Bicondylar tibial plateau fracture dislocations with an intact anterolateral cortical Rim: Prevalence, fracture characteristics, and complications

PURPOSE: Bicondylar tibial plateau (BTP) fracture-dislocations with an intact anterolateral (AL) cortical rim present a unique treatment challenge due to posterolateral joint impaction. The purpose of this study was to determine the prevalence of this pattern within a large cohort of bicondylar tibial plateau fractures and describe fracture characteristics and complication rates.

METHODS: Patients undergoing open reduction and internal fixation of a BTP fracture at two Level 1 trauma centers between 2010 and 2023 were identified. Radiographs and CT scans were reviewed to identify medial fracture-dislocations with an intact anterolateral cortical rim. Posterior shearing injuries were excluded. Demographic, surgical, and outcome variables were collected.

RESULTS: In total, 46/455 patients (10 %) met inclusion criteria (average age 53 years, 52 % female, 71 % high-energy). The average posterolateral depression was 9 mm and 40 % of fractures had >50 % lateral plateau involvement. Twenty-seven (59 %) patients were treated with single medial plating and 9 (20 %) with dual medial plating. One (2.2 %) lateral meniscal tear was repaired. A single-incision approach was used in 34 cases (74 %), most commonly medial-only (63 %). Eight (17 %) patients required reoperation, including 2 (4.3 %) for deep infection. The post-operative medial proximal tibial and posterior proximal tibial angles were 88° (IQR: 86-89) and 9° (IQR: 7-11), respectively. The post-operative articular stepoff or gap was <5 mm for 89 % of cases.

CONCLUSION: In this series, 1 in 10 bicondylar tibial plateau fracture-dislocations presented with an intact anterolateral cortical rim. The dominant surgical strategy of medial-only plating with low rates of meniscal repair in this series resulted in good restoration of condylar width and relatively low infection rates. Long-term studies are needed to determine the degree to which a separate lateral approach or lateral plating may influence functional outcomes, but a medial-only strategy can be utilized when soft tissue swelling precludes an additional lateral incision.