Posterolateral Tibial Plateau Fractures Research Articles

Treatment of Isolated Posterolateral Tibial Plateau Fracture with a Horizontal Belt Plate through the Anterolateral Supra-Fibular-Head Approach.

The posterolateral tibial plateau fracture was not easy to be exposed and fixed with usual techniques. The aim of this study was to investigate the biomechanical stability and clinical outcome of the isolated posterolateral tibial plateau fracture fixed with a single horizontal belt plate through the anterolateral supra-fibular-head approach. Fracture models were created by 18 synthetic tibias and fixed with three different fixation modes. Each group was fixed and tested on the loading machine, and final vertical displacement of the fragment was detected and calculated. Clinically, a retrospective analysis of 12 cases of posterolateral tibial plateau fracture from January 2013 to December 2017 was performed. There were 8 males and 4 females, aged 33-72 years, with an average age of 49.6 years. Isolated posterolateral tibial plateau fractures were identified according to preoperative X-ray and computed tomography scan. Through the modified anterolateral supra-fibular-head approach, the fracture was reduced and fixed by a prebending T-shaped distal radius plate and rafting screws, with bone substitute grafting or autogenous iliac bone implantation. Patients were followed up to a minimum one year of time period, and the outcome was evaluated clinically and radiologically. The biomechanical study shows that horizontal belt plate fixation for the isolated PL tibial plateau fracture can provide sufficient stability, allowing early knee functional exercise and partial weight bearing. For clinical case series, the average operation time in this group was 73.3 ± 10.2 mins (range: 55-90), and the average duration of hospitalization was 9.1 ± 3.3 days (range: 5-16). Patients were followed up for 12-24 months with an average of 16.5 months, and all patients achieved radiological fracture union after an average of 13.7 weeks. At one year after operation, the average knee score of the Hospital for Special Surgery (HSS) scale was 93.2 ± 4.2 points(range: 90-98), the average score of SMFA was 21.1 ± 5.6 points (range: 14-31), and the average knee range of motion (ROM) was 121.48° ± 8.88° (range: 105°-135°). There were 8 cases that were very satisfied and 3 cases that were satisfied with the operation. For an isolated posterolateral tibial plateau fracture, the supra-fibular-head approach can fully expose the fracture site; the horizontal belt plate fixation of the fracture is stable and reliable to allow for early-stage knee rehabilitation, and the outcome of medium-term clinical follow-up was satisfactory.

Posterolateral Fractures of the Tibial Plateau Revisited: A Simplified Treatment Algorithm.

High-energy fractures of the proximal tibia with extensive fragmentation of the posterolateral (PL) quadrant of the tibial plateau are challenging to manage. Herein, we present a review of the literature on the patterns and options of approach and fixation of the PL fragment of the tibial plateau to optimize the treatment of this specific injury pattern. We searched PubMed (1980-May 2020) to identify and summarize the most relevant articles evaluating both the morphology and treatment recommendations, including the choice of approach and fixation strategy, for the PL tibial plateau fracture. We found PL fragment can present in several patterns as a pure split, split depression, contained pure depression, and noncontained depression (rim crush), which are mostly determined by the position of the knee and the force magnitude applied during the course of the accident. Based on previous concepts described by Schatzker and Kfuri, we suggest a simplified treatment algorithm highlighting the two concepts (buttressing and containment) used for plating the PL tibial plateau fragments. Based on the available current evidence, we propose an algorithm for these two morphological types of PL tibial plateau fracture. Shear-type fractures need buttressing (the "rule of thumb"), whereas noncontained peripheral rim-type fractures need peripheral repair and containment. Contained pure depression fractures are not frequent and need percutaneous-assisted elevation and subchondral rafting, either controlled by fluoroscopy or arthroscopically. It is believed that such an approach would simplify their assessment and preoperative planning and would assist the clinicians to appreciate and manage more consistently these complex injuries.

Staple arthroscopic fixation of tibial ACL avulsion with concomitant lobenhoffer approach for a posterolateral tibial plateau fracture

Staple arthroscopic fixation of tibial ACL avulsion with concomitant lobenhoffer approach for a posterolateral tibial plateau fracture

Clinical results after surgical treatment of posterolateral tibial plateau fractures ("apple bite fracture") in combination with ACL injuries.

