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Bicondylar Tibial Plateau Fractures

A Critical Analysis Review

Adam K. Lee, MD Abstract

» Bicondylar tibial plateau fractures represent a broad category of
Seth A. Cooper, MD
complex, high-energy injuries associated with a high surgical
Cory Collinge, MD complication rate.

» Computed tomography and magnetic resonance imaging aid in

Investigation performed at Vanderbilt diagnosis, classification, and surgical planning and should be
University Medical Center, Nashville, considered during the initial evaluation or after provisional stabili-
Tennessee zation is performed as part of staged treatment.

» No one classification system has superior descriptive traits or

reliability. Simply classifying the fracture as unicondylar (partial
articular) or bicondylar (complete articular) is the most reliable
approach.

» Malalignment, especially in the coronal plane, and instability predict

poor outcomes and should direct surgical intervention. Articular
displacement is less predictive.

» Dual plating is the most stable type of fixation biomechanically but is

associated with soft-tissue complications.

» Single lateral locked plating is an alternative fixation type for

bicondylar fractures without a large posteromedial coronal fracture
line.

» Hybrid external fixators are another means of fixation that avoid large
exposures and associated soft-tissue disruption.

» No one fixation strategy is superior in all cases. Patient and injury

characteristics should be evaluated on a case-by-case basis to
optimally direct the treatment of these complex injuries.

B
icondylar tibial plateau frac-
tures are complex injuries that
are frequently difficult to treat.
Bicondylar plateau fractures
involve some portion of both the medial
and lateral articular surfaces, with associ-
ated disruption of the articular fragments
from the metaphysis. These fractures ac-
count for 18% to 39% of all tibial plateau
fractures and typically result from moderate
to high-energy trauma1-8. They are com-
monly associated with substantial soft-
tissue injury, and 8% to 43% of these
fractures are open9-17. Compartment syn-
drome is reported in association with 3% to
27% of these fractures9,11,14,15,18-20. Asso-
ciated pathology around the knee is also
common, with ligament disruption seen in
association with 43% to 80% of these
fractures16,18,21-25 and meniscal tears seen

Disclosure: No funding source played a role in this investigation. On the Disclosure of Potential
COPYRIGHT © 2018 BY THE JOURNAL Conflicts of Interest forms, which are provided with the online version of the article, one or more of the
OF BONE AND JOINT SURGERY, authors checked “yes” to indicate that the author had a relevant financial relationship in the
INCORPORATED biomedical arena outside the submitted work (http://links.lww.com/JBJSREV/A292).

