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

Rim Plating of Posterolateral Fracture Fragments (PLFs) Through a Modified Anterolateral Approach in Tibial Plateau Fractures

Posterolateral fracture fragments in tibial plateau fractures have proven to be particularly difficult to reduce and adequately repair internally through anterior or anterolateral approaches, although they are safer. Posterior and posterolateral approaches offer a direct approach for the reduction and fixation of plates, but they have several limitations. Here, we have proposed a modified anterolateral approach, which ensures a safe and effective technique for the reduction and fixation of posterolateral fracture fragments, aided by our innovative rim plate.

Intra-articular tibial plateau fracture characteristics according to the "Ten segment classification"

BACKGROUND

Currently existing classifications of tibial plateau fractures do not help to guide surgical strategy. Recently, a segment-based mapping of the tibial plateau has been introduced in order to address fractures with a fracture-specific surgical approach. The goal of the present study was to analyze incidence and fracture specifics according to a new 10-segment classification of the tibial plateau.

METHODS

A total of 242 patients with 246 affected knees were included (124 females, 118 males, mean age 51.9±16.1years). Fractures were classified according to the OTA/AO classification. Fracture pattern was analyzed with respect to a 10-segment classification based on CT imaging of the proximal tibial plateau 3cm below the articular surface.

RESULTS

161 Patients suffered an OTA/AO type 41-B and 85 patients an OTA/AO type 41-C tibial plateau fracture. Females had an almost seven times higher risk to suffer a fracture due to low-energy trauma (OR 6.91, 95% CI (3.52, 13.54), p<0.001) than males. In 34% of the patients with affection of the medial tibial plateau, a fracture comminution, primarily due to low-energy trauma (p<0.001), was observed. In type B fractures, the postero-latero-lateral (65.2%), the antero-latero-lateral (64.6%) and the antero-latero-central (60.9%) segment were most frequently affected. Every second type C fracture showed an unique fracture line and zone of comminution. The tibial spine was typically involved (89.4%). A typical fracture pattern of high-energy trauma demonstrated a zone of comminution of the lateral plateau and a split fracture in the medial plateau. The most frequently affected segments were the postero-latero-central (85.9%), postero-central (84.7%), and antero-latero-central (78.8%) segment.

CONCLUSION

Posterior segments were the most frequently affected in OTA/AO type B and C fractures. Acknowledging the restricted visibility of posterior segments, whose reduction and fixation is crucial for long-term success, our findings implicate the use of posterior approaches more often in the treatment of tibial plateau fractures. Also, low-energy trauma was identified as an important cause for tibial plateau fractures.

A combined approach for the treatment of lateral and posterolateral tibial plateau fractures

INTRODUCTION

The treatment of tibial plateau fractures involving the lateral and posterolateral column is a demanding and fine surgical challenge. The purpose of this study was to evaluate the safety and clinical efficacy of combined approach for the treatment of lateral and posterolateral tibial plateau fractures.

METHODS

A prospective study was performed in 17 patients with lateral and posterolateral tibial plateau fractures between January 2009 and December 2012. There were 12 males and 5 females with a mean age of 40 years. All of them received dual-plate fixation through the combined approach, with the patients in a floating position. The combined approaches included a conventional anterolateral approach and an inverted L-shaped posterolateral approach. Operation time, intraoperative blood loss, fracture healing time, Hospital for Special Surgery (HSS) knee score, knee flexion and extension range of motion, and complications were recorded to evaluate treatment effects.

RESULTS

There were no intraoperative complications related to this technology. Mean operation time was 144min with a mean intraoperative blood loss volume of 233mL. The mean follow-up was 23 months. All 17 patients had good postoperative fracture healing. Mean union time was 12 weeks. At the final follow-up, the average HSS score was 92.5, with the average knee flexion of 125° and an average knee extension of 2°. Two patients had complications in postoperative incisions with aseptic fat liquefaction. After thorough debridement, second-stage wounds healing were achieved. No neurovascular injury occurred. No collapse of reduced articular surface was detected.

CONCLUSIONS

The combined approach with dual-plate offers direct and complete surgical exposure and provide an effective method for the treatment of lateral and posterolateral tibial plateau fractures.

Complications and outcomes of the transfibular approach for posterolateral fractures of the tibial plateau

OBJECTIVE

Evaluate complication rates and functional outcomes of fibular neck osteotomy for posterolateral tibial plateau fractures.

DESIGN

Retrospective case series.

SETTING

University hospital.

PATIENTS

From January 2013 to October 2014, 11 patients underwent transfibular approach for posterolateral fractures of the tibial plateau and were enrolled in the study. All patients who underwent transfibular approach were invited the return to the hospital for another clinical and imaging evaluation.

INTERVENTION

Transfibular approach (fibular neck osteotomy) with open reduction and internal fixation for posterolateral fractures of the tibial plateau.

MAIN OUTCOME MEASUREMENTS

Complications exclusively related to the transfibular approach: peroneal nerve palsy; knee instability; loss of reduction; nonunion and malunion of fibular osteotomy; and functional outcomes related to knee function.

RESULTS

Two patients failed to follow-up and were excluded from the study. Of the 9 patients included in the study, no patients demonstrated evidence of a peroneal nerve palsy. One patient presented loss of fracture reduction and fixation of the fibular neck osteotomy, requiring revision screw fixation. There were no malunions of the fibular osteotomy. None of the patients demonstrated clinically detectable posterolateral instability of the knee following surgery. American Knee Society Score was good in 7 patients (77.8%), fair in 1 (11.1%), and poor in 1 (11.1%). American Knee Society Score/Function showed 80 points average (60-100, S.D:11).

