Surgical Approach for Posterior Lateral Tibial Plateau Fractures
For posterior lateral tibial plateau fractures, use an extended lateral approach with either lateral femoral epicondyle osteotomy or Gerdy's tubercle osteotomy to achieve direct visualization and anatomic reduction of the posterior articular surface, as standard anterolateral approaches provide inadequate exposure for these fractures.
Approach Selection Based on Fracture Location
The key determinant is the fracture's relationship to the posterolateral ligamentous complex 1:
- Fractures posterior to the posterolateral complex (25% of cases): These require extended lateral approaches in 80% of cases and mandate prone or lateral patient positioning 1
- Fractures at the level of the posterolateral complex (36% of cases): Often require extended approaches for adequate visualization 1
- Fractures anterior to the posterolateral complex (38% of cases): May be managed with standard lateral approaches 1
Recommended Extended Lateral Approaches
Lateral Femoral Epicondyle Osteotomy
- Provides excellent visualization of the posterolateral articular surface without requiring fibular osteotomy 2
- Allows direct access to posterior fracture fragments while preserving soft tissue attachments 2
- Most commonly utilized extended approach, performed in 17.5% of lateral plateau fractures 1
Gerdy's Tubercle Osteotomy (Tscherne-Johnson Approach)
- Involves osteotomy of Gerdy's tubercle with external rotation to create a window for joint visualization 3
- Alternative technique uses partial tenotomy of the anterior half of the iliotibial band while maintaining posterior insertion 3
- Achieved articular depression reduction from 18mm to 1mm in posterior plateau fractures 3
- Demonstrated excellent outcomes with average knee flexion >120° and minimal complications (1/76 infection rate) 3
Combined Anterolateral Approach with Gerdy's Tubercle Osteotomy
- Recent data from 20 patients showed this approach allows direct exposure and manipulation of posterior lateral bone blocks 4
- Achieved 16 excellent, 3 good, and 1 fair HSS knee scores at 12-24 month follow-up 4
- Fracture healing occurred within 9-12 weeks without complications including infection, nerve injury, or displacement 4
Novel Posterolateral Approach Without Fibular Osteotomy
For isolated posterolateral fractures, a combined approach through a single posterolateral skin incision provides 5:
- Lateral arthrotomy for joint surface visualization
- Posterolateral exposure for fracture reduction and buttress plate fixation
- Avoids fibular osteotomy and maintains soft tissue attachments to bone fragments 5
- Achieved anatomic reduction in 6/7 patients with no complications or loss of reduction 5
Critical Technical Considerations
Patient Positioning: Fractures extending posterior to the posterolateral complex require prone or lateral positioning rather than supine positioning to facilitate adequate exposure 1
Fixation Strategy: Use buttress plate fixation on the posterior aspect of the tibial plateau, as these fractures cannot be adequately stabilized through anterior or lateral approaches alone 5
Avoid Standard Lateral Approaches: Standard anterolateral approaches without extension provide insufficient visualization of posterolateral articular depression and risk inadequate reduction 5, 2
Common Pitfalls
- Attempting reduction through inadequate exposure: Standard lateral approaches miss posterior articular fragments, leading to residual depression and poor outcomes 5
- Fibular osteotomy complications: While some surgeons perform fibular head osteotomy, newer approaches avoid this to reduce soft tissue trauma and fragment devascularization 5, 2
- Inadequate preoperative CT evaluation: Failure to identify the exact relationship of the fracture to the posterolateral complex results in inappropriate approach selection 1