Proximal tibial intra-articular osteotomy for treatment of complex Schatzker type IV tibial plateau fractures with lateral joint line impaction: description of surgical technique and report of nine cases

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.

Schatzker IV tibial plateau fractures: are they always unicondylar?

Objective

The objectives of this study were to describe the incidence and morphology of medial tibial plateau fractures that extend into the lateral articular surface and to describe trends in their management.

Design

Retrospective.

Setting

Level I Urban Trauma Center.

Patients

Seventy consecutive patients sustaining OTA/AO 41 B1 and B3 fractures.

Intervention

Open reduction internal fixation of medial tibial plateau fractures.

Main Outcome Measurements

Incidence of medial tibial plateau fractures that extend into the lateral articular surface. Secondary outcomes include localization of lateral articular surface depression, neurovascular injury, and trends in surgical management.

Results

Seventy patients were included with 9 fractures (12.9%) isolated to the medial condyle (MC) and 61 fractures (87.1%) extending to the lateral condyle (LC). Compartment syndrome was present in 2 patients (2.9%), peroneal nerve palsy in 2 (2.9%), and arterial injury in 1 (1.4%). Initial external fixation was used more frequently in the LC group compared with the MC group (P = 0.028). Of the 61 fractures in the LC group, 49 (80.3%) included lateral articular surface depression which localized to the posteromedial quadrant of the lateral articular surface in 36 of 49 fractures (73.5%). Lateral articular surface depression depth ≥10.6 mm was associated with the use of dual incisions (P < 0.001).

Conclusions

Schatzker IV fractures frequently extend to the lateral condyle and often present with depression of the posteromedial lateral articular surface. Fractures with lateral articular surface depression depth ≥10.6 mm were more likely to undergo fixation with dual incisions.

Level of Evidence

Therapeutic level IV.

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.

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

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

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.

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.

Medial sided articular impaction in tibial plateau fractures

INTRODUCTION

Tibial plateau fractures are a heterogenous group of injuries with a variable amount of articular injury and are commonly associated with lateral sided articular impaction. Previous work has focused on describing the morphology of tibial plateau fractures, but has neglected description of medial sided articular impaction. The aim of this investigation was to assess the morphology of medial sided articular impaction in tibial plateau fractures, with specific attention directed toward the frequency, location, size, and associated fracture patterns.

METHODS

Skeletally mature patients presenting to a Level I trauma center from 2008-2018 with a tibial plateau fracture (AO/OTA 41B-C) were identified retrospectively. Fractures were classified by AO/OTA and Schatzker type. Radiographs and computed tomography (CT) scans were reviewed to identify and localize medial sided articular impaction. The location and surface area of impaction was characterized by creating frequency diagram heat maps from axial CT scans. Descriptive statistics were performed using standard measures.

RESULTS

Of the 1032 tibial plateau fractures included, 82 (7.9%) were noted to have medial sided articular impaction. Rate of impaction varied by fracture type (p = 0.03): Schatzker II, 2% (7 of 381); Schatzker IV, 21% (19 of 96); and Schatzker VI, 11% (56 of 524). Average total surface area of impaction was 9% of the total and 19% of the medial plateau area. Area of impaction varied by fracture type (p = 0.004): Schatzker II, 6% (95% confidence interval [CI], 4%-7%); Schatzker IV, 11% (95% CI, 9%-13%), and Schatzker VI, 9% (95% CI, 7%-11%). The area of impaction occurred primarily along the lateral aspect of the medial plateau in Schatzker II fractures, in the anteromedial quadrant of Schatzker IV fractures, and was evenly distributed across the medial plateau in Schatzker VI fractures.

CONCLUSIONS

Surgeons should be aware that medial articular impaction is present in approximately 8% of tibial plateau fractures. Schatzker IV fractures are most likely to have medial impaction and a larger proportion of the joint surface involved in these injuries.