CONCLUSION

The transfibular approach for posterolateral fractures is safe and useful for visualizing posterolateral articular injury. The surgeon must gently protect the peroneal nerve during the entire procedure and fix the osteotomy with long screws to prevent loss of reduction.

LEVEL OF EVIDENCE

Therapeutic level IV.

[Posttraumatic deformities of the knee joint : Intra-articular osteotomy after malreduction of tibial head fractures]

Malreduction of tibial head fractures often leads to malalignment of the lower extremity, pain, limited range of motion and instability. The extent of the complaints and the degree of deformity requires an exact analysis and a standardized approach. True ligamentous instability should be distinguished from pseudoinstability of the joint. Also extra- and intra-articular deformities have to be differentiated. In intra-articular deformities the extent of articular surface displacement, defects and clefts must be accurately evaluated. A specific surgical approach is necessary, which allows adequate visualization, correct osteotomy and refixation of the fractured area of the tibial head. In the long-term course good clinical results are described for intra-articular osteotomies. If the joint is damaged to such an extent that it cannot be reconstructed or in cases of advanced posttraumatic osteoarthritis, total knee arthroplasty may be necessary; however, whenever possible and reasonable, anatomical reconstruction and preservation of the joint should be attempted.

The morphological features of different Schatzker types of tibial plateau fractures: a three-dimensional computed tomography study

BACKGROUND

Tibial plateau fractures are of great challenge to treat with open reduction and internal fixation, because fractures vary from simple to complex, with little or extensive articular involvement. Hence, recognition and comprehension of the fracture features will help orthopedic surgeons understand the injury mechanism better and manage these fractures by planning optimal surgical procedures. This study aimed to evaluate the morphological characteristics of tibial plateau fractures based on the Schatzker classification.

METHODS

A total of 186 patients with 188 tibial plateau fractures from 2010 to 2014 in our hospital were reviewed using a computed tomography scan and three-dimensional (3D) reconstruction. The main fracture line angles (FLA) of Schatzker types I, II, and IV were measured. For each fracture, depression depth was measured, and the depression zone was also located. Depression zones were overlapped to obtain a frequency diagram.

RESULTS

Schatzker type I and II fractures had three subtypes: single anterolateral fracture, single posterolateral fracture, and complex fracture (the anterolateral and posterolateral parts). Schatzker type IV fractures were also divided into three subtypes: single posteromedial fracture, single anteromedial fracture, and the whole medial fracture. For various Schatzker types and subtypes of fracture, fracture depression clustered and occurred at different locations of the tibial plateau. A significant difference was observed in the depression depth among the different Schatzker types (P < 0.01, Kruskal-Wallis test), especially between Schatzker type III and other types (Nemenyi test). There was no difference in the depression depth among the subtypes of Schatzker type II, whereas the difference was significant between the two subtypes of Schatzker type IV.

CONCLUSIONS

Schatzker type I, II, and IV fractures could be divided into three corresponding subtypes by FLA. Various Schatzker types of fractures differed in location and depth of depression. A proper operative approach should be made based on the morphological characteristics of individual types of tibial plateau fractures.

"Fracturoscopy" is Superior to Fluoroscopy in the Articular Reconstruction of Complex Tibial Plateau Fractures-An Arthroscopy Assisted Fracture Reduction Technique

OBJECTIVE

To analyze the anatomic accuracy of fracture reduction controlled by fluoroscopy as compared with arthroscopically assisted reduction ("fracturoscopy") in patients with complex tibial plateau fractures (AO/OTA 41-C). Quality of fracturoscopy-guided reduction was checked with postoperative computed tomography.

DESIGN

Prospective observational study.

SETTING

Urban level 1 trauma center.

PATIENTS

Seventeen consecutive patients, with a complex, bicondylar tibial plateau fracture.

INTERVENTION

The intraoperative, open insertion of an arthroscope (2.4-mm or 2.8-mm optics), to visualize the articular surface and fracture reduction.

MAIN OUTCOME MEASUREMENTS

Ability to detect residual fracture depression or gap after previous open reduction under fluoroscopic guidance.

RESULTS

An open fracture reduction with fluoroscopic guidance was performed in all cases. In 7 cases, open reduction and fluoroscopy resulted in satisfactory fracture reduction (fluoroscopy group). In 10 of 17 cases, subsequent "fracturoscopy" showed persistent fracture depression (≥2 mm, fracturoscopy group) with the need for intraoperative correction. Patients in the fracturoscopy group demonstrated significantly greater preoperative fragment depression (12.55 ± 6.56 mm) and a larger preoperative fracture gap (7.83 ± 5.49 mm) compared with patients with a satisfactory reduction under fluoroscopy (depression 4.97 ± 4.02 mm, P = 0.016; gap 2.47 ± 1.07 mm, P = 0.023). Fluoroscopy was not successful in achieving satisfactory reduction in cases in which the postero-latero-central region was affected (P = 0.004, χ test). Postoperative computed tomography demonstrated satisfactory articular reconstruction in all cases.

CONCLUSIONS

Intraoperative fracturoscopy permitted a significantly improved visualization of fracture fragment displacement, specifically in the postero-latero-central region of the tibial plateau, as compared with fluoroscopy. Fracturoscopy is recommended for fractures involving the postero-latero-central region of the tibial plateau.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Predictors of reduction loss in tibial plateau fracture surgery: Focusing on posterior coronal fractures

INTRODUCTION

Some studies have reported that fracture pattern was associated with reduction loss after surgery. The purpose of this study was to evaluate various factors that can influence reduction loss, including fracture patterns in unicondylar and bicondylar tibial plateau fractures.

MATERIALS AND METHODS

A total of 138 tibial plateau fractures that underwent open reduction and internal fixation using plates were retrospectively reviewed. The OTA/AO classification, fracture pattern, degree of comminution, and existence of reduction loss were evaluated based on simple radiographs and computed tomography. Patient information, including age, gender, and occupation, were acquired through chart reviews. The effect of each variable on reduction loss was evaluated through multiple logistic regression analysis.

