Scott D. Cordes

Definitions

There are several classifications for tibial plateau fractures, the most common being the Schatzker classification. Three fracture types involve the lateral condyle: (I) a split fracture of the lateral tibial plateau; (II) a split compression fracture of the lateral tibial plateau; and (III) a compression fracture of the lateral tibial plateau. A type IV fracture involves the medial tibial plateau. Type V is a bicondylar fracture and type VI is a tibial plateau fracture with metaphyseal diaphyseal disassociation. This chapter will address the surgical management of the three fracture patterns involving the lateral tibial plateau.

Indications

1. Knee instability in extension greater than 10 degrees with valgus or varus stress

The following are relative guidelines for consideration of operative treatment.

2. Radiographic lateral tibial plateau tilt greater than 5 degrees (relative)

3. Radiographic depression of the lateral tibial plateau greater than 3 mm (relative)

4. Radiographic evidence of condylar widening of greater than 5 mm (relative)

Contraindications

The following are relative guidelines for consideration of nonoperative treatment.

1. Advanced age (relative)

2. Systemic disease (relative)

3. Severe osteopenia (relative)

4. Pre-existing osteoarthritis (relative)

Preoperative Preparation

1. Standard X-rays anteroposterior (AP), lateral, 45 degree oblique views); consider obtaining a 10 to 15 degree caudad AP view. The X-ray beam in this view matches the posterior slope of the proximal tibia (tibial plateau view).

Special Instruments, Position, and Anesthesia

1. Place the patient supine on a standard operating table. Positioning a sand bag beneath the ipsilateral buttocks may enhance access to the lateral aspect of the knee.

2. Pad all bony prominences.

3. Use general, epidural, or spinal anesthetic.

4. Use routine orthopedic surgical instrumentation.

5. Use a large fragment bone set (4.5 cortical screws and 6.5 cancellous screws with L or T buttress plates, large bone reduction clamps, and a selection of Kirschner wires for provisional fracture fixation).

6. For limited internal fixation, a large cancellous cannulated screw tray (6.5, 7.0, or 7.3) is required.

7. Autogenous bone graft or synthetic bone filler will be necessary depending on the surgeon’s choice. If autogenous iliac bone graft is chosen, the ipsilateral iliac crest should be prepped and draped.

Tips and Pearls

1. Assess the status of the leg compartments. Examine and document the status of the peroneal and tibial nerves and the distal pulses.

2. Perform a careful ligament examination. Assess for any varus–valgus instability with the knee in full extension.

What To Avoid

1. Avoid undermining the soft tissue flaps more than necessary.

2. Avoid further bony devascularization by minimizing soft tissue dissection.

3. Be aware of the peroneal nerve location. Attempt to protect it throughout the procedure to minimize the chance of injury.

4. Avoid injury to the lateral meniscus. Attempt to preserve and protect it throughout the procedure.

Postoperative Care Issues

1. The splint or cast can usually be removed approximately 2 to 6 weeks after surgery and range of motion exercises commenced. The exact timing of removal depends on the complexity of the fracture, the stability of the fixation, and the quality of the bone.

2. Protective weight bearing is continued for approximately 6 to 12 weeks after surgery. This again depends on the complexity of the fracture, the stability of the fixation and the quality of the bone. Radiographic analysis of healing can help guide advancement of weight bearing.

Operative Technique

Type I (split fracture)