Delay in surgical fixation may lead to failure to Achieve Fracture Reduction in Tibial Plateau Fractures

Adelaide, Australia: David Stuart Kitchen et al 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.

Patients with displaced tibial plateau fractures (TPFs) routinely undergo open reduction internal fixation with the aim to restore articular surface and joint congruency. There are limited data regarding the influence time to surgery has on fracture reduction in tibial plateau fractures.

The decreased ability to achieve fracture reduction with increased time from injury is likely multifactorial, with the initiation of the inflammatory phase of fracture healing likely involved. Callus formation, in conjunction with local soft tissue swelling, poses challenges to achieving reduction. In addition to increased difficulty in manipulating fracture fragments as healing progresses, cancellous bone loss, occurring as early as five days post injury in the fractured tibial plateau, may also contribute to impaired fracture reduction.

Frequently TPFs are associated with soft tissue injury, which is a common cause for delayed surgical intervention in an effort to decrease potential surgical site infections (SSIs).

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.

Questionnaires assessing the KOOS (Knee Injury and Osteoarthritis Outcome Scores) and Lysholm scores were collected at each outpatient

follow-up visit. The KOOS quality of life (KOOS QOL), pain score (KOOS Pain),and Lysholm scores were analysed to determine a patient's post injury level of function and symptomatology.

Fracture reduction was assessed on radiographs taken on the 1st or 2nd postoperative day. Fractures were defined as reduced if residual articular steps were less than 2 mm, with steps greater than 2 mm being defined as not reduced.

Results of the study-

• The final cohort of 117 patients consisted of 74 males and 43 females.

• The overall mean time to theatre for all patients was 5.9 (0–26) days.

• Sixty one patients were taken to theatre >5 days after their injury (52.1%), with the remaining fifty-six being operated <5 days from injury (47.9%).

• Demographic status, including fracture type (p = 0.17), mechanism of injury (p = 0.91), and gender (p = 0.48), were found not to influence time to theatre.

• Two patients had superficial SSI postoperatively (1.7%), and of these, one was taken to theatre Day 3 and the other Day 10 post injury.

• Comparable levels of joint depression were observed in both the <5- and >5-day time-to-theatre cohorts, with 8.08 mm (1.6–43) and 8.15 mm (1.5–54), respectively (p = 0.75).

• Neither fracture reduction nor preoperative joint depression was found to influence PROMs at any of the time points assessed.

• Radiographic assessment revealed that fracture reduction was achieved in 77 cases, with 40/117 fractures being malreduced.

• Time to theatre was shown to have a significant relationship with the ability to achieve fracture reduction (p = 0.002, OR = 0.83, 95% CI = 0.74 to 0.93), with the odds of obtaining reduction decreasing 17% with every subsequent day post injury.

• Patients with a time to theatre of >5 days were significantly less likely to have their fracture reduced when compared with those with a time to theatre of <5 days (p = 0.009, OR = 0.28, 95% CI = 0.11 to 0.73).

• Patients with reduced fractures were operated on between Days 0 and 24, with a mean time to theatre of 4.8 days following injury. Patients whose fractures were not reduced had been treated between Days 1 and 26, with a mean time to theatre of 8.0 days. Increased preoperative articular step was associated with an increased time to theatre (p = 0.009), but this effect was not shown when assessing patients taken to theatre <5 days with those taken >5 days (p = 0.309).

The authors concluded that delay in surgical fixation negatively affects the ability to reduce articular steps in TPFs. The odds of achieving fracture reduction in TPFs decreases by 17% for each day surgical intervention is delayed post injury. Interestingly, fracture type and mechanism of injury did not influence fracture reduction or time to theatre.

Further reading:

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

David Stuart Kitchen, Jack Richards, Peter J. Smitham , Gerald J. Atkins and Lucian B. Solomon. J. Clin. Med. 2022, 11, 138.

https://doi.org/10.3390/jcm11010138