The influence of coronal alignment changes according to the degree of articular congruency in lateral tibial plateau fracture reduction

doi:10.21203/rs.3.rs-4716484/v1

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The influence of coronal alignment changes according to the degree of articular congruency in lateral tibial plateau fracture reduction

https://doi.org/10.21203/rs.3.rs-4716484/v1

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Purpose

Surgical treatment of tibial plateau fractures involves anatomic reduction and rigid fixation. A residual articular depression may alter the joint contact pressure and lower limb alignment and precipitate posttraumatic osteoarthritis. The degree of acceptable articular incongruency remains controversial, and the correlation between malreduction and malalignment has not been thoroughly investigated. We investigated the correlation between postoperative articular congruency in different fracture zones in the sagittal plane and whole lower limb alignment after surgery for lateral tibial plateau fractures.

Materials and Methods

Among the 254 patients surgically treated for plateau tibia fractures between January 2010 and December 2022 at a single center, 67 patients of all ages with lateral tibial plateau fractures (Schatzker types I–III) were selected and retrospectively reviewed. All patients underwent open reduction and internal fixation (ORIF) via plate and screw construct, with or without an augmentation procedure. We used simple radiographs and preoperative three-dimensional computed tomography to measure lower extremity alignment variables, intra-articular step-offs, and fracture zones in the sagittal plane. We stratified the fracture site into three zones in the sagittal plane at the joint center of the lateral tibial plateau. Malreduction was defined as an articular step-off ≥ 2 mm. Malalignment was defined as a difference > 5° in hip-knee-ankle angle (HKA).

Results

HKA strongly correlated with postoperative articular step-off (Spearman's ρ = -0.69; p < 0.001). Postoperative valgization of HKA was significantly associated with increased articular incongruency (β= -0.96, p < 0.001), particularly with step-offs ≥ 2 mm (β= -3.77, p < 0.001). Linear regression of articular step-offs and fracture locations did not demonstrate any significance. However, 13 of 24 malreduced fractures (54%) were in zone 2. Only zone 2 significantly affected postoperative valgization when assessing the association between fracture location and HKA (β = -2.68, p < 0.001). Articular incongruency located in zone 2 showed a significant association with HKA valgization after controlling for fractures in zones 1 and 3 (β = -0.775, p < 0.001).

Conclusion

This study highlighted that the articular step-off should be minimized to < 2 mm during surgery for lateral tibial plateau fractures to prevent valgus malalignment of the whole lower limb.

tibial plateau fracture

reduction

alignment

Tibial plateau fractures are intra-articular fractures of the knee joint and account for 5–8% of all lower limb fractures.¹⁾ Lateral tibial fractures account for two-thirds of all tibial plateau fractures.²⁾ Surgical treatment involves anatomical reduction of the fracture to restore the joint surface to minimize the risks of post-traumatic arthritis and allow early mobilization of the joint using rigid fixation.^3,4) However, the level of articular congruity required to achieve an acceptable outcome and a low risk of posttraumatic osteoarthritis remains controversial.⁵⁾ A few studies have reported an acceptable degree of articular incongruency c, based on a wide range from 2–10 mm, in cases of tibial plateau fractures.^6,7) Other studies have shown that step-offs > 2 mm result in a higher joint contact pressure in lateral tibial plateau fractures.^8,9)

Malalignment that leads to a shift in the weight-bearing axis and load transfer accelerates the progression of secondary osteoarthritis.^10,11) A biomechanical study showed that valgus malalignment after tibial fractures results in greater contact stress on the lateral plateau.¹²⁾ Whole lower limb alignment is assessed using the hip-knee-ankle angle (HKA) in the coronal plane, with the knee joint in full extension during weight-bearing. The tibiofemoral contact point on the lateral tibial plateau is positioned slightly anteromedial to the center of the lateral articular surface during the full extension of a normal knee.¹³⁾ We hypothesized that articular step-offs in the anterior or posterior regions of the lateral tibial plateau would alter the tibiofemoral contact point, affecting whole lower limb alignment.