The anterior cruciate ligament (ACL)-tear is a common injury in orthopaedic trauma. Depending on the energy of impact fractures of the posterolateral tibial plateau are often associated. Different morphologic variants of posterolateral tibial plateau impaction fractures have been described in the setting of an ACL-tear. Up to now an algorithm of treatment for a combined injury of a posterolateral tibial head fracture and an injury to the anterior cruciate ligament is missing. We present a retrospective study with clinical and radiological analysis of posterolateral fractures in combination with ACL-tear. Impressions with a depth of more than 2mm and/or a width that outreaches more than half of the posterior horn of the lateral meniscus with additional 3. degree positive pivot-shift-test indicated surgical treatment of the fracture with additional ACL repair or reconstruction. Clinical evaluation included follow-up examination, Visual Analog Scale (VAS), International Knee Documentation Committee Score (IKDC), functional and radiological Rasmussen score. 20 patients were included with a mean age of 43.6 ± 12.4 years. Mean follow-up was 18,2 ± 13,5months. The fracture was arthroscopically reduced and percutaneously fixed with a screw osteosynthesis (Group 1), reduced via a dorsal approach without (Group 2) or with an autologous bone graft (Group 3). Subjective IKDC score was 79,15 ± 6,07. Functional Rasmussen scores ranged from 27 to 30 (mean 28 ± 2.71). Radiological Rasmussen scores ranged from 16 to 18 points (mean 16.75 ± 1.33). According to IKDC score (p = 0.60), functional Rasmussen score (p = 0.829) and radiological Rasmussen score (p = 0.679) no significant discrepancy between the groups were seen. There was no failure of the ACL graft recorded. Posterolateral tibial plateau fractures in combination with an ACL-tear, can cause persistent instability and increase rotational instability. Indication for treatment of these fractures is still under debate. From the biomechanical aspect the lack of more than 50% of the posterior horn of the lateral meniscus and dislocation/depression of more than 2mm results in an increased rotational instability of the ACL deficient knee. Combined surgical treatment with ACL repair or reconstruction is a safe procedure that results in good, short-term clinical outcome, if our algorithm is followed. In addition this study shows, that majority of posterolateral tibial plateau fractures can be treated arthroscopically.

A novel arthroscopically assisted reduction technique for three patterns of posterolateral tibial plateau fractures

BackgroundPosterolateral tibial plateau fractures (PTPF) remain a challenge for orthopedics surgeons because the special anatomical structures of the posterolateral corner of knee joint including the fibular head, the lateral collateral ligament, and the peroneal nerve, which impedes the exposure of the fracture fragments and need irregular implants to get a stable fixation. The purpose of present study was to introduce a new articular fracture fragments restoration technique for three patterns of PTPF and investigate the relationship between associated soft injuries and fracture patterns.MethodsFrom May 2016 to April 2018, 31 patients with PTPF who had undertaken arthroscopically assisted reduction and fixation (AARF) were enrolled in present study. Demographic data, pre-operation, and post-operation X plan films, three-dimensional computed tomography (CT) scans and magnetic resonance imaging (MRI) were reviewed. Present samples were divided into three patterns with lateral inclination (LI), posterior inclination (PI), and parallel compression (PC) according to the orientation of the articular fragment inclination. Rasmussen anatomical score was used to assess the radiological results. Rasmussen functional score, Hospital for Special Surgery knee-rating Score (HSS), and range of motion (ROM) of the knee joint at the final follow-up were measured to evaluate the clinical outcomes.ResultsIn this series, the post-operation tibial plateau angle (TPA) was 9.7° ± 3.5°(range 4.0°–15.8°) and the Rasmussen anatomical score was 17.7 ± 0.7(range 16–18); clinical outcomes showed that the HSS score was 92.7 ± 21.8 (range 90–96) and the Rasmussen functional score was 27.9 ± 1.0 (range 26–30). Of all the patients, the anterior cruciate ligament (ACL) injuries including the ACL tibial attachment ruptures occurred in 16 patients (51.6%), meniscus lesions happened in 19 patients (61.3%), medial collateral ligament (MCL) injuries were founded in 13 patients (41.9%). The number of ACL injuries including the ACL tibial attachment ruptures in the PI fracture pattern (12 cases) is significantly higher than LI (2 cases) and PC (2 cases) fracture pattern (p < 0.05).ConclusionProfound understanding the different patterns of PTPF and using our reduction technique will facilitate to restore the main articular fracture fragments. The PI fracture patterns have a significant high incidence of the ACL ruptures.Level of evidenceTherapeutic study, Level IV.

