Fractures & Osteotomy

Tibial plateau fractures and realignment procedures, including HTO and DFO for unicompartmental arthritis and malalignment.

Overview

Corrective osteotomy addresses deformity by restoring anatomic axes, a strategy critical for avoiding future complications in surgical correction following epiphyseal injury around the knee joint [5]. Both open-wedge high tibial osteotomy and tibial condylar valgus osteotomy improve short-term clinical outcomes postoperatively [1]. Properly performed proximal tibial osteotomy yields satisfactory clinical results with appropriate patient selection [104]. The age of the patient does not have to be taken into consideration for the indication of high tibial osteotomy [15]. New osteotomy concepts have survived early development and are popular in many European countries, but further research is needed to achieve global acceptance and higher levels of evidence [2].

In pediatric populations, non-operative treatments for lower-extremity rotational problems are usually ineffective [6]. Rotational osteotomies are effective for these problems but are associated with significant complication rates [6]. Proximal femoral osteotomies have different indications and treatment strategies in adolescence [16]. For patellofemoral pathology, subjects undergoing autologous chondrocyte implantation combined with patellofemoral osteotomy showed significantly greater improvements in multiple clinical outcomes compared to those undergoing isolated autologous chondrocyte implantation [8].

Internal fixation remains an effective option in select clinical circumstances for orthopaedic trauma, with successful healing and avoidance of complications largely determined by surgical technique [18]. Definitive internal fixation of both bones yields the best results in almost all series for ipsilateral femoral and tibial fractures (floating knee) [103]. The main indication for fixation of osteochondral fractures and loose bodies following traumatic patellar dislocation is large fragments, while smaller and poor-quality fragments are excised [105]. It is critical for surgeons to understand common fracture types, evaluation methods, treatment options, and expected complications to avoid adverse outcomes [3].

Anatomy & Pathophysiology

Kinematics and Alignment

Knee kinematics are influenced by both intraarticular and extra-articular parameters, exhibiting significant interindividual variability [20]. The functional knee phenotype concept better represents the variability of coronal knee alignment than the conventional system of valgus, varus, and neutral [22]. Inverse kinematic alignment accommodates a greater proportion (93%) of native limb alignment compared to adjusted mechanical alignment and restricted kinematic alignment, which require more adjustments to bring outlier knees within target zones [33]. Comparative anatomical studies suggest that understanding shared kinematic principles can improve the design of external bracing systems and total knee replacements [23].

Realignment osteotomy around the knee is primarily used to correct biomechanical abnormalities and asymmetric loading across the knee joint due to malalignment [21]. Kinematic changes resulting from open and closed high tibial osteotomy should be considered when selecting the surgical technique for patients with medial osteoarthritis [31]. High tibial osteotomy (HTO) resulted in normalisation of several dynamic knee function parameters such as walking speed, knee flexion, and external knee flexion moment [24]. Decreasing tibial length relative to femoral length alters lower extremity biomechanics in such a manner that places the ACL at risk for injury [27].

Osseous and Articular Geometry

Highly variable proximal tibia anatomy causes controversies for proper tibial component rotational alignment in total knee arthroplasty [36]. There is no evidence that the stability of the knee can be derived from its radiographic surface geometry [37]. A systematic use of the simulated measured resection mechanical alignment technique for total knee arthroplasty leads to many cases with imbalance [38]. The finite element model reliably simulates patellofemoral kinematics and contact pressures [43].

Ligamentous and Meniscal Biomechanics

Increasing posterior tibial slope (PTS) in a native knee with intact cruciate ligaments affected 6 DOF knee kinematics and decreased resultant forces in the medial and lateral meniscus by up to 35% in response to combined rotatory loads [34]. A biomechanical study is required to verify the function of the PCL against an extension-distraction force in the knee [25]. PKF and DKF are distinct and constant anatomical structures of the lateral compartment of the knee, whose anatomical characteristics and their tensioning in IR presume a function of controlling rotational knee stability [42].

Clinical Implications and Complications

Mechanical axis realignment and sagittal plane correction are fundamental considerations in the management of complex knee instability presenting as a symptomatic thrust [28]. Kinematic changes correlate with poorer postoperative functional results, so that in patients with preexisting pathological patellar height a modification of the classical osteotomy technique should be discussed [35]. Knee stiffness is the main complication of new femoral derotation technique based on guided growth in children but resolves with time [29]. In addition to biomechanical changes, the biological environment of the joint can be improved after AKO [26]. By adhering to the principles of anatomic ACLR, surgeons can produce an appropriately sized and located graft for the individual patient, thereby best restoring native knee kinematics and maximizing function [39].

Classification

New Periprosthetic Femur Fracture (PPF) Classification: A recent system for PPF following total knee arthroplasty (TKA) classifies fractures based on location and implant type [64]. This classification is easy to use, demonstrates good interobserver reliability, and allows for specific treatment recommendations [64].

Periprosthetic Femur Fracture Management: Treatment selection depends on fracture location relative to the implant. Intramedullary nails are indicated for proximal periprosthetic femoral fractures above TKA [4]. Fixed-angle devices are best for fractures originating at the component [4]. Revision arthroplasty is indicated for very distal fractures or those associated with implant loosening [4].

Tibial Plateau Fracture Classification: Frequently used systems for tibial plateau fractures display moderate intra- and inter-observer reliability [50]. A classification based on injury mechanism and morphological characteristics provides instructive value for preoperative evaluation of fracture features and soft tissue problems, guiding clinical management for better functional outcomes [52]. The 10-segment classification helps quantify the posterior fracture line in tibial plateau fractures to balance pros and cons for different posterior surgical approaches [65].

Giant Cell Tumour Around the Knee: The classification of lesions into 'simple fracture' and 'complex fracture' guides decisions regarding the best surgical method for patients with giant cell tumour around the knee, accounting for different degrees of fracture [72].

Humeral Fracture Classification: A simple classification of multifocal humeral fractures is suggested to assist surgeons in choosing the most suitable type of synthesis for surgical treatment [10].

Tibia Fracture Registry Accuracy: Classification accuracy in the Swedish Fracture Register is high, showing substantial agreement for AO/OTA type and moderate agreement for AO/OTA group [73].