To the best of our knowledge, only a few studies have investigated the correlation between articular incongruency and malalignment, and no studies have investigated the effect of fracture location on whole lower limb alignment.^8,14) Therefore, we aimed to investigate 1) the correlation between postoperative articular congruency and malalignment and 2) the effect of different fracture zones in the sagittal plane on whole lower limb alignment after surgical treatment for lateral tibial plateau fractures.

In this study, 254 patients who were surgically treated for tibial plateau fractures between January 2010 and December 2022 at a tertiary referral trauma center were retrospectively reviewed. Overall, 67 patients of all ages with lateral tibial plateau fractures (Schatzker types I–III) were included. The exclusion criteria were as follows: 1) Schatzker types IV–VI (n = 46), 2) concomitant injury in the ipsilateral limb (n = 57), 3) previous fracture or replaced joint on the ipsilateral limb (n = 6), and absence of standing full-leg radiographs or less than one year of follow-up (n = 59). Institutional Review Board approval (GCIRB2024-041) was obtained from our institution (Gachon University Gil Hospital, Incheon, South Korea) before the study, and the protocol was approved.

Surgical procedures and postoperative rehabilitation

All diagnoses and surgeries were conducted by three experienced orthopedic surgeons specialized in knee trauma and arthroplasty. All procedures aimed to restore alignment, coronal sagittal tibial slope, normal condylar width, and congruent articular surface. The surgical approach was chosen according to the fracture pattern and configuration, confirmed using preoperative three-dimensional computed tomography (3D-CT). Schatzker I and II were treated via an anterolateral approach with a lazy S or hockey stick incision centered over Gerdy's tubercle. After elevation of the anterior compartment musculature and iliotibial band, submeniscal arthrotomy was performed to assess the articular surface and meniscus tear, followed by book-opening of the proximal aspect of the tibia at the fracture site, tagging of the meniscus, fracture reduction, and placement of the Kirschner wire. After confirmation of reduction using C-arm image intensification, internal fixation was performed using a plate-and-screw construct (Fig. 1).

Our technique included an arthroscopic reduction and fixation of Schatzker type III tibial plateau fractures with a bulls-eye screw placement without fluoroscopy control. Under arthroscopic guidance, an anterior cruciate ligament drill guide was placed, and a K-wire was passed to the midpoint of the depressed fragment through a guide at a 40° angle to the coronal axis of the tibia. A tunnel was created over the K-wire using a drill. The depressed fragment was further augmented with gentle impacts over the K-wire. After arthroscopic reduction control, cannulated rafting screw was placed over the K-wire (Fig. 2). Fracture centers involving the posterolateral quadrant of the tibial plateau were categorized using the three-part sub-classifications, as previously described by Sim et al.¹⁶⁾ Articular depressions located anterior to the fibular head were treated using an extended anterolateral approach for direct fracture manipulation. Articular depressions located between the anterior and posterior border of the fibular head were manipulated utilizing the trans-fibular approach with fibular head osteotomy for direct visualization and manipulation, after which osteosynthesis was performed on the fibular head using a tension band wire. Articular depressions located posterior to the fibular head were treated using a posteromedial approach, with the patient in the prone position. Additional augmentation with allogenous or autologous bone grafts and arthroscopic soft tissue procedures were performed, at the discretion of the surgeons.

Postoperative weight bearing was restricted to toe-touch weight bearing for 8–12 weeks, depending on the overall fracture stability. Passive and active assisted range of motion exercises were initiated to achieve 90° knee flexion at five weeks and full range of motion at eight weeks. Patients who had radiologic union were allowed to assume full weight bearing at a mean time of 13 weeks. Bone union was confirmed using CT during the postoperative outpatient follow-up at approximately six months postoperatively.

