Comparative study of internal and hybrid external fixation in tibial condylar fractures

Physiotherapy assessment and treatment of patients with tibial external fixator: a systematic scoping review

PURPOSE

To map evidence regarding physiotherapy assessment and treatment of patients with tibial external fixator (EF), and to point out literature gaps for further research.

METHODS

Systematic scoping review conducted in four databases. We included both experimental and non-experimental studies involving patients with tibial EF and outcomes of interest. We recorded study design, population, sample size, sample age, reason for EF use, type of surgery, type of EF used, instruments used for assessing function, pain, quality of life, satisfaction, psychosocial aspects, and physiotherapy treatment descriptions from included studies. We categorised data accordingly to outcomes assessed and physiotherapy treatments description.

RESULTS

Eighty-six studies were included involving 3070 patients. Causes of fixator use were traumatic conditions, acquired and congenital deformities, and non-traumatic conditions, like compartmental osteoarthritis. Function was assessed in about three-quarters of included studies, though other outcomes were not presented in most studies. Only one study described satisfactorily the physiotherapy treatment. Almost half of the studies did not provide any description of the rehabilitation process.

CONCLUSIONS

There is little evidence about the assessment of function, pain, quality of life, satisfaction, psychosocial aspects, and other outcomes in tibial EF patients. Physiotherapy treatment in these patients is poorly reported.Protocol registration: Open Science Framework: doi:10.17605/OSF.IO/UT2DA.

Do number and location of plates impact infection rates after definitive fixation of high energy tibial plateau fractures?

PURPOSE

Surgical trauma may confer additional infectious risk after operative fixation for high energy tibial plateau fractures. This study aims to determine the impact of plate number and location on infection rates after these injuries.

METHODS

This retrospective cohort study completed at two level one trauma centers included patients who underwent staged fixation for a tibial plateau fracture between 2015 and 2019. Plate number and location (lateral, medial, posteromedial, and anterior quadrants) used in the definitive fixation construct were collected from post-operative radiographs. Deep infection rate was primary the outcome.

RESULTS

A total of 244 patients met inclusion criteria. The overall infection rate was 13.9% (34/244). Infection rates increased with each additional quadrant utilized (8.0% one quadrant, 13.0% two quadrants, 27.3% three quadrants, 100% four quadrants; p < 0.001), independent of plate number, fracture severity, operative time, number of incisions, external fixator pin and plate construct overlap, and days in the external fixator on multivariate analysis.

CONCLUSIONS

Infection risk increases with each quadrant utilized in the fixation of high energy tibial plateau fractures. Providers should attempt to limit the dissection of soft tissue for hardware placement in the fixation of these injuries to limit infection risk.

LEVEL OF EVIDENCE

Level III, retrospective therapeutic study.

Complications of the surgical treatment of fractures of the tibial plateau: prevalence, causes, and management

Open reduction and internal fixation is the gold standard treatment for tibial plateau fractures. However, the procedure is not free of complications such as knee stiffness, acute infection, chronic infection (osteomyelitis), malunion, non-union, and post-traumatic osteoarthritis. The treatment options for knee stiffness are mobilisation under anaesthesia (MUA) when the duration is less than 3 months, arthroscopic release when the duration is between 3 and 6 months, and open release for refractory cases or cases lasting more than 6 months. Early arthroscopic release can be associated with MUA. Regarding treatment of acute infection, if the fracture has healed, the hardware can be removed, and lavage and debridement can be performed along with antibiotic therapy. If the fracture has not healed, the hardware is retained, and lavage, debridement, and antibiotic therapy are performed (sometimes more than once until the fracture heals). Fracture stability is important not only for healing but also for resolving the infection. In cases of osteomyelitis, treatment should be performed in stages: aggressive debridement of devitalised tissue and bone, antibiotic spacing and temporary external fixation until the infection is resolved (first stage), followed by definitive surgery with grafting or soft tissue coverage depending on the bone defect (second stage). Intra-articular or extra-articular osteotomy is a good option to correct malunion in young, active patients without significant joint damage. When malunion is associated with extensive joint involvement or the initial cartilage damage has resulted in knee osteoarthritis, the surgical option is total knee arthroplasty.

