Chapter 55: Tibial Plateau Fractures

J. L. Marsh, Matthew D. Karam

Chapter Outline

Introduction to Tibial Plateau Fractures

Overview of Injuries of Tibial Plateau Fractures

Fractures of the tibial plateau involve the articular surface of the proximal tibia. Proximal tibia fractures that do not involve the articular surface present different issues, and will be covered in Chapter 10. Small rim avulsions occur in conjunction with knee dislocations and other knee ligament injuries, and are covered in Chapter 10. Despite these exclusions, tibial plateau fractures discussed in this chapter are a diverse group of fractures that represent a wide spectrum of severity, which ranges from simple injuries with predictably excellent outcomes after nonoperative treatment to complex fracture patterns that challenge even the most experienced surgeons (Fig. 55-1). Imaging studies need to be of good quality to demonstrate the location of the fracture, the fracture pattern, and the degree of displacement, and there is controversy on which type of imaging is optimal. Assessing associated soft tissue injuries around the knee is critically important. Certain fracture patterns have a high risk of limb-threatening complications such as compartment syndrome, although for other fracture patterns these risks are negligible. Treatment concepts based on restoring or preserving limb alignment will lead to a satisfactory outcome for most patients; poor alignment often will result in a poor outcome. New methods have changed the surgical management of both low-energy lateral plateau fractures and high-energy medial and bicondylar fractures, but more data are necessary to determine if these new methods are improving patient outcomes. 
Figure 55-1
These two AP images illustrate the range of injury severity that occur in tibial plateau fractures.
 
They also illustrate how fracture classification does not always capture this wide range. A: It is technically a bicondylar fracture classified as OTA/AO C1 or Schatzker 6. It is minimally displaced (black arrows), has a low risk for complications, and will be relatively easily treated. B: It is also technically a bicondylar fracture classified as OTA/AO C2 and Schatzker 6. The differences in appearances, displacement, comminution, risks, and required treatment techniques are obvious.
They also illustrate how fracture classification does not always capture this wide range. A: It is technically a bicondylar fracture classified as OTA/AO C1 or Schatzker 6. It is minimally displaced (black arrows), has a low risk for complications, and will be relatively easily treated. B: It is also technically a bicondylar fracture classified as OTA/AO C2 and Schatzker 6. The differences in appearances, displacement, comminution, risks, and required treatment techniques are obvious.
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Figure 55-1
These two AP images illustrate the range of injury severity that occur in tibial plateau fractures.
They also illustrate how fracture classification does not always capture this wide range. A: It is technically a bicondylar fracture classified as OTA/AO C1 or Schatzker 6. It is minimally displaced (black arrows), has a low risk for complications, and will be relatively easily treated. B: It is also technically a bicondylar fracture classified as OTA/AO C2 and Schatzker 6. The differences in appearances, displacement, comminution, risks, and required treatment techniques are obvious.
They also illustrate how fracture classification does not always capture this wide range. A: It is technically a bicondylar fracture classified as OTA/AO C1 or Schatzker 6. It is minimally displaced (black arrows), has a low risk for complications, and will be relatively easily treated. B: It is also technically a bicondylar fracture classified as OTA/AO C2 and Schatzker 6. The differences in appearances, displacement, comminution, risks, and required treatment techniques are obvious.
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Tibial plateau fractures represent approximately 1% of fractures in adults.127 Fractures in men occur at a younger age and tend to be the result of high-energy trauma; women have increasing incidence with advancing age particularly the sixth and seventh decades, which indicates these fractures are occurring in osteopenic bone. Moore et al.127 reporting on a population of 752 patients with tibial plateau fractures found an average age of 44 years with 62% of fractures occurring in men. 

Major Historical Papers of Interest Related to Tibial Plateau Fractures

The principles and techniques of treating tibial plateau fractures have evolved dramatically over the last 50 years. In the decades of the 1950s, 60s, and 70s these fractures were predominately treated nonoperatively and published results indicated that favorable outcomes were possible using a variety of techniques including traction, cast bracing, and even spica casting.8,9,45,50 Apley controlled deformity using longitudinal traction, encouraged early knee motion, and reported satisfactory results.8,9 Lansinger et al. in a 20-year follow-up of patients originally reported by Rasmussen showed that nonoperative treatment for fractures with less than 10 degrees of coronal instability resulted in favorable outcomes.105,144 Duwelius and Connolly treated patients with closed reduction with or without percutaneous pin fixation and mobilized them early in a cast brace. They found 89% good and excellent clinical results.51 Spica casting after closed reduction led to good and excellent results in 85% of patients.50 Cast bracing was frequently used for tibial plateau fractures as an isolated treatment with satisfactory results.45 Although mostly of historical interest, the favorable results in these papers provide indirect evidence that the articular surface of the proximal tibia is tolerant of modest deformities and treatment will result in favorable outcomes if external forces are used to achieve reasonable limb alignment even without a perfectly reduced articular surface. 
With improved methods of internal fixation, operatively reducing and fixing tibial plateau fractures became common in the 1980s. These techniques had the advantages of reducing the articular surface, aligning the limb, and mobilizing the knee early after injury with less encumbering external devices. Similar to nonoperative techniques, favorable results were reported for the majority of patients.156,159,184 Criteria were developed for which fractures needed to be surgically reduced but this remains an area of controversy even today and different surgeons continue to use different criteria for operative intervention. Guidelines for treatment based on measured millimeters of displacement of the articular surface were proposed but have never been based on anything more than opinion. 
Classifying the fractures for the purposes of selecting optimal treatment became of increased importance. The Schatzker classification defined pathoanatomy and suggested treatment strategies and this classification remains central to the language of tibial plateau fractures and will be further discussed in this chapter.158,159 The OTA/AO classification also works well for the proximal tibia and remains the key international classification of fractures. Neither of these classifications included fracture dislocation patterns, an important association in high-energy patterns. 
As more tibial plateau fractures were surgically treated, surgical complications, some of them severe, became relatively common. Surgical methods for reducing and fixing tibial plateau fractures have evolved over the last three or four decades in part from the need to identify techniques that minimize complications and other techniques that optimize the treatment of complications when they occur. 

Assessment of Tibial Plateau Fractures

Mechanisms of Injury for Tibial Plateau Fractures

Type of Accident

Diverse patterns of tibial plateau fractures result when the knee sustains one of a variety of mechanisms of injury. In middle-aged or elderly patients, simple falls lead most commonly to lateral, or less commonly, medial side fracture patterns. Split depression fractures of the lateral plateau are most common. When the bone is very osteopenic, insufficiency fractures in elderly patients can occur and be missed on plain radiographs.142 Higher speed injuries in younger patients from sports or similar mechanism can cause split fractures or rim avulsion fractures associated with knee ligament injuries. Motor vehicle accidents and falls from heights and pedestrian-struck injuries often produce more severe patterns, which may involve both condyles and have a high risk for associated neurovascular injuries, compartment syndrome, and communicating open wounds. In one study of severe plateau fractures treated with external fixation, 16 of 21 injuries were motor vehicle related and in another study of bicondylar fractures treated with dual approaches, 68 out of 83 were motor vehicle related or a fall from a height.12,118 In contrast, a study of elderly patients with a mean age of 74 years reported 58% of fractures caused by a simple fall.94 

Forces Causing Injury

The magnitude, type, and direction of forces that injure the knee dictate the fracture pattern. The greater the energy absorbed by the proximal tibia the more severe the fracture and the more the fragments are displaced and comminuted. The energy of fracture results from a combination of the forces applied and the quality of the bone.7 Generally, axially loading forces are more rapid and release greater energy than angular forces. In cadavers, it is possible to produce typical split fractures with pure valgus forces, local compression fractures with axial forces, and split depression fractures with combinations of both forces.97 The intact medial collateral ligament (MCL) acts like a hinge for the lateral femoral condyle and in this cadaver study it is needed to be present for the lateral plateau to fracture.97 This means that clinically the MCL should not be torn in these lateral patterns. 
The proximal tibia is most likely to be subjected to a valgus force because of the normal 5 to 7 degrees of valgus alignment of the knee and because of a propensity to be struck from the lateral side. A valgus force loads the lateral tibial plateau to failure from direct impact with the lateral femoral condyle. A combination of valgus and axial compression produces lateral side depression, split depression, or less commonly, lateral split or total lateral condyle fractures.97 Younger patients with good bone tend to have split fractures with less depression and elderly patients with osteopenic bone have a greater component of compression with a less prominent split fragment. Most commonly, in lateral fracture patterns, there is at least a small component of both a split fracture and depression at the peripheral margin of the fracture. Less commonly than lateral side fractures, varus injuries lead to failure of the medial plateau. These injuries can involve the entire medial plateau and in some cases, the fracture-shearing plane may extend well into the lateral plateau. In other cases, the fracture involves lesser portions of the medial plateau. A posteromedial shearing fracture of the medial plateau is a common medial side pattern and can occur as an isolated split fracture, or in as many as one-third of bicondylar fractures it is part of the bicondylar fracture pattern.14 The mechanism has been described as knee flexion, varus and internal rotation of the medial femoral condyle.42,181 
Tibial plateau fractures most often occur with the leg in a weight-bearing position so axial load is typically some component of the injuring force. Generally, the greater the axial load component the more energy at failure and the more severe the fracture pattern. Bicondylar patterns result when axial load predominates, with the severity varying based on the magnitude of the axial forces. Occasionally, in a patient with a valgus knee, an axial force may shear the medial tibial condyle and produce a medial plateau fracture or fracture dislocation. 
Another type of tibial plateau fracture pattern occurs at the metaphyseal region from direct trauma and/or a combination of axial load and bending forces. These are classic bumper injuries or other crush, direct blow, or similar mechanisms where the tibial shaft is separated from the condyles with proximal extensions of fracture lines into the plateau. These severe injuries have a high risk of complications both because of the anatomic area of the injury and the high degree of energy transfer. Open fractures, severe closed soft tissue injury, trifurcation injury, and compartment syndrome are all associated with this mechanism.13 

Associated Injuries with Tibial Plateau Fractures

Patients with tibial plateau fractures frequently have associated injuries. These may be other ipsilateral or contralateral skeletal injuries and injuries to other systems that may influence how the plateau fracture is managed. In one study of bicondylar tibial plateau fractures, 13 of 41 patients had other major skeletal injuries in addition to the plateau fracture and these associated injuries were found to affect the patients’ functional outcome.12 In another study knee dislocation events were identified or confirmed based on MRI in 46% of Schatzker type IV patterns. In addition, Schatzker type IV, V, and VI patterns demonstrated a high incidence of ligament injury.172 High-energy tibial plateau fractures have a small risk of vascular injury and a high risk for compartment syndrome. These associated injuries are discussed in the next section on history and physical examination. 
Tibial plateau fractures also have typical local soft tissue injuries that are important to recognize since they may influence fracture management and prognosis. Not surprisingly, the force that produces medial or lateral plateau fractures may lead to associated collateral ligament injuries. MCL injuries can be associated with lateral plateau fractures from valgus forces. These associated collateral ligament injuries were once felt to be common because of the instability apparent on examination, but this instability can occur because of the loss of osseous support from the depression of the lateral plateau articular surface. The bony failure on one side of the joint actually protects the collateral ligament on the opposite side. One mechanical study indicated that an intact MCL functioning as a pivot point for the lateral femoral condyle was a necessary requirement to produce a lateral plateau fracture.97 In another study, the incidence of associated collateral ligament injury was only 3% each for both MCL and lateral collateral ligament (LCL).1 The diagnosis can be made with MRI or with a stress view demonstrating medial joint opening. 
There are also frequent associated intra-articular soft tissue injuries to both the cruciate ligaments and the menisci.1,168,172 These injuries play a role in managing tibial plateau fractures and will be further discussed in the Associated Soft Tissue Injuries section. Certain peripheral fractures of the margins of the tibial plateau are virtually pathognomonic of cruciate ligament injury and in these injured knees, it is appropriate to emphasize treating the ligament injuries rather than the plateau fracture itself. These fractures include the Segond fracture, reverse Segond fracture, anteromedial tibial margin fractures, and semimembranosus tendon insertion site fractures.34,40,138,147 

Signs and Symptoms of Tibial Plateau Fractures

The mechanism of injury provides clues to the fracture pattern and should direct the necessary degree of vigilance for associated injuries. Split lateral plateau fractures typically result from low-energy forces from falls and twisting injuries. The risk of associated neurovascular injury or compartment syndrome is very low. On the other hand, patients whose injuries result from falls from a height, motor vehicle accidents, or pedestrian struck are more likely to have tibial plateau fracture patterns that have a much higher risk of these associated injuries that must be managed urgently or emergently. Although the history is important, it is the fracture pattern that guides treatment decisions and determines the risks for complications. The clinician should be aware that the mechanism of injury in isolation might be deceiving. Relatively high-energy fractures can occur when the history suggests more innocuous mechanisms. 
The physical examination of the knee and leg is critically important to diagnose associated injuries and complications, to plan for surgical treatment, and to decide on optimal timing of interventions. In all injured limbs, particularly in patients with certain fracture patterns, a thorough neurovascular examination is mandatory. Metaphyseal–diaphyseal dissociation patterns and fracture dislocations are such injuries that are at particular risk for vascular or neurologic injury. 
Certain types of tibial plateau fractures have a high risk for compartment syndrome. Medial condylar fracture dislocations treated with temporary external fixation and Schatzker VI patterns in particular were shown to have a high rate of compartment syndrome.174 
In one study, 10% of all tibial plateau fractures were diagnosed with an associated compartment syndrome and the risk was particularly high in the high-energy fractures with 30% in Schatzker VI patterns.37 The compartments of the lower leg should be evaluated with serial examinations for signs of compartment syndrome. Presence of the well-recognized signs, including tense compartments and pain with passive stretching, should raise the suspicion of an associated compartment syndrome, and measuring compartment pressures is indicated. If the diagnosis is clear on physical examination fasciotomy may be performed without pressure measurements. Patients who have high-energy fracture patterns, who are not able to provide a history, and who are difficult to examine should have compartment pressures measured at presentation and these measurements may need to be repeated based on the clinical findings and the results of the initial measurement. 
Tibial plateau fractures may have communicating open wounds, which need to be identified on physical examination of the injured limb (Fig. 55-2). 
Figure 55-2
This is an open tibial plateau fracture with extensor mechanism disruption caused by a lawn mower blade.
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A well-aligned limb is important to the eventual outcome of patients with tibial plateau fractures. The eventual alignment of the knee after fracture healing is determined by a combination of the presence or absence of extra-articular fracture deformity, residual articular depression, and knee instability. Initial assessments of limb alignment are frequently made based on the appearances of the fracture on radiographs, but deformity may be apparent on inspection. In lateral tibial plateau fractures assessing for valgus instability of the knee may provide a guide to the need for surgical treatment.105,144 If instability is present it is likely caused by fracture displacement and will not resolve without reducing the fracture. However, pain from the injury often makes it difficult to examine the knee for coronal instability, limiting the value of this assessment. 
In all patients, particularly when an open reduction is planned, the soft tissue envelope around the knee must be carefully examined. The timing, and in some fractures, the type of surgical approach will be dictated by this examination. High-energy tibial plateau fractures have a significant risk of soft tissue complications from surgical approaches, so the examination of the soft tissues is very important. Important features of the soft tissues are the severity of swelling, visible contusions, and the size, character, and location of fracture blisters (Fig. 55-3). 
There are hemorrhagic fracture blisters.
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Figure 55-3
This is a severe closed soft tissue injury associated with a high-energy tibial plateau fracture.
There are hemorrhagic fracture blisters.
There are hemorrhagic fracture blisters.
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Imaging and Other Diagnostic Studies for Tibial Plateau Fractures

Radiographs

The diagnosis of a tibial plateau fracture is typically made on plain radiographs, and for some fractures, this may be the only imaging necessary. Anteroposterior (AP), lateral, and an AP view in the plane of the plateau (10- to 15-degree caudal view) are the standard examinations (Fig. 55-4). The caudal view provides a better view of the articular surface and helps assess displacement and depression better than the standard AP view.88,125 Hohl found that the standard AP view could not reliably determine the amount of articular depression, but that a 14-degree caudal view accurately estimated central and posterior displacement but could overestimate anterior displacement and depression.125 Less frequently, oblique views are obtained to assess the location of fracture lines or degree of displacement, but are not routine. Computerized tomographic (CT) scans have largely supplanted the need for these adjunctive views. When there is substantial fracture displacement, particularly in bicondylar or fracture dislocation patterns, radiographs in traction will better assess the fracture anatomy (Fig. 55-5). Traction restores the gross geometry of the proximal tibia, decreases overlap, and better defines the fracture pattern than the original radiographs. Manual traction may be applied solely for the purposes of such radiographs, but in severe fractures, radiographs obtained after applying a joint-spanning external fixator will provide the necessary traction for assessment of fracture anatomy. When applying the fixator, care should be taken to avoid having metal bars or clamps overlying the proximal tibia in the plane of the important radiographic views. 
Figure 55-4
 
The AP radiograph of this patient with an isolated lateral depression tibial plateau fracture (A) shows slight ellipses of the nonprofiled medial and lateral plateaus. The anterior margin projects more superiorly than the posterior margin. In the 15-degree caudal (B) view the proximal articular surface is nearly a single radiodense line providing better assessment of the isolated depression of the lateral articular surface.
The AP radiograph of this patient with an isolated lateral depression tibial plateau fracture (A) shows slight ellipses of the nonprofiled medial and lateral plateaus. The anterior margin projects more superiorly than the posterior margin. In the 15-degree caudal (B) view the proximal articular surface is nearly a single radiodense line providing better assessment of the isolated depression of the lateral articular surface.
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Figure 55-4
The AP radiograph of this patient with an isolated lateral depression tibial plateau fracture (A) shows slight ellipses of the nonprofiled medial and lateral plateaus. The anterior margin projects more superiorly than the posterior margin. In the 15-degree caudal (B) view the proximal articular surface is nearly a single radiodense line providing better assessment of the isolated depression of the lateral articular surface.
The AP radiograph of this patient with an isolated lateral depression tibial plateau fracture (A) shows slight ellipses of the nonprofiled medial and lateral plateaus. The anterior margin projects more superiorly than the posterior margin. In the 15-degree caudal (B) view the proximal articular surface is nearly a single radiodense line providing better assessment of the isolated depression of the lateral articular surface.
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Figure 55-5
These images show the advantages of traction in realigning a fractured tibial plateau.
 
Distraction allows better imaging and facilitates fixing the fracture. The initial AP and lateral images show a severe fracture but little additional information can be gained because of the malalignment and overlap (A and B). An AP film after distraction with a spanning fixator dramatically improves the ability to assess this injury (C). A single screw was placed between the condyles and 10 days later, the fracture was treated with a locking plate (D).
Distraction allows better imaging and facilitates fixing the fracture. The initial AP and lateral images show a severe fracture but little additional information can be gained because of the malalignment and overlap (A and B). An AP film after distraction with a spanning fixator dramatically improves the ability to assess this injury (C). A single screw was placed between the condyles and 10 days later, the fracture was treated with a locking plate (D).
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Figure 55-5
These images show the advantages of traction in realigning a fractured tibial plateau.
Distraction allows better imaging and facilitates fixing the fracture. The initial AP and lateral images show a severe fracture but little additional information can be gained because of the malalignment and overlap (A and B). An AP film after distraction with a spanning fixator dramatically improves the ability to assess this injury (C). A single screw was placed between the condyles and 10 days later, the fracture was treated with a locking plate (D).
Distraction allows better imaging and facilitates fixing the fracture. The initial AP and lateral images show a severe fracture but little additional information can be gained because of the malalignment and overlap (A and B). An AP film after distraction with a spanning fixator dramatically improves the ability to assess this injury (C). A single screw was placed between the condyles and 10 days later, the fracture was treated with a locking plate (D).
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CT Scans

Axial CT scans are routinely obtained for many or most tibial plateau fractures. They provide excellent details of the fracture pathoanatomy and serve as a critically important aid to preoperative planning for operative approaches and fixation techniques. Although CT may be used to help decide on the need for surgery, there is not good data to indicate that the additional detail apparent on a CT helps determine which fractures will benefit from surgery. CT typically demonstrates more articular displacement and comminution than is apparent on plain films.108 CT has been shown to help surgical planning and to lead to more reliability of classifying the fracture and deciding on a treatment plan.27,35,196 The location of depressed fragments, the size of articular segments, and the location and orientation of fracture lines are important details in planning an operative strategy and they are best visualized on CT. Three-dimensional (3D) reconstructions have been increasingly utilized and found to demonstrate spatial relationships of fracture fragments better than plain radiographs.84 In one study, the addition of spiral CT with 3D reconstructions frequently resulted in modifications and adjustments in operative plans compared to using plain radiographs alone.108,196 (Fig. 55-6). 
Figure 55-6
 
An AP radiograph (A) shows a high-energy bicondylar tibial plateau fracture but further characteristics of the injury are difficult to define. An axial CT cut (B) and coronal reconstruction (C) show the degree of comminution and identify major fragments but do not provide details about the overall size and alignment of the fragments. High-quality 3D reconstructions (D and E) provide additional assessment of the fracture morphology for preoperative planning.
An AP radiograph (A) shows a high-energy bicondylar tibial plateau fracture but further characteristics of the injury are difficult to define. An axial CT cut (B) and coronal reconstruction (C) show the degree of comminution and identify major fragments but do not provide details about the overall size and alignment of the fragments. High-quality 3D reconstructions (D and E) provide additional assessment of the fracture morphology for preoperative planning.
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Figure 55-6
An AP radiograph (A) shows a high-energy bicondylar tibial plateau fracture but further characteristics of the injury are difficult to define. An axial CT cut (B) and coronal reconstruction (C) show the degree of comminution and identify major fragments but do not provide details about the overall size and alignment of the fragments. High-quality 3D reconstructions (D and E) provide additional assessment of the fracture morphology for preoperative planning.
An AP radiograph (A) shows a high-energy bicondylar tibial plateau fracture but further characteristics of the injury are difficult to define. An axial CT cut (B) and coronal reconstruction (C) show the degree of comminution and identify major fragments but do not provide details about the overall size and alignment of the fragments. High-quality 3D reconstructions (D and E) provide additional assessment of the fracture morphology for preoperative planning.
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Current multidetector row CT provides CT datasets of the fractured plateau that may be visualized in any two-dimensional plane or with high-quality 3D images.55 3D images from multidetector CT scans provide details of the fractured proximal tibia, which enables the surgeon to assess comminution, depression, and fracture location more accurately than previously possible.106,113 Similar to plain films, realigning the fracture with a spanning fixator or other traction techniques before scanning will enhance the quality of the information available from the study. 
3D intraoperative imaging with multiplaner reconstruction may increasingly be part of operatively reducing and fixing displaced tibial plateau fractures. Early reports indicate that this imaging technology allows the surgeon to better assess the articular surface reduction and the placement of hardware during the operation than is possible with standard C-arm fluoroscopy.96,99 Although the future role of these devices is currently uncertain, it is likely that better intraoperative imaging will continue to improve the ability to accurately and minimally invasively reduce and fix tibial plateau fractures. 

MRI

MRI assesses the location of fracture lines and the degree of articular displacement and also identifies occult fracture areas better than plain films78 and has been found to be equivalent to traditional 2D CT.100 MRI provides additional information about injuries to the soft tissue structures of the knee that is not obtained with other imaging modalities (Fig. 55-7). However, whether MRI should be a routine part of evaluating tibial plateau fractures or whether it should be used instead of CT scanning is controversial. CT scans better visualize the fracture anatomy than an MRI but MRI demonstrates associated soft tissue injuries, particularly those of the menisci and ligaments that are not visualized on CT. When tibial plateau fractures were assessed with both techniques, CT was found to be sensitive and specific in identifying ligament injuries since most of them had at least small bony avulsions, but MRI was necessary to detect meniscal injuries.131 
Figure 55-7
The lateral radiograph shows an unusual anterior fracture subluxation (AO/OTA B3) (A).
 
Sagittal MRI scans show the fracture (black arrow) (B) and the torn posterior cruciate ligament (white arrow) (C).
Sagittal MRI scans show the fracture (black arrow) (B) and the torn posterior cruciate ligament (white arrow) (C).
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Figure 55-7
The lateral radiograph shows an unusual anterior fracture subluxation (AO/OTA B3) (A).
Sagittal MRI scans show the fracture (black arrow) (B) and the torn posterior cruciate ligament (white arrow) (C).
Sagittal MRI scans show the fracture (black arrow) (B) and the torn posterior cruciate ligament (white arrow) (C).
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The information present on MRI is important if the surgeon incorporates management of these soft tissue injuries into a treatment strategy but whether this strategy improves patient outcome is an area of controversy. MRI was shown to lead to higher observer agreement for both fracture classification and treatment plan than either plain films alone or plain films with the addition of a CT scan.198 When a proximal tibia stress fracture is suspected and plain films are negative, MRI is the imaging modality of choice.29 Using MRI, Stannard et al.172 demonstrated a 71% incidence of ligamentous injuries, with the use of MRI, noting significantly more in high-energy fracture patterns compared to low-energy patterns. 

Classification of Tibial Plateau Fractures

The fracture pattern dictates the treatment plan and the risk for complications and to some extent the patient outcome. Since different fracture patterns require very different treatment strategies, it is important to group similar injuries together and to separate different injuries from each other. In this way, treatments can be matched to fracture patterns to optimize outcomes. To accomplish these goals, fracture classifications must be reasonably reliable and reproducible. 
For tibial plateau fractures, word descriptions of injury patterns are frequently used substituting for formal classification. The OTA/AO117,132 and Schatzker classifications159 are both important and widely utilized in current practice. Other fracture classifications are of historical interest. 

