Department of Trauma Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
Department of Trauma Surgery, Martini Hospital, Groningen, the Netherlands.
Clin Orthop Relat Res. 2024 Oct 1;482(10):1744-1752. doi: 10.1097/CORR.0000000000003057. Epub 2024 May 9.
Much controversy remains about whether minimally displaced tibial plateau fractures should be treated operatively or nonoperatively. It is generally accepted that gaps and stepoffs up to 2 mm can be tolerated, but this assumption is based on older studies using plain radiographs instead of CT to assess the degree of initial fracture displacement. Knowledge regarding the relationship between the degree of fracture displacement and expected functional outcome is crucial for patient counseling and shared decision-making, specifically in terms of whether to perform surgery.
QUESTIONS/PURPOSES: (1) Is operative treatment associated with improved patient-reported outcomes compared with nonoperative treatment in minimally displaced tibial plateau fractures (fractures with up to 4 mm of displacement)? (2) What is the difference in the risk of complications after operative versus nonoperative treatment in minimally displaced tibial plateau fractures?
A multicenter, cross-sectional study was performed in patients treated for tibial plateau fractures between 2003 and 2019 at six hospitals. Between January 2003 and December 2019, a total of 2241 patients were treated for tibial plateau fractures at six different trauma centers. During that time, the general indication for open reduction and internal fixation (ORIF) was intra-articular displacement of > 2 mm. Patients treated with ORIF and those treated nonoperatively were potentially eligible; 0.2% (4) were excluded because they were treated with amputation because of severe soft tissue damage, whereas 4% (89) were excluded because of coexisting conditions that complicated outcome measurement including Parkinson disease, cerebrovascular accident, or paralysis (conditions causing an inability to walk). A further 2.7% (60) were excluded because their address was unknown, and 1.4% (31) were excluded because they spoke a language other than Dutch. Based on that, 1328 patients were potentially eligible for analysis in the operative group and 729 were potentially eligible in the nonoperative group. At least 1 year after injury, all patients were approached and asked to complete the Knee injury and Osteoarthritis Outcome Scale (KOOS) questionnaire. A total of 813 operatively treated patients (response percentage: 61%) and 345 nonoperatively treated patients (response percentage: 47%) responded to the questionnaire. Patient characteristics including age, gender, BMI, smoking, and diabetes were retrieved from electronic patient records, and imaging data were shared with the initiating center. Displacement (gap and stepoff) was measured for all participating patients, and all patients with minimally displaced fractures (gap or stepoff ≤ 4 mm) were included, leaving 195 and 300 in the operative and nonoperative groups, respectively, for analysis here. Multivariate linear regression was performed to assess the association of treatment choice (nonoperative or operative) with patient-reported outcomes in minimally displaced fractures. In the multivariate analysis, we accounted for nine potential confounders (age, gender, BMI, smoking, diabetes, gap, stepoff, AO/OTA classification, and number of involved segments). In addition, differences in complications after operative and nonoperative treatment were assessed. The minimum clinically important differences for the five subscales of the KOOS are 11 for symptoms, 17 for pain, 18 for activities of daily living, 13 for sports, and 16 for quality of life.
After controlling for potentially confounding variables such as age, gender, BMI, and AO/OTA classification, we found that operative treatment was not associated with an improvement in patient-reported outcomes. Operative treatment resulted in poorer KOOS in terms of pain (-4.7 points; p = 0.03), sports (-7.6 points; p = 0.04), and quality of life (-7.8 points; p = 0.01) compared with nonoperative treatment, but those differences were small enough that they were likely not clinically important. Patients treated operatively had more complications (4% [7 of 195] versus 0% [0 of 300]; p = 0.01) and reoperations (39% [76 of 195] versus 6% [18 of 300]; p < 0.001) than patients treated nonoperatively. After operative treatment, most reoperations (36% [70 of 195]) consisted of elective removal of osteosynthesis material.
No differences in patient-reported outcomes were observed at midterm follow-up between patients treated surgically and those treated nonsurgically for tibial plateau fractures with displacement up to 4 mm. Therefore, nonoperative treatment should be the preferred treatment option in minimally displaced fractures. Patients who opt for nonoperative treatment should be told that complications are rare, and only 6% of patients might undergo surgery by midterm follow-up. Patients who opt for surgery of a minimally displaced tibial plateau fracture should be told that complications may occur in up to 4% of patients, and 39% of patients may undergo a secondary intervention (most of which are elective implant removal).
