Ever seen Cirque du Soleil? (Or any other circus)? It’s really remarkable what human bodies are capable of—making fantastic leaps, bearing tremendous loads, and count on it, sticking landing after gymnastic landing. I sometimes find myself distracted while watching these kinds of acts. How many landings do they make in each show? How many shows a year? What percentage of landings do they make? It’s gotta be 99.99… and how many more 9s after that? It had better be quite a few; the injuries from any misses no doubt would be spectacular.
Back here on earth, the authors of this month’s Editor’s Spotlight article about tibial fractures [
] remind us that the World Health Organization recommends we take 10,000 steps a day, or something shy of 4 million steps a year. Since most of us are not Cirque du Soleil high-flyers, all it takes is one errant step—out of nearly 4 million—to find ourselves belly up on a gurney in somebody’s emergency department. With numbers like that, it’s amazing this doesn’t happen more often. 12
In comes the trauma team. Tibial plateau fracture, right into the joint. A CT scan shows a 3- or 4-mm stepoff. Go or no go? Hot topic, no doubt, but I think for many of these fractures at most centers, the answer often is surgery. But our indications—as another commentator [
] on this month’s spotlight article [ 2 ] points out—derive largely from historical sources, many of which are not as robust as we wish they were. By and large, small amounts of articular incongruence result preferentially in a surgical recommendation today [ 12 ] just as was the case three decades ago or more. 10
In this month’s
Clinical Orthopaedics and Related Research ® , a group from Groningen, in the Netherlands, found that patients treated without surgery, despite gaps and joint stepoffs of 4 mm or more, by and large did fine [ ]. The analysis went beyond the usual “the patient dodged knee replacement” (though 97% did at 5 years) and actually asked the patients how their knees felt. Patient-reported outcome scores and quality of life scores were quite high, and, importantly, the groups with less displacement (< 2 mm or 2 to 4 mm) did no worse than did those with more (> 4 mm). The study was large, so clinically important differences in these regards would’ve been expected to turn up, if any were present. 12
Thoughtful people have questioned our aggressive approaches to these fractures for a while now [
], and so I find it to some degree surprising that our indications result in so much surgery being done for such small amounts of displacement. 9
Nonetheless, it seems clear from this paper that we’re operating on too many patients with these injuries. The decision to do so, although it may be well-intentioned, can cause real harm. The best estimate I could find of the risk of a devastating surgical site infection after open reduction internal fixation (ORIF) of tibial plateau fractures is about 5% [
], and based on that study’s design, it’s certain that infections occur even more frequently than that. Patients who develop infections can expect persistent pain and severely impaired function; both in that study [ 4 ] and comparing outcomes scores in that study to those in this month’s 4 CORR ® article [ ], we see that infection reduces Knee Injury and Osteoarthritis Outcome Scores (KOOS) by about 30% to 40%. And not surprisingly, TKAs performed in patients with infection after ORIF of the tibial plateau are much more likely to develop periprosthetic joint infection after the arthroplasty [ 12 ]. But, importantly, even if the tibial plateau ORIF is not complicated by infection, the TKA that follows still is at risk for just about all of the serious complications that surgeons worry about [ 6 ]. 11
Our indications for surgery after tibial plateau fracture therefore deserve sober-minded reconsideration. When we do too much surgery, it’s the surgeon who buys the ticket, but it’s the patient who takes the ride [
How bad should the fracture be before we recommend surgery? When should we pass? How should we decide in situations where there are gaps in the evidence? Join me in the Take 5 interview that follows to go deeper on this important topic with Frank F. A. IJpma MD, PhD, senior author of “Functional Outcome After Nonoperative Management of Tibial Plateau Fractures in Skeletally Mature Patients: What Sizes of Gaps and Stepoffs Can be Accepted?”
Take 5 Interview with Frank F. A. IJpma MD, PhD, senior author of “Functional Outcome After Nonoperative Management of Tibial Plateau Fractures in Skeletally Mature Patients: What Sizes of Gaps and Stepoffs Can be Accepted?”