Biomechanical analysis of “Barrel hoop plate” technique for the posterolateral fragments of tibial plateau fractures with different displacement tendency

ObjectivesThe purpose of our study is to evaluate the three-dimensional biomechanical properties of “Barrel Hoop plate” in two kinds of artificial posterolateral tibial plateau fracture fragment (PLF) by using of synthetic models, each of which has an initial amplifying displacement tendency. Material and methodsThirty-six tibiae models were randomly assigned into two groups with different displacement tendencies: posterior displacement (PD) and lateral displacement (LD). Each model was then fixed with three patterns: Anterolateral plate (AP), Posterolateral plate (PP), and “Barrel Hoop plate” (BHP). Displacement in three axes of vertical, sagittal and horizontal axis was captured by Optotrak Certus motion analysis system. Bluehill 2 software was used for load control and data collection. ResultsIn Model-PD, when the load was over 1000 N, the posterior displacement of Group-PP and Group-BHP were less than Group-AP (P<0.01). The inferior displacement in the vertical axis of Group-PP was larger than both Group-AP and Group-BHP in all the loading set (P<0.01).In Model-LD, both of the lateral displacement in Group-AP and Group-BHP was less than that of Group-PP when the load was over 1000 N (P<0.01). The inferior displacement of Group-AP was less than that of Group-PP in the load of 1500 N (P<0.01). Both of the posterior displacement of Group-AP and Group-BHP was less than that of Group-PP when the loading was 1500 N (P<0.01). The stiffness of Group PP was less than that of Group AP (P<0.01). ConclusionsThe results demonstrated that the 2.7 mm “Barrel Hoop plate” had a greater capacity of anti-three-dimension axes displacement of PLF. The 3.5 mm Anterolateral plate had the advantage in anti-lateral displacement and anti-inferior displacement but was weak at anti-posterior displacement of PLF. The 2.7 mm Posterolateral plate was stronger in anti-posterior, however, weak in anti-inferior displacement capacity.

Effects of surgical approaches and morphological characteristics on the follow up outcomes of patients with posterolateral tibial plateau fractures.

This study aimed to study the effects of surgical approaches and identify the morphological characteristics associated with the 1-year follow-up outcome of patients with posterolateral tibial plateau fractures after successful surgery.We followed 200 postoperative patients for 1 year. The modified Hospital for Special Knee Surgery score (HSS score) was used to evaluate the functional recovery of the knee. We supposed 4 morphological characteristics in CT images acting as possible risk factors, including the anteroposterior diameters of posterolateral broken bone fragments (fragment-diameter), the damage to the posterolateral cortex of the tibial head (cortex-damage), the combinational fracture of the proximal fibula (fibula-fracture) or fracture of the medial tibial condyle (medial-condyle-fracture). Multivariate regression models were used to analyze the effect of these factors on the HSS score after adjusting the 2 surgical approaches and other confounders.The average HSS score was 85.1 ± 5.8 for all the patients. We treated 155 patients with the anterolateral approach and 45 patients with the posterolateral approach. The surgical approach, fragment-diameter, fibula-fracture, and medial-condyle-fracture were correlated with the HSS scores (P < .05). After adjusting for the above factors, the Schatzker type, age and gender, compared with anterolateral approach, the posterolateral approach could improve the HSS scores by an average of 3.7 points. The fragment-diameter <20 mm and posterolateral approach interacted on the HSS scores. Comparing posterolateral and anterolateral approaches, we found that the HSS scores of patients with fragment-diameter <20 mm increased by 6.1 points (95% CI: 4.1–8.2) in the posterolateral approach, while those with fragment-diameter ≥20 mm did not significantly improve the HSS scores.The surgical approach, fragment-diameter, fibula-fracture, and medial-condyle-fracture were independent risk factors associated with the follow-up outcome of patients with posterolateral tibial plateau fractures after successful surgery. The posterolateral approach could significantly improve the HSS score in the studied hospital.

Incidence of Displaced Posterolateral Tibial Plateau and Lateral Femoral Condyle Impaction Fractures in the Setting of Primary Anterior Cruciate Ligament Tear

