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

Evaluation and Management of Posterior Tibial Plateau Fractures

Tibial plateau fractures are caused by high-energy or low-energy trauma and result in complex injuries that require careful management of both osseous injuries and associated soft tissues. The posterior aspect of the tibial plateau can be involved in a variety of fracture patterns, requiring systematic evaluation, imaging, and advanced surgical planning to address these complex injuries. Early classification systems failed to classify posterior plateau fractures; however, three-dimensional imaging and newer classification schemes, including the Quadrant System and 3D systems, have incorporated posterior column lesions. There has been a growing body of literature focused on fixation principles and plating options for posterior column fractures. Furthermore, there are multiple approaches for surgeons to choose between, including a direct posterior, posteromedial, posterolateral (including Lobenhoffer and lateral condyle osteotomy), and combined posterior approach. This article presents a guide for managing posterior tibial plateau fractures, including the initial evaluation and management, descriptions of the surgical approaches, principles of fixation, and the associated outcomes and complications.

What Is the Patient-reported Outcome and Complication Incidence After Operative Versus Nonoperative Treatment of Minimally Displaced Tibial Plateau Fractures?

BACKGROUND

Much controversy remains about whether minimally displaced tibial plateau fractures should be treated operatively or nonoperatively. It is generally accepted that gaps and stepoffs up to 2 mm can be tolerated, but this assumption is based on older studies using plain radiographs instead of CT to assess the degree of initial fracture displacement. Knowledge regarding the relationship between the degree of fracture displacement and expected functional outcome is crucial for patient counseling and shared decision-making, specifically in terms of whether to perform surgery.

QUESTIONS/PURPOSES

(1) Is operative treatment associated with improved patient-reported outcomes compared with nonoperative treatment in minimally displaced tibial plateau fractures (fractures with up to 4 mm of displacement)? (2) What is the difference in the risk of complications after operative versus nonoperative treatment in minimally displaced tibial plateau fractures?

METHODS

A multicenter, cross-sectional study was performed in patients treated for tibial plateau fractures between 2003 and 2019 at six hospitals. Between January 2003 and December 2019, a total of 2241 patients were treated for tibial plateau fractures at six different trauma centers. During that time, the general indication for open reduction and internal fixation (ORIF) was intra-articular displacement of > 2 mm. Patients treated with ORIF and those treated nonoperatively were potentially eligible; 0.2% (4) were excluded because they were treated with amputation because of severe soft tissue damage, whereas 4% (89) were excluded because of coexisting conditions that complicated outcome measurement including Parkinson disease, cerebrovascular accident, or paralysis (conditions causing an inability to walk). A further 2.7% (60) were excluded because their address was unknown, and 1.4% (31) were excluded because they spoke a language other than Dutch. Based on that, 1328 patients were potentially eligible for analysis in the operative group and 729 were potentially eligible in the nonoperative group. At least 1 year after injury, all patients were approached and asked to complete the Knee injury and Osteoarthritis Outcome Scale (KOOS) questionnaire. A total of 813 operatively treated patients (response percentage: 61%) and 345 nonoperatively treated patients (response percentage: 47%) responded to the questionnaire. Patient characteristics including age, gender, BMI, smoking, and diabetes were retrieved from electronic patient records, and imaging data were shared with the initiating center. Displacement (gap and stepoff) was measured for all participating patients, and all patients with minimally displaced fractures (gap or stepoff ≤ 4 mm) were included, leaving 195 and 300 in the operative and nonoperative groups, respectively, for analysis here. Multivariate linear regression was performed to assess the association of treatment choice (nonoperative or operative) with patient-reported outcomes in minimally displaced fractures. In the multivariate analysis, we accounted for nine potential confounders (age, gender, BMI, smoking, diabetes, gap, stepoff, AO/OTA classification, and number of involved segments). In addition, differences in complications after operative and nonoperative treatment were assessed. The minimum clinically important differences for the five subscales of the KOOS are 11 for symptoms, 17 for pain, 18 for activities of daily living, 13 for sports, and 16 for quality of life.

RESULTS

After controlling for potentially confounding variables such as age, gender, BMI, and AO/OTA classification, we found that operative treatment was not associated with an improvement in patient-reported outcomes. Operative treatment resulted in poorer KOOS in terms of pain (-4.7 points; p = 0.03), sports (-7.6 points; p = 0.04), and quality of life (-7.8 points; p = 0.01) compared with nonoperative treatment, but those differences were small enough that they were likely not clinically important. Patients treated operatively had more complications (4% [7 of 195] versus 0% [0 of 300]; p = 0.01) and reoperations (39% [76 of 195] versus 6% [18 of 300]; p < 0.001) than patients treated nonoperatively. After operative treatment, most reoperations (36% [70 of 195]) consisted of elective removal of osteosynthesis material.

CONCLUSION

No differences in patient-reported outcomes were observed at midterm follow-up between patients treated surgically and those treated nonsurgically for tibial plateau fractures with displacement up to 4 mm. Therefore, nonoperative treatment should be the preferred treatment option in minimally displaced fractures. Patients who opt for nonoperative treatment should be told that complications are rare, and only 6% of patients might undergo surgery by midterm follow-up. Patients who opt for surgery of a minimally displaced tibial plateau fracture should be told that complications may occur in up to 4% of patients, and 39% of patients may undergo a secondary intervention (most of which are elective implant removal).

LEVEL OF EVIDENCE

Level III, therapeutic study.

Patient-Reported Outcomes following Tibial Plateau Fractures: Mid- to Short-Term Implications for Knee Function and Activity Level

Background: Patients with complex proximal tibial plateau fractures (TPFs) tend to overestimate the prognosis of their injury, potentially due to factors such as a limited understanding, optimism, and the influence of the pain intensity. Understanding the reasons behind this misperception is crucial for healthcare providers to effectively communicate with patients and establish realistic expectations for treatment outcomes. The purpose of this study was to analyze the outcomes of TPFs, with a particular focus on patient-reported outcome measures concerning functional recovery, pain levels, and overall satisfaction with treatment. The authors aim to provide valuable insights into the realistic expectations and potential limitations that patients may encounter during their recovery journey. Methods: In this retrospective single-center study, all surgically treated TPFs between January 2014 and December 2019 with a minimum follow-up of 12 months were included. Several patient-reported outcome measures were obtained, including the International Knee documentation Committee Score (IKDC), Lyholm score, Tegner score, and visual analog scale (VAS) for pain. Fractures were classified according to Schatzker, and then subgrouped into simple (Schatzker I-III) and complex (Schatzker IV-VI) fractures. Results: A total of 54 patients (mean age 51.1 ± 11.9 years, 59.3% female) with a mean follow-up time of 3.9 years were included. Schatzker II fractures were present in 48% (n = 26) of the cases, with Schatzker III in 6% (n = 3), Schatzker IV fractures in 6% (n = 3), and Schatker VI fractures in 41% (n = 22) of the cases. All outcome scores showed a significant improvement between the first year after surgery and the last follow-up (mean: 3.9 years). Simple fractures showed significantly lower patient-reported outcomes when compared to the preinjury state; however, good to excellent results were observed. Patient-reported outcomes of complex fractures showed no significant changes in the study period with good to excellent results. When it comes to the Lysholm score, there were no significant differences in the outcome between simple and complex fractures. Furthermore, there was a return-to-sports rate of 100%, with high rates of changing sporting activity in 25% (simple fractures) and 45% in complex fractures. Conclusions: The data from this study showed that both simple and complex tibial plateau fractures show favorable outcomes at the midterm follow-up, and that injury severity does not correlate with worse results. While patients may tend to overestimate the recovery speed, this research highlights the importance of long-term follow-up, demonstrating a substantial improvement between one year post-surgery and the final evaluation. Return-to-sports rates were high, with adjustments needed for certain activities. However, patients should recognize the need to shift to lower-impact sports and the lengthy recovery process.

