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Functional outcomes after surgical treatment of tibial plateau fractures
Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx
Contents lists available at ScienceDirect
Journal of Clinical Orthopaedics and Trauma journal homepage: www.elsevier.com/locate/jcot
Functional outcomes after surgical treatment of tibial plateau fractures Daniel Xing Fu Hap*, Ernest Beng Kee Kwek Department of Orthopaedic Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, 308433, Singapore
a r t i c l e i n f o
a b s t r a c t
Article history: Received 3 February 2019 Received in revised form 14 April 2019 Accepted 15 April 2019 Available online xxx
Tibial plateau fractures are significant because of its intra-articular nature. In this study, we aim to evaluate the functional outcomes of tibial plateau fractures after surgical treatment and to determine the rates of return to work and sports after recovery. This is a retrospective study conducted at a single tertiary-level institution. Forty-one patients with tibial plateau fractures were operatively treated during our study period. Patient information including injury mechanism, surgical treatment and associated injuries were documented. Pre-operative and postoperative radiographs were reviewed to confirm Schatzker type and adequacy of reduction. Follow up data for thirty-one patients was obtained nineteen to forty-two months post-surgery. All patients were administered functional outcome questionnaires using the Western Ontario and McMaster University Osteoarthritis index (WOMAC) and Short Form 36 (SF-36) general health survey. Data regarding return to work and sports was also collected. Data analysis was done to determine the relationship between fracture type, adequacy of reduction and functional outcome. The average WOMAC score for patients with Schatzker I to III was 6.3 out of a maximum score of 96, significantly lower than the Schatzker IV to VI group, whose average score was 18.4 (p ¼ 0.0012). The SF36 score for the Schatzker I to III group was also significantly higher than the VI to VI group (p ¼ 0.0031). 71% of patients reported partial to full return to work, while 65% of patients did not return to sports after injury. In conclusion, the functional outcome of operatively treated tibial plateau fractures is satisfactory, with poorer functional outcome being associated with higher energy fractures. (Schatzker IV to VI) Majority of patients were able to return to their pre-injury employment but only a small minority were able to return to sports. © 2019 Delhi Orthopedic Association. All rights reserved.
Keywords: Tibial plateau Functional outcome WOMAC score SF-36
1. Introduction Tibial plateau fractures are common fractures which constitute approximately 1% of all fractures.1 These fractures are significant because of its intra-articular nature, and many studies have been done on the management and outcome of such fractures. Studies have suggested that the long term prognoses of such fractures are generally favourable, but there is still no unified consensus on the functional outcome of such fractures after surgical fixation2,10,16,17,19 Mechanisms of injury of tibial plateau fractures range from falls to road traffic accidents, and happen because of axial compression
* Corresponding author. E-mail addresses: [email protected] (D.X.F. Hap), ernest_kwek@ttsh. com.sg (E.B.K. Kwek).
forces or indirect shearing forces on the knee joint.3 Due to the involvement of the articular surface, improper management of tibial plateau fractures can lead to devastating consequences: pain, deformity, limited range of motion and eventually osteoarthritis of the knee joint4 As such, the aims of surgical fixation of tibial plateau fractures are centred around achieving anatomic reduction of the joint surface and restoring the mechanical alignment of the lower limb.5 In current literature, high-energy tibial plateau fractures have generally been found to be associated with poorer functional outcomes6 as well as a lower rate of return to sports.7 However, existing literature investigating rates of return to work after tibial plateau fractures are scarce. The primary aim of this study was to determine the functional outcome after operative management of tibial plateau fractures. The secondary aim was to determine the rate of return to work and sports.
https://doi.org/10.1016/j.jcot.2019.04.007 0976-5662/© 2019 Delhi Orthopedic Association. All rights reserved.
Please cite this article as: Hap DXF, Kwek EBK, Functional outcomes after surgical treatment of tibial plateau fractures, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2019.04.007
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D.X.F. Hap, E.B.K. Kwek / Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx
2. Materials and methods This is a retrospective study conducted at a single tertiary-level centre. Between January 2008 and December 2009, a total of 40 consecutive patients with 40 tibial plateau fractures were treated with open reduction and internal fixation at our institution. Indications for surgery were as follows: open fractures, unstable fractures or severely displaced fractures, or fractures with an articular step-off of more than 2 mm. All patients who underwent surgical fixation were included in the study. To ensure uniformity of the study population, we excluded patients with open fractures of the tibial plateau. Other exclusion criteria include pathological fractures, fractures definitively treated with external fixators or frames and patients who were lost to follow-up. A minimum follow-up period of 18 months was achieved for all subjects involved in the study. Specifically, the follow-up period ranged from 19 to 42 months, with the average follow-up duration being 31 months. All hospital case-notes and patient records were reviewed. Information pertaining to nature and mechanism of injury, complication of injury or treatment and associated injuries was obtained. All initial and post-operative radiographs were reviewed. This allowed us to determine the Schatzker classification of the fracture, the exact treatment rendered in addition to reviewing the operative notes, as well as the adequacy of reduction. 2.1. Follow-up We were able to contact 30 out of all 40 patients for interview. Of the 40 patients, 10 patients were lost to follow-up; 9 were foreign workers who were untraceable and 1 patient died at the age of 98 years old. Basic demographic data of all remaining 30 patients are as follows. There were 20 men and 10 women. The ages of the patients at the time of injury ranged from 21 to 72 years old, with a mean of 50 years. The mechanisms of injury were evenly spread out between motor vehicle accidents (11 patients e 37%), pedestrians hit by motor vehicles (9 patients e 30%) and falls from standing height (10 patients e 33%). The pre-operative radiographs for all patients were reviewed and classified according to the Schatzker classification. There were 4 type I (13%), 9 type II (29%), 8 type III (26%), 1 type IV (3%), 2 type V (6%) and 6 type VI (23%) fractures (See Table 1). . 23 patients had isolated tibial plateau fractures, while 7 patients had associated injuries. Of these 7 patients, 2 patients were victims of polytrauma, 1 patient with a Lisfranc fracture on the same side, 2 patients with meniscal injuries, 1 patient with an ACL tear and 1 patient with concomitant ACL, PCL and LCL injuries. The 2 patients with meniscal injuries both had medial meniscus tears which were diagnosed intra-operatively during submeniscal arthrotomy. The remaining 2 patients with ligamentous injuries had pre-operative magnetic resonance imaging (MRI) scans done. All 30 patients were contacted by phone and were asked to complete 2 functional outcome questionnaires, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Short-Form 36