JBJS REVIEWS 2018;6(2):e4 · http://dx.doi.org/10.2106/JBJS.RVW.17.00050 1

 | Bicondylar Tibial Plateau Fractures
in association with up to 22%23-26.
Operatively treated bicondylar tibial
plateau fractures have been associated
with a high overall complication rate of
28% to 39%3,5,6,15, including deep
wound infections6,9,14,15,18,27-30, non-
unions, and failed treatment requiring
additional surgery12,15,29,31. Compared
with unicondylar plateau fractures,
bicondylar fractures have poorer out-
comes in terms of pain scores, length of
stay, infection, loss of reduction, and
osteoarthritis progression3,6,28,32. Given
the complexity of the injuries and the
potential for complications, research
efforts have sought to elucidate the best
way to diagnose, characterize, and treat
bicondylar tibial plateau fractures. How-
ever, there is little high-level evidence on
this topic. The purpose of the current
review is to present a critical analysis of the
current literature on diagnostic imaging,
classification, and treatment of bicondylar
tibial plateau fractures.
Evaluation
History
Bicondylar tibial plateau fractures most
often occur as a result of high-energy
trauma. The most common mechanisms
reported in 2 large series of bicondylar in-
jures were automobile collisions, falls from
a height, motorcycle collisions, and pe-
destrians being struck by a vehicle14,15. The
mechanism should be well documented in
the history as it can give the treating team
clues as to the energy involved and possible
associated injuries. A high index of suspi-
cion for associated injuries is necessary as
concomitant injuries occur in association
with 60% of bicondylar plateau fractures
and portend a worse outcome1,33-35. Un-
like some other high-energy fractures, these
injuries have a peak incidence in the fifth
decade with a broad range of occurrence
between the second and eighth
decades3,5,7,27,36-43. Medical, social, and
surgical histories are relevant in individual
situations, but few studies on such fractures
have specifically evaluated associations be-
tween patient history and outcomes. Dia-
betes does not appear to increase the risk of
nonunion or infection, although it has
been associated with increased lengths of
2 FEBRUARY 2018
stay and readmission rates15,28. Smoking
was shown to increase the risk of deep in-
fection and infectious complications in 2
recent studies of bicondylar fractures and
all tibial plateau fractures, respectively14,28.
A review of systems also should include
questions directed at neurological symp-
toms (paresthesia and anesthesia) and in-
creasing pain or pain out of proportion to
injury given the relatively high rates of
peroneal nerve injury (8% to 16%) and
compartment syndrome34.
Physical Examination
Basic principles of physical examination
should be followed when assessing a pa-
tient who has a bicondylar tibial plateau
fracture. Limb alignment, open wounds,
and soft-tissue status should be assessed
and documented. Open injuries are
common (prevalence, 8% to 43%), and
thorough descriptions and photographs
are recommended to help plan the opera-
tive approach and to aid in tracking of the
soft-tissue status9-16. Varus and valgus
stress examinations may help in directing
surgical indications (as discussed below)
and should be performed if open treat-
ment is not otherwise clearly indicated.
Neurovascular findings including foot and
ankle motor function, sensation, and
pulses should be documented and reex-
amined serially. Leg compartment pres-
sures should be examined serially given the
high rate of compartment syndrome.
Compartment Syndrome
Compartment syndrome occurs in asso-
ciation with 11% to 27% of bicondylar
tibial plateau fractures and is not infre-
quently missed, with potentially disastrous
consequences9,14,15,18-20,34,44,45. The
most commonly affected compartment in
the leg is the anterior compartment, fol-
lowed by the lateral compartment46. A
high index of suspicion should be main-
tained for compartment syndrome in
these cases, with clinical examination still
being the gold standard for diagnosis in the
awake and reliable patient. Poorly con-
trolled pain and marked pain with passive
stretch of the toes are 2 hallmark findings
of compartment syndrome in this
population47,48. Soft and compressible leg
compartments are reassuring but not in-
fallible findings. Progressive numbness of
the foot or distal leg should be interpreted
as an evolving compartment syndrome
until proven otherwise. Clinical monitor-
ing should be considered during the first
24 to 48 hours after the injury. In the
obtunded or unreliable patient, the diag-
nosis of compartment syndrome may be
easily overlooked or delayed. Compart-
ment pressure monitoring is a reasonable
option if there is a question about the
presence of compartment syndrome. A
number of methods that are available for
the evaluation of compartment pressures
can provide nearly immediate feedback as
to whether compartment syndrome exists
or is likely to evolve49-51. These methods
range from traditional solid-state trans-
ducers to arterial lines. Although these
methods offer valuable information, none
has been found to be a perfect tool. One
must combine these data with a clinical
examination when evaluating these pa-
tients for compartment syndrome.
Imaging
Thorough imaging assessment is essential
when directing the treatment of bicondylar
tibial plateau fractures. Initial orthogonal
radiographs aid in assessing axial stability,
coronal and sagittal alignment, and the
degree of comminution. Quality images
are vital and should include orthogonal
images centered at the injured joint as well
as images of the remainder of the tibia
showing the relative convexity of the lateral
plateau and concavity of the medial pla-
teau. Radiographs of the contralateral knee
may be useful as a comparison template for
fixation. Radiographs are also the modality
that is most commonly used for the post-
operative evaluation of alignment, articular
congruity, fracture-healing, and posttrau-
matic arthrosis.
Advanced imaging techniques
have been increasingly used to charac-
terize these injuries and have been
shown to be valuable tools for directing
operative treatment in terms of the ap-
proach and fixation strategies52,53. The
increased use of computed tomography
(CT) and magnetic resonance imaging
(MRI) have given surgeons insights
· VOLUME 6, ISSUE 2 · e4

