Selection of surgical approaches to the posterolateral tibial plateau fracture by its combination patterns

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.

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.

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.

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.

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

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

A new strategy to fix posterolateral depression in tibial plateau fractures: Introduction of a new modified Frosch approach and a "Barrel hoop plate" technique

AIMS

The articular congruity of tibial plateau has been stressed to be associated with the long-term function outcomes. Approach selection and fixation pattern to manipulate the posterolateral (PL)-depression of tibial plateau are both key issues which trauma surgeons should focus on. In order to provide a strong purchase of PL-depression, we developed a new modified Frosch approach and a "Barrel hoop plate" technique to provide bony reconstruction of PL-depression.

MATERIALS AND METHODS

Eleven consecutive patients of tibial plateau fractures involved in PL-depression were surgically treated at our single level-I trauma center. Our newly designed "Barrel hoop plate" was used to fix the PL-depression via a modified Frosch approach. The demography and treatment information were summarized of all the patients. X-ray and CT-scan of the knee joint were used to assess the reduction after operation. Besides evaluation of the HSS knee score, medial tibial plateau angle(mTPA), posterior slope angle(PSA) and articular step-off were measured to assess the malreduction degrees.

RESULTS

The average operation time was 123 ± 20 min. The mean blood loss was 148 ± 45 mL. The fractures were healed radiographically at 13 ± 1 weeks post-operation. After 15 ± 2 months follow-up, all the patients were pain-free with full range of motion and stable knees. Radiologically, good fracture reduction was achieved in all cases. According to the final assessment, the mTPA, m-PSA and l-PSA were 85° ± 2°, 11° ± 5° and 10° ± 6°, respectively. The average range of motion was 128° ± 10°in flexion and 4° ± 4° in extension, and the average HSS score was 91 ± 3.

CONCLUSION

Our new approach is a modification of the Frosch approach with a decreased soft tissue exposure and a low risk of neurovascular vessel injury. The concurrent application of the "Barrel hoop plate" technique could not only provide a reconstruction of the PL tibial plateau, but also hoop the ruptured tibia plateau rim and secure the depression as a raft. This new technique prevented the PL-tibial plateau reduction loss and the made the patients' early range of motion come true.

Gastrocnemius raphe split approach for complex proximal tibia fractures-Applicability and advantages

Posterior column fractures of the tibial plateau have been considered problem injury as many authors reported poor outcome. Commonly used surgical approaches have limitations in addressing complex fractures involving the posterior column, leading to malreduction and subsequent leading to chronic posteroinferior subluxation, arthritis and chronic pain. There is thus a need for a surgical approach, which can provide adequate exposure to both quadrant of posterior column, in addition to allowing sufficient space for fracture manipulation and implant placement. The authors have evaluated the applicability of the posterior midline gastrocnemius raphe split approach to deal with coomplex posterior column fragment in tibial plateau fractures. A midline gastrocnemius splitting approach was used alone or along with other approaches in 22 patients with tibial plateau fractures involving the posterior column. The mean age of the patients was 36 years and the female to male ratio was 1:6 (3 and 18). At an average follow up of 12 months (Range 6-14 months), Radiological evidence of union was noted at an average 13 weeks (Range, 10-15weeks) and no loss of reduction was seen at follow-up. All cases had regained painless knee flexion that averaged 120°. The midline gastrocnemius splitting approach is a versatile approach, which allows adequate exposure on either side of the posterior tibial plateau. This can easily combined with other approaches, where the anteromedial and anterolateral coloumn or associated ligament injury demand attention.

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

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

A surgical protocol for bicondylar four-quadrant tibial plateau fractures

PURPOSE

Bicondylar tibial plateau fractures involving four articular quadrants are severe and complex injuries, and they remain a challenging problem in orthopaedic trauma. The aim of this study was to introduce a new treatment protocol with dual-incision and multi-plate fixation in the floating supine patient position as well as to report the preliminary clinical results.

