Abstract
Background
Schatzker IV-C is a high-energy tibial plateau fracture often accompanied by lateral meniscus injuries. While imaging examinations are routine preoperative measurements, the correlation between CT imaging shift parameters of the lateral plateau and lateral meniscal injury in Schatzker IV-C fractures remains uncovered.
Methods
This retrospective study enrolled a total of 60 patients with Schatzker IV-C tibial plateau fractures at the First People’s Hospital of Hefei. Prior to surgery, CT imaging was used to measure the numerical values of lateral plateau depression (LPD) and lateral plateau widening (LPW). The degree of lateral meniscus injury was confirmed based on intraoperative direct vision, with patients being classified into meniscus injury and non-meniscus injury groups. Dichotomous logistic regression was employed to evaluate the correlation between LPD, LPW, and lateral meniscus injury, while the optimal cut-off points for predicting lateral meniscal injury with LPD and LPW were determined using receiver operator characteristic (ROC) curves.
Results
The meniscus injury group exhibited a mean LPD of 15.3 ± 3.5 mm, which was significantly higher than the non-meniscus injury group’s mean LPD of 8.4 ± 3.4 mm (P < 0.05). Similarly, the meniscus injury group had a larger mean LPW of 9.4 ± 1.8 mm compared to the non-meniscus injury group’s mean LPW of 6.9 ± 0.9 mm (P < 0.05). The optimal cut-off points for predicting lateral meniscal injury were determined to be 8.40 mm for LPD (with a sensitivity of 95%, specificity of 85%, and AUC of 0.898) and 7.90 mm for LPW (with a sensitivity of 75%, specificity of 90%, and AUC of 0.897).
Conclusions
Patients with Schatzker IV-C tibial plateau fractures are at a significantly higher risk of lateral meniscal injury when the LPD exceeds 8.40 mm and/or the LPW exceeds 7.90 mm. Our results may provide novel reference metrics for the early diagnosis of lateral meniscal injury in Schatzker IV-C tibial plateau fracture patients when the MRI examination is not available.
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Introduction
The classification of tibial plateau fractures encompasses various categories, with the Schatzker Staging System being widely accepted as the most commonly used clinical method [1,2,3]. Schatzker IV is a relatively uncommon form of medial tibial plateau fracture characterized by splitting or depression of the articular surface. This type of fracture represents approximately 10–30% of all tibial plateau fractures among patients [4, 5]. Based on the relationship between the fracture line and the intercondylar eminence, Wahlquist et al. [6] further differentiated Schatzker IV fractures into three subcategories, namely subtypes A, B, and C fractures. Type A fractures have the fracture line located on the medial side of the eminence, type B fractures have the fracture line on the intercondylar eminence, and type C fractures have the fracture line on the lateral side of the eminence. Schatzker IV-C fracture is characterized by severe injury with significant force, often accompanied by dislocation, lateral meniscus entrapment, and various ligament injuries [5, 7]. In their study, Barrow et al. found that meniscus injury incidence in Schatzker IV tibial plateau fractures was 25% [8]. Furthermore, other studies have reported occurrence rates of 63% for lateral meniscus tears and 44.4% for medial meniscus tears [9]. Because the location of the fracture line influences the severity of soft tissue injury, with a higher prevalence of lateral meniscus entrapment when the fracture line is closer to the lateral side [6, 9], Schatzker IV-C fractures-related lateral meniscus injury will significantly increase the contact stress and instability in the knee joint, which results in the development of traumatic arthritis and joint stiffness [10,11,12,13]. Therefore, timely diagnosing and treating the meniscus injury after Schatzker IV-C fractures is imperative to achieve optimal patient outcomes.
