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Posterior Approaches to the Proximal Tibia

Stephen A. Kottmeier M.D.
Assoc. Professor – State University N.Y. @ Stony Brook



1. “Medial – POSTERIOR” patterns and access

a. consistent pattern of primarily posterior displacement. high-energy trauma mechanisms
and associated with significant ligament and soft tissue injuries

b. may be biconylar and not conform to Schatzker Type VI ( not have complete
disassociation between the joint and the diaphysis)
c. moore fracture dislocation classification more applicable – distinguish between moore
type 1 moore type 2 shearing type B

d. Proper analysis of the lateral radiograph and CT scans clarifies the fracture pattern and
allows planning of appropriate treatment

e. inherently unstable and difficult to adequately reduce and stabilize by conventional
techniques and approaches

f. “ posteromedial” approach with the patient supine
o adequate for the posteromedial condyle, but does not allow access to the lateral
condyle
o varus deforming forces and knee flexion complicate reduction

g. “Medial posterior” approach with the patient prone
• axial traction and hyperextension facilitate reduction
• neurovascular bundle protected / popliteal subperiosteal elevation (medial to lateral)
• direct approach / efficient effective buttress fixation

h. concern - extension deficit

i. extensile option –medial gastrocnemius detachment allows access to “lateral posterior”
access



Carlson DA. Bicondylar fracture of the posterior aspect of the tibial plateau.
A case report and a modified operative approach. J Bone J oint Surg Am. 1998
J ul;80(7):1049-52


2. “Lateral – POSTERIOR” patterns and access

a .isolated posterior coronal fractures of lateral tibial plateau-uncommon injury /
underappreciated

b .direction, magnitude, and location of the force, as well as the position of the knee at
impact, determine the fracture pattern, location, and degree of displacement.
( typically a combination of valgus and axial compression forces with knee in flexion)

c. stability in flexion a concern with residual impaction in the posterolateral tibial plateau.

d.incomplete restoration of the joint surface results in chronic postero-inferior joint
subluxation

e. low-energy injury- isolated posterolateral tibial condylar fracture (+/-fibular head split
fracture) higher energy injury- anterior subluxation of the tibia on the femur may result in an
associated anterior cruciate ligament rupture

a. posterior fractures on the lateral plateau usually cause massive depression and
destruction of the chondral surface

g.may be “inapparent” on initial radiographs AP radiograph ( little displacement identified)
-accurate analysis of the lateral view and CT clarify the significance of the posterolateral
fracture component



h. not well described by Schatzker classification system
-the AO/OTA system classified this posterior coronal fracture as partial or B-type(41-B),
with further subclassification - “B”-type ( partial articular fracture / tibial shaft in
continuity with the anterior articular surface of the tibial plateau)



i. - conventional anterior, or anterolateral approaches in the supine position –suboptimal
exposure and access -stabilization techniques limited, with lag screws put from anterior to
posterior


• split or split-depression fractures do not have an intact posterior cortex
- reduction complicated by posterior displacement of the lateral tibia fragment with
knee flexion (prone position preferred)
• posterolateral approach - direct exposure of fracture with reduction underdirect
visualization,and fixation with preferentially posteriorly located buttress plate
• biomechanical principles require placement of a posterior antiglide buttressplate
• posterolateral approach - direct fracture visualization, anatomic reduction of the
posterolateral articular split or split-depression is possible, as is the bone grafting.
Buttress plating to maintain reduction of plateau is also possible.
• the direct posterolateral plate could be used as a buttress and plays an important role in
maintaining the reduction of the posterolateral fragment, which could also support the
articular surface and is strong enough to resist axial loading



j. no extensile option
• cannot be extended distally (trifurcation vessels traversing the interosseus membrane)
• -mass of muscle and tissue medial to the fibula make an exposure past approximately 8 to
10 cm distal to the lateral joint line difficult


Carlson DA. Bicondylar fracture of the posterior aspect of the tibial plateau.
A case report and a modified operative approach. J Bone J oint Surg Am. 1998
J ul;80(7):1049-52




3.“DUAL” access (prone …. medial posterior and lateral-posterior)


Carlson DA. Bicondylar fracture of the posterior aspect of the tibial plateau.
A case report and a modified operative approach. J Bone J oint Surg Am. 1998 J ul;80(7):1049-52



4. “Posterior-LATERAL” patterns and access ( + / - proximal fibular osteotomy)

a.Displaced posterolateral tibia plateau fractures
• -most depression and comminution is in the posterior half of the lateral tibial condyle
(may extend anteriorly, with or without breaching the anterior or lateral cortex of the
tibia)
• fragments are often covered by the fibula head and the ligamentous structures in the
corner region of the popliteus muscle ( difficult to reduce and fixate)

b. anterior approach ( to treat posterolateral fractures)
• -difficult to perform and appreciate the reduction of the comminuted portion (no intact
posterior bone column to elevate and buttress the depressed and comminuted fracture
fragments against)
• . may lose reduction of the posterior fragments after reducing the anterior portion of
the fracture (when using an anterolateral approach).
• . osteotomy of the anterior tibial cortex may be required (if the fracture does not extend
to involve the anterior tibial cortex).

