Tibial Plateau Fractures in Low- and Middle-Income Countries: A Systematic Review of Treatment Modalities, Functional Outcomes, and Complications

Abstract

Background

Tibial plateau fractures (TPFs) are complex intra-articular injuries associated with long-term disability if not optimally treated. In low- and middle-income countries (LMICs), where high-energy trauma is prevalent and health system resources are constrained, management strategies, and outcomes differ substantially from those reported in high-income countries. This systematic review synthesizes evidence from LMICs on treatment approaches, functional outcomes, and complications following TPFs.

Materials and Methods

We systematically searched PubMed, EMBASE, Scopus, and regional databases for studies conducted in LMICs, published up to May 2025. Eligible studies included adult patients with TPFs managed surgically, reporting functional or radiological outcomes. Data were extracted on demographics, fracture type, surgical technique, and outcomes. Risk of bias was assessed using the Newcastle–Ottawa Scale and Cochrane ROB-2 tools.

Results

Fifteen studies comprising 1,213 patients from South Asia, and Africa were included. Patients were predominantly male (65–75%) with mean ages between 35 and 45 years; road traffic accidents were the leading cause. Dual plating yielded superior alignment and higher Knee Society Scores (75–85) but carried increased infection rates (10–18%). Ilizarov and hybrid fixators achieved high union rates (>90%) with acceptable function, although pin-tract infections (15–20%) and malalignment (10–12%) were common. Arthroscopic-assisted fixation improved articular reduction but was limited to tertiary centres. A randomized trial demonstrated that immediate weight-bearing enhanced gait recovery without increased implant failure. Across studies, complication rates exceeded those reported in high-income countries, reflecting systemic barriers such as limited rehabilitation access, implant scarcity, and inadequate soft tissue care.

Conclusion

In LMICs, satisfactory union and functional recovery can be achieved following TPF surgery, but complication rates remain high. Dual plating offers superior stability, while Ilizarov fixation provides a resource-appropriate alternative. System-level improvements in rehabilitation, infection prevention, and trauma infrastructure are critical to narrowing outcome disparities with high-income countries.

Keywords

tibial plateau fracture - LMIC - external fixation - dual plating - Ilizarov - functional outcome

Tibial plateau fractures (TPFs) are among the most complex periarticular fractures encountered in orthopaedic trauma practice. They typically result from high-energy mechanisms such as road traffic accidents (RTAs) in younger patients or from low-energy falls in elderly individuals with osteoporotic bone. These fractures are clinically significant due to their impact on knee joint stability, alignment, and long-term function. Even when managed appropriately, they are associated with prolonged rehabilitation and an increased risk of posttraumatic osteoarthritis, stiffness, and chronic disability.[1]

In high-income countries (HICs), management strategies for TPFs have been standardized through the widespread use of advanced imaging, specialized implants, and multidisciplinary rehabilitation. Dual plating techniques using anterolateral and posteromedial approaches are frequently employed for bicondylar fractures, and minimally invasive techniques, including arthroscopic-assisted fixation, have become increasingly common. However, this level of standardization and resource availability is not universal. In low- and middle-income countries (LMICs), where the majority of global trauma burden resides, there remain significant variations in practice due to limited surgical expertise, cost constraints, and inconsistent access to implants.[2]

The public health significance of these injuries in LMICs is underscored by the high prevalence of RTAs, which disproportionately affect younger populations who are economically active. A prospective cohort study from Ethiopia involving 191 patients demonstrated that TPFs accounted for a notable proportion of periarticular injuries, with RTAs being the leading cause in over 40% of cases.[3] Similarly, Mfaume et al. reported from Uganda that bicondylar and high-energy fractures were common among young males involved in motorcycle accidents, reflecting regional road safety and trauma system challenges.[4] These findings highlight the socioeconomic implications of TPFs, where prolonged recovery or disability translates into lost productivity and increased health care costs for families and health systems already under strain.

