Finite element analysis of five internal fixation strategies for Schatzker IV tibial plateau fractures

doi:10.12307/2026.799

Abstract

Abstract: BACKGROUND: Schatzker IV tibial plateau fractures are highly challenging due to their involvement of the primary weight-bearing area and high rate of soft tissue complications. Although traditional double plating provides mechanical stability, it violates the minimally invasive principle and is associated with more postoperative complications, especially in elderly patients or those with high-energy trauma. Currently, there is a lack of an internal fixation strategy that can meet both mechanical stability and minimally invasive requirements.
OBJECTIVE: To establish a three-dimensional model of Schatzker IV tibial plateau fractures using the finite element method and compare the biomechanical stability of five fixation methods to provide an optimal surgical option for the treatment of Schatzker IV tibial plateau fractures.
METHODS: A healthy male volunteer underwent knee CT scanning, and a Schatzker IV tibial plateau fracture model was constructed using finite-element software. Five internal-fixation configurations were defined as Groups A, B, C, D, and E. Group A: isolated medial plate; Group B: medial plate plus two posteromedial tension screws; Group C: medial plate plus two lateral tension screws; Group D: posteromedial double plating; Group E: medial-lateral double plating. Under identical boundary and constraint conditions, finite-element analysis software was employed to evaluate the biomechanical performance of five internal fixation models.
RESULTS AND CONCLUSION: (1) The finite element analysis results showed that the minimally invasive combinations (Groups B and C) had comparable overall biomechanical performance to traditional double plating. (2) Group B is an ideal choice for elderly patients because it has the lowest fracture fragment stress (9.039 2 MPa), which can effectively prevent osteoporosis-related collapse, and the percutaneous screw technique reduces the risk of soft tissue complications. (3) Group C has potential for application in young patients, thanks to its minimal implant displacement (4.388 mm), providing excellent stability, and the lateral tension screws avoid vascular and nerve injuries associated with the posteromedial approach.

Key words: tibial plateau fracture, finite element analysis, Schatzker IV, internal fixation, mechanical stability, minimally invasive

CLC Number:

Liu Mingxiang, Zhou Zulong, Fang Run, Kong Lingchao, Wu Chaofan, Wu Chaoqun, Zhang Chengnan, Ning Rende. Finite element analysis of five internal fixation strategies for Schatzker IV tibial plateau fractures[J]. Chinese Journal of Tissue Engineering Research, 2026, 30(27): 7002-7008.