Classification of Tibial Plateau Fractures by Description

Although there are two well accepted and commonly used classifications of tibial plateau fractures, most surgeons still classify fractures by describing them. Word descriptions provide more meaning than lettered or numbered classifications, particularly since many surgeons are often not familiar with the exact numbers or letters of a classification. Fracture descriptions in the tibial plateau work well for management decisions and convey information necessary for patient care, but do not work for databases or for clinical research. 
Fracture description in the tibial plateau must first localize the fracture and then convey the general characteristics of the fracture. For instance, whether the medial or lateral or both plateaus are involved provides a reasonable start in describing the fracture. The terms split, split depression, local compression, and bicondylar fracture are well accepted commonly utilized terms and convey meaning that is understood by most surgeons. These terms are incorporated in the Schatzker classification which is described below. Similar to other fractures, the amount the fracture is displaced, angulated, and comminuted, and the presence or absence of subluxation or dislocation are standard descriptions used for tibial plateau fractures. The amount of articular surface depression, usually measured in millimeters, is a quantitative method to assess and characterize the severity of tibial plateau fractures. Surgical indications for local compression and split depression fractures have been based on this measurement. Unfortunately, this measurement cannot be made very reliably between observers significantly limiting its usefulness.121 

OTA/AO Classification of Tibial Plateau Fractures

The OTA/AO alphanumeric code for articular fractures is well suited to the proximal tibia117 (Fig. 55-8). It has several advantages over the commonly used Schatzker classification. It identifies both articular and nonarticular fractures of the proximal tibia and by the use of the rule of squares provides a way to distinguish proximal tibia from tibial shaft fractures.132 The rule of squares identifies a proximal tibia fracture as one where the center of the fracture is within a square with one side along the articular surface and the length of a side defined by the width of the metaphyseal segment. Fractures outside of this square are tibial shaft fractures. There is more than one category of medial plateau fracture which is desirable since it is clinically important to distinguish subtypes of medial plateau fractures for treatment. For the total articular C patterns, the degree of comminution of both the metaphysis and the articular surface is subcategorized, providing important distinctions for treatment and prognosis. The OTA/AO classification therefore distinguishes ranges of severity in high-energy patterns better than the Schatzker classification. It is well accepted for trauma databases and has been frequently used in recent publications on tibial plateau fractures. It is increasingly becoming a standard and well accepted way to classify proximal tibia fractures. The entire classification has been updated and republished and there were no changes made to the proximal tibia section.117 
Figure 55-8
The OTA/AO classification of the proximal tibia fractures.
 
“A” type fractures are extra-articular. “B” type fractures are partial articular. “C” type fractures are complete articular.
“A” type fractures are extra-articular. “B” type fractures are partial articular. “C” type fractures are complete articular.
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“A” type fractures are extra-articular. “B” type fractures are partial articular. “C” type fractures are complete articular.
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“A” type fractures are extra-articular. “B” type fractures are partial articular. “C” type fractures are complete articular.
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Figure 55-8
The OTA/AO classification of the proximal tibia fractures.
“A” type fractures are extra-articular. “B” type fractures are partial articular. “C” type fractures are complete articular.
“A” type fractures are extra-articular. “B” type fractures are partial articular. “C” type fractures are complete articular.
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“A” type fractures are extra-articular. “B” type fractures are partial articular. “C” type fractures are complete articular.
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“A” type fractures are extra-articular. “B” type fractures are partial articular. “C” type fractures are complete articular.
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In this classification, the tibia is 4 and the proximal tibia is 1, so the plateau region is 41. The rule of squares is used to distinguish these fractures from tibial shaft fractures, 42. The subtypes of 41 are similar to the ends of the other long bones. 
Type A: These are nonarticular fractures of the proximal tibia. Technically, they are not tibial plateau fractures since the articular surface is not involved. 
Type B: These are partial articular fractures. Although this terminology applies well to the tibial plateau it is not commonly utilized since the verbal descriptions of split and split depression are more common. However, these are lateral side terms and the OTA/AO classification allows similar, although less common, medial side injuries to be classified. In addition, severe medial side patterns may present as fracture dislocations where the intact lateral plateau dislocates anterolaterally as the distal femur stays with the displaced medial plateau. The classification does not directly account for or subclassify this injury pattern. 
  •  
    B1—simple articular split
  •  
    B2—split depression
  •  
    B3—comminuted split depression
Type C: These are complete articular fractures and in the proximal tibia are frequently called bicondylar fractures. One advantage of the OTA/AO is the ability to subclassify these fractures based on comminution. 
  •  
    C1—noncomminuted total articular fractures
  •  
    C2—metaphyseal comminution with simple articular fracture lines
  •  
    C3—total comminuted articular fractures including the articular surface

Schatzker Classification of Tibial Plateau Fractures

The Schatzker classification has been the most widely used classification of tibial plateau fractures and is familiar to most surgeons (Fig. 55-9).159 Some of the categories are similar to previous classifications. For instance, Hohl75 in 1969 classified split, split depression, and central depression fractures. Many surgeons may not be familiar with the numbers of the six types but most are familiar with the meaning of the verbal descriptions of each type and this is an important advantage of the Schatzker classification. Since the six types are typically treated differently, the classification fulfils some of the goals of an ideal classification. Types 1 to 3 were described as lateral and less severe. These three categories reasonably identify the types of fractures that occur on the lateral side of the plateau. 
Figure 55-9
The Schatzker classification of tibial plateau fractures.
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Unfortunately, there are some problems with this classification with regard to types 4 to 6 which are the medial (type 4) and the more severe higher energy bicondylar (type 5) and shaft dissociated (type 6) patterns. Type 4 is the only category for a medial-sided fracture but medial plateau fractures occur in several distinct patterns. For instance, there is no way to distinguish a posteromedial split fracture from a medial total condylar fracture. In reporting a series of posteromedial plateau fractures treated by internal fixation, Bhattacharyya et al.20 pointed out difficulties with categorizing these fractures in the Schatzker classification. 
The Schatzker 5 pattern is commonly referred to as bicondylar. In the diagram in the original publication159 and most subsequent diagrams of the Schatzker 5 pattern, the intercondylar eminences are intact with fractures of both condyles. This pattern occurs only rarely if at all. The category Schatzker 6 is important since it identifies a pattern where the diaphysis is separated from the metaphysis with fractures proximally involving the articular surface. Complications are frequent and treatment must be designed to minimize risks. However, because of the problems with the Schatzker 5 category the 6 category is often used for any bicondylar fracture. The common bicondylar pattern where both condyles are broken without any intact articular surface or intercondylar eminences, but the shaft is not separated from the metaphysis, is not easily classified in the Schatzker classification. In addition, similar to the OTA/AO classification the Schatzker classification does not specifically classify fracture dislocation patterns. Despite these problems, the terms in the Schatzker classification appear frequently in this chapter and in the vernacular of most surgeons, so it is important to be familiar with them. 
Type 1: Split or cleavage fracture—Pure split fractures have a single fracture line creating a marginal fracture across the lateral plateau. These fractures are less common than type 2 since any split is usually accompanied by some degree of marginal depression along the split fracture line. They occur more commonly in younger patients. Schatzker et al.159 identified four of these fractures from among 70 reviewed and Hohl75 found them in only 3% of plateau fractures (Fig. 55-10A–C). 
Figure 55-10
A split fracture (OTA/AO B1, Schatzker 1) illustrated in a drawing (A), an AP radiograph (B), and coronal CT cut (C).
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Type 2: Split or cleavage depression—These are the most common lateral tibial plateau fractures in most series although Schatzker et al.159 found that the type 3 fracture was slightly more common and Hohl75 found them to occur with equal frequency. The depression is the marginal impaction at the edges of the split fragment. The relative size of the split fragment and the amount of depression is variable ranging from minimally displaced fractures to explosion fractures of the entire lateral side of the joint and with a fractured fibular head (Fig. 55-11A–C). 
Figure 55-11
 
A split depression fracture (OTA/AO B2 and B3, Schatzker 2) illustrated in a drawing (A), an AP radiograph (B), and a coronal CT cut (C). These images show a more severe high-energy pattern than is typical for this fracture type. Note the lateral femoral condyle impaled in the lateral tibial plateau illustrating a valgus stress injury mechanism.
A split depression fracture (OTA/AO B2 and B3, Schatzker 2) illustrated in a drawing (A), an AP radiograph (B), and a coronal CT cut (C). These images show a more severe high-energy pattern than is typical for this fracture type. Note the lateral femoral condyle impaled in the lateral tibial plateau illustrating a valgus stress injury mechanism.
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Figure 55-11
A split depression fracture (OTA/AO B2 and B3, Schatzker 2) illustrated in a drawing (A), an AP radiograph (B), and a coronal CT cut (C). These images show a more severe high-energy pattern than is typical for this fracture type. Note the lateral femoral condyle impaled in the lateral tibial plateau illustrating a valgus stress injury mechanism.
A split depression fracture (OTA/AO B2 and B3, Schatzker 2) illustrated in a drawing (A), an AP radiograph (B), and a coronal CT cut (C). These images show a more severe high-energy pattern than is typical for this fracture type. Note the lateral femoral condyle impaled in the lateral tibial plateau illustrating a valgus stress injury mechanism.
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Type 3: Local compression or pure central depression—Local compression fractures are lateral. Although it is implied that this type of fracture does not have a split fragment, only local depression, frequently there is a small split through the lateral cortex. However, the split is small enough and minimally displaced and does not provide an easy window of access to the depression. This fracture tends to occur in an older age group (Fig. 54-12A, B).159 
Figure 55-12
A local compression fracture (OTA/AO B2, Schatzker 3) illustrated in a drawing (A) and in a coronal CT cut (B).
There may be a subtle split fragment.
There may be a subtle split fragment.
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Type 4: Medial condyle fractures—The entire condyle is split as a single fragment or it may have a comminuted joint depression component. The fracture line is usually through the intercondylar region but may be through the opposite lateral condyle but some portion of the lateral condyle is left unfractured. With large medial condyle fractures, the intact lateral condyle displaces laterally from the femur leading to a fracture dislocation pattern. These severe injuries have a risk of associated injuries including compartment syndrome, peroneal nerve, and vascular injury and persistent joint subluxation and/or dislocation. Wahlquist et al.185 found that the more the fracture line moves laterally the greater the risk for these associated complications. Schatzker et al.159 felt that these fractures had the worst prognosis. Chan et al.34 found a high incidence of associated ACL tears with posteromedial fracture patterns (Fig. 55-13A–C). 
Figure 55-13
 
A medial condylar fracture dislocation (OTA/AO B3, Schatzker4) illustrated in a drawing (A) and in two rotations of 3D imaging (B and C). Note the dislocation of the lateral plateau from the femoral condyle.
A medial condylar fracture dislocation (OTA/AO B3, Schatzker4) illustrated in a drawing (A) and in two rotations of 3D imaging (B and C). Note the dislocation of the lateral plateau from the femoral condyle.
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Figure 55-13
A medial condylar fracture dislocation (OTA/AO B3, Schatzker4) illustrated in a drawing (A) and in two rotations of 3D imaging (B and C). Note the dislocation of the lateral plateau from the femoral condyle.
A medial condylar fracture dislocation (OTA/AO B3, Schatzker4) illustrated in a drawing (A) and in two rotations of 3D imaging (B and C). Note the dislocation of the lateral plateau from the femoral condyle.
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Type 5: Bicondylar fracture—This pattern was originally described by Schatzker as a fracture where both the medial and lateral tibial plateaus are fractured. The distinguishing feature was that the metaphysis and diaphysis remain intact and not fractured. The intercondylar eminences may or may not be fractured. The diagram in Schatzker et al.159 from 1979 shows them to be intact. The type 5 fracture in this diagram has fractures of both plateaus with the intercondylar area intact. This is extremely uncommon and Schatzker et al.159 in the original paper identified only 2 out of 70. There are patterns where some portion of both condyles are fractured and some portion of one or both condyles remains intact. For instance, there are medial and lateral partial condylar fractures but typically the intact portion is not the area of the intercondylar eminences. More commonly, these are posterior or anterior fracture patterns where the fractures of the two plateaus are mostly in the coronal plane leaving the anterior or posterior portion of both intact (Fig. 55-14A–C).32 Barei et al.14 noted that approximately one-third of bicondylar fractures have a posteromedial fracture and described the characteristics of this associated pattern. This information is important when a surgeon is planning to treat a bicondylar fracture with laterally based locking plates. 
Figure 55-14
A bicondylar fracture.
 
The illustration shows the intercondylar eminence intact (A) but in most bicondylar fractures the entire proximal tibia is completely fractured (OTA/AO C3) as in the AP radiograph (B) and the coronal CT (C). If the shaft is dissociated from the metaphysis, this would be a Schatzker 6.
The illustration shows the intercondylar eminence intact (A) but in most bicondylar fractures the entire proximal tibia is completely fractured (OTA/AO C3) as in the AP radiograph (B) and the coronal CT (C). If the shaft is dissociated from the metaphysis, this would be a Schatzker 6.
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Figure 55-14
A bicondylar fracture.
The illustration shows the intercondylar eminence intact (A) but in most bicondylar fractures the entire proximal tibia is completely fractured (OTA/AO C3) as in the AP radiograph (B) and the coronal CT (C). If the shaft is dissociated from the metaphysis, this would be a Schatzker 6.
The illustration shows the intercondylar eminence intact (A) but in most bicondylar fractures the entire proximal tibia is completely fractured (OTA/AO C3) as in the AP radiograph (B) and the coronal CT (C). If the shaft is dissociated from the metaphysis, this would be a Schatzker 6.
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Type 6: Shaft dissociated from the metaphysis—In most classic bicondylar patterns, the shaft is separated from the condyles (there is no articular surface intact or in continuity with the shaft below). The defining characteristic of the Schatzker 6 pattern was a diaphyseal metaphyseal dissociation with varying comminution of the articular surface.159 According to this definition the distal extent of the fracture is more distal in type 6 compared to type 5. Unfortunately, just when the change from 5 to 6 should occur is not precisely defined and subject to observer interpretation and therefore variability. The degrees of displacement and comminution of the two articular surfaces are variable and there is no subclassification of this pattern. The classic Schatzker 6 from the original diagrams is a proximal shaft fracture with extension into the joint. One of the weaknesses of this classification is the wide range of patterns requiring different management strategies that all fit in the 6 category. These are mostly high-energy fractures (Fig. 55-15A–C). 
Figure 55-15
A shaft dissociated fracture (OTA/AO C2, Schatzker 6) illustrated in a drawing (A) and in AP (B) and lateral radiographs (C).
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Reliability of Tibial Plateau Fracture Classification

Studies have assessed the observer reliability of classifying tibial plateau fractures. Similar to many fracture classifications, the OTA/AO and the Schatzker classifications of tibial plateau fractures have been found to have less than excellent interobserver reliability. In one study the OTA/AO was found to be more reliable than the Schatzker classification and to be more reliable at the type than the group level.186 Another study found that simple use of unicondylar versus bicondylar and split versus split depression was more reliable than either the Schatzker or the OTA/AO classification.38 One study looked at fracture characteristics that form the basis of all plateau classification and found that even simple terms like displaced versus nondisplaced and comminuted versus not comminuted led to significant observer disagreement.121 These studies indicate that the common fracture classifications and even the terminology used for tibial plateau fractures are only modestly reliable. 

Outcome Measures for Tibial Plateau Fractures

Overview of Tibial Plateau Fracture Outcomes

An overview of the results of operative treatment of tibial plateau fractures is difficult since the wide range of fracture patterns leads to variable results and the factors that potentially affect outcome are different for different patterns. Certain split fractures may be percutaneously stabilized to prevent displacement with minimal risk and near-perfect outcomes after a relatively rapid recovery. On the other hand, high-energy Schatzker 6 patterns with OTA/AO type C3 comminution have high risks of injury and treatment-related complications and a recovery time that may last years leading to variable functional outcomes. 
The factors that most predictably lead to favorable outcomes are also controversial. They include patient factors, injury factors, and factors involved with treatment. Since treatment is under the surgeons’ control it leads to the most controversy and the relative importance of limb alignment, articular reduction, and associated ligament and meniscal injuries are all areas that spark controversy. 
In general, tibial plateau fractures have favorable outcomes if knee alignment is maintained and complications are avoided. The proximal articular surface of the tibia is relatively resistant to posttraumatic arthrosis and most patients recover knee function and do not need reconstructive surgery. Knee replacement after a tibial plateau fracture is very rare indicating that pain is relatively minimal and that reasonable and long-lasting knee function is restored in most patients. Over an 11-year period during which 13,821 knee arthroplasties were performed at the Mayo Clinic only 62 knee arthroplasties were performed in patients with a prior fracture of the tibial plateau.193 In another study of tibial plateau fracture patients greater than 60 years old, only 2 of 151 required knee arthroplasty.193 
In comparing outcomes and arthrosis rates for different lower extremity articular fractures, the articular surface of the proximal tibia appears to be more tolerant to fractures than the ankle or hip.116 Five to 11 years after injury a series of high-energy plateau fractures treated by external fixation were found to have good knee function and a low rate of arthrosis. The general health status of the patients equaled age-matched controls and the knee score averaged 90 on a 100-point scale.191 These results are in contradiction to another group of patients with 5 to 11 years of follow-up after high-energy tibial plafond fractures where patients had decreased general health status compared to age-matched controls and significant residual ankle pain and decreased function.119 This may be because of the less congruent nature of the articulation, the characteristics of the cartilage, a load-sharing effect of the menisci, or perhaps other factors. A recent review of 311 tibial plateau fractures demonstrated a 10-year Kaplan–Meier survival analysis for the primary outcome of end-stage arthritis as 96%; a secondary outcome measure of minor arthritis revealed a survival of 87%.124 
The time to recovery after a tibial plateau fracture clearly depends on the fracture pattern but as a general rule, can be expected to take at least a year. One study found significant residual strength deficits at 1 year after plateau fracture in the majority of patients tested.63 Another study showed that recovery stabilized after 2 years.191 
In most studies, the fracture pattern has an effect on patient outcome.175 In one study medial condylar fractures and bicondylar fractures with a medial tilt were found to have less favorable results than lateral side patterns, and varus was more poorly tolerated than valgus.82 One study showed that the presence of a proximal fibula fracture was a poor prognostic sign.24 Another study showed better results in unicondylar than bicondylar fractures.143 As an exception in one study of internal fixation of tibial plateau fractures with an average of 2.7 years of follow-up, there was no association between fracture pattern and outcome.104 
One treatment principle that appears to be universally agreed upon to improve outcome is to avoid excising the meniscus. Honkonen81 found that removal of the meniscus for exposure led to posttraumatic degenerative arthritis in 74% of cases. However, identifying and repairing injured menisci, although advocated, has insufficient data to show that it leads to better outcomes. 
Generally, less favorable outcomes for all types of tibial plateau fractures have been found with increased patient age.12,81,94,191 For instance, one study showed dramatically different outcomes in patients older than 40 compared to those under 40. At 8 years after injury, only 12 of 21 patients in the over 40 age group were equal to age-matched controls on patient-derived outcome measures.191 Another study of patients greater than 50 years of age with tibial plateau fractures found that regardless of the fracture pattern or operative or nonoperative treatment only 35% (14/40 patients) were satisfied with their result.161 In another study, patients over 60 were found to have mediocre functional outcomes and frequent degenerative changes.94 One study reported that favorable results were achieved in 82% of operatively treated patients older than 55 but increasing age still correlated with poorer outcomes.176 One study found recovery of knee function was slower in patients older than 40.63 As an exception to the above studies, a recent study of operative treatment, with 5 to 27 years of follow up, did not find a negative effect with increased age.143 
The quality of the articular reduction and its effect on outcome is an important and controversial issue. Brown et al.25 in a cadaver model showed that articular step-offs increased contact loading but less than they expected. Some clinical studies have identified that the quality of articular reduction is an important determinant of outcome,.12,20,22 but other authors have felt that limb alignment is the most critical factor and that in well-aligned limbs articular step-offs are less important.21,42,49,51,81,105,143,161 Some of this controversy can be resolved by the fact that in many fracture patterns the articular reduction and eventual alignment of the knee are fairly closely linked to each other since large residual articular displacements lead to limb malalignment. One study of ORIF of plateau fractures found that neither the fracture pattern nor the quality of reduction affected patient outcome at an average of more than 8 years after injury.191 Two studies followed similar high-energy fractures treated by external fixation and one found that knee scores were significantly better in patients with anatomic articular reductions, whereas the other found that good outcomes were predictable in well-aligned stable knees.103,161 Another recent study found that malalignment of greater than five degrees led to a higher incidence of arthrosis (27% vs. 9%) at a follow-up of between 5 and 27 years after operative treatment.143 

Tibial Plateau Fracture Outcome Assessment Metrics

A Medline search (2007 to 2012) using the operator tibial plateau fracture revealed 301 entries and the titles and abstracts were reviewed. A variety of outcomes instruments were reported including generic health status measures, most notably the SF-36 and SMFA. In addition, disease-specific patient-reported outcome instruments included Hospital for Special Surgery (HSS) Knee Score, Oxford Knee Score, Western Ontario and McMaster Universities Arthritis Index (WOMAC), Rasmussen Score, Knee injury and Osteoarthritis Outcome Score (KOOS), and Lysholm score. Unfortunately there is not a consensus on which knee score is best for patient follow-up studies for tibial plateau fractures and the diversity of scores used makes meaningful comparisons between studies difficult. In addition, there is not any studies that provide a broad enough patient distribution to allow a normative score distribution. For that reason the expected score at a given time after a plateau fracture in a patient following a typical course is unknown. 
The vast majority of reports also included secondary outcomes such as articular reduction, residual pain, knee range of motion, patient satisfaction, patient return to work/sport, and hospital length of stay. Adverse events such as need for reoperation, compartment syndrome, deep infection, and nerve injury were typically reported. 

Pathoanatomy and Applied Anatomy Relating to Tibial Plateau Fractures

Surgical and Applied Anatomy for Tibial Plateau Fractures

Fracture patterns in the proximal tibia are dictated by the forces applied combined with the osseous anatomy of the proximal tibia (Fig. 55-16). Occasionally, muscle forces or ligament attachments play a part in the fracture pattern. The tibia gradually flares from the relatively narrow diaphysis to the proximal tibia. In the proximal quarter, the anterior proximal tibia widens to become the tibial tubercle for attachment of the patellar tendon. Just above this, the proximal lateral tibia abruptly flares from the smooth anterolateral surface to form the lateral tibial condyle, which serves as the origin of the anterior compartment muscles, and more proximally has Gerdy tubercle for the insertion of the iliotibial band. Posteriorly on the lateral side, the fibular head serves as a palpable landmark and as the site of attachment of the fibular collateral ligament and the biceps tendon. It defines the position of the peroneal nerve, which rests on the posterior neck of the fibula. The proximal fibula buttresses the lateral plateau, and associated fractures of the proximal fibula result in a greater degree of valgus instability and indicate a more severe lateral fracture. The proximal tibiofibular joint is a synovial joint that may communicate with the knee joint. 
Figure 55-16
 
A: Represents a lateral knee x-ray. B: Denotes the subchondral arcs of both the medial tibial plateau (white triangles) and lateral tibial plateau (black triangles). Of particular interest is the relative concavity of the medial tibial plateau and slight convexity of the lateral plateau. C: It is a lateral of the same knee following an isolated local compression injury of the anterolateral tibia plateau; note the loss of congruity of the lateral subchondral density as denoted by the unfilled triangles. The concave medial plateau (white triangles) is still intact.
A: Represents a lateral knee x-ray. B: Denotes the subchondral arcs of both the medial tibial plateau (white triangles) and lateral tibial plateau (black triangles). Of particular interest is the relative concavity of the medial tibial plateau and slight convexity of the lateral plateau. C: It is a lateral of the same knee following an isolated local compression injury of the anterolateral tibia plateau; note the loss of congruity of the lateral subchondral density as denoted by the unfilled triangles. The concave medial plateau (white triangles) is still intact.
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Figure 55-16
A: Represents a lateral knee x-ray. B: Denotes the subchondral arcs of both the medial tibial plateau (white triangles) and lateral tibial plateau (black triangles). Of particular interest is the relative concavity of the medial tibial plateau and slight convexity of the lateral plateau. C: It is a lateral of the same knee following an isolated local compression injury of the anterolateral tibia plateau; note the loss of congruity of the lateral subchondral density as denoted by the unfilled triangles. The concave medial plateau (white triangles) is still intact.
A: Represents a lateral knee x-ray. B: Denotes the subchondral arcs of both the medial tibial plateau (white triangles) and lateral tibial plateau (black triangles). Of particular interest is the relative concavity of the medial tibial plateau and slight convexity of the lateral plateau. C: It is a lateral of the same knee following an isolated local compression injury of the anterolateral tibia plateau; note the loss of congruity of the lateral subchondral density as denoted by the unfilled triangles. The concave medial plateau (white triangles) is still intact.
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On the medial side, the flare to the medial tibial condyle is more gradual, directly medial, and more abrupt and flared posteromedial. Angular forces to the knee and compression and axial loading lead to failure through these flared condyles on the lateral or medial sides or with straight axial loading on both sides. The medial plateau is more resistant to failure than the lateral plateau. 
The articular surface of the lateral tibial plateau is flat or slightly convex in relation to the medial tibial plateau that is concave which provides greater congruity with the medial femoral condyle than on the lateral side. This anatomy is important when using radiographs and fluoroscopy during surgical treatment since it allows separate assessment of the two plateaus on the lateral radiographs. The lateral plateau is also higher than the medial plateau accounting for the few degrees of varus of the tibial plateau in relation to the shaft. The proximal articular surface slopes in relation to the shaft from the front, which is high, to the back, which is low. Hashemi et al. in a study on MRIs found that the average values were around 5 degrees for sagittal slope and 3 degrees for coronal slope. However, these angular relationships of the tibial plateau had significant variation between individuals with the range of varus coronal slope between −1 and 6 degrees and the sagittal slope was from 0 to 14 degrees on the lateral side and −3 to 10 degrees on the medial side.73 These variations between individuals are potentially important for tibial plateau fracture surgery since small degrees of malalignment may be considered important. Assessing alignment in comparison to the nonfractured side is prudent. 
Both the medial and lateral articular surfaces are covered by hyaline cartilage and are partially covered by the fibrocartilaginous menisci, both of which are attached to their respective plateaus by the menisci tibial ligaments (coronary ligaments). There is greater meniscal coverage of the lateral plateau than the medial plateau. The intercondylar eminence and medial and lateral tibial spines, which are nonarticular, separate the two plateaus. They also serve as attachment for the anterior cruciate ligament (ACL) anterior to the medial spine and the posterior cruciate ligament (PCL) that extends down to the posterior surface of the proximal tibia. 
The proximal anterior two-thirds of the tibia are largely subcutaneous. The posterior tibia is deep beneath the structures crossing the popliteal fossa making direct surgical exposures in this area difficult. The anterior tibia is more accessible but particularly the medial surface is at risk for surgical incisions in high-energy fractures. The pes tendons, gracilis, sartorius, and semitendinosus insert on the anteromedial portion of the proximal tibia distal to the insertion of the patellar tendon on the tibial tubercle. Before the insertion, these tendons give off expansions to the fascia of the lower leg. The posterior aspect of the pes expansions must be incised to retract the pes tendons anteriorly during the posteromedial approach. The anterior compartment muscles, tibialis anterior, and extensor digitorum longus arise from the inferior surface of the lateral condyle of the tibia. The origin must be elevated to place an anterolateral tibial plate. The medial head of the gastrocnemius arises from the posterior femur just above the posterior medial femoral condyle. It can be retracted laterally or if necessary, the origin can be incised to enhance exposure of the posteromedial and posterior tibial plateau. 
The common peroneal nerve runs under the cover of the biceps femoris and is on the back of the neck of the fibula. It is not at risk during most surgery for tibial plateau fractures as long as the surgeon remains aware of the position of the fibula. Rarely, a posterolateral approach may be chosen in which case the peroneal nerve must be identified and mobilized. It is at risk from direct lateral impact mechanisms and with high-energy fractures of the tibial plateau, particularly medial plateau fractures which produce varus alignment. The tibial nerve in the popliteal fossa is rarely injured and rarely part of surgical approaches for tibial plateau fractures. 
The popliteal artery, which is at risk in knee dislocations, is rarely injured with tibial plateau fractures. However, the trifurcation of the popliteal artery occurs in an area where plateau displacement is likely with certain fracture patterns and the anterior tibial artery is bound at the interosseous membrane and is at particular risk in shaft-dissociated patterns. Occult injury to the anterior tibial artery may account in part for the compartment syndromes frequently associated with these fracture patterns. 