Utilization of cannulated screw fixation of Jail and TiRobot-assisted percutaneous indirect reduction technique for AO/OTA type 41B2 tibial plateau fracture treatment

PURPOSE

The present study was designed to investigate the precise procedure and effectiveness of percutaneous minimally invasive fixation assisted by TiRobot in managing AO/OTA type 41B2 tibial plateau fracture to provide an alternative solution for clinical application.

METHODS

In total, 10 participants with AO/OTA type 41B2 tibial plateau fractures diagnosed by preoperative imaging examinations were enrolled in this study between May 2019 and May 2022. They were 5 males and 5 females, with an average age of 45.6 ± 11.3 years old (range 27-62 years old). All of them had closed fractures, including 6 cases with anterior cruciate ligament (ACL) tibial insertion avulsion fractures, 1 case with medial collateral ligament (MCL) tear, and 4 cases with a lateral meniscus tear. From injury through surgery, the entire time frame was 4.0 ± 1.5 days (range, 2-7 days). Following indirect percutaneous reduction assisted by TiRobot, the Jail method was used to treat all patients with minimally invasive internal fixation. Patients with ligament or meniscus injurieswere treated with arthroscopic surgery in one stage. The standardized functional exercise was performed postoperatively. The knee function was measured using the Hospital for Special Surgery (HSS) score, and the fracture reduction was assessed through the Rasmussen radiology score.

RESULTS

All patients were followed up for 12.7 ± 6.8 months (6-24 months).The fracture healing time was 11.8 ± 0.8 weeks (10-13 weeks), and the X-rays revealed satisfactory fracture reduction.The knee joint's Rasmussen score was 17.8 ± 0.4 (in the range of 17-18) a year after the procedure, with 8 patients receiving outstanding ratings and 2 cases receiving satisfactory scores. The HSS score was 93.8 ± 2.3 (range, 89 to 96), of which 10 cases were excellent. The motion range of the kneewas 138.7°±2.7° (range, -5° to 0° to 135°). No adverse effects or serious complications, such as internal fixation failure, postoperative infection, popliteal vascular injury, and common peroneal nerve injury, were observed during the last follow-up visit.

CONCLUSIONS

The intelligent assistance and accurate guidance of TiRobot can simplify and standardize procedures of percutaneous minimally invasive fixation in theSchatzker type Ⅲ tibial plateau fracture treatment. This technique increases the precision of indirect percutaneous reduction and screw fixation while minimizing bone grafting.

The effect of addition of 2DCT scans and 3DCT scans for the classification of tibial plateau fractures: a systematic review

PURPOSE

In this systematic review, we evaluate the effect of radiographs and 2D and 3D imaging techniques on the interobserver agreement of six commonly used classification systems for tibial plateau fractures.

METHODS

In accordance with PRISMA guidelines, PubMed, Cochrane, Embase and Web of Science were searched for studies regarding the effect of 2D and 3D imaging techniques on the interobserver agreement of tibial plateau classification systems. Studies validating new classification systems, not providing own data or only providing information on the interobserver agreement for radiographs were excluded. Studies were scored based on the ROBINS-I risk of bias tool.

RESULTS

Our review analysed 14 studies on different classification systems used for tibial plateau fractures in clinical practice, with the Schatzker classification being the most commonly used classification system. The results showed that the addition of 2D CT led to a significant improvement of interobserver agreement for one study. However, other included studies showed varying levels of interobserver agreement, ranging from fair to substantial according to the interpretation by Landis and Koch. The addition of 3D CT resulted in a significant deterioration in one study for the Schatzker classification. Similar to the addition of 2D CT, the interobserver agreement for the Schatzker classification with the addition of 3D CT were heterogeneous ranging from fair to almost perfect according to the interpretation by Landis and Koch.

CONCLUSIONS

The use of 2D CT can be recommended for classifying tibial plateau fractures with the Schatzker classification, AO/OTA classification and Hohl classification. The value of 3D CT on the interobserver agreement of commonly used classification systems remains uncertain and unproven. Therefore, we do not recommend the use of 3D CT for the classification of tibial plateau fractures. Overall, the advancement of imaging techniques is not in line with the advancement in interobserver agreement on fracture classification.

3D-validation of a simple tool to measure tibiofemoral axial rotation in tibial plateau fractures

OBJECTIVES

Rotated tibial plateau fractures (TPF) frequently involve multiple planes of movement, yet current presurgical assessment methods do not account for tibiofemoral axial rotation. This study introduces and validates a simple tool to measure rotation-the Gerdy-Tibial-Tuberosity-Surgical-Epicondylar-Axis (GTT-SEA) angle.

METHODS

Forty-seven preoperative 2D CT from a TPF database at a tertiary trauma center were retrieved, and 3D models reconstructed. Three observers made repeated 2D and 3D measurements of the GTT-SEA angle, spaced 4 weeks apart, for 20 patients. Inter- and intra-observer agreement and 2D-3D correlation were calculated. A reference angle was defined from non-operated patients, to classify 28 patients with MRI into neutral, external rotation, and internal rotation groups. The classification agreement and soft tissue involvement between groups were analyzed.

RESULTS

Mean 2D GTT-SEA angle was 17.65 ± 2.36° in non-operated patients, and 13.86 ± 3.90° in operated patients. 3D GTT-SEA angle was 18.92 ± 4.53° in non-operated patients, and 14.76 ± 6.03° in operated patients. 2D-3D correlation was moderate to good (ICC 0.64 ~ 0.83). Two-dimensional (ICC 0.70) and 3D (ICC 0.55) inter-observer agreements were moderate; 2D (ICC 0.82 ~ 0.88) and 3D (ICC 0.76 ~ 0.95) intra-observer agreements were good to excellent. Rotation classification agreement was slight (kappa 0.17) for 2D and good (kappa 0.76) for 3D. More popliteofibular ligament injury was detected in rotated knees (p = 0.016).

CONCLUSIONS

The GTT-SEA angle offers simple, accessible, yet reliable measurement of tibiofemoral axial rotation. Though a true reference range remains to be determined, this tool adds valuable information to existing TPF classifications, potentially allowing assessment of soft tissue involvement in TPF.

CLINICAL RELEVANCE STATEMENT

The GTT-SEA angle will benefit patients who sustain tibial plateau fractures, by allowing physicians to more accurately measure and plan for the injury in 3D, and raising suspicion for otherwise undetected soft tissue injuries, which can impact operative outcomes.

KEY POINTS

• Traumatic fractures of the tibial plateau may contain rotation-induced soft tissue injuries. • A new tool to measure axial rotation between the femur and tibia was found to have moderate to excellent inter- and intra-rater reliability. • The tool may have potential in predicting soft tissue injury and assisting with the decision to receive MRI.

Does the Schatzker III Tibial Plateau Fracture Exist?

