Patients with complex proximal tibial fractures overestimate the prognosis of their injury

Low rate of secondary interventions for post-traumatic osteoarthritis and satisfactory mid-to-long-term outcomes following tibial plateau fractures

BACKGROUND

The purpose of this study was to quantify the incidence of total knee arthroplasty (TKA) and other osteoarthritis-related procedures following surgical and conservative treatment of tibial plateau fractures (TPF). Secondary goal was to analyse the long-term clinical outcomes and identify risk factors for secondary interventions and poor outcomes.

METHODS

All patients diagnosed with TPF at a single level 1 university trauma centre between January 1, 2008 and December 31, 2016 were retrospectively reviewed. Clinical outcomes were measured by use of the Knee injury and Osteoarthritis Outcome Score (KOOS), the International Knee Documentation Committee Score (IKDC) and the Tegner Activity Score (TAS). Joint-preserving interventions and conversions to TKA were recorded as well as demographic data, injury mechanisms, treatment specifics and complications.

RESULTS

105 cases of TPF, 89 with surgical and 16 with conservative treatment, with a median follow-up of 10.4 years (interquartile range, IQR 9-13), were included. The conversion rate to TKA was 2%, with all cases occurring in the conservative treatment group. 9% underwent a joint-preserving intervention. Higher body mass index (BMI) was associated with an increased risk for secondary intervention (HR 1.4, p = 0.03). The overall KOOS was 78.7 (IQR 69-87) for surgical and 86 (IQR 70-93) for conservative treatment. The IKDC score was 63.6 ± 16.5 for surgical and 66.3 ± 22.2 for conservative treatment and the median TAS was 3 (IQR 3-4 vs. 3-6) for both groups. In the surgical treatment cohort, a negative correlation was found between Schatzker classification (Spearman´s rp = -0.24, p = 0.03), duration of surgery (Spearman´s rp = -0.23, p = 0.03), American Society of Anesthesiologists (ASA) risk classification (Spearman´s rp = -0.28, p = 0.01) and the IKDC score. A higher TAS was observed for non-smokers (median 3, IQR 3-4) compared to smokers (median 2.5, IQR 2-3, p = 0.02).

CONCLUSIONS

There was a low incidence of TKA and joint-preserving, osteoarthritis-related procedures following TPF. Both conservative and surgical treatments can achieve satisfactory long-term clinical outcomes, when appropriately indicated. Obese patients are at increased risk for secondary interventions. The expectations of patients with a higher ASA risk score and complex fractures, accompanied by longer surgical times, should be managed carefully to ensure a realistic outlook on functional outcomes.

Fulfillment of expectations and patient satisfaction following surgical treatment of complex proximal tibial fractures

AIM

The aim of this study was to investigate on fulfillment of expectations and patient satisfaction after surgical treatment of complex proximal tibial fractures.

METHODS

In this prospective study 114 patients who suffered a complex tibial fracture (AO/OTA-Type B and C) were enrolled. At follow-up, based on the Hospital For Special Surgery-Knee Surgery Expectations Survey (HFSS-KSES), an individualized questionnaire was used to evaluate whether the preoperative formulated expectations had been fulfilled. In addition, condition of the knee joint (rated 0-4), overall satisfaction (rated 0-4) with the outcome, the Knee injury and Osteoarthritis Outcome Score (KOOS), and SF-12 was used.

RESULTS

Fulfillment of expectations for abilty to run, to knee, and regain an intact status of the knee joint performed worst in the HFSS-KSE. Highest fulfillment was reached for psychological well-being and to interact socially. No statistical difference was found between the two fracture groups (AO/OTA-Type B vs. C). In the study cohort n = 81 patients (83.5%) were satisfied or very satisfied with the outcome. Mean satisfaction in the study cohort was 3.5. Satisfaction correlated highly significant with all items of the HFSS-KSE survey. Results vary in the different fracture groups. Satisfaction also correlates highly significant with the condition of the knee joint as well as with all dimensions of the KOOS score and the PCS of the SF-12 survey.