(SF-36) general health survey. Information regarding return to work and sports was also obtained from the patients. The functional outcome measures in this study are the WOMAC score, SF-36 score, rates of return to occupation and return to sports. 2.2. Statistical analysis The data collected was analyzed using the Mann-Whitney U test (MWU) and Kruskal-Wallis equality of populations rank test. Dichotomous variables were analyzed using the chi-squared test. A P value of <0.05 was considered statistically significant. All statistical analysis was carried out using SPSS Statistics version 17.0. 3. Results The functional outcomes were based largely on the WOMAC and SF-36 scores. The WOMAC questionnaire has a total of 96 points, with a higher score denoting a poorer functional outcome. The SF36 survey has a maximum of 100 points, with higher survey scores indicating a better quality of life. The mean WOMAC score of all 30 patients is a mean of 9.2 points out of a possible total score of 96. The lowest score is 0 from the Schatzker Type I group, while the highest score is 42, from the Schatzker Type VI fracture group, belonging to a polytrauma patient. The mean WOMAC scores across all 6 Schatzker fracture types show a statistically significant increasing trend from Type I to Type VI (p ¼ 0.008), signifying a corresponding drop in functional outcome (See Fig. 1). The anomaly noted in the Schatzker Type IV group can be attributed to the fact that there is only 1 patient in that group. In most literature, Schatzker Types I to III fractures are usually conventionally grouped as low energy injuries, while Types IV to VI fractures as high energy injuries. When we compared the Type I to III group (20 patients) to the Type IV to VI group (10 patients), the Schatzker Type IV to VI fracture group had a significantly higher (p ¼ 0.001) WOMAC score (15.8 points) than the Type I to III group (6.3 points), signifying a poorer functional outcome. The study population was further dichotomized by mechanism of injury into low impact (11 patients) and high impact injuries (19 patients). Injuries sustained from accidents involving a motor vehicle were considered high impact, and sports injuries or falls were considered low impact. The mean WOMAC score of the high impact injury group, at 11.9 points, is similarly significantly higher (p ¼ 0.033) than that of the low impact group which had a mean score of 4.4 points. Post-operative radiographs were also analyzed to determine anatomical alignment. There were 4 patients with varus knees and 26 cases with valgus knees. Interestingly, patients with a varus knee post-operatively had a significantly higher (p ¼ 0.04) WOMAC score (12.8 points) than patients with a valgus knee (8.6 points). Using the SF-36 score as an outcome measure, the outcome scores ranged from a best of 92 points (from Schatzker I group) to a lowest of 32 points (from Schatzker VI group). The mean SF-36
Table 1 Schatzker Classification and the mechanism of injury. Fracture Type
Pedestrian in Moving Vehicle Accident
Driver or Passenger in Moving Vehicle Accident
Fall
Total Number (%)
Schatzker I Schatzker II Schatzker III Schatzker IV Schatzker V Schatzker VI Total Number (%)
0 4 3 0 1 1 9 (30%)
1 1 2 1 0 5 10 (33.3%)
3 4 3 0 1 0 11 (36.7%)
4 9 8 1 2 6
(13.3%) (30%) (26.7%) (3.3%) (6.7%) (20%)
Please cite this article as: Hap DXF, Kwek EBK, Functional outcomes after surgical treatment of tibial plateau fractures, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2019.04.007
D.X.F. Hap, E.B.K. Kwek / Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx
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Fig. 1. Mean WOMAC scores across all Schatzker groups.
scores show a significantly decreasing trend from Type I to Type VI fractures which corresponds to a poorer functional outcome trend (p ¼ 0.004) (See Fig. 2). Again, the exception in the trend was in the Type IV fracture group. Comparing the SF-36 scores of the Type I to III with the Type VI to VI groups yielded similar findings as the WOMAC scores. Type I to III injuries had a significantly higher (p ¼ 0.0034) SF-36 score (80.3 points) than the Type IV to VI group (67.4 points), signifying a better functional outcome for the Type I to III injury group. The SF-36 scores in the group of patients who suffered a high impact injury (72.5 points) was also significantly lower (p ¼ 0.01) than those who had low impact injuries (83.2 points). The functional outcome questionnaire scores were analyzed against the following variables as well: age, anatomical reduction, operative technique, seniority of surgeon, co-morbidities of patients as well as the presence of post-operative complications. Immediate post-operative radiographs as well as radiographs taken at 6 months post-surgery of all patients were reviewed to ascertain if anatomical reduction was achieved and whether there was any further fracture displacement post-fixation, Patients who had an articular step-off of 2 mm or less after operative treatment were considered to have achieved anatomical reduction. There were no cases of post-operative implant failure or late collapse that
led to an interval increase in articular step-off. 16 patients had anatomical reduction while 14 patients did not. There was no statistically significant difference in the functional outcome scores between these 2 groups. In terms of surgeon seniority, 7 patients were operated on by junior surgeons while 23 patients were operated on by senior surgeons. There was no significant difference in functional outcome scores between the 2 groups. Operative technique was analyzed to determine its relationship to functional outcome. The techniques used for the cases were dichotomized into 1.) Image intensifier (II) guided, where fragments were reduced using intra-operative fluoroscopy only, and 2.) Sub-meniscal arthrotomy, where reduction of the joint line is carried out with direct visualization of the articular surface by lifting up the meniscus. 15 fractures were reduced with fluoroscopic imaging guidance, while 15 fractures were reduced with a submeniscal arthrotomy. We did not find any significant difference in the functional outcome scores between these 2 groups of reduction techniques. Type II diabetes mellitus and hypertension were the top 2 comorbidities among the study population. 9 patients had hypertension, while 7 patients had diabetes. Again, there was no significant difference in functional outcome between patients with comorbidities and those with no past medical history. When using
Fig. 2. Mean SF-36 scores across all Schatzker groups.
