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Return to Sports Activity After Tibial Plateau Fractures: 89 Cases With Minimum 24-Month Follow-up
Tobias M. Kraus, Frank Martetschläger, Dirk Müller, Karl F. Braun, Philipp Ahrens, Sebastian Siebenlist, Ulrich Stöckle
and Gunther H. Sandmann
Am J Sports Med 2012 40: 2845 originally published online November 1, 2012
DOI: 10.1177/0363546512462564

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Return to Sports Activity
After Tibial Plateau Fractures
89 Cases With Minimum 24-Month Follow-up
Tobias M. Kraus,*y MD, Frank Martetschläger,z MD, Dirk Müller,z MSc,
Karl F. Braun,z MD, Philipp Ahrens,z MD, Sebastian Siebenlist,z MD,
Ulrich Stöckle,y MD, and Gunther H. Sandmann,z MD
Investigation performed at the Department of Trauma Surgery, Klinikum rechts der Isar,
Technical University Munich, Munich, Germany

Background: Tibial plateau fractures requiring surgery are severe injuries. For professionals, amateurs, and recreational athletes,
tibial plateau fractures might affect leisure and professional life.
Hypothesis: Athletic patients will be affected in their sporting activity after a tibial plateau fracture. Despite a long rehabilitation
time and program, physical activity will change to low-impact sports.
Study Design: Case series; Level of evidence, 4.
Methods: A total of 89 consecutive patients (age range, 14-76 years) were included in the study and were surveyed by a ques-
tionnaire. Inclusion criteria were surgical treatment of tibial plateau fractures between 2003 and 2009 with a minimum follow-up of
24 months. The sporting activity was determined at the time of injury, 1 year postoperatively, and at the time of the survey at an
average of 52.8 months postoperatively. The clinical evaluation included the Lysholm score, the Tegner activity scale, the activity
rating scale (ARS), and a visual analog scale (VAS) for pain perception. Fractures were classified and analyzed using both the
Arbeitsgemeinschaft für Osteosynthesefragen (AO) and the Schatzker classifications.
Results: At the time of injury, 88.8% of all patients were engaged in sports compared with 62.9% 1 year postoperatively and 73.0% at
the time of the survey. Of the professional or competitive athletes (n = 11 at the time of injury), only 2 returned to competition at the time
of the survey. The number of different sporting activities declined from 4.9 at the time of injury to 3.6 at the time of the survey (P \ .001).
The sports frequency and the activity duration per week, being 2.8 sessions and 4.5 hours at the time of injury, respectively, declined to
2.4 sessions and 3.8 hours (P \ .001 and P = .007, respectively) at the time of the survey, respectively. The Lysholm score (98.7 points
before accident) and the VAS for pain perception (0.2 before accident) illustrated significant declines to 76.6 points for the Lysholm
score and 2.6 for the VAS (P \ .001 and P \ .001, respectively) at the time of the survey. The high-energy traumas, Schatzker IV
to VI, had significant worse results in the clinical scores compared with the low-energy traumas (Lysholm, P \ .001; Tegner, P = .027).
Conclusion: The majority of patients could not return to their previous level of activity, and for patients playing competitive sports,
this injury can be a career ender. Overall, we noticed a postinjury shift toward activities with less impact. However, at the time of
the survey, 73% of all patients were engaged in sports.
Keywords: knee; tibial plateau fracture; sports injury; sports activity

Tibial plateau fractures are common injuries in impact many patients sustaining tibial plateau fractures are young,
sports such as downhill skiing or soccer.9,12,15 Because active, and in the middle of their working life, these injuries
may have an enormous effect on a person. The various frac-
ture patterns range from undislocated split fractures and
*Address correspondence to Tobias M. Kraus, BG Traumacenter
Tübingen, Eberhard Karls University, Schnarrenbergstrasse 95, D- slightly or severely displaced depression fractures to com-
72076 Tübingen, Germany (e-mail: kraus.tobias@gmail.com). plex comminuted fractures with severe destruction of the
y
Department of Traumatology and Reconstructive Surgery, BG Trau- joint lines and cartilage lesions. Therefore, individual treat-
macenter Tübingen, Eberhard Karls University, Tübingen, Germany. ment plans need to be applied to decide between nonopera-
z
Department of Trauma Surgery, Klinikum rechts der Isar, Technical
University Munich, Munich, Germany.
tive treatment, simple screw fixation, or plate fixation with
T.M. Kraus and F. Martetschläger contributed equally to this article. conventional or locking plates. Because the clinical outcome
The authors declared that they have no conflicts of interest in the after tibial plateau fractures is closely related to the quality
authorship and publication of this contribution. of reduction,19,28 each surgical technique must aim for an
anatomic reconstruction of the injured joint.
The American Journal of Sports Medicine, Vol. 40, No. 12
DOI: 10.1177/0363546512462564
However, despite modern techniques and new angular
Ó 2012 The Author(s) stable implants, an anatomic restoration of displaced or

