Download PDF
J Knee Surg 2022; 35(09): 959-970
DOI: 10.1055/s-0040-1721026
Original Article

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

Vincenzo Giordano
1   Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro, RJ, Brazil
2   Clínica São Vicente, Rede D'or São Luiz, Rio de Janeiro, RJ, Brazil
,
Robinson Esteves Pires
3   Departamento de Ortopedia, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
,
Frederico Silva Pimenta
3   Departamento de Ortopedia, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
,
Túlio Vinícius de Oliveira Campos
3   Departamento de Ortopedia, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
,
Marco Antônio Percope de Andrade
3   Departamento de Ortopedia, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
,
Peter V. Giannoudis
4   Academic Department of Trauma & Orthopaedic Surgery, School of Medicine, University of Leeds, Leeds, United Kingdom
› Author Affiliations Funding None.
› Further Information
    Permissions and Reprints

Abstract

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.

Keywords

tibial plateau - tibial plateau fracture - posterolateral corner - treatment algorithm - treatment strategy

Note

This article does not contain any studies with human participants or animals performed by any of the authors.


Authors' Contributions

V.G. and R.E.P. performed conceptualization. V.G. designed data curation and provided resources and supervision. V.G., R.E.P., F.S.P., T.V.O.C., M.A.P.A., and P.V.G. involved in formal analysis, methodology, project administration, investigation, validation, visualization, and review and editing. V.G. supported in writing original draft.