Please cite this article as: Hap DXF, Kwek EBK, Functional outcomes after surgical treatment of tibial plateau fractures, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2019.04.007
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age as a factor, we also did not find a significant difference in functional outcomes between younger and older patients, which we defined as patients above 50 years old. Only 2 patients (7%) developed complications as a result of the fracture. One patient developed compartment syndrome postoperatively and had to undergo emergency fasciotomy. The other patient developed wound infection requiring multiple wound debridements with retention of implants. There were no cases of fracture non-union in our series. The mean SF-36 score of these 2 patients was significantly poorer (p ¼ 0.006) at 57.1, compared to a mean score of 78.3 in patients with no post-operative complications. Similarly, the mean WOMAC score of these 2 patients, at 28.5 points, was significantly higher (p ¼ 0.007) than patients without postoperative complications (7.4 points), signifying a poorer outcome. Information regarding return to work was obtained during the interview. One patient was already unemployed before the injury. Out of the remaining 29 patients, 7 (24%) were unable to return to work. 7 patients (24%) were able to partially return to work as they were not able to return to their previous vocation due to physical limitations, while 15 patients (52%) were able to fully return to work (see Fig. 3). 67% of patients from Schatzker types I to III were able to return to work, compared to only 50% of patients with Schatzker types IV to VI injuries. However, this was not statistically significant. (p ¼ 0.076). All patients in this study participated in at least recreational sports or exercise pre-morbidly. We noted that only 4 patients (13%) had fully returned to pre-morbid sporting activities. 7 patients (23%) had only partially returned to sports and exercise, while a large majority of patients (64%) were not able to start on any sports or exercise at all (p ¼ 0.26). The most commonly cited reason is that of fear of recurrent injury. 4. Discussion Much research has been performed regarding the ideal treatment for tibial plateau fractures, and many studies have set out to compare outcome differences between surgically treated and conservatively managed tibial plateau fractures.8 Surgically treated tibial plateau fractures have generally shown good functional results.8,9 The results from our study show that surgical treatment of tibial plateau fractures lead to favourable functional outcomes. Rademakers et al.10 found that surgically treated monocondylar fractures had significantly better functional outcome compared to bicondylar fractures, with Schatzker type VI fractures having the poorest outcome. This is echoed by the study done by Barei et al.11 which concluded that severity of tibial plateau injury is
Fig. 3. Pie-chart showing the return-to-work status among all patients.
significantly related to the functional outcome. Likewise, the study by Jagdev et al.6 found that the incidence of osteoarthritis increases with the Schatzer grading. Our results concur with these authors as we found that overall functional scores are satisfactory, with Schatzker IV to VI fractures having a significantly poorer functional outcome compared to type I to III fractures. In a more recent study, Trikha et al.12 reported excellent outcomes even in high-energy tibial plateau fractures, with the study cohort achieving a mean Insall knee score of 95.42 out of 100 after surgical fixation. Similarly, Evangelopoulous et al.13 found that patients with Schatzker Types IV to VI tibial plateau fractures achieved satisfactory Lysholm's knees scores and Knee Injury and Osteoarthritis Outcomes Scores (KOOS) after surgical treatment. Existing literature have identified several factors which can potentially influence functional results of tibial plateau fractures, although some authors offer differing opinions. Age of injury has been described by some studies to significantly affect functional outcome, with the older age group achieving a less satisfactory outcome.14 Rademakers et al.10 however found no correlation between age and functional results and described excellent results for all patients across all ages. In our study, functional outcome was not significantly affected by age as well. Few papers in our literature search studied the relationship between post-operative knee alignment and functional outcome of surgically treated tibial plateau fractures. It has been shown that knee malalignment greatly increases the risk of disease progression of knee osteoarthritis.15 Rademakers et al.10 found that radiological malalignment of the knee joint post-operatively is more likely to result in severe osteoarthritis, which in turn conferred poorer functional outcome. On the other hand, Singleton et al.5 found that restoration of mechanical axis after tibial plateau fractures did not lead to a significantly better Oxford knee score, WOMAC score or Iowa knee score. Our study found a significant difference between varus and valgus knees post-operatively, with varus knees having a poorer functional outcome. Further prospective studies should be conducted to investigate this correlation. Intuitively, articular displacement of the joint seems like a very likely influencing factor in functional outcomes of tibial plateau fractures. However, our results did not show any significant correlation between articular step-off and functional outcome. Similarly, studies by Rademakers,10 Stevens16 and Weigel17 all found that articular displacement has no correlation with functional outcome in the long or short term. Honkonen18 also found that the amount of articular step-off was inconsequential in degenerative arthritis of the knee after tibial plateau fractures. In contrast, Tillman et al.19 found that knee function is optimal when the plateau depression is minimal, but the paper did not specify the acceptable range of articular displacement. Many studies found varying degrees of residual articular displacement after surgical treatment to be acceptable. Schatzker et al.20 found that a plateau depression of up to 7 mm was acceptable. Honkonen, on the other hand, described that an articular step-off of 3 mm or less had no adverse effects on outcome.21 There was however, no consensus as to what is considered an acceptable articular step-off that would confer good functional outcome. Our study finding that post-operative complications led to significantly poorer functional outcome scores is in keeping with results in recent literature. Kugelman et al.22 reported that postoperative complication of a deep infection after surgical fixation of tibial plateau fractures was a predictor of decreased knee range of motion at long term follow-up. While studies have shown that tibial plateau fractures are associated with soft tissue injuries such as meniscal tears,23,24 the effect of these soft tissue injuries on functional outcomes after fracture fixation has yet to be extensively researched on. Warner
Please cite this article as: Hap DXF, Kwek EBK, Functional outcomes after surgical treatment of tibial plateau fractures, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2019.04.007
