Advanced Trauma Care With Tricalcium Phosphate Bone Grafts for Tibial Plateau Fractures: A Report of Three Cases

Abstract

Advances in implants and biological therapies have significantly improved trauma care, offering surgeons a variety of solutions for complex cases. This study evaluates the outcomes of three patients with complex Schatzker type V tibial plateau fractures, treated with open reduction and internal fixation supplemented by tricalcium phosphate bone void filler. The surgical approach was selected based on the specific fracture pattern. Postoperative outcomes were assessed using the Oxford Knee Score (OKS), Visual Analog Scale (VAS) for pain, and EQ-5D-5L for quality of life. The results indicated high patient satisfaction (mean score of 8.67 ± 2.31) and low pain levels (mean VAS of 2.67 ± 2.31). The mean OKS was 32 (± 8.66), and the mean EQ-5D-5L VAS score was 88.33 (± 16.07). Follow-up assessments revealed a good to excellent range of motion, with no significant complications. No additional articular step-off was observed at follow-up. The study suggests that tricalcium phosphate bone grafts may be a promising biomaterial for enhancing recovery in complex tibial plateau fractures by providing mechanical support and promoting osteointegration.

Keywords: biocompatible materials; bone graft substitutes; open reduction and internal fixation (orif); tibial plateau fracture; tricalcium phosphate.

Figure 1. Preoperative radiographs of Patient 1

Radiographs showing a bicondylar tibial plateau fracture (Schatzker V), with depression of the lateral tibial plateau (red arrows) and a split of the medial tibial plateau (yellow arrows), in both the AP view (A) and the oblique view (B).

Figure 2. Preoperative CT scans of Patient 1

Coronal views (A-C) show a bicondylar tibial plateau fracture (Schatzker V), with depression of the lateral tibial plateau (red arrows) and a split of the medial tibial plateau (yellow arrow). Sagittal view (D) displays the depression fragment (red arrow). Axial view (E) highlights the fibular head (green asterisk) as a reference point for the lateral and medial sides, with the depression fragment (circular red dotted line) and split fracture line (yellow dotted line) outlined.

Figure 3. Preoperative CT scan 3D reconstructions of Patient 1

The 3D reconstructions from the CT scan provide detailed visualization of the fracture pattern on the anterior (A), medial (B), posterior (C), and lateral (D) sides.

Figure 4. Postoperative radiographs of Patient 1 at three months

The radiographs demonstrate the positioning of the plates on the anterolateral and posteromedial sides, shown in both the AP (A) and lateral (B) views. The depressed fragment has been reduced and is being supported by the bone graft.

Figure 5. Postoperative radiographs of Patient 1 at 18 months

The radiographs show no significant changes in articular congruency compared to those taken at three months postoperative. There is clear evidence of fracture healing and successful integration of the bone graft.

Figure 6. Preoperative radiographs of Patient 2

In both the AP (A) and lateral (B) views, the radiographs reveal what appears to be a simple split fracture of the tibia at the medial plateau (yellow arrow). However, the presence of a fibular head fracture (green arrow) suggests the possibility of a more complex injury.

Figure 7. Preoperative CT scans of Patient 2

The coronal views from the CT scans (A, B) show a medial tibial plateau fracture (yellow arrow), a fibular head fracture (green arrow), and a fracture line extending to the lateral tibial plateau (red arrow). The sagittal view (C) displays the medial plateau fracture line (yellow arrow) and a coronal plane fracture line (red arrow). In the axial view (E), the medial fracture line is outlined by the yellow dotted line, and the coronal plane fracture is outlined by the oval-shaped red dotted line.

Figure 8. Preoperative CT scan 3D reconstructions of Patient 2

The 3D reconstructions from the CT scan provide a detailed view of the fracture pattern from several angles: anterior (A), medial (B), posterior (C), and posterolateral (D). Additionally, the axial view (E) offers further details, highlighting the fibular head (green asterisk) and the anterior tibial tuberosity (blue asterisk) for spatial reference.

Figure 9. Postoperative radiographs of Patient 2 at three months

The radiographs illustrate the positioning of the plate on the anteromedial side, as seen in both the AP (A) and lateral (B) views, with the bone graft visible as a radiopaque line on the medial side.

Figure 10. Preoperative radiographs of Patient 3

The radiographs show a bicondylar tibial plateau fracture (Schatzker V) in both the AP view (A) and the lateral view (B). The lateral tibial plateau fracture is outlined by the red arrow, and the medial tibial plateau fracture line is outlined by the yellow arrow in the AP view (A).

Figure 11. Preoperative CT scans of Patient 3

The coronal CT scan view (A) shows the bicondylar tibial plateau fracture (Schatzker V), with the split fracture of the lateral tibial plateau (red arrow) and the split fracture of the medial tibial plateau (yellow arrow) clearly visible. The sagittal CT scan view (B) highlights details of the medial tibial plateau fracture (yellow arrow). In the axial view (E), the fibular head (green asterisk) serves as a reference point for the lateral and medial sides, with both split fractures of the lateral (red dotted line) and medial plateau (yellow dotted line) outlined. Comminution between the two larger fragments, lateral and medial, is also visible.

Figure 12. Preoperative CT scan 3D reconstructions of Patient 3

The CT scan 3D reconstructions provide detailed visualization of the fracture pattern from the anterior (A), medial (B), posterior (C), and lateral (D) sides.

Figure 13. Postoperative radiographs of Patient 3 at three months

The radiographs, in both AP (A) and lateral (B) views, show a successful reduction of the articular surface. Both the anterolateral and medial plates, along with the bone graft, provide support to the original fracture.

Figure 14. Method of application of the tricalcium phosphate bone filler (AdvanCore®)

In the left image (A), a syringe containing bone graft granules has had its top cut off to facilitate easier graft application. In the right image (B), the syringe is being used to compact and position the graft at the fracture site.