Tibial plateau fracture management: ARIF versus ORIF - clinical and radiological comparison

Utilization of cannulated screw fixation of Jail and TiRobot-assisted percutaneous indirect reduction technique for AO/OTA type 41B2 tibial plateau fracture treatment

PURPOSE

The present study was designed to investigate the precise procedure and effectiveness of percutaneous minimally invasive fixation assisted by TiRobot in managing AO/OTA type 41B2 tibial plateau fracture to provide an alternative solution for clinical application.

METHODS

In total, 10 participants with AO/OTA type 41B2 tibial plateau fractures diagnosed by preoperative imaging examinations were enrolled in this study between May 2019 and May 2022. They were 5 males and 5 females, with an average age of 45.6 ± 11.3 years old (range 27-62 years old). All of them had closed fractures, including 6 cases with anterior cruciate ligament (ACL) tibial insertion avulsion fractures, 1 case with medial collateral ligament (MCL) tear, and 4 cases with a lateral meniscus tear. From injury through surgery, the entire time frame was 4.0 ± 1.5 days (range, 2-7 days). Following indirect percutaneous reduction assisted by TiRobot, the Jail method was used to treat all patients with minimally invasive internal fixation. Patients with ligament or meniscus injurieswere treated with arthroscopic surgery in one stage. The standardized functional exercise was performed postoperatively. The knee function was measured using the Hospital for Special Surgery (HSS) score, and the fracture reduction was assessed through the Rasmussen radiology score.

RESULTS

All patients were followed up for 12.7 ± 6.8 months (6-24 months).The fracture healing time was 11.8 ± 0.8 weeks (10-13 weeks), and the X-rays revealed satisfactory fracture reduction.The knee joint's Rasmussen score was 17.8 ± 0.4 (in the range of 17-18) a year after the procedure, with 8 patients receiving outstanding ratings and 2 cases receiving satisfactory scores. The HSS score was 93.8 ± 2.3 (range, 89 to 96), of which 10 cases were excellent. The motion range of the kneewas 138.7°±2.7° (range, -5° to 0° to 135°). No adverse effects or serious complications, such as internal fixation failure, postoperative infection, popliteal vascular injury, and common peroneal nerve injury, were observed during the last follow-up visit.

CONCLUSIONS

The intelligent assistance and accurate guidance of TiRobot can simplify and standardize procedures of percutaneous minimally invasive fixation in theSchatzker type Ⅲ tibial plateau fracture treatment. This technique increases the precision of indirect percutaneous reduction and screw fixation while minimizing bone grafting.

Suprapatellar intramedullary nail combined with screw fixation has comparable surgical outcomes to minimally invasive locking plate fixation in ipsilateral tibial plateau and shaft fractures

PURPOSE

To compare union rate, union time, alignment, and complication rate in ipsilateral tibia plateau and shaft fractures treated via suprapatellar intramedullary nailing with screw fixation and minimally invasive locking plate fixation.

MATERIALS AND METHODS

A retrospective study was conducted on 48 patients who underwent minimally invasive plate fixation (n = 35) or suprapatellar intramedullary nailing with screw fixation (n = 13), for the treatment of ipsilateral tibial plateau and shaft fractures with at least 1-year follow-up. Union rate, union time, radiologic alignment, and complication rate such as malalignment, nonunion, and fracture-related infection (FRI) were investigated.

RESULTS

Demographic data were not different between the two groups. Coronal plane alignment was 0.17 ± 4.23 in the plate group and -0.48 ± 4.17 in the intramedullary nail group (p = 0.637). Sagittal plane alignment was -0.13 ± 5.20 in the plate group and -1.50 ± 4.01 in the suprapatellar intramedullary nail group (p = 0.313). Coronal and sagittal malalignment recorded equal results: (p > 0.99), FRI (p = 0.602), nonunion and union times recorded (p = 0.656) and (p = 0.683, 0.829), respectively, and showed no significant difference between the two groups.

CONCLUSION

Suprapatellar intramedullary nailing with screw fixation had similar surgical outcomes with minimally invasive locking plate fixation in ipsilateral tibial plateau and shaft fractures in terms of union rate, union time, alignment, and complication rate. Thus, frequent use of intramedullary nailing combined with screw fixation is anticipated in patients with ipsilateral tibial plateau and shaft fractures when the soft tissue condition is not desirable.