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et al.25 reported that after fixation of tibial plateau fractures, there was no significant difference in functional outcome scores (SF-36, Lower Extremity Functional Scale and Knee Outcome Survey Activities of Daily Living Scale) between patients with and without meniscal tears and complete medial collateral ligament ruptures. Our study did not focus on analyzing the effect of associated ligamentous injuries as a majority of our study patients did not have a pre-operative MRI scan of the knee. With regards to return to sports, our study found that 36% of patients were able to return to recreational sports or exercise, but only 13% reported a full return to their pre-injury level of sporting activity. In contrast, Kugelman et al.7 reported a 52.4% return to recreational athletics at 15 months after surgical fixation of tibial plateau fractures. Possible explanations to this difference include a higher mean age in our study population (50 years vs 46 years in Kugelman's paper) as well as cultural differences and perception towards sports and exercise. Kraus et al.26 also found that a majority of patients were unable to return to their pre-injury level of sports after sustaining tibial plateau fractures requiring surgery, with only 2 out of 11 competitive athletes being able to return to competition at 2 years follow-up. Compared to return to sports, we found more encouraging rates of return to work, with 75% of patients able to return to work at least partial capacity, and 52% being able to fully return to work at a pre-injury level. Literature on rates of return to work after surgical treatment of tibial plateau fractures is scarce. To our knowledge, only 1 paper by Kraus et al.27 specifically looked into return to work after surgically treated tibial plateau fractures. The authors found that patients who had a higher workload had a longer duration of incapacity of work post-injury, compared to those with a lower workload and could only return to less physically demanding jobs with reduced working hours. Essentially, this highlights the impact of a tibial plateau fracture on the patient's quality of life and ability to return to work, even after surgical fixation and a period of rehabilitation. Our study is limited by several factors. It is a retrospective study with cases from a single institution. In addition, the average followup duration of 31 months was insufficient to determine a long-term outcome and is unlikely enough time for post-traumatic osteoarthritis to develop We also had a small sample size of 30 patients and had 10 patients who were lost to follow-up, of which 9 were foreign workers who had sustained their injuries from industrial accidents. There was also logistical difficulty in recalling patients for objective clinical assessment of knee function and we were not able to obtain a correlation between the functional outcome scores and actual clinical findings. Finally, the patients in our series did not routinely get an MRI scan of the knee perioperatively and some of the ligamentous or meniscal injuries may have been missed out. 5. Conclusion In conclusion, functional outcomes of surgically treated tibial plateau fractures are generally favourable, based on the outcome measures of WOMAC and SF-36 scores. The functional results are largely dependent on the Schatzker type of the fracture and the force of impact causing injury. Poor functional outcome is conferred by high impact injuries as well as Schatzker Types IV to VI fractures. Majority of patients were able to return to work. However, more than 60% of patients were unable to return to pre-morbid sporting activities or exercise, despite having a favourable score based on functional outcome questionnaires. Declaration of interests
5
References 1. Gill TJ, Moezzi DM, Oates KM, Sterett WI. Arthroscopic reduction and internal fixation of tibial plateau fractures in skiing. Clin Orthop Relat Res. 2001 Feb;(383):243e249. 2. Chin Terence YP, David B, Michael B, et al. Functional outcome of tibial plateau fractures treated with the fine-wire fixator. Injury, Int J Care Injured. 2005;36: 1467e1475. 3. Kennedy JC, Bailey WH. Experimental tibial-plateau fractures. Studies of the mechanism and classification. J Bone Joint Surg Am. 1968 Dec 01;50(8): 1522e1534. 4. Volpin G, Dowd GS, Stein H, Bentley G. Degenerative arthritis after intraarticular fractures of the knee. Long-term results. J Bone Joint Surg Br. 1990;72B:634e638. 5. Singleton N, Sahakian Muir D. Outcome after tibial plateau fracture: how important is restoration of articular congruity? J Orthop Trauma. 2017 Mar;31(3):158e163. 6. Jagdev SS, Pathak S, Kanani H, Salunke A. Functional outcome and incidence of osteoarthritis in operated tibial plateau fractures. Arch Bone Jt Surg. 2018 Nov;6(6):508e516. 7. Kugelman DN, Qatu AM, Haglin JM, Konda SR, Egol KA. Participation in recreational athletics after operative fixation of tibial plateau fractures: predictors and functional outcomes of those getting back in the game. Orthop J Sports Med. 2017 Dec 11;5(12), 2325967117743916. 8. Jensen DB, Rude C, Duus B, Bjerg-Nielsen A. Tibial plateau fractures. A comparison of conservative and surgical treatment. J Bone Joint Surg Br. 1990;72: 49e52. 9. Su Edwin P, Westrich Geoffrey H, Rana Adam J, Kapoor Komal, Helfet David L. Operative treatment of tibial plateau fractures in patients older than 55 years. Clin Orthop Relat Res. 2004;421:240e248. 10. Rademakers MV, Kerkhoffs GMMJ, Sierevelt IN, Raaymakers ELFB, Marti RK. Operative treatment of 109 tibial plateau fractures: five- to 27- year follow-up results. J Orthop Trauma. 2007;21:5e10. 11. Barei David P, Nork SE, Mills WJ, Coles Chad P, Henley MB, Benirschke SK. Functional outcomes of severe bicondylar tibial plateau fractures treated with dual incisions and medial and lateral plates. J Bone Joint Surg Am. 2006;88: 1713e1721. 12. Trikha V, Gaba S, Agrawal P, Das S, Kumar A, Chowdhury B. CT based management of high energy tibial plateau fractures: a retrospective review of 53 cases. J Clin Orthop Trauma. 2019 Jan-Feb;10(1):201e208. 13. Evangelopoulos D, Chalikias S, Michalos M, et al. Medium-term results after surgical treatment of high-energy tibial plateau fractures. J Knee Surg. 2019 Feb 6. https://doi.org/10.1055/s-0039-1677822. 14. Keating JF. Tibial Plateau fractures in the older patient. Bull Hosp Jt Dis. 1999;58(1):19e23. 15. Sharma Leena, Song Jing, Felson David T, Cahue September, Shamiyeh Eli, Dunlop Dorothy D. The role of knee alignment in disease progression and functional decline in knee osteoarthritis. J Am Med Assoc. 2001;286(2): 188e195. 16. Stevens David G, Beharry R, Mckee MD, James PW, Emil HS. The long-term functional outcome of operatively treated tibial plateau fractures. J Orthop Trauma. 2001;15:312e320. 17. Weigel Dennis P, Lawrence Marsh J. High-energy fractures of the tibial plateau: knee function after longer follow-up. J Bone Joint Surg Am. 2002;84: 1541e1551. 18. Honkonen SE. Degenerative arthritis after tibial plateau fractures. J Orthop Trauma. 1995;9:273e277. 19. Tillman M, Michael JP, Harvery JP. Tibial plateau fractures: definiton, demographics, treatment rationale, and long-term results of closed traction management or operative reduction. J Orthop Trauma. 1987;1:97e119. 20. Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto experience 1968 -1975. Clin Orthop. 1979;138:94e104. 21. Honkonen SE. Indications for surgical treatment of tibial condyle fractures. Clin Orthop. 1994;302:199e205. 22. Kugelman DN, Qatu AM, Strauss EJ, Konda SR, Egol KA. Knee stiffness after tibial plateau fractures: predictors and outcomes (OTA-41). J Orthop Trauma. 2018 Nov;32(11):e421ee427. 23. Gardner MJ, Yacoubian S, Geller D, et al. Prediction of soft-tissue injuries in schatzker II tibial plateau fractures based on measurements of plain radiographs. J Trauma. 2006 Feb;60(2):319e323. 24. Durakbasa MO, Kose O, Ermis MN, Demirtas A, Gunday S, Islam C. Measurement of lateral plateau depression and lateral plateau widening in a Schatzker type II fracture can predict a lateral meniscal injury. Knee Surg Sports Traumatol Arthrosc. 2013 Sep;21(9):2141e2146. 25. Warner SJ, Garner MR, Schottel PC, et al. The effect of soft tissue injuries on clinical outcomes after tibial plateau fracture fixation. J Orthop Trauma. 2018 Mar;32(3):141e147. €ger F, Müller D, et al. Return to sports activity after tibial 26. Kraus TM, Martetschla plateau fractures: 89 cases with minimum 24-month follow-up. Am J Sports Med. 2012 Dec;40(12):2845e2852. 27. Kraus Tobias M, Abele Charlotte, Freude Thomas, et al. Duration of incapacity of work after tibial plateau fracture is affected by work intensity. BMC Muscoskelet Disord. 2018;19:281.
