Correlation of Parameters on Preoperative CT Images With

Injury, Int. J. Care Injured 48 (2017) 745–750

Contents lists available at ScienceDirect

Injury

journal homepage: www.elsevier.com/locate/injury

Correlation of parameters on preoperative CT images with

intra-articular soft-tissue injuries in acute tibial plateau fractures: A

review of 132 patients receiving ARIF

a,b,c b,c,d b,c,d b,c,d

Hao-Che Tang , I-Jung Chen , Yu-Cheng Yeh , Chun-Jui Weng ,

b,c,d b,c,d b,c,d,

Shih-Sheng Chang , Alvin Chao-Yu Chen , Yi-Sheng Chan *

Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan

College of Medicine, Chang Gung University, Taoyuan 333, Taiwan

Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan

Department of Orthopaedic Surgery, Division of Sports Medicine Section, Chang Gung Memorial Hospital, Linkou, Taiwan

A R T I C L E I N F O A B S T R A C T

Introduction: Tibial plateau fractures often occur in conjunction with soft-tissue injuries of knees. The

Keywords:

hypothesis of this study is that parameters of CT imaging can predict intra-articular soft-tissue injuries.

Tibial plateau fracture

Patients and methods: Patients who underwent arthroscopically assisted reduction and internal ﬁxation

(ARIF) for acute tibial plateau fractures performed by a single orthopedic surgeon between 2005 and 2015

Arthroscopy

were included in this retrospective study. Patients with concomitant ipsilateral femoral fractures, who

Meniscus tear

ACL avulsion had received revision surgery or who had undergone index surgery more than 30 days from the event

were excluded. We measured lateral plateau depression and widening, medial plateau depression and

displacement, and column involvement observed on preoperative CT scans. Intra-articular soft-tissue

injuries were diagnosed based on ﬁndings from knee arthroscopy. The correlation of imaging parameters

with soft-tissue injuries was analyzed by the area under a receiver operating characteristic (AUROC)

curve and multivariate logistic regression.

Results: One-hundred and thirty-two patients were enrolled in the study. The average age was 45.7 Æ 13.1

years (range: 18–75 years). Lateral tibial plateau depressions >11 mm were signiﬁcantly associated with

increased risk of lateral meniscus tears (p = 0.001). However, there was no signiﬁcant threshold of lateral

tibial plateau widening that could be used to predict lateral meniscus tear. Greater risk of anterior

cruciate ligament (ACL) avulsion fracture was observed in younger patients, patients with high-energy-

pattern tibial plateau fractures, patients with fractures involving anteromedial or posterolateral columns,

and patients with medial tibial plateau displacement >3 mm (p < 0.05).

Conclusion: Measuring lateral tibial plateau depression and column involvement on preoperative CT scans

can help predict a higher risk of lateral meniscus tear and ACL avulsion fracture respectively in patients

with acute tibial plateau fractures.

Introduction and the stability of the knee will be compromised [10–13], which

can lead to progression of osteoarthritis [14,15].

Intra-articular soft-tissue injuries associated with tibial plateau Preoperative CT scans for tibial plateau fractures have been

fractures are common [1–6]. These include meniscus tears, widely used. Compared to plain radiographic ﬁlms, CT imaging can

cruciate ligament tears, and cruciate ligament avulsion fractures. offer much more detail about the pattern of fracture and thus can

When intra-articular soft-tissue injury is identiﬁed, acute repair improve surgical planning [16]. However, the intra-articular soft-

along with appropriate fracture reduction and ﬁxation can lead to a tissue conditions can hardly be identiﬁed on CT scans. Although

good outcome [7,8]. If meniscus tears or cruciate ligament injuries MRI was regarded as a tool for diagnosis of internal derangements

are left untreated, the contact stress of the knee will increase [9] of the knee, longer scan time and higher cost limit the MRI use in

the setting of acute tibial plateau fractures. In addition, MRI was

more accurate in diagnosing ACL injuries than meniscus injuries

* Correspondence to: No. 5, Fusing St., Gueishan, Taoyuan, 333, Taiwan. [17–19].

