Updated Three-Column Concept in surgical treatment for tibial plateau fractures - A prospective cohort study of 287 patients

Relationship of Fracture Morphological Characteristics with Posterolateral Corner Injuries in Hyperextension Varus Tibial Plateau Fractures

BACKGROUND

Hyperextension varus tibial plateau fracture (HVTPF) is known to present with concomitant injuries to the posterolateral corner (PLC). However, the exact rate and characteristics of these injuries remain unclear. The primary objective of this study was to explore the rate and characteristics of PLC injuries in HVTPFs. The secondary objective was to investigate the relationship between the fracture morphological features and the associated PLC injuries.

METHODS

Patients with HVTPFs were subdivided into 2 groups: group I (without fracture of the posterior column cortex) and group II (with fracture of the posterior column cortex). Fracture characteristics were summarized qualitatively based on fracture maps and quantitatively based on the counts of morphological parameters. Knee ligamentous and meniscal injuries were assessed using magnetic resonance imaging. The association between fracture characteristics and PLC injuries was analyzed.

RESULTS

We included a total of 50 patients with HVTPFs in our study: 28 in group I and 22 in group II. The rate of PLC injuries was 28.6% in group I and 27.3% in group II. In group I, patients with PLC injuries showed fracture lines closer to the anterior rim of the medial plateau and had smaller fracture areas. Furthermore, 6 of the 8 patients with PLC injuries in group I also had posterior cruciate ligament injuries.

CONCLUSIONS

The rate of PLC injuries is relatively high in HVTPFs. In HVTPFs without fracture of the posterior column cortex, a small fracture area strongly suggests an accompanying PLC injury, and PLC injury is frequently combined with posterior cruciate ligament injury.

LEVEL OF EVIDENCE

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

3D-printed model is a useful addition in orthopedic resident education for the understanding of tibial plateau fractures

This study aimed to explore the role of the three-dimension (3D) printed models in orthopedic resident training of tibial plateau fractures. A total of 41 residents from our institution were divided into two groups. The intervention group, consisting of 20 residents, had access to 3D-printed models illustrating thirteen tibial plateau fractures. In contrast, the control group, comprising 21 residents, received digital images of thirteen identical tibial plateau fractures. Evaluation of learning outcomes included the accurate identification of tibial plateau fracture patterns, deduction of traumatic mechanisms, preoperative plan, assessment time, and subjective questionnaire responses. The participants with 3D printed models scored significantly higher in both the Schatzker classification and Luo three-column classification compared to those without 3D printed models. Residents in the intervention group performed better in accuracy in deducing traumatic mechanisms compared to the control group. In addition, the sum score of preoperative plan in the intervention group was significantly higher than that in the control group. Specifically, participants with 3D printed models scored higher in surgical approach choice and implants placement than these in the control group. Residents exposed to 3D printed models also spent less time to complete the assessment than those with access only to digital imaging. Subjective assessments indicated that 3D-printed models boosted confidence in fracture identification, improved preoperative plan for fracture management and enhanced the understanding in injury mechanism of tibial plateau fractures. Furthermore, residents agreed that the use of 3D-printed models heightened their interest in learning tibial plateau fractures. Therefore, the addition of 3D printed models significantly contributed to a comprehensive understanding of tibial plateau fractures, the improvement in fracture identification, inferring injury mechanisms and preoperative plan.

Tibiofemoral axial rotation in tibial plateau fractures: A retrospective radiographic assessment of 203 tibial plateau fractures

BACKGROUND

Defining the injury-force mechanism in tibial plateau fractures (TPFs) could help define implant type and position, as well as soft tissues at risk. The aim of this study was to provide an analysis of injury-force-mechanisms in TPFs, including axial rotation.

METHODS

The injury-force mechanism was determined for 203 fractures that presented over a period of 3.5 years. Fractures were classified as flexion-varus/valgus/neutral or (hyper)-extension-varus/valgus/neutral by observing articular depression area on CT/MRI. Fractures were subclassified into rotation-neutral, internal- or external-rotation according to the Gerdy-tibial-tuberosity-surgical-epicondylar-axis (GTT-SEA) angle. Soft-tissue injury was documented if MRI was performed.

RESULTS

Flexion-valgus was the most common injury-force mechanism (n = 85, 41.9%), followed by extension-valgus (n = 57, 28.1%). Other mechanisms were less common (9.4% extension-varus, 5.9% flexion-neutral, 4.9% flexion-varus, 3.9% hyperextension-valgus, 3.4% extension-neutral and 2.5% hyperextension-varus). The GTT-SEA angle could be measured in 194 (95.6%) of 203 classified patients, revealing internal rotation in 83 (42.8%) and external rotation in 53 (27.3%). No significant difference was found between injury-force mechanism type and axial rotation group (P = 0.964) or extent of rotation (H(8) = 7.116, P = 0.524). Only 41 (21.1%) of 194 fully classified fractures underwent MRI, all revealing soft-tissue injury to some extent. High-grade posterolateral injuries occurred mainly in rotated TPF.

CONCLUSION

Our results describe the common forms of axial rotation present in TPF and explore their association with injury-force mechanism and soft-tissue injury. Applying the injury-force mechanism patterns and addressing rotational forces could, together with preoperative MRI and intra-operative stability assessment, help determine the need to surgically address associated soft-tissue injury.

CT of Periarticular Adult Knee Fractures: Classification and Management Implications

Periarticular knee fractures, which include fractures of the distal femur, tibial plateau, and patella, account for 5%-10% of musculoskeletal injuries encountered in trauma centers and emergency rooms. These injuries are frequently complex, with articular surface involvement. Surgical principles center on reconstruction of the articular surface as well as restoration of limb length, alignment, and rotation to reestablish functional knee biomechanics. Fixation principles are guided by fracture morphology, and thus, CT with multiplanar reformats and volume rendering is routinely used to help plan surgical intervention. Fractures involving the distal femur, tibial plateau, and patella have distinct management considerations. This comprehensive CT primer of periarticular knee fractures promotes succinct and clinically relevant reporting as well as optimized communication with orthopedic trauma surgeon colleagues by tying fracture type and key CT findings with surgical decision making. Fracture patterns are presented within commonly employed fracture classification systems, rooted in specific biomechanical principles. Fracture typing of distal femur fractures and patellar fractures is performed using Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) classification schemes. Tibial plateau fractures are graded using the Schatzker system, informed by a newer explicitly CT-based three-column concept. For each anatomic region, the fracture pattern helps determine the surgical access required, whether bone grafting is warranted, and the choice of hardware that achieves suitable functional outcomes while minimizing the risk of articular collapse and accelerated osteoarthritis. Emphasis is also placed on recognizing bony avulsive patterns that suggest ligament injury to help guide stress testing in the early acute period. ©RSNA, 2024 Supplemental material is available for this article.