Data collection

Baseline patient demographics, such as age, sex, fracture classification, and type of operations, were obtained. The Schatzker classification system was assessed using simple radiographs and preoperative 3D-CT.¹⁷⁾ A routine knee 3D-CT scan was used, with a 2 mm slice thickness. The 3D-CT measures included preoperative and 1-year postoperative intra-articular step-offs and fracture zones in the sagittal plane (Fig. 1). We further stratified the fracture site into three zones in the sagittal plane at the joint center of the lateral tibial plateau (Fig. 2). Other variables assessed via simple radiographs included HKA, the medial proximal tibial angle (MPTA), and lateral distal femoral angle (LDFA), as shown in Fig. 3. The alignment variables were measured by calculating the difference between the injured and contralateral leg on the postoperative orthoradiogram obtained at the final follow-up one year postoperatively. Malreduction was defined as an articular step-off ≥ 2 mm. Malalignment was defined as a difference of > 5° in HKA. All radiographs were assessed using picture archiving and communication system (PACS) software (INFINITT Healthcare, South Korea). Two of the above-mentioned orthopedic surgeons and a fourth-year training resident conducted all the measurements. All discrepancies were discussed until a consensus was reached, and the average of three different measurements was used for analysis.

Statistical analysis

All statistical analyses were performed using PASW Statistics version 18.0 (IBM Corp., Armonk, NY, USA). Baseline patient demographics and radiographic measurements were assessed using the Shapiro–Wilk test for distribution and simple descriptive statistics using either the mean ± standard deviation or median (IQR: interquartile range). The correlation between articular step-offs and radiographic alignment measurements was assessed by Spearman's rank correlation coefficient and linear regression analysis. Statistical significance was set at P-value < 0.05.

Demographic data and radiographic measurements

Among the 67 patients included in this study, 44 were male, with a median patient age of 49 (39–58). According to the Schatzker classification, 10 fractures were classified as type I fractures, 46 as type II fractures, and 11 as type III fractures. The median postoperative articular step-off was 0.75 (0–2.08) mm. The median MPTA, LDFA, and HKA were 1.30 (-0.76–3.08), -0.82 (-2.16–1.13), and − 1.91 (-3.49–0.19) mm, respectively. Twenty-one fractures were centered in Zone 1, 31 fractures in Zone 2, and the remaining fractures were located in Zone 3. Twenty-four fractures (36%) were malreduced. The basic patient characteristics and radiographic measurements are summarized in Table 1.

Correlation between postoperative articular step-offs and lower limb alignment

Among the radiographic lower limb alignment measures, only HKA showed a strong correlation to postoperative articular step-off (Spearman's ρ = -0.69; p < 0.001). Linear regression analysis was employed to test if the articular step-off predicts malalignment and revealed that postoperative valgization of HKA was significantly associated with increased articular incongruency (β = -0.96, p < 0.001), particularly with step-offs ≥ 2 mm (β = -3.77, p < 0.001), as shown in Table 2 and Fig. 4.

Table 2

Correlations between step-offs and fracture location in the sagittal plane and malalignment ──────────────────────────────────────────
	B	SE	t	P-value
Step-offs	− .958	.136	-7.059	< 0.001
Step-offs (> 2 mm)	-3.767	.659	-5.713	< 0.001
Zone 1	.561	.851	.659	.512
Zone 2	-2.681	.531	-5.044	< 0.001
Zone 3	1.941	.980	1.981	.051
Step-offs (zone 2)	− .775	.171	-4.546	< 0.001
Abbreviations: B, beta value, SE, standard error. t, t-values

Correlation between fracture location and lower limb alignment

Linear regression of articular step-offs and fracture locations did not demonstrate any significance. However, 13 of 24 malreduced fractures (54%) were in zone 2. Only zone 2 showed a significant effect on postoperative valgization when assessing the association between fracture location and HKA (β = -2.68, p < 0.001). Articular incongruency located in zone 2 showed a significant association with HKA valgization after controlling for fractures in zones 1 and 3 (β = -0.775, p < 0.001). The correlation between fracture location and HKA is shown in Table 2.

The principal findings of this study were that 1) articular incongruency significantly predicted valgization of the affected knee joint (β = -0.96, p < 0.001), particularly as articular depression exceeded 2 mm (β = -3.77, p < 0.001), and that 2) the articular incongruency in middle one-third portion of the lateral tibial plateau in the sagittal plane showed a significant correlation with HKA valgization (β = -0.775, p < 0.001).

