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SYSTEMATIC REVIEW PROTOCOL
Rehabilitation for tibial plate
au fractures in adults: a
scoping review protocol
Tri M. Phan1 � John Arnold2 � Lucian B. Solomon1,3
1Trauma and Orthopedics Hospital, Ho Chi Minh City, Vietnam, 2School of Health Sciences and Sansom Institute for Health Research, University of
South Australia, Adelaide, Australia, and 3Discipline of Orthopaedics and Trauma, The University of Adelaide, Adelaide, Australia
Review objective: Based on the observation that rehabilitation practices for tibial plateau fractures are inconsistent
and lack uniformity in the published literature, this scoping review will seek to identify all relevant studies that have
reported on rehabilitation for tibial plateau fractures in order to comprehensively map the characteristics of the
practices. This scoping review will then be used to identify commonalities across the included studies in order to
identify potential focus questions for subsequent systematic reviews.
Keywords physical therapy; proximal tibial fractures; rehabilitation; tibial plateau fractures; weight-bearing
JBI Database System Rev Implement Rep 2017; 15(10):2437–2444.
Background
T ibial plateau fractures (TPFs) which involve the
proximal tibia in its articular and meta-epiphy-
seal segments are one of the commonest intra-artic-
ular fractures, representing approximately 1% of all
fractures in adults.1-3 These fractures are caused
mainly by axial loading with concomitant varus/
valgus or flexion/extension bending, and have vari-
ous morphology involving the lateral, medial or both
tibial condyles with many degrees of articular de-
pression widening and angulation.4-7 Tibial plateau
fractures are frequently complex intra-articular in-
juries with a variety of fracture patterns, portending
a poor prognosis due to associated complications,
i.e. compartment syndrome, cartilage destruction,
soft-tissue envelope damage, post-surgery infection,
knee instability or stiffness, and post-traumatic os-
teoarthritis.8-11 As such, they are managed mainly in
hospital settings, and they not only pose challenges
for the surgeon,12,13 but also have an enormous
impact on patients and devastating socio-economic
consequences due to the time taken off work for
the patient and impaired functional integrity of the
knee.14-17
Achieving fracture reduction and stabilization
is only the initial step; good postoperative
Correspondence: Tri M. Phan, phanminhtri.md@gmail.com
There is no conflict of interest in this project.
DOI: 10.11124/JBISRIR-2016-002949
JBI Database of Systematic Reviews and Implementation Reports
©2017 Joanna Briggs Institute. Unauthorize
rehabilitation is necessary as early mobilization
may limit complications following intra-articular
fractures, including knee joint stiffness, muscle
and bone atrophy, synovial adhesions and capsular
contractions to adversely impact on outcomes.18-22
However, there is no consensus about rehabilitation
practices as immobilization and protection from
weight bearing varies widely among orthopedic
surgeons.
There is confusion as to whether range of motion
exercises should be passive, active assisted or active
in nature.23 While some authors have recommended
passive exercises immediately postoperatively,24-26
after the second postoperative day27 or once wounds
were sealed and dry,28 others considered immediate
active motion protected in a hinged knee orthosis,29
or never employed continuous passive motion re-
gime for their patients.29 In addition, there is large
variation regarding the immobilization time, ranging
from 10 days30 to six weeks postoperatively.28,31,32
Regarding weight bearing after TPFs fixation,
there remains confusion in the rehabilitation prac-
tices with recommendations varying from no weight
bearing from four to 12 weeks,8,25,26,28,33 partial
weight bearing from six to 12 weeks,24,29,30,34,35
partial weight bearing prescribed on an individual
basis,36 full weight bearing from nine to 12 weeks
postoperatively,29,30,36 or when union observed on
plain film is significant.37-39
While commencing weight bearing too early may
increase the risk for implant failure, leading to the
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SYSTEMATIC REVIEW PROTOCOL T.M. Phan et al.
loss of fracture reduction and malunion,40 there is
a substantial difference in energy expenditure
between non and partial weight-bearing gait,
impacting on patient independence and hospital
length of stay.23
A preliminary search of the literature in
Cochrane Database of Systematic Reviews, JBI
Database of Systematic Reviews and Implementa-
tion Reports, CINAHL, PubMed, PROSPERO and
Epistemonikos identified that no systematic or
scoping review has addressed the proposed topic.