Lack of standardisation in the management of complex tibial plateau fractures: a multicentre experience

OBJECTIVE

In recent years, the trauma mechanisms and fracture types in tibial plateau fractures (TPF) have changed. At the same time, treatment strategies have expanded with the establishment of new classification systems, extension of diagnostics and surgical strategies. Evidence-based recommendations for treatment strategies are rare. The aim of this study is to assess the extent of standardization in the treatment of complex TPF.

MATERIAL AND METHODS

For the study, specialists in trauma surgery/orthopaedics were presented thin-slice CT data sets of three complex TPFs including 3D reconstructions. A standardized questionnaire on fracture morphology and planned treatment strategy was then completed.

RESULTS

A total of 23 surgeons from 7 hospitals (Trauma center levels I-III) were included. All three fractures were most frequently classified as Schatzker type V (fracture I: 52.2%, II: 56.5%, III: 60%). Averaged over all three fractures, 55% of the respondents chose the same patient positioning. The combination of a posteromedial and anterolateral approach was the most frequently chosen approach at 42.7%. Double plating was favored for the surgical treatment of all fractures (70.7%). Preoperative MRI, extended approaches and intraoperative fraturoscopy were significantly more common in level I trauma centres.

CONCLUSION

There are major differences in the management of complex TPF. 360° treatment is carried out in all departments regardless of the level of care, but without further standardization in terms of preoperative imaging, classification, initial treatment, approach, fixation and intraoperative imaging. There are major differences within the departments with different level of care.

Tibial plateau fracture morphology based on injury force mechanism is predictive for patient-reported outcome and conversion to total knee arthroplasty

PURPOSES

The aim of this study was to assess the relationship between injury mechanism-based fracture patterns and patient-reported outcome as well as conversion rate to total knee arthroplasty (TKA) at follow-up.

METHODS

A multicenter cross-sectional study was performed including 1039 patients treated for a tibial plateau fracture between 2003 and 2019. At a mean follow-up of 5.8 ± 3.7 years, patients completed the Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaire. For all patients, the injury force mechanism was defined based on CT images. Analysis of variance (ANOVA) was used to assess the relationship between different injury mechanisms and functional recovery. Cox regression was performed to assess the association with an increased risk on conversion to TKA.

RESULTS

A total of 378 (36%) patients suffered valgus-flexion, 305 (29%) valgus-extension, 122 (12%) valgus-hyperextension, 110 (11%) varus-flexion, 58 (6%) varus-hyperextension, and 66 (6%) varus-extension injuries. ANOVA showed significant different KOOS values between injury fracture patterns in all subscales (P < 0.01). Varus-flexion injuries had the lowest average KOOS scores (symptoms 65; pain 67; ADL 72; sport 35; QoL 48). Varus-flexion mechanism was associated with an increased risk on a TKA (HR 1.8; P = 0.03) whereas valgus-extension mechanism was associated with a reduced risk on a TKA (HR 0.5; P = 0.012) as compared to all other mechanisms.

CONCLUSION

Tibial plateau fracture patterns based on injury force mechanisms are associated with clinical outcome. Varus-flexion injuries have a worse prognosis in terms of patient-reported outcome and conversion rate to TKA at follow-up. Valgus-extension injuries have least risk on conversion to TKA.

Staged treatment of bicondylar tibial plateau fractures: influence of frame configuration and quality of reduction on outcomes

PURPOSE

Despite evolving treatment, the surgical management of high-energy tibial plateau fractures (TPF) remains challenging, associating high rates of complications. In recent decades, staged management has emerged as an encouraging option. The main goal of our study was to evaluate the influence of bridging external fixation (EF) frame configuration and the resultant quality of reduction (QOR) on outcomes after staged-treatment of bicondylar TPF.

METHODS

A retrospective review was conducted of patients with bicondylar TPF treated at our level-I trauma center using a staged-treatment protocol from January 2010 to January 2020. Data on baseline characteristics, injuries, treatments, and clinical/radiological results were collected. The QOR was evaluated on CT images after EF and on plain films after ORIF.

RESULTS

Sixty-eight patients were eligible for analysis. By our criteria, QOR was good in 57.4% and 70.6% after EF and ORIF, respectively. A squared EF configuration was associated with superior EF QOR (p = 0.032), while better EF QOR was linked to improved ORIF QOR (p = 0.016). No relationship between ORIF delay and ORIF QOR was identified. Postoperative complications were documented in 19 patients. Average ROM at one-year follow-up was 114.9 ± 12.6°, and non-influenced by anterior femoral pin placement.

CONCLUSIONS

Staged management of bicondylar TPF resulted in a reasonable rate of complications. A direct relationship between QORs obtained with EF and after ORIF was found. Squared frames were associated with faster and better reductions, regardless of the surgeon's background. Considering our results, we advocate for the wider use of squared EF configurations in these patients.

Evaluation and Management of Posterior Tibial Plateau Fractures

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

Incidence and Characteristics of Knee Ligament and Meniscal Injuries in Patients With Posterolateral Tibial Plateau Fractures

Background

Anterior cruciate ligament (ACL) tears are commonly seen with concomitant injuries to the posterolateral tibial plateau, while the occurrence of ACL injuries in posterolateral tibial plateau fractures (PTPFs) remains unclear.

Purpose

To (1) explore the incidence of knee ligament (anterior or posterior cruciate ligament, medial or lateral collateral ligament) and medial or lateral meniscus injuries in patients with PTPF and (2) find reliable PTPF-related parameters to predict the risk of knee ligament and meniscal injuries.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

Patients diagnosed with PTPF who had computed tomography and magnetic resonance imaging (MRI) data were identified. Morphological parameters of the PTPF were measured on sagittal computed tomography images. Knee ligament and meniscal injuries were assessed using MRI. The association of ACL injuries with meniscal injuries was analyzed. Receiver operating characteristic (ROC) analysis was used to determine the value and cutoff point of the PTPF morphological parameters for diagnosing complete in-substance ACL tears.

Results

Overall, 113 patients with PTPF were included. ACL injuries were present in 94 (83.2%) patients, including 43 (38.1%) avulsion fractures and 28 (24.8%) complete in-substance tears. Patients with in-substance ACL tears had a higher incidence of lateral meniscus posterior horn tears compared with the other patients (PBonferroni < .001). ROC analysis revealed that both the fracture depression angle (cutoff point, 25.5°) and the posterior articular surface loss percentage (cutoff point, 37.5%) had a sensitivity >90% and a specificity >80% for the diagnosis of complete in-substance ACL tears.

