Comparation of Gerdy’s Tubercle Osteotomy Versus Conventional Anterolateral Approach for Posterolateral Tibial Plateau Fractures: A Retrospective Cohort Study

Comparation of Gerdy’s Tubercle Osteotomy Versus Conventional Anterolateral Approach for Posterolateral Tibial Plateau Fractures: A Retrospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparation of Gerdy’s Tubercle Osteotomy Versus Conventional Anterolateral Approach for Posterolateral Tibial Plateau Fractures: A Retrospective Cohort Study Lei Li, Shanhua Duojie, Yi Zhu, Wei Xu, Hui Sun This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8261527/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 27 Apr, 2026 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted 10 You are reading this latest preprint version Abstract Background The optimal reduction strategy for posterolateral tibial plateau fractures (PLFs) remains controversial due to limited visualization and fixation challenges. This study compared radiographic and functional outcomes between the anterolateral approach with Gerdy’s tubercle osteotomy (ALa-GTO) and the conventional anterolateral approach with intra-articular fracture gap or cortical window osteotomy (ALa-ICO). Methods A retrospective cohort study was conducted involving 32 patients with PLFs and articular depression ≥ 4 mm. Participants were allocated to either ALa-GTO (n = 15) or ALa-ICO (n = 17). Perioperative parameters, radiographic outcomes (articular reduction, posterior slope angle [PSA], Rasmussen radiographic score [RRS]), and functional outcomes (VAS, HSS, SF-36) were assessed with a minimum 12-month follow-up. Results The ALa-GTO group demonstrated significantly shorter operative time (105.0 ± 2.4 vs. 113.8 ± .3 minutes, p = 0.013), superior PSA maintenance at 3 months and 1 year (p < 0.01), and less articular depression at all timepoints (p < 0.05). VAS scores were significantly lower in the ALa-GTO group at midterm and final follow-up (p < 0.01). SF-36 subscales revealed better physical function and role-physical outcomes in the ALa-GTO group (p < 0.001), though HSS scores did not differ significantly (p = 0.345). All osteotomy sites healed without failure, and complication rates were comparable. Conclusion The ALa-GTO technique provides enhanced direct visualization and reduction capability, and is associated with improved early radiographic outcomes and function compared to the ALa-ICO approach. It represents a viable surgical alternative for the management of PLFs. Trial registration Not applicable. Tibial plateau fracture Posterolateral Approach Reduction Gerdy’s tubercle osteotomy Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Tibial plateau fractures (TPFs) represent frequent intra-articular injuries, comprising approximately 1% of all fractures in the adult skeleton [ 1 ]. These fractures result from a spectrum of mechanisms, ranging from low-energy falls to high-energy trauma such as motor vehicle collisions [ 2 ]. The primary objectives of surgical intervention are to restore joint stability, achieve limb alignment, and reestablish the congruity of the articular surface [ 3 ]. Nevertheless, obtaining an adequate reduction remains challenging due to factors including severe comminution, substantial fracture displacement, and limited visualization during surgery [ 3 – 5 ]. Suboptimal outcomes have been reported in up to 30% of surgically managed TPFs [ 5 , 6 ]. Over the past decades, multiple classification systems and morphological studies utilizing computed tomography (CT) have been developed to characterize these fractures more precisely [ 2 , 4 , 7 – 12 ]. Among these, both the “three-column” [ 7 – 9 ] and “four-quadrant” [ 10 , 11 ] classifications emphasize the particular significance of posterolateral involvement. Fractures extending into the posterolateral region have garnered considerable clinical interest, as their presence is frequently associated with less favorable outcomes [ 5 , 6 , 13 ]. Posterolateral tibial plateau fractures (PLFs) are recently defined as distinct articular fractures involving either the posterolateral quadrant of the tibial plateau or a fracture line extending to the cortex of the posterolateral column [ 14 ]. Since the initial description by Waldrop et al. in 1988 [ 15 ], the epidemiology, injury mechanisms, and morphological features of PLFs have been increasingly elucidated. PLFs account for 44.2% of lateral and bicondylar TPFs [ 12 , 16 ], with this proportion rising to 62.69% among elderly patients [ 17 ], indicating that such fractures are not uncommon. Cadaveric studies have demonstrated correlations between specific fracture patterns and injury mechanisms, particularly the direction of force vectors and the position of the knee at the time of impact [ 4 ]. It is now widely accepted that varying angles of knee flexion under valgus or varus loading may contribute to the observed diversity in fracture morphology [ 4 , 16 , 18 ]. In response, several classification systems have been proposed by various authors to categorize PLFs based on their morphological characteristics [ 12 , 16 , 19 – 21 ]. These efforts aim to inform more systematic surgical strategies and have provided valuable theoretical and practical guidance for the management of these complex injuries. The optimal surgical approach for the management of PLFs remains a subject of ongoing debate within orthopedic trauma circles [ 14 , 22 ]. Surgical strategies for accessing these fractures may broadly be categorized as either anterior or posterior. Numerous posterior approaches have been described, including those by Lobenhoffer, Bhattacharyya, Carlson, and Frosch, as well as techniques involving transfibular neck osteotomy with or without osteotomy and the Luo approach, among others [ 18 , 22 ]. These approaches offer several advantages, such as direct visualization of the posterior cortical and articular rim fracture lines, facilitated buttress plate application, and an optimal trajectory for posteroanterior screw placement [ 18 ]. However, they are also associated with notable limitations. The confined operative field increases the risk of iatrogenic injury to neurovascular and ligamentous structures in the posterolateral corner, including the common peroneal nerve, branches of the popliteal artery, and the posterolateral ligament complex [ 23 ]. Additionally, posterior approaches have been linked to postoperative knee flexion lag and challenges related to subsequent hardware removal following fracture healing [ 24 ]. Interestingly, some surgeons have advocated for the use of modified anterolateral or lateral approaches to manage PLFs. These include the traditional anterolateral approach [ 15 , 25 ], the extended anterolateral approach [ 22 , 26 , 27 ], the supra-fibular head approach [ 28 ], femoral epicondyle osteotomy [ 29 – 32 ], fibular resection osteotomy [ 30 , 33 ], digastric fibular head osteotomy [ 30 ], and Gerdy's tubercle osteotomy (GTO) approaches [ 34 – 36 ], among others (Table 1 ). The traditional anterolateral approach has long been a standard strategy for lateral tibial plateau fractures-both isolated lateral condyle fractures (Schatzker I-III) and complex patterns involving the lateral plateau (Schatzker IV-VI). Its advantages include technical familiarity, a relatively low risk of iatrogenic injury, and generally favorable outcomes [ 37 ]. However, both traditional and extended anterolateral approaches, as well as the supra-fibular head approach (collectively referred to as anterolateral approaches, ALa) provide limited direct exposure of the posterolateral fragment. Visualisation typically requires detachment of the iliotibial band (ITB) and anterolateral ligament (ALL) from Gerdy’s tubercle [ 15 , 38 ]. This detachment may compromise the healing of the tendon-bone interface, particularly when early continuous passive motion (CPM) is initiated postoperatively to maintain knee mobility [ 39 ]. The ITB and ALL serves as a secondary stabilizer of the lateral knee, contributing to resistance against varus and internal rotation forces [ 40 , 41 ], and functions as an accessory structure to the fibular collateral ligament (FCL), the primary lateral stabilizer. Consequently, alternative exposure techniques such as femoral epicondyle osteotomy or fibular osteotomies inherently risk iatrogenic injury to the FCL. With the exception of the GTO approach, all aforementioned techniques provide only improved visualization; an additional bony access, such as an intra-articular osteotomy or cortical window is often required to reduce depressed articular fragments [ 38 ]. In contrast, the GTO approach (ALa-GTO) offers the dual advantage of enhanced visualization and direct reduction capability. Furthermore, it relies on bony healing of the osteotomized tubercle rather than the less reliable soft-tissue healing of the reattached ITB and ALL. Despite these potential benefits, no comparative study has yet evaluated the outcomes of the ALa-GTO approach against those of anterolateral approaches combined with intra-articular fracture gap or cortical window osteotomy (ALa-ICO). The purpose of this study was to compare the radiological and functional outcomes of patients with PLFs treated with these two surgical strategies. Table 1 Literature review of the anterior approaches (anterior, anterolateral or lateral) for the treatment of PLFs or the PLC injuries (In order of publication year). Authors Year n Approach Osteotomy or not* of important bony structures Iliotibial band processing Results Conclusion Level of Evidence Waldrop JI 15 1988 18 Lateral approach with lateral cortical window N Elevating the periosteal insertion of iliotibial band 17 achieved a final rating of excellent or good; one (6%) achieved a rating of fair. Procedure produces good or excellent results in most cases (94%). IV Garofalo R 36 2007 / Anterolateral approach Y (Gerdy’s tubercle osteotomy) Detachment of tubercle of Gerdy and reflection upward of iliotibial band / Surgical step allowing a good mobilization of multiple layers of iliotibial tract from distal to proximal makes an excellent exposure of posterolateral corner (PLC) with absence of mobidity. V Bowers AL 29 2008 2 Lateral approach Y (Lateral femoral epicondylar osteotomy) Iliotibial band split longitudinally in line with its fibers directly over lateral femoral epicondyle / Intraarticular disorders at posterolateral corner may be addressed in an open manner with anatomic reduction and preserved postoperative function of lateral collateral ligament. Ⅴ Hsieh CH 25 2010 15 Anterior approach with lateral cortical window N / Average HSS score was 92. No postoperative neural or vascular injures and no wound complication. Approach had no complications and was associated with satisfactory outcomes IV Yu B 33 2010 82 Approach with osteotomy of fibular head Y (Partial or full fibular head osteotomy) Iliotibial band reflected from its insertion on Gerdy’s tubercle Encouraging results. Mean score of Rasmussen’s functional grading system was 27.9. New approach provides excellent visualization, which can facilitate reduction and internal fixation for lateral or PLFs. IV Johnson EE 35 2013 76 Tscherne-Johnson extensile approach Y (Fracture lines around Gerdy’s tubercle completed or the tubercle were osteotomized Partial tenotomy of anterior half of iliotibial band, leaving posterior iliotibial band insertion attached to Gerdy’s tubercle Average knee ROM was 2°of flexion to greater than 120°of flexion. In 66 patients, average articular depression improved from 7.4 mm to 1 mm. Infection occurred in one. Approach reliably increases direct visualization of lateral plateau articular fractures and maintains iliotibial band insertion. IV Chen HW 26 2015 15 Extended anterolateral approach N Backside of iliotibial band cut and opened to separate distal fiber bundles from Gerdy’s tubercle. Then knee flexed to peel iliotibial band along upper edge of fibular head. Average of Rasmussen functional score was 25.0 ± 2.8. No wound complications, nonunion, valgus knee deformities, plate loosening or breakages, or fracture re-displacements. Approach provides excellent visualization, facilitates reduction and internal fixation of PLFs. IV Chen HW 27 2015 10 Extended anterolateral approach N Backside of iliotibial band cut and opened to separate distal fiber bundles from Gerdy’s tubercle. Then knee flexed to peel iliotibial band along upper edge of fibular head. Average HSS knee score of 95.3 ± 6.5 points. No complications found. Approach with a proximal tibial compression plate offers direct and complete surgical exposure and provide an effective method for surgical treatment of PLFs. IV Yoon YC 31 2015 1 Anterolateral approach ( combined lateral femoral epicondylar osteotomy and a submeniscal approach) Y (Lateral femoral epicondylar osteotomy) / / Combined approach can be used as an alternative surgical technique for treatment of PLFs. V Hu SJ 28 2016 7 Anterolateral supra-fibular-head approach with lateral cortical window N Distal fiber bundles of iliotibial band released from Gerdy’s tubercle. Average of knee ROM was 121.4°± 8.8°, Average of HSS score was 96.7° ± 2.6°, and average SMFA dysfunction score was 22.4 ± 3.8. Approach can provide direct visualization of PLF quadrant and posteriorly plate placement provide raft fixation. IV Durigan JR 32 2023 13 Lateral approach Lateral femoral epicondyle osteotomy Iliotibial band incised longitudinally. Mean Knee Society Score was 92 ± 13, mean Function Score was 95 ± 9.6. Mean Lysholm Knee Score was 92 ± 11.7, and mean International Knee Documentation Committee Score was 85 ± 12.6. Approach through osteotomy of the lateral femoral epicondyle allowed direct reduction and stable osteosynthesis of fractures without functional impairment. IV Gu YQ 34 2024 20 Anterolateral approach Gerdy's Tubercle Osteotomy (an L-shaped osteotomy along outer edge of the tibial intercondylar spine in the non-load-bearing area of anterior lateral tibial condyle, adjacent to Gerdy’s tubercle on inner side.) Iliotibial band longitudinally split HSS 9score indicating 16 cases rated as excellent, 3 cases as good, and 1 case as fair. Fracture healing transpired without any complications. Anterolateral approach, combined with Gerdy’s tubercle osteotomy, allows for direct exposure and manipulation of the posterolateral bone block fracture. IV Level of Evidence: Level I, Randomized controlled trial; Level II, Prospective cohort study and Observational study with dramatic effect; Level III, Retrospective cohort study and Case-control study; Level IV, Case series and historically controlled study; Level V, Mechanism-based reasoning. /, No description or no clear expression. ROM, Range of joint motion; HSS, Hospital for special