Perhaps an explanation of the injury. The top of the tibia is pretty much covered with articular cartilage. OE articular cartilage is utterly smooth, lubricated and nourished by the juice inside the joint, supported by bone underneath it. Bottom of the femur articulates with the top of the Tibia, with a layer of fluid between the two, cushioning it and lubricating it.

Bone has a hard shell on the outside, which is you are thinking about when someone says bone. The inside is more like a sponge, but made out of bone. It is alive, the spongy bone is more like internal support than a sponge, like the cantilever section of the Bay Bridge in San Francisco. It can make itself stronger when it is under stress by adding material to the cortex(shell) as well as the cancellous(spongy) bone on the inside.

In someone is active, say a 20 year old kid playing basketball every day, that bone is strong, and will stand up to serious abuse. 20 year old bone is vital, with excellent healing potential, kid that age is going to have good blood flow, inside of the vessels will be clean and smooth, no cholesterol sticking to it. With that nice hard cortical bone, your fixation will work well, you can get the pieces together tightly and get the articular surface it is supporting close to where it used to be. It is not ever going to be as good as it was, but if you can get the broken pieces back where they belong, the cracks between the pieces will be small, it will be smoother and less prone to premature wear, like a bearing that is not quite smooth.

60 year old bone is a different story. Less active, so the bone is under less stress, hence not as strong and vibrant. The cortical bone is not as solid, so it may not screw together as well, inside of the blood vessels not as smooth so flow is reduced due to being more turbulent, perhaps with thickening of the the lining of the vessel of the blood vessel so it is narrowed. Cartilage not as thick, bone supporting it is not as strong or elastic, can make it brittle.

The injury she had, the end of the femur(thigh bone) crashed into the top of the tibia and knocked the corner off of it, maybe in more than one piece. The end of the smaller bone on the outside of your leg, the fibula, articulates with the outside of the tibia, it glides up and down when you work your ankle, you can feel it move on the outside of the leg, right below the knee. It appears she knocked the end of the fibula off too, right below where it articulates with the tibia. There is probably some element of crush injury to the cartilage and to the underlying cortical and cancellous bone at the top of the tibia, makes cartilage on that side tend to sit lower than the undamaged side, hence the appellation, joint depression fracture.

Lateral tibial plateau here 1984 at age 36.

Pretty much split the tibia right down the middle and really boogered up the cartilage & joint. Four hour surgery, two lag bolts pulling the bone together and then clean up the joint. Twelve weeks in a plaster cast, thigh to ankle, 12 more weeks in a removeable canvass brace with increasingly more rigorous physical therapy. Very painful because of adhesions. Then removed the bolts as they caused some "pin burn."

At this juncture (37 years out), I ride my bike 60 miles a week (for the last 30 years) and can play gentlemen's tennis. The OEM joint still feels and works pretty good.

Sounds like your wife's event was a little more tramatic and a total knee might be her best bet. Do the docs want to heal up the tibia first and then follow with the replacement in a few months? Or will the bone hold the screws to reconstruct the tibial plateau, and also take the knee replacement hardware in one swell foop?

Good luck to your wife. Swimming and biking (real or stationary) are great low impact re-hab exercises.

That sure looks crunchy, with not a lot of large chunks you can screw together?

When I had my fracture I was buddies with the assistants and they would always pull up the xray for me while I waited. I quickly learned on how to zoom in / out and change contrast and took very nice x-ray pics that I could share with my friends and contacts. This was pre-COVID though, so now they may force you to stay in your seat and not get your germs over the computer!

Tobra has good insights why with a younger person it will be easier to fix. I'd read up more myself if it was me or my loved one. This looks to be interesting. I'd be avoiding the sawzall at all cost, but I am probably an outlier. One and done may be the best solution for most people here.

https://online.boneandjoint.org.uk/doi/abs/10.1302/1358-992X.96BSUPP_3.SCOT2014-007

Good luck to your wife, make sure she knows this will be a longer ordeal but that it will heal and she will walk again. It is good for any broken leg person to hear that. It seems very far out when it is happening to you ...

G

Update:
Surgery next Weds. to repair with plate, screws and graft material. 3 to 4 hours on table and 8 to 12 weeks of no weight bearing. 3D CT tomorrow so ortho can plan his repair. Lots of titanium!
Same answer from both orthos - too much damage for TKR right now as there appears to be a less significant hairline fracture as well and the broken piece has left too deep a crater. We went with my guy as she is more comfortable with him and his explanation of things and his efforts and success in keeping me going. Also, very direct about things and she is a no BS gal.
Looks like I will be playing caregiver for quite a while. Been doing house stuff to aid her mobility and I may even be ADA compliant.