Conclusion

ACL injuries were seen in 83.2% of the study patients. Complete in-substance ACL tears were associated with an increased incidence of lateral meniscus posterior horn tears. Among PTPF parameters, fracture depression angle and posterior articular surface loss percentage showed a high predictive value for the presence of complete in-substance ACL tears, thereby reducing delays in diagnosis and treatment.

Importance of the Posterior Plate in Three-Column Tibial Plateau Fractures: A Finite Element Analysis and Clinical Validation

OBJECTIVE

Dual-plate fixation was thought to be the gold standard for treating complicated bicondylar tibial plateau fractures, yet it was found to be hard to accommodate the posterior column in three-column fractures. Currently, column-specific fixation is becoming more and more recognized, but no comprehensive investigation has been performed to back it up. Therefore, the objective of this study was to validate the importance of posterior column fixation in the three-column tibial fractures by a finite element (FE) analysis and clinical study.

METHODS

In FE analysis, three models were developed: the longitudinal triple-plate group (LTPG), the oblique triple-plate group (OTPG), and the dual-plate group (DPG). Three loading scenarios were simulated. The distribution of the displacement and the equivalent von Mises stress (VMS) in each structure was calculated. The comparative measurements including the maximum posterior column collapse (MPCC), the maximum total displacement of the model (MTD), the maximum VMS of cortical posterior column (MPC-VMS), and the maximum VMS located on each group of plates and screws (MPS-VMS). The clinical study evaluated the indicators between the groups with or without the posterior plate, including operation time, blood loss volume, full-weight bearing period, Hospital for Special Surgery Knee Scoring system (HSS), Rasmussen score, and common postoperative complications.

RESULTS

In the FE analysis, the MPCC, the MPC-VMS, and the MTD were detected in much lower amounts in LTPG and OTPG than in DPG. In comparison with DPG, the LTPG and OTPG had larger MPS-VMS. In the clinical study, 35 cases were included. In the triple-plate (14) and dual-plate (21) groups, the operation took 115.6 min and 100.5 min (p < 0.05), respectively. Blood loss in both groups was 287.0 mL and 206.6 mL (p < 0.05), and the full-weight bearing period was 14.5 weeks and 16.2 weeks (p < 0.05). At the final follow-up, the HSS score was 85.0 in the triple-plate group and 77.5 in the dual-plate (p < 0.05), the Rasmussen score was 24.1 and 21.6 (p < 0.05), there were two cases with reduction loss (9.5%) in the dual-plate group and one case of superficial incision infection found in the triple-plate group.

CONCLUSION

The posterior implant was beneficial in optimizing the biomechanical stability and functional outcomes in the three-column tibial plateau fractures.

Introduction and An Analysis of Inter- and Intra-observer Validity to the Classification of Hoffa-Like Tibial Plateau Fractures

OBJECTIVE

The posterior coronal shearing fractures of the tibial plateau are rare and can be easily missed or ignored. Our team defined these fractures as Hoffa-like fracture of the tibial plateau and conducted a series of studies. The aim of this study is to introduce the characteristics of the Hoffa-like fracture of the tibial plateau, propose a new classification system and evaluate its validity.

METHODS

Sixty-one patients with Hoffa-like fractures of the tibial plateau were treated in five trauma centers (I-III) from 2017 to 2020. A new classification system was developed based on the morphological fracture patterns in CT and radiographic of the first 30 cases. Ten cases of suspected tibial plateau Hoffa-like fractures were supplemented additionally to the 61 cases to increase the accuracy. CT and radiographic images of the 71 cases were reviewed independently by four reviewers on two separate occasions and classified according to the new classification system. Cohen's kappa coefficient (κ) was used to analyze the reliability on separate observers at the same time and to analyze the classification made by same observer at different times (intra-observer), which measures inter-observer and intra-observer agreements.

RESULTS

Out of the 61 patients, 46 (75.4%) isolated coronal fractures involving the medial condyle of tibial plateaus and 53 (86.9%) combined with intercondylar spine fractures. The κ-values were calculated for the new classification system (mean κ = 0.74 inter-observer, mean κ = 0.79 intra-observer, indicating substantial agreement).

CONCLUSION

The novel classification lends insight into fracture morphology of the tibial plateau Hoffa-like fractures, has good inter- and intra-observer validity, and it aids in treatment.

Introduction of 3D-classification and its derived surgical sequence of Schatzker type IV tibial plateau fractures

INTRODUCTION

Schatzker IV tibial plateau fractures usually have a worse prognosis due to their high variability and the accompanied bony and soft tissue injuries. This study aimed to introduce an injury mechanism-based new classification of Schatzker IV tibial plateau fractures and evaluate its reliability. Additionally, this study aimed to evaluate the outcomes of operative Schatzker IV tibial plateau fractures treated according to the surgical sequences determined by the new classification.

MATERIALS AND METHODS

A total of 63 cases of operative Schatzker IV tibial plateau fractures that were treated following the new surgical sequences were enrolled in our study. The CT images of these patients were reviewed and classified twice according to the new 3D classification by 4 independent observers. The reliability of the classification was calculated through kappa analysis. The classification-determined surgical sequence was evaluated by observing the postoperative efficacy during the follow-up.

RESULTS

Both the intra-observer (the mean k = 0.897, CI 0.806-0.971) and inter-observer (the mean k = 0.883, CI 0.786-0.961) reliability of 3D-classification showed excellent agreement according to Landis and Koch. All the patients were followed up for 6-28 months (average 12.8 months). As for the evaluation of the postoperative efficacy, according to KSS, 53 cases were rated as excellent, 8 cases as good, and 2 cases as fair results.

CONCLUSIONS

The new proposed classification showed high intra-observer and inter-observer reliability in our study. The surgical sequence determined by the classification can help surgeons to acquire good reduction and rigid internal fixation. Therefore the new classification of Schatzker IV tibial plateau fractures and the derived surgical sequences are worthy of further popularization and application in clinical trials.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL RELEVANCE STATEMENT

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

KEY POINTS

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

Pediatric proximal tibial fractures: How does the trauma mechanism guide the operative strategy?

PURPOSE

Pediatric proximal tibial fractures (PTF) are rare but potentially debilitating. So far, no system for guiding surgical treatment based on injury-force mechanism has been documented, while adult tibial plateau fractures have benefited greatly from such an approach. This study reviews the diagnosis and treatment experience at a tertiary trauma center and introduces the reduction-traction method.

METHODS

Pediatric patients (0-17 years old) diagnosed with PTF were identified in the hospital database from 2017 to 2021. Their injury mechanism, injury location, treatment type, and treatment outcomes were recorded. Images were reviewed to establish an injury-force classification according to Mubarak et al., 2009. When appropriate, patients were treated using a "reduction-traction" approach.