A Meta-analysis Comparing External Fixation against Open Reduction and Internal Fixation for the Management of Tibial Plateau Fractures

Aim

This article aims to compare the outcomes between open reduction and internal fixation (ORIF) and external fixation (ExFix) in tibial plateau fractures.

Background

Open reduction and internal fixation and external fixation are common methods for managing tibial plateau fractures without a consensus of choice.

Materials and methods

PubMed, Cochrane Library, Ovid, CINAHL®, Scopus, and Embase were searched. Clinical studies in humans comparing ExFix and ORIF for tibial plateau fractures were included. Case reports, pathological, and biomechanical studies were excluded. Two investigators reviewed the studies independently, and any discrepancies were resolved. The quality and heterogeneity of each study were assessed in addition to calculating the odds ratio (OR) of the surgical outcomes and complications at a 95% confidence interval, with p <0.05 as statistical significance.

Results

Of the 14 included studies, one was a randomised trial, one was a prospective study, and 12 were retrospective studies. The 865 fractures identified across the studies constituted 458 (52.9%) in the ExFix group and 407 (47.1%) in the ORIF group. Most studies indicated a better outcome for ORIF as compared to ExFix. Open reduction and internal fixation had a lower incidence of superficial infection and postoperative osteoarthritis, while ExFix revealed a lower proportion with heterotopic ossification (HTO).

Conclusion

ExFix has a higher rate of superficial infections and osteoarthritis, whereas ORIF has a higher incidence of HTO. Larger studies are needed to compare outcomes and investigate the findings of this study further.

Clinical significance

This up-to-date meta-analysis on tibial plateau management will help surgeons make evidence-based decisions regarding the use of ORIF versus ExFix.

How to cite this article

Naja AS, Bouji N, Eddine MN, et al. A Meta-analysis Comparing External Fixation against Open Reduction and Internal Fixation for the Management of Tibial Plateau Fractures. Strategies Trauma Limb Reconstr 2022;17(2):105–116.

Post-operative complications of tibial plateau fractures treated with screws or hybrid external fixation

PURPOSE

To assess the complications and second surgeries rates at 1 year follow-up in a group of patients underwent minimally invasive fixation with screws or hybrid external fixation (HEF) for tibial plateau fractures (TPF). The hypothesis was that low Schatzker (I-IV) TPF would have shown a lower complication rate with respect to high Schatzker (V-VI) TPF.

METHODS

148 patients who underwent minimally invasive surgery with screws or HEF for TPF were included and pooled in two groups: mono-condylar (Schatzker I-IV) and bi-condylar (Schatzker V-VI). The rate of second surgeries and complications, such as stiffness, infection, wound dehiscence and malunion occurred within 1 year, were reported.

RESULTS

Statistically significant difference between mono-condylar and bi-condylar groups was found in terms of stiffness (18% vs. 37%, p = 0.01), malunion (4% vs 21%, p = 0.004) and second surgeries (32% vs. 48%, p = 0.049). Associated procedures performed during TPF fixation increased risk of second surgeries (OR 2.1, p < 0.001). No differences in terms of second surgeries and complications were found in bi-condylar group treated with screws and HEF.

CONCLUSION

Bi-condylar TPF treated with minimally invasive surgery developed a significantly higher rates of stiffness, malunion and second surgeries within 1 year compared to mono-condylar fractures. Moreover, when an associated procedure was performed, the risk of a reoperation was nearly doubled. Trial registration number PG 0012506 CE AVEC 620/2018/Oss/IOR.

Weight Discharge in Postoperative of Plateau Fracture Tibialis: Systematic Review of Literature

Tibial plateau fractures are a risk to the functional integrity of the knee, affecting the axial alignment and capable of leading to pain and disability of the individual. Early weight bearing and joint mobilization can prevent these functional deficits. the goal of the present study was to conduct a systematic review of the literature about studies that quote the beginning, evolution, and progression criteria for weight-bearing in postoperative period of tibial plateau fractures. We selected articles published in the last 12 years, in Portuguese and English, that described the time of onset and progression of weight-bearing, considering the severity of the fracture. Thirty-six articles were selected. There is no consensus in the literature as to the beginning and evolution of weight-bearing in the postoperative period of tibial plateau fractures; however, a relationship between the severity of the fracture and the fixation method has been observed.

