Critical appraisal of bone graft meta-analysis in tibial plateau fractures

We read with great interest the meta-analysis by Alshahrani et al, which compared autologous bone grafts and bone substitutes in the management of tibial plateau fractures. This comprehensive review offers valuable data; however, several methodological aspects should be carefully considered to strengthen the interpretation of its findings. Tibial plateau fractures exhibit wide variability in terms of injury mechanism and prognosis. In the included studies, fracture classification was not consistently reported, and studies on simple, mixed, and complex patterns were pooled together, which may have introduced bias. Furthermore, the bone substitutes assessed, namely, calcium phosphate cement, calcium sulfate, bioactive glass, and various composites, differ greatly in composition, mechanical properties, and degradation behavior. The primary outcome of joint depression was analyzed in very small subgroups, limiting statistical power, and was treated as continuous data despite the small sample sizes. The follow-up durations were short, although bone graft incorporation may take months to years, and shorter follow-up may miss later complications. Finally, the search strategy did not specify language criteria, which may have contributed to the inability to locate one of the included studies during our search, potentially indicating the inclusion of non-English articles. Addressing these methodological concerns would increase the robustness, validity, and clinical applicability of this important meta-analysis.