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

Modified Oblique Lobenhoffer (MOL) approach for posterolateral and posteromedial column access in tibial plateau fractures: a detailed cadaveric anatomical study

BACKGROUND

Tibial plateau fractures involving posteromedial (PM) and posterolateral (PL) columns are complex injuries that require an appropriate approach. The management of the PL column in these cases can be controversial, and limitations using deep posteromedial interval approaches have been referenced. In this paper, a modification of the Lobenhoffer approach, designed to optimize the access to the PL column, is described in detail. The aim of this study was to assess the feasibility of this approach in a cadaveric anatomical study.

MATERIALS AND METHODS

In total, five fresh-frozen cadaveric specimens were used for detailed anatomical study surrounding the approach. Relationships with cutaneous and deep neurovascular structures were evaluated. The exposure area of the PL and PM columns using this approach was assessed.

RESULTS

The cadaveric study showed safe and adequate exposure. Oblique skin and fascia incision just medial to the posterior midline was safe to protect the medial sural cutaneous nerve and the small saphenous vein. Elevation of the popliteus and tibialis posterior muscles offered safe protection of the anterior tibial artery and popliteal neurovascular bundle during retractor placement. Adequate full proximal exposure of the PM and PL columns, including the posterolateral lateral (PLL) and posterolateral central (PLC) segments, was obtained in all specimens.

CONCLUSIONS

The Modified Oblique Lobenhoffer (MOL) approach can be a feasible option to access PL and PM columns in tibial plateau fractures.

LEVEL OF EVIDENCE

IV.

Exposure of Hoffa Fractures Is Improved by Posterolateral and Posteromedial Extensile Approaches: A Qualitative and Quantitative Anatomical Study

BACKGROUND

The current literature lacks recommendations regarding surgical approaches to best visualize and reduce Hoffa fractures. The aims of this study were to (1) define surgical corridors to the posterior portions of the lateral and medial femoral condyles and (2) compare the articular surface areas visible with different approaches.

METHODS

Eight fresh-frozen human cadaveric knees (6 male and 2 female donors; mean age, 68.2 ± 10.2 years) underwent dissection simulating 6 surgical approaches to the distal femur. The visible articular surface areas for each approach were marked using an electrocautery device and subsequently analyzed using image-processing software. The labeled areas of each femoral condyle were statistically compared.

RESULTS

At 30° of flexion, visualization of the posterior portions of the lateral and medial femoral condyles was not possible by lateral and medial parapatellar approaches, as only the anterior 29.4% ± 2.1% of the lateral femoral condyle and 25.6% ± 2.8% of the medial condyle were exposed. Visualization of the lateral femoral condyle was limited by the posterolateral ligamentous structures, hence a posterolateral approach only exposed its central (13.1% ± 1.3%) and posterior (12.4% ± 1.1%) portions. Posterolateral extension by an osteotomy of the lateral femoral epicondyle significantly improved the exposure to 53.4% ± 2.7% and, when combined with a Gerdy's tubercle osteotomy, to 70.9% ± 4.1% (p < 0.001). For the posteromedial approach, an arthrotomy between the anteromedial retinaculum and the superficial medial collateral ligament, and one between the posterior oblique ligament and the medial gastrocnemius tendon, allowed visualization of the central (13.5% ± 2.2%) and the posterior (14.6% ± 2.3%) portions of the medial femoral condyle, while a medial femoral epicondyle osteotomy significantly improved visualization to 66.1% ± 5.5% (p < 0.001).

CONCLUSIONS

Visualization of the posterior portions of the femoral condyles is limited by the specific anatomy of each surgical corridor. Extension by osteotomy of the femoral epicondyles and Gerdy's tubercle significantly improved articular surface exposure of the femoral condyles.

CLINICAL RELEVANCE

Knowledge of the surgical approach-specific visualization of the articular surface of the femoral condyles might be helpful to properly reduce small Hoffa fragments.

Depression fractures of the posterolateral tibial plateau: Treatment by lateral femoral epicondyle osteotomy approach

OBJECTIVE

The best surgical exposure and fixation method for fractures affecting the posterolateral corner of the tibial plateau remain debatable. This study describes a surgical approach to treat lateral depressions of the posterolateral tibial plateau with or without rim involvement by osteotomy of the lateral femoral epicondyle associated with osteosynthesis with a one-third tubular horizontal belt plate to stabilize the fracture fragment.

METHOD

We evaluated 13 patients with fractures of the tibial plateau affecting the posterolateral region. Assessments included the degree of the depression (in millimeters), quality of the reduction, complications, and function.

RESULTS

All fractures and osteotomies consolidated. The patients had a mean age of 48 years and were mostly men (n=8). Regarding the quality of the reduction, the mean reduction obtained was 15.8 mm, and 8 patients achieved anatomical reduction. The mean (± standard deviation) Knee Society Score was 92±13 (range 65-100), and the mean Function Score was 95±9.6 (range 70-100). The mean Lysholm Knee Score was 92±11.7 (range 66-100), and the mean International Knee Documentation Committee Score was 85±12.6 (range 63-100). All these scores reflect good results. None of the patients developed superficial or deep infection or presented healing disorders. Sensitive or motor complications of the fibular nerve were not observed.

