Arnold JB, Tu CG, Phan TM, Rickman M, Varghese VD, Thewlis D, Solomon LB. 

Abstract

Objective: To identify and describe the characteristics of existing practices for postoperative weight bearing and management of tibial plateau fractures (TPFs), identify gaps in the literature, and inform the design of future research.

Methods: Seven electronic databases and clinical trial registers were searched from inception until November 17th 2016. Studies were included if they reported on the surgical management of TPFs, had a mean follow-up time of ≥1year and provided data on postoperative management protocols. Data were extracted and synthesized according to study demographics, patient characteristics and postoperative management (weight bearing regimes, immobilisation devices, exercises and complications).

Results: 124 studies were included involving 5156 patients with TPFs. The mean age across studies was 45.1 years (range 20.8-72; 60% male), with a mean follow-up of 34.9 months (range 12-264). The most frequent fracture types were AO/OTA classification 41-B3 (29.5%) and C3 (25%). The most commonly reported non-weight bearing time after surgery was 4-6 weeks (39% of studies), with a further 4-6 weeks of partial weight bearing (51% of studies), resulting in 9-12 weeks before full weight bearing status was recommended (55% of studies). Loading recommendations for initial weight bearing were most commonly toe-touch/<10kg (28%), 10kg-20kg (33%) and progressive (39%). Time to full weight bearing was positively correlated with the proportion of fractures of AO/OTA type C (r=0.465, p=0.029) and Schatzker type IV-VI (r=0.614, p<0.001). Similar rates of rigid (47%) and hinged braces were reported (58%), most frequently for 3-6 weeks (43% of studies). Complication rates averaged 2% of patients (range 0-26%) for abnormal varus/valgus and 1% (range 0-22%) for non-union or delayed union.

Conclusions: Postoperative rehabilitation for TPFs most commonly involves significant non-weight bearing time before full weight bearing is recommended at 9-12 weeks. Partial weight bearing protocols and brace use were varied. Type of rehabilitation may be an important factor influencing recovery, with future high quality prospective studies required to determine the impact of different protocols on clinical and radiological outcomes.

Summary:

One of the H&Ps I presented was a 31 year old patient complaining of right knee trauma from a bicycle accident. He was diagnosed with a tibial plateau fracture and was taken to the OR for surgery, after the surgery the surgeon wanted him to be non weight bearing for 2 months. I chose this article because it reviewed current literature and practices for how long patients were kept no weight bearing after repair of tibial plateau fractures and the outcomes associated with the length of non weight bearing status. This review evaluated 124 studies including 5156 patients with tibial plateau fractures and followed them for 12-264 months. The most common protocol followed for no weight bearing was 4-6 weeks followed by 4-6 weeks of partial weight bearing with progressively increased load, the total time to full weight bearing was 9-12 weeks. Severity of the fracture played an important role in in the thought process behind weight bearing status. The researchers did not identify a relationship between complication rates and weight bearing status, specifically early weight bearing in unicondylar tibial plateau fractures. Retrospective studies suggest that early weight bearing can be accomplished without compromising stability. There were no prospective trials that compared different weight bearing protocols. The authors identify a need for high quality prospective studies comparing outcomes with different weight bearing protocols on both clinical and radiological outcomes.