Modified Oblique Lobenhoffer (MOL) approach for posterolateral and posteromedial column access in tibial plateau fractures: a detailed cadaveric anatomical study.

BACKGROUND: Tibial plateau fractures involving posteromedial (PM) and posterolateral (PL) columns are complex injuries that require an appropriate approach. The management of the PL column in these cases can be controversial, and limitations using deep posteromedial interval approaches have been referenced. In this paper, a modification of the Lobenhoffer approach, designed to optimize the access to the PL column, is described in detail. The aim of this study was to assess the feasibility of this approach in a cadaveric anatomical study. MATERIALS AND METHODS: In total, five fresh-frozen cadaveric specimens were used for detailed anatomical study surrounding the approach. Relationships with cutaneous and deep neurovascular structures were evaluated. The exposure area of the PL and PM columns using this approach was assessed. RESULTS: The cadaveric study showed safe and adequate exposure. Oblique skin and fascia incision just medial to the posterior midline was safe to protect the medial sural cutaneous nerve and the small saphenous vein. Elevation of the popliteus and tibialis posterior muscles offered safe protection of the anterior tibial artery and popliteal neurovascular bundle during retractor placement. Adequate full proximal exposure of the PM and PL columns, including the posterolateral lateral (PLL) and posterolateral central (PLC) segments, was obtained in all specimens. CONCLUSIONS: The Modified Oblique Lobenhoffer (MOL) approach can be a feasible option to access PL and PM columns in tibial plateau fractures. LEVEL OF EVIDENCE: IV.

[Application of a new universal locking anatomical plate in treatment of tibial plateau posterolateral column fractures].

Objective: To investigate the effectiveness of a new tibial plateau posterolateral column universal locking anatomical plate (hereinafter referred to as "new universal locking anatomical plate") in the treatment of tibial plateau posterolateral column fractures. Methods: Between October 2020 and December 2021, 14 patients with tibial plateau posterolateral column fracture were treated with a new universal locking anatomical plate. There were 7 males and 7 females with an average age of 59 years ranging from 29 to 75 years. There were 5 cases on the left side and 9 cases on the right side. The causes of injury included falling from height in 5 cases, traffic accident in 7 cases, and other injuries in 2 cases. The time from injury to operation ranged from 3 to 10 days, with an average of 6 days. According to Schatzker classification, there were 4 cases of type Ⅱ, 8 cases of type Ⅴ, and 2 cases of type Ⅵ. All fractures involved the posterolateral tibial plateau. Three column classification: two columns (anterolateral column+posterior column) in 4 cases, three columns in 10 cases. The operation time, intraoperative blood loss, fracture healing, and complications were recorded. The reduction of tibial plateau fracture was evaluated by Rasmussen radiographic score, and the recovery of knee function was evaluated by Hospital for Special Surgery (HSS) score. Results: All 14 cases completed the operation successfully. The operation time was 95-180 minutes, with an average of 154 minutes, and the intraoperative blood loss was 100-480 mL, with an average of 260 mL. All patients were followed up 6-19 months, with an average of 12.5 months. All fractures healed, and the healing time was 15-24 weeks, with an average of 18.7 weeks. During the follow-up, there was 1 case of common peroneal nerve palsy and 1 case of traumatic osteoarthritis. There was no other complication such as vascular injury, incision infection, deep venous thrombosis of lower limbs, heterotopic ossification, bone nonunion, and failure of internal fixation. The reduction of tibial plateau fractures was good immediately after operation, and the Rasmussen radiological score was 10-18, with an average of 15.7; 3 cases were excellent, 10 cases were good, and 1 case was fair, with an excellent and good rate of 92.9%. The scores and grades of HSS at 3 months after operation and at last follow-up significantly improved when compared with those before operation ( P<0.05). There was no significant difference between 3 months after operation and last follow-up ( P>0.05). Conclusion: For the fractures involving the posterolateral column of the tibial plateau, the new universal locking anatomical plate can provide strong fixation, satisfactory postoperative fracture reduction, and good recovery of knee function.

[Application of modified anterolateral supra-fibular-head approach in treatment of tibial plateau fractures involving posterolateral column].

