Aims. Proper preoperative planning benefits fracture reduction, fixation, and stability in tibial plateau fracture surgery. We developed and clinically implemented a novel workflow for 3D surgical planning including patient-specific drilling guides in tibial plateau fracture surgery. Methods. A prospective feasibility study was performed in which consecutive tibial plateau fracture patients were treated with 3D surgical planning, including patient-specific drilling guides applied to standard off-the-shelf plates. A postoperative CT scan was obtained to assess whether the screw directions, screw lengths, and plate position were performed according the preoperative planning. Quality of the fracture reduction was assessed by measuring residual intra-articular incongruence (maximum gap and step-off) and compared to a historical matched control group. Results. A total of 15 patients were treated with 3D surgical planning in which 83 screws were placed by using drilling guides. The median deviation of the achieved screw trajectory from the planned trajectory was 3.4° (interquartile range (IQR) 2.5 to 5.4) and the difference in entry points (i.e. plate position) was 3.0 mm (IQR 2.0 to 5.5) compared to the 3D preoperative planning. The length of 72 screws (86.7%) were according to the planning. Compared to the historical cohort, 3D-guided surgery showed an improved surgical reduction in terms of median gap (3.1 vs 4.7 mm; p = 0.126) and step-off (2.9 vs 4.0 mm; p = 0.026). Conclusion. The use of 3D surgical planning including drilling guides was feasible, and facilitated accurate screw directions, screw lengths, and plate positioning. Moreover, the personalized approach improved fracture reduction as compared to a historical cohort. Cite this article: Bone Jt Open 2024;5(1):46–52

Classification systems for tibial plateau fractures suffer from poor interobserver agreement, and their value in preoperative assessment to guide surgical fixation strategies is limited. For tibial plateau fractures four major characteristics are identified: lateral split fragment, posteromedial fragment, anterior tubercle fragment, and central zone of comminution. These fracture characteristics support preoperative assessment of fractures and guide surgical decision-making as each specific component requires a respective fixation strategy. We aimed to evaluate the additional value of 3D-printed models for the identification of tibial plateau fracture characteristics in terms of the interobserver agreement on different fracture characteristics. Preoperative images of 40 patients were randomly selected. Nine trauma surgeons, eight senior and eight junior registrars indicated the presence or absence of four fracture characteristics with and without 3D-printed models. The Fleiss kappa was used to determine interobserver agreement for fracture classification and for interpretation, the Landis and Koch criteria were used. 3D-printed models lead to a categorical improvement in interobserver agreement for three of four fracture characteristics: lateral split (Kconv = 0.445 versus K3Dprint = 0.620; P < 0.001), anterior tubercle fragment (Kconv = 0.288 versus K3Dprint = 0.449; P < 0.001) and zone of comminution (Kconv = 0.535 versus K3Dprint = 0.652; P < 0.001). The overall interobserver agreement improved for three of four fracture characteristics after the addition of 3D printed models. For two fracture characteristics, lateral split and zone of comminution, a substantial interobserver agreement was achieved. Fracture characteristics seem to be a more reliable way to assess tibial plateau fractures and one should consider including these in the preoperative assessment of tibial plateau fractures compared to the commonly used classification systems

