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

Surgical Procedure for Proximal Tibial Fracture with Medial and Lateral Plating Using Anterior and Posterior Approaches

The optimal surgical approach for proximal tibial fractures requiring medial and lateral plating involves a combination of anterior and posterior approaches to achieve proper reduction and stable fixation, with specific techniques based on fracture pattern and location.

Patient Positioning and Preparation

• Begin with the patient in prone position for the posterior approach, which allows direct access to posteromedial and posterolateral fragments that are difficult to visualize and fix from anterior approaches 1
• Prepare and drape the entire limb circumferentially to allow intraoperative repositioning if needed 2
• Ensure appropriate neurophysiological monitoring is in place to detect potential nerve injuries during the procedure 3

Posterior Approach - First Stage

Posteromedial Approach

• Make a direct posteromedial skin incision and develop a deep interval between the medial collateral ligament and posterior oblique ligament 1
• Expose the posteromedial pillar and posterior flare of the proximal tibia 1
• Reduce the fracture fragment through direct manipulation or indirect techniques 1
• Fix the fragment with subchondral lag screws and an anti-glide plate at the tip of the fragment 1, 4

Posterolateral Approach

• Create a lateral skin incision and carefully dissect the peroneal nerve 1, 5
• Perform an osteotomy of the fibular neck and divide the tibiofibular syndesmosis 1, 5
• Reflect the fibular head upward in one layer with the meniscotibial ligament and iliotibial tract attachment 1
• This maneuver relaxes the lateral collateral ligament, allows lateral joint opening and internal rotation of the tibia, exposing the posterolateral and posterior aspects of the tibial plateau 1, 5
• Apply fixation with buttress plates on the posterolateral side 1, 5
• Fix the fibular head back with a lag screw or tension-band system during closure 1

Patient Repositioning

• After completing the posterior fixation, reposition the patient to supine for the anterior approach 2
• Redrape the limb maintaining sterility 2

Anterior Approach - Second Stage

Anterolateral Approach

• Make an anterolateral incision for exposure of the lateral tibial plateau 2, 6
• Develop the interval between the anterior compartment muscles and the iliotibial band 2
• Reduce any remaining depression of the articular surface using bone tamps or elevators 2
• Fill metaphyseal defects with bone graft or bone graft substitutes 2, 6
• Apply a lateral locking plate using minimally invasive plate osteosynthesis (MIPO) technique 6

Anteromedial Approach (if needed)

• If additional access to the medial plateau is required, make an anteromedial incision 2
• Develop the interval between the pes anserinus and the medial collateral ligament 4
• Apply medial buttress plating after appropriate reduction 2

Fixation Principles

• Ensure subchondral support of the articular surface with rafting screws or specialized proximal tibial plates 2, 6
• Apply the "three-column fixation" concept, addressing lateral, medial, and posterior columns of the proximal tibia for complex fractures 2
• Use locking plates for metaphyseal comminution and osteoporotic bone 6
• Consider additional lag screws for specific fragments to enhance stability 6

Wound Closure and Post-operative Care

• Perform meticulous layered closure with attention to the soft tissue envelope 1
• Consider drain placement based on the extent of dissection and bleeding 2
• Apply a hinged knee brace to allow early range of motion while protecting the repair 2, 6
• Begin immediate post-operative mobilization with non-weight bearing for at least 6 weeks 6
• Progress to weight bearing based on clinical and radiographic evidence of healing 6

Potential Complications and Management

• Monitor for peroneal nerve injury, particularly with the posterolateral approach 1, 5
• Watch for varus/valgus deformity development, which may require revision surgery 1
• Be vigilant for wound complications, especially with extensive surgical approaches 1, 2
• Consider early bone grafting for cases with significant initial bone defects 6

This combined anterior and posterior approach strategy allows for direct visualization and reduction of complex proximal tibial fractures, with studies showing satisfactory reduction in most cases and good functional outcomes 1, 2.