Incidence of posterolateral tibia plateau fractures and concomitant injuries in Chinese patients who underwent an anterior cruciate ligament reconstruction

doi:10.21203/rs.3.rs-3777090/v1

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Research Article

Incidence of posterolateral tibia plateau fractures and concomitant injuries in Chinese patients who underwent an anterior cruciate ligament reconstruction

https://doi.org/10.21203/rs.3.rs-3777090/v1

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Objective

The purpose of the present study was to report the incidence and classify the morphological subtypes of posterolateral tibial plateau fractures accompanying anterior cruciate ligament (ACL) tears in an East China population, as well as to evaluate the implications of such injuries on the functional recovery following ACL reconstruction.

Methods

488 cases of patients treated for ACL rupture between January 2016 and June 2020 were retrospectively reviewed, and their posterolateral tibial plateau fractures were classified based on MRI assessment. Functional outcomes were evaluated at a two-year postoperative follow-up using a range of validated scoring systems.

Results

The study identified a high incidence of posterolateral tibial plateau fractures (41.6%) among ACL injury cases, with type ⅢA and ⅢB fractures occurring more frequently. Patients with high-grade fractures experienced significantly lower functional recovery than those with low-grade injuries. Major findings included noncontact mechanism predominance in ACL injuries, a higher occurrence rate of type ⅢA and ⅢB fractures among older females, and a substantial association with meniscal and medial collateral ligament tears.

Conclusions

The incidence and distinct morphological classification of posterolateral tibial plateau fractures are clinically significant in ACL injury cases. The higher grade posterotibial plateau fractures are associated with worse functional outcomes in patients undergoing an ACLR.

Anterior cruciate ligament rupture

Posterolateral tibial plateau fracture

Incidence

China population

Recent trends indicate an upward trajectory in the incidence of anterior cruciate ligament (ACL) ruptures, estimated at 40–60 cases per 100,000 individuals in 2014(1). The United States reports over 250,000 instances of ACL ruptures annually, predominantly related to sports activities (1). These injuries frequently coincide with damage to the meniscus and other ligaments (2–4). Historically, bone injuries such as compression fractures of the posterolateral tibial plateau and lateral femoral condyle were often associated with ACL ruptures but were largely overlooked. Current research highlights these concomitant injuries(5–7). Bernholt et al. observed that nearly 50% of 825 patients with ACL ruptures in the U.S. exhibited concurrent femoral condyle or posterolateral tibial plateau fractures as per MRI evaluations (8, 9). Similarly, Kolb et al. reported that in Germany, 90.43% of 115 patients with ACL ruptures presented with posterolateral plateau contusions (10, 11). Since there are obvious racial differences in knee anatomy between Eastern and Western populations, it is necessary to calculate the incidence of this type of injury in the Chinese population (12).

Misaligned posterolateral tibial plateau fractures can augment the posterior slope of the tibial plateau, which, as biomechanical experiments and clinical studies have demonstrated, increases strain on ACL grafts and the risk of reconstructive surgery failure (13, 14). The complexity of posterolateral tibial plateau fractures varies, with severity gauged by the depth and size of articular surface damage (9–11). The need for concurrent reconstruction in varying severities is debated. Some experts advocate for combined treatment for enhanced outcomes (11), while others have not established definitive treatment strategies or surgical indications for high-grade fractures that could lead to suboptimal clinical results (15). Whether ACL reconstruction combined with internal fracture fixation improves outcomes in patients with concurrent high-grade posterolateral tibial plateau fractures remains to be ascertained.

This study aimed to delineate the prevalence of combined ACL rupture and posterolateral tibial plateau fractures in East China, categorize these injuries, and assess the clinical outcomes following ACL reconstruction without treatment for the tibial fractures-at a 2-year follow-up. We hypothesized that the occurrence of combined ACL and posterolateral tibial plateau fracture in East China is distinct from that in European and American populations. Furthermore, we speculated that patients with ACL injuries and high-grade associated fractures experience less favorable postsurgical recovery compared to those with low-grade fractures.

Ethical approval for this study was obtained from the Second Affiliated Hospital Ethics Committee of Soochow University (Approval No.2021000145). We retrospectively reviewed the clinical data of patients diagnosed with ACL rupture from January 2016 to June 2020. Data were sourced from the Second Affiliated Hospital of Soochow University and the Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University. The inclusion criteria encompassed all hospitalized patients with confirmed diagnoses of ACL rupture. A cohort of 488 patients, comprising 167 females and 321 males with a mean age of 34.7 years, was identified for the study. Follow-ups were conducted at the two-year postoperative mark (Fig. 1). Pre-operative MRIs were assessed by two experienced orthopedic surgeons. Exclusion criteria were defined to eliminate patients who did not receive ACL reconstruction, those with incomplete preoperative MRIs, individuals sustaining multiple knee ligament injuries, subjects lost to a two-year follow-up, patients displaying suboptimal tunnel position or unreliable internal fixation upon postoperative radiographic evaluation, and individuals with past ACL reconstructions. Inclusion further detailed the identification of posterolateral tibial plateau fractures, concomitant meniscal, collateral ligament, and posterior cruciate ligament injuries, with subsequent classification based on fracture morphology and associated injuries.

