Incidence and recovery of anterior cruciate ligament rupture combined with posterolateral tibial plateau fracture in the East China population: a 2-year follow-up study

doi:10.21203/rs.3.rs-3120715/v1

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Incidence and recovery of anterior cruciate ligament rupture combined with posterolateral tibial plateau fracture in the East China population: a 2-year follow-up study

https://doi.org/10.21203/rs.3.rs-3120715/v1

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Objective: This study aimed to describe the incidence of ACL ruptures combined with posterolateral tibial plateau fractures in the East China population and evaluate the clinical outcomes of ACL reconstruction without treatment for posterolateral tibial plateau fracture at a 2-year follow-up.

Methods: Based on the inclusion criteria, the study included patients with ACL rupture or ACL avulsion fracture. MRI scans were reviewed to determine the incidence of ACL rupture combined with posterolateral tibial plateau fracture and concomitant injury. Clinical outcomes were evaluated using the SF-12 scale, the IKDC Subjective Knee Assessment Scale, the Lysholm Knee Rating Scale, the Tegner Activity Level Scale, and the KOOS score at a 2-year follow-up.

Results: 488 cases were enrolled, with 74.6% having noncontact injury mechanisms. Fractures with higher severity had a higher rate of meniscus damage, and patients with high-grade subtypes of fractures had a higher incidence of MCL tears than patients with low-grade fracture types. The Lysholm scores of the high-grade subtypes were 85.45 and 86.37, and the postoperative Tegner scores of the high-grade subtypes were 5.5. There were significant differences in functional recovery between patients with high-grade subtypes and patients with low-grade tibial plateau fractures.

Conclusions: The study found a high prevalence of displaced posterolateral tibial plateau impaction fractures in the setting of ACL tears, and they can be classified into distinct morphologic subtypes. The functional recovery of patients with high-grade subtypes of fractures is significantly lower than that of patients with low-grade injuries, suggesting that patients with high-grade injuries need surgical treatment to obtain satisfactory treatment results.

Anterior cruciate ligament ruptures

Posterolateral tibial plateau fracture

Incidence

Treatment

Chinese

According to recent global trends, the incidence of anterior cruciate ligament (ACL) ruptures has been increasing and was estimated to be approximately 40–60 per 100,000 people in 2014(1). In the United States alone, more than 250,000 people suffer from ACL ruptures yearly, usually during sports and exercise(1). ACL ruptures are often accompanied by meniscus and ligament injuries(2–4). In the early years, bone injury or compression fracture of the posterolateral tibial plateau and lateral femoral condyle often accompanied ACL rupture but did not receive enough attention(5–7). Recent studies from various places have brought attention to this issue. Bernholt et al. found that the probability of combined femoral condyle or posterolateral tibial plateau fracture was close to 50% on knee magnetic resonance imaging (MRI) of 825 patients with ACL rupture in the United States(8, 9). Kolb et al. also reported the situation in Germany, who found that 90.43% of 115 patients with ACL rupture had posterolateral plateau contusions(10, 11). However, the incidence of this combination of injuries in China, which has a large population, remains unclear.

A posterolateral tibial plateau fracture that is out of position can increase the posterior slope of the tibial plateau, which biomechanical experiments and clinical studies have shown to increase the stress of ACL grafts and the risk of ACL reconstruction failure(12, 13). There are different types of posterolateral tibial plateau fractures. The severity is based on the depth of the involved plateau and the size of the damage to the articular surface(9, 11). Whether combined reconstruction is necessary for fractures of different severities is controversial, with some scholars proposing combined fracture treatment for better results(11). In contrast, others have not given clear treatment strategies or specific surgical indications for high-grade fractures that may lead to poor clinical outcomes(14). Therefore, whether ACL reconstruction combined with internal fracture fixation is unknown for patients with ACL reconstruction and high-grade posterolateral tibial plateau fracture.

This study aimed to describe the incidence of ACL rupture combined with posterolateral tibial plateau fracture in people in East China, classify the injuries, and evaluate the clinical outcomes of ACL reconstruction without treatment for posterolateral tibial plateau fracture at a 2-year follow-up. The study hypothesized that the incidence of anterior cruciate ligament rupture combined with posterolateral tibial plateau fracture in East China differs from that in Europe and the United States. The study also hypothesized that patients with ACL injury complicated with high-grade subtype fractures have a worse postoperative effect than patients with low-grade fractures and require internal fixation treatment.