High energy trauma with complex fracture of the right tibial plateau, compartment syndrome and infection in a professional freestyler motorcyclist

BACKGROUND AND AIM OF THE WORK

High-energy tibial plateau fractures are complex lesions that may be associated with extensive soft tissue damages and severe complications, such as compartment syndrome and neurological injuries. This case report interests a professional motocross freestyler with complex tibial plateau fracture associated to compartment syndrome and partial common peroneal nerve impairment which complicated with a dehiscence of the surgical wound and infection after plate and screws fixation. One year later, despite the complexity of the fracture, the gravity of the soft tissue lesions and subsequent complications, the patient healed. This satisfactory result depended on the correct management in terms of type of treatment and timing.

Subdivision of injured area for Schatzker IV tibial plateau fracture repair: A report of 12 cases

BACKGROUND

Treatment of Schatzker IV tibial plateau fractures is challenging due to the wide variety of potential fracture morphologies and injury to multiple ligaments. Subdivision of the injured area into three zones may simplify the preoperative plan. In this study, we reported 12 cases of Schatzker IV tibial plateau fracture that were treated with pre-operative plans based on a new subdivision of the injured area.

METHODS

From January 2012 to April 2016, 12 patients with a Schatzker IV tibial plateau fracture were treated in our hospital with preoperative plans guided by the new sub-division method. Clinical and radiological results were evaluated during follow-up.

RESULTS

In all cases, the incisions healed without skin necrosis, and the average Lysholm knee score was 73 points (range, 53-90) at the final follow-up.

CONCLUSION

Sub-division of the injured area represented a useful strategy for preoperative surgical planning in the treatment of Schatzker IV tibial plateau fractures.

Preoperative Plan with 3D Printing in Internal and External Fixation for Complex Tibial Plateau Fractures

OBJECTIVE

To compare short-term treatment effects of internal and external fixation in the treatment of complicated tibial plateau fractures by preoperative planning with 3D printing.

METHODS

Sixty-nine patients with tibial plateau fractures were examined. 3D printing was used to establish the model in all patients before the operation. Thirty-four patients were treated with an external fixator (9-Schatzker Type V, 25-Schatzker Type VI) and 35 patients were treated with internal fixation (12-Schatzker Type V, 23-Schatzker Type VI). The time span of the study was 2 years after the operation. All patients were followed up in the clinic of the attending physician who recorded patient follow-up information at the same time. Finally, the Rasmussen functional score, radiographic parameters, complication rates, hospital days and operative parameters of the two groups were analyzed.

RESULTS

The short-term (within 2 years) Rasmussen score in the external fixation group was close to that of the internal fixation group; the differences were not significant (P > 0.05). The fractures were reduced adequately using both forms of surgical treatment. There is no significant difference between internal and external fixation in terms of radiographic parameters after 2 years (Mann-Whitney U-tests, P > 0.05). Thrombosis was detected in 7 cases (2 external fixation, 5 internal fixation). Superficial infection was detected in 3 cases (1 external fixation, 2 internal fixation). Deep infection was detected in 3 cases (0 external fixation, 3 internal fixation). Knee stiffness was detected in 4 cases (2 external fixation, 2 internal fixation); 1 (2.7%) case of screw pullout occurred in the internal fixation group. The external fixation group had shorter operation times (172.94 ± 50.00 min vs 253.86 ± 64.59 min), less bleeding volume (395.88 ± 121.10 mL vs 864.29 ± 238.12 mL), and fewer days (17.03 ± 5.03 days vs 30.17 ± 8.64 days) of hospitalization compared to the internal fixation (t-test, P = 0.00); subgroup analysis of all patients with complex tibial plateau fractures revealed that for patients with tibial plateau fracture type VI, the functional score of external fixation (26.79 ± 2.04) is better than that (25.54 ± 1.69) of internal fixation (t- test, P = 0.026) and the overall infection rate of external fixation is lower than that of internal fixation (χ² - test, P = 0.047).