RESULTS

Of 138 knees, reduction loss was observed in 40 knees (29.0%). Reduction loss was found in 11 (20.4%) of the type B knees (54 knees) and 29 (34.5%) of the type C knees (84 knees), according to the OTA/AO classification. The multiple logistic regression analysis for all cases revealed that the existence of comminution and coronal fracture influenced the occurrence of reduction loss, with odds ratios of 9.148 and 4.823, respectively (P<0.001 and P=0.001, respectively). In type B and type C, according to the OTA/AO classification, the existence of comminution and coronal fracture had causal relationships with the occurrence of reduction loss. The odds ratios of comminution and coronal fracture for reduction loss for type B were 9.114 and 9.117, respectively (P=0.019 and P=0.031, respectively), and the odds ratios for type C were 8.490 and 4.782, respectively (P=0.001 and 0.009, respectively).

CONCLUSIONS

When a tibial plateau fracture has a coronal fracture, if it is difficult to fix its fragments rigidly with medial or lateral plate fixation; therefore, buttress plating or direct fixation of fragments through the posteromedial, posterolateral, or posterior approach should be considered.

The extended posterolateral approach for split depression lateral tibial plateau fractures extending into the posterior column: 2 years follow up results of a prospective study

OBJECTIVE

To prospectively study the outcome of surgically treated split depression lateral tibial plateau fractures extending into the posterior column using the extended posterolateral approach.

METHODS

Twenty-one patients with split depression lateral tibial plateau fractures (AO: 41-B3) with extension into the posterior column were treated with open reduction and internal fixation through an extended posterolateral approach with osteotomy of the fibular neck±Gerdy tubercle. Follow up radiographs was assessed for quality of articular reduction and limb axis. Functional assessment was performed at last follow up using the Tegner-Lysholm score. Complications pertaining to the surgical approach were recorded.

RESULTS

The approach was performed in 15 patients with a fibular neck osteotomy alone and 6 patients required a Gerdy's tubercle osteotomy also. All fractures and osteotomies had united. Anatomical articular reduction was achieved in 16 patients. Radiological limb alignment was restored in all patients except for a reversed posterior slope in 1 patient. Arthritic changes were seen in 3 patients. The mean Tegner-Lysholm score was 87.3 (range: 76-95) at last follow up. No specific complications related to the surgical approach like common peroneal nerve injury and lateral instability of the knee was encountered.

CONCLUSION

The extended posterolateral approach offers excellent exposure posterior to the fibular head to perform articular reduction and fixation achieving satisfactory radiological and functional results in split depression lateral tibial plateau fractures extending into the posterior column.

What's new in the management of complex tibial plateau fractures?

The management of complex tibial plateau fractures is ever evolving. The severity of the injury to the surrounding soft tissues influences the timing and the method of fixation. Minimal invasive techniques continue to dominate our philosophy of reduction and reconstruction whereas augmentation of depressed intra-articular fragments remains an accepted strategy to maintain reduction and prevent secondary collapse. Locking plates, conventional plates and fine wire fixators all have been used successfully with satisfactory outcomes. In this article we report on the latest advances made in the management of these complex injuries.

The anterolateral supra-fibular-head approach for plating posterolateral tibial plateau fractures: A novel surgical technique

OBJECTIVE

The posterolateral (PL) tibial plateau quadrant is laterally covered by the fibular head and posteriorly covered by a mass of muscle ligament and important neurovascular structures. There are several limitations in exposing and fixing the PL tibial plateau fractures using a posterior approach. The aim of this study is to present a novel anterolateral supra-fibular-head approach for plating PL tibial plateau fractures.

METHODS

Five fresh and ten preserved knee specimens were dissected to measure the following parameters:1) the vertical distance from the apex of the fibular head to the lateral plateau surface, 2) the transverse distance between the PL platform and fibula collateral ligament (FCL), and 3) the tension of the FCL in different knee flexion positions. Clinically, isolated PL quadrant tibial plateau fractures were treated via an anterolateral supra-fibular-head approach and lateral rafting plate fixation. The outcome of the patients was assessed after a short to medium follow-up period.

RESULTS

The distance from the apex of the fibular head to the lateral condylar surface was 12.2 ± 1.6 mm on average. With the knee extended and the FCL tensioned, the transverse distance between the PL platform and the FCL was 6.7 ± 1.1 mm. With the knee flexed to 60° and the FCL was in the most relaxed position, the distance increased to 21.1 ± 3.0 mm. Clinically, a series of 7 cases of PL tibial plateau fractures were treated via this anterolateral supra-fibular-head approach. The patient was placed in a lateral decubitus position with the knee flexed to approximately 60 degrees. After the posterior retraction of the FCL, the plate was placed more posteriorly to provide a raft or horizontal belt fixation of the PL tibial plateau fragment. After an average of 14.3 months of follow up, the knee range of motion(ROM) was 121.4° ± 8.8° (range: 105°-135°), the HSS score was 96.7 ± 2.6 (range: 90-100), and the SMFA dysfunction score was 22.4 ± 3.8 (range: 16-28) points.

CONCLUSION

The anterolateral supra-fibular-head approach can provide direct visualization of the posterolateral tibial plateau quadrant and put the plate more posteriorly to provide a raft for the fragments such that good clinical outcomes can be anticipated.

Results of a modified posterolateral approach for the isolated posterolateral tibial plateau fracture

BACKGROUND

There are few posterolateral approaches that do not require the common peroneal nerve (CPN) dissection. With the nerve exposure, it would pose a great challenge and sometimes iatrogenic damage over the surgical course. The purpose was to present a case series of patients with posterolateral tibial plateau fractures treated by direct exposure and plate fixation through a modified posterolateral approach without exposing the common peroneal nerve (CPN).