2845
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2846 Kraus et al The American Journal of Sports Medicine

comminuted tibial plateau fractures can be challenging even same extremity (n = 3), bilateral tibial plateau fracture
for experienced trauma surgeons. While studies in the 1970s (n = 1), residence outside the country (n = 4), psychosis
and 1980s focused on nonoperative versus operative treat- or addictive disorder (n = 6), handicapped/walking disabil-
ment,§ recent studies focused on open reduction versus ity before the tibial plateau fracture (n = 5), severe pre-
arthroscopically assisted treatment7,11,13 and new angular existing condition (n = 3), age over 76 years on the day of
stable implants25 or bone substitution material.4,26 Only surgery (n = 19), re-osteosynthesis after initial treatment
very few studies have addressed the knee function in the elsewhere (n = 9), and pathological fractures (n = 1). Three
long-term follow-up,28,38 and to our knowledge, no study patients were excluded after high tibial osteotomy during
has considered the sequelae after tibial plateau fractures the follow-up period to correct a varus malalignment, and
with regard to return to sports or heavy work. another 3 patients were excluded after a conversion to total
Therefore, the aim of this study was to determine the knee arthroplasty during the follow-up period.
sporting abilities of patients after operative treatment of tibial One patient died during the follow-up period, and 14
plateau fractures. In particular, we focused on participation patients were lost to follow-up. Six patients refused to par-
in different types of sports and their intensity. We hypothe- ticipate in this study. The remaining 89 patients were
sized that despite good clinical results, the majority of included in this study (81.7% of all patients fulfilling the
patients would give up their ambitious sporting activity and inclusion criteria) (Figure 1). All fractures were classified
that the sports disciplines would change to low-impact sports. according to the Arbeitsgemeinschaft für Osteosynthese-
fragen (AO) and the Schatzker32 classifications.

MATERIALS AND METHODS Operative Techniques

Data Acquisition Patients were placed in a supine position with the ability to
bend the knee to 90° of flexion. For unicondylar lateral
Patients who underwent surgical treatment for a tibial pla- fractures, a standard straight lateral approach was used.
teau fracture were surveyed by a questionnaire to determine After arthrotomy, the knee joint was inspected for fracture
their sporting activity. As previously described by Naal patterns and injuries of the ligaments, meniscus, and car-
et al26 and Salzmann et al,30 the survey included a sports tilage. The anterior horn of the meniscus was released for
and activity questionnaire for assessment at the time of better exposure and reinserted with absorbable sutures
injury, 1 year postoperatively, and at the time of the survey after fixation of the fracture.
in 32 different sports and recreational activities. The ques- After anatomic reduction, the fractures were fixed with
tionnaire also inquired about the patient’s overall satisfaction screws and angular stable L- or T-plates for buttressing.
with the surgery (very satisfied = 1, satisfied = 2, partially In isolated split fractures, reduction was usually controlled
satisfied = 3, not satisfied = 4) and about the use of any arthroscopically, and fixation was performed using cannu-
pain medication during sports activity (regularly, occasion- lated 7.0- or 7.3-mm titanium screws. In impaction frac-
ally, never). The modified Lysholm score18,34 and a visual tures, the fragments were elevated through the fracture or
analog scale (VAS) for pain (0 representing ‘‘no pain’’ and through a cortical window. If necessary, remaining bony
10 representing ‘‘maximal imaginable pain’’) were used to defects were augmented with autologous cancellous bone
assess clinical outcomes. The Tegner activity scale34 and harvested from the iliac crest or with bone substitution
the activity rating scale (ARS)22 were used to determine material (Chronos, Synthes Inc, Umkirch, Germany). The
activity levels. All of these scores were obtained at 3 different fracture was finally fixed using a buttress plate. In bicondy-
points in time: at the time of injury, 1 year postoperatively, lar fractures, an additional medial approach was used for
and at the time of the survey, 52.8 6 23.1 months (4.4 years) sufficient reduction and for addressing the medial fragment.
postoperatively. The study protocol was approved by our local For postoperative rehabilitation, weightbearing was lim-
ethics committee (IRB 5178/11). ited to 20 kg for 6 weeks after surgery. Knee flexion was lim-
ited to 60° in cases of meniscal reinsertion. Weightbearing
Inclusion and Exclusion Criteria was gradually increased from week 6 to week 12 after radio-
graphic evaluation 6 weeks postoperatively. Full weight-
Between January 2003 and April 2009, a total of 172 bearing was initiated at 12 weeks after surgery.
patients with tibial plateau fractures were treated opera-
tively at our department (level I trauma center); 109 frac-
Statistics
tures fulfilled the inclusion criteria: operatively treated
tibial plateau fractures in patients with closed epiphyseal Statistical analysis was performed using the software pack-
cartilage with a minimum follow-up of 24 months. The age SPSS (Version 19, IBM Corp, Somers, New York). All
exclusion criteria for this study included nonoperatively data were tested for normal distribution. Afterward, nor-
treated tibial plateau fractures and patients with multiple mally distributed data were compared using t tests. Nonnor-
traumas or concomitant injuries in case the tibial plateau mally distributed data were compared using Wilcoxon
fracture was not the most severe injury (n = 5). Further- signed-rank and Mann-Whitney U tests (paired/unpaired).
more, we excluded patients with attendant injuries in the Group data were compared using 1-way analysis of variance.
Unless otherwise stated, descriptive results were demon-
§
References 2, 3, 6, 16, 24, 31, 32, 36. strated as the mean 6 standard deviation. The level of