Tibial Plateau Fracture Treatment Options

Nonoperative Treatment of Tibial Plateau Fractures

Indications/Contraindications for Nonoperative Treatment of Tibial Plateau Fractures

Not all fractures of the proximal tibial articular surface require surgery and not all displaced intra-articular fractures need to be surgically reduced. The proximal tibial articular surface tolerates small to modest articular displacements and in properly selected fractures, nonoperative treatment results in predictably excellent outcomes despite articular irregularities. Progressive incapacitating posttraumatic arthritis is actually very unusual. 
In current practice, it is rare to obtain a closed reduction of a displaced proximal tibia fracture for definitive nonoperative management and for many displaced fractures, it is impossible. Nonoperative treatment is therefore indicated for tibial plateau fractures that will heal without a significant deformity or for elderly patients or patients with associated medical problems where operative intervention is high risk or otherwise undesirable and for whom a deformity will be clinically acceptable. 
In selecting cases for nonoperative treatment, predicting the presence or absence of a deformity after treatment is very important (Fig. 55-17A–D). Angular deformity is not well tolerated by the articular surface since typically the knee will be malaligned in a direction that increases the weight-bearing load on the most damaged portion of the articular surface. Malalignment increases the propensity for knee instability and is cosmetically objectionable. 
Figure 55-17
AP and lateral radiographs of a 28-year-old patient who slipped and fell.
 
The fracture of the lateral plateau is hard to see on the AP radiograph (A) but the lateral radiograph (B) shows the anterior plateau depression (white arrows). Follow-up radiographs (C and D) 6 months after injury show healing. The patient was back to work and the clinical outcome was excellent and the leg remained well aligned. AP knee radiograph (E) and coronal CT scan (F) of a 59-year-old patient who fell sustaining a medial tibial plateau fracture that was nondisplaced. This patient underwent surgical management to prevent late displacement and varus malalignment.
The fracture of the lateral plateau is hard to see on the AP radiograph (A) but the lateral radiograph (B) shows the anterior plateau depression (white arrows). Follow-up radiographs (C and D) 6 months after injury show healing. The patient was back to work and the clinical outcome was excellent and the leg remained well aligned. AP knee radiograph (E) and coronal CT scan (F) of a 59-year-old patient who fell sustaining a medial tibial plateau fracture that was nondisplaced. This patient underwent surgical management to prevent late displacement and varus malalignment.
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The fracture of the lateral plateau is hard to see on the AP radiograph (A) but the lateral radiograph (B) shows the anterior plateau depression (white arrows). Follow-up radiographs (C and D) 6 months after injury show healing. The patient was back to work and the clinical outcome was excellent and the leg remained well aligned. AP knee radiograph (E) and coronal CT scan (F) of a 59-year-old patient who fell sustaining a medial tibial plateau fracture that was nondisplaced. This patient underwent surgical management to prevent late displacement and varus malalignment.
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Figure 55-17
AP and lateral radiographs of a 28-year-old patient who slipped and fell.
The fracture of the lateral plateau is hard to see on the AP radiograph (A) but the lateral radiograph (B) shows the anterior plateau depression (white arrows). Follow-up radiographs (C and D) 6 months after injury show healing. The patient was back to work and the clinical outcome was excellent and the leg remained well aligned. AP knee radiograph (E) and coronal CT scan (F) of a 59-year-old patient who fell sustaining a medial tibial plateau fracture that was nondisplaced. This patient underwent surgical management to prevent late displacement and varus malalignment.
The fracture of the lateral plateau is hard to see on the AP radiograph (A) but the lateral radiograph (B) shows the anterior plateau depression (white arrows). Follow-up radiographs (C and D) 6 months after injury show healing. The patient was back to work and the clinical outcome was excellent and the leg remained well aligned. AP knee radiograph (E) and coronal CT scan (F) of a 59-year-old patient who fell sustaining a medial tibial plateau fracture that was nondisplaced. This patient underwent surgical management to prevent late displacement and varus malalignment.
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The fracture of the lateral plateau is hard to see on the AP radiograph (A) but the lateral radiograph (B) shows the anterior plateau depression (white arrows). Follow-up radiographs (C and D) 6 months after injury show healing. The patient was back to work and the clinical outcome was excellent and the leg remained well aligned. AP knee radiograph (E) and coronal CT scan (F) of a 59-year-old patient who fell sustaining a medial tibial plateau fracture that was nondisplaced. This patient underwent surgical management to prevent late displacement and varus malalignment.
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Unfortunately, predicting healing without deformity can be difficult. To make this judgment, a surgeon must use information about the fracture pattern, knowledge of outcomes of various types of fractures, and the alignment both on injury radiographs and on clinical examination. The type of fracture is critically important to choosing nonoperative treatment and to achieving a good result. Although the amount of articular displacement and the risk for deformity have some relationship to each other, it is not a direct relationship. Localized depressions of up to 10 or more millimeters of the lateral plateau may result in stable knees and good outcomes when treated nonoperatively, if the depression involves a small portion of the articular surface. Depressions with associated displaced split fragments or those that involve larger portions of the lateral articular surface will be more likely to lead to valgus malalignment. Different from the lateral plateau, a minimally displaced medial total condylar fracture has a greater potential for displacement that may lead to unacceptable varus deformity. The medial articular surface is less well protected by the meniscus, so it is more important to minimize the amount of articular steps or other displacements on this side of the knee. 
These examples demonstrate that basing decisions on operative versus nonoperative treatment for tibial plateau fractures on a predetermined number of millimeters of displacement of the articular surface is not sensible and does not account for important knowledge about how different tibial plateau fracture patterns have more or less propensity to lead to deformity and subsequent favorable or unfavorable outcomes (Table 55-1). 
 
Table 55-1
Tibial Plateau Fractures
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Table 55-1
Tibial Plateau Fractures
Nonoperative Treatment
Indications Relative Contraindications
Non- or minimally displaced fracture Greater displacement where deformity is predictable
Small depressions of the lateral plateau without deformity Knee instability
Patients with significant medical comorbidities Displaced medial side patterns
Elderly patients or those with low functional demands where small deformities are well tolerated
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Techniques for Nonoperative Treatment of Tibial Plateau Fractures

Bracing Tibial Plateau Fractures.
Cast braces can be used to unload the injured side of the joint. They were once commonly used to stabilize the injured joint while permitting some degree of joint mobility.45,46,162 DeCoster et al.45 showed that alignment within 7 degrees of normal was obtained in all 30 plateau fractures treated with a cast brace, this included initial fractures classified as nondisplaced, minimally displaced, and displaced. Delamarter and Hohl46 used cast bracing as both a primary nonoperative treatment and as an adjunct to ORIF and showed that 85% maintained alignment in the cast brace. Currently, cast braces are not commonly used since most unstable plateau fractures are treated surgically and most surgical techniques achieve enough stability that a cast brace is not necessary. Tibial plateau fractures that are inherently stable or stabilized surgically do not need this additional protection and a lighter removable brace is preferred. 
Although injured knees with tibial plateau fractures tolerate up to 6 weeks of cast immobilization before becoming increasingly stiff, most surgeons prefer early mobilization with a hinged brace, which allows joint mobility and provides some coronal support. 

Weight-bearing Guidelines for Nonoperative Treatment of Tibial Plateau Fractures

Most patients with nonoperatively treated tibial plateau fractures should be kept non–weight-bearing during the initial weeks after injury. The duration of non–weight-bearing depends on the fracture pattern but is typically 4 to 8 weeks. Scotland and Wardlaw reported that patients with plateau fractures treated in a cast brace could weight bear early, within a few days or weeks after injury162; however, this technique is not often used in current practice. 

Outcomes for Nonoperative Treatment of Tibial Plateau Fractures

Excellent results treating tibial plateau fractures nonoperatively have been reported. Although there are no recent reports, older series provide important information. Since the indications to treat plateau fractures nonoperatively have narrowed considerably, the older series can be considered worst case when compared with those treated nonoperatively in current practice. 
Apley8 and Moore et al.127 both used initial traction and joint movement to manage tibial plateau fractures and felt early joint mobility and exercises contributed to their favorable outcomes. Jensen et al.89 compared traction to surgery and found equivalent outcomes, although not surprisingly surgery led to shorter hospital stays. On the other hand, motion must not be critical since Drennan et al. reported 85% good and excellent results with good motion at follow up in patients treated with closed reduction and a spica cast for 6 weeks.50 
Lansinger et al.105 reported on a 20-year follow-up of nonoperatively treated patients originally reported by Rassmusen. Surgical treatment was reserved for patients with greater than 10 degrees of coronal plane instability in full extension.144 The patients achieved 90% good and excellent results, which indicate that lack of significant instability in full extension is associated with good results after nonoperative treatment. Although this information is helpful in clinical decision-making in some cases, it is of limited value since it is often difficult to reliably examine an acutely injured knee to determine the degree of instability. 
Other authors have identified other predictors of outcome after plateau fractures treated nonoperatively. Waddell et al.184 found that plateau depression or widening of less than 10 mm was usually well tolerated. Honkonen80 found that 5 mm of widening and 3 mm of step-off were well tolerated but that any medial side displacement or tilt should be avoided. 
Scotland and Wardlaw162 reported excellent results for 29 patients treated in a cast brace and emphasized early weight bearing and return to function. DeCoster et al.45 followed 30 plateau fractures treated with a cast brace and found that the outcome of the knee was less favorable for more complex bicondylar fractures. Duwelius and Connolly51 reported good results after nonoperative or limited surgical approaches and noted that excellent clinical outcomes did not correlate well with the radiographic appearances of the knee. 
These results indicate that favorable outcomes are possible for many tibial plateau fractures without surgery, despite articular incongruities and displacements. It is important to maintain limb alignment and this may require external support with a cast brace and for some fractures traction or other methods. In current practice, patients with fractures similar to those in many of the above studies are treated operatively, which assures accurate limb alignment, early motion, and better reductions with less external support. However, the favorable results of nonoperative treatment should be considered when a patient with a tibial plateau fracture has significant comorbidities, is elderly with osteopenic bone, has poor skin, or does not want an operation. An excellent outcome without surgery is possible for many tibial plateau fracture patterns. 

Operative Treatment of Tibial Plateau Fractures

Indications/Contraindications for Surgical Treatment of Tibial Plateau Fractures

Operative treatment of tibial plateau fractures is indicated for displaced unstable tibial plateau fractures where near normal limb alignment can not be predicted based on the fracture pattern or physcial examination. In young healthy patients, this will include almost all bicondylar and shaft dissociated patterns, and all but minimally displaced medial plateau fractures and lateral plateau fracture patterns where valgus alignment will occur without surgically reducing and fixing the fracture. For the lateral patterns, the presence of a split fragment, a depression affecting over half of the lateral articular surface, a fibular head fracture, valgus alignment on injury radiographs, and clinical valgus alignment on exam are all strong indications for surgery. 
The number of millimeters of depression of the articular surface measured on radiographs has been frequently used to indicate surgery. Unfortunately, depression is difficult to measure accurately and reliably on plain radiographs. Martin et al. found that when observers make measurements independently from each other, their measurements are different from each other by 12 mm or more 10% of the time. In addition, the size and location of the depressed area all make a difference in whether a certain amount of depression will be clinically significant.121 The number of millimeters is not reliable and too simplistic to be a good way to decide on surgical indications. 
In elderly, less active, or medically unfit patients the indications for operative treatment are narrower and the risks and benefits of surgical intervention must be carefully assessed on a case by case basis. In these patients, a deformity will be less significant, functional demands are less, and surgery is potentially more difficult with more osteopenic bone (Fig. 55-18A–C). The results of surgery in elderly patients are generally less satisfactory than in young patients.12,81,94,161,191 
Figure 55-18
 
Nonoperative treatment plays a greater role in elderly patients with limited function, medical comorbidities, and osteopenic bone. A 76-year-old female with medical comorbidities slips and falls. An AP radiograph (A) and CT cuts (B) show a significant joint depression lateral plateau fracture. Three years after nonoperative treatment, radiographs (C) show slight valgus alignment with a relatively preserved joint. She returned to her previous level of activity.
Nonoperative treatment plays a greater role in elderly patients with limited function, medical comorbidities, and osteopenic bone. A 76-year-old female with medical comorbidities slips and falls. An AP radiograph (A) and CT cuts (B) show a significant joint depression lateral plateau fracture. Three years after nonoperative treatment, radiographs (C) show slight valgus alignment with a relatively preserved joint. She returned to her previous level of activity.
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Figure 55-18
Nonoperative treatment plays a greater role in elderly patients with limited function, medical comorbidities, and osteopenic bone. A 76-year-old female with medical comorbidities slips and falls. An AP radiograph (A) and CT cuts (B) show a significant joint depression lateral plateau fracture. Three years after nonoperative treatment, radiographs (C) show slight valgus alignment with a relatively preserved joint. She returned to her previous level of activity.
Nonoperative treatment plays a greater role in elderly patients with limited function, medical comorbidities, and osteopenic bone. A 76-year-old female with medical comorbidities slips and falls. An AP radiograph (A) and CT cuts (B) show a significant joint depression lateral plateau fracture. Three years after nonoperative treatment, radiographs (C) show slight valgus alignment with a relatively preserved joint. She returned to her previous level of activity.
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Fracture Classification and Pattern Dictates the Operative Approach

There are two frequently used surgical approaches to reduce and internally fix tibial plateau fractures: the anterolateral approach and the posteromedial approach. They are used in isolation for fractures on the lateral and medial side of the knee respectively, and not uncommonly, they are used together for patterns that involve both condyles. These two approaches with common variants can be used to treat virtually all tibial plateau fractures. In current practice, most other approaches have become unusual or reserved for special circumstances. Recently, a number of posterior approaches that are different from the posteromedial approach have been described and have become popular for some posterior fracture patterns.26 
In fractures of the tibial plateau, the fracture pattern dictates the operative approach, fixation technique, risk for complications, and to some extent the outcome. These differences stratify nicely based on the OTA/AO and Schatzker classifications. There is some variability in the procedures recommended in the literature for each of these patterns but the general principles are similar enough to allow a pattern-based discussion. The following sections will outline the general range of surgical techniques and implants used for each of these basic patterns and the fracture-specific results reported in the literature. 

Technique Overview

The treatment techniques that result in the most favorable patient outcomes depend on the patient and the fracture pattern. A variety of techniques are currently popular, have good results reported in the literature, and new techniques continue to be developed. However, for a given patient with a given fracture pattern there is little evidence to indicate one technique is superior to others. For instance, for one of the most common fracture patterns, a split depression lateral plateau fracture, currently acceptable techniques for visualizing the articular surface reduction include fluoroscopic, arthroscopic, and joint arthrotomy with infra or anterior meniscal incision. The same fracture might be stabilized with either small or large plates and screws, or screws alone. The screws may be traditional nonlocked or may be locked to the plate. Numerous materials to fill the void created after reducing the fracture would be considered acceptable choices. As another example, there has been a wave of popularity for treating OTA/AO C fractures and Schatzker 6 patterns with locking plates without any evidence that outcomes are better than with previous techniques. It is even difficult to know which fractures are benefited by surgical management. 
In planning to operatively treat a tibial plateau fracture, the fracture pattern will dictate the operative approach, the technique of reducing the fracture, and the appropriate use of internal or external fixation devices. In addition to assessing the fracture pattern, the surgeon must decide how to visualize the articular reduction and whether to assess and manage associated meniscal and ligament injuries as part of an operative treatment plan. 

Techniques to Visualize the Articular Reduction

Accurately reducing the displaced articular surface is an important aspect of treating displaced plateau fractures. In planning a surgical case, the surgeon has choices on how to assess and visualize the reduction. The articular reduction can be assessed indirectly by fluoroscopy, with an arthroscope, or directly through an arthrotomy to see the articular surface. Some surgeons favor one approach over another and others choose different approaches based on the fracture pattern. 
If the fracture pattern permits, many surgeons prefer to directly assess the fracture reduction through a joint arthrotomy. In lateral side patterns, the meniscus can either be incised anteriorly or elevated with a submeniscal arthrotomy. Both approaches allow the articular reduction to be assessed under direct vision. This direct visualization may be enhanced with the use of a joint-spanning femoral distractor. The meniscus and arthrotomy are repaired during closure. 
Arthroscopic techniques to assess and direct fracture reduction have been utilized by some surgeons for a wide range of fracture patterns for over two decades (Fig. 55-19A, B).87 With arthroscopic techniques, the fractured articular surface is visualized less invasively than with wide arthrotomies and detaching or elevating the meniscus. In addition to assisting with fracture reduction, arthroscopy has the further advantage of allowing associated intra-articular soft tissue injuries to be directly assessed and treated.182 Faster rehabilitation and more accurate reductions compared to open techniques with arthrotomy have been reported.135 Most authors have reported results that are similar to or better than more traditional open procedures,59,85,107,111,169 but directly comparing the two techniques is difficult because of potential differences in case selection.79,111 Although mostly utilized for split, split depression and local compression fracture arthroscopy has been utilized for higher energy fractures.36,87,169 Good results have been reported for arthroscopic treatment for elderly patients, mostly for lower energy fractures.151 Fluoroscopy is an integral tool in treating tibial plateau fractures since it is utilized to assess the placement and final position of hardware in relation to fracture lines and the articular surface. Final assessment of fracture reduction is frequently by fluoroscopy. Therefore, using fluoroscopy to assess the reduction is frequently part of the operative plan. However, utilizing fluoroscopy exclusively as a guide to reducing depressed fragments is challenging and not universally accepted. It has the advantage of being less invasive than joint arthrotomy and does not require the extra equipment and joint distraction required for arthrosocpy. Koval et al.102 indirectly reduced 18 plateau fractures using fluoroscopy and fixed them with screws and had 13 excellent reductions. They noted more difficulty accurately reducing fractures with depressed fragments, although interestingly, all cases with incomplete reductions had excellent outcomes. Other authors have reported similar experiences with simple cases amenable to fluoroscopic assesment alone and more complex cases requiring adjunctive arthrotomies or arthroscopy.52,72,98 In a comparative study, Lobenhoffer et al. found that fluoroscopic assessment of the plateau with a C-arm was equivalent to and technically easier than assessing it with an arthroscope. Patients assessed with fluoroscopy alone did not have clinical problems secondary to unrecognized soft tissue injuries.110 
Figure 55-19
These pictures illustrate the arthroscopic assessment of a split fracture (A) and the fracture line after it has been reduced (B).
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Treatment of Soft Tissue Injuries Associated with Tibial Plateau Fractures

Soft tissue injuries are frequent with tibial plateau fractures and need to be considered in developing an operative plan. There are two important types of soft tissue injuries. First, there are injuries to menisci and ligaments and second, there is the injury to the surrounding soft tissue envelope that increases the risks for complications and must be considered when managing tibial plateau fractures. 
Management of Ligament and Meniscal Injuries.
There is a high incidence of ligament and meniscal injuries associated with tibial plateau fractures. Some surgeons obtain an MRI routinely to assess tibial plateau fractures and the associated soft tissue injuries and others reserve it for cases where there is a particular concern about the status of the ligaments or the menisci that would not be otherwise assessed through the operative approach. When assessed by MRI, one study found that even minimally displaced tibial plateau fractures indicated for nonoperative treatment had a high percentage of these injuries (meniscal 80%, ligament 40%).168 In another study of MRI findings in 103 patients with operatively treated tibial plateau fractures, all but one patient had some soft tissue injury with lateral meniscus (91%) most commonly followed by ACL (77%), posterolateral corner (68%), and medial meniscus (44%).62 Similarly, in knees evaluated arthroscopically during operative treatment of tibial plateau fractures, 71% (70/98) were found to have meniscal or ligament injuries at a rate of 57% for meniscal, 25% for ACL, 5% PCL, and 3% each for MCL and LCL.1 The authors of this study could not demonstrate a strong association with fracture type although ACL injuries were more common in total condylar and Schatzker 6 patterns. In another study, the incidence of meniscal injury in split depression patterns was found to correlate with the degree of depression and condylar widening.61 Looking specifically at ligament injuries using stress radiographs and intraoperative findings, Delamarter et al.47 found that in 39 tibial plateau fractures evaluated there were 22 MCL, 8 LCL, 1 ACL, and 8 combined ligament injuries. Unfortunately, the clinical significance of these soft tissue injuries when associated with a tibial plateau fracture is not known. 
The treatment of these associated soft tissue injuries is controversial. Conservatively managing MCL injuries is generally favored so most surgeons do not currently advocate diagnostic or treatment strategies for an associated MCL injury. In addition, the medial ligament does not present long-term problems and residual laxity usually relates to bony depression rather than collateral ligament laxity. At an average of nearly 3 years after injury, Moore et al. 126 tested 208 patients with unicondylar tibial plateau fractures for varus or valgus laxity using stress radiographs. They found that when compared to the uninjured knee, there was no increased laxity to suggest chronic collateral ligament damage. None of these patients were treated with ligament repair. This was despite calcification in collateral ligaments in one out of seven knees. This information suggests that after reducing and fixing a lateral plateau fracture, a routine postoperative brace or immobilizer is sufficient to treat the associated collateral ligament injury. 
Assessing and managing other intra-articular meniscal and ligament injuries that are frequently present is controversial. Some authors recommend an aggressive approach to both diagnosis and surgical repair.18,87,172,182 Other authors have found that the patients function and outcomes are excellent without addressing these injuries.30,118 The meniscus is important in preventing post traumatic OA and many operative techniques stress meniscal repair.15 However, the vast majority of minimally displaced tibial plateau fractures have excellent outcomes without addressing associated meniscal or ligament injuries. For these minimally displaced fractures, as for all tibial plateau fractures, it is difficult to know which soft tissue injuries need to be managed surgically to improve patient outcome. Many severe tibial plateau fractures have excellent outcomes after being treated surgically with techniques that do not routinely evaluate or repair meniscal injuries.118 These results indicate that meniscal injuries either heal or are not symptomatic in patients after tibial plateau fractures. Reattaching an avulsed ACL or PCL, particularly when it is associated with a fracture fragment, is recommended by the authors of some series of high-energy fractures.17,40 In one comparative study better results were found in fractures where the ligaments were surgically repaired compared to fractures treated without ligament repair.43 However, other series of high-energy fractures have reported good results without ligament repair.116,118,186,191 and many reports on high-energy fractures do not indicate whether ligament injuries were addressed surgically.11,52,68 
Management of the Soft Tissue Envelope.
Some tibial plateau fractures have a severe injury to the overlying soft tissues. The worst soft tissue injuries typically occur with bicondylar fractures, fracture dislocations, and shaft-dissociated patterns. These high-energy patterns may require extensive surgical approaches with substantial implants and the potential risk of wound complications with these procedures is increased because of the injury to the soft tissues. Open tibial plateau fractures may be clinically obvious but subtle wounds or abrasions in the zone of injury must be assessed with suspicion for being an open fracture. When there is doubt, these suspicious wounds should be explored. Fracture blisters occur when the soft tissue injury is severe and may be red or white; red blisters represent a deeper dermal injury. Tense swelling and deep contusions are additional signs of severe fracture-associated soft tissue injury. Severe closed soft tissue injuries take many days or even weeks after the injury to recover. 
Open soft tissue injuries should be urgently debrided in the operating room. Soft tissue coverage may be needed and this can frequently be accomplished with a rotational flap from the medial or less commonly lateral head of the gastrocnemius. 

