Lateral Plateau Frx: Approach & Fixation

- Discussion: Tibial Plateau Frx Menu
    - lateral plateau frxs include:
          - type I fractures 
          - type II fractures 
          - type III fractures 
          - local compression frx which are similar to type iii frx

- Surgical Stratedgy:
    - extensile surgical approach that exposes whole frx zone & adjacent normal tissue;
    - comminuted type II fractures will often require more extensive exposure than type I fractures, however, in both cases, "booking open" the fracture
             site will yield exellent access to the entire lateral compartment;
    - fixation strategy involves ORIF of comminuted articular surface w/ subchondral reduction & buttressing of split frag that forms lateral wall;

- PreOp Planning (positioning, and implants);
    - w/ significant frx shortening (and resultant valgus) consider using AO large distractor & relying on ligamentotaxis to maintain reduction and provide exposure;
           - usually is distractor is placed on the same side as the frx;
           - one pin is inserted into the femoral condyle and one in the mide tibia;
    - supine position:
           - tape a rolled sheet onto table (as with a total knee replacement), in order to allow the knee to remain hyperflexed during procedure (when required);
    - supine w/ leg flexed:
           - leg can be positioned as for arthroscopy;
           - a leg holder is applied to the proximal thigh, and the table is broken to allow the knee to flex past 90 deg;
                  - the opposite leg is then held in a GYN leg holder;
                  - this technique allows varus to be applied to the knee which improves fracture exposure;

- Limited Hockey Stick Incision: 
     - most useful in situations where only cannulated screws will be used (and plate butressing is not required); 
              - if butressing is necessary, consider external fixation (circular frame fixation); 
     - statedgy involves booking open fracture site which yields excellent exposure of lateral compartment, especially if arthroscopy is used (placed underneath meniscus); 
              - this approach is also especially useful w/ concomitant meniscal tears;
              - this incision should not interfere w/ total knee incision (should it be necessary in the future);
     - technique: (see: lateral capsular anatomy of the knee)
              - incision is made from a point above the fibular head to Gerdy's tubercle; 
              - it can be biased either anteriorly or posteriorly to lie directly over the fracture;
              - carry the dissection directly down to the IT band, and then palpate the anterior frx line;
              - split the IT band in line with its fibers directly over the fracture site;
              - fracture site and the joint capsule are now visible;
              - just below joint line, make a horizontal inframeniscal incision, which extends from a point anterior to frx fragment to a point posterior to frx fragment; 
              - infra-meniscal incision needs to be large enough to allow the meniscus to be elevated and the frx to be "booked open";
              - once the split fragment is booked open, there should be excellent access to the compartment; 

- Longitudinal Incision:

    - most indicated when a butress plate is required;
    - this approach will not interfere w/ a TKR incision if one is needed in the future;
    - slightly lateral parapatellar (or midline incision) is made from about 10 cm above the patella to about 3-4 cm below the lowest extent of the frx;
    - incision is carried directly down to the superificial retinaculum, and a full thickness flap is elevated once underneath the superficial retinaculum;
           - the flap is mobilized laterally and distally, so that with the knee flexed Gerdy's tuberlce is exposed;
    - deep dissection: (see: lateral capsular anatomy of the knee);
           - most important step in reconstruction of any intra articular frx, is to expose fracture w/o devasclarizing the fragments;
           - flex the knee to 90 deg, and incise thru the IT band (along its fibers) directly over the split frx site; 

