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

Enhancing agreement in classification and surgical approach selection for tibial plateau fractures: The role of identifying metaphyseal fracture exit. - A Cross-sectional study

Objectives

To determine if identifying the metaphyseal exit can enhance intra- and inter-observer agreement in utilizing the Kfuri and Schatzker anatomical classification and selecting the appropriate surgical approach for tibial plateau fractures.

Methods

Design: Cross-sectional observational study.Setting: Academic hospital with access to advanced imaging technologies.Patient Selection Criteria: Tibial plateau fracture cases from January 2019 to March 2021 with complete image sets (AP and lateral knee radiographs, CT scans). Exclusion criteria included periprosthetic, neglected, or pathological fractures.Outcome Measures and Comparisons: Primary outcome measures were intra- and inter-observer agreement in fracture classification and surgical approach selection, quantified using Cohen's and Fleiss Kappa coefficients.

Results

The study analyzed 63 cases. Intra-observer agreement improved from moderate to 'very good,' especially in the third evaluation phase when the metaphyseal exit was identified alongside 3D CT imaging. Inter-observer agreement was generally low but improved when comprehensive image sets were available. Notably, the most experienced evaluator demonstrated significantly higher agreement in both fracture classification and surgical approach selection.

Conclusions

The identification of metaphyseal exit points significantly enhances agreement in fracture classification and surgical approach selection, addressing limitations of traditional systems. While surgeon experience and imaging availability remain critical, incorporating the metaphyseal exit into the Kfuri and Schatzker classification offers a reproducible framework for guiding treatment decisions.

Level of evidence

III Diagnostic Study.

Current concepts in tibial plateau fracture management: a Spanish Orthopaedic Trauma Association review

This article summarizes a symposium on topics regarding the current management of tibial plateau fractures presented by the Spanish Orthopaedic Trauma Association as a guest nation society at the Orthopaedic Trauma Association Annual Meeting in October 2023 in Seattle, Washington. These topics include staged treatment strategies, surgical planning, fracture classification, and factors influencing weight bearing. A staged protocol for treating high-energy fractures of the proximal tibia using spanning external fixation with quadrangular configuration is a simple and reproducible way to apply the device and reduce and span these fractures. Multicolumnar fractures can behave differently based on their categorization using the main deformity direction concept, defined as a theoretical vector representing the global displacement or deformity of the columns in a specific direction, and this can help surgeons decide on the definitive treatment. With the classification of columnar involvement and their variants, surgeons can use computed tomography scans to formulate solutions to approach and fix individual fracture patterns. Finally, a finite element analysis may inform the surgeon's decision for immediate weight bearing of a split plateau fracture after fixation with locking screw plates or cannulated screws.

Lateral epicondyle osteotomy results in improved radiologic and functional outcomes in severe lateral tibial plateau fractures: a retrospective cohort study

BACKGROUND

This study evaluated the clinical and radiological outcomes of lateral tibial plateau fractures involving the central and postero-lateral regions, comparing an extended lateral approach with lateral epicondyle osteotomy (ECO) to a conventional approach without an extention (No-ECO).

METHODS

A retrospective cohort study was conducted at two centers, examining complex lateral tibial plateau fractures treated with either an extended lateral approach with ECO or without it. Only AO/OTA type B3/C3 fractures involving the antero-latero-central (ALC) and postero-latero-central (PLC) segments were included. Fracture reduction quality was assessed via post-operative CT scans, and clinical outcomes and complications were evaluated over a minimum of 24-month follow-up.

RESULTS

A total of 110 patients (mean age: 51.3 ± 11.1 years) were included, with an average follow-up of 52.7 ± 16.9 months. The ECO group (n = 56) consisted of more severe injuries, indicated by higher external fixator use (48.2% vs. 22.2%, p = 0.0044) and additional affected segments. Postoperative CT scans revealed that the ECO group had significantly less fracture step-off (0.8 mm vs. 3.0 mm, p = 0.0002) and angulation at the ALC/PLC (8.1° vs. 20.1°, p = 0.0002) segment and PLC/PLL (postero-latero-lateral) (2.2° vs. 7.5°, p = 0.02) segments. Clinically, the ECO group achieved superior IKDC scores (71.7 vs. 63.7, p = 0.0097). A negative correlation was found between postoperative ALC/PLC depression and IKDC scores (r=-0.36, p = 0.0002).

CONCLUSION

Patients treated with ECO had a significantly better clinical and radiologic postoperative outcomes, with the quality of fracture reduction positively correlating with the clinical IKDC score. This was achieved despite more severe injuries, as indicated by higher external fixator use and number of affected segments.

LEVEL OF EVIDENCE

III Retrospective Cohort Study.

TRIAL REGISTRATION

The study was retrospectively registered and conducted according to the guidelines of the Declaration of Helsinki and approved by the local Ethics Committee (PV7319).

Fibular head osteotomy: A new technique for better exposure of postero-lateral tibial plateau fracture

OBJECTIVE

Various osteotomy techniques have been explored for exposing the posterolateral tibial plateau in previous studies. However, these methods are often complex, cause significant damage to normal anatomical structures, compromise knee joint stability, and pose risks to knee function, thus limiting their clinical application. This study proposes a new fibular head osteotomy technique for treating posterolateral tibial plateau fractures, aiming to achieve favorable surgical outcomes.

METHODS

Thirteen patients who underwent surgical treatment for posterolateral tibial plateau fractures between March 2020 and August 2023 at our hospital were included in this study. The study was approved by the clinical ethics committee of our institution. All patients provided informed consent before participation. Surgeries were performed through a modified Frosch approach combined with partial fibular head osteotomy, while preserving part of the biceps femoris tendon attachment to the fibula. Postoperative fracture reduction quality was assessed using X-rays and computed tomography (CT) scans, in accordance with the Rasmussen radiology scoring system. Knee joint function was evaluated at the final follow-up using the Hospital for Special Surgery (HSS) scoring system. The healing of the fibular head osteotomy site and the presence of any complications were also assessed.

RESULTS

All 13 patients were followed up with for an average of 12.2 months (range: 9-17 months). All fractures, collapse, and deformities were corrected. The mean Rasmussen radiological score was 15.5 ± 2.5 (range: 10-18), with four cases rated as excellent, eight as good, and one as fair. The mean Hospital for Special Surgery (HSS) score was 89.8 ± 6.4 (range: 78-98), with 10 cases rated as excellent and 3 as good. No posterolateral knee instability was observed during physical examination at the final follow-up. There were no complications such as surgical site infection or common peroneal nerve injury.

CONCLUSIONS

Partial fibular head osteotomy combined with preservation of the biceps femoris tendon attachment is an effective technique for treating posterolateral tibial plateau fractures. This method allows for successful fracture reduction and fixation without compromising knee joint function.

