could be of particular relevance in cases of complex fractures of the tibial plateau extending to its posterior sections. There are examples in the literature of such application of arthroscopic support for osteosynthesis. Thus, the minimally invasive use of percutaneously cannulated screws is described in groups of patients with injuries of types I-IV according to J. Schatzker [31]. The authors conclude that this technique provides complete fusion of fragments and faster postoperative recovery of patients, but is acceptable only for simple fractures with minimal diastasis between bone fragments, and also implies good technical equipment and preparation for such operations.

However, most authors believe that the use of arthroscopic control in the reposition of bone fragments is advisable only in cases of pure impression of the tibial condyles [32, 36]. When splitting the tibial condyles, the risks of developing compartment syndrome increase due to the ingress of the fluid used for arthroscopy into the fascial sheaths of the leg [29, 37, 45]. Therefore, the most effective way to visualize the fracture zone of the tibial condyles is its direct examination from a fairly convenient and safe surgical access.

The standard anterolateral surgical approach is currently regarded by most surgeons as the method of choice for fractures of the lateral tibial condyle, as it provides good visualization of the anterior and lateral parts of this condyle, which forms the tibial plateau. After making a slightly curved skin incision from a level 2-3 cm above the joint space to a level just below the tuberosity of the tibial joint, arthrotomy of the knee joint is performed along the joint space under the body of the lateral meniscus, then the latter is retracted upward, exposing the articular surface of the tibial plateau. However, this access makes it impossible to reposition fragments of the posterior column of the lateral tibial condyle due to its insufficient visualization, which is prevented by the tension of the soft tissues of the joint capsule and its posterolateral tendon-ligament complex. Therefore, the possibilities of repositioning bone fragments in fractures of the tibial condyles from the discussed surgical approach are limited to the anterior and lateral, and also partially to the central segment of the tibial plateau.

For adequate visualization of bone fragments in this area, P. Lobenhoffer in 1997 proposed a modification of the posterolateral approach with osteotomy of the head of the fibula. Such transfibular path after osteotomy of the head of the indicated bone, capsulotomy, mandatory dissection of the ligament of the lateral meniscus and detachment of the posterolateral ligamentous structures then allows visualization of the entire posterolateral column of the tibial plateau. The disadvantages of this approach include significant trauma and the likelihood of iatrogenic neuropathy of the common peroneal nerve [33].

In later publications, the authors discuss the feasibility of this approach for complete reposition of isolated fractures of the posterior column of the tibial plateau [42]. In the same works, the authors offer another modification of the posterolateral approach, which involves entering the popliteal fossa without osteotomy of the fibular head between the tendons of the biceps femoris muscle and the lateral head of the gastrocnemius muscle.

In a comparative analysis, some researchers point to the impossibility of stabilizing fragments of the posterolateral column in unicondylar fractures of the tibial plateau from the classical anterolateral approach due to the lack of direct visualization of bone fragments. The transfibular technique using the posterolateral approach turned out to be the most acceptable in such clinical cases, which was shown by the long-term results of its application.

Other authors in a similar study preferred the posterolateral approach over the head of the fibula in 20 patients for osteosynthesis of fractures of the posterior tibial column, emphasizing its simplicity, safety, and high efficiency [33].

The conducted studies on the anatomical material showed a high risk of damage from the posterolateral approach of the anterior tibial artery below the head of the fibula during osteosynthesis of the tibial plateau, if the extraction of bone fragments is carried out distally to the articular surface of the lateral condyle of the tibial tibia by an average of 46.3 ± 9, 0 mm, where this artery passes through the interosseous membrane [47]. In another similar study, the indicated distance approached 76 mm, and the distance from the articular surface of the tibial plateau to the common peroneal nerve at the point of intersection of the neck of the fibula was 42 mm on average. The angle between these formations was about 15° [28].
D. A. Shakun proposes to single out early (up to 7 days from the moment of injury) and delayed (7–14 days from the moment of injury) operations and, depending on the timing, apply initially transosseous osteosynthesis, and then internal osteosynthesis.

All authors consider surgery with the use of stable osteosynthesis to be the main method of treatment for early functional treatment, which is carried out starting from the 7th day after surgery [6].

The use of external fixation devices (including new layouts of pin-and-rod and rod devices) for this injury should be “performed only according to strict indications” in the presence of massive soft tissue wounds that do not allow open reposition [6, 14]. The use of new transosseous osteosynthesis configurations “provides up to 90.0 % of favorable treatment outcomes” for impression fractures [14]. With this method of treatment, the effectiveness of transosseous osteosynthesis is determined by the "direction of the applied pressure on the bone fragment", which makes it possible to obtain positive results in 95.1 % of patients. The use of damped hinges in the reposition of fractures of the bones forming the knee joint led to positive results in 95.1 % of cases.

Some authors prefer to fill impression defects with an autograft, the “gold standard of orthopedics”, taken from the iliac wing or from the femoral condyle. It is the autograft that has not only osteoinductive and osteoconductive, but also osteogenic properties, i.e. it contains living cells that can differentiate into osteoblasts, release biologically active substances that promote cell differentiation into osteoblasts [9, 26]. An impression defect, “starting with a volume of 0.5 cm2”, requires the use of a plastic material to stabilize the “cartilaginous and subchondral zone of the joint”.

As before, in bone grafting, it is also proposed to use lyophilized spongy allografts to fill defects, with the use of which positive results were obtained in 91.3 % of cases, “the volume of active and passive movements in the knee joints was completely restored in 40 cases (76.9 %)" [17].