- Anterior Meniscal Detachment: 
          - see: lateral meniscus;
          - just below the joint line, make a horizontal inframeniscal incision, which extends from a point anterior to the frx
                 fragment to a point posterior to the frx fragment;
                 - infra-meniscal incision needs to be large enough to allow the meniscus to be elevated and the frx to be "booked open"; 
          - sharply detach the anterior horn of menisci from its bony insertion; 
                  - the anterior horn will later be repaired at the end of the case;
          - this allows the surgeon to pull up on meniscus together w/ the attached capsule, for more optimal view of articular surface;
          - meniscus is retracted proximally, and the joint inspected directly;
                  - if the arthrotomy is made above the meniscus, the meniscus will keep most of articular surface hidden from view;
          - the knee is hyperflexed and internally rotated;
          - meniscal re-attachment:
                  - two small drill holes are made at the origin of the anterior horn and are directed to exit medial to the patellar tendon;
                  - pass a suture thru the meniscus, and use a suture passer to thread the sutures through the drill holes; 
          - references:
                  - Meniscal detachment to approach lateral tibial plateau fractures.
                  - The use of an anterior incision of the meniscus for exposure of tibial plateau fractures requiring open reduction and internal fixation.
                  - Meniscal detachment to approach lateral tibial plateau fractures.

- Alternative Extensile Measures:
    - tubercle osteotomy:
           - however, always avoid tubercle osteotomy in bicondylar frx since, this might be the only intact portion of bone anteriorly;
           - if tibial tubercle is already fractured, then it may be detached - as would be in an osteotomy;
    - patellar tendon Z-plasty:
           - contra-indicated if there is concomitant tibial tubercle frx;
           - for improved exposure, consider cutting the patella in a "Z pattern" (longitudinal split w/ half attach to tubercle and half
                  attached to patella) with repair of the tendon with heavy suture at the end of the case (see repair of patellar tendon rupture);
           - in this technique, the adjacent parapatellar retinaculum should be left intact;
    - wide IT band flap:
           - a wide exposure is required for comminuted type II frx;
           - knee is flexed to 90 deg, and the iliotibial band is retracted or split to expose midlateral capsule;
           - incision is made thru the lateral 1/3 of the quadriceps, it is continued down along the lateral edge of the patella,
                  and is then continued down along lateral edge of the patella (incising the lateral retiancular expansion);
                  - the incision is continued distally below the frx line;
           - 2nd deep capsular incision is made thru inferior 1/3 of IT band (crossing Gerdy's tubercle) which is split in line with
                  its fibers so that it intersects with the longitudinal capsular incision;
                  - alternatively capsular incision is carried below Gerdy's tuberlce, & tubercle is then detached w/ osteotome & IT band
                           is left attached to facilitate subsequent wound closure;
                  - this tongue of IT band and capsule is then elevated superiorly off the tibia, elevating the meniscus off the tibia in the process;
                  - this technique has been criticized for devascularizing the frx fragment;

- Reduction:
    - knee is stressed into varus position for visualization of lateral plateau;
    - if a depressed split fracture is difficult to reduce, consider application of a universal distractor to assist w/ the reduction;
    - further periosteal stripping may be necessary to assist w/ reduction;
           - staying w/in periosteal sleeve avoids damage to anterior tibial muscle and anterior tibial artery;
    - depressed articular fragments are elevated with a punch, supported by bone graft, and buttressed with a lateral T or L shaped plate
          - k wire fixation:
                   - k wires are inserted to maintain provisional fixation;
                   - take care that k wire position does not interfere with plate application;
           - bone graft that supports elevated fragments cannot hold them in anatomic relationship and is often secondarily depressed when patient starts ROM exercises; 
           - references:
                   - Evaluation of Popliteal Artery Injury Risk With Locked Lateral Plating of the Tibial Plateau
                   - The arterial vascularization of the lateral tibial condyle: anatomy and surgical applications.
                   - Anatomic location of the peroneal nerve at the level of the proximal aspect of the tibia: Gerdy's safe zone.


- Post Operative Care and Complications

A New Surgical Approach in the Treatment of Depressed Lateral Condylar Fractures of the Tibia

A New Surgical Approach to Fractures of the Lateral Tibial Plateau

Early weight bearing of lateral tibial plateau fractures.

A new posterolateral approach without fibula osteotomy for the treatment of tibial plateau fractures.

Posterolateral transfibular approach to tibial plateau fractures: technique, results, and rationale.

Combined Arthroscopic Treatment of Tibial Plateau and Intercondylar Eminence Avulsion Fractures


Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Friday, June 15, 2012 11:01 am