Rethinking the functional relevance of posterolateral tibial plateau fractures in anterior cruciate ligament injury

Posterolateral tibial plateau fractures (PLTFs) are increasingly recognised in anterior cruciate ligament (ACL)-injured knees, yet their functional relevance remains unsettled. In our view, the recent study by Willinger et al. adds valuable prospective data on the association between PLTFs and lateral-sided soft-tissue pathology, but its findings should be interpreted with caution. The main concern is that PLTFs were analysed as a relatively uniform lesion despite substantial morphologic heterogeneity. Small cortical impressions are unlikely to have the same biomechanical significance as deeper depression defects associated with loss of submeniscal bony support or altered local slope geometry. In addition, preoperative pivot shift is an incomplete surrogate for the functional effect of PLTFs within a multifactorial instability pattern influenced by meniscal, anterolateral, and osseous restraints. The imaging framework also does not quantify structural variables likely to determine mechanical relevance. We therefore believe the study supports only a narrow conclusion: PLTF presence alone is not a reliable surrogate for greater preoperative pivot-shift laxity, whereas the significance of high-grade PLTF phenotypes remains unresolved.