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IntroductionFractures of the tibial plateau are in constant progression. They affect an elderly population suffering from a number of comorbidities, but also a young population increasingly practicing high-risk sports. The conventional open surgical technique used for tibial plateau fractures has several pitfalls: bone and skin devascularisation, increased risks of infection and functional rehabilitation difficulties. Since 2011, Poitiers University Hospital is offering to its patients a new minimally invasive technique for the reduction and stabilisation of tibial plateau fractures, named ‘tibial tuberoplasty’. This technique involves expansion of the tibial plateau through inflation using a kyphoplasty balloon, filling of the fracture cavity with cement and percutaneous screw fixation. We designed a study to evaluate the quality of fracture reduction offered by percutaneous tuberoplasty versus conventional open surgery for tibial plateau fracture and its impact on clinical outcome.Methods and analysisThis is a multicentre randomised controlled trial comparing two surgical techniques in the treatment of tibial plateau fractures. 140 patients with a Schatzker II or III tibial plateau fracture will be recruited in France. They will be randomised either in tibial tuberoplasty arm or in conventional surgery arm. The primary outcome is the postoperative radiological step-off reduction blindly measured on CT scan (within 48 hours post-op). Additional outcomes include other radiological endpoints, pain, functional abilities, quality of life assessment and health-economic endpoints. Outcomes assessment will be performed at baseline (before surgery), at day 0 (surgery), at 2, 21, 45 days, 3, 6, 12 and 24 months postsurgery.Ethics and disseminationThis study has been approved by the ethics committee Ile-De-France X and will be conducted in accordance with current Good Clinical Practice (GCP) guidelines, Declaration of Helsinki and standard operating procedures. The results will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals.Trial registration numberClinicaltrial.gov:NCT03444779.

Purpose A four-column classification system offers a different way of evaluating tibial plateau fractures. The aim of this study is to compare the intra-observer and inter-observer reliability between four-column and classic classifications. Methods This is a reliability study, which included patients presenting with tibial plateau fractures between January 2013 and September 2015 in a level-1 trauma centre. Four orthopaedic surgeons blindly classified each fracture according to four different classifications: AO, Schatzker, Duparc and four-column. Kappa, intra-observer and inter-observer concordance were calculated for the reliability analysis. Results Forty-nine patients were included. The mean age was 39 ± 14.2 years, with no gender predominance (men: 51%; women: 49%), and 67% of the fractures included at least one of the posterior columns. The intra-observer and inter-observer concordance were calculated for each classification: four-column (84%/79%), Schatzker (60%/71%), AO (50%/59%) and Duparc (48%/58%), with a statistically significant difference among them ( p  = 0.001/ p  = 0.003). Kappa coefficient for intr-aobserver and inter-observer evaluations: Schatzker 0.48/0.39, four-column 0.61/0.34, Duparc 0.37/0.23, and AO 0.34/0.11. Conclusions The proposed four-column classification showed the highest intra and inter-observer agreement. When taking into account the agreement that occurs by chance, Schatzker classification showed the highest inter-observer kappa, but again the four-column had the highest intra-observer kappa value. The proposed classification is a more inclusive classification for the posteromedial and posterolateral fractures. We suggest, therefore, that it be used in addition to one of the classic classifications in order to better understand the fracture pattern, as it allows more attention to be paid to the posterior columns, it improves the surgical planning and allows the surgical approach to be chosen more accurately.

The aim of this study was to compare the radiographic results and clinical outcome of unreamed tibial nailing (UTN) and Ilizarov external fixation (IEF) for the treatment of type IIIA open fractures of the tibia. Sixty-one patients with open type IIIA tibial shaft fractures were treated with an IEF (n = 32) or UTN (n = 29). Both groups were compared for union time, secondary outcomes of nonunion, infections, mechanical failure of the implant, and malunion. The average time-to-bone healing was 19 weeks (range 14-23 weeks) for IEF and 21 weeks (range 16-36 weeks) for UTN; it was significantly shorter in the IEF group (P = 0.039). One patient had refracture in the IEF group. Malunion occurred in four patients for each group. Posttraumatic osteomyelitis occurred in two patients in the IEF group and in three patients in the UTN group. In the IEF group, additional surgical procedures were indicated in three cases including sequestrectomy (n = 1), and pin replacement (n = 2). In the UTN group, seven patients needed additional surgery including bone grafting (n = 3), nail exchanged (n = 1), and posttraumatic osteomyelitis (n = 3). The results of the current study showed that IEF technique had a notable incidence of pin-tract infection, joint contracture, and shorthening related to treatment of the delayed union. The UTN technique had the disadvantage of a posttraumatic osteomyelitis and delayed union requiring additional surgery. We believe that the decision to use IEF or UTN should be made on a case-by-case basis.

