Proximal Tibia Fractures


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Proximal Tibia Fractures


Daniel Axelrod MD1, Richard Jenkinson MD MSc FRCSC2, and Hans Kreder MD MPH FRCSC2


Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada


Division of Orthopaedic Surgery, Department of Surgery, Sunnybrook Hospital, University of Toronto, Toronto, ON, Canada


Clinical scenario



  • You are an orthopedic staff on call and are asked to see a 48‐year‐old male who has fallen from a ladder. He has sustained a closed injury to his right proximal tibia. Radiographs reveal a bicondylar tibial plateau fracture.
  • You review the case and decide that this patient will require an operation. When considering the operative treatment options, you wonder if treatment with external fixation leads to a decreased rate of complications when compared to open reduction and internal fixation.
  • When considering treatment for this patient, you anticipate he will require bone graft to fill a bone defect after reducing the fracture fragment. Should you use bone substitute, iliac crest bone graft, or neither?
  • Lastly, you are describing the likely postoperative course for this patient. He asks if he will return to having full preoperative range of motion (ROM). Unsure, you review the most recent evidence on predictive factors for postoperative knee stiffness in patients treated operatively for tibial plateau fractures.

Top three questions



  1. Amongst adult patients presenting with bicondylar tibial plateau fracture, does open reduction and internal fixation, when compared to external fixation with use of limited open techniques, lead to fewer operative complications?
  2. Amongst adult patients who have proximal tibial fractures with metaphyseal bone defects, does iliac crest bone grafting (ICBG), when compared to bone substitute (calcium phosphate or other), improve patient‐reported and radiographic outcomes?
  3. Amongst adult patients who have undergone operative treatment for a tibial plateau fracture, what patient and injury‐specific factors, when compared to the general population, yield improvement in knee ROM at one‐year follow‐up?

Question 1: Amongst adult patients presenting with bicondylar tibial plateau fracture, does open reduction and internal fixation, when compared to external fixation with use of limited open techniques, lead to fewer operative complications?


Rationale


There are a number of treatment options for complex proximal tibia fractures.1 External fixation, combined with limited open techniques can potentially reduce complications but potentially limit the ability to obtain optimal reductions.2 Open plating techniques can allow a more precise reduction, but risk complications. When performing an open reduction and internal fixation (ORIF), the surgeon must consider choice of incision and approach(es) to achieve surgical goals while limiting complications as well as considering the need for future procedures.


Clinical comment


In patients with orthopedic injuries, it is often a challenge to decide amongst treatment options, as it is often unknown which treatments offer the lowest acceptable rate of complications, while still remaining a cost‐effective option. Treatment with ORIF with two plates inserted via an anterior or two incisions may have a higher complication and re‐operation rate. Patients often prefer to avoid the prolonged use of external devices as is necessary compared with limited ORIF with circular external fixator. There is insufficient evidence to definitively guide choice between ORIF, hybrid external fixation, and unilateral locked plating in proximal tibia fractures.


Available literature and the quality of the evidence


Level I: 2 prospective comparative trials were identified in the literature.


Level II: 1 meta‐analysis of both randomized and nonrandomized trials.


Findings


A trial from the Canadian Orthopaedic Trauma Society (COTS) compared closed/limited open reduction and circular external fixation with ORIF via midline or two‐incision methods using nonlocking implants.3 The patients were limited to high‐energy fractures classified as Schatzker 5/6 injuries (AO 41‐C). The authors identified Hospital for Special Surgery knee scores at two years postoperatively as their primary outcome with an a priori power calculated to predict a 25% difference with their sample size of 82 patients. There was no significant difference in HSS knee scores at two years (primary outcome) between groups (p = 0.31). However, the external fixation group was found to have a trend to earlier functional recovery with better HSS knee scores at six months postoperatively (p = 0.064). The ORIF group was found to have a 17% (8/40) infection rate versus 4.7% (2/43) in the external fixation group (p = 0.032). The ORIF group was found to have a larger number of unplanned procedures (37 vs 16, p = 0.001) which were often of significant magnitude, including one above‐knee amputation. Other secondary outcomes of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, quality of reduction, development of osteoarthritis, and Short Form 36 (SF‐36) scores were similar between groups.


Jiang et al. randomized 84 patients with bicondylar tibial plateau fractures to either double plating through two incisions or lateral locked plating with the LISS device.4 Some limitations of this study include concerns that details of the randomization process were not clear and that a priori primary and secondary outcomes were not discussed. However, a power calculation for HSS scores was presented, which is presumably the primary outcome. This group found no significant difference in HSS score at 12 or 24 months postoperatively (p = 0.215 and p = 0.84). They also found no significant difference in infection rate (2/43 using double plating vs 3/41 using LISS p = 0.96) or other complications.


A recent meta‐analysis was completed comparing patients receiving external fixation versus ORIF for complex tibial plateau fractures.5

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Nov 28, 2021 | Posted by in ORTHOPEDIC | Comments Off on Proximal Tibia Fractures

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