From the Guidelines
For an elderly patient with a tibial plateau depression of 18 mm, total knee replacement (TKR) is the most appropriate treatment option when there is significant associated osteoarthritis, as it provides the best outcome in terms of morbidity, mortality, and quality of life. According to the American Academy of Orthopaedic Surgeons (AAOS) clinical practice guideline summary: management of osteoarthritis of the knee (nonarthroplasty), third edition 1, the goal of treatment is to provide pain relief and improve the patient's functioning.
Key considerations in the treatment plan include:
- Pain management with acetaminophen 1000 mg three times daily or NSAIDs like celecoxib 200 mg daily if not contraindicated
- Protected weight-bearing using crutches or a walker
- Surgical options like open reduction internal fixation (ORIF) with bone grafting for isolated fractures without significant arthritis
- Total knee replacement (TKR) for patients with pre-existing symptomatic knee arthritis, highly comminuted fractures, or those with limited functional demands
The 18 mm depression indicates a severe fracture that would likely cause joint incongruity and accelerate arthritis if not properly addressed 1. The decision between ORIF and TKR should be made after thorough clinical evaluation, radiographic assessment including CT scans, and consideration of the patient's overall health status, bone quality, and functional goals.
In elderly patients, TKR is often preferred due to its ability to provide significant pain relief and improve functional outcomes, especially in those with significant osteoarthritis 1. The AAOS guideline highlights the importance of individualized treatment decisions, taking into account the patient's unique characteristics, such as age, sex, and comorbidities.
Overall, the treatment plan should prioritize the patient's quality of life, functional goals, and overall health status, with TKR being a viable option for elderly patients with significant tibial plateau depression and associated osteoarthritis.
From the Research
Treatment Plan for Elderly Tibial Plateau Depression
- The treatment plan for an elderly patient with a tibial plateau depression of 18 mm depends on various factors, including the patient's overall health, activity level, and the presence of any underlying conditions such as osteoarthritis 2.
- According to a study published in 2023, primary total knee arthroplasty (TKA) may be a suitable option for elderly patients with tibial plateau fractures and pre-existing osteoarthritis, as it allows for immediate weightbearing and a faster recovery 2.
- However, another study published in 2001 found that surgical treatment of tibial plateau fractures in elderly patients using open reduction and internal fixation with AO/ASIF buttress plates can also produce good results, with no accelerated degenerative change in the operated knee joint resulting in total knee arthroplasty 3.
- A study published in 1999 found that non-operative management, open reduction and internal fixation, and external fixation can all be effective treatment options for tibial plateau fractures in older patients, with functional outcome more closely related to initial fracture pattern than treatment method 4.
- In terms of joint depression, a study published in 2023 found that treatment using periarticular rafting constructs without bone graft may be a valid option for achieving good final results without the morbidity associated with the use of bone graft/substitutes 5.
Knee Replacement Appropriateness
- Knee replacement may be appropriate for elderly patients with tibial plateau fractures and pre-existing osteoarthritis, particularly if the fracture is severe and the patient has poor bone quality 2.
- However, a study published in 1999 found that only 2 out of 151 patients with tibial plateau fractures went on to have a knee replacement, suggesting that knee replacement is not always necessary for these patients 4.
- The decision to proceed with knee replacement should be made on a case-by-case basis, taking into account the patient's individual circumstances and the severity of the fracture 6, 2.