Speaker: Consider complete pathology, surgical techniques for tibial plateau fractures
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Key takeaways:
- Surgeons should consider the 3D orientation of tibial plateau fractures prior to fixation.
- Size and orientation of the tibial plateau fracture dictate the location of the medial plate.
WAILEA, Hawaii — When it comes to treating tibial plateau fractures, surgeons need to fully understand the complete fracture pathology and all of the components, according to a presenter here.
“What you need to think about is the three-dimensional orientation because more and more of these higher-energy fractures have coronal plane fracture lines or fracture dislocations,” J. Tracy Watson, MD, professor of orthopedic surgery and chief of the orthopaedic trauma service in the department of orthopaedic surgery at Saint Louis University, said in his presentation at Orthopedics Today Hawaii. “I would suggest to think about the column classification. You are basing it on the three-dimensional anatomy: anterior column, posterior column [and] medial column. Wherever the fracture line exists, that is where you are going to place the plate.”
Watson added the size and orientation of the fracture will dictate the location of the medial plate, as well as the secondary incision.
“You also have to think about your articular rim,” Watson said. “Having an intact cortical rim is important and [so is] tibial tubercle integrity so you do not get an extension lag.”
Methods of articular elevation are dependent on the degree of comminution and depression, according to Watson. Although a tibioplasty may work well in older patients with low-energy fractures, Watson said surgeons should use a subchondral pad to elevate the articular fragment in patients with high-energy fractures.
“The mantra is: Thou shall not varus, specifically for these higher-energy fractures,” Watson said. “In order to do that, you have to make sure that you buttress the medial side appropriately.”
When reducing varus medial column fractures, Watson said the distal femur should follow the medial tibial condyle.
“The way that you can do this is by placing an eccentric king tong [clamp]on the tibial condyle laterally and the femoral condyle medially,” Watson said. “What you are doing is you are pushing and translating that tibia medially to reduce that medial condyle. It is, oftentimes, a large defect for these, what I would consider, straightforward fractures.”
Watson added that the posterior column and direct posterior apex location should be reduced through the prone approach and smaller plates should be used.
“[Smaller plates] work nicely. They are strong. They do not fail. You do not need these big, gigantic plates anymore. And do not forget your cortical rim plates for the rim and for the tubercle, because you need stable tubercle fixation to gain early motion,” Watson said.
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Watson JT. Tibia plateau fractures: Five tips in 5 minutes. Presented at: Orthopedics Today Hawaii; Jan. 7-11, 2023; Wailea, Hawaii.
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