A key area of debate in the management of TPFs in LMICs is the choice between open reduction and internal fixation (ORIF) and external fixation. Dual plating with ORIF is often considered the gold standard for bicondylar fractures, offering anatomical restoration and superior mechanical stability.[1] [5] Neogi DS et al. compared single lateral locked plating with dual plating and found that while dual plating achieved better reduction and stability, it was associated with higher rates of soft tissue complications.[1] Raj et al. in a more recent comparative analysis, reinforced these findings, noting that while dual plating ensured better alignment, wound-related complications remained a concern, particularly in high-energy injuries with compromised soft tissue envelopes.[5]

External fixation, on the other hand, has been widely employed in LMICs due to its relative affordability, shorter surgical times, and reduced demands on perioperative infrastructure. The Ilizarov method and hybrid external fixators have been reported extensively in Egyptian and South Asian contexts. El-Gafary et al. reported excellent union rates with Ilizarov external fixation for high-energy TPFs, whereas Subramanyam et al. from India demonstrated that adjunctive minimal internal fixation combined with Ilizarov provided superior stability and allowed early mobilization.[2] [6] In Pakistan, Anis et al. showed that hybrid fixators were effective in achieving union in combined column fractures, although complications such as pin-tract infections remained common.[7]

Importantly, functional outcomes and quality-of-life measures are increasingly being reported in LMIC studies, reflecting a global shift toward patient-centered orthopaedic care. In Nepal, Thapa et al. assessed the functional outcomes and quality of life of patients undergoing surgical fixation of TPFs and found significant improvements in both physical function and health-related quality of life at 2 years.[8] Similarly, Ahmad et al. in Pakistan highlighted that patient comorbidities such as diabetes, obesity, and smoking significantly influenced recovery trajectories, underscoring the importance of contextualizing surgical outcomes within broader patient health profiles.[9]

Innovations in LMICs are also reshaping treatment paradigms. Arthroscopic-assisted fixation, although resource-intensive, has been trialed in Egypt with promising results. Zawam and Gad demonstrated that arthroscopic assistance improved articular reduction and visualization, whereas Toreih and Rakha showed that combining arthroscopy with circular fixation enhanced outcomes in intra-articular fractures.[10] [11] Furthermore, Ibrahim et al. conducted a randomized clinical trial in Egypt examining the impact of immediate weight-bearing on recovery following fixation of TPFs.[12] Their findings suggested that early mobilization enhanced gait parameters and reduced fall risk, challenging the conventional delayed-loading approach that dominates LMIC practice.

Despite these advances, challenges remain pervasive. Complications such as infection, stiffness, and malunion are reported across LMIC studies, with infection rates ranging between 7 and 20% depending on fixation modality.[5] [6] [7] Pin-tract infections are particularly problematic in external fixation, while wound breakdown and hardware failure are more common in plating. Moreover, systemic challenges—including limited access to computed tomography (CT) imaging, shortages of implants, and insufficient postoperative physiotherapy services—contribute to variability in outcomes.[3]

Given these complexities, a comprehensive synthesis of LMIC evidence is urgently required to guide both surgical practice and health system planning. This review, therefore, consolidates current literature on TPF management in LMICs, focusing on treatment modalities, complications, functional outcomes, and broader health system implications. In doing so, it highlights not only the surgical strategies but also the contextual challenges unique to resource-constrained environments.

Materials and Methods

This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines.

Eligibility Criteria

We included original clinical studies that met the following criteria:

1. Population: Adult patients (≥18 years) with TPFs.

2. Setting: Studies conducted in LMICs, defined using the 2025 World Bank classification.[13]

3. Intervention: Any form of operative or non-operative treatment, including plating (single or dual), Ilizarov or hybrid external fixation, arthroscopic-assisted fixation, and early mobilization strategies.

4. Outcomes: At least one of the following outcomes reported: union rates, complications, functional outcome measures (e.g., Knee Society Score [KSS], Rasmussen score, SF-36, EQ-5D), quality of life or gait analysis.

5. Study design: Prospective or retrospective cohorts, randomized controlled trials (RCTs), or case series with ≥20 patients.

Exclusion criteria were case reports, cadaveric/biomechanical studies, review articles, and studies from HICs unless they included LMIC-specific subcohorts.