Background: Bone bruising of the posterolateral tibial plateau and the lateral femoral condyle sulcus terminalis has a well-established association with anterior cruciate ligament (ACL) tears. Impaction fractures of the femur and tibia may occur in these locations; however, there is a paucity of literature describing these fractures. Purpose: The primary objective was to quantify the incidence, size, and location of impaction fractures of the posterolateral tibial plateau and lateral femoral condyle in patients with primary ACL tears. The secondary objective was to investigate the association between impaction fractures and concomitant meniscal and ligamentous injuries. Study Design: Case series; Level of evidence 4. Methods: Patients with available magnetic resonance imaging (MRI) scans who were treated for primary ACL tear by a single surgeon were identified. MRI scans were reviewed with denotation of posterolateral tibial and femoral condylar contusions and displaced impaction fractures. Measurements of the lateral tibial plateau were taken in all patients with displaced lateral tibial plateau fractures and in a subset of control patients without tibial plateau fracture present to characterize the size and location of the bony lesion. Associations of impaction fractures with concomitant meniscal or ligamentous injuries were evaluated through use of chi-square testing. Results: There were 825 knees identified with available MRI scans. Lateral tibial plateau bone bruising was present in 634 knees (76.8%), and lateral femoral condyle bone bruising was present in 407 knees (49.3%). Posterolateral tibial plateau impaction fractures were present in 407 knees (49.3%), and lateral femoral condylar impaction fractures were present in 214 knees (25.9%). Patients with posterolateral tibial plateau impaction fractures were older than patients without these fractures (42.6 vs 32.7 years; P < .001), whereas patients with lateral femoral condylar impaction fractures were younger (23.8 vs 32.7 years; P < .001). There were 71 knees (8.6%) with a posterolateral tibial plateau impaction fracture with greater than 10% loss of lateral tibial plateau depth, and this group had an increased incidence of lateral meniscus posterior root tears (22.1% vs 12.0%; P = .02). Conclusion: Posterolateral tibial plateau impaction fractures occurred with a high incidence (49.3%) in patients with primary ACL tears and demonstrated an increased association with lateral meniscus posterior horn root tears as their size increased. Lateral femoral condylar impaction fractures occurred in 25.9% of patients with primary ACL tears and entailed an increased incidence of lateral meniscal tears and medial meniscal ramp lesions.

A Novel Method of the Treatment for Posterolateral Tibial Plateau Fractures.

Reduction and fixation of posterolateral tibial plateau fracture via a posterolateral approach is challenging, and the posterolateral approach itself may injure the posterolateral ligament complex of the knee and can result in knee instability. We developed a new curved support plate (CSP) that can pass, via traditional anterolateral approach, through the superior tibiofibular interval and effectively support the posterolateral fragments. The purpose of our study was to determine the biomechanical reliability of the new plate and report the preliminary efficacy of the CSP for posterolateral tibial plateau fracture. In the biomechanical experiment, 40 synthetic tibias were used to create posterolateral shearing tibial fracture models, which were randomly assigned to groups A to D. Vertical displacement of the posterolateral fragments was measured under axial loads of 500 to 1,500 N. The new plate and 3.5-mm lateral locking plate exhibited similar control over fragment displacement. From June 2016 to August 2017, eight patients with posterolateral tibial plateau fracture underwent treatment with the CSP. Hospital for Special Surgery (HSS) knee score, knee flexion and extension ranges of motion, and complications were recorded to evaluate treatment effects. Eight patients (five men and three women, mean age 44 years [range, 23-66 years]) were enrolled in the study. Mean follow-up time was 13 months (range, 7-19 months). All patients achieved radiographic bone union by 3.3 months (range, 3-4 months) postoperatively. There were no complications of neurovascular injury, deep vein thrombosis, infection, and implant loosening throughout the follow-up period. At final follow-up, mean HSS score was 92.6 (88-96), with a mean knee flexion of 131.25 degrees (120-135 degrees) and a mean knee extension of 1 degree (0-5 degrees). Fixation of posterolateral tibial plateau fracture was easily and successfully achieved using our newly designed CSP, which may provide a new choice for posterolateral tibial plateau fractures.

Advances in selection of surgical approach and internal fixation for posterolateral tibial plateau fractures

There haven't been an uniform criterion for the treatment of posterolateral tibial plateau fracture till now. For this type of fractures, surgical approaches are divided into two main parts, non-osteotomy approach and osteotomy approach. The non-osteotomy approach includes posterolateral approach, anterolateral approach, lateral approach, posteromedial approach and posterior approach. Each of them includes advantage and disadvantage. Posterolateral approach is the most effective exposure of posterolateral tibial plateau fracture. Satisfactory reduction and buttress fixation could be achieved under direct view. Posterolateral tibial plateau fracture could also be exposed from the gap between fibular head and posterolateral tibial plateau via anterolateral approach, but the raft plate should be placed backwardly to achieve the best fixation result. With a single lateral incision of the tibial plateau, the anterolateral and posterolateral plateau fragments could be fixed simultaneously through the anterolateral and posterolateral interval of the deep tissue. The anatomy of the posteromedial approach is simpler, however, it's difficult to view all the comminuted fragments of the posterolateral tibial plateau. The injury risk of popliteal blood vessels and nerves is relatively high, therefore it's rarely used right now. The osteotomy approach includes fibular head, lateral femoral epicondyle and tibial Gerdy tuberosity osteotomy. The osteotomy approaches of lateral femoral epicondyle and tibial Gerdy tuberosity are usually used in the cases associated with the anterolateral approach of the knee. The best view of the posterolateral tibial plateau could be obtained via the fibular head osteotomy approach. But the extra damage is too severe to recommend routinely. On the other hand, there are several fixation options when posterolateral tibial plateau fractures are treated. The buttress plate was verified to be the best fixation method and the rim plating provided a novel idea for this fracture pattern. The fibular support is a reliable method for posterolateral compression fracture as well. We will summarize the selection of surgical approaches and internal fixation methods to provide a reference for the clinical doctors. Key words: Tibial plateau; Posterolateral; Surgical approach; Osteotomy; Fracture fixation, internal