E-mail address: [email protected] (Y.-S. Chan).

http://dx.doi.org/10.1016/j.injury.2017.01.043

746 H.-C. Tang et al. / Injury, Int. J. Care Injured 48 (2017) 745–750

Fig.1. A 54 year-old male sustained left tibial plateau fracture in a traffic accident. (A) anterior-posterior view of the plain film (B) lateral view of the plain film (C) coronal view

of the CT scan (D) sagittal view of the CT scan; a = lateral tibial plateau depression; b = lateral tibial plateau widening; c = medial tibial plateau displacement in coronal plane;

d = medial tibial plateau displacement in sagittal plane; no medial tibial plateau depression in this case.

Reports in the literature show that greater articular depression Two authors evaluated the preoperative CT scans. Both authors

and widening of the lateral tibial plateau are associated with a were blinded to the results of physical examination and surgical

higher incidence of soft-tissue injuries in patients with lateral ﬁndings during image measurement. The mean values of fracture

tibial plateau fractures [20–22]. Although intra-articular soft- displacement measured by the two authors were used in the

tissue injuries of the knee occur in both medial and lateral tibial analysis. Schatzker classiﬁcations of tibial plateau [23] were

plateau fractures [1–4], those studies did not include tibial plateau applied and recorded based on evaluation of the preoperative CT

fractures involving the medial compartment. scans. Lateral or medial joint-line depression was measured as the

In this study, we retrospectively evaluated preoperative CT distance between the non-injured joint line to the maximal

scans and arthroscopic ﬁndings in patients with acute tibial articular depression point on coronal or sagittal CT images. To

plateau fractures, in the hopes of ﬁnding ways to predict intra- evaluate lateral tibial plateau widening, two lines perpendicular to

articular soft-tissue injuries in these patients. The hypothesis was the joint line were drawn on the coronal view. These lines were

that both the degree of displacement and column involvement tangential to the lateral femoral epicondyle and the most lateral

seen on preoperative CT scans could be used to predict intra- point of the lateral tibial plateau, respectively. The distance

articular soft-tissue injuries associated with tibial plateau frac- between the two parallel lines was then measured, and deﬁned as

tures. The study was approved by the local institutional review the amount of lateral widening. Instead of measuring the degree of

board. medial widening, we measured the greatest amount of displace-

ment of the medial tibial plateau fragment from the proximal tibia

Patients and methods on coronal or sagittal views (Fig.1). The reason for this was that the

relative position of medial tibial plateau and medial femoral

We retrospectively enrolled patients who had received condyle was usually retained by the medial collateral ligament.

arthroscopy-assisted reduction with internal ﬁxation (ARIF) In addition, we evaluated the fracture involvement based on the

surgery for tibial plateau fractures between January 2005 and “three-column classiﬁcation” on the transverse view of the CT

June 2015. All surgeries had been performed by a single surgeon at scans [24] (Fig. 2). According to the concept of three-column, the

our institute. Patients with concomitant ipsilateral femoral tibial plateau was divided into medial, lateral and posterior

fractures, who did not have preoperative CT scans, or who columns. The posterior column was further divided into postero-

underwent index surgery delayed for more than 30 days, or those lateral and posteromedial columns. Pure articular depression

with revisions for tibial plateau fractures were excluded from the without a fracture line across the column was deﬁned as lack of

study. column involvement.

Each patient’s sex and age, the interval from the accident to the

index surgery, and surgical ﬁndings were recorded by another

author. Surgical ﬁndings were based on results from the knee

arthroscopic examination, which included the status of the

meniscus tear, cruciate ligament tear, or cruciate ligament avulsion

fracture (Fig. 3).

Numerical data were presented as means Æ standard deviation

(SD), while categorical data were expressed as absolute frequen-

cies and percentages. The association of soft-tissue injuries and the

Fig. 2. Transverse view of the CT scan. The tibial plateau fracture involved the Fig. 3. Left knee arthroscopic examination of the same patient revealed peripheral

anterolateral column, anteromedial column and posterolateral column. AL tear (arrowhead) of lateral meniscus (A) and ACL avulsion fracture from the tibial

anterolateral column, AM anteromerial column, PL posterolateral column, PM footprint (B). LFC lateral femoral condyle, LM lateral meniscus, MM medial

posteromedial column, L lateral, M medial. meniscus.

H.-C. Tang et al. / Injury, Int. J. Care Injured 48 (2017) 745–750 747

Table 1

Distribution of soft-tissue injuries in Schatzker classiﬁcation.