Objectives. CT-based three-column classification (TCC) has been widely used in the treatment of tibial plateau fractures (TPFs). In its updated version (updated three-column concept, uTCC), a fracture morphology-based injury mechanism was proposed for effective treatment guidance. In this study, the injury mechanism of TPFs is further explained, and its inter- and intraobserver reliability is evaluated to perfect the uTCC. Methods. The radiological images of 90 consecutive TPF patients were collected. A total of 47 men (52.2%) and 43 women (47.8%) with a mean age of 49.8 years (. sd. 12.4; 17 to 77) were enrolled in our study. Among them, 57 fractures were on the left side (63.3%) and 33 were on the right side (36.7%); no bilateral fracture existed. Four observers were chosen to classify or estimate independently these randomized cases according to the Schatzker classification, TCC, and injury mechanism. With two rounds of evaluation, the kappa values were calculated to estimate the inter- and intrareliability. Results. The overall inter- and intraobserver agreements of the injury mechanism were substantial (κ. inter. = 0.699, κ. intra. = 0.749, respectively). The initial position and the force direction, which are two components of the injury mechanism, had substantial agreement for both inter-reliability or intrareliability. The inter- and intraobserver agreements were lower in high-energy fractures (Schatzker types IV to VI; κ. inter. = 0.605, κ. intra. = 0.721) compared with low-energy fractures (Schatzker types I to III; κ. inter. = 0.81, κ. intra. = 0.832). The inter- and intraobserver agreements were relatively higher in one-column fractures (κ. inter. = 0.759, κ. intra. = 0.801) compared with two-column and three-column fractures. Conclusion. The complete theory of injury mechanism of TPFs was first put forward to make the TCC consummate. It demonstrates substantial inter- and intraobserver agreement generally. Furthermore, the injury mechanism can be promoted clinically. Cite this article: B-B. Zhang, H. Sun, Y. Zhan, Q-F. He, Y. Zhu, Y-K. Wang, C-F. Luo. Reliability and repeatability of tibial plateau fracture assessment with an injury mechanism-based concept. Bone Joint Res 2019;8:357–366. DOI: 10.1302/2046-3758.88.BJR-2018-0331.R1

Aims. Tibial plateau fractures (TPFs) are complex injuries around the knee caused by high- or low-energy trauma. In the present study, we aimed to define the distribution and frequency of TPF lines using a 3D mapping technique and analyze the rationalization of divisions employed by frequently used classifications. Methods. In total, 759 adult patients with 766 affected knees were retrospectively reviewed. The TPF fragments on CT were multiplanar reconstructed, and virtually reduced to match a 3D model of the proximal tibia. 3D heat mapping was subsequently created by graphically superimposing all fracture lines onto a tibia template. Results. The cohort included 405 (53.4%) cases with left knee injuries, 347 (45.7%) cases with right knee injuries, and seven (0.9%) cases with bilateral injuries. On mapping, the hot zones of the fracture lines were mainly concentrated around the anterior cruciate ligament insertion, posterior cruciate ligament insertion, and the inner part of the lateral condyle that extended to the junctional zone between Gerdy’s tubercle and the tibial tubercle. Moreover, the cold zones were scattered in the posteromedial fragment, superior tibiofibular syndesmosis, Gerdy’s tubercle, and tibial tubercle. TPFs with different Orthopaedic Trauma Association/AO Foundation (OTA/AO) subtypes showed peculiar characteristics. Conclusion. TPFs occurred more frequently in the lateral and intermedial column than in the medial column. Fracture lines of tibial plateau occur frequently in the transition zone with marked changes in cortical thickness. According to 3D mapping, the four-column and nine-segment classification had a high degree of matching as compared to the frequently used classifications. Cite this article: Bone Joint Res 2020;9(6):258–267

Aims. Our objective was to conduct a systematic review and meta-analysis, to establish whether differences arise in clinical outcomes between autologous and synthetic bone grafts in the operative management of tibial plateau fractures. Methods. A structured search of MEDLINE, EMBASE, the online archives of Bone & Joint Publishing, and CENTRAL databases from inception until 28 July 2021 was performed. Randomized, controlled, clinical trials that compared autologous and synthetic bone grafts in tibial plateau fractures were included. Preclinical studies, clinical studies in paediatric patients, pathological fractures, fracture nonunion, or chondral defects were excluded. Outcome data were assessed using the Risk of Bias 2 (ROB2) framework and synthesized in random-effect meta-analysis. The Preferred Reported Items for Systematic Review and Meta-Analyses guidance was followed throughout. Results. Six studies involving 353 fractures were identified from 3,078 records. Following ROB2 assessment, five studies (representing 338 fractures) were appropriate for meta-analysis. Primary outcomes showed non-significant reductions in articular depression at immediate postoperative (mean difference -0.45 mm, p = 0.25, 95%confidence interval (CI) -1.21 to 0.31, I. 2. = 0%) and long-term (> six months, standard mean difference -0.56, p = 0.09, 95% CI -1.20 to 0.08, I. 2. = 73%) follow-up in synthetic bone grafts. Secondary outcomes included mechanical alignment, limb functionality, and defect site pain at long-term follow-up, perioperative blood loss, duration of surgery, occurrence of surgical site infections, and secondary surgery. Mean blood loss was lower (90.08 ml, p < 0.001, 95% CI 41.49 to 138.67) and surgery was shorter (16.17 minutes, p = 0.04, 95% CI 0.39 to 31.94) in synthetic treatment groups. All other secondary measures were statistically comparable. Conclusion. All studies reported similar methodologies and patient populations; however, imprecision may have arisen through performance variation. These findings supersede previous literature and indicate that, despite perceived biological advantages, autologous bone grafting does not demonstrate superiority to synthetic grafts. When selecting a void filler, surgeons should consider patient comorbidity, environmental and societal factors in provision, and perioperative and postoperative care provision. Cite this article: Bone Jt Open 2022;3(3):218–228