CONCLUSION

Using 3D printed models in combination with external fixation has more advantages for short-term treatment of complex tibial plateau fractures. In particular, relatively better functional recovery and lower rates of infection can be achieved for Schatzker type VI fractures. The external fixation treatment was preferred in cases of Schatzker VI tibial plateau fractures.

Early Revision Surgery for Tibial Plateau Fractures

OBJECTIVE

To describe patients' outcomes after revision of tibial plateau fracture fixation within 12 months of the initial surgical procedure. To assess differences in objective outcome scores [International Knee Documentation Committee (IKDC), short form-36, arthrosis score, physical examination] depending on whether patients were treated for malreduction, malunion, or nonunion.

DESIGN

Retrospective case series.

PATIENTS

Twenty-seven patients who underwent revision within 1 year of primary surgery and with a minimum follow-up of 1 year.

MAIN OUTCOME MEASUREMENT

IKDC Subjective Knee Form, alignment, osteoarthritis, timed up and go test, range of motion, and physical and mental health (using the short form-36 survey).

RESULTS

At the most recent follow-up, the mean IKDC subjective knee score of all patients within the study group was 62 (SD 17). In the malreduction group, the mean was 71 (SD 17), in the malunion group the mean was 56 (SD 17), and in the nonunion group, the mean was also 56 (SD 12; χ 0.94; P = 0.624). Comparing the malreduction group with the malunion and nonunion groups combined, there was a significantly higher IKDC score (P = 0.019) in the malreduction group.

CONCLUSION

A suboptimal outcome after open reduction and internal fixation of a tibial plateau fracture is common. If the underlying cause of the fracture is malreduction, malunion, or a nonunion, salvage of the joint without a knee replacement is worthwhile. When using a strategy incorporating revision plate fixation, osteotomy (intra- and/or extraarticular), debridement, and bone grafting when needed, patients should experience favorable long-term outcomes, including less residual pain and functional limitations.

LEVEL OF EVIDENCE

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

Reconstruction of a Neglected Tibial Plateau Fracture Malunion with an Open-Book Osteotomy: A Case Report

CASE

Surgical management of tibial plateau fractures can be challenging, and complications can be devastating. We report the case of a lateral tibial plateau fracture malunion with an associated intra-articular depression, which we treated with an open-book osteotomy, obviating the need for an early corrective osteotomy or knee arthroplasty.

CONCLUSION

A tibial plateau fracture malunion can be reconstructed. The surgical team should give priority to salvage options, which can obviate or delay the need for and the implications of an early total knee arthroplasty, especially in a young and active patient.

Incidence and risk factors for deep surgical site infection after open reduction and internal fixation of closed tibial plateau fractures in adults

This study aimed to investigate the incidence and risk factors of deep surgical site infection (DSSI) during hospitalisation after closed tibial plateau fractures treated with open reduction and internal fixation (ORIF). We performed this retrospective study at a university-affiliated hospital with an advanced trauma centre. The data of adult patients with closed tibial plateau fractures treated with ORIF from January 2012 to February 2017 were extracted from the electronic medical records. Demographics, injury-related and surgery-related variables of DSSI and non-DSSI groups were compared by univariate test. Multivariate logistic analysis models were used to investigate the independent risk factors. In total, 676 patients with complete data met the inclusion criteria and were included, and of them, 17 developed DSSI (2.51%) during hospitalisation. Approximately 60% (9/17) of DSSI was caused by Staphylococcus aureus. Compared to the non-DSSI group, DSSI patients had a significantly longer stay in hospital (25.8 vs 15.2 days). Independent risk factors of DSSI identified by multivariate analysis were higher BMI (>26.0) (OR, 1.58; 95% CI, 1.09 to 3.27; P = 0.032), prolonged surgical duration (>138 min) (OR, 4.26; 95% CI, 1.54 to 11.19; P = 0.005) and current smoking (OR, 3.42; 95% CI, 1.47 to 8.62; P = 0.01). A relatively low incidence rate of DSSI (2.51%) was found in this study, and several significant risk factors were identified. Smoking cessation programmes should be implemented immediately after hospitalisation, especially for obesity and morbid obesity patients. Detailed and comprehensive preoperative assessment and a considerate operative plan should be guaranteed to reduce surgical duration.