Other Considerations: New osteotomy concepts have survived early development and are popular in many European countries, but further research is needed to achieve global acceptance and higher levels of evidence [2]. It is critical for surgeons to understand common fracture types, evaluation methods, treatment options, and expected complications to avoid adverse outcomes [3]. Classification based on fracture location can help guide treatment for periprosthetic femoral fractures above total knee replacements [4]. When a fracture of the lateral portion of the distal tibial epiphysis is recognized and the fragment is replaced, a good anatomical and functional result may be expected [7]. Plate on plate osteosynthesis is a novel method for periplate fracture fixation that may prove valuable due to the increasing population age and unique types of fractures [9]. The role of varus osteotomy for valgus arthritic knees remains poorly defined [12]. Low-angulation osteotomy resulted in a much higher percentage of union of femoral neck fractures than other types in cases of non-union following fracture [53].

Clinical Presentation

Evaluation of fracture patients requires a thorough understanding of common fracture types, evaluation methods, treatment options, and expected complications to avoid adverse outcomes [3]. For tibial plateau fractures, recognizing recurrent features aids surgeons during diagnosis, preoperative planning, and execution of surgical strategies [13]. In the wrist, fractures of the capitate are diagnosed and reported with undeserved rarity, requiring a higher index of suspicion for recognition [11]. Similarly, diagnosis of a sleeve fracture of the superior pole of the patella may be missed unless there is a high index of suspicion due to the small size of fracture fragments in growing children [63].

Inspection and palpation must account for hidden injuries. Recognition of the pattern between oblique fractures of the medial malleolus and concomitant fractures of the anterolateral aspect of the tibial plafond is necessary for successful treatment because the tibial plafond fracture may be hidden on routine radiographs [60]. For anterior-process fractures of the calcaneus, correct initial diagnosis and treatment are important, particularly if the fracture fragment is large [49]. Early excision of fragments for these calcaneal fractures is usually not necessary or advisable [49].

Range-of-motion and stability assessments guide specific interventions. Good anatomical and functional results may be expected when a fracture of the lateral portion of the distal tibial epiphysis is recognized and the fragment is replaced [7]. For lower-extremity rotational problems in children, non-operative treatments are usually ineffective [6]. Rotational osteotomies are effective for these conditions but are associated with significant complication rates [6].

Special tests and classification systems dictate surgical strategy. Classification of periprosthetic femoral fractures by location guides treatment selection [4]. Proximal periprosthetic femoral fractures: Intramedullary nails are best [4]. Fractures originating at the component: Fixed-angle devices are best [4]. Very distal periprosthetic femoral fractures or those with implant loosening: Revision arthroplasty is indicated [4]. A simple classification of multifocal humeral fractures helps surgeons choose the most suitable type of synthesis for surgical treatment [10].

Red-flag patterns require prompt intervention to prevent morbidity. Femoral stress fractures require prompt diagnosis to prevent progression to complete or displaced fractures that necessitate aggressive treatment and carry a higher risk of chronic morbidity [59] [62]. Diagnosis of union based on radiographs 3 months after distal tibia fracture injury is only moderately reliable and accurate but has a high negative predictive value [14]. Careful analysis of patient and fracture variables helps determine causes of fixation failure and maximize success of subsequent interventions [51]. Careful observation of proximal fibular fractures following conservative treatment or in the post-operative period is important to avoid complaints that may arise at a later stage [54].

Specific osteotomy outcomes and adjunctive procedures influence presentation expectations. Both open-wedge high tibial osteotomy and tibial condylar valgus osteotomy improve short-term clinical outcomes postoperatively [1]. No complications were seen in type I lateral hinge fractures after a medial opening-wedge high tibial osteotomy [61]. Type II lateral hinge fractures after a medial opening-wedge high tibial osteotomy resulted in delayed unions with correction loss in some cases [61]. The role of varus osteotomy for valgus arthritic knees remains poorly defined [12]. Subjects undergoing autologous chondrocyte implantation combined with patellofemoral osteotomy show significantly greater improvements in multiple clinical outcomes compared to those undergoing isolated autologous chondrocyte implantation [8]. The clinical performance of locked plates generally has been good, but several unique complications have been noted [56].

Investigations

Plain radiography: Classification of periprosthetic femoral fractures based on fracture location helps guide treatment [4]. Diagnosis of union based on radiographs 3 months after distal tibia fracture injury is only moderately reliable and accurate [14], though it has a high negative predictive value [14]. Focusing on bone morphology allows surgeons to easily perform visual assessment using preoperative radiographs for medial open wedge high tibial osteotomy [101]. A variety of reliable skeletal maturity estimation systems using routine knee radiographs are described for planning surgeries about the knee [109]. Orthopaedic surgeons can use skeletal maturity estimation systems using routine knee radiographs and MRI to inform preoperative workups without requiring additional hand radiographs [109].

MRI: Over two-thirds of patients who sustained a tibial spine fracture were noted to have concomitant pathology on MRI [99]. 56.7% of injuries seen on MRI in tibial spine fractures correlated to what was seen at the time of surgery [99]. MRI is recommended for earlier diagnosis of avulsion of the anterior cruciate ligament from the femoral condyle as plain radiographs may not visualize osteochondral fragments in skeletally immature patients [100]. Magnetic resonance imaging parameters of a healed osteochondral fragment and patients with satisfactory functional results correspond with arthroscopic evidence of fragment stability in osteochondritis dissecans of the knee [110]. Orthopaedic treatment for acute minimally displaced cartilaginous tibial eminence fractures in children is only indicated under strict MRI control [117].

CT: Preoperative CT scans may improve surgical planning for patellar fractures by identifying secondary fracture lines poorly visualized on radiographs [86]. Computed tomography permits a more adequate assessment of the size of the fracture gap and the rotatory alignment of spiral tibia fracture fragments as compared with plain radiography [107]. CT scanning provided useful information for the planning of fixation with a tibial tuberosity fracture with a proximal triplane extension [113].

Other Considerations: Understanding recurrent features of tibial plateau fractures can aid surgeons during diagnosis, preoperative planning, and execution of surgical strategies [13]. ARIF led to better radiological results than ORIF in the treatment of tibial plateau fractures [108]. In questionable cases of traumatic separation of the upper femoral epiphysis in a newborn infant, arthrography will allow diagnosis before healing has progressed to the point of fixed deformity [111]. A higher index of suspicion would lead to the recognition and treatment of more capitate fractures [111]. When a fracture of the lateral portion of the distal tibial epiphysis is recognized and the fragment is replaced, a good anatomical and functional result may be expected [7]. Corrective osteotomy at both levels is advisable to restore all anatomic axes and avoid future problems following epiphyseal injury around the knee joint [5]. Double level osteotomy for medial osteoarthritis and bifocal varus malalignment has excellent short-term results while maintaining physiologic radiographic joint parameters [112]. The presence of residual radiolucency is an important contraindication to removing compression plates from forearm bones [114]. Non-union is defined as a fracture where reparative processes have ceased [116]. Clinical, roentgenographic, and histological criteria are outlined for the diagnosis of non-union [116]. Suture fixation is the recommended strategy for cartilaginous tibial eminence fractures in children in situations other than acute minimally displaced fractures under strict MRI control [117].