Aims. To investigate health-related quality of life (HRQoL) of older adults (aged ≥ 60 years) after tibial plateau fracture (TPF) compared to preinjury and population matched values, and what aspects of treatment were most important to patients. Methods. We undertook a retrospective, case-control study of 67 patients at mean 3.5 years (SD 1.3; 1.3 to 6.1) after TPF (47 patients underwent fixation, and 20 nonoperative management). Patients completed EuroQol five-dimension three-level (EQ-5D-3L) questionnaire, Lower Limb Function Scale (LEFS), and Oxford Knee Scores (OKS) for current and recalled prefracture status. Propensity score matching for age, sex, and deprivation in a 1:5 ratio was performed using patient level data from the Health Survey for England to obtain a control group for HRQoL comparison. The primary outcome was the difference in actual (TPF cohort) and expected (matched control) EQ-5D-3L score after TPF. Results. TPF patients had a significantly worse EQ-5D-3L utility (mean difference (MD) 0.09, 95% confidence interval (CI) 0.00 to 0.16; p < 0.001) following their injury compared to matched controls, and had a significant deterioration (MD 0.140, 95% CI 0 to 0.309; p < 0.001) relative to their preoperative status. TPF patients had significantly greater pre-fracture EQ-5D-3L scores compared to controls (p = 0.003), specifically in mobility and pain/discomfort domains. A decline in EQ-5D-3L greater than the minimal important change of 0.105 was present in 36/67 TPF patients (53.7%). Following TPF, OKS (MD -7; interquartile range (IQR) -1 to -15) and LEFS (MD -10; IQR -2 to -26) declined significantly (p < 0.001) from pre-fracture levels. Of the 12 elements of fracture care assessed, the most important to patients were getting back to their own home, having a stable knee, and returning to normal function. Conclusion. TPFs in older adults were associated with a clinically significant deterioration in HRQoL compared to preinjury level and age, sex, and deprivation matched controls for both undisplaced fractures managed nonoperatively and displaced or unstable fractures managed with internal fixation. Cite this article: Bone Jt Open 2023;4(4):273–282

The aim was to report operative complications, radiographic and patient-reported outcomes following lateral tibial plateau fracture fixation augmented with calcium phosphate cement (CPC). From 2007–2018, 187 patients (median age 57yrs [range 22–88], 63% female [n=118/187]) with a Schatzker II/III fracture were retrospectively identified. There were 103 (55%) ORIF and 84 (45%) percutaneous fixation procedures. Complications and radiographic outcomes were determined from outpatient records and radiographs. Long-term follow-up was via telephone interview. At a median of 6 months (range 0.1–138) postoperatively, complications included superficial peroneal nerve injury (0.5%, n=1/187), infection (6.4%, n=12/187), prominent metalwork (10.2%, n=19/187) and post-traumatic osteoarthritis (PTOA; 5.3%, n=10/187). The median postoperative medial proximal tibial angle was 89o (range 82–107) and posterior proximal tibial angle 82o (range 45–95). Three patients (1.6%) underwent debridement for infection and 27 (14.4%) required metalwork removal. Seven patients (4.2%) underwent total knee replacement for PTOA. Sixty percent of available patients (n=97/163) completed telephone follow-up at a median of 6yrs (range 1–13). The median Oxford Knee Score was 42 (range 3–48), Knee injury and Osteoarthritis Outcome Score 88 (range 10–100), EuroQol 5-Dimension score 0.812 (range −0.349–1.000) and Visual Analogue Scale 75 (range 10–100). There were no significant differences between ORIF and percutaneous fixation in patient-reported outcome (all p>0.05). Fixation augmented with CPC is safe and effective for lateral tibial plateau fractures, with a low complication rate and good long-term knee function and health-related quality of life. Percutaneous fixation offers a viable alternative to ORIF with no detriment to patient-reported outcome

