A new posterolateral approach without fibula osteotomy for the treatment of tibial plateau fractures

Horizontal Rafting Plate for Treatment of the Tibial Plateau Fracture

Objective

This study aimed to investigate the value of a horizontal rafting plate in treating tibial plateau fractures.

Methods

The data of 24 patients in whom a horizontal rafting plate was used to treat a tibial plateau fracture between October 2014 and January 2018 were retrospectively analyzed, including 16 males and 8 females, aged 21–63 years old, with an average of 40 ± 14.68 years. The fractures included 13 in the left knee and 11 in the right knee. The places where the horizontal rafting plate were used included the anterior margin of tibia, anterolateral tibia, and posterolateral tibia. All cases were followed up for 12–24 months, with an average follow‐up of 17.5 ± 5.0 months. At the last follow‐up, the Rasmussen radiological criteria were used to evaluate the effect of fracture reduction and fixation. The knee joint function was evaluated using the Rasmussen functional score. Computed tomography (CT) scanning and three‐dimensional reconstruction were performed preoperatively and postoperatively, with the quality of reduction of the fractured articular surface clarified by the final follow‐up. The flexion and extension abilities of the knee joint were also measured in the postoperative follow‐up.

Results

Preoperative CT scanning showed that the gap of the tibial plateau was 8.00 ± 1.40 (5–24) mm. The heights of the fracture of the articular surface at all three sites during the final follow‐ups were significantly different from the height before the surgery (P < 0.05). The vertical distance between the articular line and the highest point of the articular surface after reduction was 0.17 ± 0.05 mm. Anatomic reductions were obtained in 24 patients. The Rasmussen functional score after surgeries was 27.25 ± 0.94 points. Bony union was achieved in all the patients. According to the Rasmussen radiological criteria, the scores during the last follow‐up were as follows: the total score was 13–18 points, with an average of 16.00 ± 1.72 points; the scores were excellent in 17 cases and good in seven cases. Therefore, 100% of results were excellent or good. No infection or fracture nonunion was found.

Conclusion

Using a horizontal plate can be an effective method for treating special types of fractures of the tibial plateau, including the anterior margin and anterolateral and posterolateral tibial plateau, with satisfactory treatment efficacy.

Pin Leverage Technique: A Simple Percutaneous Technique for Elevation of Posterolateral Tibial Plateau Fractures

Depressed lateral tibial plateau fractures with a large central or posterior fragment can be seen in isolation or association with complex proximal tibia fractures. Conventionally elevation of the large depressed fragment is done by bone tamp through a medial metaphyseal window in isolated fractures, or the fractured window in associated complex fracture scenarios. Though various instruments have been devised for this purpose, reaching the posterior aspect of lateral condyle through the medial metaphyseal window is not always easy, considering the difficulty in aiming and trajectory. Excessive maneuvering can result in the widening of the medial metaphyseal window, leaves a large metaphyseal void, intraarticular penetration of elevating device, and comminution of the depressed fragment. Described herein is an alternate percutaneous technique for effective reduction of selected lateral tibial plateau depression fractures using Steinmann pin. Twenty- one patients with at least 1-year follow-up with successful outcomes have benefitted from this reduction technical tip thus far.

Open approaches for cruciate ligament reconstruction in knee dislocations: A technical note and case series

INTRODUCTION

Arthroscopic surgery is the gold standard for cruciate ligament reconstruction in multi-ligament knee injuries. However, hospitals in limited-resource settings often lack arthroscopic-trained surgeons or equipment. Open approaches for treating knee dislocations can overcome many of these limitations.

METHODOLOGY

This study aims to describe techniques for open approaches in a supine patient to address the cruciate ligaments in multi-ligament knee injuries and to review associated complications and clinical outcomes in a retrospective case series.

RESULTS

Ten patients with multi-ligament knee injuries who had undergone open cruciate ligament reconstruction between July 2016 and November 2018 were retrospectively identified. Open approaches were performed owing to the extravasation of arthroscopy fluid into the posterior compartment (3) or a large traumatic arthrotomy (7). Complications and patient-reported outcomes were analysed. Eight of the 10 patients were followed up at 10 months postoperatively (range, 5-23 months). None had iatrogenic neurovascular damage. Median outcomes scores were: visual analogue scale, 45 (range, 0-100); Knee Injury and Osteoarthritis Outcome Score-Physical Function Short Form, 81.4 (range, 75-100); Lysholm, 85 (range, 67-92).

DISCUSSION

Open approaches were safe and useful in treating cruciate ligaments and should be considered in arthroscopy fluid extraversion and large traumatic arthrotomies.

Outcome after polyaxial locking plate osteosynthesis in proximal tibia fractures: a prospective clinical trial

Background

The aim of this study was to evaluate the clinical and/or radiologic outcome using different polyaxial locking plates for the treatment of proximal tibia fractures, the Non-Contact-Briding plate (NCB-PT®) by Zimmer or the Variable Angle Locking Compression Plate (VA-LCP®) by Synthes.

Methods

This study enrolled 28 patients with proximal tibia fractures (AO/ OTA 41 B-C) and indication for locking plate osteosynthesis. All patients were treated with a polyaxial locking plate system. Depending on the fracture morphology, patients were either treated with a NCB-PT® or VA-LCP®. The implant was chosen according to the surgeon’s experience and preference, in case of a higher degree of comminution the tendency was observed to use the NCB-PT® plate. After a time interval of 12 months postoperative we conducted clinical (e.g. range of motion, the Rasmussen score) and radiological (e.g. primary/secondary loss of reduction) follow-ups.

Results

Patients provided with the NCB-PT® (9 patients) showed longer operation time, use of longer implants, longer interval from injury to surgery and lower clinical scores after the 12 months follow-up compared with the VA-LCP® group (19 patients). Interestingly, the results showed no significant differences regarding the clinical and radiologic outcome.

Conclusions

The small number of patients as well as the heterogeneity of fractures constitute a limitation of this study. Nevertheless, the differentiated use of implants is associated with comparable clinical and radiological outcomes. This trial emphasizes the need for further prospective randomised trials with higher patient numbers.

Trial registration

Retrospectively registered 21.12.2020. Registration number NCT04680247.

A modified Frosch approach for posterior tibial plateau fractures: Technical note and case series

Achieving the best possible articular congruity following a tibial plateau (TP) fracture is associated with better long-term functional outcomes; TP has an essential role in the movements of the knee joint and is well established that a not optimal reduction leads to articular instability and early osteoarthritis. In recent times, 3D reconstruction from CT scan has greatly contributed to improve the surgical treatment of these fractures since an accurate preoperative plan gives the possibility to decide the best interventional strategy before the surgical incision. Reduction of the posterior part of tibial plateau is not easily achievable with standard surgical access. Several posterolateral approaches, proposed by authors such as Frosch and Lobenhoffer, have been described over the years; these approaches can be divided into 2 groups: with or without osteotomy of the fibula. Main disadvantages of these techniques are the large skin incision, the difficulty of exposing the lateral face of the tibia, the high frequency of damages of the posterolateral TP corner, and in some cases the necessity of performing fibular head osteotomy . The surgical approach presented in this paper is a simple innovation of the well-known Frosch approach: skin incision is about 12 centimeters in length and runs in a "S" shape with the center positioned over the head of the fibula. It starts 2 centimeters laterally to the tibial crest 6 centimeters below the tibial tuberosity and is directed proximally, curving posteriorly at the level of fibular head and returning straight in the most proximal part; it terminates 4 centimeters posteriorly the lateral femoral condyle. This innovative approach allows the trauma surgeon to achieve an optimal exposure and control of posterior tibial plateau fractures, with the great advantage of being able to treat the lateral tibial plateau with the same surgical incision.

Easy Surgical Approach of the Posterolateral Corner of the Knee

Background

The anatomy of the posterolateral corner (PLC) of the knee is complex. The approach of the PLC can be a challenging and stressful surgical time.

Indications

The indications are posterolateral meniscal repair, open lateral meniscus allograft transplantation, posterolateral tibial plateau fracture, and PLC reconstruction for grade III sprains.