Number LM tear MM tear ACL tear ACL avulsion PCL tear PCL avulsion PT tear

Schatzker I 4 3 1 1 1 1 0 0

Schatzker II 25 14 5 1 6 1 0 0

Schatzker III 20 13 1 1 2 0 0 0

Schatzker IV 8 1 1 0 5 0 1 1

Schatzker V 52 29 5 3 28 1 0 0

Schatzker VI 23 11 2 3 7 1 0 0

Total 132 71 15 9 49 4 1 1

LM lateral meniscus, MM medial meniscus, ACL anterior cruciate ligament, PCL posterior cruciate ligament, PT popliteal tendon.

Schatzker classiﬁcation was determined by Pearson’s chi-square tendon tear. The incidence of intra-articular soft-tissue injuries for

test. The amount of the fracture displacement, which results in the each Schatzker classiﬁcation is listed in Table 1. The distribution of

greatest discrimination of soft-tissue injuries, was examined using intra-articular soft-tissue injuries in low-energy and high-energy

the area under a receiver operating characteristic curve (AUROC). patterns is listed in Table 2. The incidence of ACL avulsion fractures

To compare areas under resulting AUROC curves, a nonparametric was signiﬁcantly higher in high-energy-pattern tibial plateau

approach was used. The AUROC analysis was also performed to fractures (Schatzker types IV, V, and VI; p = 0.001).

calculate the cut-off values, sensitivity, speciﬁcity, overall correct- The threshold of lateral tibial plateau depression associated

ness, and positive and negative predictive values. The threshold of with lateral meniscus tear was 11 mm (p = 0.001). In 64 patients

fracture displacement was calculated by obtaining the maximal with lateral tibial plateau depressions >11 mm, 45 patients had

AUROC. The association of column involvement and soft-tissue lateral meniscus tears (positive predictive value = 70.3%). In 68

injuries was determined with multivariate logistic regression. The patients with lateral tibial plateau depressions <11 mm, 26

dependent variables were recorded as presence or absence of the patients had lateral meniscus tear (negative predictive value =

soft-tissue injuries. The independent variables were the column 61.8%). However, no signiﬁcant threshold of lateral tibial plateau

involvement and patient age (signiﬁcant in the univariate widening, medial plateau depression or medial plateau displace-

analysis). All statistical tests were two-tailed, and the value of ment was found for lateral meniscus tears. The average lateral

p < 0.05 was considered statistically signiﬁcant. Data were ana- tibial plateau depression and widening in the fractures with/

lyzed with IBM SPSS statistics 20 (IBM Corp, Armonk, NY, USA). without lateral meniscus tear is listed in Table 3. The incidence of

ACL avulsion fracture is signiﬁcantly associated with medial tibial

Results plateau displacement, and the threshold was 3 mm (p = 0.014). The

positive predictive value based on the threshold was 49.2%, and the

Between January 2005 and June 2015, 152 patients with tibial negative predictive value was 74.6%. There was no signiﬁcant

plateau fractures received ARIF performed by a single surgeon at threshold of fracture displacement for the medial meniscus tears,

our institute. One patient who received the index surgery after a ACL tears, PCL tears, PCL avulsions or popliteal tendon tears.

delay of 39 days was excluded. Fifteen patients without preopera- The inﬂuence of column involvement on intra-articular soft-

tive CT scans and 4 patients with concomitant ipsilateral femoral tissue injuries was statistically signiﬁcant only in ACL avulsion

fracture were also excluded from this study. fractures (Table 4). Tibial plateau fractures that involved ante-

A total of 132 patients met the inclusion criteria, including 60 romedial and posterolateral columns had a relatively higher risk of

males and 72 females, with an average age of 45.7 Æ 13.1 years concurrent ACL avulsion fracture. The odds ratio for anteromedial

(range: 18–75 years). The incidence of soft-tissue injuries, except column involvement was 4.11 (p = 0.012), and the odds ratio for

for ACL avulsion fractures, was not signiﬁcantly different by sex or posterolateral involvement was 3.61 (p = 0.015). The incidence of

age. In contrast, a signiﬁcantly greater incidence of ACL avulsion ACL avulsion fractures in patients with anteromedial involvement

fractures was observed in younger patients (p = 0.012). The mean was 50.7% (38/75), while 45.2% (38/84) patients with posterolat-

age of 49 patients with ACL avulsion fractures was 41.1 Æ12.3 years eral involvement had ACL avulsion fractures. If both anteromedial

(range: 18–71 years), and the mean age of 83 patients without ACL and posterolateral columns were involved, the overall incidence of

avulsion fractures was 48.5 Æ12.9 years (range: 19–75 years). ACL avulsion fracture was 50% (29/58).