Background

The Schatzker classification system for tibial plateau fractures is one of the most commonly used systems. However, there has been controversy if a Schatzker III type fracture truly exists by their original definition. We aimed to correlate the radiographic and CT images of type III fractures, describe the additional propagating fracture patterns and determine if these fractures do exist by their original description.

Methods

This multicenter retrospective cohort observational study included patients with tibial plateau fractures across five trauma centers over 9 years were identified. All X-rays and CT scans were assessed. Two independent fellowship trained, Orthopaedic trauma surgeons reviewed all knee X-rays and classified them according to the Schatzker system. The CTs were subsequently reviewed and the fractures were reclassified based on CT findings.

Results

569 Tibial plateau fractures in 566 patients were analyzed. All X-ray classified Schatzker III fractures were reclassified to a Schatzker II type after review of CT scans by both assessors independently as there were always at least two or more fracture lines propagating from the depressed fragment to the lateral cortex in all cases. The interobserver variability as assessed by the kappa correlation coefficient (κ) for X-rays and CT-based classifications were κ = 0.274 and κ = 0.906, respectively. The majority of cases had two lateral cortical breaks (83.8%). In addition, the depression occurred mostly in the anterolateral and posterolateral positions (60.3%) of the lateral tibial plateau.

Conclusion

This study did not support the existence of true Schatzker Type III fractures.

The AO classification system for tibial plateau fractures: An independent inter and intraobserver agreement study

PURPOSE

Classifying tibial plateau fractures is paramount in determining treatment regimens and systemizing decision making. The original AO classification described by Müller in 1996 and the Schatzker classification of 1970 are the most cited classifications for tibial plateau fractures, demonstrating substantial to almost perfect agreement. The main problem with these classifications schemes is that they lack the detail required to convey the variety of fracture patterns encountered. In 2018, the AO foundation published a new classification system for proximal tibia fractures, highlighting a more complete and detailed number of categories and subcategories. We sought to independently determine inter and intraobserver agreement of the AO classification system, compared to the previous systems described by Müller and Schatzker.

METHODS

One hundred seven consecutive tibial plateau fractures were screened, and a representative data set of 69 was created. Six independent evaluators (three knee surgeons, three senior orthopedic residents) classified the fractures using the original AO, the Schatzker and the new AO classifications. After six weeks, the 69 cases were randomized and reclassified by all evaluators. The Kappa coefficient (k) was calculated for inter- and intraobserver correlation and is expressed with 95% confidence intervals.

RESULTS

interobserver agreement was moderate for all three classifications. k = 0.464 (0.383-0.560) for the original AO; k = 0.404 (0.337-0.489) for Schatzker; and k = 0.457 (0.371-0.545) for the base categories of the new AO classification. The inclusion of subcategories and letter modifiers to the new classification worsened agreement to k = 0.358 (0.302-0.423) and k = 0.174 (0.134-0.222), respectively. There were no significant differences between knee surgeons and residents for the new classification. Intra-observer correlation was also moderate for each of the scores: k = 0.630 (0.578-0.682) for the original AO; k = 0.623 (0.569-0.674) for Schatzker; and k = 0.621 (0.566-0.678) for the new AO base categories; without differences between knee surgeons or residents.

CONCLUSIONS

This study demonstrated an adequate inter and intra-observer agreement for the new AO tibial plateau fractures classification system for its base categories, but not at the subcategory or letter modifier levels.

3D mapping: has the mystery of proximal tibia fractures been solved?

PURPOSE

One of the major limitations of the 2D fracture evaluation (Schatzker classification) is its failure to adequately assess fracture lines in the frontal plane and fracture displacement in the antero-posterior direction. 3D fracture line mapping includes steric assessment which can aid decision making with regards to the surgical approach and fixation scheme. We hypothesized that there are consistent fracture patterns and zones of comminution for proximal tibial fractures.

METHODS

Radiographic data of 228 proximal tibia fractures were retrospectively included in this study. Fracture lines and zones of comminution were graphically superimposed onto a 3D template of an intact tibia after virtual reduction and normalization to identify major patterns of fracture and comminution.

RESULTS

Out of 206 male and 21 female patients, 89 had a fracture of the lateral condyle only (Schatzker I and II), 53 involved the medial plateau only (Schatzker IV) and 86 had a high-grade fracture involving both the condyles (Schatzker V and VI). 64.5% of the fracture lines involving the medial plateau alone were in the coronal plane, and this number was even lesser (44.2%) in medial plateau involvement of bicondylar fractures. In bicondylar fractures, lines were usually not seen to pass directly through the posteromedial region.

CONCLUSIONS

Medial tibial plateau fractures have a mix of coronal or sagittal fracture alignment. A clearer understanding of the 3D orientations of fractures based on CT scans can aid in diagnosing the pattern of fracture and adequate positioning of plates can be done to eventually improve operative outcomes.

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.

Mismatch between Clinical-Functional and Radiological Outcome in Tibial Plateau Fractures: A Retrospective Study

BACKGROUND

The evaluation of tibial plateau fractures (TPF) encompasses the assessment of clinical-functional and radiological parameters. In this study, the authors aimed to investigate the potential correlation between these parameters by utilizing both the clinical-functional and the modified radiological Rasmussen score.

METHODS

In this retrospective monocentric study conducted at a level-I trauma center, patients who underwent surgery between January 2014 and December 2019 due to a TPF were included. The clinical-functional Rasmussen score prior to the injury, at 1-year postoperatively, and during the last follow-up (minimum 18 months) was assessed using a standardized questionnaire. Additionally, the modified radiological Rasmussen score was determined at the 1-year postoperative mark using conventional radiographs in two planes.

RESULTS

A total of 50 patients were included in this study, comprising 40% (n = 20) men, and 60% (n = 30) women, with an average age of 47 ± 11.8 years (range 26-73 years old). Among them, 52% (n = 26) had simple fractures (classified according to Schatzker I-III), while 48% (n = 24; according to Schatzker IV-VI) had complex fractures. The mean follow-up was 3.9 ± 1.6 years (range 1.6-7.5 years). The functional Rasmussen score assessed before the injury and at follow-up showed an "excellent" average result. However, there was a significant difference in the values of complex fractures compared to before the injury. One year postoperatively, both the clinical-functional score and the modified radiological score demonstrated a "good" average result. The "excellent" category was more frequently observed in the functional score, while the "fair" category was more common in the radiological score. There was no agreement between the categories in both scores in 66% of the cases.

CONCLUSIONS

The data from this retrospective study demonstrated that patients with TPF are able to achieve a nearly equivalent functional level in the medium-term after a prolonged recovery period, comparable to their pre-injury state. However, it is important to note that the correlation between clinical-functional and radiological parameters is limited. Consequently, in order to create prospective outcome scores, it becomes crucial to objectively assess the multifaceted nature of TPF injuries in more detail, both clinically and radiologically.