Hoffa-mimicking fracture of the tibial plateau

We report the case of a teenage male who had a slip and fall from a motorcycle and sustained injury to his left knee. A clinicoradiological evaluation revealed a closed displaced osteochondral fragment of the posterolateral tibial plateau. The patient underwent open reduction and internal fixation with two cannulated headless screws. The patient recovered uneventfully on follow-up. The Hoffa-like displaced posterolateral tibial plateau fracture with no associated ligament damage is a rare injury. Further, there are very few reported cases on the surgical approach and fixation techniques in this pattern of injury.

Triple-incision treatment of the posterior condylar triad in the lateral prone position

BACKGROUND

Posterior tibial plateau bicondylar fracture combined with anterior cruciate ligament injury, also known as the "Posterior Condylar Triad", is a regular combination injury. The traditional surgical strategy involves first fixing the posterior condyle in the prone position and then treating the anterior cruciate ligament avulsion injury after the patient turns over. This surgical strategy is cumbersome, requires multiple surgical preparations, prolongs the surgical time, and increases the patient's risk. Our centre proposed one lateral prone position with three incisions to treat the "Posterior Condylar Triad".

METHODS

This was a retrospective analysis of the clinical data of 11 "Posterior Condylar Triad" patients who underwent surgical treatment at our centre from February 2017 to August 2020. Using a unified surgical strategy, the patient rotates the limb in a lateral prone position. The posterior condyle fracture of the tibial plateau is treated through a posterior medial incision and posterior lateral Frosch approach. Finally, anterior cruciate ligament avulsion fracture is treated through a small incision on the medial side of the patella. All patients were encouraged to perform functional exercises of the knee joint early after surgery. The postoperative complications (deep vein thrombosis, poor wound healing, deep infection, internal fixation failure and fracture reduction loss) and knee joint function (knee joint range of motion, Lysholm score and SF36 scale) of the patients were recorded 1 year after surgery.

RESULTS

All patients' fractures healed smoothly, with an average fracture healing time of 17.0 weeks, ranging from 12 to 22 weeks. There were 2 patients with deep vein thrombosis (DVT) after the operation. One patient experienced wound fat liquefaction, and no patients reported serious complications, such as loss of fracture reduction, failure of internal fixation, or deep infection. One year after surgery, the average range of motion (ROM) of the affected limb's knee joint was 3.6-120.5°, the average Lysholm score was 86.7, ranging from 61 to 100, and the average SF36 score was 76.96, with a range of 52.45-94.75.

CONCLUSION

The "Posterior Condylar Triad" is a serious injury, and our proposed surgical strategy can simplify the surgical process, avoid large-scale changes in patient position during surgery, shorten surgical time, and reduce the risk of surgical anaesthesia, enabling patients to achieve good clinical prognosis.

Treatment of posterolateral tibial plateau fractures through the articular line approach

BACKGROUND

Posterolateral tibial plateau fractures pose significant challenges for orthopedic surgeons due to the anatomical risks associated with the posterolateral approach. Despite numerous surgical techniques available, there lacks a consensus on the optimal approach.

METHODS

Articular line incision approach was employed on 12 patients suffering from posterolateral tibial plateau fractures. Preoperative CT scans were utilized to assess the fractures, followed by an articular line incision to expose and fix the fractures with a 3.5 mm low-profile lateral locking compression plate. The surgical outcomes were evaluated through postoperative recovery metrics including pain levels, knee joint stability, and recovery time.

RESULTS

All patients achieved articular surface reduction and stable fixation without complications, loss of reduction, or infection. Postoperative assessments showed normal knee extension, with patients returning to pre-injury work levels. The average range of motion (ROM) of the knee joint was 123.3°, and the average Hospital for Special Surgery (HSS) score was 96.4, indicating successful recovery outcomes.

CONCLUSION

The articular line incision approach for posterolateral tibial plateau fractures provides a viable alternative to traditional methods. It offers the benefits of reduced trauma, shortened recovery times, and minimized risk of infection, making it a recommendable technique for such fractures.

TRIAL REGISTRATION

Not applicable.

The Intact Meniscal "Bucket-Handle" Technique to Expose Complex Lateral Tibial Plateau Fractures

There is no consensus on the optimal surgical approach to treat complex tibial plateau fractures, but careful selection of the appropriate surgical approach with clear access to the joint is crucial for successful anatomic reduction. Several articles have described techniques using a fibular or lateral femoral epicondylar osteotomy for improved visualization. Detachment of the anterior horn could facilitate treatment; however, inadequate reattachment of the anterior horn could hinder the healing process and create residual subluxation of the meniscus. This Technical Note describes a surgical technique to provide clear access to the articular surface for the treatment of complex lateral tibial plateau fractures by releasing the posterior meniscocapsular fibers up to the popliteus tendon and folding the lateral meniscus into the intercondylar notch, which exposes the articular surface.

Treatment of posterolateral tibial plateau fractures: a narrative review and therapeutic strategy

The posterolateral tibial plateau is crucial for maintaining knee stability during flexion, and fractures in this area often involve ligament and meniscus injuries, necessitating effective management. However, treating posterolateral tibial plateau fractures (PLF) poses significant challenges due to the complex anatomy. Therefore, this review aims to explore contemporary concepts of PLF, from identification to fixation, and proposes a comprehensive treatment strategy. In this article, the authors detail the injury mechanisms, fracture morphology, PLF classification systems, surgical approaches, and techniques for open reduction and internal fixation (ORIF) as well as arthroscopic-assisted internal fixation (ARIF). The findings indicate that PLF is typically caused by flexion-valgus forces, resulting in depression or split-depression patterns. For isolated PLF, the supra-fibular head approach is often preferable, whereas posterior approaches are more suitable for combined fractures. Additionally, innovative plates, particularly the horizontal belt plate, have shown satisfactory outcomes in treating PLF. Currently, the 'bicondylar four-quadrant' concept is widely used for assessing and managing the tibial plateau fractures involving PLF, forming the cornerstone of the comprehensive treatment strategy. Despite challenges in surgical exposure and implant placement, ORIF remains the mainstream treatment for PLF, benefiting significantly from the supra-fibular head approach and the horizontal belt plate. Furthermore, ARIF has proven effective by providing enhanced visualization and surgical precision in managing PLF, emerging as a promising technique.