surgery; Materials and methods Patient Cohort and Preoperative Protocol Between January 2023 and March 2024, thirty-two consecutive patients with PLFs exhibiting articular depression of ≥ 4 mm were treated surgically using either the ALa-GTO or ALa-ICO reduction technique at a single academic trauma center. Ethical approval for this retrospective cohort study was obtained from the Institutional Review Board of the First Affiliated Hospital of University of Science and Technology of China (2024-RE-104). Inclusion criteria consisted of: (1) skeletal maturity (age ≥ 18 years); (2) radiological confirmation of posterolateral articular depression or displacement ≥ 4 mm requiring operative management; (3) acute closed fractures (within 72 hours of injury); and (4) availability of complete preoperative imaging (CT or magnetic resonance imaging, MRI) and a minimum follow-up of 12 months. Exclusion criteria were: (1) polytraumatized patients (Injury Severity Score [ISS] ≥ 16); (2) open fractures or significant soft-tissue injury; (3) associated neurovascular injuries requiring urgent intervention; and (4) delayed presentation (> 3 weeks post-injury) with established malunion. The cohort was divided into two groups according to the surgical technique used: 15 patients were treated using the ALa-GTO, while 17 underwent reduction via the ALa-ICO. Preoperative evaluation included a comprehensive radiographic assessment of the knee joint with standardized anteroposterior and lateral radiographs, three-dimensional CT reconstruction for fracture characterization, and MRI to evaluate associated soft-tissue injuries. All patients were managed preoperatively according to a standardized protocol consisting of cryotherapy, edema control, multimodal analgesia, and thromboprophylaxis. The timing of surgery was based on the resolution of the peau d’orange sign, a clinical indicator of soft-tissue readiness. Patients’ demographic data, confounding factors, injury-causing factors, fracture classification, mechanism of injury force [ 9 ], and soft-tissue injuries [ 42 ] are summarized in Table 2 . All fractures were classified based on Schatzker classification, Three-column classification [ 8 ], and PLFs morphological classification [ 20 ] according to the preoperative X-ray and CT images. Associated soft tissue injuries were evaluated by preoperative MRI and intraoperative examination. Table 2 Demographics and baseline characteristics. Variables ALa-GTO group (n = 15) ALa-ICO group (n = 17) χ2 / t value P Age(years) 49.4 ± 2.4 47.1 ± 2.1 0.740 0.465 Gender (Male/n) 7 8 0.022 0.982 Side of injury (Left/n) 9 10 0.005 0.946 BMI (kg/m 2 ) 22.2 ± 0.7 23.2 ± 0.6 1.075 0.291 Smoking (n) 5 5 0.057 0.811 Diabetes (n) 4 4 0.042 0.840 Injury-causing factors (n) 0.849 Traffic accident 10 12 0.817 Fall from height 3 2 Other injuries 2 3 Schatzker classification (n) 0.883 Ⅱ 5 6 0.928 Ⅲ 6 8 Ⅴ 2 2 Ⅵ 2 1 Three-column classification (n) 0.900 Posterolateral one-column 4 5 0.578 Lateral and posterolateral two-column 6 5 Medial and posterior two-column 2 2 Medial, lateral and posterior three-column 3 5 PLFs morphological classification (n) BSF MSDF LSDF 3 8 4 4 10 3 0.817 0.850 Injury force mechanism (n) 1.000 Flexion-valgus 10 12 0.000 Extension-valgus 4 4 Flexion-varus 1 1 Extension-varus 0 0 Soft tissue injury Meniscus 5 7 0.861 0.850 Cruciate ligament 7 8 Collateral ligament 3 2 Time from Fracture to surgery(days) 4.3 ± 0.3 4.5 ± 0.3 0.470 0.642 Follow-up duration(months) 22.9 ± 0.8 21.0 ± 0.9 1.535 0.135 ALa-GTO, Anterolateral approach with Gerdy’s tubercle osteotomy; ALa-ICO, Anterolateral approach with intra-articular fracture gap or cortical window osteotomy; BMI, Body mass index; PLFs, Posterolateral tibial plateau fractures; BSF, block-type splitting fracture; MSDF, mild slope-type depression fracture; LSDF, local sinkhole-type depression fracture. Surgical technique All procedures were performed by a designated senior orthopedic trauma team under laminar airflow conditions with fluoroscopic guidance. Patients were placed supine on a radiolucent operating table. A sterile pneumatic tourniquet was applied to the proximal thigh. The affected limb was maintained at 30° of flexion using a sterile foam bolster placed beneath the ipsilateral knee to facilitate exposure of the posterolateral aspect of the joint. After reduction and fixation of the medial and/or posteromedial fractures if that existed, two different strategies of anterolateral approach were implemented. Ala-GTO group: A standard anterolateral approach was employed. After layered soft-tissue dissection, the ITB and ALL was exposed to identify Gerdy’s tubercle. A rectangular osteotomy fragment (approximately 2.0 × 1.0 × 1.5 cm) was demarcated using multiple 2.0 mm K-wires and resected en bloc with an oscillating saw. The fragment-free of articular cartilage and with the ITB and ALL insertions preserved was reflected proximally, allowing full visualization of the lateral meniscus through careful anterior and posterior dissection around ITB and ALL (Fig. 1 ). The lateral meniscus was sutured and retracted proximally to enable submeniscal exposure of the lateral tibial plateau. Under direct visualization-enhanced by internal rotation of the leg and knee adduction-the depressed posterolateral fragments were reduced via the osteotomy window using bone elevators. Prior to reduction of the articular depression, a periosteal elevator or small Hoffman retractor should be placed through supra-fibular space and posterior to posterolateral tibial cortex to prevent posterior displacement of the PLFs’ fragment or separated splitting slice [ 20 ]. Provisional fixation was obtained with 1.5 mm K-wires, and the defect was filled with allograft cancellous bone. The Gerdy’s tubercle fragment was reduced anatomically and fixed with a 3.5 mm locking screw to restore ITB tension. A pre-contoured lateral locking plate was applied after partial elevation of the tibialis anterior muscle, positioned 5 mm distal to the joint line and as posterior as possible within the supra-fibular space. Four parallel rafting screws-including two supporting the reduced posterolateral articular surface-were placed within 5 mm of the subchondral bone. For fragments smaller than 15 mm, supplemental fixation was provided using either oblique 3.5 mm “jail” screws engaging both cortices or 2.0 mm K-wires. The lateral meniscotibial ligament complex was reattached by tying the meniscal sutures to the plate. Wound closure was performed in layers using interrupted absorbable sutures (2 − 0 Vicryl® for subcutaneous tissue, 3 − 0 Monocryl® for skin). A representative case is shown in Fig. 2 . Ala-ICO group: A conventional anterolateral approach was utilized. A longitudinal incision was made through the ITB, preserving approximately 30% of its insertion on Gerdy’s tubercle. The lateral meniscotibial ligament complex was incised, and the lateral meniscus was mobilized using traction sutures. Submeniscal visualization of the depressed articular surface was enhanced through internal rotation of the leg and adduction of the knee. A rectangular cortical window (15 × 10 mm) was created approximately 5 cm distal to the articular margin using K-wire drilling and an oscillating saw. The ITB was retracted in a “book-opening” fashion to achieve approximately 60° of joint visualization. Under fluoroscopic guidance, depressed fragments were elevated through the subcortical corridor of the cortical window or the intra-articular fracture gap using curved bone tamps until articular congruity was confirmed. The metaphyseal defect was grafted with allogeneic cancellous bone, and the cortical window was anatomically reduced. The hardware for fixation was implanted the same as the Ala-GTO group. The lateral meniscocapsular complex was repaired circumferentially with horizontal mattress sutures to restore meniscal stability. Wound closure was performed in layers using standard technique. A representative case is shown in Fig. 3 . Multipolar fluoroscopic imaging, including anteroposterior, lateral, and 45°oblique views, was obtained to assess articular reduction. Reduction was considered acceptable when a residual articular step-off of ≤ 1 mm was achieved and coronal and sagittal alignment were within 5° of the contralateral limbs. Hardware position was verified to ensure appropriate screw length and the absence of intra-articular penetration. Per protocol [ 8 ], all ruptured menisci were repaired to the best degree possible. Disrupted ligamentous insertions were also repaired. Lateral collateral ligament ruptures were repaired if the knee was found to be unstable to varus load on exam while medial collateral ligament injuries were treated nonoperatively in most cases. Rupture of the body of cruciate ligaments was treated non-surgically at the time of initial fracture fixation and addressed surgically at the later date if indicated. The range of motion and stability of the knee joint were evaluated before the incision was closed. After hemostasis were achieve, the wound was washed with saline, and the dissected deep fascia was unstitched. The subcutaneous tissue and skin were closed over suction drains. Postoperative rehabilitation A standardized, phased rehabilitation protocol was applied according to the specific surgical approach. Patients in the Ala-GTO group began early active mobilization by postoperative day 3, with unrestricted range of motion beyond 90° of flexion using a locked hinged brace (adjustable 0-120°). This regimen was permitted due to preserved ITB continuity and stable tubercle fixation. In contrast, the Ala-ICO group adhered to a restricted range of motion protocol (0–90° flexion) for 6 weeks to mitigate the risk of instability related to ITB detachment. All patients started protected weight-bearing (30% body weight) using bilateral crutches at 4 weeks postoperatively. Full weight-bearing was permitted only after radiographic evidence of bridging callus across at least three cortices was confirmed. Functional rehabilitation advanced through defined stages: static proprioception training (week 6), dynamic gait training (week 8), and low-impact sport-specific exercises (month 4). Outcomes assessment and follow-up A retrospective comparative analysis was conducted in 32 consecutive patients with PLFs who were treated using two distinct surgical approaches. Perioperative parameters assessed included the time from fracture to surgery, operative duration, intraoperative blood loss, fluoroscopy time and the use of bone graft or graft substitute. All patients were followed regularly with clinical examination and standardized radiographic assessment, including thin-slice multiplanar CT scans and plain radiographs, obtained on the first postoperative day, and at 3, 12 months. Times to bony union, time to full weight-bearing, range of joint motion (ROM) and all complications observed during follow-up were documented. During routine follow-up, quantitative assessment included measurement of the depression depth of the posterolateral articular surface and posterior slope angle (PSA) on coronal and sagittal reconstructions from three-dimensional CT (3D-CT). Fracture healing and tibial alignment were evaluated using the validated 18-point Rasmussen radiographic scale (RRS) [ 43 ], which incorporates three parameters: residual articular depression (≤ 2 mm = 6 points), coronal plateau width discrepancy (≤ 5 mm = 6 points), and mechanical axis deviation (≤ 5° = 6 points). The quality of reduction, based on the total RRS score, was categorized as anatomic/excellent (18 points), satisfactory/good (12–17 points), marginal/fair (6–11 points), or unacceptable/poor (< 6 points) [ 43 ]. Postoperative pain was assessed using the visual analogue scale (VAS) [ 44 ]. At a minimum follow-up of 12 months, knee function, including ROM, was evaluated with the hospital for special surgery (HSS) knee score [ 45 ], and overall health status was measured using the physical component summary (PCS) of the 36-item short form survey (SF-36) [ 46 ]. Comprehensive adverse event monitoring consisted of the following: articular subsidence of 2 mm or more accompanied by hardware failure; coronal or sagittal malalignment exceeding 5 degrees [ 47 ]; and wound complications that necessitated reoperation. The primary complication outcome measures therefore comprised loss of reduction accompanied by hardware failure, malunion, surgical site complications, iatrogenic nerve injury, and compartment syndrome. All radiographic and clinical evaluations were performed independently by the first author and the corresponding authors. Statistical Analysis All statistical analyses were conducted using SPSS Statistics (version 28.0; IBM Corp.) with a two-tailed significance level set at α = 0.05. Continuous variables were assessed for normality using the Kolmogorov–Smirnov test, with a threshold of D > 0.10 indicating deviation from normality. Normally distributed data are presented as mean ± standard deviation (SD) and were compared using repeated-measures analysis of variance with Bonferroni post-hoc adjustment. Categorical variables were shown as number (%) and tested by the chisquared test. Fisher’s exact test was implemented when 20% of cells had expected values of < 5. Results Demographic analysis The two cohorts demonstrated statically equivalent mean follow-up time (14–28 months, P = 0.135) with balanced baseline characteristics (Table 2 ), including age, gender distribution, fracture side, injury-causing factors, Schatzker classification, three-column classification, injury force mechanism, PLFs classification, soft tissue injury, or time from fracture to surgical intervention (all P > 0.05). Operative details As shown in Table 3 , the Ala-GTO cohort demonstrated significantly reduce mean operative time (105.0 ± 2.4 minutes vs 113.8 ± .3 minutes, P = 0.013) and fluoroscopy time (10.7 ± 0.7 times vs 13.0 ± 0.7, P = 0.019). However, no significant differences were detected between the two groups in terms of intraoperative blood loss, and utilization of bone substitute (all P > 0.05). In Ala-GTO group, the fragments of GTO were fixed by one locking screws in 14 cases, and only in one elder-patient the GTO fragment was fixed by min-plate for metacarpophalangeal fractures because of osteoporosis. Table 3 Operative and follow-up outcomes. Variables ALa-GTO group (n = 15) ALa-ICO group (n = 17) χ 2 / T value P Operation time(minutes) 105.0 ± 2.4 113.8 ± 2.3 2.627 0.013 * Blood loss (ml) 91.3 ± 6.8 94.1 ± 5.6 0.321 0.609 Fluoroscopy times 10.7 ± 0.7 13.0 ± 0.7 2.482 0.019 * Use of bone graft or bone graft substitute (n) 0.736 0.695 bone graft 3 5 bone graft substitute 12 12 Fracture healing time (weeks) 14.1 ± 0.4 13.7 ± 0.3 0.861 0.396 Full load-bearing time (weeks) 12.4 ± 0.3 11.9 ± 0.2 1.346 0.188 PSA(°) Preoperative 20.9 ± 0.6 20.9 ± 0.5 0.065 0.949 1 day 9.6 ± 0.3 9.8 ± 0.4 0.376 0.800 3 months 10.0 ± 0.4 11.3 ± 0.4 2.214 0.042 * 1 year 10.3 ± 0.4 11.8 ± 0.4 2.710 0.01 * Depression depth of the articular surface (mm) Preoperative 11.1 ± 0.5 11.5 ± 0.7 0.391 0.699 1 day 0.7 ± 0.1 1.0 ± 0.1 3.274 0.003 * 3 months 0.9 ± 0.0 1.1 ± 0.1 2.591 0.015 * 1 year 0.9 ± 0.1 1.3 ± 0.1 3.965 0.0004 * RRS Preoperative 7.6 ± 0.6 7.8 ± 0.5 0.296 0.769 1 day 17.6 ± 0.2 17.4 ± 0.2 0.729 0.472 3 months 17.3 ± 0.3 17.0 ± 0.4 0.693 0.494 1 year 16.9 ± 0.5 16.1 ± 0.6 1.084 0.287 VAS score Preoperative 6.3 ± 0.3 6.8 ± 0.2 1.409 0.169 1 day 5.4 ± 0.3 5.8 ± 0.1 1.185 0.246 3 months 2.7 ± 0.2 3.6 ± 0.2 3.097 0.004 * 1 year 0.9 ± 0.2 1.6 ± 0.2 6.841 < 0.0001 * ROM (°) Extension 3.5 ± 0.7 4.4 ± 0.6 0.930 0.400 Flexion 131.1 ± 1.6 127.7 ± 2.3 1.155 0.257 HSS score 93.4 ± 0.6 92.5 ± 0.7 0.961 0.345 SF-36 (v2) 59.5 ± 1.5 58.9 ± 1.3 0.308 0.760 ALa-GTO, Anterolateral approach with Gerdy’s tubercle osteotomy; ALa-ICO, Anterolateral approach with intra-articular fracture gap or cortical window osteotomy; PSA, Posterior slope angle; RRS, Rasmussen radiographic scale; VAS,Visual analogue scale; ROM, Range of joint motion; HSS, Hospital for special surgery; SF-36, 36-item short form survey. * P 0.05). 