The classification schema for posterolateral tibial plateau fractures utilized in this investigation followed the morphological framework proposed by Bernholt et al.(9). This entailed characterizing compression fractures on sagittal T1-weighted MRI as displacements or depressions of subchondral or cortical bone at the tibial plateau's posterior rim. Overall, there are 3 main categories of posterolateral tibial plateau fractures, with an additional subcategory created for each of the posterior 2 categories. Type I fractures are a depression in the proximal posterior cortex of the lateral tibial plateau without involving the articular surface. Type II fractures involve the articular surface, resulting in a reduced depth of the posterolateral tibial plateau. Type II fractures are divided into two subtypes according to the amount of tibial plateau bone loss, type IIA fractures have a depth of tibial plateau bone loss less than 10%, and type IIB fractures have a depth of bone loss greater than 10%. Type III fractures are compression fractures with displaced bone fragments, subdivided according to the type of bone fragments, type IIIA fractures are composed of shear-type fragments, and type IIIB fractures are composed of compression-type fragments(Fig. 2).

ACL rupture management comprised autologous hamstring tendon anatomical reconstruction employing an Endbutton plate on the femoral side and interference screw fixation on the tibial side (Smith & Nephew USA). Three surgeons of equal seniority performed these surgeries. Subsequent imaging confirmed appropriate tunnel positioning and satisfactory internal fixation. Due to the paucity of understanding concerning posterolateral tibial plateau fractures, no arthroscopic or open reduction and internal fixation procedures were conducted at the time.

Follow-up communications were made via telephone or email. Emotional and physical rehabilitations were gauged using the SF-12, the International Knee Documentation Committee (IKDC) Subjective Knee Assessment Form, the Lysholm Knee Rating Scale, the Tegner Activity Level Scale, and the Knee Injury and Osteoarthritis Outcome Score (KOOS), all of which have demonstrated extensive validation for discerning subjective knee outcome discrepancies(16–18) .

We analyzed the clinical profiles of patients with posterolateral tibial plateau fractures and contusions using chi-square and variance analyses (ANOVA), combined with a post hoc Tukey test for age associations. Comparisons of two-year postoperative SF-12 Mental and Physical Component Summaries (MCS, PCS), Lysholm, Tegner, IKDC, and KOOS scores among different fracture types were performed using one-way ANOVA. Statistical computations were facilitated by SPSS software (V20.0, IBM), with an alpha threshold of p = 0.05 for significance.

488 patients met the follow-up criteria for study inclusion (Fig. 1), consisting of 321 males (65.8%) and 167 females (34.2%), with a mean body mass index (BMI) of 24.53. Noncontact injury mechanisms accounted for 74.8% of injuries within the cohort (Table 1). Amongst the participants, posterolateral tibial plateau compression fractures were documented in 203 knees (41.6%), and lateral femoral condyle compression fractures in 140 knees (28.7%). Co-occurrence of both fracture types was observed in 124 knees (13.2%). Patients were categorized into two groups based on fracture presence and type: 285 (58.4%) had no fractures, 98 (20.1%) with type Ⅰ, 41 (8.4%) with type ⅡA, 15 (3.1%) with type ⅡB, 22 (4.5%) with type ⅢA, and 27 (5.5%) with type ⅢB fractures. The causes of injury include car accident, sports injury, fall while riding electric vehicle, etc. The classification of different types of injury causes is shown in Table 2.

Table 1 Baseline characteristics of patients

Female gender n(%)	Patients(n=488)
Female gender n(%)	321(65.8)
Age, mean(SD)	34.7(+11.3)
BMI	24.5(+3.2)
Injury types
Contact injury n(%)	123(25.2)
Noncontact injury n(%)	365(74.8)
Fracture condition
No fracture n(%)	285(58.4)
Type I n(%)	98(20.1)
Type ⅡA n(%)	41(8.4)
Type ⅡB n(%)	15(3.1)
Type ⅢA n(%)	22(4.5)
Type ⅢB n(%)	27(5.5)

Table 2

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 (%).

Table 3 Comparison of injury mechanisms in patients with different types of injuries

	Contact injury	Noncontact injury	p-value
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)	0.847
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.