Tibial Plateau Fracture: Implementing the Modified Frosch Approach for Dual-Benefit Achievement

The increasing prevalence of tibial plateau fractures has led more orthopedic surgeons to focus on effective reduction and stabilization, which requires thorough preoperative assessment. The advent of computed tomography (CT) scans and three-dimensional reconstruction has revolutionized fracture analysis, enabled precise delineation, and improved surgical planning. Historically, the tibial plateau classification based on 2D radiographs was the standard. However, the use of CT imaging has refined this with advancements in imaging, which categorizes fractures based on anatomical columns and cortical involvement. Recently, the classification has also included landmarks like the fibular tubercle and superficial medial collateral ligament, providing a more comprehensive quadrant-based classification. In practice, we utilized a single-incision approach to address anterolateral and posterolateral fragments simultaneously. This technique is recognized for its safety, minimizing risks to vital structures like the peroneal nerve and arteries. By preserving ligament integrity and neurovascular structures, tailored surgical approaches can optimize outcomes. Integrating advanced imaging techniques and refined classifications has significantly improved the management of tibial plateau fractures. These advancements allow surgeons to plan and execute surgeries with greater precision, enhancing patient outcomes. As the field evolves, ongoing research and innovation will likely lead to even more effective strategies, underscoring the importance of staying current with the latest orthopedic developments for optimal patient care.

Finite element analysis of a novel anatomical plate in posterolateral plateau fractures

Objective

This study aims to analyze the biomechanical characteristics of posterolateral plateau fractures fixed by a novel anatomical plate using finite element analysis.

Methods

A three-dimensional digital model of the full length of right tibiofibula was obtained by CT scanning. A posterolateral tibial plateau fracture model was then created. The acquired fracture model was assembled with 4 groups of internal fixations: Group A, novel anatomical plate; Group B, straight buttress plate; Group C, oblique T-shaped locking plate; Group D, two lag screws. Axial loads of 500, 1,000 and 1,500 N perpendicular to the horizontal plane were used to simulate the stress on the lateral plateau of a 65 kg person standing, walking and fast running.

Results

Vertical displacements of the posterolateral fragments in each of the four groups gradually increased under loads from 500 N to 1,500 N. The maximum displacement of the fracture fragment in four groups were all located on the lateral side of the proximal part, and the displacement gradually decreased from the proximal part to the distal end. The maximum displacement values under the axial load of 1,500 N was in the following order: novel anatomical plate (1.2365 mm) < oblique T-shaped locking plate (1.314 mm) < two lag screws (1.3747 mm) < straight buttress plate (1.3932 mm). As the axial load increased, the stress value of the different internal fixation models gradually increased. The stress behavior of the same internal fixation model under different loads was similar. The maximum stress value under the axial load of 1,500 N was in the following order: novel anatomical plate (114.63 MPa) < oblique T-shaped locking plate (277.17 MPa) < two lag screws (236.75 MPa) < straight buttress plate (136.2 MPa).

Conclusion

The patients with posterolateral plateau fractures fixed with a novel anatomical plate in standing, walking and fast running can achieve satisfactory biomechanical results, which lays the foundation for future applications. At the same time, clinical fracture types are often diverse and accompanied by damage to the soft tissue. Therefore, the ideal surgical approach and appropriate internal fixation must be selected based on the patient's injury condition.

Biomechanical analysis of tibial plateau posterolateral fracture fragment fixation and introduction of a lateral tibia plateau hook plate system

BACKGROUND

Fixing the posterolateral fragments of tibial plateau fractures has been challenging owing to potential neurovascular injuries and fibular head blocks. Several surgical approaches and fixation techniques have been reported, with distinct limitations. We propose a novel lateral tibia plateau hook plate system and compare its biomechanical stability with other fixation methods.

METHODS

Twenty-four synthetic tibia models were simulated to present posterolateral tibial plateau fractures. These models were randomly assigned to three groups. Group A models were fixed with the lateral tibia plateau hook plate system, Group B with variable-angle anterolateral locking compression plates, and Group C with direct posterior buttress plates. The models' biomechanical stability was evaluated using static (gradually increased axial compressive loads) and fatigue (cyclically loaded from 100 to 600 N for 2000 cycles each) tests.

RESULTS

Groups A and C models exhibited comparable axial stiffness, subsidence load, failure load, and displacement in the static test. Group A model exhibited higher subsidence and failure loads than Group B model. Groups A and C models exhibited comparable displacement at 100 N cyclic loading in the fatigue test. Group C model was more stable at higher loads. Group C model endured the highest subsidence cycle numbers, followed by Groups A and B models.

CONCLUSIONS

The lateral tibia plateau hook plate system provided similar static biomechanical stability as the direct posterior buttress plates and comparable dynamic stability under limited axial loading. This system is a potential posterolateral treatment choice owing to its convenience and safety, in treating tibia plateau fractures.

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.

An imageology-based feasibility study of plating posterolateral tibial plateau fractures via an anterolateral trans-fibular-head approach

BACKGROUND

There are many difficulties in the reduction and fixation of the tibial plateau fractures involving posterolateral quadrant using general plates via traditional approaches. By imaging the area above the fibulae capitulum, this study was performed to investigate the feasibility of the trans-fibular-head approach and to design an ideal anatomical plate.

METHODS

MRI and CT scans of the knee joint were collected from 205 healthy volunteers (103 males, 102 females). Gender and height were used to divide the volunteers into groups separately: (1) A1 group and A2 group according to gender, (2) B1 group and B2 group according to height. Based on the images, several parameters were defined and measured to describe the space above the head of the fibula. In addition, differences in these parameters between genders and height were compared.

RESULTS

The narrowest distance in the bony region was (10.96 ± 1.39) mm, (5.41 ± 0.97 mm) in the bone-ligament region. The narrowest distance of bony region in the A1 group was more than that in the A2 group (11.21 ± 1.62 mm, 10.85 ± 1.47 mm, p = 0.029). The narrowest distance of the bony region was (10.21 ± 1.42) mm and (11.65 ± 1.39) mm in the B1 group and B2 group, respectively (p = 0.002). The narrowest distance of the bone-ligament region was (5.39 ± 0.78) mm and (5.22 ± 1.21) mm in the A1 group and A2 group, respectively. No statistically significant differences were observed between the A1 group and the A2 group in terms of the narrowest distance of the bone-ligament region. In the B1 group, the narrowest distance of the bone-ligament region (5.18 ± 0.71 mm) was not significantly less than that (5.31 ± 0.91 mm) in the B2 group.

CONCLUSION

The space above the fibular capitellum was ample enough to place the plate for treating tibial plateau fractures involving posterolateral quadrant. The divisions of the lateral tibial plateau by 3-dimensional CT and the parameters of each region were crucial for providing guidance for designing the anatomical plate for the trans-fibular-head approach.

The prone posteromedial approach to the knee revisited: a safe and effective strategy for posterior tibial plateau fractures

PURPOSE

To compare outcomes of patients with posterior tibial plateau fractures who underwent repair indirectly with an anterior approach to those who underwent direct repair with a prone "Lobenhoffer" operative approach.