Introduction The aim of this study was to analyze the pathoanatomy of the posterior fragment on the basis of a comprehensive CT examination, including 3D reconstructions, in a large patient cohort. Materials and methods One hundred and forty one consecutive individuals with an ankle fracture or fracture-dislocation of types Weber B or Weber C and evidence of a posterior tibial fragment in standard radiographs were included in the study. The mean patient age was 49 years (range 19–83 years). The exclusion criteria were patients below 18 years of age, inability to provide written consent, fractures of the tibial pilon, posttraumatic arthritis and pre-existing deformities. In all patients, post-injury radiographs were obtained in anteroposterior, mortise and lateral views. All patients underwent CT scanning in transverse, sagittal and frontal planes. 3D CT reconstruction was performed in 91 patients. Results We were able to classify 137 cases into one of the following four types with constant pathoanatomic features: type 1: extraincisural fragment with an intact fibular notch, type 2: posterolateral fragment extending into the fibular notch, type 3: posteromedial two-part fragment involving the medial malleolus, type 4: large posterolateral triangular fragment. In the 4 cases it was not possible to classify the type of the posterior tibial fragment. These were collectively termed type 5 (irregular, osteoporotic fragments). Conclusion It is impossible to assess the shape and size of the posterior malleolar fragment, involvement of the fibular notch, or the medial malleolus, on the basis of plain radiographs. The system that we propose for classification of fractures of the posterior malleolus is based on CT examination and takes into account the size, shape and location of the fragment, stability of the tibio-talar joint and the integrity of the fibular notch. It may be a useful indication for surgery and defining the most useful approach to these injuries.

Background Tibial plateau fractures are traumatic injuries with severities ranging from nondisplaced to complicated fractures. This study describes the epidemiological characteristics of patients with tibial plateau fractures treated in five trauma clinics. Methods This retrospective, cross-sectional study included 1165 patients with tibial plateau fractures treated between December 2015 and May 2017. Subjects were selected from the medical records of five institutions based on the inclusion and exclusion criteria. Age, sex, laterality, fracture type, trauma mechanism, vehicle type, classification, and associated injuries were assessed via univariate and bivariate analyses. Results In total, 23.3% of patients with tibial fractures treated during the study period had tibial plateau fractures. Of those affected, 73% were men and 50% were younger than 40 years. Furthermore, 95.7% of fractures were caused by traffic accidents, 82.6% of which involved motorcycles. Fractures were closed in 93.1% of cases, and 78% of subjects had associated injuries. The most common fractures, according to Schatzker classification, were type VI (23%) and V (19.1%) fractures. Conclusions Tibial plateau fractures are frequent injuries in our setting and mostly occur in men in their 30 s and 40 s. These fractures are typically caused by motorcycle traffic accidents. Level of Evidence. IV.

High-energy tibial pilon fractures continue to represent a significant challenge to the treating orthopaedic surgeon. Pre-operative evaluation includes a careful clinical assessment of the associated soft tissue injury, which frequently dictates surgical management. Staged surgical reconstruction remains the standard treatment protocol at most trauma centres. This includes application of a temporary spanning external fixator for approximately one to four weeks, followed by open reduction and internal fixation once the surrounding soft tissues are amendable. Despite careful soft tissue management protocols, the risk of wound complications continues to be relatively high compared to other orthopaedic trauma procedures. The functional long-term outcomes of these injuries remain limited, and recent data has emphasised that the majority of patients do not regain their pre-operative work status. In addition, the health-related quality of life scores fare poorly when compared to other orthopaedic and non-orthopaedic patient populations, and many patients develop post-traumatic arthritis within the tibiotalar joint. It has been shown that the quality of fracture reduction may significantly correlate with the long-term functional outcomes. While the orthopaedic community has come a long way with regard to safe management of high-energy tibial pilon fractures, the clinical outcomes continue to remain limited. In particular, the persistently high rates of wound complications and the limited functional long-term outcomes leave significant room for improvement. Future investigators may focus on further innovations to minimise the risk of wound complications. The surgical team may emphasise the quality of fracture reduction as an important treatment goal.

