The Knee 19 (2012) 94–98

Contents lists available at ScienceDirect

The Knee

Biomechanical analysis of four different fixations for the posterolateral shearing tibial
plateau fracture
Wei Zhang a, Cong-Feng Luo a,⁎, Sven Putnis b, Hui Sun a, Zhi-Min Zeng a, Bing-Fang Zeng a
a
Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, Shanghai JiaoTong University, 600 Yishan Road, Shanghai, 200233, China
b
Trauma & Orthopaedic Department, St. George's Hospital, London, UK

a r t i c l e i n f o a b s t r a c t

Article history: The posterolateral shearing tibial plateau fracture is uncommon in the literature, however with the increased
Received 5 September 2010 usage of computer tomography (CT), the incidence of these fractures is no longer as low as previously
Received in revised form 24 December 2010 thought. Few studies have concentrated on this fracture, least of all using a biomechanical model. The purpose
Accepted 4 February 2011
of this study was to compare and analyse the biomechanical characteristics of four different types of internal
fixation to stabilise the posterolateral shearing tibial plateau fracture. Forty synthetic tibiae (Synbone, right)
Keywords:
Tibial plateau
simulated the posterolateral shearing fracture models and these were randomly assigned into four groups;
Posterolateral Group A was fixed with two anterolateral lag screws, Group B with an anteromedial Limited Contact Dynamic
Shearing fractures Compression Plate (LC-DCP), Group C with a lateral locking plate, and Group D with a posterolateral buttress
Biomechanics plate. Vertical displacement of the posterolateral fragment was measured using three different strengths of
Internal fixation axial loading force, and finally loaded until fixation failure. It was concluded that the posterolateral buttress
plate is biomechanically the strongest fixation method for the posterolateral shearing tibial plateau fracture.
© 2011 Elsevier B.V. All rights reserved.

1. Introduction clinical technique reports of using a posterolateral buttress plate for a

Tibial plateau fractures are common, but reports of posterolateral
shearing tibial plateau fractures are comparatively rare. The mecha-
nism of this fracture is a combination of valgus stress and axial
compression forces with knee in flexion [1,2]. The fracture line of a
posterolateral shearing tibial plateau fracture appears in the coronal
plane, making it difficult to identify using plain AP radiographs of the
knee [3–5]. As computer tomography (CT) is becoming commonly
used in the diagnosis and evaluation of intra-articular fractures, this
kind of fracture has been found with increasing frequency. Recently a
number of authors have presented a more detailed description of the
incidence and morphology of the posterolateral fragment in tibial
plateau fractures [4–6]. Since the posterolateral fragment is unstable,
open reduction and internal fixation (ORIF) is indicated to restoring
congruity and stability of the knee [7].
The treatment for this kind of fracture remains controversial.
Different methods for reduction and fixation of the posterolateral
shearing tibial plateau fracture have been described [8–11]. Currently
there are no published biomechanical studies looking at the efficacy of
these different types of fixations for the posterolateral fragment. The
implants commonly in use are two anterolateral parallel lag-screws,
an anteromedial T-shaped Limited Contact Dynamic Compression
Plate (LC-DCP) and a lateral locking plate. Recently, there are some
⁎ Corresponding author. Tel.: + 86 21 64369181x58800; fax: + 86 21 64083239.
E-mail addresses: zw_850228528@126.com (W. Zhang), cong_fengl@yahoo.com.cn
(C.-F. Luo).
posterolateral shearing tibial plateau fracture, positioned ideally to
prevent fixation failure and collapse of the joint [12,25].
The purpose of our study is to compare the biomechanical
performance of a posterolateral buttress plate with the other three
conventional internal fixation methods currently in use. A synthetic
tibia model was used to simulate a posterolateral shearing fracture.
Our hypothesis was that the posterolateral buttress plate would
provide adequate stability and present the best biomechanical
strength.
2. Materials and methods
In this study, 40 synthetic tibiae were used to make models of a
posterolateral shearing tibial plateau fracture. All the models were
randomly assigned into four groups and fixed with four different
internal fixations. Each specimen was fixed vertically on the bedstead
of a material testing machine for the biomechanical testing.
2.1. Materials
Forty synthetic tibiae (right Synbone, type 1110. Synbone AG,
Swiss) were used to make models of a posterolateral shearing tibial
plateau fracture. The four different implants chosen for the fixation of
fracture models were 6.5 mm lag screws, a 4.5 mm 6-hole T-shaped
LC-DCP (Kanghui Medical Ltd., Changzhou, China), a 3.5 mm lateral
LCP proximal tibial plate (Synthes GmbH, Oberdorf, Switzerland), and
a 3.5 mm straight LC-DCP(Kangli Medical Ltd., Suzhou, China. Each