3-D CT evaluation demonstrated better maintenance of articular reduction in the Ala-GTO cohort. PSA were significantly closer to anatomical values in the Gerdy’s group at both 3 months (10.0° ± 0.4° vs. 11.3° ± 0.4°, P = 0.042) and 1 year postoperatively (10.3° ± 0.4° vs. 11.8° ± 0.4°, P = 0.01). Multiplanar CT assessments consistently showed superior articular congruency in the Gerdy’s group across all follow-up intervals (P = 0.003, 0.015 and 0.0004). The comprehensive RRS and distribution of RRS grade were comparable between groups during follow-up (all P > 0.05, Table 3 and Fig. 4 ). Functional outcomes Both groups progressed to full weight-bearing at a similar rate (P > 0.05). Significantly better pain control, assessed by VAS, was observed in the Ala-GTO group at midterm (2.7 ± 0.2 vs. 3.6 ± 0.2; p < 0.01) and final follow-up (0.9 ± 0.2 vs. 1.6 ± 0.2; p 0.05). The Gerdy’s group showed higher HSS scores at 12 months (93.4 ± 0.6 vs. 92.5 ± 0.7); however, these differences did not reach statistical significance (p = 0.345) (Table 3 ). The excellent or good functional outcomes (HSS ≥ 85) were achieved in 94.4% of patients in both groups. Although the general health (GH) of SF-36(v2) in Ala-GTO group had no significant difference from that in control group (P = 0.760), SF-36 subscale analysis (Fig. 5 ) revealed technique-specific advantages: the GTO group demonstrated significantly better physical function (PF: 86.7 ± 5.2 vs. 74.3 ± 6.8; P < 0.001), role-physical (RP: 84.1 ± 7.3 vs. 71.9 ± 8.1; P < 0.001), and role-emotional (RE: 94.2 ± 0.2 vs. 88.8 ± 0.2; P < 0.01) scores. In contrast, the Ala-ICO group exhibited better bodily pain (BP) outcomes (6.28 ± 2.1 vs. 10.8 ± 2.4; P 0.05), indicating comparable psychosocial adaptation between groups. Complication Profile A complete follow-up rate of 100% was achieved. No between-group differences were observed in hardware integrity, and there were no cases of secondary displacement, malreduction, or post-traumatic arthrosis. All GTO sites healed uneventfully. Superficial wound complications occurred at a similar rate in both groups (one case each; 6.7% vs. 5.9%; p = 0.792); each was successfully managed with vacuum-assisted closure. One patient in the Ala-ICO group developed severe motion restriction (flexion < 60°) due to noncompliance with rehabilitation protocols following a concurrent cerebrovascular event. Discussion Until now, PLFs represent technically challenging articular injuries, owing to limited surgical access constrained laterally by the fibular head, posteriorly by critical neurovascular structures, and anteriorly by metaphyseal cortices [ 18 ]. Established biomechanical principles indicate that articular reduction within ≤ 2 mm is essential to maintain physiologic load distribution; deviation beyond this threshold progressively jeopardizes meniscal function, promotes chondrocyte apoptosis through aberrant shear stresses, and elevates the risk of secondary arthroplasty [ 48 ]. Achieving anatomic reduction of the posterolateral fragment is critical, as it directly influences joint stability, knee kinematics, and long-term survivorship [ 15 , 18 , 49 ]. In 2013, Solomon et al. demonstrated that a direct posterolateral approach for unicondylar PLFs yields superior fracture reduction, enhanced stabilization, and improved early functional outcomes compared to an indirect conventional anterolateral approach [ 50 ]. Despite the successful discovery of various posterior approaches for PLFs treatment, the substantial clinical value of anterolateral and lateral strategies should not be overlooked. Originally described for treatment of posterolateral corner (PLC) injuries and Hoffa fractures of the knee [ 36 , 51 , 52 ], Gerdy's tubercle osteotomy performed via an anterolateral approach (Ala-GTO), has been adapted to address PLFs. It was reported that the Ala-GTO not only facilitates direct visualization of the PLFs fragment through a controlled expansion of the surgical corridor but also preserving the integrity of the lateral collateral ligament [ 34 – 36 ]. Although the advantage seemed noticeable comparing with the conventional anterolateral approach, to our knowledge, this represents the first study to directly compare these two anterior approaches. Our study found that the Ala-GTO technique was associated with superior early clinical outcomes compared with the conventional Ala-ICO approach. Compared with articular surface exposure method in the Ala-ICO approach [ 38 ], GTO preserves the attachment integrity of the ITB and ALL. Eliminating the restraining tension of the ITB and ALL permits knee internal rotation and adduction as much as possible, maximizing posterolateral plateau visualization. Consequently, as our findings illustrate, GTO facilitates precise fracture reduction under direct exposure and simplified fixation without requiring much more intraoperative fluoroscopy, a necessity when ICO is employed to combine indirect visualization with real-time imaging. Furthermore, the technique obviates extensive meniscal suture suspension while preserving the meniscotibial attachment partially, which attaches to the GTO fragment. This collective benefit contributes to a reduction in operative time. Postoperatively, the Ala-GTO group maintained significantly superior PSA at 3 months and 1 year, demonstrated minimal articular surface collapse immediately postoperatively and at 3 months and 1 year, reported reduced late-term knee pain, and achieved higher SF-36 scores compared to the Ala-ICO group. However, no significant difference in functional joint outcomes was observed between the techniques. Concerns regarding GTO fragment healing and early postoperative mobilization appear clinically acceptable based on our data. To date, no cases exhibited nonunion. The fixation strategy, employing a single long locking screw augmented with a proportion of anterolateral plate coverage for GTO fragment fixation, ensures sufficient stability to allow early knee joint rehabilitation. The GTO technique offers the advantage of preserving the inherent attachment of the ITB to the Gerdy’s tubercle, converting scar healing into bony healing, and thereby enhancing knee function. Furthermore, a key modification in our method involves the osteotomy of Gerdy’s tubercle. As previously documented, the ALL functions as a ligamentous structure that becomes taut during internal rotation at 30° of knee flexion [ 53 , 54 ]. It serves as a secondary stabilizer to the anterior cruciate ligament (ACL), resisting anterior tibial translation and internal tibial rotation, as well as preventing the pivot-shift phenomenon [ 55 ]. However, during conventional surgical exposure for lateral tibial plateau fractures via an anterolateral approach, the tibial insertion of the ALL is frequently detached from the proximal tibia, often resulting in scar healing and subsequent ligamentous laxity. The ALL originates near the lateral epicondyle of the distal femur and inserts on the proximal tibia near Gerdy’s tubercle [ 41 ], with anatomical studies confirming its close relationship to the ITB [ 56 ]. Based on these anatomical and biomechanical considerations, we modified the GTO procedure to include Gerdy’s tubercle along with the attachments of both the ITB and ALL, aiming to preserve the functional integrity of these stabilizers. This modification likely contributes to the improved functional outcomes observed in patients treated with this technique compared to those managed with the conventional approach. In accordance with the two principal surgical approaches, fixation strategies for PLFs can be broadly categorized into two types: posterior buttress plating and lateral rafting plate fixation [ 57 ]. The posterior buttress plate functions by converting shear forces into compressive forces [ 18 ], and has been biomechanically established as the construct with the highest strength in our previous studies [ 58 , 59 ]. Nevertheless, the clinical necessity of such high fixation strength for the posterolateral fragment has been subject to ongoing debate [ 57 ]. From a physiological perspective, the loads borne by the posterolateral column of the tibial plateau are limited, generally not exceeding 1000 N, making it unlikely for the posterolateral fragment to experience extreme mechanical stress during rehabilitation [ 57 ]. With recent advancements in hybrid fixation techniques used in conjunction with conventional lateral rafting plating, such as “magic screw” [ 20 , 57 ] or “jail screw” [ 60 – 62 ] fixation, as well as the development of novel anterolateral plate designs [ 59 , 63 ], the biomechanical performance of anterior-based fixation methods has been shown to approximate or even exceed that of posterior plating for PLFs. Consequently, the indications for anterior fixation via modified anterior approaches are likely to expand, potentially benefiting a broader patient population. When utilizing anterolateral approaches for the management of PLFs, the lateral rafting plate is typically positioned as far posteriorly as possible to provide adequate support to the reduced posterolateral articular surface [ 20 , 57 ]. As a consequence, this posterior positioning may result in inadequate coverage of Gerdy’s tubercle [ 35 ]. In previous reports on the treatment of Hoffa fractures and posterolateral corner (PLC) injuries, the GTO fragment was typically reduced and stabilized using a single lag screw [ 36 , 51 , 52 ]. By contrast, in the only available report addressing PLCs via a GTO approach, the Gerdy’s tubercle fragment was fixed using an additional contoured small T-shaped plate [ 34 ]. In our cohort, the GTO fragments were most commonly fixed with a single locking screw, the threaded tail of which engages the cortex to provide resistance against shear displacement. One case with an osteoporotic fragment, however, was fixed using a mini-plate to achieve rigid fixation. At present, there remains no consensus regarding the optimal fixation method for the GTO fragment. Although this study provides clinically relevant insights, several inherent limitations must be acknowledged. The observational design was limited by a small cohort and short-term follow-up, which may restrict the generalizability and long-term interpretation of the outcomes, such as the risk of arthroplasty [ 3 ]. Additionally, the nonrandomized retrospective nature of the methodology introduces potential selection bias and residual confounding. Future multicenter randomized controlled trials with extended surveillance periods (≥ 5 years) are necessary to establish definitive evidence regarding therapeutic durability and mechanistic causality. Conclusion This comparative study evaluated Gerdy’s tubercle osteotomy performed via an anterolateral approach for the treatment of PLFs, in comparison with a conventional anterolateral approach involving detachment of the ITB and ALL from Gerdy’s tubercle, which additionally required a separate reduction route to achieve articular compression. The Gerdy’s tubercle osteotomy not only facilitated improved intraoperative visualization of the posterolateral fracture fragment but also provided direct bony access for reduction. Rather than scar healing following ITB and ALL releases, the osteotomy enabled bone healing. Furthermore, the issue of ITB and ALL tightness was ameliorated. The anterolateral approach with Gerdy’s tubercle osteotomy represents a viable alternative for the management of PLFs and is associated with more favorable early clinical outcomes compared to the conventional anterolateral approach. Abbreviations PLFs posterolateral tibial plateau fractures ALa-GTO anterolateral approach with Gerdy’s tubercle osteotomy ALa-ICO conventional anterolateral approach with intra-articular fracture gap or cortical window osteotomy PSA posterior slope angle; RRS:Rasmussen radiographic score ITB iliotibial band; ALL:anterolateral ligament; FCL:fibular collateral ligament ROM range of joint motion; VAS:visual analogue scale HSS hospital for special surgery; PCS:physical component summary SF-36 36-item short form survey; GH:general health BP bodily pain (BP); MH:mental health (MH) VT vitality; SF:social functioning; PLC:posterolateral corner Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of the First Affiliated Hospital of University of Science and Technology of China (No. 2024-RE-104) and strictly adhered to the Declaration of Helsinki. Prior to commencement, written informed consent was secured from every participant upon detailed explanation of this study. Consent for publication Not applicable. Competing interests The authors declare that they have no conflicts of interest related to the subject matter or materials discussed in this manuscript. No financial, personal, or professional affiliations have influenced the content or conclusions of this work Funding This study was supported by Anhui Provincial Natural Science Foundation (No.2308085QH257) and Funded by Anhui Postdoctoral Scientific Research Program Foundation (No.2025C1245). Author Contribution **Lei Li:** Writing – original draft, Methodology, Formal analysis. **Shanhua Duojie:** Writing – review & editing, Data curation. **Yi Zhu:** Writing – review & editing, Conceptualization. **Wei Xu:** Writing – review & editing, Supervision, Methodology, Data curation, Conceptualization. **Hui Sun:** Writing – review & editing, Supervision, Methodology, Conceptualization. Acknowledgement We sincerely appreciate the support from all physicians in the Department of Traumatic Orthopedics at The First Affiliated Hospital of USTC and Shanghai Sixth People's Hospital for this research. Data Availability Data is provided within the manuscript. References van Dreumel RL, van Wunnik BP, Janssen L, Simons PC, Janzing HM. Mid- to long-term functional outcome after open reduction and internal fixation of tibial plateau fractures. Injury. 