Publication History

Received: 12 August 2020

Accepted: 05 October 2020

Article published online:
09 November 2020

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Giordano V, Schatzker J, Kfuri Jr M. The “hoop plate” for posterior bicondylar shear tibial plateau fractures: description of a new surgical technique. J Knee Surg 2017; 30 (06) 509-513
    Article in Thieme ConnectPubMedGoogle Scholar
  • 2 Zhai Q, Luo C, Zhu Y. et al. Morphological characteristics of split-depression fractures of the lateral tibial plateau (Schatzker type II): a computer-tomography-based study. Int Orthop 2013; 37 (05) 911-917
    CrossrefPubMedGoogle Scholar
  • 3 Bernholt DL, DePhillipo NN, Grantham WJ. et al. Morphologic variants of posterolateral tibial plateau impaction fractures in the setting of primary anterior cruciate ligament tear. Am J Sports Med 2020; 48 (02) 318-325
    CrossrefPubMedGoogle Scholar
  • 4 Li Q, Zhang YQ, Chang SM. Posterolateral fragment characteristics in tibial plateau fractures. Int Orthop 2014; 38 (03) 681-682
    CrossrefPubMedGoogle Scholar
  • 5 Stallenberg B, Gevenois PA, Sintzoff Jr SA, Matos C, Andrianne Y, Struyven J. Fracture of the posterior aspect of the lateral tibial plateau: radiographic sign of anterior cruciate ligament tear. Radiology 1993; 187 (03) 821-825
    CrossrefPubMedGoogle Scholar
  • 6 Meulenkamp B, Martin R, Desy NM. et al. Incidence, risk factors, and location of articular malreductions of the tibial plateau. J Orthop Trauma 2017; 31 (03) 146-150
    CrossrefPubMedGoogle Scholar
  • 7 Carlson DA. Posterior bicondylar tibial plateau fractures. J Orthop Trauma 2005; 19 (02) 73-78
    CrossrefPubMedGoogle Scholar
  • 8 Chang SM, Zheng HP, Li HF. et al. Treatment of isolated posterior coronal fracture of the lateral tibial plateau through posterolateral approach for direct exposure and buttress plate fixation. Arch Orthop Trauma Surg 2009; 129 (07) 955-962
    CrossrefPubMedGoogle Scholar
  • 9 Frosch KH, Balcarek P, Walde T, Stürmer KM. A new posterolateral approach without fibula osteotomy for the treatment of tibial plateau fractures. J Orthop Trauma 2010; 24 (08) 515-520
    CrossrefPubMedGoogle Scholar
  • 10 Lobenhoffer P, Gerich T, Bertram T, Lattermann C, Pohlemann T, Tscheme H. Spezielle posteromediale und posterolaterale zugänge zur versorgung von tibiakopffrakturen. Unfallchirurg 1997; 100 (12) 957-967
    CrossrefPubMedGoogle Scholar
  • 11 Solomon LB, Stevenson AW, Baird RPV, Pohl AP. Posterolateral transfibular approach to tibial plateau fractures: technique, results, and rationale. J Orthop Trauma 2010; 24 (08) 505-514
    CrossrefPubMedGoogle Scholar
  • 12 Tao J, Hang DH, Wang QG. et al. The posterolateral shearing tibial plateau fracture: treatment and results via a modified posterolateral approach. Knee 2008; 15 (06) 473-479
    CrossrefPubMedGoogle Scholar
  • 13 Carlson DA. Bicondylar fracture of the posterior aspect of the tibial plateau. A case report and a modified operative approach. J Bone Joint Surg Am 1998; 80 (07) 1049-1052
    CrossrefPubMedGoogle Scholar
  • 14 Cho JW, Kim J, Cho WT. et al. Approaches and fixation of the posterolateral fracture fragment in tibial plateau fractures: a review with an emphasis on rim plating via modified anterolateral approach. Int Orthop 2017; 41 (09) 1887-1897
    CrossrefPubMedGoogle Scholar
  • 15 Cho JW, Samal P, Jeon YS, Oh CW, Oh JK. Rim plating of posterolateral fracture fragments (PLFs) through a modified anterolateral approach in tibial plateau fractures. J Orthop Trauma 2016; 30 (11) e362-e368
    CrossrefPubMedGoogle Scholar
  • 16 Hu SJ, Chang SM, Zhang YQ, Ma Z, Du SC, Zhang K. The anterolateral supra-fibular-head approach for plating posterolateral tibial plateau fractures: A novel surgical technique. Injury 2016; 47 (02) 502-507
    CrossrefPubMedGoogle Scholar
  • 17 Kfuri M, Schatzker J. Revisiting the Schatzker classification of tibial plateau fractures. Injury 2018; 49 (12) 2252-2263
    CrossrefPubMedGoogle Scholar
  • 18 Zhang W, Luo CF, Putnis S, Sun H, Zeng ZM, Zeng BF. Biomechanical analysis of four different fixations for the posterolateral shearing tibial plateau fracture. Knee 2012; 19 (02) 94-98
    CrossrefPubMedGoogle Scholar
  • 19 Sohn HS, Yoon YC, Cho JW, Cho WT, Oh CW, Oh JK. Incidence and fracture morphology of posterolateral fragments in lateral and bicondylar tibial plateau fractures. J Orthop Trauma 2015; 29 (02) 91-97
    CrossrefPubMedGoogle Scholar
  • 20 Xiang G, Zhi-Jun P, Qiang Z, Hang L. Morphological characteristics of posterolateral articular fragments in tibial plateau fractures. Orthopedics 2013; 36 (10) e1256-e1261
    CrossrefPubMedGoogle Scholar
  • 21 Crist BD, Martin SL, Stannard JP. Tibial plateau fractures. In: Stannard JP, Schmidt AH. eds. Surgical Treatment of Orthopaedic Trauma. 2nd ed.. New York: Thieme; 2016: 913-945