CONCLUSIONS

In this series of patients with depression fractures of the posterolateral tibial plateau, a surgical approach through osteotomy of the lateral femoral epicondyle allowed direct reduction and stable osteosynthesis of the fractures without functional impairment.

S2k Guideline for Tibial Plateau Fractures - Classification, Diagnosis, and Treatment

Tibial plateau fractures are mostly complex and surgically demanding joint fractures, which require a comprehensive understanding of the fracture morphology, ligamentous and neurovascular injuries, as well as the diagnostic and therapeutic options for an optimal clinical outcome. Therefore, a standardised and structured approach is required. The success of the treatment of tibial plateau fractures relies on the interdisciplinary cooperation between surgical and conservative physicians in an outpatient and inpatient setting, physical therapists, patients and service providers (health insurance companies, statutory accident insurance, pension providers). On behalf of the German Society for Orthopaedics and Trauma Surgery (DGOU), the German Trauma Society (DGU) and the Society for Arthroscopy and Joint Surgery (AGA), under the leadership of the Fracture Committee of the German Knee Society (DKG), a guideline for tibial plateau fractures was created, which was developed in several voting rounds as part of a Delphi process. Based on the current literature, this guideline is intended to make clear recommendations and outline the most important treatment steps in diagnostics, therapy and follow-up treatment. Additionally, 25 statements were revised by the authors in several survey rounds using the Likert scale in order to reach a final consensus.

[Intra-articular proximal tibia fractures]

The incidence of proximal intra-articular tibial fractures is continuously increasing. In addition to high-energy trauma in young patients, osteoporotic fractures occur more frequently in geriatric patients. After a thorough clinical examination including X‑ray and computed tomography (CT) imaging, consolidation of the soft tissue is followed by surgical treatment to achieve the best possible anatomic reconstruction of the articular surface. Nonanatomic reduction with articular gaps >2.5 mm leads to a significantly increased risk of osteoarthritis. Selection of the surgical approach and planning of the osteosynthesis are based on the fracture morphology and the existing soft tissue damage. In addition to arthroscopically assisted percutaneous procedures, sophisticated osteosynthesis is often necessary, which requires several surgical approaches. In this context, posterior surgical approaches are becoming increasingly more important. Primary knee arthroplasty can also play a role, particularly in older patients.

Extension of the Medial Approach to the Tibial Plateau via an Osteotomy of the Tibial Insertion of the Superficial Medial Collateral Ligament

The treatment of medial tibial plateau fractures can be challenging due to poor exposure of the articular surface. Therefore, a medial epicondyle osteotomy may be needed. Current methods describe osteotomy of the medial femoral epicondyle. However, this method requires additional detachment of the medial meniscus in order to ensure proper visualization. The aim of this study is to present a new technique using distal osteotomy of the superficial medial collateral ligament and to analyze the area of the exposed articular surface area. On each of eight fresh-frozen human cadaveric knees (mean age: 79.4 ± 9.4 years), an osteotomy and proximal reflection of the distal insertion of the superficial medial collateral ligament combined with a submeniscal arthrotomy was performed, followed by a medial epicondyle osteotomy. Using a three-dimensional measurement arm (Absolute Arm 8320-7, Hexagon Metrology GmbH), the exposed area was analyzed and compared to the entire medial articular surface using ANOVA (p < 0.05). Through the medial epicondyle osteotomy, 39.9 ± 9.7% of the anteromedial articular surface was seen. This area was significantly smaller compared to the osteotomy of the distal insertion of the superficial collateral ligament with an exposed articular surface of 77.2 ± 16.9% (p = 0.004). Thus, the distal osteotomy exposed 37.3% more of the articular surface compared to the medial epicondyle osteotomy. None of these techniques were able to adequately expose the posteromedial- and medial-most aspects of the tibial plateau. A distal superficial collateral ligament osteotomy may be superior to a medial epicondyle osteotomy when an extension of the anteromedial approach to the tibial plateau is required. A distal superficial medial collateral ligament osteotomy combines the advantages of better exposure of the medial articular surface with preservation of the blood supply to the medial meniscus. However, surgeons should carefully consider whether such an extended approach is necessary, as it significantly increases invasiveness.

Comparative Analysis of Posterior Approach Versus Anterior Approach for Posterior Tibial Plateau Fractures: A Systematic Review and Meta-analysis

BACKGROUND

Posterior tibial plateau fractures can lead to significant posttraumatic instability if not treated properly. It remains unclear which surgical approach achieves better patient outcomes. The objective of this systematic review and meta-analysis was to assess postoperative outcomes in patients undergoing anterior, posterior, or combined approach for posterior tibial plateau fractures.

METHODS

The PubMed, Embase, Web of Science, The Cochrane Library, and Scopus were searched for studies published before October 26, 2022, comparing anterior, posterior, or combined approaches for posterior tibial plateau fractures. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Outcomes included complications, infections, range of motion (ROM), operation time, union rates, and functional scores. Significance was set at p < 0.05. Meta-analysis was conducted with STATA software.

RESULTS

In total, 29 studies with a total of 747 patients were included for quantitative and qualitative analysis. Compared with other approaches, the posterior approach for posterior tibial plateau fractures was associated with a better ROM and shorter operative time. The complication rates, infection rates, union time, and hospital for special surgery (HSS) scores were not significantly different between surgical approaches.