Fixation Technique Principles for Tibial Plateau Fractures

Principles of Plates and Screw Fixation of Tibial Plateau Fractures.
Plates and screws are the most frequent implants used to stabilize tibial plateau fractures and all major manufacturers have recently developed precontoured periarticular plates and locking plates, resulting in more plate choices than have ever been available in the past. 
The simplest implants used for fixation of tibial plateau fractures are lag screws used to compress simple fracture lines in isolation or in conjunction with other fixation devices. For compression, partially threaded screws are most common and 6.5-mm screws work well for major plateau fracture lines although smaller screws may work equally well. 
Plates serve different functions depending on the fracture pattern and where they are placed anatomically. A common plate application is for the anterolateral proximal tibia where it is used as a buttress and to substitute for the damaged lateral cortex that occurs with lateral split depression plateau fractures. These plates are precontoured for this anatomic region which makes obtaining an accurate fit for buttressing the lateral tibial condyle much easier. 3.5-mm implants and screws are the most common size having largely supplanted the 4.5-mm implants that were common in the past. 3.5-mm implants are less bulky and easier to fit on the bone and the smaller 3.5-mm screws allow more screws to be placed closer to the articular surface to support reduced fragments. Multiple holes in the head of the plate allow 3.5-mm screws to be placed parallel and close to the articular surface to support the reduced articular surface and minimize the chances for postoperative settling. This technique has been called “rafting screws.”91,101 It is similar to an older technique that utilized mulitple K-wires beneath a lateral fragment as a way to prevent secondary displacement.19 The high incidence of articular reduction loss after surgically treating lateral plateau fractures, reported in 31% of cases in one series, means that newer techniques not utilized in this series, such as rafting screws, should be very seriously considered.4 
Posteromedial plates serve a different mechanical function than anterolateral plates. In this area the plate must function as an antiglide device to resist shearing forces. Again, 3.5-mm implants are most common and specially contoured plates are becoming available from several manufacturers. In this area the plate position in relation to the apex of the fracture is more important than the exact placement of screws. A screw near the apex of the fracture will assure close apposition of the plate in this critical area. 
Precontoured plates for fractures of the proximal tibia have several advantages. They decrease time spent for intraoperative plate contouring, facilitate limited approaches when the bone is not completely visualized to allow contouring, and may assist with reduction by fitting the fractured bone to the precontoured plate. However Goyal et al.69 have shown that there is significant variation in the shape of the proximal tibia leading to suboptimal fit of precontoured plates to cadaver specimens, even in ideal laboratory settings. The relevance of this finding to maintaining fracture reduction is uncertain but surgeons can be certain that perfect plate contact with the bone will not frequently be obtained, and modifications to the plate or screw type may need to be made. 
Lateral plates used for bicondylar and Schatzker 6 fractures must resist axial, rotational, and bending forces. Locking screws to the plate has been a big advance in resisting these mechanical forces and these implants are currently very popular. They are bigger and use bigger screws than those used for unicondylar fractures based on the need to resist substantial deforming forces. From their lateral position, they must prevent the tendency of bending forces to create a varus deformity. By resisting varus collapse they have decreased the need for dual plates and for definitive external fixation. 
These plates have been designed to be inserted through a limited approach with external targeting of the distal screws. They can now be used with either locked or nonlocked screws. The so-called hybrid techniques use nonlocked screws to pull the bone to the precontoured plate and then locked screws are added to resist angular deviation. Some manufacturers now offer polyaxial designs with flexibility in the direction of screw insertion combined with fixed angle stability.70 Although many manufacturers have made locking technology for many of their implants, the use of locking screws for unicondylar tibial plateau fractures where the plate functions as a buttress (lateral plateau) or for antiglide (posteromedial plateau) is of uncertain value. 
Principles of External Fixation of Tibial Plateau Fractures.
The way in which external fixation is used for tibial plateau fractures has dramaticlly changed in the last decade. The advent of locking plates applied through limited approaches has significantly decreased the amount of external fixation used for definitive treatment of shaft-dissociated and bicondylar patterns. However, external fixation is now frequently used as a temporary treatment by spanning the knee. This technique restores length and aligns the fracture during soft tissue recovery prior to definitive treatment with internal fixation. 
Definitive external fixation still has a role in complex tibial plateau fractures based on surgeon preference or in cases with severe soft tissue injury, when despite delay, internal fixation is not felt to be safe. Most data indicate that external fixation is equally as effective or more so than plate fixation.10,191 One randomized study of bicondylar fractures by the Canadian Orthopaedic Trauma Association found that patients treated with external fixation had similar or better outcomes with less complications than those treated with dual plating.30,71 Defintive external fixation can be performed using a variety of different frames and both wires and pins have been effective. The frame and the bone fixation elements must be designed to overcome the deforming forces. Some fixator constructs may be as effective at resisiting deforming forces in bicondylar fractures as dual plates (Fig. 55-20A, B).5 
Figure 55-20
Two examples of definitive external fixation frames for tibial plateau fractures.
 
A pin frame with a one-third ring and hinges for fracture alignment (A) and a ring frame with spatial hinges (B).
A pin frame with a one-third ring and hinges for fracture alignment (A) and a ring frame with spatial hinges (B).
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Figure 55-20
Two examples of definitive external fixation frames for tibial plateau fractures.
A pin frame with a one-third ring and hinges for fracture alignment (A) and a ring frame with spatial hinges (B).
A pin frame with a one-third ring and hinges for fracture alignment (A) and a ring frame with spatial hinges (B).
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Temporary spanning frames should be simple and easily applied. Pin bar frames are most common allowing pin spread and frame geometry to be designed based on the needs of the fracture and associated soft tissue injury (Fig. 55-21). The tibial pins should be placed in a way to not interfere with subsequent procedures for internal fixation keeping potentially contaminated pin sites away from future incisions and internal fixation devices. Radiolucent carbon bars facilitate imaging after the frame is applied. The major goal is to restore and then maintain length and align the fracture and knee joint. This may require significant distraction forces. Spanning frames need to be utilized only for severe fractures with marked displacement, shortening, or joint subluxation. They are rarely necessary for routine lateral plateau fractures and are usually not needed for medial plateau and bicondylar fractures that are only minimally displaced. Widely displaced fractures with soft tissue injuries such as tense swelling, fracture blisters, compartment syndrome, or open wounds are the best indications for temporary spanning frames. The use of a staged protocol has been reported to decrease the wound complication rate but there are no comparative studies.54 
Figure 55-21
A picture of a simple pin to bar joint spanning external fixator.
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Principles of IM Nailing of Tibial Plateau Fractures.
Intramedullary nails have been and can be used for select tibial plateau fractures by surgeons using special techniques (Fig. 55-22A–D). The indications for and complexities associated with nailing very proximal tibia fractures will be covered in Chapter 57
Figure 55-22
 
A high-energy Schatzker 6 tibial plateau fracture (A) was treated with a spanning fixator (B) and then nailing (C and D). Although unusually applied for tibial plateau fractures, nailing can be used for patterns such as this one where there is significant distal extension of the fracture into the shaft associated with a relatively simple articular component.
A high-energy Schatzker 6 tibial plateau fracture (A) was treated with a spanning fixator (B) and then nailing (C and D). Although unusually applied for tibial plateau fractures, nailing can be used for patterns such as this one where there is significant distal extension of the fracture into the shaft associated with a relatively simple articular component.
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A high-energy Schatzker 6 tibial plateau fracture (A) was treated with a spanning fixator (B) and then nailing (C and D). Although unusually applied for tibial plateau fractures, nailing can be used for patterns such as this one where there is significant distal extension of the fracture into the shaft associated with a relatively simple articular component.
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Figure 55-22
A high-energy Schatzker 6 tibial plateau fracture (A) was treated with a spanning fixator (B) and then nailing (C and D). Although unusually applied for tibial plateau fractures, nailing can be used for patterns such as this one where there is significant distal extension of the fracture into the shaft associated with a relatively simple articular component.
A high-energy Schatzker 6 tibial plateau fracture (A) was treated with a spanning fixator (B) and then nailing (C and D). Although unusually applied for tibial plateau fractures, nailing can be used for patterns such as this one where there is significant distal extension of the fracture into the shaft associated with a relatively simple articular component.
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A high-energy Schatzker 6 tibial plateau fracture (A) was treated with a spanning fixator (B) and then nailing (C and D). Although unusually applied for tibial plateau fractures, nailing can be used for patterns such as this one where there is significant distal extension of the fracture into the shaft associated with a relatively simple articular component.
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Principles of Void Filling of Tibial Plateau Fractures.
More than with most other fracture patterns reducing depressed tibial plateau articular fragments, typically those of the lateral plateau lead to empty areas in bone or voids beneath the reduced fragments. The cancellous trabeculae are compressed by the injury resulting in loss of substance after the articular fragments are reduced. Given the excellent healing potential of these cancellous fractures, these voids do not present a risk for failure of healing problems. Rather, they are an area that lacks support for the reduced articular fragments increasing the risk that the articular fragments will redisplace despite internal fixation. To minimize this risk, it has been a principal of lateral plateau fracture surgery to fill metaphyseal voids to increase stability and prevent redisplacement. Classically, the most common material for “grafting” the void has been autograft most frequently from the iliac crest.104,156,184 In severe cases, tricortical iliac graft has been recommended,163 and where support of reduced fragments is not possible replacement of the lateral plateau with a patellar graft.86,197 For many surgeons, allograft has supplanted autograft. Allograft has the advantage of being readily available in unlimited quantaties and offers similar handling properties to autograft without donor site morbidity.165 
Investigators have assessed a variety of commercially available graft substitutes in mechanical and clinical studies. The optimal material is currently uncertain but this is an area of changing practice. Since subsidence after surgically reducing and fixing lateral plateau fractures is a real problem, new methods to support the reduced articular surface are important. Interporous coraline hydroxyapatite has excellent bone in growth properties,77 and in 1989 Bucholz et al.28 found it to be equivalent in clincial outcome to autograft in patients with tibial plateau fractures. In goats, 3 months after creating a cylindrical defect and filling it with beta tricalcium phospate, investigators found less collapse and more new bone than in similar defects filled with autograft.195 
Most recent work has focused on phase-changing cements which have been shown to have better rather than equivalent mechanical properties to autologous and allograft bone grafts. In a split depression fracture model in cadavers, a calcium phosphate (Ca-P) cement was significantly stiffer in compression compared to cancellous bone.179 In a goat lateral plateau model without internal fixation, Ca-P cement augmentation led to less secondary displacement than cancellous bone.194 
Ca-P cement for tibial plateau fractures has been reported in several level four studies and the results have been generally favorable.83,95,109,123,170 However, in all of these studies there remains a small but persistent rate of subsidence of the lateral articular surface. For instance, Lobenhoffer et al. noted partial loss of reduction 4 to 8 weeks after surgery in 2 of 25 cases treated with Ca-P cement. In a randomized controlled trial Russell et al.153 found that Ca-P cement resulted in less articular subsidence than autograft. In a meta-analysis, fractures in metaphyseal regions treated with Ca-P cement maintained reduction better than those treated with autograft and patients treated with Ca-P cement had less symptoms than controls treated without graft.11 Further clinical investigation will be necessary to confirm these results and it will be challenging to prove that outcomes are improved. However, the potential for better support for the reduced articular surface should be welcomed since loss of reduction remains one of the problems with surgery for these fractures. 
Principles of Post-operative Care.
The postoperative care of tibial plateau fractures has not been the subject of very many studies. The optimal postoperative program should minimize complications and loss of reduction of the fracture and maximize knee motion while speeding recovery and return to function. 
A period of non–weight-bearing or minimal weight bearing is necessary to minimize the chances of displacing the reduced fracture. The duration depends on the fracture pattern and the strength of the fixation but it probably takes 6 to 12 weeks for any meaningful increase in resistance to displacement from fracture healing, so most surgeons will not progress weight bearing until sometime in this range. One paper recommended early weight bearing for operatively and nonoperatively treated lateral plateau fractures with a cast brace to unload the lateral side and demonstrated little secondary displacement.164 Although cast braces are less commonly used in current practice, this information should be considered when poor patient compliance with weight bearing restrictions is anticipated. 
Mobilizing the knee postoperatively is the second issue that is potentially important in the postoperative care of tibial plateau fractures. Fractures treated nonoperatively can regain excellent knee motion after being immobilized for up to 6 weeks.50,65 However, since most fractures treated nonoperatively in current practice can be safely moved post injury, most surgeons will recommend knee motion immediately or within a few weeks, usually in a hinged brace. 
Gausewitz and Hohl65 felt that that early motion was much more important after operative treatment, because knees immobilized for longer than 2 weeks tended to be stiff. In current practice, surgeons strive to fix fractures in a way that will allow motion during the early weeks of recovery sometimes in a hinged brace. In recent years temporary periods of immobilizing injured joints with a spanning fixator have been used with increased frequency for some severe tibial plateau fractures. Marsh et al.118 have shown that the knee can recover excellent motion (range of flexion greater than 130 degrees) after up to 6 weeks of immobility using spanning fixation. Other investigators have also found that cross joint external fixation does not seem to be a frequent obstacle to regaining motion.54 Continuous passive motion (CPM) has been used following total knee arthroplasty; however, to our knowledge its use has not been specifically referenced following fixation of tibial plateau fractures. 
Principles of Surgical Procedures.
The following section details seven surgical procedures commonly utilized in the operative management of tibial plateau fractures. Surgical procedures no. 1, no. 2, and no. 3 deal specifically with lateral-sided injuries, including lateral split fractures (surgical procedure no. 1, split fracture of the lateral plateau—limited approach techniques with arthroscopic or fluoroscopic assessment of reduction), split lateral depression fractures (surgical procedure no. 2, split depression fractures of the lateral plateau—reduction and buttress plate fixation and void filler), and pure lateral depression fractures (surgical procedure no. 3, local compression—limited approach techniques with arthroscopic or fluoroscopic assessment of reduction and screw fixation or plate fixation and void filler). The operative management of tibial plateau fractures also requires medial-sided access (the preferred approach is the posteromedial approach) and is discussed in surgical procedure no. 4 (posteromedial approach for isolated medial condylar fractures). 
For bicondylar fracture patterns of the tibial plateau, a combination of approaches and techniques is often needed. In some bicondylar patterns, by using a combination of approaches, or single-sided approach the fractured articular surface is put together as a block (surgical procedure no. 1, no. 2) which is then managed via one of several options including dual plating (surgical procedure no. 5), lateral locking plate (surgical procedure no. 6), or external fixation (surgical procedure no. 7). 

Limited Approach Techniques with Arthroscopic or Fluoroscopic Assessment of Reduction (Surgical Procedure no. 1—Applicable to OTA/AO B1 or Schatzker 1—Split Fractures of the Lateral Plateau)

Preoperative Planning for Limited Fixation of Tibial Plateau Fractures (Table 55-2)
 
Table 55-2
Limited Approach Fixation of Tibial Plateau Fractures
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Table 55-2
Limited Approach Fixation of Tibial Plateau Fractures
Preoperative Planning Checklist
  •  
    OR Table: Radiolucent
  •  
    Position/positioning aids: Supine
  •  
    Fluoroscopy location: C-arm enters from opposite side of the fractured extremity
  •  
    Equipment: Large reduction clamps, cannulated screws, noncannulated screws
  •  
    Tourniquet (sterile/nonsterile): Nonsterile
X
Simple split fractures of the medial and lateral plateau are the strongest indications for limited approach techniques which assess the reduction with arthroscopy or fluoroscopy (Fig. 55-23A–C). These fracture patterns do not have large depressed fragments and reducing the split fragment will accurately align and stabilize the joint and restore the congruity of the articular surface. The fracture can often be fixed with percutaneously applied screws alone. Preoperatively, the location and orientation of the fracture lines should be accurately determined with a CT scan. This planning can guide the surgeon to apply reduction forceps and direct screw paths to optimally reduce and securely fix the split fracture. Large reduction forceps with a span to extend between the two plateaus are helpful. 
Figure 55-23
 
Injury (A) and postoperative (B) AP radiographs of a split fracture that was treated with fluoroscopically assisted percutaneous reduction and 6.5-mm cannulated screws. Large reduction forceps assisted in reducing the fracture (C). This is a common approach for this fracture pattern and could be combined with an arthroscopic assessment of the reduction.
Injury (A) and postoperative (B) AP radiographs of a split fracture that was treated with fluoroscopically assisted percutaneous reduction and 6.5-mm cannulated screws. Large reduction forceps assisted in reducing the fracture (C). This is a common approach for this fracture pattern and could be combined with an arthroscopic assessment of the reduction.
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Figure 55-23
Injury (A) and postoperative (B) AP radiographs of a split fracture that was treated with fluoroscopically assisted percutaneous reduction and 6.5-mm cannulated screws. Large reduction forceps assisted in reducing the fracture (C). This is a common approach for this fracture pattern and could be combined with an arthroscopic assessment of the reduction.
Injury (A) and postoperative (B) AP radiographs of a split fracture that was treated with fluoroscopically assisted percutaneous reduction and 6.5-mm cannulated screws. Large reduction forceps assisted in reducing the fracture (C). This is a common approach for this fracture pattern and could be combined with an arthroscopic assessment of the reduction.
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X
Positioning for Limited Fixation of Tibial Plateau Fractures.
The patient is positioned supine on a radiolucent table. The hip is bumped to neutral extremity rotation, with the leg elevated on either a nonsterile radiolucent platform or sterile bump(s) as necessary. 
Surgical Approach for Limited Fixation of Tibial Plateau Fractures.
A formal surgical approach is not required, small percutaneous stab incisions for clamp and drill placement are made as necessary. The major area of controversy in this fracture type is the optimal technique to assess the accuracy of the reduction (see techniques to visualize the articular reduction). Arthroscopic techniques directly visualize the articular fracture through a minimally invasive approach but fluoroscopic techniques, when used well, may be equally as effective. To fix the fracture with screws only, the split fragment needs to be compressed to prevent displacement. Plate fixation requires an open approach and applies more bulky hardware. A mechanical study in cadavers has shown no difference between pure split fractures fixed with 6.5-mm interfragmentary screws alone and those fixed with screws with the addition of a buttress plate or the addition of an antiglide screw and washer at the apex of the fracture.101 
Technique for Limited Fixation of Tibial Plateau Fractures (Table 55-3)
Table 55-3
Limited Approach Fixation of Split Lateral Tibial Plateau Fractures
Surgical Steps
  •  
    Obtain adequate preoperative imaging, including images of the opposite knee, and usually a CT scan
  •  
    Confirm position of reduction clamp placement which is based on preoperative planning
  •  
    Assess reduction on orthogonal images
  •  
    Placement of subchondral screws ± washers
  •  
    Remove reduction clamps and confirm maintenance of reduction
X
The fracture line is clearly identified with intraoperative fluoroscopy. The orientation of the fluoroscopic image and the fracture line are adjusted in relation to each other so the surgeon knows the exact direction of the split fragment fracture line. Stab incisions are then made for reduction clamp placement perpendicular to the major fracture line. The fracture reduction is then confirmed with fluoroscopic images, guidewires, and cannulated screws are then placed through small incisions perpendicular to fracture lines and parallel to the joint line within 1.5 cm from the articular surface. 6.5-mm screws are most commonly chosen. 
Postoperative Care for Limited Fixation of Tibial Plateau Fractures.
Patients are instructed in range of motion exercises in a hinged brace. The range is not restricted but limited weight bearing is recommended for 4 to 6 weeks. 
Potential Pitfalls and Preventative Measures for Limited Fixation of Tibial Plateau Fractures (Table 55-4)
 
Table 55-4
Limited Approach Fixation of Tibial Plateau Fractures
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Table 55-4
Limited Approach Fixation of Tibial Plateau Fractures
Potential Pitfalls and Preventions
Pitfalls Preventions
Unrecognized oblique fracture of medial condyle Careful preoperative planning
Consider posteromedial approach and direct reduction
Intra-articular screw placement
Failure to have reduction forceps or screw path perpendicular to fracture line
Careful fluoroscopic assessment
Preoperative planning
X
A major exception to reducing and fixing a split fracture through percutaneous techniques is an isolated oblique shearing fracture of the posteromedial condyle. A split fracture in this area is less amenable to percutaneous techniques because of more difficult posterior access and relatively higher deforming shearing forces. These fractures will more often be handled by a posteromedial open approach and an antiglide plate. 
Outcomes for Limited Fixation of Tibial Plateau Fractures.
Numerous authors have reported satisfactory results after closed reduction and screw fixation alone for split fractures and combinations of split and split depression fractures and even for relatively minimally displaced bicondylar fractures (Fig. 55-24).52,72,98,102,155 The results of treatment of Schatzker type 1 or OTA/AO B1 fractures in isolation are difficult to report with great precision because they are often combined with other lateral side patterns. However, in most series these fractures seem to have close to or the best outcomes of all plateau fracture types studied. For instance, Honkonen81 in a study of seven types of tibial plateau fractures treated with various operative and nonoperative techniques and followed for an average of 7.6 years found the least incidence of secondary arthritis in lateral split fractures. In Schatzker’s original report, which described the six fracture types, the only type that had all satisfactory results were the type 1 lateral split fracture.159 Koval et al.102 treated 18 displaced fractures by closed reduction and percutaneous screw fixation; the seven type 1 fractures had four excellent, two good, and one fair result. 
Figure 55-24
 
AP (A) and lateral (B) radiographs and an axial CT cut (C) show a low-energy split lateral plateau fracture (OTA/AO B3, Schatzker 2). Intraoperative images and immediate postopertaive image (D, E and F) show treatment with fluoroscopically assisted reduction, a 3.5-mm lateral plate, rafting screws, and Ca-P cement. The fracture at 1 year appears to have settled slightly (G and H). The clinical outcome was excellent.
AP (A) and lateral (B) radiographs and an axial CT cut (C) show a low-energy split lateral plateau fracture (OTA/AO B3, Schatzker 2). Intraoperative images and immediate postopertaive image (D, E and F) show treatment with fluoroscopically assisted reduction, a 3.5-mm lateral plate, rafting screws, and Ca-P cement. The fracture at 1 year appears to have settled slightly (G and H). The clinical outcome was excellent.
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AP (A) and lateral (B) radiographs and an axial CT cut (C) show a low-energy split lateral plateau fracture (OTA/AO B3, Schatzker 2). Intraoperative images and immediate postopertaive image (D, E and F) show treatment with fluoroscopically assisted reduction, a 3.5-mm lateral plate, rafting screws, and Ca-P cement. The fracture at 1 year appears to have settled slightly (G and H). The clinical outcome was excellent.
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Figure 55-24
AP (A) and lateral (B) radiographs and an axial CT cut (C) show a low-energy split lateral plateau fracture (OTA/AO B3, Schatzker 2). Intraoperative images and immediate postopertaive image (D, E and F) show treatment with fluoroscopically assisted reduction, a 3.5-mm lateral plate, rafting screws, and Ca-P cement. The fracture at 1 year appears to have settled slightly (G and H). The clinical outcome was excellent.
AP (A) and lateral (B) radiographs and an axial CT cut (C) show a low-energy split lateral plateau fracture (OTA/AO B3, Schatzker 2). Intraoperative images and immediate postopertaive image (D, E and F) show treatment with fluoroscopically assisted reduction, a 3.5-mm lateral plate, rafting screws, and Ca-P cement. The fracture at 1 year appears to have settled slightly (G and H). The clinical outcome was excellent.
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AP (A) and lateral (B) radiographs and an axial CT cut (C) show a low-energy split lateral plateau fracture (OTA/AO B3, Schatzker 2). Intraoperative images and immediate postopertaive image (D, E and F) show treatment with fluoroscopically assisted reduction, a 3.5-mm lateral plate, rafting screws, and Ca-P cement. The fracture at 1 year appears to have settled slightly (G and H). The clinical outcome was excellent.
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X

Reduction and Buttress Plate Fixation and Void Filling (Surgical Procedure no. 2—Applicable to OTA/AO B2 or B3 or Schatzker 2—Split Depression Fractures of the Lateral Plateau)

Preoperative Planning for Buttress Plate Fixation and Void Filling.
This is the most common operation for displaced tibial plateau fractures. Careful preoperative planning should include assessment of the fracture pattern as lateral split fragments are associated with varying amounts of articular depression in varying locations in the lateral plateau. The split fragment may be big and the depression small or a small split fragment may be part of a large joint depression fracture. An associated fibular head fracture increases the degree of knee instability and may be a negative factor for prognosis.24 By accurately reducing the lateral plateau, the goal of preventing or minimizing the valgus alignment that would occur without surgical treatment is realized. Review of an axial CT scan will quantify the amount and location of the articular depression in the lateral plateau. The location of the split fragment will be a clue for incision and eventual access to elevate the depressed fragments (Table 55-5). 
 
Table 55-5
ORIF of Tibial Plateau Fractures
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Table 55-5
ORIF of Tibial Plateau Fractures
Preoperative Planning Checklist
  •  
    OR table: Radiolucent
  •  
    Position/positioning aids: Supine
  •  
    Fluoroscopy location: C-arm enters from opposite side of fractured extremity
  •  
    Equipment: Large reduction clamps, bone void filler, femoral distractor, long K-wires
  •  
    Tourniquet: Nonsterile
  •  
    Implants: Precontoured 3.5-mm plates for the lateral tibial plateau
X
Positioning for Buttress Plate Fixation and Void Filling.
The patient is positioned supine on a radiolucent table, the hip is bumped to neutral extremity rotation, and the leg is elevated on a radiolucent platform (Fig. 55-25B). The C-arm should be on the medial side leaving the lateral side free for the surgeons to work while the knee is assessed fluoroscopically. 
Figure 55-25
AP and lateral images show a split lateral depression fracture (A).
 
