Tibial plateau fractures have a broad spectrum of presentations, depending on the mechanism and energy of the trauma. Many classification systems are currently available to describe these injuries. In 1974, Schatzker proposed a classification based on a two-dimensional representation of the fracture. His classification with the six-principles types became one of the most utilized classification systems for tibial plateau fractures. More than four decades after this original publication, we are revisiting each fracture type in the light of information made available by computed tomography, which today comprises a standard tool in assessing articular fractures. The classification we are proposing relies on the fact that the tibial plateau has two anatomical columns, lateral and medial. We are introducing a virtual equator which splits the articular surface in the coronal plane. The equator divides each column into two quadrants, the anterior (A) and the posterior (P). Unicondylar fracture types (I to IV) have now additional modifiers A (anterior) and P (posterior) to describe the exact spatial location of the primary fracture plane. Bicondylar fracture types (V and VI) have the modifiers (A and P) of the main fracture plane for each column, and lateral (L) and medial (M) to denote the column. We are introducing the concept of the main fracture plane. Recognition of the exact location of the principal fracture plane is essential for preoperative planning of patient positioning, surgical approach and for determining where to apply the hardware to achieve stable fixation. The new three-dimensional classification is based on the template of the original Schatzker classification. It covers the mechanism of the injury, the energy of the trauma, the morphologic characteristics of the fracture and its location in three dimensions.

This meta-analysis aimed to determine the bone union rate of bone defects treated with the different autologous bone graft techniques. The PubMed and the Cochrane Library databases were searched using the terms: ‘fracture’ AND (‘bone loss’ OR ‘defect’ OR ‘defects’) AND ‘bone graft’, restricted to English language, to human species, and to a publication period from January 1999 to November 2014. Data were extracted by one of the reviewers and then checked by the second. A quality of evidence score and a methodology score were used. Heterogeneity was assessed. A random effects model approach was used to combine estimates. Out of 376 selected studies only 34 met the inclusion criteria. The summary pooled union rate was 91 % (95 % CI: 87–95 %) while union rate after additional procedures raised to 98 % (95 % CI 96–99 %). No association between union rate and bone defect size was found. (Univariable regression model: vascularized: P = 0.677; non-vascularized: 0.202. Multivariable regression model: vascularized: P = 0.381; non-vascularized: P = 0.226). Vascularized graft was associated with a lower risk of infection after surgery when compared to non-vascularized graft (95 % CI 0.03 to 0.23, p < 0.001). The results of this meta-analysis demonstrate the effectiveness of autologous graft for bone defects. Furthermore, from the available clinical evidence bone defect size does not seem to have an impact on bone union when treated with autologous bone graft techniques.

Background: Transplantation of fresh osteochondral allografts (OCAs) is an attractive treatment option for symptomatic articular cartilage lesions in young, healthy patients. Because the lack of OCA bone integration can be a cause of treatment failure, methods for speeding and enhancing OCA bone integration to mitigate this potential complication are highly desirable. Purpose: To determine if autogenous bone marrow aspirate concentrate (BMC) treatment of large femoral condylar OCAs would be associated with superior radiographic OCA bone integration compared with nontreated allografts during the critical first 6 months after surgery. Study Design: Cohort study; Level of evidence, 3. Methods: A review of patients enrolled in a prospective registry who were treated with transplantation of large OCAs to one or both femoral condyles at our institution from March 12, 2013 to March 14, 2016 was performed. Patients were stratified into 2 groups based on BMC treatment versus no BMC treatment; the treatment was nonrandomized and was rooted in a shift in practice and a continuing effort to optimize OCA transplantation at our institution. Patients were excluded if they did not have orthogonal view radiographs performed at 6 weeks, 3 months, and 6 months postoperatively. Each condyle undergoing OCA transplantation was assessed individually by an independent musculoskeletal radiologist, who was blinded to the treatment group and time point. OCAs were assessed with respect to graft integration (0%-100%; 0 = no integration, 100 = complete integration) and degree of sclerosis (0-3; 0 = normal, 1 = mild sclerosis, 2 = moderate sclerosis, and 3 = severe sclerosis) of the graft at each time point. Results: This study identified 17 condyles in 15 patients who underwent OCA transplantation without BMC and 29 condyles in 22 patients who underwent OCA transplantation with BMC. The BMC group had significantly ( P = .033) higher graft integration scores at 6 weeks, 3 months, and 6 months after surgery. Graft sclerosis was significantly ( P = .017) less in the BMC group at 6 weeks and 3 months, with no significant difference at 6 months after surgery. When combining the groups to examine the influence of smoking on graft integration, nonsmokers had significantly ( P = .007) higher graft integration scores at 6 months. Conclusion: Large femoral condylar OCAs treated with autogenous BMC before implantation showed superior radiographic integration to bone and less sclerosis during the initial 6-month postoperative period. BMC treatment of OCAs may mitigate the failure of OCA bone healing.

Three-dimensional imaging has changed the understanding and management of tibial plateau fractures. In the 1970s, Schatzker proposed a classification for tibial plateau fractures, which highlighted the morphology of the six principal types. More recently, this original classification was complimented by an extended one underscoring the importance of understanding where the split wedge fragment(s) is/are located in three dimensions. The extended classification introduced the split wedge fragment and the continuity of the rim as the determinants of joint stability and the critical role that this plays in the management of tibial plateau fractures. The current manuscript re-emphasizes contemporary concepts of tibial plateau stability and depicts key issues which must be considered when planning the definitive surgical fixation of tibial plateau fractures.

Update: This article was updated on April 30, 2020, because of a previous error. On pages 1 and 10, in the byline section and author affiliation section, “Augusto de Almeida Armando Teixeira” now reads “Armando Augusto de Almeida Teixeira.” An erratum has been published: JBJS Essent Surg Tech. 2020 June 2;10(2):e0099ER. Background: Critical-size bone defects are defined as bone defects where spontaneous regeneration is not expected without treatment ¹ . The characteristics of bone defects (etiology, location, size, presence of infection, and soft-tissue conditions) vary greatly and, to be effective, the treatment method should address this variability. The induced-membrane technique, or Masquelet technique, is a method for treating critical-size bone defects ^2,3 of various sizes and anatomic locations. It has been used to treat infected and noninfected bone defects and may be performed with a variety of fixation methods ^2,3 . Description: The induced-membrane technique is a 2-stage procedure. The first stage consists of debridement followed by insertion of a polymethylmethacrylate (PMMA) spacer in the bone defect. The presence of the PMMA leads to a foreign-body reaction with the development of a thick pseudosynovial membrane that is extremely vascularized and rich in growth factors. The filling of the bone defect with the cement spacer prevents fibrous tissue invasion and allows the development of an optimal vascularized gap for bone-grafting. After 6 to 8 weeks, the membrane around the spacer is carefully opened for the removal of the spacer, which is then replaced by bone graft ^2,3 , which can be expanded with allograft or biomaterials. Alternatives: Alternatives include vascularized or nonvascularized autologous bone graft, allograft, bone transport methods, titanium cages, megaprostheses, shortening, and amputation. Rationale: Posttraumatic bone defects frequently are associated with soft-tissue injury and infection that impair the local vascularization and the healing potential. The highly vascularized induced membrane may play a role in restoring the local regenerative capacity. Numerous studies have demonstrated its successful use in the treatment of posttraumatic bone defects in the hand, forearm, humerus, femur, tibia, and foot. The induced-membrane technique is especially advantageous in the treatment of infected bone defects because the presence of the spacer helps in the treatment of the infection by reducing dead space, acting as a local antibiotic carrier, and promoting some degree of bone stability ^3–5 .