Introduction
Tibial plateau fractures have been documented in the literature as early as the 1820s, and the mainstay of treatment was nonoperative until the 1950s. Many reports in the 1970s and beyond suggest that open reduction and internal fixation is indicated for most displaced tibial plateau fractures. With modern advances in fracture treatment principles, techniques, imaging methods, and implants, operative intervention has become the standard treatment for the majority of tibial plateau fractures.
Over the years, operative treatment of tibial plateau fractures has shown improved outcomes, which has led to expanding indications. Advanced imaging techniques allow surgeons to better visualize fracture morphology in three dimensions, creating a better understanding of applied anatomy. With the development of medial, lateral, and posterior approaches to the proximal tibia, surgeons can safely reduce and apply fixation to almost any fracture pattern. Furthermore, specialty plates and bone graft substitutes that may obviate the need for autograft have made surgery a more attractive option with less morbidity. While the current mainstay for the treatment of tibial plateau fractures involves surgical intervention, nonoperative treatment may be indicated in certain fractures and patient populations. Techniques of conservative treatment, including historical methods and modern immobilization devices, can lead to good outcomes when applied appropriately. In this chapter, we describe the selection criteria, historical treatment methods with modern adaptations, as well as outcomes of nonoperative treatment.
Indications
Indications for nonoperative treatment are driven by patient factors, socioeconomic factors, and fracture characteristics.
Patient Factors
Patient-specific factors, including ambulatory status, medical comorbidities, risk of anesthesia, and patient’s ability to receive transfusion, must be taken into consideration. For example, nonsurgical treatment should be considered in a low-demand, nonambulatory, or minimally ambulatory patient who uses the affected limb for transfers or short distances only. This low-demand scenario may be seen in patients with hemiplegia or paraplegia, morbid obesity, advanced age, or severe deconditioning.
Nonoperative treatment may be considered in patients with multiple medical comorbidities, who are at high risk of complications from anesthesia and surgery. Medical comorbidities, such as diabetes (especially uncontrolled) and renal failure, may drive treatment decisions. A markedly elevated hemoglobin A1c (HbA1c) indicates poor diabetic control and is associated with other conditions such as malnutrition with hypoalbuminemia and anemia. Patients with a poor host classification grade, initially described by Cierny et al., may be at extremely high risk for complication from acute intervention, and conservative treatments should be strongly considered. The host classification indicates the number of Immune system-compromising factors include diabetes, renal disease requiring dialysis, malnutrition, nicotine use, Age >80, malignancy, alcoholism, and more. ( Fig. 3.1 ). Additionally, a systematic review indicated that diabetes increased rates of malunion, infection, and reoperation rates in operative lower extremity fractures and increased rates of nonunion in fractures below the knee.
While a set point for HbA1c has not been universally established for fracture care, the arthroplasty literature uses a benchmark of 7% as an agreed-upon preoperative target. A recent study in the Journal of Arthroplasty found that a threshold of 7.7 was a specific risk factor that could predict periprosthetic joint infection. This threshold may be considered as a reference point in fracture care to predict infection risk and can be used as a tool in the decision-making process. In patients with uncontrolled diabetes, tibial plateau fractures may be treated initially nonoperatively, and once glucose control is established, patients may then become candidates for procedures such as arthroplasty in a delayed fashion.
Similarly, patients with renal failure have poor wound and fracture healing as well as an increased risk of mortality when undergoing noncardiac surgery and should be considered for nonoperative modalities. In a recent metaanalysis of the joint arthroplasty literature, Kim et al. found that patients with chronic kidney disease (CKD) have a higher rate of mortality and periprosthetic joint infection based on the unadjusted odds ratio. After total hip arthroplasty, the risk of periprosthetic joint infection was higher in patients who were on dialysis than in CKD patients not on dialysis. Other medical conditions that may influence treatment decisions include active infection, recent myocardial infarction, or stroke, especially when high doses of anticoagulants are required, leading to a high risk of bleeding complications.