2015;46:1608–12. Yao X, Zhou K, Lv B, Wang L, Xie J, Fu X, et al. 3D mapping and classification of tibial plateau fractures. 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09:59:45","extension":"xml","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":187490,"visible":true,"origin":"","legend":"","description":"","filename":"a0778b013d364965b41ea35c0b1d1caa1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8261527/v1/3b3e9d84635f39226f5384fb.xml"},{"id":99317465,"identity":"3f314d25-4d31-43b3-bcd1-1be8974b092b","added_by":"auto","created_at":"2025-12-31 16:30:16","extension":"html","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":201939,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8261527/v1/c7db14e831c1387df5787dd4.html"},{"id":99319870,"identity":"111976f1-8a72-4973-ba40-af0e1a111bcd","added_by":"auto","created_at":"2025-12-31 16:37:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":98148,"visible":true,"origin":"","legend":"\u003cp\u003eIllustration showing the modified Gerdy’s tubercle osteotomy for a right knee. A rectangular osteotomy fragment was resected en bloc with an oscillating saw. The fragment of Gerdy’s tubercle together with iliotibial band and anterolateral ligament insertions preserved was reflected proximally. Subsequently, the depressed posterolateral fragments could be directly visualized and manipulated by internal rotation of the leg and knee adduction. ITB, Iliotibial band; ALL, Anterolateral ligament; FCL, Fibular collateral ligament; PLT, Popliteus tendon; GT, Gerdy’s tubercle; FH, Fibular head.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8261527/v1/1b8fc27115e73778a4a29519.png"},{"id":99318835,"identity":"af075d5a-3aa9-4157-a22b-ca7904f8aead","added_by":"auto","created_at":"2025-12-31 16:35:14","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1199015,"visible":true,"origin":"","legend":"\u003cp\u003eThe patient sustained a Schatzker type II TPF following a fall from height. (A-D) Preoperative radiographs and 3-D CT reconstructions demonstrate a posterolateral split-depression fracture with significant articular impaction and an elevated PSA. (E-H) Surgical intervention was performed through an extended anterolateral approach combined with Gerdy’s tubercle osteotomy. This technique facilitated exposure of the posterolateral fragment while preserving the ITB and ALL on the Gerdy’s tubercle. Reduction was performed through the osteotomy window to elevate the depressed articular segment. Kirschner wires were temporarily used to maintain the Gerdy’s tubercle reduction, and followed by a locking screw fixation. Finally, a subchondral raft screw formation of the posterior-positioned lateral plates (3.5-mm system plates) was attempted. (I-L) Immediate postoperative imaging confirms anatomical reduction of the fracture. One-year follow-up radiographs show maintained reduction without evidence of articular subsidence. (M-N) Functional evaluation at 16 months postoperatively demonstrates pain-free ambulation and nearly normal knee function.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8261527/v1/85e60e0a30cffa42f123f4f4.png"},{"id":99320127,"identity":"17d28f50-8769-458d-8db4-494300085107","added_by":"auto","created_at":"2025-12-31 16:38:16","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1330788,"visible":true,"origin":"","legend":"\u003cp\u003eThe patient with a Schatzker type II tibial plateau fracture sustained from an e-bicycle accident. (A-D) Preoperative 3-D CT scan demonstrating significant depression of the posterolateral articular fragment and an increased PSA. (E-F) Intraoperative views following an extended anterolateral approach with the ITB and ALL9 stripping off from Gerdy’s tubercle. Articular reduction was performed using an cortical open window technique, with elevation of the depressed fragment via the cortical window using a metallic bone tamp. (G-J) Postoperative day one radiographs confirming anatomical reduction of the posterolateral depression. 12 months follow-up radiographs show maintained alignment with evidence of mild reduction loss of the articular surface. (K-L) At the 14-month postoperative evaluation, the patient demonstrates near-normal knee function but reports chronic dull pain over the anterolateral knee after prolonged ambulation.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8261527/v1/5fbcaf8288afccb06797c901.png"},{"id":99317629,"identity":"63db60b4-7552-4dd1-bafd-8d9f5e56e63a","added_by":"auto","created_at":"2025-12-31 16:30:30","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1505815,"visible":true,"origin":"","legend":"\u003cp\u003eBar chart showing the distribution of RRS grade of two cohorts in three time points [the first postoperative day (1D), at 3 months (3M) and one year (1Y)] during follow-up. Values labelled in bars are the percentages of patients of each grade. No differences were noted between the two groups in these time points (p = 1.000, 0.7120, 0.5310, chi-squared test). ALa-GTO, Anterolateral approach with Gerdy’s tubercle osteotomy; ALa-ICO, Anterolateral approach with intra-articular fracture gap or cortical window osteotomy;\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8261527/v1/f5a8e65818126b8bea966344.png"},{"id":99318809,"identity":"5af168a6-3fdf-42dd-8f74-6d5bbd30e5f0","added_by":"auto","created_at":"2025-12-31 16:34:48","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":255993,"visible":true,"origin":"","legend":"\u003cp\u003eBox plot demonstrating the comparisons of all eight SF-36 subscores and two summary scores between two cohorts. ALa-GTO, Anterolateral approach with Gerdy’s tubercle osteotomy; ALa-ICO, Anterolateral approach with intra-articular fracture gap or cortical window osteotomy; GH, General health; PF, Physical functioning; RP, Role limitations-Physical; RE, Role limitations-Emotional; SF, Social functioning; BP, Bodily pain; VT, Vitality; MH, Mental helath; PCS, Physical component summary; MCS, Mental component summary. **, P\u0026lt;0.01; ***, P\u0026lt;0.001.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8261527/v1/0255c746b13ab4bae5319757.png"},{"id":108438047,"identity":"36a78694-80a3-4e85-a4c9-a5b29d75481f","added_by":"auto","created_at":"2026-05-04 16:05:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5635035,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8261527/v1/05113ca6-30be-42d2-a557-d543eac27438.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparation of Gerdy’s Tubercle Osteotomy Versus Conventional Anterolateral Approach for Posterolateral Tibial Plateau Fractures: A Retrospective Cohort Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTibial plateau fractures (TPFs) represent frequent intra-articular injuries, comprising approximately 1% of all fractures in the adult skeleton [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. These fractures result from a spectrum of mechanisms, ranging from low-energy falls to high-energy trauma such as motor vehicle collisions [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The primary objectives of surgical intervention are to restore joint stability, achieve limb alignment, and reestablish the congruity of the articular surface [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Nevertheless, obtaining an adequate reduction remains challenging due to factors including severe comminution, substantial fracture displacement, and limited visualization during surgery [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Suboptimal outcomes have been reported in up to 30% of surgically managed TPFs [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Over the past decades, multiple classification systems and morphological studies utilizing computed tomography (CT) have been developed to characterize these fractures more precisely [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8 CR9 CR10 CR11\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Among these, both the \u0026ldquo;three-column\u0026rdquo; [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] and \u0026ldquo;four-quadrant\u0026rdquo; [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] classifications emphasize the particular significance of posterolateral involvement. Fractures extending into the posterolateral region have garnered considerable clinical interest, as their presence is frequently associated with less favorable outcomes [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePosterolateral tibial plateau fractures (PLFs) are recently defined as distinct articular fractures involving either the posterolateral quadrant of the tibial plateau or a fracture line extending to the cortex of the posterolateral column [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Since the initial description by Waldrop et al. in 1988 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], the epidemiology, injury mechanisms, and morphological features of PLFs have been increasingly elucidated. PLFs account for 44.2% of lateral and bicondylar TPFs [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], with this proportion rising to 62.69% among elderly patients [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], indicating that such fractures are not uncommon.\u003c/p\u003e \u003cp\u003eCadaveric studies have demonstrated correlations between specific fracture patterns and injury mechanisms, particularly the direction of force vectors and the position of the knee at the time of impact [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. It is now widely accepted that varying angles of knee flexion under valgus or varus loading may contribute to the observed diversity in fracture morphology [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In response, several classification systems have been proposed by various authors to categorize PLFs based on their morphological characteristics [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. These efforts aim to inform more systematic surgical strategies and have provided valuable theoretical and practical guidance for the management of these complex injuries.\u003c/p\u003e \u003cp\u003eThe optimal surgical approach for the management of PLFs remains a subject of ongoing debate within orthopedic trauma circles [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Surgical strategies for accessing these fractures may broadly be categorized as either anterior or posterior. Numerous posterior approaches have been described, including those by Lobenhoffer, Bhattacharyya, Carlson, and Frosch, as well as techniques involving transfibular neck osteotomy with or without osteotomy and the Luo approach, among others [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. These approaches offer several advantages, such as direct visualization of the posterior cortical and articular rim fracture lines, facilitated buttress plate application, and an optimal trajectory for posteroanterior screw placement [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, they are also associated with notable limitations. The confined operative field increases the risk of iatrogenic injury to neurovascular and ligamentous structures in the posterolateral corner, including the common peroneal nerve, branches of the popliteal artery, and the posterolateral ligament complex [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Additionally, posterior approaches have been linked to postoperative knee flexion lag and challenges related to subsequent hardware removal following fracture healing [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInterestingly, some surgeons have advocated for the use of modified anterolateral or lateral approaches to manage PLFs. These include the traditional anterolateral approach [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], the extended anterolateral approach [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], the supra-fibular head approach [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], femoral epicondyle osteotomy [\u003cspan additionalcitationids=\"CR30 CR31\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], fibular resection osteotomy [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], digastric fibular head osteotomy [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], and Gerdy's tubercle osteotomy (GTO) approaches [\u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], among others (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The traditional anterolateral approach has long been a standard strategy for lateral tibial plateau fractures-both isolated lateral condyle fractures (Schatzker I-III) and complex patterns involving the lateral plateau (Schatzker IV-VI). Its advantages include technical familiarity, a relatively low risk of iatrogenic injury, and generally favorable outcomes [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. However, both traditional and extended anterolateral approaches, as well as the supra-fibular head approach (collectively referred to as anterolateral approaches, ALa) provide limited direct exposure of the posterolateral fragment. Visualisation typically requires detachment of the iliotibial band (ITB) and anterolateral ligament (ALL) from Gerdy\u0026rsquo;s tubercle [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. This detachment may compromise the healing of the tendon-bone interface, particularly when early continuous passive motion (CPM) is initiated postoperatively to maintain knee mobility [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. The ITB and ALL serves as a secondary stabilizer of the lateral knee, contributing to resistance against varus and internal rotation forces [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], and functions as an accessory structure to the fibular collateral ligament (FCL), the primary lateral stabilizer. Consequently, alternative exposure techniques such as femoral epicondyle osteotomy or fibular osteotomies inherently risk iatrogenic injury to the FCL. With the exception of the GTO approach, all aforementioned techniques provide only improved visualization; an additional bony access, such as an intra-articular osteotomy or cortical window is often required to reduce depressed articular fragments [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. In contrast, the GTO approach (ALa-GTO) offers the dual advantage of enhanced visualization and direct reduction capability. Furthermore, it relies on bony healing of the osteotomized tubercle rather than the less reliable soft-tissue healing of the reattached ITB and ALL. Despite these potential benefits, no comparative study has yet evaluated the outcomes of the ALa-GTO approach against those of anterolateral approaches combined with intra-articular fracture gap or cortical window osteotomy (ALa-ICO). The purpose of this study was to compare the radiological and functional outcomes of patients with PLFs treated with these two surgical strategies.