External fixation versus open reduction and internal fixation in the treatment of Complex Tibial Plateau Fractures: A systematic review and meta-analysis

Objective The aim of this meta-analysis was to compare the functional outcomes and complications of external fixation (EF) versus open reduction and internal fixation (ORIF) in the treatment of complex tibial plateau fractures. Methods Based on a comprehensive search of major databases through PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL), 19 studies comparing EF versus ORIF in treatment of complex tibial plateau fractures (Schatzker V-VI/ OTA C1, C2, and C3) were included in the studies. There was one randomized controlled trial, two prospective comparative studies, 14 retrospective comparative studies, and two conference papers. From these studies, the data regarding functional and surgical outcomes as well as complications were obtained and pooled to conduct a comparison between the two methods of treatment. Results 1191 tibial plateau fractures were determined by the systematic review. Of those fractures, 543 were treated using EF, and 648 were treated using ORIF with plate and screws. All the studies included the young patients with traumatic tibial plateau fractures with mean ages from 40 to 60 years. The analysis of pooled data revealed significantly better functional outcome in patients operated with EF (standard mean difference [SMD] = 0.29, 95% confidence interval [CI] = 0.04-0.55, P = 0.02, I2= 0%). However, according to categorical functional outcomes, no significant differences were found (OR 0.80, 95%CI: 0.47, 1.34, P=0.39, I2= 31%). The range of movement at the knee joint was significantly better in patients treated by EF (mean difference [MD] = 7.86, 95%CI = 3.56 -12.17, P = 0.0003). The surgical time in the EF group was significantly shorter compared to the ORIF group (MD = -52.11, 95%CI = -99.62-(-4.60), P = 0.03). Similarly, the intraoperative blood loss was significantly lesser in the EF group (MD = -341.53, 95%CI = -528.18- (-154.88), P = 0.0003). Although the superficial infection was more frequent in the EF group (odds ratio [OR] = 3.22, P = 0.0002), there were no differences in the deep infection and overall infection rates. Also, there were no differences in reoperation rate, knee stiffness, compartment syndrome, and venous thromboembolism. The radiographic osteoarthritis was more common in the EF group (OR = 1.56, P = 0.04); however, there was no difference in the need for total knee arthroplasty between the two treatment modalities. Conclusion EF provides better functional outcomes and range of motion compared to ORIF in the treatment of complex tibial plateau fractures. With shorter surgical time and lesser intraoperative blood loss, EF can be considered as a definite treatment method in open injuries, polytrauma patients, and chronically morbid patients who cannot withstand prolonged surgery. Level of evidence Level III, Therapeutic Study.