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Prone Posteromedial Approach for Posterior Column Tibial Plateau Fractures

Foster, Brock MD; Rodriguez-Buitrago, Andres MD; Obremskey, William T. MD

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Journal of Orthopaedic Trauma: August 2020 - Volume 34 - Issue - p S35-S36
doi: 10.1097/BOT.0000000000001832
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Abstract

Posterior column tibial plateau fracture stabilization has been recognized as important in maintaining a well-reduced joint line.1 Inadequate reduction or stabilization has been found to increase the risk of surgical failure.2,3

Restoring the mechanical axis of the knee has been found to be the most important prognostic factor in treating tibial plateau fractures.4,5 Coronal alignment is most commonly discussed, but recreating sagittal plane mechanical alignment is also critically important. Anterior translation of the distal fragment with the posterior sag of the femur and a posterior plateau fragment is best treated with posterior reduction and buttress plate fixation. As such, approaches that allow access to these fragments are important to joint line reduction and stabilization.

Reduction and stabilization of these fragments can be accomplished in a variety of ways.6–9 One surgical option is the posteromedial approach in the prone position. The sloppy lateral or supine position has also been described and allows access to the anterior and anterolateral plateau while still providing access to the posterior column.8 However, if the posterior fracture line is too far posterior or lateral, reduction and stabilization from a supine position can be challenging. Prone positioning provides improved access to the posteromedial and posterolateral tibial plateau. Described here are the steps we used to reduce and stabilize a posterior column tibial plateau fracture from a prone position.

The case presented here is of a 60-year-old man who sustained a posterior column shear-type tibial plateau fracture after a fall down the stairs. The patient was indicated for open reduction and internal fixation using a buttress plate because of tibiofemoral incongruence and sagittal instability.

The patient is intubated on the hospital bed. A nonsterile tourniquet is applied before prone positioning on a radiolucent flat top table, with 2 gel rolls placed longitudinally under the chest. The operative leg is elevated off the bed with bumps, pillows, or foam positioners placed under the knee and thigh before preparing and draping the limb. Unimpeded knee extension is necessary to reduce the fracture, which is difficult if the thigh and the knee are not in an elevated position. Preoperative antibiotics are given within 1 hour of incision. We prefer to use Ancef even in patients with a penicillin allergy if the reaction is not severe.

An inverted “L” incision is used to provide improved access to the entire posterior tibia, from the popliteal crease proximally then taken down the medial border of the gastrocnemius distally. During superficial dissection, a bump is placed under the ankle to relieve gastrocnemius tension. Subcutaneous dissection is taken down to the gastrocnemius fascia. Care should be taken to avoid injury to the small saphenous vein and saphenous nerve (located posterior to the sartorius tendon). The interval between the posterior border of the gastrocnemius and the semimembranosus tendon is developed to provide access to the posteromedial proximal tibia. The soleus muscle is dissected from the posteromedial tibia. The popliteus muscle belly is then elevated off the posterior tibia subperiosteally to protect the popliteal neurovascular bundle from iatrogenic injury. Dissection of the posterior tibia is then facilitated from the joint line proximally to the lateral border of the tibia. Excessive distal and lateral dissection can result in injury to the posterior tibial recurrent artery.

The semimembranosus tendon can be tagged and divided if more anterior exposure is necessary. The medial collateral ligament is located anterior to this and should be protected. Access to articular impaction is provided through the posterior fracture window. An arthrotomy may be used to visualize articular reduction at the posteromedial joint line or by longitudinally splitting the medial collateral ligament and performing an arthrotomy deep to the longitudinal split. The location of arthrotomy, if required, is dependent on where the fracture line exits the tibial plateau.

Reduction of the posterior column fragment can only be performed with the knee in full extension. Several towel bumps can be applied under the knee to accomplish this. Multiple reduction aids can help facilitate anatomic alignment. Use of an elevator or osteotome to lever the 2 fragments back into the position is frequently effective. Provisional reduction may be maintained with K-wires or a point-to-point clamp placed percutaneously from the posterior to anterior. Provisional application of small or minifragment plates may also be useful before definitive plate application. Anatomic reduction is then maintained with an undercontoured buttress plate. In this case, an anatomic small fragment posterior proximal tibial T-plate was applied. If needed, separate posterolateral and posteromedial plates can be used to achieve buttress fixation of separate fragments.

After reduction and stabilization, the knee should be examined through a range of motion and varus/valgus stresses. Any instability should be addressed based on the perceived location and etiology of instability. Bony instability should be addressed with further reduction and stabilization, whereas soft-tissue instability may be treated with repair, reconstruction, or appropriate bracing when weight bearing is initiated.

The tourniquet is released, hemostasis achieved, and the wound is irrigated copiously. One gram of vancomycin powder is placed adjacent to the plate(s) before closure. If the semimembranosus was tenotomized, it may be primarily repaired with a nonabsorbable suture or stabilized with a suture anchor. Layered closure is performed.

A brace typically is not used, and the patient may begin immediate range-of-motion exercises. Weight bearing is initiated at 6–12 weeks, depending on bone quality, reduction quality, severity of bone injury, patient compliance, and associated injuries. Antibiotics are continued for 24 hours postoperatively. Chemical deep vein thrombosis prophylaxis is recommended for 4 weeks postoperatively. Sutures are removed at 3 weeks, and intermittent follow-up is used to confirm fracture reduction and implant position as well as evaluate the range of motion and healing of the skin and bone. Outcomes are generally related to the severity of articular injury, articular reduction, and recreation of mechanical alignment. Arthrosis at long-term follow-up is common, but conversion to total knee arthroplasty is uncommon with appropriate reduction and healing.

REFERENCES

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Keywords:

posteromedial; prone; plateau; fracture

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