The distal femur is a reliable guide for tibial plateau fracture reduction: a study of measurements on 3D CT scans in 84 healthy knees

Background

Limited data have been published regarding the typical coronal dimensions of the femur and tibia and how they relate to each other. This can be used to aid in judging optimal operative reduction of tibial plateau fractures. The purpose of the present study was to quantify the width of tibial plateau in relation to the distal femur.

Methods

We reviewed 3D computed tomography (CT) scans taken between 2013 and 2016 of 42 patients (84 knees). We measured positions of the lateral tibial condyle with respect to the lateral femoral condyle (dLC) and the medial tibial condyle with respect to the medial femoral condyle (dMC) in the coronal plane. Positions of the articular edges of the lateral and medial tibia were also measured with respect to the femur (dLA and dMA).

Results

The mean (± standard deviation) measurements were as follows: dLC, − 0.1 ± 1.9 mm; dMC, − 4.7 ± 4.1 mm; dLA, 0.9 ± 1.0 mm; and dMA, 0.1 ± 1.5 mm. The mean (± standard deviation) ratio of tibial to femoral condylar width was 0.91 ± 0.03, and the ratio of tibial to femoral articular width was 1.01 ± 0.04.

Conclusions

The articular width of the tibia laterally and medially was slightly wider than the femoral articular width. These small differences and deviations indicate that the femur might be used as a reference to judge tibial plateau width reduction.

Severe tibial plateau fractures (Schatzker V-VI): open reduction and internal fixation versus hybrid external fixation

Tibial plateau fractures (TPF) are highly prone to complications and adverse effects. Their treatment has long been a matter of controversy, as fracture patterns and possible damage to soft tissues can easily aggravate complications. On the one hand, open reduction and internal fixation (ORIF) techniques provide a good approach to joint shape restoration and biomechanics, but they may also provoke a higher rate of soft-tissue complications. On the other, hybrid external fixation (HEF), although allowing little facility for reduction, may, theoretically, produce much less damage to the soft tissues. We present 93 cases of TPF classified as type V or VI that were followed up for at least 24 months. There were no statistical differences among them in relation to consolidation, secondary malalignment or range of motion, according to whether ORIF or HEF was employed. However, when external fixation followed open reduction, both superficial and deep-infection rates were higher.

Surgical fixation methods for tibial plateau fractures

BACKGROUND

Fractures of the tibial plateau, which are intra-articular injuries of the knee joint, are often difficult to treat and have a high complication rate, including early-onset osteoarthritis. Surgical fixation is usually used for more complex tibial plateau fractures. Additionally, bone void fillers are often used to address bone defects caused by the injury. Currently there is no consensus on either the best method of fixation or bone void filler.

OBJECTIVES

To assess the effects (benefits and harms) of different surgical interventions, and the use of bone void fillers, for treating tibial plateau fractures.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (12 September 2014), the Cochrane Central Register of Controlled Trials (2014 Issue 8), MEDLINE (1946 to September Week 1 2014), EMBASE (1974 to 2014 Week 36), trial registries (4 July 2014), conference proceedings and grey literature (4 July 2014).

SELECTION CRITERIA

We included randomised and quasi-randomised controlled clinical trials comparing surgical interventions for treating tibial plateau fractures and the different types of filler for filling bone defects.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, selected studies, extracted data and assessed risk of bias. We calculated risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CIs). Only very limited pooling, using the fixed-effect model, was possible. Our primary outcomes were quality of life measures, patient-reported outcome measures of lower limb function and serious adverse events.