Although magnetic resonance imaging (MRI) has a high diagnostic accuracy for assessing meniscal and ligament injuries, and is often considered the gold standard for preoperative soft tissue diagnosis [14], MRI examinations have lengthy wait times and high costs. The scanning process is time-consuming, and there is limited availability of MRI [15, 16]. Moreover, acute tibial plateau fractures can cause diffuse soft tissue edema around the knee joint, potentially resulting in the overdiagnosis of meniscal injuries [17]. Additionally, preoperative scanning is not commonly performed, and it lacks widespread adoption in primary healthcare facilities in our country [17,18,19]. Meanwhile, CT imaging can assist orthopedic surgeons in accurately assessing lateral plateau depression through three-dimensional reconstruction techniques. Therefore, the preferred preoperative examination for acute tibial plateau fractures is CT rather than MRI [20]. CT scans have been widely adopted for assessing various tibial plateau fractures and obtained detailed fracture-related information, including the fracture line location, the extent of fracture block fragmentation, and any changes in the displacement of the lateral plateau’s articular surface [21, 22]. In recent years, growing evidence shows that preoperative knee X-rays and CT imaging parameters can effectively predict the presence of combined soft tissue injuries, particularly lateral meniscal injuries, in patients with tibial plateau fractures [17, 23,24,25,26,34]. To address these examinations’ limitations, we adopted intraoperative direct visualization for precise and definitive information on meniscus injuries. Additionally, considering the impact of anatomical tibial slope on X-ray examination, we utilized coronal plane CT scans to obtain more objective measurements [35]. These distinctions set our study apart from previous research.
The incidence of tibial plateau fracture-related meniscal injury ranges from 21 to 99%, with lateral meniscal injury being the predominant type. Bennett et al. [36] reported three meniscal damage cases among nine patients (33.3%) with type IV tibial plateau fractures. Stannard et al. [37] noted a strong association between high-energy tibial plateau fractures and soft tissue injuries. They observed one medial meniscal tear and 5 cases of lateral meniscal tear among 13 patients with Schatzker type IV fractures. Michael et al. [38] observed that medial meniscal tears were commonly present in Schatzker type IV tibial plateau fractures (86%). Bingshan Yan et al. [9] found that lateral meniscal tears in Schatzker type IV tibial plateau fractures were 63%, while medial meniscal tears were 44.4%. Although meniscal injury in Schatzker type IV fractures has been previously documented, few studies have reported the incidence of tissue injuries following Schatzker type IV-C fractures. In the current study, we reported the possibility of ACL injury (86.7%), lateral meniscal injury (66.7%), medial meniscal injury (41.7%), partial posterior cruciate ligament (PCL) injury (63.3%), the incidence of lateral collateral ligament (LCL) injury (65%), and medial collateral ligament (MCL) injury (31.7%). Our results may complement the relationship between Schatzker type IV-C fracture and soft tissue injury.
This study highlights the close association between lateral plateau displacement and lateral meniscus injury in Schatzker IV-C fractures. Although, Mustonen et al. [18] introduce that there is no correlation between meniscal damage and the type or degree of depression in tibial plateau fractures, increasing reports suggest a higher incidence of soft tissue injuries in patients with a more significant displacement of the tibial lateral plateau fracture [19, 23, 25, 26]. To identify reliable indicators for early prediction of associated soft tissue injuries, researchers have focused on the correlation between preoperative X-ray and CT measurements and lateral meniscus damage [25, 39]. Gardner et al. [40] found 83% of patients exhibiting lateral meniscus injury on MRI once LPD length more than 6 mm and width exceeding 5 mm on preoperative X-ray measurements among 62 patients with Schatzker II fractures. Durakbasa et al. [39] found that LPD ≥ 14 mm and/or LPW ≥ 10 mm was correlated to the high risk of lateral meniscus tear based on preoperative X-rays measurements among 20 patients with Schatzker II tibial plateau fractures. Ringus et al. [41] measured LPD using coronal CT scans in 85 patients with Schatzker I-VI tibial plateau fractures, revealing an 8-fold increased risk for lateral meniscus tear with LPD ≥ 10 mm. Tang et al. [25] demonstrated that LPD exceeding 11 mm on preoperative CT scans was accompanied by 70.3% lateral meniscus injury among 132 patients with acute tibial plateau fractures (including 8 Schatzker IV fractures). However, they did not reveal the correlation between LPW measurements and meniscal tears. Kolb et al. [17] compared preoperative LPW measurements obtained from CT scans with MRI results and found 40% increased lateral meniscus tear risk with every LPW exceeding 1 mm among 55 patients with Schatzker I-III tibial plateau fracture. Hengrui Chang et al. [28] investigated CT imaging parameters and arthroscopic findings in 102 patients with acute tibial plateau fractures (including 22 cases of Schatzker IV fractures). They found a positive correlation between LPD > 6.3 mm and the risk of lateral meniscus tear. Salari et al. [26] utilized CT measurements and intraoperative visualization and found a 21% increased risk of meniscal tear with each 1 mm increase in maximum articular surface depression/displacement (AID) in 70 patients with Schatzker I-II tibial plateau fractures. Meanwhile, they also found 100% lateral meniscus tear when AID exceeds 4.3 mm. Ying Pu et al. [27] investigated the correlation between lateral tibial plateau CT imaging parameters and lateral meniscus injury through arthroscopy in 296 patients with Schatzker II fractures. They found a higher possibility of lateral meniscus injury when LPD exceeds 9 mm and/or LPW more than 7.5 mm. In summary, our findings generally support previous studies, indicating that both LPD and LPW are important indicators for preoperative prediction of associated soft tissue injuries. However, our study suggests minimum LPD and LPW values of 8.40 mm and 7.90 mm, respectively, for predicting lateral meniscus injury. Our research specifically emphasizes the strong association between lateral plateau displacement and lateral meniscus injury in Schatzker IV-C fractures for the first time. Inconsistencies with previous studies’ result may stem from variations in factors such as Included research subjects, patient Schatzker classification, measurement methods, and sample sizes.
