ORIGINAL ARTICLE
Incidence, Risk Factors, and Location of Articular
Malreductions of the Tibial Plateau
Brad Meulenkamp, MD, FRCSC,* Ryan Martin, MD, FRCSC,† Nicholas M. Desy, MD, FRCSC,†
Paul Duffy, MD, FRCSC,† Rob Korley, MD, FRCSC,† Shannon Puloski, MD, FRCSC,†
and Richard Buckley, MD, FRCSC†
Objectives: To define the incidence, risk factors, and anatomic
location of articular malreductions in operatively treated lateral tibial
plateau fractures.
Design: Prospective Cohort Study.
Setting: Academic Level 1 Trauma Centre.
Patients/Participants: Study subjects were patients entered into
a prospective cohort study of tibial plateau fractures.
Interventions: Surgical fixation of tibial plateau fractures and
postoperative computed tomographies (CTs).
Main Outcome Measures: The primary outcome was incidence
of articular malreduction. Secondary outcomes included risk factors
for malreduction and a descriptive analysis of malreduction location.
Results: Sixty-five postoperative CTs were reviewed. Twenty-one
reductions (32.3%) had a step or gap more than 2 mm. The
frequency of malreductions in patients undergoing submeniscal
arthrotomy or fluoroscopic-assisted reduction alone was 16.6% and
41.4%, respectively (P = 0.0021). Age, body mass index, OTA/AO
fracture type, operative time, use of bone graft or bone graft sub-
stitute, and use of locking plates were not predictive of malreduction.
Malreductions were heavily weighted to the posterior quadrants of
the lateral tibial plateau.
Conclusions: When examined using cross-sectional imaging the
rate of articular malreductions was high at 32.3%. Fluoroscopic
reduction alone was a predictor for articular malreduction. Most
Accepted for publication September 27, 2016.
From the *Division of Orthopedic Surgery, University of Ottawa, Ottawa, ON,
Canada; and †University of Calgary, Cumming School of Medicine,
Section of Orthopaedic Surgery, Calgary, AB, Canada.
Grant funding was provided through the Canadian Orthopaedic Foundation
“Hip Hip Hooray” and the Calgary Orthopaedic Research and Education
Fund.
The authors report no conflict of interest.
Presented as a poster at the Orthopaedic Trauma Association Annual
Meeting, October 9, 2015, San Diego, CA.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal’s Web site (www.jorthotrauma.
com).
Reprints: Brad Meulenkamp, MD, FRCSC, The Ottawa Hospital Civic
Campus, 1035 Carling Avenue Room J129, Ottawa, ON K1Y 4E9,
Canada (e-mail: brad.meulenkamp@gmail.com).
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DOI: 10.1097/BOT.0000000000000735
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malreductions were located in the posterior quadrants of the lateral
plateau.
Key Words: tibial plateau fracture, malreduction
Level of Evidence: Therapeutic Level II. See Instructions for
Authors for a complete description of levels of evidence.
(J Orthop Trauma 2017;31:146–150)
INTRODUCTION
Tibial plateau fractures are common injuries,
accounting for 1% of all fractures. Seventy percent of
fractures are isolated to the lateral plateau, with 10%–30%
bicondylar and less than 10% isolated medial condyle frac-
tures.1 Displaced fractures are treated with open reduction
and internal fixation. Goals of treatment include restora-
tion of extremity axial alignment, joint stability and
congruity, allowing for early motion, and prevention of
osteoarthritis.
Short-term results of surgical fixation of tibial plateau
fractures are good; however, longer-term outcomes have
demonstrated a significantly higher risk of end-stage arthritis
and total knee arthroplasty,2 whereas historical literature has
recommended accepting a step deformity of up to 10 mm,
the contemporary literature suggests that articular malreduc-
tions of as little as 2 mm may be associated with inferior
clinical outcomes.3
It has been shown for many fractures that a surgeon’s
ability to interpret either fluoroscopic or plain film
x-rays for malreductions is both insensitive and poorly
specific (see Figure, Supplemental Digital Content 1,
http://links.lww.com/BOT/A803).4 Despite the vast literature
around tibial plateau fractures, to our knowledge, there are
no series examining postoperative reductions using axial imag-
ing. It is our goal to define the incidence of articular malreduc-
tions after surgical fixation of lateral tibial plateau fractures
using cross-sectional imaging, to identify patient or surgeon
factors associated with malreductions, and to define any
regional patterns of malreduction location.
PATIENTS AND METHODS
Subjects
Sixty-nine patients were recruited to a prospective
comparative cohort study of OTA-41B/C-type tibial plateau
J Orthop Trauma  Volume 31, Number 3, March 2017
J Orthop Trauma  Volume 31, Number 3, March 2017 Tibial Plateau Malreductions