CONCLUSIONS

The posterior approach for posterior tibial plateau fractures offers advantages such as improved ROM and shorter operative time. However, there are concerns regarding prone positioning in patients with medical or pulmonary comorbidities and indications in polytrauma cases. Further prospective studies are needed to determine the optimal approach for these fractures.

LEVEL OF EVIDENCE

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

Factors influencing the outcome after surgical reconstruction of OTA type B and C tibial plateau fractures: how crucial is the restoration of articular congruity?

INTRODUCTION

Only few and inconsistent data about the impact of articular congruity and tolerable residual intraarticular steps and gaps of the joint surface after tibial plateau fractures exist. Therefore, aim of this study was to investigate the correlation between OTA type B and C tibial plateau fracture outcomes and postoperative articular congruity using computed tomography (CT) data.

MATERIALS AND METHODS

Fifty-five patients with a mean age of 45.5 ± 12.5 years and treated for 27 type B and 28 C tibial plateau fractures with pre- and postsurgical CT data were included. Primary outcome measure was the correlation of postoperative intraarticular step and gap sizes, articular comminution area, the postoperative medial proximal tibial angle (MPTA), and the Lysholm and IKDC score. Receiver-operating characteristic (ROC) curves were used to determine threshold values for step and gap heights according to the following outcome scores: IKDC > 70; Lysholm > 80. Secondary outcome measures were the correlation of fracture severity, the number of complications and surgical revisions and the outcome scores, as well as the Tegner activity score before injury and at final follow-up.

RESULTS

After a mean follow-up of 42.4 ± 18.9 months, the mean Lysholm score was 80.7 ± 13.3, and the mean IKDC score was 62.7 ± 17.6. The median Tegner activity score was 5 before the injury and 4 at final follow-up (p < 0.05). The intraarticular step height, gap size, comminution area and MPTA deviation were significantly negatively correlated with the IKDC and Lysholm scores. The cutoff values for step height were 2.6 and 2.9 mm. The gap size threshold was 6.6 mm. In total, an average of 0.5 ± 0.8 (range 0-3) complications occurred, and on average, 0.5 ± 1.1 (range 0-7) surgical revisions had to be performed. The number of complications and surgical revisions also had negative impacts on the outcome. Neither fracture severity nor BMI or patient's age was significantly correlated with the IKDC or Lysholm score.

CONCLUSIONS

Tibial plateau fractures are severe injuries, which lead to a subsequent reduced level of patient activity. Precise reconstruction of the articular surface with regard to intraarticular step and gap size, residual comminution area and joint angle is decisive for the final outcome. Complications and surgical revisions also worsen it.

LEVEL OF EVIDENCE

III.

Supine Posterior Hoop Plating of Bicondylar Posterior Coronal Shear Tibial Plateau Fractures Without Fibular Osteotomy

Tibial plateau posterolateral fragments, especially those associated with articular depression, are difficult to capture and support with anteriorly or lateral based implants. Applying implants to the posterior plateau has traditionally involved a prone approach or fibular osteotomy, especially when access to both the medial and lateral sides is necessary, such as a bicondylar posterior coronal shear fracture pattern. By combining two previously described techniques for posterolateral rim plating and bicondylar hoop plating, we describe a novel technique to apply a posterior bicondylar hoop implant in the supine position without fibular osteotomy for bicondylar posterior coronal shear injuries.

Anterolateral versus modified posterolateral approach for tibial plateau fractures with involvement of the posterior column: a cadaveric study

INTRODUCTION

The aim of this study was to compare the reduction quality of the anterolateral (AL) and modified posterolateral approach (PL) in lateral tibial plateau fractures involving the posterior column and central segments.

METHODS

Matched pairs of pre-fractured cadaveric tibial plateau fractures were treated by either AL approach (supine position) or PL approach (prone position). Reduction was controlled by fluoroscopy and evaluated as satisfying or unacceptable. Afterwards, the reduction was examined by 3D scan.

RESULTS

10 specimens (3 pairs 41B3.1, 2 pairs 41C3.3) were evaluated. PL approach achieved significantly (p 0.00472) better fracture reduction results (0.4 ± 0.7 mm) of the posterior column compared to the AL group (2.1 ± 1.4 mm). Fracture steps involving the central area of the lateral plateau were insufficiently reduced after fluoroscopy using both approaches.

CONCLUSION

Optimal reduction of displaced tibial plateau fractures involving the posterolateral column necessitates a posterior approach, which can be conducted in prone or lateral positioning. The anterolateral approach is indicated in fractures with minor displacement of the posterolateral rim but fracture extension in the latero-central segments. In these cases, an additional video-assisted reduction or extended approaches are helpful.

Current concepts review. Management of proximal tibial fractures

The management of proximal tibial fractures has evolved significantly in recent years. While the main goals of treatment - stability, restoration of the mechanical axis, and smooth articular surfaces - remain the same, methods have advanced substantially. In diagnostics, technical progress in CT and MR imaging has led to a better three-dimensional understanding of the injury. Newly developed classification systems such as the three-column concept of Luo et al. and the 10-segment concept of Krause et al. take this into account. Accordingly, there is a trend towards tailored approaches for particular fracture localizations. Parallel to this development, there is increasing evidence of the advantages of arthroscopically assisted surgical procedures. This Current Concepts article reviews classifications, diagnostics, treatment options as well as complications in fractures of the proximal tibia.

