Minimally Invasive Anteromedial-Assisted Reduction and Subchondral Rafting Fixation for an Isolated Posterolateral Tibial Plateau Fracture: A Novel Technique

Minimally Invasive Anteromedial-Assisted Reduction and Subchondral Rafting Fixation for an Isolated Posterolateral Tibial Plateau Fracture: A Novel Technique | 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 Minimally Invasive Anteromedial-Assisted Reduction and Subchondral Rafting Fixation for an Isolated Posterolateral Tibial Plateau Fracture: A Novel Technique Reuben Cedric Nappoly, Pavan Kumar Reddy, Paulson Varghese, Blessing Samuel V R, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7357583/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 29 Nov, 2025 Read the published version in SN Comprehensive Clinical Medicine → Version 1 posted 9 You are reading this latest preprint version Abstract Isolated posterolateral tibial plateau fractures pose challenges due to complex regional anatomy and limited surgical access. We introduce a novel minimally invasive anteromedial-assisted technique for a depressed posterolateral tibial plateau fracture. A guided K-wire and bone punch are employed to indirectly elevate the articular fragment, while a pre-bent 2.4 mm T-plate is slid subchondrally to support the reduced segment. Intraoperative arthroscopy and postoperative CT confirmed anatomic reduction and stable implant placement. This method avoids extensive soft-tissue dissection, combining internal subchondral support with arthroscopic confirmation to restore joint congruence. The patient regained full, pain-free knee motion by 12 weeks. Tibial plateau fractures minimally invasive subchondral buttress Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Posterolateral tibial plateau fractures are rare and challenging to treat due to complex anatomy and limited exposure. Accurate anatomical reduction of the joint surface is crucial for restoring joint congruity and preventing long-term post-traumatic arthritis [ 1 , 2 ]. These injuries often correspond to Schatzker type II or III and are identified using Luo’s three-column classification. Advances in CT and 3D imaging have improved understanding of fracture patterns and supported personalized surgical planning [ 3 , 5 ]. Traditional approaches, such as direct posterolateral exposure or fibular osteotomy, allow visualization of the fragment but require extensive soft tissue dissection and pose significant neurovascular risks [ 6 , 7 ]. Currently, the trend is toward minimally invasive, soft-tissue-sparing techniques. New methods for accessing posterolateral fragments through safer corridors [ 8 , 9 ], along with recent reports describing indirect reduction, arthroscopically assisted fixation, and percutaneous stabilization, have expanded options for these fractures [ 10 , 12 ]. However, the best approach for isolated posterolateral depressions remains uncertain. The main objectives include achieving anatomic articular reduction, providing strong subchondral support to prevent secondary collapse, and preserving the surrounding soft tissue envelope [ 13 ]. Case Presentation A 31-year-old woman presented with left knee pain and swelling after a low-energy fall. She had localized lateral knee tenderness with restricted painful motion, but an intact neurovascular exam. Plain radiographs showed a depressed fracture of the posterolateral tibial plateau. 3D CT confirmed an isolated posterolateral depression [Figure 1]. She was planned for anatomic reduction and stable fixation using a minimally invasive technique. The patient was positioned supine on a radiolucent table with a leg bolster in place. Under fluoroscopic guidance, a 1.5 mm K-wire was drilled from the anteromedial proximal tibia toward the depressed fragment. A cannulated drill followed this wire to create a subchondral channel, through which a bone punch was used to elevate the depressed articular fragment. Once the fragment was adequately lifted, a lateral-to-medial 1.5 mm K-wire was placed beneath it as a temporary raft for support. Next, a second 1.5 mm K-wire was inserted from the anterolateral cortex, directed toward the posterolateral rim. This wire guided a 2.0 mm osteotome, which was carefully advanced to create a subchondral trough. A pre-contoured 2.4 mm T-shaped plate (from a foot plating set) was slid into this trough through a minimal anterolateral approach to the proximal tibia, beneath the reduced fragment, and fixed with one cortical and two lateral locking screws. A 4.0 mm rafting screw was then placed parallel to the