Treatment

High Tibial Osteotomy (HTO) and Knee Osteotomies

Indications: Patient age does not influence clinical outcomes after high tibial osteotomy, so age need not be considered for indication [15]. An individualized osteotomy approach is recommended for valgus knee malalignment to achieve careful preoperative planning that considers the location of the deformity and the resultant joint line [46].

Surgical Approach / Technique: Both open-wedge high tibial osteotomy and tibial condylar valgus osteotomy improved short-term clinical outcomes postoperatively [1]. Enhanced surgical knowledge of anatomical structures at potential risk during medial open-wedge high tibial osteotomy or plate fixation helps avoid possible injuries [30]. Directing the plane of the medial open-wedge high tibial osteotomy toward the 'safe zone' significantly reduces the risk of lateral cortex fracture compared to directing it at a lower level [41].

Implant Selection: The new fixation device (TomoFix) allows stable fixation of the osteotomy without bone grafting [80]. A stepped staple for upper tibial osteotomy was designed to allow both fragments to be fully engaged by the staple, addressing the discrepancy in continuity of the cortex created by wedge osteotomy [47].

Other Considerations: New osteotomy concepts have survived early development and are popular in many European countries, but further research is needed to achieve global acceptance and higher levels of evidence [2].

Periprosthetic Fractures

Indications: Classification based on fracture location guides treatment of periprosthetic femoral fractures above total knee replacements: intramedullary nails for proximal fractures, fixed-angle devices for fractures originating at the component, and revision arthroplasty for very distal fractures or those with implant loosening [4].

Implant Selection: Both plate and nail fixation present unique benefits and pitfalls for treating periprosthetic fractures about a well-fixed prosthesis [97].

Rotational Osteotomies

Indications: Non-operative treatments for lower-extremity rotational problems in children are usually ineffective, and while rotational osteotomies are effective, they are associated with significant complication rates [6]. The indication for concomitant tibial tubercle osteotomy in the treatment of recurrent patellar dislocation (combined with derotational distal femoral osteotomy and medial patellofemoral ligament reconstruction) should be individualized according to each patient's specific anatomical and clinical characteristics [66].

Pediatric Fractures and Deformity Correction

Indications: Corrective osteotomy at both levels is advisable to restore all anatomic axes and avoid future problems following epiphyseal injury around the knee joint [5]. Nondisplaced pediatric tibial eminence fractures are amenable to nonsurgical management, while displaced fractures are managed with arthroscopic reduction and fixation [57]. Conservative management can be utilized for non-displaced pediatric ankle fractures, but surgery should be considered for fractures involving substantial physeal or joint displacement [58]. Invasive primary treatment of pediatric both-bone diaphyseal forearm fractures seemed to prevent re-displacement, and the need for re-operation of severe fractures was less common in the invasive treatment group than in the non-invasive treatment group [81].

Proximal Femoral Osteotomies

Indications: Proximal femoral osteotomies in adolescence have various indications and treatment strategies [16].

Implant Selection: A fluted intramedullary rod for subtrochanteric fractures achieved union in all instances with no failure of the implant [17].

Distal Femur and Tibia Fractures

Surgical Approach / Technique: Routine operative management of tibial condyle fractures is not recommended, though fixation is paramount to allow early motion [123]. Regardless of fixation type, approximately one-third of patients experienced moderate to severe pain after severe open tibial fracture [127].

Forearm and Upper Extremity Fractures

Indications: Ender nailing of acute humerus fractures is indicated only for fractures recalcitrant to closed reduction and immobilization or in non-compliant patients [55].

Implant Selection: Patella fractures treated with suture tension band fixation are considered a safe and promising alternative to traditional metallic fixation methods [96].

General Fracture Management Principles

Surgical Approach / Technique: Achieving an anatomic reduction is the essential, and often most formidable, step in osteosynthesis [45]. Internal fixation remains an effective option in select clinical circumstances for orthopaedic trauma, with successful healing and avoidance of complications largely determined by surgical technique [18]. Staged internal plate fixation of severe lower extremity fractures using a temporary external fixator requires a set goal of definitive internal fixation at the time of initial external fixation [94]. The performance of an innominate osteotomy allowed open reduction of central acetabular fractures to be accomplished with ease and with little added risk of morbidity [32]. A simple transverse osteotomy with threaded-pin fixation for tibial torsion deformities avoids the postoperative fixation problems of simple transverse osteotomy and the difficulties of Z-type operations [40]. Transarticular fixation is highly successful in achieving union of the fractured femur, stability, and relief of pain in all patients with one operation for non-union of supracondylar fractures [92].

Implant Selection: Dual plating is indicated for certain cases, particularly old ununited fractures where intramedullary nailing is difficult, but is contraindicated in severely comminuted fractures requiring extensive dissection [68]. The implant device plays the major role in fixation stability for intertrochanteric fractures, while reduction positions exert only a minor influence [90].

Adjuncts: Functional fracture bracing has proven safer and less expensive than operative management for many fractures, and physiologically induced motion at the fracture site enhances osteogenesis [74]. The indication for fibula plating in distal lower-leg fractures with tibial nailing should be made individually [77].

Other Considerations: Non-union often results from a combination of adverse situations, and its prevention depends to a great extent on the application of well-established sound principles of fracture management [83]. The incidence of non-union can be decreased and many aspects of unsolved fractures resolved by accurate reduction, accurately placed adequate internal fixation, and carefully supervised postoperative care [84]. Union of an ununited long-bone fracture is achieved surgically in four basic steps: host bone preparation, bone-graft application, fixation, and postoperative care [88]. The treatment method and postoperative protocol for patellar fractures must be individualized, taking into account the fracture pattern, bone quality, and various patient factors [128]. Augmented percutaneous cementoplasty does not seem to improve pain relief, fracture incidence, and operative time when compared with non-augmented percutaneous cementoplasty for metastatic impending fractures of the proximal femur [98]. Pain relief was obtained in all cases postoperatively following the procedure described in the referenced study [121]. Spontaneous reduction of fractures through epiphyseal plates without residual roentgenographic evidence probably occurs at other joints and will be diagnosed only by manipulation under anesthesia [129].

