Anatomic reduction and stable fixation is the gold standard in the
treatment of displaced tibial plateau fractures. However, this goal is not
always achievable, and extra-articular and intraarticular malunions are often
the result of conservative and operative treatment. A proximal tibial
osteotomy can restore the mechanical axis or shift the mechanical axis to the
uninjured compartment. In almost all severe AO type-C fractures, comminution
and joint depression occur in the lateral compartment. In general, anatomic
reconstruction of the large depressed medial fragments is easier to perform
secondary to an easier operative exposure. Hence, the majority of primary and
secondary malunions after tibial plateau fractures lead to a valgus (and
intra-articular depression) malalignment. The combination osteotomy described
in the present report restores intra-articular anatomy and provides varus
correction, typically provides a good functional outcome, and preserves the
salvage option of total knee arthroplasty. Nevertheless, optimal recovery
requires a protracted period of convalescence.
Osteotomy of the
fibula1: In order to
achieve full correction, a mid-third, oblique osteotomy of the fibula is
routinely performed, as long as a fibular head osteotomy is not required to
approach the intra-articular malunion.
Exposure of the proximal part of the
tibia1: A straight
lateral parapatellar incision is utilized. The iliotibial tract is incised to
the Gerdy tubercle, and the fascia of the anterior tibial muscle is opened 1
cm from the tibial crest and the muscle is detached from the bone (Figs.
1-A, 1-B, and
1-C).
Proximal tibial
osteotomy1,2:
The neurovascular bundle is protected by blunt Hohmann retractors
(Fig. 2-A). A transverse or
oblique osteotomy is performed, starting 4 cm distal to the lateral articular
surface and finishing 1 to 2 cm distal to the medial joint line, depending on
individual anatomy. The osteotomy is started laterally with use of an
oscillating saw to the depth of the medial cortex
(Fig. 2-B), which is then
perforated with several passes of a small drill-bit and osteotomes
(Figs. 2-C and 2-D), allowing
bending of the medial cortex by gentle osteoclasis to preserve an osseous
hinge. The medial hinge is protected, usually with reduction forceps
(Figs. 3-A and 3-B), and a bone
spreader is used to open the osteotomy site until the desired correction is
achieved (Fig. 3-C).
The intra-articular correction is performed through the opening wedge
osteotomy as visualized through a lateral
arthrotomy2-4
(Fig. 4-A). The depression of
the tibial plateau can best be identified and approached with the knee in
100° of flexion. This position is facilitated by supporting the foot of
the patient on a sandbag mounted onto the operating table. Further approach to
the knee joint depends on the location of the joint incongruency. With a
standard lateral arthrotomy, the anterior 50% to 60% of the lateral plateau
can easily be visualized and approached
(Fig. 4-A). To expose more
posteriorly situated depressions, an osteotomy of the Gerdy tubercle and
reflection of the attached iliotibial tractallow visualization of
approximately 80% of the lateral plateau
(Figs. 4-B and 4-C). Finally,
an additional osteotomy of the fibular head after release of the peroneal
nerve allows full anterior dislocation of the lateral tibial plateau
(Figs. 4-D and 4-E). This
extended approach is necessary for reconstruction of a posterolateral
malunion.
Through the lateral arthrotomy, the lateral meniscus, if it is still
present, can be temporarily detached to assess the tibial plateau and provide
direct visualization during the elevation of the depression. Damaged regions
of the meniscus are removed while the peripheral meniscal remnants are
preserved. The depressed cartilage zone is then marked circumferentially with
a 2-mm drill-bit. With these drill-holes used for guidance, the depressed zone
is osteotomized in the vertical plane with a small osteotome.
The intra-articular
osteotomy2-4
can also be performed through the opening-wedge tibial plateau osteotomy with
a small bone distractor in situ. For this approach, including the elevation of
the depressed lateral tibial plateau, it is helpful to create a small
metaphyseal cortical window at the site of the tibial plateau osteotomy (Figs.
5-A, 5-B,
5-C, 5-D). It allows better
access to the subchondral site and free handling of curved osteotomes and
impactors (Fig. 6).
The intra-articular malunion may consist of one large or multiple small
osteochondral fragments. With a curved impactor inserted through the window,
the depressed area of the plateau is elevated to conform to the lateral
femoral condyle in both extension and flexion, creating an overcorrection of 1
mm. The correction is maintained by impacting cancellous autograft bone
beneath the elevated segment. The lower extremity alignment is evaluated
clinically by adjusting the bone spreader, and then the intra-articular
correction, the ligamentous stability, and the weight-bearing position of the
knee are all checked. A further important step in the procedure is dynamic
testing of the knee from full flexion to full extension to verify that
articular congruence is optimal and that any osseous pivot shift has
disappeared. The technique is shown in Figures
7-A, 7-B,
7-C, 7-D,
7-E, 7-F,
7-G.