Aims. In contrast to operations performed for other fractures, there is a high incidence rate of surgical site infection (SSI) post-open reduction and internal fixation (ORIF) done for tibial plateau fractures (TPFs). This study investigates the effect of induced membrane technique combined with internal fixation for managing SSI in TPF patients who underwent ORIF. Methods. From April 2013 to May 2017, 46 consecutive patients with SSI post-ORIF for TPFs were managed in our centre with an induced membrane technique. Of these, 35 patients were included for this study, with data analyzed in a retrospective manner. Results. All participants were monitored for a mean of 36 months (24 to 62). None were subjected to amputations. A total of 21 patients underwent two-stage surgeries (Group A), with 14 patients who did not receive second-stage surgery (Group B). Group A did not experience infection recurrence, and no implant or cement spacer loosening was noted in Group B for at least 24 months of follow-up. No significant difference was noted in the Lower Extremity Functional Scale (LEFS) and the Hospital for Special Surgery Knee Score (HSS) between the two groups. The clinical healing time was significantly shorter in Group B (p＜0.001). Those with longer duration of infection had poorer functional status (p＜0.001). Conclusion. Management of SSI post-ORIF for TPF with induced membrane technique combined with internal fixation represents a feasible mode of treatment with satisfactory outcomes in terms of infection control and functional recovery. Cite this article: Bone Joint Res 2021;10(7):380–387

We describe our technique and the early results of compaction morselised bone grafting (CMBG) for displaced tibial plateau fractures using fresh frozen allograft. This technique has been performed by the senior author since July 2006 on eight patients. Clinical and radiological follow-up was performed on seven remaining patients at an average 12 months (range 4–19) following surgery. One patient died of an unrelated cause three months following surgery. One patient underwent a manipulation under anaesthesia at three months for knee stiffness. One patient developed a painless valgus deformity and underwent corrective osteotomy at 15 months. The height of the tibial plateau on radiographs has been maintained to an excellent grade (less than 2 mm depression) in all but one patient. CMBG using fresh frozen allograft in depressed tibial plateau fractures provides structural support sufficient to maintain the height of the tibial plateau, is associated with few complications in complex patients with large bone loss and has theoretical advantages of graft incorporation and remodelling

Introduction. Periprosthetic medial tibial plateau fractures (TPF) are rare but represent a serious complication in unicompartmental knee arthroplasty (UKA). Most common treatment of these fractures is osteosynthesis with canulated screws or plates. Aim. The aim of this study was to evaluate these two different treatment options of periprosthetic fractures. The hypothesis was that osteosynthetic treatment with plates show significantly higher maximum fracture loads than fixation with cannulated screws. Materials and Methods. 12 matched paired fresh frozen tibias with periprosthetic tibial plateau fractures were used for this study. In group A osteosyntheses with angle-stable plates were performed, whereas in group B cannulated screws were utilized to fixate the periprosthetic fractures. DEXA bone density measurement and standard X-rays (ap and lateral) were accomplished before loading the tibias under standardised conditions with a maximum load of up to 10.0kN. Results. In the plate group all tibias fractured with a median load of Fmax=2.64 (0.45–5.68) kN, whereas in the group with cannulated screws fractures occurred at a mean load of Fmax=1.50 (0.27–3.51) kN. The difference was statistically significant with p<0.05. Discussion. Angle-stable plates showed significantly higher fracture load resistance than fixation with cannulated screws. Therefore osteosynthesis with angle-stable plates in periprosthetic tibial plateau fractures should be recommended. MULTIPLE DISCLOSURES

