Is “Early Total Care” a Safe and Effective Alternative to
“Staged Protocol” for the Treatment of Schatzker IV–VI Tibial Plateau Fractures in Patients Older Than 50 Years?
Amrut Borade, MBBS, MS, Harish Kempegowda, MBBS, MS, Raveesh Richard, MD, Jove Graham, PhD, Michael Suk, MD, and Daniel S. Horwitz, MD
Objectives:To compare“Early Total Care”(ETC) with“Staged Protocol”(SP) for the treatment of Schatzker IV–VI tibial plateau fractures in patients older than 50 years regarding safety and effectiveness.
Design:Retrospective cohort study.
Setting:An academic level 1 US trauma center.
Patients/Participants: Eighty-one patients older than 50 years with Schatzker grade IV–VI tibial plateau fractures were included.
Intervention: Fifty-three patients were treated under SP with immediate external fixation followed by definitive internal fixation.
Twenty-eight patients were treated under ETC with immediate internal fixation.
Main Outcome Measurements: Comparison of perioperative findings, time to bony and clinical union, soft-tissue and bony complications, radiological outcome, and secondary procedures.
Results: The 2 groups were comparable without significant difference regarding age, sex, side of involvement, body mass index, smoking status, American Society of Anesthesiologist classification, associated injuries, comorbidities, follow-up dura- tion, and fracture classification. No statistically significant differ- ence was found regarding the perioperative complications, quality of reduction, time to union, Rasmussen score at union or at thefinal follow-up, soft-tissue/bony complications, and the rate of the secondary procedures.
Conclusion: ETC seems to be a safe, efficacious, and effective alternative to the SP for the treatment of some Schatzker IV–VI fractures in patients older than 50 years.
Key Words:Early Total Care, Staged Protocol, external fixation, soft tissue complications,.50 years
Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
(J Orthop Trauma2017;31:e400–e406)
INTRODUCTION
The incidence of tibial plateau fractures in patients older than 65 years has been reported to be 8%,1,2and the management of these fractures has been an issue of debate. Classification of tibial plateau fractures has been used in decision making regard- ing their management, and the grade of the fracture has been correlated with the severity of the mechanism of injury.3–5High- energy tibial plateau fractures are prone to various complications including soft tissue–related problems and wound complications, with reports ranging from 13% to 88%.6,7 A high-energy mechanism of injury tends to cause injury to the surrounding soft tissues resulting in either an open fracture or a closed soft- tissue injury. Initial treatment with external fixation [staged protocol (SP)] is chosen by many surgeons in these cases to facilitate soft-tissue recovery before definitive internalfixation.8 The concept of early total care (ETC) for thefixation of long bone fractures provides advantages in preventing pulmonary complications and in reducing length of hospital stay.9,10 Key milestones in increasing the utilization of ETC have been advan- ces in osteosynthesis techniques and trauma resuscitation, includ- ing developments in cardiorespiratory monitoring and supportive ventilation.10In elderly patients with osteoporotic bones, high- grade tibial plateau fractures can result from a relatively low- energy mechanism of injury (ie, fall). In these cases, it may be possible to have less severe soft-tissue injury even with coexisting fractures of the tibial plateau classified as high grade. Immediate internalfixation of these fractures is considered by some surgeons taking into account the associated less severe soft-tissue injury.
We conducted this study to compare Schatzker IV–VI tibial plateau fractures in patients older than 50 years treated under ETC and under SP regarding the occurrence of com- plications and the secondary procedures required. We hypoth- esized that ETC protocol for the management of tibial plateau fractures can be as safe and effective as a SP.
PATIENTS AND METHODS
This study was conducted at a level 1 trauma center. A retrospective review of the charts between 2006 and 2015 was conducted after approval from the institutional review board.
Accepted for publication July 26, 2017.
From the Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA.
The authors report no conflict of interest.
