Functional Outcome After Nonoperative Management of Tibial Plateau Fractures in Skeletally Mature Patients: What Sizes of Gaps and Stepoffs Can be Accepted? : Clinical Orthopaedics and Related Research®

Secondary Logo

Journal Logo

FEATURED ARTICLES

Functional Outcome After Nonoperative Management of Tibial Plateau Fractures in Skeletally Mature Patients: What Sizes of Gaps and Stepoffs Can be Accepted?

Vaartjes, Thijs P. BSc1; Assink, Nick MSc1; Nijveldt, Robert J. MD, PhD2; van Helden, Svenhjalmar H. MD, PhD2; Bosma, Eelke MD, PhD3; El Moumni, Mostafa MD, PhD1; Duis, Kaj ten MD1; Hogervorst, Mike MD1; Doornberg, Job N. MD, PhD1; de Vries, Jean-Paul P. M. MD, PhD4; Hoekstra, Harm MD, PhD5; IJpma, Frank F. A. MD, PhD1

Author Information
Clinical Orthopaedics and Related Research: December 2022 - Volume 480 - Issue 12 - p 2288-2295
doi: 10.1097/CORR.0000000000002266

Abstract

Introduction

The World Health Organization recommends taking 10,000 steps a day to stay healthy [22], which equates to approximately 3 million steps per person each year. A tibial plateau fracture may have a major impact on a patient’s mobility, social activities, and ability to work. Adequate treatment is crucial to minimize the risks of progressive posttraumatic arthritis and patient disability [1, 5, 10, 11]. Assessment of fracture displacement is essential to choose the best treatment strategy for tibial plateau fractures [8]. Gap and stepoff measurements, which provide information about fracture displacement, are used for clinical decision-making when choosing between operative or nonoperative treatment. Nonoperative management usually consists of a knee brace or long-leg cast for several weeks and is considered a good option for the treatment of minimally displaced tibial plateau fractures [5, 10, 11].

A frequently reported indication for nonoperative treatment of tibial plateau fractures includes minimal displacement with an articular fracture gap and/or stepoff of less than 2 mm [12, 13]. However, in a review of previous studies, Giannoudis et al. [4] reported that articular gaps and stepoffs up to 10 mm are well tolerated and could be accepted for nonoperative treatment. However, we are not aware of any evidence regarding fracture displacement and the functional outcome after nonoperative treatment of tibial plateau fractures. Most studies of tibial plateau fracture treatment are focused on functional outcomes after surgery [7, 19, 21]. Moreover, few studies have primarily focused on the correlation between initial fracture displacement and functional outcome [7, 15, 16, 18]. Additionally, several studies [4] have used standard radiographs to assess fracture displacement, whereas over time, clinical decision-making has become increasingly based on CT images. CT images have been shown to increase the accuracy of assessing fracture displacement [12]. There seems to be no consensus on the impact of minimal fracture displacement on functional outcome. Because the degree of fracture displacement is important for patient counseling regarding the indications for surgery and prognosis, it is crucial to assess what sizes of gaps and stepoffs could be accepted for the nonoperative treatment of tibial plateau fractures.

We therefore asked: (1) In patients treated nonoperatively for tibial plateau fractures, what is the association between initial fracture displacement, as measured by gaps and stepoffs at the articular surface on a CT image, and functional outcome? (2) What is the survivorship of the native joint, free from conversion to total knee prosthesis, among patients with tibial plateau fractures who were treated without surgery?

Patients and Methods

Study Design and Setting

A multicenter cross-sectional study was performed in patients who were treated nonoperatively for a tibial plateau fracture between January 2003 and December 2018 at the University Medical Center Groningen (The Netherlands), Isala (The Netherlands), University Hospitals Leuven (Belgium), and Martini hospital (The Netherlands). These include, respectively, three Level 1 trauma centers and one Level 2 trauma center.

Participants

Patients with a preoperative (diagnostic) CT image and follow-up of at least 1 year were eligible for inclusion. A gap and/or stepoff of more than 2 mm, as measured on a CT scan, was an indication for recommending surgery. Some patients with gaps and/or stepoffs exceeding 2 mm might not have had surgery due to shared decision-making. The exclusion criteria were age younger than 18 years at the time of injury, pathologic fractures, isolated tibial eminence avulsions (such as cruciate ligament injuries), and patients who were deceased at the time of follow-up. Between 2003 and 2018, 530 patients were treated nonoperatively for a tibial plateau fracture, of which 45 had died at follow-up, 30 were younger than 18 years at the time of injury, and 10 had isolated tibial eminence avulsions, leaving 445 patients for follow-up analysis. All eligible patients were approached by posted mail and asked to provide informed consent and complete validated patient-reported outcome measures. A total of 46% (203 of 445) of the patients participated. The mean age at the time of injury was 53 ± 16 years, 70% (142 of 203) of patients were women, and the mean follow-up duration after injury was 6 ± 3 years (Table 1).

