Tibial plateau fracture reduction involves restoration of alignment and articular congruity. Restorations of sagittal alignment (tibial slope) of medial and lateral condyles of the tibial plateau are independent of each other in the fracture setting. Limited independent assessment of medial and lateral tibial plateau sagittal alignment has been performed to date. Our objective was to characterize medial and lateral tibial slopes using fluoroscopy and to correlate X-ray and CT findings.

Phase One: Eight cadaveric knees were mounted in extension. C-arm fluoroscopy was used to acquire an AP image and the C-arm was adjusted in the sagittal plane from 15° of cephalad tilt to 15 ° of caudad tilt with images captured at 0.5° increments. The “perfect AP” angle, defined as the angle that most accurately profiled the articular surface, was determined for medial and lateral condyles of each tibia by five surgeons. Given that it was agreed across surgeons that more than one angle provided an adequate profile of each compartment, a range of AP angles corresponding to adequate images was recorded. Phase Two: Perfect AP angles from Phase One were projected onto sagittal CT images in Horos software in the mid-medial compartment and mid-lateral compartment to determine the precise tangent subchondral anatomic structures seen on CT to serve as dominant bony landmarks in a protocol generated for calculating medial and lateral tibial slopes on CT. Phase Three: 46 additional cadaveric knees were imaged with CT. Tibial slopes were determined in all 54 specimens.

Phase One: Based on the perfect AP angle on X-ray, the mean medial slope was 4.2°+/-2.6° posterior and mean lateral slope was 5.0°+/-3.8° posterior in eight knees. A range of AP angles was noted to adequately profile each compartment in all specimens and was noted to be wider in the lateral (3.9°+/-3.8°) than medial compartment (1.8°+/-0.7° p=0.002). Phase Two: In plateaus with a concave shape, the perfect AP angle on X-ray corresponded with a line between the superiormost edges of the anterior and posterior lips of the plateau on CT. In plateaus with a flat or convex shape, the perfect AP angle aligned with a tangent to the subchondral surface extending from center to posterior plateau on CT. Phase Three: Based on the CT protocol created in Phase Two, mean medial slope (5.2°+/-2.3° posterior) was significantly less than lateral slope (7.5°+/-3.0° posterior) in 54 knees (p<0.001). In individual specimens, the difference between medial and lateral slopes was variable, ranging from 6.8° more laterally to 3.1° more medially. In a paired comparison of right and left knees from the same cadaver, no differences were noted between sides (medial p=0.43; lateral p=0.62).

On average there is slightly more tibial slope in the lateral plateau than medial plateau (2° greater). However, individual patients may have substantially more lateral slope (up to 6.8°) or even more medial slope (up to 3.1°). Since tibial slope was similar between contralateral limbs, evaluating slope on the uninjured side provides a template for sagittal plane reduction of tibial plateau fractures.