Long-term outcome after surgical treatment of intra-articular tibial plateau fractures in skiers

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.

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.

Long-term sequelae of septic arthritis after tibial plateau fracture fixation: does timing matter?

INTRODUCTION

Septic arthritis following surgical treatment of a tibial plateau fracture is a rare complication, but it does occur, and the impact on long-term function is relatively unknown. The purpose of this study was to determine the long-term sequelae of septic arthritis among patients treated with internal fixation for a tibial plateau fracture and to determine the effect of timing (early or late infection) on the rate of such sequela.

MATERIALS AND METHODS

A retrospective comparative study was designed using the trauma database of a single level I academic trauma center. Patients who developed culture-positive septic knee arthritis after internal fixation of a tibial plateau fracture, with 1-year follow-up, were included in the study. The number of debridement procedures required was recorded. Rates of long-term complications and implant removal were identified. Complications rates were compared between patients who developed early (within 30 days of definitive fixation) and late (more than 30 days) septic arthritis.

RESULTS

The mean number of debridement procedures per patient was six. Fourteen patients (88%) required implant removal, and thirteen (81%) developed knee arthritis. There was a significantly lower rate of complications in the early septic arthritis group compared to the late group (3 of 6 patients or 50%, vs 10 of 10 patients or 100%; p = 0.036).

CONCLUSIONS

Patients who developed septic arthritis following internal fixation of a tibial plateau fracture were likely to endure long-term sequelae. Early infection and detection led to fewer complications. Surgeons treating infectious complications in tibial plateau fracture patients should specifically seek to rule out septic arthritis, anticipate that implant removal may be necessary, and counsel these patients appropriately regarding the anticipated natural history of their condition.

LEVEL OF EVIDENCE

III.

Clinical and radiographic results after arthroscopic repair of lateral meniscus tear in lateral-depression tibial plateau fracture

INTRODUCTION

To evaluate the clinical and radiographic results of AR/IF and meniscus repair for treating lateral meniscus (LM) tears associated with lateral tibial plateau fractures and to identify the factors associated with LM tear.

MATERIALS AND METHODS

Forty-two patients with lateral plateau fractures (Schatzker types II and III) treated by AR/IF were included retrospectively. Radiographic evaluations using the Rasmussen system and computerized tomography (CT) were performed. Clinical evaluations were also conducted at final follow-up. Second-look arthroscopy was applied during metal removal.

RESULTS

All fractures were healed after 46.3 months of follow-up. The mean Tegner activity level was not decreased significantly, going from 7.1 ± 2.1 pre-injury to 6.6 ± 2.3 at final follow-up (p = 0.301). However, the amount of depression noted on CT imaging was significantly decreased from 8.9 mm ± 4.4 to 1.2 mm ± 1.3 (p = 0.000). The mean Rasmussen radiologic score at final follow-up was 14.5 ± 5.3 points. Osteoarthritis was progressed in six patients (14.3%). Twenty-five patients had concomitant LM tear, with 18 cases treated by repair and the remaining ones treated by partial meniscectomy. Preoperative joint depression (> 11 mm) was significantly associated with the risk of LM tear (p = 0.024; odds ratio (OR): 9.0, 95% confidence interval (CI): 1.018-79.545) and most of those lesions could be repaired (p = 0.001). Postoperatively, 16 repaired patients were evaluated by second-look arthroscopy; 15 had healed completely and one had healed partially.

CONCLUSION

LM tears are frequently combined with lateral tibial plateau fracture, especially in correlation with more than 11 mm of joint depression, though most of those lesions can be repaired at the time of fracture fixation. AR/IF with arthroscopic meniscus repair could achieve good clinical and radiographic outcomes when treating Schatzker types II and III tibial plateau fractures.

STUDY DESIGN

Level IV retrospective cohort study.

Does Time to Theatre Affect the Ability to Achieve Fracture Reduction in Tibial Plateau Fractures?

