Skip to main content
SpringerLink
Log in

How can the articular surface of the tibial plateau be best exposed? A comparison of specific surgical approaches

  • Trauma Surgery
  • Published:
Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

Introduction

The correct choice of a fracture-specific surgical approach with an articular accessibility in complex tibial plateau fractures to facilitate durable fracture fixation of the anatomic articular reconstruction is under debate, as the most important risk factor for malreduction in complex tibial plateau fractures is an impaired visualization of the articular surface.

Materials and methods

Six established surgical approaches were simulated on 12 cadaver knees. The visible articular surface was labeled with an electrocautery device for each approach and subsequently analyzed with ImageJ. Areas of each hemiplateau were compared using the Student’s t test.

Results

In the lateral tibial plateau, the dorsal 19.0 ± 5.8% of the articular surface could be exposed via the postero-lateral approach. Via the antero-lateral arthrotomy, 36.6 ± 9.4% of the anterior articular surface was visible. The additional osteotomy of the lateral femoral epicondyle significantly increased the exposure to 65.6 ± 7.7% (p < 0.001). In the medial tibial plateau, the osteotomy of the medial femoral epicondyle significantly improved visualization of the medial articular surface (62.3 ± 8.6%) compared to the postero-medial approach (14.0 ± 7.3%) and the antero-medial approach (36.9 ± 9.2%) of the articular (p < 0.001).

Conclusions

Visualization of the tibial articular surface is limited through specific surgical approaches. Extension by osteotomy of the femoral epicondyle led to a significant improvement in the articular exposure without, however, obtaining sufficient visibility of the posterior joint segments, which should be included in the preoperative strategy. The proposed surgical approach-specific map of the tibial plateau may constitute an important instrument in the toolbox of an experienced surgeon to treat complex tibial plateau fractures at the highest level.

Level of evidence

Level IV.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

References

  1. McNamara IR, Smith TO, Shepherd KL, Clark AB, Nielsen DM, Donell S, Hing CB (2015) Surgical fixation methods for tibial plateau fractures. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD009679.pub2

    Article  PubMed  PubMed Central  Google Scholar 

  2. Bhattacharyya T, McCarty LP 3rd, Harris MB, Morrison SM, Wixted JJ, Vrahas MS, Smith RM (2005) The posterior shearing tibial plateau fracture: treatment and results via a posterior approach. J Orthop Trauma 19(5):305–310

    PubMed  Google Scholar 

  3. Giannoudis PV, Tzioupis C, Papathanassopoulos A, Obakponovwe O, Roberts C (2010) Articular step-off and risk of post-traumatic osteoarthritis. Evidence today. Injury 41(10):986–995. https://doi.org/10.1016/j.injury.2010.08.003

    Article  CAS  PubMed  Google Scholar 

  4. Singleton N, Sahakian V, Muir D (2017) Outcome after tibial plateau fracture: how important is restoration of articular congruity? J Orthop Trauma 31(3):158–163. https://doi.org/10.1097/BOT.0000000000000762

    Article  PubMed  Google Scholar 

  5. Wasserstein D, Henry P, Paterson JM, Kreder HJ, Jenkinson R (2014) Risk of total knee arthroplasty after operatively treated tibial plateau fracture: a matched-population-based cohort study. J Bone Jt Surg Am 96(2):144–150. https://doi.org/10.2106/JBJS.L.01691

    Article  Google Scholar 

  6. Weigel DP, Marsh JL (2002) High-energy fractures of the tibial plateau. Knee function after longer follow-up. J Bone Jt Surg Am 84-A(9):1541–1551

    Article  Google Scholar 

  7. Eggli S, Hartel MJ, Kohl S, Haupt U, Exadaktylos AK, Roder C (2008) Unstable bicondylar tibial plateau fractures: a clinical investigation. J Orthop Trauma 22(10):673–679. https://doi.org/10.1097/BOT.0b013e31818b1452

    Article  PubMed  Google Scholar 

  8. Krause M, Preiss A, Meenen NM, Madert J, Frosch KH (2016) "Fracturoscopy" is superior to fluoroscopy in the articular reconstruction of complex tibial plateau fractures—an arthroscopy assisted fracture reduction technique. J Orthop Trauma 30(8):437–444. https://doi.org/10.1097/BOT.0000000000000569