LEVEL OF EVIDENCE

Level III.

Correlation of preoperative CT imaging shift parameters of the lateral plateau with lateral meniscal injury in Schatzker IV-C tibial plateau fractures

BACKGROUND

Schatzker IV-C is a high-energy tibial plateau fracture often accompanied by lateral meniscus injuries. While imaging examinations are routine preoperative measurements, the correlation between CT imaging shift parameters of the lateral plateau and lateral meniscal injury in Schatzker IV-C fractures remains uncovered.

METHODS

This retrospective study enrolled a total of 60 patients with Schatzker IV-C tibial plateau fractures at the First People's Hospital of Hefei. Prior to surgery, CT imaging was used to measure the numerical values of lateral plateau depression (LPD) and lateral plateau widening (LPW). The degree of lateral meniscus injury was confirmed based on intraoperative direct vision, with patients being classified into meniscus injury and non-meniscus injury groups. Dichotomous logistic regression was employed to evaluate the correlation between LPD, LPW, and lateral meniscus injury, while the optimal cut-off points for predicting lateral meniscal injury with LPD and LPW were determined using receiver operator characteristic (ROC) curves.

RESULTS

The meniscus injury group exhibited a mean LPD of 15.3 ± 3.5 mm, which was significantly higher than the non-meniscus injury group's mean LPD of 8.4 ± 3.4 mm (P < 0.05). Similarly, the meniscus injury group had a larger mean LPW of 9.4 ± 1.8 mm compared to the non-meniscus injury group's mean LPW of 6.9 ± 0.9 mm (P < 0.05). The optimal cut-off points for predicting lateral meniscal injury were determined to be 8.40 mm for LPD (with a sensitivity of 95%, specificity of 85%, and AUC of 0.898) and 7.90 mm for LPW (with a sensitivity of 75%, specificity of 90%, and AUC of 0.897).

CONCLUSIONS

Patients with Schatzker IV-C tibial plateau fractures are at a significantly higher risk of lateral meniscal injury when the LPD exceeds 8.40 mm and/or the LPW exceeds 7.90 mm. Our results may provide novel reference metrics for the early diagnosis of lateral meniscal injury in Schatzker IV-C tibial plateau fracture patients when the MRI examination is not available.

Comparison of clinical and radiographic outcomes of arthroscopic-assisted percutaneous fixation versus open reduction internal fixation of lateral tibial plateau fractures

PURPOSE

Treatment for tibial plateau fractures continues to evolve but maintains primary objectives of anatomic reduction of the joint line and a rapid recovery course. Arthroscopic-assisted percutaneous fixation (AAPF) has been introduced as an alternative to traditional open reduction internal fixation (ORIF). The purpose of the study is to compare clinical and radiographic outcomes in patients with low-energy Schatzker type I-III tibial plateau fractures treated with AAPF versus ORIF.

METHODS

A retrospective chart review was performed at a level 1 trauma centre to compare outcomes of 120 patients (57 AAPF, 63 ORIF) with low-energy lateral Schatzker type I-III tibial plateau fractures who underwent tibial plateau fixation between 2009 and 2018. Demographic information, injury characteristics, and surgical treatment were recorded. The main outcome measurements included reduction step-off, joint space narrowing, time to weight bearing, and implant removal.

RESULTS

There was no difference in age, gender distribution, BMI, ASA, Schatzker classification distribution, initial displacement, blood loss, and reduction step-off between the two groups (p > 0.05). Shorter tourniquet time (74.1 ± 21.7 vs 100.0 ± 21.0 min; p < 0.001), shorter time to full weight bearing (47.8 ± 15.2 vs. 69.1 ± 17.2 days; p < 0.001), and lower rate of joint space narrowing (3.5% vs. 28.6% with more than 1 mm, p < 0.001) were associated with the AAPF cohort, with no difference in pain, knee range of motion, or implant removal rate between the two cohorts.

CONCLUSION

AAPF may be a viable alternative to ORIF for the management of low-energy tibial plateau fractures with outcomes not inferior compared to the traditional ORIF method.

