Compartment Syndrome in Tibial Plateau Fractures: Do Previously Established Predictors Have External Validity?

Identifying key risk factors for acute compartment syndrome in tibial diaphysis fracture patients

Acute compartment syndrome (ACS) is a severe orthopedic issue that, if left untreated, can result in lasting nerve and muscle damage or even necessitate amputation. The association between admission laboratory blood test indicators and the occurrence of ACS in patients with tibial diaphysis fractures is currently a subject of debate. The objective of this research was to identify the contributing factors for ACS in individuals suffering from tibial diaphysis fractures. In this retrospective study, we collected data on a total of 705 individuals from our hospital, comprising 86 ACS patients and 619 non-ACS patients with tibial diaphysis fractures. These participants were categorized into two distinct groups: the ACS group and the non-ACS group. Despite the inherent limitations associated with retrospective analyses, such as potential biases in data collection and interpretation, we conducted a comprehensive analysis of demographics, comorbidities, and admission lab results. Our analytical approach included univariate analysis, logistic regression, and receiver operating characteristic (ROC) curve analysis techniques, aiming to mitigate these limitations and provide robust findings. The statistical analysis revealed several predictors of ACS, including gender (p = 0.011, OR = 3.200), crush injuries (p = 0.004, OR = 4.622), lactic dehydrogenase (LDH) levels (p < 0.001, OR = 1.003), and white blood cell (WBC) count (p < 0.001, OR = 1.246). Interestingly, the study also found that certain factors, such as falls on the same level (p = 0.007, OR = 0.334) and cholinesterase (CHE) levels (p < 0.001, OR = 0.721), seem to provide a degree of protection against ACS. In order to better predict ACS, the ROC curve analysis was employed, which determined threshold values for LDH and WBC. The established cut-off points were set at 266.26 U/L for LDH and 11.7 × 109 cells per liter for WBC, respectively. Our research has successfully pinpointed gender, crush injuries, LDH levels, and white blood cell (WBC) count as crucial risk factors for the development of ACS in patients experiencing tibial diaphysis fractures. Furthermore, by establishing the cut-off values for LDH and WBC, we have facilitated a more personalized assessment of ACS risk, enabling clinical doctors to implement targeted early interventions and optimize patient outcomes.

Analysis of acute extremity compartment syndrome using a genealogic population database

INTRODUCTION

Acute extremity compartment syndrome ("CS") is an under-researched, highly morbid condition affecting trauma populations. The purpose of this study was to analyze incidence rates and risk factors for extremity compartment syndrome using a high-quality population database. Additionally, we evaluated heritable risk for CS using available genealogic data. We hypothesized that diagnosis of extremity compartment syndrome would demonstrate heritability.

MATERIALS AND METHODS

Adult patients with fractures of the tibia, femur, and upper extremity were retrospectively identified by ICD-9, ICD-10, and CPT codes from 1996 to 2020 in a statewide hospital database. Exposed and unexposed cohorts were created based on a diagnosis of CS. Available demographic data were analyzed to determine risk factors for compartment syndrome using logistic regression. Mortality risk at the final follow-up was evaluated using Cox proportional hazard modeling. Patients with a diagnosis of CS were matched with those without a diagnosis for heritability analysis.

RESULTS

Of 158,624 fractures, 931 patients were diagnosed with CS. Incidence of CS was 0.59% (tibia 0.83%, femur 0.31%, upper extremity 0.27%). Male sex (78.1% vs. 46.4%; p < 0.001; RR = 3.24), younger age at fracture (38.8 vs. 48.0 years; p < 0.001; RR = 0.74), Medicaid enrollment (13.2% vs. 9.3%; p < 0.001; RR = 1.58), and smoking (41.1% vs. 31.1%; p < 0.001; RR 1.67) were significant risk factors for CS. CS was associated with mortality (RR 1.61, p < 0.001) at mean follow-up 8.9 years in the CS cohort. No significant heritable risk was found for diagnosis of CS.

CONCLUSIONS

Without isolating high-risk fractures, rates of CS are lower than previously reported in the literature. Male sex, younger age, smoking, and Medicaid enrollment were independent risk factors for CS. CS increased mortality risk at long-term follow-up. No heritable risk was found for CS.

LEVEL OF EVIDENCE

III.