joint surface along the original wire trajectory for additional support. Arthroscopy was conducted to directly examine the joint and confirm the anatomic reduction of the articular surface. Final fluoroscopy confirmed the implant position [Figure 2]. The patient’s postoperative recovery was smooth. Early knee movement started right away. At six weeks, radiographs showed maintained alignment, and CT confirmed a well-aligned articular surface without fragment subsidence. By 12 weeks, she had achieved full, pain-free knee motion and returned to her normal activities [Figures 3 and 4]. Discussion Posterolateral tibial plateau fractures are challenging because standard anterolateral plating often leaves the posterior rim unsupported [ 3 ], risking fragment collapse. Direct posterior buttress plating can counteract posterior displacement [ 4 , 5 ], but these approaches require extensive dissection near the popliteal vessels and peroneal nerve, incurring significant iatrogenic risk [ 3 , 6 ]. Percutaneous lag screws can fix simple posterolateral fragments [ 7 ], but these constructs are far less stable than plate fixation [ 8 ]. The “hoop” or “rim” plate, a significant advancement, offers circumferential support and multiple subchondral rafting screws that wrap a small, contoured plate around the posterolateral rim [ 10 – 12 ]. Zhang et al. reported that such a barrel-shaped hoop plate resisted fragment displacement more effectively than standard lateral or posterior plates [ 12 ]. The plate is inserted through an anterolateral supra-fibular-head window [ 11 , 13 ], which avoids a formal posterior dissection while providing strong posterolateral support. However, hoop plating does not address the metaphyseal void under the elevated fragment. Campbell et al. introduced an “intraosseous shelf” plate to solve this [ 14 ]. A small L-shaped mini-plate is bent and inserted under the reduced articular fragment, acting as a fixed-angle subchondral buttress. This supports an uncontained defect and allows bone grafting without bulky structural grafts. Our technique builds on this internal shelf concept. We introduce a pre-bent 2.4 mm T-plate from an anteromedial route to create an internal buttress under the posterolateral fragment, thereby shifting load bearing to the true site of instability. Broadly, fixation strategies for posterolateral fragments can be categorized as follows: Conventional buttress: Lateral locking or T-shaped plates, or lag screws, inserted through anterolateral or posterior approaches (providing external buttress, often incomplete). Hoop/rim plates: Small plates wrapped around the posterolateral rim through a supra-fibular-head window, providing circumferential support and multiple rafting screws. Internal shelf plates: Mini-fragment plates positioned subchondrally beneath the articular fragment, providing internal support through a cortical window. Novel anatomic plates: Purpose-designed hooks, clips, or inverted plates contoured to specific anatomy and surgical approaches. Our anteromedial-assisted technique incorporates these principles. It utilizes an indirect anteromedial corridor to elevate the fragment, avoiding posterolateral neurovascular structures, and provides internal subchondral support with a contoured T-plate. A small anterolateral window allows for the insertion of the plate under the fragment, functioning like an internal shelf for an isolated posterior depression. A percutaneous rafting screw adds multiplanar support. Importantly, arthroscopy is employed to confirm the reduction of the joint surface. Arthroscopic-assisted reduction (ARIF) ensures anatomic restoration [ 3 ], distinguishing this method from approaches that rely solely on fluoroscopy. Conclusion Fixation of posterolateral tibial plateau fractures has evolved from standard lateral plating to more specialized, anatomy-specific solutions. Posterior buttress plates, circumferential hoop plates, and internal shelf plates exemplify this progression. Our minimally invasive anteromedial-assisted technique incorporates these principles: it allows indirect fragment elevation, provides subchondral support with an internal T-plate, and uses arthroscopy to verify reduction. This approach offers a safe, reproducible option for isolated depressed posterolateral tibial plateau fractures, aiming for optimal anatomic results. Declarations Funding No funds, grants, or other support were received to assist with the preparation of this manuscript. Conflicts of interest/Competing interests The authors declare that they have no