Combined Posteromedial and Anterolateral Approach in the "floating position" - Two Column Fracture of the Tibia Head

Abstract

Background The posterior tibial plateau is often affected in intra-articular tibial fractures. Moreover, treating these posterior fractures is recognised as an important prognostic factor. Open reduction and internal fixation of lateral and posterior two column tibial plateau fractures can be achieved via a combined reversed L-shape approach and an anterolateral approach in the floating position without intraoperative repositioning of the patient. Material and Methods The operative procedure starts in the posterior position with visualisation of the posterior column after lateral retraction of the medial head of the M.gastrocnemius. The posterior fragment is then reduced and fixated. This is followed by reversed patient tilt, and slight flexion and varus stress on the knee. An anterolateral approach is performed with visualisation of the lateral column, direct reduction and internal fixation of the lateral tibia plateau. Results Since June 2014, 14 two column tibial plateau fracture patients with posterior and lateral column involvement have been treated according to this technique. The median follow-up was 306 days (IQR 194 - 438); 1 patient was lost to follow-up. During the last outpatient visit, 7 patients reported pain to some extent. At a median of 110 days (IQR 96 - 181), 10 patients showed a full range of motion. One deep infection was noted postoperatively. At the 3 to 4 month postoperative CT control, 10 of 14 patients showed successful reduction with restored alignment, whereas in 8 of 14 patients there was a congruent articular surface without significant articular steps (< 2 mm). Conclusion We have demonstrated that the surgical treatment of two column fractures of posterior and lateral tibial plateau fractures is technically possible via a combined posterior reversed L-shaped and anterolateral approach in a floating position without the necessity of intraoperatively repositioning of the patient. Although the number of patients was limited, the clinical and radiographic outcome was rather good.