Skip to main content
Download PDF

Functional outcomes and quality of life after surgically treated tibial plateau fractures

BMC Psychology volume 11, Article number: 146 (2023) Cite this article

Abstract

Background

Tibial plateau fractures (TPF) are uncommon and challenging for orthopedic surgeons with controversial reported outcomes. In this study, we aimed to evaluate the functional outcomes and quality of life (QOL) of patients with surgically treated TPF.

Methods

A total of 80 consecutive patients and 82 controls participated in this case control study. The patients were all surgically treated in our tertiary center from April 2012 to April 2020. The functional outcome was evaluated using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) scale. Moreover, we used the Short Form 36 health survey (SF-36) health survey to evaluate the QOL.

Results

No significant difference was observed in the overall mean SF-36 score in the two groups. We found a significant positive correlation between the scores of the SF-36 and WOMAC questionnaires (r = 0.642, p < 0.001) and between the ROM and the WOMAC questionnaire score (r = 0.478, p < 0.001). Further, ROM and SF-36 showed a weak positive correlation (r = 0.248, p = 0.026). Age had a weak negative correlation with the pain subscale of SF-36 (r = − 0.255, p = 0.22), even though it was not correlated with the total score or other subscales (p > 0.05).

Conclusion

QoL after TPF is not significantly different from that of a matched control group. Also, neither age nor BMI correlates with the QoL and functional outcome.

Peer Review reports

Introduction

With an incidence rate of 10.3 per 100,000 people annually and 1% of all fractures, TPF is not uncommon [1,2,3,4,5]. TPF usually occurs in young patients and after high-energy traumas [6, 7]. These fractures are associated with a high rate of complications, including soft tissue injury, nerve damage, vascular injury, infection, delayed union, nonunion, and osteoarthritis (OA), which makes them one of the most challenging injuries to treat [7,8,9,10]. Also, due to their intraarticular nature, it is of utmost importance to achieve anatomical reduction and limb alignment [5, 8, 11].

Several treatment methods have been used and suggested, including closed reduction and casting, open reduction and internal fixation (ORIF), external fixation, or a combination of these methods [7]. The most common treatment method for TPF is ORIF performed by plates and screws, which has been associated with acceptable clinical results. However, this method is associated with complications, the most important of which are: excessive bone damage and soft tissue damage, high risk of infection, and functional rehabilitation problems with delayed activity and scar formation [12, 13]. Another treatment method for these patients is closed reduction and plastering, which is not recommended for adults due to the difficulty of maintaining the reduction in plaster and the possibility of complications such as malunion. Also, considering that this method requires a long period of immobility, it can lead to knee stiffness, and this method is mostly used for patients who are not medically eligible for surgery [14,15,16]. Hybrid treatment can be the most ideal treatment method for these patients. In this method, it can be used in compound injuries as well as in fractures with extensive soft tissue damage as a definitive fixation option, in which the hybrid external fixator combines an Ilizarov ring with a standard AO frame [14, 17]. Also, with the use of new devices, the techniques have improved significantly [18]. However, the complication rate still remains high, and these fractures are associated with poor prognosis as up to 58% of the patients develop OA [7, 19,20,21,22]. Because fractures in this area are associated with several complex injuries such as soft tissue damage, deep abrasions, combined injuries and blister formation due to extensive edema and crushing at the fracture site along with ligament injuries that lead to instability and often it is difficult to manage these patients and the postoperative complications will still be high in these patients [14].

This type of fracture and its surgical management remains a challenge due to its complexity [23]. Also, several studies which evaluated functional outcomes and quality of life (QoL) after TPF and OA have reported unsatisfactory results [23, 24]. Moreover, the proximal tibia fractures resulted in worse outcomes than outcomes of midshaft or distal tibial fractures [25]. However, to the best of our knowledge, no study compared the results of their evaluation against a matched control group. In this study, we aimed to investigate the patient-reported functional outcomes and QoL of the patients after surgical treatment of TPF and compare the QoL with a matched control group. The aim of this study was to answer two questions: 1. What is the functional outcome in patients with TPF and 2. Will the quality of life of patients after surgery be different compared to the normal and healthy group or not?