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Vol. 40, No. 12, 2012 Return to Sports After Tibial Plateau Fractures 2847

TABLE 1
172 patients with operatively treated tibial plateau fractures Patient Demographicsa
(Jan 2003 to April 2009)
Demographics Value

No. of patients 89
No. of fractures 89
Male, n (%) 44 (49.4)
109 patients 63 patients excluded Female, n (%) 45 (50.6)
fulfill inclusion criteria (see exclusion criteria Follow-up, mean 6 standard 52.8 6 23.1 (24-97)
for details) deviation (range), mo
Age at operation, mean 6 standard 47.2 6 13.6 (14-76)
deviation (range), y
95 patients 14 patients Fracture: AO classification, n (%)
contacted lost to follow-up A1 0 (0)
A2 1 (1.1)
A3 2 (2.2)
B1 10 (11.2)
6 patients refused participation B2 18 (20.2)
B3 34 (38.2)
C1 2 (2.2)
C2 2 (2.2)
C3 20 (22.5)
89 patients are included in the study Fracture: Schatzker classification, n (%)
(81.7% recall rate) I 9 (10.1)
II 32 (36.0)
III 18 (20.2)
Figure 1. Patient flow diagram. IV 4 (4.5)
V 3 (3.4)
VI 23 (25.8)
significance was set at P \ .05 for all tests; all confidence
a
intervals are calculated for a 95% confidence level. AO, Arbeitsgemeinschaft für Osteosynthesefragen.

system (LISS) plates, and 1 (1.9%) was a conventional

RESULTS plate.
Bone defects had to be addressed in 39 cases (43.8% of
Demographics all fractures); the bone substitute was chosen according
to the surgeon’s preference: b-TCP ceramic bone substitute
A total of 89 questionnaires were collated for evaluation
(Chronos, Synthes Inc) was used in 24 fractures (61.5% of
(81.7% recall rate). The average postoperative follow-up
all defects), cancellous bone from the iliac crest was used in
was 52.8 6 23.1 months, or 4.4 years (range, 24-97
9 fractures (23.1% of all defects), donor allogenous femoral
months). The mean age at the time of surgery was 47.2
head spongiosa was used in 5 fractures (12.8% of all
6 13.6 years (range, 14-76). The study cohort consisted of
defects), and a combined procedure (allogenous bone 1
44 men (49.4%) and 45 women (50.6%) (Table 1).
Chronos [Synthes Inc]) was performed in 1 patient (2.6%).

