Abstract
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Partial tibial plateau fractures may occur as a consequence of either valgus or varus trauma combined with a rotational and axial compression component.
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High-energy trauma may result in a more complex and multi-fragmented fracture pattern, which occurs predominantly in young people. Conversely, a low-energy mechanism may lead to a pure depression fracture in the older population with weaker bone density.
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Pre-operative classification of these fractures, by Müller AO, Schatzker or novel CT-based methods, helps to understand the fracture pattern and choose the surgical approach and treatment strategy in accordance with estimated bone mineral density and the individual history of each patient.
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Non-operative treatment may be considered for non-displaced intra-articular fractures of the lateral tibial condyle. Intra-articular joint displacement ⩾ 2 mm, open fractures or fractures of the medial condyle should be reduced and fixed operatively. Autologous, allogenic and synthetic bone substitutes can be used to fill bone defects.
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A variety of minimally invasive approaches, temporary osteotomies and novel techniques (e.g. arthroscopically assisted reduction or ‘jail-type’ screw osteosynthesis) offer a range of choices for the individual and are potentially less invasive treatments.
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Rehabilitation protocols should be carefully planned according to the degree of stability achieved by internal fixation, bone mineral density and other patient-specific factors (age, compliance, mobility). To avoid stiffness, early functional mobilisation plays a major role in rehabilitation. In the elderly, low-energy trauma and impression fractures are indicators for the further screening and treatment of osteoporosis.
Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160067. Originally published online at www.efortopenreviews.org
Introduction
Partial tibial plateau fractures may occur as a consequence of a valgus or varus trauma combined with a rotational and axial compression component. In the following article, we focus mainly on unicompartmental AO type B1-B3 fractures. Soft-tissue damage, joint depression and fragment dislocation, as well as bone stock, patient compliance and concomitant injuries, may influence decision-making. However, due to these difficulties, a clear treatment strategy is required to achieve an anatomical reduction and, subsequently, an optimal clinical and functional result.
Three-dimensional (3D) pre-operative imaging (CT scans with two-dimensional (2D) and 3D reconstructions) is essential to fully understand the fracture morphology and may therefore influence the treatment strategy. Additionally, if clinical examination is difficult, a pre-operative MRI scans may be necessary to visualise concomitant intra-articular pathologies (e.g. meniscus), which also need to be addressed.
Mechanism of trauma
The typical valgus and varus bending mechanism can result in a corresponding lateral or medial plateau split fracture with a varying degree of articular surface depression. This situation leads to axis malalignment and pathological load distribution, which ultimately causes poor functional outcome and post-traumatic osteoarthritis. Concomitant ligament disruption, meniscus or cartilage damage will further weaken clinical results.
A high-energy traumatic mechanism may result in a more complex and multi-fragmented fracture pattern, which predominantly occurs in young people. Conversely, a low-energy mechanism may lead to a pure depression fracture in the older population who have reduced bone density. Thoughtful evaluation of the patient’s history and fracture morphology (using CT) in accordance with existing classification systems may help to understand the fracture mechanism 1 and expected bone quality/density to develop the appropriate operative treatment strategy.
Classification
Previous classification systems rely on conventional radiography evaluations (Müller AO/OTA 2 or Schatzker) 3 and injury mechanisms (Moore 1 ). However, recent CT-oriented classification systems provide more detailed information pertaining to the fracture morphology, degree of joint depression and appropriate surgical approach. 4,5 Luo et al 4 recently described a CT-based three-column model to evaluate tibial plateau fractures and clinical decision-making (Fig. 1). According to the authors: ‘one independent articular depression with a break of the column wall is defined as a fracture of the relevant column. Pure articular depression without fracture of the three columns (Schatzker type III) is defined as a zero-column fracture’. 6
The ‘medial’, ‘lateral’ and ‘posterior’ column of the Luo classification. Pure impression fractures are defined as ‘zero-column fractures’. Reprinted from Luo CF, Sun H, Zhang B, Zeng BF. Three-column fixation for complex tibial plateau fractures. J Orthop Trauma 2010;24:683-692, with permission from Wolters Kluwer Health.
Citation: EFORT Open Reviews 2, 5; 10.1302/2058-5241.2.160067
Krause et al 5 investigated fracture patterns from a total of 242 patients with 246 affected knees and suggested ‘ten segment’ mapping of the tibial plateau (Fig. 2).
Classifying tibial plateau fractures by ten segments in a CT model may help to choose an appropriate approach. Reprinted from Krause M, Preiss A, Müller G, et al. Intra-articular tibial plateau fracture characteristics according to the “Ten segment classification”. Injury 2016;47:2551-2557, with permission from Elsevier.
