Surgical approaches, choice and positioning of implants in the surgical treatment of proximal tibia fractures in adults: a scoping review protocol

Abstract

Introduction

Tibial plateau fractures present a complex orthopaedic challenge and usually require surgical intervention to restore joint alignment and stability as well as to prevent complications. In practice, determining the most appropriate surgical approach, implant selection and positioning remains a challenge and depends on the surgeon’s experience and patient-specific factors. Therefore, this scoping review aims to map the current evidence on surgical fixation methods for proximal tibia fractures in adults. In particular, we seek to first assess study types and their distribution across levels of evidence and second to identify knowledge gaps to support evidence-based surgical planning.

Methods and analysis

The proposed scoping review will be conducted in accordance with the JBI methodology for scoping reviews and will be reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. Information for this study will be gathered from Medline, Cochrane and Embase. Data analysis will involve categorising the studies by their level of evidence and extracting predefined parameters, including fracture characteristics, surgical approach, implant type and key findings relevant to the review question. The study focuses on surgically stabilised intra-articular proximal tibia fractures in adults. Only English- and German-language studies that are available in full text and published after 1995 will be included.

Ethics and dissemination

No ethical approval is required. The findings of the proposed review will be disseminated through publications in peer-reviewed journals.

Review registration

Open Science Framework, osf.io/g9zfu.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This study protocol is in accordance with the JBI methodology for scoping reviews.

• The planned scoping review will provide an overview of the evidence on surgical approaches, choice and positioning of implants in the surgical treatment of proximal tibia fractures in adults.

• The screening and review process will be conducted independently by two reviewers.

• The search is limited to English- and German-language studies published after 1995.

• Databases to be searched are MEDLINE, the Cochrane Database of Systematic Reviews and Embase, excluding grey literature.

Introduction

Musculoskeletal trauma is not only of great individual and medical relevance but also represents an economic burden worldwide.^{1 2} Among these injuries, tibial plateau fractures were reported with incidences ranging from 10.3 to 32 per 100 000 per year.³,⁶ These fractures are frequently caused by high-energy events, such as falls from height or road traffic accidents.⁶,⁸ The different types of proximal tibia fractures can vary widely in severity and complexity.⁸,¹⁰ Therapy ranges from conservative treatment to surgical reduction and fixation.^{11 12} Surgical treatment presents surgeons with the challenge of meticulously reconstructing the articular surfaces and joint alignment, allowing for early mobilisation and optimising long-term outcomes.¹¹ Further difficulties exist regarding postsurgical complications like post-traumatic osteoarthritis,^{1 2} knee stiffness, infection, malunion or non-union.¹³ Moreover, evidence indicates that surgical success is closely linked to the surgeon’s experience^{14 15} and early consideration of the surgical approach and implant selection and positioning is crucial.¹⁶ Despite the clinical importance of these decisions, current treatment recommendations often rely heavily on expert opinion and are not consistently supported by high-quality evidence. Existing treatment recommendations and guidelines appear to be strongly eminence based, empirical and in lack of randomised controlled trials (RCTs). As an example, the German S2k Guidelines for Tibial Plateau Fractures¹⁷ do not contain a schematic indication of evidence and recommendation grades, as the evidence is not systematically processed. The recommendations are based on expert consensus from representatives of specialist societies, developed using the Appraisal of Guidelines for Research and Evaluation framework. The main reason for this approach to creating guidelines seems to be the lack of high-quality evidence. Considering this, a clearer understanding of the existing literature is needed. Our preliminary search of MEDLINE, the Cochrane Database of Systematic Reviews, JBI Evidence Synthesis and Embase revealed no recent or ongoing scoping or systematic reviews directly addressing our research interest. A systematic review published in 2022¹⁸ offered a general overview of surgical approaches for tibial plateau fractures considering fracture classifications. However, it did not provide detailed information on the level of evidence, implant choices/options or the specific criteria for surgical decision-making.

Review objectives

To address the aforementioned gap in the literature, we aim to conduct a scoping review on the surgical fixation of proximal tibial fractures in adults. Considering the broad scope of the research question and the expected heterogeneity in the study designs and outcomes, a scoping review represents the most appropriate methodological approach. The objective is to map the current evidence on surgical approaches, implant types and their positioning in the treatment of proximal tibia fractures in adults. Furthermore, we seek to identify which study types have been published and how they are distributed across different levels of evidence, and to provide an overview of the key findings reported in the literature. This evidence mapping will help establish a basis for evidence-based decision-making in surgical planning of proximal tibia fractures, identify knowledge gaps and guide the direction of future research.