CONCLUSION

In patients who suffered a complex proximal tibial fracture, fulfillment of preoperative expectations is only limited. Nevertheless, overall satisfaction with the outcome is high, and correlates to a high degree with fulfillment of joint functionality and current health status. The fracture type does not influence these results.

Return to Skiing After Proximal Tibial Fracture: Postoperative Reality and Initial Expectations

Background/Objectives: The aim of this study was to investigate patient-reported outcomes of patient expectations and fulfillment of expectations in alpine skiers who had a skiing accident and suffered a complex proximal tibial fracture (AO/OTA-Type B or C) which was treated surgically with open reduction and internal fixation. Methods: In this prospective study, 38 consecutive patients who suffered a complex tibial fracture (AO/OTA-Type B and C) caused by a skiing accident were evaluated. Before surgical treatment with open reduction and internal fixation, patient expectations were evaluated regarding outcomes on knee functionality (e.g., pain) and the return to skiing. At follow-up ≥ 1 year after surgery, an individualized questionnaire was used to evaluate whether their preoperatively formulated expectations had been fulfilled (rated 0-2). In addition, the Knee injury and Osteoarthritis Outcome Score (KOOS), and SF-12 was used. Results: Preoperatively, 76% (n = 29) of patients stated that it was "not so important" to be able to return to their initial skiing level, 50% (n = 19) of patients did not expect to be able to ski again, 34% (n = 13) expected to return to skiing at a significantly lower level, and 16% (n = 6) expected to return to skiing with minor restrictions at most. Postoperatively, the return to skiing rate on initial level was 32% (n = 12); 50% (n = 19) stated that their initial skiing level was not reached again but they were able to ski with moderate restrictions, 10% (n = 4) patients stated that no return to skiing was possible, 50% (n = 19) stated that their expectations were fully met, and n = 7 (18%) stated that their preoperative expectations were not met at all. The mean SF-12 physical component score (PCS) was 52, and the mean mental component score (MCS) was 49.9. The mean Numeric Rating Scale (NRS) was 2.3. The mean KOOS for pain was 86.1 (SD 17.1), for symptoms 62.2 (SD 12.9), for ADL 90.7 (SD 14.4), for sports 74.2 (SD 25.7), and for quality of life (QOL) 66.6 (21.0). Conclusions: After suffering from a complex proximal tibial fracture (AO/OTA-Type B or C) in a skiing accident, preoperative patient expectations to return to skiing is limited. This patient-reported outcome of patient expectations was confirmed by the findings of the patient-reported fulfillment of expectations at least one year after surgery as only 32% of patients returned to their initial skiing level, 50% returned to skiing with limitations, and 50% of patients did not meet their preoperative expectations to return to alpine skiing. The results of this study emphasize the importance of directing patients towards realistic expectations by managing the patients' understanding of the severity of their injury and realistic outcomes, and providing realistic forecasts of postoperative outcomes.

Patient-Reported Outcomes following Tibial Plateau Fractures: Mid- to Short-Term Implications for Knee Function and Activity Level