0968-0160/$ – see front matter © 2011 Elsevier B.V. All rights reserved.
doi:10.1016/j.knee.2011.02.004
 W. Zhang et al. / The Knee 19 (2012) 94–98
specimen was fixed vertically on the table of a material testing
machine (Instron 5569, USA) and the vertical displacement of the
posterolateral fragment was measured by an electronic gauge (Type
FCS1-5-15, Shanghai, China) . The gauge's length and precision was
15 mm and 0.005 mm respectively. All the materials were purchased
from a single manufacturing batch to ensure the same properties,
with consistency in their material and geometry, ensuring better
control of specimen variability.
2.2. Modelling
We treated 323 tibial plateau fractures from September 2005 to
September 2008, among which 116 cases were posterolateral
shearing fractures. The fracture model was made based on the
fracture morphology measured on transverse, sagittal and coronal
plane CT scans of 116 posterolateral shearing tibial plateau fractures.
The CT transverse plane of the articular surface of the tibial plateau
was defined as the standard measuring plane. The maximum
anteroposterior diameter (APD) of the posterolateral fragment was
marked as “a”, and the maximum APD of the lateral tibial plateau
was marked as “b”, a/b equated to approximately 1/3. We drew a
rectangle with a and b as its sides, and then drew a horizontal line
through the posterior 1/3 (Point A) of the lateral side and a vertical
Fig. 1. The model of posterolateral shearing tibial plateau fracture.
95
line through the lateral 1/3 (Point B) of the posterior side, the
intersection of these two points was named Point C. Finally a line
was made through Point C which angles at 120° with the straight line
AC. The sagittal angle of the posterolateral fragment was approxi-
mately 80°. The cortical split length (length from the articular rim to
the distal tip) on the coronal plane was approximately 30 mm
[Fig. 1][Table 1]. Our data was very similar to that described by Shi-
Min Chang who reported the length as 28 mm (24–35 mm) [12]. A
thin blade saw was used to make the osteotomy; simulating a
posterolateral shearing tibial plateau fracture. All geometric mea-
surements were taken by a single surgeon.
2.3. Group
Forty posterolateral shearing fracture models were randomly
assigned into four groups. Each group was instrumented with
different implants: (A) two anterolateral 6.5 mm parallel lag-screws,
(B) an anteromedial 4.5 mm 6-hole T-shaped LC-DCP, (C) a lateral
3.5 mm 6-hole LCP proximal tibial plate, and (D) a posterolateral
3.5 mm 6-hole straight buttress plate [Fig. 3]. In Group A, two lag
screws were placed at 10 mm and 20 mm from the lateral edge and
8 mm below the joint line. In Group B, the plate was anatomically
contoured to the anteromedial cortex prior to fixation and the plate
96 W. Zhang et al. / The Knee 19 (2012) 94–98

