Lack of consensus in surgical decision-making for borderline lateral tibial plateau fractures: A multinational survey study

Background Despite advances in classification systems and imaging, there remains no clear consensus regarding the degree of articular depression that warrants surgical management in lateral tibial plateau fractures. We aimed to quantify inter-rater agreement in surgical decision-making for borderline unicondylar split-depression (Schatzker II) fractures and identify factors influencing treatment recommendations. Methods A cross-sectional survey was distributed to orthopaedic trainees and staff. Six borderline Schatzker II tibial plateau fractures (articular depression ≤7.5 mm, condylar widening <5 mm) were presented with radiographs and CT imaging. Respondents indicated whether they would offer surgery and ranked factors influencing their decision (fracture pattern, depression, malalignment, instability, age, activity level, arthritis, and comorbidities). Cases were categorized as high (>80%) or low (<80%) agreement. Results A total of 189 respondents completed the survey. Agreement to operate ranged from 51% to 99%. Three cases reached consensus: two were treated surgically (7.5 mm/3.5 mm and 3.0 mm/1.0 mm depression/widening), and one non-operatively (3.2 mm/0 mm). The remaining three cases (1.0–3.2 mm depression; 0–2.5 mm widening) demonstrated low agreement (50–58.5%). Articular depression (92.9%) and fracture pattern (63.7%) were the most frequently cited decision-making factors. Training level did not significantly influence operative recommendations; however, trauma-trained surgeons more frequently emphasized depression, malalignment, and instability. Conclusion Substantial variability exists in surgical decision-making for borderline lateral tibial plateau fractures. Mechanical instability and malalignment drive agreement, whereas small degrees of articular depression generate disagreement. Evidence-based thresholds are needed to guide operative indications.