MATERIALS AND METHODS

9 consecutive cases of isolated posterior fractures of the posterolateral tibial plateau were operated by open reduction and plate fixation through the modified posterolateral approach without exposing the CPN between June 2009 and January 2012. Articular reduction quality was assessment according to the immediate postoperative radiographs. At 24 month followup, all patients had radiographs and were asked to complete a validated outcome measure and the modified Hospital for Special Surgery (HSS) Knee Scale.

RESULTS

All patients were followedup, with a mean period of 29 months (range 25-40 months). Bony union was achieved in all patients. In six cases, the reduction was graded as best and in three cases the reduction was graded as middle according to the immediate postoperative radiographs by the rank order system. The average range of motion arc was 127° (range 110°-134°) and the mean postoperative HSS was 93 (range 85-97) at 24 months followup. None of the patients sustained neurovascular complication.

CONCLUSIONS

The modified posterolateral approach through a long skin incision without exposing the CPN could help to expand the surgical options for an optimal treatment of this kind of fracture, and plating of posterolateral tibial plateau fractures would result in restoration and maintenance of alignment. This approach demands precise knowledge of the anatomic structures of this region.

Open Reduction and Internal Fixation of the Isolated Tibial Lateral Plateau Posterior Fracture Using Direct Posterior Split Gastrocnemius Approach

Open reduction and internal fixation of the isolated tibial lateral plateau posterior fractures using direct posterior split gastrocnemius approach is a safe and effective method.

A posterior reversed L-shaped approach for the tibial plateau fractures-A prospective study of complications (95 cases)

PURPOSE

This study was aiming to investigate intraoperative and postoperative complications and outcomes of a posterior reversed L-shaped approach (PRLA) in the treatment of the tibial plateau fractures.

METHODS

Inclusion criterion was tibial plateau fractures treated through the PRLA either separated or combined with other approaches. Main exclusion criterion was poly-trauma patients. Ninety-five patients with tibial plateau fractures from a prospectively collected database were included and followed in this study. The intraoperative and postoperative complications consisted of vascular and nerve injury, wound infection, dehiscence, haematoma, nonunion, skin necrosis and skin paresthesia. Hospital for Special Surgery Knee Score (HSS) was adopted to evaluate patients' knee function while Short Form 36 Health Survey (SF-36) was used to investigate the patients' general health status.

RESULTS

Patients' average age was 46.2 years old (range, 22.0-89.0). The fractures were mainly from high energy injuries involving posterior (and medial) column. 78 of 95 cases were combined with an additional anterolateral approach due to the lateral column involvement. The average follow-up was 52.0 months (range, 12.4-102.6). The total complications rate was 4.2% (4/95). Intraoperative complications occurred in two patients (2.1%). One suffered a popliteal artery injury resulted from an antero-posteriorly drilled K-wire. The patient had a loss of 7° knee extension at one year's follow-up. The other endured an injury of nutrient vessel within the medial head of gastrocnemius. Postoperative skin paresthesia occurred in two patients (2.1%). The other complications associated with the PRLA were not observed. The mean HSS score was 96.1 (range, 80-100). The mean SF-36 score was 94.2 (range, 80-100).

CONCLUSIONS

The posterior reversed L-shaped approach allows satisfied visualization of the medial and posterior tibial plateau and has promising clinical results with low complication occurrence. It can be recommended as a routine approach for the treatment of the tibial plateau fractures involving the posterior column.

Prone and direct posterior approach for management of posterior column tibial plateau fractures

INTRODUCTION

The three-column fixation concept is becoming popular in orthopedic practice. Posterior column fracture is an uncommon type of tibial plateau fracture. The supine position for the surgical approach is familiar to most surgeons; however, it is difficult to achieve good reduction and fixation in posterior column fracture.

HYPOTHESES

The prone position and direct posterior approach can achieve proper reduction and fixation for posterior column tibial plateau fracture, yielding good functional outcome.

MATERIALS AND METHODS

Between January 2010 and January 2012, 184 tibial plateau fractures were diagnosed and operated on in our institution. Sixteen posterior column tibial plateau fractures (10 male and 6 female patients, with a mean age of 41.5 ± 14.3 years) were diagnosed by preoperative plain films and CT scans. Ten patients presented with fracture-dislocation of the knee joint. A direct posterior approach in prone position was used to reduce the tibial condyle and fix it with an anti-glide buttress plate. Radiographic evaluation included reduction quality and bone union. Functional evaluation included Lysholm score and Tegner activity score.

RESULTS

All fractures healed within 6 months, without secondary displacement. Ten knees had postoperative anatomic reduction (0mm step-off) and 6 had acceptable reduction (< 2mm step-off). At 34.4 ± 9.6 months, median extension was 3 (5-10) and flexion 135 (100-145). The mean Lysholm score was 95 (75-100) and the mean Tegner activity score was 6 (5-8). All patients were satisfied with the operation. No cases of post-traumatic osteoarthritis of the knee occurred during follow-up.

CONCLUSIONS

The prone position and direct posterior approach has great advantages in terms of reduction and stable fixation, yielding good results.