Periprosthetic Tibial Plateau Fractures After Unicompartmental Knee Arthroplasty Are Successfully Treated With Open Reduction and Internal Fixation

Periprosthetic tibial fractures after unicompartmental knee arthroplasty (UKA) are rare but devastating events. Given the relative infrequency of these injuries, treatment strategies are not well defined. The goal of this retrospective case series is to report the findings for a series of patients who underwent open reduction and internal fixation (ORIF) of periprosthetic fracture after UKA, including radiographic alignment, Knee Society Score (KSS), and failure rate. Patients were identified by the International Classification of Diseases code for periprosthetic tibial plateau fractures. Electronic medical records and radiographs were retrospectively reviewed. Fracture patterns and coronal and sagittal alignment of UKA components were measured on radiographs. Clinical outcomes, including range of motion assessment, visual analog scale pain score, and KSS, were collected at final follow-up. Eight patients satisfied the inclusion criteria for this study. Fractures occurred at a median of 14 days (range, 5-52 days) after UKA, and all showed a vertical shear pattern that exited at the meta-diaphyseal junction. Of the 8 fractures, 7 (87.5%) healed to radiographic and clinical union after the initial ORIF. One patient required reoperation for hardware failure. Mean visual analog scale pain score and KSS at final follow-up were 3 and 85±14, respectively. Periprosthetic tibial plateau fractures after UKA commonly occur as a vertical shear fracture exiting at the metadiaphyseal junction. The use of ORIF with a 3.5-mm plate in buttress mode is a reliable method for treatment of these fractures. Restoration of alignment and motion is achievable, but residual pain may affect patient-reported outcome scores. [Orthopedics. 2022;45(5):287-292.].

Outcomes of arthroscopic-assisted lateral tibial plateau fixation: a systematic review

PURPOSE

The purpose of this study is to evaluate and summarize the current literature on outcomes of arthroscopic-assisted tibial plateau fixation (AATPF) when applied for only lateral tibial plateau fractures.

METHODS

A comprehensive search of nine databases was conducted: ClinicalTrials.gov, Cochrane Library via Wiley, Embase and MEDLINE via Ovid, Global Index Medicus, PubMed, Scopus, SPORTDiscus via EBSCO, and Web of Science Core Collection. The study was performed in concordance with PRISMA guidelines. Studies eligible for inclusions included Schatzker I-III lateral tibial plateau fractures with a minimum of 6-month follow-up. Data extraction was performed by two authors independently using a predesigned form.

RESULTS

A total of 17 studies, 7 prospective and 10 retrospective, including 565 patients (age 15-82 years old) treated with AATPF were included in this review with follow-up ranging from 6 to 138 months. All 10 studies that used categorical functional outcomes demonstrated excellent/very good or good outcomes in > 90% of patients. When compared to patients managed with the traditional open reduction internal fixation (ORIF), patients treated with AATPF had statistically significantly better range of motion mean difference [5.21° (95% CI - 2.50 to 12.92, p < 0.0001)], lower blood loss [66.19 mL (95% confidence interval (CI) 32.54-99.84 mL, p < 0.0001)], shorter hospital stay [- 1.41 days (95% CI - 3.39 to 0.58 days, p < 0.0001)], better Hospital Special Surgery score [11.31 (95% CI 6.49-16.12, p < 0.0001)], and higher Rasmussen radiographic score [1.26 (95% CI - 0.72 to 3.23, p < 0.0001)].

CONCLUSION

AATPF is a promising treatment of lateral tibial plateau fractures with some advantages over the traditional ORIF.

LEVEL OF EVIDENCE

Therapeutic Level III.

Outcomes following balloon tibioplasty versus conventional osteosynthesis techniques for Schatzker type III tibial plateau fractures: a systematic review

Introduction

Schatzker type III fractures of the tibial plateau require elevation of the depressed portions to regain articular congruity. Balloon tibioplasty has been used as an alternative to conventional metal instruments for elevation of the lateral tibial plateau. This study compared functional outcomes following balloon tibioplasty or conventional osteosynthesis techniques in patients with type III fractures of the tibial plateau.

Materials and methods

A systematic literature search was performed using PubMed, EMBASE, and Cochrane Library to identify studies published through March 29, 2021, pertaining to balloon tibioplasty or conventional osteosynthesis techniques for type III fractures. Non-human studies, opinion or editorial pieces, systematic reviews, case series (< 5 patients), and articles published in a non-English language were excluded. Primary outcomes were Rasmussen clinical score, range of motion, and Knee Society Score (KSS). A Joanna Briggs Institute (JBI) risk of bias assessment was performed for all studies.