The leg is elevated on a radiolucent platform (B). The surgical incision and local bony anatomy are marked on the leg (C). A continuous incision between the IT band and the anterior compartment fascia and a horizontal submeniscal arthrotomy is made followed by application of a femoral distractor across knee joint (D). Sutures are used to retract the meniscus and the posterior soft tissues remain intact on the split fragment (D). With joint distraction the lateral joint depression fragment is well visualized (E). Intraoperative fluoroscopy is utilized for joint elevation (osteotome), provisional K-wire fixation of elevated joint, plate positioning, and placement of calcium phosphate bone void filler (F). Closure is obtained by reapproximating the iliotibial band and anterior compartment. Horizontal sutures on the peripheral border of the meniscus will be tied onto the capsule on the outside (G). The postoperative images show the plate position, elevation of the lateral joint line, and calcium phosphate cement (H).
The leg is elevated on a radiolucent platform (B). The surgical incision and local bony anatomy are marked on the leg (C). A continuous incision between the IT band and the anterior compartment fascia and a horizontal submeniscal arthrotomy is made followed by application of a femoral distractor across knee joint (D). Sutures are used to retract the meniscus and the posterior soft tissues remain intact on the split fragment (D). With joint distraction the lateral joint depression fragment is well visualized (E). Intraoperative fluoroscopy is utilized for joint elevation (osteotome), provisional K-wire fixation of elevated joint, plate positioning, and placement of calcium phosphate bone void filler (F). Closure is obtained by reapproximating the iliotibial band and anterior compartment. Horizontal sutures on the peripheral border of the meniscus will be tied onto the capsule on the outside (G). The postoperative images show the plate position, elevation of the lateral joint line, and calcium phosphate cement (H).
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The leg is elevated on a radiolucent platform (B). The surgical incision and local bony anatomy are marked on the leg (C). A continuous incision between the IT band and the anterior compartment fascia and a horizontal submeniscal arthrotomy is made followed by application of a femoral distractor across knee joint (D). Sutures are used to retract the meniscus and the posterior soft tissues remain intact on the split fragment (D). With joint distraction the lateral joint depression fragment is well visualized (E). Intraoperative fluoroscopy is utilized for joint elevation (osteotome), provisional K-wire fixation of elevated joint, plate positioning, and placement of calcium phosphate bone void filler (F). Closure is obtained by reapproximating the iliotibial band and anterior compartment. Horizontal sutures on the peripheral border of the meniscus will be tied onto the capsule on the outside (G). The postoperative images show the plate position, elevation of the lateral joint line, and calcium phosphate cement (H).
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The leg is elevated on a radiolucent platform (B). The surgical incision and local bony anatomy are marked on the leg (C). A continuous incision between the IT band and the anterior compartment fascia and a horizontal submeniscal arthrotomy is made followed by application of a femoral distractor across knee joint (D). Sutures are used to retract the meniscus and the posterior soft tissues remain intact on the split fragment (D). With joint distraction the lateral joint depression fragment is well visualized (E). Intraoperative fluoroscopy is utilized for joint elevation (osteotome), provisional K-wire fixation of elevated joint, plate positioning, and placement of calcium phosphate bone void filler (F). Closure is obtained by reapproximating the iliotibial band and anterior compartment. Horizontal sutures on the peripheral border of the meniscus will be tied onto the capsule on the outside (G). The postoperative images show the plate position, elevation of the lateral joint line, and calcium phosphate cement (H).
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Figure 55-25
AP and lateral images show a split lateral depression fracture (A).
The leg is elevated on a radiolucent platform (B). The surgical incision and local bony anatomy are marked on the leg (C). A continuous incision between the IT band and the anterior compartment fascia and a horizontal submeniscal arthrotomy is made followed by application of a femoral distractor across knee joint (D). Sutures are used to retract the meniscus and the posterior soft tissues remain intact on the split fragment (D). With joint distraction the lateral joint depression fragment is well visualized (E). Intraoperative fluoroscopy is utilized for joint elevation (osteotome), provisional K-wire fixation of elevated joint, plate positioning, and placement of calcium phosphate bone void filler (F). Closure is obtained by reapproximating the iliotibial band and anterior compartment. Horizontal sutures on the peripheral border of the meniscus will be tied onto the capsule on the outside (G). The postoperative images show the plate position, elevation of the lateral joint line, and calcium phosphate cement (H).
The leg is elevated on a radiolucent platform (B). The surgical incision and local bony anatomy are marked on the leg (C). A continuous incision between the IT band and the anterior compartment fascia and a horizontal submeniscal arthrotomy is made followed by application of a femoral distractor across knee joint (D). Sutures are used to retract the meniscus and the posterior soft tissues remain intact on the split fragment (D). With joint distraction the lateral joint depression fragment is well visualized (E). Intraoperative fluoroscopy is utilized for joint elevation (osteotome), provisional K-wire fixation of elevated joint, plate positioning, and placement of calcium phosphate bone void filler (F). Closure is obtained by reapproximating the iliotibial band and anterior compartment. Horizontal sutures on the peripheral border of the meniscus will be tied onto the capsule on the outside (G). The postoperative images show the plate position, elevation of the lateral joint line, and calcium phosphate cement (H).
View Original | Slide (.ppt)
The leg is elevated on a radiolucent platform (B). The surgical incision and local bony anatomy are marked on the leg (C). A continuous incision between the IT band and the anterior compartment fascia and a horizontal submeniscal arthrotomy is made followed by application of a femoral distractor across knee joint (D). Sutures are used to retract the meniscus and the posterior soft tissues remain intact on the split fragment (D). With joint distraction the lateral joint depression fragment is well visualized (E). Intraoperative fluoroscopy is utilized for joint elevation (osteotome), provisional K-wire fixation of elevated joint, plate positioning, and placement of calcium phosphate bone void filler (F). Closure is obtained by reapproximating the iliotibial band and anterior compartment. Horizontal sutures on the peripheral border of the meniscus will be tied onto the capsule on the outside (G). The postoperative images show the plate position, elevation of the lateral joint line, and calcium phosphate cement (H).
View Original | Slide (.ppt)
The leg is elevated on a radiolucent platform (B). The surgical incision and local bony anatomy are marked on the leg (C). A continuous incision between the IT band and the anterior compartment fascia and a horizontal submeniscal arthrotomy is made followed by application of a femoral distractor across knee joint (D). Sutures are used to retract the meniscus and the posterior soft tissues remain intact on the split fragment (D). With joint distraction the lateral joint depression fragment is well visualized (E). Intraoperative fluoroscopy is utilized for joint elevation (osteotome), provisional K-wire fixation of elevated joint, plate positioning, and placement of calcium phosphate bone void filler (F). Closure is obtained by reapproximating the iliotibial band and anterior compartment. Horizontal sutures on the peripheral border of the meniscus will be tied onto the capsule on the outside (G). The postoperative images show the plate position, elevation of the lateral joint line, and calcium phosphate cement (H).
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X
Anterolateral Approach for Buttress Plate Fixation and Void Filling.
The anterolateral approach is the most common approach to surgically reduce and internally fix tibial plateau fractures. It is the workhorse approach for split depression fractures of the lateral plateau. The proximal portion of the anterolateral approach is variable based on surgeon preferences for joint exposure. For fluoroscopic or arthroscopic reductions, the proximal exposure develops subcutaneous access posteriorly toward the fibular head for placement of a lateral tibial L-shaped plate. The knee joint is not opened or further exposed. Alternatively, two different exposures can be used to directly visualize the lateral joint. In one of them, the deep dissection is brought posteriorly along the tibial margin of the joint line, incising the coronary ligament to create a submeniscal arthrotomy. This approach has been credited to the AO group.130 The coronary ligament is repaired at the end of the procedure and has been found to heal in a dog model of this submeniscal arthrotomy.33 
The second approach extends the skin incision proximally and an anterolateral joint arthrotomy is created. In this approach, exposure of the joint is from above the meniscus. The ability to visualize the tibial fragments is increased by incising the anterior portion of the coronary ligament and the intermeniscal ligament detaching the anterior horn of the lateral meniscus that can then be retracted laterally with the split fragment opening the joint through the fracture. These are repaired with sutures at the end of the procedure.139 Arthroscopic evaluation of the anterior horn has shown that the incised meniscus heals.136,139 Although the treatment approach for lateral split depressed tibial plateau fractures is fairly straightforward and familiar to most surgeons, the tendency to postoperative settling of the articular fragments is significant leading to a knee aligned in valgus despite surgery (Fig. 55-24A–H).4 The more severe the split depression fracture and the more osteopenic the bone, the greater the risk and severity of this problem. To avoid these problems, surgical techniques need to accurately and completely reduce the fracture, the implant needs to be placed to support the reduced fragments, and the void must be filled with the optimal material. Newer techniques with 3.5-mm plates, multiple “rafting screws,” and Ca-P cements to fill the void may be better than the previous techniques. 
Technique for Buttress Plate Fixation and Void Filling (Table 55-6)
 
Table 55-6
ORIF of Split Depression Lateral Tibial Plateau Fractures
Surgical Steps
  •  
    Expose proximal lateral tibia
  •  
    Submeniscal arthrotomy
  •  
    Apply femoral distractor across knee joint (Fig. 55-24C)
  •  
    Open split portion of fracture
  •  
    Reduce joint component and provisionally stabilize with K-wires (Fig. 55-24E)
  •  
    Reduce split component and provisionally stabilize with K-wires
    •  
      Restore condylar width using a large clamp across condyles
  •  
    Apply lateral plate (Fig. 55-24E)
X
The surgical procedure with a submeniscal arthrotomy and a femoral distractor will be described (Fig. 55-25A–H). The incision is based over Gerdy tubercle and is extended distally over the anterior compartment (Fig. 55-25C). The anterior compartment muscles are incised continuously with the iliotibial band and provide access to the anterolateral surface of the tibia and the coronary ligament. The proximal lateral tibia is exposed but care should be taken along the posterolateral border of the tibia as the anterior tibial artery passes through the interosseous membrane from back to front. 
The lateral split fragment will be exposed and partially reflected during the approach but care should be taken to minimize the stripping of soft tissues from this fragment particularly posteriorly. When the split fracture is reduced the capsule and iliotibial band that remain attached to the fragment will likewise be restored to their normal position and tension. The joint is exposed to facilitate fracture reduction and this is accomplished through the anterior fracture line in the lateral split fragment augmented with a posteriorly directed horizontal arthrotomy beneath the lateral meniscus. With a long enough inframeniscal incision the meniscus can be retracted proximally to expose the tibial side of the lateral joint beneath the meniscus (Fig. 55-25E). The depressed lateral articular surface is directly visualized. Cross joint distraction facilitates visualizing the joint through this submeniscal arthrotomy (Fig. 55-25D). 
Opening the fracture through the split fragment allows the depressed fragments to be manipulated and directly reduced to align with the margins of the intact areas of the plateau. Care should be taken to work from below (Fig. 55-25F), with tamps and elevators keeping as much of the cancellous bone beneath fragments intact as possible. Generally speaking, the more fragments can be elevated in situ from below and the less they are completely freed and placed on the back table, the more favorable the eventual reduction will be. The surgeon must carefully assess for and reduce marginal impactions and depressions of the articular surface. Otherwise, the depressed central fragment will be incompletely elevated to match a marginally depressed area, leading to an unsatisfactory reduction. The fragments may be temporarily fixed with K-wires (Fig. 55-25F). When assessed with fluoroscopy, the lateral side needs to be restored to its normal position, slightly higher than the medial side. Overreduction is better than underreduction, given a tendency to postoperative settling. Comparative images of the opposite side may be helpful in assessing whether the reduction has completely restored the height of the lateral side. 
The fracture is fixed with a laterally based buttress plate positioned over the split fragment. Current practice favors 3.5-mm plates with 3.5-mm screws (Fig. 55-25F, H). Screws are placed close to the articular surface to help support the reduced articular fragments. Three or four of these so-called rafting screws may be utilized. AP and lateral fluoroscopy assists in obtaining optimal implant position. Mechanically, multiple smaller screws provide better support to reduced articular fragments than a smaller number of larger screws.137 Precontoured plates facilitate implant fit to the bone but they must be carefully positioned to optimally achieve this. The proximity of the plate to the subchondral bone partially dictates the screw support for the articular fragments. 
The use of locking screws is controversial. Nonlocked screws facilitate compressing the plate to bone enhancing its buttress effect and narrowing the condylar width. Fixation in firm uninjured bone on the medial side prevents the screws from settling. They do not have to resist the bending and rotational forces as do lateral plates used to treat bicondylar fractures. Some surgeons might advocate that optimal support for the articular fragment is obtained by locking a rafting screw to the plate. 
Void filler is frequently necessary as part of this operative approach. After reducing but before internally fixing the fracture or after both of these steps, the void created by the fracture and the reduction process can be filled with one of several materials to support the articular fragment. If Ca-P cements are used, the screws should be placed prior to the cement to avoid fracture of the material which is brittle when it is set. If graft is used, it should be firmly impacted beneath the reduced fragments (Fig. 55-25F). 
Postoperative Care for Buttress Plate Fixation and Void Filling.
Patients are instructed in range-of-motion exercises which they perform in a hinged brace. The range is not restricted. The duration of non–weight-bearing depends on the severity of the fracture and varies between 4 and 10 weeks. 
Potential Pitfalls and Preventative Measures for Buttress Plate Fixation and Void Filling (Table 55-7)
 
Table 55-7
Tibial Plateau Fractures
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Table 55-7
Tibial Plateau Fractures
Potential Pitfalls and Preventions
Pitfalls Preventions
Injury to anterior tibial artery Dissect with care along the posterolateral border of the proximal tibia
Soft tissue stripping/devitalizing lateral split fragment Minimize posterior stripping of soft tissue attachments
Inadequate visualization Use of cross joint/femoral distractor
Use of temporary external fixator
Creating a large subchondral void when elevating depressed fragment Care in elevation to preserve as much cancellous bone as possible
Incomplete elevation of the depressed articular surface Assess reduction compared to opposite knee
Address marginal impaction
Settling of articular surface Place rafting screws close to articular surface
Place rafting screws prior to bone void filler
Adequate use of bone void filler to support reduction
X
Outcomes for Buttress Plate Fixation and Void Filling.
Of the three types of lateral plateau fractures, split depression fractures have slightly poorer outcomes than split or local compression fractures partially because of the likelihood of these occurring in elderly patients and partly because some very severe lateral plateau injuries are in this category. In elderly patients, Keating94 found that split depression fractures had worse outcomes than all other types except the shaft dissociated pattern. To a certain extent the results depend on the ability to reduce and maintain the articular reduction of the lateral plateau and for some fractures and in patients with osteopenic bone this can be difficult. Ali et al.4 reported a high percentage of patients that lost reduction after surgical treatment particularly elderly patients. Despite these concerns most authors report generally favorable outcomes. Savoie et al.156 had 18 of 21 and Lachiewicz and Funcik104 had 16 of 17 good and excellent results in operatively treated split depression fractures. 

Limited Approach Techniques with Arthroscopic or Fluoroscopic Assessment of Reduction and Screw or Plate Fixation and Void Filling (Surgical Procedure no. 3—Applicable to Schatzker 3—Local Compression Fractures)

The issues that depressed lateral side fracture patterns present are intermediate to the previous two. Usually, substantial lateral joint depression fractures are accompanied by at least a marginal split fragment and the appropriate operative techniques are described above. Very small isolated depressions of the lateral articular surface may or may not need to be treated operatively. To reduce a local depression fracture without a significant split fragment, the lateral wall should be left intact which then requires a technique to access the depressed area. This entire procedure can be accomplished using minimally invasive techniques. 
Preoperative Planning for Limited Approach Techniques with Arthroscopic or Fluoroscopic Assessment of Reduction and Screw or Plate Fixation and Void Filling.
See above for surgical procedures no. 1 and no. 2 (Table 55-8). 
Table 55-8
Limited Approach Articular Elevation and Fixation of Tibial Plateau Fractures
Preoperative Planning Checklist
  •  
    OR table: Radiolucent
  •  
    Position/positioning aids: Supine
  •  
    Fluoroscopy location: C-arm enters from opposite side of fractured extremity
  •  
    Equipment: Cannulated drill system to open cortex and target depressed fragment, screws, bone void filler, osteotomes, bone tamp
  •  
    Tourniquet (sterile/nonsterile): Nonsterile
X
Positioning for Limited Approach Techniques with Arthroscopic or Fluoroscopic Assessment of Reduction and Screw or Plate Fixation and Void Filling.
See above for surgical procedure no. 2. 
Surgical Approach for Limited Approach Techniques with Arthroscopic or Fluoroscopic Assessment of Reduction and Screw or Plate Fixation and Void Filling.
Surgical approach depends on the location of depressed articular surface. See surgical approaches for surgical procedures no. 1 and no. 2. These procedures will typically be accomplished with percutaneous approaches. 
Technique-limited Approach Techniques with Arthroscopic or Fluoroscopic Assessment of Reduction and Screw or Plate Fixation and Void Filling.
The surgical management of lateral depression fractures of the tibial plateau requires elevation of subchondral bone and the associated articular surface. The reduction is judged either fluoroscopically or arthroscopically. Access to the depressed fragment cannot be obtained from a fracture line as described above in surgical procedure no. 2. Methods for targeting regions of depression include use of intraoperative fluoroscopy in conjunction with either a cannulated or noncannulated drill or reamer where a guidewire is placed into the depressed cavity from the exterior surface of the tibia (e.g., ACL reamer) (Fig. 55-26A–E). Once the position is confirmed either arthroscopically or fluoroscopically the cortex can then be opened over the wire, providing access for tamps or awls to reduce the articular fragments. The cortex can be opened either anterolaterally or anteromedially depending on the direction of displacement of the articular fragment. Once access is obtained to the depressed fragment, careful elevation, monitored with fluoroscopy or arthroscopy, is then achieved with an instrument such as a hemostat, curette, Cobb elevator, osteotome, or bone tamp.141 More recently, some have advocated the use of an inflatable balloon to elevate depressed articular fragments. The reduced fragment is supported with subchondral screws targeted to the correct location beneath the fragment, and void filler can be used to fill the resulting cavity (Table 55-9). 
Figure 55-26
 
Intraoperative fluoroscopy images illustrate the sequence of reducing a local compression lateral tibial plateau fracture. An initial cannulated screw is placed to support any possible split-fragment and cannulated wires target the posterior depression (A and B). In this case a curette is introduced through the cortex to elevate the depressed fragment (C, D). Alternatively, a cannulated drill and impactor system could be used. The depressed fragment is supported with a second cannulated screw and calcium phosphate cement (E).
Intraoperative fluoroscopy images illustrate the sequence of reducing a local compression lateral tibial plateau fracture. An initial cannulated screw is placed to support any possible split-fragment and cannulated wires target the posterior depression (A and B). In this case a curette is introduced through the cortex to elevate the depressed fragment (C, D). Alternatively, a cannulated drill and impactor system could be used. The depressed fragment is supported with a second cannulated screw and calcium phosphate cement (E).
View Original | Slide (.ppt)
Intraoperative fluoroscopy images illustrate the sequence of reducing a local compression lateral tibial plateau fracture. An initial cannulated screw is placed to support any possible split-fragment and cannulated wires target the posterior depression (A and B). In this case a curette is introduced through the cortex to elevate the depressed fragment (C, D). Alternatively, a cannulated drill and impactor system could be used. The depressed fragment is supported with a second cannulated screw and calcium phosphate cement (E).
View Original | Slide (.ppt)
Figure 55-26
Intraoperative fluoroscopy images illustrate the sequence of reducing a local compression lateral tibial plateau fracture. An initial cannulated screw is placed to support any possible split-fragment and cannulated wires target the posterior depression (A and B). In this case a curette is introduced through the cortex to elevate the depressed fragment (C, D). Alternatively, a cannulated drill and impactor system could be used. The depressed fragment is supported with a second cannulated screw and calcium phosphate cement (E).
Intraoperative fluoroscopy images illustrate the sequence of reducing a local compression lateral tibial plateau fracture. An initial cannulated screw is placed to support any possible split-fragment and cannulated wires target the posterior depression (A and B). In this case a curette is introduced through the cortex to elevate the depressed fragment (C, D). Alternatively, a cannulated drill and impactor system could be used. The depressed fragment is supported with a second cannulated screw and calcium phosphate cement (E).
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Intraoperative fluoroscopy images illustrate the sequence of reducing a local compression lateral tibial plateau fracture. An initial cannulated screw is placed to support any possible split-fragment and cannulated wires target the posterior depression (A and B). In this case a curette is introduced through the cortex to elevate the depressed fragment (C, D). Alternatively, a cannulated drill and impactor system could be used. The depressed fragment is supported with a second cannulated screw and calcium phosphate cement (E).
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Table 55-9
Limited Approach Articular Elevation and Fixation of Tibial Plateau Fractures
Surgical Steps
  •  
    Obtain adequate preintervention imaging, including well leg
  •  
    Confirm location of depressed articular surface
  •  
    Elevate articular surface (osteotome, bone tamp)
  •  
    Apply bone void filler
  •  
    Assess reduction on orthogonal images
  •  
    Reduce joint component and provisionally stabilize with K-wires
  •  
    Apply plate or screws to support reduced articular surface
X
Postoperative Care for Limited Approach Techniques with Arthroscopic or Fluoroscopic Assessment of Reduction and Screw or Plate Fixation and Void Filling.
Similar to surgical procedures no. 1 and no. 2 above. 
Potential Pitfalls and Preventative Measures Limited Approach Techniques with Arthroscopic or Fluoroscopic Assessment of Reduction and Screw or Plate Fixation and Void Filling (Table 55-10)
 
Table 55-10
Tibial Plateau Fractures
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Table 55-10
Tibial Plateau Fractures
Potential Pitfalls and Preventions
Pitfalls Preventions
Settling of articular surface Place rafting screws close to articular surface
Place rafting screws prior to bone void filler
X
Treatment-specific Outcomes for Limited Approach Techniques with Arthroscopic or Fluoroscopic Assessment of Reduction and Screw or Plate Fixation and Void Filling.
Isolated compression fractures are less severe injuries than most of the other plateau patterns and for this reason have generally favorable outcomes. Keating94 found that in elderly patients split and local compression fractures had better outcomes than all other types. Lachiewicz104 found that all the local compression fractures treated surgically had excellent outcomes. Savoie et al. found all good and excellent outcomes in surgically treated patients with local compression fractures. In one series better results were reported with arthroscopic treatment than with open reduction.59 

Medial Antiglide Plating via a Posteromedial Surgical Approach (Surgical Procedure no. 4—Applicable to Isolated Medial Side Patterns—OTA/AO B1, B2 or B3, Schatzker 4)

Preoperative Planning for Medial Antiglide Plating (Table 55-11)
 
Table 55-11
ORIF of Posteromedial Tibial Plateau Fractures
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Table 55-11
ORIF of Posteromedial Tibial Plateau Fractures
Preoperative Planning Checklist
  •  
    OR table: Radiolucent
  •  
    Position/positioning aids: Supine or prone
  •  
    Fluoroscopy location: Supine and prone—opposite side of injured limb
  •  
    Equipment: Plates, screws, reduction clamps
  •  
    Tourniquet (sterile/nonsterile): Nonsterile
X
In these patterns, at a minimum, the far side of the lateral plateau is intact and will serve as the fixation point for the displaced medial side. The fracture line may be through the medial plateau only or may extend to the intercondylar eminences or into the articular surface of the lateral plateau. Fractures may be minimally displaced or present as fracture dislocations where the forces that fracture the medial condyle are continued and dislocate the lateral plateau from the lateral femoral condyle. Comminution at the margin of the fracture is common and may be severe in medial fracture dislocation patterns and involve the lateral plateau. 
Positioning for Medial Antiglide Plating.
A posteromedial approach is preferred. The patient is positioned supine or prone based on surgeon preference. Supine positioning is easier and allows simultaneous access to an anterolateral approach for bicondylar fractures. However, posterior access to the knee in the supine position requires flexion and external rotation of the limb which produces a varus force and tends to deform the fracture. These deforming forces do not occur in the prone position. 
Posteromedial Approach for Medial Antiglide Plating.
The posteromedial approach is used to reduce and fix the medial side of the proximal tibia and particularly the posteromedial fragment (Fig. 55-27A–F). It has the advantage of relatively good soft tissue cover and it is widely separated from the anterolateral approach allowing these two approaches to be combined when necessary.66 In addition, the posteromedial fracture fragments often have extra-articular fracture lines, which are not comminuted and are relatively easy to reduce. A posteromedial plate when optimally positioned is well suited to resist deforming forces. An antiglide plate is placed directly over the area of maximal displacement at the apex of the fracture. 
Figure 55-27
The posteromedial approach allows access to the entire posterior aspect of the knee.
 
AP and lateral images show a comminuted posterior medial fracture pattern (A and B) treated with a spanning fixator which restored provisional length and alignment (C). A CT scan in traction shows a comminuted posterior fracture pattern (D). A posteromedial approach, fracture reduction, and two 3.5-mm pelvic reconstruction plates were performed 10 days later. At 8 months after the injury the fracture is healed and alignment is excellent (E and F). Note that the most posterior plate is past the midline and that the lateral comminution was reduced through the posteromedial approach.
AP and lateral images show a comminuted posterior medial fracture pattern (A and B) treated with a spanning fixator which restored provisional length and alignment (C). A CT scan in traction shows a comminuted posterior fracture pattern (D). A posteromedial approach, fracture reduction, and two 3.5-mm pelvic reconstruction plates were performed 10 days later. At 8 months after the injury the fracture is healed and alignment is excellent (E and F). Note that the most posterior plate is past the midline and that the lateral comminution was reduced through the posteromedial approach.
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AP and lateral images show a comminuted posterior medial fracture pattern (A and B) treated with a spanning fixator which restored provisional length and alignment (C). A CT scan in traction shows a comminuted posterior fracture pattern (D). A posteromedial approach, fracture reduction, and two 3.5-mm pelvic reconstruction plates were performed 10 days later. At 8 months after the injury the fracture is healed and alignment is excellent (E and F). Note that the most posterior plate is past the midline and that the lateral comminution was reduced through the posteromedial approach.
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Figure 55-27
The posteromedial approach allows access to the entire posterior aspect of the knee.
AP and lateral images show a comminuted posterior medial fracture pattern (A and B) treated with a spanning fixator which restored provisional length and alignment (C). A CT scan in traction shows a comminuted posterior fracture pattern (D). A posteromedial approach, fracture reduction, and two 3.5-mm pelvic reconstruction plates were performed 10 days later. At 8 months after the injury the fracture is healed and alignment is excellent (E and F). Note that the most posterior plate is past the midline and that the lateral comminution was reduced through the posteromedial approach.
AP and lateral images show a comminuted posterior medial fracture pattern (A and B) treated with a spanning fixator which restored provisional length and alignment (C). A CT scan in traction shows a comminuted posterior fracture pattern (D). A posteromedial approach, fracture reduction, and two 3.5-mm pelvic reconstruction plates were performed 10 days later. At 8 months after the injury the fracture is healed and alignment is excellent (E and F). Note that the most posterior plate is past the midline and that the lateral comminution was reduced through the posteromedial approach.
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AP and lateral images show a comminuted posterior medial fracture pattern (A and B) treated with a spanning fixator which restored provisional length and alignment (C). A CT scan in traction shows a comminuted posterior fracture pattern (D). A posteromedial approach, fracture reduction, and two 3.5-mm pelvic reconstruction plates were performed 10 days later. At 8 months after the injury the fracture is healed and alignment is excellent (E and F). Note that the most posterior plate is past the midline and that the lateral comminution was reduced through the posteromedial approach.
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X
The treatment principles are fairly straightforward but these fractures are difficult to accurately reduce and small errors may lead to significant articular step-offs or angular malalignment. Nondisplaced or minimally displaced fractures may be stabilized with cannulated screws to prevent displacement. When the fracture needs to be reduced, the forces on these large fragments are significant and the fracture needs to be fixed with plates. Occasionally, adjunctive cross joint external fixation is used for a period of time to hold the knee out of varus (Fig. 55-28A–E). 
Figure 55-28
Even subtle medial plateau fractures tend to align in varus as seen in the initial radiographs in this case (A).
 
