Network meta-analysis of various surgical approaches for the treatment of posterolateral tibial plateau fractures

Objective

This study aimed to systematically compare the clinical efficacy and safety of different surgical approaches in the treatment of posterolateral tibial plateau fractures. Specifically, it evaluated operative time, intraoperative blood loss, fracture healing time, postoperative knee function, and complication rates, to provide evidence-based guidance for clinical surgical approach selection.

Methods

A comprehensive literature search was conducted in seven major databases—CNKI, PubMed, Web of Science, Cochrane Library, Scopus, VIP, and EMBASE—from their inception to May 2025. Controlled studies comparing different surgical approaches for posterolateral tibial plateau fractures were included. Primary outcomes were operative time, intraoperative blood loss, fracture healing time, postoperative Hospital for Special Surgery (HSS) knee scores, and incidence of postoperative complications. A network meta-analysis was performed using Stata 16.0. A network diagram and league table were generated to present both direct and indirect comparisons among surgical approaches. Surface Under the Cumulative Ranking curve (SUCRA) values were used to rank the interventions. Study quality was assessed using the MINORS scale. Inconsistency testing and publication bias analysis were also conducted to ensure robustness of the results.

Results

A total of 26 studies involving 1864 patients and seven surgical approaches were included. The network meta-analysis showed that the Modified Extended Anterolateral Approach (MEALA) ranked highest across all primary outcomes: operative time (SUCRA: 97.8 %), intraoperative blood loss (94.9 %), fracture healing time (95.0 %), postoperative HSS score (98.2 %), and complication rate (78.5 %). Additionally, the Transfibular Head Approach (TFHA) demonstrated advantages in minimizing intraoperative blood loss and controlling complications. No significant inconsistency or publication bias was detected based on node-splitting analysis and funnel plot assessment, indicating robust results.

Conclusion

The Modified Extended Anterolateral Approach demonstrates superior overall performance in the treatment of posterolateral tibial plateau fractures, particularly in reducing operative time, minimizing intraoperative trauma, and enhancing postoperative functional recovery. The Transfibular Head Approach also shows potential benefits in complication management. Surgical approach selection should be individualized based on fracture morphology and surgeon experience. Further high-quality randomized controlled trials are warranted to validate these findings.