This study was conducted after obtaining approval from the Second Affiliated Hospital Ethics Committee of Soochow University (No.2021000145). The study reviewed clinical data from patients diagnosed with ACL rupture or ACL insertion avulsion fracture between January 2016 and June 2020. The data were collected from the Second Affiliated Hospital of Soochow University and the Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University. Inclusion criteria included all hospitalized patients diagnosed with ACL rupture or insertion avulsion fracture. Four hundred eighty-eight patients (167 females and 321 males) with an average age of 34.7 years were enrolled in the study, and follow-up was conducted two years after surgery (Fig. 1). Two experienced joint surgeons reviewed the MRI images of these patients. The exclusion criteria included patients who did not undergo ACL reconstruction surgery or ACL insertion avulsion fracture reduction and fixation, patients with missing preoperative MRI images, patients with multiple knee ligament injuries, patients who were lost to follow-up for two years, patients with poor tunnel position and unreliable internal fixation in postoperative re-examination radiographs, and patients with a history of anterior cruciate ligament reconstruction. The inclusion criteria included the presence of tibial posterolateral plateau fractures, damage to the meniscus, medial and lateral collateral ligaments, and posterior cruciate ligament, and the classification of patients based on fracture morphology and combined injuries.

The classification of posterolateral tibial plateau fractures used in this study was based on the morphology-based classification described by Bernholt et al. in the American Journal of Sports Medicine(9). Compression fractures of the posterolateral tibial plateau were defined as displacement or depression of the subchondral or cortical bone at the posterior edge of the tibial plateau on T1-weighted sagittal MRI.

All patients with anterior cruciate ligament (ACL) rupture were treated with autologous hamstring tendon anatomical reconstruction, femoral side Endobutton plate, and tibial side compression screw fixation. All patients with ACL avulsion fractures were treated with arthroscopic reduction. The suture line passed through the tendon insertion point, wrapped around the tendon, and fixed on the tibial cortical surface through the tibial tunnel. Three equally senior doctors performed these operations. Postoperative imaging examination showed that the position of the bone tunnels was good, and the position of internal fixation was satisfactory. No arthroscopic or open reduction and internal fixation were performed for posterolateral tibial plateau fracture due to insufficient understanding of this type of injury at that time.

Patients enrolled in the study were followed up by telephone or email. Emotional recovery was assessed using validated scoring systems, including the SF-12 scale, the International Knee Documentation Committee (IKDC) Subjective Knee Assessment Scale, the Lysholm Knee Rating Scale, the Tegner Activity Level Scale, and the Knee Injury and Osteoarthritis Outcome Score (KOOS). These metrics were chosen because they have been extensively validated for accurately capturing differences in knee subjective outcome scores(15–17).

The clinical characteristics of patients with posterolateral tibial plateau fractures and contusions were analyzed using the chi-square test to assess the correlation with other knee structural injuries. The two-year postoperative SF-12 MCS, PCS, Lysholm, Tegner, IKDC, and KOOS scores of patients with different types of fractures were compared using one-way analysis of variance (ANOVA). Statistical analysis was performed using SPSS statistical software (V20.0, IBM), and the alpha level was set for statistical significance at P = 0.05.

Between January 2016 and June 2020, 683 patients with a primary ACL tear or ACL insertion fracture were hospitalized at two treatment centers, and 617 patients underwent MRI scans at our hospital. Among them, 602 patients received ACL reconstruction or ACL insertion fracture reduction and internal fixation, while 15 patients did not receive surgery. After meeting the follow-up conditions, 488 patients were finally enrolled, including 321 males (65.8%) and 167 females (34.2%). The mean body mass index of the included patients was 24.53.

The mechanism of injury was noncontact in 74.6% of the patients in the cohort(Table 1). Among the enrolled patients, 203 knees (41.6%) had posterolateral tibial plateau compression fractures, and 140 knees (28.7%) had lateral femoral condyle compression fractures. Compression fractures of the lateral femoral condyle and posterolateral tibial plateau co-occurred in 124 knees (13.2%). The 488 patients were divided into two groups according to the presence or absence of fractures and the type of fracture. There were 285 (58.4%) patients without fractures, 98 (20.1%) with type Ⅰ fractures, 41 (8.4%) with type ⅡA fractures, 15 (3.1%) with type ⅡB fractures, 22 (4.5%) with type ⅢA fractures, and 27 (5.5%) with type ⅢB fractures.