Cause of Accident and Operative Treatment Sports and Recreational Activities

In our series, 54.0% of all tibial plateau fractures were Throughout the year before the injury, 88.8% of the
caused by sports accidents. Downhill skiing was the patients were engaged in an average of 4.9 6 2.6 different
most common sporting accident, with 31.5% of all cases disciplines (range, 1-12), and a total of 12.4% were engaged
(Figure 2). Traffic accidents (20.2%), especially motorcy- in competitive or professional sports. One year postopera-
cle accidents (11.2%), and falls (17.9%) were other com- tively, 62.9% of the patients were engaged in an average
mon causes of tibial plateau fractures. The severity of of 3.0 6 1.8 different sports and recreational disciplines
the tibial plateau fractures correlated with the cause of (range, 1-8), demonstrating a significant decrease (P \
the accident (Figure 2). .001). At the time of follow-up at a mean of 52.8 months
In the evaluated 89 patients, 63 fractures (70.8%) were after surgery, 73.0% of the patients were engaged in an
treated with open reduction and internal fixation, 21 frac- average of 3.6 6 2.0 different sports and recreational disci-
tures (23.6%) were arthroscopically assisted, and 5 mini- plines (range, 1-9), again illustrating a significant increase
mally displaced fractures (5.6%) were treated with (P \ .001) when compared with physical activity 1 year
percutaneous screws. Plates were used in 53 fractures postoperatively.
(59.6% of all fractures); of these plates, 50 (94.3%) were The tibial plateau fracture marked the end of a profes-
angular stable, 2 (3.8%) were less invasive stabilization sional sports career in 9 of 11 competitive athletes

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2848 Kraus et al The American Journal of Sports Medicine

Other cause of 100%

accident: 7 (7.9%) 90%
Downhill skiing:
80%
28 (31.5%)
Motorcycle accident: 70%
10 (11.2%)
60%
50%
40%
Traffic accident:
8 (9.0%) 30%
20%
Fall from height 10%
(eg, ladder): 0%
6 (6.7%) Lifetime Before fracture 1 year At time of survey
Sports, other: after fracture (4.4 y)
Fall 9 (10.1%) Professional or competitive sports Recreational sports
(eg, domestic
No sports participation
accident): Bicycle accident:
10 (11.2%) 11 (12.4%)
Figure 3. Level of sports activity: competitive, recreational,
Figure 2. Cause of the accident in percentages. and no sports.

(81.8%); 1 of 11 patients (9.1%) returned to competitive or Rowing

professional sports 1 year after surgery, and 2 of 11 patients Waterskiing
Sailing
(18.2%) participated in competitive or professional sports at Dancing
the time of the survey (Figure 3). In our series, 4 patients Horseback riding
Martial arts
(4.5%) had to give up their job or change jobs to less physi-
Volleyball
cally demanding work as a consequence of their knee injury. Basketball
Patients’ participation in sports decreased after the injury Handball
Soccer
along with the frequency of sporting activity, 2.8 6 1.6 Badminton
sessions/week (range, 0.5-7), with an average duration of Table tennis
4.5 6 3.7 hours/week (range, 1-22) before the injury. One Tennis (doubles)
Tennis (singles)
year postoperatively, the sports frequency and the duration Golf
of activities declined significantly to 2.2 6 1.3 sessions/ Ice skating
Ice hockey
week (range, 0.5-6; P \ .001) and to 3.4 6 2.9 hours/week Snowboarding
(range, 0.5-15 h/wk; P = .011), respectively. At the time of Cross-country skiing
follow-up (52.8 months), the sports frequency and the dura- Downhill skiing
Aqua fit
tion of activities increased significantly when compared Gymnastics
with 1 year after injury to 2.4 6 1.4 sessions/week (range, Aerobics
Fitness training
0.5-7; P = .003) and to 3.8 6 2.8 hours/week (range, 0.5-15; Swimming
P = .026), respectively (Figure 3). Mountain biking
Distribution patterns among the top 5 cited sports activ- Cycling
Mountaineering/climbing
ities changed from the time of injury to postoperative peri- Mountain hiking
ods. Patients switched from higher-impact sports such as Inline skating
Jogging
downhill skiing (58.4% before accident) and jogging Nordic walking
(28.1% before accident) to lower-impact sports such as Nor-
70.00 0.00 70.00
dic walking (22.5% 1 year after fracture). Cycling remained
the number 1 cited activity; however, the amount of Before fracture 1 y after surgery At time of survey
patients engaged in cycling decreased from 78.7% to
65.2% (Figure 4). Figure 4. Organization of sports activities at the time of
injury (left), 1 year after surgery, and at the time of the survey
Clinical Outcome (right) in percentages of all patients.