Socioeconomic Considerations
Various socioeconomic scenarios can affect the surgeon’s ability to provide optimal operative treatment, such as in the setting of a contagious pandemic or in areas of conflict or poverty where resources can be limited. During the unexpected COVID-19 pandemic, some patients opted for nonoperative treatment, limiting their visits and exposure to a large hospital system and utilizing telehealth and home therapy. In underdeveloped countries, orthopedic surgeons may encounter limited access to sterile operating rooms and may elect to proceed with nonoperative treatment of tibial plateau fractures. In these unusual circumstances, surgical treatment may not be an option. Lastly, the religious and cultural beliefs of patients may indicate nonoperative management. For example, if the patient’s belief system precludes them from receiving a transfusion, the surgeon may choose nonoperative treatment, especially in the setting of polytrauma.
Fracture Characteristics
The characteristics of the fracture provide the basis for nonoperative versus operative treatment decision making. Historically, the most stringent criteria for operative intervention are articular step-off more than 3 mm, condylar widening of more than 5 mm relative to contralateral side, and lateral tilt or valgus malalignment of more than 5 degrees. Other authors indicate that up to 10 mm of step-off and 10 degrees of malalignment can be treated nonoperatively, and beyond this cutoff, surgery is almost universally indicated. Specifically, for lateral plateau fractures, up to 3 mm of articular step-off, 5 mm of condylar widening, and 5 degrees of valgus malalignment are well tolerated without adverse effects. Bicondylar fractures and displaced medial plateau fractures likely require operative intervention. Additionally, knee instability will require surgical treatment. Preexisting arthritis of a severe nature may also be a reason to strongly consider closed fracture treatment and then delayed arthroplasty without fear of surgical site infection, multiple incisions, and stress risers from preexisting hardware. Lastly, closed treatment with systemic and/or local antibiotics may be considered in the setting of open injury and significant contamination where the presence of a metallic foreign body may drive infection.
Patient Evaluation
The decision to operate or not may be easy in the healthy, uncomplicated patient, but in a chronically ill patient with multiple comorbidities, the adage “the decision is more important than the incision” applies. To make the best decision on how a fracture should be treated, a thorough patient workup should be completed, including history and physical examination, appropriate basic and advanced imaging studies, and risk-benefit discussion between the surgeon and the patient. This complete approach will mitigate risk and allow for optimization of the patient’s function and overall outcome.
History and Physical Examination
A comprehensive history and physical examination should be performed on all patients with tibial plateau fractures. Investigation of the patient’s medical comorbidities, ambulatory and functional status, allergies including metal allergy, previous anesthesia complications, social history including occupation, tobacco, and other drug use must be completed. A complete neurovascular examination should be performed, including palpation of pulses, Doppler examination, and ankle-brachial index assessment in high-energy trauma. Sensory examination involves evaluating the injured limb as well as the contralateral limb for preexisting neuropathy. A visual inspection of the skin should be completed, looking for any preexisting skin conditions, including signs of vascular disease or cellulitis. The location of open wounds and compromised skin should be noted in the context of proposed incisions.
Stability of the knee should be checked, as it is paramount in the decision-making process of operative versus nonoperative treatment. As described by Lansinger et al., stability is tested by examination of the knee with the leg in full extension. Often after tibial plateau fractures, knee hemarthrosis creates a painful distension of the knee and can be aspirated to allow the patient to tolerate a clinical examination better. Anesthesia may be required for stability examination, such as with a peripheral nerve block (if compartment syndrome is not suspected), spinal anesthesia, or general anesthesia in the operating room. According to a 20-year follow-up study by Lansinger et al., a 10-degree increase in lateral or medial deviation of the mechanical axis of the involved knee compared with the uninjured side is defined as unstable and a clear indication for surgery. The authors also concluded that instability measured with a knee flexed more than 20 degrees was clinically irrelevant. Using this simple physical examination maneuver to screen patients, Lansinger was able to select surgical candidates and achieve excellent or good results in over 90% of patients over the 20-year follow-up. The 10% of patients who achieved fair or poor results were those with depressed fractures where the articular surface was depressed more than 10 mm. They concluded that patients with stability of the extended knee should be treated nonoperatively irrespective of the roentgenographic appearance of the fracture.