Table 1

Injury types and causes of injury in 488 patients
Cause of fracture	No fracture (n = 285)	Type I (n = 98)	Type ⅡA (n = 41)	Type ⅡB (n = 15)	Type ⅢA (n = 22)	Type ⅢB (n = 27)
Car Accident	33(11.6)	9 (8.7)	2 (4.9)	3 (25.0)	9 (40.9)	13 (48.1)
Fall while walking	44(15.4)	10 (10.0)	9 (22.0)	1 (8.3)	1 (5.3)	0 (0.0)
Fall on an electric bike	28(9.8)	9 (8.7)	3 (7.3)	2 (16.7)	4 (21.1)	8 (29.6)
Injured while playing basketball	66(23.2)	39 (37.5)	7 (17.1)	3 (25)	3 (15.8)	3 (11.1)
Injured while playing football	39(13.7)	8 (10.0)	6 (14.6)	2 (16.7)	1 (5.3)	1 (3.7)
Sprain while running	48(16.8)	11 (12.5)	5 (12.2)	2 (16.7)	1 (5.3)	2 (7.4)
Other sports injuries	15(5.3)	8 (10.0)	9 (22.0)	2 (16.7)	2 (10.5)	0 (0.0)
Crushed	12(4.2)	0 (0.0)	1 (2.4)	0 (0.0)	1 (5.3)	0 (0.0)
The value is expressed as n (%).

The study found that both type ⅢA and ⅢB patients with posterolateral tibial plateau compression fractures were significantly older than those with noncompression fractures and other fractures (P = 0.008)(Table 3). The incidence of type ⅢA compression fracture of the posterolateral tibial plateau in women (63.6%) was significantly higher than that in men (36.4%) (P = 0.003) (Table 4). At the same time, there was no significant difference in the incidence of other types between genders. Most type ⅢA and ⅢB fractures were caused by contact injury (77.3% and 51.9%, respectively), despite 74.6% of the patients in the case having noncontact injury mechanisms(Table 2).

Table 2

Comparison of injury mechanisms in patients with different types of injuries
	Contact injury	Noncontact injury	P
No fracture	45/285 (15.8)	240/285 (84.2)	0.001
Type Ⅰ	28/98 (28.6)	70/98 (71.4)	0.421
Type ⅡA	15/41 (36.6)	26/41 (63.4)	0.086
Type ⅡB	5/15 (33.3)	10/15 (66.7)	0.474
Type ⅢA	17/22 (77.3)	5/22 (22.7)	0.001
Type ⅢB	14/27 (51.9)	13/27 (48.1)	0.001
Total number of cases	124/488 (25.4)	364/488 (74.6)
Numerical values are expressed as n/N (%), and the bold font is statistically significant.

Table 3

Age distribution of patients with different types of injuries
		Age (years)
	n (%)	Mean ± SD	minimum	maximum
No fracture	285 (58.4)	34.5 ± 11.5	15	73
Type Ⅰ	98 (20.1)	32.3 ± 9.9	13	55
Type ⅡA	41 (8.4)	35.6 ± 10.3	15	58
Type ⅡB	15 (3.1)	34.2 ± 10.9	20	62
Type ⅢA	22 (4.5)	41.2 ± 13.5	18	64
Type ⅢB	27 (5.5)	38.8 ± 11.7	20	58
Total number of cases	488	P = 0.008
Numerical values are expressed as n/N (%).

Table 4

Sex distribution of different types of injuries
	Man	Woman	P
No fracture	190/285 (66.7)	95/285 (33.3)	0.62
Type Ⅰ	68/98 (69.4)	30/98 (30.6)	0.4
Type ⅡA	29/41 (70.7)	12/41 (29.3)	0.49
Type ⅡB	8/15 (53.3)	7/15 (46.7)	0.3
Type ⅢA	8/22 (36.4)	14/22 (63.6)	0.003
Type ⅢB	18/27 (66.7)	9/27 (33.3)	0.92
Total number of cases	321/488 (65.8)	167/488 (34.2)
Numerical values are expressed as n/N (%), and the bold font is statistically significant.

