Surgical Management of Tibial Plateau Fractures: Current Concepts and Strategies

Tibial plateau fractures are considered severe injuries of the lower extremity and require a differentiated treatment approach. The goal of surgical therapy is the anatomical reconstruction of the articular surface, while simultaneously restoring axial, length, and rotational alignment, in order to prevent long-term functional impairment and the development of post-traumatic gonarthrosis. A successful treatment is based on comprehensive diagnostics, including radiography, computed tomography, CT angiography in cases with suspected dislocation, and, if necessary, additional magnetic resonance imaging to assess associated ligamentous and meniscal injuries. The ten-segment classification and the three-column model have proven to be effective tools for preoperative planning and for selecting the optimal surgical approach. The concept of stepwise extension of the surgical approach as needed allows complete and generally soft-tissue sparing exposure of the affected joint surfaces. Intraoperative three-dimensional imaging significantly improves reduction control and is associated with greater anatomical accuracy and lower revision rates. Concomitant ligamentous and meniscal lesions should be addressed, either simultaneously or in a staged manner, depending on their relevance for joint stability. While partial meniscal tears may be left untreated in stable situations, displaced or unstable ruptures require (possibly arthroscopically assisted) repair and only rarely (partial) resection. Bony avulsion injuries of ligaments should be included in the fracture fixation, whereas intraligamentous ruptures or high-grade instabilities can be successfully treated with direct suture, augmentation, or secondary reconstruction. In summary, a stepwise extendable surgical approach, in combination with complete articular surface exposure, intraoperative 3D imaging control, and function-oriented management of concomitant injuries, has proven to be an evidence-based strategy to achieve stable, anatomical restoration and optimal long-term functional outcomes.