Different patterns of tibial plateau fractures associated with hyperextension injuries of the knee with or without varus/valgus component

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).

Posterior Cruciate Ligament Avulsion with Posterior Tibial Rim Fracture: A Case Report

Introduction

Posterior cruciate ligament (PCL) avulsion fractures are the most common type of isolated PCL injuries. Avulsion from the tibia is more common than femoral attachment. They can present as isolated tibial avulsion or as a component of posterior tibial rim fractures. The size, geometry of the fragment, and associated ligamentous injury dictate the method of fixation.

Case Report

A 32-year-old patient presented with posterior rim tibial plateau fracture with PCL avulsion after a motor vehicle accident. We used Burke and Schaffer approach and fixed the ligamentous avulsion and rim fracture using high tensile sutures and knotless swivel lock anchors.

Conclusion

PCL avulsions can present either as an isolated injury or as a part of a complex injury involving the anterior or posterior tibial rim. These complex injuries occur due to the hyperextension mechanism which results in either anterior tibial plateau compression fracture or posterior rim avulsion injuries. The treatment of such injuries requires addressing both ligamentous and bony components. The size, geometry of the fragment, and associated ligamentous injury dictate the method of fixation. We described the fixation of both ligamentous and rim avulsion using sutures and knotless anchors.

Classification and morphology of hyperextension tibial plateau fracture

PURPOSE

This study was aimed at analyzing the incidence and characteristics of hyperextension tibial plateau fractures (HTPFs) by using a computed tomography (CT)-based "four-column and nine-segment" classification.

METHODS

In the coronal plane, HTPFs are divided into four types: pure hyperextension, hyperextension-varus, hyperextension-valgus, and hyperextension-bicondylar. Fractures in the sagittal plane were divided into three types: type 1, pure depression; type 2, cleavage extending to the posterior cortex with no displacement; and type 3, cleavage extending to the posterior cortex with a significant displacement. A retrospective analysis of CT images of the tibial plateau fractures from December 2007 to December 2021 was conducted. Fracture mapping was analyzed and drawn using the new classification system.

RESULTS

A total of 136 (10.9%, 136/1253) fractures fulfilled the radiographic criteria for HTPF pattern in 136 knees (53.5 ± 13.3 years). There were 11 knees with pure hyperextension fracture (8.1%), 23 with hyperextension-varus fracture (16.9%), 46 with hyperextension-valgus fracture (33.8%), and 56 with hyperextension-bicondylar fracture (41.2%) in the coronal plane. Furthermore, there were 64 (47.1%), 47 (34.6%), and 25 (18.4%) cases of type 1, type 2, and type 3 fractures, respectively, in the sagittal plane. In the three-dimensional heat map, the fracture lines were mainly located at the anterior rim of the tibial plateau, while the posterior articular surface was rarely involved.

CONCLUSIONS

The main manifestations of HTPF are anterior compression and posterior avulsion injury. The CT-based four-column and nine-segment classification system could be used to categorize the injury characteristics of HTPF in the coronal and sagittal planes.