[Osteosynthesis of bicondylar tibial plateau fracture in a prone position : Video article]

Abstract

Objective: The aim of the surgical treatment of intra-articular bicondylar tibial plateau fractures is the anatomical reconstruction and direct biomechanical optimal fixation of the fractured articular surface and the leg axis, taking the frequently associated soft tissue damage into account.

Indications: This article presents a cadaver model of a simulated complex bicondylar tibial plateau fracture 41C3 according to the AO classification with fracture involvement of all 10 segments and indications for surgery due to a posteromedial shearing fracture and lateral articular destruction with posterolaterocentral impaction.

Contraindications: Pronounced soft tissue damage with acute or incompletely healed infections in the area of the surgical approach.

Surgical technique: In the presented video of the operation, which is available online, the direct treatment of an intra-articular complex tibial plateau fracture from dorsal in a prone position is shown in detail: posterolateral ca. 13 cm long skin incision immediately above the fibular head with subsequent gentle preparation of the peroneal nerve at the medial border of the biceps femoris muscle. Retraction of the lateral head of the gastrocnemius muscle medially. Proximal detachment of the soleus muscle from the fibular head and retraction of the popliteus muscle medially. Horizontal capsule incision for fracture visualization. Opening of the lateral window ventral to the lateral collateral ligament. If necessary, osteotomy of the lateral femoral epicondyle for improved posterolaterocentral fracture visualization. Angular stable osteosynthetic fixation. Posteromedial approach medial to the medial gastrocnemius head. Retraction of the medial head of the gastrocnemius muscle laterally, horizontal capsular incision with sparing of the semimembranosus muscle medially and posterior cruciate ligaments laterally, fracture reduction, fixation with posteromedial support plate, image converter control, wound closure.

Follow-up: Postoperative cooling and elevation of the operated limb. Depending on the fracture 6-10 weeks partial loading of maximum 20 kg. Prior to full load bearing clinical radiological follow-up checks to determine the bony consolidation and material positioning.

Results: This is an established and safe delivery strategy for complex fracture patterns with dorsally running fractures. The risk of intraoperative malreduction is low. Postoperative reduction losses depend on fracture, operation and especially patient-specific characteristics.

Keywords: Epicondyle; Fracture fixation; Osteotomy; Surgical access; Treatment outcome.