^k

 

 

 

^DEFINITION

^{A direct approach with the patient in a prone position to the posterior aspect of the tibial plateau for reduction and stable fixation of tibial plateau fractures which are hard to visualize from conventional anterolateral or extensile medial approaches. Most applicable to fracture-dislocations of the knee (FIG 1).}

^{The approach to the posterior aspect of the proximal tibia was originally described in the French surgical literature by Cadenat3 in 1933. Later, the approach was further described in the English literature by}

^{Darrach5 in 1945 and Harmon7 in 1945. Kaplan9 in 1946 provided an excellent description of the anatomy of the approach, although none of these authors described the use of the posterior approach to the proximal tibia for fracture fixation.}

^{More recently, Lobenhoffer et al10 in 2004 described a limited posterior approach for tibial plateau fracture fixation that has been popularized by subsequent authors that uses the medial aspect and dissection of the extensile approach for the treatment of posteromedial tibial plateau fractures. This can be combined with anterolateral approach for bicondylar tibial plateau fractures during staged}

^{management, but it is hard to perform concurrently with an anterolateral tibial plateau approach. Carlson4 added the posterolateral incision and dissection for the treatment of posterior dominant bicondylar fractures.}

 

^{FIG 1 • A 49-year-old female sustained this tibial plateau fracturedislocation during a motorcycle hill-}

^{climbing competition. AP and lateral images of the left knee that demonstrate an intact proximal tibial}

^{cortex and impaction of the posteromedial femur which makes this fracture pattern an excellent candidate for a direct posterior approach.}

^{Further modification of the posterolateral approach by adding an osteotomy of the proximal fibula has}

^{been described Yu et al15 to improve exposure to the proximal posterolateral tibial plateau. In some circumstances, the fibular osteotomy comes as part of the fracture and this can be exploited to improve fracture visualization.}

 

 

^ANATOMY

 

^{Dissection and approach to the posterior aspect of the proximal tibia is performed primarily through three tissue planes: medial, middle, and lateral, all of which are part of the extensile posterior approach (FIG 2A,B).}

 

 

^{The medial tissue plane is bounded superiorly by the semimembranosus muscle, the medial head of the gastrocnemius laterally, and the soleus and popliteus inferiorly. The inferior medial geniculate neurovascular bundle is at risk during this dissection if not disrupted by fracture displacement (FIG 3).}

 

 

 

^{FIG 2 • Classic approach to the posterior aspect of the knee as described by Kaplan. A. The skin incision. Red line demonstrates the lateral incision. Green line demonstrates the medial incision. B. The superficial dissection with the popliteal vein and common peroneal nerve dissected. Arrow on peroneal nerve.}

 

 

⁵²⁰

 

 

 

 

^{FIG 3 • Posteromedial tibial plateau approach described by Lobenhoffer10 and popularized by Smith et al. The posteromedial approach offers easy access to the posterior aspect of the medial tibial plateau.}

^{Reduction and application of buttress fixation of the medial coronal plane splits in the medial plateau are facilitated by this exposure which is posterior to the hamstring tendons and the medial collateral ligament. Visualization of the concave surface of the medial tibial plateau is difficult. Reduction is provisionally performed via cortical reads, and the reduction of the articular surface is confirmed radiographically.}

 

 

^{The middle tissue dissection is bounded medially by the medial head of the gastrocnemius, laterally by the lateral head of the gastrocnemius, and inferiorly by the popliteus muscle. The posterior tibial nerve, artery, and venous drainage are at greatest risk during this approach. The rich venous return coming from the gastrocnemius heads is tedious to dissect during this approach plane (FIG 4).}

 

^{The lateral dissection is bounded superiorly by the popliteus muscle, medially by the lateral head of gastrocnemius, laterally by the posterior aspect of the fibula and the common peroneal nerve, and inferiorly by the soleus. The common peroneal nerve and popliteal artery and nerve are at risk (FIG 5). Proximal fibular osteotomy can be used to improve exposure (FIG 6).}

 

^PATHOGENESIS

 

^{Direct posterior approaches to the tibial plateau are indicated for reduction and stabilization of fractures of the posterior aspect of the tibial plateau that can either be isolated to a single condyle or bicondylar in nature.}

