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. 2025 Oct 14;15:35885. doi: 10.1038/s41598-025-19687-z

Biomechanical comparison between rim plating and posterior buttress plating for posterolateral tibia plateau fractures

Yong-Cheol Yoon 1,#, Youngwoo Kim 2,#, Chang-Soo Chon 3, Jae-Woo Cho 4, Chang-Wug Oh 5, Jong-Keon Oh 4,✉
PMCID: PMC12521349  PMID: 41087463

Abstract

This study aimed to compare the biomechanical efficacy of rim plating versus conventional posterior buttress plating for fixing posterolateral tibial plateau fractures (PLTPFs). Sixty synthetic tibial models were divided into three groups: posterior buttress plating with a 3.5-mm locking compression T-plate, rim plating with a 2.7-mm variable-angle cloverleaf plate and two anteroposterior screws, and rim plating alone. Static compression and cyclic loading tests were conducted to assess mechanical stability under simulated physiological conditions. Failure loads averaged 2235.75 N, 2017.46 N, and 1743.95 N for the three groups, respectively, all exceeding the 1500-N threshold corresponding to approximately 250% of body weight. Cyclic loading exerted minimal displacement across groups, with no significant differences in stability. Rim plating demonstrated slightly lower failure loads than traditional posterior buttress plating but provided sufficient biomechanical support for PLTPFs. Its performance under static and cyclic loading indicates its feasibility as an alternative that offers adequate stability while potentially reducing surgical invasiveness. These results suggest that rim plating is a biomechanically viable alternative for the management of PLTPFs, offering adequate stabilization with the potential advantage of reduced surgical invasiveness.

Keywords: Cyclic fatigue testing, Posterolateral tibial plateau fracture, Rim plating, Static compression testing, Surgical fixation methods

Subject terms: Engineering, Medical research, Experimental models of disease

Introduction

Tibial plateau fractures encompass a broad spectrum of injuries, ranging from low-energy damage often observed in individuals with osteoporosis to high-energy trauma commonly associated with vehicular accidents, industrial accidents, and sports injuries1,2. High-energy incidents frequently produce substantial articular and intercondylar comminution, compounded by soft tissue damage due to the anatomical structure of the tibia, which features a bone-to-skin area on the anteromedial side and is divided into four compartments3. Such complexities render the treatment of these fractures challenging, typically necessitating surgical intervention. The primary treatment objectives include anatomic joint surface restoration, stable fixation, and soft tissue preservation4,5.

Posterolateral tibial plateau fractures (PLTPFs), characterized by a single fracture segment within the posterolateral quadrant or the fracture line extending to the posterolateral cortical bone, pose unique diagnostic and therapeutic challenges6. PLTPFs were initially believed to comprise only 7–10% of all tibial plateau fractures. However, the widespread use of computed tomography for fracture diagnosis has revealed that they may constitute up to 44.2% of intra-articular and 54.3% of lateral tibial plateau fractures7. These fractures critically affect knee flexion stability, especially when associated with excessive axial and valgus loading at 30°–60° of flexion—conditions under which anterior cruciate ligament injuries may occur8. Displacements exceeding 3 mm can significantly increase local stress by > 75%, accelerating articular cartilage wear and exacerbating joint degeneration, potentially leading to post-traumatic arthritis9.

The prevalence and complexity of PLTPFs often demand surgical intervention. However, the posterolateral tibia presents significant anatomical challenges. The fibular head obstructs access to approximately 61.7% of the total posterolateral part, and vital structures—such as the popliteal vessels and common peroneal nerve—are close, necessitating a meticulous surgical approach10. Furthermore, the thickness and toughness of the posterolateral capsule can obscure intra-articular lesions, whereas inadequate or unstable fixation may elevate failure rates11. Despite numerous studies exploring various approaches and fixation methods, no standard surgical strategy has been established12.

Rim plating has emerged as a promising approach, optimizing soft tissue preservation while maintaining fixation strength comparable to that of traditional methods13–15. The posteromedial or posterolateral approaches, utilizing direct buttress plating for biomechanically superior fixation, are commonly used. However, these are hindered by narrow surgical fields, the risk of neurovascular injury, and complications such as soft tissue trauma or implant irritation10.