Table 1 Synbone AG, Swiss) was cut with a power saw at a length of 5 cm
The statistical data and approximate data of models (based on 116 cases of tibial (measured vertically from the intercondylar notch) and clamped on
plateau fracture).
the upper side of the material testing machine. This was then used as
a/b Transverse Sagittal angle Cortical split an applicator to deliver axial forces on both tibial plateau surfaces
plane angle length simultaneously. The distal femur was fixed in 90° flexion to simulate
Statistical data 0.338 ± 0.016 118 ± 3.2° 78 ± 4.1° 30 ± 1.2 mm the injury mechanism (an axial force with the knee in flexion). A K-
Approximate data 1/3 120° 80° 30 mm wire was inserted into the posterolateral fragment (but not exceeding
the fracture line) and attached to an electronic gauge [Fig. 4], this
setup allowed us to assess the relative vertical displacement of the
posterolateral fragment. Malreduction has been defined as an intra-
articular step of 2 mm, which is a figure we also used, failure was
defined as the force when the vertical displacement of the
posterolateral fragment was 3 mm or greater [13]. A compressive
force was applied with a loading speed of 1 mm/min. The specimens
were first axially loaded to evaluate the four different implants'
stability, and then loaded to failure. Three different axial peak loads of
500 N (N), 1000 N and 1500 N were chosen. During a pilot study, it
was found that there were no fixation failures.
The software used for data analysis was Bluehill 2 (Bluehill 2,
2.17.649, USA).

Fig. 2. The vertical displacement of the posterolateral fragment under three different
axial loads.Values are mean displacements (measured in mm). P values were calculated
with LSD. The mean displacements of the posterolateral buttress plate (Group D) were
significantly smaller than the other three groups (P = 0.00).
was held using two parallel cancellous screws proximally, and three
consecutive cortical screws in the last three distal screw holes. In
Group C, the plate was anatomically contoured to match the lateral
proximal tibia, after inserting four proximal locking screws parallel to
the articular surface, we inserted three consecutive locking screws in
the last three distal screw holes. In Group D, a contoured straight LC-
DCP was used as a buttress plate. This plate was used to buttress the
posterolateral fragment obliquely (proximally from the lateral aspect
and distally from the medial aspect). Two cancellous screws were
placed into the posterolateral fragment, and three cortical screws
were inserted distally with one in the last hole. Each fracture was
reduced and fixed by a single orthopaedic surgeon.
2.4. Biomechanical testing
Each specimen was fixed vertically on the bedstead of a material
testing machine. A synthetic femur (right Synbone, type2200,
2.5. Statistical analysis
As the data was normally distributed, we can use parametric
statistical methods for data analysis. Descriptive statistics was used to
determine ranges, means and standard deviations. ANOVA was used
for data from the four groups under the same load. If P b 0.05, a Least-
Significant Difference (LSD) post hoc multiple comparison was used
for both the vertical displacement and the load to failure data. Data
was analysed using SPSS 16.0 statistical software (SPSS Inc, Chicago,
IL), P b 0.05 was considered to be statistically significant.
3. Results
The vertical displacement of the posterolateral fragment under three different axial
loads is summarised in Table 2 [Fig. 2]. The mean displacements at 500 N-load,
1000 N-load and 1500 N-load of the posterolateral buttress plate (Group D) were
significantly smaller than the other three groups (P = 0.00).
The failure load of each specimen is shown in Table 2 [Fig. 2]. It was 3465 ± 210 N for
the posterolateral buttress plate (Group D), 2316±190 N for the lateral LCP proximal tibial
plate(Group C), 1820 ± 186 N for the anteromedial T-shaped LC-DCP (Group B), and
1670± 156 N for the anterolateral lag screws (Group A). The posterolateral buttress plate
(Group D) can bear more load than the other three groups (P= 0.00).

Fig. 3. Four groups of different implants: (A) two anterolateral 6.5 mm parallel lag-screws, (B)an anteromedial 4.5 mm 6-hole T-shaped LC-DCP, (C) a lateral 3.5 mm 6-hole LCP
proximal tibial plate, (D) a posterolateral 3.5 mm 6-hole straight buttress plate.
 W. Zhang et al. / The Knee 19 (2012) 94–98 97

Fig. 4. The biomechanical machine. The vertical displacement of the posterolateral fragment was measured by an electronic gauge using an inserted K-wire.