The impact of fasciotomy on inpatient outcomes in lower leg fracture management

BACKGROUND

While lower extremity fractures are common injuries, concomitant compartment syndrome can lead to significant implications and surgical release (fasciotomy) is essential. The aim of this study was to identify potential predictors of compartment release and risk factors related to complications. Using a large nationwide cohort, this study compared patients suffering from lower extremity fractures with and without compartment syndrome during their primary in-hospital stay following trauma.

METHODS

A retrospective analysis was conducted using the prospective surgical registry of the working group for quality assurance in surgery in Switzerland, which collects data from nearly 85% of all institutions involved in trauma surgery. Inclusion criteria Patients who underwent surgical treatment for tibia and/or fibula fractures between January 2012 and December 2022 were included in the study. Statistics Statistical analysis was performed using Chi-square, Fisher's exact test, and t test. Furthermore, a regression analysis was conducted to determine the independent risk factors for fasciotomy and related complications. In the present study, a p value less than 0.001 was determined to indicate statistical significance due to the large sample size.

RESULTS

The total number of cases analyzed was 1784, of which 98 underwent fasciotomies and 1686 did not undergo the procedure. Patients with fasciotomies were identified as significantly younger (39 vs. 43 years old) and mostly male (85% vs. 64%), with a significantly higher American Society of Anesthesiologists (ASA) score (ASA III 10% vs. 6%) and significantly more comorbidities (30% vs. 20%). These patients had significantly longer duration of surgeries (136 vs. 102 min). Furthermore, the total number of surgical interventions, the rate of antibiotic treatment, and related complications were significantly higher in the fasciotomy group. Sex, age, comorbidities, and fracture type (both bones fractured) were identified as relevant predictors for fasciotomy, while ASA class was the only predictor for in-hospital complications. Outcomes Patients who underwent fasciotomy had a significantly longer hospital stay (18 vs. 9 days) and a higher complication rate (42% vs. 6%) compared to those without fasciotomy. While fasciotomy may have played a role, other factors such as variations in patient characteristics and injury mechanisms may also contribute. Additionally, in-house mortality was found to be 0.17%, with no patient death recorded for the fasciotomy group.

CONCLUSIONS

Fasciotomy is vital. The knowledge about the further course is, however, helpful in resource allocation. We found significant differences between patients with and without fasciotomy in terms of age, sex, complication rate, length of stay, comorbidities, duration of operations, and use of antibiotics during their primary in-hospital stay. While the severity of the underlying trauma could not be modulated, awareness of the most relevant predictors for fasciotomy and related complications might help mitigate severe consequences and avoid adverse outcomes.

Tibial Plateau Fractures Complicated by Compartment Syndrome Are Associated With a 3 Times Higher Cost of Care

OBJECTIVES

To determine the impact of acute compartment syndrome (ACS) and identify cost drivers of 1-year total treatment costs for operative tibial plateau fractures.

DESIGN

Retrospective review.

SETTING

Level 1 trauma center.

PATIENTS

337 patients with tibial plateau fractures, 24 of which were complicated by ACS.

OUTCOMES

The primary outcome was total treatment cost over the first year for operatively treated tibial plateau fractures. The secondary objective was to use regression analysis to identify significant cost drivers.

RESULTS

The diagnosis of ACS was associated with 2.85 times higher total treatment cost ( P < 0.001). ACS demonstrated increased total treatment cost when controlling for polytrauma ( P < 0.001) and postoperative infection ( P < 0.001). Regression analysis identified 5 variables significantly associated with total cost of care: body mass index, injury severity score, ACS, staged external fixation, and locking fixation ( P < 0.001; R 2 = 0.57). The diagnosis of ACS had the largest impact on total cost with a 3.5× greater impact on cost compared with the next highest variable, staged external fixation.

CONCLUSIONS

Tibial plateau fractures complicated by ACS are associated with 2.85 times higher treatment costs over a 1-year period. There were 5 significant variables identified by regression analysis with ACS having the highest impact on total treatment. Together, these 5 factors account for 57% of treatment cost variability.