RESULTS

Twenty-nine patients were identified, and followed-up for a mean of 6.8 months. The most common cause of injury was falling from height < 2 m, often from a trampoline. The tibial plateau and proximal tibial metaphysis were most commonly involved. Thirteen patients were treated non-operatively, 10 with open reduction and internal fixation, and six with arthroscopic surgery. A bimodal distribution according to age was noted in the injury mechanism, injury site, and treatment type. No adverse outcomes were recorded, and all patients resumed sports activities. The "reduction-traction" technique produced favorable outcomes in three patients.

CONCLUSIONS

Pediatric PTF has a bimodal distribution with high risk before three years and after 15 years. The injury-force classification can supplement the Salter-Harris classification in guiding surgical treatment. The "reduction-traction" approach in children differs from adults, and results in good outcomes.

Free subchondral screws in tibial plateau fractures: do they hinder a total knee arthroplasty? Strategies to prevent complications

Open reduction and internal fixation of extended lateral column tibial plateau fractures through a tibial condyle osteotomy and limited arthrotomy with the use of free subchondral locking screws is a straightforward and safe technique. However, these free subchondral screws are enclosed in the subchondral bone and therefore virtually impossible to remove after bone healing. The question arises whether these free subchondral screws might hinder a future total knee arthroplasty. In order to refute this, we retrospectively reviewed all surgically managed tibial plateau fractures in our tertiary center during one year and assessed the number, position and configuration of these in situ subchondral screws and K-wires. In addition, we performed a cadaver study, wherein we prepared 7 tibial plateaus for a total knee arthroplasty tibial component placement with free subchondral screws in situ. In this experiment, we demonstrated that free subchondral screws do not interfere with total knee arthroplasty, but they can increase operative time in some cases. We also provide recommendations to avoid difficulties and potential complications.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Current concepts review. Management of proximal tibial fractures

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

Medial Head of the Gastrocnemius Tenotomy Through a Posteromedial Approach Significantly Improves Surgical Accessibility of the Tibial Plateau

OBJECTIVES

Compare accessible area of the posterior tibial plateau through a modified posteromedial (PM) approach before and after tenotomy of the medial head gastrocnemius. We report the outcomes of 8 patients who underwent gastrocnemius tenotomy during PM approach.

METHODS

A modified PM approach was performed on 10 cadaveric legs, and the surgically accessible area was outlined. Next, a medial head gastrocnemius mid substance tenotomy was completed, and the accessible area was again outlined. Tibia specimens were imaged in a micro-CT scanner to measure accessible surface area and linear distance along the joint line. In addition, 8 patients who underwent tenotomy for tibial plateau fracture had outcomes recorded.

RESULTS

The modified PM approach with tenotomy provided significantly more access to the posterior plateau than without tenotomy. The modified PM approach before tenotomy allowed access to 1774 mm 2 (SD = 274) of the posterior plateau surface and 2350 mm 2 (SD = 421, P < 0.0001) with tenotomy. A linear distance of 38 mm (SD = 7) and 57 mm (SD = 7, P < 0.00001) was achieved before and after tenotomy, respectively. In the clinical series, the average knee arc of motion was 116 degrees (95-135).

CONCLUSIONS

The modified PM approach with medial head gastrocnemius tenotomy significantly improves surgical access to the posterior plateau. Patients who received tenotomy have acceptable functional outcomes. This cadaveric study provides an alternative approach for treatment of posterolateral tibial plateau fractures which may mitigate damage to neurovascular structures.

Functional Outcome After Nonoperative Management of Tibial Plateau Fractures in Skeletally Mature Patients: What Sizes of Gaps and Stepoffs Can be Accepted?

BACKGROUND

Gap and stepoff measurements provide information about fracture displacement and are used for clinical decision-making when choosing either operative or nonoperative management of tibial plateau fractures. However, there is no consensus about the maximum size of gaps and stepoffs on CT images and their relation to functional outcome in skeletally mature patients with tibial plateau fractures who were treated without surgery. Because this is important for patient counseling regarding treatment and prognosis, it is critical to identify the limits of gaps and stepoffs that are well tolerated.

QUESTIONS/PURPOSES

(1) In patients treated nonoperatively for tibial plateau fractures, what is the association between initial fracture displacement, as measured by gaps and stepoffs at the articular surface on a CT image, and functional outcome? (2) What is the survivorship of the native joint, free from conversion to a total knee prosthesis, among patients with tibial plateau fractures who were treated without surgery?

METHODS

A multicenter cross-sectional study was performed in all patients who were treated nonoperatively for a tibial plateau fracture between 2003 and 2018 in four trauma centers. All patients had a diagnostic CT scan, and a gap and/or stepoff more than 2 mm was an indication for recommending surgery. Some patients with gaps and/or stepoffs exceeding 2 mm might not have had surgery based on shared decision-making. Between 2003 and 2018, 530 patients were treated nonoperatively for tibial plateau fractures, of which 45 had died at follow-up, 30 were younger than 18 years at the time of injury, and 10 had isolated tibial eminence avulsions, leaving 445 patients for follow-up analysis. All patients were asked to complete the validated Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire consisting of five subscales: symptoms, pain, activities of daily living (ADL), function in sports and recreation, and knee-related quality of life (QOL). The score for each subscale ranged from 0 to 100, with higher scores indicating better function. A total of 46% (203 of 445) of patients participated at a mean follow-up of 6 ± 3 years since injury. All knee radiographs and CT images were reassessed, fractures were classified, and gap and stepoff measurements were taken. Nonresponders did not differ much from responders in terms of age (53 ± 16 years versus 54 ± 20 years; p = 0.89), gender (70% [142 of 203] women versus 59% [142 of 242] women; p = 0.01), fracture classifications (Schatzker types and three-column concept), gaps (2.1 ± 1.3 mm versus 1.7 ± 1.6 mm; p = 0.02), and stepoffs (2.1 ± 2.2 mm versus 1.9 ± 1.7 mm; p = 0.13). In our study population, the mean gap was 2.1 ± 1.3 mm and stepoff was 2.1 ± 2.2 mm. The participating patients divided into groups with increasing fracture displacement based on gap and/or stepoff (< 2 mm, 2 to 4 mm, or > 4 mm), as measured on CT images. ANOVA was used to assess whether an increase in the initial fracture displacement was associated with poorer functional outcome. We estimated the survivorship of the knee free from conversion to total knee prosthesis at a mean follow-up of 5 years using a Kaplan-Meier survivorship estimator.