Considering the lack of current evidence, together
with characteristics of a scoping review in exam-
ining ‘‘the extent, range and nature of research
activity . . . to determine the value of undertaking
a full systematic review’’,41(p.6) we recommend
a scoping review to map the relevant literature.
This scoping review will be conducted in accor-
dance with the methodology for JBI scoping
reviews.42,43
Inclusion criteria
Types of participants
The review will consider studies that include patients
over 16 years of age undergoing rehabilitation prac-
tices for TPFs. Patients under 16 will be excluded as
many will still have open growth plates, as open
growth plates fractures differ dramatically from
fractures that occur at skeletal maturity.44 Studies
that recruited people following periprosthetic frac-
tures, pathological fractures or multiple fractures of
the same limb will be excluded. Periprosthetic and
pathological fractures will be excluded as their treat-
ment and outcomes are preponderantly related to
one of the prosthesis or neoplastic process. Cases
with multiple ipsilateral lower limb fractures will be
excluded as they affect the overall healing and reha-
bilitation of the limb.
Concepts
The review will consider all research studies that
address rehabilitation practices for TPFs in adults
including weight-bearing status, application of im-
mobilization device (brace, cast, immobilizers), post-
operative motion and exercises.
Context
The review will consider studies conducted in
hospital settings.
JBI Database of Systematic Reviews and Implementation Reports
©2017 Joanna Briggs Institute. Unauthorize
Sources
This review will consider quantitative studies that
may include, but will not be limited to, randomized,
quasi-randomized controlled trials, case-control and
case series studies.
Search strategy
The search strategy aims to find both published and
unpublished literature. A three-step search will be
utilized in each component of this review. An initial
limited search of MEDLINE and CINAHL will be
undertaken followed by an analysis of the text words
contained in the title and abstract, and of the index
terms used to describe relevant articles. A second
search using all the identified keywords and index
terms will then be undertaken across all included
databases. Third, the reference list of all included
studies will be searched for additional studies. Stud-
ies published in English will be considered for inclu-
sion in this review. No time limit will be imposed on
studies for inclusion in this review.
The databases to be searched will include:
�
d r
MEDLINE
�
 CINAHL
�
 Embase
�
 Cochrane Database of Systematic Reviews,
Cochrane Central Register of Controlled Trials
(CENTRAL)
�
 JBI Database of Systematic Reviews and
Implementation Reports
�
 Scopus
�
 PEDRO.
The search for unpublished studies will include:
�
 ClinicalTrials.gov
�
 International Clinical Trials Registry Platform
�
 UK Clinical Trials Gateway
�
 ProQuest Dissertations and Theses
�
 Grey Literature (The New York Academy of
Medicine)
�
 Open Grey (System for Information on Grey
Literature in Europe)
�
 MedNar
�
 Trove (theses).
Initial keywords to be used will be, but will not belimited to: ‘‘tibial plateau’’ OR ‘‘proximal tibial’’
OR ‘‘knee fractures’’ AND ‘‘rehabilitation’’ OR
‘‘exercise’’ OR ‘‘joint loading’’ OR ‘‘weight
bearing’’ OR ‘‘physical therapy’’ OR ‘‘knee
function’’ OR ‘‘scoping review’’.
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SYSTEMATIC REVIEW PROTOCOL T.M. Phan et al.
Data extraction
A data extraction form for this scoping review will
be developed, based on those from JBI SUMARI (a
draft of the adapted form is shown in Appendix I) as
well as discussion among all reviewers. The reported
variables will include specific details about authors,
populations, study method, type of tibial plateau
fractures, types of treatments, type of rehabilitation
practices and duration, outcome of significance and
key findings relating to the scoping review objective.
This may be further refined at the review stage.
Two reviewers will extract data independently.
Any disagreement will be resolved by discussion with
a third reviewer. The author of the primary study
will be contacted if further clarification of the data is
required.
Data mapping
After the data have been extracted, we will: i) map
the key concepts and available evidence, ii) summa-
rize the existing research findings, and iii) identify
research gaps in the existing literature. The key
findings will be mapped and presented in formats
reflecting the objectives of this scoping review as
appropriate (diagrammatic, tabular summary or de-
scriptive format). The process will be further refined
toward the end of the review when reviewers have
the greatest awareness of the contents of the included
studies.42
Acknowledgements
Tri M. Phan is supported by an Endeavour Executive
Fellowship from the Australian Government.