Among the 132 patients, there were 4 (3.1%) Schatzker type I

fractures, 25 (18.9%) Schatzker type II fractures, 20 (15.2%) Discussion

Schatzker type III fractures, 8 (6.0%) Schatzker type IV fractures,

52 (39.4%) Schatzker type V fractures, and 23 (17.4%) Schatzker In this study, we demonstrate the correlation of preoperative

type VI fractures. Seventy-one patients (53.8%) had lateral imaging parameters with knee arthroscopic ﬁndings in patients

meniscus tears; 15 patients (11.4%) had medial meniscus tears; with acute tibial plateau fractures. The major difference of this

9 patients (6.8%) had ACL tears; 49 patients (37.1%) had ACL study from prior studies is that both medial and lateral tibial

avulsion fractures; 4 patients (3.0%) had PCL tears; 1 patient (0.8%) plateau fractures were included. In addition, the knee arthroscopy

had a PCL avulsion fracture; and 1 patient (0.8%) had a popliteal could examine the knee joint more thoroughly and accurately than

Table 2

Distribution of soft-tissue injuries in low-energy and high-energy pattern tibial plateau fractures.

Number LM tear MM tear ACL tear ACL avulsion PCL tear PCL avulsion PT tear

Schatzker 49 30 7 3 9 2 0 0

I-III

Schatzker 83 41 8 6 40 2 1 1

IV-VI

Total 132 71 15 9 49 4 1 1

p = 0.188 p = 0.416 p = 0.807 p = 0.001 p = 0.588 p = 0.441 p = 0.441

LM lateral meniscus, MM medial meniscus, ACL anterior cruciate ligament, PCL posterior cruciate ligament, PT popliteal tendon.

748 H.-C. Tang et al. / Injury, Int. J. Care Injured 48 (2017) 745–750

Table 3

Lateral tibial plateau depression and widening in patients with/without lateral meniscus tear.

LM tear No LM tear

Lateral depression (mm) Lateral widening Lateral depression (mm) Lateral widening

(mm) (mm)

Schatzker I – 1.1 Æ 1.8 (0–3.2) – 0

Schatzker II 12 Æ 7.1 (4.4–29) 2.9 Æ 2.9 (0–8) 14.2 Æ 3.1 (7–17.2) 4.9 Æ 3.3 (0–10.5)

Schatzker III 13.1 Æ 5.3 (2.7–20.3) – 8.4 Æ 3.1 (4.3–12.5) –

Schatzker V 17.3 Æ 9.1 (2.7–35) 4 Æ 3.7 (0–13.9) 8.8 Æ 10.5 (0–38.4) 1.9 Æ 3.4 (0–10.7)

Schatzker VI 19.3 Æ 16.2 (0–54.7) 4.3 Æ 4 (0–10.7) 7.2 Æ 6.3 (0–18.5) 7.7 Æ 6.7 (0–21)

Total 14.8 Æ 10.2 (0–54.7) 2.9 Æ 3.4 (0–13.9) 9.3 Æ 8.1 (0–38.4) 3.5 Æ 4.8 (0–21)

LM lateral meniscus.

the lateral arthrotomy. The results revealed that a higher incidence ﬁxation for Schatzker type 2 fractures. They compared these

of lateral meniscus tears can be expected in patients who sustained measurements with intraoperative ﬁndings and found that the

tibial plateau fractures with increased lateral tibial plateau depression 14 mm and/or the widening 10 mm was associated

depression. The most signiﬁcant threshold for lateral tibial plateau with higher risk of lateral meniscus tear. Ringus et al. measured the

depression is 11 mm, and the positive and negative predictive lateral plateau depression on CT scans of patients undergoing open

values are 70.3% and 61.8%, respectively. However, we did not reduction internal ﬁxation for lateral tibial plateau fractures [21].

identify a threshold for the lateral tibial plateau widening that can An eight-fold increase in risk of lateral meniscus tear was observed

signiﬁcantly predict the occurrence of a lateral meniscus tear. if the depression was 10 mm. However, soft-tissue injuries other

The association of the lateral tibial plateau depression and than lateral meniscus tears were not mentioned in these studies.

widening with soft-tissue injuries in patients with lateral tibial The reason may be traced to the limited access to the knee joint

plateau fractures has been reported in the literature. Gardner et al. with lateral arthrotomy.