Lateral osteotomy via the supra-fibular-head approach combined with lateral locking plating for simple posterolateral tibial plateau fracture

Objective To explore the clinical efficacy of lateral osteotomy via the supra-fibular-head approach combined with lateral locking plating for simple posterolateral tibial plateau fractures. Methods From January 2014 to February 2017, 11 patients with simple posterolateral tibial plateau fracture were treated at Department of Orthopaedics, General Hospital of Middle Military Command of PLA. They were 8 males and 3 females, aged from 21 to 55 years (average 41.8 years). In all of them the supra-fibular-head approach was used for lateral osteotomy according to the size and orientation of the fracture block. After the fracture was reset, a full bone graft was implanted under direct visualization, followed by fixation of the posterolateral bone mass with a lateral locking plate which was placed as far as possible above the fibular head. The patients were encouraged 6 weeks after surgery to do knee functional exercise within 90°. The therapeutic efficacy was evaluated at the final follow-up according to the Rasmussen’s criteria for knee functions. Results The average operative time was 74 minutes (from 55 to 90 minutes); the average intraoperative blood loss was 70 mL (from 40 to 120 mL). All the patients were followed up for 12 to 35 months (average, 17.5 months). No neurovascular injury or incision infection was observed. Bony union was achieved in all patients after 10 to 15 weeks (average, 12.5 weeks). Follow-ups found no implant loosening/breakage, genu valgum, genu varum, fracture redisplacement, or knee instability. According to the Rasmussen’s function evaluation of the knee joint, 10 cases were rated as excellent and one as good. Conclusion Lateral osteotomy via the supra-fibular-head approach combined with lateral locking plating is a preferred treatment for simple posterolateral tibial plateau fractures. Key words: Knee joint; Fracture fixation, internal; Osteotomy; Posterolateral tibial plateau fracture; Surgical approach

VIS-IT: Visualizing the Injured Tibia-A Cadaveric Study of Limb Positioning for Posterolateral Tibial Plateau Fracture Visualization.

Posterolateral tibial plateau (PLTP) fractures are often associated with anterior cruciate ligament (ACL) incompetence, such as tibial eminence fractures. Both occur from a pivot shift like mechanism. Malreductions of the tibial plateau most frequently occur in the posterolateral quadrant. Acquiring adequate intraoperative visualization of the PLTP poses a challenge. We hypothesized that visualization of PLTP could be improved by positioning the knee at 110 degrees of flexion with the addition of a varus anterolateral rotatory vector. This position and maneuver take advantage of both the nonisometric nature of the lateral soft tissues and, when present, ACL incompetence. In this cadaveric study, we digitally quantified the percentage of the lateral tibial plateau visualized under different conditions after performing an anterolateral surgical approach with submeniscal arthrotomy. Four conditions were assessed for articular visualization: (1) 30 degrees of knee flexion, (2) 110 degrees of knee flexion, (3) 110-degrees of knee flexion plus varus anterolateral rotatory vector, (4) 110-degrees of knee flexion plus varus anterolateral rotatory vector with ACL sacrifice (ACL incompetence model). In the ACL competent models, maximal lateral tibial plateau exposure was obtained with the knee positioned at 110 degrees of flexion with a varus anterolateral rotatory vector (58.2%, range: 52.9-63.4%). Articular visualization was further improved with the ACL incompetent model (82.4%, range: 77.1-87.7%), modeling a tibial eminence fracture.

A Novel Design of a Plate for Posterolateral Tibial Plateau Fractures Based on Computed Tomography Mapping of the Proximal Tibiofibular Joint.

