CT-based three-dimensional virtual reduction with implant templating for tibial plateau fractures involving the posterolateral region: a retrospective cohort study of early postoperative CT reduction quality

Tibial plateau fractures involving the posterolateral region remain technically challenging because of their deep location, limited surgical exposure, and surrounding anatomical constraints. This study investigated whether CT-based three-dimensional virtual reduction with implant templating was associated with better early postoperative CT reduction quality than conventional CT-based planning. This single-center retrospective cohort study included 91 patients surgically treated for tibial plateau fractures involving the posterolateral region between July 2021 and March 2025. Thirty-five patients were planned using CT-based three-dimensional virtual reduction with implant templating, whereas 56 were planned using conventional CT-based planning. The primary outcomes were residual posterolateral articular step-off and gap on CT within 7 days after surgery. Exploratory secondary outcomes included documented planning-to-implementation concordance, perioperative outcomes, early complications, reoperation, 3-month pain and knee flexion range of motion, and 12-month Knee Injury and Osteoarthritis Outcome Score (KOOS) subscale scores. Multivariable linear regression adjusted for prespecified covariates was used to assess the primary outcomes. The three-dimensional planning group had smaller residual step-off (2.80 [interquartile range, 2.40–3.10] vs. 3.55 [3.00–4.10] mm; P < 0.001) and gap (2.97 ± 0.63 vs. 3.63 ± 0.73 mm; P < 0.001) in the posterolateral quadrant than the conventional planning group. These associations remained after adjustment (step-off: β = −0.75 mm, 95% confidence interval [CI] − 1.08 to − 0.41; gap: β = −0.61 mm, 95% CI − 0.92 to − 0.30; both P < 0.001). Exploratory outcomes showed higher documented fixation-strategy concordance, lower 3-month pain scores, and greater knee flexion ROM in the three-dimensional planning group. No clear between-group differences were observed in surgical-approach concordance, perioperative outcomes, early complications, reoperation, or 12-month KOOS subscale scores. In this retrospective cohort, CT-based three-dimensional virtual reduction with implant templating was associated with modestly smaller residual posterolateral articular step-off and gap on early postoperative CT than conventional CT-based planning. No clear between-group differences were observed in 12-month KOOS subscale scores, and prospective multicenter validation is needed.