Nanoscopy and an extended lateral approach can improve the management of latero-central segments in tibial plateau fractures: a cadaveric study

Introduction

The objective of this investigation was to compare different techniques to improve visualization and reduction in tibial plateau fractures involving the central lateral segments.

Methods

Matched pairs of pre-fractured cadaveric tibial plateau fractures that include the central lateral segments were treated by either an anterolateral approach (supine) or PL approach (prone). Reduction was stepwise extended by additional fracturoscopy (FS), nanoscopy (NS) and lastly by epicondyle osteotomy (ECO). Reduction was analyzed by 3D scan and visualization of the lateral plateau was quantified.

Results

Ten specimens (3 pairs 41B3.1, 2 pairs 41C3.3) were analyzed. Fracture steps involving the antero-latero-central (ALC) segment were insufficiently reduced after fluoroscopy using both approaches (AL 2.2 ± 1.2 mm vs PL 2.2 ± 1.0 mm, p 0.95). Additional NS and ECO achieved optimized fracture reduction in the ALC segment (NS AL 1.6 ± 1.3 mm vs PL 0.8 ± 0.9 mm, p 0.32). NS provided visualization of the entire lateral plateau (PL 102.9% ± 7.4, AL 108.8 ± 19.2%), while fracturoscopy only allowed visualization of the ALL segment and partially of PLL and ALC segments (PL 22.0 ± 23.4%, AL 29.7 ± 18.3%).

Conclusion

Optimized reduction of tibial head fractures with involvement of latero-central segments requires additional video-assisted reduction or extended approaches. Nanoscopy helps visualizing of the entire lateral plateau, when compared to fracturoscopy and may become a valuable reduction aid.

Lateral epicondyle osteotomy approach vs. olecranon osteotomy approach: an anatomic study of cadavers

BACKGROUND

Exposure of the articular surface is the key to successful open reduction and internal fixation treatment for coronal shear fractures of the distal humerus. The olecranon osteotomy approach has previously been described as one of the most effective exposure approaches. Nevertheless, this approach cannot expose the anterior trochlea, and it is impossible to reduce and fix the capitellum under direct vision. The purpose of this study was to compare the exposure of the articular surface of the distal humerus between the lateral epicondyle osteotomy approach (group L) and the olecranon osteotomy approach (group O).

METHODS

Each approach was performed on 8 freshly frozen upper limbs of adult cadavers. After each approach was completed, a 0.5-mm Kirschner wire is inserted along the edge to mark the visible part of the articular surface. Then, the soft tissue of each elbow is removed, and a surface-scanning system is used to create a digital 3-dimensional model. The visible part of the articular surface obtained by each surgical approach was mapped and quantified using markers created by Kirschner wires.

RESULTS

The lateral epicondyle osteotomy approach and the olecranon osteotomy approach exposed 0.8 ± 0.0 and 0.6 ± 0.0 of the distal humeral articular surface (P < .001), 1.0 ± 0.0 and 0.3 ± 0.1 of the capitellum (P < .001), 0.6 ± 0.0 and 0.7 ± 0.0 of the trochlea (P < .001), 0.7 ± 0.0 and 0.5 ± 0.1 of the anterior trochlea (P < .001), and 0.5 ± 0.0 and 1.0 ± 0.0 of the posterior trochlea, respectively (P < .001).

CONCLUSION

Compared with the olecranon osteotomy approach, the lateral epicondyle osteotomy approach could more fully expose the total articular surface of the distal humerus, capitellum, and anterior trochlea, but the olecranon osteotomy approach could more fully expose the trochlea and posterior trochlea.

Feasibility of the modified inverted L-shaped approach for posterolateral tibial plateau fracture: A retrospective study

Approaches for treating posterolateral tibial plateau fractures vary among surgeons, and the inverted L-shaped approach is a known option. This article aims to introduce a new modified posterolateral inverted L-shaped approach for isolated posterolateral tibial plateau fractures and study its feasibility. Medical records of patients with posterolateral tibial plateau fractures were reviewed. Plain radiographs were obtained during the follow-up period, and the hospital for special surgery (HSS) score was used to assess the function of the injured limb. Perioperative complications were recorded and followed-up. In total, 32 patients with posterolateral tibial plateau fractures were treated using a modified posterolateral approach. The mean age of the patients was 44 ± 11 years (28-64 years). All patients successfully underwent surgery and were followed-up for a mean duration of 13 ± 2 months (10-16 months). On plain radiographs, fracture lines were fuzzy 3 months after surgery and disappeared 12 months after surgery. No perioperative complications occurred during the follow-up period. The HSS score was evaluated 12 months after surgery, and the mean score was 91 ± 5 points (81-97 points), including 25 excellent cases and 7 good cases. The modified posterolateral inverted L-shaped approach has the advantages of small soft tissue dissection, fracture reduction under direct vision, easy internal fixation, and a lower risk of neurovascular injury. This approach is feasible for the treatment of isolated posterolateral tibial plateau fractures, and further high-quality randomized control trials are required to confirm its clinical efficacy.

Comparison of tibial plateau fracture surgical outcomes between young and elderly patients: are outcomes really poorer in the elderly?