Technique Description

The skin incision is straight, realized with the knee positioned at 90° of flexion, passing slightly posterior to the lateral epicondyle, anterior to the fibular head (FH), and ending on Gerdy's tubercle. The subcutaneous tissues are dissected posteriorly so as to expose the FH and the biceps femoris (BF) tendon. The aponeurosis of the peroneus muscles is incised vertically opposite to the anterior side of the FH. The common fibular nerve is exposed at the neck of the fibula. Metzenbaum scissors are then inserted subaponeurotically, posteriorly, and parallel to the BF tendon, superficially to the nerve. An incision is made opposite the scissor's blades, freeing the common fibular nerve. The BF tendon is spread forward and the lateral gastrocnemius is pulled posteriorly. Metzenbaum scissors are inserted in a closed position between the lateral gastrocnemius and the posterolateral joint capsule, and then spread to create a triangular door with a proximal base. The base consists of the BF tendon, the posterior side of the lateral gastrocnemius, and the anterior side of the posterolateral joint capsule. A counter-angled Hohmann retractor can now be applied against the posterior tibial plateau to retract the lateral gastrocnemius posteriorly and medially, exposing the PLC of the knee.

Results

Noble structures are easily exposed and protected. The common fibular nerve is dissected and reclined posteriorly, and the popliteus vessels are reclined posteriorly and medially, protected by the lateral gastrocnemius. Passing under the BF tendon allows a better vision of the PLC along with less constraint than passing above, as the working window is further away from the femoral insertion of the lateral gastrocnemius.

Discussion/Conclusion

The present surgical approach allows a simple, safe, and reproducible exposure of the PLC of the knee.

Treatment of Isolated Posterolateral Tibial Plateau Fracture with a Horizontal Belt Plate through the Anterolateral Supra-Fibular-Head Approach

The posterolateral tibial plateau fracture was not easy to be exposed and fixed with usual techniques. The aim of this study was to investigate the biomechanical stability and clinical outcome of the isolated posterolateral tibial plateau fracture fixed with a single horizontal belt plate through the anterolateral supra-fibular-head approach. Fracture models were created by 18 synthetic tibias and fixed with three different fixation modes. Each group was fixed and tested on the loading machine, and final vertical displacement of the fragment was detected and calculated. Clinically, a retrospective analysis of 12 cases of posterolateral tibial plateau fracture from January 2013 to December 2017 was performed. There were 8 males and 4 females, aged 33-72 years, with an average age of 49.6 years. Isolated posterolateral tibial plateau fractures were identified according to preoperative X-ray and computed tomography scan. Through the modified anterolateral supra-fibular-head approach, the fracture was reduced and fixed by a prebending T-shaped distal radius plate and rafting screws, with bone substitute grafting or autogenous iliac bone implantation. Patients were followed up to a minimum one year of time period, and the outcome was evaluated clinically and radiologically. The biomechanical study shows that horizontal belt plate fixation for the isolated PL tibial plateau fracture can provide sufficient stability, allowing early knee functional exercise and partial weight bearing. For clinical case series, the average operation time in this group was 73.3 ± 10.2 mins (range: 55-90), and the average duration of hospitalization was 9.1 ± 3.3 days (range: 5-16). Patients were followed up for 12-24 months with an average of 16.5 months, and all patients achieved radiological fracture union after an average of 13.7 weeks. At one year after operation, the average knee score of the Hospital for Special Surgery (HSS) scale was 93.2 ± 4.2 points(range: 90-98), the average score of SMFA was 21.1 ± 5.6 points (range: 14-31), and the average knee range of motion (ROM) was 121.48° ± 8.88° (range: 105°-135°). There were 8 cases that were very satisfied and 3 cases that were satisfied with the operation. For an isolated posterolateral tibial plateau fracture, the supra-fibular-head approach can fully expose the fracture site; the horizontal belt plate fixation of the fracture is stable and reliable to allow for early-stage knee rehabilitation, and the outcome of medium-term clinical follow-up was satisfactory.

Why address posterior tibial plateau fractures?

Management of posterior tibial plateau fractures has gained much interest over the past few years. Fracture morphology, trauma mechanism, and soft-tissue injury have been identified as the key factors determining the treatment strategy and outcome. We provide a rationale for the operative management of posterior tibial plateau fractures by discussing the interplay between fracture morphology, trauma mechanism, and soft-tissue injury. The trauma mechanism has proven to be an important tool, not only to understand fracture morphology, but also to assess concomitant soft-tissue (i.e. ligamentous) injury. Subsequently, soft-tissue injury might play a role in future classification and diagnostic work-up of tibial plateau fractures, particularly in fractures with posterior involvement. Plate osteosynthesis using a posterior approach is safe and should be considered routinely in coronal fractures of the posterior tibial plateau, as illustrated.

The concept of direct approach to lateral tibial plateau fractures and stepwise extension as needed

Malreduction after tibial plateau fractures mainly occurs due to insufficient visualization of the articular surface. In 85% of all C-type fractures an involvement of the posterolateral-central segment is observed, which is the main region of malreduction. The choice of the approach is determined (1) by the articular area which needs to be visualized and (2) the positioning of the fixation material. For simple lateral plateau fractures without involvement of the posterolateral-central segment an anterolateral standard approach in supine position with a lateral plating is the treatment of choice in most cases. For complex fractures the surgeon has to consider, that the articular surface of the lateral plateau only can be completely visualized by extended approaches in supine, lateral and prone position. Anterolateral and lateral plating can also be performed in supine, lateral and prone position. A direct fixation of the posterolateral-central segment by a plate or a screw from posterior can be only achieved in prone or lateral position, not supine. The posterolateral approach includes the use of two windows for direct visualization of the fracture. If visualization is insufficient the approach can be extended by lateral epicondylar osteotomy which allows exposure of at least 83% of the lateral articular surface. Additional central subluxation of the lateral meniscus allows to expose almost 100% of the articular surface. The concept of stepwise extension of the approach is helpful and should be individually performed as needed to achieve anatomic reduction and stable fixation of tibial plateau fractures.

Fibular Neck Osteotomy Approach in Treatment of Posterolateral Tibial Plateau Fractures: A Retrospective Case Series

Background

The surgical strategies for posterolateral tibial plateau fractures are still inconsistent. Although a number of operative approaches were previously reported for surgical treatment of fractures of the posterolateral column in the tibial plateau, some approaches fail to provide direct visualization of the articular surface and do not allow enough space to access the posterolateral area of the lateral tibial plateau, thereby leading to unsatisfactory reconstruction of the knee and poor articular activity.

Material/Methods

We retrospectively reviewed records of 21 patients who underwent fibular neck osteotomy approach for posterolateral fractures. Radiographs taken during follow-up were used to evaluate the quality of fracture reduction and lower-limb axis. The Tegner-Lysholm score was used to assess patient functional performance. Complications, including incision infection, osteotomy nonunion, peroneal nerve injury, and fragment displacement, were evaluated.

Results

We included 12 males and 9 females, with an age range of 27–67 years (mean age, 42.43 years). No intraoperative complications or postoperative complications were found. The mean operative duration was 128.05 min (range: 86–167 min). No patients were lost to clinical or radiographic follow-up. All patients had complete follow-up (range: 13–28 months, mean: 19.57 months). Anatomical fracture reduction was achieved in 14 patients. Radiological limb alignment was restored in all patients. The mean Tegner-Lysholm score was 87.07 (range: 74–95) and the average knee society score (KSS) was 91.67 (range: 86–94) at the final follow-up.

Conclusions

In this retrospective study, the results suggest that the fibular neck osteotomy approach is a good choice for treatment of posterolateral tibial plateau fractures.

Biomechanical analysis of "Barrel hoop plate" technique for the posterolateral fragments of tibial plateau fractures with different displacement tendency

OBJECTIVES

The purpose of our study is to evaluate the three-dimensional biomechanical properties of "Barrel Hoop plate" in two kinds of artificial posterolateral tibial plateau fracture fragment (PLF) by using of synthetic models, each of which has an initial amplifying displacement tendency.

MATERIAL AND METHODS

Thirty-six tibiae models were randomly assigned into two groups with different displacement tendencies: posterior displacement (PD) and lateral displacement (LD). Each model was then fixed with three patterns: Anterolateral plate (AP), Posterolateral plate (PP), and "Barrel Hoop plate" (BHP). Displacement in three axes of vertical, sagittal and horizontal axis was captured by Optotrak Certus motion analysis system. Bluehill 2 software was used for load control and data collection.

