Treatment
The goal in treatment of TPFs is the restoration of a stable, appropriately aligned limb with a well-aligned, functional joint. Rigid fixation of and restoration of the articular surface in addition to restoration of the mechanical axis of the tibia are paramount in preserving the normal function of the knee. Nondisplaced or minimally displaced (3 mm or less) lateral plateau fractures or the presence of significant medical comorbidities may be an indication to manage conservatively with bracing and therapy, but a widely displaced TPF commonly will be managed operatively.[6] Coronal plane stability is an important indication for TPF management as well, and instability greater than 5 degrees in the coronal plane is a common indication for surgical treatment.[54,55]
Initial management of the soft-tissue envelope in TPF can be paramount in preventing complications. Given the risk of soft-tissue compromise, the choice of whether or not to use an external fixator should be considered.[56] In high-energy injuries temporary external fixation can help realign and stabilize the fracture and allow access for soft-tissue care during a period of waiting for the soft-tissue envelope to improve. The utility of external fixation for routine use in TPF is debatable, and some advocate for immediate fixation in patients in whom the soft-tissue envelope is in good condition.[57,58] Timing for external fixator application has been previously studied, and although immediate stabilization of the joint with external fixation upon patient arrival may restore a more normal anatomic alignment, there is no evidence of an increase in complications if the application of the fixator is done nonemergently.[59] Single-stage fixation, without application of external fixation, may also be associated with equivalent outcomes in select unicondylar fractures with no increase in the rate of complications, allowing earlier definitive fixation of fractures and reducing costs to the healthcare system.[60,61]
Arthroscopic management of unicondylar TPF may be appropriate in some fracture patterns because of the less invasive nature of arthroscopic reduction and internal fixation (ARIF) relative to open reduction and internal fixation (ORIF). Recent studies have suggested that ARIF fixation of both lateral and medial unicondylar fractures (Schatzker I to IV) could be associated with equivalent or better clinical outcomes and no greater incidence of complications.[62–65] Perhaps because of the less invasive nature of the procedure, management of TPF with ARIF is also associated with earlier return to athletic competition when compared with ORIF.[66] Arthroscopic evaluation has also been used immediately following ORIF of the tibial plateau to evaluate and treat coexisting ligamentous pathology as well as to verify fracture reduction. This technique was not shown to lead to better functional outcomes ultimately in one study.[67] Arthroscopic treatment of TPF is limited by surgeon familiarity with the technique and poor interobserver reliability with regard to arthroscopic evaluation of fracture type or severity.[68]
The anterolateral approach to the knee is a commonly used approach for lateral plateau fractures. This approach begins with a curvilinear incision 10 cm in length centered over Gerdy's tubercle and remains lateral to the patellar tendon (Figure 5). The incision is then extended deep to the iliotibial band proximally and the fascia of the anterior compartment distally. The tibialis anterior muscle is elevated, and the coronary ligament is divided. Exposure of the lateral tibial plateau is completed by elevating the lateral meniscus with holding sutures.[19]
Figure 5.
Anterolateral approach to the tibial plateau. Illustration by Lauren Domingue.
The posteromedial approach to the posterior aspect of the medial condyle begins with an incision of 6 cm to 8 cm along the medial gastrocnemius distal to the joint line (Figure 6). The medial gastrocnemius is retracted laterally. The pes anserine tendons can either be retracted medially or, if more exposure is needed, incised and repaired at the end of the procedure. Blunt dissection down to the popliteus followed by release of the popliteus from the tibia reveals the posterior aspect of the medial tibial plateau. This approach is used in the treatment of fractures along the posteromedial portion of the tibial plateau and can also be extended for exposure of the posterior and even posterolateral aspect of the tibia for use in management of comminuted lateral plateau fractures (Table 1).[14,19,69,70]
Figure 6.
Posteromedial approach to the tibial plateau. Illustration by Lauren Domingue.
