Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.
Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.
Injury. 2024 Nov;55(11):111879. doi: 10.1016/j.injury.2024.111879. Epub 2024 Sep 13.
Tibial plateau fractures are often associated with high-energy trauma necessitating external fixation as a means of temporization. There is evidence that pin placement and fracture distraction may result in transient increases in compartment pressures, and the optimal timing of external fixator placement is unknown. This study sought to determine the effect of early versus late external fixator placement on the risk of compartment syndrome after a tibial plateau fracture.
The Trauma Quality Improvement Program was retrospectively queried between 2015 and 2019 for adult patients with a tibial plateau fracture who underwent external fixator placement. Patients with concomitant tibial shaft and/or distal femur fractures, requiring lower extremity fasciotomy before external fixation, or external fixation >7 days after admission were excluded. The primary study outcome was inpatient compartment syndrome. Secondary outcomes were inpatient acute respiratory failure/unplanned intubation, surgical site infection, and venous thromboembolism (VTE). A time threshold of delayed external fixation was identified at which the odds of compartment syndrome no longer significantly decreased with increasing time using a Markov Chain Monte Carlo simulation of a restricted cubic spline model. The odds of each outcome were compared between patients who underwent early versus delayed external fixation on or after the time threshold, adjusting for potential confounding by patients, injury, and hospital characteristics. Significance was defined as p < 0.05.
A threshold for delayed external fixation was identified at 28.8 h from admission. Of the 3,185 eligible patients, 2,656 (83.4 %) were classified as early external fixation and 529 (16.6 %) were classified as delayed external fixation. Delayed external fixation was associated with lower adjusted odds (aOR) of compartment syndrome (aOR: 0.31, 95 % Confidence Interval (CI): 0.13-0.74, p = 0.008) and higher aOR of acute respiratory failure/unplanned intubation (aOR: 2.13, 95 % CI: 1.13-4.0.2, p = 0.019), however no significant differences in adjusted odds of surgical site infection or VTE were observed.
Patients with tibial plateau fractures who underwent closed reduction and external fixation within 28.8 h of admission were associated with greater odds of compartment syndrome than those undergoing external fixation after this time threshold.
胫骨平台骨折常与高能创伤相关，需要外固定作为临时固定手段。有证据表明，钢针的放置和骨折的分离可能导致间隙压力的短暂升高，而外固定器的最佳放置时间尚不清楚。本研究旨在确定早期与晚期外固定器放置对胫骨平台骨折后发生筋膜间室综合征的风险的影响。
回顾性查询 2015 年至 2019 年期间的创伤质量改进计划，纳入接受外固定器治疗的胫骨平台骨折成年患者。排除同时存在胫骨骨干和/或股骨远端骨折、需要下肢筋膜切开术才能进行外固定器治疗或在入院后 7 天以上进行外固定器治疗的患者。主要研究结局为住院期间的筋膜间室综合征。次要结局为住院期间急性呼吸衰竭/计划性插管、手术部位感染和静脉血栓栓塞症（VTE）。使用受限立方样条模型的马尔可夫链蒙特卡罗模拟确定外固定器延迟的时间阈值，在此时间阈值之上，随着时间的推移，筋膜间室综合征的发生几率与外固定器放置时间之间的关联不再显著降低。根据患者、损伤和医院特征进行潜在混杂因素的调整后，比较接受早期与延迟外固定器治疗的患者之间的每种结局的发生几率。显著性定义为 p<0.05。
确定了外固定器延迟的时间阈值为入院后 28.8 小时。在 3185 名符合条件的患者中，2656 名（83.4%）被归类为早期外固定器治疗，529 名（16.6%）被归类为延迟外固定器治疗。与早期外固定器治疗相比，延迟外固定器治疗的调整后 odds（aOR）更低（aOR：0.31，95%置信区间（CI）：0.13-0.74，p=0.008），且调整后 odds 更高（aOR：2.13，95%CI：1.13-4.02，p=0.019）的急性呼吸衰竭/计划性插管。然而，手术部位感染或 VTE 的调整后 odds 无显著差异。
在入院后 28.8 小时内接受闭合复位和外固定器治疗的胫骨平台骨折患者发生筋膜间室综合征的几率高于在此时间阈值后接受外固定器治疗的患者。