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLiterature review of the anterior approaches (anterior, anterolateral or lateral) for the treatment of PLFs or the PLC injuries (In order of publication year).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYear\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eApproach\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOsteotomy or not* of important bony structures\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIliotibial band processing\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eResults\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eConclusion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLevel of Evidence\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWaldrop JI \u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1988\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLateral approach with lateral cortical window\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eElevating the periosteal insertion of iliotibial band\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e17 achieved a final rating of excellent or good; one (6%) achieved a rating of fair.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eProcedure produces good or excellent results in most cases (94%).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGarofalo R \u003csup\u003e36\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAnterolateral approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eY (Gerdy\u0026rsquo;s tubercle osteotomy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDetachment of tubercle of Gerdy and reflection upward of iliotibial band\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSurgical step allowing a good mobilization of multiple layers of iliotibial tract from distal to proximal makes an excellent exposure of posterolateral corner (PLC) with absence of mobidity.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBowers AL \u003csup\u003e29\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLateral approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eY (Lateral femoral epicondylar osteotomy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIliotibial band split longitudinally in line with its fibers directly over lateral femoral epicondyle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIntraarticular disorders at posterolateral corner may be addressed in an open manner with anatomic reduction and preserved postoperative function of lateral collateral ligament.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eⅤ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHsieh CH \u003csup\u003e25\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAnterior approach with lateral cortical window\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAverage HSS score was 92. No postoperative neural or vascular injures and no wound complication.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eApproach had no complications and was associated with satisfactory outcomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYu B \u003csup\u003e33\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eApproach with osteotomy of fibular head\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eY (Partial or full fibular head osteotomy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIliotibial band reflected from its insertion on Gerdy\u0026rsquo;s tubercle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEncouraging results. Mean score of Rasmussen\u0026rsquo;s functional grading system was 27.9.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNew approach provides excellent visualization, which can facilitate reduction and internal fixation for lateral or PLFs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJohnson EE \u003csup\u003e35\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTscherne-Johnson extensile approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eY (Fracture lines around Gerdy\u0026rsquo;s tubercle completed or the tubercle were osteotomized\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePartial tenotomy of anterior half of iliotibial band, leaving posterior iliotibial band insertion attached to Gerdy\u0026rsquo;s tubercle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAverage knee ROM was 2\u0026deg;of flexion to greater than 120\u0026deg;of flexion. In 66 patients, average articular depression improved from 7.4 mm to 1 mm. Infection occurred in one.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eApproach reliably increases direct visualization of lateral plateau articular fractures and maintains iliotibial band insertion.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChen HW \u003csup\u003e26\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExtended anterolateral approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBackside of iliotibial band cut and opened to separate distal fiber bundles from Gerdy\u0026rsquo;s tubercle. Then knee flexed to peel iliotibial band along upper edge of fibular head.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAverage of Rasmussen functional score was 25.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8. No wound complications, nonunion, valgus knee deformities, plate loosening or breakages, or fracture re-displacements.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eApproach provides excellent visualization, facilitates reduction and internal fixation of PLFs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChen HW \u003csup\u003e27\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExtended anterolateral approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBackside of iliotibial band cut and opened to separate distal fiber bundles from Gerdy\u0026rsquo;s tubercle. Then knee flexed to peel iliotibial band along upper edge of fibular head.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAverage HSS knee score of 95.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6.5 points. No complications found.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eApproach with a proximal tibial compression plate offers direct and complete surgical exposure and provide an effective method for surgical treatment of PLFs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYoon YC \u003csup\u003e31\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAnterolateral approach ( combined lateral femoral epicondylar osteotomy and a submeniscal approach)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eY (Lateral femoral epicondylar osteotomy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCombined approach can be used as an alternative surgical technique for treatment of PLFs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHu SJ \u003csup\u003e28\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAnterolateral supra-fibular-head approach with lateral cortical window\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDistal fiber bundles of iliotibial band released from Gerdy\u0026rsquo;s tubercle.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAverage of knee ROM was 121.4\u0026deg;\u0026plusmn; 8.8\u0026deg;, Average of HSS score was 96.7\u0026deg; \u0026plusmn; 2.6\u0026deg;, and average SMFA dysfunction score was 22.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eApproach can provide direct visualization of PLF quadrant and posteriorly plate placement provide raft fixation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDurigan JR \u003csup\u003e32\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLateral approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLateral femoral epicondyle osteotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIliotibial band incised longitudinally.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMean Knee Society Score was 92\u0026thinsp;\u0026plusmn;\u0026thinsp;13, mean Function Score was 95\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6. Mean Lysholm Knee Score was 92\u0026thinsp;\u0026plusmn;\u0026thinsp;11.7, and mean International Knee Documentation Committee Score was 85\u0026thinsp;\u0026plusmn;\u0026thinsp;12.6.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eApproach through osteotomy of the lateral femoral epicondyle allowed direct reduction and stable osteosynthesis of fractures without functional impairment.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGu YQ \u003csup\u003e34\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAnterolateral approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGerdy's Tubercle Osteotomy (an L-shaped osteotomy along outer edge of the tibial intercondylar spine in the non-load-bearing area of anterior lateral tibial condyle, adjacent to Gerdy\u0026rsquo;s tubercle on inner side.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIliotibial band longitudinally split\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHSS 9score indicating 16 cases rated as excellent, 3 cases as good, and 1 case as fair. Fracture healing transpired without any complications.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAnterolateral approach, combined with Gerdy\u0026rsquo;s tubercle osteotomy, allows for direct exposure and manipulation of the posterolateral bone block fracture.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003cp\u003eLevel of Evidence: Level I, Randomized controlled trial; Level II, Prospective cohort study and Observational study with dramatic effect; Level III, Retrospective cohort study and Case-control study; Level IV, Case series and historically controlled study; Level V, Mechanism-based reasoning. /, No description or no clear expression. ROM, Range of joint motion; HSS, Hospital for special surgery;\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient Cohort and Preoperative Protocol\u003c/h2\u003e \u003cp\u003eBetween January 2023 and March 2024, thirty-two consecutive patients with PLFs exhibiting articular depression of \u0026ge;\u0026thinsp;4 mm were treated surgically using either the ALa-GTO or ALa-ICO reduction technique at a single academic trauma center. Ethical approval for this retrospective cohort study was obtained from the Institutional Review Board of the First Affiliated Hospital of University of Science and Technology of China (2024-RE-104).\u003c/p\u003e \u003cp\u003eInclusion criteria consisted of: (1) skeletal maturity (age\u0026thinsp;\u0026ge;\u0026thinsp;18 years); (2) radiological confirmation of posterolateral articular depression or displacement\u0026thinsp;\u0026ge;\u0026thinsp;4 mm requiring operative management; (3) acute closed fractures (within 72 hours of injury); and (4) availability of complete preoperative imaging (CT or magnetic resonance imaging, MRI) and a minimum follow-up of 12 months. Exclusion criteria were: (1) polytraumatized patients (Injury Severity Score [ISS]\u0026thinsp;\u0026ge;\u0026thinsp;16); (2) open fractures or significant soft-tissue injury; (3) associated neurovascular injuries requiring urgent intervention; and (4) delayed presentation (\u0026gt;\u0026thinsp;3 weeks post-injury) with established malunion.\u003c/p\u003e \u003cp\u003eThe cohort was divided into two groups according to the surgical technique used: 15 patients were treated using the ALa-GTO, while 17 underwent reduction via the ALa-ICO. Preoperative evaluation included a comprehensive radiographic assessment of the knee joint with standardized anteroposterior and lateral radiographs, three-dimensional CT reconstruction for fracture characterization, and MRI to evaluate associated soft-tissue injuries. All patients were managed preoperatively according to a standardized protocol consisting of cryotherapy, edema control, multimodal analgesia, and thromboprophylaxis. The timing of surgery was based on the resolution of the \u003cem\u003epeau d\u0026rsquo;orange\u003c/em\u003e sign, a clinical indicator of soft-tissue readiness.\u003c/p\u003e \u003cp\u003ePatients\u0026rsquo; demographic data, confounding factors, injury-causing factors, fracture classification, mechanism of injury force [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], and soft-tissue injuries [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. All fractures were classified based on Schatzker classification, Three-column classification [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], and PLFs morphological classification [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] according to the preoperative X-ray and CT images. Associated soft tissue injuries were evaluated by preoperative MRI and intraoperative examination.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics and baseline characteristics.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eALa-GTO group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eALa-ICO group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eχ2 / t value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge(years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e49.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.740\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.465\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender (Male/n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.982\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSide of injury (Left/n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.946\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI (kg/m\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e22.