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Tibial plateau fracture: 360 degree approach, posterior approach(Stage 1), using variable angle LCP proximal tibial plate (DePuy-Synthes)



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Few fractures have seen such a change in their accepted management, classification and surgical strategy as much as proximal tibial plateau fractures over the last decade.

From my perspective, there are a couple of likely reasons for this.

In part it’s been driven by the increased incidence of these fractures, due to an ageing population who are increasingly active though despite this present with osteoporotic bones.

In part the widespread availability of MRI scanning has allowed much better delineation of the extent of these fractures and assisted with development of new classification systems which help guide management.

Because of these factors there has been a drive to rethink the accepted management strategies of the previous decades to improve outcomes. As a result, new surgical approaches coupled to a new generation of innovative implants specifically designed to manage these injuries have evolved, and continue to evolve.

The majority of tibial plateau fractures involve the lateral plateau and are approached with a standard anterolateral approach, combined with meniscal elevation.  For those fractures with medial or posterior involvement, there are further approaches required which encompass a direct medial, posteromedial, direct posterior or even a posterolateral access.  These newer medially based approaches, when considered together with lateral approaches are often referred to in the scientific literature as the “360° strategy”, given the circumferential exposure of the tibia it is possible when combining them.

The Schatzker classification of tibial plateau fractures is based on the plain films and identify six subtypes of fracture.  The type V (bi-condylar) and type VI (bi-condylar with complete separation of joint surface from the tibial shaft) represent the highest energy injuries and are detailed in this case.  There is a more recent classification by Luo, based on CT scans which divides the tibial plateau into three columns, medial, lateral and posterior.  This is a useful classification to help plan the surgical approach to the fracture, depending on the precise fracture configuration.  Further detail of the classifications is given within the operative technique.

Historically, bi-condylar tibial plateau fractures were fixed using a single anterior midline incision but reported wound breakdowns and deep infection rates of over 20% associated with this approach has led to this changing.  Barei & Egol in the early 2000s popularised a staged approach to these high energy bi-condylar tibial plateau fractures, initially using a spanning external fixator to allow the soft tissues to settle followed subsequently by standard internal fixation, though using dual incisions to minimise soft tissue stripping, this strategy led to a reduction in infection rates to below 10%.

In my own practice I use the VA-LCP anterolateral system and the LCP posteromedial system manufactured by DePuy-Synthes.  These plates have an anatomical fit and very useful if using the 360° strategy.  They also come in steel or titanium and are well designed and contoured to both the posteromedial wall and also the anterolateral wall.  The anterolateral plates have a variable angle option which is often needed with comminuted fractures.

Though it is helpful when dealing with poor bone quality to have anatomical locking plates available, it is not mandatory. The principle of the fixation of these injuries is anatomical reduction and absolute stability for the “articular block”, though with relative stability required for the metaphyseal-diaphyseal component, which can be achieved just as readily with standard locking compression plates.

Readers will find the following OrthOracle instruction techniques also of interest:

Tibial plateau fracture: Posterior column fracture fixed with Synthes proximal tibial LISS plate

Author: Peter Biberthaler MD.

Institution: Technical University of Munich, Klinikum rechts der Isar, Munich, Germany.

Clinicians should seek clarification on whether any implant demonstrated is licensed for use in their own country.

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