n tips & techniques

Section Editor: Steven F. Harwin, MD

Posterior Coronal Plating of Bicondylar Tibial

Plateau Fractures Through Posteromedial
and Anterolateral Approaches in a Healthy
Floating Supine Position
Shi-Min Chang, MD, PhD; Xin Wang, MD; Jia-Qian Zhou, MD; Yi-Gang Huang, MD, PhD; Xiao-Zhong Zhu, MD

lateral condyle fractures, leav- ator or calcaneal traction in a

Abstract: Bicondylar tibial plateau fractures pose a signifi- ing a skin bridge at least 7 to Brown brace (Shanghai Medi-
cant challenge for treating surgeons. If the articular surface of 8 cm in width.2 Slight knee cal Equipment Factory, Shang-
the medial plateau has a second split component in the poste- flexion of approximately 30° hai, China) for 1 to 3 weeks to
rior coronal plane, it is difficult to get direct visualization and
and external rotation of the allow soft tissue injuries to
ensure plate fixation when the patient is in the supine position.
ipsilateral hip make access to heal and swelling to subside.
Using a technique in which a single preparation and draping of
the posteromedial edge of the If a spanning fixator is used
both legs is needed, patients were operated on using a healthy
proximal tibial easier.3 and future surgery is planned,
floating supine position maneuver through dual posteromedial
However, if the articular physicians should avoid insert-
and anterolateral incisions and triple plate fixations. By flexing
and adducting the contralateral healthy hip over the injured surface of the medial plateau ing pins in the areas where in-
leg, more lateral rotation of the fractured knee can be achieved, has a second split component cisions will be made. Surgery
providing better access and visualization of the posterior me- in the posterior coronal plane, is undertaken when adequate
dial plateau using a posteromedial gastrocnemius approach. it is difficult to get direct vi- soft tissue healing is achieved.
sualization and achieve plate Plain radiographs and com-
fixation because ipsilateral hip puted tomography scans with

B icondylar tibial plateau

fractures (Schatzker type
V and VI and AO/OTA type
The patient is usually placed
in the supine position intraop-
eratively. Generally, a postero-
external rotation is restricted
while patients are in the supine
position. Usually, patients need
3-dimensional reconstruction
of the knee should be obtained
for preoperative planning.
41C) are caused by high- medial incision is used for the to be in the prone position for The tibial plateau can be
energy trauma and are cur- medial condyle split fragment the posteromedial plateau op- classified into 4 quadrants: an-
rently treated operatively us- manipulation and fixation, eration4-10 and then be maneu- teromedial, anterolateral, pos-
ing dual-incision approaches and an anterolateral incision vered into the supine position teromedial, and posterolateral.
with plate and screw fixation.1 is used for the comminuted for the anterolateral plateau op- Optimal skin incisions can be
eration. This article describes a selected based on the quadrants
modified positioning approach that the fracture involves.11 If
Drs Chang, Wang, Zhou, Huang, and Zhu are from the Department of that provides access to the pos- the medial plateau was split
Orthopaedic Surgery, Tongji Hospital, Tongji University, Shanghai, People’s teromedial and anterolateral into a large shearing postero-
Republic of China.
aspects of the knee in a single medial fragment, slight knee
Drs Chang, Wang, Zhou, Huang, and Zhu have no relevant financial re-
lationships to disclose. supine preparation and drape. flexion of approximately 30°
Drs Chang and Wang contributed equally to this article. and external rotation of the ip-
Correspondence should be addressed to: Shi-Min Chang, MD, PhD, Preoperative Planning silateral hip usually afford suf-
Department of Orthopedic Surgery, Tongji Hospital, Tongji University, 389
Bicondylar tibial plateau ficient exposure for reduction
Xincun Rd, Shanghai 200065, People’s Republic of China (shiminchang@
yahoo.com.cn). fractures are initially stabilized and plate fixation.3 However, if
doi: 10.3928/01477447-20120621-03 with a spanning external fix- the medial plateau was further