The medial joint has several coronal fracture lines seen on the lateral view (arrows) (B). A posteromedial approach and two small fragment plates, one between the pes tendons, were supplemented by 4 weeks of adjunctive cross joint external fixation (C). Three-year follow-up radiographs show neutral alignment and a preserved joint (D and E).
The medial joint has several coronal fracture lines seen on the lateral view (arrows) (B). A posteromedial approach and two small fragment plates, one between the pes tendons, were supplemented by 4 weeks of adjunctive cross joint external fixation (C). Three-year follow-up radiographs show neutral alignment and a preserved joint (D and E).
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Figure 55-28
Even subtle medial plateau fractures tend to align in varus as seen in the initial radiographs in this case (A).
The medial joint has several coronal fracture lines seen on the lateral view (arrows) (B). A posteromedial approach and two small fragment plates, one between the pes tendons, were supplemented by 4 weeks of adjunctive cross joint external fixation (C). Three-year follow-up radiographs show neutral alignment and a preserved joint (D and E).
The medial joint has several coronal fracture lines seen on the lateral view (arrows) (B). A posteromedial approach and two small fragment plates, one between the pes tendons, were supplemented by 4 weeks of adjunctive cross joint external fixation (C). Three-year follow-up radiographs show neutral alignment and a preserved joint (D and E).
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Technique for Medial Antiglide Plating (Table 55-12)
 
Table 55-12
ORIF of Posteromedial Tibial Plateau Fractures
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Table 55-12
ORIF of Posteromedial Tibial Plateau Fractures
Surgical Steps
  •  
    Open interval between posterior pes and medial gastrocnemius
  •  
    Avoid saphenous vein and nerve
  •  
    Expose posteromedial tibia subperiosteally
  •  
    Place retractor along posterior tibia to protect popliteal fossa structures
  •  
    Apply reduction clamp
  •  
    Reduce fracture
  •  
    Provisional fixation
  •  
    Confirm reduction of fracture and overall joint alignment fluoroscopically
  •  
    Fix with interfragmentary screws and antiglide plate
X
The approach is based on the posteromedial border of the tibia (Fig. 55-29A–D). The patient is most commonly positioned supine which allows access to the front of the knee for a second anterolateral approach or to apply a distractor.66 The leg is externally rotated allowing easy access (Fig. 55-29A). Alternatively, the patient can be positioned prone which makes the posterior to anterior hardware easier to place and facilitates fracture reduction by knee extension.43 The subcutaneous dissection must avoid the saphenous nerve and vein and the incision must be posterior enough to allow hardware to be placed from the posterior aspect of the tibia without the posterior skin flap obstructing the screw paths. The deep interval is between the posterior border of the pes anserine tendons and the medial head of the gastrocnemius (Fig. 55-29B). A retractor under the gastrocnemius medial head protects the popliteal fossa structures. The origin of the medial head may be incised to increase exposure but this is rarely necessary.20,43 To directly visualize the bone, the popliteus origin must be lifted and retracted laterally. This directly exposes the apex of the fracture (Fig. 55-29C). 
Figure 55-29
This figure shows clinical photographs of a posteromedial approach.
 
The patient is positioned supine and the leg is externally rotated. The incision is made over the posteromedial border of the tibia or even over the medical side of the medial head of the gastrocnemius (A). Care is taken to avoid the saphenous vein and nerve and the fascia is opened in line with the posterior border of the pes anserinus. The medial head of the gastrocnemius is exposed (B). A retractor is placed on bone posteriorly to retract the gastrocnemius and protect the neurovascular structures and incising the origin of the popliteus exposes the apex of the fracture (C). Plate(s) are positioned posteriorly over the apex of the fracture to buttress the fragment (D).
The patient is positioned supine and the leg is externally rotated. The incision is made over the posteromedial border of the tibia or even over the medical side of the medial head of the gastrocnemius (A). Care is taken to avoid the saphenous vein and nerve and the fascia is opened in line with the posterior border of the pes anserinus. The medial head of the gastrocnemius is exposed (B). A retractor is placed on bone posteriorly to retract the gastrocnemius and protect the neurovascular structures and incising the origin of the popliteus exposes the apex of the fracture (C). Plate(s) are positioned posteriorly over the apex of the fracture to buttress the fragment (D).
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Figure 55-29
This figure shows clinical photographs of a posteromedial approach.
The patient is positioned supine and the leg is externally rotated. The incision is made over the posteromedial border of the tibia or even over the medical side of the medial head of the gastrocnemius (A). Care is taken to avoid the saphenous vein and nerve and the fascia is opened in line with the posterior border of the pes anserinus. The medial head of the gastrocnemius is exposed (B). A retractor is placed on bone posteriorly to retract the gastrocnemius and protect the neurovascular structures and incising the origin of the popliteus exposes the apex of the fracture (C). Plate(s) are positioned posteriorly over the apex of the fracture to buttress the fragment (D).
The patient is positioned supine and the leg is externally rotated. The incision is made over the posteromedial border of the tibia or even over the medical side of the medial head of the gastrocnemius (A). Care is taken to avoid the saphenous vein and nerve and the fascia is opened in line with the posterior border of the pes anserinus. The medial head of the gastrocnemius is exposed (B). A retractor is placed on bone posteriorly to retract the gastrocnemius and protect the neurovascular structures and incising the origin of the popliteus exposes the apex of the fracture (C). Plate(s) are positioned posteriorly over the apex of the fracture to buttress the fragment (D).
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When substantially displaced, reducing the fracture is difficult and using aids such as large and small reduction forceps, awls and elevators, and intraoperative distraction techniques manually or with fixed skeletal distraction are often necessary. The primary shearing fracture line may be associated with locally depressed fragments. Depending on their size and location, their reduction may need to be incorporated into the operative plan. Usually this can be accomplished with the posteromedial approach through the major posterior fracture line even when the depressed fragments are in the lateral plateau. As with all plateau fractures, the techniques to visualize and assure accurate reduction should be planned ahead and executed intraoperatively. Despite accurately reducing an extra-articular fracture line, large medial plateau fracture fragments may have residual tilts or other joint malreductions that need to be assessed and corrected since they will lead to limb malalignment. Fluoroscopic techniques are usually necessary since visualizing the joint through the posteromedial approach is difficult unless important posterior soft tissue structures are incised.20 
Fixing the fracture with an antiglide plate will supplement interfragmentary screws which, depending on the plate configuration, may be applied through proximal portions of the plate. Most commonly, 3.5-mm plates will be strong enough to provide the antiglide effect necessary (Fig. 55-29D). 
Postoperative Care for Medial Antiglide Plating.
Similar to the lateral side patterns, patients are instructed in range-of-motion exercises in a hinged brace. The range is not restricted but limited weight bearing is recommended for 4 to 10 weeks depending on the pattern. 
Potential Pitfalls and Preventative Measures for Medial Antiglide Plating (Table 55-13)
 
Table 55-13
Tibial Plateau Fractures—Posteromedial Approach
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Table 55-13
Tibial Plateau Fractures—Posteromedial Approach
Potential Pitfalls and Preventions
Pitfalls Preventions
Injury to saphenous nerve/vein Careful dissection in superficial tissues
Difficult screw placement from posterior to anterior The skin incision needs to be posterior enough
Careful leg positioning before surgical prep checking to see if required angle feasible
Difficult to visualize fragments Retractor under medial head of gastrocnemius
Injury to structures in popliteal fossa Retractor directly on bone under medial head of gastrocnemius protects structures
Use of soft tissue protector on drill bit and tap
Angular malalignment Nonarticular fracture reduction does not assure articular reduction and should be closely assessed intraoperatively. Obtaining accurate alignment is one of the most difficult aspects of this procedure
X
Careful patient positioning is critical. In the supine position the incision must be placed far enough posterior, and the leg appropriately allowed to externally rotate to gain the proper access for plate and screw placement. One must exercise caution in the placement of retractors in the popliteal fossa. Cortical keys of large fracture fragments on the posterior cortex of the tibia do not insure accurate articular reduction. In addition to extra-articular fracture reduction the overall limb alignment and the articular reduction must be carefully assessed with intraoperative fluoroscopy. 
Treatment-specific Outcomes for Medial Antiglide Plating.
Unfortunately there are few results reported for these difficult and less common fractures when they occur in isolation. In many series there are too few medial patterns to meaningfully report results. Schatzker et al.159 felt that the medial side patterns had the worst prognosis of the six types. Honkonen81 found less satisfactory outcomes and a high percentage of posttraumatic arthritis in medially tilted fractures and bicondylar patterns with a medial tilt. Both Bhattacharyya et al.20 and Carlson32 warned of the possibility of flexion deformities particularly after posterior approaches for these fractures. 

Dual Plating; Lateral Locking Plating; and External Fixation—(Surgical Procedures no. 5, 6, and 7—Applicable to OTA/AO 41 C Fractures or Schatzker 5 and 6 Bicondylar or Metaphyseal–Diaphyseal Dissociation Fractures)

These are the most difficult and complex fracture patterns and have a wide range of injury severity. All OTA/AO 41 C and Schatzker 5 and 6 patterns are presented together in this section since distinguishing between them is not clear enough to merit separate discussions of treatment and results. The advent of locking plates has brought new information, controversy, and increased the variety of operative strategies for these complex fracture patterns. Without a plate with fixed angle stability from the lateral side, surgeons had two choices: (1) a lateral plate combined with a medial plate (Fig. 55-30A–C) or occasionally combined with a medial external fixator150 and (2) an external fixator with enough stability to support the entire fracture. Many of these fracture patterns are now effectively stabilized with a laterally based locking plate as the only major implant (Fig. 55-31A–E). The shift to this technique has been rapid and dramatic. However, there are issues to be considered in planning and executing this strategy. Important decisions that require good judgment include knowing which patterns are amenable to a lateral locking plate alone and which need to be fixed on both sides with two plates and which would be safer with an external fixator. Case selection is critical and new information and new generations of locking implants may continue to change which fractures can be stably fixed with a lateral locked plate only (Fig. 55-32A–D). The currently available information on these fractures will be presented in the following categories. 
Figure 55-30
 
Some bicondylar fractures are still best treated with medial and lateral plates particularly if the medial side fracture is small, comminuted, or split in the coronal plane. This case was treated with dual plates through separate posteromedial and anterolateral approaches. Radiographs (A) and CT scans (B) in a spanning external fixator are shown. Postoperative AP and lateral radiographs show two short medial plates and a longer anterolateral plate (C).
Some bicondylar fractures are still best treated with medial and lateral plates particularly if the medial side fracture is small, comminuted, or split in the coronal plane. This case was treated with dual plates through separate posteromedial and anterolateral approaches. Radiographs (A) and CT scans (B) in a spanning external fixator are shown. Postoperative AP and lateral radiographs show two short medial plates and a longer anterolateral plate (C).
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Figure 55-30
Some bicondylar fractures are still best treated with medial and lateral plates particularly if the medial side fracture is small, comminuted, or split in the coronal plane. This case was treated with dual plates through separate posteromedial and anterolateral approaches. Radiographs (A) and CT scans (B) in a spanning external fixator are shown. Postoperative AP and lateral radiographs show two short medial plates and a longer anterolateral plate (C).
Some bicondylar fractures are still best treated with medial and lateral plates particularly if the medial side fracture is small, comminuted, or split in the coronal plane. This case was treated with dual plates through separate posteromedial and anterolateral approaches. Radiographs (A) and CT scans (B) in a spanning external fixator are shown. Postoperative AP and lateral radiographs show two short medial plates and a longer anterolateral plate (C).
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Figure 55-31
For many bicondylar fractures, the reduction can be maintained with a laterally based locking plate alone.
 
This unusual bicondylar fracture (A and B) with extensor mechanism disruption (OTA/AO type C3) had anterior skin pressure and needed urgent spanning external fixation (C). A CT scan after external fixation (D) showed a split in the medial plateau, but it was minimally displaced, allowing the fracture to be treated with a lateral locking plate through a limited anterior lateral approach with indirect reduction and screw fixation of the medial side (E). The photograph shows the small anterior incisions for reduction instruments and screws and the locking plate placed through the anterolateral incision. At 6 months after the injury, the patient’s fracture has healed and alignment has been maintained (F and G).
This unusual bicondylar fracture (A and B) with extensor mechanism disruption (OTA/AO type C3) had anterior skin pressure and needed urgent spanning external fixation (C). A CT scan after external fixation (D) showed a split in the medial plateau, but it was minimally displaced, allowing the fracture to be treated with a lateral locking plate through a limited anterior lateral approach with indirect reduction and screw fixation of the medial side (E). The photograph shows the small anterior incisions for reduction instruments and screws and the locking plate placed through the anterolateral incision. At 6 months after the injury, the patient’s fracture has healed and alignment has been maintained (F and G).
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This unusual bicondylar fracture (A and B) with extensor mechanism disruption (OTA/AO type C3) had anterior skin pressure and needed urgent spanning external fixation (C). A CT scan after external fixation (D) showed a split in the medial plateau, but it was minimally displaced, allowing the fracture to be treated with a lateral locking plate through a limited anterior lateral approach with indirect reduction and screw fixation of the medial side (E). The photograph shows the small anterior incisions for reduction instruments and screws and the locking plate placed through the anterolateral incision. At 6 months after the injury, the patient’s fracture has healed and alignment has been maintained (F and G).
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Figure 55-31
For many bicondylar fractures, the reduction can be maintained with a laterally based locking plate alone.
This unusual bicondylar fracture (A and B) with extensor mechanism disruption (OTA/AO type C3) had anterior skin pressure and needed urgent spanning external fixation (C). A CT scan after external fixation (D) showed a split in the medial plateau, but it was minimally displaced, allowing the fracture to be treated with a lateral locking plate through a limited anterior lateral approach with indirect reduction and screw fixation of the medial side (E). The photograph shows the small anterior incisions for reduction instruments and screws and the locking plate placed through the anterolateral incision. At 6 months after the injury, the patient’s fracture has healed and alignment has been maintained (F and G).
This unusual bicondylar fracture (A and B) with extensor mechanism disruption (OTA/AO type C3) had anterior skin pressure and needed urgent spanning external fixation (C). A CT scan after external fixation (D) showed a split in the medial plateau, but it was minimally displaced, allowing the fracture to be treated with a lateral locking plate through a limited anterior lateral approach with indirect reduction and screw fixation of the medial side (E). The photograph shows the small anterior incisions for reduction instruments and screws and the locking plate placed through the anterolateral incision. At 6 months after the injury, the patient’s fracture has healed and alignment has been maintained (F and G).
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This unusual bicondylar fracture (A and B) with extensor mechanism disruption (OTA/AO type C3) had anterior skin pressure and needed urgent spanning external fixation (C). A CT scan after external fixation (D) showed a split in the medial plateau, but it was minimally displaced, allowing the fracture to be treated with a lateral locking plate through a limited anterior lateral approach with indirect reduction and screw fixation of the medial side (E). The photograph shows the small anterior incisions for reduction instruments and screws and the locking plate placed through the anterolateral incision. At 6 months after the injury, the patient’s fracture has healed and alignment has been maintained (F and G).
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Figure 55-32
 
In bicondylar fractures treated with lateral locking plate, it is difficult to predict the need for additional medial fixation. An initial anteroposterior (AP) radiograph shows a widely displaced fracture dislocation pattern (A) with improved alignment after the spanning external fixator was applied (B). A laterally based locking plate stabilized the fracture. An immediate postoperative (C) and a 4-month AP (D) radiograph shows slight loss of reduction into varus.
In bicondylar fractures treated with lateral locking plate, it is difficult to predict the need for additional medial fixation. An initial anteroposterior (AP) radiograph shows a widely displaced fracture dislocation pattern (A) with improved alignment after the spanning external fixator was applied (B). A laterally based locking plate stabilized the fracture. An immediate postoperative (C) and a 4-month AP (D) radiograph shows slight loss of reduction into varus.
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In bicondylar fractures treated with lateral locking plate, it is difficult to predict the need for additional medial fixation. An initial anteroposterior (AP) radiograph shows a widely displaced fracture dislocation pattern (A) with improved alignment after the spanning external fixator was applied (B). A laterally based locking plate stabilized the fracture. An immediate postoperative (C) and a 4-month AP (D) radiograph shows slight loss of reduction into varus.
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Figure 55-32
In bicondylar fractures treated with lateral locking plate, it is difficult to predict the need for additional medial fixation. An initial anteroposterior (AP) radiograph shows a widely displaced fracture dislocation pattern (A) with improved alignment after the spanning external fixator was applied (B). A laterally based locking plate stabilized the fracture. An immediate postoperative (C) and a 4-month AP (D) radiograph shows slight loss of reduction into varus.
In bicondylar fractures treated with lateral locking plate, it is difficult to predict the need for additional medial fixation. An initial anteroposterior (AP) radiograph shows a widely displaced fracture dislocation pattern (A) with improved alignment after the spanning external fixator was applied (B). A laterally based locking plate stabilized the fracture. An immediate postoperative (C) and a 4-month AP (D) radiograph shows slight loss of reduction into varus.
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In bicondylar fractures treated with lateral locking plate, it is difficult to predict the need for additional medial fixation. An initial anteroposterior (AP) radiograph shows a widely displaced fracture dislocation pattern (A) with improved alignment after the spanning external fixator was applied (B). A laterally based locking plate stabilized the fracture. An immediate postoperative (C) and a 4-month AP (D) radiograph shows slight loss of reduction into varus.
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Mechanical Studies Related to Fixation of Bicondylar Tibial Plateau Fractures.
Mechanical studies have compared lateral locking plates alone to dual plates in bicondylar tibial plateau fracture models and the results have been mixed. Gosling et al.67 and Mueller et al.129 in paired cadaver models found no significant difference with vertical loading between dual plates and lateral locking plates. Egol et al.53 found that dual plates were better at resisting displacement but did not think the differences were likely to be clinically important. Higgins et al.74 in a matched pair cadaver model of bicondylar fracture found that that subsidence was enough greater with lateral locked plates compared to dual plates, to raise clinical concerns about using lateral locked plates alone for these fractures. In a medial plateau fracture model medial buttress plating was found to be stronger than a lateral locked plate.145 One study demonstrated that bone quality was the most important parameter in determining fixation strength regardless of the technique to stabilize the fracture.6 The clinical relevance of these types of studies is predicated on knowing how stiff the implant should be and how much deforming force must be resisted to promote healing while not allowing secondary displacement. 
Soft Tissue Injury and Management related to Fixation of Bicondylar Tibial Plateau Fractures.
The soft tissues must be carefully assessed and managed with attempts to minimize associated complications from substantive implants required to treat these fractures. Surgical timing, temporary spanning external fixation, and recognizing the risk for compartment syndrome are all important to optimizing outcomes. In addition, these fractures are effectively and relatively safely managed with definitive external fixation so when a surgeon chooses a locking plate, he or she must be confident that the risk for severe complications can be minimized. Temporary joint spanning external fixation has an important role for initially managing some of these fractures. The external fixator spans both the fracture and the knee and as much as possible the pins avoid the entire zone of injury. Frames are most commonly constructed from pin to bar components. When placing pins, the location of future incisions and implants should be considered. The goal is to maintain length and alignment in the days or weeks after injury while the soft tissue injury recovers and the definitive procedures can be planned. However, careful attention to technique is required to achieve these goals. A knee-spanning fixator applied with pins in poor position and the fracture short and/or malaligned may cause more harm than benefit. Case selection for this technique is important since not all of these fractures require a joint-spanning external fixator. Proximal tibia fractures that have the greatest potential to benefit have one or more of the following: significant displacement and shortening, open fracture, a severe closed soft tissue injury, compartment syndrome, a fracture dislocation, and/or a long anticipated delay to definitive surgery. 
Dual Plating for Bicondylar Tibial Plateau Fractures (Surgical Procedure no. 5)
Preoperative Planning for Dual Plating of Tibial Plateau Fractures (Table 55-14)
Table 55-14
Bicondylar or Metaphyseal Diaphyseal Dissociation Tibial Plateau Fractures
Preoperative Planning Checklist
  •  
    OR table: Radiolucent
  •  
    Position/positioning aids: Supine
  •  
    Fluoroscopy location: C-arm enters from same side of fractured extremity if beginning medial, then opposite side of fractured extremity for placement of lateral plate
  •  
    Equipment: Plates, screws, femoral distractor, reduction clamps, bone void filler, external fixator
  •  
    Tourniquet (sterile/nonsterile): Nonsterile
X
In some bicondylar patterns the fracture needs to be fixed on two sides based on the characteristics of the medial side injury (Fig. 55-30A–C). A medial plate is necessary when the medial condyle is comminuted, very displaced, or is a relatively small fragment. If the medial condyle is split coronally creating a posteromedial fragment, this may need to be separately fixed with a posteromedial plate. The choice between a lateral locking plate alone and dual plates is largely driven by these characteristics of the medial side injury. The exact fracture pattern must be carefully assessed and the correct choice does not easily divide along classic classification categories or subcategories. 
When dual plates are planned to treat a tibial plateau fracture, the first important factor is the associated soft tissue injury. Periods of joint-spanning external fixation are frequently chosen and delays of 3 weeks or longer prior to definitive surgery are not uncommon.166 The fixator should be placed so pins avoid the region of the subsequent dual plating approach. 
Positioning for Dual Plating of Tibial Plateau Fractures. The patient is positioned supine on radiolucent table, the hip is bumped to neutral extremity rotation, and the leg is elevated on a radiolucent platform. If procedure will start with the medial-sided injury the leg is brought toward a figure-of-four position. 
Surgical Approach(es) for Dual Plating of Tibial Plateau Fractures
Anterolateral Approach (see Surgical Procedure #2) 
Posteromedial (see Surgical Procedure #4) 
Combined Anterior and Posteromedial Approaches
These are the workhorse approaches for dual plating. Fractures of both condyles are frequently treated with combined approaches utilizing an anterolateral approach and posteromedial approach as described above.66 Dual approaches provide access to complex bicondylar fractures but strip less soft tissue attachments than extensile anterior approaches. The patient is positioned supine and the leg must externally rotate for the posteromedial portion of the approach. Anterolateral and posteromedial incisions are nearly at 180 degrees from each other so short skin bridges are not an issue. Direct access to each injured condyle to reduce the fracture and to place implants is obtained, which minimizes the soft tissue dissection required. 
Anteromedial
The anteromedial tibial plateau is easily accessed through distal extension of a medial arthrotomy similar to a total knee approach. However, it is unusual for fracture patterns to involve the anteromedial tibia in isolation. An anteromedial approach should not be used in conjunction with the common anterolateral approach. Usually, medial patterns involve the posteromedial plateau, which requires a posteromedial approach. Occasionally through the same incision, a separate anteromedial interval in front of or between the pes tendons can be used to reduce and fix the front of the medial joint through the posteromedial approach. 
Posterolateral
Not infrequently, there is posterolateral comminution, which is difficult to stabilize from an anterolateral approach with the fibular head in the way.32 If the posterior plateau is comminuted far onto the lateral side, it is difficult to reach through the posteromedial approach. In these cases, a posterolateral approach between the lateral gastrocnemius and the biceps femoris with mobilization of the peroneal nerve will provide access to the posterolateral tibial plateau. This can be combined with a posteromedial approach as described by Carlson.31,32 
Extensile Anterior Approaches
Extensile approaches from the anterior portion of the knee have been utilized for complex tibial plateau fractures.57,76,157 The exposure obtained is similar to familiar approaches for knee arthroplasty. They provide simultaneous access to both the medial and lateral sides of the tibial plateau. Exposures where the extensor mechanism is elevated with a tibial tubercle fracture or through incision of the patellar tendon combined with anterior meniscal incision provide an intra-articular exposure to reduce fractures that are not possible with any other approach. Unfortunately, these exposures when combined with dual plating, lead to excessive soft tissue stripping, devascularization of damaged fracture fragments, and when they resulted in infection and/or wound breakdown disastrous results followed. For these reasons, alternative techniques should be chosen if at all possible. Current opinion and data indicate that dual plates can be reasonably safely applied to the fractured proximal tibia but that dual approaches are safer than extensile approaches. 
Posterior Approaches
Posterior approaches done in the prone position through the popliteal fossa have been used to treat posterior fracture patterns180 but have fallen out of favor because of the need to mobilize the neurovascular bundle. There has been some renewed interest in these approaches for posterior fracture patterns in either prone,26,60 or with a combination of positioning techniques.112 Bhattacharyya et al.20 treated a series of patients with an approach that divides the medial head of the gastrocnemius tendon and Bendayan16 described an approach where the medial gastrocnemius was split. Most recently, Fakler et al.56 utilized the Lobenhoffer approach for posteromedial fractures. This approach uses the same interval as the previously described posteromedial approach between the pes tendons and the medial gastrocnemius. Carlson described combined posteromedial and posterolateral approaches to the back of the tibial plateau.31,32 These are efficacious for posterior shearing patterns where direct posterior plating is mechanically optimal. A posterior approach in the prone position has the advantage of reducing the fracture with the knee in extension with a more direct view of the fracture and screw paths. In addition, taking the medial head down makes for a more extensile exposure to visualize comminuted fractures. These advantages are offset by the more difficult positioning compared to the supine posteromedial approach and lack of readily available access to the lateral side for bicondylar fractures. Luo et al.112 reported on 29 cases in which a “floating position” was utilized allowing access for both an anterolateral and posterior approach to manage complex tibial plateau fractures. 
Technique for Dual Plating of Tibial Plateau Fractures (Table 55-15)
Table 55-15
Bicondylar or Metaphyseal Diaphyseal Dissociation Tibial Plateau Fractures with Dual Plates
Surgical Steps
  •  
    Expose proximal posteromedial tibia
  •  
    Reduce and fix the medial side fracture(buttress plate(s)/screws)
  •  
    Be conservative in the number of screws and consider the subsequent anterolateral fixation
  •  
    Expose proximal lateral tibia
  •  
    Possible submeniscal arthrotomy
  •  
    Possible application of femoral distractor across knee joint
  •  
    Open split portion of fracture
    •  
      Preserve posterior soft tissue attachments
  •  
    Reduce joint component and provisionally stabilize with K-wires
  •  
    Reduce split component and provisionally stabilize with K-wires
    •  
      Restore condylar width using a large clamp across condyles
    •  
      Assess reduction and overall limb alignment fluoroscopically
  •  
    Apply lateral plate
X
In these fracture patterns two separate operations are performed, one on the medial and one on the lateral side of the plateau (Fig. 55-30A–C). Although each side must take into account the other side, they are modestly separate techniques. The medial side is typically approached first. Reducing and fixing the medial side restores this section of the plateau and the lateral side will then be reduced and buttressed against it. Additional points to consider in planning this dual approach include the following: (1) the incisions should be nearly 180 degrees from each other anterolateral and posteromedial; (2) this is a lot of surgery, be prepared with enough time; (3) the initial stages of the operation on the medial side must be accurate or the final result will be unsatisfactory; (4) medial side screws must account for the lateral side injury, they can usually be targeted anteriorly avoiding the lateral fracture zone; (5) limit the number of screws early in the case. There will be a lot of screws in the end and the lateral screws can be used to lock in the provisionally fixed medial side decreasing the need for excessive medial to lateral screws; (6) and consider that access is required to both sides when positioning the patient. 
Postoperative Care for Dual Plating of Tibial Plateau Fractures
Although these are the most severe tibial plateau fractures, adequate dual plate fixation will usually allow safe early range of motion in a brace similar to isolated lateral or medial side patterns. However, exceptions are not uncommon and where the surgical approaches and fixation were limited the knee may be immobilized sometimes with periods of adjunctive cross joint external fixation. These are difficult judgments and the more extensive the surgical approaches the more important is post-operative range of motion for the knee. Non weight bearing for a minimum of eight weeks is typically recommended. 
Potential Pitfalls and Preventative Measures for Dual Plating of Tibial Plateau Fractures (Table 55-16)
 