 

^{The posterior fracture of the tibial plateau is most commonly associated with fracture-dislocation injuries of the knee wherein the tibia subluxates anteriorly and the femoral condyles impact the posterior aspect of the proximal tibia. Rotation and degree of knee flexion at the time of injury determine condylar involvement, whereas degree of axial loading drives the amount of joint impaction.}

 

^{Most common in Moore types 1 and 2 fracture-dislocations of the knee}

 

 

^{We see this most commonly in skiers who sustain Schatzker 4 injuries as described by Potocnik et al.11}

 

^{Occasionally, Schatzker 2 split depression injuries involve the posterior aspect of the lateral tibial plateau and are amenable to a direct posterolateral approach.}

 

^{NATURAL HISTORY}

 

^{Most high-energy periarticular injuries are treated in a staged manner wherein the knee is initially stabilized in an external fixator (see Cha 47), allowing the soft tissue envelope to evolve to the point that swelling is resolving and any fracture blisters have reepithelialized.}

 

^{The decision to proceed with open reduction and internal fixation can been made once the soft tissue envelope is no longer being actively damaged and has moved past the acute inflammatory phase (generally}

^{>5 days).}

 

^{Healing of metaphyseal fractures generally occurs slowly by creeping substitution and therefore requires prolonged periods of protected weight bearing (10 to 12 weeks).}

 

^{PATIENT HISTORY AND PHYSICAL FINDINGS}

 

^{Advanced trauma life support (ATLS) guidelines. Comprehensive physical examination to determine all associated injuries.}

 

^{Examination of the affected lower leg. Documenting the neurovascular status of the limb. Ankle-brachial indices should be obtained; values less than 0.9 should trigger a vascular consult.}

 

^{Soft tissue injuries should be documented as well as previous scars.}

 

^{A high index of suspicion should be maintained for compartment syndrome before and after placement of external fixation, if used.}

 

 

⁵²¹

 

 

 

^{FIG 4 • Extensile posterior approach to the proximal tibia as described by Trickey13 and more recently by}

^{Tscherne and Johnson.8 Access to the posterior tibial plateau via the extensile posterior approach. Surgical access to the PCL insertion and origin.}

 

 

 

^{FIG 5 • Posterolateral approach to tibial plateau. Posterolateral tibial plateau as seen through the posterolateral approach to the tibial plateau. Note, the position of fibular head tends to obscure much of the view. This approach offers limited access to posterolateral tibial plateau. Improved access can be obtained by a fibular osteotomy.}

 

 

⁵²²

 

 

 

^{FIG 6 • With fibular osteotomy. Fibular osteotomy improves the view of the posterolateral plateau.}

 

^{IMAGING AND OTHER DIAGNOSTIC STUDIES}

 

^{Orthogonal radiographs of the knee to include anteroposterior (AP) and lateral images.}

 

^{Contralateral knee orthogonal images: AP and lateral. The author's preference is to control for subtle anatomic differences between individuals. The contralateral radiographs allow the surgeon to reconstruct the fractured knee in the mirror image of its uninjured partner.}

 

^{A computed tomography (CT) of the knee is invaluable in determining the exact location of the articular injury to the tibial plateau (FIG 7). This includes the location of the impaction that needs to be elevated. The CT scan should be obtained after spanning external fixation when a staged operative approach is selected.}

^{Sagittal and coronal reconstructions may also be helpful.}

 

 

 

^{FIG 7 • Axial CT clearly demonstrates the position of articular impaction of the posterolateral tibial plateau. Direct visualization and reduction of the articular surface is possible via a posterolateral approach.}

 

 

^{Magnetic resonance imaging (MRI) has been found to improve the detection of associated meniscal and}

^{ligamentous injuries occurring with tibial plateau fractures.12 However, we do not routinely obtain MRIs after tibial plateau fractures.}

 

^{Associated Diagnosis}

^{Anterior cruciate ligament (ACL) injuries Posterior cruciate ligament (PCL) injuries Lateral and medial meniscus injuries Popliteal artery intimal tear}

^{Peroneal or posterior tibial nerve injuries Compartment syndrome}

 

 