LEVEL OF EVIDENCE

Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A Novel Approach in the Management of Tibial Plateau Fractures with Compartment Syndrome

Background

Compartment syndrome in tibial plateau fractures presents a formidable challenge for treating orthopedic surgeons. The most common strategy is early fasciotomy and external fixation, followed by a second stage definitive fixation. We conducted a prospective study of tibial plateau fractures of Schatzker Type V and VI with impending compartment syndrome treated by single-stage double incision fasciotomy and dual internal fixation and Vacuum-Assisted Closure (VAC).

Materials and Methods

The study was between May 2014 and February 2019. 21 patients with impending compartment syndrome who underwent single-stage double incision fasciotomy and Open Reduction and Internal Fixation (ORIF) with dual plate were included in the study. The functional and radiological outcome was measured using the modified Rasmussen functional and radiological scoring and The Western Ontario and McMaster Universities Arthritis Index (WOMAC).

Results

The mean age of patients was 38.7 years (Standard deviation of ± 9.48). The mean follow-up period was 27 months (Standard deviation of ± 6.51). The mean functional and radiological modified Rasmussen score was 27.28 (range 21 to 29) & 8 (range 7 to 10), respectively. 4 patients had excellent outcomes, and 17 patients had good results. The mean WOMAC score was 8.04 (Standard deviation of ± 5.35). Five patients had a score of 0, 14 patients had a score of 1-10 and 2 had a score of 11-20.

Conclusions

The early double incision fasciotomy and definitive internal fixation with dual plate and VAC as single-stage surgery in patients with impending compartment syndrome help to obtain excellent to good functional outcomes with reduced complications.

The impact of both-bone forearm fractures on acute compartment syndrome: An analysis of predisposing factors

OBJECTIVES

Acute compartment syndrome (ACS) is a severe medical condition that, if left untreated, can cause permanent nerve and muscle damage, and may even require amputation. The objective of this study was to identify the risk factors associated with the development of ACS in patients with both-bone fractures of the forearm.

METHODS

Between November 2013 and January 2021, a retrospective data collection was conducted on 611 individuals who experienced both-bone forearm fractures at a level 1 trauma center. Among these patients, 78 patients were diagnosed with ACS, while the remaining 533 patients did not have ACS. Based on this division, the patients were categorized into two groups: the ACS group and the non-ACS group. Demographics (including factors such as age, gender, body mass index, crush injury, etc.), comorbidities (including conditions such as diabetes, hypertension, heart disease, anemia, etc.), and admission lab results (including complete blood count, comprehensive metabolic panel, and coagulation profiles, etc.) were analyzed using univariate analysis, logistic regression, and ROC curve analysis.

RESULTS

Predictors of ACS were identified through the final multivariable logistic regression analysis, which revealed that crush injury (p < 0.001, OR = 10.930), the levels of neutrophils (NEU) (p < 0.001, OR = 1.338) and the levels of creatine kinase (CK) (p < 0.001, OR = 1.001) were significant risk factors. Additionally, age (p = 0.045, OR = 0.978) and albumin (ALB) level (p < 0.001, OR = 0.798) were found to provide protective effects against ACS. Furthermore, the receiver operating characteristic (ROC) curve analysis determined cut-off values for NEU and CK to predict ACS: 7.01/L and 669.1 U/L respectively.

CONCLUSIONS

Our study identified crush injury, NEU, and CK as significant risk factors for ACS in patients with both-bone forearm fractures. We also determined the cut-off values of NEU and CK, allowing for the individualized evaluation of ACS risk and the implementation of early targeted treatments.

Acetabular fracture pattern is altered by pre-injury sacroiliac joint autofusion

PURPOSE

Acetabular fracture shape is determined by the direction of force applied. We perceive an anecdotally observed connection between pre-existing autofused sacroiliac joints (aSIJ) and high anterior column (HAC) injuries. The purpose of this study was to compare variations in acetabular fracture patterns sustained in patients with and without pre-injury sacroiliac (SI) joint autofusion.

METHODS

All adult patients receiving unilateral acetabular fixation (level 1 academic trauma; 2008-2018) were reviewed. Injury radiographs and CT scans were reviewed for fracture patterns and pre-existing aSIJ. Fracture types were subgrouped presence of HAC injury (includes anterior column (AC), anterior column posterior hemitransverse (ACPHT), or associated both column (ABC)).

ANALYSIS

Logistic regression determined the association between aSIJ and HAC.