Level III, therapeutic study.
对于胫骨平台骨折是否应采用手术或非手术治疗仍存在较大争议。一般认为，间隙和台阶可达 2mm 是可以接受的，但这种假设是基于使用普通 X 线片而不是 CT 来评估初始骨折移位程度的较老研究。了解骨折移位程度与预期功能结果之间的关系对于患者咨询和共同决策至关重要，尤其是在是否进行手术方面。
问题/目的：（1）与非手术治疗相比，手术治疗是否能改善胫骨平台骨折（最大 4mm 移位）患者的患者报告结果？（2）胫骨平台骨折最小移位（最大 4mm 移位）患者手术与非手术治疗后并发症风险有何差异？
在 2003 年至 2019 年期间，在六家医院对胫骨平台骨折患者进行了一项多中心、横断面研究。在 2003 年 1 月至 2019 年 12 月期间，六家不同的创伤中心共治疗了 2241 例胫骨平台骨折患者。当时，切开复位内固定（ORIF）的一般适应证是关节内移位>2mm。接受 ORIF 和非手术治疗的患者均有可能入选；由于严重软组织损伤而接受截肢的患者占 0.2%（4 例），合并包括帕金森病、中风或瘫痪等影响结局测量的共存疾病的患者占 4%（89 例）。由于地址不详而被排除的患者占 2.7%（60 例），由于语言不同而被排除的患者占 1.4%（31 例）。在此基础上，1328 例患者有潜在手术治疗可能，729 例患者有潜在非手术治疗可能。在受伤后至少 1 年，所有患者均被联系并要求完成膝关节损伤和骨关节炎结局评分（KOOS）问卷。共有 813 例手术治疗患者（应答率：61%）和 345 例非手术治疗患者（应答率：47%）回答了问卷。患者特征包括年龄、性别、BMI、吸烟和糖尿病，从电子病历中获取，并与发起中心共享影像学数据。对所有参与患者进行了测量，所有胫骨平台骨折最小移位患者（间隙或台阶≤4mm）都被纳入研究，分别有 195 例和 300 例在手术和非手术组中进行分析。多变量线性回归用于评估治疗选择（非手术或手术）与胫骨平台骨折最小移位患者的患者报告结果之间的关系。在多变量分析中，我们考虑了 9 个潜在混杂因素（年龄、性别、BMI、吸烟、糖尿病、间隙、台阶、AO/OTA 分类和受累节段数）。此外，还评估了手术和非手术治疗后并发症的差异。KOOS 五个子量表的最小临床重要差异分别为症状 11 分、疼痛 17 分、日常生活活动 18 分、运动 13 分和生活质量 16 分。
在控制了年龄、性别、BMI 和 AO/OTA 分类等潜在混杂变量后，我们发现手术治疗与患者报告结果的改善无关。与非手术治疗相比，手术治疗在疼痛（-4.7 分；p=0.03）、运动（-7.6 分；p=0.04）和生活质量（-7.8 分；p=0.01）方面的 KOOS 评分较差，但这些差异足够小，可能没有临床意义。与非手术治疗相比，手术治疗患者的并发症（4%[195 例中有 7 例]与 0%[300 例中无 1 例]；p=0.01）和再手术（39%[195 例中有 76 例]与 6%[300 例中有 18 例]；p<0.001）更多。手术后，大多数再手术（36%[195 例中有 70 例]）由择期去除内固定材料组成。
胫骨平台骨折最大 4mm 移位患者的手术治疗与非手术治疗在中期随访时患者报告结果无差异。因此，非手术治疗应是最小移位骨折的首选治疗方法。选择非手术治疗的患者应被告知并发症罕见，只有 6%的患者可能在中期随访时需要手术。选择手术治疗胫骨平台骨折最小移位的患者应被告知并发症可能发生在多达 4%的患者中，39%的患者可能需要二次干预（其中大多数是择期取出植入物）。
III 级，治疗性研究。