regarding fracture morphology and as-
sociated injuries.
CT is a sensitive modality for the
diagnosis of articular collapse and frac-
ture comminution and/or displace-
ment24. CT has allowed for further
description of previously unrecognized
fracture patterns and fragments that
have bearing on fixation strategies and
outcomes. To our knowledge, Khan
et al. were the first to describe a coronal
fracture plane54. Coronal fractures can
be present on the medial and/or lateral
plateau54-66. The posteromedial coronal
fragment has been characterized by
multiple authors as occurring in associ-
ation with 39% to 74% of bicondylar
plateau fractures and has been shown to
involve an average of 25% to 58% of the
medial plateau area55,56,67. Other authors
have described a posterolateral fragment
occurring in 44% to 54% of cases64,65.
Yang et al. described an imaging classifi-
cation system in which the posterolateral
and posteromedial fragments make up a
posterior column; in their series, posterior-
column involvement was noted in associ-
ation with 51% of Schatzker type-V and
22% of Schatzker type-VI fractures66.
Tibial tubercle fractures also have been
identified as an associated injury, with a
prevalence of 16% to 22%7,40. Addition-
ally, CT has shown discordant sagittal
plane deformity in the medial and lateral
condyles in patients with bicondylar frac-
tures, with increased posterior slope in the
lateral plateau as the most common de-
formity68. Information regarding fracture
morphology gathered from preoperative
CT scans is important for planning treat-
ment and predicting outcomes.
Associated soft-tissue pathology
around the knee is also common, with
ligament disruption seen in association
with 43% to 80% of bicondylar tibial
plateau fractures and meniscal tears seen
in association with up to 22% of such
fractures16,18,21-26. MRI has been used
increasingly to aid in soft-tissue injury
diagnosis. Mui et al. concluded that CT
was acceptable to use as an initial screen
for ligamentous injury (sensitivity,
80%) but that MRI was better for the
diagnosis of meniscal injuries23. In
FEBRUARY 2018 · VOLUME 6, ISSUE 2 · e4
another series, MRI demonstrated liga-
mentous injuries in association with
80% of bicondylar tibial plateau frac-
tures and meniscal tears in association
with 49%22. Xu et al. compared radio-
graphs, CT, and MRI for the diagnosis
of periarticular pathology in a study of
71 tibial plateau fractures (Schatzker
types III through VI) and found that CT
was the most sensitive method for diag-
nosing osseous pathology and that MRI
was the most sensitive method for diag-
nosing ligamentous injury, meniscal
pathology, and cartilage delamination,
with both of these methods being more
sensitive than radiographs for the diag-
nosis of soft-tissue pathology24.
There is little high-level evidence
directing the imaging evaluation of
bicondylar tibial plateau fractures. Ra-
diographs are useful guides of alignment
and postoperative metrics. CT provides
additional information regarding spe-
cific fracture fragments and subtle an-
gular inconsistencies and should be
considered for routine use in treatment
planning. MRI is useful for the diagnosis
of associated soft-tissue pathology and
may be used to further direct treatment.
Classification
Many classification systems have been
used to describe the breadth of pathol-
ogy associated with tibial plateau
fractures52,54,69,70. Most commonly
used classification systems include
bicondylar injuries as a distinct subset,
and most systems are based on radio-
graphic findings. No widely used clas-
sification system is universally accepted
or inclusive of all fracture morphologies,
and no system has demonstrated con-
sistently good reliability. Advanced
imaging classification systems may be
used to further characterize specific
fracture fragments and to aid in directing
treatment, but no high-level evidence
exists to support one classification sys-
tem with regard to reliability and the
direction of treatment.
In the classic classification system
described by Schatzker et al., injuries are
categorized on the basis of fracture fea-
tures seen on anteroposterior
Bicondylar Tibial Plateau Fractures |
radiographs69. Types I through IV rep-
resent unicondylar fractures. Type V
describes bicondylar fractures with an
intact metaphysis (“inverted Y”), and
type VI represents bicondylar fractures
with metaphyseal disruption69. The re-
liability of this system has been studied
by multiple investigators, with interob-
server kappa coefficients (indicating the
degree of agreement among observers)
ranging from 0.32 to 0.68 (fair to sub-
stantial agreement) with radiographs,
0.61 to 0.73 (substantial agreement)
with the addition of CT, and up to 0.85
(almost perfect agreement) with
MRI31,52,53,71-73.
The Arbeitsgemeinschaft für
Osteosynthesefragen (AO) and the Or-
thopaedic Trauma Association (OTA)
expanded on the work of the Müller
group by describing a comprehensive
fracture-classification system (AO/
OTA)70. This alphanumeric system is
used to identify the fractured bone, the
location of the fracture in the bone, and
other associated characteristics (rela-
tionship to the joint, degree of commi-
nution). Bicondylar plateau fractures are
labeled 41-C (tibia, proximal end,
complete-bicondylar articular involve-
ment). These type-C fractures are fur-
ther assigned to groups on the basis of
the degree of joint and metaphyseal
comminution. When these groups are
included, the interobserver reliability of
this system has been found to be similar
to that of the Schatzker system, with
kappa coefficients ranging from 0.43 to
0.62 (moderate to substantial
agreement)31,71,72. The reliability im-
proves when only broad types (A, B, and
C) and not subtypes (C1, C2, C3) are
considered71.
More recently, Yang et al. and Luo
et al. proposed a CT-based 3-column
classification system in which the axial
view of the plateau is divided into an-
terolateral, anteromedial, and posterior
columns; fractures are categorized as 0,
1, 2, or 3-column injuries66,74. Bicon-
dylar plateaus are classified as 2 or
3-column fractures. Evaluation of the