^{NONOPERATIVE MANAGEMENT}

 

^{Less than 2 mm of joint depression}

 

^{Less than 10 degrees of valgus or varus instability}

 

^{No evidence of tibial subluxation relative to the femur on AP and lateral images.}

 

^{Knee immobilizer for 2 weeks, followed by initiation of active-assisted knee range of motion in a hinged knee brace. Non-weight bearing for 6 weeks, followed by progressive weight bearing to full weight bearing over a 4-week period.}

 

^{SURGICAL MANAGEMENT}

^{Preoperative Planning}

 

^{Careful review of the radiographs and axial CT scan images to determine the injury pattern and location of joint impaction is key to determining the surgical tactic.}

 

 

⁵²³

 

^{Injuries to the posterior lateral and/or medial plateau fracture are accessible via direct posterior approaches.}

 

^{The presence of a posterior horn meniscal detachment or PCL avulsion injury will further drive me to strongly consider direct posterior approaches for reduction and fixation.}

 

^Positioning

 

^{Prone positioning of the patient on a radiolucent flat-top table or AMSCO type table with a carbon fiber “diving board” extension.}

 

^{Bolsters are placed under the chest to allow the abdomen to remain free and the patients face to remain free of compression (FIG 8).}

 

^{Attention needs to be paid to not inadvertently extend and retract the shoulders during positioning to avoid unnecessary traction on the brachial plexus.}

 

 

 

 

^{FIG 8 • Prone positioning.}

 

^Approach

 

^{There are three basic direct posterior approaches that are the surgical windows of the extensile exposure.}

 

 

^{The lateral window between the lateral head of the gastrocnemius, the fibular head, and proximal fibula. Structure at risk is common peroneal nerve.}

 

^{The middle window between the gastrocnemius muscle heads. Popliteal neurovascular bundle is at risk. This is generally an unnecessary window that I have abandoned in favor of a more extensile medial and/or lateral approach (FIG 9).}

 

^{The medial window between the semitendinosus, semimembranosus, and the medial head of the gastrocnemius muscle}

 

 

 

^{FIG 9 • The reflection of the medial and lateral heads of the gastrocnemius demonstrates the neurovascular complex that complicates a dissection through this plane. This clinical image correlates to FIG 4.}

 

^TECHNIQUES

• ^{Medial Incision Planning}

^{The medial incision is laid out one-third above the knee joint and two-thirds below the knee joint. The incision should be centered over the medial femoral condyle (TECH FIG 1).}

 

 

 

 

^{TECH FIG 1 • Classic incision (blue), lateral incision (red), and medial (yellow) incision. Denoted as different colored lines same knee.}

 

 

 

• ^{Medial Superficial Dissection}

  ⁵²⁴

   

  ^{The superficial dissection is carried through the skin and subcutaneous tissue to the fascia overlaying the medial gastrocnemius head. The semimembranosus muscle will be seen in superior medial aspect of the incision. The tendon of the semitendinosus will be directly medial (TECH FIG 2).}

   

   

   

  ^{TECH FIG 2 • Superficial medial window dissection. A. Retracted medial head gastrocnemius. B.}

  ^{Semitendinosus tendon and semimembranosus muscle. C. Soleus muscle.}

• ^{Medial Deep Dissection}

   

  ^{Release of the soleus from the posterior aspect of the proximal tibia completes the deep dissection (TECH FIG 3A).}

   

   

   

  ^{TECH FIG 3 • A. Deep medial dissection; the posteromedial tibial plateau is exposed below the medial meniscus: 1, semimembranosus muscle; 2, posterior cruciate ligament; 3, retracted medial gastrocnemius muscle; 4, semitendinosus muscle. B. The entire posteromedial tibial plateau can be visualized once the medial collateral ligament is release anteriorly. Note the inferior medial geniculate neurovascular bundle is preserved (asterisk).}

   

   

  ^{Dissection can be improved by releasing the posterior aspect of the medial collateral ligament from the medial femoral condyle. The incision can be extended distally along the medial border of the medial gastrocnemius head to allow access to the posteromedial tibial shaft (TECH FIG 3B).}

   

  ⁵²⁵

• ^{Medial Reduction and Clamp Application}

   