RESULTS

A total of 371 patients received unilateral acetabular fixation (2008-2018); 61 (16%) demonstrated CT evidence of idiopathic aSIJ. These patients were older (64.1 vs. 47.4, p < 0.01), more likely to be male (95% vs. 71%, p < 0.01), less likely to be smokers (19.0% vs. 44.8%, p < 0.01), and were injured from lower energy mechanisms (21.3% vs. 8.4%, p = 0.01). The most common patterns with autofusion were ACPHT (n = 13, 21%) and ABC (n = 25, 41%). Autofusion was associated with greater odds of patterns involving a high anterior column injury (ABC, ACPHT, or isolated anterior column; OR = 4.97, p < 0.01). After adjusting for age, mechanism, and body mass index, the connection between autofusion and high anterior column injuries remained significant (OR = 2.60, p = 0.01).

CONCLUSIONS

SI joint autofusion appears to change mode of failure in acetabular injuries; a more rigid posterior ring may precipitate a high anterior column injury.

LEVEL OF EVIDENCE

Prognostic level III.

Radiographic parameters associated with fracture-related infection in high energy bicondylar tibial plateau fractures managed with two-stage treatment: Identifying the bad actors

INTRODUCTION

High energy tibial plateau fractures are fraught with complications, particularly fracture-related infection (FRI). Previous studies have evaluated patient demographics, fracture classification, and injury characteristics as risk factors for FRI in patients with these injuries. This study evaluated the relationship between radiographic parameters (fracture length relative to femoral condyle width (FLF ratio), initial femoral displacement (FD ratio), and tibial widening (TW ratio)) and fracture-related infection following internal fixation in high energy bicondylar tibial plateau fractures.

METHODS

225 patients treated for bicondylar tibial plateau fractures at two level I trauma centers were retrospectively reviewed. Patient characteristics, fracture classification, and radiographic measurements were analyzed to determine association with FRI.

RESULTS

The rate of FRI was 13.8%. Increased fracture length, FLF ratio, FD ratio, TW ratio, and fibula fracture were each associated with FRI on regression analysis, independent of clinical variables. Cutoff values were identified for each parameter and patients were risk stratified based on these radiographic parameters. High-risk patients had a 2.68- and 12.36-times risk of FRI compared to medium and low-risk patients, respectively.

DISCUSSION

This study is the first to examine the relationship between radiographic parameters and FRI in high energy bicondylar tibial plateau fractures. Fracture length, FLF ratio, FD ratio, TW ratio, and fibula fracture were identified as radiographic parameters associated with FRI. More importantly, risk stratifying patients based on these parameters accurately identified patients at increased risk of FRI. Not all bicondylar tibial plateau fractures are created equal and radiographic parameters can be utilized to help identify the bad actors.

Predictors of acute compartment syndrome in patients with tibial fractures: a meta-analysis

STUDY DESIGN

This is the first meta-analysis focusing on the risk factors related to ACS after tibial fractures.

BACKGROUND

Acute compartment syndrome (ACS) is a serious complication that affects 2-9% of tibial fracture patients. It is importance of identifying the predictors of ACS in patients with tibial fractures.

QUESTIONS/PURPOSES

We performed a meta-analysis to identify the risk factors of ACS after tibial fracture.

METHODS

We searched articles in the English databases, such as PubMed, Embase, and the Cochrane Library and the Chinese databases including CNKI and WAN FANG. We collected data related to ACS from included studies and analyzed data by RevMan 5.3 and STATA 12.0.

RESULTS

The rate of ACS was 2.7% (10,708 of 398,414 patients) from 16 included articles. Our data showed that younger age (p < 0.00001, OR =  - 7.93, 95% CI [- 9.34, - 6.25]), male patients (p < 0.00001, OR = 2.17, 95% CI [2.07, 2.28]), patients without a history of hypertension (p < 0.00001, OR = 0.69, 95% CI [0.64, 0.74]), with a history of smoking (p < 0.00001, OR = 1.38, 95% CI [1.30, 1.46]), and patients with fibular fractures (p = 0.001, OR = 2.68, 95% CI [1.47, 4.87]), closed fracture (p = 0.02, OR = 0.86, 95% CI [0.75, 0.98]), high-energy injury (p = 0.003, OR = 0.37, 95% CI [0.19, 0.71]), motorized accident (p = 0.0009, OR = 0.41, 95% CI [0.24, 0.69]), proximal fracture, AO-C-type fracture, comminuted fracture, and Schatzker grade IV-VI fracture were associated with the development of ACS. Additionally, femoral displacement ratio and tibial widening ratio in the ACS groups were significantly higher than in the non-ACS group.