Management of tibial plateau fractures: a fresh review

Tibial plateau fractures are complex injuries which carry significant morbidity and economic burden. They can present complex geometry depending upon the direction of the force and position of the limb and are often associated with significant soft-tissue injury. While the goals of adequate reduction, stable fixation, and early mobilization remain unchanged, the management of these injuries can be challenging even to experienced orthopaedic surgeons. Lacking consensus, this review aims to provide a summary of current state of orthopaedic practice in the face of tibial plateau fractures. A PubMed search for relevant recent articles as well as a reading of classical articles on tibial plateau fractures was carried out. The focus remained on articles concerned with management modalities and recent advances. A review of some classification systems was also done and included. A great majority of these fractures need operative fixation while respecting the soft tissues. Numerous methods have been reported in the literature including but not limited to plates, screws, external fixators, arthroscopy assisted methods, balloon-cement tibioplasty, or a combination thereof. There is a shortage of randomized controlled trials comparing various operative methods. This article provides a review of various techniques and latest advances made in the management of tibial plateau fractures. The key to achieving optimal functional outcome is using a tailored approach to the individual patient accounting for factors related to the injury pattern, type of host, surgical skills and experience, and local availability of implant devices while taking care of soft tissue. While there is no gold standard, a staged procedure is recommended with early spanning and definitive fixation at later stage by any appropriate methods while respecting the soft tissue, achieving anatomical reduction and adequate fixation and, early rehabilitation.

Lateral tibial plateau fractures with posterior comminution. Can a rim plate offer sufficient support?

Tibial plateau fractures with posterior comminution are difficult to reduce and stabilise. Standard lateral approach doesn't offer adequate visualisation. Posterior approach is suitable for isolated posterior fractures. The addition of a specifically contoured rim plate can enable fixation of posterior fragments through a modified lateral approach.The purpose of this study was to evaluate the advantages and limitations of this novel technique. We present a prospective series of 16 tibial plateau fractures with posterolateral depression, operated over a period of 7 years (04.2014-09.2021). The mean age of the patients was 52 years .They were followed for an average period of one year.Clinical and functional assessment was performed according to the criteria of Knee Society Clinical Rating Score. The lateral and posterior component of the fracture was stabilised by a horizontal rim plate, through a posterolateral approach, with or without fibular osteotomy. 9 patients had excellent, 5 had good, 2 had average ratings. The average objective rating was 87,5 (70- 97), and the average functional rating was - 74,4 (40-100). The average ROM was 110° (100°-120°). Two of the fractures healed in 5° varus and 8° valgus respectively. One knee joint ended up with 10° flexion deficit. Three knees had medio- lateral instability, with no functional impairment. In 4 cases the K wires of the weber fibular osteotomy fixation migrated. The absence of late articular collapse of the treated fractures may be attributed to the initial stability of fixation.The addition of a rim plate addresses the posterior comminution and makes early rehabilitation safe.

Posteromedial Submeniscal Arthrotomy and Fixation with a Posteromedial Rim Plate in a Comminuted Medial Tibial Plateau Fracture

Medial tibial plateau fractures generally present as simple metaphyseal fractures; however, certain cases may present as comminuted articular fractures. Medial and posteromedial anatomical plates have traditionally been used for their management; nevertheless, not all cases can be successfully managed using these implants. We present a comminuted posteromedial Schatzker type VI tibial plateau fracture case. Direct visualization and subsequent fixation using a posteromedial rim plate were achieved through a posteromedial approach and submeniscal arthrotomy. The adequate joint reduction and the obtained stability allowed satisfactory clinical and radiological outcomes. This variation of the classic posteromedial approach and the use of a posteromedial rim plate provide an alternative when facing comminuted medial tibial plateau fractures.

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.

Preoperative Mixed-Reality Visualization of Complex Tibial Plateau Fractures and Its Benefit Compared to CT and 3D Printing

BACKGROUND

Various studies have shown the benefit of three-dimensional (3D) computed tomography (CT) reconstruction and especially 3D printing in the treatment of tibial plateau fractures (TPFs). This study aimed to investigate whether mixed-reality visualization (MRV) using mixed-reality glasses can provide a benefit for CT and/or 3D printing in planning treatment strategies for complex TPFs.

METHODS

Three complex TPFs were selected for the study and processed for 3D imaging. Subsequently, the fractures were presented to specialists in trauma surgery using CT (including 3D CT reconstruction), MRV (hardware: Microsoft HoloLens 2; software: mediCAD MIXED REALITY) and 3D prints. A standardized questionnaire on fracture morphology and treatment strategy was completed after each imaging session.

RESULTS

23 surgeons from 7 hospitals were interviewed. A total of 69.6% (n = 16) of those had treated at least 50 TPFs. A change in fracture classification according to Schatzker was recorded in 7.1% of the cases and in 78.6% an adjustment of the ten-segment classification was observed after MRV. In addition, the intended patient positioning changed in 16.1% of the cases, the surgical approach in 33.9% and osteosynthesis in 39.3%. A total of 82.1% of the participants rated MRV as beneficial compared to CT regarding fracture morphology and treatment planning. An additional benefit of 3D printing was reported in 57.1% of the cases (five-point Likert scale).

CONCLUSIONS

Preoperative MRV of complex TPFs leads to improved fracture understanding, better treatment strategies and a higher detection rate of fractures in posterior segments, and it thus has the potential to improve patient care and outcomes.

Influence of articular step-off on contact mechanics in fractures of the posterolateral-central tibial plateau - a biomechanical study

BACKGROUND

The posterior quadrants of the tibial plateau are frequently involved in OTA type C tibial plateau fractures. The biomechanical influence of a residual articular step-off of the posterolateral-central (PLC) segment, which is difficult to visualize intraoperatively, remains unclear. Therefore, aim of this study was to investigate the contact area and stress of the tibial plateau in cases of different articular step-offs of the PLC segment.

METHODS

Seven human cadaveric knees were used to simulate articular impressions of the PLC segment with step-offs of 1 mm, 3 mm, and 5 mm. The knees were axially loaded up to 150 N during a total of 25 dynamic cycles of knee flexion up to 90°. Pressure mapping sensors were inserted into the medial and lateral joint compartments beneath the menisci to measure articular contact area and stress.

RESULTS

Between 60° and 90° of knee flexion, increasing PLC segment impressions of the tibial plateau led to increasing contact stress and a significantly reduced contact area. The largest decrease in the contact area was 30 %, with an articular step-off of 5 mm (0.003). An increase in contact stress, especially from a 3-mm step-off, was measured, with a doubling of the mean contact stress at 3-mm and 5-mm step-offs and 90° knee flexion (p = 0.06/0.05).

CONCLUSION

From a biomechanical point of view, posterior impressions of the PLC segment greater than a 1-mm step-off should be addressed as anatomically as possible, especially in active patients with the need for higher knee flexion angles.

Area of the plateau depression and higher age predict post-operative subsidence in split-depression lateral tibial fracture

INTRODUCTION

The aim of this study was to determine factors that affect post-operative subsidence in split-depression lateral plateau tibial fracture (OTA/AO 41B3.1) which was treated with raft construct through a locking plate.

PATIENTS AND METHODS

The retrospective study evaluated all split-depression lateral plateau tibial fracture cases treated with raft construct through a locking plate between 01/2015 and 04/2020 with a minimum of 12-month follow-up. Data on the patients' age, sex, time from injury to surgery, type of plate, and use of subchondral bone defect filler were retrieved from the hospital database. The measurements of total plateau area (TPA), depressed lateral plateau area (DPA), and maximal plateau depression (MPD) were performed on the patients' pre-operative CT scans. The percentage of DPA to TPA (%DPA) was calculated. Post-operative radiographs were used for the evaluation of plateau subsidence. A subsidence greater than 2 mm was considered a failure.