None. Please cite this article as: Hap DXF, Kwek EBK, Functional outcomes after surgical treatment of tibial plateau fractures, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2019.04.007
Contents lists available at ScienceDirect
Journal of Clinical Orthopaedics and Trauma journal homepage: www.elsevier.com/locate/jcot
Functional outcomes after surgical treatment of tibial plateau fractures Daniel Xing Fu Hap*, Ernest Beng Kee Kwek Department of Orthopaedic Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, 308433, Singapore
a r t i c l e i n f o
a b s t r a c t
Article history: Received 3 February 2019 Received in revised form 14 April 2019 Accepted 15 April 2019 Available online xxx
Tibial plateau fractures are significant because of its intra-articular nature. In this study, we aim to evaluate the functional outcomes of tibial plateau fractures after surgical treatment and to determine the rates of return to work and sports after recovery. This is a retrospective study conducted at a single tertiary-level institution. Forty-one patients with tibial plateau fractures were operatively treated during our study period. Patient information including injury mechanism, surgical treatment and associated injuries were documented. Pre-operative and postoperative radiographs were reviewed to confirm Schatzker type and adequacy of reduction. Follow up data for thirty-one patients was obtained nineteen to forty-two months post-surgery. All patients were administered functional outcome questionnaires using the Western Ontario and McMaster University Osteoarthritis index (WOMAC) and Short Form 36 (SF-36) general health survey. Data regarding return to work and sports was also collected. Data analysis was done to determine the relationship between fracture type, adequacy of reduction and functional outcome. The average WOMAC score for patients with Schatzker I to III was 6.3 out of a maximum score of 96, significantly lower than the Schatzker IV to VI group, whose average score was 18.4 (p ¼ 0.0012). The SF36 score for the Schatzker I to III group was also significantly higher than the VI to VI group (p ¼ 0.0031). 71% of patients reported partial to full return to work, while 65% of patients did not return to sports after injury. In conclusion, the functional outcome of operatively treated tibial plateau fractures is satisfactory, with poorer functional outcome being associated with higher energy fractures. (Schatzker IV to VI) Majority of patients were able to return to their pre-injury employment but only a small minority were able to return to sports. © 2019 Delhi Orthopedic Association. All rights reserved.
Keywords: Tibial plateau Functional outcome WOMAC score SF-36
1. Introduction Tibial plateau fractures are common fractures which constitute approximately 1% of all fractures.1 These fractures are significant because of its intra-articular nature, and many studies have been done on the management and outcome of such fractures. Studies have suggested that the long term prognoses of such fractures are generally favourable, but there is still no unified consensus on the functional outcome of such fractures after surgical fixation2,10,16,17,19 Mechanisms of injury of tibial plateau fractures range from falls to road traffic accidents, and happen because of axial compression
* Corresponding author. E-mail addresses: [email protected] (D.X.F. Hap), ernest_kwek@ttsh. com.sg (E.B.K. Kwek).
forces or indirect shearing forces on the knee joint.3 Due to the involvement of the articular surface, improper management of tibial plateau fractures can lead to devastating consequences: pain, deformity, limited range of motion and eventually osteoarthritis of the knee joint4 As such, the aims of surgical fixation of tibial plateau fractures are centred around achieving anatomic reduction of the joint surface and restoring the mechanical alignment of the lower limb.5 In current literature, high-energy tibial plateau fractures have generally been found to be associated with poorer functional outcomes6 as well as a lower rate of return to sports.7 However, existing literature investigating rates of return to work after tibial plateau fractures are scarce. The primary aim of this study was to determine the functional outcome after operative management of tibial plateau fractures. The secondary aim was to determine the rate of return to work and sports.
https://doi.org/10.1016/j.jcot.2019.04.007 0976-5662/© 2019 Delhi Orthopedic Association. All rights reserved.
Please cite this article as: Hap DXF, Kwek EBK, Functional outcomes after surgical treatment of tibial plateau fractures, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2019.04.007
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D.X.F. Hap, E.B.K. Kwek / Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx
2. Materials and methods This is a retrospective study conducted at a single tertiary-level centre. Between January 2008 and December 2009, a total of 40 consecutive patients with 40 tibial plateau fractures were treated with open reduction and internal fixation at our institution. Indications for surgery were as follows: open fractures, unstable fractures or severely displaced fractures, or fractures with an articular step-off of more than 2 mm. All patients who underwent surgical fixation were included in the study. To ensure uniformity of the study population, we excluded patients with open fractures of the tibial plateau. Other exclusion criteria include pathological fractures, fractures definitively treated with external fixators or frames and patients who were lost to follow-up. A minimum follow-up period of 18 months was achieved for all subjects involved in the study. Specifically, the follow-up period ranged from 19 to 42 months, with the average follow-up duration being 31 months. All hospital case-notes and patient records were reviewed. Information pertaining to nature and mechanism of injury, complication of injury or treatment and associated injuries was obtained. All initial and post-operative radiographs were reviewed. This allowed us to determine the Schatzker classification of the fracture, the exact treatment rendered in addition to reviewing the operative notes, as well as the adequacy of reduction. 2.1. Follow-up We were able to contact 30 out of all 40 patients for interview. Of the 40 patients, 10 patients were lost to follow-up; 9 were foreign workers who were untraceable and 1 patient died at the age of 98 years old. Basic demographic data of all remaining 30 patients are as follows. There were 20 men and 10 women. The ages of the patients at the time of injury ranged from 21 to 72 years old, with a mean of 50 years. The mechanisms of injury were evenly spread out between motor vehicle accidents (11 patients e 37%), pedestrians hit by motor vehicles (9 patients e 30%) and falls from standing height (10 patients e 33%). The pre-operative radiographs for all patients were reviewed and classified according to the Schatzker classification. There were 4 type I (13%), 9 type II (29%), 8 type III (26%), 1 type IV (3%), 2 type V (6%) and 6 type VI (23%) fractures (See Table 1). . 23 patients had isolated tibial plateau fractures, while 7 patients had associated injuries. Of these 7 patients, 2 patients were victims of polytrauma, 1 patient with a Lisfranc fracture on the same side, 2 patients with meniscal injuries, 1 patient with an ACL tear and 1 patient with concomitant ACL, PCL and LCL injuries. The 2 patients with meniscal injuries both had medial meniscus tears which were diagnosed intra-operatively during submeniscal arthrotomy. The remaining 2 patients with ligamentous injuries had pre-operative magnetic resonance imaging (MRI) scans done. All 30 patients were contacted by phone and were asked to complete 2 functional outcome questionnaires, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Short-Form 36