More recently, a modified anterolateral approach utilizing curved bending of a 2.7-mm miniplate for rim plating has been introduced. Kim et al. demonstrated its feasibility through cadaveric studies13. Additionally, anteroposterior (AP) direction rafting screws, known as “magic” or “jail” screws, have shown promising results when added to conventional plating16. However, no biomechanical experiments have evaluated the efficacy of rim plating through a modified anterolateral approach for PLTPFs.

This study aimed to compare the biomechanical performance between rim plating (with or without AP screws) and traditional posterior buttress plating. We hypothesized that rim plating would provide sufficient fixation strength comparable to posterior plating under static and cyclic loading.

Materials and methods

Posterolateral fracture preparation

In this study, 60 synthetic left tibial models (Model LSH 1800, Synbone AG, Malans, Switzerland) were used to simulate PLTPFs. These composite models, including cortical and cancellous bone analogs, were selected for their standardized size and mechanical properties, which closely replicate the stiffness of healthy adult bone. Each model measured 416 mm in length, with a plateau width of 78 mm and a canal diameter of 10 mm. The use of synthetic models, rather than cadaveric specimens, minimized inter-sample variability and ensured reproducibility in biomechanical testing17.

To ensure anatomical relevance and morphological accuracy, the fracture design followed the CT-based classification proposed by Sohn et al.7. This classification describes PLTPFs as vertically oriented, inverted cone-shaped fragments involving the posterior articular surface and posterolateral cortical rim. According to Sohn’s study, the mean sagittal fracture angle was 78.5°, and the posterolateral fragment comprised approximately 14.5% of the total articular surface area.

Thus, fractures were created using a sagittal osteotomy with a thin oscillating saw, starting from the articular surface and proceeding posteriorly at a 78° angle relative to the tibial shaft axis. After osteotomy, implants were applied in situ according to each fixation strategy. All models were mounted in custom jigs to standardize implant placement across specimens.

Fixation groups

Three distinct fixation constructs were tested, each representing a different surgical strategy for managing PLTPFs. The rationale for each construct was based on biomechanical and cadaveric studies, particularly by Sun et al. and Kim et al.13,16

  1. Posterolateral buttress plate fixation (Group A, Fig. 1):

Fig. 1.

Fig. 1

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Various views of Group A fixation technique on a synthetic bone model: (a) Posterior view showing the 3.5-mm locking compression plate T-Plate placement; (b) Lateral view of the model highlighting the fracture line and plate positioning; and (c) Superior view demonstrating the alignment of the plate with the tibial plateau’s contour.

  • 2.

    Group A, serving as the control group, utilized the standard posterior buttress plating technique. A 3.5-mm locking compression T-plate (Depuy Synthes, Oberdorf, Switzerland) was contoured to fit the posterior tibial curvature via a posterolateral approach. The plate was aligned flush with the posterior rim and secured using three 3.5-mm locking screws (40 mm) in the plate head to stabilize the subchondral fragment, and two bicortical 3.5-mm cortical screws (40 mm) in the distal segment for axial and rotational stability. This construct, directly countering posterior shear forces, is the most rigid option based on prior studies.

  • 3.

    Rim plating with an additional AP screw (Group B, Fig. 2):

Fig. 2.

Fig. 2

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Various views of Group B fixation technique with anterior-posterior (AP) screws on a synthetic bone model: (a) Anterior view illustrating the placement of the 2.7-mm variable angle locking compression plate cloverleaf plate along with AP screws; (b) Oblique view depicting the cloverleaf plate and AP screw position relative to the fracture line; and (c) Posterior view showing the configuration of the plate and screws on the tibial plateau surface, with AP screws providing additional fixation.

  • 4.

    Group B employed a 2.7-mm variable-angle locking compression plate (VA-LCP) cloverleaf plate (Depuy Synthes), placed along the lateral subchondral rim via an anterolateral approach. Fixation included two 2.7-mm locking screws (60 mm) and two 2.7-mm cortical screws (40 mm) arranged in a rafting configuration. A 3.5-mm cortical “magic screw” (50 mm) was inserted from the anteromedial cortex at a 30–45° oblique angle to support the posterolateral fragment. This additional screw trajectory aimed to enhance subchondral support, as described by Sun et al.18

  • 5.

    Rim plating only (Group C, Fig. 3):

Fig. 3.

