Summary

This study reveals that 46.8% of patients with tibial plateau fractures have central pivot injuries (CPI) detected by MRI. Among these, 6% required surgery. The research also found a higher incidence of combined anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries in central quadrant fractures. MRI is recommended for patients at high risk of CPI.

Abstract

Introduction

Tibial plateau fractures represent 1-2% of all fractures and are frequently associated with soft tissue injuries of the knee, including ligaments. Current evidence indicates that major knee ligament injuries occur in approximately 71% of these cases. Specifically, cruciate ligament injuries are present in about 37% of tibial plateau fractures, with the incidence of Anterior Cruciate Ligament (ACL) injuries ranging from 21.6% to 57% and Posterior Cruciate Ligament (PCL) injuries ranging from 15.7% to 28%. However, these studies have small sample sizes, and to date, no research has provided data on the percentage of central pivot injuries (CPI) that necessitate surgical intervention. The primary objective of this study was to assess the incidence of CPI in patients with tibial plateau fractures. Additionally, we sought to report the frequency of surgical interventions for cruciate ligament injuries and identify risk factors associated with CPI in this patient population.

Methodology

Retrospective cohort study of patients with tibial plateau fractures operated between June 2016 and July 2023 at a Level I Trauma Center. Patients over 18 years old with tibial plateau fractures, complete preoperative imaging studies (radiography, CT scan, and knee MRI), and postoperative follow-up of more than 12 months were included. Patients with prior cruciate ligament injuries and other associated fractures were excluded. MRIs were reviewed by expert musculoskeletal radiologists, who classified ACL and PCL injuries as complete, partial, or at the insertion site. Surgical interventions for CPI were categorized into two types: first-stage (performed concurrently with open reduction and internal fixation, ORIF) and second-stage (delayed surgical intervention). Data were analyzed both descriptively and analytically using STATA 18.0. Chi-square tests and relative risk measures were employed, with statistical significance set at p<0.05.

Results

Of the 539 patients who underwent surgery for tibial plateau fractures, 385 met the inclusion criteria, including 23 females. The fracture patterns were distributed as follows: 2% Schatzker I, 31.9% Schatzker II, 3.8% Schatzker III, 10.1% Schatzker IV, 34% Schatzker V and 17,9 % Schatzker VI. Among these patients, 52 had injuries to both cruciate ligaments, 104 had isolated ACL injuries, and 24 had isolated PCL tears, resulting in 180 patients with at least one cruciate ligament injury. Of the patients with CPI, 69% (124/180) had Schatzker types IV/V/VI fractures. Out of the 385 patients with tibial plateau fractures, 23 (6%) required ligament surgeries (13% [23/180] of those with at least one major ligament injury), either as first or second-stage procedures. Risk factor analysis revealed an association between fractures of the central quadrants and isolated ACL injury (p<0.0001, RR=2.36) as well as combined ACL and PCL injury (p=0.02, RR=2.24).

Conclusion

This study reports a 46.8% incidence of CPI among 385 tibial plateau fractures diagnosed via MRI. Of these, 6% required surgical intervention and were associated with injuries in the central quadrants of the tibial plateau. Consequently, MRI should be considered for at least those patients at higher risk.