CONCLUSION

Many factors were found to be associated with the development of ACS following tibial fractures. We provide references when we met the above characteristics of patients to rapidly identify and highly concern ACS.

Periarticular multimodal analgesia in decreasing perioperative pain in tibial plateau fractures: A double blind randomized controlled pilot study

INTRODUCTION

The use of periarticular multimodal analgesia injections is increasing and has become commonplace in some surgeries. However, there is no data on the effectiveness of local periarticular multimodal analgesia for tibial plateau fractures. We hypothesized that closed tibial plateau fracture patients receiving the local multimodal analgesic medications would experience a decrease in VAS pain scores.

METHODS

Patients aged between 18 and 79 with an isolated closed tibial plateau fracture (AO 41-B and C) were prospectively enrolled and randomized in a 1:1 double blinded fashion to either a placebo or active medication treatment arm. After ORIF, gel-foam sponges soaked in either multimodal analgesic solution or normal saline. Patients were followed for 24 h post-operatively with Visual Analog pain Scores (VAS). Patients were monitored post-operatively for complications including compartment syndrome, infection, and non-union.

RESULTS

The planned study was terminated prior to completion due to higher than anticipated rates of infection (18%), distributed equally among active (3) and placebo (2) groups, raising concerns that this may have been due to the presence of the delivery device. Twenty-eight patients were enrolled, 15 in the active group and 13 in the placebo group. Patients in the active medication group had significantly decreased pain scores at hours 4 (p = 0.005, 4.2 vs 6.9), 8 (p = 0.05, 5 vs 7), and 12 (p = 0.02, 3.8 vs 6.2). Pain scores at hours 16 (p = 0.10, 4.5 vs 6.5), 20 (p = 0.08, 4.6 vs 6.4), and 24 (p = 0.10, 4.8 vs 6.5) were also decreased but did not reach significance.

DISCUSSION

The use of local multimodal periarticular analgesic for closed tibial plateau fractures appears to be beneficial for short-term pain control post-operatively. Concerns regarding an implantable delivery vehicle leading to infection has warranted a change in method of drug administration. Completion of the full study will permit us to validate or refute these findings.

LEVEL OF EVIDENCE

Therapeutic Level 1.

Is the timing of fixation associated with fracture-related infection among tibial plateau fracture patients with compartment syndrome? A multicenter retrospective cohort study of 729 patients

BACKGROUND

Tibial plateau fractures with an ipsilateral compartment syndrome are a clinical challenge with limited guidance regarding the best time to perform open reduction and internal fixation (ORIF) relative to fasciotomy wound closure. This study aimed to determine if the risk of fracture-related infection (FRI) differs based on the timing of tibial plateau ORIF relative to closure of ipsilateral fasciotomy wounds.

METHODS

A retrospective cohort study identified patients with tibial plateau fractures and an ipsilateral compartment syndrome treated with 4-compartment fasciotomy at 22 US trauma centers from 2009 to 2019. The primary outcome measure was FRI requiring operative debridement after ORIF. The ORIF timing relative to fasciotomy closure was categorized as ORIF before, at the same time as, or after fasciotomy closure. Bayesian hierarchical regression models with a neutral prior were used to determine the association between timing of ORIF and infection. The posterior probability of treatment benefit for ORIF was also determined for the three timings of ORIF relative to fasciotomy closure.

RESULTS

Of the 729 patients who underwent ORIF of their tibial plateau fracture, 143 (19.6%) subsequently developed a FRI requiring operative treatment. Patients sustaining infections were: 21.0% of those with ORIF before (43 of 205), 15.9% at the same time as (37 of 232), and 21.6% after fasciotomy wound closure (63 of 292). ORIF at the same time as fasciotomy closure demonstrated a 91% probability of being superior to before closure (RR, 0.75; 95% CrI, 0.38 to 1.10). ORIF after fasciotomy closure had a lower likelihood (45%) of a superior outcome than before closure (RR, 1.02; 95% CrI; 0.64 to 1.39).