The tibial plateau fracture impacts the knee joint’s weight-bearing area. Restoring alignment, length, stability, and joint congruity is crucial for better outcomes. Residual step-offs > 2 mm occur in up to 32% of all complex tibial plateau fractures.⁶⁾ The current literature did not reach a consensus on the degree of articular congruity required for optimal outcomes. Some studies have suggested that articular incongruity can be tolerated up to 10 mm in the case of tibial plateau fractures,^6,7) whereas several biomechanical studies showed that impressions of 1–2 mm resulted in decreased contact areas and increased contact pressure.^8,9,18) However, these studies are cadaveric studies, and in vivo studies remain lacking. Bai et al. reported that articular step-offs resulted in valgus angulation, resulting in increased average and maximum contact pressures in the knee joint.⁸⁾ Furthermore, Singleton et al. showed that articular depression after tibial plateau fracture treatment resulted in the valgization of the mechanical axis; however, this effect was clinically insignificant.⁷⁾ Maquet et al. suggested that malalignment after tibial condylar fractures changes the load distribution and results in post-traumatic arthritis of the knee joint. Furthermore, 13 of 24 malreduced fractures (54%) in our study were in zone 2. Fracture location did not clearly indicate the incidence of postoperative articular step-offs; however, the articular incongruency in zone 2 showed a significant correlation with HKA valgization. The importance of the reduction of the posterolateral fragment has been well highlighted in the literature.^{6,16,18–21)} However, our study suggests that achieving articular congruency in the middle one-third of the lateral plateau tibial fragment may also be important.

The relationship between valgus malalignment and tibiofemoral disease remains unclear; however, several studies on meniscectomy, tibial osteotomy, and fixation of tibial plateau fractures have suggested that increased contact pressure and accumulated load of pressure precipitate posttraumatic arthritis.^10–12) Surgically managed tibial plateau fractures have an increased likelihood of developing osteoarthritis (OA) and requiring a subsequent total knee arthroplasty compared with a matched group from the general population.²²⁾ Moreover, tibial plateau fractures commonly result from high-energy injuries and are associated with complications such as meniscal tears, ligamentous injury, and compartment syndrome.^23,24) Meniscal tears are present in 55% of patients with tibial plateau fractures.²³⁾ A few authors suggested that valgic overcorrection does not affect the lateral compartment of the knee joint after high tibial osteotomy, whereas Bick et al. provided evidence of progressive overall meniscal degeneration in the lateral compartment via follow-up MRI examinations.^25–27) Torn meniscus knee joints have a smaller stressed contract area than healthy knee joints under any flexion angle and have larger contact pressures.²⁸⁾

Traditional methods of surgical fixation involve an open approach to the proximal tibia, followed by reduction of the fracture fragments under fluoroscopic guidance. Depressed fragments are reduced, and the subchondral region is filled with bone graft or a bone graft substitute, such as polymethylmethacrylate (PMMA) or calcium phosphate bone cement, followed by rigid internal fixation with plates and screws. However, malreduction is reported to reach up to 32.3% in the literature.⁶⁾ The incidence of malreduction in our study was 36% (24 of 67). Lateral tibial fractures account for two-thirds of all tibial plateau fractures, and malreductions were found to predominate in the posterior quadrants.⁶⁾ This poses a major challenge to surgeons regarding the restoration of articular congruity since visualization of the posterolateral segment is difficult.^6,18) The lack of intraoperative visualization is one of the main reasons for inadequate reduction after complex tibial plateau fractures.²⁹⁾ A fluoroscopic-guided reduction technique without submeniscal arthrotomy was found to be a statistically significant risk factor for malreduction.⁶⁾

Numerous techniques have been introduced to access the posterolateral quadrant fragment: the posterior approach; the posterolateral approach, with or without fibular osteotomy; the posteromedial approach; and the modified anterolateral approach.¹⁹⁾ In our institution, posterolateral tibial plateau fracture fixation was individualized utilizing the three-column subdivision system based on the fibular head position.¹⁶⁾ The posterolateral compartment of the tibial plateau was segmented into three zones based on the fibular position and an individualized surgical approach was proposed for each zone: 1) in anterior zone I, an extended anterolateral approach with the patient in the supine position; 2) in middle zone II, a transfibular approach with the patient in the supine position; and 3) in posterior zone III, a posteromedial approach with the patient in the prone position.