No reproduced copyrighted materials are used within this manuscript. Waiver of patient consent granted by IRB for retrospective chart review.
Reprints: Daniel S. Horwitz, MD, Department of Orthopaedic Surgery, Geisinger Medical Center, 100 N Academy Avenue, Danville, PA 17822- 2130 (e-mail: [email protected]).
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/BOT.0000000000000995
Patients older than 50 years with Schatzker IV–VI tibial pla- teau fractures were included in the study. Only the patients who were definitively treated with internalfixation with plating were included. A minimum follow-up of 6 months was con- sidered necessary for inclusion. Patients with inadequate re- cords were excluded. Patients were categorized into 2 groups based on whether they were treated with the SP or the ETC.
The treatment of the patients under the SP group or the ETC group was based on the treating surgeon’s discretion. Gener- ally, the factors considered important while making the deci- sion were the general condition of the patient, presence of associated injuries, deformity, knee dislocation or subluxation, and local soft-tissue conditions. The presence of excessive swelling, blisters, compartment syndrome, internal degloving, ecchymosis, and open fractures with contaminated wounds was considered important for choosing initial temporary external fixation. Once the soft tissues were considered to be satisfac- torily recovered (based on the clinical signs of resolution of edema and return of skin wrinkling), all the patients were treated with definitive internal fixation with plating. Patients in the ETC group underwent definitive internal fixation with plating when the patient was medically ready for surgical inter- vention. The median duration between injury and internalfix- ation in the ETC group was 3.8 days [interquartile range (IQR):
1–6]. Postoperative rehabilitation protocol for all the patients after internalfixation consisted of touch down weight bearing with active range-of-motion (ROM) exercises for 6 weeks fol- lowed by partial weight bearing for 6 weeks and full weight bearing at 12 weeks. Radiographic union was defined as bridg- ing callus formation in at least 2 radiographic planes. Clinical union was defined as painless weight bearing.11,12
Patient charts were reviewed for demographic charac- teristics, medical comorbidities, intraoperativefindings, peri- operative systemic complications, time to bony and clinical union, soft-tissue and bony complications, radiological out- come, and secondary procedures. Radiological outcome was assessed with the Rasmussen scoring system at the time of union and at thefinal follow-up.13,14
The statistical analysis was performed using R (R 3.0.3;
Vienna, Austria) and SAS (SAS 9.4; Cary, NC) statistical software. To compare the ETC and SP groups, Student t testing was used for mean of normally distributed variables, x2 or Fisher exact tests were used for percentages, and Wilcoxon test was used for ordinal and discrete variables, for example, length of stay. Ninety-five percentage confidence interval (CI) was generated using 2000 bootstrapped samples.
RESULTS
There were 155 patients found to be potentially eligible.
The patients with inadequate follow-up and missing data were excluded. Eighty-one patients were confirmed to be eligible and were included in the study. There were 53 cases treated in the SP group and 28 cases treated in the ETC group. Patient demographic characteristics are described in Table 1. There were 22 males (42%) in the SP group and 8 males (29%) in the ETC group. As noted in the table, there was no statistically significant difference in sex, body mass index, American Society of Anes-
intensive care unit level care, smoking status, medical comor- bidities, and number of open or closed fractures in the 2 groups.
Preoperatively, skin blisters were observed in 2 patients and compartment syndrome was observed in 3 patients. All these patients were managed with the SP. There were 93% Schatzker type class V and VI cases in the SP group compared with 90%
Schatzker type class V and VI cases in the ETC group. Fall as a mechanism of injury was observed in 86% cases in the ETC group compared with 58% cases in the SP group. As expected, the interval between injury and internalfixation was significantly higher for the SP group. Median total length of stay in the SP group was 7.3 days (IQR: 3.8–15.3) and in the ETC group was 2.5 days (IQR: 1.6–4.0) (P,0.0001). Operative time for inter- nal fixation in the SP group was significantly higher than the ETC group (P= 0.0008). Clinical and radiological outcomes are noted in Table 2. The time to union in both the groups was similar with the median interval from injury to union for the SP group being 21.9 weeks (IQR: 14.9–29.9) and for the ETC group being 20.9 weeks (IQR: 11.4–36). No significant difference was found between the 2 groups regarding the Rasmussen score at time of union and the perioperative complications (vascular complications, electrolyte imbalance, pulmonary complications, and acute renal failure). As noted in Table 3, no significant difference was found in the soft-tissue complications, the bony complications, or the secondary proce- dures required in the 2 groups.