A significant age distinction was found between patients with type ⅢA and ⅢB compression fractures of the posterolateral tibial plateau and those with noncompression fractures or different fracture types (p = 0.008) (Table 4). Furthermore, the prevalence of type ⅢA fractures were significantly higher in women (63.6%) than men (36.4%) (p = 0.003) (Table 5), while other fracture types did not demonstrate gender disparities. Contact injuries were the predominant cause for type ⅢA and ⅢB fractures (77.3% and 51.9%, respectively), despite most of the cohort experiencing noncontact injuries (Table 3).

Table 4

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
Numerical values are expressed as n/N (%).

Table 5

Sex distribution of different types of injuries
	Man	Woman	p-value
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.

Posterolateral tibial plateau compression fractures demonstrated a significant association with specific meniscal injuries (Table 6). Type Ⅰ and Ⅱ compression fractures were uncorrelated with meniscal tears. Non-fractured knees and those with type ⅢA fractures had a higher incidence of lateral meniscus tears compared to the rest. Conversely, type ⅢB fractures corresponded to higher instances of medial meniscus tears and posterior root injuries than those documented without type ⅢB compression fractures (51.9% vs 71.8%; OR 0.423; 95% CI, 0.194–0.924; p = 0.027 and 7.4% vs 0.9%; OR 9.14; 95% CI, 1.597–52.397; p = 0.003). Furthermore, we observed no significant differences in medial meniscus ramp lesion frequency when comparing patients without compression fractures to all compression fracture cases.

Table 6

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- value	Incidence	p- value	Incidence	p- value	Incidence	p- value	Incidence	p- value
No fracture	175/285 (61.4)	0.016	5/285 (1.8)	0.481	194/285 (68.1)	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 (68.3)	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	321/488		7/488		345/488		8/488		6/488
Numerical values are expressed as n/N (%), and the bold font is statistically significant.

Our investigation also revealed an association between posterolateral tibial plateau fractures and other ligament injuries, beyond the ACL (Table 7). 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 lateral 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 7

Different types of injuries combined with ligament injuries
	medial collateral ligament injury		lateral collateral ligament injury		Posterior Cruciate Ligament Injury
	Incidence	p- value	Incidence	p- value	Incidence	p- value
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	119/488		41/488		52/488
Numerical values are expressed as n/N (%), and the bold font is statistically significant.

The study's analysis did not yield significant differences in SF-12 (Physical Component Summary), preoperative Tegner, and IKDC scores among the different fracture types (Table 8). However, a discernible difference in functional outcomes was evident at the two-year postoperative point between patients with high-grade (type ⅢA and ⅢB) and low-grade tibial plateau fractures, notably reflected in the Lysholm scores (p = 0.001) and postoperative Tegner scores (p = 0.001).

Table 8 2-year follow-up of patients with different types of injuries

	n (%)	SF-12 (PSC)	SF-12 (MSC)	Lysholm	TEGNER (preoperation)	TEGNER (postoperation)	IKDC	KOOS (PAIN)	KOOS (SYMPTOM)	KOOS (ADL)	KOOS (SPORT)		KOOS (QOL)
No fracture	285 (58.4)	52.88	60.86	92.82	6.6	6.1	91.44	93.75	96.15	98.88	87.9	82.61
Type I	98 (20.1)	52.2	59.97	91.04	6.5	6	89.68	93.06	94.72	98.34	85.66	77.49
Type IIA	41 (8.4)	51.96	59.59	91.83	6.5	5.9	90.49	94.04	95.82	98.9	87.81	77.9
Type IIB	15 (3.1)	51.83	60.6	89.67	6.5	6	90.67	93.89	97.14	99.17	87.66	81.67
Type IIIA	22 (4.5)	51.96	58.12	85.45	6.4	5.5	87.63	90.53	91.07	96.66	82.27	72.16
Type IIIB	27 (5.5)	51.96	58.5	86.37	6.4	5.5	89.01	92.18	91.27	97.45	83.7	72.69
p-value		0.735	0.001	0.001	0.457	0.001	0.066	0.01	0.001	0.002	0.037	0.001

The bold font is statistically significant.

Our investigation primarily reveals that noncontact mechanisms led to 74.6% of ACL injuries, while 41.6% of cases had accompanying posterolateral plateau fractures, with type ⅢB fractures associated with a significantly higher occurrence of medial meniscus tears and posterior root injuries. Patients with type ⅢA fractures showed a higher incidence of medial collateral ligament (MCL) tears compared to other types. Notably, functional recovery differed markedly between patients with high-grade subtypes (ⅢA and ⅢB) and those with less severe tibial plateau fractures, as evidenced by Lysholm scores of 85.45 and 86.37 and postoperative Tegner scores of 5.5 for high-grade subtypes.

