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

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVES

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

METHOD

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

RESULTS

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

CONCLUSION

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

Comparative Analysis of Posterior Approach Versus Anterior Approach for Posterior Tibial Plateau Fractures: A Systematic Review and Meta-analysis

BACKGROUND

Posterior tibial plateau fractures can lead to significant posttraumatic instability if not treated properly. It remains unclear which surgical approach achieves better patient outcomes. The objective of this systematic review and meta-analysis was to assess postoperative outcomes in patients undergoing anterior, posterior, or combined approach for posterior tibial plateau fractures.

METHODS

The PubMed, Embase, Web of Science, The Cochrane Library, and Scopus were searched for studies published before October 26, 2022, comparing anterior, posterior, or combined approaches for posterior tibial plateau fractures. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Outcomes included complications, infections, range of motion (ROM), operation time, union rates, and functional scores. Significance was set at p < 0.05. Meta-analysis was conducted with STATA software.

RESULTS

In total, 29 studies with a total of 747 patients were included for quantitative and qualitative analysis. Compared with other approaches, the posterior approach for posterior tibial plateau fractures was associated with a better ROM and shorter operative time. The complication rates, infection rates, union time, and hospital for special surgery (HSS) scores were not significantly different between surgical approaches.

CONCLUSIONS

The posterior approach for posterior tibial plateau fractures offers advantages such as improved ROM and shorter operative time. However, there are concerns regarding prone positioning in patients with medical or pulmonary comorbidities and indications in polytrauma cases. Further prospective studies are needed to determine the optimal approach for these fractures.

LEVEL OF EVIDENCE

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

Optimal surgical timing and approach for tibial plateau fracture

BACKGROUND:

Tibial plateau fracture is a common fracture encountered in the clinic.

OBJECTIVE:

This study determined the optimal timing and surgical approach for patients with tibial plateau fracture.

METHODS:

Fifty-two patients with complex tibial plateau fractures were treated in our hospital (the People’s Hospital of Zhongjiang County) between 2013 and 2015. These patients were recruited as participants in this study; all patients were randomly allocated into two groups of 26 patients each. Patients in Group 1 underwent single-incision, single-plate knee surgeries via an antero-lateral approach, and patients in Group 2 underwent anterior median incisions of the knee for double-plate surgeries. The effects of the approaches were compared and analyzed.

RESULTS:

The best time to perform surgery was 6–8 days post-injury. The anterior median incision, double-plate method approach was better than the antero-lateral, single-incision, single-plate method. For the former method, the healing among middle-aged and young patients was better than that of elderly patients, and that healing of men was slightly better than that of female patients. However, the degree of healing among patients was > 80% at 5 months postoperatively. The purpose of surgical management has been fully achieved.

CONCLUSION:

The optimal timing of surgery for patients with complex tibial plateau fractures is 6–8 days post-injury. The surgical approach needs to be determined based on the actual condition of the patient. However, the treatment effect of an anterior median incision, double-plate method is better, and the recovery rate may approach 80% at 5 months postoperatively.