Risk Factors for Surgical Site Infection following External Fixation and Osteosynthesis of Patients with Tibial Plateau Fracture

Abstract

Tibial plateau fractures account for approximately 1% of all fractures and normally occur as low- or high-energy injuries. This study aims to assess risk factors for site infection following external fixation and osteosynthesis of patients with tibial plateau fracture. A retrospective study was conducted involving the records of patients with Schatzker types I, II, III, IV, V, and VI tibial plateau fractures submitted to external fixation by the emergency ward staff, followed by internal fixation with definitive osteosynthesis after improvement of the soft tissues by the knee surgery team. The following data were collected: energy of fracture, presence/absence of exposed fracture, time between injury and emergency care, time between external fixation and definitive osteosynthesis, comorbidities, number of access routes, duration of surgery, number of participants in surgery, type of surgeon (resident or professor), distance from Schanz screws to focus of the fracture, type of fracture according to the Schatzker classification, and patient age. Among the 137 patients studied, mean age was 43.4 ± 13.8 years, 72.9% were male, 5.1% had diabetes; 43% had Schatzker VI tibial fracture; 82.4% of the fractures were caused by high-energy trauma; 90.5% had closed fractures; 100% used an external fixator prior to definitive osteosynthesis; and 49.6% had dual surgical access (medial and lateral). The prevalence of infection at the surgical site was 19.7%. In the comparison of patients with and without infection, a significant difference was found in the distance between the Schanz screws and focus of fracture (p = 0.0093), which was smaller in patients with infection at the surgical site. A longer time of external fixator use was also associated with the occurrence of infection at the surgical site (p = 0.0283). In conclusion, the positioning of Schanz screw that is an important factor for infection of surgical site, with risk of infection higher in individuals with screws closer to the focus of fracture. Duration of external fixator use may also increase risk of infection after definitive osteosynthesis.

Keywords

tibial plateau fractures - treatment - external fixation - definitive osteosynthesis - infection

Ethical Approval

This study was approved by the São José do Rio Preto Medical School Institutional Review Board (IRB ID: 40492920.4.0000.5415).

Publication History

Received: 25 June 2024

Accepted: 23 July 2025

Article published online:
14 August 2025

• References

• 1 Rudran B, Little C, Wiik A, Logishetty K. Tibial plateau fracture: anatomy, diagnosis and management. Br J Hosp Med (Lond) 2020; 81 (10) 1-9
• 2 Shao J, Chang H, Zhu Y. et al. Incidence and risk factors for surgical site infection after open reduction and internal fixation of tibial plateau fracture: a systematic review and meta-analysis. Int J Surg 2017; 41: 176-182
• 3 Marsh JL, Smith ST, Do TT. External fixation and limited internal fixation for complex fractures of the tibial plateau. J Bone Joint Surg Am 1995; 77 (05) 661-673
• 4 Li J, Zhu Y, Zhao K. et al. Incidence and risks for surgical site infection after closed tibial plateau fractures in adults treated by open reduction and internal fixation: a prospective study. J Orthop Surg Res 2020; 15 (01) 349
• 5 Momaya AM, Hlavacek J, Etier B. et al. Risk factors for infection after operative fixation of Tibial plateau fractures. Injury 2016; 47 (07) 1501-1505
• 6 Ruffolo MR, Gettys FK, Montijo HE, Seymour RB, Karunakar MA. Complications of high-energy bicondylar tibial plateau fractures treated with dual plating through 2 incisions. J Orthop Trauma 2015; 29 (02) 85-90
• 7 Morris BJ, Unger RZ, Archer KR, Mathis SL, Perdue AM, Obremskey WT. Risk factors of infection after ORIF of bicondylar tibial plateau fractures. J Orthop Trauma 2013; 27 (09) e196-e200
• 8 Coelho A, Parés-Alfonso I, Companys R. et al. Risk factors for infection of tibial plateau fractures. Rev Esp Cir Ortop Traumatol 2024; 68 (01) 44-49
• 9 Lin S, Mauffrey C, Hammerberg EM, Stahel PF, Hak DJ. Surgical site infection after open reduction and internal fixation of tibial plateau fractures. Eur J Orthop Surg Traumatol 2014; 24 (05) 797-803
• 10 Metsemakers WJ, Smeets B, Nijs S, Hoekstra H. Infection after fracture fixation of the tibia: analysis of healthcare utilization and related costs. Injury 2017; 48 (06) 1204-1210
• 11 Whitehouse JD, Friedman ND, Kirkland KB, Richardson WJ, Sexton DJ. The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost. Infect Control Hosp Epidemiol 2002; 23 (04) 183-189
• 12 Henkelmann R, Frosch KH, Glaab R. et al; Committee TRAUMA of the AGA-Society for Arthroscopy and Joint Surgery. Infection following fractures of the proximal tibia - a systematic review of incidence and outcome. BMC Musculoskelet Disord 2017; 18 (01) 481
• 13 Barei DP, Nork SE, Mills WJ, Henley MB, Benirschke SK. Complications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision technique. J Orthop Trauma 2004; 18: 649-657
• 14 Forni JEN, Aran SC, Godinho JPP, Jalikj W. Cost-effectiveness analysis of Schatzker V tibial plateau fractures treated with locking plate in a university hospital. Int J Sci 2021; 10: 12-16
• 15 Li J, Zhu Y, Liu B, Dong T, Chen W, Zhang Y. Incidence and risk factors for surgical site infection following open reduction and internal fixation of adult tibial plateau fractures. Int Orthop 2018; 42 (06) 1397-1403
• 16 Colman M, Wright A, Gruen G, Siska P, Pape HC, Tarkin I. Prolonged operative time increases infection rate in tibial plateau fractures. Injury 2013; 44 (02) 249-252
• 17 Zhu Y, Liu S, Zhang X, Chen W, Zhang Y. Incidence and risks for surgical site infection after adult tibial plateau fractures treated by ORIF: a prospective multicentre study. Int Wound J 2017; 14 (06) 982-988