There are several limitations in the current study. Firstly, manual measurements have inherent subjectivity, which may introduce potential bias into the results. Secondly, we included a relatively small number of patients with Schatzker IV-C fractures which may introduce bias into our results. Thirdly, we were unable to differentiate degenerative or traumatic meniscal lesions. Thus, whether existing pre-existing meniscus injury prior to the fracture may cannot completely guarantee. Lastly, this study did not address the specific location and classification of meniscal injuries.
Conclusions
Schatzker IV-C tibial plateau fracture was accompanied by a high risk of lateral meniscal injury when LPD exceeds 8.40 mm and/or LPW exceeds 7.90 mm. Meanwhile, our results may better explain the correlation between Schatzker IV-C tibial plateau fracture and soft tissue injury and provide potential predictors (LPD and LPW) for early diagnosing Schatzker IV-C tibial plateau fracture-related meniscus injury. Additionally, our findings may enable orthopedic surgeons to anticipate lateral meniscal injuries in Schatzker IV-C tibial plateau fractures through the numerical value of LPD and LPW measured by preoperative coronal CT scans.
Data availability
The datasets generated and analyzed during the current study are not publicly available due to ethical restrictions regarding patient data and anonymity, but may be available from the corresponding author upon reasonable request.
Abbreviations
- LPD:
-
Lateral plateau depression
- LPW:
-
Lateral plateau widening
- ORIF:
-
Open reduction internal fixation
- ROC:
-
Receiver operating characteristic
- AUC:
-
Area under the curve
References
Yang G, Zhu Y, Luo C, Putnis S. Morphological characteristics of Schatzker type IV tibial plateau fractures: a computer tomography based study. Int Orthop. 2012;36(11):2355–60.
Kfuri M, Schatzker J. Revisiting the Schatzker classification of tibial plateau fractures. Injury. 2018;49(12):2252–63.
Schatzker J, Mcbroom R, Bruce D. The Tibial Plateau fracture: the Toronto experience 1968–1975. Clin Orthop Relat Res (1976–2007). 1979;138:94–104.
Khatri K, Sharma V, Goyal D, Farooque K. Complications in the management of closed high-energy proximal tibial plateau fractures. Chin J Traumatology = Zhonghua Chuang shang za zhi. 2016;19(6):342–7.
Stannard J. Fracture dislocation of the knee. J Knee Surg. 2016;29(4):300–2.
Wahlquist M, Iaguilli N, Ebraheim N, Levine J. Medial tibial plateau fractures: a new classification system. J Trauma. 2007;63(6):1418–21.
Giordano V, do Amaral NP, Koch HA, RP EA, de Souza FS. Dos Santos Neto JF: outcome evaluation of staged treatment for bicondylar tibial plateau fractures. Injury. 2017;48(Suppl 4):34–s40.
Zakrzewski P, Orłowski J. [Meniscuses and ligaments injuries in tibial plateau fractures in comparative evaluation of clinical, intraoperative and MR examination]. Chir Narzadow Ruchu Ortop Pol. 2005;70(2):109–13.
Yan B, Sun J, Yin W. The prevalence of soft tissue injuries in operative Schatzker type IV tibial plateau fractures. Arch Orthop Trauma Surg. 2021;141(8):1269–75.
Huang X, Zhi Z, Yu B, Chen F. Stress and stability of plate-screw fixation and screw fixation in the treatment of Schatzker type IV medial tibial plateau fracture: a comparative finite element study. J Orthop Surg Res. 2015;10:182.