CONCLUSION

Data from this multicenter cohort confirms previous reports of a high FRI risk in patients with a tibial plateau fracture and ipsilateral compartment syndrome. Our results suggest that ORIF at the time of fasciotomy closure has the highest probability of treatment benefit, but that infection was common with all three timings of ORIF in this difficult clinical situation.

Five-year outcomes of trauma-specific function in patients after acute blunt popliteal artery injury: a matched cohort analysis

BACKGROUND

Few studies focus on the trauma-specific functional outcomes after surgical revascularization and risk factors contributing to poor outcomes in patients with acute blunt popliteal artery injury (PAI). The objective of this study was to investigate the long-term trauma-specific functional outcomes in patients with acute blunt PAI and identify the associated risk factors.

METHODS

There were 36 patients with acute blunt PAI who require surgical revascularization at a national trauma center of West China Hospital of Sichuan University between March 2010 and April 2019. After propensity matching, each patient was matched to one patient who did not have a concomitant vascular injury in control cohort. Functional outcomes were assessed with trauma-specific functional scores, physical examination of range of motion, nerve functional status and knee stability. A logistics regression model was established to determine the independent risk factors.

RESULTS

The 5-year (range 2-10 years) follow-up showed that 22 patients (22/36, 61.1%) had functional deficit due to limited activity or chronic neurological symptoms. Patients in vascular cohort had significantly decreased FIM score and AHFS score compared with matched patients without vascular involvement (P = 0.003 and P < 0.001), whereas there was no statistically significant difference in KSS (P = 0.136). Spearman correlation analysis of functional scores in vascular cohort showed that the FIM score was positively correlated with AHFS score (r = 0.926, P < 0.001), but not correlated with the KSS (r =  - 0.007, P = 0.967). Additionally, there was significant difference in the range of motion of ankle between two groups (P < 0.001 and P = 0.034). Logistic regression analysis further demonstrated nerve injuries and compartment syndrome were risk factors for poor ankle function after surgery (OR 22.580, P = 0.036 and OR 12.674, P = 0.041).

CONCLUSION

Most patients who sustained blunt PAI had significant functional deficit associated with limited activity and chronic neurological symptoms of ankle and foot, and poor functional outcomes were related to nerve injury and compartment syndrome. Therefore, early and effective decompression for compartment syndrome remains the only potentially modifiable risk factor for improving functional outcomes following PAI.

Compartment Syndrome in High-Energy Tibial Plateau Fractures

High-energy tibial plateau fractures carry a high risk of associated acute compartment syndrome. Clinicians should be familiar with several demographic, clinical, and radiographic factors that are associated with compartment syndrome development after tibial plateau fracture. Once the diagnosis of compartment syndrome is made, emergent decompressive fasciotomies are needed. Fracture fixation complicates the treatment course and elements of postoperative management. Deep surgical site infection is a common complication, and controversy remains regarding the ideal timing of fixation and soft tissue closure for these complex injuries.

Acute Compartment Syndrome in Type IIIB Open Tibial Shaft Fractures Using a 2-Stage Orthoplastic Approach

OBJECTIVE

To determine the rate of acute compartment syndrome (ACS) in a series of patients with Gustilo-Anderson type IIIB open tibial shaft fractures that were treated using a specific 2-stage orthoplastic protocol.

DESIGN

Consecutive cohort study.

PATIENTS/PARTICIPANTS

Ninety-three (n = 93) consecutive patients with a type IIIB open tibial shaft fracture (OTA/AO-42) treated using a 2-stage orthoplastic approach, between August 2015 and January 2018. After exclusions, 83 (n = 83) were eligible for analysis.

INTERVENTION

Colloid resuscitation and 2-stage orthoplastic reconstruction of type IIIB open tibial shaft fracture. Stage 1 consists of "3-vessel view" early debridement and temporary internal fixation, with stage 2 consisting of a single-stage fix and flap.

MAIN OUTCOME MEASUREMENTS

Rate of ACS. Secondary outcomes included early/late sequelae of missed ACS, deep infection, arterial injury, nonunion, and flap failure.