RESULTS

There were 41 consecutive cases of split-depression lateral plateau tibial fracture in the reviewed period. Five cases were excluded, three of them were lost to follow up, 1 patient had no pre-operative CT scan and 1 had a history of cancer. A failure was identified in 11 (31%) cases. Patients in the failure group were older (61.0 vs 50.7 years, p = 0.01), and had a higher incidence of fractures extending into intercondylar eminence (100% vs 56%, p = 0.02). Multiple logistic regression identified DPA (OR = 3.6; 95%CI 1.4-9.5, p < 0.01) and age (OR = 1.2; 95% CI 1.0-1.4, p = 0.02) as predictive factors for plateau subsidence. DPA cut-off value for predicting subsidence greater than 2 mm was 5.8 cm² [Area Under the ROC Curve 0.89 (95% CI 0.74-0.97), sensitivity 91%, specificity 80%, p < 0.01)].

CONCLUSION

Age and depressed lateral plateau area (DPA) in split-depression lateral plateau tibial fracture treated with raft construct through a locking plate are risk factors for post-operative subsidence greater than 2 mm.

Changing patterns in the epidemiology of tibial plateau fractures: a 10-year review at a level-I trauma center

PURPOSE

Mobility patterns of western societies have been changing due to ongoing demographic change. Therefore, continuously updated epidemiological data on fracture morphology and treatment strategies are needed.

METHODS

This retrospective single-center study included all tibial plateau fractures (TPF) between January 2011 and December 2020 in a level-I trauma center in Central Europe. Epidemiology, trauma mechanism and fracture morphology were analyzed. Age- and sex-specific differences regarding fracture classification (Schatzker, AO/OTA, Moore) and changes during the study period are highlighted.

RESULTS

A total of 607 patients (55.2% women, 44.8% men, mean age 52.9 years (± 17.9)) were included in the study, 462 (76.1%) thereof having undergone surgical treatment. Over the decade, an increase in mean age (+ 7.4 years; p = 0.10), incidence (+ 68%; p < 0.05) and low-energy trauma was observed, with the highest peak in elderly women. Within classifications, AO/OTA 41-B3 (24.9%), Schatzker II (26.8%) and Moore V (46.6%) fractures were the most common.

CONCLUSION

Incidence (+ 68%), mean age and fractures with signs of knee dislocation of tibial plateau fracture increased over the last decade and low-energy trauma mechanism are more frequent. As the increase in incidence is mainly seen in older women, the comorbidities and need for immediate postoperative full weight-bearing have to be considered in treatment strategies.

The influence of 3D printing on inter- and intrarater reliability on the classification of tibial plateau fractures

PURPOSE

Tibial plateau fractures continue to be a challenging task in clinical practice and current outcomes seem to provide the potential for further improvement. Especially presurgical understanding of the orientation of fracture lines and fracture severity is an essential key to sufficient surgical treatment. The object of this study was to evaluate the reliability of modern axial CT-based classification systems for tibial plateau fractures. In addition, the diagnostic-added value of 3D printing on the classification systems was investigated.

METHODS

22 raters were asked to classify 22 tibial plateau fractures (11 AO B- and 11 AO C-fractures) with the AO, the 10-Segment and the Revisited Schatzker classification in a three-step evaluation: first only using CT scans, second with 3D volumetric reconstructions and last with 3D-printed fracture models. Inter- and intraobserver agreement and the subjective certainty were analyzed. Statistics were done using kappa values, percentage match and a univariant one-way analysis of variance.

RESULTS

The AO classifications interobserver percentage match and kappa values improved for all raters and recorded an overall value of 0.34, respectively, 43% for the 3D print. The 10-Segment classification interobserver agreement also improved with the 3D-printed models and scored an overall kappa value of 0.18 and a percentage match of 79%. Equally the Revisited Schatzker classification increased its values to 0.31 and 35%. The intraobserver agreement showed a moderate agreement for the AO (0.44) and Revisited Schatzker classification (0.42) whereas the 10-Segment classification showed a fair agreement (0.27). Additionally, the raters changed their classification in 36% of the cases after evaluating the fracture with the 3D-printed models and the subjective certainty regarding the decisions improved as categories of self-reliant diagnostic choices were selected 18% (p < 0.05) more often after using the 3D-printed models.

CONCLUSION

Based on the measured outcomes it was concluded that the new classification systems show an overall slight to fair reliability and the use of 3D printing proved to be beneficial for the preoperative diagnostics of tibial plateau fractures. The 10-Segment classification system showed the highest percentage match evaluation of all classification systems demonstrating its high clinical value across all levels of user experience.

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.

Tibial slope in the posterolateral quadrant with and without ACL injury

INTRODUCTION

An increased tibial slope is a risk factor for rupture of the anterior cruciate ligament. In addition, a tibial bone bruise or posterior lateral impression associated with slope changes also poses chronic ligamentous instability of the knee joint associated with an anterior cruciate ligament (ACL) injury. In the majority of cases, the slope is measured in one plane X-ray in the lateral view. However, this does not sufficient represent the complex anatomy of the tibial plateau and especially for the posterolateral quadrant. Normal values from a "healthy" population are necessary to understand if stability of the knee joint is negatively affected by an increasing slope in the posterolateral area. Until now there are no data about the physiological slope in the posterolateral quadrant of the tibial plateau.

MATERIALS AND METHODS

In 116 MRI scans of patients without ligamentous lesions and 116 MRI scans with an ACL rupture, tibial slope was retrospectively determined using the method described by Hudek et al. Measurements were made in the postero-latero-lateral (PLL) and postero-latero-central (PLC) segments using the 10-segment classification. In both segments, the osseous as well as the cartilaginous slope was measured. Measurements were performed by two independent surgeons.

RESULTS

In the group without ligamentous injury the mean bony PLL slope was 5.8° ± 4.8° and the cartilaginous PLL slope was 6.7° ± 4.8°. In the PLC segment the mean bony slope was 6.6° ± 5.0° and the cartilaginous slope was 9.4° ± 5.7°. In the cohort with ACL rupture, the bony and cartilaginous slope in both PLL and PCL were significantly higher (P < 0.001) than in the group without ACL injury (bony PLL 9.8° ± 4.8°, cartilage PLL 10.4° ± 4.7°, bony PLC 10.3° ± 4.8°, cartilage PLL 12.8° ± 4.3°). Measurements were performed independently by two experienced surgeons. There were good inter- (CI 87-98.7%) and good intraobserver (CI 85.8-99.6%) reliability.

CONCLUSION

The bony and the cartilaginous slope in the posterolateral quadrant of the tibial plateau are different but not independent. Patients with an anterior cruciate ligament injury have a significantly steeper slope in the posterolateral quadrant compared to a healthy group. Our data indicate that this anatomic feature might be a risk factor for a primary ACL injury which has not been described yet.

LEVEL OF EVIDENCE

III.