I did not grab the photo in the office; her work. Now have x rays here.

That all sounds like good (relatively) news, more trouble in the short term, but better results, hopefully. Thanks for the update. Thoughts and prayers for your missus' successful surgery and full and speedy recovery!

Wow, shows you how diligent one ought to be to try and prevent a knee injury. I've come close on 2 occasions many years apart with severe bursitis and major swelling rendering the knee immobile for days following some kind of injury. X-ray 1st time, not on 2nd.

And even just that is a total btich.

Given what has been said here about rehab, I think I skated some issues with my shoulder replacement. One month in a sling and 3 months of 2wice weekly PT. It wasn't linear either. I gained a lot pf movement in the first 2 weeks. The other 10 concentrated on more range and strength.

I'd sure rather go through that than what the knee PT seems to be.

You may want to ask about bone morphogenetic/morphogenic protein. Expensive, but might be reasonable given her age and nature of the injury. I don't know if they like the continuous passive motion devices on the proximal tibia fractures, ask about that too.

DO NOT MESS AROUND WITH THE POSTOPERATIVE CARE

After a month she might get the idea that "a little bit" of weight is okay, no.

Also, the physical therapist is not intent on tormenting her and making her suffer, it will just seem that way.

That's just what I was gonna say. :cool:

Well, off to the races then, starting the journey of repair and recovery! Just make sure everyone knows it is going to be a marathon, not a sprint. Let's see a post op x-ray, we are all mechanical guys. I am always impressed by the craftsmanship going into these repairs.

And go for any supporting treatments that may be recommended as Tobra says. On my fracture there was ultrasound treatment to stimulate bone healing. In clinical trials it fares relatively poorly but it did wonders for me. Like many treatments, people are idiots applying the treatment (skipping, doing it wrong etc.), but if you do it correctly it can really help. I paid quite a bit out of pocket for that, but if you sit in a chair all day with a broken leg, taking a few weeks off the process is worth its weight in gold!

G

I will try to post some post op X Ray's. Both the doc and his tech have REPEATEDLY stressed the non weight bearing issue with her. Got the Walker to shuffle and a chair to roll her around. Zero gravity chairs arrived today for better/ more comfortable elevation on the wedge pillow. In for the long haul.
Will discuss the protein.

She will get used to the non-weightbearing pretty easily, at least I did.
My next depressive surprise is I expected after 14weeks of non weightbearing that healing would be complete. I somehow thought I would be at least able to bike within a short additional period of time. NOT.
Weightbearing in my case started off slowly, 20lbs for the first week. 50lbs the second week. It was another month before complete weightbearing. A lot of pool walking in that month- you can control the amount of weight on your legs by the water depth.
Once you can completely weightbear, the physical rehab can really get started. The only pain med I ever used was before rehab- it hurt, but I had a great therapist and we worked hard. (We are still friends 10+ years later.) It took at least another 6months. But the outcome was terrific and it was worth every hour and every tear, there were a lot of both.
Good luck
gary

There are two types of bone growth stimulators

Ultrasound and pulsed electromagnetic field. Theory with ultrasound is it irritates the bone and stimulates it to heal. EMF creates charge that promotes healing, in theory. Neither is very well supported by the literature, but I have seen both work.

Bone healing is an interesting science and being laid up I read a lot about it at the time. U/S made a lot of sense to me. When reading some of the studies on effectiveness, like I mentioned, big reason they did not work was because only 60% of the people applied them properly / on schedule. Well, DUH! But of course, treatments need to take into account the ease / compliance of use. It is beyond me how you can be laying there with a broken limb and not find the time to put an U/S device on your fracture 20 minutes a day ... :rolleyes:

That whole thing reminds me of the effectiveness of contraceptive pills: 99% effective if taken properly, only 91% effective deployed in the general population.

My GP has pretty poorly insulated patient rooms. I hear him next room often, first thing out of his mouth with mid aged and older patients: "HAVE YOU BEEN TAKING YOUR MEDICINE?"

G

20 mins, hell, I'd be laying around for hours with the thing running if it was going to help! ;^)