4. Discussion Barei et al. studied the CT scans of 146 cases of bicondylar tibial
plateau fractures, and found that 28.8% (42 cases) had coronal
The posterolateral shearing tibial plateau fracture is a unique type fractures or posterior shearing fractures [4]. A “three-column” concept
of tibial plateau fracture [14], which is not well described by the of tibial plateau fracture was described in recent literature, this new
Schatzker or AO classification systems [15,16]. These systems use two- classification system is based on the CT scan, giving more information
dimensional images, which usually directs surgeons to pay attention to the surgeon for improved decision making [6,17]. According to the
to medial and lateral fixation without thinking of posterior fixation three-column classification system, a posterolateral shearing tibial
[17]. Khan et al. classified tibial plateau fractures into seven groups plateau fracture belongs to the posterior column fracture group.
including lateral, medial, posterior, anterior, rim, bicondylar, and The management of posterolateral shearing tibial plateau fracture
subcondylar, with the posterolateral tibial plateau of P1 subgroups remains controversial and challenging. The aims of treatment are
(posterolateral shearing) [18]. anatomical reduction of articular surface, restoration of normal
The mechanism of posterolateral shearing tibial plateau fracture is alignment of knee joint, and provision of sufficient stability to allow
a combination of valgus and axial compression forces with the knee early movement [22]. In our study, the four different implants were
joint in flexion, resulting in a fracture line of the posterior aspect in the two anterolateral parallel lag-screws, an anteromedial T-shaped LC-
coronal plane [1,2], making it difficult to identify using AP plain DCP, a lateral locking plate and a posterolateral buttress plate. The
radiographs alone [4]. CT scanning, especially 3-dimensional recon- posterolateral fragment often appears to be a part of bicondylar tibial
structions, are a valuable tool for the diagnosis and accurate analysis plateau fractures which is usually associated with severe soft tissue
of tibial plateau fractures; helping to identify the articular surface injury [23]. Two anterolateral 6.5 mm parallel lag-screws inserted via
depression and the fracture line which was neglected on the plain a limited incision can reduce the dissection of soft tissue. However,
film. Wicky et al. reported a cohort of 42 cases with tibial plateau the fragment is difficult to visualise to facilitate anatomical reduction
fractures, which were assessed by plain radiographs and 3-dimen- and can be easy to displace. An anteromedial 4.5 mm 6-hole T-shaped
tional Computerised Tomography (3-D CT) separately. As a result, 43% LC-DCP is a common choice for the fixation, but the medial
(18/42) of the fractures were under-evaluated by plain radiographs parapatellar approach does not provide adequate exposure and if
[19]. Macarini et al. studied 25 cases of tibial plateau fractures; after CT we try to reduce and fix the fragment, it will result in further extensive
scan fracture analysis, only 48% of the cases had the same dissection. C.-F. Luo et al. considered that the difficultly in anatom-
classification as before the CT scan and 60% of the cases had changes ically reducing and sufficiently stabilising the posterolateral fragment
in the operative plan [20]. Most authors agree that a CT scan adds via the anteromedial approach would lead to posterior articular
invaluable information to the treatment of tibial plateau fractures malreduction [24]. With the advent of lateral locking plates, stable
[1,4,21]. As the use of computer tomography (CT) increases, some fixation of bicondylar tibial plateau fracture can be achieved from the
fractures can be difficult to fit into the classification systems currently lateral aspect alone [11]. However, it is still controversial that a lateral