RESULTS

In Model-PD, when the load was over 1000 N, the posterior displacement of Group-PP and Group-BHP were less than Group-AP (P<0.01). The inferior displacement in the vertical axis of Group-PP was larger than both Group-AP and Group-BHP in all the loading set (P<0.01). In Model-LD, both of the lateral displacement in Group-AP and Group-BHP was less than that of Group-PP when the load was over 1000 N (P<0.01). The inferior displacement of Group-AP was less than that of Group-PP in the load of 1500 N (P<0.01). Both of the posterior displacement of Group-AP and Group-BHP was less than that of Group-PP when the loading was 1500 N (P<0.01). The stiffness of Group PP was less than that of Group AP (P<0.01).

CONCLUSIONS

The results demonstrated that the 2.7 mm "Barrel Hoop plate" had a greater capacity of anti-three-dimension axes displacement of PLF. The 3.5 mm Anterolateral plate had the advantage in anti-lateral displacement and anti-inferior displacement but was weak at anti-posterior displacement of PLF. The 2.7 mm Posterolateral plate was stronger in anti-posterior, however, weak in anti-inferior displacement capacity.

A Novel Method of the Treatment for Posterolateral Tibial Plateau Fractures

Reduction and fixation of posterolateral tibial plateau fracture via a posterolateral approach is challenging, and the posterolateral approach itself may injure the posterolateral ligament complex of the knee and can result in knee instability. We developed a new curved support plate (CSP) that can pass, via traditional anterolateral approach, through the superior tibiofibular interval and effectively support the posterolateral fragments. The purpose of our study was to determine the biomechanical reliability of the new plate and report the preliminary efficacy of the CSP for posterolateral tibial plateau fracture. In the biomechanical experiment, 40 synthetic tibias were used to create posterolateral shearing tibial fracture models, which were randomly assigned to groups A to D. Vertical displacement of the posterolateral fragments was measured under axial loads of 500 to 1,500 N. The new plate and 3.5-mm lateral locking plate exhibited similar control over fragment displacement. From June 2016 to August 2017, eight patients with posterolateral tibial plateau fracture underwent treatment with the CSP. Hospital for Special Surgery (HSS) knee score, knee flexion and extension ranges of motion, and complications were recorded to evaluate treatment effects. Eight patients (five men and three women, mean age 44 years [range, 23-66 years]) were enrolled in the study. Mean follow-up time was 13 months (range, 7-19 months). All patients achieved radiographic bone union by 3.3 months (range, 3-4 months) postoperatively. There were no complications of neurovascular injury, deep vein thrombosis, infection, and implant loosening throughout the follow-up period. At final follow-up, mean HSS score was 92.6 (88-96), with a mean knee flexion of 131.25 degrees (120-135 degrees) and a mean knee extension of 1 degree (0-5 degrees). Fixation of posterolateral tibial plateau fracture was easily and successfully achieved using our newly designed CSP, which may provide a new choice for posterolateral tibial plateau fractures.

Clinical results after surgical treatment of posterolateral tibial plateau fractures ("apple bite fracture") in combination with ACL injuries

PURPOSE

The anterior cruciate ligament (ACL)-tear is a common injury in orthopaedic trauma. Depending on the energy of impact fractures of the posterolateral tibial plateau are often associated. Different morphologic variants of posterolateral tibial plateau impaction fractures have been described in the setting of an ACL-tear. Up to now an algorithm of treatment for a combined injury of a posterolateral tibial head fracture and an injury to the anterior cruciate ligament is missing.

METHODS

We present a retrospective study with clinical and radiological analysis of posterolateral fractures in combination with ACL-tear. Impressions with a depth of more than 2 mm and/or a width that outreaches more than half of the posterior horn of the lateral meniscus with additional 3. degree positive pivot-shift-test indicated surgical treatment of the fracture with additional ACL repair or reconstruction. Clinical evaluation included follow-up examination, Visual Analog Scale (VAS), International Knee Documentation Committee Score (IKDC), functional and radiological Rasmussen score.

RESULTS

20 patients were included with a mean age of 43.6 ± 12.4 years. Mean follow-up was 18,2 ± 13,5 months. The fracture was arthroscopically reduced and percutaneously fixed with a screw osteosynthesis (Group 1), reduced via a dorsal approach without (Group 2) or with an autologous bone graft (Group 3). Subjective IKDC score was 79,15 ± 6,07. Functional Rasmussen scores ranged from 27 to 30 (mean 28 ± 2.71). Radiological Rasmussen scores ranged from 16 to 18 points (mean 16.75 ± 1.33). According to IKDC score (p = 0.60), functional Rasmussen score (p = 0.829) and radiological Rasmussen score (p = 0.679) no significant discrepancy between the groups were seen. There was no failure of the ACL graft recorded.

CONCLUSIONS

Posterolateral tibial plateau fractures in combination with an ACL-tear, can cause persistent instability and increase rotational instability. Indication for treatment of these fractures is still under debate. From the biomechanical aspect the lack of more than 50% of the posterior horn of the lateral meniscus and dislocation/depression of more than 2 mm results in an increased rotational instability of the ACL deficient knee. Combined surgical treatment with ACL repair or reconstruction is a safe procedure that results in good, short-term clinical outcome, if our algorithm is followed. In addition this study shows, that majority of posterolateral tibial plateau fractures can be treated arthroscopically.

A novel arthroscopically assisted reduction technique for three patterns of posterolateral tibial plateau fractures

Background

Posterolateral tibial plateau fractures (PTPF) remain a challenge for orthopedics surgeons because the special anatomical structures of the posterolateral corner of knee joint including the fibular head, the lateral collateral ligament, and the peroneal nerve, which impedes the exposure of the fracture fragments and need irregular implants to get a stable fixation. The purpose of present study was to introduce a new articular fracture fragments restoration technique for three patterns of PTPF and investigate the relationship between associated soft injuries and fracture patterns.

Methods

From May 2016 to April 2018, 31 patients with PTPF who had undertaken arthroscopically assisted reduction and fixation (AARF) were enrolled in present study. Demographic data, pre-operation, and post-operation X plan films, three-dimensional computed tomography (CT) scans and magnetic resonance imaging (MRI) were reviewed. Present samples were divided into three patterns with lateral inclination (LI), posterior inclination (PI), and parallel compression (PC) according to the orientation of the articular fragment inclination. Rasmussen anatomical score was used to assess the radiological results. Rasmussen functional score, Hospital for Special Surgery knee-rating Score (HSS), and range of motion (ROM) of the knee joint at the final follow-up were measured to evaluate the clinical outcomes.

Results

In this series, the post-operation tibial plateau angle (TPA) was 9.7° ± 3.5°(range 4.0°–15.8°) and the Rasmussen anatomical score was 17.7 ± 0.7(range 16–18); clinical outcomes showed that the HSS score was 92.7 ± 21.8 (range 90–96) and the Rasmussen functional score was 27.9 ± 1.0 (range 26–30). Of all the patients, the anterior cruciate ligament (ACL) injuries including the ACL tibial attachment ruptures occurred in 16 patients (51.6%), meniscus lesions happened in 19 patients (61.3%), medial collateral ligament (MCL) injuries were founded in 13 patients (41.9%). The number of ACL injuries including the ACL tibial attachment ruptures in the PI fracture pattern (12 cases) is significantly higher than LI (2 cases) and PC (2 cases) fracture pattern (p < 0.05).

Conclusion

Profound understanding the different patterns of PTPF and using our reduction technique will facilitate to restore the main articular fracture fragments. The PI fracture patterns have a significant high incidence of the ACL ruptures.

Level of evidence

Therapeutic study, Level IV.

Extended approach to the lateral tibial plateau with central meniscal subluxation in fracture repair: feasibility and first clinical and radiographic results

Purpose

Anatomic reduction in tibial plateau fractures remains to be demanding. For further visualisation of and approach to the joint surface an extended lateral approach using a lateral femoral epicondyle osteotomy and subluxation of the lateral meniscus was recently described. First clinical and radiographic mid-term results of this technique are presented in this feasibility study.

Method

Ten complex tibial plateau fractures treated with extended lateral approach and lateral meniscal subluxation were prospectively analysed. Clinical and radiographic results were objectified according to the Rasmussen scores.

Results

After a median follow-up of 8.6 (IQR 4.3) months good to excellent clinical and radiographic results were noted. The clinical Rasmussen Score showed a median of 25 (IQR 2.8) and radiographic a median of 17 (IQR 2.0) points.

Conclusion

Good to excellent clinical and radiological scores were obtained after using an extended lateral approach with lateral femoral epicondyle osteotomy and central meniscus subluxation. No approach specific complications could be observed.