The overall satisfaction with surgery, on a scale from 1 required regular pain medication. The VAS for pain
(very satisfied) to 4 (not satisfied), averaged 1.6 6 0.9 increased significantly from 0.2 6 0.5 (range, 0-3) before
(range, 1-4); 57.3% of patients were very satisfied, 31.5% the injury to 3.7 6 2.7 (range, 0-10) 1 year after the frac-
were satisfied, 4.5% were partially satisfied, and 6.7% ture (P \ .001) and decreased again significantly to 2.6 6
were not satisfied with the outcome. Overall, 87.6% of 2.4 (range, 0-9) at the time of the survey (52.8 months)
the patients required no pain medication to play sports (P \ .001). The Lysholm score decreased significantly
or recreational activities, 12.4% of the patients required from 98.7 6 3.6 (range, 80-100) before the injury to 66.2
occasional pain medication, and 4.5% of the patients 6 24.1 (range, 0-100) 1 year after the fracture (P \ .001)

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Vol. 40, No. 12, 2012 Return to Sports After Tibial Plateau Fractures 2849

TABLE 2
Arbeitsgemeinschaft für Osteosynthesefragen (AO) Classification: Specific Resultsa

Type A Type B Type C All

No. of participants 3 62 24 89
Mean age, y 56 47 46 47
Mean follow-up time, mo 91 52 50 53
Change in VAS 1.2 (0.5 to 1.9) 2.0 (1.5 to 2.5) 3.7 (2.7 to 4.7) 2.4 (2.0 to 2.9)
Loss in Lysholm score 24.0 (–19.1 to 67.1) 15.6 (11.7 to 19.4) 39.0 (28.6 to 49.3) 22.2 (17.8 to 26.5)
Loss in number of different sports activities 0.33 (–1.1 to 1.8) 1.3 (0.8 to 1.7) 2.6 (1.5 to 3.7) 1.6 (1.2 to 2.1)
Loss in sports activities per week 0.0 (—) 0.7 (0.4 to 1.0) 0.9 (0.4 to 1.5) 0.7 (0.5 to 1.0)
Loss in sports hours per week 0.0 (—) 1.1 (0.5 to 1.7) 1.7 (0.1 to 3.2) 1.2 (0.6 to 1.8)
Loss in ARS 0.0 (—) 3.6 (2.5 to 4.7) 5.8 (3.9 to 7.6) 4.0 (3.1 to 5.0)
Loss in Tegner score 0.7 (–0.8 to 2.1) 1.3 (0.9 to 1.6) 2.3 (1.7 to 3.0) 1.5 (1.2 to 1.9)
Self-reported satisfaction, 1 (best) to 4 (worst) 1.33 (–0.1 to 2.77) 1.6 (1.4 to 1.8) 1.7 (1.2 to 2.1) 1.6 (1.4 to 1.8)

a
Values are expressed as mean (95% confidence interval). VAS, visual analog scale; ARS, activity rating scale.