METHODS

A total of 44 patients with a posterior column tibial plateau fracture that underwent repair were identified. Twenty-two patients with 22 tibial plateau fractures were fixed using a prone Lobenhoffer approach. They were compared to 22 patients treated with an indirect reduction using a supine approach for similar fracture patterns. Data collection at minimum 1 year included: patient-reported outcome scores (SMFA), patient-reported pain, knee range of motion, complications and need for reoperation. Radiographs were reviewed for knee alignment, residual depression and fracture healing.

RESULTS

All demographics were similar between the groups except BMI, which was lower in the prone group (P < 0.05). Fracture type according to age, Schatzker and three-column classification was matched between cohorts. There was no difference in outcomes including: pain, radiographic knee alignment, residual articular depression, functional outcome (SMFA), complications and need for reoperations. Knee flexion at 1 year was greater in the prone group (127.8 vs. 115.8; P = 0.018). In addition, surgical time was less in the prone group (mean 73.7 min vs. 82.3 min; P = 0.015).

CONCLUSION

The Lobenhoffer approach with direct reduction of posterior fracture fragments for complex tibial plateau fractures is an excellent option for these injuries. It allowed for faster surgery with improved ultimate knee range of motion in posterior column tibial plateau fractures.

Biomechanics and finite element analysis of a novel plate designed for posterolateral tibial plateau fractures via the anterolateral approach

Surgical management of posterolateral tibial plateau (PLTP) fractures is challenging. One reason for this challenge is the lack of suitable internal fixation devices. Our aim was to introduce a novel plate via the anterolateral approach for managing PLTP fractures. The biomechanical testing and finite element analysis (FEA) were performed. PLTP fracture models were created using synthetic tibias (n = 10 within each group). These models were randomly assigned to three groups (groups A-C) and fixed with the lateral locking plate, the posterior buttress plate, and the novel plate, respectively. The vertical displacement of the posterolateral fragments was evaluated using biomechanical testing and FEA under axial loads of 250 N, 500 N, and 750 N. We also evaluated the stress distribution and maximum stress of each fracture model using FEA. Biomechanically, under the same loads of 250 N, 500 N, or 750 N, the vertical displacement was significantly different among the three fixation groups (p ≤ 0.001). FEA data indicated that the maximum displacement from group A to C was 3.58 mm, 3.23 mm, and 2.78 mm at 750 N, respectively. The maximum stress from group A to C was 220.88 MPa, 194.63 MPa, and 156.77 MPa in implants, and 62.02 MPa, 77.71 MPa, and 54.15 MPa in bones at 750 N, respectively. The general trends at 250 N and 500 N were consistent with those at 750 N. Based on our biomechanical and FEA results, the novel plate could be a good option for treating PLTP fractures. The novel plate showed stable and reliable features, indicating its suitability for further clinical application.

Revisiting the flexion-valgus type unicondylar posterolateral tibial plateau depression fracture pattern: classification and treatment

OBJECTIVE

This study aimed to reclassify posterolateral tibial plateau fractures caused by a flexion-valgus force and describe this fracture pattern to provide a relatively programmed surgical treatment based on morphological characteristics that may improve reduction and stabilization.

METHODS

We retrospectively reviewed the fracture pattern and injury mechanism of patients with posterolateral tibial plateau fractures who underwent surgery at the First Affiliated Hospital of Nanjing Medical University between January 2014 and April 2020. The cohort was divided into three types. Type I was a depression fracture of the posterolateral platform with an intact posterolateral cortex. Type II was a depression fracture of the posterolateral platform with a disrupted posterolateral cortex. Type III was a depression fracture of the posterolateral platform in combination with anterior cruciate ligament (ACL) rupture or tibial insertion avulsion fracture of the ACL. The lateral window of the modified Frosch approach with an L-type locking plate was used for patients with type I and type III fractures. For patients with type II fractures, both lateral and posterolateral windows of the modified Frosch approach were used for surgery, and a T-plate on the posterior side with an L-plate on the lateral side were used for fixation. The Rasmussen radiology scoring was used to evaluate the quality of surgical reduction and the Rasmussen functional scoring evaluation standard was used to evaluate knee joint function.

RESULTS

A total of 69 tibial plateau fractures (36 male, 33 female) involving the posterolateral platform were discovered and included in this study. All patients suffered flexion-valgus force at the moment of the accident. There were 32 cases of Type I fracture, 28 cases of Type II fracture, and 9 cases of Type III fracture. The patients were followed up for 12-30 (mean 20.8 ± 9.4) months. The postoperative Rasmussen radiological scores for the three types of fractures were 15-17 (mean 16.31 ± 0.78), 14-17 (mean 15.93 ± 0.94), and 14-17 (mean 16.22 ± 0.97), respectively. The postoperative Rasmussen functional scores for the three types of fractions were 27-30 (mean 27.97 ± 0.90), 27-29 (mean 27.36 ± 0.56), and 27-29 (mean 27.56 ± 0.73), respectively.

CONCLUSION

Flexion-valgus posterolateral tibial plateau fractures were divided into three types based on the integrity of the posterolateral wall and ACL injuries. We hope the classification can play a certain reference role in recognizing and treating flexion-valgus-type posterolateral tibial plateau fractures.

Clinical Analysis of the Frosch Approach in the Treatment of Posterolateral Tibial Plateau Fractures Combined with Lateral Tibial Plateau Fractures

OBJECTIVE

The treatment of posterolateral tibial plateau fractures is difficult, and providing sufficient exposure and effective fixation is a challenge. There is great controversy regarding the surgical approach for posterolateral tibial plateau fractures. The purpose of the study was to investigate the clinical effects of open reduction and internal fixation using the Frosch approach for the treatment of posterolateral tibial plateau fractures combined with lateral tibial plateau fractures.

METHODS

Data from 19 patients with posterolateral tibial plateau fractures combined with lateral tibial plateau fractures treated from May 2018 to January 2022 were retrospectively analyzed. There were nine men and 10 women, ranging in age from 22 to 62 years, with an average age of 45.6 years. All patients were treated using the Frosch approach. Under direct vision, the posterolateral and lateral fractures were reduced, and full bone grafting was performed. We reshaped the oblique "T" shaped plate for the distal radius and placed it on the posterolateral tibial plateau to fix the posterolateral fractures. The lateral inverted "L" shaped locking plate was placed on the lateral tibial plateau to fix the lateral tibial plateau fractures. Within 2 weeks after the operation, the patients were instructed to perform knee joint function exercises within 90°. At the last follow-up, the Rasmussen radiological criteria were used to evaluate the effectiveness of fracture reduction and fixation. And the knee joint function was evaluated using Rasmussen functional score.