The automized fracture edge detection and generation of three-dimensional fracture probability heat maps

With proven impact of statistical fracture analysis on fracture classifications, it is desirable to minimize the manual work and to maximize repeatability of this approach. We address this with an algorithm that reduces the manual effort to segmentation, fragment identification and reduction. The fracture edge detection and heat map generation are performed automatically. With the same input, the algorithm always delivers the same output. The tool transforms one intact template consecutively onto each fractured specimen by linear least square optimization, detects the fragment edges in the template and then superimposes them to generate a fracture probability heat map. We hypothesized that the algorithm runs faster than the manual evaluation and with low (< 5 mm) deviation. We tested the hypothesis in 10 fractured proximal humeri and found that it performs with good accuracy (2.5 mm ± 2.4 mm averaged Euclidean distance) and speed (23 times faster). When applied to a distal humerus, a tibia plateau, and a scaphoid fracture, the run times were low (1-2 min), and the detected edges correct by visual judgement. In the geometrically complex acetabulum, at a run time of 78 min some outliers were considered acceptable. An automatically generated fracture probability heat map based on 50 proximal humerus fractures matches the areas of high risk of fracture reported in medical literature. Such automation of the fracture analysis method is advantageous and could be extended to reduce the manual effort even further.

Proximal avulsion of five ligaments and revised diagonal principle in tibial plateau fractures

PURPOSE

The aim of the study was to analyze the incidence of proximal avulsion of the five main ligaments and to revise the diagonal tension/compression concept in tibial plateau fractures.

METHODS

Computed tomographic images of 1263 cases of tibial plateau fractures were retrospectively analyzed by the OTA/AO classification and four-column nine-segment classification. The correlation between proximal avulsion of five ligaments and the injury mechanism was analyzed.

RESULTS

In total, 1263 tibial plateau fractures in 1253 patients were included. A total of 92 cases (7.3%) associated with proximal avulsions were identified among the 1263 tibial plateau fracture cases obtained from our institution's database. The 92 avulsions occurred in 82 patients, among whom 10 patients had two different avulsions in a single knee. The incidence of proximal avulsion fracture of the medial and lateral collateral ligament was 3.6% (45/1263) and 2.1% (26/1263), respectively. The incidence of avulsion of the anterior cruciate ligament and avulsion of the posterior cruciate ligament was much lower at 0.2% (2/1263) and 0.1% (1/1263), respectively. Proximal avulsion of the patellar ligament occurred in 18 cases (incidence rate = 1.4%). Several combinations of injuries, composed of distal tibial plateau fractures and proximal avulsion of ligaments, were identified.

CONCLUSIONS

Among the patients with tibial plateau fracture, the incidence of proximal avulsion of the five ligaments was 7.3% (92/1263). The four-column and nine-segment classification is an exhaustive method for recording injuries in these ligaments. The revised diagonal injury concept is useful for understanding the injury mechanism and choosing the appropriate surgical strategy.

Anterior displacement of an avulsed posterio-latero-central tibial plateau fracture repaired with Herbert screws

Introduction

Tibial plateau fractures are very complex articular fractures with a rare incidence of approximately 10.3%. These fractures may constitute a severe injury to the knee joint and other complications.

Presentation of case

A 23- year-old male injured his right knee after a crush accident and was diagnosed with a posterio-latero-central (PLC) sheared fracture of the tibial plateau without an injury to knee ligaments. CT with a reconstruction of the right knee showed that the fracture was accompanied by a free fragment inserted into the anterior compartment of the knee. The free fragment was repositioned to its native location and was fixed with three Herbert screws. Also, we found a peripheral avulsion of the posterio-lateral (PL) portion of the lateral meniscus from the capsular attachment, which was repaired with vicryl absorbable suture. An above knee cast was put in 15-degree flexion for three weeks followed by a restoration of knee movements and weight-bearing after ten weeks of surgery. The patient had a full range of motions and no signs of joint laxity after one year of operation.

Discussion conclusion

This study revealed that the surgical repair allowed a quick return to movement for a PLC sheared fracture of the tibial plateau and can be fixed sufficiently to achieve excellent postoperative recovery.

•

An avulsion posterio-latero-central tibial plateau fracture was inserted in the anterior compartment of the knee.

•

The free fragment was large causing a locking knee but there was no injury for knee ligaments.

•

Lateral meniscus was avulsed from the capsular attachment and was repaired with vicryl absorbable suture.

•

The fragment was fixed by three Herbert screws with excellent outcome after the surgery.

Revisiting the management of tibial plateau fractures

Three-dimensional imaging has changed the understanding and management of tibial plateau fractures. In the 1970s, Schatzker proposed a classification for tibial plateau fractures, which highlighted the morphology of the six principal types. More recently, this original classification was complimented by an extended one underscoring the importance of understanding where the split wedge fragment(s) is/are located in three dimensions. The extended classification introduced the split wedge fragment and the continuity of the rim as the determinants of joint stability and the critical role that this plays in the management of tibial plateau fractures. The current manuscript re-emphasizes contemporary concepts of tibial plateau stability and depicts key issues which must be considered when planning the definitive surgical fixation of tibial plateau fractures.

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.

Two-level fixation with headless compression screws for tibial plateau fractures

PURPOSE

Reduction and fixation of tibial plateau fractures associated with small, "floating" intra-articular fragments proposes a challenge. We use fully threaded headless compression screws for (interfragmentary) fixation of such fragments before final plate fixation when standard fixation of intra-articular fragments with k-wires or lag screws is deemed insufficient. Our aim is to describe our technique and clinical experience of this two-level fixation.

METHODS

Between 2006 and 2021, 29 patients with a comminuted tibial plateau fracture were treated with this two-level fixation in this retrospective case series. Clinical baseline and surgical variables were collected for all patients. Clinical outcome variables were available for 28 patients with a median follow-up of 16.5 months (IQR 5-24). Functional outcomes were measured with the Knee Injury and Osteoarthritis Outcome Score (KOOS) and reported by 22 patients at a median of 5.2 years (IQR 3.5-9.8).

RESULTS

Reduction was anatomic or good in 82% of cases, fair in 14%, and a malreduction in 4%. Arthrosis was graded as grade 0 in 25% of cases, 1 in 39%, 2 in 21%, and 3 in 14%. Flexion was 110 degrees (IQR 100-130). Five patients had an extension deficit of 5 to 10 degrees. Median KOOS for symptoms and stiffness was 69 points (IQR 45-78), for pain 71 (IQR 45-88), for ADL 85 (IQR 52-95), for sports 30 (IQR 11-55), and for quality of life 34 (IQR 19-56).

CONCLUSION

The use of fully threaded headless compression screws is a simple and helpful addition in the treatment of comminuted tibial plateau fractures.

[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.

Biomechanical Comparison of 2 Double Plating Methods in a Coronal Fracture Model of Bicondylar Tibial Plateau Fractures

OBJECTIVES

Because management of bicondylar tibial plateau fractures are complicated even for expert surgeons, with using a coronal fracture model, we aimed to compare 2 kinds of double locked plating techniques that consisted of the lateral locking plate and the medial locking plate inserted medial anteriorly (MA-ly) or medial posteriorly (MP-ly).

METHODS

Fourteen fresh-frozen tibias stabilized with the MA or MP methods were allocated into 2 groups with similar bone mineral density values. Implanted samples were tested under incremental fatigue loading conditions using a customized load applicator. An optical motion tracking system was used to assess relative displacements and rotations of fracture fragments during loading. Static and dynamic global stiffness, failure load, failure cycles, as well as movements of fracture fragments were measured.

RESULTS

There were no significant differences between the 2 fixation methods regarding global stiffness, failure load, or failure cycles (P = 0.67-0.98, depending on the parameter). The kinematic evaluations, however, revealed that different positions of the medial locking plates altered the directions of movements for the medial-anterior or medial-posterior fracture segments.