Surgical management of displaced tibial plateau fracture (TPF) is often delayed due to accompanying soft tissue injuries sustained at the time of injury. The primary aim of this study was to assess the effect of time to surgery on fracture reduction in cases of TPF. The secondary aim was to assess the effect of preoperative demographics and residual articular step on Lysholm Scores and Knee Injury and Osteoarthritis Outcome Scores (KOOS) following fixation. Patients between 2006 and 2017, managed by a single surgeon, were prospectively enrolled in the study. Reduction of articular step, defined as <2 mm, was assessed by a single blinded examiner. A total of 117 patients were enrolled, 52 with Schatzker II, 4 with Schatzker IV, and 61 with Schatzker VI fractures. Patients were followed up to a mean of 3.9 years. Analysis showed that the ability to achieve fracture reduction was negatively influenced by time to theatre, with the odds of achieving reduction decreasing 17% with each subsequent day post injury (p = 0.002). Furthermore, an increased time to theatre was associated with a reduced Lysholm score at one year (p = 0.01). The ability to achieve fracture reduction did not influence PROMs within the study period. We conclude that delay in surgical fixation negatively affects fracture reduction in TPF and may delay recovery. However, residual articular step does not necessarily influence PROMs over the mid-term.

Complex Tibial Plateau Fractures Treated with a Hybrid External Fixator – Long Term Results

Introduction: High energy tibial plateau fractures represent a challenge because of the combined bone and soft tissue injury. The iatrogenic impact can further increase the likelihood for crippling complications. Less invasive treatment protocols have been developed to improve the results.

Objective: We present the long-term results of limited internal fixation combined with a small wire external fixator.

Patients and Methods: Fourteen patients were followed for at least 10 years. Initial and final functional results, complications and presence of joint degeneration were registered according to validated rating scores.

Results: Of all patients included in the study, thirteen showed an excellent initial rating and one had an average result at baseline. 10 years later, eight patients still showed excellent grading results, four – good ones, one – average and one – poor results. Ten knees (71%) had osteoarthritis. Postphlebitic syndrome was diagnosed in two cases. Three knees showed medio-lateral instability, one showed a varus and one – a valgus deformity. Knee arthroplasty was performed in one case.

Conclusion: The limited internal fixation combined with a hybrid ex fix can be considered as an alternative to the ORIF, especially when the soft tissues are severely compromised. Despite the inevitable joint degeneration, the associated overall morbidity is low and the long term function is quite satisfactory.

Intraoperative 3D imaging in intraarticular tibial plateau fractures - Does it help to improve the patients' outcomes?

BACKGROUND

In tibial plateau fractures (TPF) the restoration of an anatomical joint surface as well as an exact subchondral screw position for postoperative stability is crucial for the outcome. The aim of this study was to determine whether the additional use of an intraoperative 3D imaging intensifier (3D) might help to improve the outcome of complex TPF.

METHODS

We performed a retrospective case-control study of a level 1 trauma center. Patients with AO/OTA 41 B3 and C-TPF operated on using a 3D imaging intensifier between November 2015 and December 2018 (3D group) were included. The outcomes of this patients were compared to patients operated without 3D imaging between January 2005 to December 2014 (2D group). The comparison of the groups was performed by matched pair analysis. The functional outcome of both groups was measured by KOOS and Lysholm Score after a follow-up period of at least 12 months. Operation time, infections and postoperative revisions were registered.

RESULTS

In total, 18 patients were included in the 3D group (mean age: 51.0± 16.4 years; 12 females) and an equal number of matching partners from the 2D group (mean age: 50.3± 15.2 years; 11 females) were found (p=0.82; p=0.79). We found 9x B3, 2x C1, 1x C2, 6x C3 fractures according to AO/OTA for each group (p=1.00) with comparable ASA score (p=0.27). The mean operation time was 127.9± 45.9 min and 116.1± 45.7 min for the 3D and 2D group (p=0.28). The mean follow-up time was 20.9± 10.7 months for the 3D and 55.5± 34.7 months for the 2D group (p< 0.001). For the 3D group a mean Lysholm overall score of 67.4± 26.8 and KOOS overall score of 72.6± 23.5 could be assessed. In contrast, a mean Lysholm overall score of 62.0± 21.4 and KOOS overall score of 65.8± 21.6 could be measured in the 2D group (p=0.39; p=0.31). Thereby, functional outcome of the 3D group showed a significant higher KOOS Sport/Rec sub score of 54.7± 35.0 in comparison to the 2D group with 26.7± 31.6 (p= 0.01). Postoperative revisions had to be performed in 27.8% of cases in both groups (p=1.00). Due to the 3D imaging an intraoperative revision was performed in 33.3% (6/18).