RESULTS

The operation time ranged from 100 to 180 min, with an average of 134.2 min; intraoperative blood loss ranged from 20 to 150 mL, with an average of 66.8 mL. The follow-up duration ranged from 14 to 58 months, with an average of 36.2 months. There were no complications, such as vascular or nerve injury or incision infection. Fracture healing was achieved in all patients, and the healing time ranged from 10 to 14 weeks, with an average of 11.2 weeks. During the follow-up period, there was no loosening or breakage of the internal fixation, varus or valgus deformity of the knee joint, re-collapse of the articular surface, or instability of the knee joint. At the last follow-up, the effectiveness of fracture reduction and fixation was excellent in 13 patients and good in six patients. And the knee joint function was excellent in 17 patients and good in two patients.

CONCLUSION

The Frosch approach for open reduction and internal fixation in the treatment of posterolateral tibial plateau fractures combined with lateral tibial plateau fractures has a definite clinical benefit and is worthy of promotion and application.

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.

Comparison of the intraarticular osteotomy and the "window" osteotomy in the treatment of tibial plateau fracture involving depressed posterolateral fragments

OBJECTIVES

The methods of reduction of depressed posterolateral fragments in tibial plateau fracture through anterolateral approaches remain controversial. This paper aimed to compare the intraarticular osteotomy technique and the "window" osteotomy technique for the reduction of depressed posterolateral fragments through anterolateral approach.

METHOD

From January 2015 to January 2022, we retrospectively reviewed the data on patients with tibial plateau fracture involving depressed posterolateral fragments treated with the intraarticular osteotomy or the "window" osteotomy. 40 patients underwent the intraarticular osteotomy were divided into group A, while 36 patients underwent the "window" osteotomy were divided into group B. The operative time, bone grafting volume, fracture healing time, complication, reduction quality and postoperative functional results were compared between the two groups.

RESULTS

The average follow-up duration was 16.6 ± 3.7 months. The average bone grafting volume for all patients in group B was essential larger than group A (p = 0.001). Compared to group B, patients in groups A had significantly shorter fracture healing time (p = 0.011). The depth of depressed articular surface, PSA and the radiographic evaluation at 2 days and 6 months after surgery in group A were significantly lower than group B (p<0.05). Based on the HSS knee-rating score, no significant difference in function results was found between the two groups (p>0.05). No significant difference was found in operation time and blood loss between the two groups (p>0.05).

CONCLUSION

The intraarticular osteotomy could obtain satisfactory clinical results in tibial plateau fracture involving posterolateral fragments.

Top 50 Cited Papers on Tibial Plateau Fracture Management: A Bibliometric Analysis and Review

Purpose

The orthopaedic surgeons, especially the young budding surgeons should have a well-balanced knowledge of the past evidence as well the current evidence in the literature for the appropriate as well as optimum management of tibial plateau fractures. Bibliometric analysis of the top-cited papers on tibial plateau fracture management can help know their concurrent interests, deficiencies and conflicting issues regarding their management. This study aimed to identify the 50 most cited research articles in tibial plateau research and analyse their characteristics.

Methods

We searched the Thompson Reuters Web of Science database for articles relevant to tibial plateau fracture and prepared a list of top 50 cited articles that included original articles and review articles concerning tibial plateau fractures. The included articles were analysed for contributing journals, corresponding author's country, publication year, cumulative citations, annual citations, citation trends over time, level of evidence and a qualitative review.

Results

The search strategy resulted in 2263 articles. The top 50 cited articles were published from 1974 to 2014 and belonged to 12 journal sources. There were 47 original articles and 3 review articles. The average citations per article were 126.2, and the annual citations per article were 6.478 per year. The top-cited articles were relevant to the strategies in the management, classification, fracture reduction, articular restoration, types and number of fixation devices, surgical approaches, associated menisco-ligamentous injuries and applicability of bone grafts/substitutes in tibial plateau fractures.

Conclusion

The current bibliometric analysis summarises the top-cited evidence concerning tibial plateau fractures and can be a potential resource for reviewing and locating the same. The analysis shows that most top-cited evidence belongs to the year 2000 onwards. Also, recent articles have a higher annual citation rate. A limited number of journals and mostly, western countries have contributed to the top-cited evidence. Whilst the top-cited evidence has touched several aspects of tibial plateau fractures, it is in the form of level IV case series. It needs better prospective evidence to establish sound recommendations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-023-00932-4.

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.

Outcomes of the Carlson Approach in the Treatment of Posterior Tibial Plateau Fractures

Objectives  To describe a series of cases of tibial fractures surgically treated using the posterior approach as described by Carlson, focusing on evaluating its functional results and complication rate. Methods  Eleven patients with tibial plateau fractures, who underwent surgical treatment using the Carlson approach from July to December 2019, were followed-up. The minimum follow-up period was defined as 6 months. The American Knee Society Score (AKSS), American Knee Society Score/Function (AKSS/Function) and the Lysholm score were used to check treatment results at 6 months after the fracture. The patients underwent standard anteroposterior and lateral radiographs to assess fracture healing, and clinical healing was determined by the absence of pain during full weight-bearing. Results  The mean follow-up period was 12 months (9-16 months). The primary mechanism of trauma was motorcycle accident, and the most prevalent side of fracture was the right side. Eight participants were male. The mean age of the patients was 28 years. All fractures healed, and none of the patients presented complications. The AKSS was excellent in 11 patients, with a mean AKSS/Function of 99.1 ± 3, and Lysholm scores with a median of 95.0 ± 5.6. Conclusions  The Carlson approach for posterior fractures of the tibial plateau can be considered safe, presenting a low complication rate and satisfactory functional results.

Bicondylar tibial plateau fracture dislocations with an intact anterolateral cortical rim: A surgical technique

A displaced medial tibial plateau fracture with central and lateral impaction, but an intact anterolateral cortical rim, is an uncommon variant of bicondylar tibial plateau fracture that presents a number of challenges. Without a lateral metaphyseal fracture line to work through, it is challenging to address central and lateral impaction. Previously published techniques for addressing this fracture pattern describe an intra-articular osteotomy of the lateral plateau to aid visualization and reduction, or use a posterolateral approach to the proximal tibia with or without an osteotomy of the proximal fibula. This study presents a technique which utilizes standard dual incision approaches and does not involve an intra-articular osteotomy of the lateral tibial plateau or a posterolateral approach. A case series was conducted evaluating radiographic and functional outcomes of 8 patients.

Clinical Outcomes of Fixation of Depressed Posterolateral Tibial Plateau Fractures Using a Direct Lateral Approach

Introduction

Fixation of plateau posterolateral fracture (PLF) is challenging because the fracture site is mostly covered by vital neurovascular structures. We operated on 15 cases of PLF using a direct lateral approach. This study aims to report on clinical results.

Material and methods

Between 2017 and 2019, 15 cases of PLFs were fixed with a direct lateral approach and a tricortical autologous bone graft from the iliac crest. A depression of more than 2 mm was indicated for the surgical treatment. Clinical evaluation included Lysholm score, International Knee Documentation Committee Score (IKDC) score, and Tegner activity scale after two years follow-up.