fractures comparing outcomes of surgery following (1) surface was determined by the OTA/AO fracture classification.
submeniscal arthrotomy–assisted reduction or (2) fluoro- Simple articular fractures were categorized as 41-B1, C1, and C2,
scopic guided reduction alone. Patients were admitted to the whereas complex articular fracture patterns were grouped into
study and had treatment based on surgeon preference alone. 41-B2, B3, and C3. Values with a P value ,0.05 were consid-
No attempts were made at randomization. All patients had ered statistically significant. The analysis was performed using
received preoperative computed tomographies (CTs) as part JMP Pro11 software (SAS Institute Inc, Cary, NC).
of the preoperative work-up. Patients were treated with plate
and screw constructs. Meniscal tears were repaired when
encountered. No patients were treated with either temporizing RESULTS
or definitive external fixators. This study passed the require- Of 69 patients enrolled in the prospective cohort study, 65
ments of the local University Conjoint Medical Ethics board. postoperative CTs were available for review. The average patient
Eligible patients obtained CTs before hospital discharge, age was 47.7 years (range 25–70). There were 39 male patients
within 48 hours of surgical fixation in keeping with the study and 26 females. The causes of injury varied in severity and energy
protocol. All CT studies were deidentified. Three independent and are listed in a supplemental file (see Table, Supplemental
assessors, 2 orthopaedic trauma fellows, and a staff orthopae- Digital Content 2, http://links.lww.com/BOT/A804). According
dic surgeon reviewed axial, sagittal, and coronal cuts of the to the OTA/AO classification,8 there were 54 OTA/AO 41B-type
CTs to identify articular malreductions. Assessors were fractures and 11 OTA/AO 41C type fractures. Based on the
blinded to treating surgeon and study treatment arm. Malre- Schatzker classification,9 there were 47 type 2 fractures, six type
ductions were defined a priori as either a step or gap defor- 3 fractures, one type 4 fracture, and 11 type 5 fractures.
mity greater than 2 mm within the weight-bearing articular Twenty-one of 65 CTs (32.3%) were identified as
surface. Bone voids were considered gaps if there was an having a malreduction. A step deformity was most common
associated increased condylar width greater than 5 mm.3 Dis- with 19 (29%) having this malreduction. The mean size of
agreements were discussed and resolved by consensus. Step step deformities was 5.1 mm (3.2–8.9). Seven gaps were
and gap malreductions were measured and the incidence of identified (11%), with a mean size of 8.4 mm (5.3–11). Five
steps and gaps were calculated. patients had both a step and gap identified.
Patient demographic, fracture characteristics, and sur-
Mapping of Malreductions gical variables are listed in Table 1. Using a fluoroscopic
We used the Cole fracture-mapping technique which guided reduction technique alone rather than submeniscal ar-
has been well described in the literature.5–7 Subject CTs throtomy was found to be a statistically significant risk factor
identified as malreductions were uploaded to OsiriX Dicom for obtaining a malreduction (P = 0.0021) (Table 2). The
(Geneva, Switzerland) software and 3-dimensional reformats
were created. Using the scout function, coronal, and sagittal cuts
were scrolled through to identify and trace the malreduced “fault TABLE 1. Patient Demographics, Fracture Characteristics, and
line” on the axial sequence. Axial cuts were chosen 3-mm distal Surgical Variables
to the articular surface, defined as the apex of the lateral tibial Malreduced Reduced
plateau. Step malreductions were traced using a “point and trace” Characteristic (n = 65) (n = 21) (n = 44)
tool, and gaps were shaded using a brush tool. The axial cuts Mean age (range) in Y 48.4 (36–69) 46 (25–70)
were then digitally transferred to Gimp Photoshop (GimpShop, BMI (range) 28.2 (19–36) 27.2 (19–40)
Tampa, FL). The images were standardized to side, and grid was Sex, % M: 14 (67) M: 30 (61)
overlaid to calibrate sizing and rotation. The posterior cruciate F: 7 (33) F: 19 (39)
ligament sulcus and posteromedial corner were found to be con- Side of injury, % L: 13 (62) L: 29 (66)
sistent rotational landmarks. Overlay images were then created R: 8 (38) R: 15 (34)
for both steps and gaps, with a resulting density map of the OTA/AO classification, % 41-B1: 0 (0) 41-B1: 5 (11)
malreductions. 41-B2: 2 (10) 41-B2: 7 (16)
41-B3: 13 (62) 41-B3: 20 (45)
Data Analysis 41-C1: 3 (14) 41-C1: 6 (14)
The analysis of malreductions was descriptive in nature. 41-C2: 3 (14) 41-C2: 4 (9)
Baseline demographic data were obtained at the time of study 41-C3: 0 (0) 41-C3: 2 (5)
enrollment. The database was then reviewed for patient demo- Plate type, % Locked: 9 (43) Locked: 24 (55)
graphic and surgical variables including age, body mass index, Conventional: 12 (57) Conventional: 20 (45)
sex, side of injury, fracture classification, type of plate used, use Use of bone graft or bone Yes: 19 (90) Yes: 39 (89)
of bone graft or bone graft substitute, reduction technique graft substitute, % No: 2 (10) No: 5 (11)
(fluoroscopic guided or submeniscal arthrotomy), operative time, Reduction technique, % Fluoro: 17 (81) Fluoro: 20 (45)
and fluoroscopic time. Univariate analyses in the form of Arthrotomy: 4 (19) Arthrotomy: 24 (55)
a logistic regression were used to identify risk factors for Fluoro time (range) in m 0.71 (0.2–1.5) 0.68 (0.1–5.0)
malreduction. Variables assessed included age, body mass index, Operative time (range) 75.8 (52–110) 67.4 (39–126)
sex, articular surface fracture complexity, type of plate used in m
(locking vs. nonlocking), use of bone graft or bone graft BMI, body mass index; F, female; L, left; M, male; R, right.
substitute, and operative time. Fracture complexity at the articular