Postoperative knee ROM was not documented because of terminal knee pain in 4 patients in the SP group, although it was mentioned that they had stiff knees. Considering the patients with documented knee ROMs, mean ROM in the SP group was 110.78 (range, 70–130) compared with 116.38 (range, 100–130) in the ETC group. There were 2 patients in the SP group and 1 patient in the ETC group who contin- ued partial weight bearing atfinal follow-up. Mean follow-up duration for our study was 19.1 months (range, 7–102), and 60% of the patients had follow-up of more than 1 year. No significant difference in the follow-up duration was observed between the 2 groups as noted in the Table 2.
DISCUSSION
Ourfindings show that ETC may be as effective and safe as SP for the treatment of some Schatzker IV–VI tibial plateau fractures in patients older than 50 years. This likely reflects that with the low-energy mechanism of injury, the soft-tissue injury may not be as severe as one would expect with a coexisting high- grade fracture. We observed ETC to be beneficial regarding decrease in the operative time of internalfixation, bypassing the procedure of externalfixation, and the burdens associated with it.
High-energy tibial plateau fractures are prone to complications irrespective of the method of stabilization, and high rates of soft-tissue complications including deep infections have been reported after internalfixation of these injuries.6,7,15At present, there are no guidelines for the treat- ment of high-grade tibial plateau fractures in the elderly. It has been speculated that the energy of injury is absorbed with the fracture of the osteoporotic bones and hence, the inci- dence of associated ligament injury is relatively low.1,16–18
soft tissues tend to be spared in these fractures. The goals of treatment of high-energy tibial plateau fractures have been considered to be anatomical reduction of the articular surface, restoration of the axial alignment, and stablefixation to pre- vent secondary displacement of the fracture fragments.3With immediate internal fixation, it is possible to achieve these goals if the soft-tissue conditions around the tibial plateau are acceptable. Assessment of soft-tissue injury in these frac- tures is subjective and not standardized.
The SP has been proposed as the preferred technique to facilitate soft-tissue recovery. Egol et al15 (57 high-energy proximal tibia fractures) and Parekh et al19(16 patients with distal femur fractures and 36 patients with proximal tibia fractures) studied the SP for the treatment of periarticular fractures around knee. Attempt for aggressive debridement with early soft-tissue coverage was recommended even with SP by Parekh et al.
Debate regarding initial external fixation versus early internalfixation for high-energy tibial plateau fractures can be noted in the orthopaedic literature as early as 1948.20A brief review of literature related to the immediate internalfixation of tibial plateau fractures is mentioned in the Table 4.