Despite the introduction of numerous techniques, current evidence suggests that restoration of articular congruency in tibial plateau fractures remains difficult, particularly with progressive subsidence of the articular fragment even after rigid fixation. We evaluated articular incongruency one year postoperatively, considering the possibility of gradual postoperative subsidence. Despite the dedicated effort to directly visualize and manipulate the articular fracture site for rigid fixation, a median articular step-off of 0.75 (0–2.08) mm remained one year postoperatively. An anatomic articular reduction in the posterolateral compartment of the tibial plateau is technically demanding. A biomechanical study demonstrated that posterior impressions of the posterolateral compartment with a step-off > 1 mm resulted in a large decrease in contact area and an increase in contact pressure.¹⁸⁾ However, in this study, the degree of articular step-off in the posterolateral compartment did not show a significant correlation with the coronal alignment change in the full weight-bearing orthoradiogram. This is self-explanatory because the tibiofemoral contact point on the lateral tibial plateau is positioned slightly anteromedial to the center of the lateral articular surface in the standing position with a fully extended knee.¹³⁾ Post-traumatic arthritis is diagnosed by assessing joint space narrowing using a full weight-bearing orthoradiogram and is characterized by pain aggravated by weight-bearing activities. The knee joint is a dynamic joint, in which the tibiofemoral contact point continuously changes throughout the whole range of motion. In this study, the articular incongruency in zone 2 showed a significant linear correlation with HKA valgization, and the majority of malreduced fractures (n = 13/24; 54%) were located in zone 2. Therefore, surgeons should address articular reduction in the center of the lateral compartment, which affects the coronal alignment of the whole lower limb, rather than primarily focusing on the posterolateral compartment, which has an accompanied risk of peroneal nerve injury during surgical manipulation via the posterolateral approach with fibular head osteotomy after common peroneal nerve dissection.

This study had some inherent limitations owing to the retrospective design and the small number of study participants. Furthermore, this study did not assess clinical outcomes and their correlations with malreduction and malalignment. Regardless, this study may serve as a reference for discussing the impact of malreduction on whole lower limb malalignment, in addition to the optimal quality of reduction in the surgical treatment of lateral tibial plateau fractures.

Tibial plateau fractures are surgically challenging for orthopedic surgeons. This study highlighted that the articular step-off should be minimized to < 2 mm during surgery for lateral tibial plateau fractures to prevent valgus malalignment of the whole lower limb. In particular, articular congruency in the middle one-third lateral tibial plateau showed a significant correlation with HKA valgization, suggesting that surgeons must attentively address articular reduction in zone 2.

Author Contribution

Footnote. These authors (Jae Ang Sim and Han Soul Kim) contributed equally to this work.Jae Ang Sim and Byung Hoon Lee made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data; or the creation of new software used in the work;Han Soul Kim drafted the work or revised it critically for important intellectual content;Byung Hoon Lee approved the version to be published; andJi-Sup Lim and Byung Hoon Lee agree to be 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.

Conflict of interest

The authors declare that they have no conflict of interest.

Acknowledgments: This research was financially supported by the Ministry of Trade, Industry, and Energy (MOTIE), Korea, under the “Infrastructure program for industrial innovation(reference number P0025775)” supervised by the Korea Institute for Advancement of Technology (KIAT).

Competing interests: The authors have no relevant financial or non-financial interests to disclose.

Ethical approval: This article does not contain any studies with human participants or animals performed by any of the authors.

Availability of data and material

Not applicable.

Consent to participate

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You are reading this latest preprint version

The influence of coronal alignment changes according to the degree of articular congruency in lateral tibial plateau fracture reduction

Status:

Version 1

Abstract

Purpose

Materials and Methods

Results

Conclusion

Figures

Introduction

Materials and methods

Surgical procedures and postoperative rehabilitation

Data collection

Statistical analysis

Results

Demographic data and radiographic measurements

Correlation between postoperative articular step-offs and lower limb alignment

Correlation between fracture location and lower limb alignment

Discussion

Conclusion

Declarations

Author Contribution

References

Tables

Additional Declarations

Status:

Version 1