What is the step-by-step procedure for a proximal tibia fracture treated with plating through an anterolateral approach?

Step-by-Step Procedure for Proximal Tibia Fracture Plating via Anterolateral Approach

The anterolateral approach is the workhorse approach for lateral tibial plateau fractures, providing excellent visualization of the lateral joint, metaphysis, and shaft extension while minimizing soft tissue complications.

Patient Positioning and Setup

1. Position the patient supine on a radiolucent operating table with a bump under the ipsilateral hip to neutralize the natural external rotation of the limb
2. Apply a tourniquet high on the thigh and prepare and drape the entire limb
3. Place a femoral distractor to assist with joint visualization and facilitate reduction 1
4. Ensure C-arm availability for intraoperative fluoroscopic guidance

Surgical Approach

1. Make a longitudinal skin incision starting 3-4 cm proximal to the joint line, 1-2 cm lateral to the patellar tendon, extending distally along the anterolateral aspect of the proximal tibia
2. Develop the subcutaneous tissue to expose the iliotibial band proximally and the tibialis anterior distally
3. Incise the iliotibial band in line with the skin incision
4. Identify and protect the anterior tibial recurrent vessels at the proximal aspect of the incision
5. Retract the tibialis anterior muscle from the lateral aspect of the proximal tibia

Joint Exposure

1. Perform a submeniscal arthrotomy by incising the coronary ligament of the lateral meniscus to visualize the articular surface 1
2. Place stay sutures in the meniscus to retract it superiorly for better joint visualization
3. Inspect the articular surface for cartilage damage and associated soft tissue injuries

Fracture Reduction

1. Elevate depressed articular fragments using one of these techniques:

   • Create a cortical window using a triple reamer from a sliding hip screw set 1
   • Use a bone tamp or elevator inserted through a metaphyseal window
   • Use a Cobb elevator or periosteal elevator for direct reduction

2. Support the elevated fragments with:

   • Cancellous bone graft or bone substitute to fill the metaphyseal void
   • Temporary K-wires to maintain reduction

3. Reduce and align the lateral condyle to restore the anatomical joint surface

   • Use pointed reduction clamps or K-wires for provisional fixation
   • Confirm reduction with direct visualization and fluoroscopy

Plate Application

1. Select appropriate plate - typically a precontoured lateral locking plate designed for the proximal tibia

2. Position the plate on the anterolateral surface of the proximal tibia

3. Secure the plate proximally with:

   • Subchondral rafting screws to support the articular surface
   • Locking screws in the proximal fragment

4. Secure the plate distally with:

   • Combination of locking and non-locking screws in the shaft
   • At least 3 bicortical screws in the shaft for adequate fixation

5. For posterolateral fragments:

   • Use a rim plate technique with screws directed posteriorly 2
   • Consider additional buttress plating if needed for complex fractures

Final Steps

1. Perform final fluoroscopic assessment in multiple planes to confirm:

   • Articular congruity
   • Proper plate and screw positioning
   • Overall limb alignment

2. Irrigate the wound thoroughly

3. Close the arthrotomy with absorbable sutures

4. Close the iliotibial band and fascia with absorbable sutures

5. Close subcutaneous tissue and skin in layers

6. Apply sterile dressing and splint as needed

Special Considerations

• For complex bicondylar fractures: Consider dual plating through separate incisions 3
• For fractures with shaft extension: Extend the approach distally along the anterolateral tibia
• For posterolateral fragments: Use a modified anterolateral approach with rim plating technique 2

Postoperative Management

1. Begin early range of motion exercises as soon as soft tissues allow
2. Restrict weight-bearing initially, progressing based on fracture healing
3. Follow radiographic healing with regular imaging until union is achieved

Potential Complications

• Infection: Higher risk with open fractures or compromised soft tissues
• Malunion: Can occur in up to 20% of cases 4
• Non-union: May require bone grafting if it occurs
• Hardware irritation: May necessitate plate removal after healing

The anterolateral approach provides safe and effective access for the majority of lateral tibial plateau fractures while minimizing soft tissue complications that can occur with more extensive approaches.