interobserver reliability of this system
has demonstrated kappa coefficients
3
 | Bicondylar Tibial Plateau Fractures
ranging from 0.28 to 0.77 (fair to sub-
stantial agreement)72,73.
Treatment
Bicondylar tibial plateau fractures are
unique injuries. Bone quality, the frac-
ture pattern, and a variety of host-related
factors can affect the treatment algo-
rithm. Many fracture characteristics
contribute to the potential for poor
outcomes, and associated soft-tissue in-
juries and patient traits further add to the
complexity of treatment, which makes
the assessment of individual factors that
affect outcome difficult.
Consideration should be given to
risk factors associated with poor out-
comes following the treatment of
bicondylar plateau fractures. Advanced
patient age (.50 years) has been asso-
ciated with unsatisfactory
outcomes27,75,76. Open fractures, com-
partment syndrome, and smoking in-
crease the odds of infection14,18. In a
series of bicondylar fractures associated
with infection, the most prevalent type
of bacteria cultured (47%) was
methicillin-resistant Staphylococcus au-
reus, a pathogen that has been associated
with poor outcomes in other orthopae-
dic infections14.
Many techniques have been de-
scribed for the operative treatment of
bicondylar plateau fractures. Closed,
percutaneous, open, and arthroscopic
reduction techniques have been reported,
with no clear advantage of one technique
over another. Similarly, fracture fixation
can be achieved with a number of external
or internal devices and supplements
through a variety of approaches.
Finally, contributing to the diffi-
culty in choosing treatment for bicon-
dylar tibial plateau fractures is the lack of
validated patient-centered outcome
measures. The Rasmussen and Iowa
scores are the only outcome instruments
designed specifically for fractures
around the knee8,77. These and the other
commonly used outcome measures have
not been validated with vigorous meth-
odology to evaluate the outcomes for
patients with bicondylar tibial plateau
fractures.
4 FEBRUARY 2018
Operative Indications
No recent studies have clearly defined
the indications for nonoperative versus
operative treatment of bicondylar tibial
plateau fractures. The respective con-
tributions of articular incongruity,
malalignment, and instability to out-
come have been studied most exten-
sively. Most studies have included all
tibial plateau fractures, but the general
principles cited apply to bicondylar
fractures. Uncertainty remains with
regard to whether a discrete articular
reduction is correlated with outcomes,
with reports of similar outcomes in pa-
tients with up to 10 mm of articular
incongruity2,8,17,78-84. That is, articular
step-off is not an absolute indication for
surgery or the sole surgical end point.
Instability and malalignment may be
better predictors of outcome and may
be more valuable for directing care4,8.
Multiple studies have shown that in-
stability to stress with the knee in ex-
tension is a predictor of poor outcome
and is therefore an indication for oper-
ative intervention78,81,85. Furthermore,
any degree of varus malalignment and
.5° of valgus malalignment have been
associated with worse outcomes; there-
fore, operative intervention should also
seek to restore a normal joint
axis4,78,81,86. Fracture instability, coro-
nal alignment, and, to a lesser extent,
articular incongruity aid in directing
treatment decisions for these difficult
injuries, although there is no high-level
evidence supporting surgical
intervention.
Timing and Staging
If operative intervention is the chosen
treatment, surgeons must consider the
timing of intervention and the use of
staging procedures as both have been
shown to affect the outcomes for pa-
tients with bicondylar tibial plateau
fractures. The patient’s overall clinical
status and the presence of soft-tissue
injury may be reasons to stage or delay
definitive surgery. Surgical tactics also
must be considered as percutaneous and
hybrid external fixation techniques may
allow for earlier definitive fixation in
patients with extensive soft-tissue in-
juries. Electing to stage fixation with an
immediate temporary external fixator
allows time for patient optimization and
soft-tissue recovery; however, staging in
this manner has been associated with an
increased rate of reoperation3,87. Staged
columnar fixation with initial fixation of
the medial plateau and subsequent de-
finitive fixation has been described in
lieu of more expensive temporary ex-
ternal fixation, with similar complica-
tion rates88. Open fractures may be
treated with initial debridement and
fixation followed by delayed closure,
with satisfactory results89. The timing of
definitive treatment related to com-
partment syndrome has been studied,
and no consensus exists regarding the
timing of definitive fixation in relation
to fasciotomy closure44,45,90. Many
variables influence the timing of defini-
tive fixation and the need for staged
procedures, with no good data existing
to define the optimal timing of fixation.
Open Reduction and
Internal Fixation
Open reduction and internal fixation is
the traditional means of fixation for
bicondylar tibial plateau fractures.
Fractures can be approached via a single
anterolateral approach, or dual medial
and anterolateral approaches with addi-
tional posterior approaches as needed.
Rarely, a midline approach may be re-
quired. The anterolateral approach and
its modifications only expose the lateral
condyle but may avoid soft-tissue
problems associated with the dual and
midline approaches63. The single mid-
line incision allows for a view of the joint
and both condyles with the elevation of
medial and lateral flaps; additionally, the
same incision scar can be used later if
total knee arthroplasty is required91.
However, as is the case with the
anterolateral-only approach, the poster-
omedial plateau cannot be addressed via
the anterior approach, and concerns
have been raised regarding skin necrosis
and deep infection. When comparing
the single midline incision with a dual
incision for the fixation of bicondylar
· VOLUME 6, ISSUE 2 · e4