Our findings suggest that the prevalence of noncontact ACL injuries and associated posterolateral tibial plateau fractures in our East China cohort is lower than previously documented in European and American populations. Differing femoral and tibial morphologies attributable to racial variations may account for this discrepancy(19–23). Other factors include China's national conditions, such as the widespread use of motorized two-wheelers and the lower engagement in contact sports, although the true incidence of ACL injuries in the vast Chinese population remains largely unquantified. An earlier large-scale study on Chinese athletes tagged the incidence at 0.47%(24), but with China's economic advances and escalating engagement in national fitness, the numbers have likely escalated. Given the significant over-40% incidence rate, these injuries warrant substantial clinical focus.

Utilizing Bernholt et al.'s classification system(9), we recognized five distinct fracture subtypes (Ⅰ, ⅡA, ⅡB, ⅢA, ⅢB) within our sample. This schema is clinically pertinent, enabling systematic evaluation of the interplay between specific posterolateral tibial compression fractures and related meniscal and ligament injuries. Our data points to a notable trend: patients with type ⅢA fractures are generally older and more frequently female. These fractures correlate with increased lateral meniscus tears in primary ACL tears, and although medial meniscus injuries were less prevalent in type ⅢB fractures, a substantial share of posterior root injuries was discovered in type ⅢB cases. Given MRI's limited sensitivity for diagnosing posterior meniscal root injuries, clinicians should remain vigilant of potential medial meniscal posterior root injuries in patients with type ⅢB fractures. Biomechanical research supports correction of excessive posterior inclination in the tibial plateau when treating ACL and meniscus injuries, especially in cases of concomitant medial meniscus posterior root ruptures(25), as type ⅢB damage tends to increase the lateral plateau's posterior slope. Furthermore, our analysis revealed that over 40% of ACL ruptures combined with high-grade tibial plateau fractures involve medial collateral ligament injuries. Despite literature suggesting that simultaneous repair of medial collateral ligament does not affect clinical effectiveness, surgeons should not restrict treatment to ACL reconstruction in cases coupled with posterolateral plateau fractures (26–29).

Long-term follow-ups in our study highlighted significant lower SF-12 MCS, Lysholm, Tegner, IKDC, and KOOS scores in patients with type ⅢA and ⅢB fractures as opposed to those without these subtypes. While mild injuries like bone contusions are known to impact the clinical outcomes post-ACL reconstruction due to initial pain and extended recovery periods, MRI evidence suggests a normalization over time (30–33). Given that higher-grade posterolateral compression fractures might induce persistent bony geometry alterations in the tibial plateau, this could provide insights into the clinical relevance recognized in our study. Previous research (34–36) underscores the influence of lateral tibial plateau geometry on knee stability and the relationship between reduced tibial plateau depth and ACL injuries. Our results imply that high-grade injuries may lead to poorer emotional recovery, and consequently, surgical intervention might be imperative to ensure satisfactory outcomes. Reference recommended surgical intervention for posterolateral plateau fractures exceeding 2 mm in displacement and depth, although their study was limited by its sample size and lack of a control group(11).

This study is not without its shortcomings. Sole reliance on MRI images instead of CT scans may obscure finer fracture details pertinent for accurately classifying fractures. We have started incorporating knee CT in recent cases and plan to appraise the utility of CT scans alongside MRIs in the future. Furthermore, our study, restricted to imaging, surgical details, and two-year follow-up data, doesn't allow for a comprehensive assessment of the clinical impact of posterolateral tibial plateau fracture classifications on postoperative outcomes. Future studies with larger cohorts and controlled methodologies should consider examining the efficacy of treating ACL ruptures and posterolateral tibial plateau fractures in a first-stage treatment for patients with high-grade injuries, potentially enhancing postoperative results and contributing to our understanding of treatment modalities for such injuries.

Our study has demonstrated a significant prevalence of posterolateral tibial plateau impaction fractures in association with ACL tears, which can be systematically classified into distinct morphological subtypes. The results reveal that functional recovery is notably compromised in patients with high-grade fractures (types ⅢA and ⅢB) compared to those with less severe injuries. This underscores the necessity of considering surgical treatment to potentially improve outcomes in patients exhibiting these more serious fractures.

ACL Anterior cruciate ligament

MRI magnetic resonance imaging

ACLR Anterior cruciate ligament reconstruction

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

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.

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.

Competing interests

The authors have no conflicts of interest to declare.

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).

Acknowledgments

None.

Author contributions

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, R Cheng, R Zhu; (V) Data analysis and interpretation: S Jiang, D Dimitriou, W Ren; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

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No competing interests reported.

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Incidence of posterolateral tibia plateau fractures and concomitant injuries in Chinese patients who underwent an anterior cruciate ligament reconstruction

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