Citation: EFORT Open Reviews 2, 5; 10.1302/2058-5241.2.160067
Based on their findings, a new classification system was developed that included implications for the treatment strategy. Unicondylar lateral tibial plateau fractures were most common (88.8%), whereas the medial plateau was only involved in 10% of unicompartmental or extended lateral type-B fractures. 5 These unicompartmental medial plateau fractures are mainly associated with low-energy injury mechanisms. A possible reason for the relatively increased involvement of the lateral tibial plateau (Fig. 3) may be its decreased bone mineral density in comparison to the medial plateau. 7
Most partial tibial head fractures affect the lateral plateau. Reprinted from Krause M, Preiss A, Müller G, et al. Intra-articular tibial plateau fracture characteristics according to the “Ten segment classification”. Injury 2016;47:2551-2557, with permission from Elsevier.
Citation: EFORT Open Reviews 2, 5; 10.1302/2058-5241.2.160067
AO type B fractures showed a wide range of different fracture patterns with 29 different segment combinations overall. The posterolateral lateral (65.2%), the anterolateral lateral (64.6%) and the anterolateral central (60.9%) segments were the most frequently involved. One-third of all AO type B fractures included central segments of the tibial spine. 5
In the non-osteopenic tibial bone, unicompartmental fractures of the medial column are rare. 5 In a prospective study in an alpine skiing region (Grenoble, France), Morin et al 8 detected unicompartmental posteromedial Moore I fractures in 13% of all injured alpine skiers, who received surgical treatment for intra-articular tibial plateau fractures. However, in the well-mineralised tibial head, fractures of the medial compartment appeared more often in multi-part tibial-head dislocation-type injuries. 1,9 Iatrogenic partial tibial fractures have been reported in a few cases after ligament reconstruction surgery and high tibial osteotomy, but the risk for these secondary fractures is low. 10
Indications for operative reduction and fixation
In general, surgical reduction and fixation is indicated for most tibial head fractures. However, the fracture morphology, articular surface displacement level, axial stability, limb alignment and the patient’s general condition should be considered. The following specific indications for surgical treatment have been reported in the literature: 11,12
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Intra-articular displacement of ⩾ 2 mm
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Metaphyseal-diaphyseal translation of > 1 cm
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Lateral tilting of the plateau > 5°
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Condylar widening > 5 mm
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Angular deformity of > 10° in either the coronal (varus-valgus) or sagittal plane (tibial slope)
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All medial tibial condyle fractures (except fissures)
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Open fracture
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Associated compartment syndrome
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Associated ligamental injury requiring repair
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Associated fractures of the ipsilateral tibia or fibula
In addition to the general condition of the patient, soft-tissue damage and swelling should be taken into consideration when planning surgery. When an increase in soft-tissue damage is expected, fracture reduction should be performed either immediately before swelling of the limb, or the limb should be immobilised by cast or external fixator to condition the soft-tissue prior to secondary surgical reduction. Concomitant ligamental injury with resulting instability should be identified before or during surgery.
Treatment options: approaches and techniques
Conventional (antero-)lateral approach
A conventional anterolateral approach may be used for reduction and fixation of the anterolateral part of the tibial plateau. The meniscotibial ligaments should be incised horizontally, and the lateral meniscus should be slightly lifted proximally to gain sufficient view of the tibial joint surface. After reduction, fixation can be performed using a proximal anterolateral tibial locking compression plate (LCP), anterolateral proximal tibial rafting LCP or lateral proximal tibial less-invasive stabilisation system LISS-plate (Fa. Synthes, Switzerland).
However, in some cases, the anterolateral approach does not provide full visualisation, especially of the posterior portion of the fracture zone. Thus, a fibular osteotomy, 13,14 lateral femoral epicondylar osteotomy 15 or posterolateral approach may be necessary.
Posterolateral approach
To improve access to the posterolateral parts of the tibia in posterior partial fractures, a modified posterolateral approach may be helpful. 16 In a lateral recumbent position, a skin incision is performed along the long biceps tendon and the proximal fibular line. Conventional anterolateral arthrotomy is suggested to visualise the joint. The common peroneal nerve is exposed and is protected until the surgery is finished.
First, dissection of the cavity between the head of the lateral gastrocnemius and the soleus muscle is conducted (Fig. 4), followed by blunt preparation between the popliteus muscle and soleus muscle without injuring the popliteal artery and vein. Holding the popliteus muscle cranially enables access to the posterolateral plateau. Fractures can be fixed using a posterolateral tibial LCP, a (small) 3.5 mm T-shaped LCDCP or, in some cases, a distal radius two-column LCP may fit. For larger or more difficult fragments, an additional temporary partial dissection of the fascia of the proximal soleus and/or an osteotomy of the fibular head may improve exposure to the posterolateral fracture site.