plateau fractures, Mandal et al. showed a
higher rate of medial joint collapse, skin
necrosis, and infection in the midline-
incision group92. Use of dual medial and
anterolateral approaches raises similar
concerns with regard to the risk of soft-
tissue complications, infection, and
nonunion when compared with a
single lateral or percutaneous
approach, although reduction and the
maintenance of alignment may be
improved9,57,60,74,93. In a meta-analysis
of 9 studies in which dual plating
through dual medial and anterolateral
approaches was compared with plating
through a lateral-only approach, the
pooled data showed a higher rate of skin
necrosis and time to union in association
with the dual approach94. Other small
series have investigated the use of
direct posterior approaches to address
posterior-column components of the
plateau injury; however, no comparative
data exist regarding soft-tissue
complications58,61,62,95-97. Most studies
involving different approaches are done
in the context of differing fixation strate-
gies, making it difficult to draw definitive
conclusions regarding the optimal ap-
proach, given the complexity and varia-
bility of injuries and surgical fixation.
Dual Plating
Early reports of dual plating of bicon-
dylar tibial plateau fractures through
anterolateral and medial approaches
Fig. 1
Figs. 1-A through 1-D Radiographs demonstrating dual plating of a bicondylar tibial plateau fracture. Fig. 1-A Preoperative
anteroposterior radiograph. Fig. 1-B Anteroposterior radiograph made after temporary external fixation. Fig. 1-C Intraoperative
fluoroscopic image made after reduction with dual plating. Fig. 1-D Long-term follow-up anteroposterior radiograph.
FEBRUARY 2018 · VOLUME 6, ISSUE 2 · e4
demonstrated discouragingly high rates
of wound infection and arthrosis30. As
technology, techniques, and the under-
standing of these complex injuries have
improved, outcomes have improved as
well (Fig. 1). Barei et al. reviewed 41
bicondylar plateau fractures that were
treated with dual plating through 2 in-
cisions and reported 2 cases of deep in-
fection (4.9%), with restoration of
coronal alignment in 90% of fractures;
unsatisfactory reduction, increased age,
and associated polytrauma were associ-
ated with poorer functional outcomes27.
In a review of patients with these in-
juries, Yu et al. reported better reduc-
tions but similar outcomes98. Luo et al.
described dual plating for the treatment
of bicondylar fractures with poster-
omedially based fragments and showed
an average Short Form-36 (SF-36) score
of 89 and an average range of motion
from 3° to 123°74. Several other studies
of similar cohorts of patients who have
been managed with dual plating have
demonstrated comparable functional
outcomes and complication
rates62,84,99-102. Ruffolo et al., in what
we believe to be the largest reported se-
ries of bicondylar fractures treated with
medial and lateral plates through 2 in-
cisions, reported on complications and
predisposing factors15. Acceptable
alignment was seen in association with
132 (94.3%) of the 140 fractures;
however, the overall rate of major
Bicondylar Tibial Plateau Fractures |
complications (27.9%; 39 of 140), in-
cluding deep infection (23.6%; 33 of
140) and nonunion (10%; 14 of 140),
was higher than previously reported.
With the dual approach and dual plate-
fixation strategy, approximately 80% of
fractures maintained alignment, with
predominately good to excellent out-
comes in spite of a high rate of major
complications. All of the above studies,
however, were retrospective reviews
without comparison groups, making
definitive conclusions difficult given the
high risk of reporting and selection bias
and the lack of standardized, validated
patient-reported outcome measures.
Two studies have compared the use
of nonlocking and locking plates as a
part of a dual-plating construct for the
fixation of bicondylar tibial plateau
fractures. Zhang et al. found that the
only significant difference between the
use of a lateral locked plate and a non-
locking plate was that a greater volume of
graft was needed to fill defects in the
nonlocking plate group (31 compared
with 20 patients; p 5 0.003)99. An et al.
found similar complication rates and a
significantly higher implant cost for
locking plates when compared with
nonlocking plates (average cost, $4,625
compared with $2,235; p , 0.001)103.
Single Lateral Locking Plate
Fixation of bicondylar tibial plateau
fractures with locking plates and
5
 | Bicondylar Tibial Plateau Fractures
minimally invasive plate-insertion tech-
niques through a single anterolateral
approach has been presented as an al-
ternative to dual plating. As there is only
1 potentially “limited” incision, it has
been theorized that less soft-tissue ma-
nipulation would lead to lower rates of
associated complications. Stannard
et al., in a study of bicondylar plateau
fractures that were treated with single-
incision, less-invasive lateral locked
plating, reported that the rate of ac-
ceptable alignment was 94.6% (35 of
37) and that the rate of superficial in-
