What is the step-by-step procedure for treating a fracture of the proximal tibia dome using plating?

Surgical Procedure for Proximal Tibial Dome Fracture Plating

The optimal surgical treatment for proximal tibial dome fractures requires complete excision of the fracture site, sufficient autogenous bone grafting, and proper fixation using a combination of external fixator with intramedullary fixation. 1

Pre-operative Assessment and Preparation

• Evaluate full blood count, urea and electrolytes as routine pre-operative investigations 1
• Assess for anemia (common in 40% of fracture patients) - consider pre-operative transfusion if Hb < 9 g/dL 1
• Review current medications to avoid adverse drug reactions, especially in elderly patients 1
• Obtain ECG for all patients 1
• Cross-match blood if Hb is 10-12 g/dL (two units recommended) 1
• Consider patient-specific factors that may affect fluid tolerance and surgical risk 2

Surgical Approach Selection

The surgical approach depends on the fracture pattern:

• Anterolateral approach: Most common for lateral plateau fractures and provides good visualization of the lateral and anterior aspects of the tibial plateau 3
• Posteromedial approach: Used for medial plateau fractures with posterior displacement 3
• Combined approaches: Required for complex bicondylar fractures 4
• Modified anterolateral approach: Effective for posterolateral fracture fragments 5

Step-by-Step Surgical Procedure

1. Patient Positioning and Preparation

• Position patient supine on a radiolucent table
• Apply tourniquet (optional based on surgeon preference)
• Prepare and drape the limb in sterile fashion
• Ensure C-arm availability for intraoperative imaging

2. Surgical Approach

• Make appropriate skin incision based on fracture pattern
• Carefully dissect through subcutaneous tissue
• Identify and protect neurovascular structures
• Create a submeniscal arthrotomy to visualize the articular surface

3. Fracture Reduction

• Completely excise the pseudarthrosis/fracture site 1
• Elevate depressed articular fragments using a bone tamp
• Temporarily fix fragments with K-wires
• Verify reduction with fluoroscopy
• Aim for anatomic reconstruction of articular surfaces and restoration of limb alignment 4

4. Bone Grafting

• Apply sufficient autogenous bone graft to fill defects 1
• Harvest bone graft from iliac crest or use synthetic substitutes if necessary
• Pack the graft firmly into the defect to provide structural support

5. Fixation

• Apply appropriate plate(s) based on fracture pattern:
  • Lateral buttress plate for lateral plateau fractures
  • Medial buttress plate for medial plateau fractures
  • Dual plating for bicondylar fractures 4
  • Consider triple plating for complex fractures with biplaner medial plateau involvement 4
• Position plate(s) to buttress the fracture fragments
• Insert locking screws to secure the plate to the bone
• Avoid placing screws through the tibial plateau into the joint
• Consider combining external fixation with intramedullary fixation for better stability 1

6. Intraoperative Assessment

• Verify reduction and fixation with fluoroscopy in multiple planes
• Check knee stability through range of motion
• Ensure proper limb alignment

7. Wound Closure

• Irrigate the wound thoroughly
• Place drain if necessary
• Close the wound in layers
• Apply sterile dressing and splint as needed

Post-operative Management

• Aim for 1-2L positive fluid balance by the end of surgery 2
• Use crystalloids rather than colloids for routine fluid administration 2
• Encourage early oral fluid intake rather than routine IV fluids 2
• Remove urinary catheters as soon as possible to reduce infection risk 2
• Monitor for signs of hypovolemia and assess fluid balance regularly 2
• Begin early range of motion exercises as tolerated
• Delay weight-bearing based on fracture pattern and fixation stability

Complications to Monitor

• Infection (particularly in open fractures) 6
• Nonunion requiring additional procedures like bone grafting 6
• Malunion (varus/valgus or procurvatum/recurvatum) 6
• Hardware failure
• Acute kidney injury, especially with restrictive fluid strategies 2
• Postoperative cognitive dysfunction related to fluid and electrolyte imbalances 2

Special Considerations

• For complex bicondylar fractures, dual or triple plating through multiple incisions may be necessary 4
• Percutaneous locked plating techniques show promising results with minimal complications for extra-articular proximal tibia fractures 6
• Rim plating may be beneficial for posterolateral fracture fragments 5
• Average time for union is approximately 20 weeks in closed fractures and 25 weeks in open fractures 6