John T. Riehl

Objectives: To evaluate the surgical techniques, outcomes, and complications of intramedullary nail (IMN) fixation for tibial plateau fractures (TPFs). Methods: Data Sources: The MEDLINE, Embase, Google Scholar, and Cochrane databases were systematically searched up to January 2025, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Study Selection: Studies reporting outcomes of IMN fixation in adult TPF patients were included. Biomechanical analyses, animal studies, and non-English articles were excluded. Data Extraction: Study quality was assessed using the Methodological Index for Nonrandomized Studies (MINORS) criteria. Data on surgical technique, radiographic outcomes, functional outcomes, and complications were extracted. Studies were categorized by whether they used supplemental plate fixation. Data Synthesis: Descriptive statistics summarized outcomes. Results: Ten studies met inclusion criteria, including 2 comparative studies, 7 case series, and one case report. Fifty-two TPFs were treated with IMN with or without percutaneous screws (group 1), 45 with IMN with supplemental plate fixation (group 2), 30 with IMN plus condylar bolt support (group 3), and 78 with open reduction and internal fixation alone (group 4). Groups 1 and 3 had a combined infection rate of 2.4%, a mean bony union time of ≤4 months, and good-to-excellent knee scores. Three cases of malalignment and knee pain in 11% were reported. Group 2 had a 2.2% infection rate, no malalignment, and knee pain in 15.6%. No cases of nonunion or malunion were observed in TPFs treated with a IMN construct. Conclusions: In the TPF patterns represented in the available literature, predominantly bicondylar Schatzker V/VI (OTA/AO 41-C) fractures, IMN with or without supplemental plating or condylar bolt fixation demonstrated clinical and radiographic outcomes comparable to open reduction and internal fixation. These findings should not be extrapolated to isolated unicondylar TPFs or to fractures with relative contraindications to IMN, such as severe articular impaction requiring bone grafting, medial plateau fracture-dislocations, or tibial tubercle involvement. Additional controlled trials are required to further define the role of IMN in TPFs. Level of Evidence: Therapeutic Level IV.

Introduction: Thumb carpometacarpal (tCMC) arthritis is a common and debilitating condition for aging people worldwide. Conservative treatments including activity modification, bracing, anti-inflammatory medications, and steroid injections remain the initial treatment of choice. Given the size of the tCMC joint, intra-articular image-guided injections (IGI) may provide more consistent and superior outcomes with comparison to peri-articular anatomic landmark injections (ALI). This study systematically reviews the accuracy and efficacy of intra-articular IGA versus ALI. Methods: To evaluate the accuracy and efficacy of intra-articular IGI versus ALI of tCMC injections for arthritis, a systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) across Pubmed/Medline, Cochrane, and Embase databases. The search used a combination of keywords and MeSH terms. Inclusion criteria were studies conducted on human subjects that contained a comparison of anatomic landmark-based injections to image guided tCMC injections. Statistical analysis was not performed due to the lack of total studies that met inclusion criteria and absence of level 1 evidence studies. Results: A preliminary search of three databases provided 245 studies. Five studies ultimately met the final inclusion criteria and were represented in this study. The two human-based studies showed no clinically significant difference in outcomes between IGI and ALI. The three cadaveric studies showed no statistical difference in the accuracy of either fluoroscopy or ultrasound-guided injections when compared with ALI. The cost of ALI was, on average, $203 less than intra-articular ultrasound IGI. Conclusion: While the current literature on this topic is limited, the current literature appears to show no significant difference between the accuracy or efficacy of intra-articular IGI and ALI. ALI injections appear to be a more cost-effective option without sacrificing outcome. These results also highlight that intra-articular placement may not be necessary for injection benefit, and future research and larger studies can be beneficial to improve comparisons and outcomes.