Review Question - QID 220408

Tibial Plateau Fractures Complications Post-traumatic arthritis QID: 220408 (OBQ24.35)

QID 220408 (Type "220408" in App Search)

A 24-year-old female presents to the trauma bay after a motor vehicle collision and sustains the injury in Figure A. She underwent initial treatment with an external fixator and presents to your clinic for discussion of definitive management. When counseling the patient on possible complications after open reduction and internal fixation (ORIF), which of the following is most accurate?

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The risk of postoperative infection is higher in older patients

80/874

The conversion rate to arthroplasty 10 years after ORIF is between 5-10%

54%

471/874

Nonunion is more common is younger patients

4/874

After the age of 60, the rate of complications dramatically increases

15%

134/874

Patients who undergo external fixator placement are more likely to have complications

21%

181/874

Select Answer to see Preferred Response

This patient sustained a displaced bicondylar tibial plateau fracture. When counseling this patient about their expected outcome, it is important to emphasize that there is a risk of post-traumatic arthritis and conversion to total knee arthroplasty (TKA), the rate of which has been shown to be between 5-10% at 10 years postoperatively (Answer 2).

ORIF is the standard of treatment of displaced tibial plateau fractures. Operative indications for tibial plateau fractures include >5-10 millimeters (mm) of articular step-off, knee joint instability, condyle widening >5 mm, and bicondylar fractures. Reconstruction of the native joint line (alignment) and stability are both critical to minimize the risk of post-traumatic arthritis. Other complications after ORIF include infection, wound breakdown, stiffness, and non-union. However, the rate of complications has not been shown to differ between older and younger patients.

Kim et al. compared complication rates between patients younger (<60 years old) and older (>60 years old) who underwent ORIF for tibial plateau fractures with a mean follow-up time of 2 years. They found no significant differences in terms of post-traumatic arthritis, loss of reduction, conversion to TKA, non-union, or injection. They concluded that ORIF is a good surgical option even in elderly patients.

Wasserstein et al. performed a retrospective case-control study of 8426 patients ages 16 and up to evaluate the rate of conversion to TKA after tibial plateau ORIF. They found that the 2-year, 5-year, and 10-year rates of conversion to TKA after tibial plateau ORIF were 0.32%, 5.3%, and 7.3%, respectively. After adjusting for comorbidities, they noted a 5.3x increase in the likelihood of TKA after sustaining a tibial plateau fracture compared to the control cohort.

Figure A is the AP radiograph of a right knee, which demonstrates a displaced bicondylar tibial plateau fracture.

Incorrect Answers:
Answers 1, 3, & 4: The rates of complications do not differ between older and younger patients
Answer 5: In high-energy tibial plateau fractures, temporizing external fixator placement can allow time for soft tissue healing, which can help decrease wound complications after definitive fixation