Results

The last follow-up was at 24 months after the operation. The mean postoperative Tegner activity scale did not change significantly compared to before the injury (6.5 (6-7) vs. 7 (6-8, p = 0.5)). The postoperative IKDC and Lysholm scores improved significantly compared to before the operation (p < 0.001). The full range of motion was seen in all patients except one who was manipulated after three months.

Conclusions

Surgical treatment using a direct lateral approach is a safe procedure for PLFs that results in good, short-term clinical and radiologic outcomes without fibular osteotomy or compromising the important neurovascular structures.

Level of evidence

IV.

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.

Clinical application of the modified posterolateral approach for treating posterior tibial plateau fractures

Objective: To investigate the therapeutic efficacy of the modified posterolateral approach on tibial plateau fractures. Methods: Forty-four patients with tibial plateau fractures were enrolled in the study and divided into two groups-control and observation-according to the different surgical procedures. The control group underwent fracture reduction via the conventional lateral approach, while the observation group underwent fracture reduction via the modified posterolateral strategy. The depth of tibial plateau collapse, active mobility, and the Hospital for Special Surgery (HSS) score and Lysholm score of the knee joint at 12 months after surgery were assessed in comparison to the two groups. Results: The amount of blood loss (p < 0.01), duration of surgery (p < 0.05), and depth of tibial plateau collapse (p < 0.001) were significantly less in the observation group compared with the control group. In addition, compared with the control group, the observation group exhibited significantly better knee flexion and extension function and significantly higher HSS and Lysholm scores at 12 months after surgery (p < 0.05). Conclusion: The modified posterolateral approach for posterior tibial plateau fractures has less intraoperative bleeding and a shorter operative time compared with the conventional lateral approach. It also effectively prevents postoperative tibial plateau joint surface loss and collapse, promotes the recovery of knee function, and has few postoperative complications and good clinical efficacy. Thus, the modified approach is worth promoting in clinical practice.

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.

Clinical Comparison of the "Windowing" Technique and the "Open Book" Technique in Schatzker Type II Tibial Plateau Fracture

Objective

Surgical treatment for Schatzker type II tibial plateau fractures remains challenging and requires high‐quality research. The aim of the study is to compare the “windowing” and “open book” techniques for the treatment of Schatzker type II tibial plateau fractures.

Methods

In this prospective study, all patients with Schatzker type II tibial plateau fractures between January 2014 and December 2017 were managed by open reduction and internal fixation using an anterolateral incision approach. “Windowing” group included 78 patients (53 men and 25 women), with an average age of 57.7 ± 13.5 years, who underwent the “windowing” technique, in which the procedure was performed through a small cortical window against the depressed zone of the lateral plateau. The “open book” group included 80 patients (56 men and 24 women), with an average age of 54.8 ± 12.4 years, who underwent the technique. The clinical outcomes included the Rasmussen classification of knee function and grading of post‐traumatic arthritis. The radiographic outcome (x‐ray and computed tomography [CT]) was the reduction quality of the lateral plateau based on the modified Rasmussen radiological assessment. The patient‐reported outcome was visual analogue scale (VAS) scores.

Results

The mean follow‐up time for the158 patients was 32 months (range, 24–42 months). The time elapsed from injury to surgery in “windowing” group and “open book” group were 3.7 ± 1.2 (range, 1–10 days) and 3.5 ± 1.4 days (range, 1–11 days), respectively, with no significant difference between the groups (P > 0.05). The operation times did not differ significantly between the “windowing” group (61.0 ± 8.3 min, range, 45–120 min) and the “open book” group (61.2 ± 10.4 min, range, 40–123 min) (P > 0.05). After surgery, CT revealed five (6.4%) and 15 (18.8%) cases of articular depression in the “windowing” and “open book” groups, respectively. Significant differences were observed in the articular depression of tibial plateau fractures between the groups (P < 0.05). However, condylar widening or valgus/varus did not differ significantly between the groups. Furthermore, no significant differences in knee function were observed during follow‐up (P > 0.05). VAS scores were similar between the groups at 24 months after surgery (P > 0.05). There were significant differences in the number of severe post‐traumatic arthritis (grades 2 and 3) cases between the groups (P < 0.05).

Conclusions

The “windowing” and “open book” techniques are both effective for the treatment of Schatzker type II tibial plateau fractures. However, the “windowing” technique provides better reduction quality, leading to a satisfactory prognosis.

Operative Repair of a Schatzker II Tibial Plateau Fracture Using a Combined Anterolateral and Posterolateral Approach Without Fibular Head Osteotomy

We present the case of a 49-year-old male pedestrian struck by a car while cycling, sustaining a displaced anterolateral tibial plateau fracture and a large coronal plane fracture of the posterolateral plateau involving approximately one-third of the anterior posterior dimension of the articular surface. The posterolateral approach without a fibular osteotomy allows direct access to the posterolateral plateau and avoids complications associated with a fibular head osteotomy. The combined anterolateral and posterolateral approach to the proximal tibia without fibular osteotomy is a viable technique to achieve biomechanically sound fixation for lateral tibial plateau fractures that involve the anterolateral and posterolateral aspects of the tibial plateau.

Lateral locking plate plus antero-posterior lag screws techniques for the management of posterolateral tibial plateau fracture: preliminary clinical results and biomechanical study

INTRODUCTION

To date, there is no consensus on the optimal surgical strategy for the treatment of posterolateral tibial plateau fracture (PLF). This study introduced a novel, simple technique for treating PLF with a lateral locking plate plus antero-posterior lag screws (LPpLS).

METHODS

We conducted a retrospective case series of 42 patients (Female/Male 19/23) with PLF treated with LPpLS between 1 July 2016 and 30 June 2019. Several pre- and postoperative outcomes were recorded, including operative time, intraoperative blood loss, CT findings, HSS, and ROM. For biomechanical studies, seventy synthetic tibiae with a simulated posterolateral split fracture were divided into seven groups. The biomechanical evaluation included displacement measurement at axial compression and fatigue testing.

RESULTS

Forty-two eligible patients were followed up for an average of 18 months (range 14-21 months). Postoperative radiographs and CT showed good positioning of plates and screws, no fracture fragment loss, and normal articular surfaces in all 42 cases. The biomechanical study showed that the axial stiffness of LPpLS was in the same fashion as the posterior buttress plate and better than the other fixation methods (P < 0.05). Additionally, the LPpLS group had a smaller displacement of fracture fragments along the X-axis (medial to lateral direction) than the BP group (P < 0.01).

CONCLUSIONS

The LPpLS technique could implement good reconstruction of the PLF, showing satisfactory therapeutic effect. The biomechanical evaluation demonstrated that the LPpLS had better stability in three-dimensional directions for PLF than other fixation strategies.