In tibial plateau fracture, anatomical reduction of articular surface with stable fixation can restore the mechanical axis and allow early mobilization. Concomitant management of ligamentous and meniscal injury is essential for preservation of knee function. Open reduction and internal fixation has a significant complication rate.Percutaneous,fluoroscopically and arthroscopically assisted osteosynthesis with special fracture reduction and fixation technique can achieve the purpose of management of tibial plateau fracture, while limiting the soft tissue damage. 18 cases, including all J. Schatzker’s type of tibial plateau fracture, were operated with minimal access surgical technique. Male patients were predominant. The age ranged from 22 to 61 (mean 33.5). Detail pre-operatives planning with CT scan were performed in 16 patients. Fluoroscopy, arthroscopy and special fracture reduction and fixation technique were applied to all cases. All 18 cases could be reviewed. Follow up period ranged from 1 to 4 years (mean 2.3 yr.). Outcome was assessed by HSS Knee Score, standing radiograph and arthroscopy (2 cases). According to HSS score, 14 patients were rated as excellent (100 to 85), 3 good (84 to 70), 1 fair (69 to 60) and none poor (< 60). Subjectively, 14 patients were satisfied with the treatment. 13 patients were working and participating in sport before injury. 15 took no analgesic, 2 took it once a week and 1 more often. In standing radiograph, only 2 patients showed minimal narrowing of joint space. There was no significant complication directly associated with the procedure. Percutaneous, fluoroscopically and arthroscopically assisted osteosynthesis is a safe and effective minimal access surgical procedure. Precise pre-operative planning and special fracture reduction and fixation technique are all crucial for success. Short-term clinical outcome is encouraging

Introduction Following any intraarticular fracture, joint range of movement and muscle strength recovery are vital factors in patient’s return to activities. Quadriceps weakness is a known complication of any injury affecting the knee. The purpose of this study was to investigate the recovery of knee ROM and quadriceps and hamstrings muscle strength in the first year after tibial plateau fracture and to assess factors that affect the recovery. Method 63 patients were recruited over a 5-year period. Data regarding the age and sex of the patient, the mechanism of injury, the grade of the fracture according to Shatzker’s classification and the treatment received were recorded. All patients underwent a standard rehabilitation regime. At 3, 6 and 12 months after injury the patients were seen by a research physiotherapist. The range of movement was recorded. Thigh muscle peak torque was measured using isokinetic dynanmometry. The uninjured limb was used as the control – the peak torque in the injured limb was expressed as a percentage of the value in the uninjured limb to give the percentage recovery in the injured limb. Results There was an initial extension deficit of 7° at 3 months, which improved to 3° at 12 months. Quadriceps strength recovery lagged behind that in the hamstrings at all times and only achieved only 77% at 12 months, compared to 90% in the hamstrings (p< 0.001). Patients under 40 outperformed those over 40 at each time point. At 12 months under 40s had achieved 85% recovery in their quadriceps, while over 40s only reached 74% (p< 0.01). Patient sex, mechanism of injury and grade of fracture had no effect on the level of recovery in this study. Conclusion Patients who sustain a tibial plateau fracture have a residual small extension deficit and objective quadriceps weakness at 1 year post injury. Patient age has a significant effect on the level of quadriceps recovery. This information is useful when counselling patients who sustain these injuries

We aimed to determine the rate of and risk factors for post-traumatic osteoarthritis (PTOA) and total knee arthroplasty (TKA) requirement after operative management of tibial plateau fractures (TPF) in older adults. We conducted a retrospective cohort study of 182 operatively managed TPFs in 180 patients ≥60 years old over a 12-year period with minimum follow up 1 year. Data including patient demographics, clinical frailty scores, mechanism of injury, management, reoperation and mortality were recorded. Radiographs were reviewed for: Schatzker classification; pre-existing knee osteoarthritis (KOA); severe joint depression >15mm; and development of PTOA. Kaplan Meier survival analysis was performed. Regression analysis was used to identify risk factors for radiographic indication for TKA and actual TKA. Forty-seven percent were Schatzker II fractures. Radiographic KOA was present at fracture in 32.6%. Fracture fixation was performed in 95.6% cases and acute TKA in 4.4%. Thirteen patients underwent late TKA (7.5%). At five-years, 11.8% (6.0-16.7 95% CI) had required TKA and 20.9% (14.4-27.4 95% CI) had a radiographic indication for TKA. Severe joint depression and pre-existing KOA were associated with worse survival for endpoints radiographic indication for TKA and actual TKA. Severe joint depression (HR 2.49(1.35-4.61 95% CI), p=0.004), pre-existing KOA (HR 2.23(1.17-4.23), p=0.015) and inflammatory arthropathy (HR 2.4(1.04-5.53), p=0.039) were independently associated with radiographic indication for TKA. In conclusion, severe joint depression and pre-existing arthritis are independent risk factors for both severe PTOA and TKA after TPFs in older adults. These features should be considered as an indication for primary management with acute TKA