[20] concluded that 83% of Schatzker type II tibial plateau fractures Similarly, our study results demonstrated that increased lateral

had lateral meniscus tears if (1) the depression was >6 mm and (2) tibial plateau depression was associated with increased risk of

the widening was >5 mm, as measured on preoperative radio- lateral meniscus tear. However, the amount of lateral tibial plateau

graphs. The incidence of medial meniscus tears increased if either widening was not associated with the incidence of lateral

the depression or the widening was >8 mm. However, the authors meniscus tear, which were different from the prior studies. The

used MRI instead of intraoperative ﬁndings to detect meniscus reason for this may be that we included patients with not only

injuries. The lower sensitivity of MRI for the detection of a Schatzker type II fractures, but also all kinds of tibial plateau

meniscus tear might have inﬂuenced the results. [17–19]. Two fractures. In the Schatzker type II fracture, the amount of the lateral

other studies were designed to correlate the preoperative image widening may reﬂect the amount of energy absorbed during the

parameters with intraoperative ﬁndings. Durakbasa et al. [22] injury. Therefore, the greater the energy applied on the lateral

measured the lateral plateau depression and widening on plain tibial plateau, the greater the degree of lateral widening and the

radiographs in 20 patients who received open reduction internal greater the incidence of lateral meniscus tear can be expected. In

the present study, all types of tibial plateau fractures were

Table 4 evaluated, and multidirectional displacement of lateral tibial

Association of soft-tissue injuries and the column involvement.

plateau was observed on CT scans. We found that it is not

OR Lower Upper p value uncommon to have minimal lateral tibial plateau widening but

with obvious anterior/posterior displacement of the lateral tibial

LM tear Age 0.999 0.972 1.027 0.958

AL 1.216 0.542 2.730 0.635 plateau in lateral tibial plateau fractures or high-energy-pattern

PL 1.215 0.534 2.766 0.643 tibial plateau fractures (Schatzker types V and VI). Therefore, the

AM 1.373 0.519 3.627 0.523

amount of lateral plateau widening might not represent the energy

PM 0.331 0.126 0.867 0.024

absorbed by the lateral tibial plateau, and the incidence of lateral

meniscus tear was not signiﬁcantly associated with the lateral

MM tear Age 1.002 0.962 1.044 0.920

AL 1.718 0.493 5.989 0.396 plateau widening.

PL 0.743 0.216 2.558 0.638 Our results also revealed that ACL avulsion fractures occurred

AM 1.340 0.323 5.552 0.687

more often in younger patients; the reason for this is unknown.

PM 0.491 0.119 2.031 0.326

Although isolated ACL avulsion fractures usually occur in

–

ACL tear Age 0.972 0.922 1.024 0.286 adolescents and young adults [25 27] because the incompletely

AL 1.066 0.244 4.650 0.932 ossiﬁed tibial eminence fails before an ACL tear, this cannot explain

PL 0.954 0.195 4.657 0.954

the results of our study. To our knowledge, no reports thus far have

AM 3.580 0.627 20.453 0.151

mentioned a relationship between age and the incidence of ACL

PM 0.211 0.038 1.161 0.074

avulsion fracture in the tibial plateau fracture. Our hypothesis is

ACL avulsion Age 0.958 0.927 0.991 0.012 that younger aged patients more likely sustained high-energy

AL 0.249 0.093 0.669 0.006 injury, and thus they more likely to have ACL avulsion fractures.

