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Plateau
1.
2. The AP and lateral radiographs demonstrate a lateral split
depression tibial plateau fracture. The CT scan of the articular
surface demonstrates impaction of the anterior portion of the
plateau (arrows).
5. The CT scan of the articular surface demonstrates impaction
of the anterior portion of the plateau (arrows).
6. CAT scan at the top of the fibular head region demonstrates a
nondisplaced crack through the lateral fragment (dotted area).
7. Multiple incisions and approaches are possible for tibial
plateau fractures. The use of a direct anterior incision will
enable further reconstructive surgery to be performed more
easily if necessary at a later date.
8. The incision is slightly lateral to the midline such that it comes down
just lateral to the tibial tubercle and over the anterior compartment
musculature rather than the tibial crest.
9. A full thickness fascial cutaneous flap is raised above the
iliotibial band towards the lateral side only. No medial
dissection is necessary.
10. ITB
The iliotibial band is then split in line with its fibers
but not through the knee capsule.
11. ITB
The retraction of the iliotibial band posteriorly exposes
the bulging joint capsule.
12. The retraction of the iliotibial band posteriorly exposes
the bulging joint capsule.
JOINT
CAPSULE
ITB
13. The Freer elevator is demonstrating the level of the
superior surface of the joint on the displaced lateral
fragment.
JOINT
CAPSULE
14. The coronary ligament is released, exposing the meniscus. Sutures
are placed within the meniscus to allow for its superior retraction.
CORONARY
LIGAMENT
16. A lamina spreader can be used to externally rotate the lateral
displaced split fragment, exposing the inside of the joint. The
iliotibial band and soft tissues need not be removed from that
fragment.
18. After elevation of the impacted articular cartilage, pointed bone
clamps are used either percutaneously from the medial side or
underneath the skin to a position that is generally anterolateral.
19. This clamp is positioned such that compression will reduce the
fracture. The fracture reduction is judged by looking anteriorly
and inferiorly as well as looking into the joint by retracting the
meniscus and keeping the leg in a varus position.
20. Intraoperative fluoroscopy in the 10-degree caudad view
confirming reduction of the joint, demonstrating the clamps
used to hold the reduction, and the direction of a lag screw.
21. A small percutaneous incision through the skin flap is
necessary in order to place the lag screw using this
anterior incision. The screw is placed through the
iliotibial band with a washer that remains outside the band.
23. TIBIA
1/3 TIBULAR
‘ANTIGLIDE PLATE’
The iliotibial band is not stripped from the lateral fragment. A very small
area at the tip of the lateral fragment is dissected free of the anterior
musculature attachment in order to allow the sliding up of an anti-glide plate.
24. TIBIA
1/3 TIBULAR
‘ANTIGLIDE PLATE’
This plate is available in various designs. In this case, a one-third
tibular plate was chosen. After fixation from distal to proximal in the
anti-glide plate, the fracture is re-examined for its reduction.
25. FRACTURE IS REDUCED
AT LEVEL OF ARTICULAR
SURFACE
The fracture is seen to be anatomically
reduced at the level of the articular surface.
The meniscus is being retracted superiorly
to allow visualization.
26. SUTURE REPAIR
OF MENISCUS
ITB
ARTICULAR
SURFACE
By keeping the iliotibial band intact, the closure can be
performed with the stay sutures in the meniscus being
pulled through the iliotibial band, giving it more secure
fixation at the level of the joint.
27. MENISCAL REPAIR SUTURES
ITB
The closure of the iliotibial band is then performed with
interrupted sutures. The meniscal repair sutures are
tied down in sequence from posterior to anterior.
28. Postoperative AP and lateral radiographs demonstrate
reduction of the articular surface and the split fragments.