Revision Arthroplasty and Complex Fixation

Surgical Approach / Technique: Most revisions require a combined approach to fixation, and a multi-zone strategy should be adopted [44]. Plate on plate osteosynthesis is a novel method that may prove valuable due to the increasing population age and unique types of fractures [9].

Complications

Surgeons must understand expected complications to avoid adverse outcomes in fracture treatment [3].

Thromboembolism: The incidence of postoperative deep venous thrombosis (DVT) in patients with isolated patella fractures is substantial [95]. The overall incidence of DVT after osteotomy around the knee is 13.8%, even with prophylactic anticoagulant use [106]. The incidence of DVT in patients with tibial fractures is relatively high, with age > 40.5 years, systemic immune-inflammation index (SII) > 858.5, and D-dimer > 1.36 mg/L identified as high-risk factors [126]. Breast cancer patients have a two-fold increased risk of complications after total hip arthroplasty (THA), including intraoperative fracture and venous thromboembolism (VTE) [130].

Infection: The rate of infection was 6% in open tibial fractures treated with the Lottes nail [140].

Nonunion / Malunion: The rate of delayed union was 16% and malunion 4% in open tibial fractures treated with the Lottes nail [140]. There was a high rate of nonunion (39%) following plating of periprosthetic greater trochanter fractures [162].

Implant Failure / Reoperation: The rate of hardware failure was 28% in periprosthetic greater trochanter fractures [162]. There was a high incidence of reoperation (20%) within the first 2 years following plating of periprosthetic greater trochanter fractures [162]. The mean postoperative complication rate after tibial tubercle osteotomy for patella alta was 7.6%, with a reoperation incidence of 14.3% primarily related to hardware removal [160]. The multiple-pin and plate technique (Deyerle treatment) for femoral neck fractures causes an increase in morbidity [157]. The only independent risk factor identified for fixation failure in arthroscopic screw fixation for symptomatic osteochondritis dissecans was the number of previous operations [163].

Aseptic Loosening: Ten-year survivorship free from aseptic loosening after total knee arthroplasty (TKA) following distal femoral osteotomy was 95% [142]. A previous osteotomy is associated with decreased implant survival in subsequent TKAs, especially if TKA components with stems and/or augmentations are used [152].

Instability / Balancing: There was a high complication rate secondary to problems with balancing the knee after TKA following distal femoral osteotomy [142].

Other Considerations: The risk of vascular injury is elevated in osteotomies around the knee [134]. Patient weight, age, and deformity genesis do not influence complication rates in lower limb corrective osteotomies [134]. It remains difficult to identify specific patient or fracture characteristics that determine an individual's risk for complications after intramedullary nailing of tibial shaft fractures [139]. Compared with unicompartmental knee arthroplasty (UKA), complication rates were higher after periarticular knee osteotomy, with an overall surgical complication rate of 23.7% [159]. The complication rate for total tibial pilon fractures is high, and neither internal plating nor definitive external fixation has proven to be more effective overall [164].

Recovery

Light activity (weeks): Early mobilization is a cornerstone of recovery across multiple fracture and osteotomy procedures. Closed intramedullary nailing of femoral shaft fractures facilitates early joint movement and early weight-bearing [67]. In medial open-wedge high tibial osteotomy, a conservative rehabilitation protocol permits full weight-bearing walking commencing at 6 weeks postoperatively [76]. For displaced pediatric supracondylar humerus fractures, surgical treatment is moderately recommended to prevent harm associated with nonsurgical management [89].

Full activity (months): Return to sport and work outcomes improve with timely surgery, optimized perioperative care, and evidence-based advice on activity resumption [91]. Patients undergoing primary or revision medial patellofemoral ligament reconstruction with concomitant tibial tubercle osteotomy demonstrate high return-to-sport rates [19]. Adult tibial eminence fracture fixation using arthroscopic K-wire folded fixation results in return to pre-injury sports levels [85]. Single-stage acute osseous correction with femoral shortening for neglected congenital knee dislocations enables return to work [137].

Complete recovery / outcome plateau (months): Open-wedge high tibial osteotomy and tibial condylar valgus osteotomy both improve short-term clinical outcomes postoperatively [1]. Femoral osteotomy achieves significant improvements in quality of life and functional capabilities, though physical recovery requires an extended duration [138]. Native distal femur fractures (NDFF) type 33 C are at greater risk of unexpected return to the operating room compared to periprosthetic fractures [93]. Most lesions of spontaneous osteonecrosis of the tibial plateau heal spontaneously with protected weight-bearing, but arthroplasty may be indicated once there is collapse or fracture of the plateau [131].

Rehabilitation protocol: The American College of Surgeons emphasizes the surgeon's responsibility for the maximum restoration of function through simplification of treatment, establishment of principles, and education [48]. Good clinical results in polytrauma patients with long bone fractures treated with damage control and intramedullary nailing are expected when principles of damage control are applied, complications are prevented through proper reduction, firm fixation, early soft tissue reconstruction, and early rehabilitation [71]. Screw fixation for certain phalangeal and metacarpal fractures allows for early range-of-motion exercises and full recovery of motion [70]. The candy box technique for inferior pole patellar fractures enhances patient prognosis by incorporating early functional exercise and ensuring strong internal fixation [75]. Postoperative rehabilitation programs and functional assessments are important for patients operated on for avulsion fracture of the tibial tuberosity following Osgood-Schlatter disease [78].

Functional milestones: Patients have very high expectations for surgical treatment of proximal tibial fractures, particularly regarding unrestricted return to sport, work, and painlessness [82]. Appropriate reduction of fracture fragments is key to achieving a good functional result in intramedullary nailing of displaced four-part proximal humerus fractures [69]. Functional return is achieved in all survivors of intertrochanteric and subtrochanteric hip fractures treated by the Ender method who could walk at the time of injury, with no non-unions reported [87]. Stable osteosynthesis in operative treatment of supracondylar-condylar femur fractures permits early postoperative function, leading to good end results [136]. A treatment protocol for ipsilateral femoral neck and shaft fractures produces excellent results with all fractures uniting and good long-term functional outcomes [132].