PL 3.612 1.288 10.133 0.015

In addition, we observed an increased incidence of ACL avulsion

AM 4.110 1.360 12.415 0.012

fractures with high-energy-pattern tibial plateau fractures. ACL

PM 1.020 0.351 2.964 0.971

avulsion fractures occurred in 48.2% of patients with Schatzker

PCL tear Age 0.985 0.918 1.057 0.673 type IV–VI fractures, while only 18.4% patients with Schatzker type

AL 3.511 0.321 38.347 0.303

I–III fractures also had ACL avulsion fractures (p = 0.001). Similar

PL 0.417 0.048 3.603 0.427

results were observed in an earlier study [3]. A signiﬁcantly higher

AM 2.039 0.182 22.880 0.564

incidence of ACL insufﬁciency was observed in Schatzker type IV–

PM 0.184 0.012 2.704 0.217

VI fractures compared with Schatzker type I–III fractures. Although

AL anterolateral, PL posterolateral, AM anteromedial, PM posteromedial, OR odds

ratio. Gardner et al. [4] evaluated the MRIs of 103 tibial plateau fractures

H.-C. Tang et al. / Injury, Int. J. Care Injured 48 (2017) 745–750 749

and found no statistically signiﬁcant difference between the risk of observed when medial tibial plateau displacement is >3 mm and

ACL avulsion fracture and the Schatzker classiﬁcation, a greater when the fracture also involves the anteromedial or posterolateral

incidence of ACL avulsion fractures was observed in patients with column. In addition, younger age and high-energy-pattern tibial

Schatzker type IV–VI fractures than in those with Schatzker type II plateau fractures are risk factors for an ACL avulsion fracture.

fractures. It is worth noting that the incidence of ACL avulsion Except for the ACL avulsion fracture, the incidence of soft-tissue

fractures in Gardner et al.’s study was much higher, with 67%, 42%, injuries has no signiﬁcant difference according to Schatzker

57%, 71%, and 57% reported in patients with Schatzker types I, II, IV, classiﬁcation.

V, and VI fractures, respectively.

In the present study, we also demonstrated that the incidence of Conﬂict of interest

ACL avulsion fracture was higher in patients with medial tibial

plateau displacement >3 mm and in those with anteromedial or None of the authors received payment or services from a third

posterolateral column involvement. party (government, commercial, private foundation, etc.) for any

The signiﬁcantly higher risk of ACL avulsion fractures in aspect of the submitted work (including but not limited to grants,

patients with increased medial plateau displacement and ante- data monitoring board, study design, manuscript preparation).

romedial involvement may be explained by the location of the ACL None of the authors had any patents, whether planned, pending

insertion on the tibial site. The anteromedial bundle of the ACL is or issued, broadly relevant to the work.

located on the anterior one-fourth, and slightly medial to the None of the authors had other relationships or activities that

center, of the tibial plateau [28,29]. The axial loading that causes readers could perceive to have inﬂuenced, or that give the

fracture of the medial plateau condyle may result in an ACL appearance of potentially inﬂuencing, what we wrote in the

avulsion fracture if the base of the ACL insertion is compromised. submitted work.

The involvement of posterolateral column involvement, however, All the authors have nothing to disclose.

may be the result of ACL avulsion fracture. In their study, Rosen

et al. [30] observed that 85% of patients with acute ACL tear had References

occult bony lesions, and 50% had lateral tibial plateau involvement.

[1] Stannard JP, Lopez R, Volgas D. Soft tissue injury of the knee after tibial plateau

Kaplan et al. [31] evaluated 100 MRIs of the knees of patients with

fractures. J Knee Surg 2010;23(4):187–92.

acute ACL tears. Occult fractures were identiﬁed in 56 knees and all

[2] Bennett WF, Browner B. Tibial plateau fractures: a study of associated soft

of them were located in the posterolateral tibial plateau. Similar tissue injuries. J Orthop Trauma 1994;8(3):183–8.

[3] Abdel-Hamid MZ, Chang CH, Chan YS, Lo YP, Huang JW, Hsu KY, et al.

results have been demonstrated in other studies [32,33]. The

Arthroscopic evaluation of soft tissue injuries in tibial plateau fractures:

insufﬁciency of ACL causes anterior translation of the tibia, which

retrospective analysis of 98 cases. Arthroscopy 2006;22(6):669–75.

allows impaction of the lateral femoral condyle onto the [4] Gardner MJ, Yacoubian S, Geller D, Suk M, Mintz D, Potter H, et al. The

incidence of soft tissue injury in operative tibial plateau fractures: a magnetic

posterolateral tibial plateau under valgus rotation and results in

resonance imaging analysis of 103 patients. J Orthop Trauma 2005;19(2):79–

posterolateral tibial plateau fracture.

84.

In this study, intra-articular soft-tissue injuries other than [5] Chan YS, Chiu CH, Lo YP, Chen AC, Hsu KY, Wang CJ, et al. Arthroscopy-assisted

lateral meniscus tears were not uncommon in patients with tibial surgery for tibial plateau fractures: 2- to 10-year follow-up results.

