What are the surgical approaches for an adult patient with no significant medical history and a condition affecting the posterior tibia plateau, such as a fracture or osteochondritis dissecans?

Surgical Approaches to the Posterior Tibial Plateau

For posterior tibial plateau fractures, use a direct posterior approach with the patient prone, which provides optimal visualization and fixation of posterior column injuries; for posterolateral fractures specifically, a combined lateral arthrotomy with posterolateral approach through a single skin incision avoids fibular osteotomy while maintaining adequate exposure. 1, 2

Approach Selection Algorithm

Direct Posterior Approach (Prone Position)

• Use this as your primary approach for isolated posterior column fractures - it affords enhanced exposure and ease of access for buttress plate fixation with posterior-to-anterior screws 1, 3
• The "FCR" technique uses a single longitudinal incision rather than a reverse L-shaped incision, reducing complications associated with raising fascial flaps 3
• This approach is essential because anterolateral and anteromedial approaches do not permit adequate reduction and fixation of posterior fragments 4

Posterolateral Approach Without Fibular Osteotomy

• For posterolateral corner fractures (approximately 7% of all tibial plateau fractures), use a combined approach through one posterolateral skin incision that includes both lateral arthrotomy for joint visualization and posterolateral access for reduction and plating 2
• This technique avoids the trauma of fibular osteotomy and release of the posterolateral corner, preventing fragment denudation 2
• Achieves direct visual exposure of the articular surface while facilitating buttress plate application without detaching fragments from soft tissue 2

Posteromedial Approach

• Required for posteromedial fragment fixation when these fragments are present, as anterior approaches cannot adequately address them 4
• Specific posteromedial approaches allow optimal reduction and plate/screw placement for these fragment patterns 4

Key Surgical Principles

Fracture Classification and Planning

• Use three-dimensional imaging and newer classification systems (Quadrant System, 3D systems) that incorporate posterior column lesions, as early classification systems failed to classify posterior plateau fractures 1
• The concept of the proximal tibia as a three-column structure has fundamentally changed treatment strategy 4

Fixation Goals

• Achieve anatomic articular reduction with buttress plate fixation on the posterior aspect of displaced posterolateral fractures 2
• Restore limb alignment and articular surface congruency to allow early knee motion 4, 5
• Bone grafting and buttress plating are usually needed after joint surface restoration to optimize outcomes 5

Critical Pitfalls to Avoid

• Never attempt to fix posterior column fractures through anterolateral or anteromedial approaches alone - these do not permit adequate reduction and fixation of posterior fragments 4
• Avoid standard posterolateral approaches with fibular osteotomy when possible, as this is unnecessarily traumatic and risks fragment denudation 2
• Do not use isolated posterior approaches for complex fractures without adequate visual control of fracture reduction 2
• Timing of surgery and soft-tissue handling are critical to treatment success - carefully evaluate the soft-tissue envelope before proceeding 1, 5

Staged Treatment Considerations

• Sequential (staged) treatment with external fixation followed by definitive osteosynthesis is recommended for more complex fracture patterns with soft-tissue complications 4
• Remember that any type of tibial plateau fracture can present with soft-tissue complications requiring staged management 4