Other Considerations: Overlooking tibial plateau fractures significantly increases patient disability in one third of cases [102]. Older patients and those with more severe tibial plateau fractures are more likely to require total knee arthroplasty after operative repair [115]. Total knee arthroplasty offers immediate stability, early mobilization, and decreased reoperation rates as a primary treatment for tibial plateau fractures in older persons with osteoporotic bone [119]. Routine postoperative radiographs following tibial plateau open reduction and internal fixation result in minimal management change for patients [120]. High tibial osteotomy offers satisfactory pain relief and functional outcomes in selected patients with high activity demands, though it carries a higher risk of revision in total knee arthroplasty [125]. Tibial plateau fractures decrease knee function compared with the contralateral side and preoperative condition, with bicondylar fractures associated with worse functional outcomes [133]. Type I and II lateral hinge fractures in medial open-wedge high tibial osteotomy using a locked plate system do not cause radiologic changes or functional deterioration during midterm followup when managed with a relatively conservative rehabilitation protocol featuring full weight-bearing walking commencing at 6 weeks postoperatively [76]. Posterolateral sheared tibial plateau fractures can be reset and fixed sufficiently to achieve excellent long-term postoperative recovery [118].

Key Evidence

• [L3] Both osteotomy procedures improved short-term clinical outcomes postoperatively. (10.1186/s12891-024-07205-7)
• [L5] New osteotomy concepts have survived early development and are popular in many European countries, but further research is needed to achieve global acceptance and higher levels of evidence. (10.1007/s00167-012-2175-3)
• [L4] Classification based on fracture location can help guide treatment, with intramedullary nails best for proximal fractures, fixed-angle devices for fractures originating at the component, and revision arthroplasty for very distal fractures or those with implant loosening. (10.5435/00124635-200401000-00003)
• [L4] Corrective osteotomy at both levels is advisable to restore all anatomic axes and avoid future problems. (10.1007/s001670050022)
• [L4] Non-operative treatments are usually ineffective, and while rotational osteotomies are effective, they are associated with significant complication rates. (10.2106/00004623-198567050-00027)
• [L4] When the fracture is recognized and the fragment is replaced a good anatomical and functional result may be expected. (10.2106/00004623-196446010-00003)
• [L4] When individual studies compared these 2 groups, significantly greater improvements in multiple clinical outcomes in subjects undergoing ACI combined with osteotomy were observed. (10.1016/j.arthro.2012.10.008)
• [L4] Plate on plate osteosynthesis is a novel method that may prove valuable due to the increasing population age and unique types of fractures. (10.1177/2325967120s00043)
• [Paper] A simple classification of multifocal fractures is suggested to help the surgeon choose the most suitable type of synthesis for surgical treatment. (10.1016/j.injury.2013.10.010)
• [L4] The injury has been diagnosed and reported with undeserved rarity, and a higher index of suspicion would lead to the recognition and treatment of more of these fractures. (10.2106/00004623-196244080-00003)
• [L4] The role of varus osteotomy remains poorly defined. (10.1007/s00167-012-2180-6)
• [L4] An understanding of these recurrent features of tibial plateau fractures can aid surgeons during diagnosis, preoperative planning, and execution of surgical strategies. (10.2106/jbjs.n.00866)
• [Paper] Diagnosis of union based on radiographs 3 months after injury is only moderately reliable and accurate but has a high negative predictive value. (10.1016/j.injury.2012.10.034)
• [L3] As a consequence, the age of the patient does not have to be taken into consideration for the indication of high tibial osteotomy. (10.1007/s00167-012-2016-4)
• [L4] The aim of this review is to show the different ways of proximal femoral osteotomies and their indications after having done a selective literature research. (10.1055/a-1023-4679)
• [L4] Union was achieved in all instances and no failure of the implant occurred. (10.2106/00004623-197961050-00014)
• [L5] Internal fixation remains an effective option in select clinical circumstances, with successful healing and avoidance of complications largely determined by surgical technique. (10.5435/jaaos-d-23-01256)
• [L3] Patients who had primary and revision surgery reported clinical and statistical improvements in nearly all PROMs over time, with low recurrent instability and high RTS rates in both groups. (10.1177/03635465251409151)
• [L5] Knee kinematics is influenced by both intraarticular and extra-articular parameters, showing significant interindividual variability. (10.1016/j.arth.2016.02.049)
• [L5] Realignment osteotomy around the knee is primarily used to correct biomechanical abnormalities and asymmetric loading across the knee joint due to malalignment. (10.1016/j.arth.2024.10.065)
• [L4] The functional knee phenotype concept better represents the variability of the coronal knee alignment than the conventional system of valgus, varus and neutral. (10.1177/2325967120s00301)
• [L5] Comparative anatomical studies suggest that understanding these shared kinematic principles can improve the design of external bracing systems and total knee replacements. (10.2106/00004623-198769070-00004)
• [L3] HTO resulted in normalisation of several dynamic knee function parameters such as walking speed, knee flexion and external knee flexion moment. (10.1007/s00167-011-1496-y)
• [Case_report] A biomechanical study is required to verify this function of the PCL against an extension-distraction force in the knee. (10.1186/1749-799x-5-67)
• [L4] In addition to biomechanical changes, the biological environment of the joint can be improved after AKO. (10.1016/j.arthro.2023.07.008)
• [L3] It is possible that decreasing tibial length relative to femoral length alters lower extremity biomechanics in such a manner that places the ACL at risk for injury. (10.1177/23259671251343811)
• [L4] Mechanical axis realignment and sagittal plane correction are fundamental considerations in the management of complex knee instability presenting as a symptomatic thrust. (10.1177/0363546503258907)
• [Paper] Knee stiffness is the main complication but resolves with time. (10.1016/j.otsr.2019.06.005)
• [L5] Enhanced surgical knowledge of anatomical structures that are at a potential risk during the different steps of osteotomy or plate fixation will help to avoid possible injuries. (10.1007/s00167-016-4181-3)
• [L5] These kinematic changes should be considered when selecting the surgical technique for patients with medial osteoarthritis. (10.1007/s00167-007-0305-0)