The outcome of 77 high energy tibial plateau fractures treated by locking or conventional plating was reviewed. The aim of the study was to determine if there was any advantage of locking plates in reducing the complication rates associated with fixation of these injuries. All patients had a high energy injury pattern (medial or bicondylar plateau fractures). There were 32 locked plates and 45 non-locking plates used. Compartment syndrome complicated 5 patients (16%) in the locked plate group and 3 (7%) in the non-locked group (p = 0.198). Superficial infection occurred in 4 (13%) patients with locked plates and 7 (16%) patients with non-locked plates. Thromboembolic complications occurred in 3 (7%) patients treated with non-locked plates. There were no thrombembolic complications in the locked plate group (p = 0.135). Overall, malunion of the plateau occurred in 10 (22%) patients treated with non-locked plates compared to 7 (22%) patients who received locked plates. This was due to residual malreduction in 4 (13%) patients in the locked plate group and 6 (13%) patients in the non-locked plate group at the time of surgery. In the remaining cases loss of reduction after fixation occurred in 4 (9%) patients who received non-locked plates and in 3 (9%) patients who were treated with locked plates. No statistically significant difference was noted in the treatment outcomes of patients managed with locked plates or non-locked plates, regardless of fracture severity. We concluded that there is no definite advantage associated with the use of locked plating for high energy tibial plateau fractures

Objective. To identify risk factors for surgical site infections and to quantify the contribution of independent risk factors to the probability of developing infection after definitive fixation of tibial plateau fractures. Methods. A retrospective analysis was performed at a Level I trauma center between 2004 and 2010. A total of 251 consecutive patients (256 cases) were divided into two groups, those with and those without a surgical site infection. Preoperative and perioperative variables were compared between these groups and risk factors were determined by univariate analyses and multivariate logistic regression. Results. The overall rate of surgical site infection after tibial plateau ORIF was 7.8% (20 of 256). The most common causative pathogens was Staphylococcus aureus (n=15, 75%). Independent predictors of surgical site infection identified by multivariate analyses were open tibial plateau fracture (odds ratio =3.9; 95% confidence interval=1.3–11.6, p =0.015) and operative time (odds ratio=2.7; 95% confidence interval=1.6 − 4.4; p < 0.001). Conclusions. Both open fracture and operative time are independent risks factors for post operative infection

Introduction: Tibial plateau fracture is an intra-articullar complex fracture. Surgery aim is to restore articular surface height, preserve knee joints stability and alignment in order to obtain maximal range of motion and to prevent future joint degenerative changes. Ilizarov external frame using ligamentotaxis, minimal invasive techniques, smooth or olive wires (sometimes augmented by screws) allows articular surface reconstruction and stabilization. In unstable fractures, bridging of the knee with slight distraction of the joint is provided by including the distal femur to the frame with an additional ring. Study Aims: To assess the results of complex tibial plateau fracture treated with Ilizarov external fixator. Materials and Methods: Between 1997–2005, twenty five patients with complex fractures of the tibial plateau, Schatzker type V–VI fractures (all closed), average age 45 years old (range 30–78) were treated by hybrid 3 ring Ilizarov external frames alone or in combination with another procedure. 11 out of 25 patients were treated with ligamentotaxis using extension of the frame to the femur with hinges on the center of joint rotation. Some of these patients (10 out of 11) required lateral minimal opening for joint surface elevation. 8 out of the 25 patients needed additional bone graft/ substitute supplementation. One needed 6.5 mm canulated cancellous screw augementation. Patients with below knee frame remain non-WB for 6 weeks and partial WB for another 6 weeks. Patients with above knee frame were allowed full WB. In 3 months the frame was removed under anesthesia and the knee was manipulated. Patients were placed in a brace or a cast-brace with full WB. Physiotherapy started early after the operation. Results: All fractures united with an average time of 12 weeks. 22 patients had full extension with 100 degree of flexion or more. 3 patients had extension lag of 10–20 degree, one of them had 20 degree of posterior slop of the tibial plateau. All patients had normal axial alignment, except one case resulted in mild valgus alignment due to osteoporotic bone (70 years old patient). One had mild unstable knee. One patient developed posttraumatic osteoarthrosis. There were no cases of postoperative infection, septic arthritis or neuro-vascular complications were reported. Pin site infection was resolved locally. Conclusion: The use of Ilizarov external fixation in the management of complex tibial plateau fractures results in satisfactory out come as an alternative to the traditional tibial plateau open surgery. This minimal invasive intervention allowed the surgeons to reduce and fixate the tibial articular surface with out further damaging the soft tissue envelope

