Surgical technique: Tscherne-Johnson extensile approach for tibial plateau fractures

Abstract

Background: The standard approach to lateral tibial plateau fractures involves elevation of the iliotibial band (IT) and anterior tibialis origin in continuity from Gerdy's tubercle and metaphyseal flare. We describe an alternative approach to increase lateral plateau joint exposure and maintain iliotibial band insertion to Gerdy's tubercle.

Description of technique: The approach entails a partial tenotomy of the anterior half of the IT band leaving the posterior IT band insertion attached to Gerdy's tubercle. Fracture lines around Gerdy's tubercle are completed or the tubercle was osteotomized and externally rotated and the joint overdistracted, allowing direct visualization of the joint depression. Joint elevation, grafting, and internal fixation are performed through this window.

Methods: We retrospectively reviewed 76 patients (two groups), Schatzker Types I to II and IV to VI fractures (66 patients), between 1989 and 2005, and 10 patients, with 10 bicondylar posterior plateau fractures, from 2002 to 2010. All patients were followed a minimum of 12 months (average, 3.9 years; range, 12 months to 10 years). Ten patients, with posterior plateau fractures, received anterolateral plateau intraarticular osteotomy for exposure of centroposterior and posterolateral articular depression.

Results: Average knee ROM was 2° of flexion (range, -3° to 5°) to greater than 120° of flexion (range, 100°-145°). In 66 patients, average articular depression improved from 7.4 mm to 1 mm (range, 0-5 mm) and, in 10 posterior fractures, from 18 mm to 1 mm (range, 0-4.5 mm). Infection occurred in one of the 76 patients; acute débridement and intravenous antibiotics resulted in control of the infection.

Conclusions: This approach reliably increases direct visualization of the lateral plateau articular fractures and maintains IT band insertion. Articular osteotomy of the anterolateral plateau provides access to extensive posterior plateau fractures.

Fig. 1

Illustration showing IT band tenotomy, line A, for a left knee. Line B shows level of tenotomy at origin of the anterior tibialis muscle. Capsular and other ligament structures removed for illustration. (Printed with permission from © Fairman Studios LLC)

Fig. 2

Illustration of lateral view of left knee showing two osteotomes elevating Gerdy’s fragment. Gerdy’s fragment is then hinged outward (direction of black arrow) based on posterior hinge (dotted line behind Gerdy’s tubercle). Associated soft tissues have been removed for illustration. (Printed with permission from © Fairman Studios LLC)

Fig. 3

Illustration showing external rotation of Gerdy’s fragment and direct access to the depressed area of the lateral plateau. Posterior insertion of IT band remains attached on the rotated Gerdy’s fragment. (Printed with permission from © Fairman Studios LLC)

Fig. 4A–J

(A) Preoperative AP radiograph of a posterior plateau fracture with involvement of posteromedial, posterocentral, and posterolateral left tibial plateau. Anterolateral joint line is intact. (B) Preoperative lateral radiograph showing extent of posterior plateau articular displacement and intact anterior plateau cortical bone. (C) Coronal CT image showing posteromedial plateau fragment, comminution of tibial eminence, and posterolateral articular fracture depression. Intact anterolateral plateau is present. (D) Axial CT image anterior and posterior medial plateau fractures, 90° rotated posterolateral joint fragment, and intact anterolateral cortical margin of the left tibial plateau. (E) Centrolateral sagittal CT scan revealing substantial posterior depression of articular cartilage with intact anterior half of plateau cortical bone. (F) Sagittal CT scan of medial tibial plateau showing a large posteromedial plateau fragment and oblique major fracture line. (G) AP fluoroscopic view of left tibial plateau fracture reduction technique. Ball-tipped clamp A compresses the lateral plate to osteotomized Gerdy’s fragment and lateral plateau bone. Ball-tipped clamp B reduces posteromedial plateau oblique articular fragment through percutaneous insertion. Two separate AP lag screws are placed into the posteromedial plateau. (H) Clinical appearance of the use of intraoperative bilateral transarticular coronal plane distractors (medial and lateral), anterolateral incision, and the use of the periarticular tong reduction clamps. (I) AP radiographs showing complete healing and axis alignment with anatomic reduction of joint surfaces 3 years after fracture. (J) Lateral radiograph of healed left plateau fracture showing reduction of posterior fractures fragments, restoration of plateau joint surfaces, and position of hardware.