fection was 5.4% (2 of 37)16. Two other
small series of bicondylar fractures that
were treated with lateral locked plating
showed similar results11,38,104. Gosling
et al. reported on a larger series and
found a higher rate of initial malre-
duction, with only 59 (85.5%) of 69 of
fractures fixed within 5° of anatomic
alignment12. Furthermore, loss of cor-
onal reduction was seen with collapse
into .5° of varus in 7 (11%) of 63 pa-
tients (Fig. 2). Lee et al. reported on a
small series of patients with similar varus
collapse and cautioned that lateral lock-
ing plates may not be suited for all
bicondylar plateau fractures43. Again, all
of those studies were retrospective re-
views without comparison groups,
making definitive conclusions difficult.
Lateral locked plates seem to have a role
in the fixation of certain bicondylar tibial
Fig. 2
Radiograph made after lateral locked
plating of a bicondylar tibial plateau
fracture. The arrowhead shows medial
cortex overlap, indicating varus collapse
or posteromedial corner malalignment.
6 FEBRUARY 2018
plateau fractures, and comparison of
dual plating to single lateral locked
plating will be discussed in the next
section.
Hasan et al., in a biomechanical
study involving a bicondylar synthetic
bone fracture model, compared 3.5-mm
locking plates with 4.5-mm locking
plates and found only small differences
in axial load to failure in favor of the 4.5-
mm plate but reported no significant
differences in inferior displacement or
elastic deformation105. Smaller 3.5-mm
locking plates are likely viable alterna-
tives to 4.5-mm locking plates and may
be associated with less soft-tissue
irritation.
Dual Plating Versus Single Lateral
Locked Plating
Several investigators have compared
dual plating and single lateral locked
plating for the treatment of bicondylar
tibial plateau fractures. In a bicondylar
plateau fracture cadaveric model,
Horwitz et al. established a protocol for
testing load to failure and subsidence
with cyclic loading of different plate
configurations and found dual plating
to be more stable than a single lateral
buttress plate106. In subsequent bio-
mechanical studies, this model was
used to compare lateral locked plating
with various configurations of dual
plating. Two studies involving a lim-
ited number of cycles demonstrated no
difference in construct stiffness, load to
failure, or medial condylar displace-
ment when lateral locked plating was
compared with dual plating107,108. In a
study of displacement after cyclic
loading, the average displacement was
9.6 mm in the single lateral locked
plating group compared with 4.9 mm
in the dual plating group11. In another
study of cyclic loading, there was a
significant increase in medial subsi-
dence for laterally based locking plates
(1.51 versus 0.78 mm) but no differ-
ence in load to failure109. The afore-
mentioned tests were performed with
use of a bicondylar fracture model that
did not include a posteromedial coro-
nal component, which is a common
feature of this type of this injury that
may contribute to varus collapse if not
addressed. Yoo et al., in a bicondylar
fracture model that included a poster-
omedial coronal component, reported
significantly higher load to failure when
dual plating with a posteromedial but-
tress was compared with single lateral
locked plating with screws that did not
engage the posteromedial fragment;
however, no difference was observed
when the comparison involved a locked
plate with screws that did engage the
posterior medial fragment110. On the
basis of these studies involving simu-
lated physiological stresses (cyclic
loading), dual plating appears to be a
significantly sounder biomechanical
construct than single lateral locked
plating, and the data suggest that this
difference is magnified in fractures with
a posteromedial coronal component.
In clinical studies comparing dual
plating and single lateral locked plating,
no configuration has proven to be con-
sistently superior in terms of fixation or
outcomes. Weaver et al. reviewed a co-
hort of patients with bicondylar plateau
fractures that were treated with either
dual plating or single lateral locked
plating and found that there was a higher
rate of medial subsidence when single
lateral locked plating was used for in-
juries with coronal fractures of the me-
dial condyle (2° versus 0.5° varus
reduction loss, p 5 0.01)56. Lee et al., in
a study involving a similar cohort,
reported longer operative times in the
dual plating group but similar results in
terms of union rates, functional out-
comes, and postoperative alignment;
although no subgroup analysis was per-
formed and significance was not met, all
cases of malalignment in the single lat-
eral locked plating group (3 of 15) oc-
curred in patients with associated
posteromedial fracture components111.
In a retrospective review of 302 bicon-
dylar fractures that were treated with
open reduction and internal fixation,
Morris et al. found that treatment with a
dual approach and dual plating was an
independent risk factor for deep infec-
tion requiring reoperation when
· VOLUME 6, ISSUE 2 · e4