The study also found that the tibia posterolateral plateau compression fracture type was significantly associated with specific meniscal injuries(Table 5). No type Ⅰ or type Ⅱ compression fractures were found to be associated with meniscal tears. Fracture-free and type ⅢA knees had an increased incidence of lateral meniscus tears (OR 0.621; 95% CI, 0.421–0.916; P = 0.016 and OR 3.439; 95% CI, 1.003–11.795; P = 0.037, respectively). Type ⅢB compression fractures had significantly higher incidences of medial meniscus tears and medial meniscus posterior root injuries than knees without type ⅢB compression fractures (OR 0.423; 95% CI, 0.194–0.924; P = 0.027 and OR 9.14; 95% CI, 1.597–52.397; P = 0.003). There was no statistically significant difference in the incidence of medial meniscus ramp in patients without compression fractures compared with all patients with compression fractures.

Table 5

Different types of injuries combined with the meniscus injury
	Lateral meniscus tear		Lateral meniscus posterior root injury		Medial meniscus tear		Medial meniscus ramp injury		Medial meniscus posterior root injury
	Incidence	P	Incidence	P	Incidence	P	Incidence	P	Incidence	P
No fracture	175/285 (61.4)	0.016	5/285 (1.8)	0.481	194/285 (61.1)	0.131	6/285 (2.1)	0.499	4/285 (1.4)	0.679
Type I	67/98 (68.4)	0.546	1/98 (1.0)	0.7	73/98 (74.5)	0.356	1/98 (1.0)	0.517	0/98 (0)	0.217
Type IIA	28/41 (68.4)	0.723	0/41 (0)	0.42	32/41 (78.0)	0.28	0/41 (0)	0.365	0/41 (0)	0.455
Type IIB	11/15 (73.3)	0.531	0/15 (0)	0.635	13/15 (86.7)	0.167	0/15 (0)	0.595	0/15 (0)	0.661
Type IIIA	19/22 (86.4)	0.037	0/22 (0)	0.563	17/22 (77.3)	0.488	0/22 (0)	0.517	0/22 (0)	0.592
Type IIIB	21/27 (77.8)	0.176	1/27 (3.7)	0.308	14/27 (51.9)	0.027	1/27 (3.7)	0.438	2/27 (7.4)	0.003
Total number of cases	321/167		7/481		345/143		8/440		6/482
Numerical values are expressed as n/N (%), and the bold font is statistically significant.

The study also found that the posterolateral tibial plateau compression fracture type was significantly associated with other ligament tears in addition to the anterior cruciate ligament(Table 6). The incidence of medial collateral ligament tears was higher in patients with no fracture and type Ⅰ and type ⅢA compression fractures than in patients with other fracture types (OR 0.413; 95% CI, 0.271–0.63; P = 0.001; OR 1.689; 95% CI, 1.04–2.742; P = 0.033 and OR 2.647; 95% CI, 1.202–5.828; P = 0.013). The incidence of fibular collateral ligament tears in type ⅡA and ⅡB fracture groups was significantly higher than in the other fracture groups (OR 2.501; 95% CI, 1.032–6.062; P = 0.037 and OR 6.069; 95% CI, 1.968–18.714; P = 0.001). The occurrence of various types of posterolateral tibial plateau fractures did not lead to an increased incidence of combined posterior cruciate ligament injury (P = 0.808).

Table 6

Different types of injuries combined with ligament injuries
	medial collateral ligament injury		lateral collateral ligament injury		Posterior Cruciate Ligament Injury
	Incidence	P	Incidence	P	Incidence	P
No fracture	50/285 (17.5)	0.001	19/285 (6.7)	0.102	37/285 (13.0)	0.048
Type Ⅰ	32/98 (32.7)	0.033	7/98 (7.1)	0.615	8/98 (8.2)	0.371
Type ⅡA	10/41 (24.4)	0.999	7/41 (17.1)	0.037	4/41 (9.8)	0.845
Type ⅡB	6/15 (40.0)	0.153	5/15 (33.3)	0.001	1/15 (6.7)	0.611
Type ⅢA	9/22 (40.9)	0.065	1/22 (4.5)	0.505	2/22 (9.1)	0.808
Type ⅢB	12/27 (44.4)	0.013	2/27 (7.4)	0.848	0/27 (0)	0.065
Total number	119/369		41/447		52/436
Numerical values are expressed as n/N (%), and the bold font is statistically significant.

