Total knee arthroplasty after complex tibial plateau fractures treated with hybrid external fixation or internal fixation: results at 10 years
Objectives. There is little information in the literature regarding the outcomes of total knee arthroplasty following reduction and fixation of fractures of the tibial plateau. The aim of our study was to evaluate the outcomes of knee arthroprotesis at 10 years after a previous complex fracture of tibial plateau treated with hybrid external fixation (HEF) or open reduction and internal fixation (ORIF). These fractures predispose the knee to the development of posttraumatic arthritis and for this reason the total knee arthroplasty implant is frequent. Malunion, intra-articular chondro-osseous defects, limb malalignment, retained internal fixation devices, and poor surrounding soft tissues may compromise the outcomes of total knee arthroplasty.
Methods. Between January 2000 and December 2012, 93 patients aged from 22 to 55 years Schatzker types V and VI and Orthopedic Trauma Association types C1, C2, AND C3 tibial plateau fractures were treated with ORIF or HEF. Of these, 75 were considered for the study, with a minimum of 10 years of follow-up. Retrospectively these patients were separated into two groups: ORIF (Group A: 32) and HEF (Group B: 43). We observed how many patients underwent knee replacement surgery and of these, we used Hospital for Special Surgery Knee (HSS) to evaluate the results. The mean time between fracture treatment and first total knee replacement was different in the two groups; in Group A it was 6.2 ± 1.6 years, while in Group B 7.3 ± 1.4 years.
Results. In Group A, the percentage of arthroplasty was 65% with an HSS knee scores of 68 points, while in Group B the percentage of arthroplasty was 49% with an HSS knee score of 75 points.
Conclusions. Most of the patients treated for a complex fracture of the tibial plateau undergo an arthroplasty, but the percentage of patients was lower in Group B with better results even if the results of the prostheses are worse compared to normal prosthetic implants.
Fractures of the tibia plateau are a relatively common occurrence considering lower limb fractures, as they contribute to approximately 1% of all fractures 1,2. Displaced intra-articular fracture is considered a major risk factor for posttraumatic osteoarthritis. Intra-articular fracture of a major weight-bearing joint of the lower extremity, such as a tibial plateau fracture, is thought to carry an even higher risk. The sparse literature on this topic reports an incidence of post-traumatic arthritis following tibia plateau fracture of 23-44% 3.
The anatomical significance in such cases is because the articular surface is involved and these fractures are usually a result of a high impact injury. It is not unusual for an orthopedic surgeon to encounter patients with a prior fracture of the tibial plateau who have disabling end-stage arthritis. However, there is paucity of information on the outcomes of total knee arthroplasty in these patients 4. There are no scientific studies that report the percentage of knee arthroplasty in relation to the type of surgical treatment (ORIF compared with HEF).
Displaced bicondylar fractures of the proximal end of the tibia involving the articular surface are difficult to treat. Previously, the standard accepted treatment for such fractures was open reduction and internal fixation with plates and screws through an extensible anterior incision 5. However, while this technique was optimal for fracture visualization, reduction, and fixation, it required extensive soft-tissue dissection over the predominantly subcutaneous proximal end of the tibia.
For several years traumatologists have been posing the problem of treating these fractures in the most complex cases and the scientific literature is oriented towards HEF because the multiplicity of pre-surgery damages (skin, bone, etc.) is directly proportional to the damage of the surgery itself, i.e. the damage of surgery is added to the damage of the trauma 6,7.
The scattered literature on this topic reports an incidence of post-traumatic arthritis following a tibial plateau fracture of 23-69%, percentages with a very high range determined by two important factors: the complexity of the fracture and the surgical damage 8,9. As the detrimental effects of excessive dissection of the tenuous soft-tissue envelope and devascularization of the osseous fragments became apparent, a number of alternative methods of treatment have been popularized, including percutaneous reduction and circular frame stabilization, minimally invasive techniques and implants. The advantages of circular frame fixation (with or without percutaneous lag screw fixation) include minimal soft-tissue disruption, the ability to correct deformity in multiple planes, early knee motion, and the option of spanning the knee in patients with concomitant ligament injury. However, there remains doubt as to the quality of articular reduction with circular fixation, and a direct comparison with standard reduction techniques has not, to our knowledge, been performed. We sought to determine the long-term incidence of end stage arthritis following tibial plateau fractures, and thus the percentage of patients who underwent TKA surgery and the clinical results of the prostheses in relation to the two different methods of treating fractures.
Materials and methods
All patients gave their informed consent. This is a retrospective cohort study that uses an institutional research trauma registry. Using an institutional computerized database, we identified 93 patients with a prior fracture of the tibial plateau between 2000 and 2012. Of these, 75 were considered for the study, with a minimum 10 years of follow-up since the latter procedure. Of these 75 patients, 32 had been treated with standard ORIF (Group A), and 43 with HEF (Group B).
Between the time of the treatment of the fracture and the time of the total knee arthroplasty, in Group A 10 patients underwent surgery (6 removal of implants, 2 arthroscopy, 2 tibial osteotomy), while in Group B 12 patients underwent surgery (8 arthroscopy, 4 tibial osteotomy). Specifically, the removal of the implants occurred both due to intolerance to the means of synthesis and for preparation for the subsequent arthroplasty treatment. Knee arthroscopy was performed for lysis of joint stiffness, treatment of chondral and meniscal lesions, and correction osteotomies were performed mainly with the aim of correcting misalignments to avoid arthrosis evolution. All patients had pain as the primary symptom that led to the decision to undergo arthroplasty.
Statistical analysis was performed with the SPSS software package. An analysis of the normal distribution of the sample was performed, and a chi-square test was used for categorical variables between the two groups. Student’s t test was used for continuous variables, such as age and range of motion; a p value of < 0.05 was considered to be significant.