METHODS

From January 2006 to December 2011, 16 consecutive patients with closed bicondylar four-quadrant tibial plateau fractures (Schatzker type VI, OTA/AO 41C2/3) were treated with posteromedial inverted L-shaped and anterolateral incisions. With the posteromedial approach, three quadrants (posteromedial, anteromedial and posterolateral) can be exposed, reduced and fixed with multiple small antiglide plates and short screws in an enclosure pattern. With the anterolateral approach, after articular elevation and bone substitute grafting, a strong locking plate with long screws to the medial cortex is used to raft-buttress the reduced lateral plateau fracture, hold the entire reconstructed tibial condyles together, and contact the condyles with the tibial shaft. All patients were encouraged to exercise knee motion at an early stage. The outcome was evaluated clinically and radiologically after a minimum two-year follow-up.

RESULTS

The average operation time was 98 ± 26 minutes (range 70-128) and the average duration of hospitalization was 29 ± 8.6 days (range 20-41). Three cases used five plates, nine cases used four plates, and four cases used three plates. All patients were followed for a mean of 28.7 ± 6.1 months (range 26-38). Fifteen incisions healed initially, while one patient developed a medial wound dehiscence and was successfully managed by debridement. All patients achieved radiological fracture union after an average of 20.2 weeks. At the two-year follow up, the average knee range of motion (ROM) was 98° ± 13.7 (range 88-125°), with a Hospital for Special Surgery (HSS) knee score of 87.7 ± 10.3 (range 75-95), and SMFA score of 21.3 ± 8.6 (range 12-33).

CONCLUSION

For bicondylar four-quadrant tibial plateau fractures, the treatment protocol of multiple medial-posterior small plates combined with a lateral strong locking plate through dual incisions can provide stable fracture fixation to allow for early stage rehabilitation. Good clinical outcomes can be anticipated.

Schatzker type IV medial tibial plateau fractures: a computed tomography-based morphological subclassification

Schatzker type IV medial tibial plateau fractures have an unfavorable prognosis, likely due to the mechanism of injury (fracture-dislocation/subluxation type) and possibly due to the involvement of the posterolateral plateau, which is different from previously thought. The aim of this study was to propose a new subclassification of Schatzker type IV fracture patterns based on 2-dimensional (2-D) computed tomography and three-dimensional (3-D) reconstruction. The authors defined Schatzker type IV medial tibial plateau fractures as AO/OTA 41 type B fractures (partial articular), with partial or total medial plateau involvement, leaving at least the anterolateral quadrant intact. The images of 42 fractures (42 patients) were evaluated. The fractures were further anatomically divided into 2 groups: Group 1 were classic medial unicondylar fractures and Group 2 were more complicated variants involving both condyles, characterized by medial condyle fractures with lateral plateau extension, usually with articular impaction of the centroposterior lateral plateau. Twelve (29%) cases involved only the medial condyle, and 30 (71%) involved both the medial and lateral condyles. Twenty-nine (69%) cases demonstrated posterior coronal fractures. The most common patterns were bicondylar posteromedial plateau fractures with posterolateral quadrant depression (bicondylar posterior fractures: 14 cases, 33%) and total/subtotal medial condyle fractures with posterolateral quadrant depression (13 cases, 31%). The isolated unicondylar posteromedial split fracture was uncommon (2 cases, 5%). Computed tomography-based reconstruction enhances the understanding of fracture anatomy and the relationships between fracture fragments. In Schatzker type IV medial tibial plateau fractures, the involvement of posterolateral quadrants is common.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Morphological characteristics of posterolateral articular fragments in tibial plateau fractures

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Posterior coronal plating of bicondylar tibial plateau fractures through posteromedial and anterolateral approaches in a healthy floating supine position

Bicondylar tibial plateau fractures pose a significant challenge for treating surgeons. If the articular surface of the medial plateau has a second split component in the posterior coronal plane, it is difficult to get direct visualization and ensure plate fixation when the patient is in the supine position. Using a technique in which a single preparation and draping of both legs is needed, patients were operated on using a healthy floating supine position maneuver through dual posteromedial and anterolateral incisions and triple plate fixations. By flexing and adducting the contralateral healthy hip over the injured leg, more lateral rotation of the fractured knee can be achieved, providing better access and visualization of the posterior medial plateau using a posteromedial gastrocnemius approach.