Arthroscopy 2008;24(7):760–8.

plateau fractures. In patients with lateral tibial plateau fractures

[6] Chiu CH, Cheng CY, Tsai MC, Chang SS, Chen AC, Chen YJ, et al. Arthroscopy-

(Schatzker types I–III), 14.3% had medial meniscus tears, 6.1% had

assisted reduction of posteromedial tibial plateau fractures with buttress plate

–

ACL tears, 18.4% had ACL avulsion fractures, and 4.1% had PCL tears. and cannulated screw construct. Arthroscopy 2013;29(8):1346 54.

[7] Ruiz-Iban MA, Diaz-Heredia J, Elias-Martin E, Moros-Marco S, Cebreiro

These soft-tissue injuries were not easily identiﬁed through the

Martinez Del Val I. Repair of meniscal tears associated with tibial plateau

lateral arthrotomy performed during the surgery. Surgeons who

fractures: a review of 15 cases. Am J Sports Med 2012;40(10):2289–95.

perform open reduction and ﬁxation of tibial plateau fractures [8] Delamarter RB, Hohl M, Hopp Jr E. Ligament injuries associated with tibial

plateau fractures. Clin Orthop Relat Res 1990;250:226–33.

should always keep possible soft-tissue injuries in mind and be

[9] Lee SJ, Aadalen KJ, Malaviya P, Lorenz EP, Hayden JK, Farr J, et al. Tibiofemoral

prepared to repair them. Arthroscopic knee examination and

contact mechanics after serial medial meniscectomies in the human cadaveric

repair during the surgery are highly recommended. knee. Am J Sports Med 2006;34(8):1334–44.

[10] Kocher MS, Foreman ES, Micheli LJ. Laxity and functional outcome after

There were some limitations to our study. First, this study was

arthroscopic reduction and internal ﬁxation of displaced tibial spine fractures

retrospective. To minimize bias, the authors who measured the

in children. Arthroscopy 2003;19(10):1085–90.

ﬁ

parameters on preoperative CT scans were blinded to the ndings [11] Shoemaker SC, Markolf KL. The role of the meniscus in the anterior-posterior

stability of the loaded anterior cruciate-deﬁcient knee. Effects of partial versus

from knee arthroscopy. Second, the selection bias might exist

total excision. J Bone Joint Surg Am 1986;68(1):71–9.

because the majority of tibial plateau fractures included in this

[12] Musahl V, Citak M, O'Loughlin PF, Choi D, Bedi A, Pearle AD. The effect of

study were high-energy-pattern fractures. In the literature, about medial versus lateral meniscectomy on the stability of the anterior cruciate

ﬁ –

55%–70% of tibial plateau fractures have lateral tibial plateau ligament-de cient knee. Am J Sports Med 2010;38(8):1591 7.

[13] Brandsson S, Karlsson J, Sward L, Kartus J, Eriksson BI, Karrholm J. Kinematics

involvement, and 10%–30% have involved both tibial plateaus [22].

and laxity of the knee joint after anterior cruciate ligament reconstruction:

In the present study, Schaztker type V and VI accounted for 56.8% of

pre- and postoperative radiostereometric studies. Am J Sports Med 2002;30

–

all tibial plateau fractures. In addition, tibial plateau fractures that (3):361 7.

[14] Alford JW, Lewis P, Kang RW, Cole BJ. Rapid progression of chondral disease in

were treated with open reduction internal ﬁxation in our institute

the lateral compartment of the knee following meniscectomy. Arthroscopy

were not included in this study. Third, the meniscus tear might 2005;21(12):1505–9.

have presented before the tibial plateau fracture occurred due to [15] Nebelung W, Wuschech H. Thirty-ﬁve years of follow-up of anterior cruciate

ligament-deﬁcient knees in high-level athletes. Arthroscopy 2005;21(6):696–

degeneration in older patients. A fourth limitation was that the

702.

severity of column involvement was not analyzed statistically.

[16] Markhardt BK, Gross JM, Monu J. Schatzker classiﬁcation of tibial plateau

fractures: use of CT and MR imaging improves assessment. Radiographics

Conclusions 2009;29(2):585–97.