RESULTS

KOOS scores in patients with a less than 2 mm, 2 to 4 mm, or greater than 4 mm gap did not differ (symptoms: 83 versus 83 versus 82; p = 0.98, pain: 85 versus 83 versus 86; p = 0.69, ADL: 87 versus 84 versus 89; p = 0.44, sport: 65 versus 64 versus 66; p = 0.95, QOL: 70 versus 71 versus 74; p = 0.85). The KOOS scores in patients with a less than 2 mm, 2 to 4 mm, or greater than 4 mm stepoff did not differ (symptoms: 84 versus 83 versus 77; p = 0.32, pain: 85 versus 85 versus 81; p = 0.66, ADL: 86 versus 87 versus 82; p = 0.54, sport: 65 versus 68 versus 56; p = 0.43, QOL: 71 versus 73 versus 61; p = 0.19). Survivorship of the knee free from conversion to total knee prosthesis at mean follow-up of 5 years was 97% (95% CI 94% to 99%).

CONCLUSION

Patients with minimally displaced tibial plateau fractures who opt for nonoperative fracture treatment should be told that fracture gaps or stepoffs up to 4 mm, as measured on CT images, could result in good functional outcome. Therefore, the arbitrary 2-mm limit of gaps and stepoffs for tibial plateau fractures could be revisited. The survivorship of the native knee free from conversion to a total knee prosthesis was high. Large prospective cohort studies with high response rates are needed to learn more about the relationship between the degree of fracture displacement and functional recovery after tibial plateau fractures.

LEVEL OF EVIDENCE

Level III, prognostic study.

A preliminary study of the surgical approach for posterior tibial plateau fractures: Based on posterior fragment segment classification

PURPOSE

The optimal surgical approach for the posterior tibial plateau fractures (PTPFs) remains controversial. This study aims to establish a method for posterior fragment segment classification to guide the choice of surgical approach and to reveal the outcome of their early reduction and health status.

METHODS

The medical records of 42 PTPFs patients treated with the strategy were collected retrospectively from December 2017 to December 2021. The posterior cortex of the tibial plateau was classified into postero-medial (PM), postero-central (PC), and postero-lateral (PL) segments. A posteromedial inverted L-shaped approach was adopted when the fractures involved the PM segment in the presence or absence of PC. The Frosch approach was performed when the PL segment was concerned. Fractures containing both PM and PL segments were treated by combined approaches. Four factors were measured to evaluate the reduction effect, including medial proximal tibial angle (MPTA), lateral posterior slope angle (LPSA), medial posterior slope angle (MPSA), and articular step-off. The Short Form 36 (SF-36) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were completed at the last follow-up to assess health status and the degree of osteoarthritis.

RESULTS

A posteromedial inverted L-shaped approach was adopted in 16 PTPFs patients, a Frosch approach was adopted in 14 PTPFs patients, and a combined approach was adopted in 12 PTPFs patients. Immediate radiographic results indicated a promising fixation performance with this treatment strategy. The results of SF-36 and WOMAC scores reported good health status in all patients with a mean follow-up time of 34.50 (23-50) months. Two patients developed superficial wound infections, and one patient had liquefaction necrosis in adipose tissue. Although skin numbness occurred in 4 patients, they recovered within 6 months.

CONCLUSION

PTPFs patients treated under the guidance of posterior fragment segment classification achieved encouraging levels of immediate fixation and health status.

[Application of a new universal locking anatomical plate in treatment of tibial plateau posterolateral column fractures]

OBJECTIVE

To investigate the effectiveness of a new tibial plateau posterolateral column universal locking anatomical plate (hereinafter referred to as "new universal locking anatomical plate") in the treatment of tibial plateau posterolateral column fractures.

METHODS

Between October 2020 and December 2021, 14 patients with tibial plateau posterolateral column fracture were treated with a new universal locking anatomical plate. There were 7 males and 7 females with an average age of 59 years ranging from 29 to 75 years. There were 5 cases on the left side and 9 cases on the right side. The causes of injury included falling from height in 5 cases, traffic accident in 7 cases, and other injuries in 2 cases. The time from injury to operation ranged from 3 to 10 days, with an average of 6 days. According to Schatzker classification, there were 4 cases of type Ⅱ, 8 cases of type Ⅴ, and 2 cases of type Ⅵ. All fractures involved the posterolateral tibial plateau. Three column classification: two columns (anterolateral column+posterior column) in 4 cases, three columns in 10 cases. The operation time, intraoperative blood loss, fracture healing, and complications were recorded. The reduction of tibial plateau fracture was evaluated by Rasmussen radiographic score, and the recovery of knee function was evaluated by Hospital for Special Surgery (HSS) score.

RESULTS

All 14 cases completed the operation successfully. The operation time was 95-180 minutes, with an average of 154 minutes, and the intraoperative blood loss was 100-480 mL, with an average of 260 mL. All patients were followed up 6-19 months, with an average of 12.5 months. All fractures healed, and the healing time was 15-24 weeks, with an average of 18.7 weeks. During the follow-up, there was 1 case of common peroneal nerve palsy and 1 case of traumatic osteoarthritis. There was no other complication such as vascular injury, incision infection, deep venous thrombosis of lower limbs, heterotopic ossification, bone nonunion, and failure of internal fixation. The reduction of tibial plateau fractures was good immediately after operation, and the Rasmussen radiological score was 10-18, with an average of 15.7; 3 cases were excellent, 10 cases were good, and 1 case was fair, with an excellent and good rate of 92.9%. The scores and grades of HSS at 3 months after operation and at last follow-up significantly improved when compared with those before operation ( P<0.05). There was no significant difference between 3 months after operation and last follow-up ( P>0.05).

CONCLUSION

For the fractures involving the posterolateral column of the tibial plateau, the new universal locking anatomical plate can provide strong fixation, satisfactory postoperative fracture reduction, and good recovery of knee function.

[Fractures of tibial shaft and tibial head in winter sports]

BACKGROUND

Injuries in alpine skiing often affect the lower extremities, in particular the knee joint and lower leg. In addition to conventional radiological diagnostics, CT and, in the case of fractures of the knee joint area, MRI also play an important role. In the case of tibial head fractures, especially if there has been a dislocation mechanism, there is an increased risk of vascular and nerve injuries. Lower leg fractures are predestined for the development of a compartment syndrome. For these reasons, an exact survey of the vascular-nerve status and a monitoring of the soft tissues should be carried out.

THERAPY

In the further therapy, whether conservative or surgical, the soft tissue situation must also be included in the planning. In the case of tibial head fractures in particular, the choice of the right approach is essential for a good result in surgical therapy. Angle-stable plate osteosynthesis and screw osteosynthesis play the most important role as osteosynthesis methods in the knee joint area. In the case of fractures in the shaft area, medullary nail osteosynthesis or angle-stable plate systems are primarily used. In the case of severely compromised soft tissue or unstable situations, it may be necessary to apply an external fixator first. The initiated therapy should enable functional follow-up treatment as early as possible.