(SF-36) general health survey. Information regarding return to work and sports was also obtained from the patients. The functional outcome measures in this study are the WOMAC score, SF-36 score, rates of return to occupation and return to sports. 2.2. Statistical analysis The data collected was analyzed using the Mann-Whitney U test (MWU) and Kruskal-Wallis equality of populations rank test. Dichotomous variables were analyzed using the chi-squared test. A P value of <0.05 was considered statistically significant. All statistical analysis was carried out using SPSS Statistics version 17.0. 3. Results The functional outcomes were based largely on the WOMAC and SF-36 scores. The WOMAC questionnaire has a total of 96 points, with a higher score denoting a poorer functional outcome. The SF36 survey has a maximum of 100 points, with higher survey scores indicating a better quality of life. The mean WOMAC score of all 30 patients is a mean of 9.2 points out of a possible total score of 96. The lowest score is 0 from the Schatzker Type I group, while the highest score is 42, from the Schatzker Type VI fracture group, belonging to a polytrauma patient. The mean WOMAC scores across all 6 Schatzker fracture types show a statistically significant increasing trend from Type I to Type VI (p ¼ 0.008), signifying a corresponding drop in functional outcome (See Fig. 1). The anomaly noted in the Schatzker Type IV group can be attributed to the fact that there is only 1 patient in that group. In most literature, Schatzker Types I to III fractures are usually conventionally grouped as low energy injuries, while Types IV to VI fractures as high energy injuries. When we compared the Type I to III group (20 patients) to the Type IV to VI group (10 patients), the Schatzker Type IV to VI fracture group had a significantly higher (p ¼ 0.001) WOMAC score (15.8 points) than the Type I to III group (6.3 points), signifying a poorer functional outcome. The study population was further dichotomized by mechanism of injury into low impact (11 patients) and high impact injuries (19 patients). Injuries sustained from accidents involving a motor vehicle were considered high impact, and sports injuries or falls were considered low impact. The mean WOMAC score of the high impact injury group, at 11.9 points, is similarly significantly higher (p ¼ 0.033) than that of the low impact group which had a mean score of 4.4 points. Post-operative radiographs were also analyzed to determine anatomical alignment. There were 4 patients with varus knees and 26 cases with valgus knees. Interestingly, patients with a varus knee post-operatively had a significantly higher (p ¼ 0.04) WOMAC score (12.8 points) than patients with a valgus knee (8.6 points). Using the SF-36 score as an outcome measure, the outcome scores ranged from a best of 92 points (from Schatzker I group) to a lowest of 32 points (from Schatzker VI group). The mean SF-36
Table 1 Schatzker Classification and the mechanism of injury. Fracture Type
Pedestrian in Moving Vehicle Accident
Driver or Passenger in Moving Vehicle Accident
Fall
Total Number (%)
Schatzker I Schatzker II Schatzker III Schatzker IV Schatzker V Schatzker VI Total Number (%)
0 4 3 0 1 1 9 (30%)
1 1 2 1 0 5 10 (33.3%)
3 4 3 0 1 0 11 (36.7%)
4 9 8 1 2 6
(13.3%) (30%) (26.7%) (3.3%) (6.7%) (20%)
Please cite this article as: Hap DXF, Kwek EBK, Functional outcomes after surgical treatment of tibial plateau fractures, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2019.04.007
D.X.F. Hap, E.B.K. Kwek / Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx
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Fig. 1. Mean WOMAC scores across all Schatzker groups.
scores show a significantly decreasing trend from Type I to Type VI fractures which corresponds to a poorer functional outcome trend (p ¼ 0.004) (See Fig. 2). Again, the exception in the trend was in the Type IV fracture group. Comparing the SF-36 scores of the Type I to III with the Type VI to VI groups yielded similar findings as the WOMAC scores. Type I to III injuries had a significantly higher (p ¼ 0.0034) SF-36 score (80.3 points) than the Type IV to VI group (67.4 points), signifying a better functional outcome for the Type I to III injury group. The SF-36 scores in the group of patients who suffered a high impact injury (72.5 points) was also significantly lower (p ¼ 0.01) than those who had low impact injuries (83.2 points). The functional outcome questionnaire scores were analyzed against the following variables as well: age, anatomical reduction, operative technique, seniority of surgeon, co-morbidities of patients as well as the presence of post-operative complications. Immediate post-operative radiographs as well as radiographs taken at 6 months post-surgery of all patients were reviewed to ascertain if anatomical reduction was achieved and whether there was any further fracture displacement post-fixation, Patients who had an articular step-off of 2 mm or less after operative treatment were considered to have achieved anatomical reduction. There were no cases of post-operative implant failure or late collapse that
led to an interval increase in articular step-off. 16 patients had anatomical reduction while 14 patients did not. There was no statistically significant difference in the functional outcome scores between these 2 groups. In terms of surgeon seniority, 7 patients were operated on by junior surgeons while 23 patients were operated on by senior surgeons. There was no significant difference in functional outcome scores between the 2 groups. Operative technique was analyzed to determine its relationship to functional outcome. The techniques used for the cases were dichotomized into 1.) Image intensifier (II) guided, where fragments were reduced using intra-operative fluoroscopy only, and 2.) Sub-meniscal arthrotomy, where reduction of the joint line is carried out with direct visualization of the articular surface by lifting up the meniscus. 15 fractures were reduced with fluoroscopic imaging guidance, while 15 fractures were reduced with a submeniscal arthrotomy. We did not find any significant difference in the functional outcome scores between these 2 groups of reduction techniques. Type II diabetes mellitus and hypertension were the top 2 comorbidities among the study population. 9 patients had hypertension, while 7 patients had diabetes. Again, there was no significant difference in functional outcome between patients with comorbidities and those with no past medical history. When using
Fig. 2. Mean SF-36 scores across all Schatzker groups.
Please cite this article as: Hap DXF, Kwek EBK, Functional outcomes after surgical treatment of tibial plateau fractures, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2019.04.007
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D.X.F. Hap, E.B.K. Kwek / Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx
age as a factor, we also did not find a significant difference in functional outcomes between younger and older patients, which we defined as patients above 50 years old. Only 2 patients (7%) developed complications as a result of the fracture. One patient developed compartment syndrome postoperatively and had to undergo emergency fasciotomy. The other patient developed wound infection requiring multiple wound debridements with retention of implants. There were no cases of fracture non-union in our series. The mean SF-36 score of these 2 patients was significantly poorer (p ¼ 0.006) at 57.1, compared to a mean score of 78.3 in patients with no post-operative complications. Similarly, the mean WOMAC score of these 2 patients, at 28.5 points, was significantly higher (p ¼ 0.007) than patients without postoperative complications (7.4 points), signifying a poorer outcome. Information regarding return to work was obtained during the interview. One patient was already unemployed before the injury. Out of the remaining 29 patients, 7 (24%) were unable to return to work. 7 patients (24%) were able to partially return to work as they were not able to return to their previous vocation due to physical limitations, while 15 patients (52%) were able to fully return to work (see Fig. 3). 67% of patients from Schatzker types I to III were able to return to work, compared to only 50% of patients with Schatzker types IV to VI injuries. However, this was not statistically significant. (p ¼ 0.076). All patients in this study participated in at least recreational sports or exercise pre-morbidly. We noted that only 4 patients (13%) had fully returned to pre-morbid sporting activities. 7 patients (23%) had only partially returned to sports and exercise, while a large majority of patients (64%) were not able to start on any sports or exercise at all (p ¼ 0.26). The most commonly cited reason is that of fear of recurrent injury. 4. Discussion Much research has been performed regarding the ideal treatment for tibial plateau fractures, and many studies have set out to compare outcome differences between surgically treated and conservatively managed tibial plateau fractures.8 Surgically treated tibial plateau fractures have generally shown good functional results.8,9 The results from our study show that surgical treatment of tibial plateau fractures lead to favourable functional outcomes. Rademakers et al.10 found that surgically treated monocondylar fractures had significantly better functional outcome compared to bicondylar fractures, with Schatzker type VI fractures having the poorest outcome. This is echoed by the study done by Barei et al.11 which concluded that severity of tibial plateau injury is
Fig. 3. Pie-chart showing the return-to-work status among all patients.