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n tips & techniques

medial condylar fractures are

reduced and fixed separately,
with a posterior plate (coronal
fragment) and a medial plate
(sagittal fragment) in antiglide
mode, usually by small un-
dercontoured reconstruction
plates with short screws that
grip only the proximal corti-
ces. The lateral condyle is a
comminuted split depression
that needs articular elevation,
a bone substitute graft, and a
heavy buttress plate with long
screws inserted to the medial
cortex to protect the lateral
1 2 plateau reduction, hold both
Figure 1: Diagram showing the fixation strategies for Figure 2: Photograph showing the patient placed in the supine condyles together, and connect
complex bicondylar tibial plateau fractures. The split position, with both legs prepared and draped. the reconstructed metaphysis
medial condyle fragment is repositioned anatomically.
to the tibial shaft.
A small plate with short screws is applied over the frac-
ture spike in antiglide mode. The depressed lateral con-
dyle is elevated, grafted, and fixed with a heavy buttress Surgical Technique
plate and long screws inserted to the medial cortex to Under intratracheal gen-
protect the lateral plateau reduction, hold both condyles
eral anesthesia, the patient
together, and connect the reconstructed metaphysis to
the shaft. is placed in the supine posi-
tion. A high-thigh pneumatic
tourniquet is applied to the
injured extremity. The authors
prepared and draped both
legs (Figure 2) and prefer to
start with the posteromedial
approach to provide a stable
medial column to which the
lateral plateau can be reduced
and stabilized. The contralat-
eral hip is flexed and adducted
and the pelvis rotated toward
the injured side. This results in
the patient’s pelvis and lower
trunk in a semilateral position,
3 and the injured leg is rotated
Figure 3: Photograph showing the contralateral healthy hip flexed laterally, allowing access to
and adducted over the injured leg by an assistant. This results
4
the posterior aspect of the
in lateral rotation of the injured limb, and a better access to the Figure 4: Schematic drawing showing the posterome-
knee (Figure 3). A scrubbed
posteromedial incision to expose the posterior coronal fragment. dial skin incision.
assistant holds the leg in posi-
tion. General anesthesia and
sufficient padding and sup-
split into 2 or 3 components, chose to prepare and drape both The operative strategy in- porting from the back allow
usually with 1 large posterior legs for intraoperative manipu- cludes dual incisions and triple the patient to easily remain in
coronal fragment, the authors lation to add exposure. plate fixation (Figure 1). Split this position.