Search Strategy

We systematically searched PubMed, Embase, Scopus, and African Journals Online from January 2000 to May 2025. Gray literature was explored via Google Scholar and ResearchGate to identify unpublished or nonindexed LMIC data. The following MeSH terms and Boolean combinations were used:

(“tibial plateau fracture” OR “proximal tibia fracture”) AND (“treatment” OR “outcome” OR “fixation” OR “Ilizarov” OR “plating” OR “arthroscopy”) AND (“low-income country” OR “middle-income country” OR “LMIC” OR specific country names).

Reference lists of included articles were hand-searched for additional studies.

Study Selection

Two reviewers independently screened titles and abstracts for eligibility. Full texts of potentially relevant articles were reviewed in duplicate. Discrepancies were resolved by consensus or arbitration by a senior author.

Data Extraction

Data were extracted using a standardized form. Extracted variables included:

• Study characteristics: year, country, design, sample size.

• Patient demographics: age, sex, mechanism of injury.

• Fracture characteristics: Schatzker classification, high versus low energy.

• Intervention details: plating (single/dual), external fixation type, arthroscopic-assisted fixation, early weight-bearing protocols.

• Outcomes: union rates, time to union, complications (infection, stiffness, malunion, hardware failure), functional outcomes (Rasmussen, Lysholm, SF-36, EQ-5D), and quality of life.

When studies reported heterogeneous outcome measures, results were standardized into functional recovery, radiological union, and complication domains.

Quality Assessment

Study quality was assessed using the Newcastle–Ottawa Scale for cohort and case–control studies, which evaluates selection, comparability, and outcome domains. RCTs were appraised using the Cochrane Risk of Bias 2.0 tool. Each study was graded as low, moderate, or high risk of bias.

Data Synthesis

Due to heterogeneity in outcome measures, meta-analysis was not feasible. Instead, a narrative synthesis was conducted, structured by treatment modality (plating, external fixation, hybrid/Ilizarov, arthroscopic-assisted fixation, mobilization strategies). Comparative results between single versus dual plating,[1] [5] Ilizarov versus hybrid fixators,[2] [6] [7] [14] and external versus ORIF[3] [15] were highlighted. Functional and quality-of-life outcomes were analyzed separately for South Asian and African cohorts to reflect contextual differences in health care delivery.

Results

Study Selection

Our database search yielded 1,245 records, of which 195 duplicates were removed. After screening titles and abstracts, 1,050 articles were reviewed, and 55 full texts were assessed for eligibility. Following exclusion of 40 studies (due to small sample size, HIC setting, pediatric populations, or insufficient data), 15 studies comprising 1,213 patients were included in this review. [Fig. 1] (PRISMA diagram) outlines the selection process.

Fig. 1 The PRISMA flowchart illustrating the study selection process. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Study Characteristics

The included studies spanned 15 LMICs, with the majority conducted in Africa (Egypt, Ethiopia, Uganda; n = 8), followed by Asia (India, Pakistan, Nepal; n = 7). Designs included prospective cohorts (n = 8), retrospective studies (n = 4), and randomized clinical trials (n = 1).

A summary of study characteristics, interventions, and outcomes is provided in [Table 1].

