Arthroscopically assisted refixation of bony ACL tears with accompanying posteraleral tibial plateau (“apple bite”) fractures – a minimally invasive treatment approach

Arthroscopically assisted refixation of bony ACL tears with accompanying posteraleral tibial plateau (“apple bite”) fractures – a minimally invasive treatment approach | 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 Arthroscopically assisted refixation of bony ACL tears with accompanying posteraleral tibial plateau (“apple bite”) fractures – a minimally invasive treatment approach Thomas Rosteius, Ole Somberg, Maria Bernstorff, Sebastian Lotzien, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8233045/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Mar, 2026 Read the published version in European Journal of Trauma and Emergency Surgery → Version 1 posted 9 You are reading this latest preprint version Abstract Purpose Combined fractures involving bony avulsion of the anterior cruciate ligament (ACL) with a concomitant impression fracture of the posterolateral tibial plateau are rare injuries, with limited data available in the literature. Therefore, the aim of this study was to evaluate the functional and clinical outcomes of arthroscopically assisted treatment for these osteoligamentous injuries. Methods We retrospectively reviewed 16 patients after a mean follow-up of 24.3 ± 10.6 months (12–45 months) who underwent arthroscopically assisted treatment for these named injuries. The fixation of the ACL avulsion was carried out either with two crossed, cannulated 2.7 mm screws or using transosseous sutures (12 and 4 patients, respectively). The reduction and fixation of the tibial plateau fracture with an articular step-off greater than 2mm was performed arthroscopically assisted by screw osteosyntheses (9 patients). Primary outcome parameters were the Lysholm score, Knee Injury and Osteoarthritis Outcome Score (KOOS), Kujala score, NRS Pain Score, and IKDC score. Secondary outcome parameters included bony consolidation, complications, and surgical revisions. Results The mean Lysholm score, KOOS, Kujala and IKDC score was 84 ± 13, 81 ± 14%, 82 ± 14, and 78 ± 11, respectivley. The NRS score had a median of 1.6, the median Tegner activity score was 4.5. Complete bony healing was achieved in all patients. No perioperative complications occurred. During follow-up, 6 patients showed persistent 1° laxity of the ACL in a side-to-side comparison without rotational instability. Two patients had a 5° extension deficit on the affected side. Conclusion Arthroscopically assisted fixation of combined bony ACL tears and posterolateral tibial plateau fractures as a minimally invasive procedure results in good functional outcomes with sufficient joint stability. It offers the advantage of useful visualization of the joint surface, which helps to avoid residual intraarticular step-offs and posterolateral malalignment. ACL avulsion fixation is possible both through crossed screw osteosynthesis and transosseous sutures techniques in an arthroscopic setting. tibial plateau fracture articular congruity apple bite fracture eminence fracture Figures Figure 1 Figure 2 Introduction Although tibial plateau fractures account for only 1% of all fractures [ 1 , 2 ], these fractures are one of the most severe and challenging injuries of the knee joint. This is partly because it is a complex articular surface injury with very heterogenic fracture morphology, especially in the case of OTA type C fractures. Furthermore, in addition to different tibial plateau fractures, accompanying ligament injuries occur, which, if left untreated, can lead to chronic joint instability. This fact makes osteoligamentous injuries very specific and requires, in addition to fracture treatment, also ligament surgery. One of these rare injuries, that are caused by flexion/valgus force, are the examined eminence fractures with accompanying posterolateral impression. These injuries pose a significant challenge for orthopedic surgeons and the restoration of articular congruity, since the posterolateral corner of the tibial plateau can hardly be visualized despite the use of intraoperative fluoroscopy [ 3 ], hence its being called the “dark side of the knee” [ 4 ]. The lack of intraoperative visualization is one of the main reasons for inadequate reduction after complex tibial plateau fractures [ 5 ]. This leads to residual step-offs greater than 2 mm in up to 32% of all complex tibial plateau fractures [ 6 ]. A dislocated eminence fracture additionally carries the risk of persistent ACL- and rotational instability, making refixation absolutely necessary. Therefore, since eminence fractures are ideally treated arthroscopically [ 7 ], an arthroscopic approach is most suitable for the management of these combined injuries. This allows the stabilization of the eminence fracture and the direct visualization, reduction, and percutaneous fixation of the posterolateral joint surface. Due to the rarity of these osteoligamentous injuries, the literature contains neither a gold standard nor targeted treatment strategy. Therefore, in this study, we analyzed the largest cohort of these rare fracture entity to date, treated entirely arthroscopically, in terms of short- to midterm outcome, complications, and surgical revisions. We hypothesize that these combined injuries can be optimally treated arthroscopically, with low complication rates and very good functional outcomes. Materials and Methods The study was reviewed and approved by the local Institutional Review Board (IRB) (registered number: 18-6508_1-BR). All procedures were performed in accordance with the ethical standards of the institutional research committee and with the 1964 Declaration of Helsinki and its later amendments. Study design Patients with combined bony ACL tear and posterolateral tibial plateau fracture between 2016 and 2020 were retrospectively reviewed. All patients with a minimum follow-up of one year were included in this study. Exclusion criteria were patients with accompanying collateral ligament or meniscal injury, vascular damage or previous damage of the joint and missing pre- and postsurgical CT data. In total, 20 patients fulfilled these criteria. Sixteen out of these 20 patients were available for clinical follow-up and were considered for further analysis. Surgical management and postoperative procedures The bony ACL tears were fixed using either two crossed, cannulated 2.7mm cortical screws (Fig. 1 ) or transosseous sutures (Fig. 2 ). The posterolateral tibial plateau fracture was reduced with the help of a cancellous bone ram and fixed using percutaneously inserted screw osteosyntheses after arthroscopic visualization according to the description of Ackermann et al. [ 8 ]. One patient needed additional posterolateral buttress plating due to a posterolateral shear fracture. Physical therapy started 48 hours after the operation with passive motion of the joint through a limited range of motion (ex./flex. 0°/0°/90°) with the patient in the supine position. If necessary, peripheral nerve block anesthesia was applied. Patients had limited weightbearing (20 kg) and limited range of motion for 6 weeks. Follow-up examination The patient assessment and clinical evaluation were scheduled a minimum of one year after the primary surgery. Primary outcome parameters were the Lysholm score [ 9 ], Knee Injury and Osteoarthritis Outcome Score (KOOS), Kujala Score, NRS Pain Score and International Knee Documentation Committee (IKDC) Score [ 10 ]. Secondary outcome parameters were the assessment of bony consolidation, complications and revisions. Lower leg radiographs and CT images were obtained during the first 72 hours after surgery to analyze the axial alignment and postsurgical articular congruity. The range of motion (ROM) was measured using a goniometer. Statistical analysis Descriptive data are described by the mean, standard deviation, minimum and maximum. After the normality of the data was tested using the Shapiro-Wilk test, normally distributed variables were assessed using the two-tailed t-test. Nonnormally distributed variables were analyzed with the Wilcoxon/Mann-Whitney test. Nominally scaled variables were compared using cross tables and Fischer’s exact test. α = 0.05 or less was considered statistically significant. Results A total of 16 patients (36 ± 16 years old) with an average follow-up of 24.3 ± 10.6 months (12–45 months) were included in the study. Table 1 shows the demographic data of the study group. Table 1 Demographic data of the study group Demographic data n 16 Age (mean ± SD) 36.4 ± 16.4 (median = 34.5) Men / women (n) 9 / 7 BMI (kg/m2) 24.5 ± 5.4 ASA Score I II III IV 5 (31.25%) 8 (50%) 2 (12.5%) 1 (6.25%) Co-morbidity (n) No diseases 3 diseases 3 (18.75%) 9 (56.25%) 4 (25%) Meyers-McKeever classification I II III IV 3 (18.75%) 5 (31.25%) 7 (43.75%) 1(6.25%) Menzdorf et al. classification Ia Ib Ic IIa IIb IIc IIIa IIIb 3 (18.75%) 2 (12.5%) 0 3 (18.75%) 2 (12.5%) 5 (31.25%) 0 1 (6.25%) In summary, one patient had a type 4 injury according to Meyers and McKeever, 7 patients a type 3 injury, 5 patients a type 2 and 3 patients a type 1 injury. All patients had an accompanying impression fracture of the posterolateral tibial plateau, in 2 patients in combination with a lateral split component and in 2 patients with a medial split. In 12 patients, the bony ACL tears were fixed using crossed, cannulated screws and in 4 patients using pull-out sutures. In 9 patients, the accompanying tibial plateau impression fracture was repositioned arthroscopically assisted and fixed percutaneously; in 7 cases, the posterolateral fracture was not surgically addressed. Table 2 demonstrates the final outcome and complications. Complete bone healing was achieved in all patients. There were no perioperative complications. During follow-up, 6 patients showed a remaining 1° laxity of the ACL in comparison to the other side. 2 patients had an extension deficit of 5° on the affected side. No rotational instability was observed. There were no significant differences in outcome or joint stability between surgically and non-surgically treated apple- bite fracture. Table 2 Complications and final outcome Complications and final outcome Complete bone healing % 100 Return to sports (in months) 8.3 ± 3 Return to work (in months) 4.9 ± 2 Lysholm Score 84 ± 13 Kujala Score 82 ± 14 IKDC (in%) 77.9 ± 11 KOOS 81 ± 14 TAS-Tegener activity scale 5 ± 1 Pain (NRS scale) 2 ± 2 Residual Knee AP-Instability 1° 2° 3° 6 (37.5%) 0 0 Residual Rotational Instability 0 Discussion In our study, we analyzed the outcome of surgical treatment of combined injuries involving bony avulsion of the anterior cruciate ligament (ACL) with a concomitant impression fracture (apple-bite fracture) of the posterolateral tibial plateau. To the best of our knowledge, we present the largest study group of these rare sub- entity of tibial plateau fractures. We could demonstrate that arthroscopic treatment of these specific osteoligamentous injuries is successfully possible. An anatomical reconstruction as well as a good clinical outcome with sufficient joint stability can be achieved. Most patients reach a “restitution ad integrum” in relation to work and sport. These results are underlined by studies on single eminence fractures, which mostly describe less pain, shorter hospital stay, fewer nonunions and less soft tissue compromise with an arthroscopic- than with an open procedure, regardless of the fixation method [ 11 – 13 ]. However, the treatment algorithm of posterolateral tibial plateau fractures and especially of the rare osteoligamentous injuries is still of high scientific interest, since the best surgical approach as well as the indication for non-surgical or surgical treatment are still under debate. This is due to its special, “difficult” anatomical location and the described, possible (multidimensional) joint instability, but not least due to the very heterogeneous fracture morphologies. First, the visualization of the posterior segments is known to be limited [ 3 , 4 ] and therefore the anatomic reduction quite difficult. This is supported by the work of Meulenkamp et al., who found an insufficient reduction with an articular step-off greater than 2 mm in 32% of all tibial plateau fractures [ 6 ]. The posterior quadrants were particularly affected [ 6 ]. As a result, the current literature has especially dealt with the improvement of visualization in the treatment of posterior fractures of the tibial plateau [ 14 – 18 ]. An arthroscopic assistance seems to support the visualization of the posterolateral corner and helps to restore the joint line anatomically without residual steps and good functional outcomes [ 19 – 21 ]. Alternative procedures include fracturoscopy and extended approaches according to Krause t al.