significantly related to the functional outcome. Likewise, the study by Jagdev et al.6 found that the incidence of osteoarthritis increases with the Schatzer grading. Our results concur with these authors as we found that overall functional scores are satisfactory, with Schatzker IV to VI fractures having a significantly poorer functional outcome compared to type I to III fractures. In a more recent study, Trikha et al.12 reported excellent outcomes even in high-energy tibial plateau fractures, with the study cohort achieving a mean Insall knee score of 95.42 out of 100 after surgical fixation. Similarly, Evangelopoulous et al.13 found that patients with Schatzker Types IV to VI tibial plateau fractures achieved satisfactory Lysholm's knees scores and Knee Injury and Osteoarthritis Outcomes Scores (KOOS) after surgical treatment. Existing literature have identified several factors which can potentially influence functional results of tibial plateau fractures, although some authors offer differing opinions. Age of injury has been described by some studies to significantly affect functional outcome, with the older age group achieving a less satisfactory outcome.14 Rademakers et al.10 however found no correlation between age and functional results and described excellent results for all patients across all ages. In our study, functional outcome was not significantly affected by age as well. Few papers in our literature search studied the relationship between post-operative knee alignment and functional outcome of surgically treated tibial plateau fractures. It has been shown that knee malalignment greatly increases the risk of disease progression of knee osteoarthritis.15 Rademakers et al.10 found that radiological malalignment of the knee joint post-operatively is more likely to result in severe osteoarthritis, which in turn conferred poorer functional outcome. On the other hand, Singleton et al.5 found that restoration of mechanical axis after tibial plateau fractures did not lead to a significantly better Oxford knee score, WOMAC score or Iowa knee score. Our study found a significant difference between varus and valgus knees post-operatively, with varus knees having a poorer functional outcome. Further prospective studies should be conducted to investigate this correlation. Intuitively, articular displacement of the joint seems like a very likely influencing factor in functional outcomes of tibial plateau fractures. However, our results did not show any significant correlation between articular step-off and functional outcome. Similarly, studies by Rademakers,10 Stevens16 and Weigel17 all found that articular displacement has no correlation with functional outcome in the long or short term. Honkonen18 also found that the amount of articular step-off was inconsequential in degenerative arthritis of the knee after tibial plateau fractures. In contrast, Tillman et al.19 found that knee function is optimal when the plateau depression is minimal, but the paper did not specify the acceptable range of articular displacement. Many studies found varying degrees of residual articular displacement after surgical treatment to be acceptable. Schatzker et al.20 found that a plateau depression of up to 7 mm was acceptable. Honkonen, on the other hand, described that an articular step-off of 3 mm or less had no adverse effects on outcome.21 There was however, no consensus as to what is considered an acceptable articular step-off that would confer good functional outcome. Our study finding that post-operative complications led to significantly poorer functional outcome scores is in keeping with results in recent literature. Kugelman et al.22 reported that postoperative complication of a deep infection after surgical fixation of tibial plateau fractures was a predictor of decreased knee range of motion at long term follow-up. While studies have shown that tibial plateau fractures are associated with soft tissue injuries such as meniscal tears,23,24 the effect of these soft tissue injuries on functional outcomes after fracture fixation has yet to be extensively researched on. Warner
Please cite this article as: Hap DXF, Kwek EBK, Functional outcomes after surgical treatment of tibial plateau fractures, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2019.04.007
D.X.F. Hap, E.B.K. Kwek / Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx
et al.25 reported that after fixation of tibial plateau fractures, there was no significant difference in functional outcome scores (SF-36, Lower Extremity Functional Scale and Knee Outcome Survey Activities of Daily Living Scale) between patients with and without meniscal tears and complete medial collateral ligament ruptures. Our study did not focus on analyzing the effect of associated ligamentous injuries as a majority of our study patients did not have a pre-operative MRI scan of the knee. With regards to return to sports, our study found that 36% of patients were able to return to recreational sports or exercise, but only 13% reported a full return to their pre-injury level of sporting activity. In contrast, Kugelman et al.7 reported a 52.4% return to recreational athletics at 15 months after surgical fixation of tibial plateau fractures. Possible explanations to this difference include a higher mean age in our study population (50 years vs 46 years in Kugelman's paper) as well as cultural differences and perception towards sports and exercise. Kraus et al.26 also found that a majority of patients were unable to return to their pre-injury level of sports after sustaining tibial plateau fractures requiring surgery, with only 2 out of 11 competitive athletes being able to return to competition at 2 years follow-up. Compared to return to sports, we found more encouraging rates of return to work, with 75% of patients able to return to work at least partial capacity, and 52% being able to fully return to work at a pre-injury level. Literature on rates of return to work after surgical treatment of tibial plateau fractures is scarce. To our knowledge, only 1 paper by Kraus et al.27 specifically looked into return to work after surgically treated tibial plateau fractures. The authors found that patients who had a higher workload had a longer duration of incapacity of work post-injury, compared to those with a lower workload and could only return to less physically demanding jobs with reduced working hours. Essentially, this highlights the impact of a tibial plateau fracture on the patient's quality of life and ability to return to work, even after surgical fixation and a period of rehabilitation. Our study is limited by several factors. It is a