used, which makes diagnosis and preoperative planning difficult [19]. locking plate can provide sufficient stability to the posterolateral
fragment; in this construct the proximal locking screws are parallel
Table 2
with the coronal fracture line and therefore only one locking screw is
The vertical displacement of the posterolateral fragment under three different axial available to gain adequate purchase into the posterolateral fragment,
loads and the average failure load of the four groups. subsequently the fixation may fail in this area. Gosling et al. reported
Group Vertical displacement (mm) Load to failure
the use of a single lateral locking plate for the treatment of bicondylar
(N) tibial plateau fractures, 14% of patients showed substantial loss of
500 N 1000 N 1500 N
reduction and instability of knee joint [23].
Group A 1.056 ± 0.045 1.855 ± 0.091 2.242 ± 0.097 1670 ± 156 When the knee joint is flexed, there is posterior and distal
Group B 0.935 ± 0.032 1.687 ± 0.053 2.136 ± 0.072 1820 ± 186
displacement of the posterolateral fragment, a posterolateral buttress
Group C 0.814 ± 0.027 1.451 ± 0.046 1.961 ± 0.084 2316 ± 190
Group D 0.375 ± 0.018 a,b,c 0.840 ± 0.068 a,b,c 1.038 ± 0.130 a,b,c 3465 ± 210 a,b,c plate will therefore be best positioned to provide strong support to the
F value 248.63 176.18 93.62 58.67 fragment and maintain stability [6,12,17,25]. S.-M. Chang and J. Tao
P value 0.000 0.000 0.000 0.000 described a modified posterolateral approach for direct reduction and
a: compared with Group A, P b 0.05; b: compared with Group B, P b 0.05; c: compared fixation, using a buttress plate to stabilise the posterolateral fragment
with Group C, P b 0.05. [12,25]. C.-F. Luo reported a posteromedial inverted L-shaped
98 W. Zhang et al. / The Knee 19 (2012) 94–98
approach with the patient set up in a “floating position” for the
posterolateral shearing tibial plateau fracture. A posterolateral
buttress plate was placed to buttress the posterolateral fragment
obliquely (from proximal laterally to distal medially). After a mean
follow-up period of 27.3 months all patients were highly satisfied
with the postoperative result [6,17].
In our study, the data indicated that the posterolateral buttress
plate can provide “adequate stability” in controlling the vertical
displacement of the fragment under axial load and presented the best
biomechanical strength. The “adequate stability” here meant the
vertical displacement of the fragment under axial load was no more
than 1 mm. We used synthetic tibia (Synbone) in our study for its
obvious advantages compared with cadaver bone: assurance of
uniformity, consistency of material, geometry, and its mechanical
properties [26]. With these models, the performance of implants can
be evaluated and compared reliably since the variability within
specimens can be well controlled. However, there are still limitations
in comparing this to a clinical situation where you have the influence
of the soft tissue envelope and the variety in anatomical shape of the
proximal tibia. In addition, we reduced the fragment anatomically, but
it may be difficult for this to be achieved in every clinical case.
5. Conclusion
The results of our study demonstrate that the posterolateral
buttress plate can provide “adequate stability” for posterolateral
shearing tibial plateau fracture and demonstrated biomechanical
superiority over other popular fixation techniques.
6. Conflict of interest statement
We did not use any funding to perform this study, and there is no
conflict of financial or personal interests in the whole study.
Acknowledgment
The authors would like to thank Sven Putnis for his hard work in
correcting the grammar and syntax and Shang-chun Guo, assistant
researcher, for her assistance and support in this study.
References
[1] Bhattacharyya Timothy, McCarty III L Pearce, Harris Mitchell B, et al. The posterior