Systematic Review of Current Approaches to Tibia Plateau: Best Clinical Evidence

If not treated adequately, tibia plateau fractures result in premature osteoarthritis and lifelong disability. The advent of newer implants and techniques to improve outcomes has necessitated the development of different surgical approaches. A Medline and EMBASE search (June 2020) was conducted to identify publications during the last 10 years that focused on surgical approaches for proximal tibia fractures/ tibia plateau management. A total of 2107123 and 2715399 articles were found related to fractures in this area with 133 and 103 review articles looking at the approach on MEDLINE and EMBASE, respectively. This article reviews the continued development of the surgical approaches to aid understanding for surgeons and identify areas for future research to help improve outcomes. Although the anterolateral approach is the most commonly applied surgical technique, having the knowledge of newer approaches (medial, posteromedial, posterolateral, or direct posterior) in the armamentarium is necessary to treat the vast array of fracture patterns. There has been a shift amongst trauma surgeons of using a combination of approaches for complex tibia plateau fractures. 

Surgical exposure to posterolateral quadrant tibial plateau fractures: an anatomic comparison of posterolateral and posteromedial approaches

BACKGROUND

Management of posterolateral tibial plateau quadrant fractures can be challenging, and two posterior approaches were frequently used for exposure, reduction, and fixation: posterolateral approach and posteromedial approach. The purpose of this study was to compare their deep anatomical structure and analyze their limits and the risk of injury to important structures during surgical dissection of two approaches.

METHOD

Five lower limb specimens were used in this study. After dissection of the skin and superficial fascia of each specimen, deep structures were dissected via posteromedial and posterolateral approach, and several parameters including perpendicular distance from the anterior tibial artery coursing through the interosseous membrane fissure to the lateral joint line and apex of fibular head and so on were measured and analyzed.

RESULT

The perpendicular distance from the ATA coursing through the interosseous membrane fissure to the lateral joint line was 49.3 ± 5.6 mm (range 41.3-56.7 mm), while the distance to the apex of fibular head was 37.7 ± 7.2 mm (range 29.0-48.0 mm). The transverse distance of the anterior tibial vascular bundle is around 10 mm. The perpendicular distance from the top accompanying vein of the ATA bundle to lateral joint line and apex of fibular head was 44.1 ± 6.3 mm and 32.5 ± 7.6 mm, respectively. The maximum proportion of posterolateral tibial plateau shielded by the fibular head from the posterior view was 61.7 ± 4.9% (range 55.6-64.1%). The average length of popliteus muscle outside the joint was 83.1 ± 6.0 mm (range 76.5-92.2 mm), and the width in the middle was 28.1 ± 4.3 mm (range 26.6-29.1 mm).

CONCLUSION

Although posterolateral approach seems more direct for exposure of posterolateral quadrant tibial plateau fracture, it has three major disadvantages in deep dissection. Posteromedial approach through the medial board of medial head of gastrocnemius-soleus may be safer, but it was hard for direct visualization of articular surface which limits it usage for only a few cases.

Posterolateral Fractures of the Tibial Plateau Revisited: A Simplified Treatment Algorithm

High-energy fractures of the proximal tibia with extensive fragmentation of the posterolateral (PL) quadrant of the tibial plateau are challenging to manage. Herein, we present a review of the literature on the patterns and options of approach and fixation of the PL fragment of the tibial plateau to optimize the treatment of this specific injury pattern. We searched PubMed (1980-May 2020) to identify and summarize the most relevant articles evaluating both the morphology and treatment recommendations, including the choice of approach and fixation strategy, for the PL tibial plateau fracture. We found PL fragment can present in several patterns as a pure split, split depression, contained pure depression, and noncontained depression (rim crush), which are mostly determined by the position of the knee and the force magnitude applied during the course of the accident. Based on previous concepts described by Schatzker and Kfuri, we suggest a simplified treatment algorithm highlighting the two concepts (buttressing and containment) used for plating the PL tibial plateau fragments. Based on the available current evidence, we propose an algorithm for these two morphological types of PL tibial plateau fracture. Shear-type fractures need buttressing (the "rule of thumb"), whereas noncontained peripheral rim-type fractures need peripheral repair and containment. Contained pure depression fractures are not frequent and need percutaneous-assisted elevation and subchondral rafting, either controlled by fluoroscopy or arthroscopically. It is believed that such an approach would simplify their assessment and preoperative planning and would assist the clinicians to appreciate and manage more consistently these complex injuries.

Anterior Tibial Artery and Its Clinical Importance in the Posterolateral Approach to the Tibial Plateau: An Angiographic Study on 219 Lower Limbs

The anterior tibial artery (ATA) is the most critical anatomical structure at risk at the distal border of the posterolateral approach to the tibial plateau. This study aimed to use available lower extremity digital subtraction angiography (DSA) images to determine the distal safe limit of this approach by measuring the distance from the tibial joint line to the ATA where it pierces the interosseous membrane. Tibial plateau mediolateral width (TP-ML-W) and the perpendicular distances from the ATA to the tibial joint line and fibular head were measured on DSA images in 219 lower extremities. To normalize the distances according to the tibial dimensions, each distance was divided by the TP-ML-W, and a ratio was obtained. Popliteal artery branching pattern was categorized according to the classification proposed by Kim et al. Comparative analysis between right and left extremities, genders, and anatomical variations were performed. There were 102 male and 26 female subjects with a mean age of 60.7 ± 15.7 years (range, 17-92 years). Ninety-one subjects had bilateral lower extremity DSA; thus, a total of 219 extremities were analyzed. The TP-ML-W was wider in male (78.3 ± 7.0) than female (70.5 ± 7.3) subjects (p = 0.001). The ATA coursed through the interosseous membrane at 50.9 ± 6.9 mm (range, 37.4-70.2 mm) distal to the tibial plateau joint line, and it was 66.5 ± 7.2% of the TP-ML-W. The ATA coursed through the interosseous membrane at 36.5 ± 6.0 mm (range, 21.9-53.8 mm) distal to the fibular head, and it was 47.7 ± 6.6% of the TP-ML-W. All measured variables were similar between the regular branching pattern of the popliteal artery (type 1A) and other observed variations among male subjects. The safe length of dissection in the posterolateral approach is average 66.5% (range, 45.7-86.7%) of the TP-ML-W. This ratio is valid for both genders. The use of a ratio instead of a distance, which is subject to personal variations, seems to be more logical and practical for planning this surgery, but the wide range should still not be ignored.

An anterolateral approach for the flexion-valgus type unicondylar tibial plateau depression fracture pattern a technical note

OBJECTIVE

The approach to pure depression fractures (PDF) of the posterolateral tibial plateau (PTP) is classically a posterior approach via a metaphyseal osteotomy window with elevation of the depressed articular fragment. Other posterolateral approaches have been described but have been criticized for affecting reduction quality, and risks to the common peroneal nerve.