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.075\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.291\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSmoking (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.057\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.811\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiabetes (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.840\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInjury-causing factors (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.849\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraffic accident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.817\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFall from height\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther injuries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSchatzker classification (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.883\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eⅡ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.928\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eⅢ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eⅤ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eⅥ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThree-column classification (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.900\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosterolateral one-column\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.578\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLateral and posterolateral two-column\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedial and posterior two-column\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedial, lateral and posterior three-column\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ePLFs morphological classification (n)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eBSF\u003c/p\u003e \u003cp\u003eMSDF\u003c/p\u003e \u003cp\u003eLSDF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e8\u003c/p\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e10\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.817\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.850\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInjury force mechanism (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFlexion-valgus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtension-valgus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFlexion-varus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtension-varus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSoft tissue injury\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeniscus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.861\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.850\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCruciate ligament\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollateral ligament\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTime from Fracture to surgery(days)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.470\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.642\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFollow-up duration(months)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e22.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.535\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.135\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eALa-GTO, Anterolateral approach with Gerdy\u0026rsquo;s tubercle osteotomy; ALa-ICO, Anterolateral approach with intra-articular fracture gap or cortical window osteotomy; BMI, Body mass index; PLFs, Posterolateral tibial plateau fractures; BSF, block-type splitting fracture; MSDF, mild slope-type depression fracture; LSDF, local sinkhole-type depression fracture.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical technique\u003c/h3\u003e\n\u003cp\u003eAll procedures were performed by a designated senior orthopedic trauma team under laminar airflow conditions with fluoroscopic guidance. Patients were placed supine on a radiolucent operating table. A sterile pneumatic tourniquet was applied to the proximal thigh. The affected limb was maintained at 30\u0026deg; of flexion using a sterile foam bolster placed beneath the ipsilateral knee to facilitate exposure of the posterolateral aspect of the joint. After reduction and fixation of the medial and/or posteromedial fractures if that existed, two different strategies of anterolateral approach were implemented.\u003c/p\u003e \u003cp\u003eAla-GTO group: A standard anterolateral approach was employed. After layered soft-tissue dissection, the ITB and ALL was exposed to identify Gerdy\u0026rsquo;s tubercle. A rectangular osteotomy fragment (approximately 2.0 \u0026times; 1.0 \u0026times; 1.5 cm) was demarcated using multiple 2.0 mm K-wires and resected en bloc with an oscillating saw. The fragment-free of articular cartilage and with the ITB and ALL insertions preserved was reflected proximally, allowing full visualization of the lateral meniscus through careful anterior and posterior dissection around ITB and ALL (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The lateral meniscus was sutured and retracted proximally to enable submeniscal exposure of the lateral tibial plateau. Under direct visualization-enhanced by internal rotation of the leg and knee adduction-the depressed posterolateral fragments were reduced via the osteotomy window using bone elevators. Prior to reduction of the articular depression, a periosteal elevator or small Hoffman retractor should be placed through supra-fibular space and posterior to posterolateral tibial cortex to prevent posterior displacement of the PLFs\u0026rsquo; fragment or separated splitting slice [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Provisional fixation was obtained with 1.5 mm K-wires, and the defect was filled with allograft cancellous bone. The Gerdy\u0026rsquo;s tubercle fragment was reduced anatomically and fixed with a 3.5 mm locking screw to restore ITB tension. A pre-contoured lateral locking plate was applied after partial elevation of the tibialis anterior muscle, positioned 5 mm distal to the joint line and as posterior as possible within the supra-fibular space. Four parallel rafting screws-including two supporting the reduced posterolateral articular surface-were placed within 5 mm of the subchondral bone. For fragments smaller than 15 mm, supplemental fixation was provided using either oblique 3.5 mm \u0026ldquo;jail\u0026rdquo; screws engaging both cortices or 2.0 mm K-wires. The lateral meniscotibial ligament complex was reattached by tying the meniscal sutures to the plate. Wound closure was performed in layers using interrupted absorbable sutures (2\u0026thinsp;\u0026minus;\u0026thinsp;0 Vicryl\u0026reg; for subcutaneous tissue, 3\u0026thinsp;\u0026minus;\u0026thinsp;0 Monocryl\u0026reg; for skin). A representative case is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAla-ICO group: A conventional anterolateral approach was utilized. A longitudinal incision was made through the ITB, preserving approximately 30% of its insertion on Gerdy\u0026rsquo;s tubercle. The lateral meniscotibial ligament complex was incised, and the lateral meniscus was mobilized using traction sutures. Submeniscal visualization of the depressed articular surface was enhanced through internal rotation of the leg and adduction of the knee. A rectangular cortical window (15 \u0026times; 10 mm) was created approximately 5 cm distal to the articular margin using K-wire drilling and an oscillating saw. The ITB was retracted in a \u0026ldquo;book-opening\u0026rdquo; fashion to achieve approximately 60\u0026deg; of joint visualization. Under fluoroscopic guidance, depressed fragments were elevated through the subcortical corridor of the cortical window or the intra-articular fracture gap using curved bone tamps until articular congruity was confirmed. The metaphyseal defect was grafted with allogeneic cancellous bone, and the cortical window was anatomically reduced. The hardware for fixation was implanted the same as the Ala-GTO group. The lateral meniscocapsular complex was repaired circumferentially with horizontal mattress sutures to restore meniscal stability. Wound closure was performed in layers using standard technique. A representative case is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMultipolar fluoroscopic imaging, including anteroposterior, lateral, and 45\u0026deg;oblique views, was obtained to assess articular reduction. Reduction was considered acceptable when a residual articular step-off of \u0026le;\u0026thinsp;1 mm was achieved and coronal and sagittal alignment were within 5\u0026deg; of the contralateral limbs. Hardware position was verified to ensure appropriate screw length and the absence of intra-articular penetration. Per protocol [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], all ruptured menisci were repaired to the best degree possible. Disrupted ligamentous insertions were also repaired. Lateral collateral ligament ruptures were repaired if the knee was found to be unstable to varus load on exam while medial collateral ligament injuries were treated nonoperatively in most cases. Rupture of the body of cruciate ligaments was treated non-surgically at the time of initial fracture fixation and addressed surgically at the later date if indicated. The range of motion and stability of the knee joint were evaluated before the incision was closed. After hemostasis were achieve, the wound was washed with saline, and the dissected deep fascia was unstitched. The subcutaneous tissue and skin were closed over suction drains.\u003c/p\u003e\n\u003ch3\u003ePostoperative rehabilitation\u003c/h3\u003e\n\u003cp\u003eA standardized, phased rehabilitation protocol was applied according to the specific surgical approach. Patients in the Ala-GTO group began early active mobilization by postoperative day 3, with unrestricted range of motion beyond 90\u0026deg; of flexion using a locked hinged brace (adjustable 0-120\u0026deg;). This regimen was permitted due to preserved ITB continuity and stable tubercle fixation. In contrast, the Ala-ICO group adhered to a restricted range of motion protocol (0\u0026ndash;90\u0026deg; flexion) for 6 weeks to mitigate the risk of instability related to ITB detachment.\u003c/p\u003e \u003cp\u003eAll patients started protected weight-bearing (30% body weight) using bilateral crutches at 4 weeks postoperatively. Full weight-bearing was permitted only after radiographic evidence of bridging callus across at least three cortices was confirmed. Functional rehabilitation advanced through defined stages: static proprioception training (week 6), dynamic gait training (week 8), and low-impact sport-specific exercises (month 4).\u003c/p\u003e\n\u003ch3\u003eOutcomes assessment and follow-up\u003c/h3\u003e\n\u003cp\u003eA retrospective comparative analysis was conducted in 32 consecutive patients with PLFs who were treated using two distinct surgical approaches. Perioperative parameters assessed included the time from fracture to surgery, operative duration, intraoperative blood loss, fluoroscopy time and the use of bone graft or graft substitute.\u003c/p\u003e \u003cp\u003eAll patients were followed regularly with clinical examination and standardized radiographic assessment, including thin-slice multiplanar CT scans and plain radiographs, obtained on the first postoperative day, and at 3, 12 months. Times to bony union, time to full weight-bearing, range of joint motion (ROM) and all complications observed during follow-up were documented.\u003c/p\u003e \u003cp\u003eDuring routine follow-up, quantitative assessment included measurement of the depression depth of the posterolateral articular surface and posterior slope angle (PSA) on coronal and sagittal reconstructions from three-dimensional CT (3D-CT). Fracture healing and tibial alignment were evaluated using the validated 18-point Rasmussen radiographic scale (RRS) [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], which incorporates three parameters: residual articular depression (\u0026le;\u0026thinsp;2 mm\u0026thinsp;=\u0026thinsp;6 points), coronal plateau width discrepancy (\u0026le;\u0026thinsp;5 mm\u0026thinsp;=\u0026thinsp;6 points), and mechanical axis deviation (\u0026le;\u0026thinsp;5\u0026deg; = 6 points). The quality of reduction, based on the total RRS score, was categorized as anatomic/excellent (18 points), satisfactory/good (12\u0026ndash;17 points), marginal/fair (6\u0026ndash;11 points), or unacceptable/poor (\u0026lt;\u0026thinsp;6 points) [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Postoperative pain was assessed using the visual analogue scale (VAS) [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt a minimum follow-up of 12 months, knee function, including ROM, was evaluated with the hospital for special surgery (HSS) knee score [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], and overall health status was measured using the physical component summary (PCS) of the 36-item short form survey (SF-36) [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eComprehensive adverse event monitoring consisted of the following: articular subsidence of 2 mm or more accompanied by hardware failure; coronal or sagittal malalignment exceeding 5 degrees [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]; and wound complications that necessitated reoperation. The primary complication outcome measures therefore comprised loss of reduction accompanied by hardware failure, malunion, surgical site complications, iatrogenic nerve injury, and compartment syndrome.\u003c/p\u003e \u003cp\u003eAll radiographic and clinical evaluations were performed independently by the first author and the corresponding authors.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eAll statistical analyses were conducted using SPSS Statistics (version 28.0; IBM Corp.) with a two-tailed significance level set at α\u0026thinsp;=\u0026thinsp;0.05. Continuous variables were assessed for normality using the Kolmogorov\u0026ndash;Smirnov test, with a threshold of D\u0026thinsp;\u0026gt;\u0026thinsp;0.10 indicating deviation from normality. Normally distributed data are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) and were compared using repeated-measures analysis of variance with Bonferroni post-hoc adjustment. Categorical variables were shown as number (%) and tested by the chisquared test. Fisher\u0026rsquo;s exact test was implemented when 20% of cells had expected values of \u0026lt;\u0026thinsp;5.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eDemographic analysis\u003c/h2\u003e \u003cp\u003eThe two cohorts demonstrated statically equivalent mean follow-up time (14\u0026ndash;28 months, P\u0026thinsp;=\u0026thinsp;0.135) with balanced baseline characteristics (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), including age, gender distribution, fracture side, injury-causing factors, Schatzker classification, three-column classification, injury force mechanism, PLFs classification, soft tissue injury, or time from fracture to surgical intervention (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eOperative details\u003c/h3\u003e\n\u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, the Ala-GTO cohort demonstrated significantly reduce mean operative time (105.