A modified posterolateral approach between the soleus and the lateral head of the gastrocnemius (2), with blunt preparation of the popliteus muscle (held cranially) enables access to the posterolateral plateau. Reprinted from Frosch KH, Balcarek P, Walde T, Stürmer KM. A new posterolateral approach without fibula osteotomy for the treatment of tibial plateau fractures. J Orthop Trauma 2010;24:515-520, with permission from Wolters Kluwer Health.
Citation: EFORT Open Reviews 2, 5; 10.1302/2058-5241.2.160067
Conventional medial approach
The medial tibial surface can be easily approached after performing a longitudinal skin incision. Although anteromedial partial proximal tibial fractures are rare, 5 this approach may help to reduce and fix posterior or lateral partial tibial head fractures using retrograde K-wires or cannulated screws. 8 In addition to the anteromedial tibial LCP and medial LISS-plate, the locked tomofix plate may be useful in selected cases. This approach can be easily extended both proximally and distally, and implant removal may be performed with little operative morbidity. However, if a second posteromedial or lateral incision is planned, care must be taken not to create an island of devascularised skin.
Posteromedial approach
Different techniques have been described to reduce posteromedial tibial head fractures. 8,21,22 While some fractures can be reduced by retrograde cannulated screw osteosynthesis 8 or by using an extended anteromedial approach, 21 anterograde fixation of partial posteromedial fractures via a posteromedial approach 22 offers direct visualisation of the fragment and a smaller incision compared with an extended anteromedial approach.
In a prone or side-lying position, the incision is performed longitudinally along the medial head of the gastrocnemius (Fig. 5). The medial border of the gastrocnemius muscle is palpated, bluntly prepared and carefully retracted laterally. Using a raspatory, subperiostal dissection of the popliteus muscle is performed and the semi-membranosus complex is retracted medially (Fig. 5). This procedure completely exposes the medial tibial condyle and the fracture may be fixed using screw osteosynthesis, small 2.7/3.5 mm LCDCP T-shaped-plates or distal radius two-column LCP.
For the posteromedial approach, the skin incision is performed along the medial head of the gastrocnemius. After blunt preparation, the semi-membranosus complex can be retracted medially and the medial gastrocnemius can be retracted laterally. After subperiostal dissection of the popliteus muscle, the posteromedial tibia can be approached. Reprinted from Galla M, Riemer C, Lobenhoffer P. [Direct posterior approach for the treatment of posteromedial tibial head fractures]. Oper Orthop Traumatol 2009;21:51-64 (In German), with permission from Springer.
Citation: EFORT Open Reviews 2, 5; 10.1302/2058-5241.2.160067
Most posterocentral partial tibial head fractures can be reduced via a posteromedial or posterolateral approach, depending on the morphology of the fracture. Posterior cruciate ligament avulsion fractures of the tibial head are not considered to be partial tibial head fractures by the authors of this article. However, avulsions of the posterior cruciate ligament often involve larger fragments. 23 Although minimally invasive arthroscopic approaches to these fractures have been reported, 24 in cases of a dislocated fragment, the minimally invasive anterograde popliteal approach, which is a modified posteromedial approach with a smaller incision, 25 may enable better reduction of the fragment under direct vision. When incising the dorsal capsule, care must be taken not to injure the posterior cruciate ligament. If in doubt, a saline solution joint injection may help to clearly identify the capsule.
Osteotomies
To reduce extended anterolateral and posterolateral partial tibial head fractures, the conventional anterolateral approach may not provide enough vision of the whole fracture. Thus, the vision can be extended by performing an osteotomy of the fibula, 13,14 the lateral femoral epicondyle 15,17 or a combined submeniscal approach to better address the posterior fragments. The femoral epicondylar osteotomy 15 has a lower risk for neurovascular damage compared with the proximal fibular osteotomy. 13,14 In 90° flexion, the iliotibial tract is horizontally incised and the area around the lateral femoral epicondyle, including the insertions of the lateral collateral ligament and the popliteus tendon, is identified and prepared. Epicondylar osteotomy is then performed circumferentially using a small osteotome and a micro-sagittal saw to create a bony wafer of 4 cm in diameter and 1 cm in depth. 15 Care has to be taken not to injure the joint surface and to remember the clockwise orientation of the bony wafer. After fracture reduction, the epicondylar bony wafer can be re-positioned by one or two cancellous screws and washers.