and improved again to 76.6 6 21.0 (range, 14-100) at the 18 (20.2%) lateral depression type III fractures, 4 (4.5%)
time of the survey (52.8 months) (P \ .001). medial depression type IV fractures, 3 (3.4%) bicondylar
Activity levels according to the Tegner scale declined sig- type V fractures, and 23 (25.8%) type VI fractures with
nificantly from 5.2 6 1.6 (range, 1-9) at the time of injury to diaphyseal discontinuity. It has to be noted that type II
3.0 6 1.8 (range, 0-9; P \ .001) 1 year postoperatively and fractures with a lateral split and a depression caused
increased again to 3.6 6 1.7 (range, 0-9; P \ .001) at the poorer results than isolated lateral split (type I) or lateral
time of the survey. Scores of the ARS decreased significantly depression (type III) fractures. The bicondylar fractures,
from 6.9 6 4.7 (range, 0-16) before the accident to 2.0 6 3.3 type V and type VI (29.2% of all fractures), showed the
(range, 0-16) 1 year postoperatively (P \ .001) and increased worst patient outcomes (Table 3). For further analysis,
again to 2.9 6 3.8 (range, 0-16; P \ .001) at the time of the we divided the patients into a low-energy trauma group
survey. Patients stated that after a tibial plateau fracture, (Schatzker I-III) and a high-energy trauma group
their sporting ability had declined significantly by –0.96 6 (Schatzker IV-VI).5 We found significantly worse results
0.7 points (range, –2 to 0; P \ .001) on a scale from –2 to 12. in the high-energy traumas compared with the low-energy
traumas in the clinical scores such as the Lysholm score (P
\ .001) and the Tegner score (P = .027) (Figure 5).
AO and Schatzker Classifications: Specific Results
Of 89 tibial plateau fractures, 3 (3.4%) fractures were Subgroup Analysis: Age, Hardware Removal,
graded as type A fractures according to the AO classifica- and Ligamentous Injuries
tion, 62 (69.7%) as type B fractures, and 24 (27.0%) as
type C fractures (Table 2). There was no statistically signif- For subgroup analysis, the collection of patients was
icant difference between type A and B fractures concerning divided with regard to the age at the time of injury as fol-
the clinical outcome (measured by the Lysholm score [P = lows: group I, \30 years of age (n = 9); group II, 30 to 60
.354] and the VAS [P = .498]) or the return to sports (mea- years of age (n = 63); and group III, .60 years of age
sured by the Tegner score [P = .458], the ARS [P = .152], (n = 17). In all groups, the clinical outcome compared
and the sports-specific questionnaire). with the preinjury value decreased as well as the activity
The bicondylar type C fractures showed significant and intensity of sports both 1 year postoperatively and at
greater losses in the Lysholm score (P \ .001) compared the time of the survey. There were no significant differen-
with type A or B fractures. We also found a significantly ces between the groups.
greater pain level in the VAS (P = .001) for type C fractures Hardware removal was recommended after a period of
compared with type A/B fractures and a significant reduc- 12 months. Removal was performed in 60 patients
tion of the Tegner score (Tegner score of –2.3 points at (67.4%) at an average of 14.4 6 6.5 months after surgery
follow-up compared with preinjury level; P = .002). Despite (range, 5-38). Twenty-nine patients refused implant
pain and reduced clinical function, patients with type C removal. Subdividing the patients into 2 groups with and
fractures continued to participate in sports and showed without hardware removal, there was no difference in
no significant differences concerning the sessions (P = the distribution of fracture patterns; in 67%, hardware
.428) and duration of sports activity (P = .357) in compari- was removed in both the high-energy and low-energy
son to the type A/B fractures. A significant change was trauma groups. There were no differences in the VAS
observed in the number of different sports activities (P = (P = .893) and the Lysholm score (P = .964). However,
.004) (Table 2). the patients who had undergone hardware removal had
Classifying the fractures by Schatzker,32 our study significantly worse results in the Tegner score (P = .028)
group comprised 9 (10.1%) lateral split type I fractures, and reported a worse outcome in self-reported satisfaction
32 (36%) lateral split with depression type II fractures, (1.72 vs 1.38; P = .083).

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2850 Kraus et al The American Journal of Sports Medicine

TABLE 3
Schatzker Classification: Specific Resultsa
I II III IV V VI All

No. of participants 9 32 18 4 3 23 89
Mean age, y 43 49 46 46 59 47 47
Mean follow-up, mo 53 48 63 41 34 55 53
Change in VAS 2.2 (0.7 to 3.8) 2.1 (1.3 to 2.9) 2.0 (0.9 to 3.1) 1.4 (0.2 to 2.6) 3.2 (1.3 to 5.1) 3.5 (2.4 to 4.6) 2.4 (2.0 to 2.9)
Loss in Lysholm score 12.2 (3.7 to 20.8) 18.0 (12.0 to 24.1) 13.9 (6.2 to 21.6) 9.25 (0.7 to 17.8) 33.7 (–18.7 to 86.0) 39.0 (28.4 to 49.5) 22.1 (17.8 to 26.5)
Loss in number of different 0.7 (0.0 to 1.3) 1.6 (0.8 to 2.3) 1.0 (0.2 to 1.8) 0.8 (0.8 to 2.3) 1.0 (–1.5 to 3.5) 2.7 (1.6 to 3.9) 1.6 (1.2 to 2.1)
sports activities
Loss in sports activities 0.5 (0.7 to 1.7) 0.9 (0.4 to 1.4) 0.4 (0.2 to 1.0) 0.1 (0.3 to 0.5) 0.7 (0.8 to 2.1) 0.9 (0.3 to 1.5) 0.7 (0.5 to 1.0)
per week
Loss in sports hours 0.6 (0.3 to 1.5) 1.6 (0.5 to 2.7) 0.5 (0.1 to 1.1) 0.0 (—) 1.0 (–1.5 to 3.5) 1.7 (0.1 to 3.3) 1.2 (0.6 to 1.8)
per week
Loss in ARS 3.3 (0.4 to 7.1) 4.4 (2.8 to 6.0) 2.3 (0.6 to 4.0) 2.5 (–3.5 to 8.5) 7.0 (–5.9 to 19.9) 5.1 (3.2 to 7.0) 4.0 (3.1 to 5.0)
Loss in Tegner score 1.2 (0.1 to 2.2) 1.6 (1.0 to 2.1) 0.8 (0.3 to 1.4) 0.5 (–1.1 to 2.1) 1.5 (–1.8 to 4.8) 2.4 (1.7 to 3.1) 1.5 (1.2 to 1.9)
Self-reported satisfaction, 1.7 (1.1 to 2.2) 1.7 (1.4 to 2.0) 1.4 (1.1 to 1.8) 1.5 (0.6 to 2.4) 1.7 (0.2 to 3.1) 1.6 (1.2 to 2.1) 1.6 (1.4 to 1.8)
1 (best) to 4 (worst)

a
Values are expressed as mean (95% confidence interval). VAS, visual analog scale; ARS, activity rating scale.