  ^{Clamp application from this position can be made medial to lateral and posterior to anterior. A}

  ^{combination of periarticular reduction clamps and pointed bone reduction clamps are easily applied to complete reductions. Additionally, a curved bone tamp can be used to elevate the joint line fragment to a reduced position, which is confirmed radiographically then secured with Kirschner wires (K-wires) (TECH FIG 4 A-C).}

   

   

   

  ^{TECH FIG 4 • A. Elevation with curved bone tam B. Provisional K-wires placed out of the way of planned}

  ^{definitive fixation. C. Final plate position. The Cobel shoulder retractor is a useful instrument to maintain the surgical window.}

• ^{Medial Stabilization}

   

  ^{Application of a medial buttress plate is preferred for the stabilization of the posteromedial articular fragment. A simple onethird tubular plate is often sufficient for fixation in this location (TECH FIG 5). Complete articular fragments should be secured to the tibial shaft if possible using 3.5- or 4.5-mm compression plates.}

   

   

   

  ^{TECH FIG 5 • Buttress plate applied to the posteromedial plateau. Inferomedial geniculate neurovascular bundle preserved.}

• ^{Lateral Incision Planning}

   

   

  ^{The lateral incision uses the lateral limb of the classic extensile posterior approach. The incision is centered over the lateral femoral condyle, one-third above joint line and two-thirds below (see TECH FIG 1).}

   

• ^{Lateral Superficial Dissection}

  ⁵²⁶

   

  ^{The superficial dissection begins with identifying and protecting the common peroneal nerve. If the nerve is tethered distally where it travels posterior to the fibular head into the lateral compartment of the leg, it should be carefully released (TECH FIG 6).}

   

  ^{The tissue plane between the lateral head of the gastrocnemius and the peroneus longus is bluntly}

  ^{dissected to reveal the popliteus tendon overlying the origin of the soleus.}

   

   

   

  ^{TECH FIG 6 • Superficial dissection. A. Common peroneal nerve. B. Lateral aspect of lateral head gastrocnemius. C. Popliteus tendon. D. Peroneus longus overlaying fibular head.}

• ^{Lateral Deep Dissection}

   

  ^{The posterior articular surface is visualized once the popliteus tendon is released, tagged, and reflected medially (TECH FIG 7A).}

   

  ^{Release of the soleus from the posterior aspect of the proximal tibia and its elevation can provide access to almost the entire posterior aspect of the tibial plateau (TECH FIG 7B). Reduction of the medial side can at times be obtained from this approach but fixation is often not possible and should be performed through the medial window previously described.}

   

   

   

  ^{TECH FIG 7 • A. Deep lateral dissection; the popliteus muscle has been released as well as half of the lateral gastrocnemius origin: (A) released popliteus tendon and (B) lateral gastrocnemius after partial release from origin. B. It is possible to visualize the entire posterior tibial plateau from the lateral window after careful release of the soleus muscle from the proximal tibia. Common peroneal nerve (asterisk). C. The popliteal neurovascular bundle is directly over the soleus muscle and is protected by the reflected soleus. Once the soleus is reflected, most of the posterior tibial plateau can be reduced and stabilized.}

   

   

   

  ^{Vigorous retraction of the soleus should be avoided to prevent injury to the posterior neurovascular structures which lie on the dorsal surface of the soleus and are tethered to the tibia as the popliteal artery trifurcates (TECH FIG 7C).}

   

• ^{Lateral Reduction and Clamp Application}

  ⁵²⁷

   

  ^{The only significant difference over the medial window is the lack of distal exposure in the lateral window; no more than 5 cm distal to the tibial articular surface. Joint elevation proceeds as previously described. The meniscus and the PCL are repaired with nonabsorbable suture as indicated.}

   

  ^{Bone graft or resorbable cements are used to file metaphyseal defects after the joint is reduced and provisionally secured with K-wires.}

• ^{Lateral Stabilization}

   

  ^{Undercontoured one-third tubular and 3.5-mm compression plates placed in a buttress fashion are the mainstay of fixation. Rarely are fixed angle (locked plates) indicated for posterior tibial plateau fixation (TECH FIG 8A-D).}