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SYSTEMATIC REVIEW PROTOCOL T.M. Phan et al.
Appendix I: Data extraction instrument
Data extraction form (tick where applicable)
Reviewer: .................................................................................... Date .........................................
Author ......................................................................................... Year .........................................
Title ............................................................................................. .................................................
Journal......................................................................................... Vol & Iss ................................
Study method 
RCT � Quasi RCT � Retrospective cohort �
Prospective cohort � Case control � Case studies �
Other:...................................................................................
Participants
Country ........................................................ .................................................
Sample size: ................................................. Age (mean (min, max))...........
Gender: Male ............................................... Female.....................................
Type of fractures and number
Open � No....................... Close � No..........................
Classification ( AO, Schatzker, Hohl and Moore, etc) and numbers
............................................................ ................................................. ..............................
............................................................ ................................................. ..............................
............................................................ ................................................. ..............................
............................................................ ................................................. ..............................
Fracture treatment: 
Nonoperative � No...................
Surgical � No ..................
Unicondylar fractures
Standard open reduction internal fixation (ORIF) No...................
Circular external fixation with limited internal fixation (hybrid fixation) No...................
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SYSTEMATIC REVIEW PROTOCOL T.M. Phan et al.
Less invasive stabilisation system (LISS) No...................
Arthroscopically assisted percutaneous reduction and internal fixation No...................
Other ............................................................................................................ No...................
Bicondylar fractures
Standard unilateral open reduction internal fixation (ORIF) No...................
Circular external fixation with limited internal fixation (hybrid fixation) No...................
Less invasive stabilisation system (LISS) No...................
Double plating open reduction internal fixation No...................
Arthroscopically assisted percutaneous reduction and internal fixation No...................
Other ............................................................................................................ No...................
Bone graft (autologous) No...................
Bone fillers (specify type) ........................................................................... No...................
Intervention: rehabilitation practices
..................................................................................................... .......................................
..................................................................................................... .......................................
..................................................................................................... .......................................
..................................................................................................... .......................................
..................................................................................................... .......................................
Intervention: device use (brace, walking aids)
..................................................................................................... ......................................
..................................................................................................... .......................................
Outcomes
Follow period (months & number of time-points)................................
Lost to follow up...................................................................................
Range of motion (ROM): 
Extension (mean (min, max)) .................................................
Flexion (mean (min, max)) .....................................................
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SYSTEMATIC REVIEW PROTOCOL T.M. Phan et al.
Radiology
Fracture reduction X-ray � CT �
Lateral plateau step (mm)............................................................ .......................................
Medial plateau step (mm) ........................................................... .......................................
Medial plateau depression (mm) ................................................. .......................................
Lateral plateau depression (mm) ................................................. .......................................
Fracture gap deformity (mm) ...................................................... .......................................
Metaphyseal-diaphyseal angulation (degree) ..............................
Healed fracture X-ray � CT � RSA �
Lateral plateau step (mm)
Medial plateau step (mm) ..................................................................................................
Medial plateau depression (mm) ................................................. .......................................
Lateral plateau depression (mm) ................................................. .......................................
Fracture gap deformity (mm) ...................................................... .......................................
Metaphyseal-diaphyseal angulation (degree) ..............................
Radiological evidence of tibiofemoral joint osteoarthritis ..........No
Time to observable callus formation (weeks) .............................
Time to radiological union (weeks).............................................
Functional outcome measures
Time to full weight bearing (weeks) ...........................................
Applied score (HSS, SF-36, WOMAC, etc.) .............................. .......................................
Mean (min, max & time-point)............................................... .......................................
................................................................................................ .......................................
................................................................................................ .......................................
................................................................................................ .......................................
Complications No � Yes �
Nonunion .....................................................................................No ...................................
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SYSTEMATIC REVIEW PROTOCOL T.M. Phan et al.
Delay union .................................................................................No ...................................
Implant failure ............................................................................No ...................................
Abnormal Valgus/varus deformity ..............................................No ...................................
Flexion/extension deformity........................................................No ...................................
Others ..........................................................................................No ...................................
Author conclusions
................................................................................................ .......................................
................................................................................................ .......................................
................................................................................................ .......................................
Reviewer conclusions
................................................................................................ .......................................
................................................................................................ .......................................
................................................................................................ .......................................
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