Flexion-valgus unicondylar tibial plateau depression fracture pattern: Classification and treatment

PURPOSE

The authors have identified a subset of unicondylar tibial plateau depression fracture patterns caused by a flexion-valgus force. The purpose of this study was to describe this fracture pattern and suggest a modified lateral approach that may allow for improved reduction and stabilization.

METHODS

The preoperative radiographs and CT scans of 102 patients who sustained unicondylar tibial plateau fractures (OTA 41B) were reviewed. Twenty-six fracture patients had posterolateral (PL) tibial plateau depression fractures. By medical record review and telephone follow-up, the injury mechanism of the 22 unicondylar tibial plateau fractures was confirmed as a flexion-valgus force. The radiographic features of those cases were analyzed and measured. To address this specific fracture pattern, a modified approach combined with a novel intra-articular osteotomy was applied.

RESULTS

According to the morphological characteristics, this tibial plateau fracture pattern could be divided into two subtypes: type A was a confined, basin-like articular surface depression fracture located in the PL quadrant, and type B was a cancellous fracture involving the PL tibial plateau resulting in a decrease in the posterior slope. One radiographic hallmark of this fracture pattern is an anatomically or a mechanically intact posterior column wall. The novel approach was applied to both types. The postoperative radiographic measurements revealed excellent reduction quality. On axial scans, the distance between the most posterior rafting screw and the tangent line of the tibial plateau rim was 3.0 ± 2.07 mm (from -1.9 to 4.3), and the angulation between them was 8.9 ± 3.02° (from -7.3 to 15.6). These results indicated excellent PL quadrant coverage from the rafting screws.

CONCLUSION

Flexion-valgus force-induced unicondylar tibial plateau depression fracture is a unique injury pattern. We suggest a novel surgical approach to address this injury's key features, which may facilitate exposure and enhance fixation strength.

Incidence and risk factors for surgical site infection following open reduction and internal fixation of adult tibial plateau fractures

PURPOSE

The aim of this study was to identify independent risk factors for surgical site infection (SSI) and quantify the incidence of SSI in tibial plateau fractures after open reduction and internal fixation (ORIF).

METHODS

This retrospective study was performed at a level 1 trauma centre from January 2015 to June 2016. Data of adult patients with tibial plateau fractures treated by ORIF were extracted from the electronic medical records. A total of 370 patients were collected. We reviewed the patients' demographics, characteristics of fracture, treatment-related variables, and indexes of laboratory examination. Multivariate logistic analysis models were performed respectively to determine independent predictors of SSI.

RESULTS

Twenty-one patients developed SSI in this study. The overall incidence of SSI after ORIF of tibial fracture was 5.7%, with six (1.6%) for deep infection and 15 (4.1%) for superficial SSI. Independent predictors of SSI identified by multivariate analysis were open fracture (odds ratio=4.53; 95% CI=1.64-15.26; p=0.000), intra-operative duration (odds ratio=2.72; 95% CI=1.17-6.29; p=0.020), and smoking (odds ratio=4.79; 95% CI=1.46-15.73; p=0.010).

CONCLUSIONS

The SSI incidence was high (5.7%) after surgical tibial plateau fractures by ORIF and open fracture, operative time, and smoking were identified as independent related risk factors. Therefore, we recommend that a smoking cessation program is introduced immediately at the time of admission to hospital. More reasonable management strategies on open injury should be utilized to reduce the SSI rate.