compared with a single incision and
single-plate fixation14. Jiang et al., in a
prospective cohort study in which dual
plating was compared with single lateral
locked plating, found no differences
between the groups in terms of outcome
measures, complications, or reoperation
rates; however, longer operative times
and incision lengths were noted in the
dual plating group and more initial
malalignment was noted in the single
lateral locked plating group112. In a
similar prospective cohort study, Neogi
et al. reported an increased operative
time and a higher rate of superficial in-
fection in association with dual plating
but noted comparable outcome mea-
sures and no differences in terms of
subsidence113. In a randomized con-
trolled trial in which bicondylar plateau
injures with relatively intact medial
condyles were treated with dual buttress
plating or single lateral locked plating,
Yao et al. found no differences between
the groups in terms of alignment, ra-
diographic outcomes, or clinical out-
comes but noted increased lengths of
stay, operative times, and delayed union
rates in the dual plating cohort114. In
summary, dual plating via anterolateral
and medial approaches seems to be a
viable option for the treatment of
bicondylar plateau fractures, but we are
aware of no high-level evidence sug-
gesting that it is superior to other
Fig. 3
Figs. 3-A through 3-D Radiographs showing a bicondylar tibial plateau fracture that was treated with a ringed fixator. Fig. 3-A
Preoperative anteroposterior radiograph. Fig. 3-B Preoperative lateral radiograph. Fig. 3-C Postoperative anteroposterior
radiograph. Fig. 3-D Postoperative lateral radiograph.
FEBRUARY 2018 · VOLUME 6, ISSUE 2 · e4
methods. Comparative studies have
suggested that there may be an increase
in superficial wound infection and/or
necrosis rates when dual plating is
compared with single-incision tech-
niques, although, to our knowledge, no
prospective studies have demonstrated
an increased rate of deep infection115.
Single lateral locked plating can be a
similarly viable treatment but may not
be as reliable for controlling fractures
with extensive posteromedial coronal or
highly unstable medial fragments. Ad-
ditional definitive research is needed to
determine the specific patient popula-
tions and fracture characteristics that
lead to more favorable outcomes with a
given approach.
Definitive External Fixation
A limiting factor for early internal fixa-
tion of tibial plateau fractures is often
soft-tissue injury36,116. Although resto-
ration of the plateau is the objective,
internal fixation may not be possible if
dissection cannot be performed through
compromised soft tissues. An alternative
to open plating is the utilization of hy-
brid or ring external fixation117 (Fig. 3).
Although dual plating has been
found to be the strongest construct
biomechanically, hybrid or ring external
fixation offers a stable construct with
potentially less-extensive soft-tissue dis-
section. In addition, this technique
Bicondylar Tibial Plateau Fractures |
allows for early motion and the restora-
tion of nearly normal range of
motion118,119. Hybrid fixation includes
a combination of an Ilizarov-type ring at
the joint and a monolateral external
fixator in place of a second, distal ring.
Fracture reduction is accomplished with
use of manual traction and, if necessary,
small anteromedial or anterolateral in-
cisions to access and elevate articular
fragments, which are then fixed with
percutaneous wires inserted distal to the
joint line120,121. Some authors have used
subchondral screws in addition to fine-
wire fixation for the repair of articular
fractures13,116,122. Schanz pins are then
placed in the diaphysis and are con-
nected to a longitudinal bar or a second
ring, which is then connected to the fine-
wire ring, joining the metaphyseal and
diaphyseal segments. Ramos et al. uti-
lized ring external fixation in a series of
30 patients, including 11 patients with
Schatzker type-I through IV fractures
and 19 patients with Schatzker type-V
and VI fractures; all fractures healed with
minimal adverse outcomes, with satis-
factory results in a majority of pa-
tients123. The average healing time
following ring external fixation as
reported in the literature is 14 weeks,
which is comparable with those of plat-
ing techniques118,120,121. The func-
tional outcomes following ring external
fixation have been promising in multiple
7
 | Bicondylar Tibial Plateau Fractures
studies, with excellent clinical outcomes
in terms of Knee Society and Rasmussen
scores33,42,124-126. The Canadian Or-
thopaedic Trauma Society performed a
prospective randomized clinical trial of
83 fractures and reported similar clinical
outcomes when circular external fixa-
tion was compared with open reduction
and internal fixation127,128.
As with any operative intervention,
ring fixator treatment is not without
complications. The most common
complication is pin-site infection. The
majority of these infections are superfi-
cial, with the reported prevalence rang-
ing from 4% to 20%39,116,121. Stamer
et al. reported a 13% rate of deep wound
infection117. Superficial infections are
amenable to antibiotic treatment and
rarely require surgical intervention.
Substantial malalignment has been
reported in 8% to 14% of patients10,82.
Katsenis et al. evaluated the radiographic
and functional outcomes minimal in-
ternal fixation augmented by small-wire
external fixation at 5 years postopera-
tively and found a statistically significant
deterioration in terms of radiographic
arthritis but noted that functional results
remained satisfactory over time122.
External Fixation Versus Open
Reduction and Internal Fixation
The Canadian Orthopaedic Trauma
Society, in what we believe to be the
largest prospective randomized con-
trolled trial in which open reduction and
internal fixation was compared with
circular external fixation, reported that
external fixation was associated with less
blood loss, a shorter length of stay, and a
lower rate of repeat operations127,128.
The open reduction and internal fixa-
tion group had a greater severity of
complications. Outcome scores and the
rate of return to preinjury activities were
greater in the external fixation group at 6
and 12 months, but these differences
were not seen at 24 months. The re-
duction quality was similar between the
2 groups. Two other studies that evalu-
ated complication rates demonstrated
no differences between internal and ex-
ternal fixation in terms of the rates of
8 FEBRUARY 2018
venous thromboembolism, compart- the superiority of one fixation strategy
ment syndrome, and deep infection but over another. Surgeons must take all of
did show that external fixation was as- these data into account and apply them
sociated with higher rates of superficial to the specifics of each patient.
infection (14.0% versus 4.7%)129,130.
Conflicting data exist with regard to Conclusion
clinical outcomes, with some studies Bicondylar tibial plateau fractures con-
showing no difference and others sist of a complex constellation of injury
showing a decreased rate of knee stiffness components that make their diagnosis
in association with open reduction and and treatment nuanced and challenging
internal fixation129,131-134. (Table I). When evaluating these frac-
With regard to construct strength, tures, one must be mindful of associated
Ali et al. compared multiple fixation injuries in multi-traumatized patients
methods in terms of failure load and and the relatively high rates of soft-tissue
subsidence and reported no statistical injuries, open fractures, and compart-
differences when dual plating was spe- ment syndrome. Radiographs are the
cifically compared with 2-ring hybrid initial imaging modality of choice and
fixation36,135,136. are used to assess reduction, alignment,
In current practice, single and dual and postoperative arthrosis. Advanced
plating appear to be the main treatments imaging should be used to assess specific
utilized. Surgeons also must be aware of fracture fragments that may need special
the alternative treatments involving the consideration when choosing fixation.
use of ring or hybrid external fixators, CT is more reliable for assessing osseous
which may be beneficial for patients detail, and MRI is more reliable for
with exceptionally traumatized soft tis- assessing articular cartilage and meniscal
sues, osteopenia, and fracture commi- abnormalities. Bicondylar fractures are
nution117. The literature is not clear as to classified with use of the Schatzker,
TABLE I Recommendations for Bicondylar Tibial Plateau
Fracture Diagnosis and Management
Grade of
Recommendations Evidence*
Advanced imaging (CT and/or MRI) should be B
used to characterize injury
Classification into unicondylar or bicondylar over B
other systems
Operative treatment C
Delayed/staged treatment C
High rate of overall complications in operative B
treatment
Similar outcome with dual approach/plating, B
single lateral locked plating, hybrid external
fixation
Similar complications with dual approach/plating, B
single lateral locked plating, hybrid external
fixation
*Grade A 5 Good evidence (Level-I studies with consistent findings) for or against
recommending intervention. Grade B 5 Fair evidence (Level-II or III studies with
consistent findings) for or against recommending intervention. Grade C 5 Poor-
quality evidence (Level-IV or V studies with consistent findings) for or against
recommending intervention. Grade I 5 There is insufficient evidence to make a
recommendation.
· VOLUME 6, ISSUE 2 · e4

