Summary

Location of Lateral Tibial Plateau Fractures Relativer to the Posterolateral Complex Predicts the Need for Extended Lateral Approaches

Abstract

Background

and purpose: Pseudoinstabilities are common in malunited tibial plateau fractures (TPFs). In addition to fracturoscopy, extended lateral approaches have been proposed to improve the quality of fracture reduction and reduce the risk of malunion and subsequent pseudoinstability. However, recommendations regarding the exact morphology of lateral tibial fractures requiring extended approaches are lacking.

Material And Methods

A retrospective observational cohort study was conducted using data from patients who underwent surgical treatment of a tibial plateau fracture involving the lateral tibial plateau (AO/OTA 41-B3 and 41-C3) at a level 1 trauma center between January 2020 and May 2024. Demographics, patient positioning, surgical approaches, and need for approach extension were recorded. The fractures were classified according to the 10-segment classification. Comprehensive examinations on preoperative computed tomography (CT) scan were performed evaluating the morphology of lateral tibial plateau fractures relative to the posterolateral ligamentous structures. A binary logistic regression was performed to determine the odds of performing an extended lateral approach. The event “extend lateral approach” (no vs. yes) was defined as the dependent variable. Overall statistical significance was set to p<0.05.

Results

143 patients (53.8% female, 46.2% male) with a mean age of 51.3  14.3 years were included. Three distinct types of lateral tibial plateau fractures were identified. The most frequent fracture types observed were anterior to the posterolateral ligamentous structures (38.5%) and at level of the posterolateral complex (36.4%), followed by a fracture location posterior to the posterolateral ligamentous structures (25.1%). Extended lateral approaches using lateral femoral epicondyle osteotomy were performed in 17.5% of cases, with fractures posterior to the posterolateral ligamentous structures more likely to have an extended approach (80.0%, p<0.001). Of the remaining Type III fractures that did not receive an extended lateral approach, 62.5% had pure posterior pathology of the posterolateral rim or wall (Type IIIb) and were treated with posterior plate fixation in prone position only. All Type I fractures were treated with a standard anterolateral approach and did not require an extended approach.

Conclusion

Lateral tibial plateau fractures show three distinct fracture types, with the fracture location relative to the posterolateral ligamentous structures predicting the need for extension of lateral approaches. For fractures extending posterior to the posterolateral complex, an extended lateral approach should be considered to improve the visualization of the articular surface and to potentially reduce the risk of malunion with subsequent pseudoinstability.