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 n tips & techniques

The surgeon stands on the duced anatomically under di-

opposite side of the operated rect visualization, and a small
limb. An inverted L-shaped undercontoured reconstructive
incision is made, centering the plate is placed onto the spike
horizontal limb at the popliteal and fixed in antiglide fashion,
crease. The medial arm of the usually with four 3.5-mm cor-
incision is made just poste- tical screws, 2 on each side of
rior to the medial edge of the the spike.
tibia (Figure 4). The medial The contralateral leg is put
condyle is exposed through a back to its normal position, and
posteromedial gastrocnemius the fracture is checked by fluo-
approach, which is similar to roscopy. The sagittal split me-
those described by Lobenhof- dial fragment is then reduced
fer et al,5 Galla and Lobenhof- and fixed with another recon-
fer,7 and Carlson.12,13 Sharp structive plate, and the entire
dissection is carried deep, and medial condyle is put onto the
the posterior fascia is incised tibia shaft. Short screws only
between the medial gastroc- grasping the proximal cortices 5
nemius (posterior border of are used to avoid interfering Figure 5: Schematic drawing showing the posteromedial gastrocnemius–
the dissection) and the pes an- lateral plateau reduction later. soleus approach.
serinus anteriorly. The medial The healthy leg is put back,
collateral ligament remains in- and the support on the patient’s
tact anteriorly and deep to the back is removed; this returns drains. No external splints are incisions with triple plate fixa-
pes anserinus. The pes tendons the patient to a true supine po- used. tions. Eight men and 4 women
are mobilized posteriorly and sition for a lateral plateau op- After the incision has with a mean age of 48 years
proximally, keeping their in- eration. A bump added under stopped bleeding and swell- (range, 39-60 years) were in-
sertion intact. A Penrose drain the ipsilateral hip further in- ing, usually 3 to 4 days post- cluded. Seven patients were
can be used for their retraction. ternally rotates the lower limb. operatively, continuous pas- injured in traffic accidents,
The medial gastrocne- The lateral tibial plateau is ex- sive motion using a machine and 5 were injured in falls
mius is then elevated poste- posed through a conventional is allowed to less than 45° of from a height. All fractures
riorly and laterally, exposing anterolateral approach. After flexion in the first week, and were Schatzker type VI (AO/
the posterior tibia (Figure 5). submeniscus arthrotomy, the increased gradually to 90° OTA types 41C2 and 41C3).
No gastrocnemius tendon re- comminuted lateral plateau is in the second week. Patients Ten cases involved 4 plateau
lease is attempted. The popli- visualized. The depressed ar- are encouraged to regain full quadrants and 2 cases involved
teal neurovascular structures ticular fragments are elevated range of motion in 4 weeks. 3 quadrants. Mean time from
are safely protected deep to with a large amount of cancel- Weight bearing is restricted to injury to operation was 9.5
the gastrocnemius muscle, lous and subchondral bone. toe-touch (5-10 kg) during the days (range, 7-12 days).
but overzealous retraction is A bone grafting substitute is first 2 months and increased No cases of infection were
avoided to prevent traction in- placed to support the elevated progressively in the third observed. One patient had a
jury to the tibial nerve. The so- fragments. Another T- or L- month. Full weight bearing is superficial dehiscence postop-
leus and popliteus muscles are shaped heavy plate with long not permitted before 3 months. eratively that healed without
then elevated from the medial screws is used to buttress the further treatment. The time of
edge of the tibia by sharp dis- reduced lateral plateau frac- Patient Series bony consolidation and full
section, exposing the fracture ture, hold the tibial condyles Between January 2006 and weight bearing averaged 21.7
site. together, and connect them to December 2008, twelve pa- weeks (range, 16-26 weeks).
The joint is then entered the tibial shaft. Locking plates tients with bycondylar tibial Patients were followed up for
posteriorly while carefully are preferred in lateral fixa- plateau fractures were pro- at least 24 months (range, 24-
protecting the capsular and lig- tion. Both incisions are closed spectively treated using this 48 months). At 1 year postoper-
ament insertions. The coronal using absorbable sutures in maneuver through dual pos- atively, no loss in reduction or
split posterior fragment is re- routine fashion over suction teromedial and anterolateral alignment was observed. Mean

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6C

6A 6B 6C 6D 6E

6F 6G 6H

6I 6J 6K 6L 6M
Figure 6: Anteroposterior (A) and lateral (B) radiographs of a Schatzker type VI, AO/OTA type 41C3.3 bicondylar, high-energy, tbial plateau fracture in a 55-year-
old man who was in a traffic accident. Three-dimensional computed tomography scans showing a medial plateau shearing fracture (C) with a second posterior
coronal split fragment (D) and a lateral plateau comminuted depression fracture with metaphyseal–diaphyseal dissociation (E). Transverse computed tomogra-
phy scan showing a 4-quadrant tibial plateau comminuted fracture (F). Intraoperative photograph of the posterior coronal split fragment of the medial condyle
(G). The posterior coronal fragment is reduced and fixed with undercontoured reconstruction plate with antiglide fashion (H). Postoperative anteroposterior (I)
and lateral (J) radiographs showing a double antiglide plate with short screws for the medial condyle fixation and 1 buttress plate with long screws for lateral
condyle fixation. Photograph of posteromedial and anterolateral incisions (K). Radiographs obtained 1.5 years postoperatively showing the healed fracture (L)
with no reduction loss (M). Abbreviations: AL, anterolateral; AM, anteromedial; PL, posterolateral; PM, posteromedial.