Morphologic study of posterior articular depression in Schatzker IV fractures

The Schatzker classification of tibial plateau fractures is widely accepted. Type IV fractures are medial tibial plateau fractures that are either split off as a wedge fragment or depressed and comminuted. Posterior articular surface depression in Schatzker type IV tibial plateau fractures can be seen as a unique variant that increases the difficulty of reduction of the articular surface. Its morphologic characteristics have not been fully studied, and the incidence is sometimes underestimated. The goal of this study was to evaluate the morphologic characteristics of posterior articular depression in Schatzker type IV fractures based on computed tomography measurements. From January 2009 to December 2011, the medical records, including digital radiologic data, of all patients treated for tibial plateau fracture at the authors' institution were retrospectively analyzed. Articular surface depression deeper than 5 mm was the criterion for study inclusion. The depression depth, precise location of the articular depression center, surface area percentage, and distance of the fracture gap to the depression center were calculated. One hundred fifteen cases of Schatzker type IV fracture were retrieved, and a total of 47.83% (55 of 115) cases had posterior articular surface depression. The average depth of the depressed articular surface was 12.41 mm, the surface area percentage was 20.15% of the entire tibial plateau, and the gap distance from the medial direction was 41.40 mm, 2.8 times longer than that from the posterior direction, which was 14.91 mm. Posterior articular surface depression occurs in nearly half of Schatzker type IV fractures, and the posterior approach provides more direct access to the depression than the medial approach.

Combined lateral femoral epicondylar osteotomy and a submeniscal approach for the treatment of a tibial plateau fracture involving the posterolateral quadrant

Exposure of a tibial plateau fracture involving the posterolateral quadrant is challenging, and several approaches for treating these fractures have been introduced. However, these approaches may have limited applicability, and they can potentially cause neurovascular, musculotendinous, or ligamentous injury of the posterolateral corner. Lateral femoral epicondylar osteotomy has been used for meniscal transplantation, total knee arthroplasty, and the treatment of posterolateral articular disorders of the femur and tibia. We encountered a case of a tibial plateau fracture involving the posterolateral quadrant without an anterior-extending fracture line. We successfully exposed, reduced, and fixed the fracture using combined lateral femoral epicondylar osteotomy and a submeniscal approach. This combined modality can be used as an alternative surgical technique for the treatment of tibial plateau fractures involving the posterolateral quadrant.

Incidence and fracture morphology of posterolateral fragments in lateral and bicondylar tibial plateau fractures

OBJECTIVES

This study aimed to evaluate the incidence and morphologic features of posterolateral fragments in lateral and bicondylar tibial plateau fractures.

DESIGN

This study used retrospective chart and computed tomography (CT) reviews.

SETTING

The study was conducted in a university hospital.

PATIENTS

All patients in whom lateral and bicondylar tibial plateau fractures had been diagnosed from May 2005 to December 2011 were reviewed.

MAIN OUTCOME MEASUREMENTS

Two hundred seventy-eight OTA type B and type C tibial plateau fractures were identified using a retrospective chart review. Of the 197 patients who underwent CTs before surgery, 7 CTs were excluded because they had no sagittal or axial view, and the remaining 190 cases were enrolled to determine the incidence and morphologic characteristics of posterolateral fragments. The parameters for the morphologic evaluation included the lateral major articular fracture angle, posterior major articular fracture angle, diagonal distance, lateral anteroposterior distance (LAPD), posterior horizontal distances, posterior cortical height, sagittal fracture angle, and articular surface area. The displacement of posterolateral fragment was measured on axial image and classified as none, minor, or major by a gap of 5 mm.

RESULTS

The incidence of posterolateral fragments included 84 cases (44.2%). Based on the OTA fracture classification system, 37 type B (35.9%) and 47 type C (54%) posterolateral fragments were identified. The mean lateral major articular fracture angle was 12.69 degrees (range, -56.02 to 72.44 degrees), and the mean posterior major articular fracture angle was 19.13 degrees (range, -39.47 to 61.10 degrees). The average diagonal distance was 32.75 mm (range, 15.03-59.14 mm). The LAPD averaged 10.22 mm (range, -11.18 to 31.17 mm), and the mean posterior horizontal distance was 22.93 mm (range, 4.1 to 49.95 mm). The average posterior cortical height was 31.12 mm (range, 10.84-63.93 mm), and the average sagittal fracture angle was 78.48 degrees (range, 41.69-105.12 degrees). The mean articular surface area was 522.18 mm2 (14.5%) of the total tibial articular surface.

CONCLUSIONS

Posterolateral fragments are not uncommon in lateral and bicondylar tibial plateaus. This fragment has an inverted conical shape that is in a vertically oriented pattern and occupied nearly one-third of the surface area of the lateral tibial plateau. The preoperative CT measurement, especially for the LAPD, can be used for determining the best fixation strategy for the posterolateral fragment.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Combined approaches for fixation of Schatzker type II tibial plateau fractures involving the posterolateral column: a prospective observational cohort study

INTRODUCTION

This study aimed to investigate the surgical techniques and the clinical efficacy of combined approaches for the treatment of Schatzker type II tibial plateau fractures involving the posterolateral column [lateral and posterolateral columns (LPCs) fractures] in a prospective cohort.

MATERIALS AND METHODS

From January 2007 through December 2010, a total of 65 patients with LPCs underwent dual-plate fixation via a combined anterior and posterior approach. The anterior and posterior approaches were the conventional anterolateral approach and a posteromedial inverted L-shaped approach, respectively, with the patients in a floating position.

RESULTS

Ultimately, 41 patients were followed up for a mean period of 52.5 months. All fractures healed. The mean time to radiographic bony union was 15.2 weeks and the mean time to full weight-bearing was 18.7 weeks. No parameter associated with knee alignment changed significantly between immediately postoperation and 2 years postoperation. No collapse of the reduced articular surface was detected. Two years postoperation, the mean Hospital for Special Surgery score was 92.3; the mean Short Form-36 score was 90.1, and the mean range of knee motion was 1.7°-123.6° (extension-flexion). Two patients suffered dehiscence of the anterolateral incision and another suffered partial necrosis at the margin of the posteromedial incision postoperatively. All healed in response conservative treatment. Another two patients experienced numbness in the posteromedial inferior region of the calf. No implant loosening, breakage, fixation failure, or other complication was observed during follow-up.

