Copyright © 2006 by The Journal of Bone and Joint Surgery, Inc.

Commentary & Perspective

Commentary & Perspective on
"Open Reduction and Internal Fixation Compared with Circular Fixator Application for Bicondylar Tibial Plateau Fractures: Results of a Multicenter, Prospective, Randomized Clinical Trial"
by the Canadian Orthopaedic Trauma Society

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.