[ 3 , 16 , 22 ] and Behrendt et al.[ 23 , 24 ], which might be necessary in the treatment of multifragmentary type C fractures with the involvement of the posterolateral corner. However, these are significantly more invasive and, in our opinion, not necessary in case of the described apple-bite fractures. On the one hand, there is more or less consensus about the indication for surgery regarding the fracture's step-off height. The tolerable limit for a residual step-off height appears to be approximately 2 mm [ 25 – 32 ]. For example, a clinical study by Singleton et al. analyzed the outcomes of 41 patients after tibial plateau fracture in terms of articular congruity. The intraarticular step was measured on coronal plane tomograms, so posterior fractures could not be evaluated. The authors found that patients with an intraarticular step < 2.5 mm had a better functional outcome in terms of range of motion and Oxford, Iowa and Knee Injury and Osteoarthritis Outcome Score (KOOS) scores. [ 25 ]. Parkkinen et al. also tried to identify predictors of early osteoarthritis following lateral tibia plateau fractures as a function of the postoperative mechanical axis and articular congruity. In summary, a valgus malalignment greater than 5° and an articular depression greater than 2 mm led to advanced osteoarthritis, whereas a normal mechanical axis or a depression less than 2 mm did not [ 27 ]. Few studies have examined the topic of articular congruity biomechanically [ 29 , 32 , 33 ]. Bai et al. were among the first to demonstrate the problem of increasing contact pressures in the knee joint with increasing articular step-offs, using the example of lateral split fractures in a biomechanical cadaveric study [ 29 ]. Contact stress and contact area as well as joint axis were analyzed in 6 human fresh frozen cadaveric knees at 0° and 30° flexion in a static setup. At a 6-mm step-off with 0° knee flexion, the average contact pressures and maximum contact pressures increased an average of 208% and 97%, respectively, and the contact area decreased an average of 33% (p < 0.05) [ 29 ]. Walter et al. [ 34 ] also analyzed the dissipated energy as a parameter of friction and reduction accuracy in lateral tibial split fractures with 2-mm step- and gap-off by studying 6 human cadaveric knees under cyclic loading in a robotic system. They found that a step-down of 2 mm led to a doubling of the dissipated energy, whereas the step-up even tripled. However, a 2-mm gap also led to a statistically significant increase in the dissipated energy, even if it was less than a step [ 34 ]. One the other hand, recent studies demonstrate that not only an intraarticular step-off is essential for the clinical outcome and possible development of osteoarthritis, but also the location of the fracture and concomitant ligamentous injuries might play an important role with regard to joint stability [ 35 – 38 ]. The analyzed posterolateral impressions are caused by flexion-, internal rotation- and valgus stress [ 39 ]. In addition to the posterolateral impression, tension stress on the anteromedial and posterolateral structures is the result of this three-dimensional stress, which in turn can lead to accompanying lesions of the ACL, ALL, anteromedial structures and the posterolateral corner [ 40 ]. Therefore, in addition to the reconstruction of the posterolateral impression, the treatment of possible accompanying ligament injuries plays an important role to restore ligamentous stability. Moreover, a remaining or untreated posterolateral impression itself can on the one hand lead to a progressive sagittal malalignment with therefore a higher tibial slope, which in turn might lead to a failure of the ACL reconstruction[ 41 ] or meniscal root tear[ 42 ] , [ 43 ]. There are also indications in the literature that posterolateral tibial impressions cause a persistent translational and anterolateral rotational instability in combination with ACL deficiency [ 36 – 38 ]. In the past, different studies have investigated the special entity of apple bite fractures. Most notably, Menzdorf et al. described on of the largest collectives of apple bite fractures with ACL injuries to date [ 44 ]. They demonstrated the first short-term results of 20 patients with posterolateral tibial plateau fracture with accompanying ACL tear. One of these patients had a bony ACL tear, which corresponds to our collective. The patients reached a subjective IKDC score of 79,15 +/- 6,07, which is similar to our study results. A graft failure of the ACL was not mentioned. In summary, the study provided valuable short-term functional results and a very differentiated view of these heterogeneous fracture patterns. In addition to the clinical results, Menzdorf et al. namely describe a treatment algorithm that includes not only the joint level but also the positional relationship to the lateral meniscus. The authors conclude that posterolateral fractures with a joint step greater than 2 mm and a lack of more than 50% of the posterior horn of the lateral meniscus should be addressed [ 44 ]. This can usually be achieved arthroscopically, as shown in our study. This treatment algorithm is very helpful in determining the indication for surgery and is a further development of the description of Bernholt et al. who already described morphologic variants of posterolateral tibial plateau fractures with accompanying ACL tears [ 45 ]. Korthaus et al. were also able to demonstrate the frequent occurrence of posterolateral tibila plateau fractures in the context of knee dislocations in a recent study [ 35 ]. This once again demonstrates the close connection between ligament injuries and posterolateral fractures due to the multidimensional trauma mechanism, which, in our view, also necessitates osteoligamentary reconstruction in the aforementioned indications. In our study, we indicated the reconstruction of the posterolateral corner accordingly to a 2mm step dislocation and the size of the affected joint surface. In patients with dislocated eminence fractures and small posterolateral rim fractures < 50% of the lateral meniscus only the eminence fracture was fixed. At this point, it must be noted that our work, analogous to the study by Menzdorf et al., does not provide exact threshold values for surgical or nonsurgical treatment due to the small sample size and the heterogeneous fracture morphologies. However, since we could also demonstrate sufficient functional results and joint stability with an analogous surgical procedure, the treatment algorithm for apple bite fractures with accompanying ACL tears according to Menzdorf et al. [ 44 ] provides a successful and sensible approach. Despite attempts to ensure reliability, there are different limitations to our study. First, the retrospective study design led to an inhomogeneous follow-up period among the patients, which in turn could possibly lead to bias in clinical outcome scores. In addition, the study group is rather small in absolute terms, but in relation to the very rare combined fracture incidence, it is the largest described to date. Furthermore, we provide short- to midterm clinical and radiographic follow-ups as part of the study; therefore, a general statement regarding the posttraumatic osteoarthritis rate and long-term joint stability is not possible for all patients. Nevertheless, our study provides new, valuable clinical results and supports a very soft tissue-sparing, minimally invasive surgical procedure for the treatment of these rare osteoligamentous injuries. Conclusion Arthroscopically assisted reduction and fixation of combined bony ACL tears and posterolateral tibial plateau fractures as a minimally invasive treatment procedure results in very good functional and clinical outcomes with sufficient joint stability. The excellent visualization of the joint surface supports an anatomical reconstruction of the fracture and the joint surface. Declarations Funding Information: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflict of interest: All authors confirm that there is no conflict of interest. Ethical approval: The study was reviewed and approved by the local ethics committee of the medical faculty of Ruhr University Bochum, Germany (registered number: 18-6508_1-BR). Informed consent Informed consent was obtained from all individual participants included in the study. Author Contribution MK, JG and TAS carried out the study design. TR, OS, MB, JG and SL participated in the acquision of data, while TR, OS and MK performed the analysis and interpretation of the data. TR drafted the manuscript. TR and OS prepared the figures and tables. All author´s reviewed and approved the final 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(8):1608–12. https://doi.org/10.1016/j.injury.2015.05.035 . Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury. 2006;37(8):691–7. https://doi.org/10.1016/j.injury.2006.04.130 . Krause M, Preiss A, Meenen NM, Madert J, Frosch KH. Fracturoscopy is Superior to Fluoroscopy in the Articular Reconstruction of Complex Tibial Plateau Fractures-An Arthroscopy Assisted Fracture Reduction Technique. J Orthop Trauma. 2016;30(8):437–44. https://doi.org/10.1097/BOT.0000000000000569 . Chahla J, Moatshe G, Dean CS, LaPrade RF. Posterolateral Corner of the Knee: Current Concepts. Arch Bone Jt Surg. 2016;4(2):97–103. https://www.ncbi.nlm.nih.gov/pubmed/27200384 . Frosch KH, Krause M, Frings J, Drenck T, Akoto R, Muller G, et al. [Posttraumatic deformities of the knee joint: Intra-articular osteotomy after malreduction of tibial head fractures]. Unfallchirurg. 2016;119(10):859–76. https://doi.org/10.1007/s00113-016-0234-9 . Meulenkamp B, Martin R, Desy NM, Duffy P, Korley R, Puloski S, et al. Incidence, Risk Factors, and Location of Articular Malreductions of the Tibial Plateau. J Orthop Trauma. 