Copyright © 2006 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Andrew H. Schmidt, MD*,
Department of Orthopaedic Surgery, Hennepin County Medical Center, Minneapolis, Minnesota
Posted December 2006
The Canadian Orthopedic Trauma Society has been a leader in
the performance of well-designed, multicenter, randomized clinical trials that
address areas of clinical controversy. This study, in which traditional open
plating of complex tibial plateau fractures with medial and lateral plates was
compared with limited (or percutaneous) reduction of the articular surface and
definitive stabilization of the metaphysis with external fixation, is another
example of their exemplary work.
Complex, bicondylar tibial plateau fractures remain a
challenge for patients and surgeons. They are associated with limb instability,
complex disruption of the articular surface of the proximal portion of the
tibia, and potential injury to the soft tissues of the knee including the
menisci, ligaments, capsule, neurovascular structures, and surrounding skin.
Patients with these injuries typically have poor outcomes, and all approaches
to management have potential complications. The standard of care for unstable
bicondylar tibial plateau fractures is surgical repair; the goal of treatment
is to reconstruct the fracture so that the injured patient can weight-bear
without pain and enjoy a functional knee that will permit the resumption of
whatever activities the patient engaged in before injury. Successful treatment
therefore requires restoration of lower-limb alignment, knee stability, and
functional range-of-motion of the knee. Whether anatomic articular reduction is
a necessity is an ongoing area of controversy.
Two contemporary management options that are advocated for
these injuries are open reduction and internal fixation of the tibial plateau
through direct incisions with use of low-profile periarticular plates, or
definitive external fixation of the proximal portion of the tibia with
percutaneous or limited open reduction and fixation of the articular surface.
The two methods differ primarily in their approach to the articular reduction
and their method of stabilization of the metadiaphyseal junction. Each approach
has potential advantages and disadvantages that have been demonstrated by
experience and documented in uncontrolled case series. The relative merits of
one approach over the other remain conjectural in the absence of a
well-designed, direct comparative trial.
Members of the Canadian Orthopedic Trauma Society enrolled a
reasonably large number of patients with Schatzker type V or VI injuries into a
randomized study comparing the two approaches. Outcomes that were measured
included the Hospital for Special Surgery (HSS) knee score, the Western Ontario
and McMaster Universities Osteoarthritis Index (WOMAC), and the Short Form-36
(SF-36) General Health Survey as well as complication and reoperation rates.
The authors found a statistically significant (but likely
clinically insignificant) difference in blood loss in favor of external
fixation (p = 0.006). The quality of the articular reduction was similar in
both groups. However, there was a dramatic (statistically significant)
difference in the duration of the hospital stay (9.9 days versus 23.4 days, p =
0.024). This was primarily due to the small subset of patients who had wound
complications after internal fixation and therefore needed multiple secondary
procedures and prolonged inpatient treatment. In terms of the functional
outcome, there was a clear early trend in favor of the external fixation group.
At two years, all functional outcome scores were comparable between groups,
with both groups showing similar deficits compared to the norm. Only the SF-36
domain of bodily pain showed differences that persisted at the two-year mark
(in favor of external fixation).
Although this study represents the highest-level evidence
that we have comparing two contemporary methods of treatment of tibial plateau
fractures, there are important limitations. Performance bias is certainly
possible. The study was done at five centers with sixteen attending surgeons
and an untold number of surgeons-in-training caring for the patients over a five-year
period; therefore, less than five patients per year per center were enrolled.
Many important decisions were left to the discretion of the surgeon rather than
dictated by a specific protocol, such as the timing of surgery, the method of
fracture reduction, and the location of the incision in the internal fixation
group. There was some apparent selection bias that occurred despite
randomization. The groups were not completely comparable with regard to the
proportion of patients in each group with Orthopaedic Trauma Association type
C3 injuries (fourteen of forty or 35% in the internal fixation group versus ten
of forty-three or 23% in the external fixation group). Although apparently not
statistically significant, this difference could bias the study in favor of the
external fixation group. Finally, this study was completed in 2003, before the
current revolution in locking-plate technology began. Although the theoretical
benefits of locking plates are by no means established, they may provide more
rigid fixation and allow earlier motion, which might in turn improve upon the
results presented here. In addition, it is not stated in the paper what
proportion of patients had midline anterior versus separate medial and lateral
incisions; this would be interesting to know in order to evaluate to what
extent the surgical approach reflects current treatment (i.e., separate rather
than midline incisions).
The authors are to be congratulated for their efforts. This
paper is important to clinicians because it establishes that the techniques of
open reduction and plating as well as circular external fixation are equally
viable approaches to complex tibial plateau fractures. It validates the tenet
that restoration of limb alignment and knee stability are primary goals of
treatment. Surgeons can therefore choose the technique that works best in their
hands, and those that prefer internal fixation can be assured that they need
not "push the indications" if soft-tissue lesions prevent open approaches. In
such circumstances, limited or even percutaneous joint fixation and external
fixation provide equivalent two-year outcomes and perhaps even have advantages
in the short term. Hopefully, the authors will continue to follow these
patients and will give us an update regarding their longer-term outcomes.
*The author did not receive any outside funding or grants in
support of his research for or preparation of this work. Neither he nor a member
of his immediate family received 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, division, center, clinical practice, or other
charitable or nonprofit organization with which the author, or a member of his
immediate family, is affiliated or associated.
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