Surgical fixation methods for treating tibial plateau fractures (breaks in the top end of the shin bone) in adults

What is the medical problem?
Fractures of the tibial plateau are injuries affecting the top end of the tibia (shin bone), which forms the lower bone surface in the knee joint. These fractures are often associated with a large amount of damage to the skin and muscle and may cause voids or defects in the bone.

What treatments are available?
Often, complex fractures are set surgically through open reduction and internal fixation (ORIF), which entails exposing the fracture to direct view and then fastening the bone fragments into place with metal plates and screws. Another method is external fixation, where wires and pins are placed into the bone around the fracture site to secure the fragments in place until they heal. External fixation can be coupled with the use of small plates or screws to hold some of the fracture fragments in position; this is called hybrid fixation.

To correct possible bone defects, bone void fillers, either bone grafts taken from the patients themselves or bone substitutes, may be used.

What evidence is available?
We found six small studies (involving 429 adults) of different fixation methods and bone fillers in September 2014. All six trials were small and at substantial risk of bias. We judged the quality of most of the available evidence to be very low, meaning that we are very uncertain about these results

Three studies evaluated different methods of fixation. One study found that hybrid fixation is more likely to result in better quality of life and lower-limb function, fewer complications requiring repeat surgery, and more people returning to pre-injury activity levels than standard ORIF. However, the possibility of a better result from ORIF could not be ruled out. Another study compared a minimally invasive, single-plate technique with a traditional open technique using two plates. This study found very little difference between the two groups in knee function, complications or reoperations. The third study compared arthroscopic surgery (which uses a tiny camera to visualise the joint) and internal fixation versus ORIF. It reported better functional outcome and knee mobility in the arthroscopy group. There were no reoperations.

Three studies compared different bone substitutes versus bone grafts for managing bone defects, but reported on only a few outcomes. One study found similar results in the two groups in the numbers of participants with good walking, stair climbing, squatting and jumping ability at one year. All three studies found similar numbers of specific complications in the two groups. One study found that all participants in the bone graft group had prolonged pain from the harvest site of the bone graft. Two studies reported similar range of motion results in the two groups, whereas the third study found better results in the bone substitute group at one year.

Conclusions
Currently, there is insufficient evidence to ascertain the best surgical methods of fixation and bone defect treatment for tibial plateau fractures in adults. Well-conducted trials are still needed to inform clinical decision-making.

Authors' conclusions: 

Currently, there is insufficient evidence to ascertain the best method of fixation or the best method of addressing bone defects during surgery. However, the evidence does not contradict approaches aiming to limit soft-tissue dissection and damage or to avoid autograft donor site complications through using bone substitutes. Further well-designed, larger randomised trials are warranted.

Read the full abstract...
Background: 

Fractures of the tibial plateau, which are intra-articular injuries of the knee joint, are often difficult to treat and have a high complication rate, including early-onset osteoarthritis. Surgical fixation is usually used for more complex tibial plateau fractures. Additionally, bone void fillers are often used to address bone defects caused by the injury. Currently there is no consensus on either the best method of fixation or bone void filler.

Objectives: 

To assess the effects (benefits and harms) of different surgical interventions, and the use of bone void fillers, for treating tibial plateau fractures.

Search strategy: 

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (12 September 2014), the Cochrane Central Register of Controlled Trials (2014 Issue 8), MEDLINE (1946 to September Week 1 2014), EMBASE (1974 to 2014 Week 36), trial registries (4 July 2014), conference proceedings and grey literature (4 July 2014).

Selection criteria: 

We included randomised and quasi-randomised controlled clinical trials comparing surgical interventions for treating tibial plateau fractures and the different types of filler for filling bone defects.

Data collection and analysis: 

Two review authors independently screened search results, selected studies, extracted data and assessed risk of bias. We calculated risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CIs). Only very limited pooling, using the fixed-effect model, was possible. Our primary outcomes were quality of life measures, patient-reported outcome measures of lower limb function and serious adverse events.

Main results: 

We included six trials in the review, with a total of 429 adult participants, the majority of whom were male (63%). Three trials evaluated different types of fixation and three analysed different types of bone graft substitutes. All six trials were small and at substantial risk of bias. We judged the quality of most of the available evidence to be very low, meaning that we are very uncertain about these results.

One trial compared the use of a circular fixator combined with insertion of percutaneous screws (hybrid fixation) versus standard open reduction and internal fixation (ORIF) in people with open or closed Schatzker types V or VI tibial plateau fractures. Results (66 participants) for quality of life scores using the 36-item Short Form Health Survey (SF-36)), Hospital for Special Surgery (HSS) scores and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function scores tended to favour hybrid fixation, but a benefit of ORIF could not be ruled out. Participants in the hybrid fixation group had a lower risk for an unplanned reoperation (351 per 1000 people compared with 450 in the ORIF group; 95% CI 197 fewer to 144 more) and were more likely to have returned to their pre-injury activity level (303 per 1000 people, compared with 121 in the ORIF group; 95% CI 15 fewer to 748 more). Results of the two groups were comparable for the WOMAC pain subscale and stiffness scores, but mean knee range of motion values were higher in the hybrid group.

Another trial compared the use of a minimally invasive plate (LISS system) versus double-plating ORIF in 84 people who had open or closed bicondylar tibial plateau fractures. Nearly twice as many participants (22 versus 12) in the ORIF group had a bone graft. Quality of life, pain, knee range of motion and return to pre-injury activity were not reported. The trial provided no evidence of differences in HSS knee scores, complications or reoperation entailing implant removal or revision fixation. A quasi-randomised trial comparing arthroscopically-assisted percutaneous reduction and internal fixation versus standard ORIF reported results at 14 months in 58 people with closed Schatzker types II or III tibial plateau fracture. Quality of life, pain and return to pre-injury activity were not reported. There was very low quality evidence of higher HSS knee scores and higher knee range of motion values in the arthroscopically assisted group. No reoperations were reported.

Three trials compared different types of bone substitute versus autologous bone graft (autograft) for managing bone defects. Quality of life, pain and return to pre-injury activity were not reported. Only one trial (25 participants) reported on lower limb function, finding good or excellent results in both groups for walking, climbing stairs, squatting and jumping at 12 months. The incidences of individual complications were similar between groups in all three trials. One trial found no cases of inflammatory response in the 20 participants receiving bone substitute, and two found no complications associated with the donor site in the autograft group (58 participants). However, all 38 participants in the autologous iliac bone graft group of one trial reported prolonged pain from the harvest site. Two trials reported similar range of motion results in the two groups, whereas the third trial favoured the bone substitute group.

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