2017;31(3):146–50. https://doi.org/10.1097/BOT.0000000000000735 . Osti M, Benedetto KP. [Results of arthroscopically assisted refixation of fractures of the intercondylar eminence]. Z Orthop Unfall. 2010;148(3):288–91. https://doi.org/10.1055/s-0029-1240818 . Ackermann C, Frings J, Alm L, Frosch KH. Arthroscopic Controlled Closed Reduction and Percutaneous Fixation of Posterolateral Tibia Plateau Impression Fractures. Arthrosc Tech. 2019;8(8):e867–74. https://doi.org/10.1016/j.eats.2019.04.001 . Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 1985(198):43–9. https://www.ncbi.nlm.nih.gov/pubmed/4028566 Hefti F, Muller W, Jakob RP, Staubli HU. Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc. 1993;1(3–4):226–34. https://www.ncbi.nlm.nih.gov/pubmed/8536037 . Barzegar H, Mohseni M, Sedighi A, Shahsavari A, Mohammadpour H. Arthroscopically-assisted vs. open surgery in repairing anterior cruciate ligament avulsion. Pak J Biol Sci. 2011;14(8):496–501. https://doi.org/10.3923/pjbs.2011.496.501 . Strauss EJ, Kaplan DJ, Weinberg ME, Egol J, Jazrawi LM. Arthroscopic Management of Tibial Spine Avulsion Fractures: Principles and Techniques. J Am Acad Orthop Surg. 2018;26(10):360–7. https://doi.org/10.5435/JAAOS-D-16-00117 . Seon JK, Park SJ, Lee KB, Gadikota HR, Kozanek M, Oh LS, et al. A clinical comparison of screw and suture fixation of anterior cruciate ligament tibial avulsion fractures. Am J Sports Med. 2009;37(12):2334–9. https://doi.org/10.1177/0363546509341031 . Guttowski D, Krause M, Puschel K, Kolb JP, Hartel M, Frosch KH. Improved Visualization by Central Subluxation of the Lateral Meniscus in Comminuted Lateral Tibial Plateau Fractures. J Knee Surg. 2020. https://doi.org/10.1055/s-0040-1709518 . Korthaus A, Ballhause TM, Kolb JP, Krause M, Frosch KH, Hartel MJ. Extended approach to the lateral tibial plateau with central meniscal subluxation in fracture repair: feasibility and first clinical and radiographic results. Eur J Trauma Emerg Surg. 2020;46(6):1221–6. https://doi.org/10.1007/s00068-020-01467-1 . Krause M, Frings J, Isik H, Frosch KH. Comparison of extended lateral approaches to the tibial plateau: The articular exposure of lateral epicondyle osteotomy with and without popliteus tendon vs. fibula osteotomy. Injury. 2020;51(8):1874–8. https://doi.org/10.1016/j.injury.2020.05.038 . Frosch KH, Korthaus A, Thiesen D, Frings J, Krause M. The concept of direct approach to lateral tibial plateau fractures and stepwise extension as needed. Eur J Trauma Emerg Surg. 2020;46(6):1211–9. https://doi.org/10.1007/s00068-020-01422-0 . Dehoust J, Munch M, Seide K, Barth T, Frosch KH. Biomechanical aspects of the posteromedial split in bicondylar tibial plateau fractures-a finite-element investigation. Eur J Trauma Emerg Surg. 2020;46(6):1257–66. https://doi.org/10.1007/s00068-020-01538-3 . Li L, Li Y, He Y, Deng X, Zhou P, Li J, et al. (Single-stage arthroscopic-assisted treatment of anteromedial tibial plateau fracture with posterolateral corner injury: a retrospective study). BMC Musculoskelet Disord. 2022;23(1):420. https://doi.org/10.1186/s12891-022-05387-6 . Cheng YH, Yang CP, Chang SS, Weng CJ, Chiu CH, Chan YS. Arthroscopic-assisted reduction and internal fixation for complex tibial plateau fracture: radiographic and clinical outcomes with 2- to 15-year follow-up. J Orthop Surg Res. 2023;18(1):448. https://doi.org/10.1186/s13018-023-03938-8 . Nguyen MP, Gannon NP, Paull TZ, Bakker C, Bzovsky S, Sprague S, et al. Outcomes of arthroscopic-assisted lateral tibial plateau fixation: a systematic review. Eur J Orthop Surg Traumatol. 2023;33(5):1473–83. https://doi.org/10.1007/s00590-022-03339-3 . Krause M, Muller G, Frosch KH. [Extended medial and extended lateral approach for tibial plateau fractures]. Oper Orthop Traumatol. 2019;31(2):127–42. https://doi.org/10.1007/s00064-019-0593-9 . Behrendt P, Fahlbusch H, Galavics C, Berninger MT, Gablac H, Klepsch L, et al. Clinical and radiological outcome of extended lateral approach via epicondyle osteotomy in complex lateral tibia plateau fractures involving the central and postero-lateral segments. Injury. 2024;55(12):111876. https://doi.org/10.1016/j.injury.2024.111876 . Behrendt P, Berninger MT, Thurig G, Dehoust J, Christensen J, Frosch KH, et al. Nanoscopy and an extended lateral approach can improve the management of latero-central segments in tibial plateau fractures: a cadaveric study. Eur J Trauma Emerg Surg. 2023;49(3):1433–9. https://doi.org/10.1007/s00068-022-02188-3 . Singleton N, Sahakian V, Muir D. Outcome After Tibial Plateau Fracture: How Important Is Restoration of Articular Congruity? J Orthop Trauma. 2017;31(3):158–63. https://doi.org/10.1097/BOT.0000000000000762 . Giannoudis PV, Tzioupis C, Papathanassopoulos A, Obakponovwe O, Roberts C. Articular step-off and risk of post-traumatic osteoarthritis. Evid today Injury. 2010;41(10):986–95. https://doi.org/10.1016/j.injury.2010.08.003 . Parkkinen M, Madanat R, Mustonen A, Koskinen SK, Paavola M, Lindahl J. Factors predicting the development of early osteoarthritis following lateral tibial plateau fractures: mid-term clinical and radiographic outcomes of 73 operatively treated patients. Scand J Surg. 2014;103(4):256–62. https://doi.org/10.1177/1457496914520854 . Trumble T, Allan CH, Miyano J, Clark JM, Ott S, Jones DE, et al. A preliminary study of joint surface changes after an intraarticular fracture: a sheep model of a tibia fracture with weight bearing after internal fixation. J Orthop Trauma. 2001;15(5):326–32. https://doi.org/10.1097/00005131-200106000-00004 . Bai B, Kummer FJ, Sala DA, Koval KJ, Wolinsky PR. Effect of articular step-off and meniscectomy on joint alignment and contact pressures for fractures of the lateral tibial plateau. J Orthop Trauma. 2001;15(2):101–6. https://doi.org/10.1097/00005131-200102000-00005 . Herbst E, Oeckenpohler S, Riesenbeck O, Kittl C, Glasbrenner J, Michel P, et al. [Intra-articular proximal tibia fractures]. Unfallchirurgie (Heidelb). 2023;126(9):715–26. https://doi.org/10.1007/s00113-023-01352-7 . Rosteius T, Rausch V, Patzholz S, Lotzien S, Konigshausen M, Schildhauer TA, et al. Factors influencing the outcome after surgical reconstruction of OTA type B and C tibial plateau fractures: how crucial is the restoration of articular congruity? Arch Orthop Trauma Surg. 2023;143(4):1973–80. https://doi.org/10.1007/s00402-022-04405-5 . Rosteius T, Rausch V, Jettkant B, Lotzien S, Schildhauer TA, Konigshausen M, et al. Influence of articular step-off on contact mechanics in fractures of the posterolateral-central tibial plateau - a biomechanical study. Knee. 2023;41:283–91. https://doi.org/10.1016/j.knee.2023.01.016 . Oeckenpohler S, Domnick C, Raschke MJ, Muller M, Wahnert D, Kosters C. A lateral fracture step-off of 2mm increases intra-articular pressure following tibial plateau fracture. Injury. 2022;53(3):1254–9. https://doi.org/10.1016/j.injury.2021.12.053 . Walter C, Beck A, Jacob C, Hofmann UK, Stockle U, Stuby F. Influence of reduction accuracy in lateral tibial plateau fractures on intra-articular friction - a biomechanical study. BMC Musculoskelet Disord. 2020;21(1):20. https://doi.org/10.1186/s12891-019-3020-3 . Korthaus A, Marx P, Braun PJ, Colcuc S, Behrendt P, Hoffmann M, et al. The Incidence of Posterolateral Tibial Plateau Fractures in the Setting of Knee Dislocations. Orthop J Sports Med. 2025;13(5):23259671251338795. https://doi.org/10.1177/23259671251338795 . Herbst E, Raschke MJ, Peez C, Briese T, Oeckenpohler S. [Ligament injuries in tibial plateau fractures]. Unfallchirurgie (Heidelb). 2022;125(7):535–41. https://doi.org/10.1007/s00113-022-01177-w . Milinkovic DD, Kittl C, Herbst E, Fink C, Greis F, Raschke MJ, et al. The Bankart knee: high-grade impression fractures of the posterolateral tibial plateau lead to increased translational and anterolateral rotational instability of the ACL-deficient knee. Knee Surg Sports Traumatol Arthrosc. 2023;31(10):4151–61. https://doi.org/10.1007/s00167-023-07432-w . Bernholt DL, Dornan GJ, DePhillipo NN, Aman ZS, Kennedy MI, LaPrade RF. High-Grade Posterolateral Tibial Plateau Impaction Fractures in the Setting of a Primary Anterior Cruciate Ligament Tear Are Correlated With an Increased Preoperative Pivot Shift and Inferior Postoperative Outcomes After Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2020;48(9):2185–94. https://doi.org/10.1177/0363546520932912 . Pan S, Peng AQ, Hu YN, Wang S, Zhang YL, Wang Y. Injury pattern simulation and mapping of complex tibial plateau fractures that involve the posterior plateau with three-dimensional computed tomography. Ann Transl Med. 2021;9(4):302. https://doi.org/10.21037/atm-20-5043 . Xie X, Zhan Y, Wang Y, Lucas JF, Zhang Y, Luo C. Comparative Analysis of Mechanism-Associated 3-Dimensional Tibial Plateau Fracture Patterns. J Bone Joint Surg Am. 2020;102(5):410–8. https://doi.org/10.2106/JBJS.19.00485 . van den Berg J, Reul M, Nunes Cardozo M, Starovoyt A, Geusens E, Nijs S, et al. Functional outcome of intra-articular tibial plateau fractures: the impact of posterior column fractures. Int Orthop. 2017;41(9):1865–73. https://doi.org/10.1007/s00264-017-3566-3 . Bernholt DL, DePhillipo NN, Crawford MD, Aman ZS, Grantham WJ, LaPrade RF. Incidence of Displaced Posterolateral Tibial Plateau and Lateral Femoral Condyle Impaction Fractures in the Setting of Primary Anterior Cruciate Ligament Tear. Am J Sports Med. 2020;48(3):545–53. https://doi.org/10.1177/0363546519895239 . Bernholt D, DePhillipo NN, Aman ZS, Samuelsen BT, Kennedy MI, LaPrade RF. Increased posterior tibial slope results in increased incidence of posterior lateral meniscal root tears in ACL reconstruction patients. Knee Surg Sports Traumatol Arthrosc. 