Salvi, A.E. Clin Orthop Relat Res (2016) 474: 854. doi:10.1007/s11999-015-4653-7
To the Editor,
I read the study by Johnson and colleagues  with great interest. In their study, the authors compared a typical surgical approach to lateral tibial plateau fractures with a less-invasive solution that increases joint exposure and maintains a partial iliotibial insertion at Gerdy’s tubercle.
In their study, Johnson and colleagues described the management of bicondylar plateau fractures undergoing a double surgical approach. Since this is a common fracture pattern, some additional considerations should be addressed on the topic.
Double surgical (medial and lateral) incisions  often are complicated by deep infection, arthrofibrosis, and posttraumatic arthritis . Additionally, surgeons must continually observe the incision on both sides of the fracture. The views are limited by the cutaneous bridge between the incisions. A midline approach  is prone to wound problems, subsequent infections, or retardation of bony union. However, a midline approach can be useful for salvage arthroplasty . Osteotomy of the tibial tubercle , although it allows a full view of the fractured plateau, is complex and rarely used .
Regardless of the approach used, the surgeon should strive for a wide and complete exposure of the articular plane. Once doing so, the surgeon should have the ability to free and mobilize the bony fracture ends. This is done to reduce and keep in place a solid synthesis. Detachment of the muscular insertions on the lateral side is mandatory. In my experience, postoperative stiffness is uncommon when a passive motion machine is used for approximately 1 hour (0 to 30 minutes from the second postoperative day, increasing 10 minutes daily thereafter). I generally apply a hinged knee brace, set from 0° to 90° for at least the first postoperative month. I recommend that patients avoid weight bearing for 3 months.
An alternative approach to the double surgical incision approach is what I call the “clock approach” (Fig. 1A–C). I have used this approach for 5 years and the results have been good. I usually flex the knee on a pad in order to have the knee in front view, and to allow gravitational forces to help align the bony fracture ends during the operation. The incision starts from the lateral condyle, runs around the kneecap in a curvilinear fashion towards Gerdy’s tubercle, passes the inferior margin of the anterior tibial tubercle, and ends on the medial surface of the tibia. When necessary, connection between superior face of the patella and its superior subcutaneous tissues can be cut using scissors to obtain a strip that can be retracted by mean of a Farabeuf or Hohmann retractor, therefore widening further the surgical vision.
Following a satisfactory reduction, it is important to suture the lateral musculature, address any meniscal pathology, and close the capsule carefully (Fig 2A–B).