Currently the debate continues in definitive fixation method for complex tibial plateau fractures. The aim of surgical management remains prevention of further damage to the articular cartilage, whilst avoiding iatrogenic risks - Low Risk Surgery (LRS). The purpose of this study was to determine the functional impact, clinical radiological outcome following tibial plateau fractures treated with either external fixation or internal fixation. 124 Schatzker IV-VI tibial plateau fractures were reviewed following surgical fixation. Fractures analysed included 24 type IV, 20 type V and 80 type VI tibial plateau fractures. The majority of Schatzker IV fractures were treated with internal fixation, but 67 of 80 Schatzker VI fractures were treated with the Ilizarov method. The average IOWA knee score, was 86 (16 to 100) and the average range of motion was 133 degrees (60 to 150). There were no differences between the circular fixator group and the internal fixation group in terms of range of motion or IOWA scores. There were comparable functional outcomes and complication rates between both groups. In summary patients with high energy tibial plateau fracture treated with internal or external fixation, have a good chance of achieving satisfactory long term knee function

Introduction: Differentially loaded radiostereometric analysis (DLRSA) uses RSA whilst simultaneously applying load to the bones under investigation. This technique allows measurement of interfragmentary displacements under measured weightbearing and joint movement. We have used this technique to prospectively monitor tibial plateau fractures and present the results of the first nine patients with six month follow up. Method: Nine 41-B3 fractures were treated with open reduction internal fixation by one surgeon. At operation, RSA beads were inserted in the depressed osteochondral fragment and the adjacent non-fractured metaphysis. Postoperative weightbearing was restricted to 20kg and knee flexion to 60° for the first six weeks. Follow up included clinical and radiological examinations and patient reported outcome scores (Lysholm, KOOS). DLRSA examinations included RSA radiographs in 60° flexion and under measured weightbearing at six weekly intervals up to six months postoperatively. Significant interfragmentary displacement was defined as translations greater than 0.5mm and/or rotations greater than 1.5°. Results: No postoperative displacement was identified on plain radiographs, except in one patient who fell two weeks postoperatively. RSA: Longitudinal Results: In all patients, the osteo-chondral fragment continued to migrate up to six months, with one exception that stabilised at three months. At six months, the osteochondral fragment translated between 0.02 and 4.15 mm and rotated between 0.2 and 7.2° (> 0.5mm and/or > 1.5° in five cases). DLRSA: Flexion Results: During 60° of flexion, translations exceeding 0.5mm were recorded in only one patient (0.7 mm at 2 weeks). Rotations exceeding 1.5° were recorded in three patients (1.6°, 2° and 2.1° all at six months). DLRSA: Weightbearing Results: Translations exceeding 0.5mm were recorded in four patients whilst full weightbearing (0.7mm in two patients at three months, and 0.6mm and 0.8 mm at 18 weeks). Rotations exceeding 1.5° were recorded in two patients. One patient recorded 2.3° under full weightbearing at three months. Another recorded 2.3° under 20kg of weight at two weeks and 1.8° under full weightbearing at 18 weeks. Patient reported outcomes improved progressively. At six months, five patients reported excellent results, two good and two fair. The two patients reporting fair results recorded low interfragmentary displacements. Discussion: Tibial plateau fractures continue to migrate up to six months after treatment. Active range of motion, partial weightbearing to six weeks and weightbearing up to one body weight after six weeks was proven a safe postoperative regimen. Greater displacements recorded over time may be attributed to loading of more than one body weight, for example, the patient that fell recorded the largest amount of migration over time