CONCLUSIONS

LPCs are not uncommon. Careful preoperative analysis of computed tomography images and impeccable preparation are necessary to avoid neglecting a posterolateral column fracture. It is inappropriate to generalize one scenario for all Schatzker type II fractures: a single approach cannot address all subtypes of these fractures. Dual-plate fixation via a combined approach is an effective treatment for LPCs.

Open reduction and internal fixation of posterolateral tibial plateau fractures through fibula osteotomy-free posterolateral approach

OBJECTIVE

To evaluate the outcome of patients with posterolateral tibial plateau fractures after open reduction and internal fixation with a fibula osteotomy-free posterolateral approach.

DESIGN

Retrospective chart and operation note review.

SETTING

A medical college-affiliated tertiary hospital.

MATERIALS AND METHODS

A retrospective chart and radiographic review of posterolateral tibial plateau fractures treated with a posterolateral approach between January 2006 and July 2010 was performed. The primary (ie, the total Rasmussen function score) and secondary (ie, the postoperative infection, knee deformity, and complications) outcomes were analyzed.

RESULTS

A total of 32 patients were identified for this study. Patients were followed for an average of 18.2 months (range, 12-36 months); the total Rasmussen function score was 24.8 ± 2.9 points. The results were rated as excellent (≥27 points) in 19 patients, good (20-26 points) in 11, and fair (10-19 points) in 2 patients. No wound infections, screw loosening or implant fracture, and nonunion, deformity, or fracture redisplacement were seen. Stretch injury of the common peroneal nerve was found in 1 patient, who obtained recovery 2 months after additional conservative management.

CONCLUSIONS

Adequate open reduction and internal fixation with a fibula osteotomy-free posterolateral approach can attain a satisfactory clinical outcome for patients with posterolateral tibial plateau fractures.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Fibular shaft allograft support of posterior joint depression in tibial plateau fractures

Posterior depression of the lateral articular surface of the tibial plateau can be difficult to elevate and support with morselized bone graft and internal fixation. Progressive collapse after open reduction and internal fixation has been described and can lead to failure in treatment. A standard anterolateral approach to the tibia may not allow direct reduction and stabilization of posterolateral joint depression given the anatomic barriers of the fibular collateral ligament and the proximal tibiofibular articulation. Posterolateral approaches to the tibial plateau have been described and may allow direct reduction of the articular depression. These approaches, however, require dissection close to the common peroneal nerve, and some approaches also require a proximal fibular osteotomy. The use of an intraosseous fibular shaft allograft as an adjunct to open reduction and internal fixation in select cases of depressed posterolateral tibial plateau fractures allows both reduction of the joint and stabilization of the articular segment through a single approach familiar to many orthopaedic surgeons.

An osteotomy anterolateral approach for lateral tibial plateau fractures merged with relatively simple and intact posterolateral corner displacement

Introduction

This study investigates the safety and efficacy of anterolateral (AL) osteotomy for the treatment of lateral tibial plateau fractures merged with relatively simple and intact posterolateral (PL) corner displacement and screens applicable patients.

Methods

Totally, 11 patients with lateral tibial plateau fractures involving the PL corner were included in this study. Of them, seven patients sustained their injuries from motor vehicle accidents (MVAs), three from sports and one from fall from height. All of them received open reduction and internal fixation through the AL approach. Operation time, incision length, range of motion (ROM), Hospital for Special Surgery (HSS) knee score, time of union and complications were retrospectively reviewed. Tibial plateau angle (TPA), lateral posterior slope angle (PSA) and articular step-off reduction after surgery were examined by a radiograph technique.

Results

Statistically, the means of operation time, incision length, ROM and follow-up period were 82 min, 11 cm, 97° and 27 months, respectively. Three patients had slight complications: superficial infection, hardware irritation and secondary valgus deformity, without severe neural or vascular injuries, which revealed the safety and efficacy of the PL treatment. The average HSS knee score was 91.2 (range 86–96). Reduction (mean TPA 87.2° and mean PSA 8.3°) was satisfactory in 10 patients, except for one patient with a radiographic articular step-off of 5 mm (case 10).

Conclusions

The AL approach is safe and effective for lateral tibial plateau fractures involving the PL corner, especially for fractures merged with simple and intact PL corner displacement (depression and/or split).

Morphological measurements of the posterior surface of the normal proximal tibia in a healthy Chinese population

BACKGROUND

To measure and calculate the morphological parameters and determine the anatomical characteristics of the posterior surface of the proximal tibia in a healthy Chinese population.

METHODS

A total of 150 volunteers with normal knees were enrolled. The parameters in the multi-slice spiral computed tomography (MSCT) three-dimensional (3-D) reconstruction images were measured and calculated by two independent qualified observers. The differences and correlation were investigated. The intraclass correlation coefficient (ICC) was used to assess inter-observer reliability.

RESULTS

The posterior margin of the tibial plateau is presented as two superior arc-shapes. The central angles of these arcs were 118°±14° (medial) and 106°±20° (lateral). The radii of these arcs both showed a skewed distribution. The median radii of the arcs were 22 mm in the medial and 20mm in the lateral. There were two significant angles present in the sagittal plane of the posterior cortex of the proximal tibia. The first angles were 39°±7° (medial) and 47°±7° (lateral). The second angles were 39°±4° (medial) and 41°±5° (lateral). Significant differences were observed in the central angles and the first angles but not in the second angles between the medial and lateral. There were no significant differences between different gender groups, and between left and right limbs. All of these parameters exhibited excellent to moderate ICC.