Electronic supplementary material

The online version of this article (10.1007/s00068-020-01467-1) contains supplementary material, which is available to authorized users.

Comparison of extended lateral approaches to the tibial plateau: The articular exposure of lateral epicondyle osteotomy with and without popliteus tendon vs. fibula osteotomy

BACKGROUND

Comminuted lateral tibial plateau fractures pose a challenge to surgeons, with non-anatomical reductions in 70-89%, involving the posterolateral articular surface. The purpose of this study was to examine the posterolateral joint visibility, using lateral extended approaches, such as the lateral femoral epicondyle osteotomy or the fibula osteotomy. Further, the study aimed to compare the combined osteotomy of the femoral footprints of the lateral collateral ligament (LCL) and popliteus tendon (PLT) to the isolated osteotomy of the femoral LCL footprint or the fibula osteotomy, in terms of posterolateral joint accessibility.

METHODS

Extended lateral (femoral or fibular LCL osteotomy) and posterolateral (additional femoral osteotomy of the PLT tendon) approaches were performed on twelve human cadaver knees. After preparation of each surgical approach, the visible articular surface was marked with diathermy. The tibial plateau was disarticulated and the markings were measured digitally with open-source processing software. Differences in mean values were tested with a paired t-test (p ≤ 0.05).

RESULTS

The greatest articular exposure was achieved with the fibula osteotomy (1011.52 ± 227.05 mm² [86.64 ± 4.84%] compared to the combined osteotomy of LCL and PLT (p = 0.036) or LCL alone (p<0.001). The lateral femoral epicondyle osteotomy of the LCL including the PLT (937.45 ± 237.84 mm² [80.29 ± 8.25%]) exposed a significantly larger articular surface of the lateral tibial plateau than without the PLT (755.71 ± 183.06 mm² [64.73 ± 6.51%], p < 0.001).

CONCLUSION

In direct comparison, the fibula osteotomy provides the largest articular visualization, however at cost of a considerably larger soft tissue damage. While the lateral femoral epicondyle osteotomy of LCL and PLT increases lateral articular visualization, it omits the risk of neurovascular or posterolateral soft tissue damage and therefore represents an important extended approach to treat comminuted lateral plateau fractures.

Prone Posteromedial Approach for Posterior Column Tibial Plateau Fractures

Tibial plateau fractures can involve fracture planes that require reduction and stabilization from a posterior approach. This includes posteromedial, posterolateral, and posterior column shear-type injuries. This video outlines the prone posteromedial approach to the tibial plateau for posterior column fracture exposure, reduction, and fixation.

Complete posterior dislocation of fractured lateral condyle of tibia with disruption of proximal tibiofibular joint: Technical note

Tibial plateau fracture-dislocations are relatively uncommon injuries. They represent instability patterns due to injured collateral ligaments or extensive condylar depression. Medial and lateral subluxations of the fractured fragments represent the majority of these injuries. Posterior dislocations with the tibial plateau fractures are extremely rare injuries. Moreover, isolated posterior dislocations of the tibial condyles with a normally maintained position of the remaining tibia have not been reported in literature. We describe a difficult case scenario in which whole of the articular segment of the lateral condyle of the tibia was separated from its anterolateral rim and completely dislocated posteriorly, with no contact with the lateral condyle of the femur. Besides this, there was a complete disruption of the proximal tibiofibular joint as well. To further add to the problem, the distal pulses in the affected limb had a reduced volume. Stepwise management of all aspects of this injury has been described in this technical note along with a six-month follow-up.

[Reduction and fixation of tibia plateau fractures : Tips and tactics based on the 3-column concept]

OBJECTIVE

The surgical management of tibial plateau fractures remains a challenge. The aim of surgery is the anatomical reconstruction of the joint surface with correct length, axis and rotation. The goal of osteosynthesis is to maintain a stable reduction to allow bone healing and functional aftercare. The continued advancements in 3D computed tomography has changed, the classification systems and, in parallel, the treatment strategies significantly changed. The 3‑column concept of Luo et al. has proven to be advantageous for planning of access, reduction and stabilisation.

INDICATIONS

Taking into consideration patient-specific factors. most displaced tibia plateau fractures are treated by surgery. However, no clear treatment recommendations exist in literature. In our clinical practice, joint displacement of more than 2 mm is generally not tolerated and surgical therapy is advised.

OPERATION TECHNIQUE

The surgical technique is preceded by the surgical strategy, which is based on the soft tissue situation and imaging results. The gold standard in imaging is computed tomography. Timing of surgery, patient positioning, surgical approaches as well as the implants are individually adapted to the fracture pattern.

RESULTS

The postoperative results are strongly influenced by fracture type, soft tissue condition, patient-specific factors, treatment method, and successful joint reconstruction. The functional postoperative results are often satisfactory even after complex tibia plateau fractures. In the literature, development of posttraumatic arthritis is reported to be 23-44%. In a study by Mehin et al. joint replacement of the knee was performed in 4.5% of cases following the surgical treatment of tibia plateau fractures.

Comparative Analysis of Mechanism-Associated 3-Dimensional Tibial Plateau Fracture Patterns

BACKGROUND

The association between tibial plateau fracture morphology and injury force mechanism has not been well described. The aim of this study was to characterize 3-dimensional fracture patterns associated with hypothesized injury force mechanisms.

METHODS

Tibial plateau fractures treated in a large trauma center were retrospectively reviewed. Three experienced surgeons divided fractures independently into 6 groups associated with injury force mechanisms proposed from an analysis of computed tomographic (CT) imaging: flexion varus, extension varus, hyperextension varus, flexion valgus, extension valgus, and hyperextension valgus. The fracture lines and comminution zones of each fracture were graphically superimposed onto a 3-dimensional template of the proximal part of the tibia. Fracture characteristics were then summarized on the basis of the fracture maps. The association between injury force mechanism and ligament avulsions was calculated.

RESULTS

In total, 353 tibial plateau fractures were included. The flexion varus type pattern was seen in 67 fractures characterized by a primary fracture apex located posteromedially and was frequently associated with concomitant anterior cruciate ligament (ACL) avulsion (44.8%). The extension varus pattern was noted in 60 fractures with a characteristic medial fragment apex at the posteromedial crest or multiple apices symmetrically around the crest and was commonly completely articular in nature (65%). The hyperextension varus pattern was seen in 47 fractures as noted by anteromedial articular impaction, 51% with a fibular avulsion and 60% with posterior tension failure fragments. The flexion valgus pattern was observed in 51 fractures characterized by articular depression posterolaterally, often (58.9%) with severe comminution of the posterolateral cortical rim. The extension valgus patterns in 116 fractures only involved the lateral plateau, with central articular depression and/or a pure split. The hyperextension valgus pattern occurred in 12 fractures denoted by anterolateral articular depression. A moderate positive association was found between flexion varus fractures and ACL avulsions and between hyperextension varus fractures and fibular avulsions.

CONCLUSIONS

Tibial plateau fractures demonstrate distinct, mechanism-associated 3-dimensional pattern characteristics. Further research is needed to validate the classification reliability among other surgeons and to determine the potential value in the diagnosis and formulation of surgical protocols.

Surgical Treatment of Lateral Tibial Plateau Fractures Involving the Posterolateral Column

OBJECTIVE

To summarize the indications and the clinical effects of a transfibular neck osteotomy approach and a combined anterolateral and posterolateral approach in the treatment of fractures of the lateral tibial plateau involving the posterolateral column.

METHODS

Eleven patients with lateral tibial plateau fractures were included in the present study. The fractures were Schatzker type II or lateral platform fractures involving posterolateral column. The anterolateral combined posterolateral approach (lateral + posterolateral locking plate fixation) was applied in 7 patients and 4 patients underwent transfibular neck osteotomy (lateral + posterolateral locking plate fixation + 1/4 tubular plate edge fixation, fibular osteotomy with Kirschner wire tension band fixation, and hollow nail fixation for upper tibiofibular joint). All cases were followed up for 12-24 months, with an average follow-up of 17.5 ± 5.0 months. At the last followup, the Rasmussen radiological criteria were used to evaluate the effect of fracture reduction and fixation. The knee joint function was evaluated using the knee function evaluation criteria of the Hospital for Special Surgery (HSS). The Lachman test and the pivot-shift test were used to evaluate the anterior and posterior and rotational stability of the knee joint. The range of knee motion was recorded.

