Acute total knee arthroplasty for traumatic proximal tibial fractures: A systematic review

Table 1 Basic studies, patients’, and fracture characteristics, mean ± SD/n (%)

Ref.	Country	Study type	Total number of patients included in the study	Number of patients who had aTKA	Age	Gender		Comorbidities	Concomitant knee OA	Evaluating abnormal bone profile (author’s remarks)	Fracture details
						Male	Female				Trauma mechanism	Fracture location	Classification
Abdelbadie et al[28], 2020	Egypt	Retrospective cohort study	43 (22 aTKA vs 21 ORIF)	22	67.1 (60-73)	8	14	86.4% of the patients [diabetes (36.4%), HT (35.5%), IHD (27.3%), CLD (4.5%)]	5 (22.7)	NA [9 (40.9) patients were on bisphosphonates]	14 high energy (6 falls, 2 RTA, 6 MCA)	TPFs	Schatzker type II (7, 31.8%), Schatzker type III (8, 36.4%), Schatzker type IV (7, 31.8%)
Asikin et al[29], 2022	Malaysia	Case report	1	1	75	1	0	NR	NR	NA	High energy (MCA)	TPFs	Schatzker type V
Boureau et al[30], 2015	France	Case series	21 (10 distal femur fractures and 11 proximal tibia fractures)	11	79 (68-96)	8	3	NR (ASA III: 6, ASA II: 5)	NR	NA (all patients showed radiologic osteopenia)	NR	TPFs	5 Schatzker II, 2 Schatzker IV, 3 Schatzker V and 1 Schatzker VI
Haufe et al[31], 2016	Germany	Case series	30	30	78.4 (59-93)	13	17	NR	NR	NA	NR	TPFs	AO/OTA: Type B (13), type C fracture (17); 6: 41B2, 5: 41B3, 5: 41C1, 7: 41C2, and 7: 41C3
Hesmerg et al[32], 2024	Netherlands	Retrospective cohort study	68 (34 matched pairs: 12 aTKA vs 22 late TKA)	12	69.0 (65.3-79.5) (median)	1	11	NR [ASA I/II: 8 (66.7%)]	NR	NA	Traffic accident 2 (16.7%), fall from height 4 (33.3%), blunt trauma 1 (8.3%); other 4 (33.3%), unknown 1 (8.3%)	TPFs	Schatzker II (2, 16.7%). Type III (3, 25.0%). Type IV (1, 8.3%). Type V (4, 33.3%). Type VI (2, 16.7%)
Huang et al[33], 2016	China	Case series	6	6	69.5 (58-78)	3	3	NR	NR	NA	All were high energy (traffic accidents and falls from height)	TPFs	4 Schatzker V and 2 Schatzker VI
Kadakia et al[34], 2007	United Kingdom	Case report	1	1	85	0	1	NR: Patient’s chest radiograph showed evidence of previous scarring	NR	NA (operative findings revealed that the bone was mushy and porotic)	Low energy (fell on the knee from standing height)	TPFs	Schatzker type IV
Mirzatolooei et al[35], 2021	Iran	Case series	11	11	54.3 ± 4.7	0	11	RA [all patients were on anti-RA agents, especially corticosteroid (prednisolone) for at least 5 years (range: 5-8)]	11 (100)	It was evaluated by DXA scan 6 months before the surgery; the mean T-score was -3.8 ± 0.7	All were low energy	PTFs	NR
Sabatini et al[36], 2023	Italy	Case series	11	11	76 ± 6 (65-84)	4	7	NR	11 (100)	NA	8 low energy (simple fall), 3 high energy (car accident)	TPFs	AO/OTA: Type B (8), type C fracture (3); one (41B1), 5 (41B3), 2 (41B2), 1 (41C1), 2 (41C2)
Sarzaeem et al[37], 2017	Iran	Case series	30	30	67.6 ± 4.2 (61-78)	19	11	NR	23 (76.7)	NA (7 had osteoporosis)	14 high energy	TPFs + PTFs	AO/OTA: Type A (5), type B (22), type C fracture (3); 5 (41A), 22 (41 B), 3 (41 C)
Sivasubramanian et al[38], 2016	Singapore	Case series	3	3	70.4 (59.2-79.0)	1	2	NR	3 (100)	NA (poor bone stock)	All high energy	TPFs	2 Schatzker II and one Schatzker III
Tapper et al[39], 2020	Finland	Case series	22	22	74 ± 12 (53-88)	6	16	NR	5 (22.7)	NA (deficient bone stock)	13 low energy, 9 high energy	TPFs	6 Schatzker II, 7 Schatzker III, 2 Schatzker IV, 5 Schatzker V, 2 Schatzker VI
Vermeire and Scheerlinck[40], 2010	Belgium	Case series	12	12	73 (58-81)	3	9	NR	5 (41.7)	NA	6 low energy, 6 high energy	TPFs	AO/OTA: Type B (9), type C fracture (3); one 41-B1, 8: 41-B3, 3: 41-C3
Wui et al[41], 2020	Malaysia	Cross-sectional study	10 (6 distal femur, 2 proximal tibial, and 2 combined distal femur and proximal tibial fractures)	2	64 (55-76)	1	1	NR	NR	NA (poor bone quality)	NR	TPFs	AO/OTA: Type C fracture (2); one 41C3.1, one 41C3.3

