What is the step-by-step procedure for a proximal tibia fracture treated with plating via anterior and posterior approaches?

Step-by-Step Procedure for Proximal Tibia Fracture Plating via Anterior and Posterior Approaches

The optimal surgical management of proximal tibia fractures requires a combined anterior and posterior approach with appropriate plating techniques to achieve anatomic reduction, stable fixation, and early mobilization.

Preoperative Planning

1. Imaging Assessment

   • Obtain high-quality CT scans to evaluate fracture patterns and displacement
   • Identify specific fracture fragments (anterior, lateral, posterior, medial)
   • Plan surgical approach based on fracture configuration

2. Patient Positioning

   • Position patient supine on a radiolucent table
   • Place a bump under the affected limb to facilitate access to posterior aspect
   • Prepare and drape the entire limb circumferentially

Anterior Approach Procedure

1. Incision and Exposure

   • Make an anterolateral incision starting 3-5 cm above the joint line, extending distally along the lateral border of the tibial crest
   • Develop the interval between the tibialis anterior and peroneus longus muscles
   • Elevate the anterior compartment muscles from the lateral tibial surface

2. Fracture Reduction

   • Elevate depressed articular fragments using a bone tamp
   • Reduce the articular surface anatomically under direct visualization
   • Temporarily fix fragments with K-wires

3. Bone Grafting

   • Fill metaphyseal defects with autologous bone graft or bone substitute
   • Support the elevated articular fragments from below

4. Anterior Plate Application

   • Apply an anatomically contoured locking plate to the anterolateral surface
   • Insert proximal locking screws parallel to the joint surface
   • Place distal screws in a bicortical fashion
   • Confirm plate position and screw length with fluoroscopy

Posterior Approach Procedure

1. Patient Repositioning

   • Either reposition patient to prone position or maintain supine with leg externally rotated

2. Posteromedial Approach

   • Make a longitudinal or S-shaped incision along the posteromedial aspect of the proximal tibia
   • Develop the interval between the medial head of gastrocnemius and semimembranosus
   • Protect the neurovascular structures (popliteal vessels and tibial nerve)
   • Retract the medial head of gastrocnemius laterally

3. Posterolateral Approach (if needed)

   • Make a separate incision along the posterolateral aspect
   • Develop the interval between the lateral head of gastrocnemius and soleus
   • Protect the common peroneal nerve

4. Posterior Fragment Reduction

   • Directly visualize posterior fragments
   • Reduce fragments anatomically
   • Temporarily fix with K-wires

5. Posterior Plate Application

   • Apply an antiglide or buttress plate to the posterior surface
   • Insert screws avoiding penetration into the joint
   • For complex bicondylar fractures with coronal plane fractures, apply a separate posteromedial plate 1

Fixation Verification and Closure

1. Final Assessment

   • Obtain fluoroscopic images in multiple planes to confirm:
     • Anatomic reduction of articular surface
     • Restoration of mechanical axis
     • Proper implant position
     • Adequate screw length

2. Wound Closure

   • Place suction drains if necessary
   • Close deep fascia with absorbable sutures
   • Close subcutaneous tissue and skin in layers

3. Postoperative Management

   • Apply a hinged knee brace
   • Begin early range of motion exercises
   • Restrict weight-bearing for 8-12 weeks depending on fracture stability

Special Considerations

1. Complex Bicondylar Fractures

   • May require triple plating (anterolateral, posteromedial, and posterolateral) for adequate stability 1
   • Consider staged procedures if soft tissue conditions are poor

2. Posterolateral Fragment Management

   • Can be addressed through a modified anterolateral approach using rim plating technique 2
   • This avoids the risks associated with direct posterior approaches

3. Minimally Invasive Options

   • Percutaneous locked plating may be considered for extra-articular proximal tibia fractures 3
   • This technique shows promising results with minimal complications and average union time of 20-25 weeks

Potential Complications and Prevention

1. Infection

   • Risk increases with open fractures and extensive surgical approaches
   • Consider staged procedures for open fractures or compromised soft tissues
   • Administer prophylactic antibiotics

2. Malunion

   • Occurs in approximately 20% of cases 3
   • Ensure anatomic reduction of articular surface and restoration of mechanical axis

3. Neurovascular Injury

   • Carefully identify and protect neurovascular structures during posterior approaches
   • Use blunt dissection near neurovascular bundles

4. Hardware Failure

   • Use locking plates for better fixation in osteoporotic bone
   • Ensure adequate screw purchase in the metaphyseal bone

The combined anterior and posterior approach with appropriate plating provides the best outcomes for complex proximal tibia fractures by allowing direct visualization and fixation of all fracture fragments, resulting in anatomic reduction and stable fixation that permits early mobilization 4, 5.