    Google Scholar
  • 22 Krause M, Menzdorf L, Preiss A, Frosch KH. Are there four tibial plateau columns? Yes there are, as illustrated by a postero-lateral apple-bite fracture. Response to a letter-to-the-editor. Int Orthop 2018; 42 (02) 443-446
    CrossrefPubMedGoogle Scholar
  • 23 Waldrop JI, Macey TI, Trettin JC, Bourgeois WR, Hughston JC. Fractures of the posterolateral tibial plateau. Am J Sports Med 1988; 16 (05) 492-498
    CrossrefPubMedGoogle Scholar
  • 24 Shen QJ, Zhang JL, Xing GS. et al. Surgical treatment of lateral tibial plateau fractures involving the posterolateral column. Orthop Surg 2019; 11 (06) 1029-1038
    CrossrefPubMedGoogle Scholar
  • 25 Bowers AL, Huffman GR. Lateral femoral epicondylar osteotomy: an extensile posterolateral knee approach. Clin Orthop Relat Res 2008; 466 (07) 1671-1677
    CrossrefPubMedGoogle Scholar
  • 26 Luo C-F, Sun H, Zhang B, Zeng B-F. Three-column fixation for complex tibial plateau fractures. J Orthop Trauma 2010; 24 (11) 683-692
    CrossrefPubMedGoogle Scholar
  • 27 Kfuri M, Schatzker J, Castiglia MT, Giordano V, Fogagnolo F, Stannard JP. Extended anterolateral approach for complex lateral tibial plateau fractures. J Knee Surg 2017; 30 (03) 204-211
    Article in Thieme ConnectPubMedGoogle Scholar
  • 28 Orapiriyakul W, Apivatthakakul T, Phornphutkul C. Posterolateral tibial plateau fractures, how to buttress? Reversed L posteromedial or the posterolateral approach: a comparative cadaveric study. Arch Orthop Trauma Surg 2018; 138 (04) 505-513
    CrossrefPubMedGoogle Scholar
  • 29 de Andrade MAP, Pimenta FS, de Abreu E Silva GM, de Oliveira Campos TV, Pires RES. Displaced osteochondral fracture of the posterolateral tibial plateau associated with an acute anterior cruciate ligament injury. Trauma Case Rep 2019; 20: 100172
    CrossrefPubMedGoogle Scholar
  • 30 Chang H, Zheng Z, Shao D, Yu Y, Hou Z, Zhang Y. Incidence and radiological predictors of concomitant meniscal and cruciate ligament in operative tibial plateau fractures: a prospective diagnostic study. Sci Rep 2018; 8 (01) 13317
    CrossrefPubMedGoogle Scholar
  • 31 Arciero RA. Anatomic posterolateral corner knee reconstruction. Arthroscopy 2005; 21 (09) 1147
    CrossrefPubMedGoogle Scholar
  • 32 Giordano V, do Amaral NP, Koch HA, E-Albuquerque RP, de Souza FS, Dos Santos Neto JF. Outcome evaluation of staged treatment for bicondylar tibial plateau fractures. Injury 2017; 48 (Suppl. 04) S34-S40
    CrossrefPubMedGoogle Scholar
  • 33 Pires RES, Giordano V, Dos Santos JK, Labronici PJ, de Andrade MA, de Toledo Lourenço PR. Expanding indications of the horizontal belt plate: a technical note. Injury 2015; 46 (10) 2059-2063
    CrossrefPubMedGoogle Scholar
  • 34 Zhang BB, Hu H, Zhan S, Mei J, Zhu Y, Luo CF. Biomechanical analysis of “Barrel hoop plate” technique for the posterolateral fragments of tibial plateau fractures with different displacement tendency. Injury 2020
    PubMedGoogle Scholar
  • 35 Adams Jr JD, Della Rocca GJ. Management of posterior articular depression in tibial plateau fractures. J Knee Surg 2016; 29 (01) 28-33
    PubMedGoogle Scholar
  • 36 Durakbasa MO, Kose O, Ermis MN, Demirtas A, Gunday S, Islam C. Measurement of lateral plateau depression and lateral plateau widening in a Schatzker type II fracture can predict a lateral meniscal injury. Knee Surg Sports Traumatol Arthrosc 2013; 21 (09) 2141-2146
    CrossrefPubMedGoogle Scholar
  • 37 Spiro AS, Regier M, Novo de Oliveira A. et al. The degree of articular depression as a predictor of soft-tissue injuries in tibial plateau fracture. Knee Surg Sports Traumatol Arthrosc 2013; 21 (03) 564-570
    CrossrefPubMedGoogle Scholar
  • 38 Mauffrey C, Roberts G, Cuellar DO, Herbert B, Hak D. Balloon tibioplasty: pearls and pitfalls. J Knee Surg 2014; 27 (01) 31-37
    PubMedGoogle Scholar
  • 39 Krause M, Preiss A, Meenen NM, Madert J, Frosch KH. “Fracturoscopy” is superior to fluoroscopy in the articular reconstruction of complex tibial plateau fractures – an arthroscopy assisted fracture reduction technique. J Orthop Trauma 2016; 30 (08) 437-444
    CrossrefPubMedGoogle Scholar
  • 40 Heiney JP, Kursa K, Schmidt AH, Stannard JP. Reduction and stabilization of depressed articular tibial plateau fractures: comparison of inflatable and conventional bone tamps. Study of a cadaver model. J Bone Joint Surg Am 2014; 96 (15) 1273-1279
    CrossrefPubMedGoogle Scholar
  • 41 Weimann A, Heinkele T, Herbort M, Schliemann B, Petersen W, Raschke MJ. Minimally invasive reconstruction of lateral tibial plateau fractures using the jail technique: a biomechanical study. BMC Musculoskelet Disord 2013; 14: 120
    CrossrefPubMedGoogle Scholar