PREVENTION

Good physical fitness, driving-specific training, but also good core stabilization have a preventative effect against injuries. In addition, the correct material coordination between ski boot, binding and ski is important for accident prevention.

The value of magnetic resonance imaging in the preoperative diagnosis of tibial plateau fractures: a systematic literature review

Purpose

The outcome of a tibial plateau fracture (TPF) depends on the fracture reduction achieved and the extent of soft-tissue lesions, including lesions in the ligaments, cartilage, and menisci. Sub-optimal treatment can result in poor knee function and osteoarthritis. Preoperative planning is primarily based on conventional X-ray and computed tomography (CT), which are unsuitable for diagnosing soft-tissue lesions. Magnetic resonance imaging (MRI) is not routinely performed. To date, no literature exists that clearly states the indications for preoperative MRI. This systematic review aimed to determine the frequency of soft-tissue lesions in TPFs, the association between fracture type and soft-tissue lesions, and the types of cases for which MRI is indicated.

Methods

A systematic review of the literature was based on articles located in PubMed/MEDLINE and the Cochrane Central Register of Controlled Trials (CENTRAL), supplemented by searching the included articles’ reference lists and the ePublication lists of leading orthopedic and trauma journals.

Results

A total of 1138 studies were retrieved. Of these, 18 met the eligibility criteria and included a total of 877 patients. The proportion of total soft-tissue lesions was 93.0%. The proportions of soft-tissue lesions were as follows: medial collateral ligament 20.7%, lateral collateral ligament 22.9%, anterior cruciate ligament 36.8%, posterior cruciate ligament 14.8%, lateral meniscus 48.9%, and medial meniscus 24.5%. A weak association was found between increasing frequency of LCL and ACL lesions and an increase in fracture type according to Schatzker's classification. No standard algorithm for MRI scans of TPFs was found.

Conclusion

At least one ligament or meniscal lesion is present in 93.0% of TPF cases. More studies with higher levels of evidence are needed to find out in which particular cases MRI adds value. However, MRI is recommended, at least in young patients and cases of high-energy trauma.

Single versus dual incision approaches for dual plating of bicondylar tibial plateau fractures have comparable rates of deep infection and revision surgery

OBJECTIVES

The use of one midline incision versus dual medial/lateral incisions for dual plating of bicondylar tibial plateau (BTP) fractures is controversial. This study aimed to compare rates of infection and secondary surgery in patients treated with dual plating for a BTP fracture using a single versus double incisions.

DESIGN

Retrospective cohort study.

SETTING

Two Level-1 trauma centers.

PATIENTS/PARTICIPANTS

Patients > 18 years with a closed AO/OTA 41-C BTP fracture without compartment syndrome treated with a single midline or dual incision (lateral with medial or posteromedial) approach for dual plating.

INTERVENTION

Dual plating through either a single anterior incision, or dual medial/lateral incisions.

MAIN OUTCOME MEASUREMENTS

Rates of deep infection and reoperation were compared using Chi-square analysis (p-value of < 0.05).

RESULTS AND CONCLUSIONS

In total 636 AO/OTA 41-C BTP fractures treated between 1/1/01 and 12/31/18 were identified and assessed. After exclusions for limited follow up, other techniques, open fracture and the need for fasciotomies, 346 patients were studied. Of these 254 had been treated with a single plate / single approach technique while 92 had been dual plated, 41 through a single anterior incision while 51 had dual plating through separate lateral and medial or posteromedial incisions. For these 92 fractures, there was no significant difference in the rate of deep infection (22.0% vs 23.5%, s=0.858) or reoperation (31.7% vs 31.4%, p=0.973) between the single and dual incision groups. Injuries that had been treated with single plating via a single incision had comparably lower rates of deep infection (10.2% vs. 22.8%, p=0.003) and reoperation (12.2% vs. 31.5%, p<0.001). There were no significant differences in any demographic parameters between patients undergoing single versus dual plating. Although retrospective, not randomized and subject to single surgeon bias these data suggest that these complications are more based on injury than the approach.

LEVEL OF EVIDENCE

III.

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.

Comparison between reliability of Schatzker's classification and CT based four quadrant classification for tibial plateau fractures

Introduction

Conventionally used Schatzker and AO/OTA classification, do not identify posterior column injuries in tibial plateau fractures. CT based Four quadrant classification, has been proposed to identify fractures of tibial plateau and help in surgical planning of treatment. However, to assess its validity, there is scanty literature about its reliability (inter and intra-observer variation) and comparison of its reliability with that of the more popular Schatzker classification in classifying tibial plateau fracture.

Material and methods

X-rays and CT scans of 35 patients (18-65 years) of closed tibial plateau fractures were assessed by 5 Orthopaedic surgeons and classified by both Schatzker's and Four Quadrant Classification. A similar observation was recorded after 2 months. All observers were blinded for the demographic and clinical details of the patients. Their responses were noted and interobserver and Intraobserver variation was calculated. Kappa Test of Cohen was used to determine the level of agreement, as per Landis and Koch's criteria. The reliability of four quadrant classification was also compared with that of Schatzker's classification.

Results

There was a moderate agreement in interobserver variation in observations for Schatzker's classification (on X-rays) which improved to substantial agreement when the observations were recorded after showing both CT and X-rays. The intraobserver variation had substantial agreement. On the other hand, there was a perfect agreement in both intra- and interobserver variation for Four Quadrant Classification. This difference between the reliability of both classifications was statistically significant (p < 0.001).

Conclusions

Four Quadrant classification is a more reliable classification having a better agreement on interobserver and intraobserver variation.

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.

Tibial plateau fractures: three dimensional fracture mapping and morphologic measurements

Purpose

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

Methods

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

Results

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

Conclusions

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

[Ligament injuries in tibial plateau fractures]

Fracture dislocations of the proximal tibia are associated with a markedly high incidence of ligament ruptures. Despite knowledge on the frequency of accompanying ligament injuries, even now neither adequate diagnostics nor targeted treatment of associated ligament injuries are the gold standard in the treatment algorithm for tibial plateau fractures. To be able to assess the risk and the type of accompanying ligament injuries in tibial plateau fractures, it is recommended to decidedly analyze the fracture morphology. For example, flexion varus fractures are very frequently associated with injuries to the anterior cruciate ligament, whereas valgus fractures are prone to ruptures of the medial collateral ligament and (hyper)extension fractures facilitate ruptures of the posterior cruciate ligament and the posterolateral corner. In order not to overlook high-grade instability, magnetic resonance imaging or intraoperative dynamic fluoroscopy can be carried out after completing osteosynthesis. Bony avulsions should either be addressed directly during osteosynthesis or indirectly retained via interfragmentary compression. In cases of direct visualization or relevant instability, intraligamentous tears should at least be intraoperatively reduced. If patients suffer from persistent instability a secondary ligament reconstruction with autologous tendons can be carried out following bony consolidation of the tibial plateau fracture.

