The concept of direct approach to lateral tibial plateau fractures and stepwise extension as needed

Abstract

Malreduction after tibial plateau fractures mainly occurs due to insufficient visualization of the articular surface. In 85% of all C-type fractures an involvement of the posterolateral-central segment is observed, which is the main region of malreduction. The choice of the approach is determined (1) by the articular area which needs to be visualized and (2) the positioning of the fixation material. For simple lateral plateau fractures without involvement of the posterolateral-central segment an anterolateral standard approach in supine position with a lateral plating is the treatment of choice in most cases. For complex fractures the surgeon has to consider, that the articular surface of the lateral plateau only can be completely visualized by extended approaches in supine, lateral and prone position. Anterolateral and lateral plating can also be performed in supine, lateral and prone position. A direct fixation of the posterolateral-central segment by a plate or a screw from posterior can be only achieved in prone or lateral position, not supine. The posterolateral approach includes the use of two windows for direct visualization of the fracture. If visualization is insufficient the approach can be extended by lateral epicondylar osteotomy which allows exposure of at least 83% of the lateral articular surface. Additional central subluxation of the lateral meniscus allows to expose almost 100% of the articular surface. The concept of stepwise extension of the approach is helpful and should be individually performed as needed to achieve anatomic reduction and stable fixation of tibial plateau fractures.

Keywords: Anatomic reduction; Osteosynthesis; Posterolateral corner; Surgical approach; Tibial plateau fracture.

Fig. 1

Lateral tibial plateau fracture with involvement of anterolatero–lateral and anterolatero-central (ALC) segments (a–d). The visualization of the ALC segment was not possible by standard anterolateral approach in this specific case (e). Extension of the approach by an osteotomy of the lateral epicondyle allowed an anatomic reduction under full visual control (f–h)

Fig. 2

Algorithm of surgical care for lateral tibial plateau fractures in supine position

Fig. 3

Algorithm of surgical care for lateral tibial plateau fractures in prone or lateral decubitus position

Fig. 4

50 year old male with a comminuted lateral tibial plateau fracture (a–d). All segments of the lateral plateau are involved including both central segments (AC—anterior cruciate ligament, PC—posterior cruciate ligament). To reduce the fracture under full visual control including the whole lateral plateau and central segments, an extended approach with osteotomy of the lateral epicondyle [10, 12, 13] and a central subluxation of the lateral meniscus [31] were stepwise performed (e). With this treatment regimen an complete anatomic reduction of the articular surface was achieved (f, g). Fixation was performed by screws, lateral plate and a spongiosa allograft block underneath the articular surface after reduction of the fracture.