INTRODUCTION

Several studies have reported that total knee arthroplasty (TKA) is a suitable solution to treat elderly patients with complex tibial plateau fractures. The purpose of the present study was to compare surgical treatment outcomes after open reduction internal fixation (ORIF) between elderly and younger patients.

MATERIALS AND METHODS

We reviewed patients with plateau fracture (OTA/AO classification types 41B and 41C) who underwent ORIF at two academic trauma centers between November 2006 and October 2019. Of the 341 patients, 76 were ultimately included in the younger group (< 60 years old) and 77 in the elderly group (≥ 60 years). The average follow-up was 24 months (range 12-96 months). The primary outcome was any common complication of plateau fracture, namely post-traumatic arthritis and alignment change. Conversion to TKA, Reduction loss, coronal malalignment, non-union, union time, infection, and limb length discrepancy (LLD) were also assessed.

RESULTS

The elderly group had a significantly higher prevalence of diabetes, but there were no other significant differences between the groups in terms of patient demographics, fracture characteristics, and operation characteristics. We detected no differences between the groups in terms of post-traumatic arthritis (p = 0.216), alignment change (p = 0.093), conversion to TKA (p = 0.681), reduction loss (p = 0.079), coronal malalignment (p = 0.484), non-union rate (p = 0.719), infection (p = 0.063), LLD (p = 0.154), or time to union (p = 0.513). Logistic regression analysis revealed that age > 60 years was not associated with treatment failure, defined as either post-traumatic arthritis greater than grade II or non-union (p = 0.468). OTA/AO classification type 41C2 (p = 0.019), type 41C3 (p = 0.008), and malreduction (p = 0.050) were significant risk factors for failure.

CONCLUSION

Age ≥ 60 years is not an independent risk factor of poor radiographic outcome and high complication rate in tibial plateau fractures. This indicates that ORIF is still a good solution to treat elderly patients, similar to their younger counterparts.

Comparison Between Treatment of Bicondylar Tibial Plateau Fractures With or Without Posterolateral Fragments Using Posteromedial and Anterolateral Approaches

BACKGROUND

The best surgical approach for treating posterolateral fragments in tibial plateau fractures remains controversial. This study compared the radiological and functional outcomes of bicondylar tibial plateau fractures, with or without posterolateral fragments, treated using the same posteromedial and anterolateral approaches.

METHODS

Twenty-six patients with 27 bicondylar tibial plateau fractures were surgically treated between June 2006 and February 2020. The patients were divided into two groups: with posterolateral fragments (PL group) and without posterolateral fragments (non-PL group). All patients were treated with the combined posteromedial and anterolateral approach. Knee function was assessed using the Lysholm score and by measuring the range of motion (ROM). Fracture reduction was assessed using Rasmussen radiological scores.

RESULTS

Fifteen bicondylar fractures were classified in the PL group and 12 in the non-PL group. No significant difference was found in the ROM and Lysholm scores between the groups. No significant difference was noted in Rasmussen radiological scores between the groups.

CONCLUSION

Using the combined posteromedial and anterolateral approach, bicondylar tibial plateau fractures with posterolateral fragments achieved reasonable functional and radiological outcomes compared to those without a posterolateral fragment. This combined approach enabled an adequate visualization and reduction of posterolateral fragments. These standard approaches may be adequate for most bicondylar tibial plateau fractures with posterolateral fragments.

Tibial plateau fractures: three dimensional fracture mapping and morphologic measurements

Purpose

The injury mechanisms and classifications of tibial plateau fractures (TPFs) are still controversial. The aim of this study is to show 3D fracture mapping of different types of tibial plateau fractures. Moreover, combined with Schatzker and ten-segment classification, we aimed to analyze the injury frequency and characteristics of different segments.

Methods

In total, 346 patients with TPFs treated at level I trauma centres from 2017 to 2021 were reviewed. The CT files of the included cases were typed and categorized. 3D reconstruction of TPFs patients’ CT files were performed using software. All fracture lines were superimposed on the standard model by the software to create TPFs 3D fracture mapping.

Results

This study included 204 male and 142 female patients (average age, 47 years [range, 18 to 83 years]) with a tibial plateau fracture. Using the Schatzker classification, we found 39 type I (11.27%), 103 type II (29.77%), nine type III (2.60%), 71 type IV (20.52%), 52 type V (15.03%), 59 type VI (17.05%) fractures, and 13 others (3.76%). The density areas of fracture lines are mainly located in the ALC and PLC segments (74.3%, 69.1%). In different views, fracture lines of different Schatzker types showed distinct distribution characteristics.

Conclusions

Schatzker classification combined with 3D fracture mapping provides a new presentation of tibial plateau fracture morphology. According to the 3D fracture mapping, different types of TPFs have distinctly different distribution characteristics of fracture lines. There are significant differences between different types of fracture injury segments.

[Change in the treatment of tibial plateau fractures]

BACKGROUND

The treatment of tibial plateau fractures has experienced a number of very different conceptual developments in recent years, not only with respect to technical innovations but also against the background of changing fracture patterns and the growing requirements of patients.

OBJECTIVE

What developments in recent years have had a significant impact on current treatment strategies for tibial plateau fractures?

