Treatment of posterior tibial plateau fractures via posteromedial and posterolateral exposures

Abstract

Tibial plateau fractures with depression of posterior aspects of the proximal tibia cause significant therapeutic problems. Posterior fractures on the medial side are mainly highly instable fracture-dislocations (Moore type I). Posterolateral fractures usually cause massive depression and destruction of the chondral surface. Surgical exposure of these fractures from anterior requires major soft tissue dissection and has a significant complication rate. However, incomplete restoration of the joint surface results in chronic postero-inferior joint subluxation, osteoarthritis and pain. We present new specific approaches for posterior fracture types avoiding large skin incisions, but allowing for atraumatic exposure, reduction and fixation. Posteromedial fracture-dislocations are exposed by a direct posteromedial skin incision and a deep incision between medial collateral ligament and posterior oblique ligament. The posteromedial pillar and the posterior flare of the proximal tibia are visualized. The inferior extent of the joint fragment can be reduced by indirect techniques or direct manipulation of the fragment. Fixation is achieved with subchondral lag screws and an anti-glide plate at the tip of the fragment. Posterolateral fractures are exposed by a transfibular approach: the skin is incised laterally, the peroneal nerve is dissected free. The fibula neck is osteotomized, the tibiofibular syndesmosis is divided and the fibula neck is reflected upwards in one layer with the meniscotibial ligament and the iliotibial tract attachment. Reflexion of the fibula head relaxes the lateral collateral ligament, allows for lateral joint opening and internal rotation of the tibia and thus exposes the posterolateral and posterior aspect of the tibial plateau. Fixation and buttressing on the posterolateral side can be achieved easily with this approach. In closure, the fibula head is fixed back with a lag screw or a tension-band system. These two exposures can be combined in bicondylar posterior fracture situations. 168 cases with tibial plateau fractures had ORIF in the authors' institution from 1988 to 1994. 26 of these patients had a total of 29 posterior exposures to treat their fractures (9 posteromedial, 12 posterolateral, 3 combined posteromedial/posterolateral and 2 posterior/anterior exposures). No specific complications occurred related to these exposures, i.e. no skin slough, no infection, no nerve palsy. The mean duration of follow-up was 4 years. Twenty-one cases healed uneventfully: 12 were excellent in Rasmussen's clinical score, 8 were good and 1 was fair. Seven patients were excellent in the radiological score, 13 good and 1 fair. Five of the 26 cases had revision surgery: 3 patients developed valgus or retrocurvatum deformity and were successfully treated by an osteotomy. They obtained a good result at follow-up. Two fractures in elderly patients were revised to an endoprosthesis.

Incidence and Morphology of the Posteromedial Fragment in Bicondylar Tibial Plateau Fractures

“…The presence of a posteriorly based medial fragment, either in isolation or as part of a bicondylar fracture, has been noted intermittently in the literature since 1967. 2,[27][28][29][30] A recent publication by Barei et al 32 served to more thoroughly characterize this fragment in the setting of a high-energy bicondylar pattern.…”

“…The posteromedial fragment has been addressed very sporadically in the literature since that time. [27][28][29][30] Barei et al 31 presented the first more detailed description of this fragment at the OTA in October 2005, followed by publication of these findings in 2008. 32 Whether this fragment requires open medial reduction and medially based fixation has been the source of recent discussion both biomechanically 17,20,22,24,33 and clinically.…”

A new anatomic locking plate for the treatment of posterolateral tibial plateau fractures

“…Lobenhoffer et al [9] introduced a posterolateral approach with fibular osteotomy with better visualization. An anterolateral approach with partial or full fibula head removed was developed by Yu [4], which do great benefit for reduction and fixation in the treatment of posterolateral tibial plateau fractures.…”

“…However, the operative treatment of posterolateral tibial plateau fractures remains a challenge due to the fibular head and ligamentous structures that impede adequate exposure of the posterolateral joint surface. Although many approaches have been reported [4, 6–9] to achieve appropriate exposure, there is no general consensus.…”

“…Recent studies [7–9] on the treatment of posterolateral tibial plateau fractures have focused on surgical approaches. There is no literature to our knowledge about a specialized anatomic locking plate for posterolateral tibial plateau fractures.…”