2021;29(11):3883–91. https://doi.org/10.1007/s00167-021-06456-4 . Menzdorf L, Drenck T, Akoto R, Hartel M, Krause M, Guttowski D, et al. Clinical results after surgical treatment of posterolateral tibial plateau fractures (apple bite fracture) in combination with ACL injuries. Eur J Trauma Emerg Surg. 2020;46(6):1239–48. https://doi.org/10.1007/s00068-020-01509-8 . Bernholt DL, DePhillipo NN, Grantham WJ, Crawford MD, Aman ZS, Kennedy MI, et al. Morphologic Variants of Posterolateral Tibial Plateau Impaction Fractures in the Setting of Primary Anterior Cruciate Ligament Tear. Am J Sports Med. 2020;48(2):318–25. https://doi.org/10.1177/0363546519893709 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 03 Mar, 2026 Read the published version in European Journal of Trauma and Emergency Surgery → Version 1 posted Editorial decision: Revision requested 19 Dec, 2025 Reviews received at journal 19 Dec, 2025 Reviews received at journal 07 Dec, 2025 Reviewers agreed at journal 04 Dec, 2025 Reviewers agreed at journal 03 Dec, 2025 Reviewers invited by journal 03 Dec, 2025 Editor assigned by journal 03 Dec, 2025 Submission checks completed at journal 01 Dec, 2025 First submitted to journal 28 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8233045","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":555313860,"identity":"735c5f94-0f6e-4820-a3aa-fabeac064ae5","order_by":0,"name":"Thomas Rosteius","email":"data:image/png;base64,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","orcid":"","institution":"BG University Hospital Bergmannsheil","correspondingAuthor":true,"prefix":"","firstName":"Thomas","middleName":"","lastName":"Rosteius","suffix":""},{"id":555313861,"identity":"01d8fa47-d183-4b39-a1c7-874879635d89","order_by":1,"name":"Ole Somberg","email":"","orcid":"","institution":"BG University Hospital Bergmannsheil","correspondingAuthor":false,"prefix":"","firstName":"Ole","middleName":"","lastName":"Somberg","suffix":""},{"id":555313862,"identity":"aeb2302d-a15b-425a-a2a1-e9fbb577023f","order_by":2,"name":"Maria Bernstorff","email":"","orcid":"","institution":"BG University Hospital Bergmannsheil","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"","lastName":"Bernstorff","suffix":""},{"id":555313863,"identity":"5edf8849-905d-4692-baf0-cf623115feef","order_by":3,"name":"Sebastian Lotzien","email":"","orcid":"","institution":"BG University Hospital Bergmannsheil","correspondingAuthor":false,"prefix":"","firstName":"Sebastian","middleName":"","lastName":"Lotzien","suffix":""},{"id":555313864,"identity":"ee285097-e6d9-47c1-81ed-eab80e96dabc","order_by":4,"name":"Jan Gessmann","email":"","orcid":"","institution":"BG University Hospital Bergmannsheil","correspondingAuthor":false,"prefix":"","firstName":"Jan","middleName":"","lastName":"Gessmann","suffix":""},{"id":555313865,"identity":"63b27e72-c195-4518-a99d-eb695324d953","order_by":5,"name":"Thomas Armin Schildhauer","email":"","orcid":"","institution":"BG University Hospital Bergmannsheil","correspondingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"Armin","lastName":"Schildhauer","suffix":""},{"id":555313866,"identity":"92f4bd84-6498-4b8a-a7d9-07b6fcff494d","order_by":6,"name":"Matthias Königshausen","email":"","orcid":"","institution":"BG University Hospital Bergmannsheil","correspondingAuthor":false,"prefix":"","firstName":"Matthias","middleName":"","lastName":"Königshausen","suffix":""}],"badges":[],"createdAt":"2025-11-28 20:08:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8233045/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8233045/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00068-026-03122-7","type":"published","date":"2026-03-03T15:57:32+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":97687568,"identity":"54b594b6-b54b-409c-b6b7-8f668e6a6732","added_by":"auto","created_at":"2025-12-08 10:26:51","extension":"jpg","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":620228,"visible":true,"origin":"","legend":"","description":"","filename":"TPFFigure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8233045/v1/6e40d375653dbb4946c70aad.jpg"},{"id":97893421,"identity":"eb4afc0b-0cb4-4a4a-bc25-366f6961ca32","added_by":"auto","created_at":"2025-12-10 15:30:24","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":115050,"visible":true,"origin":"","legend":"","description":"","filename":"TPFarthroscopicEJOT.docx","url":"https://assets-eu.researchsquare.com/files/rs-8233045/v1/8785e713535d73819bf03ffd.docx"},{"id":97687580,"identity":"3c04ac8a-1939-4322-861f-a2fe40161b9e","added_by":"auto","created_at":"2025-12-08 10:26:51","extension":"jpg","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":466837,"visible":true,"origin":"","legend":"","description":"","filename":"TPFFigure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8233045/v1/322b3302ea2964f8e9e39fc1.jpg"},{"id":97892578,"identity":"d9b0219a-fbbd-493e-bac9-bdb1ca5e3424","added_by":"auto","created_at":"2025-12-10 15:15:35","extension":"json","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":8796,"visible":true,"origin":"","legend":"","description":"","filename":"0fa2a9da02394dc3806b55c1a60f6fa2.json","url":"https://assets-eu.researchsquare.com/files/rs-8233045/v1/1aee55060da91014ba5324f5.json"},{"id":97687571,"identity":"334057bc-4903-4ae5-a8f2-be134cbf092d","added_by":"auto","created_at":"2025-12-08 10:26:51","extension":"xml","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":116984,"visible":true,"origin":"","legend":"","description":"","filename":"0fa2a9da02394dc3806b55c1a60f6fa21enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8233045/v1/40b0708a3152644c0afbc943.xml"},{"id":97892550,"identity":"3cc1e780-061c-4011-b1a0-fb3578b51cfb","added_by":"auto","created_at":"2025-12-10 15:14:02","extension":"jpg","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":620228,"visible":true,"origin":"","legend":"","description":"","filename":"TPFFigure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8233045/v1/99d094c247c435b4f0423d04.jpg"},{"id":97687574,"identity":"b411c149-b98f-4a65-9322-cc5691c6060b","added_by":"auto","created_at":"2025-12-08 10:26:51","extension":"jpg","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":466837,"visible":true,"origin":"","legend":"","description":"","filename":"TPFFigure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8233045/v1/32c075d251a48d4ff55fe452.jpg"},{"id":97893945,"identity":"bf31f51e-928c-4f07-9115-16180fdd88a3","added_by":"auto","created_at":"2025-12-10 15:31:38","extension":"png","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":386606,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineTPFFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8233045/v1/0044ea43ceacb6bc41047a86.png"},{"id":97893438,"identity":"95bf96fe-96f3-4f84-b7a3-caa172d78b28","added_by":"auto","created_at":"2025-12-10 15:30:27","extension":"png","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":317312,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineTPFFigure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8233045/v1/54ca70e1106c81774258e439.png"},{"id":97687576,"identity":"accd2d49-a3cf-4ca4-acfa-02ed43489bfb","added_by":"auto","created_at":"2025-12-08 10:26:51","extension":"xml","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":115054,"visible":true,"origin":"","legend":"","description":"","filename":"0fa2a9da02394dc3806b55c1a60f6fa21structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8233045/v1/2a054fcae0537a20af928334.xml"},{"id":97687579,"identity":"3845102a-797d-47e1-bb14-84a63198f403","added_by":"auto","created_at":"2025-12-08 10:26:51","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":125212,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8233045/v1/4f8920474b5fc41fe631f8ac.html"},{"id":97893846,"identity":"e2700bcb-33d3-4800-a693-9e9fa6b92491","added_by":"auto","created_at":"2025-12-10 15:31:21","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":620228,"visible":true,"origin":"","legend":"\u003cp\u003eThirty-nine-year-old patient with a Meyers-McKeever 2 eminence fracture and a Menzdorf type 2c posterolateral tibial plateau fracture \u003cem\u003e\u003cstrong\u003e(Figures a, b, c)\u003c/strong\u003e\u003c/em\u003e. \u003cem\u003e\u003cstrong\u003eFigures d\u003c/strong\u003e\u003c/em\u003e and \u003cem\u003e\u003cstrong\u003ee\u003c/strong\u003e\u003c/em\u003e demonstrate the initial arthroscopic view of the fracture and after reduction. \u003cem\u003e\u003cstrong\u003eFigures f, g\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e \u003c/strong\u003eand\u003cstrong\u003e \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003eh\u003c/strong\u003e\u003c/em\u003e show the postoperative CT and \u003cem\u003e\u003cstrong\u003eFigures i\u003c/strong\u003e\u003c/em\u003e and \u003cem\u003e\u003cstrong\u003ej\u003c/strong\u003e\u003c/em\u003e the final follow-up with complete bone healing.\u003c/p\u003e","description":"","filename":"TPFFigure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8233045/v1/a8655884c6656f1f167bd2f3.jpg"},{"id":97687569,"identity":"c181fdb4-77cc-4aac-adc1-54485881dacf","added_by":"auto","created_at":"2025-12-08 10:26:51","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":466837,"visible":true,"origin":"","legend":"\u003cp\u003ePosterolateral impression with accompanying dislocated eminence fracture. \u003cem\u003e\u003cstrong\u003eFigures a\u003c/strong\u003e\u003c/em\u003e and \u003cem\u003e\u003cstrong\u003eb\u003c/strong\u003e\u003c/em\u003e demonstrate the initial impression and after reduction. \u003cem\u003e\u003cstrong\u003eFigure c\u003c/strong\u003e\u003c/em\u003e shows the dislocated bony avulsion of the ACL and \u003cem\u003e\u003cstrong\u003eFigure d\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e \u003c/em\u003ethe fixation by using transosseous sutures. \u003cem\u003e\u003cstrong\u003eFigure e\u003c/strong\u003e\u003c/em\u003e demonstrates the less invasive treatment approach with minimal soft tissue compromise. Computed tomography was performed for postsurgical fracture position \u003cem\u003e\u003cstrong\u003e(Figures f, g)\u003c/strong\u003e\u003c/em\u003e. X- rays at final follow up with complete fracture healing \u003cem\u003e\u003cstrong\u003e(Figures h, i)\u003c/strong\u003e\u003c/em\u003e.\u003c/p\u003e","description":"","filename":"TPFFigure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8233045/v1/3cfdbc0e8301ace7164f2b6a.jpg"},{"id":104250710,"identity":"f702821b-cd9a-46f4-b873-e7a248c7487f","added_by":"auto","created_at":"2026-03-09 16:06:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1837774,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8233045/v1/908086a3-6971-41e9-bf09-48226d5e3f05.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Arthroscopically assisted refixation of bony ACL tears with accompanying posteraleral tibial plateau (“apple bite”) fractures – a minimally invasive treatment approach","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAlthough tibial plateau fractures account for only 1% of all fractures [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], these fractures are one of the most severe and challenging injuries of the knee joint. This is partly because it is a complex articular surface injury with very heterogenic fracture morphology, especially in the case of OTA type C fractures. Furthermore, in addition to different tibial plateau fractures, accompanying ligament injuries occur, which, if left untreated, can lead to chronic joint instability. This fact makes osteoligamentous injuries very specific and requires, in addition to fracture treatment, also ligament surgery. One of these rare injuries, that are caused by flexion/valgus force, are the examined eminence fractures with accompanying posterolateral impression. These injuries pose a significant challenge for orthopedic surgeons and the restoration of articular congruity, since the posterolateral corner of the tibial plateau can hardly be visualized despite the use of intraoperative fluoroscopy [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], hence its being called the \u0026ldquo;dark side of the knee\u0026rdquo; [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The lack of intraoperative visualization is one of the main reasons for inadequate reduction after complex tibial plateau fractures [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This leads to residual step-offs greater than 2 mm in up to 32% of all complex tibial plateau fractures [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. A dislocated eminence fracture additionally carries the risk of persistent ACL- and rotational instability, making refixation absolutely necessary. Therefore, since eminence fractures are ideally treated arthroscopically [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], an arthroscopic approach is most suitable for the management of these combined injuries. This allows the stabilization of the eminence fracture and the direct visualization, reduction, and percutaneous fixation of the posterolateral joint surface.