METHODS

Narrative review of publications listed in PubMed on the topic of treatment of complex tibial plateau fractures.

RESULTS

While the two-dimensional classifications are becoming less important, computed tomography (CT)-based three-dimensional assessment of fracture progression and an access strategy based on it are coming to the fore. Direct dorsal approaches have been shown to be superior, particularly in the case of relevant posteromedial and/or posterolateral fracture involvement. The step-by-step approach extension via specific osteotomies of ligamentous attachments also enables a needs-dependent and fracture-dependent complete joint visualization and reduction control. In the treatment of geriatric tibial plateau fractures, primary treatment with endoprostheses is becoming increasingly more important to enable early mobilization under full load bearing with significantly shorter rehabilitation times.

CONCLUSION

Modern developments in the context of fracture treatment around the tibial plateau have led to a relevant reduction of infections and improved surgical outcomes; however, the high demands and the improved understanding of fractures still underline the great challenge in the treatment of complex fracture patterns.

Intra- and inter-observer reliability assessment of widely used classifications and the "Ten-segment classification" of tibial plateau fractures

BACKGROUND

Ten-segment classification provides a different approach to the evaluation of tibial plateau fractures. The purpose of this study was to assess the intra- and inter-observer reliability of three widely used classification systems (Schatzker, Arbeitsgemeinschaft für Osteosynthesefragen (AO/OTA), and the updated three-column concept (uTCC)) with ten-segment classification in two-dimensional computed tomography (2D-CT) and three-dimensional computed tomography (3D-CT).

METHOD

Ninety 2D-CT and 3D-CT scans of patients with tibial plateau fractures were included in this retrospective cohort study. The included data were independently classified by six observers of different years of seniority and were independently observed and classified again after eight weeks. Inter-observer and intra-observer reliability of the four fracture classifications made by the six observers was analyzed using the kappa statistic. Kappa values were interpreted according to the categorical rating by Landis and Koch.

RESULTS

When the inter-observer reliability was based on 2D-CT/3D-CT analysis, the mean Kappa values for the Schatzker, AO/OTA, uTCC, and ten-segment classification were 0.64/0.66, 0.56/0.59, 0.53/0.65, and 0.60/0.73, respectively. When intra-observer reliability was based on 2D-CT/3D-CT, the mean Kappa values for the Schatzker, AO/OTA, uTCC, and ten-segment classification were 0.68/0.83, 0.69/0.83, 0.74/0.85, and 0.80/0.91, respectively.

CONCLUSIONS

The use of 3D-CT is important for the reliable diagnosis and recognition of tibial plateau fracture features compared to 2D-CT. When using 3D-CT, ten-segment classification showed high intra- and inter-observer agreement.

A lateral fracture step-off of 2mm increases intra-articular pressure following tibial plateau fracture

INTRODUCTION

The aim of this study was to evaluate the effects of increasing posttraumatic step-offs after lateral tibial plateau fracture reduction on the intra-articular pressure.

MATERIALS AND METHODS

In eight fresh-frozen human cadaveric knees with intact menisci, a standardized sagittal osteotomy of the lateral tibial condyle was performed as an OTA/AO type 41-B1 fracture-model. The fragment was fixed by a customized sled including an angular stable tibia plate to evaluate step-offs from 0 mm to 8 mm in 1mm increments. In a servo-hydraulic testing machine, an axial force was applied to the tibial plateau in 0° (700N), 15° (700N), 30° (700N), 60° (350N), and 90 ° (350N) of flexion while the joint pressure was recorded by two pressure sensors.

RESULTS

A 1mm step-off did not result in an increased joint pressure. At 60° of flexion a 2mm step-off increased the lateral joint pressure by 61.84kPa (P = 0.0027). In 30° of flexion, a 3mm step raised the lateral joint pressure by 66.80kPa (p = 0.0017), whereas in 0°, 15° and 90° of flexion, a 4mm step increased the pressure by >50kPa (P < 0.05). Concomitant medial joint pressure increments were lower than those in the lateral plateau. A significant increase of 19-24kPa in the medial joint pressure was detected in 90° of flexion with a 1mm lateral step (P = 0.0075), in 15° and 60° of flexion with a 2mm step (P < 0.05), in 0° of flexion with a 4mm step (P = 0.0215) and in 30° of flexion with a 7mm step (P = 0.0487).

CONCLUSION

Lateral fracture step-offs of 2mm or larger should be reduced intraoperatively to avoid large increases in lateral joint pressure.

[Open reduction and internal fixation with plate via posteromedial approach of retaining pes anserinus tendon in the treatment of tibial plateau fracture]

OBJECTIVE

To compare the effects of cutting and retaining the pes anserinus tendon on effectiveness following tibial plateau fracture.

METHODS

A clinical data of 40 patients with tibial plateau fracture treated with open reduction and internal fixation with plate via posteromedial approach between January 2015 and January 2020 was retrospectively analyzed, including 18 patients retained the pes anserinus tendon (study group) and 22 patients cut the pes anserinus tendon (control group) during operation. There was no significant difference in gender, age, side of affected knee, cause of injury, Schatzker classification, time from injury to operation, and associated ligament injury between the two groups ( P>0.05). The operation time, intraoperative blood loss, hospital stay, anatomic reduction rate, incidence of complications, fracture healing time, knee flexion and extension range of motion at 2 weeks and 12 months, and knee extension range of motion at 3 months after operation were recorded and compared between the two groups. The visual analogue scale (VAS) score was used to evaluate the early postoperative pain improvement at 1, 3, and 14 days after operation and hospital for special surgery (HSS) score was used to evaluate the improvement of knee function at 3, 6, and 12 months after operation.