Reinforcement strategy for lateral rafting plate fixation in posterolateral column fractures of the tibial plateau: The magic screw technique

BACKGROUND

A posterolateral column fracture of the tibial plateau (PLCF) is not uncommon, especially lateral and bicondylar tibial plateau fractures. Currently, there is no consensus on the methods of surgical treatment for PLCF, including the surgical approach or the fixation strategy. Though various posterior approaches have been explored and can allow posterior buttress plate fixation, the necessity of a posterior approach with fixation for PLCFs is increasingly questioned. Meanwhile, there is no literature to analyse the morphological features of PLCFs. None of the available surgical techniques can solve all of the problems of PLCFs.

METHODS

From February 2016 to June 2016, an inconsecutive series of 16 patients who suffered Schatzker type II tibial plateau fractures involving the posterolateral column were selected based on an analysis of the morphological characteristics of PLCFs. The patients were all treated by lateral rafting plate fixation with magic screw implantation through the extended lateral approach.

RESULTS

According to PLCF morphology, 4 patients had mild slope-type depression fractures (MSDF) of the articular surface, and the other 12 patients had block-type splitting fractures (BSF). After a 12-month follow-up period, there were no complications related to the fixation technique and no significant changes in limb alignment. At the final follow-up, the average range of motion (ROM) of the affected knees was 2.3°-125°, and the average HSS score was 94.2.

CONCLUSIONS

The selected patients who suffered Schatzker type II fractures involving the posterolateral column could be successfully treated via lateral rafting plate fixation with the magic screw technique. For PLCF treatment, magic screw fixation is a valuable technique that may reduce the utilization of posterior approaches and posterior fixations.

Characteristics of postoperative weight bearing and management protocols for tibial plateau fractures: Findings from a scoping review

OBJECTIVE

To identify and describe the characteristics of existing practices for postoperative weight bearing and management of tibial plateau fractures (TPFs), identify gaps in the literature, and inform the design of future research.

METHODS

Seven electronic databases and clinical trial registers were searched from inception until November 17th 2016. Studies were included if they reported on the surgical management of TPFs, had a mean follow-up time of ≥1year and provided data on postoperative management protocols. Data were extracted and synthesized according to study demographics, patient characteristics and postoperative management (weight bearing regimes, immobilisation devices, exercises and complications).

RESULTS

124 studies were included involving 5156 patients with TPFs. The mean age across studies was 45.1 years (range 20.8-72; 60% male), with a mean follow-up of 34.9 months (range 12-264). The most frequent fracture types were AO/OTA classification 41-B3 (29.5%) and C3 (25%). The most commonly reported non-weight bearing time after surgery was 4-6 weeks (39% of studies), with a further 4-6 weeks of partial weight bearing (51% of studies), resulting in 9-12 weeks before full weight bearing status was recommended (55% of studies). Loading recommendations for initial weight bearing were most commonly toe-touch/<10kg (28%), 10kg-20kg (33%) and progressive (39%). Time to full weight bearing was positively correlated with the proportion of fractures of AO/OTA type C (r=0.465, p=0.029) and Schatzker type IV-VI (r=0.614, p<0.001). Similar rates of rigid (47%) and hinged braces were reported (58%), most frequently for 3-6 weeks (43% of studies). Complication rates averaged 2% of patients (range 0-26%) for abnormal varus/valgus and 1% (range 0-22%) for non-union or delayed union.

CONCLUSIONS

Postoperative rehabilitation for TPFs most commonly involves significant non-weight bearing time before full weight bearing is recommended at 9-12 weeks. Partial weight bearing protocols and brace use were varied. Type of rehabilitation may be an important factor influencing recovery, with future high quality prospective studies required to determine the impact of different protocols on clinical and radiological outcomes.

Complications in the management of closed high-energy proximal tibial plateau fractures

PURPOSE

To report complications in the management of complex closed proximal tibial fractures.