METHODS

In this case series, we describe a standard anterolateral approach with a window osteotomy through the metaphysis. Elevation of the PTP fracture is done through the osteotomy site.

RESULTS

The standard anterolateral approach avoids limitations of posterior or posterolateral approaches. Adequate reduction and good fixation of PDF of the PTP is attained.

CONCLUSION

The anterolateral approach with osteotomy of the lateral condyle is reproducible and familiar. This avoids the need for a fibula osteotomy and the risks of neurovascular injury, while allowing adequate visualisation and fracture reduction.

LEVEL OF EVIDENCE

IV.

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.

Partial Fibular Head Osteotomy is an Alternative Option in Treatment of Posterolateral Tibial Plateau Fractures: A Retrospective Analysis

Objective

This study aimed to evaluate the short-term effects of partial fibular head osteotomy for treating posterolateral tibial plateau fractures.

Methods

A retrospective analysis was performed on 25 patients with posterolateral tibial plateau fractures who were treated using a partial fibular head osteotomy approach. Computed tomography was performed for fracture typing and evaluation. The mode of injury, time from injury to surgery, time for fracture union, range of motion of the knee, and complications were recorded. Knee joint function was evaluated using the Hospital for Special Surgery Mayo Score (HSS).

Results

The mean follow-up period was 21.5 (range, 12–36) months. Fracture united in all patients and the average clinical healing time for fractures was 11.2 ± 1.9 (range, 8–16) weeks. The mean time from injury to surgery was 3.1 ± 1.8 (range, 1–10) days. The mean range of flexion was 131.6° ± 12.5° (range, 110°–145°). The mean range of extension was 1.4°–4.2° (range, −5°–10°). The mean HSS at the final follow-up was 93.5 ± 5.4 (range, 79–100). None of the patients exhibited symptoms of common peroneal nerve injury, knee instability, or upper tibiofibular joint injury. One patient had a superficial infection and was treated with surgical dressing.

Conclusion

The partial fibular head osteotomy approach is a feasible alternative for treating posterolateral 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.

Arthroscopic anatomy of the posterolateral corner of the knee: anatomic relations and arthroscopic approaches

INTRODUCTION

Although open-surgical techniques for the reconstruction of the posterolateral corner (PLC) are well established, the use of arthroscopic procedures has recently increased. When compared with open surgical preparation, arthroscopic orientation in the PLC is challenging and anatomic relations may not be familiar. Nevertheless, a profound knowledge of anatomic key structures and possible structures at risk as well as technical variations of arthroscopic approaches are mandatory to allow a precise and safe surgical intervention.

MATERIALS AND METHODS

In a cadaveric video demonstration, an anterolateral (AL), anteromedial (AM), posteromedial (PM) and posterolateral (PL) portal, as well as a transseptal approach (TSA) were developed. Key structures of the PLC were defined and sequentially exposed during posterolateral arthroscopy. Finally, anatomic relations of all key structures were demonstrated.

RESULTS

All key structures of the PLC can be visualized during arthroscopy. Thereby, careful portal placement is crucial in order to allow an effective exposure. Two alternatives of the TSA were described, depending on the region of interest. The peroneal nerve can be visualized dorsal to the biceps femoris tendon (BT), lateral to the soleus muscle (SM) and about 3 cm distal to the fibular styloid (FS). The distal attachment of the fibular collateral ligament (FCL) can be exposed on the lateral side of the fibular head (FH). The fibular attachment of the popliteofibular ligament (PFL) is exposed at the tip of the FS.

CONCLUSION

Arthroscopy of the posterolateral recessus allows full visualization of all key structures of the posterolateral corner, which provides the basis for anatomic and safe drill channel placement in PLC reconstruction. A sufficient exposure of relevant anatomic landmarks and precise portal preparation reduce the risk of iatrogenic vascular and peroneal nerve injury.

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.

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.

The treatment of posterolateral tibial plateau fracture with a newly designed anatomical plate via the trans-supra-fibular head approach: preliminary outcomes

BACKGROUND

There are no ideal plates or approaches for anatomical restoration and rigid fixation of posterolateral tibial plateau fractures. This study aimed to evaluate the short-term preliminary outcomes of our novel anatomical plate placed via the trans-supra-fibular approach to treat posterolateral tibial plateau fractures.

METHODS

From May 2016 to May 2018, 23 consecutive patients with posterolateral tibial quadrant fractures underwent open reduction with internal fixation via the trans-supra-fibular-head approach with our newly developed plate. The tibial plateau-tibial shaft angle (TPTSA), lateral posterior tibial slope angle (LPSTA), step-off, and condylar widening were measured on radiological images pre-operatively, 3 days post-operatively, 3 months post-operatively, and at the final follow-up examination. The radiological Rasmussen score was calculated, and the Hospital for Special Surgery (HSS) knee score was assessed to evaluate the functional outcomes.

RESULTS

The LTPSA, TPTSA, step-off, and condylar widening at 3 days post-operatively, 3 months post-operatively, and at the final follow-up were significantly different (p = 0.001) compared with those pre-operatively, as was the radiological Rasmussen score (p = 0.001). The HSS score at the final follow-up was 89.10 ± 5.94 (range, 78-98), which was significantly higher than that at the 3-month follow-up 84.36 ± 6.76 (range, 74-96); p = 0.001).

CONCLUSIONS

Our newly designed anatomical plate placed via the trans-supra-fibular approach can effectively treat posterolateral tibial plateau fractures. We noted minor trauma, stable fixation, and satisfactory clinical results.

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.

Solving the enigma of posterolateral tibial plateau fractures, the clue protocol

The study aim is to evaluate functional and radio- logical outcomes following a suggested protocol based on the four-column classification for management of posterolateral column tibial plateau fractures. A prospective cohort study was performed in level I academic center on 42 patients with mean age of 36 years (22-59). Eleven patients had isolated posterolateral column fractures whereas 31 patients had associated columns fractures. According to the suggested protocol, all cases of isolated posterolateral column fracture started treatment via arthroscopic evaluation of soft tissue injuries (menisci and liga- ments), arthroscopically assisted reduction and inter- nal fixation by rafting screws followed by ORIF if plating was needed. If associated with other columns fractures, columns were fixed sequentially in an anti-clockwise direction starting from anteromedial column. Average follow up was 26 months. Mean time to union was 16.3 (12-22) weeks. No radiological evidence of loss of coronal or sagittal alignment was detected at final follow up. Five patients had an average depression of 5 millimeters that did not need further intervention at this short-term follow up. Mean KOOS was 81 (72- 88). The average knee range of motion was (0° - 127°). One patient had temporary common peroneal nerve injury, one patient had deep infection and two had superficial wound infection. implementing the suggested protocol gives good to excellent radiological and functional results as regard posterolateral tibial plateau fracture. A larger study group with longer follow up is needed.