Early Versus Delayed Definitive Fixation Relative to Fasciotomy Closure in High-Energy Tibial Plateau Fractures with Compartment Syndrome
Authors: Flagstad Ilexa , Albright Patrick , Pedri Tony , Kleinsmith Rebekah M. , Schmidt Andrew , Alley Maxwell , Westberg Jerald R. , Moreno Andres Fidel , Henry Greer , Tatman Lauren M. , Obremskey William T. , Tornetta Paul , Cunningham Brian P. 
Published: March 2024

Objectives:
To evaluate the timing of definitive fixation of tibial plateau fractures relative to fasciotomy closure with regards to alignment and articular reduction.

Methods:

Design: Retrospective Case Series

Setting:
Four Level I trauma centers

Patient Selection Criteria:
Patients with tibial plateau fractures with ipsilateral compartment syndrome treated with fasciotomy between 2006-2018 met inclusion criteria. Open fractures, patients under the age of 18, patients with missed or delayed treatment of compartment syndrome, patients with diagnosis of compartment syndrome after surgical fixation, and patients whose plateau fracture was not treated with open reduction and internal fixation (ORIF) were excluded. Patients were divided into two groups depending on the relative timing of fixation to fasciotomy closure: early fixation (EF) was defined as fixation before or at the time of fasciotomy closure and delayed fixation (DF) was defined as fixation after fasciotomy closure.

Outcome Measures and Comparisons:
Radiographic limb alignment (categorized as anatomic alignment (no varus/valgus), ≤ 5° varus/valgus, or > 5° varus/valgus) and articular reduction (categorized as anatomical alignment with no residual gap or step off, <2mm, 2-5mm, and >5mm of articular surface step off) was compared between early and delayed fixation groups. Additionally, superficial and deep infection rates were compared between those in the EF and DF cohorts. Subgroup analysis within the EF cohort was performed to compare baseline characteristics and outcomes between those that received fixation prior to closure and those that underwent concurrent fixation and closure within one operative episode.

Results:
A total of 131 patients met inclusion criteria for this study. Sixty-four patients (48.9%) were stratified into the delayed fixation group and 67 patients (51.1%) were stratified into early fixation. In the EF cohort, 57 (85.1%) were male with an average age of 45.3 ± 13.6 years and an average BMI of 31.0 ± 5.9. The DF cohort was primarily male (44, 68.8%), with an average age of 46.6 ±13.9 and an average BMI of 28.4 ± 7.9. Fracture pattern distribution did not differ significantly between the early and delayed fixation cohorts (p = 0.754 for Schatzker classification and p = 0.569 for AO/OTA classification). The relative risk of infection for the DF cohort was 2.17 [95%CI = 1.04, 4.54] compared to the EF cohort. . Patients in the early fixation cohort were significantly more likely to have anatomic articular reduction compared to their delayed fixation counterparts (37.5% vs. 52.2%; p < 0.001).

Conclusions:
This study demonstrated higher rates of anatomic articular reduction in patients that underwent fixation of tibial plateau fractures prior to or at the time of fasciotomy closure for acute compartment syndrome compared to their counterparts that underwent definitive fixation for tibial plateau fracture after fasciotomy closure. The relative risk of overall infection in the for those that underwent fasciotomy closure after definitive fixation for tibial plateau fracture was 2.17 compared to the cohort that underwent closure before or concomitantly with definitive fixation.

Level of Evidence:
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.