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Meulenkamp et al J Orthop Trauma  Volume 31, Number 3, March 2017

are indeed common, with the incidence in keeping with

TABLE 2. Risk Factors for Tibial Plateau Articular Surface
previously published rates using the same reduction criteria
Malreduction
and orthogonal radiographs.3 We found malreductions to be
Odds 95% Confidence heavily weighted to the posterior quadrants of the lateral tibial
Parameter Ratio P Interval
plateau using the Cole mapping technique, with 77% of mal-
Age 1.01 0.6321 0.96–1.07 reductions extending into the posteromedial quadrant. Addi-
Male sex 1.52 0.4485 0.51–4.50 tionally, we identified that using a fluoroscopic reduction
BMI 1.05 0.4197 0.94–1.17 alone, rather than in association with a submeniscal arthrot-
Complex articular surface 1.17 0.7908 0.37–3.65 omy, is a surgical risk factor associated with malreductions.
fracture (41-B2, B3, C3)
There has been recent renewed interest in posterior and
Nonlocked plate fixation 1.6 0.3781 0.56–4.56
posterolateral plateau fracture variants.10–13 The incidence of
Bone graft/substitute 1.22 0.8229 0.22–6.86
posterolateral fragments have been shown in CT studies to be
Fluoroscopic-assisted 7.2 0.0021 1.85–28.02
reduction alone anywhere from 11% to 36% of OTA B-type fractures and
Operative time 1.02 0.1945 0.99–1.04 54% of OTA C-type fractures, with the majority displaced
at presentation.10,14 This realization has led to the develop-
BMI, body mass index. ment of a novel “3-column” fracture classification of tibial
plateau fractures.15 The implication for these findings is the
suggestion that a posterolateral- or posterior-based surgical
malreduction rate in patients undergoing fluoroscopic guided approach may lead to more direct access to these displaced
reduction alone was 46% (17/37), whereas it was 14.3% (4/ fractures, with the goal to obtain and maintain an anatomic
28) when patients underwent a submeniscal arthrotomy. articular reduction.11,16,17 We echo these recommendations,
Fracture lines and their corresponding malreductions however, more work needs to done to define what specific
were stratified based on quadrant location on either side of the fracture patterns most benefit from posterior-based approaches.
plateau. The distribution of fracture lines was found to be The importance of articular reductions in tibial plateau
heterogenous throughout the lateral quadrants of tibial plateau fractures has long been debated with outcome-based accept-
(Fig. 1A), whereas malreductions were found to predominate able criteria evolving over the past 40 years. In the laboratory,
in the posterior quadrants (Fig. 1B). Specifically, fractures it has been shown that articular contact stresses increase up to
lines were more likely to be reduced in the anterior quadrants 75% greater than baseline with a 3-mm step.18 Lucht and
with only 23% of malreductions extending to the anterolateral Pilgaard as well as Lansinger deemed functional results to
quadrant despite 83% of fracture lines extending here. By be acceptable if articular depression was less than
comparison, 80% of fracture lines extended to the posterome- 10 mm,19,20 whereas Rasmussen and Blokker both advocated
dial quadrant, with 77% of malreductions persisting here. No to decrease acceptable reduction criteria to 5 mm of articular
malreductions were identified on the medial tibial plateau. step.21,22 Critiquing these studies, however, reveals that re-
Step deformities in particular were found to be almost exclu- ductions were judged based on radiological views that are
sively in the posterior quadrants of the lateral plateau (Fig. 2), known to have poor sensitivity and specificity, heteroge-
whereas gaps were found more centrally (Fig. 3), but also neous, physician-based, and nonvalidated outcome measures
predominantly in the posterior quadrants. that may not capture relevant deficiencies and small series
numbers with short follow-up. More recently, Barei et al3
demonstrated inferior results with articular malreductions as
DISCUSSION small as 2 mm in their large series of bicondylar tibial plateau
Displaced tibial plateau fractures require meticulous fractures. Recent work has shown that the risk of total knee
reduction and stable fixation to minimize complications such replacement after tibial plateau fractures reaches 5 times that
as stiffness, instability, and osteoarthritis. This study illus- of a matched cohort of patients at 10 years.2 Realizing that
trates that articular malreductions of the lateral tibial plateau universal satisfactory outcomes are not guaranteed, it is