Table 1. - Patient characteristics (n = 203)
Parameter Value
Age in years 53 ± 16
Women 70 (142)
Smoking 13 (26)
Diabetes 7 (15)
BMI in kg/m2 27 ± 4.6
Schatzker classification
 Type I 18 (37)
 Type II 27 (54)
 Type III 39 (80)
 Type IV 12 (25)
 Type V 2 (4)
 Type VI 1 (3)
Three-column classification
 One column 58 (118)
 Two columns 35 (71)
 Three columns 7 (14)
Gap 2.1 ± 1.3 mm
Stepoff 2.1 ± 2.2 mm
Conversion to total knee prosthesis 3 (7)
Follow-up in years 6 ± 3
Data presented as mean ± SD or % (n).

CT-based Gap and Stepoff Measurements

All knee radiographs and CT images, which were taken within 2 weeks after the patient’s injury, were reassessed through consensus by two observers (NA, FFAIJ) with experience in tibial plateau fracture management. All tibial plateau fractures were classified according to the Schatzker classification [14] and three-column classification [20]. Gap and stepoff measurements were taken using CT images. Gap was defined as separation of fracture fragments along the articular surface. Stepoff was characterized as separation of fracture fragments perpendicular to the articular surface [1]. For each patient, the maximum value of the gap or stepoff on any of the axial, coronal, or sagittal CT slices was measured (Fig. 1). Measurements were performed with a digital measurement tool in the Mimics Medical software package (Version 21.0, Materialise). The relationship between the measured initial fracture displacement (gaps and stepoffs) and functional outcome was assessed.

F1
Fig. 1:
A-B The measurements of the fracture displacement are displayed in the (A) coronal (gap 3.7 mm) and (B) sagittal (stepoff 3.8 mm) views.

Patient-reported Outcomes

All eligible patients were approached by posted mail and asked to complete the standardized Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire [2]. Additionally, patients were asked whether they received a total knee prosthesis. The KOOS is a validated questionnaire consisting of five subscales: symptoms, pain, activities of daily living (ADL), function in sports and recreation, and knee-related quality of life (QOL). A normalized score (100 indicating no symptoms and 0 indicating extreme symptoms) was calculated for each subscale. Scores of the subscales are calculated by adding the individual items (questions) and transforming scores to a range from 0 to 100, with higher scores indicating better function. The minimum clinically important differences (MCID) for five subscales of the KOOS are: symptoms = 11, pain = 17, ADL = 18, sport = 13, and QOL = 16.

Data Sources

Baseline characteristics of the participants were retrieved from the patients’ electronic records. The scores of the KOOS questionnaire were calculated from the patient survey of the responding patients.

Primary and Secondary Study Outcomes

Our primary study goal was to assess whether an increased gap and/or stepoff is associated with poorer functional outcome after nonoperative management of tibial plateau fractures. To achieve this, we reassessed CT scans for initial fracture displacement (gaps and/or stepoffs) and related these measurements to a validated patient-reported outcome (KOOS questionnaire) at follow-up.

Our secondary study goal was to assess the survivorship of the knee free from conversion to total knee prosthesis after nonoperative management of tibial plateau fractures. To achieve this, we asked all patients whether they had conversion to total knee prosthesis at follow-up and determined the survivorship of the native knee among patients with tibial plateau fractures who were treated without surgery. Two authors (NA, FFAIJ) reassessed radiographs taken at the time of injury and at follow-up for the presence of osteoarthritis according to the Kellgren-Lawrence classification [6]. Conversion to a total knee prosthesis was considered a worse outcome (or endpoint), and therefore, KOOS scores obtained after placement of the prosthesis could not be included in the analysis.

Ethical Approval

The institutional review boards of all participating centers approved the study procedures, and the study was performed in accordance with the relevant guidelines and regulations.