MAIN RESULTS

We included six trials in the review, with a total of 429 adult participants, the majority of whom were male (63%). Three trials evaluated different types of fixation and three analysed different types of bone graft substitutes. All six trials were small and at substantial risk of bias. We judged the quality of most of the available evidence to be very low, meaning that we are very uncertain about these results.One trial compared the use of a circular fixator combined with insertion of percutaneous screws (hybrid fixation) versus standard open reduction and internal fixation (ORIF) in people with open or closed Schatzker types V or VI tibial plateau fractures. Results (66 participants) for quality of life scores using the 36-item Short Form Health Survey (SF-36)), Hospital for Special Surgery (HSS) scores and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function scores tended to favour hybrid fixation, but a benefit of ORIF could not be ruled out. Participants in the hybrid fixation group had a lower risk for an unplanned reoperation (351 per 1000 people compared with 450 in the ORIF group; 95% CI 197 fewer to 144 more) and were more likely to have returned to their pre-injury activity level (303 per 1000 people, compared with 121 in the ORIF group; 95% CI 15 fewer to 748 more). Results of the two groups were comparable for the WOMAC pain subscale and stiffness scores, but mean knee range of motion values were higher in the hybrid group.Another trial compared the use of a minimally invasive plate (LISS system) versus double-plating ORIF in 84 people who had open or closed bicondylar tibial plateau fractures. Nearly twice as many participants (22 versus 12) in the ORIF group had a bone graft. Quality of life, pain, knee range of motion and return to pre-injury activity were not reported. The trial provided no evidence of differences in HSS knee scores, complications or reoperation entailing implant removal or revision fixation. A quasi-randomised trial comparing arthroscopically-assisted percutaneous reduction and internal fixation versus standard ORIF reported results at 14 months in 58 people with closed Schatzker types II or III tibial plateau fracture. Quality of life, pain and return to pre-injury activity were not reported. There was very low quality evidence of higher HSS knee scores and higher knee range of motion values in the arthroscopically assisted group. No reoperations were reported.Three trials compared different types of bone substitute versus autologous bone graft (autograft) for managing bone defects. Quality of life, pain and return to pre-injury activity were not reported. Only one trial (25 participants) reported on lower limb function, finding good or excellent results in both groups for walking, climbing stairs, squatting and jumping at 12 months. The incidences of individual complications were similar between groups in all three trials. One trial found no cases of inflammatory response in the 20 participants receiving bone substitute, and two found no complications associated with the donor site in the autograft group (58 participants). However, all 38 participants in the autologous iliac bone graft group of one trial reported prolonged pain from the harvest site. Two trials reported similar range of motion results in the two groups, whereas the third trial favoured the bone substitute group.

AUTHORS' CONCLUSIONS

Currently, there is insufficient evidence to ascertain the best method of fixation or the best method of addressing bone defects during surgery. However, the evidence does not contradict approaches aiming to limit soft-tissue dissection and damage or to avoid autograft donor site complications through using bone substitutes. Further well-designed, larger randomised trials are warranted.

Autograft transfer from the ipsilateral femoral condyle in depressed tibial plateau fractures

Introduction :

The rationale for operative treatment of depressed tibial plateau fractures is anatomic reduction, stable fixation and grafting. Grafting options include autogenous bone graft or bone substitutes.

Methods :

The autograft group included 18 patients with depressed tibial plateau fractures treated with autogenous bone grafting from the ipsilateral femoral condyle following open reduction and internal fixation. According to Schatzker classification, there were 9 type II, 4 type III, 2 type IV and 3 type V lesions. The average time to union and the hospital charges were compared with the bone substitute group. The latter included 17 patients who had an excellent outcome following treatment of split and/or depressed lateral plateau fractures, using a similar surgical technique but grafting with bone substitutes (allografts).

Results :

Excellent clinical and radiological results were detected in the autograft group after an average follow-up of 28 months (range 12-37). The average time to union in the autograft group was 14 weeks (range 12-16), while in the bone substitute group it was 18 weeks (range 16-20). The mean total cost was 1276 Euros for the autograft group and 2978 Euros for the bone substitute group.

Discussion :

The use of autogenous graft from the ipsilateral femoral condyle following open reduction and internal fixation of depressed tibial plateau fractures provided enough bone to maintain the height of the tibial plateau and was not associated with any donor site morbidity. Using this method, the surgical time was not significantly elongated and the rehabilitation was not affected. It also exhibited faster fracture healing without postoperative loss of reduction and it was less expensive than the use of bone substitutes.