Musahl V, Citak M, O’Loughlin PF, Choi D, Bedi A, Pearle AD. The effect of medial versus lateral meniscectomy on the stability of the anterior cruciate ligament-deficient knee. Am J Sports Med. 2010;38(8):1591–7.
Alford JW, Lewis P, Kang RW, Cole BJ. Rapid progression of chondral disease in the lateral compartment of the knee following meniscectomy. Arthroscopy: The Journal of Arthroscopic & Related Surgery : Official Publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2005;21(12):1505–9.
Forman JM, Karia RJ, Davidovitch RI, Egol KA. Tibial plateau fractures with and without meniscus tear–results of a standardized treatment protocol. Bull Hosp Jt Dis. 2013;71(2):144–51.
Hashemi SA, Ranjbar MR, Tahami M, Shahriarirad R, Erfani A. Comparison of Accuracy in Expert Clinical Examination versus magnetic resonance imaging and arthroscopic exam in diagnosis of Meniscal tear. Adv Orthop. 2020;2020:1895852.
Behairy NH, Dorgham MA, Khaled SA. Accuracy of routine magnetic resonance imaging in meniscal and ligamentous injuries of the knee: comparison with arthroscopy. Int Orthop. 2009;33(4):961–7.
De Smet AA, Mukherjee R. Clinical, MRI, and arthroscopic findings associated with failure to diagnose a lateral meniscal tear on knee MRI. AJR Am J Roentgenol. 2008;190(1):22–6.
Kolb JP, Regier M, Vettorazzi E, Stiel N, Petersen JP, Behzadi C, Rueger JM, Spiro AS. Prediction of Meniscal and Ligamentous Injuries in lateral Tibial Plateau Fractures based on measurements of lateral Plateau Widening on Multidetector Computed Tomography Scans. Biomed Res Int. 2018;2018:5353820.
Mustonen AO, Koivikko MP, Lindahl J, Koskinen SK. MRI of acute meniscal injury associated with tibial plateau fractures: prevalence, type, and location. AJR Am J Roentgenol. 2008;191(4):1002–9.
Spiro AS, Regier M, Novo de Oliveira A, Vettorazzi E, Hoffmann M, Petersen JP, Henes FO, Demuth T, Rueger JM, Lehmann W. The degree of articular depression as a predictor of soft-tissue injuries in tibial plateau fracture. Knee Surg Sports Traumatol Arthroscopy: Official J ESSKA. 2013;21(3):564–70.
Liu XD, Wang HB, Zhang TC, Wan Y, Zhang CZ. Comparison between computed tomography and magnetic resonance imaging in clinical diagnosis and treatment of tibial platform fractures. World J Clin Cases. 2020;8(18):4067–74.
Markhardt BK, Gross JM, Monu JU. Schatzker classification of tibial plateau fractures: use of CT and MR imaging improves assessment. Radiographics: A Review Publication of the Radiological Society of North America Inc. 2009;29(2):585–97.
Markhardt BK, Gross JM, Monu J. Schatzker classification of tibial plateau fractures: use of CT and MR imaging improves assessment. Radiographics. 2009;29(2):585–97.
Wang Y, Cao F, Liu M, Wang J, Jia S. Incidence of soft-tissue injuries in patients with Posterolateral Tibial Plateau Fractures: a retrospective review from 2009 to 2014. J Knee Surg. 2016;29(6):451–7.
Hua K, Jiang X, Zha Y, Chen C, Zhang B, Mao Y. Retrospective analysis of 514 cases of tibial plateau fractures based on morphology and injury mechanism. J Orthop Surg Res. 2019;14(1):267.
Tang HC, Chen IJ, Yeh YC, Weng CJ, Chang SS, Chen AC, Chan YS. Correlation of parameters on preoperative CT images with intra-articular soft-tissue injuries in acute tibial plateau fractures: a review of 132 patients receiving ARIF. Injury. 2017;48(3):745–50.
Salari P, Busel G, Watson JT. A radiographic zone-based approach to predict meniscus injury in lateral tibial plateau fracture. Injury. 2021;52(6):1539–43.
Pu Y, Lei Z, Wenge D, Yue X, **aowei J, Kejie W, Yiwen Z, Zhihui H, **aoyu D. Correlation between CT images of lateral plateau and lateral meniscus injuries in patients with Schatzker II tibial plateau fractures:a retrospective study. BMC Musculoskelet Disord. 2022;23(1):9.