Table 55-16
Tibial Plateau Fractures—Dual Plates
View Large
Table 55-16
Tibial Plateau Fractures—Dual Plates
Potential Pitfalls and Preventions
Pitfalls Preventions
Previous pin sites in surgical field Careful placement of initial external fixator pins
Drawing out planned incisions prior to pin placement may be helpful
Malreduction of posteromedial fragment leading to unsatisfactory lateral plating Direct assessment of fracture reduction
Medial screw fixation interrupting lateral plate reduction/fixation Target medial screws anteriorly to avoid traversing articular fracture until entire joint is reduced
Limit number of medial screws
Limited access for reduction and fixation Careful preoperative positioning and use of intraoperative bumps
X
Outcomes for Dual Plating of Tibial Plateau Fractures
Dual plating of fractures of the proximal tibia has been reported in numerous case series and was compared to external fixation in one randomized controlled trial. In the 1980s and early 1990s this technique developed a bad reputation because of a high incidence of wound breakdown and devastating infections when dual plates were applied via a single midline incision with medial and lateral dissections. The term “dead bone sandwich” was used as a way to criticize this technique. A variety of advances have decreased the complication rates. One of the most important of these is adopting a staged protocol which initially manages the fracture with a joint-spanning external fixator, allowing a delay to the dual plating procedure for soft tissue recovery. This staged technique is most valuable in severe fractures because of the high risk for soft tissue compromise.54 Another important change has been the use of dual approaches rather than a single anterior extensile approach. 
Surgeons should still be wary of these severe fractures. Even when treated with modern medial and lateral plating techniques deep infection rates of between 8.4% and 18% have been reported.13,30,166 Multiple surgical procedures are often necessary after a patient develops a deep infection. Shah and Karunakar noted that the risk might be particularly high in cases where a fasciotomy had been necessary.166 These infection rates are not trivial and every effort should be made to minimize these complications. 
The general sense of recent literature is that the healing rate after dual plating is high. With a careful technique, alignment is usually satisfactory. Barei et al.13 reported 91% and 72% satisfactory coronal and sagittal alignment respectively; in addition, they reported only 1 nonunion out of 83 cases. The accuracy of reducing the articular surface is hard to measure or judge. The Canadian Orthopaedic Trauma Society study demonstrated a significant proportion of articular malreductions despite dual approach open reductions. The authors did not feel the outcome was compromised by these malreduced articular surfaces.30 However, Barei et al.12 found that the accuracy of articular reduction correlated with outcome. 
Lateral Locking Plating for Bicondylar Tibial Plateau Fractures (Surgical Procedure no. 6)
Preoperative Planning for Lateral Locked Plating of Bicondylar Tibial Plateau Fractures
Preoperative planning is critical for the successful use of a lateral locking plate only. The posteromedial fragment(s) must be fully characterized on imaging. The surgeon should be convinced that adequate stability may be obtained without direct buttressing of this fragment. Consideration of leg lengths and alignment preoperatively must be made and assessed intraoperatively with the use of fluoroscopy and contralateral extremity imaging (Table 55-17). 
Table 55-17
Bicondylar or Metaphyseal Diaphyseal Dissociation Tibial Plateau Fractures—Lateral Locking Plate
Preoperative Planning Checklist
  •  
    OR table: Radiolucent
  •  
    Position/positioning aids: Supine
  •  
    Fluoroscopy location: C-arm enters from opposite side of fractured extremity
  •  
    Equipment: Plates, screws, femoral distractor, reduction clamps, bone void filler, external fixator
  •  
    Tourniquet (sterile/nonsterile): Nonsterile
X
Positioning for Lateral Locked Plating of Bicondylar Tibial Plateau Fractures
See surgical procedure no. 2. 
Surgical Approach for Lateral Locked Plating of Bicondylar Tibial Plateau Fractures
See surgical procedure no. 1 to 5. Use of lateral locked plating assumes either the proximal block of the tibia is non- or minimally displaced or it has been reduced and stabilized using techniques previously described in procedures 1 to 5. Often, even with significant metaphyseal disruption and displacement, the intra-articular fracture lines are amenable to very limited approach techniques such as described in surgical procedure no. 1. If there is a split depression component to the bicondylar pattern, the techniques used in surgical procedure no. 2 are indicated. Occasionally, a laterally based locking plate will be used after a posteromedial procedure as described in surgical procedure no. 4 and in these cases the recommendations for dual plating described in surgical procedure no. 5 need to be considered. The following description will be for the placement of the lateral locking plate. 
Technique for Lateral Locked Plating of Bicondylar Tibial Plateau Fractures (Table 55-18)
Table 55-18
Bicondylar or Metaphyseal Diaphyseal Dissociation Tibial Plateau Fractures—Lateral Locking Plate
Surgical Steps
  •  
    Expose proximal lateral tibia
  •  
    Small incision in anterior compartment fascia preserving cuff of tissue for fascial closure
  •  
    For some cases, apply femoral distractor across knee joint thereby facilitating the ability to directly visualize the articular surface for joint reduction and fixation and when appropriate meniscal repair
  •  
    Achieve accurate limb alignment in coronal and sagittal plane
  •  
    Slide in lateral plate with external targeter in place
  •  
    Keep tip of plate against bone
  •  
    Pin the plate to the proximal and distal tibia in the correct position and with accurate alignment
  •  
    Compress the plate to the bone proximally and distally with a nonlocking screw or clamp
  •  
    Assure accurate alignment in both planes
  •  
    Place proximal and distal screws favoring locking screws proximally and nonlocking screws distally
X
When the timing is optimal for the definitive procedure, the techniques for either a laterally based locking plate or a definitive external fixator are similar. Obtaining length and alignment during the procedure is important and this may be accomplished by a pre-existing joint-spanning external fixator. Alternatively, a fixator or femoral distractor may be applied at the time of the surgery or an able assistant may be able to apply the necessary traction forces. 
The first step is to accurately restore the proximal tibial articular surface and fix the medial and lateral condyles to each other building a proximal articular block. The techniques required depend on the intra-articular fracture pattern. In OTA/AO type A fractures, the proximal tibia is not fractured. In cases with non- or minimally displaced articular extensions, cannulated screws to fix the split are satisfactory. As the fracture becomes more complex, there is an increased need to incorporate other previously described techniques of joint reduction and fixation. Void filler may occasionally be necessary when significant joint depressions have been reduced.70 The severity of these injuries and the risks for complications should lean the cautious toward approaches that are more limited than those for isolated medial and lateral injuries. 
Once a proximal block has been restored, that block and the tibial shaft must be reduced and fixed to each other restoring length and alignment. This is facilitated by distraction, a fluoroscopically compatible table, and careful implant position on the proximal and distal fragment. To decrease complications and to speed healing, the area of the metaphyseal injury should be largely skipped and treated with a no-touch technique spanned by the locking implant. 
However, when the fracture line is simple and oblique a compression technique with direct reduction of the fracture and plating and often including an interfragmentary screw may be appropriate. There is a wide selection of proximal tibial locking plates made by different manufacturers. The technique is fairly similar for all of them. An incision over the anterolateral tibia must be long enough and appropriately positioned to accommodate the head of the tibial plate and the insertion of the proximal screws into the plate head. The top of the plate will be just below the joint line and in the sagittal plane it must be in line with the shaft. A small incision in the fascia at the top of the anterior compartment is necessary to allow the plate to slide along the anterolateral tibia (Fig. 55-33A, B). Care should be taken to keep the plate directly on bone. This can be felt as the plate is inserted and assessed fluoroscopically (Fig. 55-31E). 
Figure 55-33
 
These figures demonstrate the skin and fascial incision (A) required for placement of a lateral-based locking plate through a limited approach in the setting of a previous fasciotomy wound closure. The fasciotomy incision was placed relatively posterior to allow the subsequent incision for the plate to be placed anterior and remain separate from the fasciotomy incision (B).
These figures demonstrate the skin and fascial incision (A) required for placement of a lateral-based locking plate through a limited approach in the setting of a previous fasciotomy wound closure. The fasciotomy incision was placed relatively posterior to allow the subsequent incision for the plate to be placed anterior and remain separate from the fasciotomy incision (B).
View Original | Slide (.ppt)
Figure 55-33
These figures demonstrate the skin and fascial incision (A) required for placement of a lateral-based locking plate through a limited approach in the setting of a previous fasciotomy wound closure. The fasciotomy incision was placed relatively posterior to allow the subsequent incision for the plate to be placed anterior and remain separate from the fasciotomy incision (B).
These figures demonstrate the skin and fascial incision (A) required for placement of a lateral-based locking plate through a limited approach in the setting of a previous fasciotomy wound closure. The fasciotomy incision was placed relatively posterior to allow the subsequent incision for the plate to be placed anterior and remain separate from the fasciotomy incision (B).
View Original | Slide (.ppt)
X
The plate must be accurately positioned both proximally and distally. If the fracture is reduced, the implant may just be placed on the bone using it to secure the reduction. If the implant will be used to assist in reducing the fracture, each step in fixing the implant proximally and distally must be sequentially assessed. Accurate plate position proximally and distally will reduce the fracture. If the plate will extend further distal than the middle of the tibia, care must be taken to not injure the superficial peroneal nerve or the anterior tibial neurovascular bundle when inserting the distal screws.44 Final fixation will be with locked screws in the head of the tibial plate and either locked or nonlocked screws distally. 
Postoperative Care for Lateral Locked Plating of Bicondylar Tibial Plateau Fractures
The postoperative plan needs to be individualized based on the case. In most cases, range of motion of the knee is prescribed in the early postoperative period. Non–weight-bearing for 8 weeks or longer is typical. 
Potential Pitfalls and Preventative Measures for Lateral Locked Plating of Bicondylar Tibial Plateau Fractures (Table 55-19)
 
Table 55-19
Tibial Plateau Fractures—Lateral Locking Plate
View Large
Table 55-19
Tibial Plateau Fractures—Lateral Locking Plate
Potential Pitfalls and Preventions
Pitfalls Preventions
Limb shortening or malalignment Temporary use of pre-existing external fixator
Temporary use of joint spanning/femoral distractor
Intraoperative radiographic assessment
Intraoperative radiographic comparison to the contralateral (uninjured) limb
Delayed/nonunion Indirect reduction and bridging metaphyseal injury
X
Obtaining length and alignment during the procedure is important and this may be accomplished by a pre-existing joint-spanning external fixator. To decrease complications and to speed healing, the area of the metaphyseal injury should be largely skipped and treated with a no-touch technique spanned by the locking implant. 
Outcomes for Lateral Locked Plating of Bicondylar Tibial Plateau Fractures
Treating tibial plateau fractures with lateral locking plates is still a relatively new treatment concept, so assessing the results and comparing them to previous techniques is important. The results reported in case series have been generally satisfactory but there have been some concerns with loss of alignment and with hardware problems related to either the position of the proximal portion of the implant or to cold welding of the locked screws. There has been some variability in the reported incidence of infection. 
The less invasive stabilization system (LISS) was the first locking plate system that began to popularize this technique and most of the results for the proximal tibia have been reported with this implant. Infection has been reported in between 0% and 22% of cases, postoperative malalignment in 0% to 23% of cases and hardware irritation in 5% to 18%.23,41,53,68,140,149,160,173 Gosling et al.68 reported a 23% malreduction rate and noted the challenges of limited approach surgery for complex proximal tibia fractures particularly with less experienced surgeons. Postoperative compartment syndrome was reported in two series accounting for 3% to 5% of cases.140,149 Peroneal nerve injury has been a rare complication.41,140 Cold welded screws during hardware removal was reported in 4/94 screws in one series41 and 2/88 screws in another series.140 It is thought that cold welding is because of improper screw trajectory and binding of the screw to the threads of the plate hole and is at a higher risk with titanium because of the intrinsic material properties of titanium metal.183 Phisitkul et al.140 stressed the risk for complications such as deep infection which occurred in 22% of fractures in their series. The risk of infection of a lateral locking plate was felt to be particularly high in patients with compartment syndrome with open fasciotomy wounds. 
Clinical studies do not provide a definitive answer to whether lateral locked plates are strong enough to prevent varus displacement in bicondylar fractures. Some authors have found no loss of alignment53,160,173 whereas Gosling et al.68 and Phisitkul et al.140 reported 14% and 8% loss of alignment respectively. Watson indicated that if the medial column was not comminuted and could be accurately reduced a lateral locking plate would suffice, but otherwise dual plating was necessary (Fig. 55-32A–D).188 The presence of a medial coronal fracture was identified as a risk factor for subsidence and loss of reduction of lateral-only locked plate fixation of bicondylar fractures.190 
Other authors have reported results of different locking plate designs. For instance, Haidukewych et al.70 reported the results of 24 type 41 A or C and 7 type B proximal tibia fractures treated with a polyaxial locked plate which allows variable trajectories of the screws before locking. Seven patients had adjunctive posteromedial plates. They found no loss of alignment. Two patients developed deep infections. Hardware removal was not reported. 

External Fixation for Bicondylar Tibial Plateau Fractures (Surgical Procedure no. 7)

Preoperative Planning for External Fixation of Bicondylar Tibial Plateau Fractures.
The surgeon must decide if there is an appropriate amount of proximal tibia that is intact or can be reconstructed that can adequately hold pins or wires that are at a minimum of 15 mm from the articular surface. The frame must be in part planned ahead so that the necessary equipment is available in the operating room (Table 55-20). 
Table 55-20
Bicondylar or Metaphyseal Diaphyseal Dissociation Tibial Plateau Fractures—External Fixation
Preoperative Planning Checklist
  •  
    OR table: Radiolucent
  •  
    Position/positioning aids: Supine
  •  
    Fluoroscopy location: C-arm enters from opposite side of fractured extremity
  •  
    Equipment: External fixator—pins and clamps (5–6 mm-diameter pins) or ring wire or hybrid constructs based on planning and surgeon preference
  •  
    Tourniquet (sterile/nonsterile): Nonsterile
X
Positioning for External Fixation of Bicondylar Tibial Plateau Fractures.
See surgical procedure no. 2. 
Surgical Approach for External Fixation of Bicondylar Tibial Plateau Fractures.
The issues in assessing the need for reduction and then reducing and internally fixing the proximal tibia before applying a definitive external fixator are exactly the same as described for a lateral locking plate above. A formal surgical approach for definitive external fixation is not required. 
Technique for External Fixation of Bicondylar Tibial Plateau Fractures (Table 55-21)
Table 55-21
Bicondylar of Metaphyseal Diaphyseal Dissociation Tibial Plateau Fractures—External Fixation
Surgical Steps
  •  
    Identify and mark potential pin or wire sites
  •  
    For pins make longitudinal stab incisions
  •  
    Carefully spread down to bone
  •  
    Carefully drill or place pin in the center of the bone or place tensioned wires
  •  
    Attach clamps or rings and provisionally tighten
  •  
    Reduce fracture and tighten clamps or ring supports
X
When definitively treating a tibial plateau fracture with an external fixator, the first step in the procedure uses the same preliminary steps of reducing and internally fixing the two condyles to each other as described for lateral locking plates. Occasionally, proximal fixation can be supplemented by direct incisions over the area of joint involvement and adjunctive antiglide plating.187 Similar to a locking plate, the external fixator will span the metaphyseal area of the fracture and stabilize the tibial condyles to the tibial shaft. The metaphyseal fracture is reduced indirectly. A wide variety of frames can be used to accomplish this. These include circular external fixators, monolateral fixators, and hybrid fixators. Many of these fixators have an adjustable frame to facilitate accurately aligning the limb since this is one of the most important technical aspects of the procedure (Fig. 55-20A, B). 
Attention must be paid to the basic principles of constructing a frame and securing the frame to the bone proximal and distal to the fracture, to make sure stability is optimized.189 Because of the limited extent of proximal tibia available for fixation and because of the presence of fracture lines, relatively small fracture fragments, and the proximity of capsular reflections from the knee, securing adequate proximal fixation is the most difficult challenge. Adequate preoperative planning before applying the frame is very important and should include a CT scan. If a pin fixator is used, hydroxyapatite-coated pins provide longer lasting purchase to the metaphyseal bone than standard noncoated pins.128 Pins may be placed medial, anteromedial, or anterolateral. The patellar tendon must be avoided. Fluoroscopy should be used to assist in placing pins in the best bone, avoiding fracture lines to the extent possible, and to ensure that they are placed deeply through the bone without being prominent on the opposite side. There must be two or preferably three proximal pins to have adequate purchase in the proximal tibia. If a circular wire frame is used, maximum wire spread is facilitated by using a fibular head wire combined with a posteromedial to anterolateral wire. Fluoroscopy is also important for accurate wire placement. Three tensioned wires are typically used to secure the proximal articular fragment(s) and they may be augmented by a single half pin. The use of olive wires increases the stability of proximal fixation and may be used to compress major fracture lines. Both pins and wires should be kept as far from the joint as possible to minimize the chances of septic arthritis from pin site inoculation. 
The bone can be fixed to the frame with pins or tensioned wires. Although many prefer wire fixation in these areas, Marsh et al.118 reported satisfactory results using an all-pin fixator. Pins or wires should be kept as far away from the articular surface as possible to minimize the chances of septic arthritis that has been reported after both pins and wires.58,118,133 In severe cases with soft tissue injuries, fracture instability, and small periarticular fragments, a cross–knee-spanning frame may be used to augment the primary frame and be removed after a few weeks of neutralizing the cross-joint forces. In one series of fine wire external fixation for bicondylar tibial plateau fractures, the knee was bridged as part of the frame in 63% of cases without adverse outcomes.93 Neutralizing the forces across the knee may decrease the risk for proximal pin- or wire-related septic arthritis. 
The advantages of external fixation are the ability to achieve alignment and stable fixation with minimal soft tissue dissection and absence of a bulky implant.192 With some frame constructs utilizing tensioned wires and circular frames, earlier weight bearing than with other techniques may be possible.2 
Postoperative Care for External Fixation of Bicondylar Tibial Plateau Fractures.
The patient’s weight-bearing status should be determined based upon the fracture pattern and the frame construct. Circular fixators may provide enough stability for weight bearing in some fracture patterns. Gentle range of motion is typically prescribed when the frame is on the same side of the knee. The patient is given pin care education similar to care provided for any external fixator frame. 
Potential Pitfalls and Preventative Measures for External Fixation of Bicondylar Tibial Plateau Fractures (Table 55-22)
 
Table 55-22
Tibial Plateau Fractures—External Fixation
View Large
Table 55-22
Tibial Plateau Fractures—External Fixation
Potential Pitfalls and Preventions
Pitfalls Preventions
Loss of fixation related to inadequate proximal fixation Preoperative assessment of fragment size/location
Placement of three proximal pins
Septic arthritis Pins and wires should be placed as distant to the joint line as possible
Unstable construct Consider joint spanning frame
X
Treatment-Specific Outcomes for External Fixation of Bicondylar Tibial Plateau Fractures.
Definitive external fixation as treatment for high-energy tibial plateau fractures has been reported in the literature since the early 1990s.118,134,171,192 Case selection for these techniques have been biased toward the high-energy bicondylar or shaft-dissociated patterns with a high incidence of open fractures and compartment syndrome. For instance, in three recent series treated by definitive external fixation, the percentage of open fractures ranged between 33% and 100%.39,93,177 Most of the results are reported in case series and most authors have found satisfactory results considering the severity of the fractures treated. The union rate without additional procedures has been high, ranging between 85% and 100%.3,39,48,177,187,191 Although stable fixation leading to good alignment is usually achieved, one author reported 4/15 open plateau fractures lost reduction during treatment and recommended limited internal fixation as an adjunct to prevent this problem.177 Another author reported loss of reduction into valgus in 3/11 elderly patients treated with a hybrid fixator,3 and in another 3/16 healed fractures had a varus deformity.64 The knee range of motion is generally good; Kataria et al.92 reported an average of 132 degrees in 48 patients with Schatzker 5 and 6 fractures. Marsh et al.118 reported that patients averaged 138 degrees of flexion. Most patients have achieved knee scores averaging 85 to 90 on 100-point scales.118,189 Weigel and Marsh found that the initial results were maintained at longer follow-up. All patients with sequential follow-up of 5 to 11 years after injury were found to improve with longer follow-up.191 Pin tract infections are common and septic arthritis is an unusual but feared complication of external fixation for tibial plateau fractures.64,118 

Comparative Studies of Fixation Techniques for Treatment of Tibial Plateau Fractures

The treatment of tibial plateau fracture patterns has been extensively reported in the literature. Despite this, the optimal technique for a given fracture is uncertain. With the complexity of these fractures and the difficulty of the techniques, there clearly is room for treatment to be based on the personal preferences and experiences of the surgeon. In addition, in most of the literature there is overlap between bicondylar patterns treated with dual plates and shaft-dissociated patterns treated with locking plates alone or external fixation, which makes it hard to compare the treatment methods. 
Hybrid external fixation has been compared with dual plate fixation for OTA/AO type C fractures (Schatzker 5 and 6) in a randomized controlled trial performed by the Canadian Orthopaedic Trauma Association.30,71 They found that dual plating resulted in a greater incidence of deep infection (18%) and repeat operations, longer hospitalization, and a marginally longer return to function. The reductions and patient outcomes were similar in the two groups, both of which had decreased general health status compared to age-matched controls. In another study, Jiang et al. found that the LISS lateral locking plate and dual plating resulted in similar outcomes. There was a trend to a slightly higher malalignment rate and more symptomatic hardware with the LISS.90 A meta-analysis compared fractures fixed with plates to those fixed with external fixators and found that there was not enough evidence to distinguish between the two techniques.114 

Management of Expected Adverse Outcomes and Unexpected Complications in Tibial Plateau Fractures (Table 55-23)

 
Table 55-23
Tibial Plateau Fractures
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Table 55-23
Tibial Plateau Fractures
Common Adverse Outcomes and Complications
Loss of reduction
Wound infection and breakdown
Septic arthritis after external fixation
Knee stiffness
Painful prominent hardware
Tibial nonunion
Posttraumatic arthritis
X

Loss of Reduction in Tibial Plateau Fractures

Low-energy tibial plateau fractures have a low risk for severe complications but significantly displaced split, split depression, and local compression fractures of the lateral plateau if untreated have a high incidence of valgus alignment of the knee. Since optimal outcome requires a well-aligned knee, one of the goals of treating lateral plateau fractures is to prevent valgus deformity. The evidence indicates that even with current techniques surgically managing these fractures is frequently complicated by losing some of the reduction postoperatively. In one study, 31% of operated knees had loss of position after surgical treatment and in patients older than 60 this percentage rose to 79%.4 The clinical significance of loss of reduction is uncertain but when it leads to malalignment, patient outcome may be compromised (Fig. 55-34A–C). Improved methods of fixing low-energy fractures such as smaller precontoured plates allowing subchondral screws to raft under the reduced articular surface may decrease the tendency for postoperative displacement.91 Calcium phosphate cement used as a void filler after reducing the articular fragments may be stronger than traditional techniques such as bone grafting.179 Whether these new techniques will decrease the incidence of loss of reduction and thereby lead to improved patient outcome is uncertain, but given the high tendency toward postoperative displacement, these refinements of technique seem warranted. 
Figure 55-34
 
