Treatment strategy for tibial plateau fractures: an update

Abstract

Tibial plateau fractures are complex injuries produced by high- or low-energy trauma. They principally affect young adults or the 'third age' population.These fractures usually have associated soft-tissue lesions that will affect their treatment. Sequential (staged) treatment (external fixation followed by definitive osteosynthesis) is recommended in more complex fracture patterns. But one should remember that any type of tibial plateau fracture can present with soft-tissue complications.Typically the Schatzker or AO/OTA classification is used, but the concept of the proximal tibia as a three-column structure and the detailed study of the posteromedial and posterolateral fragment morphology has changed its treatment strategy.Limb alignment and articular surface restoration, allowing early knee motion, are the main goals of surgical treatment. Partially articular factures can be treated by minimally-invasive methods and arthroscopy is useful to assist and control the fracture reduction and to treat intra-articular soft-tissue injuries.Open reduction and internal fixation (ORIF) is the gold standard treatment for these fractures. Complex articular fractures can be treated by ring external fixators and minimally-invasive osteosynthesis (EFMO) or by ORIF. EFMO can be related to suboptimal articular reduction; however, outcome analysis shows results that are equal to, or even superior to, ORIF. The ORIF strategy should also include the optimal reduction of the articular surface.Anterolateral and anteromedial surgical approaches do not permit adequate reduction and fixation of posterolateral and posteromedial fragments. To achieve this, it is necessary to reduce and fix them through specific posterolateral or posteromedial approaches that allow optimal reduction and plate/screw placement.Some authors have also suggested that primary total knee arthroplasty could be an option in specific patients and with specific fracture patterns. Cite this article: Prat-Fabregat S, Camacho-Carrasco P. Treatment strategy for tibial plateau fractures: an update. EFORT Open Rev 2016;1:225-232. DOI: 10.1302/2058-5241.1.000031.

Keywords: posterolateral knee approach; posteromedial knee approach; staged sequential surgical treatment; three-column concept; tibial plateau fractures.

Fig. 1

Substantial soft tissue injuries with a broken bone inside. Extensive haemorrhagic and serous blisters 36 hours after injury in an obese female patient who suffered a low-energy trauma and sustained a partial articular fracture (Schatzker 3/ AO OTA 41B2).

Fig. 2

40-year-old patient who sustained a motorcycle injury. (a) Posterolateral fracture comminution and posteromedial fracture fragment; (b) Percutaneous medial fracture reduction and fixation with two cannulated screws. Through an anterolateral approach and an epiphysio-metphyseal window the posterolateral fracture was reduced with a bone elevator. Filling of the bone defect with bone allograft, L-shaped proximal tibia plate.

Fig. 3

Posteromedial coronal fracture. (a) Scheme of the typical coronal posteromedial fragment displacement; (b) even if adequate reduction can be achieved from an anteromedial approach, the fixation obtained from the medial aspect of the tibia is suboptimal; (c) optimal reduction and fixation with a posteromedial approach using an adequately placed buttress plate and appropriate direction of the screws.

Fig. 4

Patient prone. Posterolateral fracture and posterolateral approach without fibular osteotomy. (a) Approach location. Identification and dissection of the CPN. Visualisation and approach to the articular fracture fragments. (b) Posterolateral fracture. Reduction and fixation with K-wires of the posterolateral fragments. Buttress plating. Fixation of the lateral column through an anterolateral approach.