c. posterolateral approach - address two types of lateral tibial plateau fracture.
#1- fracture isolated to the posterior half of the lateral tibial condyle.
#2-fracture involving the majority or the entire lateral tibial condyle ( comminution located
posteriorly)
• This approach was developed as an alternative to the anterolateral approach to the
tibial plateau for the treatment of two fracture subtypes: depressed and split depressed
fractures in which the comminution and depression are located in the posterior half of
the lateral tibial condyle

• - two “windows”
#1- conventional, lateral standard arthrotomy (visual monitoring of the reduction of the fracture
for reduction and internal fixation
#2dorsal access (posterolateral-same incision)

d. advantages (relative to prone lateral posterior approach )
• .may be performed supine or lateral position
• preserves posterolateral ligamentous complex ( fracture fragments not denuded or
devitalized)
• extensile options exist (fibular osteotomy)
• may buttress the lateral aspect of the tibia ( simultaneous access to the lateral aspect of
the tibial plateau).(Lateral posterior prone may not allow sufficient visual control of
fracture reduction and only permits posterior buttressing)

e. disadvantage
• .may be difficult to address additional medial plateau fractures when in lateral postion
plateau, -option-staged procedures (change patient position)


Frosch KH, Balcarek P, Walde T, Stürmer KM. A new posterolateral approach
without fibula osteotomy for the treatment of tibial plateau fractures. J Orthop
Trauma. 2010 Aug;24(8):515-20.




Frosch KH, Balcarek P, Walde T, Stürmer KM. A new posterolateral approach
without fibula osteotomy for the treatment of tibial plateau fractures. J Orthop
Trauma. 2010 Aug;24(8):515-20.


Posterolateral ( transfibular neck approach )

• exposes the posterolateral aspect of the tibial plateau between the posterior margin of the
iliotibial band and the posterior cruciate ligament.
• the approach allows lateral buttressing of the lateral tibial plateau
• may be combined with a simultaneous posteromedial and/or anteromedial approach to the
tibial plateau
• adequate posterior placement of a lateral buttress late ( plate can be placed more
posteriorly than can occur through an anterolateral approach)
• concerns
fragment denudation / iatrogenic compromise to posterolateral ligamentous complex
• allows a “circumferential approach” to the tibial plateau when combined with
an anteromedial and or a posteromedial approach

REFERENCES

Bhattacharyya T, McCarty LP 3rd, Harris MB, Morrison SM, Wixted J J , Vrahas MS,
Smith RM. The posterior shearing tibial plateau fracture: treatment and results
via a posterior approach. J Orthop Trauma. 2005 May-J un;19(5):305-10.

Carlson DA. Posterior bicondylar tibial plateau fractures. J Orthop Trauma.
2005 Feb;19(2):73-8.

Carlson DA. Bicondylar fracture of the posterior aspect of the tibial plateau.
A case report and a modified operative approach. J Bone J oint Surg Am. 1998
J ul;80(7):1049-52

Brunner A, Honigmann P, Horisberger M, Babst R. Open reduction and fixation of
medial Moore type II fractures of the tibial plateau by a direct dorsal approach.
Arch Orthop Trauma Surg. 2009 Sep;129(9):1233-8.

Chang SM, Zheng HP, Li HF, J ia YW, Huang YG, Wang X, Yu GR. Treatment of
isolated posterior coronal fracture of the lateral tibial plateau through
posterolateral approach for direct exposure and buttress plate fixation. Arch
Orthop Trauma Surg. 2009 J ul;129(7):955-62.

Fakler J K, Ryzewicz M, Hartshorn C, Morgan SJ , Stahel PF, Smith WR. Optimizing
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tibial head: description of the Lobenhoffer approach. J Orthop Trauma. 2007
May;21(5):330-6.

Frosch KH, Balcarek P, Walde T, Stürmer KM. A new posterolateral approach
without fibula osteotomy for the treatment of tibial plateau fractures. J Orthop
Trauma. 2010 Aug;24(8):515-20.

Tao J , Hang DH, Wang QG, Gao W, Zhu LB, Wu XF, Gao KD. The posterolateral
shearing tibial plateau fracture: treatment and results via a modified
posterolateral approach. Knee. 2008 Dec;15(6):473-9.

Solomon LB, Stevenson AW, Baird RP, Pohl AP. Posterolateral transfibular
approach to tibial plateau fractures: technique, results, and rationale. J Orthop
Trauma. 2010 Aug;24(8):505-14.

Luo CF, Sun H, Zhang B, Zeng BF. Three-column fixation for complex tibial
plateau fractures. J Orthop Trauma. 2010 Nov;24(11):683-92.

Galla M, Lobenhoffer P. [The direct, dorsal approach to the treatment of
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Lobenhoffer P, Gerich T, Bertram T, Lattermann C, Pohlemann T, Tscheme H.
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