Complications of the surgical treatment of fractures of the tibial plateau: prevalence, causes, and management

Overview

This review, published in EFORT Open Reviews in 2022 by Gálvez-Sirvent, Ibarzábal-Gil and Rodríguez-Merchán, describes the complications of surgery for tibial plateau fractures, how common they are, why they occur and how they are managed. These fractures make up about 1% of all fractures and occur in two peaks: young patients after high-energy trauma and older patients with osteoporotic bone. Open reduction and internal fixation with locked plates is the standard treatment, and a hybrid external fixator may be used when the soft tissues are badly damaged.

Stiffness and infection

Knee stiffness affects roughly 3 to 18% of patients. Options depend on how long it has lasted: manipulation under anaesthesia within about 3 months, arthroscopic release at 3 to 6 months, and open release for longer or refractory cases. Infection rates have fallen with staged treatment and minimally invasive approaches. Risk factors include open fractures, compartment syndrome, external fixation, long operating time and smoking. If the fracture has not healed, the hardware is usually kept while lavage, debridement and antibiotics are given, because stability also helps to clear infection. Osteomyelitis is treated in two stages, with radical debridement, an antibiotic spacer and temporary external fixation, followed by definitive reconstruction.

Malunion, non-union and osteoarthritis

Joint collapse over 5 mm, malalignment over 5 degrees or a change in tibial slope over 10 degrees are limits for considering correction. Osteotomy suits young, active patients without major joint damage, whereas total knee arthroplasty is used when there is extensive joint damage or osteoarthritis. Non-union is uncommon, at about 0.1 to 1.1%, and is treated with revision fixation and bone graft. Unrecognised ligament injuries can cause residual instability.