RESULTS

Bone healing was achieved in all patients with fractures treated with a transfibular neck osteotomy approach and a combined anterolateral and posterolateral approach. At the last follow-up, both the Lachman test and the pivot-shift test results were negative. All patients had complete knee extension. For the combined anterolateral and posterolateral approach, the knee flexion angle was 110°-130°, with an average of 122.86° ± 7.56°. For the transfibular neck osteotomy approach, the knee flexion angle was 115°-130°, with an average of 120.00° ± 7.07°. For the patients in which the combined anterolateral and posterolateral approach was used, the Rasmussen score was 12-18 points, with an average of 16.00 ± 2.56 points. The results were excellent in 4 cases and good in 3 cases; therefore, 100% of results were excellent or good. For patients in which the transfibular neck osteotomy approach was used, the Rasmussen score was 10-18 points, with an average of 15.25 ± 3.77 points. The results were excellent in 2 cases, good in 1 case, and acceptable in 1 case; therefore, 75% of results were excellent or good. The HSS score for the combined anterolateral and posterolateral approach was 76-98 points, with an average of 88.43 ± 7.55 points. The results were excellent in 5 cases and good in 2 cases; therefore, 100% of results were excellent or good. The HSS score for the transfibular neck osteotomy approach was 74-96 points, with an average of 87.25 ± 9.43 points. The results were excellent in 3 cases and good in 1 case; therefore, 100% of results were excellent or good. There were no significant differences in operation time, surgical blood loss, fracture healing time, postoperative imaging score, and knee function evaluation between the two approaches. One patient who underwent transfibular neck osteotomy had a 3-mm step that gradually appeared, but no significant abnormalities were found in the width of the platform and the lower limb force line. One patient in whom the combined anterolateral and posterolateral approach was used showed numbness in the common peroneal nerve. No common peroneal nerve injury occurred through the transfibular neck osteotomy approach.

CONCLUSIONS

The anterolateral combined posterolateral approach and the transfibular neck osteotomy approach are effective in the surgical treatment of lateral tibial plateau fractures involving the posterolateral column. However, the transfibular neck osteotomy approach is more suitable for the posterolateral plateau articular surface damaged with bone separation and displacement, deep collapse, cases involving a large range of the posterolateral column, especially fractures of the lateral tibial plateau in the upper tibiofibular syndesmosis area of the line connecting the anterior and posterior margin of the fibular head to the midpoint of the plateau.

How can the articular surface of the tibial plateau be best exposed? A comparison of specific surgical approaches

INTRODUCTION

The correct choice of a fracture-specific surgical approach with an articular accessibility in complex tibial plateau fractures to facilitate durable fracture fixation of the anatomic articular reconstruction is under debate, as the most important risk factor for malreduction in complex tibial plateau fractures is an impaired visualization of the articular surface.

MATERIALS AND METHODS

Six established surgical approaches were simulated on 12 cadaver knees. The visible articular surface was labeled with an electrocautery device for each approach and subsequently analyzed with ImageJ. Areas of each hemiplateau were compared using the Student's t test.

RESULTS

In the lateral tibial plateau, the dorsal 19.0 ± 5.8% of the articular surface could be exposed via the postero-lateral approach. Via the antero-lateral arthrotomy, 36.6 ± 9.4% of the anterior articular surface was visible. The additional osteotomy of the lateral femoral epicondyle significantly increased the exposure to 65.6 ± 7.7% (p < 0.001). In the medial tibial plateau, the osteotomy of the medial femoral epicondyle significantly improved visualization of the medial articular surface (62.3 ± 8.6%) compared to the postero-medial approach (14.0 ± 7.3%) and the antero-medial approach (36.9 ± 9.2%) of the articular (p < 0.001).

CONCLUSIONS

Visualization of the tibial articular surface is limited through specific surgical approaches. Extension by osteotomy of the femoral epicondyle led to a significant improvement in the articular exposure without, however, obtaining sufficient visibility of the posterior joint segments, which should be included in the preoperative strategy. The proposed surgical approach-specific map of the tibial plateau may constitute an important instrument in the toolbox of an experienced surgeon to treat complex tibial plateau fractures at the highest level.

LEVEL OF EVIDENCE

Level IV.

[Surgical approaches to tibial plateau fractures]

Intra-articular tibial plateau fractures can present a surgical challenge due to complex injury patterns and compromised soft tissue. The treatment goal is to spare the soft tissue and an anatomical reconstruction of the tibial articular surface. Depending on the course of the fracture, a fracture-specific access strategy is recommended to provide correct positioning of the plate osteosynthesis. While the anterolateral approach is used in the majority of lateral tibial plateau fractures, only one third of the joint surface is visible; however, posterolateral fragments require an individual approach, e. g. posterolateral or posteromedial. If necessary, osteotomy of the femoral epicondyles can improve joint access for reduction control. Injuries to the posterior columns should be anatomically reconstructed and biomechanically correctly addressed via posterior approaches. Bony posterior cruciate ligament tears can be refixed via a minimally invasive posteromedial approach.

Arthroscopic Controlled Closed Reduction and Percutaneous Fixation of Posterolateral Tibia Plateau Impression Fractures

Posterolateral impression fractures of the tibial plateau are common, and open reduction and fixation can be demanding, including exposure of the peroneal nerve. Based on a patient example, the surgical technique of an arthroscopic controlled closed reduction and percutaneous screw fixation of a posterolateral tibia plateau impressed fracture is described. A patient sustained a posterolateral impression currently described as an "apple bite" fracture of the tibial plateau. The surgical technique includes standard arthroscopic portals and posteromedial and (transseptal) posterolateral portals. The posterolateral tibial plateau is visualized by incision of popliteomeniscal fibers, retraction of the popliteus tendon, and exposure of the posterolateral plateau. The impression area is marked with a K-wire using an anterior cruciate ligament target device. A cannulated ram is placed over the K-wire. The fracture is lifted under arthroscopic guidance and can be supported with allograft bone chips. To stabilize the reduction, 3 K-wires are positioned from anterior to posterior, and 3 cannulated screws are inserted directly under the joint surface to support the fractured area. In comparison with open surgical techniques, this procedure is exclusively performed under arthroscopic control and enables an anatomic reduction and fixation of the posterolateral tibial plateau.

Two column classification of tibial plateau fractures; description, clinical application and reliability

PURPOSE

In this era of life highly comminuted and multi planar tibial plateau fractures involving the posterior corners are more commonly seen and addressed in the literature than before. Among these several types have not been described in the currently used classification systems. In fact simple classification systems ignore several fracture types and leniently grouped the fractures with different mechanism, morphology, treatment modalities and prognosis in same category. On the other hand, more extensive nature classifications with detailed subdivisions are difficult to remember for clinicians. The clinical reliability of these classifications is another problem. All these issues demand the potential need of a new classification. The aim of this study was to describe a quadrant specific two column classification of tibial plateau fractures and to analyse its inter-observer and intra-observer reliability, clinical assessment and application.

MATERIALS AND METHODS

From January 2009 to December 2015, 44 patients with tibial plateau fractures were studied retrospectively. The antero-posterior (AP), lateral X-rays and computed tomography (CT) with axial transverse, sagittal, coronal and three dimensional (3D) reconstruction images were performed for all the patients. All of the fractures were categorized according to quadrant specific two column classification and the traditional Schatzker's classification. The comparative analysis for inter-observer and intra-observer reliability of the new classification and the Schatzker's classification was conducted by four observers.

RESULTS

Three cases didn't match any type in the Schatzker's classification. While on the other hand, all cases were classified by two column classification. The mean kappa values for inter-observer reliability by using the Schatzker's classification was 0.723 (range, 0.674-0.823), representing substantial agreement, whereas the mean kappa value was 0.939 (range: 0.897-0.974), representing almost perfect agreement according to two column classification. The mean kappa values for intra-observer reliability using the Schatzker's classification and two column classification were 0.789 (range: 0.590-0.864) and 0.955 (range:0.923-0.948) showing substantial agreement and almost perfect agreement.

CONCLUSION

The quadrant specific two column classification is anatomically oriented, CT based and clinically valid. The different fracture types according to anatomic location are represented alphanumerically so that treatment matched to specific fracture type (quadrant specific anatomic fixation) for optimal outcomes. Furthermore, it demonstrates higher inter-observer and intra-observer reliability. This classification can be adopted to strengthen the traditional Schatzker's classification, particularly in the multi planar and posteriorly extended plateau fractures. It can be used as a reliable research tool. The database can be used to distinguish different fracture types, individual type incidences, specific treatment and also prognosis. Authors suggest a large multi-centre study.