conflicts of interest relevant to this work. Ethics approval Not applicable. This is a single-patient case report describing a surgical technique in which the patient received standard clinical care. Written informed consent for participation and publication was obtained. Consent to participate. Written informed consent was obtained from the patient to participate in this study. Written consent for publication Written informed consent was obtained from the patient for publication of this case report and accompanying images. Availability of data and material Not applicable. Code availability Not applicable. Author Contributions Reuben Cedric Nappoly: Conception and design of the study, surgical procedure, data acquisition, data analysis and interpretation, drafting of the manuscript, and corresponding author responsibilities. Pavan Kumar Reddy: Assistance in surgical procedure, data collection, and critical revision of the manuscript for important intellectual content. Paulson Varghese: Contribution to surgical planning, intraoperative assistance, postoperative data collection, and manuscript review. Blessing Samuel V. R.: Literature review, assistance in data interpretation, and manuscript editing. Srikrishna Gurunatha Chetty: Clinical oversight, expert input in surgical technique, data interpretation, and critical manuscript revision. Viju Daniel Varghese: Contribution to study design, data interpretation, and final manuscript approval. All authors read and approved the final manuscript. References Krause M, Preiss A, Müller G, Madert J, Fehske K, Neumann MV, et al. Intra-articular tibial plateau fracture characteristics according to the “Ten segment classification.” Injury. 2016 Nov 1;47(11):2551–7. Giordano V, Pires RE, Pimenta FS, Campos TV de O, Andrade MAP de, Giannoudis PV. Posterolateral Fractures of the Tibial Plateau Revisited: A Simplified Treatment Algorithm. J Knee Surg. 2022 Jul;35(9):959–70. Sohn HS, Yoon YC, Cho JW, Cho WT, Oh CW, Oh JK. Incidence and fracture morphology of posterolateral fragments in lateral and bicondylar tibial plateau fractures. J Orthop Trauma. 2015 Feb;29(2):91–7. Sassoon AA, Torchia ME, Cross WW, Cass JR, Sems SA. Fibular shaft allograft support of posterior joint depression in tibial plateau fractures. J Orthop Trauma. 2014 Jul;28(7):e169-175. Yan Z, Zou C, Kenmegne GR, Pan X, Ghimire N, Silva KMN, et al. Newly designed plate for the treatment of posterolateral tibial plateau fractures: a finite element analysis. J Orthop Surg Res. 2024 Mar 26;19(1):201. Carlson DA. Posterior bicondylar tibial plateau fractures. J Orthop Trauma. 2005 Feb;19(2):73–8. Zhang D, Nazarian A, Rodriguez EK. Post-traumatic elbow stiffness: Pathogenesis and current treatments. Shoulder Elbow. 2020 Feb;12(1):38–45. Huang YG, Chang SM. The posterolateral approach for plating tibial plateau fractures: problems in secondary hardware removal. Arch Orthop Trauma Surg. 2012 May;132(5):733–4. Campbell ST, Earhart J, Marchand LS, Bilodeau RE, Barth K, Ricci WM, et al. Intraosseous Shelf Plate Fixation for Depressed Articular Fragments in Tibial Plateau Fractures: A Technical Trick and Case Series. J Orthop Trauma. 2024 Jul 1;38(7):e272–6. Liu CD, Hu SJ, Chang SM, Du SC, Chu YQ, Qi YM, et al. Treatment of posterolateral tibial plateau fractures: a narrative review and therapeutic strategy. International Journal of Surgery. 2025 Jan;111(1):1071. Behrendt P, Berninger MT, Thürig G, Dehoust J, Christensen JH, Frosch KH, et al. Anterolateral versus modified posterolateral approach for tibial plateau fractures with involvement of the posterior column: a cadaveric study. Eur J Trauma Emerg Surg. 2023 Feb;49(1):201–7. Solomon LB, Stevenson AW, Baird RPV, Pohl AP. Posterolateral transfibular approach to tibial plateau fractures: technique, results, and rationale. J Orthop Trauma. 2010 Aug;24(8):505–14. Cho TJ, Seo JB, Lee HR, Yoo WJ, Chung CY, Choi IH. Biologic characteristics of fibrous hamartoma from congenital pseudarthrosis of the tibia associated with neurofibromatosis type 1. J Bone Joint Surg Am. 2008 Dec;90(12):2735–44. Frosch KH, Balcarek P, Walde T, Stürmer KM. A new posterolateral approach without fibula osteotomy for the treatment of tibial plateau fractures. J Orthop Trauma. 2010 Aug;24(8):515–20. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 29 Nov, 2025 Read the published version in SN Comprehensive Clinical Medicine → Version 1 posted Editorial decision: Revision requested 06 Sep, 2025 Reviews received at journal 06 Sep, 2025 Reviews received at journal 01 Sep, 2025 Reviewers agreed at journal 29 Aug, 2025 Reviewers agreed at journal 27 Aug, 2025 Reviewers invited by journal 27 Aug, 2025 Editor assigned by journal 18 Aug, 2025 Submission checks completed at journal 18 Aug, 2025 First submitted to journal 12 Aug, 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. 