Material and methods

Participants

This prospective case–control study took place in Shafa Yahyaian hospital, Tehran, Iran, from April 2012 to April 2020. All consecutive patients with TPF presenting to our hospital, either through the emergency department or clinic, were included in the study. Sampling of patients was done as available and among all referring patients. The institutional review board and the ethics committee of Iran University of Medical Sciences approved this study. All participants provided verbal informed consent.

Inclusion and exclusion criteria

The inclusion criteria were a diagnosis of TPF, no fractures in the other knee or spine, no history of knee surgery, cooperation for follow-up, and at least six months of follow-up after surgery. The exclusion criteria were history of any previous surgery on the lower limbs that affects the outcome of treatment, less than six months of follow-up, defects in clinical and radiological finding or demographic information, lack of cooperation or reluctance to participate in the study and less than 18 years of age.

Study groups

A matched population of 82 subjects with no history of TPF or any other pathology in the knee or fibula was enrolled from the community as the control group. Sampling of the control group was done randomly and from healthy people who referred to the hospital. The groups were matched in terms of age, gender, and BMI of the patients. Patients' information was collected in two parts using a two-part checklist. Demographic and clinical data and follow-up time were recorded. All patients were followed up and visited after the operation to evaluate the operation outcomes, QoL, and postoperative functional results.

Outcome measurement instruments

We used the WOMAC scale to evaluate patient-reported outcomes, which was used after these fractures [7, 26, 27]. The WOMAC questionnaire is scored on a 0–100 scale and consists of 25 items in 5 domains which are answered by a Likert scale and evaluates pain, clinical symptoms and stiffness, daily function, exercise, and QoL [28]. A higher score on this scale shows inferior outcomes. This scale has been widely approved for the Iranian population in terms of reliability and validity [13, 14].

Furthermore, QoL was assessed using the SF-36 health survey, which is an established method in patients with this type of fracture [23, 29], and has been validated in Persian [30]. SF-36 consists of 36 items in 8 subscales, including pain, energy/fatigue, role limitations due to physical health, physical functioning, role limitations due to emotional problems, emotional wellbeing, social functioning, and general health. The score in each subscale and the total score were converted to a 0–100 scale, in which a higher score indicates a better status [31].

Statistical analysis

We used SPSS version 25.0 to analyze data. The Chi-Square test was used to evaluate the relationship between the categorical variables. We used the Kolmogorov–Smirnov method to check the distribution of the data. To compare the quantitative variable between two groups, independent samples t-test was used. The Mann–Whitney U test was considered a suitable substitute if the data lacked the parametric criteria. Spearman and Pearson's tests were used to assess correlation. A p value less than 0.05 was considered significant for statistical tests.

Results

Overall, 162 participants (80 cases and 82 controls) were enrolled in the study. Age and BMI were comparable between the groups (Table 1).

Table 1 Demographic characteristics in two groups
Full size table

The total mean WOMAC score in patient was 77.83 ± 16.81 (Table 2). The patients were followed up for 48.20 ± 22.43 months. Also, comorbidities were comparable in the groups (p value = 0.651). No significant difference was observed for the mean score of SF-36 and its subscales in the two groups (Table 3).

Table 2 Mean WOMAC score and subscales in patient group
Full size table
Table 3 Comparison of mean SF-36 score and subscales in two groups of patients
Full size table

We also found a significant positive correlation between the scores of the SF-36 and WOMAC questionnaires (r = 0.642, p < 0.001) and between the ROM and the WOMAC questionnaire score (r = 0.478, p < 0.001). Further, ROM and SF-36 showed a weak positive correlation (r = 0.248, p = 0.026). BMI was not significantly correlated with the WOMAC or SF-36 scores or any of the subscales (p > 0.05). Also, age was not significantly correlated with the WOMAC score or any of its subscales (p > 0.05). Age had a weak negative correlation with the pain subscale of SF-36 (r = − 0.255, p = 0.22), even though it was not correlated with the total score or other subscales (p > 0.05).

Discussion

In this study, we evaluated the patient-reported functional outcome using the WOMAC questionnaire and QoL using the SF-36 questionnaire and after TPF and compared QoL with a matched control group. The QoL in patients was not significantly different from the control group, either in the total score or in any specific items. We found no correlation between age and ROM, the WOMAC score, or any of its subscales; however, we found a weak negative correlation between age and pain subscale of SF-36. Furthermore, BMI had no correlation with ROM, the WOMAC or SF-36 scores, or any subscales.

