Surgical exposure to posterolateral quadrant tibial plateau fractures: an anatomic comparison of posterolateral and posteromedial approaches

Abstract

Background Management of posterolateral tibial plateau quadrant fractures can be challenging, and two posterior approaches were frequently used for exposure, reduction, and fixation: posterolateral approach and posteromedial approach. The purpose of this study was to compare their deep anatomical structure and analyze their limits and the risk of injury to important structures during surgical dissection of two approaches. Method Five lower limb specimens were used in this study. After dissection of the skin and superficial fascia of each specimen, deep structures were dissected via posteromedial and posterolateral approach, and several parameters including perpendicular distance from the anterior tibial artery coursing through the interosseous membrane fissure to the lateral joint line and apex of fibular head and so on were measured and analyzed. Result The perpendicular distance from the ATA coursing through the interosseous membrane fissure to the lateral joint line was 49.3 ± 5.6 mm (range 41.3–56.7 mm), while the distance to the apex of fibular head was 37.7 ± 7.2 mm (range 29.0–48.0 mm). The transverse distance of the anterior tibial vascular bundle is around 10 mm. The perpendicular distance from the top accompanying vein of the ATA bundle to lateral joint line and apex of fibular head was 44.1 ± 6.3 mm and 32.5 ± 7.6 mm, respectively. The maximum proportion of posterolateral tibial plateau shielded by the fibular head from the posterior view was 61.7 ± 4.9% (range 55.6–64.1%). The average length of popliteus muscle outside the joint was 83.1 ± 6.0 mm (range 76.5–92.2 mm), and the width in the middle was 28.1 ± 4.3 mm (range 26.6–29.1 mm). Conclusion Although posterolateral approach seems more direct for exposure of posterolateral quadrant tibial plateau fracture, it has three major disadvantages in deep dissection. Posteromedial approach through the medial board of medial head of gastrocnemius–soleus may be safer, but it was hard for direct visualization of articular surface which limits it usage for only a few cases.

Modified Oblique Lobenhoffer (MOL) approach for posterolateral and posteromedial column access in tibial plateau fractures: a detailed cadaveric anatomical study

“…Several authors agree that the Luo approach can improve access to the PM and PL column [ 1 , 23 ]. Nevertheless, other authors referred limitations in the PL column exposure using the Luo approach [ 12 , 13 , 31 , 32 ]. Orapiriyakul et al.…”

“…7 ) without requiring additional posterolateral approaches [ 4 ]. These posterolateral approaches also have their own limitations and risks, including potential injury to the lateral collateral ligament, the common peroneal nerve, the lateral sural cutaneous nerve and especially the anterior tibial artery which represents the distal limit for exposure and plating in these approaches [ 13 , 22 , 29 ]. In this regard, the MOL approach offers the additional advantage to overcome the distal limitation imposed by the anterior tibial artery in posterolateral approaches.…”

“…Direct dissection of the popliteal neurovascular bundle is not required in the MOL approach (or in other deep posteromedial interval approaches). Normally, the elevation of the popliteus muscle protects the popliteal artery and the ATA, but anatomical variants should be considered [ 13 ]. Several studies reported that 0.8–6% of cases with a pattern where the ATA runs through the anterior surface of the popliteus muscle [ 40 , 41 ].…”

“…In this sense, various approaches, including extended anterolateral, lateral or posterolateral incisions, have been described to specifically address the PL column [ 3 , 4 , 20 – 28 ]. However, these approaches lack access to the PM column and also come with their own limitations and risks [ 13 , 22 , 29 ]. Other authors have proposed direct posterior approaches between gastrocnemius muscles to address both PL and PM columns, but requiring more complex dissection [ 30 – 33 ].…”