    Article  PubMed  Google Scholar 

  9. Meulenkamp B, Martin R, Desy NM, Duffy P, Korley R, Puloski S, Buckley R (2017) Incidence, risk factors, and location of articular malreductions of the tibial plateau. J Orthop Trauma 31(3):146–150. https://doi.org/10.1097/BOT.0000000000000735

    Article  PubMed  Google Scholar 

  10. Haller JM, O'Toole R, Graves M, Barei D, Gardner M, Kubiak E, Nascone J, Nork S, Presson AP, Higgins TF (2015) How much articular displacement can be detected using fluoroscopy for tibial plateau fractures? Injury 46(11):2243–2247. https://doi.org/10.1016/j.injury.2015.06.043

    Article  PubMed  Google Scholar 

  11. Barei DP, O'Mara TJ, Taitsman LA, Dunbar RP, Nork SE (2008) Frequency and fracture morphology of the posteromedial fragment in bicondylar tibial plateau fracture patterns. J Orthop Trauma 22(3):176–182. https://doi.org/10.1097/BOT.0b013e318169ef08

    Article  PubMed  Google Scholar 

  12. Bowers AL, Huffman GR (2008) Lateral femoral epicondylar osteotomy: an extensile posterolateral knee approach. Clin Orthop Relat Res 466(7):1671–1677. https://doi.org/10.1007/s11999-008-0232-5

    Article  PubMed  PubMed Central  Google Scholar 

  13. Engh GA (1999) Medial epicondylar osteotomy: a technique used with primary and revision total knee arthroplasty to improve surgical exposure and correct varus deformity. Instr Course Lect 48:153–156

    CAS  PubMed  Google Scholar 

  14. Fakler JK, Ryzewicz M, Hartshorn C, Morgan SJ, Stahel PF, Smith WR (2007) Optimizing the management of Moore type I postero-medial split fracture dislocations of the tibial head: description of the Lobenhoffer approach. J Orthop Trauma 21(5):330–336. https://doi.org/10.1097/BOT.0b013e318055603c

    Article  PubMed  Google Scholar 

  15. Frosch KH, Balcarek P, Walde T, Sturmer KM (2010) A new posterolateral approach without fibula osteotomy for the treatment of tibial plateau fractures. J Orthop Trauma 24(8):515–520. https://doi.org/10.1097/BOT.0b013e3181e5e17d

    Article  PubMed  Google Scholar 

  16. Galla M, Lobenhoffer P (2003) The direct, dorsal approach to the treatment of unstable tibial posteromedial fracture-dislocations. Unfallchirurg 106(3):241–247. https://doi.org/10.1007/s00113-002-0554-9

    Article  CAS  PubMed  Google Scholar 

  17. Potocnik P, Acklin YP, Sommer C (2011) Operative strategy in postero-medial fracture-dislocation of the proximal tibia. Injury 42(10):1060–1065. https://doi.org/10.1016/j.injury.2011.03.041

    Article  PubMed  Google Scholar 

  18. Scheibel MT, Schmidt W, Thomas M, von Salis-Soglio G (2002) A detailed anatomical description of the subvastus region and its clinical relevance for the subvastus approach in total knee arthroplasty. Surg Radiol Anat 24(1):6–12

    Article  CAS  Google Scholar 

  19. Solomon LB, Stevenson AW, Lee YC, Baird RP, Howie DW (2013) Posterolateral and anterolateral approaches to unicondylar posterolateral tibial plateau fractures: a comparative study. Injury 44(11):1561–1568. https://doi.org/10.1016/j.injury.2013.04.024

    Article  PubMed  Google Scholar 

  20. Tscherne H, Lobenhoffer P (1993) Tibial plateau fractures. Management and expected results. Clin Orthop Relat Res 292:87–100

    Article  Google Scholar 

  21. Yoon YC, Sim JA, Kim DH, Lee BK (2015) Combined lateral femoral epicondylar osteotomy and a submeniscal approach for the treatment of a tibial plateau fracture involving the posterolateral quadrant. Injury 46(2):422–426. https://doi.org/10.1016/j.injury.2014.12.006