Hospital for Special Surgery An illustrative case of com- eral approaches in the healthy Discussion
knee score was 87.3 (range, 78- minuted biconcylar tibial pla- floating supine position and Bicondylar tibial plateau
95). Patients were satisfied with teau fracture, operated on with triple plate fixation, is present- fractures result from high-
their treatment outcomes. posteromedial and anterolat- ed in Figure 6. energy injuries and are often

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 n tips & techniques

combined with marked trauma with small implants to create a with associated chest trauma. during traditional open reduc-
to the surrounding soft tissues. stable strut that facilitates lat- Furthermore, intraoperative tion and plate fixation or to
Management is challenging, eral fixation. The main purpos- repositioning of the patient use a limited open reduction
requiring a combination of ac- es of an anterolateral approach means a second skin prepa- technique with external fixator
curate bone reduction and fix- are (1) to elevate the commi- ration and draping, which is protection.
ation and minimal soft tissue nuted articular depression with time consuming. In patients In 2010, Luo et al22 intro-
invasion. Currently, the treat- bone substitute grafting to fill with bicondylar fractures, it duced a floating position using
ment protocols can be clas- the gap and (2) to fix the me- also means that the first opera- 1 preparation and drape for
sified into 3 categories: open dial cortex with a heavy but- tion, usually to the medial pla- posteromedial and anterolat-
reduction and internal fixation, tress plate and long screws, teau, is finished and the skin is eral approaches. The patient
limited open reduction with thus protecting the lateral closed. It leaves no opportuni- was placed in the lateral de-
percutaneous screw fixation plateau reduction and holding ty for secondary adjustment or cubitus position with the in-
and hybrid fixator stabiliza- both condyles together, secur- revision of the first procedure. jured leg up. The lower leg and
tion, and indirect reduction ing their contact with the tibial Compared with changing pelvis were first rotated to a
and application of fine-wire shaft (Figure 1). Recently, lat- patients’ positions intraopera- prone position to perform pos-
circular external fixator. Each eral locking plates have be- tively, the advantages of the teromedial approach to fix the
method has advantages and come more popular.19,20 current maneuver are a single posterior and medial tibial pla-
disadvantages.14 The authors Generally speaking, the skin preparation and draping, teau fractures with an inverted
reserve the use of external fix- surgical approach and patient reduction in operative time, L-shaped incision. Then, the
ation devices in the treatment position depend on fracture and the opportunity for tech- lower leg and pelvis were ro-
of complex bicondylar tibial location and displacement. nical adjustment through the tated back to the lateral posi-
plateau fractures to span the Weil et al3 reported that, with first incision, if needed. The tion to perform an anterolat-
fracture site until the patient the ipsilateral knee in slight main disadvantage is that an eral approach to fix the lateral
is amenable to definitive fixa- flexion and the hip in external additional scrubbed assistant tibial plateau.
tion with open reduction and rotation, the medial plateau is needed to keep the healthy In contrast with the injured-
plate fixation. This treatment is accessed easily in a pos- leg in position. side rotation method presented
principle is in accordance with teromedial supine approach. The indications for this by Luo et al,22 the current ap-
those of Krupp et al.15 However, when the articular healthy floating supine posi- proach used rotation of the
The characteristics of the surface of the medial plateau tion are bicondylar tibial pla- healthy lower leg and pelvis.
most complex bicondylar has a second posterior split teau fractures with a posterior By preparing and draping both
fractures follow a regular pat- component in the coronal coronal fragment that requires legs, the contralateral healthy
tern.16-18 The concave medial plane, it is recommended that a separate plate fixation. It is hip is flexed and adducted over
plateau is split in a medio- management is performed possible to operate on 3 (an- the injured leg. This maneu-
lateral direction with a ma- through a posterior approach teromedial and posterome- ver makes the patient’s lower
jor posteromedial fragment, for direct visualization and dial) or 3 (plus posterolateral) trunk rotate and results in the
whereas the convex lateral pla- manipulation with the patient quadrants of bicondylar tibial injured limb rotated laterally,
teau is depressed into various in the prone position4-10 and, plateau fractures from the pos- providing better access and
amounts of multifragments preferably, with 2 antiglide teromedial gastrocnemius ap- visualization of the posterior
with broadening of the lateral buttress plates.21 However, in proach while the patient is in coronal fragment in the medial
compartment. In the authors’ some clinical instances it may the supine position. However, plateau. This floating supine
practice, bicondylar tibial pla- be desirable place the patient this maneuver is not allowed position allows for a healthy-
teau fractures are usually treat- in a supine instead of a prone for patients with associated side maneuver, which is safer
ed through posteromedial and position. spine fractures, contralateral than the injured-side manipu-
anterolateral incisions with 2 The position of a patient leg fractures, and pelvic frac- lation.
plate fixations. The main pur- on the operating table should tures and for patients who are Furthermore, in the au-
pose of the posteromedial ap- afford maximum safety to the obese. For those contraindica- thors’ opinion, intraoperative
proach is to achieve an exact patient and convenience for tions, spine and pelvic frac- fluoroscopic examinations of
anatomic fracture reduction the surgeon. However, prone tures should be treated first. the knee in standard antero-
and fix the split fragment over positions are limited in some It is the authors’ practice to posterior and lateral views are
the spike in antiglide fashion instances, such as in patients change the patient’s position easier to achieve in the supine

