When are tibial plateau depression fractures indicated for surgical intervention?

From the Guidelines

Tibial plateau depression fractures are considered surgical when there is significant articular depression, joint instability, or malalignment, particularly when the depression exceeds 3 mm or when there is condylar widening greater than 5 mm, as evidenced by studies such as those by Tang et al 1. The decision to operate on tibial plateau depression fractures is based on several key factors, including:

• The degree of articular surface depression, with depressions greater than 3 mm often requiring surgical intervention to restore joint congruity
• The presence of joint instability or malalignment, which can lead to abnormal load distribution across the knee and increase the risk of post-traumatic arthritis
• The type of fracture, with Schatzker types II-VI fractures typically requiring surgical management
• The presence of associated injuries, such as ligamentous injuries or meniscal tears, which can affect joint stability and function
• The patient's overall health and activity level, with more active patients often requiring surgical intervention to restore optimal function.

In terms of specific indications for surgery, fractures with lateral tibial plateau depression of >11 mm are at higher risk of lateral meniscus tear and ACL avulsion fracture, and may require surgical management 1. Other surgical indications include:

• Open fractures, which require prompt surgical debridement and stabilization to prevent infection
• Compartment syndrome, which requires emergency surgical intervention to prevent irreversible muscle and nerve damage
• Varus/valgus malalignment greater than 5 degrees, which can lead to abnormal load distribution across the knee and increase the risk of post-traumatic arthritis.

The surgical approach typically involves:

• Elevation of the depressed fragment to restore joint congruity
• Bone grafting to support the articular surface and promote healing
• Internal fixation with plates and screws to stabilize the fracture and allow for early range of motion. Postoperatively, patients usually follow a progressive weight-bearing protocol, starting with non-weight bearing for 6-12 weeks, followed by partial weight bearing as healing progresses, and physical therapy focusing on range of motion and quadriceps strengthening is essential for optimal recovery 1.

From the Research

Tibial Plateau Depression Fractures

• Tibial plateau fractures are peri-articular knee fractures of the proximal tibia, and their presentation can vary greatly due to the bimodal mechanism of injury and patient characteristics 2.
• The definitive management of tibial plateau fractures depends on the severity, ranging from conservative to surgical management, with surgery required for more severe fractures to restore articular congruity, mechanical alignment, ligamentous stability, and to permit early mobilisation 2.

Indications for Surgical Management

• Surgical indications for tibial plateau fractures include depression greater than 4 mm, displacement greater than 10 mm, and instability greater than 10 degrees 3.
• The presence of articular depression, particularly posterior articular depression, presents unique challenges for obtaining and maintaining fracture reduction, and requires a thorough understanding of the fracture, specific approaches, reduction techniques, and stabilization strategies 4.

Treatment Strategies

• Treatment strategies for tibial plateau fractures with articular depression include elevation of the fragment(s), filling the residual defect with bone graft or bone substitute, and "raft" support of the articular fracture reduction with screws through a medially and/or laterally based plate 4.
• Open reduction and internal fixation (ORIF) with free subchondral screws can be used to treat lateral tibial plateau fractures with involvement of the lateral column and depression of the articular surface 5.

Outcomes and Complications

• The outcomes of surgical management of tibial plateau fractures are generally good, with successful results accounting for 86.8% of cases, and excellent or good results in 36.8% and 50% of cases, respectively 3.
• However, surgical management is not without complications, including postoperative arthritis, bicondylar and comminuted fractures, meniscal removal, instability, malalignment, and articular incongruity 2, as well as deep and superficial infections, malunion, arthrofibrosis, and myositis ossificans 3, 6.