Methods

The proposed scoping review will be conducted in accordance with the JBI methodology for scoping reviews¹⁹ and will be reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR).²⁰ This project has been registered on Open Science Framework, osf.io/g9zfu. The scoping review is planned to be conducted between January 2025 and June 2027. An initial database search was conducted in January 2025, and the searches are planned to be updated in February 2026 prior to final study selection.

Review question

What is the current state of evidence regarding surgical procedures in terms of surgical approaches, choice and positioning of implants for the treatment of proximal tibial fractures in adults?

Inclusion criteria

We will include English- and German-language studies that examined the operative treatment of tibial plateau fractures in a native joint regarding clinical and radiological outcomes as well as biomechanical stability, as these are the working languages of the research team. We will only include studies published after 1995, as the surgical management of proximal tibial fractures has substantially evolved since the mid-1990s, including advances in cross-sectional imaging, the establishment of standardised classification systems, the development of fracture-specific surgical approaches and the introduction of modern implant technologies (eg, locking implants), which limits the comparability of earlier studies with current clinical practice.¹¹ The included studies must be available in the full-text version. In case the full-text version is not available through institutional access, we will attempt to obtain it by contacting the corresponding authors via email.

Participants

We will analyse studies reporting on adult patients aged 18 years or older that had a primary proximal tibial fracture treated with surgical fixation. We will not include studies that primarily examined paediatric or adolescent tibial plateau fractures as these tend to be treated differently than fractures of the mature skeleton.

Concept

This scoping review aims to map the current evidence on the surgical fixation of proximal tibia fractures in adults, focusing on surgical approaches, implant selection and implant positioning.

Context

We will focus on studies from all healthcare systems and countries, in hospital and clinical settings, without restriction on region or patient sex, but limited to literature published in English and German.

Exclusion criteria

The following studies will be excluded if they:

• use arthroscopic-assisted reduction and internal fixation;

• examine extra-articular proximal tibial fractures;

• report on mixed fracture populations without separate data for tibial plateau fractures;

• include children or adolescents;

• focus primarily on bone grafts;

• use biomechanical or synthetic models (eg, finite-element analysis);

• examine external fixators as definitive treatment;

• focus exclusively on pre- and postoperative management without involving the actual therapeutic intervention;

• are narrative reviews.

Types of sources

Given the broad scope of the review question, this scoping review will include a wide range of study designs to provide a comprehensive overview of the existing evidence. Eligible study designs will encompass both experimental and quasi-experimental methods, including RCTs, non-RCTs, pre–post (before-and-after) studies and interrupted time-series analyses.

Analytical observational study designs, such as prospective cohort studies, retrospective cohort studies, case–control studies and analytical cross-sectional studies, will also be included. Descriptive observational studies, including case series, individual case reports and descriptive cross-sectional studies, will be considered. However, given the large number of case reports identified during the preliminary search and their limited methodological rigour, case reports will be included for evidence mapping purposes only; no predefined parameters will be extracted from them.

Systematic reviews and other forms of evidence synthesis will be included if they meet the eligibility criteria to provide an overview of the breadth and depth of existing evidence. To avoid double counting of primary data, no patient-level data will be extracted from systematic reviews. However, systematic reviews will be included for the extraction of relevant conceptual and methodological information aligned with the objectives of this scoping review, such as the reported surgical approaches, implant strategies and main research questions. Commentaries, opinion papers and narrative reviews will be excluded.

Search strategy

An initial limited search of MEDLINE, the Cochrane Database of Systematic Reviews and Embase was conducted to identify relevant publications on the topic. In a second step, text words in the titles and abstracts of the identified publications were used to generate a search strategy (see table 1), which will then be applied to the aforementioned databases, with modifications for the selected databases being made using Boolean operators.

Table 1. Search strategy organised by population, concept and context.

PCC element	Search keywords
Population	proximal tibia fracture, tibia plateau fracture, tibial plateau fractures
Concept	approach, ORIF, procedure, heal, fracture gap size, partial weight bear, stability, internal fixation, fracture fixation, fixation, repair, treatment, osteosynthesis, hardware, implant choice, implant positioning, exposure, outcome, reduction, screw, plate, orthopaedic procedures, fracture healing, mechanics, internal fixators, fracture fixation
Context	Context was defined for inclusion criteria but not incorporated into the search terms.

