Many methods exist for fixation. The location of the depression makes some fractures more amenable to arthroscopic treatment. Consideration must be given to the accessibility of the depressed portion and the tools available to elevate the fracture site. Visualization is often difficult due to bleeding, and extra outflow portals may be necessary. Positioning of the C-arm and arthroscopy equipment should be determined prior to patient prepping to be certain that the necessary views are obtainable.

Preoperative Planning and Timing of Surgery

The most significant determinate for the timing of the surgery is the condition of the soft tissue. Internal fixation requires manipulation of the already damaged tissue. If this is done prematurely, wound infection and sloughing may occur. To help prevent this, internal fixation should be delayed up to 8 days to allow for proper skin conditions. A technique such as limited open reduction, arthroscopic reduction, or the use of a small wire fixator may be preformed sooner than internal fixation due to the limited incisions.

Special Instruments

1. Internal fixation plating systems with a variety of shapes and lengths depending on the fracture pattern are available. T and L buttress plates and precontoured fixation plates are commonly used to best approximate the fracture pieces and prevent displacement. Plates should be used that allow for can-cellous screw fixation in the proximal portion and cortical screws for the distal portion. Low-profile plates allow for easier wound closure.
   
2. Alternative treatment with a small wire or hybrid fixa-tor is useful for severely comminuted fractures. Wires with or without olive extensions can reduce and maintain reduction using tension wire techniques.
   
3. Split fractures without depression can be reduced with percutaneous 6.5- or 7.0-mm cancellous lag screws with or without washers.
   
4. Arthroscopic reduction requires bone tamps with varying angles and widths to allow access to all portions of the joint. The reverse sides of contoured curettes are often helpful.
   
5. Bone graft is often necessary to fill defects, either autogenous or allograft. The small cancellous crouton type is easy to pack and can be further compressed.

Anesthesia

Options are general anesthesia or spinal anesthesia.

Patient and Equipment Positions

1. The patient should be in the supine position.
   
2. The leg should have the ability to flex and rotate to allow for indirect reduction.
   
3. The entire lower extremities are prepped and draped with a sterile tourniquet.
   
4. The C-arm image intensifier should be positioned before surgery to allow full exposure of the fracture in anteroposterior (AP), lateral, and oblique planes.

Surgical Procedure

1. A midline incision is made from the top of the patella distally for the length of the fracture and chosen plate.
   
2. A full-thickness flap is raised from the tibial crest to the joint line on the side of the fractures plateau.
   
3. A horizontal incision through the coronary ligament inferior to the meniscus allows for easy visualization of meniscal tears and judging of the adequacy to the articular surface reduction.
   
4. Further visualization for lateral plateau fractures can be achieved with partial incision of the iliotibial band (ITB).
   
5. Depressed fractures can be elevated through a bone window or through the fracture line using bone tamps and elevators.
   
6. Graft is used to fill the defect.
   
7. The fracture is reduced through direct and indirect techniques such as fracture reduction clamps and bone distractors.
   
8. It may be necessary to use temporary fixation with Kirschner wires (K-wires) until internal fixation can be aligned.
   
9. The plateau is reduced with cancellous screws below the plateau and cortical screws at the more distal positions. Proximal screws can be used either incorporated or outside the plate.
   
10. Further exposure for combined medial and lateral plateau fractures may require tibial tubercle osteotomy or Z-plasty of the patellar tendon.
    
11. For fractures requiring medial and lateral plates, a combination of buttress plate, semitubular plate, or small wire fixator can be used. When using the small wire fixator, the wires should be placed 10 mm below the surface to avoid the synovial recess.
    
12. Direct repair of tibial spine avulsion fractures can be done through these exposures.
    
13. Any meniscal repairs are done at the time of closure.
    
14. The full-thickness graft and ITB are closed over suction drains.

Dressings, Braces, Splints, and Casts

1. The postoperative dressing is a bulky Jones dressing. This is removed 48 hours postoperatively.
   
2. The suction drain is removed in 24 hours if drainage if less than 30 mL per 8 hours.
   
3. When the patient can tolerate it, a hinged knee brace should be applied.

1. The full-thickness incision allows for adequate exposure and maintains the integrity of the soft tissue.
   
2. Lateral extension through removal of the ITB greatly expands exposure if necessary.
   
3. Use of a femoral distractor across the knee aids in reduction of difficult fractures.

Pitfalls and Complications

1. The risk of infection is 12%. The soft tissue is often in poor condition. Wait enough time for the edema to subside to avoid later wound complications. Minimize soft tissue stripping.
   
2. If wound breakdown occurs, aggressive management is necessary.
   
3. If persistent wound problems prevent closure, a gastrocnemius of free flap may be necessary.
   
4. Pay close attention for evidence of nonunion. These patients may need bone grafting.
   
5. Loss of fixation can be avoided by recognizing osteopenia and using buttress plates for these patients.
   
6. Arthrosis may develop as a result of initial cartilage damage or due to joint incongruity.
   
7. Rare complications include neurovascular injury and compartment syndrome.

Postoperative Care

1. The patient is placed in a bulky Jones dressing for the first 48 hours.
   
2. The drain is removed at 24 hours if drainage has subsided.
   
3. A hinged knee brace is placed after removal of the Jones dressing
   
4. If the wound condition allows, continuous passive motion (CPM) and physical therapy is begun at the time of placement into a hinged knee brace.
   
5. Physical therapy consists of passive and active assist initially advancing to active range of motion as the wound heals.
   
6. Depending on the fixation achieved, the patient is started on non–weight bearing or partial weight bearing ambulation.
   
7. Most patients can be advanced to 50% weight bearing by 6 to 8 weeks.
   
8. Further advancement is dependent on progress of callus formation.
   
9. External fixation devices can be removed at 6 to 8 weeks and hinge bracing used as an adjuvant.
   
10. Full activity is achieved in most cases at 3 to 4 months but may be delayed up to 18 months for the most severe and complicated fractures.

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