Elsøe et al. Evaluated QoL, functional and radiological outcomes in 28 patients with lateral TPF. They showed that patients had a high level of satisfaction and their functional outcomes were not significantly different from the reference population [26]. These results were consistent with our study, which shows that patients with PTF regain their functional ability after surgery as before the fracture. These findings show the quality of life of patients with TPF after surgery, which consists of different dimensions such as pain, energy/fatigue, role limitations due to physical health, physical functioning, role limitations due to emotional problems, emotional well-being, social functioning and general health, was not different in the case and control groups.

As already mentioned, TPF can result in OA [3, 32]. Vandreumel et al.,(7) Assessed 71 consecutive patients with TPF to evaluate mid- to long-term functional outcomes after surgical treatment of TPF. In their study, they did not report a relationship between mean WOMAC score and age for any subscale. These findings align with our results that age and BMI do not affect the WOMAC score. These findings show that TPF surgery significantly improves functional outcomes (WOMAC score and SF-36 score) of patients, regardless of the demographic characteristics of patients (such as BMI and age). The reason for the difference between this finding in our study and other studies can be justified due to the fact that the case and control groups are identical (with the aim of controlling confounders. Another study reported that treating TPF results in 73.3% excellent to good functional outcomes and satisfactory QoL assessment [18]. This report is concordant with our findings.

The fact that the literature regarding the functional outcome of surgically treated TPF is controversial may be due to different inclusion criteria, various classification systems and fixation techniques, or missing functional outcome data [33].

Our studies had weak and strong points that should be pointed out. The first limitation of the study is the retrospective design which causes known limitations. Also, in this study, we did not report the type of fracture and treatment method, which could be noteworthy. Moreover, the patients were followed for less than ten years; thus, we could not report long-term outcomes.

Conclusion

Our study showed, the TPF although challenging, do not necessarily result in inferior QoL. As we found that the QoL of patients after surgical treatment of TPF was not significantly different from that of a matched control group. Also, neither age nor BMI correlates with the QoL and functional outcomes as measured by SF-36 and WOMAC questionnaires.

Availability of data and materials

Given that the data of this study is a small part of the data of a large study and according to the forecast of a series of articles will be extracted serially from this data. Data will not be available until the end of the project, although the datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

BMI:

Body mass index

WOMAC:

Western Ontario and McMaster Universities Arthritis Index

TPF:

Tibial plateau fractures

QoL:

Quality of life

SF-36:

Short Form 36 health survey

References

  1. Beisemann N, Vetter SY, Keil H, Swartman B, Schnetzke M, Franke J, Grützner PA, Privalov M. Influence of reduction quality on functional outcome and quality of life in the surgical treatment of tibial plateau fractures: A retrospective cohort study. Orthop Trauma Surg Res. 2022;108(7):102922.

    Article  Google Scholar 

  2. Elsoe R, Larsen P, Nielsen NP, Swenne J, Rasmussen S, Ostgaard SE. Population-based epidemiology of tibial plateau fractures. Orthopedics. 2015;38(9):e780–6.

    Article  PubMed  Google Scholar 

  3. Moore TM, Patzakis MJ, Harvey JP. Tibial plateau fractures: definition, demographics, treatment rationale, and long-term results of closed traction management or operative reduction. J Orthop Trauma. 1987;1(2):97–119.

    Article  PubMed  Google Scholar 

  4. Rademakers MV, Kerkhoffs GMMJ, Sierevelt IN, Raaymakers ELFB, Marti RK. Operative treatment of 109 tibial plateau fractures: five- to 27-year follow-up results. J Orthop Trauma. 2007;21(1):5–10.

    Article  PubMed  Google Scholar 

  5. Baloch SR, Rafi MS, Junaid J, Shah M, Siddiq F, Ata-Ur-Rahman S, et al. Ilizarov fixation method of tibia plateau fractures: a prospective observational study. Cureus. 2020;12(10): e11277.

    PubMed  PubMed Central  Google Scholar 

  6. Krieg JC. Proximal tibial fractures: current treatment, results, and problems. Injury. 2003;34(Suppl 1):A2-10.

    Article  PubMed  Google Scholar 

  7. van Dreumel RL, van Wunnik BP, Janssen L, Simons PC, Janzing HM. Mid- to long-term functional outcome after open reduction and internal fixation of tibial plateau fractures. Injury. 2015;46(8):1608–12.

