Tibial plateau fractures resulting from high-energy injuries require a careful and extensive preoperative examination. In fact, Barei et al. reported discrepancies between CT plain scan and X-ray diagnosis[19]. Based on our report, a CT scan is essential after traction external fixation placement. It allows for a comprehensive understanding of the fracture morphology, degree of comminution, and displacement, therefore, making it critical for determining the surgical approach. A two pronged or staged approach is necessary due the extensive soft tissue damage caused by tibial plateau high-energy injuries. In the first-stage of treatment, the calcaneal traction or trans-articular external fixator placement can be applied to reduce the patient’s pain and alleviate further vascular and nerve injury, thereby facilitating soft tissue management. In the second stage, internal fixation can be performed to treat the damaged bone. Skin abrasions and multiple blisters that follow high energy injuries peak around 7 days post injury and take about 16 days to heal. It is imperative that the reconstruction surgery occurs within 3 weeks of injury to avoid resetting complications.
Tibial plateau fractures with severe soft tissue damage are commonly categorized in the classification Schatzker V and Schatzker VI. Out of the 18 cases examined in this study, 14 were classified as Schatzker VI. Internal double-plate fixation enhances fracture stability. Meanwhile, the use of autologous iliac bone to reconstruct the lateral column provides a good guarantee for stability and anatomical reduction. Unlike allograft usage, autologous iliac bone grafting does not induce an immune rejection. Therefore, the tibial platform can be reconstructed safely with autologous free iliac bone. Our investigation has revealed that the iliac bone block can not only support the articular surface, but also reduce stress. After the completion of the iliac bone transplantation, the locking screw can be used to fix the iliac bone, the remaining tibial platform, and the internal fixation together to fully ensure the stability of the tibial plateau after reconstruction. Fortunately, the structure of the autogenous ilium is similar to that of the tibial plateau. The arc-shaped depression of the inner plate of the iliac bone is similar to the shape of the tibial condyle; the arc structure and bone quality of the iliac crest is similar to the edge of the tibial plateau; and the migration structure of the iliac crest to the inner plate of the ilium is similar to that of the tibial plateau edge to the tibial plateau. Therefore, the correspondence of these series of organizational structures fully coincides with the anatomical needs of the iliac reconstruction of the tibial plateau. Furthermore, the autologous large iliac bone can easily be used for height adjustment and metaphysic fixation during the operation, thereby playing a crucial role in restoring force line and maintaining stability.
Since tibial plateau fracture is an intra-articular fracture, it is essential to perform anatomical reduction of the articular surface to reduce incidences of traumatic arthritis post surgery. Multiple studies have demonstrated that the pressure distribution in the knee joint changes significantly upon a > 1.5 mm collapse of the articular surface, and the local pressure increases significantly when the articular surface collapse reaches > 3 mm[20]. In either of these cases, the joint varus becomes deformed and leads to instability of the knee joint[21]. Yet another group of studies have established that the accurate reduction and strong fixation of articular cartilage can assist in the healing of the cartilage in the form of hyaline cartilage. Based on our results and that of others, the reconstruction of the tibial plateau with the iliac bone graft can successfully reduce the articular surface and the collapsed bone, and early functional exercises can be achieved with strong internal fixation. Finally, quadriceps atrophy and traumatic knee arthritis can also be reduced, periarticular tissue adhesion can be prevented, and knee function can be restored to the maximum extent using such an approach.
In summary, a complex tibial plateau fracture with extensive soft tissue damage can be successfully remedied using a staged treatment. The lateral column reconstruction using a large iliac bone can restore the lower limb force line, ensure smooth articular surface, restore platform width, and assist in the locking plate fixation.
We acknowledge that this study had some limitations; including Tscherne soft tissue classification limitations[22], small number of cases, non-diverse age population, and a short follow-up.