   

   

   

  ^{TECH FIG 8 • A. Posteromedial approach with the posteromedial fragment reflected by the bone hook. Medial articular surface visible. B. Comminution under the posterior tibial spine elevated to reduced position. C. Hydroxyapatite bone center fills the void created by articular elevation. Use of cements is useful in posterior approaches, as the fixation is not as well developed as it is for other approaches. D. Posteromedial fragment reduced and fixed with buttress plate.}

   

   

   

• ^{Skin Closure}

  ⁵²⁸

   

  ^{The meniscal insertions are repaired as indicated. No. 5 braided suture passed through drill holes placed at the meniscal insertion points after a locked stitch (ie, Kessler stitch) has been placed in the respective posterior meniscal horn is generally all that is needed. We use a Hewson suture passer and tie the stitch over a button in these circumstances.}

   

  ^{Next, the capsule is repaired with 0 braided nonabsorbable suture. If muscle origins or insertions were released to facilitate exposure (medial head gastrocnemius, lateral head gastrocnemius, popliteus), they are also repaired.}

  ^{The skin is then closed with a subcutaneous resorbable suture and the skin is closed with a monofilament absorbable suture such as Monocryl placed in a simple interrupted fashion. I prefer an absorbable suture due to the fact that patients are often uncomfortable during the suture removal and not infrequently permanent sutures are inadvertently left behind.}

  ^{A well-padded dressing is applied and the patient is then placed in a knee immobilizer after they are returned to a supine position.}

   

   

   

  ^{PEARLS AND PITFALLS}

   

  ^{Difficulty in locating the articular surface of the tibia}

• ^{Center posterior incisions over the middle of the lateral and/or medial femoral condyles. One-third of the incision superior to the posterior flexion crease of the knee and two-thirds below posterior flexion crease of the knee to start. Extend proximally and distally as needed. No heroism in not using intraoperative imaging to help with incision planning}

   

  ^{Flexion contractures of the knee}

• ^{Avoiding the transverse incision across the popliteal space prevents wound tension from playing a role in the patient avoiding full extension, which can lead to flexion contractures.}

• ^{Active extension during the day}

• ^{Knee immobilizer at night}

   

  ^{Insufficient exposure of the proximal tibia during approach especially in persons with copious soft tissue envelopes}

• ^{Partial release of the gastrocnemius heads will greatly improve visualization.}

   

  ^{Struggling with visualization of the articular surface}

  • ^{When positioning, a contralateral bolster improves medial access and an ipsilateral bolster improves lateral access.}

     

    ^{Painful prominent screws which are especially apparent when the patient kneels}

  • ^{Do not leave the screws placed posterior to anterior long. When the swelling diminishes, anterior prominence will lead to very annoying premature hardware removal.}

     

    ^{Difficulty with extension of approach to improve fixation}

• ^{Avoid curving the proximal aspects of the incisions, as this prevents extension if necessary.}

   

  ^{Inadvertent bleeding from the inferior extent}

  • ^{During the posterolateral approach, avoid dissection of more than 5 cm distal to the lateral joint line, as this will jeopardize the peroneal}

 

	of the wound during the artery. deep dissection of the lateral window     Insufficient ▪ Avoid insufficient fixation as a result of the limits of the posterior metaphyseal fixation to approaches. Repositioning and placing long plates anterolaterally via the diaphysis when percutaneous approaches is better than the alternative malunion. proximal tibial comminution extends distally to the diaphysis of the tibia

 

 

^{POSTOPERATIVE CARE}

 

^{Non-weight bearing on the injured lower extremity for at least 6 to 8 weeks followed by a 4-week period of progressive weight bearing}

 

^{Early passive and active-assisted range of motion to start in the hospital. Constant passive motion machine are used during the inpatient stay.}

 

^{Knee immobilizer for use at night. Special attention is paid to maintaining full knee extension after direct posterior approaches that tend to develop flexion contractures.}

 

^{Deep venous thrombosis prophylaxis. Most commonly Lovenox for 4 weeks unless contraindicated by preexisting patient medical conditions}

 