FIGURE 1. Quadrant distribution

of fracture lines (A) and malre-
ductions (B).

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J Orthop Trauma  Volume 31, Number 3, March 2017
FIGURE 2. Overlay map of step malreductions of the tibial
plateau.
advocated that in addition to meticulous soft tissue handling
and restoration of the mechanical axis, anatomic articular
reduction should also be a priority.
Given the variable evidence of importance of articular
reductions, some question the need to perform a submeniscal
arthrotomy in fear of increasing surgical insult. The concern is
related to further soft tissue dissection leading to both an
increased risk of devascularizing fracture fragments, and
increasing the risk of arthrofibrosis and knee stiffness.
Although this has not yet been sorted in the literature, further
study may provide more insight to this concern. We have
clearly shown that a submeniscal arthrotomy allows for more
anatomic articular reconstruction; however, articular visuali-
zation with an arthrotomy is still minor and malreductions can
still be anticipated. This is particularly true given the posterior
tibial plateau which is especially difficult to access. To
FIGURE 3. Overlay map showing density of gap malre-
ductions of the tibial plateau. Darker shadings correspond to
overlapping gaps. Editor’s Note: A color image accompanies
the online version of this article.
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Tibial Plateau Malreductions
decrease articular malreductions, we encourage accessory
measures of visualization for displaced fractures in the
posterior plateau quadrants including, but not limited to
a submeniscal arthrotomy. Many other strategies also exist,
including alternative surgical approaches,11,12,16,17 arthro-
scopic assistance,23,24 use of a distractor, and accessory fluo-
roscopic views.25 An advantage of the submeniscal
arthrotomy is that it also allows the surgeon to also address
meniscal tears, which have been shown to reach 45% in some
fracture subtypes.26
This study has several limitations. Most importantly, it
presents data that are purely radiological without associated
patient outcome scores. Two-year outcome data are currently
being analyzed and will be presented in a subsequent article.
Additionally, while we did use 3 independent reviewers for
malreduction identification on CT, no radiologist was included
and no inter or intraobserver reliability testing was performed.
Also, majority of our patients were OTA B-type fractures with
a limited number of C-type fractures. This limits our ability to
extrapolate our results to include medial plateau and may
underestimate the rate of medially based malreductions. The
main strength of this study is that it is a consecutive cohort of
similar fractures with careful CT evaluation.
We have demonstrated that articular malreductions are
common after tibial plateau fracture fixation, reaching more than
30%. We have also defined malreduction location, with a large
predisposition for the posterior aspect of the lateral tibial plateau.
From a radiological outcome perspective, we would advocate
using adjuncts to assist in visualizing and reducing fractures of
the lateral plateau, including submeniscal arthrotomy. The
importance of obtaining an anatomic articular reduction as it
relates to clinical outcomes remains controversial.
ACKNOWLEDGMENTS
The authors are thankful to the Center for Clinical and
Translational Science (Mayo Clinic, Rochester, Minnesota)
for their help with statistical analysis.
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