Table 1 Basic characteristics of included studies

First author, year	Country (region)	Study design	Sample size (n)	Mean age (y)	Male (%)	Mechanism of injury	Fracture types (Schatzker)	Intervention	Key outcomes reported	Citation
Neogi DS, 2015[1]	India (Asia)	Prospective cohort	61	42	49	RTAs, falls	V–VI (bicondylar)	Single vs. dual plating	Union, malalignment, infection	[1]
El-Gafary, 2014[2]	Egypt (Africa)	Prospective cohort	30	36	71	RTAs, falls	V–VI	Ilizarov external fixation	Union, function, pin infection	[2]
Subramanyam, 2019[6]	India (Asia)	Retrospective cohort	30	43	74	RTAs	V–VI	Ilizarov ± minimal internal fixation	Union, malalignment, pin infection	[6]
Anis, 2024[7]	Pakistan (Asia)	Prospective cohort	113	36	80	RTAs	Combined column	Hybrid external fixation	Union, function, pin infection	[7]
JPOA, 2017[15]	Pakistan (Asia)	Retrospective cohort	42	37	78	RTAs	VI	Dual plating	Union, pin infection, function	[15]
Thapa, 2022[8]	Nepal (Asia)	Cross-sectional	121	38	70	RTAs, falls	I–VI	ORIF (CS/plating)	SF-36, EQ-5D, function	[8]
Ahmad, 2024[9]	Pakistan (Asia)	Retrospective cohort	51	40	66	RTAs	II–VI	Mixed (ORIF/ex-fix)	Risk factors, Male better recovery	[9]
Raj, 2023[5]	India (Asia)	Retrospective cohort	56	37	72	RTAs	V–VI	Single vs. dual plating	Union, better outcome in dual plating	[5]
Mfaume, 2023[4]	Uganda (Africa)	Cross-sectional	283	37	92	RTAs	II–VI	Mixed (plating, ex-fix)	Prevalence, epidemiology	[4]
Toreih, 2023[10]	Egypt (Africa)	Prospective cohort	45	39	71	RTAs	II–VI	Arthroscopic-assisted fixation + Ilizarov	Reduction quality, delayed union, pin infection	[10]
Zawam, 2019[11]	Egypt (Africa)	Prospective cohort	25	39	65	RTAs	I–III	Arthroscopic-assisted ORIF	Reduction quality, functional outcomes	[11]
El-Barbary, 2005[14]	Egypt (Africa)	Prospective cohort	29	41	72	RTAs	VI	Ilizarov ± minimal fixation	Union, pin infection, functional outcomes	[14]
El-Harmel, 2024[16]	Egypt (Africa)	Prospective cohort	30	40	70	RTAs	II–V	ORIF with rafting plate	Delayed Union, alignment, complications	[16]
Ibrahim, 2025[12]	Egypt (Africa)	RCT	106	38	71	RTAs	I– IV	ORIF + immediate vs. delayed weight-bearing	Immediate weight bearing, falls, union	[12]
Worku, 2025[3]	Ethiopia (Africa)	Prospective cohort	191	45	74	RTAs, falls	I–VI	Mixed (ORIF, ex-fix)	Union, complications, function	[3]

Abbreviations: ORIF, open reduction and internal fixation; RCT, randomized controlled trial; RTA, road traffic accident.

Patient Demographics

Across all studies, the mean patient age was 35 to 45 years, with a consistent male predominance (65–75%). The majority of injuries resulted from high-energy mechanisms, particularly RTAs, which accounted for 55 to 80% of cases in African and South Asian series.[3] [4] [8] Low-energy falls, more common in elderly patients, were underrepresented in LMIC data compared with HIC literature.

Fracture classification: Most cohorts reported a predominance of bicondylar fractures (Schatzker V–VI), accounting for 40 to 50% of cases. This reflects the high-energy trauma burden in LMICs. For instance, Mfaume et al.[4] in Uganda noted that over 60% of fractures were bicondylar, whereas Thapa et al.[8] in Nepal reported that Schatzker VI accounted for nearly half of cases.

Treatment Modalities

Plating Techniques

• Dual plating was evaluated in four studies.[1] [5] [8] [15] These demonstrated high union rates (>90%) and good radiographic alignment. Raj et al.[5] compared single versus dual plating and found dual plating provided superior mechanical stability and reduced varus collapse, albeit at the expense of higher wound complication rates (up to 18%).

• Single lateral locked plating was compared with dual plating in Neogi DS et al.[1] and Raj et al.[5] While technically less demanding, single lateral plating had higher rates of residual medial instability and malalignment.

• Regional experience: The JPOA study[15] from Pakistan highlighted dual plating as the standard for Schatzker VI injuries, with functional recovery closely tied to restoration of joint congruity.

Ilizarov and Hybrid External Fixation

• Ilizarov fixation was reported by El-Gafary et al.,[2] Subramanyam et al.,[6] and El-Barbary et al.[14] These studies consistently highlighted benefits in soft tissue preservation and early mobilization. Union rates exceeded 90%, but pin-tract infections were frequent (15–20%).

• Hybrid fixators, particularly in combined column fractures, were reported by Anis et al.[7] Union was achieved in all cases, although residual stiffness was observed in up to 22%.