METHOD

A retrospective study was conducted to analyze the infectious and noninfectious complications encountered in the management of high-energy Schatzker type V and VI tibial plateau fractures. All patients were treated at the level 1 trauma centre between January 2011 and March 2014. Sixty two patients were included in the study. The mean patient age was (43.16 ± 11.59) years with 60 males and 2 females. Infectious complications like superficial and deep infection, wound dehiscence, malalignment in the immediate postoperative period and in follow-up period were noted.

RESULTS

The overall complication rate was 30.65% (19 out of 62). Infectious complications were noted in 20.97% cases (13/62). In majority of the cases (8/13), superficial infection was seen which managed with regular dressing and antibiotic administration. The patients (5/13) who had developed deep-seated infection were subjected to repeated debridements, flap coverage, implant removal or amputation depending upon the host response. Thirteen patients had experienced noninfectious complications. Hardware related complications were noticed in six patients and four among them received a secondary procedure. Malalignment was observed in seven patients but only single patient underwent subsequent operative intervention.

CONCLUSION

Proximal tibial plateau fractures especially Shatzker type V and VI are associated with extensive soft tissue damage even in closed injuries. The complications encountered in the management of these fractures can be minimized with appropriate patient selection and minimal soft tissue dissection.

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

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

The morphological features of different Schatzker types of tibial plateau fractures: a three-dimensional computed tomography study

BACKGROUND

Tibial plateau fractures are of great challenge to treat with open reduction and internal fixation, because fractures vary from simple to complex, with little or extensive articular involvement. Hence, recognition and comprehension of the fracture features will help orthopedic surgeons understand the injury mechanism better and manage these fractures by planning optimal surgical procedures. This study aimed to evaluate the morphological characteristics of tibial plateau fractures based on the Schatzker classification.

METHODS

A total of 186 patients with 188 tibial plateau fractures from 2010 to 2014 in our hospital were reviewed using a computed tomography scan and three-dimensional (3D) reconstruction. The main fracture line angles (FLA) of Schatzker types I, II, and IV were measured. For each fracture, depression depth was measured, and the depression zone was also located. Depression zones were overlapped to obtain a frequency diagram.

RESULTS

Schatzker type I and II fractures had three subtypes: single anterolateral fracture, single posterolateral fracture, and complex fracture (the anterolateral and posterolateral parts). Schatzker type IV fractures were also divided into three subtypes: single posteromedial fracture, single anteromedial fracture, and the whole medial fracture. For various Schatzker types and subtypes of fracture, fracture depression clustered and occurred at different locations of the tibial plateau. A significant difference was observed in the depression depth among the different Schatzker types (P < 0.01, Kruskal-Wallis test), especially between Schatzker type III and other types (Nemenyi test). There was no difference in the depression depth among the subtypes of Schatzker type II, whereas the difference was significant between the two subtypes of Schatzker type IV.

CONCLUSIONS

Schatzker type I, II, and IV fractures could be divided into three corresponding subtypes by FLA. Various Schatzker types of fractures differed in location and depth of depression. A proper operative approach should be made based on the morphological characteristics of individual types of tibial plateau fractures.

An extended anterolateral approach for posterolateral tibial plateau fractures

PURPOSE

The best approach for treating posterolateral tibial plateau fractures remains controversial. The clinical results of an extended anterolateral approach on such fractures are discussed in this study.

METHODS

Between 2010 and 2011, ten patients with posterolateral tibial plateau fracture were treated using an extended anterolateral approach with a proximal tibial locking compression plate. The epidemiological data, operation details, and clinical outcomes over 26.4 ± 2.3 months (range 24-30 months) of follow-up were prospectively collected and analyzed.