Statistical Analysis

We used IBM SPSS software, version 23.0 for Windows (IBM Corp), for statistical analyses. Continuous variables are presented as the mean and SD for normally distributed data and median and IQR for nonnormally distributed data. Descriptive statistics were used to describe the study population. The study population was divided into groups based on the size of the gap or stepoff (< 2 mm, 2 to 4 mm, and > 4 mm), and ANOVA was used to assess differences between the groups in terms of functional outcome. Post hoc sample size calculation showed that at least 16 patients would be needed in each group to detect an MCID of 10 points in KOOS score by using 80% statistical power, α = 0.05, and an SD of 10. We used linear regression to analyze the relationship between the gap or stepoff and KOOS score. The model was adjusted for potential confounders, including gender, age at the time of injury, BMI, and the number of columns involved (Supplementary Digital Content 1; https://links.lww.com/CORR/A828). We estimated the survivorship of the knee free from conversion to total knee prosthesis at a mean follow-up of 5 years using a Kaplan-Meier survivorship estimator. The significance level was set at p < 0.05.

Analysis of Nonparticipants

For the nonresponse analysis, we used an independent-samples t-test for continuous variables and a chi-square test for noncontinuous variables. The nonresponse analysis showed no differences in age between responders and nonresponders (53 ± 16 years versus 54 ± 20 years; p = 0.89). Women responded more often (70% [142 of 203] versus 59% [142 of 242]; p = 0.01). There was no difference in the mean stepoff between responders and nonresponders (2.1 ± 2.2 mm versus 1.9 ± 1.7 mm; p = 0.13). The mean gap was slightly smaller in the nonresponders group (2.1 ± 1.3 mm versus 1.7 ± 1.6 mm; p = 0.02). There was not much difference in fracture classification between responders and nonresponders (Schatzker I 18% [37 of 203] versus 11% [26 of 242]; Schatzker II 27% [54 of 203] versus 25% [61 of 242]; Schatzker III 39% [80 of 203] versus 35% [85 of 242]; Schatzker IV 12% [25 of 203] versus 16% [39 of 242]; Schatzker V 2% [4 of 203] versus 6% [15 of 242]; Schatzker VI 1% [3 of 203] versus 7% [16 of 242]). Also, there were few differences between responders and nonresponders in fracture classification according on the three-column concept (involvement of one column 58% [118 of 203] versus 52% [127 of 242]; two columns 35% [71 of 203] versus 36% [86 of 242]; three columns 7% [14 of 203] versus 12% [29 of 242]).

Results

Relationship Between Fracture Displacement and Functional Outcome

Nonoperative treatment of minimally displaced tibial plateau fractures resulted in a good functional outcome regardless of the gap (Fig. 2) or stepoff (Fig. 3). KOOS scores in patients with a less than 2 mm, 2 to 4 mm, or more than 4 mm gap did not differ in symptoms (83 ± 17 versus 83 ± 21 versus 82 ± 20; p = 0.98), pain (85 ± 19 versus 83 ± 22 versus 86 ± 17; p = 0.69), ADL (87 ± 18 versus 84 ± 21 versus 89 ± 15; p = 0.44), sports (65 ± 33 versus 64 ± 34 versus 66 ± 33; p = 0.95), and QOL (70 ± 26 versus 71 ± 28 versus 74 ± 28; p = 0.85) (Table 2). KOOS scores in patients with a less than 2 mm, 2 to 4 mm, or more than 4 mm stepoff did not differ in symptoms (84 ± 17 versus 83 ± 21 versus 77 ± 20; p = 0.32), pain (85 ± 20 versus 85 ± 18 versus 81 ± 21; p = 0.66), ADL (86 ± 19 versus 87 ± 18 versus 82 ± 21; p = 0.54), sport (65 ± 33 versus 68 ± 30 versus 56 ± 40; p = 0.43), and QOL (71 ± 26 versus 73 ± 24 versus 61 ± 33; p = 0.19) (Table 3).