Results

A total of 95 studies were identified, with 10 studies (and 132 total patients) meeting inclusion criteria: 1 study focused on balloon tibioplasty, 8 studies reported outcomes following conventional osteosynthesis, and 1 study compared outcomes of the two techniques. Mean follow-up times varied widely, from 4 to 76.3 months. Where reported, balloon tibioplasty resulted in good to excellent functional outcomes as indicated by Rasmussen clinical scores (mean 28.3 in a case series; mean 28.9 in a randomized controlled trial) and range of motion (≥ 140° in both studies) 1–2 years following surgery. KSS was not reported consistently enough for comparison. Studies ranged from low to high risk of bias according to the JBI assessment.

Conclusions

Balloon tibioplasty can lead to excellent functional outcomes in patients with depression fractures of the lateral tibial plateau. More research is needed to directly compare outcomes following treatment with balloon tibioplasty or conventional osteosynthesis techniques.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-02973-1.

Arthroscopy-Assisted Reduction Percutaneous Internal Fixation Versus Open Reduction Internal Fixation for Tibial Plateau Fracture: A Systematic Review and Meta-analysis

Background:

Arthroscopy-assisted reduction percutaneous internal fixation (ARIF) has emerged recently as an alternative treatment method in treating lower-energy tibial plateau fractures. To date, the comparison of clinical efficacy between ARIF and open reduction internal fixation (ORIF) is limited, with divergent conclusions.

Purpose:

To review studies on the clinical efficacy of ARIF and ORIF in the treatment of tibial plateau fracture.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

A search was conducted using the PubMed, Web of Science, Cochrane Library, and EMBASE databases between inception and August 20, 2020, for retrospective and prospective studies evaluating ARIF versus ORIF in the treatment of tibial plateau fracture. We identified 6 clinical studies that met the inclusion criteria, with 231 patients treated with ARIF and 386 patients treated with ORIF. The risk of bias and the quality of evidence of the included studies were assessed. The 2 treatment types were compared in terms of clinical results and complications by using odds ratios (ORs), mean differences (MDs), or standardized mean differences (SMDs), with 95% confidence intervals (CIs). Heterogeneity among studies was quantified using the I² statistic.

Results:

The quality of the studies was high. Compared with ORIF, treatment with ARIF led to better clinical function (SMD = 0.31; 95% CI, 0.14 to 0.48; I² = 15%; P = .0005), shorter hospital stay (MD = –2.37; 95% CI, –2.92 to –1.81; I² = 0%; P < .001), and more intra-articular lesions found intraoperatively (OR = 3.76; 95% CI, 1.49 to 9.49; I² = 66%; P = .005). There were no complications or significant differences between the techniques in the radiological evaluation of reduction.

Conclusion:

Compared with ORIF, the ARIF technique for tibial plateau fractures led to faster postoperative recovery and better clinical function and the ability to find and treat more intra-articular lesions during the operation. However, the radiological evaluation of reduction and complications were not significantly different between the 2 groups.

Comparison of outcomes of ORIF versus bidirectional tractor and arthroscopically assisted CRIF in the treatment of lateral tibial plateau fractures: a retrospective cohort study

Background

Lateral tibial plateau fractures (TPFs) are often treated with conventional open reduction and internal fixation (ORIF) through standard anterolateral sub-meniscal arthrotomy. There has been increasing support for “bidirectional rapid redactor” device-assisted closed reduction and internal fixation (CRIF) for treating TPFs. The aim of the present study is to compare the clinical and radiological outcomes between CRIF and ORIF procedures.

Methods

We performed a retrospective cohort study of 55 lateral TPF patients (Schatzker types I–III) who accepted surgical treatment at our trauma level 1 center between January 2016 and January 2018. They were divided into the CRIF group (32 patients) and the ORIF group (23 patients) based upon the different surgical protocols. The patients’ clinical outcome analysis was evaluated by using the Knee Society Score (KSS) and Rasmussen’s clinical score. For radiological assessment, changes in tibial plateau width (TPW), articular depression depth (ADD), medial proximal tibial angle (MPTA), and posterior tibial slope angle (PTSA) were evaluated using radiographs and computed tomography (CT) scan.

