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

Step-by-Step Procedure for Proximal Tibial Fracture Plating with Multiple Approaches

The optimal surgical approach for proximal tibial fractures requiring medial, lateral, anterior, and posterior plating involves a comprehensive multi-column fixation technique with specific patient positioning and sequential surgical steps to achieve anatomic reduction and stable fixation.

Preoperative Planning

• Obtain high-quality CT scans and MRI to assess fracture pattern, degree of comminution, and involvement of different columns (medial, lateral, posterior) 1
• Plan for appropriate patient positioning based on the approaches needed - consider "floating position" for combined approaches 2
• Prepare necessary implants including small fragment plates, lag screws, and buttress plates for all columns 2

Patient Positioning

• For combined anterior/lateral with posterior approaches, position the patient in "floating position" (lateral decubitus with the affected limb uppermost) to allow access to multiple surfaces 2
• Alternatively, begin in supine position for anterior/lateral approaches, then reposition to prone for posterior approaches 3

Surgical Approaches

1. Anterolateral Approach (Lateral Column)

• Make a straight or L-shaped incision along the anterolateral aspect of the proximal tibia 2
• Develop the interval between the anterior compartment muscles and the iliotibial band 2
• Expose the lateral tibial plateau while protecting the anterior tibial artery and deep peroneal nerve 1
• Reduce depressed fragments using a bone tamp and fill defects with bone graft 2
• Apply lateral buttress plate with subchondral lag screws 2

2. Posteromedial Approach (Medial Column)

• Position a direct posteromedial skin incision between the medial border of the gastrocnemius and the pes anserinus 4
• Develop the interval between medial collateral ligament and posterior oblique ligament 3
• Visualize the posteromedial pillar and posterior flare of the proximal tibia 3
• Reduce the fracture through direct manipulation or indirect techniques 3
• Apply antiglide plate at the tip of the fragment with subchondral lag screws 4

3. Posterolateral Approach (Posterior Lateral Column)

• Make a lateral skin incision and carefully identify and protect the peroneal nerve 3
• Perform osteotomy of the fibular neck and divide the tibiofibular syndesmosis 3
• Reflect the fibular head upward in one layer with the meniscotibial ligament and iliotibial tract attachment 3
• This maneuver relaxes the lateral collateral ligament, allows lateral joint opening and internal rotation of the tibia 3
• Expose the posterolateral and posterior aspect of the tibial plateau 3
• Apply buttress plate on the posterolateral side 3
• Fix the fibular head back with a lag screw or tension-band system during closure 3

4. Anterior Approach (For Central Depression)

• Use a midline anterior approach if needed for central depression fragments 1
• Perform subperiosteal dissection to expose the fracture site 1
• Elevate depressed fragments and support with bone graft 2
• Apply anterior buttress plate if necessary 2

Fracture Reduction Technique

• Begin with indirect reduction techniques using ligamentotaxis with the knee in extension and valgus/varus stress 3
• For depressed fragments, create a cortical window and use a bone tamp to elevate fragments 2
• Fill metaphyseal defects with bone graft or bone substitute 2
• Use pointed reduction clamps for displaced fragments 2
• Apply temporary K-wires to maintain reduction 2

Fixation Strategy

• Apply "three-column fixation" concept for complex tibial plateau fractures 2
• Begin with posterior column fixation (most difficult to access) 2
• Proceed to medial column fixation 2
• Complete with lateral column fixation 2
• Use subchondral lag screws for articular fragments 3
• Apply buttress plates in antiglide fashion at each column 2

Specific Considerations

• For posteromedial fracture-dislocations (Moore type I), focus on direct reduction and antiglide plate fixation 3
• For posterolateral fractures with depression, the transfibular approach provides the best visualization 5
• For fractures extending into the diaphysis, consider a single lateral locking plate using MIPO technique 6
• For bicondylar posterior fractures, combine both posteromedial and posterolateral approaches 3

Closure and Post-Operative Management

• Perform meticulous layered closure of each approach 2
• Apply sterile dressings and hinged knee brace 2
• Begin immediate knee mobilization to prevent stiffness 6
• Maintain non-weight bearing for at least 6 weeks 6
• Progress to partial weight bearing based on radiographic evidence of healing 6

Potential Complications and Prevention

• Wound complications: Use separate incisions with adequate skin bridges (≥7 cm) between approaches 2
• Neurovascular injury: Careful identification and protection of peroneal nerve during posterolateral approach 3
• Malreduction: Use intraoperative fluoroscopy to confirm articular congruity (aim for <2mm step-off) 2
• Secondary displacement: Ensure adequate buttressing of all columns 2
• Knee stiffness: Begin early range of motion exercises 6

This comprehensive approach to proximal tibial fractures using multiple surgical approaches allows for direct visualization, anatomic reduction, and stable fixation of complex fracture patterns, leading to improved outcomes and reduced complications 2.