Hyperextension Varus Bicondylar Tibial Plateau Fracture Pattern: Diagnosis and Treatment Strategies

Objectives: The authors have identified a subset of bicondylar tibial plateau fractures with a hyperextension varus deformity (HEVBTP). The radiographic hallmarks of this pattern are (1) sagittal plane malalignment with loss of the normal posterior slope of the tibial plateau, (2) tension failure of the posterior cortex, (3) compression of the anterior cortex, and (4) varus deformity in the coronal plan. The purpose of this study was to describe this fracture pattern, to compare the associated injuries with non-HEVBTP fractures, and to suggest treatment strategies that may allow for improved reduction and stabilization. Design: Retrospective Cohort Study. Setting: Level 1 trauma center. Patients: Preoperative radiographs and CT scans were reviewed in 208 patients who sustained 212 bicondylar tibial plateau fractures (OTA 41C). Twenty-five fractures in 23 patients fulfilled the radiographic criteria for HEVBTP fracture pattern. The remaining 187 bicondylar tibial plateau fractures were used as a control group. Intervention: Initial spanning external fixation, followed by open reduction internal fixation and bone grafting with/without augmentation. Main Outcome Measurement: Associated injury rate compared with OTA 41C patients without HEVBTP pattern, nonunion rates, and loss of reduction rates. Results: Thirty-two percent of the HEVBTP fractures demonstrated significant associated injuries compared with 16% in the control group. The incidence of popliteal artery disruption requiring repair was 12% in the HEVBTP group compared with 1% in the control group. Patients with HEVBTP had either partial or complete peroneal nerve injury in 16% of cases (8% in control group) and 12% of patients developed a leg compartment syndrome (10% in control group). Conclusions: The HEVBTP pattern is a unique fracture. The surgeon must recognize the possible associated injuries that accompany this injury. We suggest fixation strategies that address this injury's individual components which may help to avoid failure