CONCLUSIONS

The mechanical stability of tibia-implant constructs fixed with the double plating methods was not remarkably affected by the location of the medial locking plate. Depending on clinical conditions and surgeons' preferences, bicondylar tibial plateau fractures can be managed with either MA or MP methods.

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.

Lateral femoral notch sign and posterolateral tibial plateau fractures and their associated injuries in the setting of an anterior cruciate ligament rupture

INTRODUCTION

ACL injury is one of the most common injuries of the knee joint in sports. As accompanying osseous injuries of the ACL rupture a femoral impression the so-called lateral femoral notch sign and a posterolateral fracture of the tibial plateau are described. However, frequency, concomitant ligament injuries and when and how to treat these combined injuries are not clear. There is still a lack of understanding with which ligamentous concomitant injuries besides the anterior cruciate ligament injury these bony injuries are associated.

MATERIALS AND METHODS

One hundred fifteen MRI scans with proven anterior cruciate ligament rupture performed at our center were retrospectively evaluated for the presence of a meniscus, collateral ligament injury, a femoral impression, or a posterolateral impression fracture. Femoral impressions were described according to their local appearance and posterolateral tibial plateau fractures were described using the classification of Menzdorf et al. RESULTS: In 29 cases a significant impression in the lateral femoral condyle was detected. There was a significantly increased number of lateral meniscal (41.4% vs. 18.6% p = 0.023) and medial ligament (41.4% vs. 22.1%; p = 0.040) injuries in the group with a lateral femoral notch sign. 104 patients showed a posterolateral bone bruise or fracture of the tibial plateau. Seven of these required an intervention according to Menzdorf et al. In the group of anterior cruciate ligament injuries with posterolateral tibial plateau fracture significantly more lateral meniscus injuries were seen (p = 0.039).

CONCLUSION

In the preoperative planning of ACL rupture accompanied with a positive femoral notch sign, attention should be paid to possible medial collateral ligament and lateral meniscus injuries. As these are more likely to occur together. A posterolateral impression fracture of the tibial plateau is associated with an increased likelihood of the presence of a lateral meniscal injury. This must be considered in surgical therapy and planning and may be the indication for necessary early surgical treatment.

Three-column subdivision for isolated posterolateral tibial plateau fractures and perspective surgical approaches

BACKGROUND

This study aimed (1) to introduce a computed tomography (CT)-based classification of the posterolateral compartment of the tibial plateau based on the fibula and to propose the individualized surgical approaches for each zone; and (2) to determine the surgical approach based on the classification, that would achieve a safe and effective reduction and could improve postoperative clinical outcomes.

METHODS

Eighteen cases of tibia plateau fracture involving the isolated posterolateral compartment in a single institution were retrospectively analyzed. The posterolateral compartment of the tibial plateau was segmented into three zones based on the fibular position and an individualized surgical approach was proposed for each zone. In anterior Zone I, surgical treatment was performed using an extended anterolateral approach and the patient was placed in the supine position; in middle Zone II, using the transfibular approach in the supine position; in posterior Zone III, using the posteromedial approach in the prone position.

RESULTS

In all cases, anatomical articular reduction (intra-articular step off in CT images <2 mm) was achieved and maintained for the follow up period. The average mechanical medial proximal tibial angle was increased from 87.6° before surgery to 88.2° in the immediate postoperative period (P = 0.060), and maintained for the follow up period (mean 89.9° at 1-year follow up). At the 1-year follow up, the knee range of motion averaged 140° and the Lysholm knee function score was 95.0 points.

CONCLUSION

An individualized surgical approach and fixation according to three-zone subdivision for isolated posterolateral tibial plateau fractures provided an effective and safe method to treat posterolateral tibial plateau fractures.

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.

A New Three-Dimensional Classification of Proximal Tibiofibular Fractures: A Multicenter Study

Objectives

To propose an updated definition of proximal tibia and fibula fracture (PTFF) and establish a three‐dimensional (3D) structure‐based classification of PTFF.

Methods

In total, 1358 adult patients (837 males and 521 females; 43.61 ± 15.13 years， 1364 affected knees) who were diagnosed with PTFF at the departments of orthopaedic surgery of four hospitals from January 2010 to December 2019 were enrolled. The new classification of PTFF, termed Wu classification, included three parts: classification of columns in the horizontal plane, regions in the frontal plane, and segments in the sagittal plane. All PTFFs were classified according to Schatzker, Luo, and Wu classification systems. Additionally, the incidence and characteristics of PTFFs were analyzed.

Results

The major internal structural fractures of PTFF were tibial plateau fracture (TPF) only (725, 53.15%), TPF and proximal fibular fracture (274, 20.09%), and isolated avulsion fracture of the posterior cruciate ligament (PCL) (189, 13.86%). Approximately a quarter of PTFF cases could not be classified using Schatzker or Luo classifications, but all PTFF cases could be classified using Wu classification. The most frequent PTFFs included all four columns in region IV, segment 2 (235, 17.23%); the posterolateral and posteromedial columns in region II, segment 2 (191, 14.00%); and the lateral and posterolateral columns in region IV, segment 2 (136, 9.97%). Isolated avulsion fracture of the anterior cruciate ligament (ACL) was categorized as three injury types, most of which involved the lateral and medial columns in region II, segment 1 (40/63, 64%). More than 97% of cases of isolated fractures of the PCL involved the posterolateral and posteromedial columns in region II, segment 2. The most frequent combined avulsion fracture of the ACL and PCL included all four columns in region II, segment 2 (18/24, 75%). All of the isolated avulsion fractures of the ACL were located in segment 1, and all those of the PCL in segment 2. The most common type of isolated proximal fibular fracture involved the posterolateral column in region III, segment 2 (23/26, 88%). The most frequent combined TPF and proximal fibular fracture involved all four columns in region IV, segment 2 (107/274, 39.05%).

Conclusions

All cases of PTFF could be classified by the new 3D Wu classification which should be beneficial for clinical diagnosis, guidance of treatment, statistical analysis, academic communication, and prognosis, and the most frequent PTFF involved all four columns in region IV, segment 2.

Radiographic detection of lateral plateau involvement in medial tibial plateau fractures (AO/OTA 41-B1.2, 1.3, 3.2 and 3.3)

PURPOSE

To assess the accuracy of radiographs in detecting the lateral plateau involvement of medial tibial plateau fractures as well as describe the impact of CT on preoperative planning for this specific fracture morphology.

METHODS

Radiograph and CT imaging of patients with a Schatzker type IV tibial plateau fractures (AO/OTA 41-B1.2, B1.3 h, B2.2. B3.2, and B3.3) between January 2013 and July 2017 were reviewed by three trauma fellowship-trained orthopedic surgeons to identify fractures of the medial condyle with an intact anterolateral articular surface.

RESULTS

Lateral plateau involvement was identified in 16 (37%) radiographs and 26 (61%) CT images (p = 0.051). Radiographic detection of lateral plateau involvement demonstrated a sensitivity of 62% and specificity of 100%, and radiographs were able to predict the recommendation for surgical intervention for lateral plateau involvement with a positive predictive value (PPV) of 75% and a negative predictive value (NPV) of 60% compared to recommendations based on CT imaging. Radiographs predicted a need for a separate surgical approach with PPV of 63% and NPV of 70% when compared to recommendations based on CT images.