[17] De Smet AA, Mukherjee R, Clinical MRI. and arthroscopic ﬁndings associated

with failure to diagnose a lateral meniscal tear on knee MRI. AJR Am J

Evaluation of preoperative CT scans can help predict intra- Roentgenol 2008;190(1):22–6.

[18] Oei EH, Nikken JJ, Verstijnen AC, Ginai AZ, Myriam Hunink MG. MR imaging of

articular soft-tissue injuries in patients with tibial plateau

the menisci and cruciate ligaments: a systematic review. Radiology 2003;226

fractures. Increased lateral tibial plateau depression, with a

(3):837–48.

threshold of 11 mm, is associated with higher risk of lateral

meniscus tear. A higher incidence of ACL avulsion fracture is

750 H.-C. Tang et al. / Injury, Int. J. Care Injured 48 (2017) 745–750

[19] Behairy NH, Dorgham MA, Khaled SA. Accuracy of routine magnetic resonance [27] Lafrance RM, Giordano B, Goldblatt J, Voloshin I, Maloney M. Pediatric tibial

imaging in meniscal and ligamentous injuries of the knee: comparison with eminence fractures: evaluation and management. J Am Acad Orthop Surg

arthroscopy. Int Orthop 2009;33(4):961–7. 2010;18(7):395–405.

[20] Gardner MJ, Yacoubian S, Geller D, Pode M, Mintz D, Helfet DL, et al. Prediction [28] Forsythe B, Kopf S, Wong AK, Martins CA, Anderst W, Tashman S, et al. The

of soft-tissue injuries in Schatzker II tibial plateau fractures based on location of femoral and tibial tunnels in anatomic double-bundle anterior

measurements of plain radiographs. J Trauma 2006;60(2)319–23 discussion cruciate ligament reconstruction analyzed by three-dimensional computed

324. tomography models. J Bone Joint Surg Am 2010;92(6):1418–26.

[21] Ringus VM, Lemley FR, Hubbard DF, Wearden S, Jones DL. Lateral tibial plateau [29] Takahashi M, Doi M, Abe M, Suzuki D, Nagano A. Anatomical study of the

fracture depression as a predictor of lateral meniscus pathology. Orthopedics femoral and tibial insertions of the anteromedial and posterolateral bundles of

2010;33(2):80–4. human anterior cruciate ligament. Am J Sports Med 2006;34(5):787–92.

[22] Durakbasa MO, Kose O, Ermis MN, Demirtas A, Gunday S, Islam C. [30] Rosen MA, Jackson DW, Berger PE. Occult osseous lesions documented by

Measurement of lateral plateau depression and lateral plateau widening in magnetic resonance imaging associated with anterior cruciate ligament

a Schatzker type II fracture can predict a lateral meniscal injury. Knee Surg ruptures. Arthroscopy 1991;7(1):45–51.

Sports Traumatol Arthrosc 2013;21(9):2141–6. [31] Kaplan PA, Walker CW, Kilcoyne RF, Brown DE, Tusek D, Dussault RG. Occult

[23] Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto fracture patterns of the knee associated with anterior cruciate ligament tears:

experience 1968–1975. Clin Orthop Relat Res 1979;138:94–104. assessment with MR imaging. Radiology 1992;183(3):835–8.

[24] Luo CF, Sun H, Zhang B, Zeng BF. Three-column ﬁxation for complex tibial [32] Stallenberg B, Gevenois PA, Sintzoff Jr. SA, Matos C, Andrianne Y, Struyven J.

plateau fractures. J Orthop Trauma 2010;24(11):683–92. Fracture of the posterior aspect of the lateral tibial plateau: radiographic sign

[25] Grifﬁth JF, Antonio GE, Tong CW, Ming CK. Cruciate ligament avulsion of anterior cruciate ligament tear. Radiology 1993;187(3):821–5.

fractures. Arthroscopy 2004;20(8):803–12. [33] Murphy BJ, Smith RL, Uribe JW, Janecki CJ, Hechtman KS, Mangasarian RA.

[26] May JH, Levy BA, Guse D, Shah J, Stuart MJ, Dahm DL. ACL tibial spine avulsion: Bone signal abnormalities in the posterolateral tibia and lateral femoral

mid-term outcomes and rehabilitation. Orthopedics 2011;34(2):89. condyle in complete tears of the anterior cruciate ligament: a speciﬁc sign?

Radiology 1992;182(1):221–4.