[Extended medial and extended lateral approach for tibial plateau fractures]

OBJECTIVE

Complete visualization of the articular surface in comminuted uni- or bicondylar tibial plateau fractures as a prerequisite for anatomical reconstruction to reduce the risk of posttraumatic osteoarthritis.

INDICATIONS

Unicondylar lateral or medial as well as bicondylar intra-articular tibial plateau fractures with central and/or dorsal fracture lines; comminuted destruction of the medial or lateral tibial plateau with dislocation of >2 mm.

CONTRAINDICATIONS

Critical soft tissue in the approach area, femoral condylar fracture, intraligamentous ruptures of the medial or lateral ligaments or the posterolateral corner.

SURGICAL TECHNIQUE

Medial: via the medial or anteromedial approach; lateral: via the antero- or posterolateral approach for open reduction and internal fixation of the tibial plateau fracture. Sharp dissection down to the medial/lateral ligamentous accompanying structures with subsequent presentation of the medial/lateral femoral epicondyle. Medial: approximately 2 × 2 cm osteotomy of the medial femoral epicondyle. Lateral: osteotomy of an approximately 1 × 1 × 0.5 cm bone block of the lateral femoral epicondyle either with protection or including the popliteus tendon running ventrally in the sulcus popliteus. In this case, a violation of the articular condyle should be avoided.

POSTOPERATIVE MANAGEMENT

Early functional posttreatment with full mobilization and 10-20 kg partial load bearing on forearm crutches, fracture-dependent for 6-12 weeks.

RESULTS

Very good visualization of the comminuted articular surface with postoperatively anatomical reconstruction of complex fracture patterns without postoperative concomitant instabilities.

Revisiting the Schatzker classification of tibial plateau fractures

Tibial plateau fractures have a broad spectrum of presentations, depending on the mechanism and energy of the trauma. Many classification systems are currently available to describe these injuries. In 1974, Schatzker proposed a classification based on a two-dimensional representation of the fracture. His classification with the six-principles types became one of the most utilized classification systems for tibial plateau fractures. More than four decades after this original publication, we are revisiting each fracture type in the light of information made available by computed tomography, which today comprises a standard tool in assessing articular fractures. The classification we are proposing relies on the fact that the tibial plateau has two anatomical columns, lateral and medial. We are introducing a virtual equator which splits the articular surface in the coronal plane. The equator divides each column into two quadrants, the anterior (A) and the posterior (P). Unicondylar fracture types (I to IV) have now additional modifiers A (anterior) and P (posterior) to describe the exact spatial location of the primary fracture plane. Bicondylar fracture types (V and VI) have the modifiers (A and P) of the main fracture plane for each column, and lateral (L) and medial (M) to denote the column. We are introducing the concept of the main fracture plane. Recognition of the exact location of the principal fracture plane is essential for preoperative planning of patient positioning, surgical approach and for determining where to apply the hardware to achieve stable fixation. The new three-dimensional classification is based on the template of the original Schatzker classification. It covers the mechanism of the injury, the energy of the trauma, the morphologic characteristics of the fracture and its location in three dimensions.

Comparison of extended anterolateral approach in treatment of simple/complex tibial plateau fracture with posterolateral tibial plateau fracture

BACKGROUND

Our hospital has recently used the extended anterolateral approach in posterolateral tibial plateau fracture. We compared the clinical effects of this method in Schatzker type II or type V/VI fractures with posterolateral tibial plateau fracture based on our patients.

METHODS

The patients from January 2013 to December 2015 were summarized, and some of them were assisted with arthroscopy. According to Schatzker classification, patients with Schatzker type II fracture were divided into group A; patients with Schatzker type V/VI fracture were divided into group B. The fracture characteristics, operation statistics, and postoperative functional evaluation of each group were compared.

RESULTS

A total of 46 patients were included in the study and were followed up for 23-45 months. There were 24 cases in group A and 22 cases in group B. The operation time and the amount of bleeding were significantly less in group A (P < 0.05). Twelve cases were assisted with arthroscopy including 6 patients in each group. The fracture healing time made no significant difference in the two groups (P > 0.05). All patients experienced no significant influence on daily life. The knee Rasmussen score was 26.8 in group A and 23.5 in group B (P > 0.05), and the knee range motion was 115.5° in group A and 106.6° in group B (P > 0.05). The excellent and good rate of reduction was 91.7% in group A and 81.8% in group B (P > 0.05), but the excellent rate of reduction was 83.3% in group A and 27.3% in group B (P < 0.05). The unfixed rate of posterolateral fracture was 16.7% in group A and 36.4% in group B (P > 0.05). One patient in group B suffered postoperative wound infection.

CONCLUSIONS

The extended anterolateral approach could obtain similar satisfactory clinical results in simple/complex tibial plateau fracture with posterolateral tibial plateau fracture. It seemed that easier operation, better posterolateral fracture reduction, and fixation occurred in relative simple fracture from our cases.

TRIAL REGISTRATION

It was a retrospective study. This study was consistent with the ethical standards of the Second Affiliated Hospital of Zhejiang University Medical College and was approved by the hospital ethics committee and the trial registration number of our hospital was 20170053.

[Osteosynthesis of bicondylar tibial plateau fracture in a prone position : Video article]

OBJECTIVE

The aim of the surgical treatment of intra-articular bicondylar tibial plateau fractures is the anatomical reconstruction and direct biomechanical optimal fixation of the fractured articular surface and the leg axis, taking the frequently associated soft tissue damage into account.

INDICATIONS

This article presents a cadaver model of a simulated complex bicondylar tibial plateau fracture 41C3 according to the AO classification with fracture involvement of all 10 segments and indications for surgery due to a posteromedial shearing fracture and lateral articular destruction with posterolaterocentral impaction.

CONTRAINDICATIONS

Pronounced soft tissue damage with acute or incompletely healed infections in the area of the surgical approach.

SURGICAL TECHNIQUE

In the presented video of the operation, which is available online, the direct treatment of an intra-articular complex tibial plateau fracture from dorsal in a prone position is shown in detail: posterolateral ca. 13 cm long skin incision immediately above the fibular head with subsequent gentle preparation of the peroneal nerve at the medial border of the biceps femoris muscle. Retraction of the lateral head of the gastrocnemius muscle medially. Proximal detachment of the soleus muscle from the fibular head and retraction of the popliteus muscle medially. Horizontal capsule incision for fracture visualization. Opening of the lateral window ventral to the lateral collateral ligament. If necessary, osteotomy of the lateral femoral epicondyle for improved posterolaterocentral fracture visualization. Angular stable osteosynthetic fixation. Posteromedial approach medial to the medial gastrocnemius head. Retraction of the medial head of the gastrocnemius muscle laterally, horizontal capsular incision with sparing of the semimembranosus muscle medially and posterior cruciate ligaments laterally, fracture reduction, fixation with posteromedial support plate, image converter control, wound closure.

FOLLOW-UP

Postoperative cooling and elevation of the operated limb. Depending on the fracture 6-10 weeks partial loading of maximum 20 kg. Prior to full load bearing clinical radiological follow-up checks to determine the bony consolidation and material positioning.

RESULTS

This is an established and safe delivery strategy for complex fracture patterns with dorsally running fractures. The risk of intraoperative malreduction is low. Postoperative reduction losses depend on fracture, operation and especially patient-specific characteristics.