    Article  PubMed  Google Scholar 

  22. Krause M, Menzdorf L, Preiss A, Frosch KH (2017) Are there four tibial plateau columns? Yes there are, as illustrated by a postero-lateral apple-bite fracture. Response to a letter-to-the-editor. Int Orthop. https://doi.org/10.1007/s00264-017-3686-9

    Article  PubMed  Google Scholar 

  23. Carlson DA (1998) Bicondylar fracture of the posterior aspect of the tibial plateau. A case report and a modified operative approach. J Bone Jt Surg Am 80(7):1049–1052

    Article  CAS  Google Scholar 

  24. Püschel K (2016) Lehre und Forschung an Verstorbenen. Rechtsmedizin 26:115–119

    Article  Google Scholar 

  25. Krause M, Muller G, Frosch KH (2018) Surgical approaches to tibial plateau fractures. Unfallchirurg. https://doi.org/10.1007/s00113-018-0515-6

    Article  PubMed  Google Scholar 

  26. Kfuri M, Schatzker J, Castiglia MT, Giordano V, Fogagnolo F, Stannard JP (2017) Extended anterolateral approach for complex lateral tibial plateau fractures. J Knee Surg 30(3):204–211. https://doi.org/10.1055/s-0037-1598077

    Article  PubMed  Google Scholar 

  27. Mihalko WM, Saeki K, Whiteside LA (2013) Effect of medial epicondylar osteotomy on soft tissue balancing in total knee arthroplasty. Orthopedics 36(11):e1353–1357. https://doi.org/10.3928/01477447-20131021-14

    Article  PubMed  Google Scholar 

  28. Schneider CA, Rasband WS, Eliceiri KW (2012) NIH image to ImageJ: 25 years of image analysis. Nat Methods 9(7):671–675

    Article  CAS  Google Scholar 

  29. Garner MR, Warner SJ, Lorich DG (2016) Surgical approaches to posterolateral tibial plateau fractures. J Knee Surg 29(1):12–20. https://doi.org/10.1055/s-0035-1564731

    Article  PubMed  Google Scholar 

  30. Chang SM, Hu SJ, Zhang YQ, Yao MW, Ma Z, Wang X, Dargel J, Eysel P (2014) A surgical protocol for bicondylar four-quadrant tibial plateau fractures. Int Orthop 38(12):2559–2564. https://doi.org/10.1007/s00264-014-2487-7

    Article  PubMed  Google Scholar 

  31. Orapiriyakul W, Apivatthakakul T, Phornphutkul C (2018) Posterolateral tibial plateau fractures, how to buttress? Reversed L posteromedial or the posterolateral approach: a comparative cadaveric study. Arch Orthop Trauma Surg 138(4):505–513. https://doi.org/10.1007/s00402-018-2875-3

    Article  PubMed  Google Scholar 

  32. Lobenhoffer P, Gerich T, Bertram T, Lattermann C, Pohlemann T, Tscheme H (1997) Particular posteromedial and posterolateral approaches for the treatment of tibial head fractures. Unfallchirurg 100(12):957–967

    Article  CAS  Google Scholar 

  33. Qiu WJ, Zhan Y, Sun H, Xu YF, Wang YK, Luo C (2015) A posterior reversed L-shaped approach for the tibial plateau fractures—a prospective study of complications (95 cases). Injury 46(8):1613–1618. https://doi.org/10.1016/j.injury.2015.05.005

    Article  PubMed  Google Scholar 

  34. Carlson DA (2005) Posterior bicondylar tibial plateau fractures. J Orthop Trauma 19(2):73–78

    Article  Google Scholar 

  35. Brunner A, Honigmann P, Horisberger M, Babst R (2009) Open reduction and fixation of medial Moore type II fractures of the tibial plateau by a direct dorsal approach. Arch Orthop Trauma Surg 129(9):1233–1238. https://doi.org/10.1007/s00402-009-0841-9

