Nonoperative Treatment of Tibial Plateau Fractures

Patient Factors

Patient-specific factors, including ambulatory status, medical comorbidities, risk of anesthesia, and patient’s ability to receive transfusion, must be taken into consideration. For example, nonsurgical treatment should be considered in a low-demand, nonambulatory, or minimally ambulatory patient who uses the affected limb for transfers or short distances only. This low-demand scenario may be seen in patients with hemiplegia or paraplegia, morbid obesity, advanced age, or severe deconditioning.

Nonoperative treatment may be considered in patients with multiple medical comorbidities, who are at high risk of complications from anesthesia and surgery. Medical comorbidities, such as diabetes (especially uncontrolled) and renal failure, may drive treatment decisions. A markedly elevated hemoglobin A1c (HbA1c) indicates poor diabetic control and is associated with other conditions such as malnutrition with hypoalbuminemia and anemia. Patients with a poor host classification grade, initially described by Cierny et al., may be at extremely high risk for complication from acute intervention, and conservative treatments should be strongly considered. The host classification indicates the number of Immune system-compromising factors include diabetes, renal disease requiring dialysis, malnutrition, nicotine use, Age >80, malignancy, alcoholism, and more. ( Fig. 3.1 ). Additionally, a systematic review indicated that diabetes increased rates of malunion, infection, and reoperation rates in operative lower extremity fractures and increased rates of nonunion in fractures below the knee.

While a set point for HbA1c has not been universally established for fracture care, the arthroplasty literature uses a benchmark of 7% as an agreed-upon preoperative target. A recent study in the Journal of Arthroplasty found that a threshold of 7.7 was a specific risk factor that could predict periprosthetic joint infection. This threshold may be considered as a reference point in fracture care to predict infection risk and can be used as a tool in the decision-making process. In patients with uncontrolled diabetes, tibial plateau fractures may be treated initially nonoperatively, and once glucose control is established, patients may then become candidates for procedures such as arthroplasty in a delayed fashion.

Similarly, patients with renal failure have poor wound and fracture healing as well as an increased risk of mortality when undergoing noncardiac surgery and should be considered for nonoperative modalities. In a recent metaanalysis of the joint arthroplasty literature, Kim et al. found that patients with chronic kidney disease (CKD) have a higher rate of mortality and periprosthetic joint infection based on the unadjusted odds ratio. After total hip arthroplasty, the risk of periprosthetic joint infection was higher in patients who were on dialysis than in CKD patients not on dialysis. Other medical conditions that may influence treatment decisions include active infection, recent myocardial infarction, or stroke, especially when high doses of anticoagulants are required, leading to a high risk of bleeding complications.

Socioeconomic Considerations

Various socioeconomic scenarios can affect the surgeon’s ability to provide optimal operative treatment, such as in the setting of a contagious pandemic or in areas of conflict or poverty where resources can be limited. During the unexpected COVID-19 pandemic, some patients opted for nonoperative treatment, limiting their visits and exposure to a large hospital system and utilizing telehealth and home therapy. In underdeveloped countries, orthopedic surgeons may encounter limited access to sterile operating rooms and may elect to proceed with nonoperative treatment of tibial plateau fractures. In these unusual circumstances, surgical treatment may not be an option. Lastly, the religious and cultural beliefs of patients may indicate nonoperative management. For example, if the patient’s belief system precludes them from receiving a transfusion, the surgeon may choose nonoperative treatment, especially in the setting of polytrauma.

Fracture Characteristics

The characteristics of the fracture provide the basis for nonoperative versus operative treatment decision making. Historically, the most stringent criteria for operative intervention are articular step-off more than 3 mm, condylar widening of more than 5 mm relative to contralateral side, and lateral tilt or valgus malalignment of more than 5 degrees. Other authors indicate that up to 10 mm of step-off and 10 degrees of malalignment can be treated nonoperatively, and beyond this cutoff, surgery is almost universally indicated. Specifically, for lateral plateau fractures, up to 3 mm of articular step-off, 5 mm of condylar widening, and 5 degrees of valgus malalignment are well tolerated without adverse effects. Bicondylar fractures and displaced medial plateau fractures likely require operative intervention. Additionally, knee instability will require surgical treatment. Preexisting arthritis of a severe nature may also be a reason to strongly consider closed fracture treatment and then delayed arthroplasty without fear of surgical site infection, multiple incisions, and stress risers from preexisting hardware. Lastly, closed treatment with systemic and/or local antibiotics may be considered in the setting of open injury and significant contamination where the presence of a metallic foreign body may drive infection.