University Medical Center Groningen, Department of Trauma Surgery, University of Groningen, Groningen, the Netherlands.
Isala Hospital, Department of Trauma Surgery, Zwolle, the Netherlands.
Clin Orthop Relat Res. 2022 Dec 1;480(12):2288-2295. doi: 10.1097/CORR.0000000000002266. Epub 2022 Jun 1.
Gap and stepoff measurements provide information about fracture displacement and are used for clinical decision-making when choosing either operative or nonoperative management of tibial plateau fractures. However, there is no consensus about the maximum size of gaps and stepoffs on CT images and their relation to functional outcome in skeletally mature patients with tibial plateau fractures who were treated without surgery. Because this is important for patient counseling regarding treatment and prognosis, it is critical to identify the limits of gaps and stepoffs that are well tolerated.
QUESTIONS/PURPOSES: (1) In patients treated nonoperatively for tibial plateau fractures, what is the association between initial fracture displacement, as measured by gaps and stepoffs at the articular surface on a CT image, and functional outcome? (2) What is the survivorship of the native joint, free from conversion to a total knee prosthesis, among patients with tibial plateau fractures who were treated without surgery?
A multicenter cross-sectional study was performed in all patients who were treated nonoperatively for a tibial plateau fracture between 2003 and 2018 in four trauma centers. All patients had a diagnostic CT scan, and a gap and/or stepoff more than 2 mm was an indication for recommending surgery. Some patients with gaps and/or stepoffs exceeding 2 mm might not have had surgery based on shared decision-making. Between 2003 and 2018, 530 patients were treated nonoperatively for tibial plateau fractures, of which 45 had died at follow-up, 30 were younger than 18 years at the time of injury, and 10 had isolated tibial eminence avulsions, leaving 445 patients for follow-up analysis. All patients were asked to complete the validated Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire consisting of five subscales: symptoms, pain, activities of daily living (ADL), function in sports and recreation, and knee-related quality of life (QOL). The score for each subscale ranged from 0 to 100, with higher scores indicating better function. A total of 46% (203 of 445) of patients participated at a mean follow-up of 6 ± 3 years since injury. All knee radiographs and CT images were reassessed, fractures were classified, and gap and stepoff measurements were taken. Nonresponders did not differ much from responders in terms of age (53 ± 16 years versus 54 ± 20 years; p = 0.89), gender (70% [142 of 203] women versus 59% [142 of 242] women; p = 0.01), fracture classifications (Schatzker types and three-column concept), gaps (2.1 ± 1.3 mm versus 1.7 ± 1.6 mm; p = 0.02), and stepoffs (2.1 ± 2.2 mm versus 1.9 ± 1.7 mm; p = 0.13). In our study population, the mean gap was 2.1 ± 1.3 mm and stepoff was 2.1 ± 2.2 mm. The participating patients divided into groups with increasing fracture displacement based on gap and/or stepoff (< 2 mm, 2 to 4 mm, or > 4 mm), as measured on CT images. ANOVA was used to assess whether an increase in the initial fracture displacement was associated with poorer functional outcome. We estimated the survivorship of the knee free from conversion to total knee prosthesis at a mean follow-up of 5 years using a Kaplan-Meier survivorship estimator.
KOOS scores in patients with a less than 2 mm, 2 to 4 mm, or greater than 4 mm gap did not differ (symptoms: 83 versus 83 versus 82; p = 0.98, pain: 85 versus 83 versus 86; p = 0.69, ADL: 87 versus 84 versus 89; p = 0.44, sport: 65 versus 64 versus 66; p = 0.95, QOL: 70 versus 71 versus 74; p = 0.85). The KOOS scores in patients with a less than 2 mm, 2 to 4 mm, or greater than 4 mm stepoff did not differ (symptoms: 84 versus 83 versus 77; p = 0.32, pain: 85 versus 85 versus 81; p = 0.66, ADL: 86 versus 87 versus 82; p = 0.54, sport: 65 versus 68 versus 56; p = 0.43, QOL: 71 versus 73 versus 61; p = 0.19). Survivorship of the knee free from conversion to total knee prosthesis at mean follow-up of 5 years was 97% (95% CI 94% to 99%).
Patients with minimally displaced tibial plateau fractures who opt for nonoperative fracture treatment should be told that fracture gaps or stepoffs up to 4 mm, as measured on CT images, could result in good functional outcome. Therefore, the arbitrary 2-mm limit of gaps and stepoffs for tibial plateau fractures could be revisited. The survivorship of the native knee free from conversion to a total knee prosthesis was high. Large prospective cohort studies with high response rates are needed to learn more about the relationship between the degree of fracture displacement and functional recovery after tibial plateau fractures.