• [L4] Inverse kinematic alignment accommodates a greater proportion (93%) of native limb alignment compared to adjusted mechanical alignment and restricted kinematic alignment, which require more adjustments to bring outlier knees within target zones. (10.1007/s00167-023-07326-x)
• [L5] Increasing PTS in a native knee with intact cruciate ligaments affected 6 DOF knee kinematics and decreased resultant forces in the medial and lateral meniscus by up to 35% in response to combined rotatory loads. (10.1002/ksa.12577)
• [L3] These kinematic changes correlate with poorer postoperative functional results, so that in patients with preexisting pathological patellar height a modification of the classical osteotomy technique should be discussed. (10.1177/2325967116s00039)
• [L5] This narrative review summarizes the complex patellofemoral joint biomechanics, the high variability of intraarticular tibia axial plane deformities, and current surgical strategies for tibial component rotational alignment. (10.1002/ksa.70485)
• [Paper] Based on the results, there is no evidence that the stability of the knee can be derived from its radiographic surface geometry. (10.1007/s00402-011-1345-y)
• [L4] A systematic use of the simulated measured resection mechanical alignment technique for total knee arthroplasty leads to many cases with imbalance. (10.1007/s00167-019-05562-8)
• [L5] By adhering to the principles of anatomic ACLR, surgeons can produce an appropriately sized and located graft for the individual patient, thereby best restoring native knee kinematics and maximizing function. (10.1016/j.arthro.2023.03.004)
• [L4] The procedure avoids the postoperative fixation problems of the simple transverse osteotomy and the difficulties of the Z-type operation. (10.2106/00004623-195537010-00022)
• [L5] Directing the plane of the osteotomy toward the 'safe zone' significantly reduces the risk of lateral cortex fracture compared to an osteotomy directed at a lower level. (10.1007/s00167-011-1706-7)
• [L5] PKF and DKF are distinct and constant anatomical structures of the lateral compartment of the knee, whose anatomical characteristics and their tensioning in IR presume a function of controlling rotational knee stability. (10.1007/s00402-020-03718-7)
• [L5] The finite element model reliably simulates patellofemoral kinematics and contact pressures. (10.1016/j.arthro.2021.08.008)
• [L5] Most revisions require a combined approach to fixation and a multi-zone strategy should be adopted. (10.1302/0301-620x.97b2.34144)
• [L5] Achieving an anatomic reduction is the essential, and often most formidable, step in osteosynthesis. (10.5435/jaaos-d-25-00956)
• [L4] An individualised osteotomy approach would be recommended to achieve careful preoperative planning that considers the location of the deformity and the resultant joint line. (10.1002/ksa.12141)
• [L4] A stepped staple was designed to allow both fragments to be fully engaged by the staple, addressing the discrepancy in continuity of the cortex created by wedge osteotomy. (10.2106/00004623-196951050-00022)
• [L5] The American College of Surgeons has played a far-reaching role in the development of better fracture therapy and rehabilitation through simplification of treatment, establishment of principles, and emphasis on education and the surgeon's responsibility for maximum restoration of function. (10.2106/00004623-195638050-00024)
• [L4] Early excision of the fragment is usually not necessary or advisable; correct initial diagnosis and treatment are important, particularly if the fracture fragment is large. (10.2106/00004623-198264040-00006)
• [L1] Frequently used systems for classification of tibial plateau fractures display moderate intra and inter-observer reliability. (10.1016/j.injury.2018.01.025)
• [L5] Careful analysis of all patient and fracture variables is helpful in determining the causes of fixation failure and maximizing the success of subsequent interventions. (10.5435/00124635-200910000-00007)
• [L4] The proposed classification system based on injury mechanism and morphological characteristics has instructive significance for preoperative evaluation of fracture features and soft tissue problems, and guides clinical management for better functional outcomes. (10.1186/s13018-019-1321-8)
• [L4] Low-angulation osteotomy resulted in a much higher percentage of union of the fracture than other types. (10.2106/00004623-195638010-00004)
• [L4] Careful observation of proximal fibular fractures following conservative treatment or in the post-operative period is important to avoid complaints that may arise at a later stage. (10.1007/s00167-004-0525-5)
• [L3] However, only fractures that are recalcitrant to closed reduction and immobilization or fractures in the non-compliant patient should be considered for this form of operative treatment. (10.2106/00004623-198769040-00013)
• [L5] The clinical performance of locked plates generally has been good, but several unique complications have been noted. (10.5435/00124635-200806000-00007)
• [L5] Nondisplaced fractures are amenable to nonsurgical management, while displaced fractures are managed with arthroscopic reduction and fixation. (10.5435/00124635-201007000-00002)
• [L5] Conservative management can be utilized for non-displaced fractures, but surgery should be considered for fractures involving substantial physeal or joint displacement. (10.1302/2058-5241.6.200042)
• [Paper] Femoral stress fractures require prompt diagnosis to prevent progression to complete or displaced fractures that necessitate aggressive treatment and carry a higher risk of chronic morbidity. (10.1016/j.csm.2005.08.003)
• [L4] Recognition of this pattern is necessary for successful treatment, as the tibial plafond fracture may be hidden on routine radiographs. (10.2106/00004623-198769030-00009)
• [L4] No complications were seen in type I fractures, while type II fractures resulted in delayed unions with correction loss in some cases. (10.1016/j.arthro.2011.06.034)
• [L5] Treatment selection depends on age, fracture pattern, associated injuries, and family factors to minimize complications and optimize outcomes. (10.5435/jaaos-d-22-00415)
• [Case_report] The diagnosis may be missed unless there is a high index of suspicion due to the small size of fracture fragments in growing children. (10.1007/s00167-004-0514-8)
• [L4] The new classification system for PPF of the femur following TKA considers fracture location and implant type, is easy to use, shows good interobserver reliability, and allows conclusions to be drawn on treatment recommendations. (10.1186/s12891-017-1855-z)
• [L4] The 10-segment classification might help to understand and quantify the posterior fracture line in order to balance pros and cons for different posterior surgical approaches to achieve the best result for the patient. (10.1007/s00264-017-3686-9)
• [L4] The indication for concomitant tibial tubercle osteotomy should be individualized according to each patient's specific anatomical and clinical characteristics. (10.1186/s13018-025-06646-7)
• [L4] Primary union was achieved in all patients with excellent clinical results regarding early joint movement, early weight-bearing, and rapid hospital discharge. (10.2106/00004623-198163080-00015)