The different types of fractures did not show a significant discrepancy in SF-12 (PSC), Tegner (preoperation), and IKDC scores (Table 7). However, there was a statistically significant difference in functional recovery between patients with high-grade subtypes (ⅢA and ⅢB) and low-grade tibial plateau fractures at two years postoperatively, especially in terms of Lysholm score (P = 0.001) and postoperative Tegner score (P = 0.001).

Table 7 2-year follow-up of patients with different types of injuries

The bold font is statistically significant.

The main findings of this study reveal that noncontact injuries accounted for 74.6% of cases, while the incidence of combined posterolateral plateau fractures was 41.6%. Type ⅢB fractures, medial meniscus tears, and medial posterior meniscus root injuries were found to be significantly more common. Patients with type ⅢA compression fractures exhibited a higher incidence of MCL tears than those with other fracture types. The Lysholm scores for high-grade subtypes (ⅢA and ⅢB) were 85.45 and 86.37, respectively. The postoperative Tegner score for the high-grade subtypes (ⅢA and ⅢB) was 5.5. There were significant differences in functional recovery between patients with high-grade subtypes (ⅢA and ⅢB) and those with low-grade tibial plateau fractures.

In our ACL injury cases, the proportion of noncontact injuries and the incidence of combined tibial posterolateral plateau fractures were lower than those reported in Europe and the United States. One possible reason for this could be the differences in the shape of the femur and tibia due to racial variations(18–22). Another contributing factor could be China's unique national conditions, such as the widespread use of motorized two-wheeled vehicles (motorcycles, electric bicycles) and the relatively low proportion of confrontational sports in national sports. However, with a population of over 1.4 billion people, the incidence of ACL injury in the Chinese population is believed to be significant, although no definitive data are available. A large sample study of Chinese athletes conducted 20 years ago showed an overall incidence of ACL injury in athletes of 0.47% (23). With the continuous improvement of China's economic strength and the development of national fitness campaigns in recent years, the incidence of ACL injury in the Chinese population has likely increased. Given the high incidence rate of over 40%, this type of injury deserves significant clinician attention.

According to Bernholt et al.'s classification(9), the fracture morphology in our cases can be categorized into five subtypes: Ⅰ, ⅡA, ⅡB, ⅢA, and ⅢB. This classification system is clinically valuable because it systematically evaluates the relationship between certain types of posterolateral tibial compression fractures and concomitant meniscal and ligament injuries. We observed that patients with type ⅢA fractures were significantly older and more frequently female than patients with other fractures. Type ⅢA fractures are associated with increased lateral meniscus tears in primary ACL tears. The incidence of medial meniscus injury in patients with type Ⅲ B fractures is significantly lower than in patients with other types of fractures. However, once medial meniscus injury occurs in type ⅢB fractures, the proportion of injury to the posterior root is the highest among all cases. As MRI has low sensitivity for diagnosing posterior meniscal root injury, clinicians should be aware of the possibility of medial meniscal posterior root injury when interpreting radiographs of patients with type ⅢB fractures. Biomechanical experiments have demonstrated that when the posterior slope of the tibial plateau exceeds 12°, excessive posterior inclination should be corrected during the treatment of ACL and meniscus injuries in cases of anterior cruciate ligament injury combined with medial meniscus posterior root rupture (24). As type ⅢB damage inevitably leads to an increase in the posterior slope of the lateral plateau, it is essential to correct this type of damage. Furthermore, among cases of ACL rupture combined with high-grade tibial plateau fractures, the incidence of medial collateral ligament injury was over 40%. Although the literature suggests that repairing the medial collateral ligament during the reconstruction of ACL rupture combined with medial collateral ligament injury does not affect clinical efficacy (25–28), it does not mean that cases of anterior cruciate ligament rupture combined with posterolateral plateau fracture and medial collateral ligament injury should only undergo ACL reconstruction.

Our follow-up of hundreds of cases revealed that SF-12 MCS, Lysholm, Tegner, IKDC, and KOOS scores of patients with type ⅢA and ⅢB fractures were significantly lower than those of nontype ⅢA and ⅢB patients, with significant differences. Previous studies (29, 30) have evaluated the impact of mild injuries, such as bone contusions, on postoperative clinical outcomes of anterior cruciate ligament reconstruction. Bone contusions associated with anterior cruciate ligament tears are linked to increased initial pain, effusion, and longer recovery times, but with time, MRI changes normalize (31, 32). Posterolateral compression fractures of the tibial plateau, especially those with higher morphological classification grades, may cause residual changes in the bony geometry of the tibial plateau, which could explain the clinical relevance identified in our study. A previous study (33) reported that the geometry of the lateral tibial plateau affects knee joint stability. Another study (34)demonstrated that reduced joint depth of the tibial plateau was associated with ACL tears. At the same time, another (35) found that a reduction in the medial-to-lateral width of the lateral plateau was linked to greater instability in the pivot-shift test.

