Is bone graft indicated in lateral tibial plateau fractures with vertical fracture lines and mild cortical depression?

Management of Lateral Tibial Plateau Fractures with Vertical Fracture Lines and Mild Cortical Depression

Bone grafting is not routinely necessary for lateral tibial plateau fractures with vertical fracture lines and mild cortical depression when using modern fixation techniques with periarticular rafting constructs. 1

Diagnostic Approach

Before determining treatment, proper imaging is essential:

1. Initial Radiographs: Standard radiographs (AP, lateral) should be obtained first to identify the fracture pattern 2

2. CT Scan: CT is recommended for further classification and characterization of tibial plateau fracture severity 2

   • CT shows 100% sensitivity (vs. 83% for radiographs) in detecting tibial plateau fractures
   • CT provides superior characterization of fracture morphology and severity
   • CT can help predict associated soft tissue injuries

3. MRI: Consider if additional soft tissue injuries are suspected 2

   • MRI is the preferred imaging modality to evaluate for additional radiographically occult fractures and/or internal derangements
   • Particularly useful for evaluating meniscal and ligamentous injuries

Treatment Algorithm for Lateral Tibial Plateau Fractures with Mild Depression

Fixation Strategy

1. Periarticular Rafting Construct:

   • Modern periarticular locking plates with subchondral "raft" screws provide sufficient support for the articular surface 1
   • This construct creates a stable framework that prevents secondary subsidence of the elevated articular fragment

2. Reduction Technique:

   • Elevation of depressed fragments through a cortical window in the lateral tibial metaphysis
   • Reduction should be performed under fluoroscopic guidance
   • Subchondral screws placed in a "jail" technique to maintain reduction 3

Bone Graft Considerations

Bone graft is NOT routinely necessary when:

• Depression is mild
• Modern periarticular locking plate with raft screws is used
• Patient has reasonable bone quality 1

Bone graft MAY be considered when:

• Severe depression (>11mm) is present 2
• Significant metaphyseal comminution exists
• Poor bone quality/osteoporosis is present
• Posterolateral depression that is difficult to support with standard fixation 4

Evidence Analysis

Recent evidence suggests that periarticular rafting constructs without bone graft can achieve good final results without the morbidity associated with bone graft/substitutes 1. This represents a shift from traditional teaching that emphasized filling metaphyseal defects with bone graft or substitutes.

The 2023 study by 1 demonstrated comparable outcomes between cases with and without bone graft supplementation when using modern fixation techniques. This suggests that the stability provided by current plating systems may be sufficient to prevent secondary collapse in cases with mild depression.

Pitfalls and Considerations

1. Avoid underestimating fracture complexity:

   • CT is essential for proper classification and surgical planning 2
   • Posterior depression may require specialized approaches or techniques 5

2. Consider associated soft tissue injuries:

   • Lateral tibial plateau depression >11mm increases risk of lateral meniscus tear and ACL avulsion 2
   • MRI may be indicated to evaluate for these injuries

3. Be cautious with severe depression or poor bone quality:

   • Traditional bone grafting may still be indicated in these scenarios
   • Consider alternative techniques like fibular shaft allograft support for posterolateral depression 4

4. Early range of motion is critical:

   • Stable fixation that allows early mobilization improves outcomes 6
   • Hinged knee braces can facilitate protected motion

By following this algorithm and considering the specific characteristics of each fracture, optimal outcomes can be achieved while avoiding unnecessary procedures and their associated complications.