The issue of assessing the severity of injury to bone and soft tissues separately has been raised in the literature, with reports of relatively low incidence of associated ligamentous and meniscal injuries in tibial plateau fracture patients with osteoporotic bone.1,16–18 Delamarter et al23 have considered the associated ligament damage as the best predictor of out- come prognosis. Despite this, the severity of soft-tissue injury in the tibial plateau fracture has been arbitrarily associated with the grade of the fractures. Watson noted that the degree of articular depression, the extent and separation of the TABLE 1. Preoperative and Perioperative Patient
Demographics
SP (n = 53) ETC (n = 28) P
Males, N (%) 22 (42) 8 (29) 0.25*
Age in y,
mean (SD) [range]
67 (8) [58–88] 70 (9) [57–90] 0.14† Injury mechanism, N (%)
Fall 31 (58) 24 (86) —
Motor vehicle crash 17 (32) 3 (11)
Pedestrian–motor vehicle accident
3 (6) 0 (0)
Motorcycle crash 1 (2) 0 (0)
Pathologic fracture 0 (0) 1 (4)
Sports 1 (2) 0 (0)
BMI, N (%) 0.17‡
18.5–24.9 6 (11) 7 (25)
25.0–29.9 20 (38) 8 (29)
30.0–34.9 15 (28) 11 (39)
35.0–39.9 7 (13) 1 (4)
40.0–50.0 3 (6) 1 (4)
.50 2 (4) 0 (0)
ASA classification, N (%) 0.19‡
I 3 (6) 0 (0)
II 18 (34) 15 (54)
III 26 (49) 13 (46)
IV 6 (11) 0 (0)
Side, N (%) 0.48*
Left 23 (43) 10 (36)
Right 28 (53) 18 (64)
Both 2 (4) 0 (0)
SICU level care required, N (%)
3 (6) 1 (4) 0.76*
Open or closed, N (%) 0.29*
Closed 48 (91) 26 (93)
Open grade I 2 (4) 2 (7)
Open grade II 3 (6) 0 (0)
Skin injuries, N (%) 26 (49) 12 (43) 0.27*
Smokers, N (%) 19 (36) 10 (36) .0.99*
Neurological disease, N (%) 8 (15) 3 (11) 0.74*
Chronic cardiovascular disease, N (%)
20 (38) 11 (39) .0.99*
Diabetes mellitus, N (%) 18 (34) 7 (25) 0.46*
Chronic pulmonary disease, N (%)
4 (8) 4 (14) 0.44*
Chronic renal disease, N (%)
5 (9) 2 (7) .0.99*
Metabolic disease, N (%) 5 (9) 3 (11) .0.99*
Hypothyroidism, N (%) 4 (8) 3 (11) 0.69*
Immunologic disease, N (%)
2 (4) 1 (4) .0.99*
Anticoagulation, N (%) 7 (13) 4 (14) .0.99*
Tourniquet used, N (%) 29 (55) 18 (64) 0.41*
Hours between injury and externalfixation, median (IQR)
18 (8–25) — —
Hours between injury and internalfixation, median (IQR)
261 (161–356) 81 (22–144) ,0.001‡
TABLE 1.(Continued) Preoperative and Perioperative Patient Demographics
SP (n = 53) ETC (n = 28) P Total length of stay (d),
median (IQR)
7.3 (3.8–15.3) 2.5 (1.6–4.0) ,0.001‡ Estimated blood loss in
mL, median (IQR)
150 (50–250) 100 (50–150) 0.16‡ Operative time in
minutes, median (IQR)
150 (126–188) 121 (98–140) 0.0008‡ Perioperative
complications
Vascular, N (%) 0 (0) 0 (0) .0.99*
Anemia, N (%) 1 (2) 1 (4) .0.99*
Electrolyte, N (%) 2 (4) 0 (0) 0.54*
Pulmonary, N (%) 1 (2) 1 (4) .0.99*
Acute renal failure, N (%)
1 (2) 0 (0) .0.99*
Pvalues represent results of Studentt,x2or Fisher exact, or Wilcoxon test com- paring variables between the groups, as indicated by footnotes. Bold entries correspond to thosePvalues,0.05.
*x2or Fisher exact test.
†Studentttest.
‡Wilcoxon rank-sum test.
ASA, American Society of Anesthesiologists; BMI, body mass index; SICU, surgical intensive care unit.
condylar fracture lines, diaphyseal–metaphyseal comminu- tion, and the integrity of the soft-tissue envelope were the important factors in determining the prognosis of these inju- ries.7 Tejwani et al5 suggested addition of the ligamentous injuries to these parameters.