F2
Fig. 2:
The KOOS subscales, representing functional outcome, are displayed for 196 nonoperatively treated patients divided into three subgroups based on the size of the articular gap. No differences in mean KOOS scores were found between subgroups, meaning that gaps up to 4 mm are well tolerated. Due to the small number of patients in the group with a gap greater than 4 mm, the results of this group need to be interpreted with caution.
F3
Fig. 3:
The KOOS subscales, representing functional outcome, are displayed for 196 nonoperatively managed patients divided into three subgroups based on the size of the articular stepoff. No differences in mean KOOS scores were found between subgroups, meaning that stepoffs up to 4 mm are well tolerated. Due to the small number of patients in the group with a stepoff greater than 4 mm, the results of this group need to be interpreted with caution.
Table 2. - Size of the articular gap and KOOS scores
Size of articular gap < 2 mm (n = 114) 2-4 mm (n = 63) > 4 mm (n = 19) p value a
KOOS symptoms 83 ± 17 83 ± 21 82 ± 20 0.98
KOOS pain 85 ± 19 83 ± 22 86 ± 17 0.69
KOOS ADL 87 ± 18 84 ± 21 89 ± 15 0.44
KOOS sports 65 ± 33 64 ± 34 66 ± 33 0.95
KOOS QOL 70 ± 26 71 ± 28 74 ± 28 0.85
Data presented as mean ± SD.
aComparison of KOOS scores (mean ± SD) between groups with increasing gap sizes (< 2 mm, 2 to 4 mm, and > 4 mm).

Table 3. - Size of articular stepoff and KOOS scores
Size of articular stepoff < 2 mm (n = 119) 2-4 mm (n = 65) > 4 mm (n = 21) p value a
KOOS symptoms 84 ± 17 83 ± 21 77 ± 20 0.32
KOOS pain 85 ± 20 85 ± 18 81 ± 21 0.66
KOOS ADL 86 ± 19 87 ± 18 82 ± 21 0.54
KOOS sport 65 ± 33 68 ± 30 56 ± 40 0.43
KOOS QOL 71 ± 26 73 ± 24 61 ± 33 0.19
Data presented as mean ± SD.
aComparison of KOOS scores between groups with increasing stepoff sizes (< 2 mm, 2-4 mm, and > 4 mm).

After correction for potential confounders including age, gender, BMI, and the number of columns involved, the linear regression analysis showed there was no relationship between gaps or stepoffs up to 4 mm and the KOOS score (Supplementary Digital Content 1; https://links.lww.com/CORR/A828). This applied to each of the five subscales of the KOOS. Stepoffs more than 4 mm were associated with lower scores for symptoms (β: -9.0 [95% CI -17.5 to -0.5]; p = 0.04) and QOL (β: -14.0 [95% CI -25.9 to -2.0]; p = 0.02).

Conversion to a Total Knee Prosthesis

Survivorship of the knee free from conversion to total knee prosthesis was 97% (95% CI 94% to 99%) at 5 years. Three percent (7 of 203) of patients had a conversion to a total knee prosthesis. The mean age of these patients was 63 ± 3 years. The mean gap was 1.7 ± 1.4 mm and the mean stepoff was 2.3 ± 0.9 mm. Four of 7 patients already had moderate (Kellgren-Lawrence Grade 3) and 3 of 7 had mild (Kellgren-Lawrence Grade 2) preexisting osteoarthritis seen on a radiograph taken at the time of injury. Indications for conversion to total knee prosthesis were progressive posttraumatic osteoarthritis (Kellgren-Lawrence Grade 4).

Discussion

Nonoperative management is considered a good treatment option for minimally displaced tibial plateau fractures [5, 10, 11]. However, there is no consensus about the maximum gap or stepoff that should lead to a recommendation for nonoperative treatment. We evaluated a large cohort of patients with tibial plateau fractures who were treated nonoperatively and correlated CT-determined fracture displacement with functional outcomes after a mean follow-up of 6 ± 3 years. Patients after nonoperative treatment of minimally displaced tibial plateau fractures are generally doing fine. We found that increasing fracture displacement with gaps and/or stepoffs up to 4 mm did not result in poorer functional outcome. The survivorship of the knee, free from conversion to a total knee prosthesis, was high. Based on these findings, we believe that minimally displaced tibial plateau fractures with a gap and/or stepoff up to 4 mm could be treated nonoperatively.

Limitations

We acknowledge that nonresponse bias is inherent to a cross-sectional study design caused by loss to follow-up and nonparticipation [3]. We attempted to reduce the risk of selection bias by approaching all eligible patients. The response proportion was quite high (46%) considering the relatively long follow-up time because patients in the northern part of the Netherlands do not migrate much. Nonresponse analysis showed only minor differences in terms of gender and fracture gap between responders and nonresponders, which does not affect our results. In our study population, results regarding gaps and stepoffs more than 4 mm should be interpreted cautiously because the number of patients in these subgroups was limited. Another limitation was the high variation in the length of follow-up, which ranged from 1 to 15 years (mean 6 ± 3 years), which was also inherent in the cross-sectional study design but does not affect our results. The consequences of gaps and stepoffs after 20 years or 30 years of follow-up are still unknown. Therefore, our findings are applicable for midterm follow-up but not for long-term follow-up. Furthermore, this study did not evaluate prospective longitudinal data about short-term patient outcomes, such as time to return to work or sports. This information could be important for active, high-demand patients during clinical decision-making about treatment options. Finally, this study did not include the region of the tibial plateau (which is possible using fracture maps) where the gaps or stepoffs were located. We tried to do so but found that this was not possible because regions are hard to define properly, and fracture lines often involve multiple regions. We believe that exact localization of fracture displacement warrants 3D fracture assessment. We do not think this limitation disqualifies our findings regarding the relationship between gaps and/or stepoffs and functional outcome because fracture displacement assessment is performed according to clinical practice.