    Article  PubMed  Google Scholar 

  36. Pires RES, Giordano V, Wajnsztejn A, Oliveira Santana EJ, Pesantez R, Lee MA, de Andrade MAP (2016) Complications and outcomes of the transfibular approach for posterolateral fractures of the tibial plateau. Injury 47(10):2320–2325. https://doi.org/10.1016/j.injury.2016.07.010

    Article  PubMed  Google Scholar 

  37. Sohn HS, Yoon YC, Cho JW, Cho WT, Oh CW, Oh JK (2015) Incidence and fracture morphology of posterolateral fragments in lateral and bicondylar tibial plateau fractures. J Orthop Trauma 29(2):91–97. https://doi.org/10.1097/BOT.0000000000000170

    Article  PubMed  Google Scholar 

  38. Bai B, Kummer FJ, Sala DA, Koval KJ, Wolinsky PR (2001) Effect of articular step-off and meniscectomy on joint alignment and contact pressures for fractures of the lateral tibial plateau. J Orthop Trauma 15(2):101–106

    Article  CAS  Google Scholar 

  39. Higgins TF, Kemper D, Klatt J (2009) Incidence and morphology of the posteromedial fragment in bicondylar tibial plateau fractures. J Orthop Trauma 23(1):45–51. https://doi.org/10.1097/BOT.0b013e31818f8dc1

    Article  PubMed  Google Scholar 

  40. Yoo BJ, Beingessner DM, Barei DP (2010) Stabilization of the posteromedial fragment in bicondylar tibial plateau fractures: a mechanical comparison of locking and nonlocking single and dual plating methods. J Trauma 69(1):148–155. https://doi.org/10.1097/TA.0b013e3181e17060

    Article  PubMed  Google Scholar 

  41. Krause M, Preiss A, Muller G, Madert J, Fehske K, Neumann MV, Domnick C, Raschke M, Sudkamp N, Frosch KH (2016) Intra-articular tibial plateau fracture characteristics according to the "Ten segment classification". Injury 47(11):2551–2557. https://doi.org/10.1016/j.injury.2016.09.014

    Article  PubMed  Google Scholar 

  42. Frosch K, Proksch N, Preiss A, Giannakos A (2012) Treatment of bony avulsions of the posterior cruciate ligament (PCL) by a minimally invasive dorsal approach. Oper Orthop Traumatol 24(4–5):348–353. https://doi.org/10.1007/s00064-012-0208-1

    Article  Google Scholar 

  43. Wang Y, Luo C, Zhu Y, Zhai Q, Zhan Y, Qiu W, Xu Y (2016) Updated three-column concept in surgical treatment for tibial plateau fractures—a prospective cohort study of 287 patients. Injury 47(7):1488–1496. https://doi.org/10.1016/j.injury.2016.04.026

    Article  PubMed  Google Scholar 

  44. Kfuri M, Schatzker J (2018) Revisiting the Schatzker classification of tibial plateau fractures. Injury 49(12):2252–2263. https://doi.org/10.1016/j.injury.2018.11.010

    Article  PubMed  Google Scholar 

Download references

Funding

This study was funded by AO Trauma, Germany e.V.

Author information

Authors and Affiliations

  1. Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany

    Matthias Krause & Karl-Heinz Frosch

  2. Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

    Matthias Krause

  3. Department of Trauma and Reconstructive Surgery, Asklepios Clinic St. Georg, Hamburg, Germany

    Sebastian Krüger & Gunnar Müller

  4. Department of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

    Klaus Püschel

Authors
  1. Matthias Krause
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sebastian Krüger
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Gunnar Müller
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Klaus Püschel
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Karl-Heinz Frosch
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Karl-Heinz Frosch.

Ethics declarations

Conflict of interest

MK has received research Grants from AO Trauma, Germany e.V. SK, GM, KP, and KHF declare that they have no conflict of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Krause, M., Krüger, S., Müller, G. et al. How can the articular surface of the tibial plateau be best exposed? A comparison of specific surgical approaches. Arch Orthop Trauma Surg 139, 1369–1377 (2019). https://doi.org/10.1007/s00402-019-03200-z

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00402-019-03200-z

Keywords

Search

Navigation