Introduction Unicompartmental knee replacement (UKR) is an increasingly utilised alternative to tibial osteotomy and total knee arthroplasty in patients with single compartment degenerative disease. We report on four fractures of the medial tibial plateau following UKR. Methods We retrospectively reviewed four cases with periprosthetic tibial plateau fractures following unicompartmental knee replacement. Each arthroplasty, performed between 1999 and 2002, was done in a community teaching hospital by a single orthopaedic surgeon and a senior level assistant. All patients had medial compartment osteoarthritis confirmed both radiographically and arthroscopically prior to arthroplasty surgery. The arthroplasties were performed by four different surgeons and three different arthroplasty systems were used. All cases were reviewed using the documented chart histories and x-ray evaluation. Each surgeon was contacted individually for the relevant case history and x-rays. The study population was composed of four females, and no males with a mean age of 63.5 years (range 58 to 68). Two patients (50%) had simultaneous bilateral UKRs performed. The remaining two patients had unilateral procedures, involving one right and one left knee. Two patients were clinically obese, and one patient had had a previous ipsilateral high tibial osteotomy. Results The total number of fractures was four, involving three left knees and one right knee. Of the bilateral arthroplasties each patient sustained a unilateral fracture of the left knee. The patient with the previous tibial osteotomy sustained an ipsilateral fracture. Two fractures involved traumatic falls, the remaining fractures had no history of trauma. The mean post-operative period to fracture was 95.75 days with a range of 5 to 195 days. Two patients had revision surgery to total knee arthroplasty. One patient underwent internal fixation of the fracture with retention of the original prosthetic components and exchange of the polyethylene bearing. The remaining patient underwent revision of the tibial component with concurrent internal fixation and was subsequently revised to total knee arthroplasty as the result of failure. Subsequent to the described surgery all fractures have healed with no further surgical intervention. Conclusions This series, whilst small, demonstrates that tibial periprosthetic fracture following UKR is a previously unreported but important cause of failure. Revision surgery to total knee replacement appears to be a reasonable salvage option

Differentially loaded radiostereometric analysis (DLRSA) uses RSA whilst simultaneously applying load to the bones under investigation. This technique allows measurement of interfragmentary translations and rotations under measured weight bearing and joint movement. We have recently introduced this technique to monitor tibial plateau fracture healing. This paper presents our preliminary results. Twelve patients with a 41 B2, B3, C2, or C3 fracture were followed for a minimum of three months. RSA beads were inserted in the largest osteochondral fragment and the adjacent metaphysis. Knee flexion was restricted to 60° for 6 weeks. After partial weight bearing (20kg) between 2 and 6 weeks, patients progressed to full weight bearing. Follow up included clinical and radiological examinations and patient reported outcome scores (Lysholm, KOOS). DLRSA examinations included RSA radiographs in 60° flexion and under measured weight bearing. Significant interfragmentary displacement was defined as translations greater than 0.5mm and/or rotations greater than 1.5°. There was no loss to follow-up. Longitudinal RSA follow-up: Follow-up RSA radiographs were compared to postoperative examinations. Osteochondral fragment depression was less than 0.5mm in seven patients and between 2 and 4mm in the remaining five patients. Significant interfragmentary displacement after three months was recorded in three patients. DLRSA flexion results: Under 60° of flexion, translations over 0.5mm were recorded in five patients (one postoperatively; one at 2 weeks; two at 6 weeks; and one postoperatively, at 2 weeks and at 3 months). Rotations over 1.5° were recorded in six patients (one postoperatively; two at 2 weeks; one at 6 weeks; one at 2 weeks, 3 months and 4.5 months; and one postoperatively, at 2 weeks, 3 months and 6 months). DLRSA weight bearing results: Under partial weight bearing at two weeks, two patients recorded significant translations, one involving a significant rotation. Under weight bearing as tolerated, three patients recorded significant translations (one at 6 weeks; and two at 18 weeks) and four patients recorded significant rotations (one at 6 weeks; one at 18 weeks; and two at 12 and 18 weeks). Patient Reported Outcomes: Both the Lysholm and KOOS scores improved between 6 weeks and 3 months. DLRSA provides new insight and perspective in tibial plateau fractures. Some fractures take more than three months to heal. Our current rehabilitation protocol was safe in most patients, however significant interfragmentary displacement was encountered in 17% at the 2 week followup, raising questions about the quality of the initial stability