RESULTS

The average surgical duration was 91.5 ± 18.7 min (range 80-130 min). An anatomic reduction rate of 90 % (9/10) was observed although one patient with a lateral comminuted fracture and dislocation presented a 2-mm joint surface depression postoperatively. The average fracture healing time was 10.6 ± 1.8 weeks (range 8-14 weeks), with an average hospital for special surgery knee score of 95.3 ± 6.5 points (range 80-100 points), an average knee flexion of 119.8° ± 17.2° (range 95°-140°) and an average knee extension of 2.1° ± 2.1° (range 0°-6°). No complications were found.

CONCLUSIONS

The extended anterolateral approach with a proximal tibial compression plate offers direct and complete surgical exposure and may provide an effective method for the surgical treatment of posterolateral tibial plateau fractures.

LEVEL OF EVIDENCE

Therapeutic, Level IV.

Morphologic study of posterior articular depression in Schatzker IV fractures

The Schatzker classification of tibial plateau fractures is widely accepted. Type IV fractures are medial tibial plateau fractures that are either split off as a wedge fragment or depressed and comminuted. Posterior articular surface depression in Schatzker type IV tibial plateau fractures can be seen as a unique variant that increases the difficulty of reduction of the articular surface. Its morphologic characteristics have not been fully studied, and the incidence is sometimes underestimated. The goal of this study was to evaluate the morphologic characteristics of posterior articular depression in Schatzker type IV fractures based on computed tomography measurements. From January 2009 to December 2011, the medical records, including digital radiologic data, of all patients treated for tibial plateau fracture at the authors' institution were retrospectively analyzed. Articular surface depression deeper than 5 mm was the criterion for study inclusion. The depression depth, precise location of the articular depression center, surface area percentage, and distance of the fracture gap to the depression center were calculated. One hundred fifteen cases of Schatzker type IV fracture were retrieved, and a total of 47.83% (55 of 115) cases had posterior articular surface depression. The average depth of the depressed articular surface was 12.41 mm, the surface area percentage was 20.15% of the entire tibial plateau, and the gap distance from the medial direction was 41.40 mm, 2.8 times longer than that from the posterior direction, which was 14.91 mm. Posterior articular surface depression occurs in nearly half of Schatzker type IV fractures, and the posterior approach provides more direct access to the depression than the medial approach.

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

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

Postero-medial approach for complex tibial plateau injuries with a postero-medial or postero-lateral shear fragment

This study demonstrates the utility of a modified postero-medial surgical approach to the knee in treating a series of patients with complex tibial plateau injuries with associated postero-medial and postero-lateral shear fractures. Posterior coronal shear fractures are underappreciated and their clinical relevance has recently been characterised. Less-invasive surgery and indirect reduction techniques are inadequate for treating these coronal plane fractures. Our approach includes an inverted 'L'-shaped incision situated within the posterior flexor knee crease, followed by the retraction or incision of the medial head of the gastrocnemius tendon, while protecting the neurovascular structures. This provides a more extensile exposure, as far as the postero-lateral corner, than previously described. Our case series included eight females and eight males. The average age was 53 years. The majority of these injuries were sustained through high-energy trauma. All patients' fractures were classified as Schatzker grade 4, or above, with a postero-medial split depression. Eight patients had associated postero-lateral corner fractures. Two were open, two had vascular compromise and one had neurological injury. The average time to surgery was 6.4 days (range 0-12), operative time 142 min (range 76-300) and length of stay 17 days (range 7-46). A total of 11 patients were treated using the postero-medial approach alone and in five the treatment was combined with an antero-lateral approach. Two patients suffered a reduced range of movement requiring manipulation and physiotherapy, and three patients had a 5-degree fixed flexion deformity. Two patients developed superficial wound infections treated with antibiotics alone. Anatomical reduction and fracture union was achieved in 15 patients. These are complex fractures to treat, and our modified posterior approach allows direct reduction and optimal positioning of plates to act as buttress devices. It can be extended across the midline to the postero-lateral corner and also allows excellent exposure of the popliteal vessels should concurrent vascular repair be required.