RESULTS

The patients in both groups were followed up 12-15 months with an average of 12.8 months. There was no significant difference in operation time, intraoperative blood loss, and fracture healing time between the two groups ( P>0.05). The hospital stay in the control group was significantly longer than that in the study group ( t=8.339, P=0.000). There was no significant difference in the anatomic reduction rate (90.9% vs. 83.3%) between the control group and the study group ( χ ²=0.058, P=0.810). There were 1 case of proximal tibial osteomyelitis, 3 cases of skin necrosis, 3 cases of traumatic arthritis, and 2 cases of lower deep venous thrombosis after operation in the control group, and 1 case of metaphyseal nonunion, 2 cases of traumatic arthritis, and 1 case of lower deep venous thrombosis in the study group, showing no significant difference in the incidence of complications (40.9% vs. 22.2%) between the two groups ( χ ²=1.576, P=0.209). In the study group, knee flexion and extension range of motion at 2 weeks and 12 months and knee extension range of motion at 3 months after operation were significantly better than those of the control group ( P<0.05). VAS scores and HSS scores in both groups improved with time after operation ( P<0.05), in addition, the HSS score and VAS score of the study group were significantly better than those of the control group ( P<0.05).

CONCLUSION

Compared with traditional pes anserinus tendon cutting group, pes anserinus tendon retaining group can significantly reduce postoperative short-term pain, improve postoperative knee range of motion and knee function within 1 year after operation.

Improved Visualization by Central Subluxation of the Lateral Meniscus in Comminuted Lateral Tibial Plateau Fractures

The goal of surgical reconstruction of comminuted tibial plateau fractures is an anatomical reconstruction and stable fixation of the articular surface. This can be difficult due to poor visualization of the posterolateral and central segments of the articular surface of the proximal tibia. To improve visualization, the lateral approach can be extended with an osteotomy of the femoral epicondyle. In most cases, use of the extended lateral approach allows the whole lateral plateau to be visualized. Nevertheless, in some cases, an osteotomy alone is not enough to expose the entire fracture, especially the central segments of the tibial plateau. For these specific cases, we developed an additional technical trick that significantly improves articular visualization; the lateral meniscocapsular fibers are dissected allowing for central subluxation of the lateral meniscus, while leaving the anterior and posterior roots intact. With central subluxation of the lateral meniscus in comminuted tibial plateau fractures, the joint surface can be completely visualized, allowing an anatomical reduction even in highly complex fractures.

Treatment of tibial plateau fractures involving the posterolateral column using the extended anterolateral approach

To summarize the surgical technique and clinical effects of the extended anterolateral approach for the treatment of Schatzker type II and Schatzker type V/VI involving the posterolateral column tibial plateau.From January 2015 through December 2018, 28 patients with tibial plateau fractures involving the posterolateral column were included in the study. Among them, 16 patients were Schatzker type II treated using an extended anterolateral approach with lateral tibial locking compression plate fixation. Twelve patients were Schatzker type V or VI treated using an extended anterolateral combined with a medial approach using lateral tibial locking compression plate plus medial locking compression plate fixation. All cases were followed up for 15 to 31 months, with an average follow-up of 22.5 ± 3.7 months. During the follow-up, the tibial plateau angle (TPA), lateral posterior angle (PA) and Rasmussen radiological criteria were used to evaluate the effect of fracture reduction and fixation; the Hospital for Special Knee Surgery score and the range of motion were used to evaluate knee function. Additionally, the Lachman and knee Valgus (Varus) stress tests were used to evaluate anteroposterior and lateral stability of the knee.All fractures healed. At the 12-month follow-up, the Schatzker type II group revealed a mean TPA of 86.38 ± 3.92°, a mean PA of 7.43 ± 2.68°, and a mean Rasmussen radiological score of 16.00 ± 2.06 points. The Schatzker type V/VI group showed a mean TPA of 84.91 ± 3.51°, a mean PA of 9.68 ± 4.01°, and a mean Rasmussen radiological score of 15.33 ± 2.99 points. During the 1-year follow-up, when the postoperative PA was re-measured, the TPA and Rasmussen score of the 2 groups did not change significantly (P > .05). At the last follow-up, the Schatzker type II group showed a knee flexion angle of 110° to 135° and a mean HHS score of 88.37 ± 10.01 points. The Schatzker type V/VI group revealed a knee flexion angle of 100° to 130° and a mean HHS score of 82.17 ± 10.76 points. Additionally, up to the last follow-up, the Lachman and knee Valgus (Varus) stress test results of the 2 groups were negative. No complications were found.The extended anterolateral approach is a good choice to treat tibial plateau fractures involving the posterolateral column.

