Anterolateral versus modified posterolateral approach for tibial plateau fractures with involvement of the posterior column: a cadaveric study

Abstract

Introduction The aim of this study was to compare the reduction quality of the anterolateral (AL) and modified posterolateral approach (PL) in lateral tibial plateau fractures involving the posterior column and central segments. Methods Matched pairs of pre-fractured cadaveric tibial plateau fractures were treated by either AL approach (supine position) or PL approach (prone position). Reduction was controlled by fluoroscopy and evaluated as satisfying or unacceptable. Afterwards, the reduction was examined by 3D scan. Results 10 specimens (3 pairs 41B3.1, 2 pairs 41C3.3) were evaluated. PL approach achieved significantly (p 0.00472) better fracture reduction results (0.4 ± 0.7 mm) of the posterior column compared to the AL group (2.1 ± 1.4 mm). Fracture steps involving the central area of the lateral plateau were insufficiently reduced after fluoroscopy using both approaches. Conclusion Optimal reduction of displaced tibial plateau fractures involving the posterolateral column necessitates a posterior approach, which can be conducted in prone or lateral positioning. The anterolateral approach is indicated in fractures with minor displacement of the posterolateral rim but fracture extension in the latero-central segments. In these cases, an additional video-assisted reduction or extended approaches are helpful.

Nanoscopy and an extended lateral approach can improve the management of latero-central segments in tibial plateau fractures: a cadaveric study

“…However, due to limited accessibility to the PLC and PLL segments when using the AL, larger remaining irregularities were noted at the fracture sites when compared to the PL approach. Similar findings were reported in a cadaveric and a clinical study that examined the radiological and clinical outcome of complex tibial plateau fractures [ 15 , 23 ]. The authors acknowledge that the ECO procedure is an invasive procedure and that only short-term clinical results have been described for ECO in tibial plateau fractures [ 24 ].…”

“…The PL approach yielded slightly better reduction of the ALC/PLC intersegmental area, which certainly demands on the fracture morphology of the PLC fragment. If the fragment is angulated posteriorly and exceeds far posterior in the PLC segment, it can be controlled better by the posterior window of the PL approach [ 15 ]. However, as mentioned by others, fluoroscopy could not overcome the issue of insufficient visualization in our study [ 6 , 12 , 16 , 17 ].…”

“…Isolated ALC fragments with a deep preoperative depression and angulation, particularly 90° deformities, are hard to reduce indirectly and may necessitate an extension of the approach to directly reduce the fragment [ 21 , 22 ]. Dislocated fragments that reach the posterior aspect of the PLC may necessitate a PL approach, which can be performed in prone or lateral position depending on the involvement of the medial plateau [ 15 ]. In fractures that only involve the anterior part of the PLC, an AL approach should be favored to spare the need for neurolysis of the peroneal nerve, which is recommended using the PL approach.…”

Clinical Analysis of the Frosch Approach in the Treatment of Posterolateral Tibial Plateau Fractures Combined with Lateral Tibial Plateau Fractures

“…Most tibial plateau fractures can be treated using standard reduction and fixation techniques; however, when posterolateral fractures are involved, owing to the obstruction of the posterolateral fibular head and the presence of important blood vessels, nerves, and other structures on the posterolateral side of the knee joint, many difficulties remain in reducing and fixing the posterolateral tibial plateau fracture fragments, making their treatment relatively challenging. There is great controversy regarding the surgical approach for posterolateral tibial plateau fractures, anterolateral approach, modified posterolateral approach, and posteromedial approach can all be used to treat posterolateral tibial plateau fractures 9,10 . The above approaches all have certain drawbacks and limitations, for instance, using traditional anterolateral approaches, it is difficult to reduce and fix posterolateral fractures under direct visualization.…”

“…There is great controversy regarding the surgical approach for posterolateral tibial plateau fractures, anterolateral approach, modified posterolateral approach, and posteromedial approach can all be used to treat posterolateral tibial plateau fractures. 9,10 The above approaches all have certain drawbacks and limitations, for instance, using traditional anterolateral approaches, it is difficult to reduce and fix posterolateral fractures under direct visualization. Many scholars have attempted to solve the problem of insufficient exposure of posterolateral tibial plateau fractures through the anterolateral approach.…”