CONCLUSIONS

Radiographs are reliable in ruling in lateral plateau involvement of medial plateau fractures, but occult lateral articular extension may only be identified in CT imaging for some cases. Surgical planning may be impacted by CT imaging for this fracture morphology, but further study is warranted to evaluate the correlation between preoperative planning and clinical outcomes.

LEVEL OF EVIDENCE

III.

The Tibial Plateau Map: Fracture Line Morphology of Intra-Articular Proximal Tibial Fractures

The purpose of this study was to characterize the patterns of a large series of tibial plateau fractures with the use of fracture mapping, with regard to different fracture types using the OTA/AO and Schatzker classification. Patients with intra-articular fractures of the tibial plateau were evaluated, using the OTA/AO and Schatzker classification on CT scans. For fracture mapping, the axial slice that completely displayed the tibial joint plane was first identified, then matched to a template congruently, and the fracture lines were identified and reproduced. In addition to epidemiological data (age and gender), the trauma mechanism (high-energy, low-energy, and pathological fracture) was recorded. In total, 271 patients with 278 intra-articular fractures of the tibial head were analyzed, including seven patients with both sides affected. The mean age was 49.1 years (men 46.3 years, women 53.5 years). The majority of fractures was caused by high-energy trauma. No significant difference could be shown with respect to trauma mechanism and resulting fracture type in terms of OTA/AO (p = 0.352) or Schatzker classification (p = 0.884). A significant difference could be found with respect to gender and resulting fracture type in terms of OTA/AO (p = 0.031). 170 (61.2%) were OTA/AO type B fractures, and 108 (38.8%) were type C fractures. Using the Schatzker classification, we found 53 type I (19.1%), 60 type II (21.6%), 27 type III (9.7%), 32 type IV (11.5%), 16 type V (5.8%), and 90 type VI (32.4%) fractures. The main affection was found in the lateral and intermedial column of the tibial plateaus, concerning both OTA/AO and Schatzker classification. The variability of intra-articular tibial head fractures is very high. In consequence, an individual analysis of fracture patterns and therapy planning by using CT scans is crucial.

3D modelling of tibial plateau fractures: Variability in fracture location and characteristics across Schatzker fracture types

INTRODUCTION

Numerous classifications have been developed to assess tibial plateau fractures (TPF). Of these, the Schatzker system is the most widely reported in the literature yet this system is limited in its characterisation of morphological fracture features underlying the fracture location. The purpose of this study was to compare 3D morphological features of TPFs across different Schatzker types.

METHODS

This study retrospectively analysed preoperative TPF imaging data to reconstruct 3D models of the fractures. Ninety-one fractures (29 female, 62 male) were analysed and classified using Schatzker. Fracture location across Schatzker types was compared based on division of the articular surface into six 'zones'. Additionally, morphological characteristics of the fractures were compared based on fracture type, including; the number, volume and shape of the fragments.

RESULTS

Schatzker II, IV and VI fractures were most common, making up 41%, 16% and 20%, respectively. Type II fractures commonly involved both the lateral and central aspect of the tibial plateau, similarly, type IV fractures incorporated the lateral condyle in most cases. Considering the morphological metrics, statistically significant differences were observed between Schatzker types for the number of; total, articular, cortical and volumetrically significant (all P < 0.001) fragments along with the volume of both primary (P < 0.001) and secondary (P = 0.02) fragments.

DISCUSSION

Assessment of underlying fracture characteristics in addition to fracture location can serve to provide greater detail relating to fracture morphology, which has the potential to assist with both surgical decision making and assessment of postoperative outcomes. Incorporating this information as part of a hierarchical or multifactorial framework for classifying fractures may help distinguish subtle differences between fracture types that are classifiable using the most current systems.

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.

Treatment of posterolateral tibial plateau fractures with a rotational support plate and special pressurizer: technical note and retrospective case series

Background

In tibial plateau fractures, the posterolateral segment of the tibia plateau is frequently affected and challenging to treat. Although there are many surgical approaches and fixation methods for the treatment of these fractures, all of these methods have limitations. We designed a new rotational support plate (RSP) and a special pressurizer that can fix the fracture directly via the anterolateral approach. This method is advantageous because it leads to little trauma, involves a simple operation, and has a reliable fixation effect. This study details the technique of treating these fractures with the RSP and special pressurizer and provides the outcomes.

Methods

From May 2016 to January 2019, the data of 12 patients with posterolateral tibial plateau fractures treated with the RSP and special pressurizer in our hospital were retrospectively analyzed. Postoperative rehabilitation was advised, knee X-rays were taken at follow-ups, and fracture healing, complications, and knee range of motion were assessed. The Hospital for Special Surgery (HSS) knee score and Knee Injury and Osteoarthritis Outcome Score (KOOS) were used to evaluate knee function at the last follow-up.

Results

The average follow-up time of all patients was 16.5 months (range, 12–25 months). The average bony union time was 3.2 months (range, 3–4.5 months). At the last follow-up, the average knee range of motion was 138° (range, 107–145°). The average HSS score was 91 (range, 64–98). The average KOOS Symptoms score was 90 (range, 75–96). The average KOOS Pain score was 91 (range, 72–97). The average KOOS ADL score was 91 (range, 74–97). The average KOOS sport/recreation score was 83 (range, 70–90). The average KOOS QOL score was 88 (range, 69–93). Skin necrosis, incision infections, and fixation failure did not occur during the follow-up period.

Conclusions

With our newly designed RSP and special pressurizer, posterolateral tibial plateau fractures can be easily and effectively reduced and fixed through the anterolateral approach, which serves as a novel treatment for posterolateral tibial plateau fractures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02544-w.

Trauma mechanism and patient reported outcome in tibial plateau fractures with posterior involvement

INTRODUCTION

Posterior tibial plateau fractures (PTPF) have a high impact on functional outcome and the optimal treatment strategy is not well established. The goal of this study was to assess the relationship between trauma mechanism, fracture morphology and functional outcome in a large multicenter cohort and define possible strategies to improve the outcome.

METHODS

An international retrospective cohort study was conducted in five level-1 trauma centers. All consecutive operatively treated PTPF were evaluated. Preoperative imaging was reviewed to determine the trauma mechanism. Patient reported outcome was scored using the Knee injury and Osteoarthritis Outcome Score (KOOS).

RESULTS

A total of 145 tibial plateau fractures with posterior involvement were selected with a median follow-up of 32.2 months (IQR 24.1-43.2). Nine patients (6%) sustained an isolated posterior fracture. Seventy-two patients (49%) sustained a two-column fracture and three-column fractures were diagnosed in 64 (44%) patients. Varus trauma was associated with poorer outcome on the 'symptoms' (p = 0.004) and 'pain' subscales (p = 0.039). Delayed-staged surgery was associated with worse outcome scores for all subscales except 'pain'. In total, 27 patients (18%) were treated with posterior plate osteosynthesis without any significant difference in outcome.

CONCLUSIONS

Fracture morphology, varus trauma mechanism and delayed-staged surgery (i.e. extensive soft-tissue injury) were identified as important prognostic factors on postoperative outcome in PTPF. In order to assess possible improvement of outcome, future studies with routine preoperative MRI to assess associated ligamentous injury in tibial plateau fractures (especially for varus trauma) are needed.