Open reduction and internal fixation of tibial plateau fractures is traditionally performed through an anterior, anterolateral or an anteromedial approach and more recently a posteromedial approach. These approaches allow satisfactory access to the majority of fracture patterns with the exception of posterolateral tibial plateau fractures.

To improve access to posterolateral tibial plateau fractures, we developed a posterolateral transfibular neck approach that exposes the tibial plateau between the posterior margin of the iliotibial band and the PCL. The approach can be combined with a posteromedial and/or an anteromedial approach to the tibial plateau. Since April 2007, we have used this approach to treat nine posterolateral tibial plateau fractures. All cases were followed up prospectively. Fracture reduction was assessed on radiographs, CT scans and arthroscopicaly. Maintenance of fracture reduction was assessed with radiostereometric analysis. Clinical outcomes were measured using Lysholm and KOOS scores.

Anatomic or near anatomic reduction was achieved in all cases. All fractures healed uneventfully and no loss of osteotomy or tibial plateau fracture reduction was identified on postoperative plain X-rays. In the cases monitored with radiostereometric analysis, the fracture fragments displaced less than 2 mm during the course of healing. All osteotomies healed either at the same rate or quicker than the tibial plateau fractures. There were no signs and no symptoms of lateral or posterolateral instability of the knee during or after the healing of the osteotomy. There were no complications related to the surgical approach, including the fibular head osteotomy. All wounds healed uneventfully and there were no symptoms related to the CPN. The patient reported outcomes recorded for this group at six months, using the Lysholm score (mean 71, median 77, range 42–95), compared favourably to the entire cohort of 33 patients treated operatively at our institution for a tibial plateau fracture and followed up prospectively during the same time period (mean 64, median 74, range 20–100).

The posterolateral transfibular approach for lateral tibial plateau fractures is an approach that should be considered for a certain specific pattern of fractures of the lateral tibial plateau. Our preliminary results demonstrated no complications through the learning curve of the development of this technique.

Sensitive and accurate measures of osteolysis around TKR are needed to enhance clinical management and assist in planning revision surgery. Therefore, our aim was to examine, in a cadaver model of osteolysis around TKR, the sensitivity of detection and the accuracy of measuring osteolysis using Xray, CT and MRI.

Fifty-four simulated osteolytic lesions were created around six cadaver knees implanted with either a cemented or cementless TKR. Twenty-four lesions were created in the femur and thirty in the tibia ranging in size from 0.7 cm3 to 14 cm3. Standard anteroposterior and lateral fluoroscopically guided radiographs, CT and MRI scans with metal reduction protocols were taken of the knees prior to the creation of lesions and at every stage as the lesion sizes were enlarged. The location, number and size of the lesions from images obtained by each method were recorded.

The sensitivity of osteolytic lesion detection was 44% for plain radiographs, 92% for CT and 94% for MRI. On plain radiographs, 54% of lesions in the femur and 37% of lesions in the tibia were detected. None of the six posterior lesions created in the tibia were detected on the AP radiographs; however, three of these six lesions were detected on the lateral radiographs. CT was able to detect lesions of all sizes, except for four lesions in the posterior tibia (mean volume of 1.2 cm3, range 1.06–1.47 cm3). Likewise, MRI was very sensitive in detecting lesions of all sizes, with the exception of three lesions, two of which were in the femur and one was in the medial condyle of the tibia (mean volume of 1.9 cm3, range 1.09–3.14 cm3). Notably, all six posterior tibial lesions, which could not be detected using AP radiographs, were detected by MRI.

This study demonstrates the high sensitivity of both CT and MRI (which uses no ionising radiation) to detect simulated knee osteolysis and can therefore be used to detect and monitor progression of osteolysis around TKR. The study also shows the limitations of plain radiographs to assess osteolysis.