Results

The CRIF group had a mean follow-up of 28.9 months, and the ORIF group had a mean follow-up of 30.7 months (p>0.05). Furthermore, there was no statistically significant difference in terms of age, gender, injury mechanism, follow-up time, time interval from injury to surgery, and Schatzker classification in the two groups. With respect to the clinical outcomes including the KSS score and Rasmussen’s clinical score, there was also no significant difference (p>0.05). Nevertheless, the CRIF group had lower intra-operative blood loss, shorter hospitalization days, and better range of movement of the knee joint than the ORIF group (p<0.05). Furthermore, CRIF had better radiological results when compared to the ORIF group using Rasmussen’s radiological score (p<0.05), although no significant difference was observed in TPW, ADD, MPTA, and PTSA between the two groups (p>0.05).

Conclusion

The present study showed that CRIF could achieve comparable clinical outcomes and better radiological results for treating lateral TPFs as compared with conventional ORIF.

Primary total knee arthroplasty in tibial plateau fractures: Literature review and our institutional experience

BACKGROUND

Displaced proximal tibia fractures in the elderly may be very difficult to manage. If osteosynthesis represents the standard of care in the younger patients, in the aged population this solution is controversial because a significant failure rate has been reported after internal fixation. Moreover, osteoarthritis progression following tibial plateau fractures is common, often requiring a subsequent total knee arthroplasty (TKA). In recent years, in order to overcome the fracture healing problems and to allow immediate full weight bearing, primary TKA after tibial plateau fractures in elderly patients has gained popularity.

MATERIAL AND METHODS

from 2015 to 2019, 11 tibial plateau fractures in elderly patients with pre-existing osteoarthritis were treated with a primary TKA. Age, gender, mechanism of trauma, pre-operative autonomy level, fractures classification, degree of osteoarthritis and intraoperative data (ligamentous stability and type of implant) were collected. After a mean follow-up of 28 months, Knee Society Score (KSS), post-operative autonomy level and Forgotten Joint Score (FJS) were evaluated. The radiological assessment (signs of loosening, limb axis and patellar height indices) and complications were also recorded.

RESULTS

according to fracture type and ligamentous competence, 6 cases of posterior-stabilized (PS) design and 5 cases of semi-constrained TKA were implanted. At the final follow up, mean KSS knee score was 83±16 and mean KSS functional score was 74±15. Mean pre-operative autonomy level assessed with the Parker scale, was significantly higher than the post-operative one (7.5±1.4 vs 5.6 ± 1.3). Mean FJS was 66 ± 14. No lines of radiolucency or limb malalignment were found at the final radiological follow-up. One major complication was recorded: one acute periprosthetic infection. One patient reported a periprosthetic femoral fracture after 26 months.

CONCLUSION

Based on our and results and those reported on literature, primary TKA is a suitable option in case of tibial plateau fractures in elderly patients with pre-existing osteoarthritis and poor bone quality, in which osteosynthesis outcome may be poor. Unlike ORIF, primary TKA may allow immediate weightbearing and a faster recovery. Nevertheless, it is a demanding surgery with a significant complications rate and should be reserved for selected patients and experienced surgeons.

Percutaneous treatment of tibial plateau fractures

In France, 11,294 proximal tibia fractures occurred in 2018 and 6880 surgical procedures were done to treat them. Most of these were tibial plateau fractures, although fractures can occur in the metaphysis only or in the intercondylar eminence. The proximal tibia's poor vascularization justifies sparing it by doing a percutaneous treatment, setting the stage for bone union. The treatment must be based on rigorous planning with 3D imaging to determine the type of fracture accurately. The goals of treatment are first to realign the lower limb and then to reduce the articular surface, while addressing any associated injuries. Percutaneous reduction is based on ligamentotaxis and the use of spatulas or balloons that spare the vascularization. Surgical navigation and arthroscopy are precious tools for verifying the reduction. There are several options for stabilization, ranging from using polymethylmethacrylate cement for a Schatzker III fracture to applying a cannulated screw or doing MIPPO (Minimal Invasive Percutaneous Plate Osteosynthesis) with an anatomical plate and adjustable locking screws placed under the depression in complex fractures. Percutaneous surgery is not about the size of the incisions; the focus is on sparing the metaphysis and its vascularization to ensure high-quality and long-lasting stability. It appears to yield better functional outcomes than open reduction and internal fixation, not only for Schatzker type I, II and III fractures, but also for complex fractures where open fixation is more damaging and the source of complications.

