The Effect of Time on the Surgical Management of Tibial Plateau Fractures
Date
2025
Authors
Kitchen, David Stuart
Editors
Advisors
Atkins, Gerald
Solomon, Bogdan
Smitham, Peter
Solomon, Bogdan
Smitham, Peter
Journal Title
Journal ISSN
Volume Title
Type:
Thesis
Citation
Statement of Responsibility
Conference Name
Abstract
Tibial plateau fractures (TPF) represent injuries affecting the weight-bearing articular surface of the proximal tibia, exhibiting a bimodal distribution primarily observed in younger patient cohorts with high-energy mechanisms or in older patients with both high and low energy mechanisms. Surgical intervention is frequently warranted due to resultant biomechanical alterations in knee function arising from alignment and articular surface disruption consequent to the injury. In both the young and older patient cohorts, there is routinely notable soft tissue swelling, which has raised concerns regarding wound healing post-surgery, particularly in the older patient group with their diminished healing capacity. Consequently, proponents of delayed operative intervention advocate for allowing sufficient time for soft tissue recovery in order to minimise the risk of wound complications post operatively. However, there is growing evidence that delaying surgery, particularly for fractures involving the articular surfaces, may reduce the likelihood of successful fracture reduction, reducing the potential benefits that operative intervention offers in these fractures. The increased difficulty in attaining adequate reduction of the fracture with increased time from injury is likely a consequence of the inflammatory healing process having more time to progress. As further callus and remodelling occur, the ability to manipulate the fracture fragments and restore the articular surface becomes increasingly difficult. These competing views, between ability to achieve fracture reduction and concerns with soft tissue complications make determining the optimal time for intervention challenging. Therefore, we investigated the effect that time had on the healing process in tibial plateau fractures, with assessment of what gene processes were involved during the early stages of the fracture healing process and how this impacted the bone around the zone of injury. In Chapter 2 we assessed how time from injury altered the bony architecture of the surrounding cancellous bone in patients with TPF. Cancellous bone samples were obtained from patients having sustained TPF from both the injured and non-injured leg. Gene expression analysis was employed using real time RT-PCR and compared to samples obtained from the matched site on the uninjured tibia, with location being confirmed using intra-operative fluoroscopy. In addition, histological assessment and bone microarchitectural analysis were performed on these samples, with micro-CT being utilised to quantify any structural differences between the matched pairs. Significant reductions in trabecular bone thickness, trabecular number and bone volume were noted with these changes being most pronounced in samples taken on or after 5 days from time of injury. Trabecular density and trabecular thickness were both found to be negatively associated with key genes known to be associated with osteoclastic bone resorption, specifically cathepsin K, tartrate resistant acid phosphatase (TRAP) in addition to the mRNA expression ratio of RANKL:OPG. To investigate whether this early bone loss was reflected in clinical findings, in Chapter 3 we assessed the effect that time from injury to surgical intervention has on the outcomes of patients after TPF. Specifically, the radiological outcomes, in addition to the patient reported outcome measures (PROMS). A cohort of 117 patients with TPF were assessed for radiological parameters of reported acceptable articular reduction, being defined as within 2 mm, with this data compared against time to surgery from injury as well as against the PROMs over an 11-year period. Time to theatre was shown to be negatively correlated with the ability to achieve anatomical reduction to within 2 mm, as well as poorer outcome scores one year following surgery (Lysholm score). The ability to achieve articular reduction to within 2 mm was not found to influence PROMs. The finding that time to theatre impacted reduction given the earlier study was in keeping with our hypothesis. However, the failure to achieve articular reduction to within expected parameters not negatively impacting PROMs was against our expected hypothesis. Thus, in Chapter 4, a systematic review and meta-analysis of the literature was next performed to determine whether articular reduction meaningfully impacted patient outcomes when taken across a larger cohort of studies. This study highlighted the high degree of heterogeneity in the selection and application of PROMs in TPF research. This study employed a novel strategy to standardise reporting of different PROMs when performing a meta-analysis to allow comparison of heterogenous data. Through this it was found that cohorts with higher percentage of patients with articular reductions to within 2 mm had excellent outcomes when compared to good outcomes. Namely, those cohorts in which more patients achieved reduction a higher outcome would be expected to be achieved. In addition, those cohorts with a higher percentage of articular reduction demonstrated improved outcomes scores, specifically for the Hospital for Special Surgery (HSS) outcome score. In conclusion this thesis confirms the hypothesis that delaying surgery negatively impacts the ability to achieve fracture reduction in the setting of tibial plateau fractures and that this effect is cumulative. This time dependent loss in the ability to reduce fractures occurs in conjunction with significant periarticular loss of bone that is also time dependent. We have confirmed the thesis that inadequate fracture reduction deleteriously impacts on patient reported outcomes after surgical intervention in tibial plateau fractures. Further to these findings this thesis describes the development of a novel technique allowing collation of heterogenous patient reported outcome measures enabling their statistical correlation in order to determine clinical significance of outcome.
School/Discipline
Adelaide Medical School : Surgical Specialties
Dissertation Note
Thesis (Ph.D.) -- University of Adelaide, Adelaide Medical School : Surgical Specialties, 2025
Provenance
This electronic version is made publicly available by the University of Adelaide in accordance with its open access policy for student theses. Copyright in this thesis remains with the author. This thesis may incorporate third party material which has been used by the author pursuant to Fair Dealing exceptions. If you are the owner of any included third party copyright material you wish to be removed from this electronic version, please complete the take down form located at: http://www.adelaide.edu.au/legals