• [L4] Dual plating is still indicated for certain cases, particularly old ununited fractures where intramedullary nailing is difficult, but is contraindicated in severely comminuted fractures requiring extensive dissection. (10.2106/00004623-196345020-00026)
• [Paper] Appropriate reduction of fracture fragments is the key for a good functional result. (10.1016/j.injury.2019.06.029)
• [L4] The technique allows early range-of-motion exercises and full recovery of motion, though traditional methods are preferred for most other fractures. (10.2106/00004623-197658040-00010)
• [Paper] Good clinical results can be expected in patients with long bone fractures if the principles of damage control are applied and complications are prevented through proper reduction, firm fixation, early soft tissue reconstruction, and early rehabilitation. (10.1016/j.injury.2017.04.016)
• [L3] The classification of 'simple fracture' and 'complex fracture' could guide decisions regarding the best surgical method for lesions in patients who have giant cell tumour around the knee with different degrees of fracture. (10.1186/s12891-022-06005-1)
• [L4] The accuracy of classification of tibia fractures in the Swedish Fracture Register is high, showing substantial agreement for AO/OTA type and moderate agreement for AO/OTA group, demonstrating the high reliability of the data for scientific analysis. (10.1016/j.injury.2015.11.002)
• [L5] Nonoperative procedures described in the manual have proven safer and less expensive than operative management for many fractures, and physiologically induced motion at the fracture site enhances osteogenesis. (10.2106/00004623-200211000-00042)
• [L5] By incorporating early functional exercise and ensuring strong internal fixation, patient prognosis could be enhanced. (10.1186/s12891-023-06946-1)
• [L4] Type I and II lateral hinge fractures in medial open-wedge high tibial osteotomy using a medial locked plate system and relatively conservative rehabilitation protocol with full weight-bearing walking commenced at 6 weeks postoperatively showed no radiologic changes or functional deterioration during midterm followup. (10.1016/j.arthro.2018.07.022)
• [L1] The indication for fibula plating should be made individually. (10.1302/2058-5241.6.210003)
• [L4] The study highlights the importance of postoperative rehabilitation programs and functional assessments for patients operated on for avulsion fracture of the tibia. (10.1007/s00167-003-0383-6)
• [L4] The new fixation device (TomoFix) allows stable fixation of the osteotomy without bone grafting. (10.1016/j.injury.2003.09.028)
• [L3] Invasive primary treatment seemed to prevent re-displacement and the need for re-operation of severe fractures was less common in the invasive treatment group than in the non-invasive treatment group. (10.1016/j.injury.2012.08.032)
• [L4] Patients have very high expectations of the surgical treatment of proximal tibial fractures, particularly regarding unrestricted return to sport, work, and painlessness. (10.1177/2325967120s00311)
• [L5] Non-union often results from a combination of adverse situations, and its prevention depends to a great extent on the application of well-established sound principles of fracture management. (10.2106/00004623-196547010-00015)
• [L4] The incidence of non-union can be decreased and many aspects of the unsolved fracture can be resolved by accurate reduction, accurately placed adequate internal fixation, and carefully supervised postoperative care. (10.2106/00004623-196244050-00006)
• [L4] All patients achieved fracture union, returned to pre-injury sports levels, and reported high satisfaction. (10.1007/s00167-006-0284-6)
• [L5] Preoperative CT scans may improve surgical planning by identifying secondary fracture lines poorly visualized on radiographs. (10.2106/jbjs.20.01478)
• [L4] Functional return was achieved in all survivors who could walk at the time of injury, with no non-unions reported. (10.2106/00004623-197658050-00004)
• [L5] Union of an ununited long-bone fracture is achieved surgically in four basic steps: host bone preparation, bone-graft application, fixation, and postoperative care. (10.2106/00004623-196547010-00016)
• [L1] The work group upgraded the recommendation for displaced fractures to moderate based on the potential for harm from nonsurgical treatment. (10.5435/jaaos-20-05-320)
• [L5] Timely surgery, optimized perioperative care including evidence-based advice for resumption of activities, and prospective data collection are the next steps to improve return to sport and work outcomes after knee osteotomy. (10.1016/j.arthro.2022.01.027)
• [L4] The procedure described was highly successful in achieving union of the fractured femur, stability, and relief of pain in all patients with one operation. (10.2106/00004623-197961070-00008)
• [L3] NDFF type 33 C fractures are at greater risk of unexpected return to the operating room. (10.1186/s13018-024-04796-8)
• [Paper] This procedure requires a set goal of definitive internal fixation at the time of initial external fixation. (10.1007/s00402-018-3049-z)
• [L3] Incidence of postoperative DVT in patients with isolated patella fractures is substantial. (10.1186/s13018-021-02240-9)
• [L4] The authors believe that this technique is a safe and promising alternative to traditional metallic fixation methods. (10.1186/s13018-021-02309-5)
• [L4] Both plate and nail fixation present unique benefits and pitfalls for treating periprosthetic fractures about a well-fixed prosthesis. (10.1016/j.otsr.2016.11.018)
• [L1] APC does not seem to improve pain relief, fracture incidence, and operative time when compared with PC. (10.1016/j.injury.2020.02.045)
• [L3] Over two-thirds of patients who sustained a tibial spine fracture were noted to have concomitant pathology on MRI, with 56.7% of injuries seen on MRI correlating to what was seen at the time of surgery. (10.1177/2325967123s00232)
• [Case_report] MRI is recommended for earlier diagnosis as plain radiographs may not visualize osteochondral fragments in skeletally immature patients. (10.1007/s00167-006-0090-1)
• [L3] Focusing on bone morphology allows surgeons to easily perform visual assessment using preoperative radiographs. (10.1186/s12891-022-05526-z)
• [L4] Overlooking these fractures significantly increased patient disability in one third of cases. (10.1186/s12891-018-2170-z)
• [L4] Definitive internal fixation of both bones yields the best results in almost all series. (10.1302/2058-5241.1.000042)
• [L5] Properly performed proximal tibial osteotomy yields satisfactory clinical results with appropriate patient selection. (10.2106/jbjs.i.00367)
• [L4] Regarding management, the main indication for fixation was large fragments, while smaller and poor-quality fragments are excised. (10.1007/s00167-022-07043-x)
• [L3] This study demonstrated that DVT occurred at a substantial rate (overall incidence of 13.8%) after osteotomy around the knee even with the use of prophylactic anticoagulant. (10.1007/s00167-020-06326-5)