ORIF, Open Reduction and Internal Fixation.

Depending on the database, the terms will be searched in titles and abstracts, and MeSH terms or Emtree terms will be used where appropriate. The final, database-specific search strings will be adapted accordingly (see online supplemental material). Filters for language (English and German) and publication date (after 1995) will be applied according to our eligibility criteria.

The generated search strategy was tested to ensure a reasonable number of results. Grey literature will not be included due to feasibility constraints and the extensive number of studies retrieved from the previously described search strategy.

In addition to the database search, a targeted form of backward citation chasing will be conducted to identify potentially relevant studies. This will be performed on a purposive sample of approximately 50 recently published studies included after full-text screening to ensure feasibility.

Study/Source of evidence selection

Once the search has been completed, all identified citations will be collected and uploaded into Zotero 6.0.36 (Corporation for Digital Scholarship, USA). Duplicates will then be removed. Subsequently, the titles and abstracts will be screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant sources will then be retrieved in full. The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. The reasons for the exclusion of sources of evidence at the full-text stage that do not meet the inclusion criteria will be recorded and reported in the scoping review. Any disagreements that arise between the reviewers at each stage of the selection process will be resolved through discussion. In case no agreement is reached, a third reviewer will be consulted to mediate and provide the final decision. Any additional records identified through citation chasing will be screened using the same title/abstract and full-text screening procedures and eligibility criteria as those applied to records identified through the database searches. The results of the search and the study inclusion process will be fully reported in the final scoping review, presented in a PRISMA-ScR flow diagram.²⁰ A schematic representation of the workflow is given in figure 1.

Figure 1. Schematic representation of the workflow of the scoping review literature search and data extraction.

Data extraction

Data extraction will be carried out by one of the reviewers using a data extraction table, which has been pilot tested in advance to ensure that all relevant data items can be captured consistently. The data extracted will include specific details about the bibliometric description, participants, concept, context, study methods and reported clinical parameters (see table 2) and key findings relevant to the review question. If these data are not provided, they will be marked as ‘n/a’ (not available).

Table 2. Data to be extracted in terms of bibliometric parameters, study methods and clinical parameters.

Category	Data items
Bibliometric	title, DOI, authors, publication year, region
Study methods	study design, level of evidence, sample size
Patient	age, sex, clinical outcome assessments (used/not used and complications)
Fracture characteristics	fracture type, classification used (AO, Schatzker and others), open/closed fracture
Surgery	approach type (anterolateral, posteromedial, posterolateral, medial, anteromedial, posterocentral, combined (two or more approaches used) and extended approach), number of surgical approaches
Implants	implant type, implant category (conventional (eg, non-locking), locking plates (eg, LCPs and VA-LCP) and others), number of implants, positioning, material
Main focus	main focus of the study (surgical approach related, implant related, or other)

AO, Arbeitsgemeinschaft für Osteosynthesefragen; DOI, digital object identifier; LCPs, locking compression plates; VA-LCP, variable-angle locking compression plate.

Data analysis and presentation

As described in the data extraction section, relevant information will be collected using a structured table. Due to the large number of included studies expected, this table will not be used to present the results in the final review. Therefore, the findings will be summarised and presented using diagrams and figures that are described narratively. Furthermore, the studies will be grouped according to their level of evidence (certainty assessment) according to the Oxford Centre for Evidence-Based Medicine.²¹ This categorisation is intended solely to support the mapping of the evidence landscape and to address the scoping review question. It will not be used for critical appraisal or quality/bias assessment. This ranking does not consider computer simulations. They are a different type of evidence than that obtained from observations and experiments²² and can be very heterogeneous in design due to the choice of assumptions regarding input parameters, boundary conditions and validation process, and therefore, their level of evidence is difficult to assess. For this reason, we will not rank computational studies. Missing data will be reported as n/a too. In vitro/cadaver studies will be grouped with the lowest evidence level. Effect measures will not be calculated, and minimal clinical importance will not be addressed. Data synthesis will be purely descriptive. Interactions of parameters will not be considered at this stage.

Ethics and dissemination

This study will not involve the recruitment of human participants or the collection of new data. Instead, it will rely solely on publicly available, previously published sources. As a result, ethical approval is not necessary. The outcomes of this research will be shared through publication in peer-reviewed journals.