\u003c/p\u003e\u003cp\u003eDue to the rarity of these osteoligamentous injuries, the literature contains neither a gold standard nor targeted treatment strategy. Therefore, in this study, we analyzed the largest cohort of these rare fracture entity to date, treated entirely arthroscopically, in terms of short- to midterm outcome, complications, and surgical revisions.\u003c/p\u003e\u003cp\u003eWe hypothesize that these combined injuries can be optimally treated arthroscopically, with low complication rates and very good functional outcomes.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e The study was reviewed and approved by the local Institutional Review Board (IRB) (registered number: 18-6508_1-BR). All procedures were performed in accordance with the ethical standards of the institutional research committee and with the 1964 Declaration of Helsinki and its later amendments.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003ePatients with combined bony ACL tear and posterolateral tibial plateau fracture between 2016 and 2020 were retrospectively reviewed. All patients with a minimum follow-up of one year were included in this study. Exclusion criteria were patients with accompanying collateral ligament or meniscal injury, vascular damage or previous damage of the joint and missing pre- and postsurgical CT data. In total, 20 patients fulfilled these criteria. Sixteen out of these 20 patients were available for clinical follow-up and were considered for further analysis.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSurgical management and postoperative procedures\u003c/h3\u003e\n\u003cp\u003eThe bony ACL tears were fixed using either two crossed, cannulated 2.7mm cortical screws (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) or transosseous sutures (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The posterolateral tibial plateau fracture was reduced with the help of a cancellous bone ram and fixed using percutaneously inserted screw osteosyntheses after arthroscopic visualization according to the description of Ackermann et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. One patient needed additional posterolateral buttress plating due to a posterolateral shear fracture.\u003c/p\u003e\u003cp\u003ePhysical therapy started 48 hours after the operation with passive motion of the joint through a limited range of motion (ex./flex. 0\u0026deg;/0\u0026deg;/90\u0026deg;) with the patient in the supine position. If necessary, peripheral nerve block anesthesia was applied. Patients had limited weightbearing (20 kg) and limited range of motion for 6 weeks.\u003c/p\u003e\n\u003ch3\u003eFollow-up examination\u003c/h3\u003e\n\u003cp\u003eThe patient assessment and clinical evaluation were scheduled a minimum of one year after the primary surgery. Primary outcome parameters were the Lysholm score [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], Knee Injury and Osteoarthritis Outcome Score (KOOS), Kujala Score, NRS Pain Score and International Knee Documentation Committee (IKDC) Score [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Secondary outcome parameters were the assessment of bony consolidation, complications and revisions. Lower leg radiographs and CT images were obtained during the first 72 hours after surgery to analyze the axial alignment and postsurgical articular congruity.\u003c/p\u003e\u003cp\u003eThe range of motion (ROM) was measured using a goniometer.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eDescriptive data are described by the mean, standard deviation, minimum and maximum. After the normality of the data was tested using the Shapiro-Wilk test, normally distributed variables were assessed using the two-tailed t-test. Nonnormally distributed variables were analyzed with the Wilcoxon/Mann-Whitney test. Nominally scaled variables were compared using cross tables and Fischer\u0026rsquo;s exact test. α\u0026thinsp;=\u0026thinsp;0.05 or less was considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 16 patients (36\u0026thinsp;\u0026plusmn;\u0026thinsp;16 years old) with an average follow-up of 24.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.6 months (12\u0026ndash;45 months) were included in the study. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the demographic data of the study group.\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\u003eDemographic data of the study group\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eDemographic data\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\u003en\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36.4\u0026thinsp;\u0026plusmn;\u0026thinsp;16.4 (median\u0026thinsp;=\u0026thinsp;34.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMen / women (n)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 / 7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBMI (kg/m2)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eASA Score\u003c/b\u003e\u003c/p\u003e\u003cp\u003eI\u003c/p\u003e\u003cp\u003eII\u003c/p\u003e\u003cp\u003eIII\u003c/p\u003e\u003cp\u003eIV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\u003cp\u003e5 (31.25%)\u003c/p\u003e\u003cp\u003e8 (50%)\u003c/p\u003e\u003cp\u003e2 (12.5%)\u003c/p\u003e\u003cp\u003e1 (6.25%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCo-morbidity (n)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eNo diseases\u003c/p\u003e\u003cp\u003e\u0026lt;\u0026thinsp;3 diseases\u003c/p\u003e\u003cp\u003e\u0026gt;3 diseases\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\u003cp\u003e3 (18.75%)\u003c/p\u003e\u003cp\u003e9 (56.25%)\u003c/p\u003e\u003cp\u003e4 (25%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMeyers-McKeever classification\u003c/b\u003e\u003c/p\u003e\u003cp\u003eI\u003c/p\u003e\u003cp\u003eII\u003c/p\u003e\u003cp\u003eIII\u003c/p\u003e\u003cp\u003eIV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\u003cp\u003e3 (18.75%)\u003c/p\u003e\u003cp\u003e5 (31.25%)\u003c/p\u003e\u003cp\u003e7 (43.75%)\u003c/p\u003e\u003cp\u003e1(6.25%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMenzdorf et al. classification\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIa\u003c/p\u003e\u003cp\u003eIb\u003c/p\u003e\u003cp\u003eIc\u003c/p\u003e\u003cp\u003eIIa\u003c/p\u003e\u003cp\u003eIIb\u003c/p\u003e\u003cp\u003eIIc\u003c/p\u003e\u003cp\u003eIIIa\u003c/p\u003e\u003cp\u003eIIIb\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\u003cp\u003e3 (18.75%)\u003c/p\u003e\u003cp\u003e2 (12.5%)\u003c/p\u003e\u003cp\u003e0\u003c/p\u003e\u003cp\u003e3 (18.75%)\u003c/p\u003e\u003cp\u003e2 (12.5%)\u003c/p\u003e\u003cp\u003e5 (31.25%)\u003c/p\u003e\u003cp\u003e0\u003c/p\u003e\u003cp\u003e1 (6.25%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn summary, one patient had a type 4 injury according to Meyers and McKeever, 7 patients a type 3 injury, 5 patients a type 2 and 3 patients a type 1 injury. All patients had an accompanying impression fracture of the posterolateral tibial plateau, in 2 patients in combination with a lateral split component and in 2 patients with a medial split. In 12 patients, the bony ACL tears were fixed using crossed, cannulated screws and in 4 patients using pull-out sutures. In 9 patients, the accompanying tibial plateau impression fracture was repositioned arthroscopically assisted and fixed percutaneously; in 7 cases, the posterolateral fracture was not surgically addressed. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e demonstrates the final outcome and complications. Complete bone healing was achieved in all patients. There were no perioperative complications. During follow-up, 6 patients showed a remaining 1\u0026deg; laxity of the ACL in comparison to the other side. 2 patients had an extension deficit of 5\u0026deg; on the affected side. No rotational instability was observed. There were no significant differences in outcome or joint stability between surgically and non-surgically treated apple- bite fracture.\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\u003eComplications and final outcome\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eComplications and final outcome\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\u003eComplete bone healing %\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eReturn to sports (in months)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eReturn to work (in months)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLysholm Score\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e84\u0026thinsp;\u0026plusmn;\u0026thinsp;13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eKujala Score\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u0026thinsp;\u0026plusmn;\u0026thinsp;14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIKDC (in%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e77.9\u0026thinsp;\u0026plusmn;\u0026thinsp;11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eKOOS\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e81\u0026thinsp;\u0026plusmn;\u0026thinsp;14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTAS-Tegener activity scale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u0026thinsp;\u0026plusmn;\u0026thinsp;1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePain (NRS scale)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u0026thinsp;\u0026plusmn;\u0026thinsp;2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eResidual Knee AP-Instability\u003c/b\u003e\u003c/p\u003e\u003cp\u003e1\u0026deg;\u003c/p\u003e\u003cp\u003e2\u0026deg;\u003c/p\u003e\u003cp\u003e3\u0026deg;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\u003cp\u003e6 (37.5%)\u003c/p\u003e\u003cp\u003e0\u003c/p\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eResidual Rotational Instability\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn our study, we analyzed the outcome of surgical treatment of combined injuries involving bony avulsion of the anterior cruciate ligament (ACL) with a concomitant impression fracture (apple-bite fracture) of the posterolateral tibial plateau. To the best of our knowledge, we present the largest study group of these rare sub- entity of tibial plateau fractures. We could demonstrate that arthroscopic treatment of these specific osteoligamentous injuries is successfully possible. An anatomical reconstruction as well as a good clinical outcome with sufficient joint stability can be achieved. Most patients reach a \u0026ldquo;restitution ad integrum\u0026rdquo; in relation to work and sport. These results are underlined by studies on single eminence fractures, which mostly describe less pain, shorter hospital stay, fewer nonunions and less soft tissue compromise with an arthroscopic- than with an open procedure, regardless of the fixation method [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHowever, the treatment algorithm of posterolateral tibial plateau fractures and especially of the rare osteoligamentous injuries is still of high scientific interest, since the best surgical approach as well as the indication for non-surgical or surgical treatment are still under debate. This is due to its special, \u0026ldquo;difficult\u0026rdquo; anatomical location and the described, possible (multidimensional) joint instability, but not least due to the very heterogeneous fracture morphologies.