The SP is preferred by many surgeons considering its safety, but it is associated with an extra surgical procedure,
prolongation of the hospital stay, chances of pin tract infection, risk of a second anesthesia, and increased risk of knee stiffness. Haller et al24 studied the risk factors for ar- throfibrosis of knee after a tibial plateau fracture. They iden- tified the use of provisional externalfixation to be statistically significantly associated with the development of arthrofibrosis (odds ratio 4.3, 95% CI, 1.26–17.7,P= 0.021). Interestingly, they reported that each extra day of externalfixation increased the odds of undergoing manipulation under anesthesia or quadricepsplasty by 10%. It has been speculated that delay of definitivefixation contributes to the increase in the risk of infection.25The ETC approach overcomes these problems. In addition, anatomical reduction is facilitated by the earlierfix- ation of the periarticular fractures. The rationale considered by the proponents of immediate open reduction internalfixa- tion of open ankle fractures is the accelerated soft-tissue heal- ing and resistance to infection after stabilization by internal fixation.26Similar views are held regarding the tibial plateau fractures by Zura et al27and Hak et al28who said that early surgical reduction and stable fixation could retard further injury to the local soft tissues. Xin et al suggested that the soft tissues around a fractured tibial plateau have a mild swelling within 12 hours of injury and hence, internalfixation can be safely performed, provided local skin tension is acceptable. In fact, their perspective was that fracture reduc- tion and hematoma evacuation with early internal fixation would facilitate resolution of the soft-tissue tension.22These authors reported no increase in the infection rate in their emergency operation group than the delayed operation group.
Our observation of statistically significantly less oper- ative time required for internal fixation in the ETC group compared with the SP group may reflect the technical difficulty (difficulty in exposure, dissection, and mobilization of fracture fragments) associated with the delayed definitive fixation. Also, fracture pattern might tend to be more complex in the SP group, which might need more operative time for the procedure. Colman et al29studied the effect of prolonged operative time on infection rate in internally fixed tibial TABLE 2. Clinical and Radiological Outcomes
SP (n = 53) ETC (n = 28) P Rasmussen score at
union, N (%)
0.31†
Poor 2 (4) 0 (0)
Fair 2 (4) 1 (4)
Good 17 (32) 8 (29)
Excellent 32 (60) 19 (68)
Weeks from injury to union, Median (IQR)
21.9 (14.9–29.9) 20.9 (11.4–36.0) 0.55† Months tofinal follow-
up, median (IQR)
11.0 (6.6–21.9) 15.4 (6.3–26.2) 0.59†
Weight-bearing status at final FU, N (%)
0.79*
Partial 2 (4) 0 (0)
Full 51 (96) 28 (100)
Rasmussen score atfinal FU, N (%)
0.25†
Poor 1 (2) 1 (4)
Fair 3 (6) 0 (0)
Good 31 (58) 14 (50)
Excellent 18 (34) 13 (46)
Functional limitation at final FU, N (%)
2 (4) 1 (4) .0.99*
Pvalues represent results of Studentt,x2or Fisher exact, or Wilcoxon test com- paring variables between the groups, as indicated by footnotes.
*x2or Fisher exact test.
†Wilcoxon rank-sum test.
FU, follow-up.