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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-7357583","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":508382787,"identity":"304aed62-522c-427b-93a2-56fe5a60f8e1","order_by":0,"name":"Reuben Cedric 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16:14:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3187670,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7357583/v1/625a3fbc-6649-4236-8a62-83b44a052df6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eMinimally Invasive Anteromedial-Assisted Reduction and Subchondral Rafting Fixation for an Isolated Posterolateral Tibial Plateau Fracture: A Novel Technique\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePosterolateral tibial plateau fractures are rare and challenging to treat due to complex anatomy and limited exposure. Accurate anatomical reduction of the joint surface is crucial for restoring joint congruity and preventing long-term post-traumatic arthritis [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These injuries often correspond to Schatzker type II or III and are identified using Luo\u0026rsquo;s three-column classification. Advances in CT and 3D imaging have improved understanding of fracture patterns and supported personalized surgical planning [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Traditional approaches, such as direct posterolateral exposure or fibular osteotomy, allow visualization of the fragment but require extensive soft tissue dissection and pose significant neurovascular risks [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Currently, the trend is toward minimally invasive, soft-tissue-sparing techniques. New methods for accessing posterolateral fragments through safer corridors [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], along with recent reports describing indirect reduction, arthroscopically assisted fixation, and percutaneous stabilization, have expanded options for these fractures [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, the best approach for isolated posterolateral depressions remains uncertain. The main objectives include achieving anatomic articular reduction, providing strong subchondral support to prevent secondary collapse, and preserving the surrounding soft tissue envelope [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 31-year-old woman presented with left knee pain and swelling after a low-energy fall. She had localized lateral knee tenderness with restricted painful motion, but an intact neurovascular exam. Plain radiographs showed a depressed fracture of the posterolateral tibial plateau. 3D CT confirmed an isolated posterolateral depression [Figure 1]. She was planned for anatomic reduction and stable fixation using a minimally invasive technique.\u003c/p\u003e\u003cp\u003eThe patient was positioned supine on a radiolucent table with a leg bolster in place. Under fluoroscopic guidance, a 1.5 mm K-wire was drilled from the anteromedial proximal tibia toward the depressed fragment. A cannulated drill followed this wire to create a subchondral channel, through which a bone punch was used to elevate the depressed articular fragment. Once the fragment was adequately lifted, a lateral-to-medial 1.5 mm K-wire was placed beneath it as a temporary raft for support.\u003c/p\u003e\u003cp\u003eNext, a second 1.5 mm K-wire was inserted from the anterolateral cortex, directed toward the posterolateral rim. This wire guided a 2.0 mm osteotome, which was carefully advanced to create a subchondral trough. A pre-contoured 2.4 mm T-shaped plate (from a foot plating set) was slid into this trough through a minimal anterolateral approach to the proximal tibia, beneath the reduced fragment, and fixed with one cortical and two lateral locking screws. A 4.0 mm rafting screw was then placed parallel to the joint surface along the original wire trajectory for additional support.\u003c/p\u003e\u003cp\u003eArthroscopy was conducted to directly examine the joint and confirm the anatomic reduction of the articular surface. Final fluoroscopy confirmed the implant position [Figure 2].