OBJECTIVE: To explore effectiveness of reduction and internal fixation via modified anterolateral supra-fibular-head approach in treatment of tibial plateau fractures involving posterolateral column. METHODS: Between January 2016 and September 2018, 19 patients diagnosed as tibial plateau fractures involving posterolateral column were treated with reduction and internal fixation via modified anterolateral supra-fibular-head approach. There were 11 males and 8 females with an average age of 43.2 years (range, 28-65 years). The causes of tibial fracture were traffic accident (12 patients), falling injury (5 patients), and falling from height (2 patients). According to the Schatzker typing, the tibial fractures were rated as type Ⅱ in 9 cases, type Ⅲ in 4 cases, type Ⅴ in 4 cases, and type Ⅵ in 2 cases. The time from injury to operation was 5-13 days (mean, 8.5 days). There were 2 patients with osteoporosis. The operation time, intraoperative blood loss, and postoperative complications were recorded. The knee X-ray film was reviewed regularly to observe the fracture healing. At last follow-up, the fracture reductions were evaluated by Rasmussen radiological score. The knee joint function was evaluated by Hospital for Special Surgery (HSS) score system. RESULTS: The average operation time was 95 minutes (range, 65-130 minutes). The average intraoperative blood loss was 220 mL (range, 150-350 mL). All incisions healed by first intention. No complications such as infection or deep venous thrombosis occurred. All patients were followed up 12-20 months (mean, 15.4 months). X-ray films showed that the fractures healed with the healing time of 12-20 weeks (mean, 14.5 weeks). No complications such as loosening or breakage of internal fixation occurred. At last follow-up, according to the Rasmussen radiological score, the fracture reductions were evaluated as excellent in 13 cases, good in 4 cases, fair in 1 case, and poor in 1 case. HSS scores of knee joint function were excellent in 14 cases, good in 3 cases, fair in 1 case, and poor in 1 case. The knee joint range of motion was 90°-135°, with an average of 113.4°. CONCLUSION: Application of modified anterolateral supra-fibular-head approach in reduction and internal fixation for tibial plateau fractures involving posterolateral column has the advantages of full exposure, less trauma, safety, and reliable reduction and fixation.

Application of modified anterolateral supra-fibular-head approach in treatment of tibial plateau fractures involving posterolateral column / 中国修复重建外科杂志

Objective: To explore effectiveness of reduction and internal fixation via modified anterolateral supra-fibular-head approach in treatment of tibial plateau fractures involving posterolateral column. Methods: Between January 2016 and September 2018, 19 patients diagnosed as tibial plateau fractures involving posterolateral column were treated with reduction and internal fixation via modified anterolateral supra-fibular-head approach. There were 11 males and 8 females with an average age of 43.2 years (range, 28-65 years). The causes of tibial fracture were traffic accident (12 patients), falling injury (5 patients), and falling from height (2 patients). According to the Schatzker typing, the tibial fractures were rated as type Ⅱ in 9 cases, type Ⅲ in 4 cases, type Ⅴ in 4 cases, and type Ⅵ in 2 cases. The time from injury to operation was 5-13 days (mean, 8.5 days). There were 2 patients with osteoporosis. The operation time, intraoperative blood loss, and postoperative complications were recorded. The knee X-ray film was reviewed regularly to observe the fracture healing. At last follow-up, the fracture reductions were evaluated by Rasmussen radiological score. The knee joint function was evaluated by Hospital for Special Surgery (HSS) score system. Results: The average operation time was 95 minutes (range, 65-130 minutes). The average intraoperative blood loss was 220 mL (range, 150-350 mL). All incisions healed by first intention. No complications such as infection or deep venous thrombosis occurred. All patients were followed up 12-20 months (mean, 15.4 months). X-ray films showed that the fractures healed with the healing time of 12-20 weeks (mean, 14.5 weeks). No complications such as loosening or breakage of internal fixation occurred. At last follow-up, according to the Rasmussen radiological score, the fracture reductions were evaluated as excellent in 13 cases, good in 4 cases, fair in 1 case, and poor in 1 case. HSS scores of knee joint function were excellent in 14 cases, good in 3 cases, fair in 1 case, and poor in 1 case. The knee joint range of motion was 90°-135°, with an average of 113.4°. Conclusion: Application of modified anterolateral supra-fibular-head approach in reduction and internal fixation for tibial plateau fractures involving posterolateral column has the advantages of full exposure, less trauma, safety, and reliable reduction and fixation.

Surgical Treatment of Lateral Tibial Plateau Fractures Involving the Posterolateral Column.

