Anterior Midline Incision is a Safe and Effective Approach for High-energy Medial Shear Fractures of the Tibial Plateau

Abstract

Objective: We present a technical trick for surgical treatment of with (Schatzker IV) medial tibial plateau fractures treated with a standardized operative protocol with early radiographic and clinical outcomes.Methods: Skeletally mature patients with a medial tibial plateau fracture (Schatzker IV) admitted to an academic level 1 trauma center between 2002 and 2017 were identified by institutional database review. Screening of operative reports selected patients treated with a single anteromedial approach following a standard surgical protocol by a single surgeon. Data relevant to initial injury characteristics, patient comorbidities, operative management, and follow-up were extracted by chart review. Preoperative and postoperative clinical documentation and radiographs were examined to measure specific injury and outcome variables. Radiographic and clinical outcomes were validated by one fellowship-trained orthopedic trauma surgeon and 2 orthopedic trauma fellows.Results: Review of 335 patients with tibial plateau fractures during the study period identified a series of 17 high-energy, medial partial articular fractures that met the inclusion criteria. Injury pattern included articular depression in all patients, meniscal injury in 59%, ligamentous injury in 65% and none had compartment syndrome. Immediate radiographic analysis showed restoration of the articular surface, condylar width, and mechanical alignment for all patients. No patient experienced wound healing complications, soft tissue infection or skin necrosis. Median time to radiographic fracture consolidation was 12.9 weeks and ambulation without achieved at 18.9 weeks. Conclusions:The use of a standard anteromedial approach to the knee via medial parapatellar arthrotomy with full-thickness medial skin flap for isolated high-energy medial column tibial plateau fractures offers improved visualization and facilitates reduction and fixation of the lateral and anterior articular impaction while enabling immediate repair or reconstruction of associated meniscal and ligamentous (anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament) pathology. Short-term and mid-term follow-up demonstrates good clinical and radiographic patient outcomes. This approach is a safe and reliable option for treatment of this unique and challenging injury pattern.

Comparative Analysis of Posterior Approach Versus Anterior Approach for Posterior Tibial Plateau Fractures

“…According to the ROBINS-1 assessment tool 41 , 5 studies 16,23,25,26,40 were with a moderate risk of bias, 11 studies 6,17,19,24,27,28,30,31,36,37,39 were rated with a serious risk of bias, and 13 studies 2,7,8,18,20-22,29,32-35,38 were rated with a critical risk of bias (Appendices 1 and 2; http://links.lww.com/JBJSREV/A970). Twelve studies did not report the underlying diseases of the patients, which raises some concerns about adjusting confounding factors 2,6-8,17-22,24,27-39 .…”

“…The included studies were conducted in the United States (2 studies, n = 44) 16,17 , China (17 studies, n = 413) 2,6,18-32 , India (3 studies, n = 85) 33-35 , Taiwan (5 studies, n = 162) 7,8,36-38 , South Korea (1 study, n = 18) 39 , and Turkey (1 study, n = 25) 40 . Fourteen studies used the anterior approach (10 open surgery, 4 arthroscopic surgery) 6-8,16,19,23,24,26,30,31,35,38-40 , 9 studies used the posterior approach 18,27-29,32-34,36,39 , and 11 studies used the anterior combined posterior approach 2,17,19-22,24,25,35,37,39 .…”