The operation is completed with the impaction of wedged corticocancellous
autograft bone into the open gap and internal fixation with an L or a
T-plate2-4.
After extending the approaches, the tibial plate is usually sufficient to be
used to fix both the Gerdy tubercle and the proximal tibial varus osteotomy at
the same time. Finally, a lag screw is sufficient to secure the osteotomy of
the fibular head. The only indication to approach the tibial plateau by
arthrotomy and an osteotomy of the tibial tuberosity is when there is a
combination of medial and lateral malunions. This approach allows full
visualization, evaluation, and intraarticular correction of both knee
compartments, whereas an approach with use of separate medial and lateral
incisions makes intraoperative orientation more difficult.
Wound closure: The anterior tibial fascia is reattached, and a lateral
fasciotomy is performed to prevent an anterior compartment syndrome. In the
presence of a lateralized patella, closing the iliotibial tract is
unnecessary.
Activity is restricted to functional passive motion until reduction of
postoperative swelling and restoration of range of motion of the knee is
accomplished. Brace protection is provided, and only toe-touch weight-bearing
with crutches is allowed for eight weeks. Thereafter, an increase to full
weight-bearing is allowed as tolerated. Physiotherapy is recommended
throughout the whole rehabilitation period in order to prevent inadequate
mobilization and to optimize leg muscle function.
If toe-touch weight-bearing is not possible, despite careful preoperative
instruction, or if poor compliance is expected, the leg is placed in a
continuous-passive-motion machine to maintain function and to reduce
postoperative swelling prior to immobilization in a cylinder cast.
Radiographs are made on both the first postoperative day as well as at
eight weeks (Figs. 8-A, 8-B,
8-C, 8-D,
8-E, 8-F, 8-G).
CRITICAL CONCEPTSINDICATIONS:Painful and disabling posttraumatic intra-articular and valgus malunion of
the tibial plateau in active patients. Valgus malunion of up to 20° and
plateau depression of up to 20 mm can be satisfactorily corrected.Both conservatively as well as operatively treated tibial plateau
fractures.CONTRAINDICATIONS:Poor general healthElderly patientsSevere loss of knee function, or the presence of advanced
osteoarthritisInfectionCompromised soft tissuesUncertain patient compliancePITFALLS:Overcorrection or undercorrection of the valgus deformityUndercorrection of the joint surface; a slight intraoperative
overcorrection of 1 mm being preferableDamage to the peroneal nerveInjury to the popliteal artery or veinCompartment syndrome of the anterior compartment resulting from failure to
perform a routine fasciotomyMalunion or nonunion resulting from failure to assess lower extremity
alignment and knee joint stability intraoperativelyAUTHOR UPDATE:Currently, we perform the surgical technique as it was described in the
original paper, without modification.
CRITICAL CONCEPTS
INDICATIONS:
Painful and disabling posttraumatic intra-articular and valgus malunion of
the tibial plateau in active patients. Valgus malunion of up to 20° and
plateau depression of up to 20 mm can be satisfactorily corrected.Both conservatively as well as operatively treated tibial plateau
fractures.
Painful and disabling posttraumatic intra-articular and valgus malunion of
the tibial plateau in active patients. Valgus malunion of up to 20° and
plateau depression of up to 20 mm can be satisfactorily corrected.
Both conservatively as well as operatively treated tibial plateau
fractures.
CONTRAINDICATIONS:
Poor general healthElderly patientsSevere loss of knee function, or the presence of advanced
osteoarthritisInfectionCompromised soft tissuesUncertain patient compliance
Poor general health
Elderly patients
Severe loss of knee function, or the presence of advanced
osteoarthritis
Infection
Compromised soft tissues
Uncertain patient compliance
PITFALLS:
Overcorrection or undercorrection of the valgus deformityUndercorrection of the joint surface; a slight intraoperative
overcorrection of 1 mm being preferableDamage to the peroneal nerveInjury to the popliteal artery or veinCompartment syndrome of the anterior compartment resulting from failure to
perform a routine fasciotomyMalunion or nonunion resulting from failure to assess lower extremity
alignment and knee joint stability intraoperatively
Overcorrection or undercorrection of the valgus deformity
Undercorrection of the joint surface; a slight intraoperative
overcorrection of 1 mm being preferable
Damage to the peroneal nerve
Injury to the popliteal artery or vein
Compartment syndrome of the anterior compartment resulting from failure to
perform a routine fasciotomy
Malunion or nonunion resulting from failure to assess lower extremity
alignment and knee joint stability intraoperatively
AUTHOR UPDATE:
Currently, we perform the surgical technique as it was described in the
original paper, without modification.