Seth S. Leopold MD: Congratulations on answering some important questions in such a robust way. What I get from this is that we need to be very strict in our indications for older patients—those who might be within 5 years or so of the end of the run—since it’s hard to see a plausible benefit to recommending surgery in those patients. But what about younger patients? How have your indications for recommending ORIF of the tibial plateau changed based on your discoveries in this paper? Frank F. A. IJpma MD, PhD: Our study suggests that patients who opt for nonoperative fracture treatment should be told that fracture gaps or stepoffs up to 4 mm, as measured on CT images, generally result in good functional outcomes. Therefore, the arbitrary 2-mm limit of gaps and stepoffs for tibial plateau fractures should be revisited. These findings apply to our study population with a mean age of 53 years after a mean follow-up of 6 years. Younger patients—those in their 20s and 30s—still have a whole life ahead of them, during which they are at risk for developing progressive osteoarthritis. But based on our discoveries, we still believe that for those younger patients, gaps up to 4 mm can be accepted provided that proper patient counseling is performed. For example, younger patients often are more active in sports, and we found that the point estimate on the sport-related outcomes score was worse in patients with stepoffs larger than 4 mm; although this finding was not validated statistically, given how many years these younger patients may have on the field, this concern is on our minds. Based on it, we would be more reserved in accepting stepoffs larger than 4 mm in younger patients. Fig. 1: Frank F. A. IJpma MD, PhD
Dr. Leopold: Your general indications to recommend surgery during the span of this study were on the aggressive side—you said that a gap and/or stepoff of more than 2 mm on a CT scan generally would’ve prompted a surgical conversation. Typically, one might expect that patients who would have not gotten that offer (or who would have declined it) despite that amount of stepoff might be patients whose health or biopsychosocial profiles are complicated; it’s sensible that surgeons preferentially recommend surgery to “healthier” patients. This causes me to think that your study group would therefore be at risk for poorer outcomes scores, but that wasn’t the case; by and large, they did fine. To me, that means that we might expect even better results than you saw here in healthier patients treated nonsurgically, or if we applied a more conservative threshold for recommending across the board. How does this issue—selection bias—tend to make you interpret your findings?
Dr. IJpma: These are interesting thoughts. I agree that it is possible that “healthier” patients with minimally displaced tibial plateau fractures were offered surgical treatment more easily. It is, however, hard to predict whether patient-reported outcomes would have been better if these “healthier” patients would have been treated nonoperatively. On the one hand, these patients probably had an active lifestyle. Therefore, minor physical impairment as a result of an injury could already have had a major impact on their lives, which could really have bothered them. On the other hand, operatively treated, high-demand patients might have fewer preexisting comorbidities, better recovery capacity, and coping mechanisms, which could be beneficial for them. We are currently conducting a multicenter study on operative versus nonoperative treatment of minimally displaced tibial plateau fractures, which hopefully will provide some answers to these questions.
Dr. Leopold: Here’s a philosophical question: A lot of surgery gets recommended based on fears that if we don’t operate, something bad might happen in the future; in the situation we’re discussing, that would be post-traumatic arthritis. This approach is so normative that it often feels like the onus is on people questioning those indications to say it’s OK not to operate. But you found that these fractures did not result in serious symptoms nearly as often as one might have expected. Why isn’t the responsibility on those pushing surgery to show that it is helpful in meaningful ways as a preventative measure rather than on people like you to show that it isn’t helpful?
Dr. IJpma: In orthopaedic trauma surgery, there are surgeon-to-surgeon variations in treatment recommendations when high-level evidence for those recommendations is lacking. The decision of whether to operate or not differs substantially between and even within countries. In the absence of evidence-based guidelines, the choice of treatment is obviously influenced by subjective factors related to the surgeons themselves (such as training, years of practice, surgical volume, surgeons’ preferences, and group dynamics). The tantalizing message that orthopaedic surgeon Ian Harris puts forward in his latest book is “Surgery is the ultimate placebo” [ ]. He suggests that many commonly performed operations might not be necessary and that any benefits they offer are related to placebo effects; that’s been covered on the editorial pages of 3 CORR® as well [ ]. For many complaints and conditions, the benefits from surgery might be lower—and the risks higher—than surgeons might think. Harris argued that many common operations became accepted practice without full examination of the evidence. It is a fascinating book and it answers some of the questions about why we probably operate too much. 7
Dr. Leopold: Another commentator on your paper  pointed out that a high percentage of your patients had fractures of the pure depression type, which we tend to see in older patients with low-energy injuries. How does this change how you might use the main findings of your paper in practice?