A Novel Design of a Plate for Posterolateral Tibial Plateau Fractures Through Traditional Anterolateral Approach

Biomechanical performance of a newly designed plate for treating posterolateral tibial plateau fractures was compared with three traditional internal fixation devices using finite element analysis (FEA) and biomechanical experiments. Forty synthetic tibias were used to create posterolateral shearing tibial fracture models, which were randomly assigned to groups A–D. The fragments were fixed with two 6.5-mm lag screws (group A), the newly designed plate (group B), a 3.5-mm lateral locking plate (group C), and a posterolateral buttress plate (group D). In the biomechanical experiment, vertical displacement of the posterolateral fragments was measured under axial loads of 500–1500 N. In the FEA, vertical displacement of the posterolateral fragments and stress distribution and maximum stress of each internal fixation were measured under axial loads of 250–750 N. Biomechanically, collective ranges of vertical displacements in the four groups were 0.356 ± 0.089–1.055 ± 0.023 mm at 500 N axial load, 0.651 ± 0.062–1.525 ± 0.03 mm at 1000 N, and 0.903 ± 0.077–1.796 ± 0.04 mm at 1500 N. Differences between the four groups were statistically significant (P < 0.05), except for groups B and C at 1500 N. FEA showed that collective ranges of vertical displacements in the four groups were 0.290–1.425 mm at of 250 N axial load, 0.580–1.680 mm at 500 N, 1.067–1.818 mm at 750 N. Maximum stress of groups A–D were, respectively, 321.940, 132.660, 100.383, and 321.940 MPa under 250 N axial load. Maximum stress of all four internal fixations increased, and the overall trends at 500 and 750 N were consistent with that at 250 N. Posterior, straight fixation was the most reliable. Fixation with the lag screw was least reliable. The new plate and 3.5-mm lateral locking plate exhibited similar control over fragment displacement. The newly designed plate was stable and reliable, indicating its suitability for clinical application.

A new anatomic locking plate for the treatment of posterolateral tibial plateau fractures

Background

Posterolateral tibial plateau fractures have become more common, and their treatment is of great importance to knee function. Additionally, there is no available literature detailing specialized anatomic locking plate for tibial plateau fractures. Therefore, the aim of the study was to evaluate the safety and clinical efficacy of an innovative anatomic locking plate for treatment of posterolateral tibial plateau fractures.

Methods

Between March 2014 and January 2016, 12 patients with posterolateral tibial plateau fracture underwent surgery with the anatomic locking plate for the posterolateral tibial plateau via the posterolateral approach. Relevant operational data for clinical evaluation were collected.

Results

The mean follow-up time was 26 months, and the mean age was 35 years for 12 patients. The mean interval between the time of injury and the surgery was 6.1 days. Radiological fracture union was evident in all patients at 12 weeks. During surgery, the blood loss ranged from 100 to 300 mL, and the duration ranged from 55 to 90 min. The Tegner–Lysholm functional score ranged from 85 to 97 at the final follow-up. Moreover, the final Rasmussen functional score ranged from 25 to 29, and Rasmussen anatomical score ranged from 13 to 18.

Conclusions

The newly designed anatomic locking plate for the posterolateral tibial plateau provided adequate fixation along the posterolateral tibial plateau. It proved to be safe and effective in a small-sample-size population (12 patients) during a 12- to 34-month follow-up.

Duration of incapacity of work after tibial plateau fracture is affected by work intensity

BACKGROUND

Tibial plateau fractures requiring surgery are severe injuries of the lower extremity. Tibial plateau fractures have an impact not only on physically demanding jobs but notably on general professional life too. The aim of this study was to assess how the professional activity of patients will be affected after a tibial plateau fracture.

METHODS

39 consecutive patients (ages 20-61 years) were retrospectively included in the study and were clinically examined at a minimum of 14 month postoperatively. Inclusion criteria were surgical treatment of tibial plateau fractures between November 2009 and December 2012. The clinical evaluation included the Lysholm score and the Oxford Knee Score. Fractures were classified and analyzed using the AO classification. Intensity of work was classified as established by the REFA Association. The patients themselves provided postoperative duration of the incapacity of work and subjective ratings.

RESULTS

17 (43.6%) women and 22 (56.4%) men were examined with a mean follow-up of 29.7 ± 10.4 months (range 14-47). According to the AO classification there were 20 (51.3%) B-type-fractures and 19 (48.7%) C-type-fractures. The median incapacity of work was 120 days (range 10-700 days) with no significant differences between B- and C-type-fractures. Four (10.3%) patients reduced their working hours by 10.5 h per week on average. Patients with low workload (REFA 0-1, median incapacity of work 90 days, range 10-390 days) had a significant shorter incapacity of work than patients with heavy workload (REFA 2-4, median incapacity of work 180 days, range 90-700 days) (p < 0.05). The median Lysholm score decreased significantly from 100 points (range 69-100) before the injury to 73 points (range 23-100) at the time of the follow-up. All patients received postoperative physiotherapy (median 25 appointments, range 6-330), with a significant higher number of appointments for C-type-fractures than for B-type-fractures (p = 0.004).

CONCLUSION

A relationship was found between workload and the duration of incapacity of work after tibial plateau fractures. The post-injury shift to less demanding jobs and the reduction of working hours highlight the impact of a tibial plateau fracture on a patient's subsequent physical ability to work.

A biomechanical evaluation of different fixation strategies for posterolateral fragments in tibial plateau fractures and introduction of the 'magic screw'

BACKGROUND

Posterior plate fixation is biomechanically the strongest fixation method for posterolateral column fracture (PLCF) of the tibial plateau; however, there are inherent deficiencies and risks of a posterior approach. Thus, the 'magic screw' was proposed to enhance fixation stability of the lateral rafting plate used for PLCF. The purpose of this study was to re-examine and compare the stability of different fixation methods for PLCF.

METHODS

Synthetic tibiae models were used to simulate posterolateral split fractures. The fracture models were randomly assigned into three groups: Group A, fixed with posterolateral buttress plates; Group B, with lateral locking compression plates (LCP); and Group C fixed with lateral LCPs and one 'magic screw'. Gradually increased axial compressive loads were applied to each specimen.

RESULTS

There was a mean subsidence hierarchy of the posterolateral fragment at different load levels: Group A had the least subsidence, followed by Group C, and Group B had the most. There were no significant differences in the mean loads at different displacements between Group A and Group C. Group A had the highest axial stiffness. Additionally, there was a significant difference in axial stiffness between Group B and Group C.

CONCLUSION

Biomechanical stability of the combined fixation of the posteriorly positioned lateral rafting plate with the 'magic screw' was much closer to that of posterior plate fixation for split-type PLCF. The necessity of posterior fixation through a posterior approach may be reduced for selected patients.

Flexion-valgus unicondylar tibial plateau depression fracture pattern: Classification and treatment

PURPOSE

The authors have identified a subset of unicondylar tibial plateau depression fracture patterns caused by a flexion-valgus force. The purpose of this study was to describe this fracture pattern and suggest a modified lateral approach that may allow for improved reduction and stabilization.

METHODS

The preoperative radiographs and CT scans of 102 patients who sustained unicondylar tibial plateau fractures (OTA 41B) were reviewed. Twenty-six fracture patients had posterolateral (PL) tibial plateau depression fractures. By medical record review and telephone follow-up, the injury mechanism of the 22 unicondylar tibial plateau fractures was confirmed as a flexion-valgus force. The radiographic features of those cases were analyzed and measured. To address this specific fracture pattern, a modified approach combined with a novel intra-articular osteotomy was applied.

RESULTS

According to the morphological characteristics, this tibial plateau fracture pattern could be divided into two subtypes: type A was a confined, basin-like articular surface depression fracture located in the PL quadrant, and type B was a cancellous fracture involving the PL tibial plateau resulting in a decrease in the posterior slope. One radiographic hallmark of this fracture pattern is an anatomically or a mechanically intact posterior column wall. The novel approach was applied to both types. The postoperative radiographic measurements revealed excellent reduction quality. On axial scans, the distance between the most posterior rafting screw and the tangent line of the tibial plateau rim was 3.0 ± 2.07 mm (from -1.9 to 4.3), and the angulation between them was 8.9 ± 3.02° (from -7.3 to 15.6). These results indicated excellent PL quadrant coverage from the rafting screws.

CONCLUSION

Flexion-valgus force-induced unicondylar tibial plateau depression fracture is a unique injury pattern. We suggest a novel surgical approach to address this injury's key features, which may facilitate exposure and enhance fixation strength.

Posterolateral tibial plateau fractures, how to buttress? Reversed L posteromedial or the posterolateral approach: a comparative cadaveric study

INTRODUCTION

The selection of a surgical approach for buttressing posterolateral tibial plateau fractures is controversial.

OBJECTIVE

This study compared the surgical exposure area between the reversed L posteromedial approach (R-PM) and the posterolateral (PL) approach using the lateral plateau width as a metric.