Difficulty in maintaining reduction of split plateau fractures is dramatically illustrated in an elderly woman with a severe split depressed lateral fracture (A). Postoperative (B), and 6-month (C) radiographs show incomplete initial reduction and subsidence at 6 months. The hardware was removed at 1 year (D), and at 18 months the patient is in need of a complex reconstruction (E).
Difficulty in maintaining reduction of split plateau fractures is dramatically illustrated in an elderly woman with a severe split depressed lateral fracture (A). Postoperative (B), and 6-month (C) radiographs show incomplete initial reduction and subsidence at 6 months. The hardware was removed at 1 year (D), and at 18 months the patient is in need of a complex reconstruction (E).
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Figure 55-34
Difficulty in maintaining reduction of split plateau fractures is dramatically illustrated in an elderly woman with a severe split depressed lateral fracture (A). Postoperative (B), and 6-month (C) radiographs show incomplete initial reduction and subsidence at 6 months. The hardware was removed at 1 year (D), and at 18 months the patient is in need of a complex reconstruction (E).
Difficulty in maintaining reduction of split plateau fractures is dramatically illustrated in an elderly woman with a severe split depressed lateral fracture (A). Postoperative (B), and 6-month (C) radiographs show incomplete initial reduction and subsidence at 6 months. The hardware was removed at 1 year (D), and at 18 months the patient is in need of a complex reconstruction (E).
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Wound Breakdown and Infection in Tibial Plateau Fractures

High-energy tibial plateau fractures often have a severely injured soft tissue envelope. Surgical approaches through the damaged soft tissues present a considerable risk for complications. Wound breakdown, exposed hardware, and proximal tibial infection are devastating complications of surgery. Fortunately, current techniques have decreased the risk. These techniques include delays to definitive surgery, the use of temporary spanning external fixation, dual approaches instead of extensile surgical approaches for plate fixation, and definitive external fixation. However, in high-energy fractures some risk remains despite careful technique. 
The potential devastating consequences of these complications means the importance of avoiding them cannot be overemphasized. Previous techniques using extensile approaches, poorly timed surgery, and excessive stripping of soft tissues to place medial and lateral implants led to an unacceptably high risk of these complications. For instance, Mallik et al.115 reported deep infection in four out of five bicondylar fractures treated with internal fixation with plates. Young and Barrack reported deep infection in seven of eight cases treated with dual plates which resulted in two amputations and five ankylosis or arthrodesis.199 In both of these series the surgical approach was not specified. 
Since these reports, techniques have changed and these changes have been important in decreasing complications. Surgery for internal fixation is not performed until the soft tissues recover from the initial injury and if necessary length and alignment are maintained with a temporary joint-spanning external fixator.54 Extensile anterior approaches, where a single incision is used to expose the medial and lateral tibia with or without extensor mechanism elevation, devascularized both the skin and the bone. These extensile approaches have been largely abandoned in favor of direct approaches to the injured proximal tibia and if necessary two approaches—one anterolateral and one posteromedial. These direct approaches leave the soft tissue envelope as minimally disturbed as possible while still providing access to reduce and stabilize complex fractures. However, despite these techniques, recent studies have reported infection rates of greater than 10% in severe fractures treated with medial and lateral plating.13,30,166 These authors have documented that multiple surgical procedures are often necessary after a patient develops a deep infection. Shah and Karunakar’s data indicated that the risk might be particularly high in cases where a fasciotomy had been necessary.166 Although these complication rates may be less than earlier reports they are not trivial. 
Delaying definitive surgery for soft tissue recovery has been an important advance which has in part been responsible for decreasing complications of high-energy proximal tibia fractures. For low-energy fractures delays are less important and if necessary the knee can be safely splinted or braced. For displaced and shortened high-energy fractures, surgical delays have been facilitated by the use of joint-spanning external fixators which restore length and alignment in a minimally invasive fashion. Definitive surgery is then delayed to wait for soft tissue recovery. Even severely injured knees appear to tolerate cross knee immobility for 6 weeks or longer and can still regain good motion and have reasonable function in the short and long term.122,191 
Locked plating for high-energy proximal tibia fractures should decrease the need for dual plating in unstable bicondylar fractures since the fixed angle screw plate device can resist common deforming forces. In addition, external screw targeting allows the plates to be applied through limited approaches. In combination, these advantages may decrease the incidence of wound complications and some publications indicate the wound complication rate is low.39,51,145 However, Phisitkul reported a 22% rate of infection in high-energy proximal tibias treated with a LISS plate.140 Open fasciotomy incisions are frequently present and may complicate treatment and increase the risk for infection. 
Treatment of wound breakdown and infection depends on the clinical presentation. The authors of a recent paper speculated that current infections were easier to treat and less severe because of more limited approaches for reducing the fracture and inserting the implant.140 Irrigation and debridement in the operating room and organism-specific antibiotics are central to all treatment techniques. 
In early postoperative infections, well-fixed hardware may be maintained and the wound packed open. If the infection can be suppressed until fracture healing, hardware removal will then give a chance for a cure. However, if the infection is aggressive or the bone is involved, hardware removal followed by external fixation may be prudent. Associated soft tissue defects may require flap coverage. Definitive stabilization can be with external fixation or repeat internal fixation after infection control and soft tissue coverage are accomplished. 
Proximal tibial infections after internal fixation of tibial plateau fractures that involve the joint and the bone may be very difficult to control and cure. Proximal tibial resection with a cement spacer and subsequent arthroplasty, knee arthrodesis, or even above knee amputation may be necessary to eradicate infection. 

Septic Arthritis After External Fixation in Tibial Plateau Fractures

External fixation used to definitively treat complex tibial plateau fractures has complications unique to that method. Septic arthritis of the knee related to proximal tibial external fixation wires or pins has been reported as an occasional complication. Rates have been as high as 10%.118 Studies have assessed the capsular reflections around the knee in an effort to define a safe zone for pins or wires. One study indicated that to be certain capsular reflections were not violated pins and wires should be kept a minimum of 14 mm below the joint.148 
To minimize the risk of this complication, it is prudent to keep external fixation pins or wires as far from the articular surface as possible. In severely comminuted fractures with multiple small fragments close to the joint or large joint depression cavities, a prolonged period of cross-knee external fixation will minimize the risk of joint sepsis in the early weeks after injury. 
With the increased popularity of laterally based locking plates external fixation with pins or wires in the very proximal tibia is used less commonly. For this reason this complication is now rarely seen. The joint-spanning external fixators that are commonly used for temporary treatment do not pose a risk for knee septic arthritis, since pins are remote form the knee and the zone of injury. 

Knee Stiffness in Tibial Plateau Fractures

Most patients regain a satisfactory range-of-knee motion after tibial plateau fractures. Current techniques emphasize early motion in stable fractures or after operatively fixing unstable fractures. In one study of 202 operatively treated patients with 1 year of follow-up, the average knee range of motion was 130 degrees (range 10 to 145 degrees).143 In another study of all high-energy fractures treated with external fixation, the knee range of motion at greater than 5 years after injury averaged 3 degrees of extension and 120 degrees of flexion.191 Early motion after surgical treatment is standard care although fixation must be strong enough to permit motion. Some patients may benefit from physical therapy although there is not any data that a therapy program improves motion. 
For severe fractures, up to several weeks of cross-knee external fixation is commonly utilized before freeing the knee. Even with this enforced immobility, most patients restore knee motion. Egol et al.54 reported that after a mean of 15 days of cross-knee external fixation prior to definitive internal or external fixation, patients averaged 106 degrees of knee flexion. Although the authors felt that the results were satisfactory they speculated that the external fixator might have contributed to the decreased range of flexion seen in some of their patients. Marsh et al.118 reported that even 6 weeks of cross-knee immobilization prior to external fixation of tibial plateau fractures resulted in excellent knee motion. 
When stiffness does occur after a tibial plateau fracture, it is challenging to treat. Knee manipulation may improve motion in some knees that are not progressing. It is preferable to wait until healing has likely occurred, usually around 3 months. After 4 months, a surgical lysis of intra-articular adhesions, either open or arthroscopic, may be necessary. 

Prominent or Painful Hardware in Tibial Plateau Fractures

Since the proximal tibia is largely subcutaneous, care must be taken to place implants in optimal positions to minimize prominent painful hardware. Screws through laterally based plates can easily be too long and prominent on the subcutaneous medial border of the tibia irritating the pes tendons. The relative, triangular shape of the proximal tibia can make anterior screws, which are too long, appear within bone on AP radiographs. Rarely, long anterior to posterior screws may cause neurovascular injury.146 
Locking plates applied to the lateral tibia may have more frequent hardware problems than traditional lower profile plates that were compressed to the bone. Titanium-locked plates may be difficult to remove because of cold welding of screws. Because plates used to treat comminuted metaphyseal fractures are frequently long and are beneath a long length of the anterior compartment removal can require substantial dissection. Plates thick enough to treat unstable metaphyseal and diaphyseal fractures make them more prominent in the proximal lateral subcutaneous area than thinner lateral buttress plates (Fig. 55-35). During acute treatment of the fracture plates can be applied to the bone and the screws inserted using a minimally invasive approach. Hardware removal may be more difficult than insertion through such limited incisions and may have greater risks than the original implant insertion. These problems are compounded if locked screws are cold welded to the plate. The incidence and severity of these problems are currently not well known but cold welded screws have been reported primarily with the LISS system.41,140 
Figure 55-35
 
This photograph of the lateral side of the knee of a patient 9 months after a ORIF shows the prominence from a locking plate which can be problematic for the patient.
This photograph of the lateral side of the knee of a patient 9 months after a ORIF shows the prominence from a locking plate which can be problematic for the patient.
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Figure 55-35
This photograph of the lateral side of the knee of a patient 9 months after a ORIF shows the prominence from a locking plate which can be problematic for the patient.
This photograph of the lateral side of the knee of a patient 9 months after a ORIF shows the prominence from a locking plate which can be problematic for the patient.
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Nonunion in Tibial Plateau Fractures

The majority of tibial plateau fractures heal without difficulty. Split depression fractures need void filler solely for the purpose of support of the reduced articular surface and not to ensure union which occurs reliably. High energy OTA/AO C3 and Schatzker 6 fractures, particularly when widely displaced and open, are felt to be at increased risk of healing delays or nonunion.178 
Treatment of nonunion of the proximal tibia is challenging. As in any nonunion, the presence or absence of infection is the first issue in deciding on treatment techniques. Infection is suspected based on the history, clinical examination, imaging, and laboratory studies. In periarticular nonunions of the proximal tibia, the mobility of the joint and the presence or absence of posttraumatic arthritis both must be considered. If the joint is salvageable, the nonunion is repaired with internal or external fixation and usually some osteoinductive material such as autologous bone graft or bone morphogenic protein is added. Accurate alignment must be restored. If the joint cannot be salvaged the nonunion should be treated along with the knee by arthrodesis or arthroplasty. 

Malunion in Tibial Plateau Fractures

Preventing malunion is one of the major goals of treating tibial plateau fractures. Tibial plateau fractures can lead to extra-articular angular malunion, intra-articular malunion, or combinations of both. Angular malunion may occur in any plane. If angular deformity is significant, it will cause functional problems, be cosmetically objectionable, and increase the risk for posttraumatic OA. The degree of deformity that will predictably cause these problems is uncertain and must be assessed on a case-by-case basis. If correction is necessary, the surgical approach and technique will depend on the direction and amount of the deformity, the presence of pre-existing implants, and the condition of the soft tissue envelope. Preoperative planning is critically important. For metaphyseal malunions, either opening or closing wedge osteotomies may be chosen and can be fixed internally or with an external fixator. 
Intra-articular malunions are more challenging to evaluate and to surgically correct. Intra-articular malunions can contribute to limb malalignment. For instance, a major split depression lateral plateau fracture that heals with the lateral joint significantly depressed will result in a limb aligned in valgus. If the alignment is unacceptable it can be corrected through an intra-articular osteotomy to restore the lateral articular surface and support the lateral femoral condyle. An alternative approach accepts the intra-articular deformity and aligns the limb with an extra-articular osteotomy. In certain challenging deformities combined intra- and extra-articular osteotomies may be the best approach120 (Fig. 55-36A–C). Toro-Arbelaez et al.178 reported a small series of five patients where deformity was corrected through an intra-articular nonunion by nonunion takedown, fragment repositioning, grafting, and internal fixation. 
Figure 55-36
 
Failed lateral plating of a split depression tibial plateau fracture demonstrates severe lateral articular deficiency (A) and valgus alignment on long leg films (B). The joint was reconstructed through an intra-articular osteotomy of the depressed articular surface and an extra-articular varus osteotomy (C).
Failed lateral plating of a split depression tibial plateau fracture demonstrates severe lateral articular deficiency (A) and valgus alignment on long leg films (B). The joint was reconstructed through an intra-articular osteotomy of the depressed articular surface and an extra-articular varus osteotomy (C).
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Figure 55-36
Failed lateral plating of a split depression tibial plateau fracture demonstrates severe lateral articular deficiency (A) and valgus alignment on long leg films (B). The joint was reconstructed through an intra-articular osteotomy of the depressed articular surface and an extra-articular varus osteotomy (C).
Failed lateral plating of a split depression tibial plateau fracture demonstrates severe lateral articular deficiency (A) and valgus alignment on long leg films (B). The joint was reconstructed through an intra-articular osteotomy of the depressed articular surface and an extra-articular varus osteotomy (C).
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Posttraumatic Arthritis in Tibial Plateau Fractures

After tibial plateau fracture, the knee is less likely to develop severe arthrosis than the hip after acetabular fracture or the ankle after tibial plafond fracture.116 In two series from the same institution, both with 5 to 11 years of follow-up, the ankle after tibial plafond fracture had developed arthrosis in over 90% of patients with the majority being moderate or severe, whereas the knee after high-energy tibial plateau fracture had arthrosis in only 36% of patients and over half of these were only mild or moderate.119,191 Rasmussen144 at 7 years of follow-up of patients treated operatively and nonoperatively found arthrosis in only 17%. Lachiewicz and Funcik104 found that 10/43 operatively treated knees had arthrosis at almost 3 years of follow-up. In operatively treated plateaus with 5 to 27 years of follow-up, Rademakers et al.143 found arthrosis in 27% of malaligned knees and only 9% with anatomic alignment. Honkonen81 found that arthrosis was increased with meniscectomy and with malalignment but it correlated poorly with articular step-offs. Keating94 found arthrosis in 68% of knees after tibial plateau fracture in patients over 60 demonstrating the effect of older age on increasing the likelihood of secondary arthritis. 
Results of fresh tibial osteochondral allografts used to treat failed tibial plateau fractures have been reported with long follow-up (mean 12 years).167 In this time interval, one-third of knees had been converted to prosthetic arthroplasty and 40% of remaining knees had moderate or severe degenerative changes. Despite this, most surviving grafts continued to provide reasonable function. A tibial osteotomy to change alignment was a frequent associated procedure and there was a trend to better results with concomitant meniscal transplantation. Mosaicplasty has been reported as another possibility to reconstruct defects in the lateral tibial plateau after fracture.152 
Reconstruction by knee arthroplasty is a good option in elderly patients with painful posttraumatic arthritis and/or deformity after a tibial plateau fracture. Recent case series have shown that relief of pain and improved function are predictably achieved but that there is a high incidence of postoperative complications and reoperations including infection, component revisions, and knee manipulation.154,193 In addition, these are frequently technically demanding arthroplasties due to pre-existing hardware, proximal tibial deformity, scarred soft tissues, and stiffness. Weiss et al.193 reported a 21% reoperation rate for knee arthroplasty after tibial plateau fracture. These results indicate that conversion of a symptomatic knee after a tibial plateau fracture to a knee arthroplasty should not be undertaken lightly (Fig. 55-37A, B). 
Figure 55-37
Total knee replacement after tibial plateau fracture is unusual.
 
It is often more difficult and complicated than a routine primary arthroplasty as illustrated in this case where removal of the failed lateral locking plate (A) was followed by a complex reconstruction (B).
It is often more difficult and complicated than a routine primary arthroplasty as illustrated in this case where removal of the failed lateral locking plate (A) was followed by a complex reconstruction (B).
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Figure 55-37
Total knee replacement after tibial plateau fracture is unusual.
It is often more difficult and complicated than a routine primary arthroplasty as illustrated in this case where removal of the failed lateral locking plate (A) was followed by a complex reconstruction (B).
It is often more difficult and complicated than a routine primary arthroplasty as illustrated in this case where removal of the failed lateral locking plate (A) was followed by a complex reconstruction (B).
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Author’s Preferred Method of Treatment for Tibial Plateau Fractures

General Preferences

In Figure 55-38, a summary flowchart describing the author’s preferred surgical treatment plan for either unicondylar or bicondylar tibial plateau fractures is demonstrated. Our preference is always for the most limited approach possible to reduce and fix the fracture as long as it is compatible with a well aligned limb and a fracture that is fixed well enough to start early motion. The more limited an approach the more important is preoperative planning to understand the fracture pattern and the important fragments and how they are displaced. Complex imaging with a CT scan is indispensible and in difficult patterns, we usually review 3D images on the computer work station to optimally assess the pathoanatomy of the proximal tibia. Since we only occasionally need to directly assess or treat associated intra-articular meniscal injuries, we usually do not obtain an MRI. 
Figure 55-38
 
This flow diagram demonstrates a general scheme for operative management for displaced tibial plateau fractures based on either a unicondylar or bicondylar fracture.
This flow diagram demonstrates a general scheme for operative management for displaced tibial plateau fractures based on either a unicondylar or bicondylar fracture.
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Figure 55-38
This flow diagram demonstrates a general scheme for operative management for displaced tibial plateau fractures based on either a unicondylar or bicondylar fracture.
This flow diagram demonstrates a general scheme for operative management for displaced tibial plateau fractures based on either a unicondylar or bicondylar fracture.
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Temporary spanning external fixation is reserved for the most severe injuries, since many fractures of the tibial plateau do not need or benefit from this two-stage approach. However, in appropriately selected cases it has been an important part of the senior author’s practice for many years.118 A simple anterior pin to single bar frame with two spread pins in both the tibia and femur usually suffices although strong distraction is required in difficult cases. The pins are spread widely to increase frame stability but occasionally a more complex frame is built. Our preference is for anterior femoral pins since they are in the plane of motion and in our opinion do not bind the quadriceps any more than other possible pin orientations. 
Most unicondylar fractures require buttressing or antiglide plating and locking screws are not necessary or helpful and only serve to increase costs. On the other hand, lateral locked plating has largely replaced definitive external fixation in our practice for most bicondylar and shaft-dissociated patterns. 

Lateral Side Fractures

The goal of operatively treating most lateral side injuries is to prevent valgus deformity. Some fracture patterns with large split fragments are amenable to screw fixation only. These are treated with true percutaneous techniques. It is important to have the screws perpendicular to the fracture line for compression and stability. Plate fixation is not necessary for pure split fractures. 
Small joint depressions are elevated under fluoroscopic control and supported with cannulated screws. Split depression fractures, where the split fragment is small or of poor quality, need a buttress plate. We use 3.5-mm precontoured plates and try to place the implant so the screws can be close under the elevated fragments. The extent of the approach is only what is required to place the plate and this approach is accomplished as the first step in the procedure. In some less severe cases we do not open or visualize the joint. The depressed fragments are reduced through the split fracture line and visualized fluoroscopically. Small residual articular irregularities are accepted without incising or elevating the meniscus. For the lateral side of complex and more severe patterns, we use a submeniscal arthrotomy to visualize reduction and to assess and treat meniscal injuries, and reduction and visualization are assisted by a cross joint external fixator or femoral distractor. The reduced fragments are supported with subchondral 3.5-mm rafting screws and if there is an obvious void it is filled with calcium phosphate cement, since current data indicates it has the best mechanical properties of the currently available void fillers. 
Some of our less severe lateral side reductions are visualized fluoroscopically only. This avoids an arthrotomy and in our hands leads to equally satisfactory reductions and minimizes disruption of the soft tissues. We rarely use arthroscopy and do not obtain preoperative MRIs. Despite the high incidence of meniscal injuries, in our experience these lateral fractures with less severe displacements do not need to be routinely assessed or managed. This approach is consistent with the good results reported for a variety of other strategies to treat plateau fractures that have not visualized the joint or addressed meniscal pathology.2,12,45,51,52,101,103,105,110,144,190,191 

Medial Side Fractures

The posteromedial approach is standard for most injuries on the medial side and most posterior injuries. The medial gastrocnemius is easily mobilized and access well past the posterior midline is possible for even posterolateral depressions. When the plate will be posterior or even posteromedial, we take care to make the incision on the posterior side of the posteromedial tibia to prevent the skin from becoming an impediment to screw paths. An incision too anterior is one of the biggest obstacles to reducing and fixing posterior patterns from the posteromedial approach. For more anterior medial patterns, we still use a posteromedial approach but the work is done between the pes tendons. When the medial side is even subtly malreduced this may lead to unacceptable limb alignment. Despite directly reducing a posteromedial spike, alignment must be assessed fluoroscopically and compared to the opposite side. We always obtain fluoroscopic images of the opposite side at the start of the case. The limb is best visualized when it is extended and in the standard AP position. The fragment must be provisionally fixed with reduction forceps during this step. Flexion and external rotation may re-create deformity so it helps to achieve screw fixation in the extended nonrotated position from anterior or anterior lateral, before re-exposing the posteromedial surface for plating in flexion and external rotation. To fix the posteromedial fragment, we have used a number of different 3.5-mm sized plates and frequently favor one or two pelvic reconstruction plates. They contour easily to any location and are narrow enough that two can be used if necessary to broaden the support over the back of the proximal tibia. 

Bicondylar Fractures

Patterns that require implants on both sides are treated with a combination of the two approaches, anterolateral for the lateral side injury and posteromedial for the medial side injury. For most patterns with a coronal split of the medial condyle creating a displaced posteromedial fragment, we will choose to approach both sides rather than using a lateral locked plate alone. These are difficult fracture patterns but if the limb is accurately aligned, good results are possible. 
The procedure is performed with the patient supine on a radiolucent table. The posteromedial approach and medial side fracture are reduced and fixed first with the leg externally rotated. It is critically important to reduce the medial side as accurately as possible since it is the first step in a sequential procedure, the end result of which is to have a well-reduced and aligned knee. During plating, care must be taken that posteromedial screw paths do not interfere with the subsequent lateral side procedure. In addition, we try to be conservative with the amount of fixation screws recognizing that there will be plates on both sides. With plates on both sides, 3.5-mm implants are usually sufficient and locking screws are rarely necessary or helpful. It is also important to move along as quickly as possible—with full procedures on both sides of the joint there is a lot of work to do. 

Shaft-dissociated Patterns

These patterns are the ones that will frequently be treated by a lateral side locking plate only. The decision is based on the characteristics of the medial side injury. If the medial side is nondisplaced or if the fragment is large and not comminuted we will reduce it indirectly and stabilize it from the lateral side with a locking plate. In more complex medial side patterns, we prefer two approaches to avoid varus collapse or inaccurate medial side reduction. 
Lateral locked plates are usually applied through very limited approaches—only what is necessary to place the head of the implant and to open the anterior compartment to slide it distally. Articular reductions are performed through limited approaches based on the fracture pattern. Distal screws are placed through the external targeting jig. We usually first use nonlocked screws proximal and distal to bring the plate to the bone. Proximal fixation is then completed with locking screws and distally the shaft is fixed with nonlocked screws. This hybrid type construct has the advantages of both locked and nonlocked plates. 
In fractures with severe soft tissue injuries, some open fractures, and some fractures associated with compartment syndrome, we use definitive external fixation with a monolateral frame or a Taylor Spatial Frame. Frames are usually needed for 3 to 4 months and weight bearing in the second half of this time in the frame is encouraged. Frames are removed in the outpatient clinic unless hydroxyapatite pins are used in which case they are removed in the operating room. 

Summary, Controversies, and Future Directions in Tibial Plateau Fractures

Brief Summary of New Trends

There are important new trends that have shaped current thinking and are leading to better understanding, management, and better outcomes for patients with tibial plateau fractures. Clinical research is needed to provide evidence so these new trends can be most appropriately integrated into the traditional surgical armamentarium. 
New imaging techniques have increased the ability to visualize both the fracture and the associated injuries to important soft tissue structures around the knee. High-quality CT scans including high-quality 2D and 3D reconstructions assist in preoperative planning particularly for complex patterns. The frequency of associated meniscal and ligament injuries and the fracture patterns in which these injuries are most likely to occur have been elucidated by MRI scans. Although to some clinicians, the value of the information these studies provide seems intuitively obvious, their role in improving patient outcome remains to be fully defined. 
In lower energy split depression fractures, new techniques are being used to optimally support the reduced articular surface. These include better implants, better methods to position implants, and better methods to fill the metaphyseal void created after reducing the articular fragments. These new techniques are important since some loss of articular reduction remains an important problem. In fractures that involve both condyles and those with shaft instability, plates with locked screws provide fixed angle stability and have become important adjuncts to maintain fracture alignment and have substantively changed practice patterns. When fixation is necessary on both the medial and lateral side of the knee, using two separate approaches appears to be as effective as and much safer than extensile approaches. In severe patterns with displacement and soft tissue injury, the use of a joint-spanning external fixator has facilitated maintaining length and alignment during a delay awaiting soft tissue recovery, which has led to safer definitive surgery. 

Future Treatment Directions

Long-term outcomes for patients with tibial plateau fractures correlate with preventing deformity, avoiding complications, and with younger age. For these reasons, further advances will require better methods to control limb alignment and minimize complications. Recent innovations in locked plating and buttressing with small-fragment precontoured plates indicate that further hardware improvements may continue to emerge; however, the most promising area for future advances are in new materials to fill metaphyseal voids as ways to prevent postsurgical settling while avoiding the morbidity of iliac crest grafts. 
Less invasive techniques to achieve fracture stability without increased soft tissue injury and increasingly without large joint arthrotomies will continue to be developed. This will require further improvements in intraoperative imaging. Currently available intraoperative 3D imaging is just a start. 
Tibial plateau fractures are articular injuries and better preservation of articular cartilage surfaces will need to be developed. Since we are near the limits of what can be done mechanically, major advances will need to be in biologic methods to help restore and preserve damaged articular surfaces. 
As the population ages better methods to restore function in elderly patients will need to be developed and clinical research will need to define the reasons for poorer outcome in this patient group. Only in this way will treatment advances be directed at improving the poor results frequently seen in these patients. 

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