Postoperative Care/Rehabilitation

Introduction

Postoperative care and rehabilitation for tibial plateau fractures remain areas of surgical management with little standardization. While a significant amount of research has focused on diagnosis, classification, surgical techniques, and operative outcomes of tibial plateau fractures, far less has evaluated appropriate postoperative care. Hence, there are a wide range of postoperative management protocols implemented by orthopedic trauma surgeons worldwide. An ideal postoperative regimen would minimize the risk of losing fracture reduction while also minimizing the risk of wound complications, loss of range of motion, patient deconditioning, and long-term sequelae of these injuries. These at times represent competing interests, with extended immobilization possibly minimizing fracture displacement, while consequently increasing the likelihood of postoperative stiffness in addition to precipitating cartilage loss and subsequent posttraumatic arthritis. The goal of this chapter is to discuss these factors and help guide orthopedic traumatologists to select the appropriate, evidence-based postoperative management protocol.

Wound Care

Tibial plateau fractures are high-energy injuries that often present with concomitant soft-tissue sequelae. High-energy plateau fractures often present significant swelling, with rates of compartment syndrome reported to be as high as 28% in bicondylar tibial plateau fractures. Furthermore, surgical site infection rates for tibial plateau fractures treated surgically have been reported as 9.9% in a recent meta-analysis and have been reported to be as high as 13.8%. ^, This must be kept in mind when addressing postoperative wound closure and wound care options.

Extensive open injuries with soft-tissue stripping and/or contaminated wounds may require second-look procedures given the high risk of infection. Options for coverage in those scenarios include negative pressure wound therapy (NPWT) followed by secondary closure, skin grafting, and flap coverage, with optimal soft-tissue coverage within 7 days to decrease complications. Details regarding choice of coverage are outside of the scope of this chapter. For a wound to be an optimal candidate for primary closure, it must be free from contamination, contain a viable soft-tissue envelope, and be able to be closed without unnecessary tension. In clean wounds with a viable soft-tissue envelope that have too much tension to be primarily closed after the index surgery, delayed primary closure via gradually tightened subcuticular stitches and the vessel loop shoe-lace method are both options.

When amenable to primary closure, wounds should be closed in a layered fashion. For skin closure, vertical mattress and horizontal mattress stitches are preferred for wounds with higher concern for tension as these suture patterns distribute the tension over a greater surface area. A 2008 study by Sagi et al. used a porcine model to explore the effect of suture patterns on cutaneous blood flow, finding that the Allgower-Donati pattern had the least effect on cutaneous blood flow for all levels of tension applied to the repair. More recently, a 2020 study by Shorten and colleagues used laser angiography to measure incisional skin perfusion in patients immediately after ankle fracture surgery. They found that vertical mattress stitches had equivalent performance to Allgower-Donati stitches and that both allowed for better perfusion than sutures in a horizontal or simple pattern. Finally, a similar study from the Mayo Clinic found vertical mattress stitches to demonstrate superior wound perfusion to staples. However, several trials, systematic reviews, and meta-analysis studies have shown no difference in clinical outcomes between the use of sutures or staples in surgical wound closure. Running subcuticular stitch, the pattern that allows for the most robust wound perfusion in both studies, would not be appropriate for the high-tension wounds seen in tibial plateau fractures. In this author’s experience, nylon suture thrown in a vertical mattress fashion provides a secure, strong closure for the vast majority of surgical wounds following fixation of tibial plateau fractures.

After closure, the ideal dressing provides a barrier against potential sources of contamination to prevent infection while also optimizing wound healing. Prior studies have shown that a moist environment helps improve wound healing by preventing tissue dehydration, promoting breakdown of dead tissue and fibrin, and stimulating faster epithelialization than a purely dry dressing. ^, A standard three-layer dressing of impregnated gauze (e.g., Xeroform (Covidien, Dublin, Ireland)), standard gauze, and waterproof outer dressing (e.g., Tegaderm (3M, Saint Paul, MN, USA)) provides an ideal healing environment while also wicking away exudate and providing a waterproof barrier on the outside. While research from the arthroplasty literature has suggested that silver-impregnated occlusive dressings are highly effective for wounds with significant drainage and may decrease acute periprosthetic joint infection rates, tibial plateau wounds are far less exudative. Dressings with such high absorptive properties are poorer options for dry wounds.

Initial reports suggested a favorable role for incisional NPWT for major lower extremity trauma to decrease risk of surgical site infection. ^, A recent meta-analysis reported a decrease in infections and hospital stays with NPWT use. However, in a recent randomized controlled trial of 1548 adults with lower extremity fractures who underwent primary closure, there was no difference in the deep surgical site infection rate between standard wound dressing and incisional wound vacuum therapy.