OPEN REDUCTION AND FIXATION OF TIBIAL PLATEAU FRACTURES

■ Apply a tourniquet except in patients with severe soft tissue injury.
■ For fractures of the lateral condyle make a straight or slightly curvilinear anterolateral incision starting 3 to 5 cm above the joint line proximally and extending distally below the inferior margin of the fracture site from just anterior to the lateral femoral epicondyle to Gerdy’s tubercle. This incision provides good exposure while avoiding skin complications. Alternatively, an L-shaped incision may be used.
■ Make the fascial incision in line with the skin incision. Do not undermine soft tissue flaps more than necessary. If necessary for exposure, reflect a portion or all of the iliotibial band from its insertion on Gerdy’s tubercle. Gain intraarticular exposure by incising the coronary or inframeniscotibial ligament and
retract the meniscus superiorly after placement of nonabsorbable meniscocapsular tagging sutures.
■ Inspect and débride or repair any meniscal tears to preserve as much of the menisci as possible.
■ To expose the longitudinal fracture of the lateral condyle, elevate the origin of the extensor muscles from the anterolateral aspect of the condyle in an extraperiosteal fashion. Reflect the muscle origin laterally until the fracture line is exposed.
■ Retract the lateral fragment to gain access to the central part of the tibial condyle. This lateral fragment often hinges open like a book, exposing the depressed articular surface and cancellous bone of the central depression.
■ Alternatively, make a cortical window below the area of depression to allow reduction of this fragment. This approach generally requires less soft tissue dissection than hinging open the lateral condylar fragment.


■ Insert a periosteal elevator well beneath the depressed articular fragments and by slow and meticulous pressure elevate the articular fragments and compressed cancellous bone in one large mass. This produces a large cavity in the metaphysis that must be filled with bone graft or substitute. Unless this is done redisplacement and settling can occur. Various types of grafts have been proposed, from transverse cortical supports to full-thickness iliac grafts. We prefer injectable bone substitutes such as calcium sulfate or phosphate bone cements for metaphyseal subchondral defect management after elevation of depressed articular segments.
■ The standard lateral approach gives only a limited view of the posterolateral plateau and provides no access to the posterior wall of the lateral tibial plateau. Certain fractures located in the posterolateral plateau require a more extensile approach. In this situation, the fascial incision follows the insertion of the extensor muscles and continues over the subcapital fibula. The entire layer is stripped distally as required. Expose the peroneal nerve and cut the fibular neck with an oscillating saw. This allows retraction of the upper segment to the back or rotation of the fibular head upward exposing the posterolateral plateau and the lateral and posterior flare of the proximal tibia.
■ If displacement of the peripheral rim is slight, and central depression of the condyle is the main deformity, remove an anterior cortical window with its proximal edge distal to the articular surface.
■ Insert a small thin osteotome, periosteal elevator, or curved bone tamp through the cortical window or fracture line into the cancellous subchondral bone and elevate to the normal level the depressed fragments of the articular surface. As the fragments are elevated and reduced, temporarily fix them with multiple small Kirschner wires. Stabilize with subchondral raft screw fixation.


■ Apply a buttress plate to the anterolateral proximal tibia. Precontoured periarticular plates
designed for tibial plateau fractures are readily available typically in either a 3.5- or 4.5-mm dimension. Depending on the fit of the implant, one may choose to place separate raft screws before affixing the plate to ensure subchondral support of newly elevated articular segments. Typically, for simple lateral condylar fractures alone (Shatzker I & II), nonlocking 3.5-mm implants are sufficient.
■ Augment the defect with cancellous bone or bone graft substitute.
■ If the meniscus has been detached peripherally, carefully suture it back to its coronary ligament attachment. If the iliotibial band has been reflected from its insertion at Gerdy’s tubercle, reattach it.