BackgroundWe designed a novel plate for the treatment of posterolateral tibial plateau fractures. We first gathered radiological data of the proximal tibiofibular joint to verify the feasibility of the novel plate and provide an anatomical basis.Material/MethodsTomographic images of 98 healthy human tibias were obtained retrospectively. The width of the lateral tibial plateau, width of the posterolateral tibial plateau to the sagittal plane of the tibial plateau and width of the proximal tibiofibular joint to the sagittal plane of tibial plateau were measured. The proximal posterolateral tibial bone cortex angle and posterolateral slope-diaphysis angle were also calculated. Paired sample t-test was used for comparing men and women, and left and right sides. We used 2 variables for Pearson correlation analysis between the width of the lateral tibial plateau and other length indices.ResultsThere were no statistically significant differences between left and right knees (P>0.05). However, there were statistically significant differences of the 3 length indices between men and women (P<0.05). The length indices were all correlated to the width of the lateral tibial plateau (P<0.01).ConclusionsThis study of the lateral tibial plateau has a high accuracy in anatomical measurement, and our novel plate design is feasible based on the data. The study provided anatomical basis for the novel plate.

Comparison of extended anterolateral approach in treatment of simple/complex tibial plateau fracture with posterolateral tibial plateau fracture

BackgroundOur hospital has recently used the extended anterolateral approach in posterolateral tibial plateau fracture. We compared the clinical effects of this method in Schatzker type II or type V/VI fractures with posterolateral tibial plateau fracture based on our patients.MethodsThe patients from January 2013 to December 2015 were summarized, and some of them were assisted with arthroscopy. According to Schatzker classification, patients with Schatzker type II fracture were divided into group A; patients with Schatzker type V/VI fracture were divided into group B. The fracture characteristics, operation statistics, and postoperative functional evaluation of each group were compared.ResultsA total of 46 patients were included in the study and were followed up for 23–45 months. There were 24 cases in group A and 22 cases in group B. The operation time and the amount of bleeding were significantly less in group A (P < 0.05). Twelve cases were assisted with arthroscopy including 6 patients in each group. The fracture healing time made no significant difference in the two groups (P > 0.05). All patients experienced no significant influence on daily life. The knee Rasmussen score was 26.8 in group A and 23.5 in group B (P > 0.05), and the knee range motion was 115.5° in group A and 106.6° in group B (P > 0.05). The excellent and good rate of reduction was 91.7% in group A and 81.8% in group B (P > 0.05), but the excellent rate of reduction was 83.3% in group A and 27.3% in group B (P < 0.05). The unfixed rate of posterolateral fracture was 16.7% in group A and 36.4% in group B (P > 0.05). One patient in group B suffered postoperative wound infection.ConclusionsThe extended anterolateral approach could obtain similar satisfactory clinical results in simple/complex tibial plateau fracture with posterolateral tibial plateau fracture. It seemed that easier operation, better posterolateral fracture reduction, and fixation occurred in relative simple fracture from our cases.Trial registrationIt was a retrospective study. This study was consistent with the ethical standards of the Second Affiliated Hospital of Zhejiang University Medical College and was approved by the hospital ethics committee and the trial registration number of our hospital was 20170053.

A Novel Design of a Plate for Posterolateral Tibial Plateau Fractures Through Traditional Anterolateral Approach

Biomechanical performance of a newly designed plate for treating posterolateral tibial plateau fractures was compared with three traditional internal fixation devices using finite element analysis (FEA) and biomechanical experiments. Forty synthetic tibias were used to create posterolateral shearing tibial fracture models, which were randomly assigned to groups A–D. The fragments were fixed with two 6.5-mm lag screws (group A), the newly designed plate (group B), a 3.5-mm lateral locking plate (group C), and a posterolateral buttress plate (group D). In the biomechanical experiment, vertical displacement of the posterolateral fragments was measured under axial loads of 500–1500 N. In the FEA, vertical displacement of the posterolateral fragments and stress distribution and maximum stress of each internal fixation were measured under axial loads of 250–750 N. Biomechanically, collective ranges of vertical displacements in the four groups were 0.356 ± 0.089–1.055 ± 0.023 mm at 500 N axial load, 0.651 ± 0.062–1.525 ± 0.03 mm at 1000 N, and 0.903 ± 0.077–1.796 ± 0.04 mm at 1500 N. Differences between the four groups were statistically significant (P < 0.05), except for groups B and C at 1500 N. FEA showed that collective ranges of vertical displacements in the four groups were 0.290–1.425 mm at of 250 N axial load, 0.580–1.680 mm at 500 N, 1.067–1.818 mm at 750 N. Maximum stress of groups A–D were, respectively, 321.940, 132.660, 100.383, and 321.940 MPa under 250 N axial load. Maximum stress of all four internal fixations increased, and the overall trends at 500 and 750 N were consistent with that at 250 N. Posterior, straight fixation was the most reliable. Fixation with the lag screw was least reliable. The new plate and 3.5-mm lateral locking plate exhibited similar control over fragment displacement. The newly designed plate was stable and reliable, indicating its suitability for clinical application.