A proposal of a new algorithm for decision-making approaches in open reduction and internal fixation of complex tibial plateau fractures - SOTA algorithm (Spanish Orthopaedic Trauma Association)

INTRODUCTION

The correct choice of surgical approaches in complex tibial plateau fractures is essential to achieve adequate reduction and fixation. Detailed fracture morphology and direction of columns displacement, that we have named the Main Deformity Direction (MDD), may aid in selecting the optimal surgical strategy. In this article we present a new algorithm based on MDD and column concepts. The aim of this study was to evaluate the outcomes of a group of tibial plateau fractures treated according to this algorithm. The secondary aim was to evaluate the incidence of the different MDD in our multicolumnar subgroup.

PATIENTS AND METHODS

Excluding isolated lateral one-column fractures, open fractures and patients not treated following this algorithm, 72 patients with tibial plateau fractures surgically treated with open reduction and internal fixation were collected retrospectively, from three trauma centers, from January 2015 to April 2019. Radiological assessment was performed to establish the columns involved and the MDD. Quality and maintenance of reduction and alignment, complications and functional outcomes were assessed.

RESULTS

Initial fracture analysis was performed in 72 patients (8 one-column, 35 two-column and 29 multicolumnar fractures). In the multicolumnar group, the posteromedial MDD was the most frequent pattern (17 of 29 patients). Four patients were excluded due to loss of follow-up, resulting 68 patients for final outcome analysis (7 one-column, 34 two-column and 27 multicolumnar). The average follow-up was 18 months (range: 6-52). Excellent/good outcomes were obtained in all one-column, 31 of 34 two-column and 25 of 27 multicolumnar fractures. Incomplete reduction was present in three patients. As complications, we had two loss of reduction, one conversion to knee arthroplasty, one nonunion and one deep infection. No patient presented neurological or vascular problems, knee instability or extension deficit.

CONCLUSION

Satisfactory results have been obtained following the principles of our algorithm. In addition to the anatomical involvement of columns and segments, we believe that identifying the Main Deformity Direction (MDD) provides useful information for decision-making, especially in multicolumnar fractures. The most frequent MDD in our multicolumnar subgroup was the posteromedial MDD, but more than one-third presented a different MDD, requiring different surgical strategies.

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.

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.

Bone metabolism is a key factor for clinical outcome of tibial plateau fractures

Purpose

Given that tibial plateau fractures (TPF) are rare, they may pose a challenge to the treating surgeon due to their variety of complex fracture patterns. Numerous studies have identified potential fracture-specific, surgery-related, and patient-related risk factors for impaired patient outcomes. However, reports on the influence of bone metabolism on functional outcomes are missing.

Methods

In a retrospective multicenter cohort study, 122 TPF of 121 patients were analyzed with respect to radiological and clinical outcomes (Rasmussen) with a mean follow-up of 35.7 ± 24.9 months. The risk factor assessment included bone metabolism-affecting comorbidities and medication.

Results

The findings showed that 95.9% of the patients reported a good-to-excellent clinical outcome, and 97.4% reported a good-to-excellent radiological outcome. Logistic regression revealed that potentially impaired bone metabolism (IBM) was an independent risk factor for the clinical (p = 0.016) but not the radiological outcome (Table 4). Patients with 41-type B fractures and a potential IBM had a seven times higher risk to present a fair-to-poor clinical outcome [OR 7.45, 95 CI (4.30, 12.92)]. The most common objective impairment was a limited range of motion in 16.4% of the patients, especially in 41-type C fractures (p = 0.06). The individual failure analysis additionally identified surgery-related options for improvement.

Conclusion

This study demonstrated that potential IBM was an independent risk factor for a poor-to-fair clinical outcome.

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.

Intraarticular osteotomy of malunited tibial plateau fractures: an analysis of clinical results with a mean follow-up after 4 years

Purpose

Malunions are a common complication after tibial plateau fractures (TPF), leading to stiffness, pseudo-instability and posttraumatic osteoarthritis. The purpose of this study was to analyse the clinical outcome after intraarticular osteotomy of malunited TPF and to perform a failure analysis.

Methods

Between 2013 and 2018, 23 patients (11 males, 12 females; 43.8 ± 12.8 years) with intraarticular osteotomy after malunited TPF were included in the retrospective study. Clinical examination and postoperative scores were collected with a minimum follow-up of 24 months. Malunion was measured on pre- and postoperative CT scans and localized according to the 10-segment classification while the leg axis in the frontal plane was measured pre- and postoperatively on long leg standing radiographs.

Results

Excellent and good clinical outcome was achieved in 73.9% (n = 17) of the cases and patient related outcome improved significantly (Tegner 3.3 ± 1.6–5 ± 1.8, p < 0.001; clinical Rasmussen 14.6 ± 3.8–24.9 ± 4.4, p < 0.001). Radiological parameters also improved as an intraarticular step-off was reduced from 9 ± 3.8 to 0.6 ± 0.8 mm (p < 0.001) and a lower limb malalignment from 7.2 ± 4.8° to 1.5 ± 1.9° (p = 0.003). Failure analysis showed that an impaired clinical result correlated with a postoperative extension (n = 3, p < 0.001) and flexion deficit (n = 4, p = 0.035).

Conclusion

Intraarticular osteotomy of malunited TPF lead to good clinical results with significant clinical and radiological improvement in most cases while an impaired patient outcome correlated with a limited range of motion. This study is the first failure analysis of intraarticular osteotomy after malunited TPF published up to now.