Although epidemiologic studies of tibial plateau fractures have been conducted, none have included geographically defined populations or a validated fracture classification based on computed tomography (CT). The goals of this study were to provide up-to-date information on the incidence and basic epidemiology of tibial plateau fractures in a large unselected patient population and to report the mechanisms of injury involved and the distribution of fractures according to a validated CT-based fracture classification. The authors conducted a population-based epidemiologic study of all patients treated for tibial plateau fracture over a 6-year period from 2005 to 2010. The study was based on an average background population of 576,364 citizens. A retrospective review of hospital records was performed. During this time, a total of 355 patients were treated for tibial plateau fracture. This group included 166 men and 189 women, and mean age was 52.6 years (SD, 18.3). The most common fracture type was AO type 41-B3, representing 35% of all tibial plateau fractures. The second most common fracture type was AO type 41-C3, representing 17% of all tibial plateau fractures. The incidence of tibial plateau fractures was 10.3 per 100,000 annually. Compared with women, men younger than 50 years had a higher incidence of fractures. The incidence of fractures increased markedly in women older than 50 years but decreased in men older than 50 years. In both sexes, the highest frequency was between the ages of 40 and 60 years. [Although epidemiologic studies of tibial plateau fractures have been conducted, none have included geographically defined populations or a validated fracture classification based on computed tomography (CT). The goals of this study were to provide up-to-date information on the incidence and basic epidemiology of tibial plateau fractures in a large unselected patient population and to report the mechanisms of injury involved and the distribution of fractures according to a validated CT-based fracture classification. The authors conducted a population-based epidemiologic study of all patients treated for tibial plateau fracture over a 6-year period from 2005 to 2010. The study was based on an average background population of 576,364 citizens. A retrospective review of hospital records was performed. During this time, a total of 355 patients were treated for tibial plateau fracture. This group included 166 men and 189 women, and mean age was 52.6 years (SD, 18.3). The most common fracture type was AO type 41-B3, representing 35% of all tibial plateau fractures. The second most common fracture type was AO type 41-C3, representing 17% of all tibial plateau fractures. The incidence of tibial plateau fractures was 10.3 per 100,000 annually. Compared with women, men younger than 50 years had a higher incidence of fractures. The incidence of fractures increased markedly in women older than 50 years but decreased in men older than 50 years. In both sexes, the highest frequency was between the ages of 40 and 60 years. [ Orthopedics. 2015; 38(9):e780–e786.]

Background The research on the biomechanical characteristics of individual implant placement for pilon fractures based on the different initial direction of fracture displacement is still insufficient. This study’s aim is to compare the stress distribution in bones and implants with various pilon fracture types. Methods Varus, valgus, dorsiflexion, and plantarflexion type fractures were categorized as type I, II, III, and IV, respectively. The buttress plate was placed medially in subtypes I A and II B, whereas it was placed anterolaterally in subtypes I B and II A ; The anterior or posterior buttress plate was utilized in subtypes III A and IV A, the lag screws were applied in subtypes III B and IV B . The maximum equivalent stress of tibia (TI-S max ) and implants (IF-S max ), stress of fracture fragments (S fe ), and axial displacement values of the fracture fragments (AD fe ) in each subtype were analyzed when the ankle was in a neutral position, 15° of varus and valgus in types I and II, 15° of dorsiflexion and plantarflexion in types III and IV. Results Under the same axial stress loading conditions, TI-S max , S fe , AD fe of subtypes I A and II A were significantly lower than subtypes I B and II B , while IF-S max of subtypes I A and II A were obviously larger than subtypes I B and II B . Additionally, TI-S max, S fe , AD fe of subtypes III A and IV A were considerably lower as IF-S max met expectations compared to subtypes III B and IV B . Conclusion Based on these results, when making decisions for open reduction and internal fixation in various pilon fractures, the choice and placement of the implant can be recommended as follows: the medial buttress plate for varus types; the anterolateral plate for valgus types; the anterior plate for dorsiflexion types; the posterior plate for plantarflexion types.

Background and Objectives: This study investigated associated meniscus and ligament injuries in tibial plateau fractures using magnetic resonance imaging (MRI) and assessed soft tissue injuries in relation to the Schatzker classification and Tscherne classification. Materials and Methods: The data of 185 patients who sustained tibial plateau fractures from January 2010 to April 2021 were retrospectively reviewed. Fractures were classified according to the Schatzker classification system. Soft-tissue injuries were assessed using the Tscherne classification. Menisci and ligaments were evaluated using preoperative MRI. Nerve injuries, compartment syndrome and wound problems were also assessed. The incidence of soft tissue injuries, as well as the relationship between the Schatzker and Tscherne classification systems, were analyzed. Results: Evidence of derangement of meniscus and ligament around the knee was found in 183 (98.9%) patients. The most common injury was a medial collateral ligament injury. The incidence of lateral collateral ligament injury, nerve injury, compartment syndrome and wound problem was higher in high-energy tibial plateau fractures. A tendency was observed between the Schatzker and the Tscherne classifications (p value < 0.001). Higher Tscherne grade was also associated with the incidence of posterior cruciate ligament injury, nerve injury and compartment syndrome. Conclusions: In tibial plateau fractures, soft tissue injuries were highly prevalent. High-energy fractures tended to exhibit higher Tscherne classification grades and showed an increased incidence of meniscus and ligament injuries. The Tscherne classification appears to be a helpful system for predicting soft tissue injuries in tibial plateau fractures. And preoperative MRI can be a helpful tool.