A preliminary study of the surgical approach for posterior tibial plateau fractures: based on posterior fragment segment classification

Tibial plateau fracture is one of the most common types of lower limb trauma. Since Luo et al proposed a three-column classification [1] of tibial plateau fracture based on CT scans, surgeons have had a more comprehensive understanding of this injury involving the posterior column. However, with the deepening of research, there are more and more controversies over its treatment, which is fully recognized by up to 38 methods of fracture classification [2]. Studies have shown that without the posterior buttress plate fixation, the rate of secondary reduction loss will be as high as 30% in PTPFs [3], which makes the PTPFs especially important.

Schatzker classification is one of the most commonly used methods to describe the morphological characteristics of tibial plateau fracture on a two-dimensional plane [4]. However, the approach could not be guided in the treatment of PTPFs where the incidence can be as high as 28%-70% [5, 6]. Luo et al. [1] depicted a three-column classification to describe fracture on the coronal plane. However, it confuses surgeons about the choice of surgical approach when the posterior of the tibial plateau is divided into a single posterior column. Therefore, Dhillon et al recommended that it should be further divided into posteromedial and posterolateral columns [7]. Similarly, the tibial plateau is further subdivided by the ten-segment classification described by Krause, which brings more attention to the 77% risk of malunion in the postero-latero-central segment [8]. Meanwhile, to better understand the fracture plane direction and guide the selection of a better surgical approach, Juan [9] proposed the concept of “main deformity direction” and placed a plate parallel to it. However, due to the anatomical factors of the knee and the complexity of the original traumatic mechanism, there was still no classification that could completely cover the injury type of tibial plateau fracture and guide the surgical approach.

Based on these classification methods, the authors suggested surgical approaches for specific fracture types based on their experience. Frosch [10] strongly recommended the concept of direct approach and stepwise extension based on ten-segment classification through their research on the articular visualization exposed by different approaches. They believed that the anterolateral approach or Frosch approach combined with the femoral epicondyle osteotomy approach, if necessary, would significantly improve the treatment of posterolateral tibial plateau fractures. Sun [11] suggested using a posteromedial inverted L approach combined with an anterolateral approach for the treatment of complex tibial plateau fractures based on the four-column classification in a floating position. Sim [12] classified isolated posterolateral plateau fractures based on three-column classification and described specific surgical approaches for the corresponding fracture types. Juriaan [13] used the “WAVE” plate to treat posterolateral plateau fracture with a posteromedial inverted L approach.

The authors mentioned above focused on the reduction and fixation of the posterolateral fragments. However, few articles had discussed the treatment of PTPFs with a specific surgical approach by dividing them into simple posterior fragment segments classification. Juan [9] put forward some valuable suggestions for the treatment of PTPFs according to the concept of main deformity directions in different posterior regions. We consider it necessary to make a more concrete classification of PTPFs and attempt to evaluate early results based on our experience to provide a more comprehensive treatment idea for orthopedic surgeons. Therefore, the purpose of this study is to describe the method of posterior fragment segment classification and to reveal the preliminary treatment results of recommended surgical approach.

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