[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.

Flexion Tibial Plateau Fractures: 3-dimensional CT Simulation-based Subclassification by Injury Pattern

Objective

To identify different injury patterns of flexion tibial plateau fractures (FTPFs) with 3D CT simulation technology. The association between these hypothesized injury patterns and concomitant injuries was also investigated.

Methods

The tibial plateau fracture cases of 297 patients consecutively treated at our trauma center from August 2016 to December 2018 were reviewed retrospectively. A total of 108 patients with FTPFs were enrolled. 3D CT simulation technology was used to reconstruct the position of the knee joint at the time of tibial plateau fracture. The 3D segments for the tibia and femur were created separately, the tibial 3D segment was aligned with the articular surface of the femoral condyle, and then the corresponding injury patterns were deduced. The magnitudes of translation and rotation incurred after the segments were repositioned were calculated by Mimics software. The associations between the hypothesized injury patterns and concomitant injuries were compared.

Results

FTPFs were classified into two groups according to the fracture region: unicondylar FTPFs (type I) and bicondylar FTPFs (type II). According to the injury patterns simulated in this study, these two types of FTPFs were further subclassified into five subgroups. Type I FTPFs were categorized into two subtypes based on the degree of rotation in the coronal plane (varus < 0°; valgus > 0°): pure flexion‐varus fractures (type IA, −10.23° ± 2.11°, 3.7%, 4/108) and pure flexion‐valgus fractures (type IB, 11.54° ± 2.63°, 26.9%, 29/108). Type II FTPFs were divided into three subgroups based on the degree of rotation in the axial plane (internal rotation >10°; flexion‐neutral −10° to 10°; external rotation <−10°): flexion‐neutral fractures (type IIA, 2.01° ± 3.43°, 13.0%, 14/108), flexion‐internal rotation fractures (type IIB, 23.66° ± 6.17°, 35.2%, 38/108) and flexion‐external rotation fractures (type IIC, −16.23° ± 4.27°, 21.3%, 23/108). The incidence of posterolateral quadrant collapse fractures among type IIB fractures was significantly increased relative to that of type IIC fractures (P < 0.001). The incidence of posterolateral quadrant split fractures, anterolateral quadrant fractures and proximal fibular fractures among type IIC fractures was significantly higher than that among type IIB fractures (P < 0.001). The number of these concomitant injuries significantly differed between type IIB and type IIC fractures (P < 0.001).

Conclusion

3D CT simulation‐based subclassification according to the pattern of injury can help surgeons better understand FTPFs and select an appropriate treatment strategy.

The Relationship between the Injury Mechanism and the Incidence of ACL Avulsions in Schatzker Type IV Tibial Plateau Fractures: A 3D Quantitative Analysis Based on Mimics Software

INTRODUCTION

 Tibial plateau fractures are often accompanied with ligamental and meniscal injuries. Among which, the combined existence of Schatzker type IV fracture with anterior cruciate ligament (ACL) avulsion has been reported rarely. The purpose of this study was to determine the injury mechanism of Schatzker type IV fracture with ACL avulsion based on Mimics software.

METHODS

 Ninety-nine Schatzker type IV tibial plateau fractures were retrospectively analyzed by quantitative three-dimensional measurements. ACL avulsions were diagnosed through the data of computed tomography and magnetic resonance imaging. We simulated the knee posture when an injury occurred and defined different injury patterns. The chi-square test was used for determining the main mechanism which causes Schatzker type IV fractures associated with ACL avulsions.

RESULTS

 There were more ACL avulsions and more displaced ACL avulsions associated with the knee in flexion in the setting of Schatzker type IV fracture (p < 0.05). More ACL avulsions were found in the injury pattern of flexion-valgus than the other injury patterns of the same level (p < 0.05). The rotation of the tibial showed no significant difference in producing ACL avulsion fractures.

CONCLUSION

 This study found that a flexed knee at the occurrence of a Schatzker type IV tibial plateau fracture is a high-risk factor for causing associated ACL avulsion and producing more displaced avulsions. Flexion-valgus pattern was the main cause of Schatzker type IV fractures associated with ACL avulsions. The findings will help orthopedists understand the injury mechanism and enhance their awareness of such injuries to avoid unfavorable prognosis.

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

Objectives

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

Methods

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

Results

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

Conclusions

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

III.

The 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.

Analysis of medial tibial plateau fracture injury patterns using quantitative 3D measurements

BACKGROUND

The Wahlquist system classifies tibial medial plateau fractures into three types based on the sagittal fracture line location, with type C at highest risk of complications. However, the injury mechanism of tibial medial plateau fractures, especially tibial rotation movement, remains unclear. The purpose of the present study was to determine the injury patterns of medial tibial plateau fractures using 3D model simulation and quantitative 3D measurements.

METHODS

Seventy-eight consecutive AO/OTA type 41-B tibial plateau fractures were retrospectively analyzed using CT-based 3D models and quantitative 3D measurements. The knee posture at the moment of fracture occurrence was simulated, and various knee angles in the sagittal, coronal, and axial planes were measured to evaluate the mechanism of medial tibial plateau fracture. The mean valgus-varus, hyperextension-flexion, and internal-external rotation angles were determined, and the chi-square test was used for comparisons of categorical varus and valgus force data to determine the main force direction in Wahlquist type C fractures.

RESULTS

Angle measurements in the coronal planes showed that 28 (35.9%) medial tibial plateau fractures resulted from a varus injury pattern, while 50 fractures (64.1%) resulted from a valgus pattern. Valgus force produced significantly more Wahlquist type C fractures (37 of 50 fractures) than varus force (2 of 28 fractures) (p < 0.05). There was no significant difference in the cases of patients with type C fractures between the tibial internal and external rotation injury patterns(P > 0.05).

CONCLUSIONS

Valgus force was the cause of 64.1% of the medial tibia plateau fractures in the present cohort. Furthermore, valgus force produced more Wahlquist type C fractures than varus force. The present findings will help orthopedists understand the injury mechanism of the Wahlquist classification system, and will facilitate the identification of the common features of medial tibial plateau fractures induced by specific injury patterns.

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.

