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

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

The optimal surgical approach for proximal tibial fractures requires both posterior and anterior approaches when dealing with complex fracture patterns involving both tibial plateaus, particularly with posterolateral or posteromedial fragments that require direct visualization for anatomic reduction and stable fixation.

Pre-operative Planning

• Obtain standard AP and lateral radiographs to identify the fracture pattern
• CT scan is essential (100% sensitivity) for precise fracture classification, characterization, and surgical planning 1
• MRI is indicated when lateral tibial plateau depression is >11mm to evaluate for associated soft tissue injuries (lateral meniscus tear, ACL avulsion) 1
• Classify fracture using Schatzker system to guide treatment approach:
  • Types I-III: Lateral plateau fractures
  • Type IV: Medial plateau fracture
  • Type V: Bicondylar fracture
  • Type VI: Plateau fracture with metaphyseal-diaphyseal dissociation 1

Patient Positioning

For Posterior Approach (First Stage)

1. Position patient prone on a radiolucent operating table
2. Place a bolster under the distal thigh to allow knee flexion of approximately 20°
3. Prepare and drape the entire lower extremity to allow intraoperative manipulation

For Anterior Approach (Second Stage)

1. Reposition patient supine after completion of posterior fixation
2. Place a bolster under the ipsilateral hip to facilitate internal rotation of the limb
3. A sterile tourniquet may be used for both approaches

Posterior Approach (Lobenhoffer Approach for Posteromedial Fragments)

1. Skin Incision:

   • Make a longitudinal or slightly curved incision centered over the posteromedial aspect of the proximal tibia
   • Incision extends approximately 10-12 cm from the popliteal crease distally 2

2. Deep Dissection:

   • Identify and protect the saphenous vein and nerve
   • Develop the interval between the medial head of gastrocnemius and pes anserinus
   • Retract the medial gastrocnemius laterally to expose the posterior capsule 2

3. Fracture Exposure:

   • Incise the posterior capsule vertically to expose the posteromedial tibial plateau
   • Identify the fracture apex and fragment
   • Carefully protect the neurovascular structures, particularly the popliteal vessels 2

4. Fracture Reduction:

   • Apply extension and valgus to the knee to aid reduction
   • Use direct manipulation with bone clamps or elevators to reduce the fragment
   • Temporary K-wire fixation to maintain reduction 2

5. Plate Fixation:

   • Apply a small fragment antiglide plate (3.5mm) to the posteromedial surface
   • Position plate to function as a buttress against shear forces
   • Secure with appropriate screws (typically 3.5mm cortical and/or 4.0mm cancellous) 2

Anterolateral Approach (for Lateral and Posterolateral Fragments)

1. Skin Incision:

   • Make a straight or slightly curved incision 2-3 cm lateral to the tibial crest
   • Extend from 3 cm below the joint line to approximately 10 cm distally 3

2. Deep Dissection:

   • Develop the interval between the tibialis anterior and the lateral compartment
   • Elevate the anterior compartment muscles from the lateral tibial surface
   • For posterolateral fragments, extend dissection posteriorly by subperiosteal elevation 3, 4

3. Fracture Exposure:

   • For lateral plateau fractures, perform a submeniscal arthrotomy to visualize the articular surface
   • For posterolateral fragments, use a modified anterolateral approach with extended subperiosteal dissection 3

4. Fracture Reduction:

   • Elevate depressed articular fragments using a bone tamp through a cortical window
   • Fill metaphyseal defects with bone graft when depression is >11mm 1
   • Use pointed reduction clamps to reduce split fragments
   • Temporary K-wire fixation to maintain reduction

5. Plate Fixation:

   • For lateral plateau: Apply a lateral locking plate
   • For posterolateral fragments: Use a rim plate or specialized posterolateral buttress plate 3
   • For complex bicondylar fractures: Consider dual plating with both medial and lateral plates

Bone Grafting Considerations

• Bone grafting is indicated when:
  • Severe depression (>11mm) is present
  • Significant metaphyseal comminution exists
  • Poor bone quality/osteoporosis is present
  • Posterolateral depression is difficult to support with standard fixation 1
• Options include:
  • Autograft (iliac crest)
  • Allograft
  • Synthetic bone substitutes
  • Periarticular rafting constructs without bone graft can achieve good results in select cases 1

Wound Closure

1. Irrigate wounds thoroughly
2. Close the deep fascia with absorbable sutures
3. Close subcutaneous tissue and skin in layers
4. Apply sterile dressing and hinged knee brace

Post-operative Management

• Early range of motion exercises to optimize functional outcomes 1
• Progressive weight-bearing based on fracture pattern and fixation stability
• Hinged knee braces to facilitate protected motion and stabilize the knee joint 1
• Physical therapy to focus on:
  • Range of motion
  • Quadriceps strengthening
  • Gait training

Potential Complications

• Postoperative arthritis
• Infection
• Malalignment
• Articular incongruity
• Instability
• Need for knee arthroplasty in severe cases 1

Special Considerations

• For posterolateral fragments, the anterior approach can be safely used with careful preoperative planning, avoiding the complications associated with direct posterior approaches 4
• For complex bicondylar fractures, staged fixation may be necessary to minimize soft tissue complications 5
• When treating fractures with short proximal fragments, consider external fixation as an adjunct to maintain alignment 6

By following this systematic approach to proximal tibial fracture plating via both posterior and anterior approaches, optimal reduction and stable fixation can be achieved, leading to improved functional outcomes and reduced complication rates.