What are the approaches for proximal tibia plating?

Approaches for Proximal Tibia Plating

The medial approach is the most effective surgical approach for proximal tibia plating, providing sufficient access while minimizing soft tissue complications through minimally invasive techniques. 1

Surgical Approaches for Proximal Tibia Plating

Medial Approach

• Provides excellent access to the medial and posteromedial aspects of the proximal tibia
• Particularly useful when there is intact medial soft tissue coverage
• Advantages:
  • Minimizes soft tissue devitalization
  • Allows for buttressing of posteromedial fragments
  • Can be performed using minimally invasive techniques (MIPO)
  • Demonstrates good healing rates with mean union time of 17-20 weeks 1, 2
• Technique:
  • Limited medial incision
  • Submuscular plate insertion
  • Minimal periosteal stripping to preserve blood supply

Lateral Approach

• Most commonly used approach for tibial plateau fractures
• Provides excellent visualization of the lateral plateau and metaphysis
• Can be performed using minimally invasive techniques
• Allows placement of lateral locking plates (LISS - Less Invasive Stabilization System)
• Advantages:
  • Familiar approach for most surgeons
  • Good access to lateral and anterolateral fracture components
  • Can be extended proximally for articular reduction when needed

Anterolateral Approach

• Useful for fractures with anterolateral involvement
• Provides good access to the lateral plateau and proximal shaft
• Can be performed using minimally invasive techniques
• Advantages:
  • Less soft tissue disruption than traditional lateral approach
  • Good visualization of anterolateral fragments
  • Facilitates placement of buttress plates

Posterior Approaches

• Indicated for posterior fragment fixation
• Options include:
  • Posteromedial approach: For posteromedial fragment fixation
  • Posterolateral approach: For posterolateral fragment access
• Often used in combination with anterior approaches for complex fractures

Minimally Invasive Plate Osteosynthesis (MIPO) Techniques

MIPO has emerged as the preferred technique for proximal tibia plating, showing excellent results across multiple studies:

• Involves small incisions for plate insertion without extensive soft tissue dissection
• Preserves periosteal blood supply and fracture hematoma
• Key benefits:
  • Reduced infection rates (5.8% deep infection rate even in open fractures) 3
  • Faster union times (average 17 weeks) 2
  • Better functional outcomes
  • Lower complication rates

Plate Options and Fixation Techniques

Locking Plates

• Less Invasive Stabilization System (LISS)
  • Functions as an "internal-external fixator"
  • Particularly useful for comminuted fractures
  • Deep infection rates comparable to IM nails or external fixators 3

Conventional Plates

• 4.5mm DCP (Dynamic Compression Plate)
• LC-DCP (Limited Contact Dynamic Compression Plate)
• Used in specific cases where locking plates may not be necessary

Surgical Technique Considerations

1. Preoperative Planning

   • Plain radiographs and CT scans for articular fracture components
   • Assess soft tissue status to determine approach

2. Patient Positioning

   • Supine position with knee flexed 30° on radiolucent table
   • Tourniquet application optional

3. Approach Selection

   • Based on fracture pattern and soft tissue condition
   • Medial approach preferred when medial soft tissue intact 1
   • Lateral/anterolateral for lateral plateau involvement

4. Reduction Techniques

   • Direct visualization for articular components
   • Indirect reduction for metaphyseal components
   • Temporary K-wire fixation

5. Plate Application

   • Submuscular tunneling
   • Minimal periosteal stripping
   • Proper plate positioning confirmed with fluoroscopy

Outcomes and Complications

• Union rates: 80-95% primary union 4, 5
• Mean time to union: 17-20 weeks for closed fractures 2, 4
• Functional outcomes: Mean Knee Society score of 88.7 5
• Complications:
  • Infection (3-10%)
  • Malunion (up to 20%)
  • Non-union (rare with proper technique)

Special Considerations

• Open Fractures:

  • Primary MIPO can be performed if soft tissue allows
  • Staged approach (temporary external fixation followed by MIPO) for severe soft tissue injury
  • Deep infection rates of 5.8% reported even in open fractures 3

• Articular Involvement:

  • May require combined approaches
  • Consider arthroscopically assisted techniques for better visualization

Pitfalls and Pearls

• Pitfalls to Avoid:

  • Excessive soft tissue stripping
  • Improper plate positioning
  • Inadequate reduction of articular surface

• Pearls:

  • Use fluoroscopy liberally to confirm reduction and implant position
  • Consider temporary external fixation for severe soft tissue injury
  • Ensure adequate soft tissue coverage over implants

The medial approach with MIPO technique offers an excellent balance of adequate exposure and soft tissue preservation for proximal tibia fractures, making it the preferred approach when medial soft tissue is intact.