    Article  PubMed  Google Scholar 

  8. Bove F, Sala F, Capitani P, Thabet AM, Scita V, Spagnolo R. Treatment of fractures of the tibial plateau (Schatzker VI) with external fixators versus plate osteosynthesis. Injury. 2018;49(Suppl 3):S12–8.

    Article  PubMed  Google Scholar 

  9. Debnath UK, Jha DK, Pujari PK. Results of ring (Ilizarov) fixator in high energy Schatzker type VI fractures of proximal tibia. J Clin Orthop Trauma. 2018;9(2):186–91.

    Article  PubMed  Google Scholar 

  10. Honkonen SE. Degenerative arthritis after tibial plateau fractures. J Orthop Trauma. 1995;9(4):273–7.

    Article  PubMed  Google Scholar 

  11. Hap DXF, Kwek EBK. Functional outcomes after surgical treatment of tibial plateau fractures. J Clin Orthop Trauma. 2020;11(Suppl 1):S11–5.

    Article  PubMed  Google Scholar 

  12. Gosling T, Schandelmaier P, Muller M, Hankemeier S, Wagner M, Krettek C. Single lateral locked screw plating of bicondylar tibial plateau fractures. Clin Orthop Relat Res®. 2005;439:207–14.

    Article  PubMed  Google Scholar 

  13. Wang Z, Zheng Z, Ye P, Tian S, Zhu Y, Chen W, et al. Treatment of tibial plateau fractures: a comparison of two different operation strategies with medium-term follow up. J Orthop Transl. 2022;36:1–7.

    Google Scholar 

  14. Subash Y. Evaluation of functional outcome following hybrid external fixation in the management of Schatzkers type V and VI tibial plateau fractures-a prospective study of 30 patients. Malays Orthop J. 2021;15(1):48.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Abdelkareem O, Eldin Elazab H, Ali M. Functional outcomes of management of tibial plateau fractures (type II) by closed reduction and percutaneous screws. Egypt J Orthop Res. 2021;2(1):47–52.

    Article  Google Scholar 

  16. Young MJ, Barrack R. Complications of internal fixation of tibial plateau fractures. Orthop Rev. 1994;23(2):149–54.

    PubMed  Google Scholar 

  17. Barei DP, Nork SE, Mills WJ, Henley MB, Benirschke SK. Complications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision technique. J Orthop Trauma. 2004;18(10):649–57.

    Article  PubMed  Google Scholar 

  18. Märdian S, Landmann F, Wichlas F, Haas NP, Schaser KD, Schwabe P. Outcome of angular stable locking plate fixation of tibial plateau fractures Midterm results in 101 patients. Indian J Orthop. 2015;49(6):620–9.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Volpin G, Dowd GS, Stein H, Bentley G. Degenerative arthritis after intra-articular fractures of the knee. Long-term results. J Bone Joint Surg Br. 1990;72(4):634–8.

    Article  PubMed  Google Scholar 

  20. Weigel DP, Marsh JL. High-energy fractures of the tibial plateau: knee function after longer follow-up. JBJS. 2002;84(9):1541–51.

    Article  Google Scholar 

  21. Manidakis N, Dosani A, Dimitriou R, Stengel D, Matthews S, Giannoudis P. Tibial plateau fractures: functional outcome and incidence of osteoarthritis in 125 cases. Int Orthop. 2010;34(4):565–70.

    Article  PubMed  Google Scholar 

  22. Jansen H, Frey SP, Doht S, Fehske K, Meffert RH. Medium-term results after complex intra-articular fractures of the tibial plateau. J Orthop Sci. 2013;18(4):569–77.

    Article  PubMed  Google Scholar 

  23. Privalov M, Euler F, Keil H, Swartman B, Beisemann N, Franke J, et al. Influence of reduction quality on functional outcome and quality of life in treatment of tibial plafond fractures: a retrospective cohort study. BMC Musculoskelet Disord. 2019;20(1):534.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Cisneros LN, Gómez M, Alvarez C, Millán A, De Caso J, Soria L. Comparison of outcome of tibial plafond fractures managed by hybrid external fixation versus two-stage management with final plate fixation. Indian J Orthop. 2016;50(2):123–30.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Naude JJ, Manjra MA, Birkholtz F, Barnard AC, Tetsworth K, Glatt V, et al. Functional outcomes and quality of life following complex tibial fractures treated with circular external fixation: a comparison between proximal, midshaft, and distal tibial fractures. Strategies Trauma Limb Reconstr. 2021;16(1):32–40.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Elsøe R, Larsen P, Rasmussen S, Hansen HA, Eriksen CB. High degree of patient satisfaction after percutaneous treatment of lateral tibia plateau fractures. Dan Med J. 2016;63(1):A5174.