Dr. IJpma: We are aware that Schatzker Type III injuries occur more often in older patients with poor bone quality. Our findings apply to our study population, which mostly consists of patients in their 50s and 60s. Some of them might have had some preexisting osteoarthritis. This is different from the active, younger patients in their 20s to 30s with thick cartilage and healthy bone. Because of these anatomical differences, our findings regarding the impact of gaps and stepoffs should be interpreted with caution in younger patients.
Dr. Leopold: It surprised me that there weren’t differences in the outcomes scores or the risk of TKA based on more severe displacement. It seems intuitive that at some degree of displacement, that finding would change; displacement has to matter in some way. This, of course, would inform our indications for recommending ORIF. Given that there will never be a perfect study on that design, how can we act in the face of that serious uncertainty?
Dr. IJpma: We could use the evidence we presented as a guideline and continue our journey to find more evidence about the association between degree of fracture displacement and functional outcomes at long-term follow-up. In general, patients can be told that if they have fracture gaps or stepoffs up to 4 mm, as measured on CT images, they are likely to obtain good functional outcomes without surgery. In our current practice, it probably comes down to the fact that we may accept a little more fracture displacement in older than in younger patients.
“Natural experiments” might be helpful to increase our knowledge on this topic. These are large observational studies in which natural variation in treatment allocation (according to the preferences and protocol in different hospitals) is utilized to study treatment effects. Which treatment a patient receives (for example, operative versus nonoperative treatment of minimally displaced tibial plateau fractures) mainly depends on the hospital to which he or she presented, mimicking a random process, which is independent from patient characteristics (geographical randomization). Several successful natural experiment studies have been conducted for difficult-to-randomize treatment options in the field of orthopaedic trauma surgery [
]. This approach might help us to assess the complex relationship between increasing fracture displacement, different treatment options, and their consequences over the long term. 1, 5 References
1. Beks RB, de Jong MB, Sweet A, et al. Multicentre prospective cohort study of nonoperative versus operative treatment for flail chest and multiple rib fractures after blunt thoracic trauma: study protocol. BMJ Open. 2019;9:e023660.
2. Cannada LK. CORR Insights®: Functional outcome after nonoperative management of tibial plateau fractures in skeletally mature patients: what sizes of gaps and stepoffs can be accepted? Published online July 4, 2022.
Clin Orthop Relat Res
. Published online July 4, 2022.
3. Harris I. Surgery, the Ultimate Placebo. NewSouth Publishing; 2016.
4. Henkelmann R, Glaab R, Mende M, et al. Impact of surgical site infection on patients’ outcome after fixation of tibial plateau fractures: a retrospective multicenter study.
BMC Musculoskelet Disord
5. Hoepelman RJ, Beeres FJP, Beks RB, et al. Non-operative vs. operative treatment for multiple rib fractures after blunt thoracic trauma: a multicenter prospective cohort study.
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6. Larson AN, Hanssen AD, Cass JR. Does prior infection alter the outcome of TKA after tibial plateau fracture? Clin Orthop Relat Res. 2009;467:1793-1799.
7. Leopold SS. A Conversation with…Ted J. Kaptchuk, expert in placebo effects. Clin Orthop Relat Res. 2021;479:1645-1650.
8. Leopold SS. Editorial: Chance encounters, overdiagnosis, and overtreatment. Clin Orthop Relat Res. 2022;480:1231-1233.
9. Marsh JL, Buckwalter J, Gelberman R, et al. Articular fractures: does an anatomic reduction really change the result? J Bone Joint Surg Am. 2002;84:1259-1271.
10. Pean CA, Driesman A, Christiano A, Konda S, Davidovitch R, Egol KA. Functional and clinical outcomes of nonsurgically managed tibial plateau fractures. J Am Acad Orthop Surg. 2017;2:375-380.
11. Stake SN, Gu A, Fassihi SC, et al. Increased revisions in conversion total knee arthroplasty after periarticular open reduction internal fixation compared with primary total knee arthroplasty: a matched cohort analysis. J Arthroplasty. 2021;36:3432-3436.e1.
12. Vaartjes TP, Assink N, Nijveldt RJ, et al. Functional outcome after nonoperative management of tibial plateau fractures in skeletally mature patients: what sizes of gaps and stepoffs can be accepted?
Clin Orthop Relat Res
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