Other osteotomy-like techniques for extended approaches of the tibial head have been reported (Fig. 6) and include fibular head partial resection, 18 tibial tuberosity osteotomy 19 and Gerdy’s tubercle osteotomy, 20 which may help in selected cases to address relevant parts of the tibial plateau. However, due to a high risk of ligamentous and neurovascular damage, the indications for osteotomy should be evaluated carefully.
Lateral view of the knee. Femoral epicondylar osteotomy (FE) is a safe distance from the common peroneal nerve (PN). Fibular head (FH) osteotomy also mobilises the distal biceps femoris insertions but the PN must be secured. Gerdy’s tubercle osteotomy (GT) or tibial tuberosity osteotomy (TT) are additional, but rarely indicated, options. LCL, lateral collateral ligament; PLT, popliteus tendon; IT, iliotibial band; PT, patellar tendon. Images created with Essential Anatomy 5, 3D4 Medical.com
Citation: EFORT Open Reviews 2, 5; 10.1302/2058-5241.2.160067
Arthroscopic reduction-internal fixation (ARIF) arthroscopically assisted reduction
In the case of a mild articular surface depression and an intact columnar wall (pure articular depression; Schatzker Type III ‘zero-column fractures’ or AO Type B2), ARIF may be considered (Fig. 7). 26 This arthroscopic procedure has the benefit of a small skin incision as well as an optimal control of the articular reduction. Intra-articular pathologies (meniscus and cartilage damage) can also be evaluated and addressed, if necessary.
Schatzker type III fractures ((a) zero column fractures; pure depression) can often be treated using arthroscopic reduction and internal fixation. The meniscus is elevated proximally (b) as a typical sign for this posterolateral depression fracture. The depressed region is accessed through an anteromedial approach using a hollow trephine (c, d) in order to minimise bone loss. A bone tamp is then used to elevate the depressed area under direct arthroscopic visualisation. Once joint congruity is restored, bone grafting and screw osteosynthesis (e) can be performed. As a sign of a perfect reduction, the meniscus should then be in its normal position (f).
Citation: EFORT Open Reviews 2, 5; 10.1302/2058-5241.2.160067
However, this technique is technically demanding and requires additional set-up. Operative planning includes the simultaneous use of the arthroscopic instruments, as well as a C-arm for detailed visualisation. The risk for compartment syndrome might be higher in comparison with conventional open reduction techniques.
Fixation techniques
If there are solitary fragments that can be fixated by screw osteosynthesis, a plate might not be necessary for fixation. However, this decision should be considered carefully, as an angular stable plate provides increased stability and decreases the risk for secondary axial or horizontal displacement of fragments. 27 Additionally, in the osteoporotic bone, locked plates are considered to support with enhanced stability. 28
‘Jail’ technique
If performing screw osteosynthesis, stability of the elevated articular surface can be increased with a jail-type configuration of screws. 29 In a biomechanical study, a novel, minimally invasive reconstruction technique of lateral tibial plateau fractures using a three-screw ‘jail’ technique was compared with a conventional two-screw osteosynthesis technique (Fig. 8). A significant increase in the maximum load and a decrease in failure by cut-out was observed when using a ‘jail-type’ screw configuration.
Jail-type of screw configuration (b) in osteosynthesis may increase the maximum load and decrease cut-out failure vs conventional screw reconstruction (a). Provided by Weimann et al 29 and used with permission from BioMed Central.
Citation: EFORT Open Reviews 2, 5; 10.1302/2058-5241.2.160067
Management of bone defects
Autograft, allograft or bone substitute
When managing impression fractures with loss of bone spongiosa substance, often bone substitutes are required to fill dead spaces. The perfect substitute should have high osteo-inductivity, osteogenicity and osteoconductivity.
The risks for harvest morbidity, infection rate and immunological reactions should be considered. Autograft of the iliac crest is still the ‘gold standard’ in terms of the aforementioned properties. 30 In some studies, however, graft substitutes have been favoured due to reduced total operative time, earlier weight-bearing and improved early functional outcome. In a systematic review, Goff et al 30 evaluated outcomes after the use of calcium phosphate cement, hydroxyapatite granules, calcium sulphate, bioactive glass, tricalcium phosphate, demineralised bone matrix, allografts and xenografts in tibial head fractures. Secondary collapse of the knee joint surface ⩾ 2 mm, which was considered clinically relevant, was reported in 11.1% of the calcium sulphate cases, 8.6% of the biological substitute cases (allograft, demineralised bone matrix and xenograft), 5.4% of the hydroxyapatite cases and 3.7% of the calcium phosphate cement cases. 30 In cadaver studies, injectable calcium phosphate cement resulted in better stability and stiffness, which theoretically could reduce both the non-weight-bearing post-operative period and the secondary articular collapse. However, one has to be cautious because these are time-zero studies with their respective limitations. 30 There is limited evidence for higher osteo-integration of tricalcium phosphates in comparison with hydroxyapatites (Fig. 9). 30-32 This bone substitute may also fill subchondral bone defects without a gap, which may not be filled by biological repair tissue during healing. 32
Onodera et al 31 found higher absorbability and osteoconductivity of tricalcium phosphate (TCP) spacers compared with hydroxyapatite spacers (HAp) in a retrospective comparative study of high tibial osteotomies. Reprinted from Onodera J, Kondo E, Omizu N, et al. Beta-tricalcium phosphate shows superior absorption rate and osteoconductivity compared to hydroxyapatite in open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 2014;22:2763-2770, with permission from Springer.