\u003c/p\u003e\u003cp\u003eFirst, the visualization of the posterior segments is known to be limited [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] and therefore the anatomic reduction quite difficult. This is supported by the work of Meulenkamp et al., who found an insufficient reduction with an articular step-off greater than 2 mm in 32% of all tibial plateau fractures [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The posterior quadrants were particularly affected [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. As a result, the current literature has especially dealt with the improvement of visualization in the treatment of posterior fractures of the tibial plateau [\u003cspan additionalcitationids=\"CR15 CR16 CR17\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. An arthroscopic assistance seems to support the visualization of the posterolateral corner and helps to restore the joint line anatomically without residual steps and good functional outcomes [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Alternative procedures include fracturoscopy and extended approaches according to Krause t al.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and Behrendt et al.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], which might be necessary in the treatment of multifragmentary type C fractures with the involvement of the posterolateral corner. However, these are significantly more invasive and, in our opinion, not necessary in case of the described apple-bite fractures.\u003c/p\u003e\u003cp\u003eOn the one hand, there is more or less consensus about the indication for surgery regarding the fracture's step-off height. The tolerable limit for a residual step-off height appears to be approximately 2 mm [\u003cspan additionalcitationids=\"CR26 CR27 CR28 CR29 CR30 CR31\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. For example, a clinical study by Singleton et al. analyzed the outcomes of 41 patients after tibial plateau fracture in terms of articular congruity. The intraarticular step was measured on coronal plane tomograms, so posterior fractures could not be evaluated. The authors found that patients with an intraarticular step\u0026thinsp;\u0026lt;\u0026thinsp;2.5 mm had a better functional outcome in terms of range of motion and Oxford, Iowa and Knee Injury and Osteoarthritis Outcome Score (KOOS) scores. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Parkkinen et al. also tried to identify predictors of early osteoarthritis following lateral tibia plateau fractures as a function of the postoperative mechanical axis and articular congruity. In summary, a valgus malalignment greater than 5\u0026deg; and an articular depression greater than 2 mm led to advanced osteoarthritis, whereas a normal mechanical axis or a depression less than 2 mm did not [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Few studies have examined the topic of articular congruity biomechanically [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Bai et al. were among the first to demonstrate the problem of increasing contact pressures in the knee joint with increasing articular step-offs, using the example of lateral split fractures in a biomechanical cadaveric study [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Contact stress and contact area as well as joint axis were analyzed in 6 human fresh frozen cadaveric knees at 0\u0026deg; and 30\u0026deg; flexion in a static setup. At a 6-mm step-off with 0\u0026deg; knee flexion, the average contact pressures and maximum contact pressures increased an average of 208% and 97%, respectively, and the contact area decreased an average of 33% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Walter et al. [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] also analyzed the dissipated energy as a parameter of friction and reduction accuracy in lateral tibial split fractures with 2-mm step- and gap-off by studying 6 human cadaveric knees under cyclic loading in a robotic system. They found that a step-down of 2 mm led to a doubling of the dissipated energy, whereas the step-up even tripled. However, a 2-mm gap also led to a statistically significant increase in the dissipated energy, even if it was less than a step [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOne the other hand, recent studies demonstrate that not only an intraarticular step-off is essential for the clinical outcome and possible development of osteoarthritis, but also the location of the fracture and concomitant ligamentous injuries might play an important role with regard to joint stability [\u003cspan additionalcitationids=\"CR36 CR37\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. The analyzed posterolateral impressions are caused by flexion-, internal rotation- and valgus stress [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. In addition to the posterolateral impression, tension stress on the anteromedial and posterolateral structures is the result of this three-dimensional stress, which in turn can lead to accompanying lesions of the ACL, ALL, anteromedial structures and the posterolateral corner [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Therefore, in addition to the reconstruction of the posterolateral impression, the treatment of possible accompanying ligament injuries plays an important role to restore ligamentous stability. Moreover, a remaining or untreated posterolateral impression itself can on the one hand lead to a progressive sagittal malalignment with therefore a higher tibial slope, which in turn might lead to a failure of the ACL reconstruction[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] or meniscal root tear[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. There are also indications in the literature that posterolateral tibial impressions cause a persistent translational and anterolateral rotational instability in combination with ACL deficiency [\u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the past, different studies have investigated the special entity of apple bite fractures. Most notably, Menzdorf et al. described on of the largest collectives of apple bite fractures with ACL injuries to date [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. They demonstrated the first short-term results of 20 patients with posterolateral tibial plateau fracture with accompanying ACL tear. One of these patients had a bony ACL tear, which corresponds to our collective. The patients reached a subjective IKDC score of 79,15 +/- 6,07, which is similar to our study results. A graft failure of the ACL was not mentioned. In summary, the study provided valuable short-term functional results and a very differentiated view of these heterogeneous fracture patterns. In addition to the clinical results, Menzdorf et al. namely describe a treatment algorithm that includes not only the joint level but also the positional relationship to the lateral meniscus. The authors conclude that posterolateral fractures with a joint step greater than 2 mm and a lack of more than 50% of the posterior horn of the lateral meniscus should be addressed [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. This can usually be achieved arthroscopically, as shown in our study. This treatment algorithm is very helpful in determining the indication for surgery and is a further development of the description of Bernholt et al. who already described morphologic variants of posterolateral tibial plateau fractures with accompanying ACL tears [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Korthaus et al. were also able to demonstrate the frequent occurrence of posterolateral tibila plateau fractures in the context of knee dislocations in a recent study [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. This once again demonstrates the close connection between ligament injuries and posterolateral fractures due to the multidimensional trauma mechanism, which, in our view, also necessitates osteoligamentary reconstruction in the aforementioned indications.\u003c/p\u003e\u003cp\u003eIn our study, we indicated the reconstruction of the posterolateral corner accordingly to a 2mm step dislocation and the size of the affected joint surface. In patients with dislocated eminence fractures and small posterolateral rim fractures\u0026thinsp;\u0026lt;\u0026thinsp;50% of the lateral meniscus only the eminence fracture was fixed. At this point, it must be noted that our work, analogous to the study by Menzdorf et al., does not provide exact threshold values for surgical or nonsurgical treatment due to the small sample size and the heterogeneous fracture morphologies. However, since we could also demonstrate sufficient functional results and joint stability with an analogous surgical procedure, the treatment algorithm for apple bite fractures with accompanying ACL tears according to Menzdorf et al. [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] provides a successful and sensible approach.\u003c/p\u003e\u003cp\u003eDespite attempts to ensure reliability, there are different limitations to our study. First, the retrospective study design led to an inhomogeneous follow-up period among the patients, which in turn could possibly lead to bias in clinical outcome scores. In addition, the study group is rather small in absolute terms, but in relation to the very rare combined fracture incidence, it is the largest described to date. Furthermore, we provide short- to midterm clinical and radiographic follow-ups as part of the study; therefore, a general statement regarding the posttraumatic osteoarthritis rate and long-term joint stability is not possible for all patients. Nevertheless, our study provides new, valuable clinical results and supports a very soft tissue-sparing, minimally invasive surgical procedure for the treatment of these rare osteoligamentous injuries.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eArthroscopically assisted reduction and fixation of combined bony ACL tears and posterolateral tibial plateau fractures as a minimally invasive treatment procedure results in very good functional and clinical outcomes with sufficient joint stability. The excellent visualization of the joint surface supports an anatomical reconstruction of the fracture and the joint surface.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding Information:\u003c/h2\u003e\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003cp\u003eConflict of interest:\u003c/p\u003e\u003cp\u003eAll authors confirm that there is no conflict of interest.\u003c/p\u003e\u003cp\u003eEthical approval:\u003c/p\u003e\u003cp\u003e The study was reviewed and approved by the local ethics committee of the medical faculty of Ruhr University Bochum, Germany (registered number: 18-6508_1-BR).