CONCLUSION

Due to the varying anatomic morphology between the postero-medial and postero-lateral surface of the proximal tibia, the internal fixation implants of these two parts should be designed differently.

Posterolateral and anterolateral approaches to unicondylar posterolateral tibial plateau fractures: a comparative study

BACKGROUND

Lateral tibial plateau fractures that are located posterolaterally are difficult to reduce through an anterolateral surgical approach because of the lack of direct visualisation of the fracture. This study compared the results of unicondylar posterolateral tibial plateau fractures in two patient cohorts: one treated through a posterolateral direct approach and the other through an anterolateral indirect approach.

PATIENTS AND METHODS

All nine patients admitted to our hospital, a tertiary care, urban, public hospital in Australia, from 2007 to 2010 with unicondylar posterolateral tibial plateau fractures were treated through a direct posterolateral transfibular approach and prospectively studied. All eight patients admitted from 2004 to 2007 with unicondylar posterolateral tibial plateau fractures were treated through an indirect anterolateral approach and retrospectively reviewed. Fracture reduction and maintenance of reduction were assessed radiographically over 2 years. Knee function was assessed clinically and using the Lysholm score.

RESULTS

Fractures managed through a direct posterolateral transfibular approach were reduced with no measurable articular step on standard radiography and had no loss of reduction over time. By contrast, fractures treated through an indirect anterolateral approach had a median postoperative articular step of 5.5mm (interquartile range=4.5). These displacements worsened over time in six of the eight patients. At 2 years, patients treated through a direct approach had significantly better Lysholm scores than those treated through an indirect approach.

CONCLUSION

This study suggests that a direct posterolateral transfibular approach to unicondylar posterolateral tibial plateau fractures results in improved reduction, stabilisation and functional outcomes at early follow-up compared to an indirect anterolateral approach.

Morphological characteristics of posterolateral articular fragments in tibial plateau fractures

Treatment of posterolateral tibial plateau fractures is controversial, and information regarding this specific fracture pattern is lacking. The purpose of this study was to elucidate the frequency and morphological features of posterolateral articular fragments in tibial plateau fractures. A retrospective radiographic and chart review was performed on a consecutive series of patients who sustained tibial plateau fractures between May 2008 and August 2012. The articular surface area, maximum posterior cortical height, sagittal fracture angle, and amount of displacement were measured on computed tomography scans using the Picture and Archiving Communication System. Thirty-six (15%) of 242 injuries demonstrated a posterolateral fracture fragment comprising a mean 14.3% of the articular surface of the total tibial plateau (range, 8% to 32%). Mean major articular fragment angle was 23° (range, 62° to -43°), mean maximum posterior cortical height was 29 mm (range, 18 to 42 mm), and mean sagittal fracture angle was 77° (range, 58° to 97°). The posterolateral plateau articular fracture fragment has morphological characteristics of a conically shaped fragment with a relatively small articular surface area and sagittal fracture angle. Recognizing these morphological features will help the clinician formulate an effective surgical plan.

Surgical technique: Tscherne-Johnson extensile approach for tibial plateau fractures

BACKGROUND

The standard approach to lateral tibial plateau fractures involves elevation of the iliotibial band (IT) and anterior tibialis origin in continuity from Gerdy's tubercle and metaphyseal flare. We describe an alternative approach to increase lateral plateau joint exposure and maintain iliotibial band insertion to Gerdy's tubercle.

DESCRIPTION OF TECHNIQUE

The approach entails a partial tenotomy of the anterior half of the IT band leaving the posterior IT band insertion attached to Gerdy's tubercle. Fracture lines around Gerdy's tubercle are completed or the tubercle was osteotomized and externally rotated and the joint overdistracted, allowing direct visualization of the joint depression. Joint elevation, grafting, and internal fixation are performed through this window.

METHODS

We retrospectively reviewed 76 patients (two groups), Schatzker Types I to II and IV to VI fractures (66 patients), between 1989 and 2005, and 10 patients, with 10 bicondylar posterior plateau fractures, from 2002 to 2010. All patients were followed a minimum of 12 months (average, 3.9 years; range, 12 months to 10 years). Ten patients, with posterior plateau fractures, received anterolateral plateau intraarticular osteotomy for exposure of centroposterior and posterolateral articular depression.

RESULTS

Average knee ROM was 2° of flexion (range, -3° to 5°) to greater than 120° of flexion (range, 100°-145°). In 66 patients, average articular depression improved from 7.4 mm to 1 mm (range, 0-5 mm) and, in 10 posterior fractures, from 18 mm to 1 mm (range, 0-4.5 mm). Infection occurred in one of the 76 patients; acute débridement and intravenous antibiotics resulted in control of the infection.

CONCLUSIONS

This approach reliably increases direct visualization of the lateral plateau articular fractures and maintains IT band insertion. Articular osteotomy of the anterolateral plateau provides access to extensive posterior plateau fractures.

The risk of injury to the anterior tibial artery in the posterolateral approach to the tibia plateau: a cadaver study

BACKGROUND

Posterolateral tibial plateau shear fractures often require buttress plating, which can be performed through a posterolateral approach. The purpose of this study was to provide accurate data about the inferior limit of dissection.

METHODS

Forty unpaired cadaver adult lower limbs were used. The anterior tibial artery was identified because it coursed through the interosseous membrane. The perpendicular distance from the lateral joint line and fibula head to this landmark was measured.

RESULTS

The anterior tibial artery coursed through the interosseous membrane at 46.3 ± 9.0 mm (range 27-62 mm) distal to the lateral tibial plateau and 35.7 ± 9.0 mm (range 17-50 mm) distal to the fibula head.

CONCLUSIONS

Displaced posterolateral tibial plateau fractures require anatomic reduction and stabilization with a buttress plate. This can be achieved by gaining access to the posterolateral tibial cortex. The distal limit of this dissection can be as little as 27 mm distal to the lateral tibial plateau. Dissection in this region should be carried out with caution.