100 and 1 lateral collateral ligament lesion. Analyzing the sus-

tained ligamentous injuries, we found no statistical signif-
90 icance in comparison to the group without ligamentous
injuries in the Tegner score (P = .693) or Lysholm score
80 (P = .374) nor in the sporting activity (h/wk) (P = .365).

70
DISCUSSION
60
Several studies have shown that an anatomic reduction of
50 the tibial plateau and thereby a reconstruction of the axis
are predictors for a good clinical outcome.19,28 Marsh et al21
40 found in their review that the cartilage injury sustained at
the time of injury may be the most important factor for the
30 development of posttraumatic osteoarthritis. Because most
studies in the literature focus on the long-term outcomes
20 and prevention of osteoarthritis, little data exist concern-
ing sporting ability and the return to sporting activity after
10
tibial plateau fractures. However, the expected outcome in
terms of possible sporting activity after tibial plateau frac-
0
tures is important to discuss, as patients today demand full
Schatzker I-III Schatzker IV-VI
functionality after an injury.
The results from the present study support the hypoth-
Lysholm before fracture Lysholm at time of survey
esis that tibial plateau fractures have a great effect on
Tegner (x10) before fracture Tegner (x10) at time of survey
patients’ sporting activity. Despite good clinical results,
patients were likely to give up their ambitious sporting
Figure 5. Clinical scores: Lysholm score and Tegner score. activity and switch to lower impact sports. Furthermore,
Scores at the time of injury and at the time of the survey our data support that high-energy traumas (Schatzker
with respect to low-energy (Schatzker I-III) and high-energy IV-VI) lead to worse results than low-energy traumas
(Schatzker IV-VI) traumas. (Schatzker I-III), which has been reported previously.5
In contrast to other studies, where typically road acci-
dents were the reason for tibial plateau fractures,19,28 we
In 14 patients (15.7%), meniscal injuries were found. found that 54.0% of our cases were sports accidents. Within
The meniscal injuries were either sutured or reinserted our high number of sports accidents, we found a notable pro-
in cases of meniscal root injuries. Ligamentous injuries portion being caused by downhill skiing accidents (n = 28;
were found in 13 patients (14.6%). Among these injuries, 31.5%). These findings might be related to the geographic
there were 4 bony anterior cruciate ligament (ACL) lesions, location of Munich being 100 km from the Alps. While
4 ligamentous ACL lesions, 2 combined ACL/posterior cru- most skiing injuries were AO type B fractures (B fractures,
ciate ligament lesions, 2 medial collateral ligament lesions, 78.6%; C fractures, 21.4%), motorcycle accidents as

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Vol. 40, No. 12, 2012 Return to Sports After Tibial Plateau Fractures 2851