Nikitin S. S. suggested using P-tricalcium phosphate in the form of cement as an impression defect filler and got good "functional results in 92.3 % of patients."

The use of arthroscopic technique allows the use of minimally invasive technologies in the treatment of impression fractures, but the depression zone in “most cases (91.7 %) consists of several immovable fragments and creates significant difficulties for the full reposition of bone fragments using closed techniques” [6]. At the same time, some authors consider it necessary to use arthroscopic technique (for certain types of fractures) in the reposition of fragments in order to improve the results of treatment and/or to control reposition after osteosynthesis.

The original method is osteotomy of the tibial tuberosity for revision access to the knee joint.

The resulting cavity is filled not only with an autograft, but also with grains of porous titanium nickelide saturated with platelet-rich autoplasma and an antibiotic, on top of which a monolithic part of the implant is placed, made of porous titanium nickelide.

When using arthroscopic technique, an impression defect is restored: through a burr hole in the metaphyseal zone [16], through a fenestration "window", the bone cavity is filled with brefoosteomatrix by crushing the cortical plate of the broken condyle until congruence is restored [11] or by filling the resulting defect with an implant made of porous titanium nickelide.
Devices for arthroscopic and visual repositioning of the tibial condyle have been developed [8]. The original methods of repositioning the sagging condyle are the use of pins and an arc of the Ilizarov apparatus [13] and a resonating hinge assembly. In order to correct the epimetaphyseal deformity of the proximal condyle of the tibia with a violation of the congruence of the articular surface as a result of impression defects, Denisov A. S. and Belokrylov N. M. (Patent No. 2195218) propose to align the tibial surface using a two-plane osteotomy, fix it in the transosseous osteosynthesis apparatus and restore by distraction biomechanical axis of the limb [25].
Transosseous osteosynthesis according to G. A. Ilizarov is currently the method of choice in the treatment of polyfragmentary and impression-compression fractures of the tibial condyles. Methods of transosseous osteosynthesis make it possible to ensure stable fixation of condylar fragments, if necessary, to replenish compression during treatment. At the same time, the use of wires in the area of ​​damage practically does not cause additional traumatization of the bone tissue. Depending on the type and nature of the fracture, a closed or open reposition is performed, the resulting defect is filled with a bone autograft or osteoinductive plastic material.
Rehabilitation is of particular importance in the treatment program for intra-articular fractures. All studies focus on early movements in the joint in the absence of axial load against the background of the use of classical physiotherapy. In particular, the use of vibration therapy is proposed. It is considered proven that vibration therapy (frequency 15 Hz, amplitude 2 mm) stimulates the regeneration of bone and cartilage tissue and improves regional blood flow.

In recent years, a sufficiently large amount of scientific material has been accumulated to solve the problem of treatment of impression fractures of the tibial condyles, which will certainly turn into a new quality. Impression (depressed) fractures have been identified as a separate group of fractures, which differ from compression and other fractures. The specifics of the tactics of treatment of impression fractures of the tibial condyles are based on the following features of impression fractures:
1. In impression fractures of the tibial condyles, a typical visual interoperative picture is:
1.1. There is a crushing of the spongy substance and a fracture of the outer cortical plate adjacent to the zone of depression and the articular surface of the epiphysis of the tibia.

1.2. In this case, several cortical fragments are formed associated with the periosteum and with the cartilaginous part of the epiphysis, which are advisable to use when accessing the impression zone, spreading them apart in the form of a leaf with the obligatory preservation of the connection with the periosteum.

1.3. The articular surface of the depressed epiphysis of the tibia is most often intact, rarely fragmented, and associated with subchondral cancellous bone, which must be preserved with minimal trauma to the cartilage during reposition.

1.4. Often the meniscus remains visually intact and not damaged (although it may be imbibed by blood), so it must be preserved to create congruence in the joint and for more effective early rehabilitation.

2. If it is impossible to mobilize the depressed cancellous bone fragment, you should not try to mobilize it, because this leads to further crushing. It is more expedient to perform its osteotomy and reposition, fixing it with needles, the ends of which are brought to the opposite side on the skin (in order to remove them at the end of the operation with stable osteosynthesis or leave them under the skin for the rehabilitation period).

3. It is necessary to fill the resulting defect with a bone autograft or implant [12].


Considering the above mentioned data, it becomes clear the importance of developing a set of therapeutic measures, including the choice of a method of bone osteosynthesis using various materials that replace a tissue defect in order to improve treatment results. Currently, many techniques and structures have been proposed for the treatment of fractures of the proximal tibial metaepiphysis, both intra-articular and extra-articular. There is a significant divergence of opinions in determining the indications for the treatment of this type of fracture, which is accompanied by a large percentage of unsatisfactory results of treatment, a high level of disability.
We have not found a sufficiently substantiated strategy for the treatment of patients with various clinical manifestations of bone tissue dysregeneration after a fracture, which would be based on a comprehensive consideration of the factors of its development and the mechanical and biological conditions of fusion.

An analysis of literature sources indicates the need to conduct studies aimed at determining the indications for choosing a method of surgical treatment of patients with various clinical manifestations of disordered reparative osteogenesis in the metaepiphyseal regions of the tibia, which will be the basis for our further work.

Funding and conflict of interest information

The study was not sponsored. The authors declare the absence of obvious and potential conflicts of interest related to the publication of this article.


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