Extended anterolateral approach for thetreatment of tibial plateau fractures with posterolateral bone fragment

Objective To investigate the differences and clinical effects of extended anterolateral approach in the treatment of simple/complex tibial plateau fractures with posterolateral bone fragment. Methods From January 2013 to December 2015, forty-six patients with posterolateral tibial plateau fractures treated in our hospital were included in our research. The posterolateral plateau fractures were reduced and fixed by the extended anterolateral approach. According to Schatzker fracture classification, patients with type II fractures were treated as simple group and patients with type V and type VI fractures were treated as complex group. According to tibial plateau three column classification, patients were divided into single column group, double column group and three column group. The operative time, bleeding volume, fracture healing time, postoperative Rasmussen score, knee mobility, reduction and fixation of fractures and postoperative complications were compared among the groups. Results All 46 patients were followed up for 23-45 months, with an average of 31.9 months. There were 24 cases in simple fracture group and 22 cases in complex fracture group. The mean operation time of simple group was 124±33.8 min, and that of complex group was 175±65.5 min, with significant difference (t=2.302, P=0.025); the mean bleeding volume of simple group was 118±93.5 ml, and that of complex group was 190±149.4 ml, with significant difference (t=1.905, P=0.028). 12 cases were treated with arthroscopy. Bone union was achieved in all patients at the last follow-up, and daily activities were not limited. The average healing time was4.58 months in simple group and 5.54 months in complex group. The excellent rate of fracture reduction was 83.3% in simple group and 27.3% in complex group (χ2=14.679, P=0.000). Posterolateral bone fragment was not completely fixed in 4 cases (16.7%) in simple group and 8 cases (36.4%) in complex group. The average Rasmussen function score was 26.8±2.1 and the range of motion of knee joint was 100°-120° (average 115.5°±6.2°) in simple group; The average Rasmussen function score was 23.5±3.4 points and the range of motion of knee joint was 95°-115° (average 106.3°±7.4°) in complex group, neither with no significant differences. According to the three-column fracture classification system, there were 6 cases in the single-column group, 24 cases in the double-column group and 16 cases in the three-column group. There were significant differences in the operative time (F=5.039, P=0.000), bleeding volume (F=5.215, P=0.000) and the excellent rate of fracture reduction (χ2=7.003, P=0.030) between these three groups. But there was no significant difference in the time of fracture healing, un-fixation rate of posterolateral bone fragment, knee joint Rasmussen score and knee jointactivity. The excellent rate of fracture reduction was 83.3% in arthroscopy assisted cases and 47.1% in arthroscopy un-assisted cases respectively (χ2=4.749, P=0.002). Postoperative wound infection occurred in 1 patient. Conclusion Extended anterolateral approach could provide good reduction and fixation of tibial plateau fractures with posterolateral bone fragment with satisfactory clinical outcomes obtained in both simple and complex fractures. The operation was relatively simple and posterolateral bone fracture could get better reduction and fixation in simple tibial plateau fractures, and arthroscopy treatment was helpful to improve fracture reduction. Key words: Tibial fractures; Arthroscopy; Comparative study; Fracture fixation, internal

Arthroscopic-assisted inflatable bone tamp reduction for treatment of posterolateral tibial plateau fractures

AimOur study aimed to assess the safety and efficacy of an innovative arthroscopic-assisted inflatable tamp reduction technique for the treatment of posterolateral tibial plateau fractures. Patients and methodsTwenty-six patients with posterolateral tibial plateau fractures were treated with arthroscopy through inflation reduction technique were enrolled. Arthroscopy was used to observe the reduction of articular surface to avoid over-reduction or de-reduction. An arthroscopic assessment of anatomic joint reduction completed the procedure. Inflatable bone tamp was used to reduce the fractures and calcium phosphate cement was used as bone substitute to augment the repairs. ResultsUnder arthroscopy, the reduction was observed to be excellent without any residual deformity in all the cases. Cement overflow into the soft tissues or the knee joint was not observed. During the follow-up period, no obvious articular surface subsidence (>5 mm) was observed and no evidence of posttraumatic osteoarthritis could be detected. Radiographs under full weight bearing revealed neither loss of reduction nor any valgus deviation. Three months after surgery, the graft was almost completely replaced by new bone. The functional evaluation following the Rasmussen score yielded excellent results. ConclusionsThis study provided a novel technique for the reduction of depressed and split-depressed pasterolateral tibial plateau fractures. Arthroscopic-assisted inflatable bone tamp reduction is an effective method for the treatment of posterolateral tibial plateau fractures.