Background: Patients with complex proximal tibial plateau fractures (TPFs) tend to overestimate the prognosis of their injury, potentially due to factors such as a limited understanding, optimism, and the influence of the pain intensity. Understanding the reasons behind this misperception is crucial for healthcare providers to effectively communicate with patients and establish realistic expectations for treatment outcomes. The purpose of this study was to analyze the outcomes of TPFs, with a particular focus on patient-reported outcome measures concerning functional recovery, pain levels, and overall satisfaction with treatment. The authors aim to provide valuable insights into the realistic expectations and potential limitations that patients may encounter during their recovery journey. Methods: In this retrospective single-center study, all surgically treated TPFs between January 2014 and December 2019 with a minimum follow-up of 12 months were included. Several patient-reported outcome measures were obtained, including the International Knee documentation Committee Score (IKDC), Lyholm score, Tegner score, and visual analog scale (VAS) for pain. Fractures were classified according to Schatzker, and then subgrouped into simple (Schatzker I-III) and complex (Schatzker IV-VI) fractures. Results: A total of 54 patients (mean age 51.1 ± 11.9 years, 59.3% female) with a mean follow-up time of 3.9 years were included. Schatzker II fractures were present in 48% (n = 26) of the cases, with Schatzker III in 6% (n = 3), Schatzker IV fractures in 6% (n = 3), and Schatker VI fractures in 41% (n = 22) of the cases. All outcome scores showed a significant improvement between the first year after surgery and the last follow-up (mean: 3.9 years). Simple fractures showed significantly lower patient-reported outcomes when compared to the preinjury state; however, good to excellent results were observed. Patient-reported outcomes of complex fractures showed no significant changes in the study period with good to excellent results. When it comes to the Lysholm score, there were no significant differences in the outcome between simple and complex fractures. Furthermore, there was a return-to-sports rate of 100%, with high rates of changing sporting activity in 25% (simple fractures) and 45% in complex fractures. Conclusions: The data from this study showed that both simple and complex tibial plateau fractures show favorable outcomes at the midterm follow-up, and that injury severity does not correlate with worse results. While patients may tend to overestimate the recovery speed, this research highlights the importance of long-term follow-up, demonstrating a substantial improvement between one year post-surgery and the final evaluation. Return-to-sports rates were high, with adjustments needed for certain activities. However, patients should recognize the need to shift to lower-impact sports and the lengthy recovery process.

Do Patients Achieve "Full Weight-bearing" Immediately Following Application of Circular Frame Fixation of the Lower Limb?

Introduction

The decision to use circular frame fixation for lower limb trauma, or elective deformity correction, often accompanies the assertion that the patient will be able to fully weight-bear through the limb immediately following surgery.

Materials and methods

About 53 patients underwent retrospective review. Included in the study were current attendees of adult specialist physiotherapy, following circular frame application to the lower leg at our Institution between August 2018 and January 2020. Cases with incomplete data, cases given postoperative status of non-weight-bearing, those with physiotherapy follow-up conducted elsewhere, or cases of polytrauma were excluded from the study.Weight-bearing assessment and rehabilitation supervision were at the discretion of the physiotherapy team. The clinical concept of 'full weight-bearing' is poorly defined, but was documented in the context of displaying a stable gait using elbow crutches and subsequently without walking aids. Comparative data was analysed using an unpaired, two-tailed Welch's t-test.

Results

Mean postoperative time to full weight-bearing using crutches was 28.3 days (0-159) (n = 40).Mean postoperative time to independent full weight-bearing with no walking aids was 230.6 days (35-393), or 7.1 months (0-12) (n= 34).No significant differences were seen between:Frames for open injuries (n= 5) vs closed injuries (n = 17; p > 0.4).Joint-spanning constructs (n= 18) vs non-spanning constructs (n = 21; p > 0.6), orTreatment of intra-articular injuries (n = 14) vs extra-articular injuries (n = 17; p > 0.2).Interpretation of these results should be made with caution due to sample size.

Conclusion

The ability to permit patients to fully weight-bear immediately after surgery is often a distinct advantage of the circular frame over other fixation modalities, for a variety of indications. However, it does not follow that patients are capable of doing so; there is a long dependency on walking aids. This would appear to be the case irrespective of open/closed injuries, intra-/extra-articular injuries, or the use of a spanning construct across the knee or ankle.

How to cite this article

Craig A, Barron E, Sharma H, et al. Do Patients Achieve "Full Weight-bearing" Immediately Following Application of Circular Frame Fixation of the Lower Limb? Strategies Trauma Limb Reconstr 2024;19(1):40-44.

Return to Skiing After Tibial Plateau Fracture

Background

Tibial plateau fractures in skiers are devastating injuries with increasing incidence. Few studies have evaluated patient-reported outcomes and return to skiing after operative fixation of a tibial plateau fracture.

Purpose

To (1) identify demographic factors, fracture characteristics, and patient-reported outcome measures that are associated with return to skiing and (2) characterize changes in skiing performance after operative fixation of a tibial plateau fracture.