    PubMed  Google Scholar 

  27. Elsoe R, Larsen P, Shekhrajka N, Ferreira L, Ostgaard SE, Rasmussen S. The outcome after lateral tibial plateau fracture treated with percutaneus screw fixation show a tendency towards worse functional outcome compared with a reference population. Eur J Trauma Emerg Surg. 2016;42(2):177–84.

    Article  PubMed  Google Scholar 

  28. Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD. Knee Injury and Osteoarthritis Outcome Score (KOOS)—development of a self-administered outcome measure. J Orthop Sports Phys Ther. 1998;28(2):88–96.

    Article  PubMed  Google Scholar 

  29. Oguzkaya S, Misir A, Kizkapan TB, Eken G, Ozcamdalli M, Basilgan S. A comparison of clinical, radiological, and quality-of-life outcomes of double-plate internal and Ilizarov external fixations for Schatzker type 5 and 6 tibia plateau fractures. Euro J Trauma Emergency Surg. 2022:1–8.

  30. Montazeri A, Goshtasebi A, Vahdaninia M, Gandek B. The Short Form Health Survey (SF-36): translation and validation study of the Iranian version. Qual Life Res. 2005;14(3):875–82.

    Article  PubMed  Google Scholar 

  31. Bahardoust M, Hajializade M, Amiri R, Mousazadeh F, Pisoudeh K. Evaluation of health-related quality of life after total hip arthroplasty: a case-control study in the Iranian population. BMC Musculoskelet Disord. 2019;20(1):46.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Júnior MK, Fogagnolo F, Bitar RC, Freitas RL, Salim R, Jansen Paccola CA. Tibial plateau fractures. Rev Bras Ortop. 2015;44(6):468–74.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Stevens DG, Beharry R, McKee MD, Waddell JP, Schemitsch EH. The long-term functional outcome of operatively treated tibial plateau fractures. J Orthop Trauma. 2001;15(5):312–20.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors sincerely appreciate of all cases and controls who contributed to this research and completed the questionnaires.

Funding

We have no funding resource for this study.

Author information

Authors and Affiliations

  1. Bone and Joint Reconstruction Research Center, Department of Orthopedics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran

    Abolfazl Bagherifard, Seyed Farzam Mirkamali, Heeva Rashidi, Nima Naderi, Mohammad Hassanzadeh & Mehdi Mohammadpour

Authors
  1. Abolfazl Bagherifard
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Seyed Farzam Mirkamali
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Heeva Rashidi
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Nima Naderi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Mohammad Hassanzadeh
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Mehdi Mohammadpour
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Conception and design: AB, SFM and MM. Analysis and interpretation of data: HR—Data collection: HR, MH and NN—AB, SFM and MM edited and read the manuscript. All authors reviewed the manuscript." All authors critically revised the manuscript, approved the final version to be published, and agree to be accountable for all aspects of the work. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Mehdi Mohammadpour.

Ethics declarations

Ethics approval and consent to participate

This study was approved by the ethics committee of Iran University of Medical Sciences, Tehran, Iran. The research team of this study adhered to the ethical principles of the Helsinki Convention regarding clinical studies in all stages of the present study. After informing the patients about the stages and results of the study, informed consent was obtained consent from the patients. Due to the fact that no interventions are performed on patients, the condition for the confidentiality of patient information is not a moral restriction by the Ethics Committee. The verbal informed consent was approved by an ethics committee by Research of Iran University of Medical Sciences.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bagherifard, A., Mirkamali, S.F., Rashidi, H. et al. Functional outcomes and quality of life after surgically treated tibial plateau fractures. BMC Psychol 11, 146 (2023). https://doi.org/10.1186/s40359-023-01195-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s40359-023-01195-2

Keywords

BMC Psychology

ISSN: 2050-7283

Contact us