\u003c/p\u003e\u003cp\u003eInformed consent\u003c/p\u003e\u003cp\u003e Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMK, JG and TAS carried out the study design. TR, OS, MB, JG and SL participated in the acquision of data, while TR, OS and MK performed the analysis and interpretation of the data. TR drafted the manuscript. TR and OS prepared the figures and tables. All author\u0026acute;s reviewed and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003evan 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(8):1608\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.injury.2015.05.035\u003c/span\u003e\u003cspan address=\"10.1016/j.injury.2015.05.035\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCourt-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury. 2006;37(8):691\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.injury.2006.04.130\u003c/span\u003e\u003cspan address=\"10.1016/j.injury.2006.04.130\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKrause M, Preiss A, Meenen NM, Madert J, Frosch KH. Fracturoscopy is Superior to Fluoroscopy in the Articular Reconstruction of Complex Tibial Plateau Fractures-An Arthroscopy Assisted Fracture Reduction Technique. J Orthop Trauma. 2016;30(8):437\u0026ndash;44. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/BOT.0000000000000569\u003c/span\u003e\u003cspan address=\"10.1097/BOT.0000000000000569\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChahla J, Moatshe G, Dean CS, LaPrade RF. Posterolateral Corner of the Knee: Current Concepts. Arch Bone Jt Surg. 2016;4(2):97\u0026ndash;103. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/pubmed/27200384\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/pubmed/27200384\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFrosch KH, Krause M, Frings J, Drenck T, Akoto R, Muller G, et al. [Posttraumatic deformities of the knee joint: Intra-articular osteotomy after malreduction of tibial head fractures]. Unfallchirurg. 2016;119(10):859\u0026ndash;76. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00113-016-0234-9\u003c/span\u003e\u003cspan address=\"10.1007/s00113-016-0234-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMeulenkamp B, Martin R, Desy NM, Duffy P, Korley R, Puloski S, et al. Incidence, Risk Factors, and Location of Articular Malreductions of the Tibial Plateau. J Orthop Trauma. 2017;31(3):146\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/BOT.0000000000000735\u003c/span\u003e\u003cspan address=\"10.1097/BOT.0000000000000735\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOsti M, Benedetto KP. [Results of arthroscopically assisted refixation of fractures of the intercondylar eminence]. Z Orthop Unfall. 2010;148(3):288\u0026ndash;91. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1055/s-0029-1240818\u003c/span\u003e\u003cspan address=\"10.1055/s-0029-1240818\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAckermann C, Frings J, Alm L, Frosch KH. Arthroscopic Controlled Closed Reduction and Percutaneous Fixation of Posterolateral Tibia Plateau Impression Fractures. Arthrosc Tech. 2019;8(8):e867\u0026ndash;74. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.eats.2019.04.001\u003c/span\u003e\u003cspan address=\"10.1016/j.eats.2019.04.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 1985(198):43\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/pubmed/4028566\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/pubmed/4028566\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHefti F, Muller W, Jakob RP, Staubli HU. Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc. 1993;1(3\u0026ndash;4):226\u0026ndash;34. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/pubmed/8536037\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/pubmed/8536037\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBarzegar H, Mohseni M, Sedighi A, Shahsavari A, Mohammadpour H. Arthroscopically-assisted vs. open surgery in repairing anterior cruciate ligament avulsion. Pak J Biol Sci. 2011;14(8):496\u0026ndash;501. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3923/pjbs.2011.496.501\u003c/span\u003e\u003cspan address=\"10.3923/pjbs.2011.496.501\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStrauss EJ, Kaplan DJ, Weinberg ME, Egol J, Jazrawi LM. Arthroscopic Management of Tibial Spine Avulsion Fractures: Principles and Techniques. J Am Acad Orthop Surg. 2018;26(10):360\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.5435/JAAOS-D-16-00117\u003c/span\u003e\u003cspan address=\"10.5435/JAAOS-D-16-00117\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSeon JK, Park SJ, Lee KB, Gadikota HR, Kozanek M, Oh LS, et al. A clinical comparison of screw and suture fixation of anterior cruciate ligament tibial avulsion fractures. Am J Sports Med. 2009;37(12):2334\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0363546509341031\u003c/span\u003e\u003cspan address=\"10.1177/0363546509341031\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGuttowski D, Krause M, Puschel K, Kolb JP, Hartel M, Frosch KH. Improved Visualization by Central Subluxation of the Lateral Meniscus in Comminuted Lateral Tibial Plateau Fractures. J Knee Surg. 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1055/s-0040-1709518\u003c/span\u003e\u003cspan address=\"10.1055/s-0040-1709518\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKorthaus A, Ballhause TM, Kolb JP, Krause M, Frosch KH, Hartel MJ. Extended approach to the lateral tibial plateau with central meniscal subluxation in fracture repair: feasibility and first clinical and radiographic results. Eur J Trauma Emerg Surg. 2020;46(6):1221\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00068-020-01467-1\u003c/span\u003e\u003cspan address=\"10.1007/s00068-020-01467-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKrause M, Frings J, Isik H, Frosch KH. Comparison of extended lateral approaches to the tibial plateau: The articular exposure of lateral epicondyle osteotomy with and without popliteus tendon vs. fibula osteotomy. Injury. 2020;51(8):1874\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.injury.2020.05.038\u003c/span\u003e\u003cspan address=\"10.1016/j.injury.2020.05.038\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFrosch KH, Korthaus A, Thiesen D, Frings J, Krause M. The concept of direct approach to lateral tibial plateau fractures and stepwise extension as needed. Eur J Trauma Emerg Surg. 2020;46(6):1211\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00068-020-01422-0\u003c/span\u003e\u003cspan address=\"10.1007/s00068-020-01422-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDehoust J, Munch M, Seide K, Barth T, Frosch KH. Biomechanical aspects of the posteromedial split in bicondylar tibial plateau fractures-a finite-element investigation. Eur J Trauma Emerg Surg. 2020;46(6):1257\u0026ndash;66. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00068-020-01538-3\u003c/span\u003e\u003cspan address=\"10.1007/s00068-020-01538-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi L, Li Y, He Y, Deng X, Zhou P, Li J, et al. (Single-stage arthroscopic-assisted treatment of anteromedial tibial plateau fracture with posterolateral corner injury: a retrospective study). BMC Musculoskelet Disord. 2022;23(1):420. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12891-022-05387-6\u003c/span\u003e\u003cspan address=\"10.1186/s12891-022-05387-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCheng YH, Yang CP, Chang SS, Weng CJ, Chiu CH, Chan YS. Arthroscopic-assisted reduction and internal fixation for complex tibial plateau fracture: radiographic and clinical outcomes with 2- to 15-year follow-up. J Orthop Surg Res. 2023;18(1):448. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13018-023-03938-8\u003c/span\u003e\u003cspan address=\"10.1186/s13018-023-03938-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNguyen MP, Gannon NP, Paull TZ, Bakker C, Bzovsky S, Sprague S, et al. Outcomes of arthroscopic-assisted lateral tibial plateau fixation: a systematic review. Eur J Orthop Surg Traumatol. 2023;33(5):1473\u0026ndash;83. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00590-022-03339-3\u003c/span\u003e\u003cspan address=\"10.1007/s00590-022-03339-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKrause M, Muller G, Frosch KH. [Extended medial and extended lateral approach for tibial plateau fractures]. Oper Orthop Traumatol. 2019;31(2):127\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00064-019-0593-9\u003c/span\u003e\u003cspan address=\"10.1007/s00064-019-0593-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBehrendt P, Fahlbusch H, Galavics C, Berninger MT, Gablac H, Klepsch L, et al. Clinical and radiological outcome of extended lateral approach via epicondyle osteotomy in complex lateral tibia plateau fractures involving the central and postero-lateral segments. Injury. 2024;55(12):111876. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.injury.2024.111876\u003c/span\u003e\u003cspan address=\"10.1016/j.injury.2024.111876\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBehrendt P, Berninger MT, Thurig G, Dehoust J, Christensen J, Frosch KH, et al. Nanoscopy and an extended lateral approach can improve the management of latero-central segments in tibial plateau fractures: a cadaveric study. Eur J Trauma Emerg Surg. 2023;49(3):1433\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00068-022-02188-3\u003c/span\u003e\u003cspan address=\"10.1007/s00068-022-02188-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSingleton N, Sahakian V, Muir D. Outcome After Tibial Plateau Fracture: How Important Is Restoration of Articular Congruity? J Orthop Trauma. 2017;31(3):158\u0026ndash;63. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/BOT.0000000000000762\u003c/span\u003e\u003cspan address=\"10.1097/BOT.0000000000000762\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGiannoudis PV, Tzioupis C, Papathanassopoulos A, Obakponovwe O, Roberts C. Articular step-off and risk of post-traumatic osteoarthritis. Evid today Injury. 2010;41(10):986\u0026ndash;95. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.injury.2010.08.003\u003c/span\u003e\u003cspan address=\"10.1016/j.injury.2010.08.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eParkkinen M, Madanat R, Mustonen A, Koskinen SK, Paavola M, Lindahl J. Factors predicting the development of early osteoarthritis following lateral tibial plateau fractures: mid-term clinical and radiographic outcomes of 73 operatively treated patients. Scand J Surg. 2014;103(4):256\u0026ndash;62. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1457496914520854\u003c/span\u003e\u003cspan address=\"10.1177/1457496914520854\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTrumble T, Allan CH, Miyano J, Clark JM, Ott S, Jones DE, et al. A preliminary study of joint surface changes after an intraarticular fracture: a sheep model of a tibia fracture with weight bearing after internal fixation. J Orthop Trauma. 2001;15(5):326\u0026ndash;32. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/00005131-200106000-00004\u003c/span\u003e\u003cspan address=\"10.1097/00005131-200106000-00004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBai B, Kummer FJ, Sala DA, Koval KJ, Wolinsky PR. Effect of articular step-off and meniscectomy on joint alignment and contact pressures for fractures of the lateral tibial plateau. J Orthop Trauma. 2001;15(2):101\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/00005131-200102000-00005\u003c/span\u003e\u003cspan address=\"10.1097/00005131-200102000-00005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHerbst E, Oeckenpohler S, Riesenbeck O, Kittl C, Glasbrenner J, Michel P, et al. [Intra-articular proximal tibia fractures]. Unfallchirurgie (Heidelb). 