OBJECTIVE: To summarize the indications and the clinical effects of a transfibular neck osteotomy approach and a combined anterolateral and posterolateral approach in the treatment of fractures of the lateral tibial plateau involving the posterolateral column. METHODS: Eleven patients with lateral tibial plateau fractures were included in the present study. The fractures were Schatzker type II or lateral platform fractures involving posterolateral column. The anterolateral combined posterolateral approach (lateral + posterolateral locking plate fixation) was applied in 7 patients and 4 patients underwent transfibular neck osteotomy (lateral + posterolateral locking plate fixation + 1/4 tubular plate edge fixation, fibular osteotomy with Kirschner wire tension band fixation, and hollow nail fixation for upper tibiofibular joint). All cases were followed up for 12-24 months, with an average follow-up of 17.5 ± 5.0 months. At the last followup, the Rasmussen radiological criteria were used to evaluate the effect of fracture reduction and fixation. The knee joint function was evaluated using the knee function evaluation criteria of the Hospital for Special Surgery (HSS). The Lachman test and the pivot-shift test were used to evaluate the anterior and posterior and rotational stability of the knee joint. The range of knee motion was recorded. RESULTS: Bone healing was achieved in all patients with fractures treated with a transfibular neck osteotomy approach and a combined anterolateral and posterolateral approach. At the last follow-up, both the Lachman test and the pivot-shift test results were negative. All patients had complete knee extension. For the combined anterolateral and posterolateral approach, the knee flexion angle was 110°-130°, with an average of 122.86° ± 7.56°. For the transfibular neck osteotomy approach, the knee flexion angle was 115°-130°, with an average of 120.00° ± 7.07°. For the patients in which the combined anterolateral and posterolateral approach was used, the Rasmussen score was 12-18 points, with an average of 16.00 ± 2.56 points. The results were excellent in 4 cases and good in 3 cases; therefore, 100% of results were excellent or good. For patients in which the transfibular neck osteotomy approach was used, the Rasmussen score was 10-18 points, with an average of 15.25 ± 3.77 points. The results were excellent in 2 cases, good in 1 case, and acceptable in 1 case; therefore, 75% of results were excellent or good. The HSS score for the combined anterolateral and posterolateral approach was 76-98 points, with an average of 88.43 ± 7.55 points. The results were excellent in 5 cases and good in 2 cases; therefore, 100% of results were excellent or good. The HSS score for the transfibular neck osteotomy approach was 74-96 points, with an average of 87.25 ± 9.43 points. The results were excellent in 3 cases and good in 1 case; therefore, 100% of results were excellent or good. There were no significant differences in operation time, surgical blood loss, fracture healing time, postoperative imaging score, and knee function evaluation between the two approaches. One patient who underwent transfibular neck osteotomy had a 3-mm step that gradually appeared, but no significant abnormalities were found in the width of the platform and the lower limb force line. One patient in whom the combined anterolateral and posterolateral approach was used showed numbness in the common peroneal nerve. No common peroneal nerve injury occurred through the transfibular neck osteotomy approach. CONCLUSIONS: The anterolateral combined posterolateral approach and the transfibular neck osteotomy approach are effective in the surgical treatment of lateral tibial plateau fractures involving the posterolateral column. However, the transfibular neck osteotomy approach is more suitable for the posterolateral plateau articular surface damaged with bone separation and displacement, deep collapse, cases involving a large range of the posterolateral column, especially fractures of the lateral tibial plateau in the upper tibiofibular syndesmosis area of the line connecting the anterior and posterior margin of the fibular head to the midpoint of the plateau.

Principios quirúrgicos en fracturas de platillos tibiales con compromiso de columna posterior / Surgical principles in posterior column tibial plateau fractures

Las fracturas de platillos tibiales son lesiones complejas que incluyen una variedad de patrones morfológicos cada vez mejor caracterizados en la literatura. Históricamente, los esquemas de clasificación se han basado en evaluar los rasgos de fractura en el plano frontal y las técnicas quirúrgicas en lograr la fijación de esos fragmentos, sin tomar en consideración el compromiso óseo que ocurre en la región posterior de los platillos tibiales. Con el advenimiento de la clasificación columnar basada en tomografía computada, se han logrado desarrollar estrategias de fijación optimizada, dando cada vez más relevancia a la columna posterior. Este artículo realiza una revisión extensa de la literatura, otorgando los fundamentos quirúrgicos que explican la importancia del tratamiento específico de la columna posterolateral y posteromedial, con el fin de restablecer la biomecánica normal de la rodilla y el razonamiento quirúrgico de las diversas vías de abordaje específicas para una reducción y osteosíntesis satisfactoria de esos fragmentos.

Tibial plateau fractures are complex injuries which include a variety of morphological patterns that have been increasingly better characterized in the literature. Historically, classifications have focused on description of fracture patterns in the frontal plane, while surgical techniques have focused on reduction of these fragments not considering the osseous defects that occur on the posterior region of the tibial plateau. With new CT scan column based classifications, strategies to optimize fixation have been developed, giving relevance to the posterior column. This article is an exhaustive review of the literature, providing the surgical foundations that explain the importance of specific treatment of the posterolateral and posteromedial column, aiming to restore normal knee biomechanics. Furthermore, this article provides the diverse specific surgical approaches rationale for a satisfactory open reduction and internal fixation of these fragments.