^OUTCOMES

^{The overall clinical success rates for the open treatment of tibial plateau fractures via a posterior approach are reported as excellent (FIG 10A-C). Most series are small (<10 patients) with infrequent use of validated clinical outcomes measures.1, 2, 4, 6}

⁵²⁹

 

 

 

 

^{FIG 10 • A. Classic pattern of articular injury that is ideal for a direct posterior approach. B,C. AP and lateral radiographs at 5 years demonstrate excellent radiographic results.}

 

 

^{Yu et al16 report in a limited series of 15 patients excellent modified Hospital for Special Surgery (HSS) knee scores (mean HSS knee score 93.4, range 86 to 100).}

 

^{Higher rates of conversion to total knee arthroplasty are observed in bicondylar injuries and patients older than 48 years. Although the total conversion rate was only 7.3%.14}

 

 

^{COMPLICATIONS}

^{Common peroneal nerve palsy Deep venous thrombosis Knee flexion contracture Arthrofibrosis}

^{Retinal injury secondary to prolonged prone positioning}

^{Insufficient fixation and malreduction resultant from an exposure which unfamiliar and not readily extensile}

 

^REFERENCES

1. ^{Bhattacharyya T, McCarty LP III, Harris MB, et al. The posterior shearing tibial plateau fracture: treatment and results via a posterior approach. J Orthop Trauma 2005;19(5):305-310.}

    

    

2. ^{Brunner A, Honigman P, Horisberger M, et al. Open reduction and fixation of medial; Moore type II fractures of the tibial plateau by a direct dorsal approach. Arch Orthop Trauma Surg 2009;129(9):1233-1238.}

    

    

3. ^{Cadenat FM. Les Voies de Pénétration des Membres. Tome II: Membre Inferieur. Paris: G. Doin, 1932.}

    

    

4. ^{Carlson DA. Posterior bicondylar tibial plateau fractures. J Orthop Trauma 2005;19(2):73-78.}

    

    

5. ^{Darrach W. Surgical approaches for surgery of the extremities. Am J Surg 1945;67:237-262.}

    

    

6. ^{De Boeck H, Opdecam Posteromedial tibial plateau fractures. Operative treatment by posterior approach. Clin Orthop Relat Res 1995;(320):125-128.}

    

    

7. ^{Harmon PH. A simplified surgical approach to the posterior tibia for bone-grafting and fibular transference. J Bone Joint Surg Am 1945;27:496-498.}

    

    

8. ^{Johnson EE, Timon S, Osuji C. Surgical technique: Tscherne-Johnson extensile approach for tibial plateau fractures. Clin Orthop Relat Res 2013;471(9):2760-2767.}

    

    

9. ^{Kaplan EB. Posterior approach to the superolateral region of the tibia. 1946;28(4):805-808.}

    

    

10. ^{Lobenhoffer P, Gerich T, Bertram T, et al. Particular posteromedial and posterolateral for the treatment of tibial head fractures [in German]. Unfallchirurg 1997;100(12):957-967.}

     

     

11. ^{Potocnik P, Acklin YP, Sommer C. Operative strategy in postero-medial fracture-dislocation of the proximal tibia. Injury 2011;42(10):1060-1065.}

     

     

12. ^{Stannard JP, Lopez R, Volgas D. Soft tissue injury of the knee after tibial plateau fractures. J Knee Surg J Knee Surg 2010;23(4):187-192.}

     

     

13. ^{Trickey EL. Rupture of the posterior cruciate ligament of the knee. J Bone Joint Surg Br 1968;50(2):334-341.}

     

     

14. ^{Wasserstein D, Henry P, Paterson JM, et al. Risk of total knee arthroplasty after operatively treated tibial plateau fracture: a matched-populationbased cohort study. J Bone Joint Surg Am 2014;96(2):144-150.}

     

     

15. ^{Yu B, Han K, Zhan C, et al. Fibular head osteotomy: a new approach for the treatment of lateral or posterolateral tibial plateau fractures. Knee 2010;17(5):313-318.}

     

     

16. ^{Yu GR, Xia J, Zhou JQ, et al. Low-energy fracture of posterolateral tibial plateau: treatment by a posterolateral prone approach. J Trauma Acute Care Surg 2012;72(5):1416-1423.}