Morphological characteristics of split-depression fractures of the lateral tibial plateau (Schatzker type II): a computer-tomography-based study

PURPOSE

The objective of this study was to evaluate the morphological characteristics of lateral tibial plateau split-depression fractures (Schatzker type II).

METHODS

A retrospective analysis of radiographic and computed tomographic (CT) data of lateral tibial plateau split-depression fractures from January 2009 to December 2010 was conducted in a level 1 trauma centre. The discontinuity arc, angle of depression centre (ADC), anterior-posterior position of articular depression centre (APDC), surface area percentage (SAP), sagittal angulation and depression depth were measured on CT images using the Picture Archiving and Communication System.

RESULTS

Based on the integrity of posterolateral wall and discontinuity arc, 140 cases of Schatzker type II fracture were divided into two subtypes: intact group (69 cases) and broken group (71 cases). The fracture of the intact group was located in the anterior part of the lateral plateau, the average ADC was 72.13°, APDC was 43.25 % of sagittal diameter, SAP was 22.16 % of total plateau, sagittal angulation was 6.59°and depression depth was 10.80 mm. Of the broken group, the average ADC, APDC, SAP, sagittal angulation and depression depth was 92.45°, 61.84 %, 22.63 %, 9.00° and 10.78 mm, respectively. Forty-seven cases in the broken group had a posterolateral fragment and 15 cases among them had articular depression centered in the posterolateral region. The difference in ADC, APDC and sagittal angulation between the two groups was statistically significant (p < 0.05), while no significant difference was observed for SAP and depression depth.

CONCLUSIONS

Of all the 140 cases in this study, 10.7 % are located in the posterolateral region. An appropriate operative approach and fixation method should be selected based on the individual morphological characteristics of lateral plateau fractures.

Proximal tibial intra-articular osteotomy for treatment of complex Schatzker type IV tibial plateau fractures with lateral joint line impaction: description of surgical technique and report of nine cases

This study presents a retrospective review of 8 patients with 9 cases of an uncommon variant of medial tibial plateau fracture treated with a surgical approach not previously described in the literature. The fracture pattern is characterized by a displaced medial tibial plateau fracture with significant central and posterior impaction of the lateral tibial articular surface but an intact lateral cortex. A novel surgical approach with an intra-articular osteotomy of the lateral tibial plateau was used to facilitate visualization, reduction, and instrumentation of the lateral articular injury. Early clinical and radiographic results of this treatment approach were reviewed. We describe the fracture pattern, surgical technique, and early results and propose this technique as a reasonable alternative for treatment of a challenging clinical entity.

A posterior inverted L-shaped approach for the treatment of posterior bicondylar tibial plateau fractures

OBJECTIVES

To present a case series of patients with posterior bicondylar tibial plateau fractures treated by direct exposure and buttress plate fixation through posterior inverted L-shaped approach.

METHODS

Between August 2007 and July 2010, eight middle aged patients were identified to have posterior bicondylar tibial plateau fractures. All the eight patients underwent direct fracture exposure, reduction under visualization, and buttress plate fixation through posterior inverted L-shaped approach.

RESULTS

All the cases were followed for an average of 28.1 months (24-36 months). All the cases had satisfactory reduction except one case, which had a 3-mm stepoff postoperatively. None of the complications such as infection, necrosis of the skin incision or the loosening and breakage of the internal fixator occurred. The average radiographic bony union time and full weightbearing time were 11.5 weeks (10-14 weeks), and 13.8 weeks (11-17 weeks) respectively. The average range of motion of the affected knee was from 3.6° to 127.8° at 1 year after the operation.

CONCLUSIONS

The posterior inverted L-shaped approach would not involve osteotomy, tendotomy or division of muscles, while allowing satisfied visualization of the entire posterior aspect of tibial plateau and appropriate placement of hardware. This approach is a safe and effective way for the treatment of posterior bicondylar tibial plateau fractures.

Anatomical evaluation of the modified posterolateral approach for posterolateral tibial plateau fracture

OBJECTIVE

The study was undertaken to evaluate the efficacy and safety of a posterolateral reversed L-shaped knee joint incision for treating the posterolateral tibial plateau fracture.

METHODS

Knee specimens from eight fresh, frozen adult corpses were dissected bilaterally using a posterolateral reversed L-shaped approach. During the dissection, the exposure range was observed, and important parameters of anatomical structure were measured, including the parameters of common peroneal nerve (CPN) to ameliorate the incision and the distances between bifurcation of main vessels and the tibial articular surface to clear risk awareness.

RESULTS

The posterolateral aspect of the tibial plateau from the proximal tibiofibular joint to the tibial insertion of the posterior cruciate ligament was exposed completely. There was no additional damage to other vital structures and no evidence of fibular osteotomy or posterolateral corner complex injury. The mean length of the exposed CPN was 56.48 mm. The CPN sloped at a mean angle of 14.7° toward the axis of the fibula. It surrounded the neck of the fibula an average of 42.18 mm from the joint line. The mean distance between the opening of the interosseous membrane and the joint line was 48.78 mm. The divergence of the fibular artery from the posterior tibial artery was on average 76.46 mm from articular surface.

CONCLUSIONS

This study confirmed that posterolateral reversed L-shaped approach could meet the requirements of anatomical reduction and buttress fixation for posterolateral tibial plateau fracture. Exposure of the CPN can be minimized or even avoided by modifying the skin incision. Care is needed to dissect distally and deep through the approach as vital vascular bifurcations are concentrated in this region. Placement of a posterior buttressing plate carries a high vascular risk when the plate is implanted beneath these vessels.