New Trends & Techniques in Open Reduction Internal Fixation of Fractures of the Tibial Plateau -

J Bone Joint Surg Br. 2009 Apr;91(4):426-33.

Musahl V, Tarkin I, Kobbe P, Tzioupis C, Siska PA, Pape HC.

Reviewed by

Dr Terry Stephens
BSc(hons), MBBS, PhD |
Unaccredited Orthopaedic Registrar

Treatment Principles
- anatomical reduction
- rigid fixation
- early movement
Traditional methods
- extensive dissection
- periosteal stripping
- compromising vascular supply
Problems
- infection
- non-union
- secondary bone grafting
- loss of reduction
locking plates & minimally invasive approaches
- preserves the soft tissue envelope

single incision
- commonly anterior lateral incision
  - allows approach for later arthroplasty
- tips
  - 1st reduce proximal lateral condyle
  - 2nd intercondylar reduction
two incision
- required if cortical contact between condylar fragments is inadequate
- small medial incision (maintain large skin bridge)
  - anti-glide plate or medial locking plate

posterior plateau fractures
- posterior lateral
  - fibular osteotomy
- posterior medial fractures
  - posterior medial incision
high energy bicondylar fractures
- often require dual incisions

unnecessary
- simple lateral splits
  - cannulated lag screws
    - x2 more biomechanically stable than x3
  - if large anatomically contoured anti-glide plate
- splits lateral depression
  - buttress plate or peri articular plate
  - with bone graft to elevate cartlidge
- medial condyle fractures
  - lag screw
  - buttress plate (to avoid shear forces)
    - large
    - communited
useful
- high energy fractures
- comminution
- osteoporotic bone
advantages
- single lateral approach
- preserves soft tissue envelope
- combine with compression lag screws

dual plating offers most stable construct

difficult to assess
- very diverse range of injuries
articular reduction important
- 10mm lucht & pilgaard 1971
- 5mm rasmussen et al 1973
- 2mm barei et al 2006
- difficult due to diverse type injury and therefore studies lacking
favourable result
- low-energy injuries
- lateral meniscus preservation
- high energy – articular displacement and anatomical reduction.

infection 5 -15%
- correlates with soft tissue injury and amount of metal
- large surgical wounds
- infection rates still high with mi techniques
avn
- particularly dual plating
non union
mal union
malposition
post traumatic arthritis
stiffness with external fixation