high-energy traumas resulted in a higher rate of AO type C outcome of bicondylar fractures has already been demon-
fractures (B fractures, 60.0%; C fractures, 40.0%). strated by several studies.35,38
There was some debate about the incidence of tibial pla- In most of the prior studies on tibial plateau fractures, the
teau fractures due to skiing in the 1980s and 1990s. While return-to-sports aspect was only evaluated incidentally and
some authors reported a low incidence of tibial plateau among a limited number of patients. A recent study by Sie-
fractures, approximately 1.5% of all skiing injuries,23 other gler et al,33 reviewing 21 patients with Schatzker I to III frac-
authors reported increasing numbers.29 It should be noted tures, measured the return to sports of patients using the
that these studies from the 1980s were based on a rather Tegner score only. They concluded that 57% of the patients
small number of patients. However, Wasden et al37 could returned to sports within a mean of 14 months, having no
show that skiers are likely to suffer from injuries of the data of the preinjury level of activity. Holzach et al13 reported
lower extremity, which might be caused by the introduc- that 14 of 16 patients returned to the previous level of activ-
tion of carving skis and a faster, more aggressive riding ity in a study with AO type B fractures after a mean follow-
style. Our study also supports the reported low occurrence up of 1 to 6.5 years. Nevertheless, assessment of the sporting
of tibial head fractures in snowboarding,1,37 including only activity has not been very meticulously carried out, only cat-
1 snowboarder compared with 28 skiers in this study. egorizing the aspect of return to sporting activity as full, with
As 54.0% of all accidents were sporting accidents, and restriction, very reduced, and none.
76.4% of our patients engaged in sports were recreational- Gill et al11 published a series of 25 tibial plateau fractures
level athletes, our data suggest that our patients with in skiing and reported that 84% of the patients returned to
a mean age of 47.2 years at the time of injury were typical full sporting activity. However, the methods used to measure
weekend warriors.17 This type of athlete usually works from the return to full sporting activity remain unclear.
9 o’clock to 5 o’clock or longer during the week and only finds In a 1997 analysis, Houben et al14 divided their 46 patients
time for sports on the weekends. They have high ambitions into 3 groups based on follow-up time: group I had a follow-up
but usually lack in fitness and skills, resulting in severe sport- \37 months, group II had a follow-up of 37 to 71 months, and
ing accidents, such as tibial plateau fractures. As these group III had the longest follow-up .71 months. They con-
patients are in the middle of their working life, and with cluded that patients who were between 37 to 71 months out
a long period of rehabilitation, tibial plateau fractures may of surgery had the best results. Patients in group I were still
have a big socioeconomic impact: 4 of our patients (4.5%) in their rehabilitation period, and group III patients, as con-
had to give up or change their job after the tibial plateau frac- cluded by the authors, already had problems with the onset
ture. In our study, the tibial plateau fracture marked the end of posttraumatic osteoarthritis. These findings are compara-
of professional sports careers in 9 of 11 cases (81.8%). This ble with the results of our study, showing better results at
high number illustrates the enormous effect of a tibial plateau the time of the survey as compared with the 1-year results,
fracture on knee joint function. In the professional athlete, although the differences are statistically not significant in
not only knee function but also muscular atrophy have to all evaluated scores. Comparable with a study published by
be addressed in a rehabilitation program. Implementation Cassard et al8 in 1999, the data of the present study suggest
of more specific rehabilitation programs as they are already that loss of function and symptoms of early osteoarthritis
used in cartilage surgery10,27 may help professional athletes might occur earlier than 71 months after injury.
to return to their previous sports level more frequently. Interestingly, the patient group that declined implant
In the current study, tibial plateau fractures have removal was more satisfied with the clinical outcome
shown not only to have a great effect on the sporting activ- than the hardware removal group. As there were no differ-
ity of professional athletes but also on the activity of the so- ences in the VAS and the Lysholm score, the limitation of
called weekend warriors. These patients, representing the the sporting activity measured in the Tegner score may be
most patients in this study, also had to adapt their sporting blamed for the reduced satisfaction.
activity. Whereas 58.4% of our cohort were downhill skiers The present study has some limitations including the
1 year before the accident, only 23.6% of the patients midterm outcomes reported, which do not allow us to
returned to the slopes at the time of the survey. More draw any conclusions regarding sporting activities at a later
severe injuries such as type C fractures resulted in a reduc- time point or the development and progression of knee oste-
tion in high-impact sports as expected. Furthermore, we oarthritis. A second limitation of the study is its retrospec-
noticed that patients avoided the type of sports in which tive design. Patients were asked for sports activities and
the accident had happened. Besides the functional limita- clinical information that, in some cases, dated back several
tion of their knee joints, many of our patients stated that years. Also, 20 patients of 109 (18.3%) in the present study
they have given up impact sports because they wanted to were lost to follow-up or declined participation, raising the
prevent sporting injuries and additional adverse effects possibility of some selection bias. Furthermore, we could
on their knee in the future. not perform a subgroup analysis for the ligamentous inju-
In agreement with results reported by Markhardt ries because the number of cases was too low.
et al,20 the return to sports is dependent on the type of frac- However, we present the results of 89 patients and their
ture. Low-energy tibial plateau fractures classified as return to sports at a mean follow-up of 52.8 6 23.1 months
Schatzker I to III5 had significantly better outcomes con- postoperatively. Sports activity was assessed by the use of
cerning the decline of sports disciplines, sports per week, specially designed questionnaires and several widely
and in the ARS and the Tegner score compared with the accepted activity scores. To our knowledge, this study is
high-energy Schatzker IV to VI fractures. The poorer the largest series to date, with the longest follow-up,

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2852 Kraus et al The American Journal of Sports Medicine

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CONCLUSION
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