TKA: Total knee arthroplasty; OA: Osteoarthritis; ORIF: Open reduction and internal fixation; NR: Not reported; NA: Not available; HT: Hypertension; IHD: Ischemic heart disease; CLD: Chronic liver disease; PTFs: Proximal tibial fractures; TPFs: Tibial plateau fractures; AO/OTA: Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association.

Table 2 Surgical and implant details, mean ± SD

Ref.	Time from injury to surgery (days)	Surgical approach	Type of prosthesis	Bone defect assessment	Use of extras	Concomitant ORIF (number of knees)
Abdelbadie et al[28], 2020	6.5 (1-21)	Medial parapatellar	22 PS	10 (45.5%) contained defect and 12 (54.5%) non contained defect	22 (100%) cementless long tibial stem, 6 (27.3%) bone graft and 4 (18.2%) metal wedge	6 (the fracture fragment was fixed by screws to act as structural bone graft)
Asikin et al[29], 2022	NR	Medial parapatellar	1 PS	NR	1 cementless tibial stem	Yes
Boureau et al[30], 2015	3.9 (1-11)	Medial parapatellar	10 RHK, one CCK	NR	11 cemented tibial stems	none
Haufe et al[31], 2016	NR	NR	24 RHK and 6 PS (MB)	NR	NR	NR
Hesmerg et al[32], 2024	58 (15-107)	NR	8 PS (6 MB), 2 CR, 2 RHK	NR	4 (33.3%) femoral stem, 12 (100%) tibial stem	NR
Huang et al[33], 2016	4 (2-6)	Medial parapatellar	3 PS femur and 3 CCK tibia	5 knees [3 contained and 2 non-contained (mean defect size was 3.2 mm)]	3 (100%) cemented tibial stem, bone defect was filled with polymethyl methacrylate or autologous bone	None
Kadakia et al[34], 2007	NR	NR	1 RHK	NR	Cemented stems in femur and tibia	None
Mirzatolooei et al[35], 2021	NR	Medial parapatellar	11 CCK	NR	NR	NR
Sabatini et al[36], 2023	5 ± 2 (2-9)	NR	6 PS and 5 CCK	NR	11 (100%) tantalum cones, wedges, cementless tibial stems	None
Sarzaeem et al[37], 2017	NR	Medial prepatellar	27 PS and 3 CCK	NR	NR	NR
Sivasubramanian et al[38], 2016	9 (6-12)	Medial parapatellar	2 PS and 1 LCCK	Intraoperatively, significant subchondral bone loss	3 (100%) tibial stems and tantalum cones- one (33.3%) femoral stem	2
Tapper et al[39], 2020	5.8 (1-16)	Medial parapatellar	2 RHK, 16 CCK, and 4 CR	NR	22 (100%) tibial stem, 19 (86.4%) femoral stem; 4 (18.2%) lateral or medial tibial augment, 1 (4.5%) tantalum cone	2
Vermeire and Scheerlinck[40], 2010	Three days (range: 1-6), one patient was operated upon after 2 weeks of trauma	NR	11 PS and 1 CCK	NR	12 (100%) tibial stem (cemented in two), 5 (41.7%) graft impaction, 2 (16.7%) augmentation blocks, one (8.3%) femoral stem	7
Wui et al[41], 2020	6 days and 15 days	Medial parapatellar	2 CCK	NR	2 (100%) tibia stem	NR

NR: Not reported; PS: Posterior stabilized; CR: Cruciate retaining; CCK: Constraint condylar knee; RHK: Rotating hinge knee.

