Modified anterior midline approach to treat hyperextension bicondylar tibial plateau fractures: Surgical technique and clinical experience with 18 cases

Current treatment strategies for hyperextension fractures of the tibial plateau: A systematic review and proposal of a treatment algorithm

OBJECTIVE

Analyze the current evidence on the treatment and outcomes of hyperextension fractures of the tibial plateau and propose a treatment algorithm.

METHODS

An electronic search at PubMed/MEDLINE, Cochrane Library, Embase, and Google Scholar database from December 24th, 2023 to June 26th, 2024 was carried out. The terms for the database search included "Hyperextension AND Tibial plateau fractures" and "Reversed Tibial Slope AND Tibial Plateau Fractures". The research inclusion criteria were scientific articles written in English that addressed hyperextension fractures of the tibial plateau. Studies that have not specifically addressed hyperextension fractures of the tibial plateau or published in a different language than English were excluded. Considering that hyperextension fractures of the tibial plateau are relatively rare and the literature is scarce, studies with all levels of evidence were included. Critical analysis of titles, abstracts, inclusion and exclusion criteria of all potentially eligible articles was performed. A treatment algorithm based on the literature and authors perspective was proposed.

RESULTS

The search identified 34 potentially eligible studies. After application of inclusion and exclusion criteria, 22 articles were carefully analyzed in terms of the most relevant topics related to hyperextension fractures of the tibial plateau. An analysis of the risk of bias of the selected studies was performed according to the Cochrane Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I).

CONCLUSION

There is no consensus regarding the gold standard treatment method for this challenging fracture pattern. The hyperextension mechanism is a predictor of worse functional outcome and life quality comparing to other types of tibial plateau fractures.

STUDY DESIGN

Systematic review of the literature (Level of evidence:1).

Intraosseous Shelf Plate Fixation for Depressed Articular Fragments in Tibial Plateau Fractures: A Technical Trick and Case Series

SUMMARY

Tibial plateau fractures with severely displaced articular injuries and significant deformity to the surrounding metaphyseal bone (including the hyperextension varus bicondylar pattern) can be challenging to stabilize due to resulting large bone voids uncontained by metaphyseal cortex. The purpose of this report was to describe a technique to support the plateau articular surface in these cases and report on outcomes of a small series. This technique uses a small or mini fragment plate, contoured to function as an intraosseous shelf plate, with the "shelf" portion inserted into the bone beneath the articular surface to support it. This technique provides fixed-angle support to the fragment. There are some advantages of this technique compared to structural allograft, large volume ceramic bone void filler, a spine cage, or other trabecular metal object, including the ability to remove the plate later, ability to tension the plate against the depressed articular surface, ability to place screws or other allograft near the implant, wide availability of the implant, and familiarity of orthopaedic trauma surgeons with placing plates and screws to hold reductions. The technique is particularly useful in patterns with uncontained articular depression and a large metaphyseal void.

[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.