• [L5] Computed tomography permits a more adequate assessment of the size of the fracture gap and the rotatory alignment of the fracture fragments as compared with plain radiography. (10.2106/00004623-198668050-00029)
• [L3] ARIF led to better radiological results than ORIF. (10.1007/s00167-016-4285-9)
• [L4] A variety of reliable skeletal maturity estimation systems using routine knee radiographs and MRI are described; orthopaedic surgeons can use these to inform preoperative workups without requiring additional hand radiographs. (10.5435/jaaos-d-24-00133)
• [L4] This study suggests that magnetic resonance imaging parameters of a healed osteochondral fragment and patients with satisfactory functional results correspond with arthroscopic evidence of fragment stability. (10.1177/0363546505274717)
• [L4] In questionable cases, arthrography will allow diagnosis before healing has progressed to the point of fixed deformity. (10.2106/00004623-197153080-00020)
• [L4] Double level osteotomy has excellent short-term results while maintaining physiological radiographic parameters. (10.1007/s00167-022-07247-1)
• [Case_report] CT scanning provided useful information for the planning of fixation with this complex, transitional fracture. (10.1016/j.injury.2015.02.003)
• [L4] The presence of residual radiolucency is an important contraindication to removing the plate. (10.2106/00004623-199072010-00028)
• [L2] Older patients and those with more severe fractures are also more likely to need total knee arthroplasty after repair of a tibial plateau fracture. (10.2106/jbjs.l.01691)
• [L5] The paper defines non-union as a fracture where reparative processes have ceased and outlines clinical, roentgenographic, and histological criteria for diagnosis. (10.2106/00004623-196446030-00023)
• [L4] Orthopaedic treatment for acute minimally displaced fractures is only indicated under strict MRI control, and suture fixation is the recommended strategy in other situations. (10.1007/s00167-015-3707-4)
• [L4] Posterolateral sheared tibial plateau fractures are rare but severe injuries that can be reset and fixed sufficiently to achieve excellent long-term postoperative recovery. (10.1186/s12891-021-04373-8)
• [L4] Total knee arthroplasty holds promise as a primary treatment for tibial plateau fractures in older persons with osteoporotic bone, offering immediate stability, early mobilization, and decreased reoperation rates. (10.5435/jaaos-d-16-00565)
• [Paper] Routine postoperative radiographs following tibial plateau ORIF resulted in minimal management change for patients. (10.1016/j.injury.2019.07.025)
• [L1] High tibial osteotomy offers satisfactory pain relief and functional outcome in selected patients with high activity demand. (10.1186/s12891-020-3177-9)
• [L3] The incidence of DVT is relatively high in patients with tibial fractures, with Age > 40.5 years, SII > 858.5, and D-dimer > 1.36 mg/L identified as high-risk factors. (10.1186/s13018-026-06738-y)
• [L2] Regardless of fixation type, approximately one-third of patients experienced moderate to severe pain at both time points during the study. (10.2106/jbjs.25.01485)
• [L5] The treatment method and postoperative protocol must be individualized, taking into account the fracture pattern, bone quality, and various patient factors. (10.5435/00124635-199711000-00004)
• [L4] Spontaneous reduction of fractures through epiphyseal plates without residual roentgenographic evidence probably occur at other joints as well and will be diagnosed only by manipulation under anesthesia. (10.2106/00004623-196244080-00012)
• [L3] However, there was a two-fold increased risk of complications after THA, including intraoperative fracture and VTE. (10.1302/0301-620x.106b4.bjj-2023-0968.r1)
• [Case_report] Most lesions of spontaneous osteonecrosis of the tibial plateau will heal spontaneously with protected weight-bearing, but once there is collapse or fracture of the plateau, arthroplasty may be indicated. (10.2106/00004623-198870030-00022)
• [L4] The developed protocol produced excellent results with all fractures uniting and good long-term functional outcomes. (10.2106/00004623-198466020-00013)
• [L3] Tibial plateau fractures decrease the function of the knee when compared with the contralateral side and to the preoperative condition, with bicondylar fractures associated with worse functional outcomes. (10.1002/ksa.12153)
• [L3] The risk of vascular injury is elevated in osteotomies around the knee, while patient weight, age, and deformity genesis do not influence complication rates. (10.1007/s00167-017-4566-y)
• [L4] Single-stage acute osseous correction with femoral shortening allowed correction of the osseous deformity without the need for soft-tissue lengthening, enabling the patient to return to work and dramatically improving his functional and psychological state. (10.2106/jbjs.i.00128)
• [L3] Significant improvements in quality of life and functional capabilities can be achieved following femoral osteotomy, though physical recovery requires an extended duration. (10.1016/j.arth.2025.06.066)
• [L2] However, based on current data it remains difficult to identify specifiers and determinants of an individual patient with specific fracture characteristics at risk for complications. (10.1016/j.injury.2020.04.021)
• [L4] The rate of infection was 6 per cent, delayed union 16 per cent, and malunion 4 per cent. (10.2106/00004623-198365070-00001)
• [L3] Ten-year survivorship free from aseptic loosening was 95% with reliable improvement in clinical function, though there was a high complication rate secondary to problems with balancing the knee. (10.1302/0301-620x.101b6.bjj-2018-1334.r2)
• [L2] A previous osteotomy is associated with decreased implant survival in subsequent TKAs, especially if a TKA component with stems and/or augmentations was used. (10.1002/ksa.70013)
• [L4] The use of the multiple-pin and plate technique causes an increase in morbidity. (10.2106/00004623-197860020-00027)
• [L3] Compared with UKA, complication rates were higher after osteotomy, with an overall surgical complication rate of 23.7%. (10.1177/23259671241257818)
• [L4] A mean postoperative complication rate of 7.6% was reported with a reoperation incidence of 14.3%, related primarily to hardware removal. (10.1177/03635465211012371)
• [L4] In this large contemporary series, there was a high incidence of reoperation (20%) within the first 2 years following plating of periprosthetic GT fractures, as well as a high rate of nonunion (39%) and hardware failure (28%). (10.1016/j.arth.2022.07.012)
• [L4] No difference in fragment survival was noted in skeletally mature versus immature patients, and the only independent risk factor identified for fixation failure was the number of previous operations. (10.1016/j.arthro.2019.08.050)
• [Paper] The complication rate is high and neither internal plating nor definitive external fixation has proven to be more effective overall. (10.1016/j.otsr.2013.06.016)

See Also

• Biomechanics
• Anatomy
• Anterior Cruciate Ligament

References

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