Fig. 3

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Various views of Group C fixation technique on a synthetic bone model: (a) Anterior view with the 2.7-mm variable angle locking compression plate cloverleaf plate without anterior-posterior (AP) screws; (b) Top-down view detailing the fracture line and plate coverage; (c) Lateral view highlighting the cloverleaf plate position relative to the synthetic bone model and (d) Posterior view of the cloverleaf plate following the contour of the tibial plateau.

  • 6.

    Group C used the same 2.7-mm VA-LCP cloverleaf plate, placed similarly via the anterolateral approach but without the AP screw. Fixation comprised two 2.7-mm cortical screws (40 mm) and two 2.7-mm locking screws (60 mm) in a rafting configuration. This setup aimed to address the posterolateral “bare area” as described by Kim et al., by extending the plate posteriorly to enhance articular surface coverage13.

This comparative design allowed evaluation of whether rim plating, either alone or with AP screw augmentation, could provide mechanical stability comparable to that of direct posterior buttress plating, while potentially reducing surgical invasiveness.

Biomechanical testing protocol

Sample preparation and allocation

Sixty synthetic tibial models were divided evenly into three groups (n = 20 per group). Each group underwent two test conditions: 10 samples for static compression testing and 10 for cyclic loading. This allocation enabled assessment of initial construct strength and fatigue resistance.

Static compression testing

A universal testing machine (OmniTest-10, Mecmesin Ltd., UK) (Fig. 4) was used for static tests. Each sample was fixed with a custom lower jig to prevent translation, simulating in vivo loading. A hemispherical upper jig (30 mm radius) was used to apply load concentrically to the posterolateral plateau surface at a rate of 3 mm/min. Testing was halted at failure, defined as either a visible fracture or a sharp drop in force on the load–displacement curve19. The loading site and direction were chosen to mimic physiological stresses during knee flexion.

Fig. 4.

Fig. 4

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Experimental setup for static compression testing, showing the hemispherical loading jig applying axial force on the posterolateral tibial plateau fragment fixed with a rim plate construct.

Cyclic loading testing

Cyclic loading simulated early postoperative rehabilitation. The same device was used to load samples dynamically from 0 to 900 N at 10 mm/min for 10,000 cycles20,21. Displacement at the joint margin was measured using a Vernier caliper (Bluetec, Korea). A displacement ≥ 3 mm was considered failure, indicating loss of construct stability.

Statistical analysis

Statistical analyses followed the standards described by Strage et al.22. One-way ANOVA was used to compare static failure loads, whereas the Kruskal–Wallis test assessed differences in cyclic displacement. Data normality was checked using Kolmogorov–Smirnov and Shapiro–Wilk tests.

Post-hoc comparisons were performed using Tukey’s HSD and Bonferroni correction23. A significance threshold of p < 0.05 was applied. All analyses were conducted using SPSS version 22 (IBM Corp., Armonk, NY, USA).

Results

Static test

Failure loads were measured in each group to assess the maximum stress that each fixation strategy could withstand before structural failure. Group A exhibited the highest mean failure load (2235.75 N), followed by Groups B (2017.46 N) and C (1743.95 N) (Fig. 5). All groups withstood loads exceeding 1500 N, indicating sufficient mechanical strength beyond typical physiological loads encountered clinically.

Fig. 5.

Fig. 5

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Box plot of load to failure for each fixation group: Group A (direct posterolateral buttress), Group B (rim plating with two anterior-posterior screws), and Group C (only rim plating). The vertical axis indicates load in Newtons (N), demonstrating the variance and mean failure loads across the three groups.

Statistical analysis revealed a significant difference in the failure load between Groups A and C (p = 0.001). No significant differences were observed between Groups A and B (p = 0.241) or between Groups B and C (p = 0.060). Effect sizes, calculated using Cohen’s d, were as follows: Group A vs. C = 1.18; Group A vs. B = 0.42; and Group B vs. C = 0.64. Post hoc power analysis (α = 0.05) results showed > 95% power for the comparison between Groups A and C, whereas the comparisons between Groups A and B and Groups B and C yielded approximately 50% power.