TABLE 3. Complications and Secondary Procedures
SP (n = 53) ETC (n = 28)
% Difference Between ETC and Staged
(Bootstrapped 95% CI) P
Wound dehiscence, N (%) 2 (4) 2 (7) 3 (23 to 17) 0.61
Superficial infection, N (%) 1 (2) 0 (0) 22 (22 to 8) .0.99
Deep infection, N (%) 2 (4) 2 (7) 3 (24 to 17) 0.61
Cellulitis, N (%) 2 (4) 0 (0) 24 (24 to 7) 0.54
Knee pain, N (%) 14 (26) 3 (11) 215 (226 to 5) 0.15
Symptomatic knee stiffness, N (%) 6 (11) 0 (0) 211 (211 to 4) 0.09
Loss of reduction, N (%) 1 (2) 1 (4) 2 (22 to 16) .0.99
Nonunion, N (%) 2 (4) 0 (0) 24 (24 to 7) 0.54
Symptomatic hardware, N (%) 0 (0) 0 (0) 0 (0 to 12) .0.99
Varus malunion, N (%) 2 (4) 0 (0) 24 (24 to 7) 0.54
Required secondary procedure, N (%) 7 (13) 2 (7) 26 (213 to 12) 0.49
Pvalue represents the results ofx2or Fisher exact tests comparing percentages between groups. Ninety-five percent CIs of percent difference are bootstrapped using 2000 samples and reflect the maximum differences in the ETC group relative to the SP group that were detectable as significant, given the sample size of the study. Note that because the ETC group
TABLE 4. Brief Review of Literature Related to the Immediate Internal Fixation of Tibial Plateau Fractures
Study Mean Age
Diagnosis With No. of Patients
Average Time
to Union Outcome Complications
Secondary
Procedures Comments Hsu et al1 66.3 y, (range:
61–80)
Schatzker IV–VI fractures: 14 patients and Schatzker I–III fractures: 6 patients
All patients achieved complete union within 6 mo.
Clinically and radiologically 90% of the patients achieved excellent and good results.
There was 1 superficial wound infection treated with medical treatment
None reported The mean interval duration between injury and internal fixation was 77.3 h (range 8–256 h) Frattini
et al16
72 y, (range: 66– 88 y)
Schatzker I–VI fractures: 49 patients. They classified patients with Schatzker type IV (N = 4), V (N = 6), and VI (N = 9) fracture as complex fractures.
4 mo (range,
2–6 mo) They reported satisfactory clinical scores in 75.5% and satisfactory radiological scores in 59.1% patients based on the Rasmussen’s grading system.
There were 3 cases of superficial infections (1 in type V and 2 cases in type VI fractures), 2 cases of deep infections in diabetic patients (type V and VI fractures), and 2 cases of severe posttraumatic osteoarthritis
Removal of implant with debridement and irrigation of the fracture site with additional plaster immobilization for 4 wk in both cases of deep infection.
Statistically significantly lower clinical (P= 0.009) and radiological (P= 0.005) scores in patients with complex fractures compared with simple fractures.
Benirschke et al21
42.4 y (range 17–67 y)
Schatzker V and VI tibial plateau fractures: 14 patients.
4 mo At thefinal
follow-up, average Hospital for Special Surgery (HSS) functional outcome score of 81.5 (range 45–100) and the HSS knee score of 84.6 (range 70–100) were reported.
None reported There were 8 patients who required bone grafting and 2 patients who required rotationalflaps.
Treatment was performed with immediate internal fixation and delayed primary closure at 5 d.
Tang et al22 Group I: 45. 3 y, group II:
45.76 y
Schatzker IV–VI tibial plateau fractures divided into 2 groups group I:
21 patients (mean age:
45.3 y) treated with internal fixation within 12 h of injury.
Group II: 21 patients (mean age: 45.7 y) treated after resolution of the soft-tissue swelling, generally after 1–2 wks of calcaneal traction or plaster application
Group I: 4.1 mo and group II: 4.3 mo
Statistically significantly higher mean HSS score at 3 mo in the early treatment group compared with the delayed fixation group (68.33 vs.
62.71,P= 0.014), but the mean HSS score atfinal follow-up did not show any significant difference.
None reported in either of the groups.
None reported They also observed a statistically significant difference in the length of hospital stay and cost of hospital stay between the 2 groups (P, 0.01).
plateau fractures. They observed longer operative times (odds ratio 1.78,P= 0.01) to be an independent predictor of infec- tion. Interestingly, they also observed that the use of external fixation was associated with longer operative times for sub- sequent internalfixation and with higher infection rate (10.9%
vs. 3.7%,P= 0.02). They observed that the Schatzker grade of the tibial plateau fracture was not significantly related to surgical site infections, and they suggested that the status of the soft tissues and the intraoperative soft-tissue handling were more important factors than the bony fracture character- istics regarding the occurrence of infection.