retrospective study with cases from a single institution. In addition, the average followup duration of 31 months was insufficient to determine a long-term outcome and is unlikely enough time for post-traumatic osteoarthritis to develop We also had a small sample size of 30 patients and had 10 patients who were lost to follow-up, of which 9 were foreign workers who had sustained their injuries from industrial accidents. There was also logistical difficulty in recalling patients for objective clinical assessment of knee function and we were not able to obtain a correlation between the functional outcome scores and actual clinical findings. Finally, the patients in our series did not routinely get an MRI scan of the knee perioperatively and some of the ligamentous or meniscal injuries may have been missed out. 5. Conclusion In conclusion, functional outcomes of surgically treated tibial plateau fractures are generally favourable, based on the outcome measures of WOMAC and SF-36 scores. The functional results are largely dependent on the Schatzker type of the fracture and the force of impact causing injury. Poor functional outcome is conferred by high impact injuries as well as Schatzker Types IV to VI fractures. Majority of patients were able to return to work. However, more than 60% of patients were unable to return to pre-morbid sporting activities or exercise, despite having a favourable score based on functional outcome questionnaires. Declaration of interests
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References 1. Gill TJ, Moezzi DM, Oates KM, Sterett WI. Arthroscopic reduction and internal fixation of tibial plateau fractures in skiing. Clin Orthop Relat Res. 2001 Feb;(383):243e249. 2. Chin Terence YP, David B, Michael B, et al. Functional outcome of tibial plateau fractures treated with the fine-wire fixator. Injury, Int J Care Injured. 2005;36: 1467e1475. 3. Kennedy JC, Bailey WH. Experimental tibial-plateau fractures. Studies of the mechanism and classification. J Bone Joint Surg Am. 1968 Dec 01;50(8): 1522e1534. 4. Volpin G, Dowd GS, Stein H, Bentley G. Degenerative arthritis after intraarticular fractures of the knee. Long-term results. J Bone Joint Surg Br. 1990;72B:634e638. 5. Singleton N, Sahakian Muir D. Outcome after tibial plateau fracture: how important is restoration of articular congruity? J Orthop Trauma. 2017 Mar;31(3):158e163. 6. Jagdev SS, Pathak S, Kanani H, Salunke A. Functional outcome and incidence of osteoarthritis in operated tibial plateau fractures. Arch Bone Jt Surg. 2018 Nov;6(6):508e516. 7. Kugelman DN, Qatu AM, Haglin JM, Konda SR, Egol KA. Participation in recreational athletics after operative fixation of tibial plateau fractures: predictors and functional outcomes of those getting back in the game. Orthop J Sports Med. 2017 Dec 11;5(12), 2325967117743916. 8. Jensen DB, Rude C, Duus B, Bjerg-Nielsen A. Tibial plateau fractures. A comparison of conservative and surgical treatment. J Bone Joint Surg Br. 1990;72: 49e52. 9. Su Edwin P, Westrich Geoffrey H, Rana Adam J, Kapoor Komal, Helfet David L. Operative treatment of tibial plateau fractures in patients older than 55 years. Clin Orthop Relat Res. 2004;421:240e248. 10. Rademakers MV, Kerkhoffs GMMJ, Sierevelt IN, Raaymakers ELFB, Marti RK. Operative treatment of 109 tibial plateau fractures: five- to 27- year follow-up results. J Orthop Trauma. 2007;21:5e10. 11. Barei David P, Nork SE, Mills WJ, Coles Chad P, Henley MB, Benirschke SK. Functional outcomes of severe bicondylar tibial plateau fractures treated with dual incisions and medial and lateral plates. J Bone Joint Surg Am. 2006;88: 1713e1721. 12. Trikha V, Gaba S, Agrawal P, Das S, Kumar A, Chowdhury B. CT based management of high energy tibial plateau fractures: a retrospective review of 53 cases. J Clin Orthop Trauma. 2019 Jan-Feb;10(1):201e208. 13. Evangelopoulos D, Chalikias S, Michalos M, et al. Medium-term results after surgical treatment of high-energy tibial plateau fractures. J Knee Surg. 2019 Feb 6. https://doi.org/10.1055/s-0039-1677822. 14. Keating JF. Tibial Plateau fractures in the older patient. Bull Hosp Jt Dis. 1999;58(1):19e23. 15. Sharma Leena, Song Jing, Felson David T, Cahue September, Shamiyeh Eli, Dunlop Dorothy D. The role of knee alignment in disease progression and functional decline in knee osteoarthritis. J Am Med Assoc. 2001;286(2): 188e195. 16. Stevens David G, Beharry R, Mckee MD, James PW, Emil HS. The long-term functional outcome of operatively treated tibial plateau fractures. J Orthop Trauma. 2001;15:312e320. 17. Weigel Dennis P, Lawrence Marsh J. High-energy fractures of the tibial plateau: knee function after longer follow-up. J Bone Joint Surg Am. 2002;84: 1541e1551. 18. Honkonen SE. Degenerative arthritis after tibial plateau fractures. J Orthop Trauma. 1995;9:273e277. 19. Tillman M, Michael JP, Harvery JP. Tibial plateau fractures: definiton, demographics, treatment rationale, and long-term results of closed traction management or operative reduction. J Orthop Trauma. 1987;1:97e119. 20. Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto experience 1968 -1975. Clin Orthop. 1979;138:94e104. 21. Honkonen SE. Indications for surgical treatment of tibial condyle fractures. Clin Orthop. 1994;302:199e205. 22. Kugelman DN, Qatu AM, Strauss EJ, Konda SR, Egol KA. Knee stiffness after tibial plateau fractures: predictors and outcomes (OTA-41). J Orthop Trauma. 2018 Nov;32(11):e421ee427. 23. Gardner MJ, Yacoubian S, Geller D, et al. Prediction of soft-tissue injuries in schatzker II tibial plateau fractures based on measurements of plain radiographs. J Trauma. 2006 Feb;60(2):319e323. 24. Durakbasa MO, Kose O, Ermis MN, Demirtas A, Gunday S, Islam C. Measurement of lateral plateau depression and lateral plateau widening in a Schatzker type II fracture can predict a lateral meniscal injury. Knee Surg Sports Traumatol Arthrosc. 2013 Sep;21(9):2141e2146. 25. Warner SJ, Garner MR, Schottel PC, et al. The effect of soft tissue injuries on clinical outcomes after tibial plateau fracture fixation. J Orthop Trauma. 2018 Mar;32(3):141e147. €ger F, Müller D, et al. Return to sports activity after tibial 26. Kraus TM, Martetschla plateau fractures: 89 cases with minimum 24-month follow-up. Am J Sports Med. 2012 Dec;40(12):2845e2852. 27. Kraus Tobias M, Abele Charlotte, Freude Thomas, et al. Duration of incapacity of work after tibial plateau fracture is affected by work intensity. BMC Muscoskelet Disord. 2018;19:281.
None. Please cite this article as: Hap DXF, Kwek EBK, Functional outcomes after surgical treatment of tibial plateau fractures, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2019.04.007