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Year |
2001 |
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Question Number |
218 |
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Category |
Select |
Question
A 35-year-old man sustained an isolated closed displaced bicondylar tibial plateau fracture after being struck by a car. Reduction and internal fixation of both condyles can be most safely achieved using which of the following surgical approaches?
1- Isolated anterior midline
2- Isolated lateral parapatellar
3- Isolated posteromedial
4- Combined anterolateral and posteromedial
5- Combined anterior midline and posterior transpopliteal
Figures
Answer (click for answer)
Preferred Response: (4). The question asks for the approach by which ORIF can take place most safely for both fractures; cosmesis is thus not an issue. Two incisions directly over where one wants to place a plate would require the least amount of flap elevation and surgical soft tissue trauma; stab incisions for isolated screw fixation are not a choice. This thus rules out choices 1, 2, & 3. Choice 5 is ruled out since the approaches described would not give you direct exposure to where your plates need to go, and the posterior approach requires careful direction through major neurovascular structures and prone positioning which would make simultaneous surgery through each incision challenging.
The referenced article reviews four cases of complex bicondylar plateau fractures, each with gross knee instability under anesthesia and a large posteromedial fragment. They used anterior midline/anterolateral incisions with a separate posteromedial incision which easily allowed them to place a buttress plate from the back. Drains and CPM were used postoperatively. All patients went onto union with no wound complications and excellent range of motion (0-5° to 125-140°). In contrast, Moore TM et al in JOT in 1987 had 9 out of 11 patients treated by medial and lateral plating through an isolated anterior incision become infected. The point is that one should carefully study the radiographs and CT plan the incisions and fixation appropriately.
The images below show an AP/LAT x-rays of one of their cases preop and postop. The arrows on the LAT preop x-ray show the posteromedial fragment not discretely visible on the AP. Note the contoured posterior buttress plate.
Reference: Georgiadis GM: Combined anterior and posterior approaches for complex tibial plateau fixations. J Bone Joint Surg Br 1994;76:285-289.