Key messages
• We do not know what is the best way to repair a complex fracture of the tibial plateau (top part of the shin bone).
• There is some evidence suggesting little or no difference between different surgical methods for fixing tibial plateau bone fragments in place and between different methods of filling holes in the bone caused by the fractures. We are not confident in the evidence.
• More research is required in this area.
What is a tibial plateau fracture?
Fractures of the tibial plateau are injuries affecting the top end of the tibia (shin bone), which forms the lower bone surface in the knee joint. These fractures are often associated with substantial damage to the skin and muscle and may cause defects (holes) in the bone.
How is a tibial plateau fracture treated?
Often, complex fractures are fixed through open surgery (open reduction and internal fixation; ORIF). This involves exposing the fracture to direct view and then fixing the bone fragments in place with metal plates and screws. Another method is external fixation, where wires and pins are placed into the bone around the fracture then attached to an external structure (like a scaffold) to secure the fragments in place until they heal. In external fixation, the surgeon can use small plates or screws to hold some of the fracture fragments in position; this is called hybrid fixation.
To correct possible bone defects, the surgeon can use bone defect fillers: either bone grafts taken from the patient or bone substitutes such as artificial bone.
What did we want to find out?
We wanted to find the best surgical methods and the best bone defect fillers for improving quality of life and leg function and reducing complications related to surgery in people with tibial plateau fractures. We considered the most important measures for these results were general quality of life scores in a 36-item Health Survey (SF-36), a leg function score called the Hospital for Special Surgery (HSS) score, and the need for reoperation.
What did we do?
We searched scientific databases for studies that compared different surgical methods for treating tibial plateau fractures and different types of filler for bone defects. We compared and summarised the results and rated our confidence in the evidence.
What did we find?
We found 15 small studies, including 948 adults. The biggest study included 135 people and the smallest study included 14 people. The studies were conducted in countries around the world (five in China). Studies followed people for between 12 and 24 months after the fracture. Pharmaceutical companies funded four studies (in full or in part).
One study (with 82 people) compared hybrid fixation with ORIF. It suggested little to no difference between the methods in SF-36 score, HSS score, and need for unplanned reoperation, but the results are very uncertain. Three studies (with 242 people) evaluated ORIF with two plates against ORIF with three plates. There may be little to no difference between the methods in terms of HSS score, but the evidence is very uncertain. These studies provided no information on SF-36 score or unplanned reoperation. Six studies (with 368 people) compared bone substitutes with bone grafts for treating bone defects. However, they provided no information on long-term SF-36 score, HSS score, or need for unplanned reoperation.
What are the limitations of this evidence?
We were not confident in the results because all studies were small, and because people knew what treatment they were receiving and may have preferred one treatment over the other. In six studies, many people did not take part in all the assessments, and we do not know if their results could have affected the final conclusions.
How up to date is this evidence?
This is an update of a review first published in 2015. The evidence is current to March 2023.
There is insufficient evidence to ascertain the best method of fixation or the best method of addressing bone defects during surgery in people with tibial plateau fractures. Further well-designed RCTs with larger sample sizes are warranted.
Tibial plateau fractures, which are intra-articular injuries of the knee joint, are often difficult to treat and have a high complication rate, including early-onset osteoarthritis. The most common treatment for complex tibial plateau fractures is surgical fixation. Additionally, orthopaedic surgeons often use bone defect fillers to address bone defects caused by the injury. Currently, there is no consensus on the best method of fixation and on whether bone defect fillers are necessary.
To assess the benefits and harms of different surgical interventions and bone defect fillers for treating tibial plateau fractures.
We searched CENTRAL, MEDLINE, Embase, and trial registries up to March 2023. We also searched conference proceedings and the grey literature.
We included randomised controlled trials (RCTs) and quasi-RCTs comparing surgical interventions for treating tibial plateau fractures and different types of filler for bone defects.
Two review authors independently screened search results, selected studies, extracted data, and assessed risk of bias. We calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, with 95% confidence intervals (CIs). Our primary outcomes (and the specific measures we considered most relevant) were generic quality of life (general health score in the 36-item Short-Form Health Survey (SF-36)), patient-reported lower limb function (Hospital for Special Surgery (HSS) score), and adverse events (frequency of unplanned reoperation). We used GRADE to assess the certainty of evidence.
We included 15 trials in the review, with a total of 948 adult participants. Nine trials compared different types of fixation, and six trials evaluated different types of bone graft substitutes. All 15 trials were small and at high risk of bias. We considered most available evidence to be of very low certainty, meaning we have very little confidence in the results. Only limited pooling was possible.
One trial compared circular fixation combined with insertion of percutaneous screws (hybrid fixation) versus standard open reduction and internal fixation (ORIF) in 82 people with open or closed Schatzker types V or VI tibial plateau fractures. At 24 months' follow-up, hybrid fixation compared with ORIF may have little or no effect on SF-36 general health score (MD 6 points higher, 95% CI 7.7 points lower to 19.7 points higher; 66 participants), patient-reported lower limb function according to the HSS score (MD 7 points higher, 95% CI 2.4 points lower to 16.4 points higher; 66 participants), or frequency of unplanned reoperation (RR 0.78, 95% CI 0.45 to 1.32; 83 fractures (82 participants)). However, the evidence for all three outcomes is very uncertain.
Three trials (with 242 participants) compared single-plating ORIF versus double-plating ORIF. There may be little to know difference in patient-reported lower limb function (HSS score) at 24 months' follow-up in people who undergo single-plating ORIF compared with those who undergo double-plating ORIF (MD 0.2 points higher, 95% CI 2.12 points lower to 2.52 points higher; 1 study, 84 participants), but the evidence is very uncertain. There were no data for quality of life or unplanned reoperation at 24 months' follow-up.
Six trials (including 368 participants) compared bone substitute versus autologous bone graft (autograft) for managing bone defects. No trials reported SF-36 general health score, HSS score, or frequency of unplanned reoperation at 24 months' follow-up.