AO/OTA, or 3-column schema with
fair reliability, and therefore simply dis-
tinguishing unicondylar from bicondy-
lar fractures with a description of specific
fracture lines and impaction may be the
most reliable means of categorizing these
injuries.
The treatment of bicondylar tibial
plateau fractures should be directed at
addressing the soft-tissue injury, restor-
ing coronal alignment and angular sta-
bility, and, perhaps to a lesser extent,
reducing the articular surface. These
goals are most often accomplished with
operative fixation. Given the heteroge-
neity of these injuries, the optimal tim-
ing of definitive operative treatment is
variable and should be considered on a
case-by-case basis. Staging definitive
treatment utilizing a temporary external
fixator or staged plating and delayed
definitive fixation may allow for soft-
tissue convalescence. Dual medial and
lateral buttress plating via dual
approaches is a reliable means of attain-
ing and maintaining reduction of
bicondylar fractures but is associated
with higher potential for superficial
wound issues. The insertion of a single
lateral locked plate via a single lateral
incision can mitigate some soft-tissue
damage risk but does not reliably address
all fracture subtypes, especially those
associated with a posteromedial coronal
fracture line. Operative treatment with
percutaneous reduction and ring or hy-
brid external fixation is an alternative to
open approaches that may further de-
crease secondary soft-tissue damage
caused by surgical approaches. No single
fixation strategy has been proven to be
associated with superior outcomes or
fewer associated complications. Each
bicondylar tibial plateau injury should
be treated with consideration of the
specific characteristics of the patient,
the soft tissues, and the fracture in the
knowledge that no single method of
treatment is likely to be able to treat the
full spectrum of possible injuries. Fur-
ther research is needed to assess how
specific fracture types may be more fa-
vorably treated to optimize patient-
reported outcomes.
FEBRUARY 2018 · VOLUME 6, ISSUE 2 · e4
Adam K. Lee, MD1,
Seth A. Cooper, MD1,
Cory Collinge, MD1
1Department of Orthopedic Surgery,
Vanderbilt University Medical Center,
Nashville, Tennessee
E-mail address for C. Collinge: ccollinge@
msn.com
ORCID iD for A.K. Lee: 0000-0002-9579-
8435
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