Study Design

Case series; Level of evidence, 4.

Methods

We reviewed all operative tibial plateau fractures performed between 2016 and 2021 at a single level-1 trauma center. Patients with a minimum of 10-month follow-up data were included. Patients who self-identified as skiers or were injured skiing were divided into those who returned to skiing and those who did not postoperatively. Patients were contacted to complete the Patient-Reported Outcomes Measurement Information System-Physical Function domain (PROMIS-PF), the Knee injury and Osteoarthritis Outcome Score-Activities of Living (KOOS-ADL), and a custom return-to-skiing questionnaire. Multivariate logistic regression was performed with sex, injury while skiing, PROMIS-PF, and KOOS-ADL as covariates to evaluate factors predictive of return to skiing.

Results

A total of 90 skiers with a mean follow-up of 3.4 ± 1.5 years were included in the analysis. The rate of return to skiing was 45.6% (n = 41). The return cohort was significantly more likely to be men (66% vs 41%; P = .018) and injured while skiing (63% vs 39%; P = .020). In the return cohort, 51.2% returned to skiing 12 months postoperatively. The percentage of patients who self-reported skiing on expert terrain dropped by half from pre- to postinjury (61% vs 29.3%, respectively). Only 78% of return skiers had regained comfort with skiing at the final follow-up. Most patients (65%) felt the hardest aspect of returning to skiing was psychological. In the multivariate regression, the male sex and KOOS-ADL independently predicted return to skiing (P = .006 and P = .028, respectively).

Conclusion

Fewer than half of skiers who underwent operative fixation of a tibial plateau fracture could return to skiing at a mean 3-year follow-up. The knee-specific KOOS-ADL outperformed the global PROMIS-PF in predicting a return to skiing.

[Primary total knee arthroplasty following trauma]

BACKGROUND

Primary total knee arthroplasty following complex knee joint trauma is only performed occasionally. In most cases a reconstruction is carried out.

OBJECTIVE

Are there confirmed indications for primary total knee arthroplasty following trauma? Which special features should be paid attention to?

MATERIAL AND METHODS

A selective literature search was carried out. The spectrum of indications and recommendations for action for primary total knee arthroplasty following trauma are presented, particularly against the background of demographic changes.

RESULTS

The spectrum of indications for primary total knee arthroplasty following trauma is limited. This has so far been carried out only in centers with the appropriate equipment and expertise, also for the management of complications but despite good overall results is still carried out only rarely. There is a lack of studies with large patient collectives.

CONCLUSION

Primary total knee arthroplasty following trauma is a safe procedure within the range of indications. The standard procedure for the vast majority of cases of complex knee trauma is a reconstruction.

[Change in the treatment of tibial plateau fractures]

BACKGROUND

The treatment of tibial plateau fractures has experienced a number of very different conceptual developments in recent years, not only with respect to technical innovations but also against the background of changing fracture patterns and the growing requirements of patients.

OBJECTIVE

What developments in recent years have had a significant impact on current treatment strategies for tibial plateau fractures?

METHODS

Narrative review of publications listed in PubMed on the topic of treatment of complex tibial plateau fractures.

RESULTS

While the two-dimensional classifications are becoming less important, computed tomography (CT)-based three-dimensional assessment of fracture progression and an access strategy based on it are coming to the fore. Direct dorsal approaches have been shown to be superior, particularly in the case of relevant posteromedial and/or posterolateral fracture involvement. The step-by-step approach extension via specific osteotomies of ligamentous attachments also enables a needs-dependent and fracture-dependent complete joint visualization and reduction control. In the treatment of geriatric tibial plateau fractures, primary treatment with endoprostheses is becoming increasingly more important to enable early mobilization under full load bearing with significantly shorter rehabilitation times.

CONCLUSION

Modern developments in the context of fracture treatment around the tibial plateau have led to a relevant reduction of infections and improved surgical outcomes; however, the high demands and the improved understanding of fractures still underline the great challenge in the treatment of complex fracture patterns.