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4 minutes vs 113.8\u0026thinsp;\u0026plusmn;\u0026thinsp;.3 minutes, P\u0026thinsp;=\u0026thinsp;0.013) and fluoroscopy time (10.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7 times vs 13.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7, P\u0026thinsp;=\u0026thinsp;0.019). However, no significant differences were detected between the two groups in terms of intraoperative blood loss, and utilization of bone substitute (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). In Ala-GTO group, the fragments of GTO were fixed by one locking screws in 14 cases, and only in one elder-patient the GTO fragment was fixed by min-plate for metacarpophalangeal fractures because of osteoporosis.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOperative and follow-up outcomes.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eALa-GTO group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eALa-ICO group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e / T value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOperation time(minutes)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e105.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e113.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.627\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.013\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBlood loss (ml)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.321\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.609\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFluoroscopy times\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.482\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.019\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUse of bone graft or bone graft substitute (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.736\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.695\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ebone graft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ebone graft substitute\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFracture healing time (weeks)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.861\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.396\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFull load-bearing time (weeks)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.346\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.188\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePSA(\u0026deg;)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.065\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.949\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.376\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.800\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.214\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.042\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.710\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.01\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDepression depth of the articular surface (mm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.391\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.699\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.274\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.591\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.015\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.965\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0004\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRRS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.296\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.769\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.729\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.472\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.693\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.494\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.084\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.287\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVAS score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.409\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.169\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.185\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.246\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.097\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.004\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.841\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eROM (\u0026deg;)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.930\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.400\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFlexion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e131.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e127.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.257\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHSS score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.961\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.345\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSF-36 (v2)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.308\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.760\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eALa-GTO, Anterolateral approach with Gerdy\u0026rsquo;s tubercle osteotomy; ALa-ICO, Anterolateral approach with intra-articular fracture gap or cortical window osteotomy; PSA, Posterior slope angle; RRS, Rasmussen radiographic scale; VAS,Visual analogue scale; ROM, Range of joint motion; HSS, Hospital for special surgery; SF-36, 36-item short form survey. \u003csup\u003e*\u003c/sup\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eRadiographic outcomes\u003c/h2\u003e \u003cp\u003eNo significant differences were observed between the two groups regarding radiographic union time (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). 3-D CT evaluation demonstrated better maintenance of articular reduction in the Ala-GTO cohort. PSA were significantly closer to anatomical values in the Gerdy\u0026rsquo;s group at both 3 months (10.0\u0026deg; \u0026plusmn; 0.4\u0026deg; vs. 11.3\u0026deg; \u0026plusmn; 0.4\u0026deg;, P\u0026thinsp;=\u0026thinsp;0.042) and 1 year postoperatively (10.3\u0026deg; \u0026plusmn; 0.4\u0026deg; vs. 11.8\u0026deg; \u0026plusmn; 0.4\u0026deg;, P\u0026thinsp;=\u0026thinsp;0.01). Multiplanar CT assessments consistently showed superior articular congruency in the Gerdy\u0026rsquo;s group across all follow-up intervals (P\u0026thinsp;=\u0026thinsp;0.003, 0.015 and 0.0004). The comprehensive RRS and distribution of RRS grade were comparable between groups during follow-up (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eFunctional outcomes\u003c/h2\u003e \u003cp\u003eBoth groups progressed to full weight-bearing at a similar rate (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Significantly better pain control, assessed by VAS, was observed in the Ala-GTO group at midterm (2.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2 vs. 3.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and final follow-up (0.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2 vs. 1.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2; p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). At final follow-up, there was no significant difference about the range of motion of the knee joint between two groups (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The Gerdy\u0026rsquo;s group showed higher HSS scores at 12 months (93.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6 vs. 92.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7); however, these differences did not reach statistical significance (p\u0026thinsp;=\u0026thinsp;0.345) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The excellent or good functional outcomes (HSS\u0026thinsp;\u0026ge;\u0026thinsp;85) were achieved in 94.4% of patients in both groups.\u003c/p\u003e \u003cp\u003eAlthough the general health (GH) of SF-36(v2) in Ala-GTO group had no significant difference from that in control group (P\u0026thinsp;=\u0026thinsp;0.760), SF-36 subscale analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) revealed technique-specific advantages: the GTO group demonstrated significantly better physical function (PF: 86.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2 vs. 74.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), role-physical (RP: 84.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.3 vs. 71.9\u0026thinsp;\u0026plusmn;\u0026thinsp;8.1; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and role-emotional (RE: 94.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2 vs. 88.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2; P\u0026thinsp;\u0026lt;\u0026thinsp;0.01) scores. In contrast, the Ala-ICO group exhibited better bodily pain (BP) outcomes (6.28\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1 vs. 10.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No significant differences were found in mental health (MH), vitality (VT), or social functioning (SF) scores (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), indicating comparable psychosocial adaptation between groups.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eComplication Profile\u003c/h2\u003e \u003cp\u003eA complete follow-up rate of 100% was achieved. No between-group differences were observed in hardware integrity, and there were no cases of secondary displacement, malreduction, or post-traumatic arthrosis. All GTO sites healed uneventfully. Superficial wound complications occurred at a similar rate in both groups (one case each; 6.7% vs. 5.9%; p\u0026thinsp;=\u0026thinsp;0.792); each was successfully managed with vacuum-assisted closure. One patient in the Ala-ICO group developed severe motion restriction (flexion\u0026thinsp;\u0026lt;\u0026thinsp;60\u0026deg;) due to noncompliance with rehabilitation protocols following a concurrent cerebrovascular event.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eUntil now, PLFs represent technically challenging articular injuries, owing to limited surgical access constrained laterally by the fibular head, posteriorly by critical neurovascular structures, and anteriorly by metaphyseal cortices [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Established biomechanical principles indicate that articular reduction within \u0026le;\u0026thinsp;2 mm is essential to maintain physiologic load distribution; deviation beyond this threshold progressively jeopardizes meniscal function, promotes chondrocyte apoptosis through aberrant shear stresses, and elevates the risk of secondary arthroplasty [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Achieving anatomic reduction of the posterolateral fragment is critical, as it directly influences joint stability, knee kinematics, and long-term survivorship [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. In 2013, Solomon et al. demonstrated that a direct posterolateral approach for unicondylar PLFs yields superior fracture reduction, enhanced stabilization, and improved early functional outcomes compared to an indirect conventional anterolateral approach [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Despite the successful discovery of various posterior approaches for PLFs treatment, the substantial clinical value of anterolateral and lateral strategies should not be overlooked. Originally described for treatment of posterolateral corner (PLC) injuries and Hoffa fractures of the knee [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e], Gerdy's tubercle osteotomy performed via an anterolateral approach (Ala-GTO), has been adapted to address PLFs. It was reported that the Ala-GTO not only facilitates direct visualization of the PLFs fragment through a controlled expansion of the surgical corridor but also preserving the integrity of the lateral collateral ligament [\u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Although the advantage seemed noticeable comparing with the conventional anterolateral approach, to our knowledge, this represents the first study to directly compare these two anterior approaches.\u003c/p\u003e \u003cp\u003eOur study found that the Ala-GTO technique was associated with superior early clinical outcomes compared with the conventional Ala-ICO approach. Compared with articular surface exposure method in the Ala-ICO approach [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], GTO preserves the attachment integrity of the ITB and ALL. Eliminating the restraining tension of the ITB and ALL permits knee internal rotation and adduction as much as possible, maximizing posterolateral plateau visualization. Consequently, as our findings illustrate, GTO facilitates precise fracture reduction under direct exposure and simplified fixation without requiring much more intraoperative fluoroscopy, a necessity when ICO is employed to combine indirect visualization with real-time imaging. Furthermore, the technique obviates extensive meniscal suture suspension while preserving the meniscotibial attachment partially, which attaches to the GTO fragment. This collective benefit contributes to a reduction in operative time. Postoperatively, the Ala-GTO group maintained significantly superior PSA at 3 months and 1 year, demonstrated minimal articular surface collapse immediately postoperatively and at 3 months and 1 year, reported reduced late-term knee pain, and achieved higher SF-36 scores compared to the Ala-ICO group. However, no significant difference in functional joint outcomes was observed between the techniques. Concerns regarding GTO fragment healing and early postoperative mobilization appear clinically acceptable based on our data. To date, no cases exhibited nonunion. The fixation strategy, employing a single long locking screw augmented with a proportion of anterolateral plate coverage for GTO fragment fixation, ensures sufficient stability to allow early knee joint rehabilitation.