Copyright © 2006 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
J. Lawrence Marsh, MD*,
University of Iowa Hospitals and Clinics, Iowa City, Iowa
Posted August 3, 2006
In this retrospective case series, Barei et al report on the most difficult-to-treat group of proximal tibial fractures—bicondylar fractures with AO/OTA type C-3 comminution. The results demonstrate that experienced surgeons at a high-volume center can treat these fractures with medial and lateral plate fixation with an acceptably low infection rate. Factors that may have been important include the use of spanning external fixation, appropriate timing of surgical intervention, and use of direct nonextensile approaches through two widely spaced incisions. Severe infections still developed in approximately 5% of patients. These types of fractures are notoriously difficult to treat, despite the generally favorable results of this study.
Current plate-fixation strategies have largely evolved to
the use of laterally based locking plates without a medial plate. Advantages of
single-sided plating are that less soft-tissue dissection occurs and the blood
supply is better preserved. The fixed-angle screws also increase stability. It
remains to be seen whether lateral locked plates alone can maintain coronal and
sagittal alignment in medially comminuted fractures such as those included in
this series. Unfortunately, the current study will not provide a good benchmark
because only the preoperative, intraoperative, and immediate postoperative
radiographs were assessed.
The only study outcome measure was the Musculoskeletal
Function Assessment (MFA) questionnaire, which was completed either by mail or,
if that was not possible, during the most recent clinic visit or during a
telephone interview. This represents one of the limitations of this study. With
almost five years of average follow-up, it would have been very interesting and
informative to know the number of patients who required repeat operations, the final
knee range of motion, the pain and function states, and the subsequent radiographic
assessment. The lack of this information highlights the obstacles to medium and
long-term follow-up of patients with traumatic injuries.
The MFA was correlated with characteristics of the patients,
the fracture, and the initial treatment. Less satisfactory outcomes were found
in older patients and in those with other associated injuries. The effect of
other injuries on the MFA is not surprising, considering that the MFA is a
general instrument and not a knee-specific instrument and that older patients
have previously been shown to have less satisfactory recovery after tibial
plateau fractures1.
The severity of initial injury was stratified with use of
the rank-order technique to avoid problems with reliability of fracture
classification. Fractures were ranked in order of severity, with a relatively
high interobserver agreement (weighted kappa = 0.66) between two experienced
clinicians and robust enough statistical power to demonstrate a positive
correlation between the severity of the injury and the MFA questionnaire. The
worse the fracture was, the worse was the outcome. While this finding seems
intuitive and logical, without the type of analysis the authors performed, this
simple association would be difficult to demonstrate in a series of severe
fractures.
The accuracy of articular reduction, as measured on postoperative
radiographs, correlated with the MFA, but these assessments did not tightly
correlate with the injury severity rank. This finding suggests that the
reduction, regardless of the severity of the injury, has an effect on outcome. To
detect this effect on a general musculoskeletal outcome measure not focused on
the knee in such a small series of patients is surprising, since the proximal aspect
of the tibia, compared with other joints, has been shown to be relatively tolerant
of residual displacement after fractures of the articular surface2.
There are some issues that potentially confound these data. Since
only immediate postoperative films were analyzed in this study, secondary
displacement of the articular surface, which commonly occurs at the tibial
plateau, may have occurred without having been accounted for3. In
addition, the interobserver tolerance of the measurement of reduction was not
tested. When different observers measure articular steps and gaps on
radiographs, there is a surprising variation in the estimations of gaps and
comminution, especially when there is hardware on both sides4,5.
Overall, by highlighting the treatment of a very challenging
group of patients and the difficulties of performing clinical research and by
trying to answer some very basic questions, these authors have provided
important and stimulating information.
*The author did not receive grants or outside funding in
support of his research for or preparation of this manuscript. He did not
receive payments or other benefits or a commitment or agreement to provide such
benefits from a commercial entity. No commercial entity paid or directed, or
agreed to pay or direct, any benefits to any research fund, foundation,
educational institution, or other charitable or nonprofit organization with
which the author is affiliated or associated.
References
1. Stevens DG, Beharry R, McKee MD, Waddell JP, Schemitsch EH. The long-term functional outcome of operatively treated tibial plateau fractures. J Orthop Trauma. 2001;15:312-20.
2. Marsh JL, Buckwalter J, Gelberman R, Dirschl D, Olson S, Brown T, Llinias A. Articular fractures: does an anatomic reduction really change the result? J Bone Joint Surg Am. 2002;84:1259-71.
3. Ali AM, El-Shafie M, Willett KM. Failure of fixation of tibial plateau fractures. J Orthop Trauma. 2002;16:323-9.
4. Martin J, Marsh JL, Nepola JV, Dirschl DR, Hurwitz S, DeCoster TA. Radiographic fractures assessments: which ones can we reliably make? J Orthop Trauma. 2000;14:379-85.
5. Kreder HJ, Hanel DP, McKee M, Jupiter J, McGillivary G, Swiontkowski MF. X-ray film measurements for healed distal radius fractures. J Hand Surg [Am]. 1996;21:31-9. Erratum in: J Hand Surg [Am]. 1996;21:532.
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