Relationship Between Fracture Displacement and Functional Outcome

Because fracture displacement is so important for determining the indication for surgery and prognosis, we assessed the relationship between the initial fracture displacement (gap and stepoff) and patient-reported outcome (KOOS). Our study revealed that fracture gaps and stepoffs up to 4 mm, as measured on CT images, might result in good functional outcome in patients who consider nonoperative treatment for a minimally displaced tibial plateau fracture. No differences in functional outcomes were found between subgroups with increasing gaps and stepoffs up to 4 mm, meaning that the arbitrary 2-mm gap or stepoff limit could be revisited. There is much controversy about what degree of fracture displacement could be accepted to justify nonoperative treatment of minimally displaced tibial plateau fractures. To our knowledge, the frequently reported 2-mm limit for gaps and stepoffs is arbitrary and seems to be based on radiographs instead of CT and is not supported by clinical evidence from recent studies. A study about fracture displacement in the treatment of tibial plateau fractures focused on the impact of residual gaps and stepoffs after operative treatment [16]. However, results regarding residual fracture displacement cannot be automatically translated to clinical recommendations regarding initial fracture displacement. Studies on initial fracture displacement and functional outcome after nonoperative treatment of tibial plateau fractures are limited. According to recent guidelines, patients with fracture displacements less than 2 mm should opt for nonoperative treatment [12, 13]. However, these guidelines do not specify whether the 2-mm limit applies to gaps and stepoffs, nor do they state which imaging modality should be used to assess gaps and stepoffs. Giannoudis et al. [4] reviewed current evidence on the correlation between articular fracture displacement and the risk of posttraumatic osteoarthritis. For tibial plateau fractures, they concluded that the acceptable range of intraarticular stepoff should be somewhere between 2 and 10 mm [4]. However, most of the articles they referred to were from the 1990s, when measurements of fracture displacement were still performed on plain radiographs, whereas over time, clinical decision-making has become increasingly based on CT images.

Conversion to a Total Knee Prosthesis

Based on our results, patients who consider nonoperative treatment for a minimally displaced tibial plateau fracture could be informed that the survivorship of the native knee, free from conversion to total knee prosthesis, is high. Progressive posttraumatic arthritis with conversion to a total knee prosthesis is considered a worse outcome after tibial plateau fracture treatment [1, 5, 10, 11]. Depending on the fracture type and treatment, the proportion of patients who undergo total knee replacement after tibial plateau fractures has ranged from 4% to 22% [17, 18, 19, 21]. Wasserstein et al. [21] recently performed a large population-based, retrospective, comparative study and reported that after operative treatment, 7.3% of patients underwent conversion to a total knee prosthesis at 10 years of follow-up, which corresponded to a hazard ratio of 5.3 relative to peers from the general population. However, these numbers represent patient outcomes after surgical management of tibial plateau fractures and do not apply to patients treated without surgery. To our knowledge, there are no studies on conversion to a total knee prosthesis after nonoperative treatment.

Conclusion

Patients with minimally displaced tibial fractures who opt for nonoperative fracture treatment should be told that fracture gaps or stepoffs up to 4 mm, as measured on CT images, could result in good functional outcome. Therefore, the arbitrary 2-mm limit of gaps and stepoffs for tibial plateau fractures could be revisited. The survivorship of the knee free from conversion to a total knee prosthesis at a mean follow-up of 5 years is high. Conversion to a total knee prothesis mostly occurred in patients older than 60 years who often had preexisting osteoarthritis. These findings can be used as a guide for personalized treatment and shared decision-making in the management of minimally displaced tibial plateau fractures. Large, prospective, cohort studies with high response rates are needed to learn more about the relationship between the degree of fracture displacement and functional recovery after tibial plateau fractures.