Citation: EFORT Open Reviews 2, 5; 10.1302/2058-5241.2.160067
In cases of symptomatic post-operative inflammatory response, septic and aseptic causes must be distinguished. When using biomaterials, the molecular surface may cause aseptic leukocyte proliferation and macrophage activation. 33
‘To tourniquet or not to tourniquet?’
Using a tourniquet during surgery may improve visibility, reduce intra-operative blood loss and swelling during surgery, and may support PMMA cement interaction with bone when polymerising. Other than missed bleeding sources and time pressure within the 2-hour ischaemia interval, various other negative effects of tourniquet use have been reported in the current literature. Kruse et al 34 reported an increased post-operative opioid use in a prospective cohort study of patients who received ankle surgery with a correlation between opioid use and intra-operative tourniquet time. In a randomised trial of patients receiving total knee arthroplasty (TKA) with or without tourniquet, Dennis et al 35 determined that there were no differences in range of motion and strength, with the exception of slightly lower quadriceps strength in the tourniquet group. Although intra-operative blood loss was reduced in the tourniquet group, there were no differences in total blood loss between both groups. 35 In a meta-analysis of 13 randomised controlled trials of studies that evaluated the effects of tourniquet use in TKA, Zhang et al 36 reported an increased risk for thromboembolic events when using a tourniquet (risk ratio (RR), 5.00; 95% confidence interval (CI), 1.31 to 19.10; p = 0.02). Other non-thromboembolic complications were also increased in the tourniquet group, such as infection, blistering, haematoma, wound oozing, bruising, nerve palsies and re-operation (RR, 2.03; 95% CI, 1.12 to 3.67; p = 0.02). 36
We suggest carefully considering whether fracture reduction of partial tibial head fractures can be performed without using a tourniquet.
Post-operative rehabilitation
Partial weight-bearing and early functional rehabilitation are recommended for at least six weeks in most cases after successful reduction and fixation with LCP have been performed Unfortunately, evidence is still missing, and there may not be a ‘one size fits all’ post-operative rehabilitation scheme for every fracture type. 27,37,38 In cases of osteopenic bones or losses of bone substance, a non-weight-bearing protocol might be indicated. Concomitant ligament injuries should also be considered when planning the rehabilitation protocol. Regardless of fracture type and concomitant injuries, full range of motion should be regained as soon as possible due to the high risk for developing a stiff knee joint. A hinged knee brace may be used in cases of a re-fixed collateral ligament. CT can be helpful to evaluate bone healing in cases of comminuted or impressed partial tibial head fractures.
If a unicondylar impression fracture was caused by a low-energy trauma in the elderly, this can be an indicator for osteopaenic bone mineral density. National guidelines for the treatment of osteoporosis suggest beginning with basic medical treatment (e.g. with 1000 IU of vitamin D per day or, in some cases, with calcium) in these cases. Further post-operative osteological investigation of bone mineral density by DXA or qCT and of endocrine status is suggested to evaluate whether the addition of bisphosphonates or other medications may be useful. 39
Knowing the fracture mechanism of partial proximal tibial fractures and classifying their morphology help to develop a peri-operative treatment strategy. Partial tibial head fractures can often be directly reduced using different approaches, which should be chosen depending on fracture location. Submeniscal arthrotomy, arthroscopy and osteotomies of the femoral epicondyle, the proximal fibula or Gerdy’s tubercle are useful tools to enhance visualisation of the joint or to decrease the invasiveness of the approach. Bone defects can be filled by iliac crest autograft, demineralised bone matrix or calcium phosphates. Osteoporosis and concomitant ligament injury should be diagnosed, peri-operatively addressed and considered for the rehabilitation strategy.
ICMJE Conflict of Interest Statement
None.
Funding
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
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