Figures/Tables 3

References

[1] AUBERT K, GERMANEAU A, ROCHETTE M, et al. Development of Digital Twins to Optimize Trauma Surgery and Postoperative Management. A Case Study Focusing on Tibial Plateau Fracture. Front Bioeng Biotechnol. 2021;9:722275.
[2] REÁTIGA AGUILAR J, RIOS X, et al. Epidemiological characterization of tibial plateau fractures. J Orthop Surg Res. 2022;17(1):106.
[3] OLADEJI LO, WORLEY JR, CRIST BD. Age-Related Variances in Patients with Tibial Plateau Fractures. J Knee Surg. 2020;33(6):611-615.
[4] KFURI M, SCHATZKER J. Revisiting the Schatzker classification of tibial plateau fractures. Injury. 2018;49(12):2252-2263.
[5] CHAPMAN JP, PATRICK MR, REB CW, et al. Comparable outcomes with intramedullary nail and plate constructs for Schatzker VI tibial plateau fractures. Eur J Orthop Surg Traumatol. 2023;33(5):1653-1661.
[6] YANG G, ZHU Y, LUO C, et al. Morphological characteristics of Schatzker type IV tibial plateau fractures: a computer tomography based study. Int Orthop. 2012; 36(11):2355-2360.
[7] MARKHARDT BK, GROSS JM, MONU JU. Schatzker classification of tibial plateau fractures: use of CT and MR imaging improves assessment. Radiographics. 2009;29(2):585-597.
[8] RAMOUTAR DN, LEFAIVRE K, BROEKHUYSE H, et al. Mapping recovery in simple and complex tibial plateau fracture fixation. Bone Joint J. 2019;101-b(8):1009-1014.
[9] CHEN P, SHEN H, WANG W, et al. The morphological features of different Schatzker types of tibial plateau fractures: a three-dimensional computed tomography study. J Orthop Surg Res. 2016;11(1):94.
[10] YAN B, SUN J, YIN W. The prevalence of soft tissue injuries in operative Schatzker type IV tibial plateau fractures. Arch Orthop Trauma Surg. 2021;141(8): 1269-1275.
[11] STEPHENS A, SEARLE H, CARLOS W, et al. Diagnostic impacts on management of soft tissue injuries associated with tibial plateau fractures: A narrative review. Injury. 2024;55(6):111546.
[12] HUA K, JIANG X, ZHA Y, et al. Retrospective analysis of 514 cases of tibial plateau fractures based on morphology and injury mechanism. J Orthop Surg Res. 2019; 14(1):267.
[13] RISITANO S, REA A, GAROFALO G, et al. Impact of Surgical Timing, Fasciotomy, and External Fixation on Infection Risk in Tibial Plateau Fractures. J Pers Med. 2025; 15(3):108.
[14] BORMANN M, BITSCHI D, NEIDLEIN C, et al. Mismatch between Clinical-Functional and Radiological Outcome in Tibial Plateau Fractures: A Retrospective Study. J Clin Med. 2023;12(17):5583.
[15] PENG J, REN W, FENG B, et al. Schatzker IV tibial plateau fractures involving the posterolateral column: Higher incidence of lateral meniscus and anterior cruciate ligament injuries with suboptimal postoperative outcomes. Injury. 2024;55(12):111921.
[16] SMITH TO, CASEY L, MCNAMARA IR, et al. Surgical fixation methods for tibial plateau fractures. Cochrane Database Syst Rev. 2024;8(8):Cd009679.
[17] XU Z, LI Y, TIAN S, et al. Preliminary exploration of finite element biomechanical preoperative planning for complex tibial plateau fractures. Sci Rep. 2025;15(1): 15913.
[18] SCHATZKER J, KFURI M. Revisiting the management of tibial plateau fractures. Injury. 2022;53(6):2207-2218.
[19] SONG Z, WANG Q, MA T, et al. Failure analysis of primary surgery and therapeutic strategy of revision surgery for complex tibial plateau fractures. J Orthop Surg Res. 2019;14(1):110.
[20] STANNARD JP, LOPEZ R, VOLGAS D. Soft tissue injury of the knee after tibial plateau fractures. J Knee Surg. 2010;23(4):187-192.
[21] BENNETT WF, BROWNER B. Tibial plateau fractures: a study of associated soft tissue injuries. J Orthop Trauma. 1994;8(3):183-188.
[22] WEI G, NIU X, LI Y, et al. Biomechanical analysis of internal fixation system stability for tibial plateau fractures. Front Bioeng Biotechnol. 2023;11:1199944.
[23] WAHLQUIST M, IAGUILLI N, EBRAHEIM N, et al. Medial tibial plateau fractures: a new classification system. J Trauma. 2007;63(6):1418-1421.
[24] LIU Z, WANG S, TIAN X, et al. The Relationship between the Injury Mechanism and the Incidence of ACL Avulsions in Schatzker Type IV Tibial Plateau Fractures: A 3D Quantitative Analysis Based on Mimics Software. J Knee Surg. 2023;36(6): 644-651.
[25] TSCHERNE H, LOBENHOFFER P. Tibial plateau fractures. Management and expected results. Clin Orthop Relat Res. 1993;(292):87-100.
[26] RUDRAN B, LITTLE C, WIIK A, et al. Tibial Plateau Fracture: Anatomy, Diagnosis and Management. Br J Hosp Med (Lond). 2020;81(10):1-9.
[27] PRAT-FABREGAT S, CAMACHO-CARRASCO P. Treatment strategy for tibial plateau fractures: an update. EFORT Open Rev. 2016;1(5):225-232.
[28] HÖRMANDINGER C, BITSCHI D, BERTHOLD DP, et al. Lack of standardisation in the management of complex tibial plateau fractures: a multicentre experience. Eur J Trauma Emerg Surg. 2024;50(6):2937-2945.
[29] HONKONEN SE. Indications for surgical treatment of tibial condyle fractures. Clin Orthop Relat Res. 1994;(302):199-205.
[30] TEKIN A, ÇAKAR M, ESENYEL CZ, et al. An evaluation of meniscus tears in lateral tibial plateau fractures and repair results. J Back Musculoskelet Rehabil. 2016; 29(4):845-851.
[31] 谭红略, 代朋乙, 刘伟峰, 等. 联合入路双钢板固定治疗陈旧性Schatzker Ⅳ型胫骨平台骨折[J]. 中国骨伤,2017,30(10):1003-0034.
[32] WANG G, WANG B, TANG Y, et al. A quantitative biomechanical study of positive buttress techniques for femoral neck fractures: a finite element analysis. Chin Med J (Engl). 2019;132(21):2588-2593.
[33] LIU CD, HU SJ, CHANG SM, et al. Treatment of posterolateral tibial plateau fractures: a narrative review and therapeutic strategy. Int J Surg. 2025;111(1): 1071-1082.
[34] 王伟, 罗强, 李天宇, 等. 联合入路双钢板内固定治疗Schatzker Ⅴ,Ⅵ型胫骨平台骨折的临床疗效分析[J]. 创伤外科杂志,2019,21(3):185-187.
[35] 方丁, 曾义高, 陈先洲, 等. 复杂胫骨平台骨折两种微创内固定方法的生物力学对比研究[J]. 实用临床医药杂志,2016,20(23):72-74.
[36] 冯大军, 叶金标. 双钢板固定结合植骨治疗SchatzkerⅤ、Ⅵ型胫骨平台骨折的临床效果研究[J]. 医疗卫生装备,2017,38(2):80-82.
[37] 王友良, 冯庆虎, 衣龙云, 等. 前正中入路双钢板固定在Schatzker分型Ⅴ,Ⅵ型胫骨平台骨折中的研究应用[J]. 生物骨科材料与临床研究,2021,18(1): 43-46,50.
[38] 高榅青, 魏锋. 双切口双钢板内固定与单侧锁定钢板内固定对Schatzker Ⅴ/Ⅵ型胫骨平台骨折患者膝关节内翻角,后倾角的影响[J]. 中国当代医药 2023,30(31):99-102.
[39] GUO J, CHEN X, LIN Z, et al. Tight junction disruption through activation of the PI3K/AKT pathways in the skin contributes to blister fluid formation after severe tibial plateau fracture. Front Bioeng Biotechnol. 2022;10:946261.
[40] 方丁, 曾义高, 陈先洲, 等. 复杂胫骨平台骨折两种微创内固定方法的生物力学对比研究[J]. 实用临床医药杂志,2016,20(23):72-74.
[41] LV H, LI W, WANG Y, et al. Prediction model for tibial plateau fracture combined with meniscus injury. Front Surg. 2023;10:1095961.