Purpose Bicondylar tibial plateau fractures involving four articular quadrants are severe and complex injuries, and they remain a challenging problem in orthopaedic trauma. The aim of this study was to introduce a new treatment protocol with dual-incision and multi-plate fixation in the floating supine patient position as well as to report the preliminary clinical results. Methods From January 2006 to December 2011, 16 consecutive patients with closed bicondylar four-quadrant tibial plateau fractures (Schatzker type VI, OTA/AO 41C2/3) were treated with posteromedial inverted L-shaped and anterolateral incisions. With the posteromedial approach, three quadrants (posteromedial, anteromedial and posterolateral) can be exposed, reduced and fixed with multiple small antiglide plates and short screws in an enclosure pattern. With the anterolateral approach, after articular elevation and bone substitute grafting, a strong locking plate with long screws to the medial cortex is used to raft-buttress the reduced lateral plateau fracture, hold the entire reconstructed tibial condyles together, and contact the condyles with the tibial shaft. All patients were encouraged to exercise knee motion at an early stage. The outcome was evaluated clinically and radiologically after a minimum two-year follow-up. Results The average operation time was 98±26 minutes (range 70-128) and the average duration of hospitalization was 29±8.6 days (range 20-41). Three cases used five plates, nine cases used four plates, and four cases used three plates. All patients were followed for a mean of 28.7±6.1 months (range 26-38). Fifteen incisions healed initially, while one patient developed a medial wound dehiscence and was successfully managed by debridement. All patients achieved radiological fracture union after an average of 20.2 weeks. At the two-year follow up, the average knee range of motion (ROM) was 98°±13.7 (range 88-125°), with a Hospital for Special Surgery (HSS) knee score of 87.7±10.3 (range 75-95), and SMFA score of 21.3±8.6 (range 12-33). Conclusion For bicondylar four-quadrant tibial plateau fractures, the treatment protocol of multiple medial-posterior small plates combined with a lateral strong locking plate through dual incisions can provide stable fracture fixation to allow for early stage rehabilitation. Good clinical outcomes can be anticipated.
Schatzker type IV medial tibial plateau fractures have an unfavorable prognosis, likely due to the mechanism of injury (fracture-dislocation/subluxation type) and possibly due to the involvement of the posterolateral plateau, which is different from previously thought. The aim of this study was to propose a new subclassification of Schatzker type IV fracture patterns based on 2-dimensional (2-D) computed tomography and three-dimensional (3-D) reconstruction. The authors defined Schatzker type IV medial tibial plateau fractures as AO/OTA 41 type B fractures (partial articular), with partial or total medial plateau involvement, leaving at least the anterolateral quadrant intact. The images of 42 fractures (42 patients) were evaluated. The fractures were further anatomically divided into 2 groups: Group 1 were classic medial unicondylar fractures and Group 2 were more complicated variants involving both condyles, characterized by medial condyle fractures with lateral plateau extension, usually with articular impaction of the centroposterior lateral plateau. Twelve (29%) cases involved only the medial condyle, and 30 (71%) involved both the medial and lateral condyles. Twenty-nine (69%) cases demonstrated posterior coronal fractures. The most common patterns were bicondylar posteromedial plateau fractures with posterolateral quadrant depression (bicondylar posterior fractures: 14 cases, 33%) and total/subtotal medial condyle fractures with posterolateral quadrant depression (13 cases, 31%). The isolated unicondylar posteromedial split fracture was uncommon (2 cases, 5%). Computed tomography-based reconstruction enhances the understanding of fracture anatomy and the relationships between fracture fragments. In Schatzker type IV medial tibial plateau fractures, the involvement of posterolateral quadrants is common.
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