"Flip lid" type of lateral tibia plateau fracture with a meniscus radial tear: A case report

Case

A 45-year-old woman sustained a unique lateral tibia plateau fracture pattern with a vertically rotated fragment composed of an intact articular surface and subchondral bone. During open reduction and internal fixation (ORIF), a full thickness radial tear of the lateral meniscus was found, which was repaired under direct visualization through arthrotomy. At final follow-up, the patient regained pain-free activity with good meniscus healing, as confirmed with a second-look arthroscopic examination.

Conclusion

This case represents an undescribed fracture pattern that indicates an associated meniscus injury. A thorough evaluation, including Magnetic Resonance Imaging should be considered. One-stage ORIF followed with meniscus repair represents a good treatment option.

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.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical outcomes of open reduction and internal fixation for intra-articular complex tibial plateau non-union with 3-year minimum follow-up

BACKGROUND

A tibial plateau fracture is one of the most challenging fractures for both knee and trauma surgeons because of the high incidence of post-traumatic knee osteoarthritis. To our knowledge, there has been no study concerning the clinical outcomes after surgery in patients with non-union of complex intra-articular tibial plateau fractures. Thus, the present study aimed to assess and report the clinical outcomes in them.

METHODS

The study included four patients with non-union of complex tibial plateau fractures who underwent failed initial fixation treatment or could not undergo initial fixation owing to concomitant injury and who were followed up with a diagnosis of non-union for a minimum of 6 months. At the latest follow-up, patient-reported outcome measures, including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Oxford 12-item Knee Score (OKS), were assessed. Additionally, the knee range of motion (ROM) was evaluated.

RESULTS

The mean duration from the initial surgery to revision surgery was 8.8 months, and the mean duration from the revision surgery to fracture union was 4.8 months. At the latest follow-up, the mean WOMAC score was 9.8 and the mean OKS was 43.5. Additionally, the mean knee ROM values were -11 degrees of extension and 100 degrees of flexion. All four patients had become able to walk without any aid after averaged 4.5-years follow up.

CONCLUSION

Favorable clinical outcomes can be achieved following revision surgery involving open reduction and IF in patients with non-union of complex tibial plateau fractures after failed initial treatment.

LEVEL OF EVIDENCE

Level IV, Case report.

Posterior tibial plateau fracture treatment with the new WAVE posterior proximal tibia plate: feasibility and first results

INTRODUCTION

Operative management of posterior tibial plateau fractures (PTPF) remains challenging. The treatment goal is to restore the alignment and articular congruence, and providing sufficient stability which allows early mobilization. The purpose of this study was to assess the feasibility and safety of the newly developed WAVE posterior proximal tibia plate.

METHODS

Between Oct 2017 and Jun 2020, 30 adult patients with a tibial plateau fracture and posterior involvement were selected for treatment with a WAVE posterior proximal tibia plate. Patient reported outcome was assessed using the Knee injury and Osteoarthritis Outcome Score (KOOS) at time of injury (pre-injury) and at 1-year follow-up. Radiological outcome was evaluated with CT-imaging.

RESULTS

Twenty-eight patients were eligible for treatment with the new implant (3 'one-column', 10 'two column' and 15 'three-column' fractures), whereas in 2 patients anatomical fit was insufficient. KOOS results showed fair outcome scores at 1 year, with a large negative impact compared to pre-injury levels; however, a trend towards better results compared to a previous PTPF reference cohort. Radiological follow-up showed insufficient posterolateral buttress in two cases and residual articular step-off (> 2 mm) in seven patients, of which five were classified as three column fractures.

CONCLUSION

Management of PTPF using the WAVE posterior proximal tibia plate is feasible and safe with satisfactory clinical and radiological results after 1 year. Nevertheless, there is a learning curve regarding optimal implant positioning to achieve the maximum benefit of the implant.

LEVEL OF EVIDENCE

4.

Injury pattern simulation and mapping of complex tibial plateau fractures that involve the posterior plateau with three-dimensional computed tomography

Background

Tibial plateau fractures involving the posterior plateau (TPFIPs) are complex intra-articular fractures that are difficult to stabilize. Understanding the characteristics of these fractures together with the injury pattern is beneficial for surgeons to choose an optimal treatment strategy. However, the complicated morphology and injury patterns of TPFIPs are poorly characterized. The purpose of this retrospective study was to investigate the injury patterns and fracture characteristics of complex TPFs by applying three-dimensional (3D) simulation and fracture mapping methods.

Methods

In total, 171 TPFIPs were retrospectively reviewed, and the injury pattern was simulated and analyzed by applying a 3D method with Mimics software, which allowed matching of the fractured articular surfaces of the tibial plateau to the femoral condyle surface. The major articular fracture lines were mapped and then superimposed on a template. The tibial motion angle after fracture injury pattern simulation and the major fracture line angle were quantitatively analyzed, while the injury patterns and fracture characteristics were qualitatively analyzed.

Results

Four main injury patterns with distinctive fracture characteristics were observed in this study. In total, 72 TPFs exhibited extension as the pattern of injury with a split posterolateral fragment, and 61 fractures exhibited the flexion-internal rotation injury pattern; compression was the main feature of posterolateral fractures. Furthermore, 21 fractures exhibited the flexion-external rotation injury pattern, with a small posteromedial fragment, and 17 fractures exhibited the flexion-neutral injury pattern, with both parts of the posterior plateau fracture and anterior dislocation being observable. The major articular fracture line angles were significantly different between the four main injury patterns (85.92°, 46.79°, 148.26°, and 16.21°, median values, P<0.05). Two injury patterns, namely, flexion-internal rotation and flexion-external rotation, exhibited rotation in the axial plane (24.13°±8.33°, −15.13°±5.14°, P<0.05).

Conclusions

In this study, a method involving a simulated injury pattern was developed and combined with evaluations of fracture characteristics, including two-dimensional (2D) and 3D analyses, to comprehensively describe both the morphologies and injury patterns of TPFIPs.

Why address posterior tibial plateau fractures?

Management of posterior tibial plateau fractures has gained much interest over the past few years. Fracture morphology, trauma mechanism, and soft-tissue injury have been identified as the key factors determining the treatment strategy and outcome. We provide a rationale for the operative management of posterior tibial plateau fractures by discussing the interplay between fracture morphology, trauma mechanism, and soft-tissue injury. The trauma mechanism has proven to be an important tool, not only to understand fracture morphology, but also to assess concomitant soft-tissue (i.e. ligamentous) injury. Subsequently, soft-tissue injury might play a role in future classification and diagnostic work-up of tibial plateau fractures, particularly in fractures with posterior involvement. Plate osteosynthesis using a posterior approach is safe and should be considered routinely in coronal fractures of the posterior tibial plateau, as illustrated.

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

Purpose

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

Methods

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

Results

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

Conclusion

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