Clinically, 10 degrees can be hard to assess, so we recommend using radiographic stress views. In the patient with tibial plateau fracture, full-length standing films are not an option. However, alignment decisions are best made with a large field of view; thus, stress radiographs should be taken on large cassettes (14 inches or larger if possible). Alignment assessment can be completed on a flat top imaging table, with a reaming rod for an intramedullary nail that is prebent to 10 degrees positioned over the top of the examined limb with the bend at the joint line while the image is being captured ( Fig. 3.2 ).
Imaging
After a complete history and physical examination, standard radiographs, including anteroposterior (AP), lateral, and plateau view, should be performed. Contralateral limb radiographs should be considered for comparison if nonoperative treatment is an option. While findings such as depression of the articular surface and fracture lines may be visible on plain radiographs, computed tomography (CT) imaging shows a more accurate assessment of the fracture morphology, location of each fragment, and occult fracture lines. CT will also better represent the amount of depression and its location.
Care should be taken to identify medial fractures, especially medial and posterior shear fractures, on CT scans as these are inherently unstable unless proven otherwise. In a recent cadaveric imaging study, Immerman et al. demonstrated that if a posteromedial fracture is present, the size of the fragment and the fracture line orientation to the posterior edges of the femoral condyles can be used as a reference for stability. They found that medial fragments occupying over 60% of the medial plateau were loaded at all flexion angles. However, fragments involving 30% of the medial plateau would contact the femoral condyle in the range of 70 to 90 degrees with high load. Fracture lines oriented between 0 and 20 degrees of external rotation to the posterior femoral condylar axis (PFCA) also allowed fragments to remain unloaded. For example, based on their cadaveric model, a fracture oriented at neutral to 20 degrees external rotation relative to the PFCA that occupies less than 30% of the medial tibial plateau would be stable from 0 to 90 degrees of flexion, allowing for early motion.
In cases where an accurate stability examination is not possible and the mechanism is suspicious for ligamentous injury, magnetic resonance imaging (MRI) may be indicated to objectively determine the stability of the knee. Numerous authors cite ligamentous stability as paramount for a successful outcome. , For instance, a medically unstable patient with 5 mm of lateral depression and intact ligaments on MRI can be treated nonoperatively with confidence in an acceptable outcome.
Techniques
Techniques of nonoperative treatment have evolved from strict immobilization in a spica cast to early range of motion with removable bracing. Most historical nonoperative treatment methods may not be tolerated by today’s patients; however, they may be required in unique circumstances. We also call on the techniques of the past to create modern nonoperative treatment options.
Cast Immobilization and Modern Bracing
In the past, fractures deemed stable on examination, were treated in a long leg plaster cast from the groin to the toes with the knee flexed 20 degrees for 4 to 16 weeks, followed by gradual range of motion exercises. , , While a long leg plaster cast may no longer be advisable, a long leg fiberglass cast or splint may be more durable in minimally displaced fractures, especially in unreliable patients. A simple Velcro knee immobilizer can be employed, especially in more reliable patients, but requires frequent adjustment and inevitably runs the risk of sliding inferiorly on the injured limb. A modern fracture brace, either locked in extension or slight flexion, can also be substituted for a traditional cast.
Modern fracture braces have improved upon the cast brace with lighter, water-resistant cuff material and the ability to modulate flexion and remove and replace the brace easily. For fractures that meet nonoperative criteria, the authors prefer application of the brace for 2 weeks in extension, followed by incremental increases in flexion at 2-week intervals until 90 degrees is reached. Ideally, 90 degrees of flexion would be achieved by 6 weeks. For distal fractures or to limit inferior translation of the brace, a modern adaptation of the cast brace can be made by incorporating the hinged knee brace to the metallic uprights of a fracture boot. As in traditional cast bracing, the hinges can be “massaged” to unload certain fracture patterns or an unloader style brace (if long enough) can be utilized. We have found that incorporating the knee brace to a foot orthosis or an articulated ankle attachment alleviates the inferior translation seen with typical knee immobilizers or ill-fitting hinged braces ( Fig. 3.3 ). This option lessens the chances of heel pressure wounds and loss of motion from the brace when the hinged axis of rotation accidentally slips below the knee joint level.