A new anatomic locking plate for the treatment of posterolateral tibial plateau fractures

BackgroundPosterolateral tibial plateau fractures have become more common, and their treatment is of great importance to knee function. Additionally, there is no available literature detailing specialized anatomic locking plate for tibial plateau fractures. Therefore, the aim of the study was to evaluate the safety and clinical efficacy of an innovative anatomic locking plate for treatment of posterolateral tibial plateau fractures.MethodsBetween March 2014 and January 2016, 12 patients with posterolateral tibial plateau fracture underwent surgery with the anatomic locking plate for the posterolateral tibial plateau via the posterolateral approach. Relevant operational data for clinical evaluation were collected.ResultsThe mean follow-up time was 26 months, and the mean age was 35 years for 12 patients. The mean interval between the time of injury and the surgery was 6.1 days. Radiological fracture union was evident in all patients at 12 weeks. During surgery, the blood loss ranged from 100 to 300 mL, and the duration ranged from 55 to 90 min. The Tegner–Lysholm functional score ranged from 85 to 97 at the final follow-up. Moreover, the final Rasmussen functional score ranged from 25 to 29, and Rasmussen anatomical score ranged from 13 to 18.ConclusionsThe newly designed anatomic locking plate for the posterolateral tibial plateau provided adequate fixation along the posterolateral tibial plateau. It proved to be safe and effective in a small-sample-size population (12 patients) during a 12- to 34-month follow-up.

Posterolateral tibial plateau fractures, how to buttress? Reversed L posteromedial or the posterolateral approach: a comparative cadaveric study.

The selection of a surgical approach for buttressing posterolateral tibial plateau fractures is controversial. This study compared the surgical exposure area between the reversed L posteromedial approach (R-PM) and the posterolateral (PL) approach using the lateral plateau width as a metric. Twenty lower extremities from fresh frozen cadavers were included. The R-PM approach was used first and the boundary of the posterior tibial cortex exposure was marked with metal pins. With the same specimens, the PL approach was then performed and the exposure area was marked. After removing all soft tissue, an imaginary line was drawn from the lateral plateau rim anterior to the fibular head (L) to the posteromedial ridge of the tibia (M). Additional metal pins were used to indicate bony reference landmarks at the joint line on the posterior tibial plateau, including the lateral tibial spine (S), the lateral boundary with the PM approach (LPM) and the lateral boundary with the PL approach (LPL). All distances were measured using S as the reference point. The average distance from S to L, referred to as the lateral plateau width (A), was 32.62mm. The average distances from S to LPM (B) and from S to LPL measured as a percentage of A were 43.72 and 81.41%, respectively. The average R-PM approach blind distance from LPM to LPL (C) as a percentage of the lateral plateau width was 58.45%, while the distance LPL to L (D), which represents the invisible blind distance with both approaches, was 15.37% of that width. The PL approach provides better access for buttressing the posterolateral tibial plateau fracture than the R-PM approach. With the R-PM approach, the blind area on the lateral plateau which can be accessed only by the PL approach starts approximately at 43.72% and ends at 81.41% of the lateral tibial plateau width. When a fracture is located in this zone, the posterolateral approach is recommended.

Analysis of the treatment of posterolateral tibial plateau fracture with three different methods

To analyze and compare the efficacy of surgical approaches and fixations of anterolateral approach, lateral approach and posterolateral approach in treating posterolateral tibial plateau fracture. A retrospective study of 44 cases from May 2010 to July 2014 were enrolled, of which there were 21 males and 23 females, and the mean age was 42.5 years old (ranged, 26 to 61 years). All the cases were divided into 3 groups according to the surgical approach, group A was anterolateral approach (19 cases), group B was lateral approach (15 cases), group C was posterolateral approach (10 cases). Operative time and bleeding volum were compared and the knee function was observed. The mean operative time of group A was (91.3±10.4) min, and the bleeding volum of which was (175.3±20.3) ml. The mean operative time of group B was(86.6±9.2) min, and the bleeding volum of which was(155.8±18.2) ml. The mean operative time of group C was (109.5±10.8) min, and the bleeding volum of which was(235.9±29.1) ml. There were significant differences in operative time and bleeding volum between group C and the other two groups(P<0.05). The mean follow-up time was 14.9 months (ranged, 10 to 35 months), and the HSS score of last follow-up was 89.6±7.5 (group A), 90.2±6.4(group B), 88.9±5.1 (group C). There were no significant differences in groups(P>0.05). The operative time of posterolateral approach was longer than anterolateral approach or lateral approach, as well as the bleeding volum which was higher in posterolateral approach, while no significant difference of the knee function was observed in these 3 different approaches.