Table 3 Risk of bias assessment of the included studies

Ref.	Patient selection	Outcome measures	Intervention description	Follow-up adequacy	Statistical clarity	Overall ROB
Abdelbadie et al[28], 2020	Moderate	Low	Low	Moderate	Moderate	Moderate
Asikin et al[29], 2022	High	Moderate	Moderate	High	Moderate	High
Boureau et al[30], 2015	High	Moderate	Low	High	Low	High
Haufe et al[31], 2016	High	Moderate	Low	High	Moderate	High
Hesmerg et al[32], 2024	Moderate	Low	Low	Moderate	Moderate	Moderate
Huang et al[33], 2016	High	Low	Low	High	Low	High
Kadakia et al[34], 2007	High	Moderate	Moderate	High	Low	High
Mirzatolooei et al[35], 2021	High	Low	Low	Moderate	Moderate	High
Sabatini et al[36], 2023	High	Low	Low	Moderate	Low	High
Sarzaeem et al[37], 2017	High	Low	Low	High	Low	High
Sivasubramanian et al[38], 2016	High	Moderate	Moderate	High	Low	High
Tapper et al[39], 2020	High	Moderate	Low	Moderate	Moderate	High
Vermeire and Scheerlinck[40], 2010	High	Moderate	Moderate	Moderate	Low	High
Wui et al[41], 2020	High	Moderate	Moderate	High	Moderate	High

Assessment was performed using the National Institutes of Health Quality Assessment Tool items for observational case series, cohort, and cross-sectional studies (https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools). ROB: Risk of bias.

Table 4 Details of the outcomes as reported in each study, mean ± SD

Ref.	Follow up (months)	Weight-bearing status postoperatively	Outcomes
			Functional	ROM	Radiological	Complication	Revision
Abdelbadie et al[28], 2020	27.2 (24-32)	20 FWB (two NWB due to concomitant fractures)	Preoperative vs postoperative KS: 50.5 (42-64) vs 83 (50-100), preoperative vs postoperative KS Function Score: 62 (50-65) vs 84 (60-100)	Preoperative vs postoperative knee flexion: 32.6 degrees (20-40) vs 115 degrees (100-140); preoperative vs postoperative extension lag: 10.4 degrees (5-20) vs 1.4 degrees (0-5)	All were corrected to within a mean of ± 3 degrees neutral mechanical axis	Total of 4 (18.2%); 2 (9.1%) valgus alignment, 1 (4.5%) superficial wound infection, 1 (4.5%) femoral PPF	None
Asikin et al[29], 2022	6	PWB (walking frame training started three days postoperatively)	NR	Painless knee ROM of 0 degree to 90 degrees	Complete bone union with no sign of loosening	None	None
Boureau et al[30], 2015	31 (6-9)	FWB	KSS: 127, KS: 84, KS Function Score: 43, OKS: 35.7, preoperative vs postoperative Parker Score: 7.4 vs 5	NR (the authors reported the ROM for the whole group and did not report the ROM of tibia fracture patients separately)	There were no cases of radiolucency through the follow up period-mean HKA angle was 177 degrees (171 degrees to 180 degrees)	Total of 2: 1 stiffness required MUA, and 1 deep infection managed by irrigation drainage and prolonged antibiotic therapy	None
Haufe et al[31], 2016	27 (12-48)	NR	Mean KS: 81.1 (94-54), mean KS Function Score: 74.5 (100 to -20), and mean WOMAC score: 78.6 (96.2-36.7)	NR	NR	Total of 7: 3 wound healing deficit, 1 intraoperative PPF, 1 PJI, 1 retained intraarticular cement, 1 loosening	NR
Hesmerg et al[32], 2024	34.8 (16.8-170.4)	NR	KOOS-PS score 73 (59-93); OKS 43 (30-47), EQ-5D-5 L index 0.87 (0.69-1); EQ-5D VAS 80 (71-94)	NR	NR	One patient had stiffness requiring MUA	NR
Huang et al[33], 2016	32.3 (25-41)	5 FWB and 1 PWB	HSS score: 89.8 (85-94)	Knee flexion: 119.2 degrees (105 degrees to 130 degrees)	NR	None	None
Kadakia et al[34], 2007	6	NR	NR	Painless knee ROM 0 degree to 100 degrees	No loosening	PJI	None
Mirzatolooei et al[35], 2021	24	PWB	Preoperative vs postoperative Tegner Activity Scale: 2.2 ± 1.4 vs 4.3 ± 1.4, KS: 88.7 ± 5.4, KS Function Score: 59.4 ± 8.2, preoperative vs postoperative median HSS scale: 42 (16-58) vs 78 (72-91); preoperative vs postoperative pain severity: 65.2 ± 12.3 vs 35.5 ± 11.3	Preoperative vs postoperative median ROM: 85 degrees (55 degrees to 98 degrees) vs 97 degrees (95 degrees to 110 degrees)	NR	2 DVT	None
Sabatini et al[36], 2023	28 ± 14 (12-48)	NR	KS: 83 ± 16 (48 to 97), KS Function Score: 74 ± 15 (32 to 88); preoperative vs postoperative Parker’s Scale was 7.5 ± 1.4 (5-9) vs 5.6 ± 1.3 (3-8) (P < 0.05); FJS: 66 ± 14, (42 to 94)	Knee flexion was 116 degrees ± 7 degrees (110 degrees to 130 degrees), 10 patients had full knee extension, one patient had an extension lag of 10 degrees	No radiolucency, all had neutral alignment (HKA between ± 3 degrees); based on patellar indices, there were no cases of patella alta; only one patient had a CDI and BPI consistent with a patella baja (CDI = 0.54 and BPI = 0.56)	1 PJI, 1 extension lag of 10 degrees, 1 femoral PPF, 1 DVT	One required DAIR to treat PJI
Sarzaeem et al[37], 2017	54 ± 13 (36-72)	PWB	KS: 90.7 ± 6.5 (67-97), KS Function Score: 69.6 ± 8.8 (41-85); preoperative vs postoperative Tegner Activity Scale: 2.5 ± 1.2 (1-5) vs 3.5 ± 1.3 (2-6); the mean VAS for satisfaction: 8.1 ± 1 (6-10) and VAS Pain Score: 1.5 ± 1.2	Knee flexion range was significantly higher than the contralateral uninjured side: 106 degrees ± 13 degrees vs 120 degrees ± 8 degrees	No case of septic or aseptic loosening	None	None
Sivasubramanian et al[38], 2016	56 (18-82)	FWB	KSS: 88, no pain	Knee flexion: 122 degrees (105 degrees to 132 degrees); no fixed flexion deformity or hyperextension	Radiological fracture union at a mean of 3 months (2 months to 5 months); alignment of within 3 degrees of the mechanical axis was achieved in 2 patients (2.8 varus and 3.0 valgus)	1 valgus alignment of 7.2 degrees	None
Tapper et al[39], 2020	19 ± 16	FWB	KSS score: 160 ± 39; OKS 27 ± 11	Knee flexion: 109 degrees ± 16 degrees; extension deficit in three patients	NR	1 stiffness, 1 PJI	2
Vermeire and Scheerlinck[40], 2010	31 (1.3-81)	7 FWB, 3 PWB, 2 NWB (due to due to concomitant fractures)	Median KS: 78 (50-100), median KS Function Score: 58 (0-100); five patients had no pain at all	Knee flexion: 115.9 degrees (95 degrees to 130 degrees); no patients had hyperextension	Nine patients had a normal knee mechanical alignment (± 3 degrees HKA) and two showed a discrete valgus alignment compared to the contralateral side. No signs of loosening	3 developed a hematoma, 1 DVT, 1 PJI	None
Wui et al[41], 2020	22.3 ± 13.9	FWB	KS: 97 and 88; KS Function Score: 80 and 90	One patient (0 degree to 90 degrees) the other (0 degree to 130 degrees)	NR	None	None