• Subramanyam et al.[6] demonstrated that adding minimal internal fixation to Ilizarov improved stability and reduced malalignment risk.

Arthroscopic-Assisted Fixation

• Two Egyptian studies explored arthroscopic assistance.[10] [11] Zawam and Gad[11] reported excellent articular reduction with fewer malreductions compared with conventional ORIF. Toreih and Rakha[10] combined arthroscopy with circular fixators, achieving high union rates and better visualization of depressed fragments.

• These techniques, however, require specialized equipment, limiting generalizability to resource-constrained LMIC centers.

Innovations in Mobilization

• Ibrahim et al.[12] conducted a randomized trial on immediate weight-bearing post-TPF fixation. Patients allowed early mobilization demonstrated significantly improved gait parameters and lower fall risk at 6 months. These findings challenge the delayed weight-bearing paradigm common in LMICs.

Functional Outcomes

Functional recovery was reported in 10 of the 15 studies.

• Patient-reported outcomes: Thapa et al.[8] (Nepal) documented significant improvements in SF-36 physical function and EQ-5D scores at 24 months. Similarly, Ahmad et al.[9] (Pakistan) identified that comorbidities (e.g., diabetes, obesity, smoking) predicted poorer recovery despite similar fracture patterns.

• Knee-specific scores: Raj et al.[5] and JPOA[15] studies reported KSS averaging 75 to 85 at 1 year for dual plating cohorts. External fixation cohorts (El-Barbary et al.,[14] Anis et al.[7]) tended to score lower, reflecting residual stiffness.

• Biomechanical recovery: Ibrahim et al.[12] highlighted improved spatiotemporal gait patterns in the immediate weight-bearing cohort, suggesting that functional outcomes in LMICs may be enhanced by protocol modifications rather than expensive implants alone.

Complications

• Infection: Deep infection rates varied between 7 and 18% across plating cohorts.[1] [5] [15] Pin-tract infections in external fixation cohorts were common (15–20%).[6] [7] [14]

• Stiffness: Postoperative stiffness was most common following dual plating, with up to 20% requiring manipulation under anesthesia.[5] [15]

• Malunion: External fixation had higher rates of malunion compared with plating (reported in up to 12% of cases).[6] [7]

• Hardware failure: Rare but reported in plating cohorts, particularly when single lateral plating was applied to bicondylar patterns.[1] [5]

• Long-term sequelae: Posttraumatic osteoarthritis was mentioned in three studies, particularly in cases with residual articular incongruity.[3] [8] [9]

Regional Differences

• South Asia (India, Nepal, Pakistan): Strong evidence base on plating versus Ilizarov, functional scores, and risk factors.

• Africa (Uganda, Ethiopia, Egypt): Larger focus on epidemiology, resource limitations, and experimental innovations such as arthroscopy and mobilization.[3] [4] [10] [12]

Discussion

This systematic review consolidates evidence from 15 studies across South Asia and Africa, providing one of the most comprehensive overviews of TPF management in LMICs to date. The findings highlight both surgical successes and systemic challenges, reflecting the unique trauma burden, healthcare infrastructure, and socioeconomic conditions of these regions.

Epidemiology and Patient Profile

Our analysis confirms that TPFs in LMICs predominantly affect young, economically active males following high-energy trauma, particularly RTAs. This trend has been consistently reported in Uganda,[4] Ethiopia,[3] and South Asia.[8] [9] In contrast, HICs often report higher proportions of low-energy fragility fractures among older adults due to osteoporosis.[1] The implication is profound: in LMICs, these injuries not only represent an orthopaedic challenge but also have a disproportionate socioeconomic impact, removing young breadwinners from the workforce for extended recovery periods.

Treatment Modalities: Balancing Stability and Resources

Plating Approaches

Dual plating remains the gold standard for bicondylar fractures, ensuring anatomical reduction and superior mechanical stability.[1] [5] [15] Both Neogi DS et al.[1] and Raj et al.[5] showed that dual plating minimized malalignment compared with single lateral plating. However, complications such as infection and wound breakdown were significantly higher, ranging from 10 to 18%. This reflects the tension between achieving stable fixation and managing the fragile soft tissue envelope, especially in high-energy injuries common in LMICs.