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n tips & techniques

position. This positioning ma- 3. Weil YA, Gardner MJ, Boraiah 10. Fakler JK, Ryzewicz M, Harts- terns. J Orthop Trauma. 2008;
S, Helfet DL, Lorich DG. Pos- horn C, Morgan SJ, Stahel PF, 22(3):176-182.
neuver also can be used with teromedial supine approach for Smith WR. Optimizing the
17. Eggli S, Hartel MJ, Kohl S,

interoperative fixators or large reduction and fixation of medial management of Moore type I
Haupt U, Exadaktylos AK,
and bicondylar tibial plateau postero-medial split fracture
distractors that are applied to fractures. J Orthop Trauma. dislocations of the tibial head:
Röder C. Unstable bicondy-
lar tibial plateau fractures: a
facilitate tibial fracture reduc- 2008; 22(5):357-362. description of the Lobenhoffer
clinical investigation. J Orthop
tion. The potential pitfalls lie approach. J Orthop Trauma.
4. Georgiadis GM. Combined an- Trauma. 2008; 22(10):673-
2007; 21(5):330-336.
in the extensive soft tissue dis- terior and posterior approaches 679.
for complex tibial plateau frac- 11. Chang SM. Selection of surgi-
section, which is dangerous 18. Higgins TF, Kemper D, Klatt J.
tures. J Bone Joint Surg Br. cal approaches to the postero-
Incidence and morphology of
for infection and wound heal- 1994; 76(2):285-289. lateral tibial plateau fracture by
the posteromedial fragment in
ing.23 its combination patterns. J Or-
5. Lobenhoffer P, Gerich T, Ber- bicondylar tibial plateau frac-
thop Trauma. 2011; 25(3):e32-
tram T, Lattermann C, Pohle- tures. J Orthop Trauma. 2009;
e33.
mann T, Tscheme H. Particular 23(1):45-51.
Conclusion posteromedial and posterolat- 12. Carlson DA. Bicondylar frac-

19. Higgins TF, Klatt J, Bachus

With single preparation and eral approaches for the treat- ture of the posterior aspect of
KN. Biomechanical analysis
ment of tibial head fractures [in the tibial plateau. A case report
draping of both legs in the su- German]. Unfallchirurg. 1997; and a modified operative ap-
of bicondylar tibial plateau
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pine position and the contra- 100(12):957-967. proach. J Bone Joint Surg Am.
locking plate fixation com-
lateral healthy hip flexed and 1998; 80(7):1049-1052.
6. De Boeck H, Opdecam P. pare to dual plate fixation?
adducted over the injured leg, Posteromedial tibial plateau 13. Carlson DA. Posterior bicondy- J Orthop Trauma. 2007;
fractures. Operative treat- lar tibial plateau fractures. J Or- 21(5):301-306
more lateral rotation of the ment by posterior approach. thop Trauma. 2005; 19(1):73-
20. Uhl RL, Gainor J, Horning J.
fractured knee can be achieved, Clin Orthop Relat Res. 1995; 78.
Treatment of bicondylar tibial
providing better access and vi- (320):125-128. 14. Canadian Orthopaedic Trauma plateau fractures with lateral
sualization of the posterior 7. Galla M, Lobenhoffer P. The Society. Open reduction and locking plates. Orthopedics.
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medial plateau. treatment of unstable tibial circular fixator application for
21. Luo CF, Jiang R, Hu CF, Zeng
posteromedial fracture-dis- bicondylar tibial plateau frac-
BF. Medial double-plating for
locations [in German]. Un- tures. Results of a multicenter,
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