ROM: Range of motion; FWB: Full weight bearing; NWB: Non-weight bearing; KS: Knee Score; PPF: Periprosthetic fracture; PWB: Partial weight bearing; NR: Not reported; MUA: Manipulation under anesthesia; OKS: Oxford Knee Score; WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index; KOOS: Knee Injury and Osteoarthritis Outcome Score; VAS: Visual Analogue Scale; HSS: Hospital of special surgery; HKA: Hip to knee to ankle; PJI: Periprosthetic joint infection; DVT: Deep venous thrombosis; DAIR: Debridement, antibiotic irrigation, and implant retention; CDI: Caton-Deschamps index; BPI: Blackburn-Peel index; KSS: Knee Society Score.

Table 5 Grading of recommendations assessment, development and evaluation system of the evidence certainty level

Outcome	Number of studies	Study design	Risk of bias	Inconsistency	Indirectness	Imprecision	Certainty
Functional outcomes (KSS)	12	10 case series + 2 cohorts	Serious	Not serious	Not serious	Serious	⊕◯◯◯: Very low
Range of motion (knee flexion)	12	10 case series + 2 cohorts	Serious	Not serious	Not serious	Serious	⊕◯◯◯: Very low
Complications (overall)	14	10 case series + 2 cohorts	Serious	Serious	Not serious	Serious	⊕◯◯◯: Very low
Revision rate	14	10 case series + 2 cohorts	Serious	Not serious	Not serious	Very serious	⊕◯◯◯: Very low
Radiological alignment	5	All were case series	Serious	Serious	Not serious	Very serious	⊕◯◯◯: Very low

KSS: Knee Society Score.