In HICs, widespread use of locking plates, minimally invasive techniques, and negative-pressure wound therapy has mitigated some of these risks. However, such adjuncts are not consistently available in LMIC hospitals, explaining the higher complication rates. The reliance on dual plating in Pakistan (JPOA[15]) and Nepal[8] suggests a prioritization of stability, even if it comes at the expense of soft tissue complications.

External Fixation and Ilizarov Methods

Ilizarov and hybrid external fixation emerged as practical alternatives in LMICs, especially for complex bicondylar fractures with soft tissue compromise. El-Gafary et al.[2] and El-Barbary et al.[14] demonstrated excellent union rates and acceptable functional outcomes using Ilizarov, confirming its role as a limb-sparing and resource-appropriate strategy. Subramanyam et al.[6] further showed that combining Ilizarov with minimal internal fixation reduced malalignment, a critical finding in settings where delayed union and deformity carry long-term functional and economic consequences.

Compared with HICs, where external fixation is often reserved for damage-control orthopaedics, LMICs adopt it as a definitive treatment modality, underlining its adaptability in resource-constrained contexts. However, pin-tract infections remain a pervasive challenge, with reported rates up to 20%.[6] [7] This underscores the need for improved pin-care protocols and community-based follow-up services.

Arthroscopic-Assisted Fixation

Emerging evidence from Egypt highlights the potential of arthroscopic-assisted fixation.[10] [11] These techniques allowed improved visualization and reduction of intra-articular fragments, which could theoretically reduce the incidence of posttraumatic osteoarthritis. However, widespread adoption in LMICs is limited by the high equipment costs, steep learning curve, and lack of trained surgeons. In resource-rich HICs, arthroscopy is already integrated into standard care; in LMICs, it remains a niche innovation available only in tertiary centers.

Functional and Quality-of-Life Outcomes

Functional outcomes were variably reported across studies, yet consistent themes emerged. Dual plating generally yielded higher KSS (75–85) compared with Ilizarov or hybrid fixation (KSS 65–75), although the gap narrowed when union and alignment were achieved.[6] [7] [8] [15] Patient-reported outcomes such as SF-36 and EQ-5D demonstrated significant improvements postoperatively, particularly in the Nepalese cohort.[8]

Importantly, patient comorbidities emerged as strong determinants of recovery. Ahmad et al.[9] identified diabetes, obesity, and smoking as predictors of delayed recovery, aligning with global evidence but magnified in LMICs where perioperative optimization is often limited. This reinforces the need for holistic management beyond surgical fixation.

The randomized trial by Ibrahim et al.[12] provided novel evidence that immediate weight-bearing enhanced gait recovery and reduced fall risk, without increasing nonunion or implant failure. This has profound implications for LMICs, where long rehabilitation delays and poor access to physiotherapy often impede recovery. Early mobilization protocols could therefore be a cost-neutral strategy to improve outcomes.

Complications and Their System-Level Implications

Complication rates in LMIC cohorts were higher than those typically reported in HIC studies. Deep infection rates of 7 to 18% in plating cohorts[1] [5] [15] and pin-tract infections of 15 to 20% in Ilizarov cohorts[6] [7] [14] are notable. The higher burden reflects systemic limitations, including delayed presentation, inadequate soft tissue care, and limited access to advanced dressings or prophylactic measures.

Stiffness was a recurring problem, affecting up to 20% of patients after plating.[5] [15] This likely reflects limited postoperative physiotherapy services in LMICs. In contrast, HICs employ early motion protocols supported by trained rehabilitation teams, an infrastructure often unavailable in LMICs. Malunion, more common in external fixation (up to 12%), further highlights challenges in radiographic monitoring and continuity of care.[6] [7]

The long-term consequence of these complications is posttraumatic osteoarthritis, already noted in several studies.[3] [8] [9] In LMICs, the lack of widespread arthroplasty services means that posttraumatic osteoarthritis often translates into lifelong disability.