shearing tibial plateau fracture: treatment and results via a posterior approach.
J Orthop Trauma 2005;19(5):305–10.
[2] Kennedy JC, Bailey WH. Experimental tibial plateau fractures. Studies of the
mechanism and a classification. J Bone Joint Surg Am 1968;50(A):1522–34.
[3] Cole PA, Bhandari M. What's new in orthopaedic trauma. J Bone Joint Surg Am
2006;88(A):2545–61.
[4] Barei DP, O'Mara TJ, Taitsman LA, et al. Frequency and fracture morphology of the
posteromedial fragment in bicondylar tibial plateau fracture patterns. J Orthop
Trauma 2008;22:176–82.
[5] Higgins TF, Kemper D, Klatt J. Incidence and morphology of the posteromedial
fragment in bicondylar tibial plateau fractures. J Orthop Trauma 2009;23(1):
45–51.
[6] Luo CF, Hu CF, Gao H, Zong B, Zeng ZM, Zeng BF. Three-column classification for
tibial plateau fractures. Chin J Orthop Trauma 2009;11(3):201–5.
[7] Moore TM. Fracture–dislocation of the knee. Clin Orthop May 1981;156:128–40.
[8] Boeck HD, Opdecam P. Posteromedial tibia1 plateau fractures operative treatment
by posterior approach. Clin Orthop Relat Res Nov 1995;320:125–8.
[9] Fakler JK, Ryzewicz M, Hartshorn C, Morgan SJ, Stahel PF, Smith WR. Optimizing
the management of Moore type I postero-medial split fracture dislocations of the
tibial head: description of the Lobenhoffer approach. J Orthop Trauma 2007;21(5):
330–6.
[10] Ruedi TP, Murphy WM. AO principles of fracture management. Stuttgart: Thieme;
2000.
[11] Ricci WM, Rudzki JR, Borrelli J. Treatment of complex proximal tibia fractures with
the less invasive skeletal stabilization system. J Orthop Trauma 2004;18(8):521–7.
[12] Chang Shi-Min, Zheng He-Ping, Li Hai-Feng, et al. Treatment of isolated posterior
coronal fracture of the lateral tibial plateau through posterolateral approach for
direct exposure and buttress plate fixation. Arch Orthop Surg 2009;129:955–62.
[13] Ali AM, El-Shafie M, Willett KM. Failure of fixation of tibial plateau fractures.
J Orthop Trauma 2002;16(5):323–9.
[14] Moore T. Fracture dislocation of the knee. Clin Orthop 1981;156:128–40.
[15] Rüedi TP, Murphy WM. AO Principles of fracture management. Davos: AO
Publishing & Stuttgart New York: Georg Thieme Verlag; 2000.
[16] Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto
experience. Clin Orthop Relat Res 1979;138:94–104.
[17] Luo CF, Sun H, Zhang B. Three-column fixation for complex tibial plateau fractures.
J Orthop Trauma 2010;24(11):683–92.
[18] Khan RM, Khan SH, Ahmad AJ, et al. Tibial plateau fractures. A new classification
scheme. Clin Orthop 2000;375:231–42.
[19] Wicky S, Blaser PF, Blanc CH, et al. Comparison between standard radiography and
spiral CT with 3D reconstruction in the evaluation, classification and management
of tibial plateau fractures. Eur Radiol 2000;10:1227–32.
[20] Macarini L, Murrone M, Marini S, et al. Tibial plateau fractures: evaluation with
multidetector-CT. Radiol Med (Torino) 2004;108:503–14.
[21] Weil YA, Gardner MJ, Boraiah S, et al. Posteromedial supine approach for reduction
and fixation of medial and bicondylar tibial plateau fractures. J Orthop Trauma
2008;22:357–62.
[22] Subasi M, Kapukaya A, Arslan H, Ozkul E, Cebesoy O. Outcome of open
comminuted tibial plateau fractures treated using an external fixator. J Orthop
Sci 2007;12(4):347–53.
[23] Gosling T, Schandelmaier P, Muller M, et al. Single lateral locked screw plating of
bicondylar tibial plateau fractures. Clin Orthop Relat Res 2005;439:207–14.
[24] Luo CF, Jiang R, Zhou MY, et al. The failure reasons of surgery for medial tibial
plateau fractures. Chin J Orthop Trauma 2006;8(7):642–6.
[25] Tao Jie, Hang Dong-hua, Wang Qiu-gen, et al. The posterolateral shearing tibial
plateau fracture: treatment and results via a modified posterolateral approach.
Knee 2008;15(5):473–9.
[26] Ali AM, Saleh M, Bolongaro S, Yang L. Experimental model of tibial plateau fracture
for biomechanical testing. J Biomech 2006;39(7):1355–60.