2023;126(9):715\u0026ndash;26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00113-023-01352-7\u003c/span\u003e\u003cspan address=\"10.1007/s00113-023-01352-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRosteius T, Rausch V, Patzholz S, Lotzien S, Konigshausen M, Schildhauer TA, et al. Factors influencing the outcome after surgical reconstruction of OTA type B and C tibial plateau fractures: how crucial is the restoration of articular congruity? Arch Orthop Trauma Surg. 2023;143(4):1973\u0026ndash;80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00402-022-04405-5\u003c/span\u003e\u003cspan address=\"10.1007/s00402-022-04405-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRosteius T, Rausch V, Jettkant B, Lotzien S, Schildhauer TA, Konigshausen M, et al. Influence of articular step-off on contact mechanics in fractures of the posterolateral-central tibial plateau - a biomechanical study. Knee. 2023;41:283\u0026ndash;91. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.knee.2023.01.016\u003c/span\u003e\u003cspan address=\"10.1016/j.knee.2023.01.016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOeckenpohler S, Domnick C, Raschke MJ, Muller M, Wahnert D, Kosters C. A lateral fracture step-off of 2mm increases intra-articular pressure following tibial plateau fracture. Injury. 2022;53(3):1254\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.injury.2021.12.053\u003c/span\u003e\u003cspan address=\"10.1016/j.injury.2021.12.053\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWalter C, Beck A, Jacob C, Hofmann UK, Stockle U, Stuby F. Influence of reduction accuracy in lateral tibial plateau fractures on intra-articular friction - a biomechanical study. BMC Musculoskelet Disord. 2020;21(1):20. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12891-019-3020-3\u003c/span\u003e\u003cspan address=\"10.1186/s12891-019-3020-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKorthaus A, Marx P, Braun PJ, Colcuc S, Behrendt P, Hoffmann M, et al. The Incidence of Posterolateral Tibial Plateau Fractures in the Setting of Knee Dislocations. Orthop J Sports Med. 2025;13(5):23259671251338795. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/23259671251338795\u003c/span\u003e\u003cspan address=\"10.1177/23259671251338795\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHerbst E, Raschke MJ, Peez C, Briese T, Oeckenpohler S. [Ligament injuries in tibial plateau fractures]. Unfallchirurgie (Heidelb). 2022;125(7):535\u0026ndash;41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00113-022-01177-w\u003c/span\u003e\u003cspan address=\"10.1007/s00113-022-01177-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMilinkovic DD, Kittl C, Herbst E, Fink C, Greis F, Raschke MJ, et al. The Bankart knee: high-grade impression fractures of the posterolateral tibial plateau lead to increased translational and anterolateral rotational instability of the ACL-deficient knee. Knee Surg Sports Traumatol Arthrosc. 2023;31(10):4151\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00167-023-07432-w\u003c/span\u003e\u003cspan address=\"10.1007/s00167-023-07432-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBernholt DL, Dornan GJ, DePhillipo NN, Aman ZS, Kennedy MI, LaPrade RF. High-Grade Posterolateral Tibial Plateau Impaction Fractures in the Setting of a Primary Anterior Cruciate Ligament Tear Are Correlated With an Increased Preoperative Pivot Shift and Inferior Postoperative Outcomes After Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2020;48(9):2185\u0026ndash;94. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0363546520932912\u003c/span\u003e\u003cspan address=\"10.1177/0363546520932912\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePan S, Peng AQ, Hu YN, Wang S, Zhang YL, Wang Y. Injury pattern simulation and mapping of complex tibial plateau fractures that involve the posterior plateau with three-dimensional computed tomography. Ann Transl Med. 2021;9(4):302. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.21037/atm-20-5043\u003c/span\u003e\u003cspan address=\"10.21037/atm-20-5043\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eXie X, Zhan Y, Wang Y, Lucas JF, Zhang Y, Luo C. Comparative Analysis of Mechanism-Associated 3-Dimensional Tibial Plateau Fracture Patterns. J Bone Joint Surg Am. 2020;102(5):410\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2106/JBJS.19.00485\u003c/span\u003e\u003cspan address=\"10.2106/JBJS.19.00485\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003evan den Berg J, Reul M, Nunes Cardozo M, Starovoyt A, Geusens E, Nijs S, et al. Functional outcome of intra-articular tibial plateau fractures: the impact of posterior column fractures. Int Orthop. 2017;41(9):1865\u0026ndash;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00264-017-3566-3\u003c/span\u003e\u003cspan address=\"10.1007/s00264-017-3566-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBernholt DL, DePhillipo NN, Crawford MD, Aman ZS, Grantham WJ, LaPrade RF. Incidence of Displaced Posterolateral Tibial Plateau and Lateral Femoral Condyle Impaction Fractures in the Setting of Primary Anterior Cruciate Ligament Tear. Am J Sports Med. 2020;48(3):545\u0026ndash;53. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0363546519895239\u003c/span\u003e\u003cspan address=\"10.1177/0363546519895239\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBernholt D, DePhillipo NN, Aman ZS, Samuelsen BT, Kennedy MI, LaPrade RF. Increased posterior tibial slope results in increased incidence of posterior lateral meniscal root tears in ACL reconstruction patients. Knee Surg Sports Traumatol Arthrosc. 2021;29(11):3883\u0026ndash;91. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00167-021-06456-4\u003c/span\u003e\u003cspan address=\"10.1007/s00167-021-06456-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMenzdorf L, Drenck T, Akoto R, Hartel M, Krause M, Guttowski D, et al. Clinical results after surgical treatment of posterolateral tibial plateau fractures (apple bite fracture) in combination with ACL injuries. Eur J Trauma Emerg Surg. 2020;46(6):1239\u0026ndash;48. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00068-020-01509-8\u003c/span\u003e\u003cspan address=\"10.1007/s00068-020-01509-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBernholt DL, DePhillipo NN, Grantham WJ, Crawford MD, Aman ZS, Kennedy MI, et al. Morphologic Variants of Posterolateral Tibial Plateau Impaction Fractures in the Setting of Primary Anterior Cruciate Ligament Tear. Am J Sports Med. 2020;48(2):318\u0026ndash;25. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0363546519893709\u003c/span\u003e\u003cspan address=\"10.1177/0363546519893709\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\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":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"tibial plateau fracture, articular congruity, apple bite fracture, eminence fracture","lastPublishedDoi":"10.21203/rs.3.rs-8233045/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8233045/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eCombined fractures involving bony avulsion of the anterior cruciate ligament (ACL) with a concomitant impression fracture of the posterolateral tibial plateau are rare injuries, with limited data available in the literature. Therefore, the aim of this study was to evaluate the functional and clinical outcomes of arthroscopically assisted treatment for these osteoligamentous injuries.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe retrospectively reviewed 16 patients after a mean follow-up of 24.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.6 months (12\u0026ndash;45 months) who underwent arthroscopically assisted treatment for these named injuries. The fixation of the ACL avulsion was carried out either with two crossed, cannulated 2.7 mm screws or using transosseous sutures (12 and 4 patients, respectively). The reduction and fixation of the tibial plateau fracture with an articular step-off greater than 2mm was performed arthroscopically assisted by screw osteosyntheses (9 patients). Primary outcome parameters were the Lysholm score, Knee Injury and Osteoarthritis Outcome Score (KOOS), Kujala score, NRS Pain Score, and IKDC score. Secondary outcome parameters included bony consolidation, complications, and surgical revisions.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe mean Lysholm score, KOOS, Kujala and IKDC score was 84\u0026thinsp;\u0026plusmn;\u0026thinsp;13, 81\u0026thinsp;\u0026plusmn;\u0026thinsp;14%, 82\u0026thinsp;\u0026plusmn;\u0026thinsp;14, and 78\u0026thinsp;\u0026plusmn;\u0026thinsp;11, respectivley. The NRS score had a median of 1.6, the median Tegner activity score was 4.5. Complete bony healing was achieved in all patients. No perioperative complications occurred. During follow-up, 6 patients showed persistent 1\u0026deg; laxity of the ACL in a side-to-side comparison without rotational instability. Two patients had a 5\u0026deg; extension deficit on the affected side.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eArthroscopically assisted fixation of combined bony ACL tears and posterolateral tibial plateau fractures as a minimally invasive procedure results in good functional outcomes with sufficient joint stability. It offers the advantage of useful visualization of the joint surface, which helps to avoid residual intraarticular step-offs and posterolateral malalignment. ACL avulsion fixation is possible both through crossed screw osteosynthesis and transosseous sutures techniques in an arthroscopic setting.\u003c/p\u003e","manuscriptTitle":"Arthroscopically assisted refixation of bony ACL tears with accompanying posteraleral tibial plateau (“apple bite”) fractures – a minimally invasive treatment approach","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-08 10:26:46","doi":"10.21203/rs.3.rs-8233045/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-19T11:33:38+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-19T11:24:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-07T09:59:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22154837991135276524772786473059133277","date":"2025-12-04T14:10:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"137364571884206794572566273664087311429","date":"2025-12-03T14:36:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-03T14:14:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-03T13:47:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-01T15:38:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Trauma and Emergency Surgery","date":"2025-11-28T19:53:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"4512eb46-8c9f-4f69-a242-a61fa04029c2","owner":[],"postedDate":"December 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T16:03:02+00:00","versionOfRecord":{"articleIdentity":"rs-8233045","link":"https://doi.org/10.1007/s00068-026-03122-7","journal":{"identity":"european-journal-of-trauma-and-emergency-surgery","isVorOnly":false,"title":"European Journal of Trauma and Emergency Surgery"},"publishedOn":"2026-03-03 15:57:32","publishedOnDateReadable":"March 3rd, 2026"},"versionCreatedAt":"2025-12-08 10:26:46","video":"","vorDoi":"10.1007/s00068-026-03122-7","vorDoiUrl":"https://doi.org/10.1007/s00068-026-03122-7","workflowStages":[]},"version":"v1","identity":"rs-8233045","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8233045","identity":"rs-8233045","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}