Level III, prognostic study.
关节面间隙和台阶测量值可提供骨折移位的信息，并可用于临床决策，以选择胫骨平台骨折的手术或非手术治疗。然而，对于接受非手术治疗的成熟骨骼胫骨平台骨折患者，CT 图像上的关节面间隙和台阶最大值及其与功能结果的关系尚未达成共识，对于治疗和预后相关的患者咨询，明确可接受的关节面间隙和台阶值非常重要。
问题/目的：（1）在接受非手术治疗的胫骨平台骨折患者中，关节面 CT 图像上的初始骨折移位（间隙和台阶测量值）与功能结果之间存在怎样的关联？（2）未接受手术治疗的胫骨平台骨折患者，其原生关节的存活率是多少？
本研究为多中心横断面研究，纳入了 2003 年至 2018 年期间在四家创伤中心接受非手术治疗的胫骨平台骨折患者。所有患者均接受了诊断性 CT 扫描，如果间隙和/或台阶超过 2mm，则提示需要手术治疗。尽管存在超过 2mm 的间隙和/或台阶，但一些患者可能未接受手术治疗，这是基于共同决策的。2003 年至 2018 年期间，共有 530 例胫骨平台骨折患者接受非手术治疗，随访期间 45 例患者死亡，30 例患者在受伤时年龄小于 18 岁，10 例患者为单纯胫骨隆突撕脱骨折，最终有 445 例患者纳入随访分析。所有患者均被要求完成经过验证的膝关节损伤和骨关节炎结果评分（KOOS）问卷，该问卷包含五个亚量表：症状、疼痛、日常生活活动（ADL）、运动和娱乐功能以及膝关节相关生活质量（QOL）。每个亚量表的评分范围为 0 至 100 分，得分越高表示功能越好。共有 46%（203 例/445 例）的患者在受伤后平均 6±3 年时参加了随访。所有膝关节 X 线片和 CT 图像均重新进行了评估，对骨折进行了分类，并进行了间隙和台阶测量。未应答者与应答者在年龄（53±16 岁与 54±20 岁；p=0.89）、性别（70%[142 例/203 例]女性与 59%[142 例/242 例]女性；p=0.01）、骨折分型（Schatzker 分型和三柱分型）、间隙（2.1±1.3mm 与 1.7±1.6mm；p=0.02）和台阶（2.1±2.2mm 与 1.9±1.7mm；p=0.13）方面差异无统计学意义。在本研究人群中，平均间隙为 2.1±1.3mm，台阶为 2.1±2.2mm。根据 CT 图像上的间隙和/或台阶（<2mm、2-4mm 或>4mm），将参与研究的患者分为骨折移位逐渐增加的组。采用方差分析评估初始骨折位移的增加是否与功能结果较差有关。我们使用 Kaplan-Meier 生存估计器估计平均 5 年随访时膝关节免于转换为全膝关节置换术的生存率。
间隙<2mm、2-4mm 或>4mm 的患者的 KOOS 评分无差异（症状：83 分与 83 分与 82 分；p=0.98，疼痛：85 分与 83 分与 86 分；p=0.69，ADL：87 分与 84 分与 89 分；p=0.44，运动：65 分与 64 分与 66 分；p=0.95，QOL：70 分与 71 分与 74 分；p=0.85）。间隙<2mm、2-4mm 或>4mm 的患者的 KOOS 评分无差异（症状：84 分与 83 分与 77 分；p=0.32，疼痛：85 分与 85 分与 81 分；p=0.66，ADL：86 分与 87 分与 82 分；p=0.54，运动：65 分与 68 分与 56 分；p=0.43，QOL：71 分与 73 分与 61 分；p=0.19）。平均随访 5 年时，膝关节免于转换为全膝关节置换术的生存率为 97%（95%CI 94%-99%）。
选择非手术治疗的胫骨平台骨折患者，如果 CT 图像上的骨折间隙或台阶达到 4mm 以内，可能会获得良好的功能结果，因此，可以重新考虑胫骨平台骨折间隙和台阶的 2mm 界限。原生膝关节免于转换为全膝关节置换术的生存率较高。需要进行大型前瞻性队列研究，以获得更高的应答率，从而进一步了解胫骨平台骨折后骨折位移程度与功能恢复之间的关系。
III 级，预后研究。