MATERIALS AND METHODS

Twenty lower extremities from fresh frozen cadavers were included. The R-PM approach was used first and the boundary of the posterior tibial cortex exposure was marked with metal pins. With the same specimens, the PL approach was then performed and the exposure area was marked. After removing all soft tissue, an imaginary line was drawn from the lateral plateau rim anterior to the fibular head (L) to the posteromedial ridge of the tibia (M). Additional metal pins were used to indicate bony reference landmarks at the joint line on the posterior tibial plateau, including the lateral tibial spine (S), the lateral boundary with the PM approach (_LPM) and the lateral boundary with the PL approach (_LPL). All distances were measured using S as the reference point.

RESULTS

The average distance from S to L, referred to as the lateral plateau width (A), was 32.62 mm. The average distances from S to _LPM (B) and from S to _LPL measured as a percentage of A were 43.72 and 81.41%, respectively. The average R-PM approach blind distance from _LPM to _LPL (C) as a percentage of the lateral plateau width was 58.45%, while the distance _LPL to L (D), which represents the invisible blind distance with both approaches, was 15.37% of that width.

CONCLUSIONS

The PL approach provides better access for buttressing the posterolateral tibial plateau fracture than the R-PM approach. With the R-PM approach, the blind area on the lateral plateau which can be accessed only by the PL approach starts approximately at 43.72% and ends at 81.41% of the lateral tibial plateau width. When a fracture is located in this zone, the posterolateral approach is recommended.

Anterolateral tibial plateau osteotomy as a new approach for the treatment of posterolateral tibial plateau fracture: A case report

RATIONALE

It is challenging to visualize and reduce a posterolateral tibial plateau fracture through an anterolateral approach as the tibial plateau fragments are often covered by the fibular head and ligamentous structures.

PATIENT CONCERNS

In this case report, we describe a patient with a depression fracture of the posterolateral quadrant combined with a split fracture of the posteromedial quadrant and an avulsion fracture of the tibial intercondylar eminence.

DIAGNOSES

Tibial plateau fracture(AO type 41-B3).

INTERVENTIONS

A posteromedial approach combined with an anterolateral approach and an osteotomy involving the proximal tibiofibular joint of the tibial plateau was used to expose, reduce, and fix the fracture.

OUTCOMES

There was no risk of injury to the common peroneal nerve or ligaments. The patient is recovering well and is satisfied with the function of the injured knee.

LESSONS

We recommend anterolateral tibial plateau osteotomy for the treatment of posterolateral tibial plateau fractures in clinical practice.

Reinforcement strategy for lateral rafting plate fixation in posterolateral column fractures of the tibial plateau: The magic screw technique

BACKGROUND

A posterolateral column fracture of the tibial plateau (PLCF) is not uncommon, especially lateral and bicondylar tibial plateau fractures. Currently, there is no consensus on the methods of surgical treatment for PLCF, including the surgical approach or the fixation strategy. Though various posterior approaches have been explored and can allow posterior buttress plate fixation, the necessity of a posterior approach with fixation for PLCFs is increasingly questioned. Meanwhile, there is no literature to analyse the morphological features of PLCFs. None of the available surgical techniques can solve all of the problems of PLCFs.

METHODS

From February 2016 to June 2016, an inconsecutive series of 16 patients who suffered Schatzker type II tibial plateau fractures involving the posterolateral column were selected based on an analysis of the morphological characteristics of PLCFs. The patients were all treated by lateral rafting plate fixation with magic screw implantation through the extended lateral approach.

RESULTS

According to PLCF morphology, 4 patients had mild slope-type depression fractures (MSDF) of the articular surface, and the other 12 patients had block-type splitting fractures (BSF). After a 12-month follow-up period, there were no complications related to the fixation technique and no significant changes in limb alignment. At the final follow-up, the average range of motion (ROM) of the affected knees was 2.3°-125°, and the average HSS score was 94.2.

CONCLUSIONS

The selected patients who suffered Schatzker type II fractures involving the posterolateral column could be successfully treated via lateral rafting plate fixation with the magic screw technique. For PLCF treatment, magic screw fixation is a valuable technique that may reduce the utilization of posterior approaches and posterior fixations.

Partial proximal tibia fractures

Partial tibial plateau fractures may occur as a consequence of either valgus or varus trauma combined with a rotational and axial compression component.

High-energy trauma may result in a more complex and multi-fragmented fracture pattern, which occurs predominantly in young people. Conversely, a low-energy mechanism may lead to a pure depression fracture in the older population with weaker bone density.

Pre-operative classification of these fractures, by Müller AO, Schatzker or novel CT-based methods, helps to understand the fracture pattern and choose the surgical approach and treatment strategy in accordance with estimated bone mineral density and the individual history of each patient.

Non-operative treatment may be considered for non-displaced intra-articular fractures of the lateral tibial condyle. Intra-articular joint displacement ⩾ 2 mm, open fractures or fractures of the medial condyle should be reduced and fixed operatively. Autologous, allogenic and synthetic bone substitutes can be used to fill bone defects.

A variety of minimally invasive approaches, temporary osteotomies and novel techniques (e.g. arthroscopically assisted reduction or ‘jail-type’ screw osteosynthesis) offer a range of choices for the individual and are potentially less invasive treatments.

Rehabilitation protocols should be carefully planned according to the degree of stability achieved by internal fixation, bone mineral density and other patient-specific factors (age, compliance, mobility). To avoid stiffness, early functional mobilisation plays a major role in rehabilitation. In the elderly, low-energy trauma and impression fractures are indicators for the further screening and treatment of osteoporosis.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160067. Originally published online at www.efortopenreviews.org

The anatomical relationship of the neurovascular structures in direct posterior lateral gastrocnemius split approach for posterolateral tibial plateau fractures

PURPOSE

To evaluate the distances between the incision and neurovascular structures in direct posterior split-gastrocnemius approach for tibial plateau fractures.

METHODS

Thirteen fresh-frozen cadavers were used in the study. The distance between the neurovascular structures medial and lateral to the incision was measured from the tibial joint line and at a level 5 cm distal to the joint line.

RESULTS

The mean distance between the incision and medial neurovascular structures was 10.09 ± 3.47 mm (range 5.63-16.51 mm) at the level of the tibial joint line and 10.39 ± 2.57 mm (range 5.79-14.09 mm) at a level 5 cm distal to the joint line. The mean distance between the incision and the common peroneal nerve was 13.44 ± 4.17 mm (range 6.28-20.72 mm) at the level of the tibial joint line and 19.56 ± 5.24 mm (range 12.58-26.74 mm) at a level 5 cm distal to the joint line.

CONCLUSIONS

In isolated posterolateral tibial plateau fractures, it is possible to apply anatomical reduction and buttress plating on the posterior surface with a direct posterior split-gastrocnemius approach. With a thorough understanding of the regional anatomy, this approach can be safely performed by experienced orthopaedists.

Treatment strategy for tibial plateau fractures: an update

Tibial plateau fractures are complex injuries produced by high- or low-energy trauma. They principally affect young adults or the 'third age' population.These fractures usually have associated soft-tissue lesions that will affect their treatment. Sequential (staged) treatment (external fixation followed by definitive osteosynthesis) is recommended in more complex fracture patterns. But one should remember that any type of tibial plateau fracture can present with soft-tissue complications.Typically the Schatzker or AO/OTA classification is used, but the concept of the proximal tibia as a three-column structure and the detailed study of the posteromedial and posterolateral fragment morphology has changed its treatment strategy.Limb alignment and articular surface restoration, allowing early knee motion, are the main goals of surgical treatment. Partially articular factures can be treated by minimally-invasive methods and arthroscopy is useful to assist and control the fracture reduction and to treat intra-articular soft-tissue injuries.Open reduction and internal fixation (ORIF) is the gold standard treatment for these fractures. Complex articular fractures can be treated by ring external fixators and minimally-invasive osteosynthesis (EFMO) or by ORIF. EFMO can be related to suboptimal articular reduction; however, outcome analysis shows results that are equal to, or even superior to, ORIF. The ORIF strategy should also include the optimal reduction of the articular surface.Anterolateral and anteromedial surgical approaches do not permit adequate reduction and fixation of posterolateral and posteromedial fragments. To achieve this, it is necessary to reduce and fix them through specific posterolateral or posteromedial approaches that allow optimal reduction and plate/screw placement.Some authors have also suggested that primary total knee arthroplasty could be an option in specific patients and with specific fracture patterns. Cite this article: Prat-Fabregat S, Camacho-Carrasco P. Treatment strategy for tibial plateau fractures: an update. EFORT Open Rev 2016;1:225-232. DOI: 10.1302/2058-5241.1.000031.