F Arnaout undertakes a systematic literature review
Abstract
Tibial plateau fractures are common injuries for which a unified approach to treatment and outcome assessment remains elusive. There have been concerns that the associated soft tissue injury may lead to wound complications after internal fixation. These concerns have led to the increased use of external fixation for complex fractures of the tibial plateau.
A systematic literature review of papers comparing these two techniques was performed. The Medline database was searched and the terms associated with tibial plateau fractures were inserted.
Twenty-three studies were retrieved but only three papers were comparative. The first study is a multi-centre RCT, the second one is a biomechanical study and the third one is case series.
External fixation has some advantages in terms of the soft tissues healing, but it has not demonstrated improved outcomes over internal fixation.
Introduction
Problem: A bicondylar tibial plateau fracture is defined as a fracture of both medial and lateral proximal tibial condyles involving the central articular surface, which supports the opposing femoral condyles.2
Tibial plateau fractures are often the result of blunt trauma and are associated with severe soft-tissue injury. Fixation techniques demand considerable surgical skills and mature judgment. The available surgical options do not always guarantee a favorable outcome.
Operative treatment includes internal and external fixation, hybrid fixation and arthroscopically assisted techniques. Operative management of high-energy fractures remains difficult and challenging and may be associated with serious complications: knee stiffness, ankylosis, deep infection, post-traumatic arthritis, mal-union and non-union. Prevention of the complications can optimise the clinical outcome in these patients.4
Incidence: Tibial plateau fracture is a common injury with an incidence of approximately 1% of all fracture and 9.2% of all tibial fractures. As an intra-articular fracture, it involves the medial or lateral or both tibial condyles. Bicondylar tibial plateau fractures are difficult to treat with a complication rate that varies from 20% to 70%.8
Current treatments: A non-operative approach with a hinged knee brace is indicated for minimally displaced fractures and in medically unfit or non-ambulatory patients. Current internal fixation techniques using open reduction, bone graft and plating techniques often with a locking plate provide the basis for internal fixation of these injuries.
New treatments: Standard open reduction and internal fixation techniques have been successful in restoring osseous alignment for bicondylar tibial plateau fractures. However, surgical morbidity, especially soft-tissue infection and wound necrosis, has been frequently reported. When extensive comminution and damaged soft tissues prohibit their use, external fixators provide an excellent fallback option for their management. For this reason, several investigators have proposed minimally invasive methods of fracture reduction followed by circular external fixation as an alternative approach.
Consequences: The results of treatment are dependent on the amount of intra-articular comminution, the presence or absence of a step deformity on the weight-bearing surface, and residual angulation deformity. Inappropriately treated fractures could lead to soft tissue infection, necrosis, and knee stiffness.6