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe patient\u0026rsquo;s postoperative recovery was smooth. Early knee movement started right away. At six weeks, radiographs showed maintained alignment, and CT confirmed a well-aligned articular surface without fragment subsidence. By 12 weeks, she had achieved full, pain-free knee motion and returned to her normal activities [Figures 3 and 4].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePosterolateral tibial plateau fractures are challenging because standard anterolateral plating often leaves the posterior rim unsupported [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], risking fragment collapse. Direct posterior buttress plating can counteract posterior displacement [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], but these approaches require extensive dissection near the popliteal vessels and peroneal nerve, incurring significant iatrogenic risk [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Percutaneous lag screws can fix simple posterolateral fragments [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], but these constructs are far less stable than plate fixation [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe \u0026ldquo;hoop\u0026rdquo; or \u0026ldquo;rim\u0026rdquo; plate, a significant advancement, offers circumferential support and multiple subchondral rafting screws that wrap a small, contoured plate around the posterolateral rim [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Zhang et al. reported that such a barrel-shaped hoop plate resisted fragment displacement more effectively than standard lateral or posterior plates [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The plate is inserted through an anterolateral supra-fibular-head window [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], which avoids a formal posterior dissection while providing strong posterolateral support.\u003c/p\u003e\u003cp\u003eHowever, hoop plating does not address the metaphyseal void under the elevated fragment. Campbell et al. introduced an \u0026ldquo;intraosseous shelf\u0026rdquo; plate to solve this [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. A small L-shaped mini-plate is bent and inserted under the reduced articular fragment, acting as a fixed-angle subchondral buttress. This supports an uncontained defect and allows bone grafting without bulky structural grafts. Our technique builds on this internal shelf concept. We introduce a pre-bent 2.4 mm T-plate from an anteromedial route to create an internal buttress under the posterolateral fragment, thereby shifting load bearing to the true site of instability.\u003c/p\u003e\u003cp\u003eBroadly, fixation strategies for posterolateral fragments can be categorized as follows:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eConventional buttress: Lateral locking or T-shaped plates, or lag screws, inserted through anterolateral or posterior approaches (providing external buttress, often incomplete).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eHoop/rim plates: Small plates wrapped around the posterolateral rim through a supra-fibular-head window, providing circumferential support and multiple rafting screws.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eInternal shelf plates: Mini-fragment plates positioned subchondrally beneath the articular fragment, providing internal support through a cortical window.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNovel anatomic plates: Purpose-designed hooks, clips, or inverted plates contoured to specific anatomy and surgical approaches.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eOur anteromedial-assisted technique incorporates these principles. It utilizes an indirect anteromedial corridor to elevate the fragment, avoiding posterolateral neurovascular structures, and provides internal subchondral support with a contoured T-plate. A small anterolateral window allows for the insertion of the plate under the fragment, functioning like an internal shelf for an isolated posterior depression. A percutaneous rafting screw adds multiplanar support. Importantly, arthroscopy is employed to confirm the reduction of the joint surface. Arthroscopic-assisted reduction (ARIF) ensures anatomic restoration [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], distinguishing this method from approaches that rely solely on fluoroscopy.