Cyclic test

Cyclic tests were conducted to evaluate the displacement of each sample group after testing. No specimens exhibited displacements exceeding 3 mm, indicating excellent dynamic stability across all groups. The average displacements recorded for Groups A, B, and C were 0.512, 0.466, and 0.652 mm, respectively. The Kruskal–Wallis test was used to compare the post-loading test displacements among the groups, yielding a p-value of 0.649. This result indicates no statistically significant differences in displacement across the three groups.

Cohen’s d values for pairwise comparisons were as follows: 0.11 for Group A vs. B, 0.28 for Group A vs. C, and 0.36 for Group B vs. C. Post hoc power analysis was not conducted for the cyclic displacement data due to the use of non-parametric testing (Kruskal–Wallis), which does not support variance-based power estimation.

Although displacement values remained consistently low across all groups, these results may have been influenced by the intrinsic stiffness of the synthetic bone models (Synbone) used in this study. These composite models lack the viscoelastic and trabecular microstructures of human cadaveric bone, potentially contributing to the reduced deformation under cyclic loading24. Furthermore, the use of locking plates with bicortical screw fixation likely enhanced construct rigidity, further minimizing micromotion at the fracture site25,26.

Discussion

This biomechanical study aimed to compare the stability of rim plating (with or without an AP rafting screw) for PLTPFs versus that of traditional posterior buttress plating. The mechanical performance of each construct was assessed under static and cyclic loading conditions to simulate the stresses experienced during early postoperative rehabilitation27.

In the static loading test, all constructs demonstrated a mean failure load exceeding 1500 N, approximately 1.5–2× body weight and within the range of normal tibiofemoral forces observed during daily activities28,29. The posterior buttress group exhibited the highest load to failure (2235.75 N), followed by the rim plating with AP screw group (2017.46 N) and the rim plating alone group (1743.95 N). The rim plating without an additional screw was significantly weaker than buttress plating. However, all three constructs withstood loads surpassing the critical functional threshold, suggesting their mechanical adequacy for clinical use. The difference between rim plating with and without an AP screw was not statistically significant (p = 0.060), indicating that rim plating alone may still be acceptable in selected scenarios, especially where minimally invasive techniques are prioritized or in patients with low-demand profiles.

To further quantify these differences, we calculated Cohen’s d effect sizes and performed a post hoc power analysis30,31. The largest effect size was observed between posterior buttress plating and rim plating alone (d ≈ 1.2), whereas comparisons involving the screw augmentation showed only small-to-moderate effects (d ~ 0.4–0.6). Correspondingly, the post hoc power analysis indicated that our sample provided > 95% power to detect the large buttress-versus-rim-alone difference but only ~ 50% power for the more subtle effect of the AP screw. This supports the lack of a statistically significant benefit from screw augmentation.

Furthermore, cyclic loading simulating early weight-bearing stress (10–900 N for 10,000 cycles) yielded < 1 mm of displacement, without significant differences between constructs. This outcome is noteworthy because a displacement greater than 3 mm under repetitive loading has been associated with reduction loss and delayed healing32. The durability of the rim plating constructs under fatigue stress supports their ability to maintain fracture stability throughout the early phase of rehabilitation. Clinically, rim plating may offer advantages due to its reduced invasiveness and minimal soft tissue disruption33,34. Conversely, posterior buttress plating provides superior mechanical rigidity, which is essential in cases requiring the utmost support; however, it may increase the risk of soft tissue irritation and other complications.

Multiple alternative fixation methods have been proposed to address the challenge of securing posterolateral fragments. For instance, Zhang et al. introduced the “Barrel Hoop Plate” technique, which showed superior stability in finite element models of mild slope-type depression fractures, whereas standard anterolateral plates performed better in sinkhole-type patterns28. Similarly, Ren et al. demonstrated that a novel rim plate designed for an anterolateral approach outperformed buttress and lateral plating in synthetic models27. Notably, their design did not include AP screw augmentation, which was incorporated into our model to enhance fixation stability.

Securing the posterolateral fracture fragment with conventional lateral plates remains challenging. Yan et al. reported that even using variable-angle screws, modern lateral tibial plates captured only 58.3–76.4% of posterolateral fragments, leaving substantial portions unsupported35. Hu et al. addressed this issue by shifting lateral plates posteriorly via an anterolateral “supra-fibular-head” window, improving fixation in finite element analysis and clinical cases36.