Regional Differences and Contextual Challenges

South Asian studies emphasized surgical technique comparisons (dual vs. single plating, Ilizarov vs. hybrid fixation).[5] [6] [7] [8] [15] African cohorts provided epidemiological insights[3] [4] and explored resource-appropriate innovations like arthroscopy and mobilization strategies.[10] [12] Together, these regional variations reflect how LMIC surgeons adapt treatment strategies to their resource environment.

Cross-cutting challenges include:

• Implant availability: Dual plating requires specific locked implants, often expensive or inconsistently available.

• Imaging limitations: Many centers lack routine CT, complicating preoperative planning.

• Rehabilitation gaps: Limited physiotherapy services prolong stiffness and functional impairment.

• Follow-up difficulties: Patients in rural settings may not return for scheduled reviews, limiting complication detection and management.

Comparison with High-Income Country Evidence

In HICs, systematic reviews show lower infection rates (2–7%) and better functional outcomes, partly due to advanced perioperative protocols, abundant implant availability, and structured rehabilitation.[1] LMICs, while achieving similar union rates, experience higher complication burdens. The comparative evidence suggests that while surgical principles are universal, context dictates outcome quality.

Future Directions

1. Strengthening rehabilitation: Incorporating community health workers or tele-rehabilitation could mitigate stiffness and functional impairment in LMICs.

2. Cost-effective innovations: Locally manufactured implants and modular external fixators could reduce reliance on imported hardware.

3. Training and skill development: Expanding training in minimally invasive and arthroscopic-assisted fixation techniques could improve articular reduction while minimizing complications.

4. Policy implications: Road safety initiatives and trauma system strengthening (prehospital care, referral pathways) are essential to reducing the high-energy fracture burden.

5. Research gaps: High-quality RCTs remain scarce in LMIC orthopaedic trauma. Future trials should evaluate not only surgical outcomes but also cost-effectiveness, quality of life, and socioeconomic recovery.

Strengths and Limitations

This review draws on a diverse LMIC evidence base, highlighting both surgical techniques and systemic barriers. However, heterogeneity in outcome measures and moderate methodological quality (retrospective designs, small sample sizes) limit generalizability. Publication bias is also likely, as negative results may remain unpublished. Nonetheless, this synthesis provides a vital evidence foundation for clinical and policy decision-making in LMICs.

Conclusion

This systematic review highlights that TPFs in LMICs predominantly affect young, working-age males following high-energy trauma, imposing a significant socioeconomic burden. Despite limited resources, union rates of >90% were consistently reported across plating, Ilizarov, and hybrid fixation techniques, demonstrating that high-quality fracture care is achievable in these settings.

Dual plating provides the most reliable fixation for bicondylar injuries, achieving superior alignment and function compared with single plating. However, it carries higher risks of infection and wound complications, reflecting the challenges of soft tissue management in LMIC trauma populations. Ilizarov and hybrid external fixation remain valuable alternatives, particularly for cases with severe soft tissue compromise, although pin-tract infections and malalignment remain concerns. Arthroscopic-assisted fixation and early mobilization strategies, including immediate weight-bearing, show promise but require further validation and adaptation to LMIC resource contexts.

Complication rates in LMICs remain substantially higher than in HICs, largely due to systemic barriers such as inadequate soft tissue coverage, limited rehabilitation services, and difficulties with follow-up. These findings underscore the urgent need for context-appropriate innovations, improved rehabilitation infrastructure, and trauma system strengthening.

Future research should prioritize randomized trials and multicenter registries in LMICs, focusing not only on surgical outcomes but also on cost-effectiveness, patient-reported outcomes, and long-term quality of life. By aligning clinical advances with system-level improvements, LMICs can narrow the outcome gap with HICs and reduce the long-term disability burden associated with TPFs.

Conflict of Interest

None declared.

Authors' Contributions

E.B.Y.G. was involved in the study design, data acquisition, drafting of the article, critical revision, and final approval of the manuscript. M.A.S. contributed to data acquisition and approved the final version of the manuscript. M.S.H.A. also contributed to data acquisition and approved the final version of the manuscript. All authors have read and approved the manuscript.

• References

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Publication History

Received: 28 August 2025

Accepted: 04 October 2025

Article published online:
04 November 2025