Our study results suggest that patients with high-grade injuries have poorer emotional recovery than those with low-grade injuries, indicating that surgical treatment may be necessary to achieve satisfactory treatment outcomes in these patients. Menzdorf et al.'s clinical study (11) reported that over half of the depression or shear fractures of posterolateral plateau fractures displaced more than 2 mm (CT or MRI sagittal view) and over half of the depth of the posterior slope of the lateral meniscus (MRI sagittal view) required surgical intervention. While we agree with this recommendation, it is essential to note that Menzdorf et al.'s study had a small sample size and lacked a control group and long-term follow-up data.

There are several limitations to our study. First, the study relied on MRI images rather than CT scans. CT scans can provide more detailed information about the morphological characteristics of the fracture, which can help to classify the fracture better. In our recent cases, we started to perform a CT scan of the knee for each patient with an ACL rupture. In future studies, we plan to compare the similarities and differences between MRI and CT images in classifying fractures of the same patient to determine whether CT is a valuable supplement or a waste of medical resources. Second, the study only included radiographic, surgical, and 2-year follow-up data, which limits our ability to analyze the impact of posterolateral tibial plateau fracture classifications on postoperative outcomes. Thus, we cannot thoroughly assess the clinical relevance of these compression fractures of the posterolateral plateau of the tibia or determine whether additional measures should be taken to address these injuries when they occur. Future studies with larger sample sizes and randomized controlled designs may provide more persuasive evidence and explore the biomechanical perspective of whether treating ACL rupture and posterolateral tibial plateau fracture as a first-stage treatment in patients with high-grade posterior lateral plateau fractures can improve postoperative efficacy, providing a theoretical basis for the treatment of this type of injury.

Notably, a high prevalence of displaced posterolateral tibial plateau impaction fractures occurs in the context of ACL tears, and these fractures can be classified into distinct morphological subtypes. Our study findings indicate that patients with type ⅢA and ⅢB fractures have significantly lower functional recovery than those with low-grade injuries. This suggests that surgical treatment may be necessary to achieve satisfactory treatment outcomes in patients with high-grade injuries.

ACL Anterior cruciate ligament

MRI magnetic resonance imaging

IKDC International Knee Documentation Committee

KOOS Knee Injury and Osteoarthritis Outcome Score

SF-12 MCS The 12-item Short-Form Health Survey Physical Component Score

SF-12 PCS The 12-item Short-Form Health Survey Mental Component Score

ANOVA Analysis of variance

Acknowledgments

None.

Author contributions

(I) Conception and design: W Xu, Y Wang; (II) Administrative support: S Jiang, X Jia; (Ⅲ) Provision of study materials or patients: D Zheng, W Xu; (IV) Collection and assembly of data: S Jiang, W Ren, G Zhao, R Zhu; (V) Data analysis and interpretation: S Jiang, W Ren; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Funding

This work was supported by the Natural Science Foundation of China (Nos. 81874008 and 81472105); the Soochow Program of Health Talent Training (No. GSWS2019010).

Availability of data and materials

All data generated or analyzed during this study are included in this article.

The data are available from the corresponding author upon reasonable request.

Ethics approval and consent to participate

The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Ethics Committee of the Second Affiliated Hospital of Soochow University (No.2021000145), and informed consent was obtained from all individual participants.

Consent for publication

Not applicable.

Competing interests

The authors have no conflicts of interest to declare.

Author Details

1 Department of Joint Surgery, the Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Gusu District, Suzhou 215000, Jiangsu, People’s Republic of China.

2 Department of Orthopedics, the Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University, 29 Xinglong Lane, Tianning District, Changzhou 213004, Jiangsu, People’s Republic of China

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No competing interests reported.

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Incidence and recovery of anterior cruciate ligament rupture combined with posterolateral tibial plateau fracture in the East China population: a 2-year follow-up study

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