Clinical results after surgical treatment of posterolateral tibial plateau fractures ("apple bite fracture") in combination with ACL injuries

PURPOSE

The anterior cruciate ligament (ACL)-tear is a common injury in orthopaedic trauma. Depending on the energy of impact fractures of the posterolateral tibial plateau are often associated. Different morphologic variants of posterolateral tibial plateau impaction fractures have been described in the setting of an ACL-tear. Up to now an algorithm of treatment for a combined injury of a posterolateral tibial head fracture and an injury to the anterior cruciate ligament is missing.

METHODS

We present a retrospective study with clinical and radiological analysis of posterolateral fractures in combination with ACL-tear. Impressions with a depth of more than 2 mm and/or a width that outreaches more than half of the posterior horn of the lateral meniscus with additional 3. degree positive pivot-shift-test indicated surgical treatment of the fracture with additional ACL repair or reconstruction. Clinical evaluation included follow-up examination, Visual Analog Scale (VAS), International Knee Documentation Committee Score (IKDC), functional and radiological Rasmussen score.

RESULTS

20 patients were included with a mean age of 43.6 ± 12.4 years. Mean follow-up was 18,2 ± 13,5 months. The fracture was arthroscopically reduced and percutaneously fixed with a screw osteosynthesis (Group 1), reduced via a dorsal approach without (Group 2) or with an autologous bone graft (Group 3). Subjective IKDC score was 79,15 ± 6,07. Functional Rasmussen scores ranged from 27 to 30 (mean 28 ± 2.71). Radiological Rasmussen scores ranged from 16 to 18 points (mean 16.75 ± 1.33). According to IKDC score (p = 0.60), functional Rasmussen score (p = 0.829) and radiological Rasmussen score (p = 0.679) no significant discrepancy between the groups were seen. There was no failure of the ACL graft recorded.

CONCLUSIONS

Posterolateral tibial plateau fractures in combination with an ACL-tear, can cause persistent instability and increase rotational instability. Indication for treatment of these fractures is still under debate. From the biomechanical aspect the lack of more than 50% of the posterior horn of the lateral meniscus and dislocation/depression of more than 2 mm results in an increased rotational instability of the ACL deficient knee. Combined surgical treatment with ACL repair or reconstruction is a safe procedure that results in good, short-term clinical outcome, if our algorithm is followed. In addition this study shows, that majority of posterolateral tibial plateau fractures can be treated arthroscopically.

Effect of fracturoscopy on the incidence of surgical site infections post tibial plateau fracture surgery

PURPOSE

Surgical treatment of tibial plateau fracture (TPF) is common. Surgical site infections (SSI) are among the most serious complications of TPF. This multicentre study aimed to evaluate the effect of fracturoscopy on the incidence of surgical site infections in patients with TPF.

METHODS

We performed a retrospective multicentre study. All patients with an AO/OTA 41 B and C TPF from January 2005 to December 2014 were included. Patients were divided into three groups: those who underwent arthroscopic reduction and internal fixation (ARIF), and those who underwent open reduction and internal fixation (ORIF) with fracturoscopy, and those treated with ORIF without fracturoscopy. The groups were compared to assess the effect of fracturoscopy. We characterised our cohort and the subgroups using descriptive statistics. Furthermore, we fitted a logistic regression model which was reduced and simplified by a selection procedure (both directions) using the Akaike information criterion (AIC). From the final model, odds ratios and inclusive 95% confidence intervals were calculated.

RESULTS

Overall, 52 patients who underwent fracturoscopy, 48 patients who underwent ARIF, and 2000 patients treated with ORIF were identified. The rate of SSI was 0% (0/48) in the ARIF group and 1.9% (1/52) in the fracturoscopy group compared to 4.7% (93/2000) in the ORIF group (OR = 0.40, p = 0.37). Regression analyses indicated a potential positive effect of fracturoscopy (OR, 0.65; 95% CI, 0.07-5.68; p = 0.69).

CONCLUSION

Our study shows that fracturoscopy is associated with reduced rates of SSI. Further studies with larger cohorts are needed to investigate this.

LEVEL OF EVIDENCE

Level III.