Chang H, Zheng Z, Shao D, Yu Y, Hou Z, Zhang Y. Incidence and Radiological Predictors of Concomitant Meniscal and Cruciate Ligament Injuries in Operative Tibial Plateau Fractures: a prospective diagnostic study. Sci Rep. 2018;8(1):13317.
Caraiani C, Dong Y, Rudd AG, Dietrich CF. Reasons for inadequate or incomplete imaging techniques. Med Ultrasonography. 2018;20(4):498–507.
Le Baron M, Cermolacce M, Flecher X, Guillotin C, Bauer T, Ehlinger M. Tibial plateau fracture management: ARIF versus ORIF - clinical and radiological comparison. Orthop Traumatol Surg Research: OTSR. 2019;105(1):101–6.
Friemert B, Oberländer Y, Schwarz W, Häberle HJ, Bähren W, Gerngross H, Danz B. Diagnosis of chondral lesions of the knee joint: can MRI replace arthroscopy? A prospective study. Knee Surg Sports Traumatol Arthroscopy: Official J ESSKA. 2004;12(1):58–64.
Irie K, Yamada T, Inoue K. A comparison of magnetic resonance imaging and arthroscopic evaluation of chondral lesions of the knee. Orthopedics. 2000;23(6):561–4.
Zawam SHM, Gad AM. Arthroscopic assisted reduction and internal fixation of Tibial Plateau Fractures. Open Access Macedonian Journal of Medical Sciences. 2019;7(7):1133–7.
Herbort M, Domnick C, Petersen W. [Arthroscopic treatment of tibial plateau fractures]. Operative Orthopadie und Traumatologie. 2014;26(6):573–88. quiz 589–590.
Moore TM, Harvey JP Jr. Roentgenographic measurement of tibial-plateau depression due to fracture. J bone Joint Surg Am Volume. 1974;56(1):155–60.
Bennett WF, Browner B. Tibial plateau fractures: a study of associated soft tissue injuries. J Orthop Trauma. 1994;8(3):183–8.
Stannard JP, Lopez R, Volgas D. Soft tissue injury of the knee after tibial plateau fractures. J Knee Surg. 2010;23(4):187–92.
Gardner MJ, Yacoubian S, Geller D, Suk M, Mintz D, Potter H, Helfet DL, Lorich DG. The incidence of soft tissue injury in operative tibial plateau fractures: a magnetic resonance imaging analysis of 103 patients. J Orthop Trauma. 2005;19(2):79–84.
Durakbasa MO, Kose O, Ermis MN, Demirtas A, Gunday S, Islam C. Measurement of lateral plateau depression and lateral plateau widening in a Schatzker type II fracture can predict a lateral meniscal injury. Knee Surg Sports Traumatol Arthroscopy: Official J ESSKA. 2013;21(9):2141–6.
Gardner MJ, Yacoubian S, Geller D, Pode M, Mintz D, Helfet DL, Lorich DG. Prediction of soft-tissue injuries in Schatzker II tibial plateau fractures based on measurements of plain radiographs. J Trauma. 2006;60(2):319–23. discussion 324.
Ringus VM, Lemley FR, Hubbard DF, Wearden S, Jones DL. Lateral tibial plateau fracture depression as a predictor of lateral meniscus pathology. Orthopedics. 2010;33(2):80–4.
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The authors would like to thank all staff members in the participating departments.
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YLL and RDN designed and conducted the study and wrote the manuscript. RF, ZZ and CNZ collected and analyzed the data. RDN and BZT reviewed and edited the manuscript. All authors read and approved the final version.
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This study was conducted in accordance with the ethical standards set forth in the Declaration of Helsinki and its later amendments or comparable ethical standards. All procedures involving human participants were approved by the Ethics Committee of The Third Affiliated Hospital of Anhui Medical University. In this retrospective study, written informed consent was obtained from all patients included.
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Liu, Y., Fang, R., Tu, B. et al. Correlation of preoperative CT imaging shift parameters of the lateral plateau with lateral meniscal injury in Schatzker IV-C tibial plateau fractures. BMC Musculoskelet Disord 24, 793 (2023). https://doi.org/10.1186/s12891-023-06924-7
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DOI: https://doi.org/10.1186/s12891-023-06924-7