There were no significant differences in the fracture or injury pattern between groups. There were 4 Schatzker type-V and 17 Schatzker type-VI fractures in the circular fixator group and 6 Schatzker type-V and 15 Schatzker type-VI fractures in the open reduction and internal fixation group. According to the OTA classification, there were 5 type-C1 fractures, 9 type-C2, and 7 type-C3 fractures in the group managed with ORIF and 4 type-C1, 6 type-C2, and 11 type-C3 fractures in the circular fixator group.
In Group A the percentage of arthroplasty was 65% with an HSS Knee score of 68 points, while in Group B the percentage of arthroplasty was 49% with an HSS Knee score of 75 points at a mean of 10 years (Tab. I).
The group managed with the hybrid fixator demonstrated a trend towards a superior range of motion of the knee in a number of parameters at 10-year follow-up compared with the group that had ORIF (i.e. the mean total arc of motion was 120° in the circular fixator group compared with 109° in the ORIF group).
Not all patients were treated for arthroplasty surgery in our institution, but also in others, and therefore neither the models of arthroplasty used nor the surgeons are the same. Clinical results were assessed on the basis of Hospital for Special Surgery knee scores obtained after the arthroplasty at an average of 9.2 years (range, 10 to 19.1 years).
Numerous authors have noted a poor outcome in patients who underwent total knee arthroplasty after a variety of fractures around the knee 10,11. Lonner et al. 12 observed that patients treated with total knee arthroplasty for post-traumatic arthrosis generally had a higher rate of complications; they reported an excellent outcome in only 71% of patients.
The current study like other studies confirms that patients with a prior fracture of the tibial plateau have an increased rate of post-operative complications and possibly a poorer outcome after total knee arthroplasty 13,14.
Fractures of the tibial plateau adversely affect the outcome of total knee arthroplasty in several ways 15,16. First, because of the intra-articular extension of the fracture, there is a higher risk of arthritis developing prematurely; thus, patients may be younger at the time of the knee arthroplasty. In addition, the potential presence of a malunion following these fractures, with alteration of the weight-bearing axis of the limb, may also accelerate the subsequent development of arthritis and create reconstructive challenges at the time of the arthroplasty 17. Previous operations, which in some cases may be multiple, can compromise the soft-tissue envelope around the knee, which may in turn predispose to wound complications and infections. In addition, soft-tissue scarring related to the initial injury or as a result of prior operations may account for the difficulty with surgical exposure, difficulty-achieving ligamentous balancing, and a poor postoperative arc of knee motion.
Thus, based on the available data in the literature, one can deduce that the outcomes of total knee arthroplasty in patients with a prior fracture are inferior to those of routine primary total knee arthroplasty.
Two important points represent the value of our study: the first is that there are no studies with such a long follow-up; the second strong point is that two different methods of treatment of these complex fractures are taken into consideration (ORIF and hybrid external fixation). This makes it possible to compare both the evolution osteoarthritis of the two treatments and the results of the implants according to the treatment used for the management of the fracture. In fact, we observed that in group B both the percentage of patients who undergo the operation is lower and that the results are slightly better. These conditions may depend on the fact that if the load axis of the knee is returned, the hybrid external fixation has two important reduced risks: necrosis of the fragments (less devascularization) and infection of the surgical sites, especially in more complex fractures. The advantages of hybrid fixator include minimal soft-tissue disruption, the ability to correct deformity in multiple planes and also during the serial controls of the treatment, as well as early knee motion.
This study has considerable limitations, since it is only retrospective, i.e. it takes into consideration patients suffering from complex fractures of the tibial plateaus treated in the same institution with two different methodologies but who were subsequently operated on for the implantation of the arthroprosthesis at different institutions by several surgeons.
However, surgeons and patients should be aware that the complication rate following this procedure is higher than that after routine primary arthroplasty. The technical challenges encountered during total knee arthroplasty in patients with a prior fracture of the tibial plateau, particularly those with major deformities, can require skills, implant systems, and methods that are usually reserved for complex revision arthroplasty.
Based on the study of the scientific literature and noting the lack of long-term follow-up studies on the subject, we thought it useful to compare these techniques by analyzing the data available to us. We notice that most of the patients treated for a complex fracture of the tibial plateau undergo an arthroplasty, but the percentage of patients is lower in Group B with better results even if the results of the prostheses are worse compared to normal prosthetic implants. It would be helpful to increase the follow-up time and therefore the data available to confirm these results.
Conflict of interest statement
The authors declare no conflict of interest.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
FC, AB, GA: resources and data; ADF: have written the first draft of the manuscript; ADF, GA: writing – review and editing; OC: supervision OC. All authors contributed to the study conception and design, and read and approved the final manuscript.
This study was approved by the Institutional Review Board of San Salvatore Academic Hospital of L’Aquila, Italy (Protocol N° 0080580/21 registred 10 th, 2021 Clinical Trials ID: NTC 2728310).
The research was conducted ethically, with all study procedures being performed in accordance with requirements of the World Medical Association’s Declaration of Helsinki.
Written informed was obtained from each participant/patient for study participation and data publication.
Figures and tables
|Parameter||ORIF (GROUP A) 32 (42%)||Hybrid external fixation (GROUP B) 43 (58%)||P value|
|% TKP||21 (63.5%)||21 (49%)|
|Mean HSS knee score after TKA at 10 yr||68||75||0.307|
|Range of motion|
|Flexion||113 ± 32||123 ± 15||0.114|
|Extension||4 ± 6||3 ± 6||0.499|
|Total ARC of motion at 10 yr||109 ± 33||120 ± 19||0.0091|
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