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eFixation of posterolateral tibial plateau fractures has evolved from standard lateral plating to more specialized, anatomy-specific solutions. Posterior buttress plates, circumferential hoop plates, and internal shelf plates exemplify this progression. Our minimally invasive anteromedial-assisted technique incorporates these principles: it allows indirect fragment elevation, provides subchondral support with an internal T-plate, and uses arthroscopy to verify reduction. This approach offers a safe, reproducible option for isolated depressed posterolateral tibial plateau fractures, aiming for optimal anatomic results.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funds, grants, or other support were received to assist with the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest/Competing interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest relevant to this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. This is a single-patient case report describing a surgical technique in which the patient received standard clinical care. Written informed consent for participation and publication was obtained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient to participate in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWritten consent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Reuben Cedric Nappoly: Conception and design of the study, surgical procedure, data acquisition, data analysis and interpretation, drafting of the manuscript, and corresponding author responsibilities.\u003cbr\u003e\u0026nbsp;Pavan Kumar Reddy: Assistance in surgical procedure, data collection, and critical revision of the manuscript for important intellectual content.\u003cbr\u003e\u0026nbsp;Paulson Varghese: Contribution to surgical planning, intraoperative assistance, postoperative data collection, and manuscript review.\u003cbr\u003e\u0026nbsp;Blessing Samuel V. R.: Literature review, assistance in data interpretation, and manuscript editing.\u003cbr\u003e\u0026nbsp;Srikrishna Gurunatha Chetty: Clinical oversight, expert input in surgical technique, data interpretation, and critical manuscript revision.\u003cbr\u003e\u0026nbsp;Viju Daniel Varghese: Contribution to study design, data interpretation, and final manuscript approval.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKrause M, Preiss A, M\u0026uuml;ller G, Madert J, Fehske K, Neumann MV, et al. Intra-articular tibial plateau fracture characteristics according to the \u0026ldquo;Ten segment classification.\u0026rdquo; Injury. 2016 Nov 1;47(11):2551\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eGiordano V, Pires RE, Pimenta FS, Campos TV de O, Andrade MAP de, Giannoudis PV. Posterolateral Fractures of the Tibial Plateau Revisited: A Simplified Treatment Algorithm. J Knee Surg. 2022 Jul;35(9):959\u0026ndash;70. \u003c/li\u003e\n\u003cli\u003eSohn HS, Yoon YC, Cho JW, Cho WT, Oh CW, Oh JK. Incidence and fracture morphology of posterolateral fragments in lateral and bicondylar tibial plateau fractures. J Orthop Trauma. 2015 Feb;29(2):91\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eSassoon AA, Torchia ME, Cross WW, Cass JR, Sems SA. Fibular shaft allograft support of posterior joint depression in tibial plateau fractures. J Orthop Trauma. 2014 Jul;28(7):e169-175. \u003c/li\u003e\n\u003cli\u003eYan Z, Zou C, Kenmegne GR, Pan X, Ghimire N, Silva KMN, et al. Newly designed plate for the treatment of posterolateral tibial plateau fractures: a finite element analysis. J Orthop Surg Res. 2024 Mar 26;19(1):201. \u003c/li\u003e\n\u003cli\u003eCarlson DA. Posterior bicondylar tibial plateau fractures. J Orthop Trauma. 2005 Feb;19(2):73\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eZhang D, Nazarian A, Rodriguez EK. Post-traumatic elbow stiffness: Pathogenesis and current treatments. Shoulder Elbow. 2020 Feb;12(1):38\u0026ndash;45. \u003c/li\u003e\n\u003cli\u003eHuang YG, Chang SM. The posterolateral approach for plating tibial plateau fractures: problems in secondary hardware removal. Arch Orthop Trauma Surg. 2012 May;132(5):733\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003eCampbell ST, Earhart J, Marchand LS, Bilodeau RE, Barth K, Ricci WM, et al. Intraosseous Shelf Plate Fixation for Depressed Articular Fragments in Tibial Plateau Fractures: A Technical Trick and Case Series. J Orthop Trauma. 2024 Jul 1;38(7):e272\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eLiu CD, Hu SJ, Chang SM, Du SC, Chu YQ, Qi YM, et al. Treatment of posterolateral tibial plateau fractures: a narrative review and therapeutic strategy. International Journal of Surgery. 