In complex tibial plateau fractures involving all three columns, Liu et al. confirmed (through finite element modeling with clinical correlation) that adding a posterior plate significantly reduced posterior column collapse and improved outcomes compared to dual plating alone37. These findings underscore the importance of tailoring the fixation strategy to the fracture’s morphology and mechanical demands.

Despite the promise of these techniques, each approach must be weighed against surgical complexity and soft tissue risk. Posterior buttress plating, while offering excellent mechanical stability, requires extensive dissection and poses risks to neurovascular structures38. Rim plating—especially when augmented with AP rafting screws—offers a less invasive option that still provides satisfactory mechanical integrity, as supported by our static and cyclic data. Despite being slightly less resistant to static failure, rim plating without AP screw augmentation demonstrated adequate strength and minimal displacement under cyclic loading. Thus, it may suffice for simpler fracture patterns or lower-demand patients39.

This study has several limitations. The use of uniform synthetic bone models allowed for standardized comparisons; however, these models do not replicate the heterogeneity and viscoelastic properties of real bone (particularly osteoporotic bone). Additionally, our sample size was limited, which could reduce the statistical power to detect subtle differences between constructs. Moreover, our fracture model was a simplified posterolateral fragment and may not capture the full complexity of comminuted or high-energy fracture patterns. We advise caution in extrapolating these results to highly comminuted injuries. Future studies should employ comminuted fracture models or cadaveric specimens to verify whether rim plating and posterior buttress plating remain effective under more complex, high-energy conditions. Displacement was measured with digital calipers, potentially lacking the precision to detect subtle micromotions at the fracture interface. Advanced measurement techniques such as digital image correlation or strain gauges should be utilized in future work to capture the subtle micromotion that our caliper method may have missed. The absence of surrounding soft tissues (ligaments, joint capsule, and musculature) further limits the physiological relevance of the model. Incorporating soft tissue structures (ligaments, menisci, and capsule) in the model—via cadaveric specimens or synthetic surrogates—would improve its physiological relevance, and we plan to do so in future studies. Although the cyclic loading protocol of 10,000 cycles is widely used to simulate early rehabilitation, it may still underestimate the cumulative fatigue experienced over a longer recovery20,21,29. Similarly, using a 1500 N load as a failure threshold provides a convenient approximation of functional loading but might not account for peak stresses during highly demanding activities. Our tests were limited to axial loading and did not evaluate torsional or shear forces that could stress the constructs in other ways. Future biomechanical evaluations will incorporate torsional and shear loading to verify construct stability under multidirectional forces. Finally, further validation using cadaveric models or hybrid models would enhance anatomical fidelity and support broader clinical generalizability.

Conclusion

Rim plating demonstrated biomechanical stability comparable to that of traditional posterior buttress plating for fixing posterolateral tibial plateau fractures. Although rim plating (especially without an AP screw) exhibited a slightly lower load to failure under static testing, both rim plating configurations consistently exceeded physiological load thresholds and maintained structural integrity under cyclic loading. These findings support rim plating as a viable, less invasive alternative for simple or non-comminuted PLTPFs with minimal soft tissue disruption. However, for complex or highly comminuted fractures requiring maximal stability, posterior buttress plating remains the superior option.

Nevertheless, this in vitro study utilized synthetic bone models and short-term axial loading without soft tissue support or biological healing. These limitations warrant caution; our results should not be directly generalized to clinical practice, particularly for complex fracture cases, until confirmed by further research.

Acknowledgements

None.

Author contributions

Y.C.Y. and Y.W.K. were responsible for designing the study. Y.W.K. conducted the experiments and completed the biomechanical testing. J.K.O. supervised the study, ensuring its design and execution met high standards. Y.C.Y. drafted the manuscript. C.S.C. and J.W.C. contributed to data collection and analysis. J.K.O. and C.W.O. also contributed to the manuscript revision. All authors contributed to shaping the manuscript, reviewed the final draft, and approved it for submission.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to the restricted access of our hospital database; however, they are available from the corresponding author upon reasonable request.

Declarations

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Yong-Cheol Yoon and Youngwoo Kim contributed equally to this work.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The datasets generated and/or analyzed during the current study are not publicly available due to the restricted access of our hospital database; however, they are available from the corresponding author upon reasonable request.

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