\u003c/p\u003e \u003cp\u003eThe GTO technique offers the advantage of preserving the inherent attachment of the ITB to the Gerdy\u0026rsquo;s tubercle, converting scar healing into bony healing, and thereby enhancing knee function. Furthermore, a key modification in our method involves the osteotomy of Gerdy\u0026rsquo;s tubercle. As previously documented, the ALL functions as a ligamentous structure that becomes taut during internal rotation at 30\u0026deg; of knee flexion [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. It serves as a secondary stabilizer to the anterior cruciate ligament (ACL), resisting anterior tibial translation and internal tibial rotation, as well as preventing the pivot-shift phenomenon [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. However, during conventional surgical exposure for lateral tibial plateau fractures via an anterolateral approach, the tibial insertion of the ALL is frequently detached from the proximal tibia, often resulting in scar healing and subsequent ligamentous laxity. The ALL originates near the lateral epicondyle of the distal femur and inserts on the proximal tibia near Gerdy\u0026rsquo;s tubercle [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], with anatomical studies confirming its close relationship to the ITB [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. Based on these anatomical and biomechanical considerations, we modified the GTO procedure to include Gerdy\u0026rsquo;s tubercle along with the attachments of both the ITB and ALL, aiming to preserve the functional integrity of these stabilizers. This modification likely contributes to the improved functional outcomes observed in patients treated with this technique compared to those managed with the conventional approach.\u003c/p\u003e \u003cp\u003eIn accordance with the two principal surgical approaches, fixation strategies for PLFs can be broadly categorized into two types: posterior buttress plating and lateral rafting plate fixation [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. The posterior buttress plate functions by converting shear forces into compressive forces [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], and has been biomechanically established as the construct with the highest strength in our previous studies [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Nevertheless, the clinical necessity of such high fixation strength for the posterolateral fragment has been subject to ongoing debate [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. From a physiological perspective, the loads borne by the posterolateral column of the tibial plateau are limited, generally not exceeding 1000 N, making it unlikely for the posterolateral fragment to experience extreme mechanical stress during rehabilitation [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. With recent advancements in hybrid fixation techniques used in conjunction with conventional lateral rafting plating, such as \u0026ldquo;magic screw\u0026rdquo; [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e] or \u0026ldquo;jail screw\u0026rdquo; [\u003cspan additionalcitationids=\"CR61\" citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e] fixation, as well as the development of novel anterolateral plate designs [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e], the biomechanical performance of anterior-based fixation methods has been shown to approximate or even exceed that of posterior plating for PLFs. Consequently, the indications for anterior fixation via modified anterior approaches are likely to expand, potentially benefiting a broader patient population.\u003c/p\u003e \u003cp\u003eWhen utilizing anterolateral approaches for the management of PLFs, the lateral rafting plate is typically positioned as far posteriorly as possible to provide adequate support to the reduced posterolateral articular surface [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. As a consequence, this posterior positioning may result in inadequate coverage of Gerdy\u0026rsquo;s tubercle [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. In previous reports on the treatment of Hoffa fractures and posterolateral corner (PLC) injuries, the GTO fragment was typically reduced and stabilized using a single lag screw [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. By contrast, in the only available report addressing PLCs via a GTO approach, the Gerdy\u0026rsquo;s tubercle fragment was fixed using an additional contoured small T-shaped plate [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. In our cohort, the GTO fragments were most commonly fixed with a single locking screw, the threaded tail of which engages the cortex to provide resistance against shear displacement. One case with an osteoporotic fragment, however, was fixed using a mini-plate to achieve rigid fixation. At present, there remains no consensus regarding the optimal fixation method for the GTO fragment.\u003c/p\u003e \u003cp\u003eAlthough this study provides clinically relevant insights, several inherent limitations must be acknowledged. The observational design was limited by a small cohort and short-term follow-up, which may restrict the generalizability and long-term interpretation of the outcomes, such as the risk of arthroplasty [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Additionally, the nonrandomized retrospective nature of the methodology introduces potential selection bias and residual confounding. Future multicenter randomized controlled trials with extended surveillance periods (\u0026ge;\u0026thinsp;5 years) are necessary to establish definitive evidence regarding therapeutic durability and mechanistic causality.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis comparative study evaluated Gerdy\u0026rsquo;s tubercle osteotomy performed via an anterolateral approach for the treatment of PLFs, in comparison with a conventional anterolateral approach involving detachment of the ITB and ALL from Gerdy\u0026rsquo;s tubercle, which additionally required a separate reduction route to achieve articular compression. The Gerdy\u0026rsquo;s tubercle osteotomy not only facilitated improved intraoperative visualization of the posterolateral fracture fragment but also provided direct bony access for reduction. Rather than scar healing following ITB and ALL releases, the osteotomy enabled bone healing. Furthermore, the issue of ITB and ALL tightness was ameliorated. The anterolateral approach with Gerdy\u0026rsquo;s tubercle osteotomy represents a viable alternative for the management of PLFs and is associated with more favorable early clinical outcomes compared to the conventional anterolateral approach.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePLFs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eposterolateral tibial plateau fractures\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eALa-GTO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eanterolateral approach with Gerdy\u0026rsquo;s tubercle osteotomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eALa-ICO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003econventional anterolateral approach with intra-articular fracture gap or cortical window osteotomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePSA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eposterior slope angle; RRS:Rasmussen radiographic score\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eITB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eiliotibial band; ALL:anterolateral ligament; FCL:fibular collateral ligament\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eROM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003erange of joint motion; VAS:visual analogue scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ehospital for special surgery; PCS:physical component summary\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSF-36\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e36-item short form survey; GH:general health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ebodily pain (BP); MH:mental health (MH)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003evitality; SF:social functioning; PLC:posterolateral corner\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e This study was approved by the Ethics Committee of the First Affiliated Hospital of University of Science and Technology of China (No. 2024-RE-104) and strictly adhered to the Declaration of Helsinki. Prior to commencement, written informed consent was secured from every participant upon detailed explanation of this study.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no conflicts of interest related to the subject matter or materials discussed in this manuscript. No financial, personal, or professional affiliations have influenced the content or conclusions of this work\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study was supported by Anhui Provincial Natural Science Foundation (No.2308085QH257) and Funded by Anhui Postdoctoral Scientific Research Program Foundation (No.2025C1245).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003e**Lei Li:** Writing \u0026ndash; original draft, Methodology, Formal analysis. **Shanhua Duojie:** Writing \u0026ndash; review \u0026amp; editing, Data curation. **Yi Zhu:** Writing \u0026ndash; review \u0026amp; editing, Conceptualization. **Wei Xu:** Writing \u0026ndash; review \u0026amp; editing, Supervision, Methodology, Data curation, Conceptualization. **Hui Sun:** Writing \u0026ndash; review \u0026amp; editing, Supervision, Methodology, Conceptualization.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe sincerely appreciate the support from all physicians in the Department of Traumatic Orthopedics at The First Affiliated Hospital of USTC and Shanghai Sixth People's Hospital for this research.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003e Data is provided within the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003evan Dreumel RL, van Wunnik BP, Janssen L, Simons PC, Janzing HM. 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Patient function continues to improve over the first five years following tibial plateau fracture managed by open reduction and internal fixation. Bone Joint J. 2020;102\u0026ndash;b:632\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInsall JN, Ranawat CS, Aglietti P, Shine J. A comparison of four models of total knee-replacement prostheses. J Bone Joint Surg Am. 1976;58:754\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWare JE Jr., Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30:473\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSun H, Zhai QL, Xu YF, Wang YK, Luo CF, Zhang CQ. Combined approaches for fixation of Schatzker type II tibial plateau fractures involving the posterolateral column: a prospective observational cohort study. 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J Orthop Sci. 2024;29:1085\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Tibial plateau fracture, Posterolateral, Approach, Reduction, Gerdy’s tubercle osteotomy","lastPublishedDoi":"10.21203/rs.3.rs-8261527/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8261527/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e \u003cb\u003eBackground\u003c/b\u003e The optimal reduction strategy for posterolateral tibial plateau fractures (PLFs) remains controversial due to limited visualization and fixation challenges. This study compared radiographic and functional outcomes between the anterolateral approach with Gerdy\u0026rsquo;s tubercle osteotomy (ALa-GTO) and the conventional anterolateral approach with intra-articular fracture gap or cortical window osteotomy (ALa-ICO).\u003c/p\u003e \u003cp\u003e \u003cb\u003eMethods\u003c/b\u003e A retrospective cohort study was conducted involving 32 patients with PLFs and articular depression\u0026thinsp;\u0026ge;\u0026thinsp;4 mm. Participants were allocated to either ALa-GTO (n\u0026thinsp;=\u0026thinsp;15) or ALa-ICO (n\u0026thinsp;=\u0026thinsp;17). Perioperative parameters, radiographic outcomes (articular reduction, posterior slope angle [PSA], Rasmussen radiographic score [RRS]), and functional outcomes (VAS, HSS, SF-36) were assessed with a minimum 12-month follow-up.\u003c/p\u003e \u003cp\u003e \u003cb\u003eResults\u003c/b\u003e The ALa-GTO group demonstrated significantly shorter operative time (105.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4 vs. 113.8\u0026thinsp;\u0026plusmn;\u0026thinsp;.3 minutes, p\u0026thinsp;=\u0026thinsp;0.013), superior PSA maintenance at 3 months and 1 year (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and less articular depression at all timepoints (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). VAS scores were significantly lower in the ALa-GTO group at midterm and final follow-up (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). SF-36 subscales revealed better physical function and role-physical outcomes in the ALa-GTO group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), though HSS scores did not differ significantly (p\u0026thinsp;=\u0026thinsp;0.345). All osteotomy sites healed without failure, and complication rates were comparable.\u003c/p\u003e \u003cp\u003e \u003cb\u003eConclusion\u003c/b\u003e The ALa-GTO technique provides enhanced direct visualization and reduction capability, and is associated with improved early radiographic outcomes and function compared to the ALa-ICO approach. It represents a viable surgical alternative for the management of PLFs.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTrial registration\u003c/b\u003e Not applicable.\u003c/p\u003e","manuscriptTitle":"Comparation of Gerdy’s Tubercle Osteotomy Versus Conventional Anterolateral Approach for Posterolateral Tibial Plateau Fractures: A Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-30 09:59:40","doi":"10.21203/rs.3.rs-8261527/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-12T13:56:56+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-08T11:42:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"116864184802759810955098699877761845733","date":"2026-01-02T05:18:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-28T17:53:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"258448438325346082048970704339701209812","date":"2025-12-28T05:11:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-25T16:27:31+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-16T14:00:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-09T16:28:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-09T10:29:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2025-12-09T10:12:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b5a4f6f8-f005-48e0-b658-b1af406f5d2a","owner":[],"postedDate":"December 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T16:05:47+00:00","versionOfRecord":{"articleIdentity":"rs-8261527","link":"https://doi.org/10.1186/s12891-026-09897-5","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2026-04-27 15:57:17","publishedOnDateReadable":"April 27th, 2026"},"versionCreatedAt":"2025-12-30 09:59:40","video":"","vorDoi":"10.1186/s12891-026-09897-5","vorDoiUrl":"https://doi.org/10.1186/s12891-026-09897-5","workflowStages":[]},"version":"v1","identity":"rs-8261527","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8261527","identity":"rs-8261527","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}