2025 Jan;111(1):1071. \u003c/li\u003e\n\u003cli\u003eBehrendt P, Berninger MT, Th\u0026uuml;rig G, Dehoust J, Christensen JH, Frosch KH, et al. Anterolateral versus modified posterolateral approach for tibial plateau fractures with involvement of the posterior column: a cadaveric study. Eur J Trauma Emerg Surg. 2023 Feb;49(1):201\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eSolomon LB, Stevenson AW, Baird RPV, Pohl AP. Posterolateral transfibular approach to tibial plateau fractures: technique, results, and rationale. J Orthop Trauma. 2010 Aug;24(8):505\u0026ndash;14. \u003c/li\u003e\n\u003cli\u003eCho TJ, Seo JB, Lee HR, Yoo WJ, Chung CY, Choi IH. Biologic characteristics of fibrous hamartoma from congenital pseudarthrosis of the tibia associated with neurofibromatosis type 1. J Bone Joint Surg Am. 2008 Dec;90(12):2735\u0026ndash;44. \u003c/li\u003e\n\u003cli\u003eFrosch KH, Balcarek P, Walde T, St\u0026uuml;rmer KM. A new posterolateral approach without fibula osteotomy for the treatment of tibial plateau fractures. J Orthop Trauma. 2010 Aug;24(8):515\u0026ndash;20. \u003c/li\u003e\n\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":"sn-comprehensive-clinical-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sncm","sideBox":"Learn more about [SN Comprehensive Clinical Medicine](https://www.springer.com/journal/42399)","snPcode":"42399","submissionUrl":"https://submission.nature.com/new-submission/42399/3","title":"SN Comprehensive Clinical Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Tibial plateau fractures, minimally invasive, subchondral buttress","lastPublishedDoi":"10.21203/rs.3.rs-7357583/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7357583/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIsolated posterolateral tibial plateau fractures pose challenges due to complex regional anatomy and limited surgical access. We introduce a novel minimally invasive anteromedial-assisted technique for a depressed posterolateral tibial plateau fracture. A guided K-wire and bone punch are employed to indirectly elevate the articular fragment, while a pre-bent 2.4 mm T-plate is slid subchondrally to support the reduced segment. Intraoperative arthroscopy and postoperative CT confirmed anatomic reduction and stable implant placement. This method avoids extensive soft-tissue dissection, combining internal subchondral support with arthroscopic confirmation to restore joint congruence. The patient regained full, pain-free knee motion by 12 weeks.\u003c/p\u003e","manuscriptTitle":"Minimally Invasive Anteromedial-Assisted Reduction and Subchondral Rafting Fixation for an Isolated Posterolateral Tibial Plateau Fracture: A Novel Technique","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-04 00:02:22","doi":"10.21203/rs.3.rs-7357583/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-06T15:58:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-06T12:20:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-01T05:24:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"76239624598113796177320142303043128228","date":"2025-08-29T05:01:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"193165956109042891587262353083136304176","date":"2025-08-27T12:11:34+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-27T07:18:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-19T03:00:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-19T01:17:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"SN Comprehensive Clinical Medicine","date":"2025-08-12T15:43:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"sn-comprehensive-clinical-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sncm","sideBox":"Learn more about [SN Comprehensive Clinical Medicine](https://www.springer.com/journal/42399)","snPcode":"42399","submissionUrl":"https://submission.nature.com/new-submission/42399/3","title":"SN Comprehensive Clinical Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"f8250cb0-51eb-41fc-b501-80263043f407","owner":[],"postedDate":"September 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:08:32+00:00","versionOfRecord":{"articleIdentity":"rs-7357583","link":"https://doi.org/10.1007/s42399-025-02190-x","journal":{"identity":"sn-comprehensive-clinical-medicine","isVorOnly":false,"title":"SN Comprehensive Clinical Medicine"},"publishedOn":"2025-11-29 15:58:37","publishedOnDateReadable":"November 29th, 2025"},"versionCreatedAt":"2025-09-04 00:02:22","video":"","vorDoi":"10.1007/s42399-025-02190-x","vorDoiUrl":"https://doi.org/10.1007/s42399-025-02190-x","workflowStages":[]},"version":"v1","identity":"rs-7357583","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7357583","identity":"rs-7357583","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}