Treatment of Tibial Plateau Fractures Involving Posterolateral Column Through the Extended Anterolateral Approach

Abstract

ObjectiveTo summarize the surgical technique and the clinical effects of extended anterolateral approach for the treatment of Schatzker type II and Schatzker type V/VI which involving the posterolateral column tibial plateau.MethodsFrom January 2015 through December 2018, a total of 28 patients with tibial plateau fracture involving posterolateral column were included in this study. Among them, 16 patients were Schatzker type II treated via extended anterolateral approach with lateral tibial locking compression plate fixation.12 patients were Schatzker type V or VI treated via extended anterolateral combine with medial approach by lateral tibial locking compression plate plus medial locking compression plate fixation. All cases were followed up for 15~31 months, with an average follow‐up of 22.5±3.7 months. During the follow-up, the tibial plateau angle (TPA), lateral posterior angle (PA) and Rasmussen radiological criteria were used to evaluate the effect of fracture reduction and fixation; the Hospital for Special Surgery (HSS) and the range of motion were used to evaluate knee function; the Lachman and knee Valgus (Varus) stress test were used to evaluate anteroposterior and lateral stability of the knee.ResultsAll fractures healed. At the 12-month follow-up: in Schatzker type II group a mean TPA of 86.38±3.92°, a mean PA of 7.43±2.68°, and Rasmussen radiological score with an average of 16.00±2.06 points, scores were excellent in 6 cases and good in 10 cases, as a result the excellent and good rate was 100%; while in in Schatzker type V/VI group a mean TPA of 84.91±3.51°, a mean PA of 9.68±4.01°, and Rasmussen radiological score with an average of 15.33±2.99 points, scores were excellent in 4 cases and good in 6 cases, as a result the excellent and good rate was 83.33%. During the one-year follow-up, when re-measured postoperative PA, TPA, Rasmussen score of the two groups did not change significantly (P > 0.05). At the last follow‐up, in Schatzker type II group, the the knee flexion angle was 110° ~135°, with an average of 125°±8.56°,a mean of HHS score 88.37±10.01 points, scores were excellent in 9 cases and good in 5 cases, as a result the excellent and good rate was 100%; in Schatzker type V/VI group, the the knee flexion angle was 100° ~130°, with an average of 120°±11.25°,a mean of HHS score 82.17±10.76 points, scores were excellent in 5 cases and good in 3 cases, as a result the excellent and good rate was 66,67%.In addition, up to the last follow-up, Lachman and knee Valgus (Varus) stress test results of the two groups were negative. No complications were found.ConclusionsAlthough there are many ways to treat posterolateral tibial plateau fractures, When choosing one or more combined approach, we must consider the condition of soft tissue injury, the shape of the whole platform fracture including the posterolateral bone block and the available fixation methods. The best approaches should provide maximum exposure of the platform, enough space for reduction and fixation, and minimum damage to the surrounding structures. For anterolateral platform fractures combine with isolated posterolateral fracture fragments, the extended anterolateral approach is more suitable as a single approach. For multiple column tibial plateau fractures a dual approach (extended anterolateral combined with medial approach) can be used to enter the whole plateau area.

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][21][22]29,[32][33][34][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][7][8][17][18][19][20][21][22]24,[27][28][29][30][31][32][33][34][35][36]…”

“…The included studies were conducted in the United States (2 studies, n 5 44) 16,17 , China (17 studies, n 5 413) 2,6,[18][19][20][21][22][23][24][25][26][27][28][29][30][31][32] , India (3 studies, n 5 85) [33][34][35] , Taiwan (5 studies, n 5 162) 7,8,[36][37][38] , South Korea (1 study, n 5 18) 39 , and Turkey (1 study, n 5 25) 40 . Fourteen studies used the anterior approach (10 open surgery, 4 arthroscopic surgery) [6][7][8]16,19,23,24,26,30,31,35,[38][39][40] , 9 studies used the posterior approach 18,[27][28][29][32][33][34]36,39 , and11studies used the anterior combin...…”