We calculated the actual variable direct cost associated with the procedure of external fixation for a tibial plateau fracture and reached an average cost of $ 8064 for the procedure in our health care setting. The procedure of externalfixation can be bypassed in the ETC.
The most important concern while undertaking the ETC is the assessment of preoperative soft-tissue condition and the possibility of postoperative soft-tissue complications. After the subjective assessment of the skin condition at the fracture site, the treating surgeon can opt for immediate internal fixation or initial externalfixation. As increasing soft-tissue complications tend to occur with the increasing severity of soft-tissue injury,20,30preoperative skin condition can be thus used for predicting the risk of soft-tissue complications. A reliable and reproducible way to assess the soft-tissue status around the tibial plateau fractures has not been established.
Dirschl et al discussed the assessment of injury severity regarding the extent of soft-tissue injury, mediolateral stabil- ity of the knee, radiographic classification of the tibial plateau fractures, and injury to the articular cartilage. They concluded
that the development of carefully validated tools is required for the assessment of the severity of injury.31 Based on the findings of our study, we suggest a protocol in Fig. 1 for the treatment of Schatzker IV–VI tibial plateau fractures in pa- tients older than 50 years. It is generally used at our center and can be extrapolated to other health care settings accordingly.
The idea of ETC of high-grade tibial plateau fracture in patients older than 50 years after a low-energy injury is a theoretical possibility. To the best of our knowledge, this is the first study evaluating this concept in clinical evidence.
Although no definite conclusion can be drawn from our results, it seems that the 2 groups are comparable. It should be noted that soft-tissue complications after the internalfixation of tibial plateau fractures tend to occur within first 90 days after surgery.32,33 Also, radiological complications tend to occur within first 6 months after the surgery.34 Hence, we believe that minimum follow-up of 6 months considered nec- essary as inclusion criteria in our study is appropriate and sufficient for the issues addressed in this study. The major limitation of our study is its modest sample size, highlighting the need for continued research. We saw no statistically sig- nificant differences in complications between the ETC (n = 28) and the SP (n = 53) groups, although readers should examine the CIs in Table 3 to see the maximum differences, our study was powered to detect. For example, we observed a 3% lower rate of wound dehiscence in the SP group as compared to the ETC group. According to the CI, the study was adequately powered such that if the rate of dehiscence in the ETC group had been 17% higher than the SP group, it would have been significant. Therefore, we cannot rule out
FIGURE 1. Suggested protocol for treatment of Schatzker IV–VI frac-
the possibility that the rate of complications in the ETC group could be higher. We note, however, that such differences would be very unlikely given that in the ETC group, only 3 complications (wound dehiscence, deep infection, and loss of reduction) had higher rate of occurrence. Multiple treating surgeons are essentially potential source of bias as the choice of either ETC or SP was based on their individual experience, preference, and judgment. A possibility of selection bias stems from the likely differences in the exact reasons for loss of follow-up in each group. Whether the patients did not come for follow-up because of recovery or death or change of the address could not be deciphered from the available data. Although interpreting and generalizing the results of this study, this possibility of bias should be kept in mind. Other study limitations include the retrospective data collection and lack of functional outcome scores for comparison. The gray zone of assessment of soft-tissue injury independent of the bony injury can account for the value of this study and need for the future research.
CONCLUSION
ETC seems to be a safe, efficacious, and effective alternative to the SP for the treatment of Schatzker IV, V, and VI fractures in some patients older than 50 years. Future research in thefield of assessment of the soft-tissue injury independent of the bony injury around the tibial plateau would be valuable to identify the patients suitable for the ETC.
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