Location of lateral tibial plateau fractures relative to the posterolateral complex predicts the need for extension of lateral approaches: A retrospective observational study

Abstract

Purpose: Extended lateral approaches have been proposed to improve visualization and therefore reduction quality of the articular surface in lateral tibial plateau fractures. However, recommendations regarding the exact morphology of lateral tibial fractures requiring extended approaches are lacking.

Methods: A retrospective observational cohort study was conducted using data from patients who underwent surgical treatment of a tibial plateau fracture involving the lateral tibial plateau (AO/OTA 41-B3 and 41-C3) at a level 1 trauma center between January 2020 and May 2024. Demographics, patient positioning, and surgical approaches were recorded. Comprehensive examinations on preoperative computed tomography (CT) scan were performed evaluating the morphology of lateral tibial plateau fractures relative to the posterolateral ligamentous structures.

Results: 143 patients (53.8% female, 46.2% male) with a mean age of 51.3 ± 14.3 years were included. Three distinct types of lateral tibial plateau fractures were identified. The most frequent fracture types observed were anterior to the posterolateral ligamentous structures (38.5%) and at level of the posterolateral complex (36.4%), followed by a fracture location posterior to the posterolateral ligamentous structures (25.1%). Extended lateral approaches using lateral femoral epicondyle osteotomy were performed in 17.5% of cases, with fractures posterior to the posterolateral ligamentous structures more likely to have an extended approach (80.0%, p < 0.001).

Conclusions: Lateral tibial plateau fractures show three distinct fracture types, with the fracture location relative to the posterolateral ligamentous structures predicting extension of lateral approaches. For fractures extending posterior to the posterolateral complex, preoperative planning should include prone or lateral patient positioning and selection of an extended lateral approach.

Level of evidence: III.

Keywords: Extended lateral approaches; Fracture type-specific approach selection; Lateral epicondyle osteotomy; Tibial plateau fracture.

Fig. 1

Flowchart of retrospective selection of the study population, consisting of patients with tibial plateau fracture who underwent open reduction and internal fixation at our department

Fig. 2

Schematic illustration of the fracture classification process. (a) Using the 3D reconstructions of the preoperative computed tomography (CT) scans, an imaginary line was drawn between the anterior and posterior aspect of the lateral epicondyle and the fibular tip, respectively, to assess the expansion of the depression zone of the lateral tibial plateau fracture relative to the anatomic course of the lateral collateral ligament (LCL). (b) Depending on the location of the depression zone, lateral tibial plateau fractures were classified into three different fractur types: Type I represent a lateral tibial plateau fracture with the main depression zone completely anterior to the LCL, whereas Type III fractures are characterized by a fracture zone posterior to the LCL. Type II fractures are borderline fractures characterized by location of the main depression zone at the level of the LCL

Fig. 3

Classification of lateral tibial plateau fractures. (a) Schematic illustration of the three different fracture types. (b) Type I fracture, anterior to the ligamentous structures of the posterolateral corner. (c) Type II fracture, at the level of the posterolateral ligamentous structure. (d) Type III fracture, posterior to the ligamentous structures of the posterolateral corner

Fig. 4

Group comparison (extended lateral approach versus non-extended lateral approach)