CONCLUSION

In our study we could show that re-reduction of the fracture or implant re-positioning were performed in relevant numbers based on the 3D imaging. This was associated with a midterm clinical benefit in regard to better KOOS Sport/Rec scores.

TRIAL REGISTRATION

AZ 488 /20-ek.

Delayed but favourable outcome of lateral tibial plateau fracture after screw fixation: A 3-year prospective cohort study of 56 patients

BACKGROUND

Although a large number of studies aimed to investigate the outcome following lateral tibial plateau fractures, the literature includes limited information on mid- to long-term follow up. The primary objective of the present study was to investigate the 3-year development in Knee Injury and Osteoarthritis Outcome Score (KOOS₅) of patients with surgically managed lateral tibial plateau fractures.

METHODS

Prospective cohort study. The study includes all patients treated surgically following a lateral tibial plateau fracture (AO-41B) in the period December 2013 to November 2016. The primary outcome measurement was the patient-reported KOOS₅ score. Secondary outcome measurements were quality of life, knee osteoarthritis, muscle strength, pain reactions, and gait function.

RESULTS

Fifty-six patients were included. Thirty-nine patients were eligible for the 3-year follow up (70%). The mean age at the time of the 3-year follow up was 58.3 years with a range of 25-89. The 3-year postoperative mean KOOS₅ scores were 75.5 (95% confidence interval: 68.6-82.3). Compared with the KOOS₅ score at 12-month follow up (61.3), a significant increase was observed (P > 0.001). In comparison with the established KOOS reference population, the study population showed statistically worse KOOS outcomes only for the subscale sport.

CONCLUSIONS

Patient-reported outcome (KOOS₅) among patients with a fracture of the lateral tibial plateau increased significantly between the 1-year and 3-year follow ups. In contrast to the 1-year follow up, patients at the 3-year follow up reported results comparable to those of a healthy reference population, excluding the Sport subscale. Guiding the patients in anticipation of a prolonged recovery period is highly important in everyday clinical practice.

Bone metabolism is a key factor for clinical outcome of tibial plateau fractures

Purpose

Given that tibial plateau fractures (TPF) are rare, they may pose a challenge to the treating surgeon due to their variety of complex fracture patterns. Numerous studies have identified potential fracture-specific, surgery-related, and patient-related risk factors for impaired patient outcomes. However, reports on the influence of bone metabolism on functional outcomes are missing.

Methods

In a retrospective multicenter cohort study, 122 TPF of 121 patients were analyzed with respect to radiological and clinical outcomes (Rasmussen) with a mean follow-up of 35.7 ± 24.9 months. The risk factor assessment included bone metabolism-affecting comorbidities and medication.

Results

The findings showed that 95.9% of the patients reported a good-to-excellent clinical outcome, and 97.4% reported a good-to-excellent radiological outcome. Logistic regression revealed that potentially impaired bone metabolism (IBM) was an independent risk factor for the clinical (p = 0.016) but not the radiological outcome (Table 4). Patients with 41-type B fractures and a potential IBM had a seven times higher risk to present a fair-to-poor clinical outcome [OR 7.45, 95 CI (4.30, 12.92)]. The most common objective impairment was a limited range of motion in 16.4% of the patients, especially in 41-type C fractures (p = 0.06). The individual failure analysis additionally identified surgery-related options for improvement.

Conclusion

This study demonstrated that potential IBM was an independent risk factor for a poor-to-fair clinical outcome.