Do you ever do that thing where you think you read/studied something, but then you don't remember it, and you look back, and you realize that you only highlighted the first two pages of an article before giving up?
I do that thing all the time.
What I learned today
Your options:
anterolateral approach - most frequently used, good for Schatzker 2, 6, 5
medial approach - Schatzker 4, or combined with anterolateral for a dual-incision approach for bicondylar fx. Hoppenfeld's book just groups this with posteromedial
posteromedial approach - medial plateau shear fx where the buttress plate is placed posterior or posteromedial (for coronal plane fx) or medial (for sagittal plane fx)
posterolateral approach - for displaced posterolateral fragment
(direct) posterior approach - due to proximity of popliteal neurovascular bundle, reserved for coronal plane shear fx of the posterior plateau or PCL insertion avulsion with extension into articular surface
A little more about each option (with picturessss!):
Anterolateral approach
Position: supine with hip bump, knee flexed to 60 deg
Incision: curvilinear/L or a lazy S (similar to below but proximally curves laterally over the IT band)
Incise and elevate the proximal medial tibialis anterior to expose the lateral tibia
For visualization of the lateral plateau, incise the capsule/retinaculum below the proximal border of the plateau. Partially detach the lateral meniscus from the plateau, while maintaining anterior attachment and using stay sutures for reattachment upon closure.
Medial approach
As I mentioned, Hoppenfeld doesn't list this as a separate approach, whereas the article that I didn't read does. The authors say it would be used for an anteromedial plate. Here’s a reminder of the interesting shape of the proximal tibia:
Position: supine with hip bump, knee bent 15 deg
Incision: 1-3 cm above joint line and in line with medial femoral epicondyle, distally bisecting the posteromedial border of the tibia and the tibial crest
Watch out for the saphenous nerve and vein posteriorly (may vary)
Incise the sartorius fascia and identify the gracilis and semitendinosus tendons
Expose the superficial MCL
Indirect reduction is performed, and the plate is applied directly “over the MCL structures without elevation or mobilization”
Posteromedial approach
Supine:
Position: supine with a contralateral hip bump (bringing the posteromedial side into view), surgeon on the contralateral side
Incision: 6 cm along posteromedial border of proximal tibia
Watch out for the saphenous nerve and vein anteriorly
Next, divide the pes anserinus longitudinally and reflect anteriorly (direct approach), or reflect all of the tendons posteriorly (may require partial resection)
Gently free the medial gastrocnemius off the bone as needed and retract laterally for plate placement
Prone:
Position: prone with a contralateral hip bump, folded blanket under ipsilateral thigh (useful for coronal shear fx, bad if there’s a lateral plateau fx that requires supine position — can’t flip the pt back and forth)
Incision: more posterior and lateral than the supine position; start above the joint line and run along the medial border of the medial gastroc
Again, retract the gastroc laterally, but don’t have to dissect out the pes tendons anteriorly
Welp, that seems plenty for today. I’ll probably wrap up the posterolateral and posterior approaches tomorrow.
Sources
Kandemir U, Maclean J. Surgical approaches for tibial plateau fractures. J Knee Surg. 2014 Feb;27(1):21-9. doi: 10.1055/s-0033-1363519. Epub 2013 Dec 19. PMID: 24357044.
Hoppenfeld’s Surgical Exposures in Orthopaedics: The Anatomic Approach Fifth Edition
Image ref: Bryson WN, Fischer EJ, Jennings JW, Hillen TJ, Friedman MV, Baker JC. Three-Column Classification System for Tibial Plateau Fractures: What the Orthopedic Surgeon Wants to Know. Radiographics. 2021 Jan-Feb;41(1):144-155. doi: 10.1148/rg.2021200106. Epub 2020 Dec 4. PMID: 33275542.