Acknowledgments

We thank Anne-Julia The and Raisa Neinhuis for their help with the data collection.

References

1. Assink N, Kraeima J, Slump CH, et al. Quantitative 3D measurements of tibial plateau fractures. Sci Rep. 2019;9:1-9.
2. de Groot IB, Favejee MM, Reijman M, Verhaar JAN, Terwee CB. The Dutch version of the knee injury and osteoarthritis outcome score: a validation study. Health Qual Life Outcomes. 2008;6:1-11.
3. Euser AM, Zoccali C, Jager KJ, Dekker FW. Cohort studies: prospective versus retrospective. Nephron Clin Pract. 2009;113:c214-c217.
4. Giannoudis PV, Tzioupis C, Papathanassopoulos A, Obakponovwe O, Roberts C. Articular step-off and risk of post-traumatic osteoarthritis. Evidence today. Injury. 2010;41:986-995.
5. Jeelani A, Arastu MH. Tibial plateau fractures – review of current concepts in management. Orthop Trauma. 2017;31:102-115.
6. Kohn MD, Sassoon AA, Fernando ND. Classifications in brief: Kellgren-Lawrence classification of osteoarthritis. Clin Orthop Relat Res. 2016;474:1886-1893.
7. Manidakis N, Dosani A, Dimitriou R, Stengel D, Matthews S, Giannoudis P. Tibial plateau fractures: functional outcome and incidence of osteoarthritis in 125 cases. Int Orthop. 2010;34:565-570.
8. Millar SC, Arnold JB, Thewlis D, Fraysse F, Solomon LB. A systematic literature review of tibial plateau fractures: what classifications are used and how reliable and useful are they? Injury. 2018;49:473-490.
9. Monticone M, Ferrante S, Salvaderi S, Motta L, Cerri C. Responsiveness and minimal important changes for the knee injury and osteoarthritis outcome score in subjects undergoing rehabilitation after total knee arthroplasty. Am J Phys Med Rehabil. 2013;92:864-870.
10. Mthethwa J, Chikate A. A review of the management of tibial plateau fractures. Musculoskelet Surg. 2018;102:119-127.
11. Papagelopoulos PJ, Partsinevelos AA, Themistocleous GS, Mavrogenis AF, Korres DS, Soucacos PN. Complications after tibia plateau fracture surgery. Injury. 2006;37:475-484.
12. Pelser P. Controversies in the management of tibial plateau fractures. SA Orthop J. 2010;9:75-82.
13. Prat-Fabregat S, Camacho-Carrasco P. Treatment strategy for tibial plateau fractures: an update. EFORT Open Rev. 2016;1:225-232.
14. Schatzker J, McBroom R. The tibial plateau fracture. The Toronto experience 1968-1975. Clin Orthop Relat Res. 1979;138:94-104.
15. Scott CEH, Davidson E, Macdonald DJ, White TO, Keating JF. Total knee arthroplasty following tibial plateau fracture: a matched cohort study. Bone Joint J. 2015;97:532-538.
16. Singleton N, Sahakian V, Muir D. Outcome after tibial plateau fracture: how important is restoration of articular congruity? J Orthop Trauma. 2017;31:158-163.
17. Timmers TK, van der Ven DJC, de Vries LS, van Olden GDJ. Functional outcome after tibial plateau fracture osteosynthesis: a mean followup of 6 years. Knee. 2014;21:1210-1215.
18. van den Berg J, Reul M, Nunes Cardozo M, et al. Functional outcome of intra-articular tibial plateau fractures: the impact of posterior column fractures. Int Orthop. 2017;41:1865-1873.
19. van Dreumel RLM, Van Wunnik BPW, Janssen L, Simons PCG, Janzing HMJ. Mid- to long-term functional outcome after open reduction and internal fixation of tibial plateau fractures. Injury. 2015;46:1608-1612.
20. Wang Y, Luo C, Zhu Y, et al. Updated three-column concept in surgical treatment for tibial plateau fractures - a prospective cohort study of 287 patients. Injury. 2016;47:1488-1496.
21. Wasserstein D, Henry P, Paterson JM, Kreder HJ, Jenkinson R. Risk of total knee arthroplasty after operatively treated tibial plateau fracture. J Bone Joint Surg. 2014;96:144-150.
22. World Health Organisation. Pacific physical activity guidelines for adults. Fram Accel Commun Phys Act Guidel. 2011;1:1-34.

Supplemental Digital Content

Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Association of Bone and Joint Surgeons