Conservative management is an option for nondisplaced and minimally displaced Schatzker I type lateral split fractures of the tibial plateau with selection of the right patient. Bracing and early range-of-motion therapy produces acceptable outcomes.[6] When surgical management of Schatzker I TPF is preferred, either partially threaded cancellous screws or buttress plating is used often, with locking-plate constructs being an option in the setting of poor bone stock.[71,72]
A Schatzker II fracture with a split depression of the lateral condyle is managed first by elevating the depression of the tibial plateau. This typically is done utilizing a bone tamp, osteotome, or elevator to restore anatomic alignment of the plateau.[73,74] Autograft bone from the iliac crest has been used in treating these injuries but is associated with a high rate of complications at the donor site; therefore, allograft or synthetic bone void filler to fill the metaphyseal void left after reduction often is preferred.[75] Structural bone allografts are shown to be effective in managing the depression component of these injuries with good clinical outcomes and no increase in the rate of complications compared with autograft.[76] After elevation of the depression, application of a plate along the lateral cortex fixed with nonlocking screws initially, with or without the addition of locking screws, is done for definitive fracture fixation. A recent cadaver study demonstrated that the use of independent screws for fixation provides comparable strength relative to plate and screw constructs, and this technique may be particularly beneficial in that it allows for less invasive treatment of TPF.[77]
Schatzker III pure depression type fractures of the lateral plateau most often occur in the setting of poor bone quality. Treatment of these fractures involves elevation of the depression and restoration of normal plateau architecture. Pure depression fractures are technically challenging because of the low bone quality frequently encountered and may require osteotomy of the lateral plateau. A variety of techniques from external fixation to joint arthroplasty are utilized with no current consensus on a superior method of treatment.[78] Recent techniques such as balloon tibioplasty and injection of calcium phosphate cement are less invasive than open fixation of these fracture patterns and provide equivalent clinical outcomes with no increase in complications.[79] Some recent studies suggest that primary joint arthroplasty is an effective alternative to fixation because of the ability to immediately bear weight and mobilize after joint replacement.[80] However, others suggest that joint arthroplasty does not lead to improved outcomes relative to ORIF and that elderly patients respond equally to either ORIF or arthroplasty.[81] Although no clear guidance is available on the optimal method of treatment currently, the best choice is the one made in consultation with and in alignment with the needs of the individual patient.
Unicondylar fractures of the medial plateau are not simply the converse of the lateral Schatzker I to III fractures. These fractures are less common but when they do occur it is usually in the setting of high-energy events with higher rates of associated neurovascular and soft-tissue injury as well as compartment syndrome.[82–84] Presence of these fractures in the elderly, especially postmenopausal women, can be a low-energy event and suggest the presence of osteoporosis.[2] Operative treatment of these fractures is necessary given the high rate of complications associated with this fracture pattern. All medial plateau fractures should be evaluated for the existence of a posterior fragment given the high incidence of damage to the posterior aspect of the tibial plateau, especially in the setting of flexion or extension varus type mechanisms of injury.[85] Fracture of the intercondylar eminence is also common in Schatzker IV injuries, and older age (over 74 y) is a particularly strong risk factor for this association.[86] Buttress plating along the posteromedial aspect of the tibia is often necessary to stabilize the posterior fragment.[87,88]
Clinical outcomes of medial plateau fractures are generally worse compared with Schatzker I to III injuries of the lateral plateau, and this is likely caused by the high-energy or poor bone quality associations of medial condyle injuries.[21] A large proportion of patients with type I to III injuries experience significant clinical improvement by 6 mo postoperatively, whereas type IV injuries often can require up to 12 mo before significant clinical improvement is realized.[20] It can take up to 5 yr postoperatively for patients with medial condylar injuries to report equivalent clinical outcome to those with injury to the lateral plateau.[20] Patients with medial condylar injury, therefore, require appropriate counseling for what to expect in the process of recovery.
Curr Orthop Pract. 2022;33(1):85-93. © 2022 Lippincott Williams & Wilkins
