Autologous versus synthetic bone grafts for the surgical management of tibial plateau fractures: a systematic review and meta-analysis of randomized controlled trials

Abstract

Aims: Our objective was to conduct a systematic review and meta-analysis, to establish whether differences arise in clinical outcomes between autologous and synthetic bone grafts in the operative management of tibial plateau fractures.

Methods: A structured search of MEDLINE, EMBASE, the online archives of Bone & Joint Publishing, and CENTRAL databases from inception until 28 July 2021 was performed. Randomized, controlled, clinical trials that compared autologous and synthetic bone grafts in tibial plateau fractures were included. Preclinical studies, clinical studies in paediatric patients, pathological fractures, fracture nonunion, or chondral defects were excluded. Outcome data were assessed using the Risk of Bias 2 (ROB2) framework and synthesized in random-effect meta-analysis. The Preferred Reported Items for Systematic Review and Meta-Analyses guidance was followed throughout.

Results: Six studies involving 353 fractures were identified from 3,078 records. Following ROB2 assessment, five studies (representing 338 fractures) were appropriate for meta-analysis. Primary outcomes showed non-significant reductions in articular depression at immediate postoperative (mean difference -0.45 mm, p = 0.25, 95%confidence interval (CI) -1.21 to 0.31, I² = 0%) and long-term (> six months, standard mean difference -0.56, p = 0.09, 95% CI -1.20 to 0.08, I² = 73%) follow-up in synthetic bone grafts. Secondary outcomes included mechanical alignment, limb functionality, and defect site pain at long-term follow-up, perioperative blood loss, duration of surgery, occurrence of surgical site infections, and secondary surgery. Mean blood loss was lower (90.08 ml, p < 0.001, 95% CI 41.49 to 138.67) and surgery was shorter (16.17 minutes, p = 0.04, 95% CI 0.39 to 31.94) in synthetic treatment groups. All other secondary measures were statistically comparable.

Conclusion: All studies reported similar methodologies and patient populations; however, imprecision may have arisen through performance variation. These findings supersede previous literature and indicate that, despite perceived biological advantages, autologous bone grafting does not demonstrate superiority to synthetic grafts. When selecting a void filler, surgeons should consider patient comorbidity, environmental and societal factors in provision, and perioperative and postoperative care provision. Cite this article: Bone Jt Open 2022;3(3):218-228.

Keywords: Autologous bone grafting; Bone grafting; Fractures of the tibial plateau; Orthopaedic surgery; Orthopaedics; Synthetic bone grafting; Tibia plateau fracture; Trauma; autologous bone grafting; blood loss; bone grafting; chondral defects; depression; perioperative blood loss; randomized controlled trials; surgical site infections; synthetic grafting.

Fig. 1

A Preferred Reported Items for Systematic Review and Meta-Analyses flow diagram summarizing the selection of studies for systematic review and meta-analysis. Five studies were suitable for meta-analysis from 3,078 identified records. *Studies could be excluded for multiple reasons. †This conference abstract was excluded due to a lack of available data after contacting the corresponding author(s).

Fig. 2

a) Forest plot of postoperative articular depression outcome data. This figure presents a forest plot of articular reduction at postoperative follow-up, using data from three studies. ^,, b) Forest plot of long-term articular depression outcome data. This figure presents a forest plot of articular reduction at long-term follow-up (≥ six months postoperatively). This panel includes data from four studies. ^,,, CI, confidence interval; IV, inverse variance; SD, standard deviation; SE, standard error.

Fig. 3

a) Sensitivity analysis of Figure 2b exploring the impact of Russell et al’s ^,,, reported effect sizes in contributing heterogeneity within the long-term articular reduction outcome. b) Sensitivity analysis of Figure 2b exploring the impact of Jónsson and Mjöberg’s ^,,, reported effect sizes in contributing heterogeneity within the long-term articular reduction outcome.CI, confidence interval; IV, inverse variance; SE, standard error.

Fig. 4

Forest plot of mechanical alignment outcome data, comparing the tibiofemoral angle of injured/uninjured lower limbs from patients in three studies. ^,, CI, confidence interval; IV, inverse variance; SE, standard error.

Fig. 5

a) Forest plot of reported duration of surgical procedures (from incision to suture time) within two studies. ^, b) Forest plot of reported perioperative blood loss (collected during surgery) from two studies. ^, CI, confidence interval; IV, inverse variance; SD, standard deviation.

Fig. 6

a) Forest plot of reported surgical site infections in four study cohorts. ^-, b) Forest plot of unanticipated secondary surgical interventions in three study cohorts. ^,, CI, confidence interval; IV, inverse variance.