RESULTS

Eighty-three (n = 83) patients were included for analysis. The median age was 45.4 years [interquartile range (IQR) 35] with a median follow-up of 1.6 years (IQR 0.8). The median number of operations was 2.0 (IQR 4). For the primary outcome, there were a total of 0 (0/83) patients who required fasciotomy or developed early/late clinical sequelae of missed ACS. Six (6/83, 7.2%) patients developed deep infection, 18 patients (18/83, 21.7%) experienced nonischemic arterial injury, 5 patients (5/83, 6.0%) experienced nonunion, with 4 patients (4/83, 4.8%) experiencing flap failure. Diabetes was the only variable associated with deep infection (P = 0.025) and nonunion (P < 0.001).

CONCLUSIONS

Patients with type IIIB open tibial shaft fractures treated with colloid resuscitation and a 2-stage orthoplastic protocol, which includes early "3-vessel view" exposure and debridement, do not appear to develop ACS. Furthermore, no sequelae of missed compartment syndrome was observed at final follow-up.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Predictors of acute compartment syndrome of the lower leg in adults following tibial plateau fractures

BACKGROUND

Acute compartment syndrome (ACS) is an underestimated complication following tibial plateau fractures. Understanding predictors of ACS in the lower leg after a fracture of the tibial plateau may guide earlier diagnosis and promptly decompressed by surgical fasciotomy. To date, however, there are few large-scale sample literatures to investigate the predictors of it. The purpose of our study was to evaluate the prevalence rate of ACS associated with tibial plateau fractures and identified any such predictors with the development of ACS.

MATERIALS AND METHODS

From January 2015 to January 2020, a total of 1119 consecutive patients (1119 fractures) including 703 males and 416 females with an average age of 40.7 years (18 to 80 years) in tibial plateau fractures who presented to a university-affiliated hospital with level-I trauma center were included. The presence of ACS and associated predictors were collected from patients' electronic medical records. Associated predictors included gender, age, fracture pattern (open or closed), mechanisms of injury, fracture classification, and underlying disease. Univariate and multivariate logistical regression analyses were performed to identify the predictors of the development of ACS following tibial plateau fractures.

RESULTS

Of the 1119 fractures of the tibial plateau, 35 (3.1%) developed an acute compartment syndrome. On multivariate analysis, only younger patient age (odds ratio (OR) 2.57; 95% confidence interval (CI), 1.26 to 6.31; P = 0.003), and Schatzker VI type fracture (OR 5.78; 95% confidence interval (CI), 1.78 to 54.34; P = 0.021) were significantly associated with the development of ACS. Other variables did not reach statistical significance.

CONCLUSION

Younger patient age and Schatzker VI type fracture were predictors of ACS of the lower leg in adults following tibial plateau fractures. Further studies in the prospective study are still needed to identify the potential risk factors associated with ACS in tibial plateau fractures.

Tibial Plateau Fracture: Anatomy, Diagnosis and Management

Tibial plateau fractures are peri-articular knee fractures of the proximal tibia. The presentation is dependent on the mechanism of injury. The tibial plateau is the bony platform of the distal half of the knee joint, and is made up of a medial and lateral condyle separated by the intercondylar eminence. The presentation of tibial plateau fractures can vary greatly as a result of the bimodal mechanism of injury and patient characteristics. The patient should be assessed for life- and limb-threatening injuries in accordance with British Orthopaedic Association Standards of Trauma guidelines. Imaging is undertaken to understand configuration of the fracture, which is classified by the Schatzker classification. Definitive management of the fracture depends on the severity, ranging from conservative to surgical management. Surgery is required for more severe tibial plateau fractures to restore articular congruity, mechanical alignment, ligamentous stability and to permit early mobilisation. Medium-term functional outcome after tibial plateau fractures is generally excellent when anatomy and stability is restored. At least half of patients return to their original level of physical activity. Surgical management of tibial plateau fractures is not without complication. Risk factors include postoperative arthritis, bicondylar and comminuted fractures, meniscal removal, instability, malalignment and articular incongruity. Tibial plateau fractures account for 1% of all fractures, and typically occur either as a fragility fracture or secondary to a high-energy impact. These latter injuries are associated with extensive soft tissue injury, life- and limb-threatening complications and long-term sequelae. While outcomes are generally good, severe injuries are at higher risk of infection and post-traumatic arthritis requiring knee arthroplasty. This article considers the anatomy, diagnosis and evidence-based management strategies for tibial plateau fracture.