Tibial plateau fractures (TPFs) which involve the proximal tibia in its articular and meta-epiphyseal segments are one of the commonest intra-articular fractures, representing approximately 1% of all fractures in adults.1-3 These fractures are caused mainly by axial loading with concomitant varus/valgus or flexion/extension bending, and have various morphology involving the lateral, medial or both tibial condyles with many degrees of articular depression widening and angulation.4-7 Tibial plateau fractures are frequently complex intra-articular injuries with a variety of fracture patterns, portending a poor prognosis due to associated complications, i.e. compartment syndrome, cartilage destruction, soft-tissue envelope damage, post-surgery infection, knee instability or stiffness, and post-traumatic osteoarthritis.8-11 As such, they are managed mainly in hospital settings, and they not only pose challenges for the surgeon,12,13 but also have an enormous impact on patients and devastating socio-economic consequences due to the time taken off work for the patient and impaired functional integrity of the knee.14-17
Achieving fracture reduction and stabilization is only the initial step; good postoperative rehabilitation is necessary as early mobilization may limit complications following intra-articular fractures, including knee joint stiffness, muscle and bone atrophy, synovial adhesions and capsular contractions to adversely impact on outcomes.18-22 However, there is no consensus about rehabilitation practices as immobilization and protection from weight bearing varies widely among orthopedic surgeons.
There is confusion as to whether range of motion exercises should be passive, active assisted or active in nature.23 While some authors have recommended passive exercises immediately postoperatively,24-26 after the second postoperative day27 or once wounds were sealed and dry,28 others considered immediate active motion protected in a hinged knee orthosis,29 or never employed continuous passive motion regime for their patients.29 In addition, there is large variation regarding the immobilization time, ranging from 10 days30 to six weeks postoperatively.28,31,32
Regarding weight bearing after TPFs fixation, there remains confusion in the rehabilitation practices with recommendations varying from no weight bearing from four to 12 weeks,8,25,26,28,33 partial weight bearing from six to 12 weeks,24,29,30,34,35 partial weight bearing prescribed on an individual basis,36 full weight bearing from nine to 12 weeks postoperatively,29,30,36 or when union observed on plain film is significant.37-39
While commencing weight bearing too early may increase the risk for implant failure, leading to the loss of fracture reduction and malunion,40 there is a substantial difference in energy expenditure between non and partial weight-bearing gait, impacting on patient independence and hospital length of stay.23
A preliminary search of the literature in Cochrane Database of Systematic Reviews, JBI Database of Systematic Reviews and Implementation Reports, CINAHL, PubMed, PROSPERO and Epistemonikos identified that no systematic or scoping review has addressed the proposed topic. Considering the lack of current evidence, together with characteristics of a scoping review in examining “the extent, range and nature of research activity … to determine the value of undertaking a full systematic review”,41(p.6) we recommend a scoping review to map the relevant literature. This scoping review will be conducted in accordance with the methodology for JBI scoping reviews.42,43
Types of participants
The review will consider studies that include patients over 16 years of age undergoing rehabilitation practices for TPFs. Patients under 16 will be excluded as many will still have open growth plates, as open growth plates fractures differ dramatically from fractures that occur at skeletal maturity.44 Studies that recruited people following periprosthetic fractures, pathological fractures or multiple fractures of the same limb will be excluded. Periprosthetic and pathological fractures will be excluded as their treatment and outcomes are preponderantly related to one of the prosthesis or neoplastic process. Cases with multiple ipsilateral lower limb fractures will be excluded as they affect the overall healing and rehabilitation of the limb.
The review will consider all research studies that address rehabilitation practices for TPFs in adults including weight-bearing status, application of immobilization device (brace, cast, immobilizers), postoperative motion and exercises.
The review will consider studies conducted in hospital settings.
This review will consider quantitative studies that may include, but will not be limited to, randomized, quasi-randomized controlled trials, case-control and case series studies.
The search strategy aims to find both published and unpublished literature. A three-step search will be utilized in each component of this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe relevant articles. A second search using all the identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of all included studies will be searched for additional studies. Studies published in English will be considered for inclusion in this review. No time limit will be imposed on studies for inclusion in this review.
The databases to be searched will include:
- Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL)
- JBI Database of Systematic Reviews and Implementation Reports
The search for unpublished studies will include:
- International Clinical Trials Registry Platform
- UK Clinical Trials Gateway
- ProQuest Dissertations and Theses
- Grey Literature (The New York Academy of Medicine)
- Open Grey (System for Information on Grey Literature in Europe)
- Trove (theses).
Initial keywords to be used will be, but will not be limited to: “tibial plateau” OR “proximal tibial” OR “knee fractures” AND “rehabilitation” OR “exercise” OR “joint loading” OR “weight bearing” OR “physical therapy” OR “knee function” OR “scoping review”.
A data extraction form for this scoping review will be developed, based on those from JBI SUMARI (a draft of the adapted form is shown in Appendix I) as well as discussion among all reviewers. The reported variables will include specific details about authors, populations, study method, type of tibial plateau fractures, types of treatments, type of rehabilitation practices and duration, outcome of significance and key findings relating to the scoping review objective. This may be further refined at the review stage. Two reviewers will extract data independently. Any disagreement will be resolved by discussion with a third reviewer. The author of the primary study will be contacted if further clarification of the data is required.
After the data have been extracted, we will: i) map the key concepts and available evidence, ii) summarize the existing research findings, and iii) identify research gaps in the existing literature. The key findings will be mapped and presented in formats reflecting the objectives of this scoping review as appropriate (diagrammatic, tabular summary or descriptive format). The process will be further refined toward the end of the review when reviewers have the greatest awareness of the contents of the included studies.42
Tri M. Phan is supported by an Endeavour Executive Fellowship from the Australian Government.
Appendix I: Data extraction instrument
Data extraction form (tick where applicable)
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