Intra-articular Extensile Approach for Tibial Plateau Fractures

Several types of tibial plateau fractures are a complex management problem. The knee joint may have a significant comminution and depression, and the physician may need to take an extensile approach for reduction and fixation of this fracture. Personally, I use the intra-articular extensile approach for tibial plateau fracture reduction and fixation. In general, fracture of the tibial plateau is a complicated problem.

A vascular evaluation is necessary. The ankle-brachial index (ABI) is needed in some types, such as in medial plateau fractures or in severe types, such as Schatzker Type V or Type VI. The ABI should be more than 0.9. Usually, medial tibial plateau fractures are considered to be a knee dislocation. A fasciotomy may be needed if compartment syndrome occurs. The soft tissue condition may be bad, and an external fixator may be initially used until the soft tissue condition improves.

The association between tibial plateau fractures and meniscal tear is not uncommon. A lateral plateau fracture will create a lateral meniscal tear, while the medial plateau fracture will cause a medial meniscal tear. A tear of the meniscus is usually peripheral. It should be recognized and dealt with. The physician may want to look at the x-ray and see if there is a depression or separation of more than 6mm, as this indicates a high chance of meniscal tear.

The posteromedial fragment is another problem with tibial plateau fractures which needs to be fixed separately. When an extensive comminuted displaced tibial plateau fracture occurs, the physician may need excellent exposure of the articular surface to allow for anatomic reduction of the joint and visualization and repair or debridement of the meniscus if it is torn. This extensile exposure is important, especially if the posterior part of the plateau is involved. The traditional way to see the articular cartilage of the tibial plateau is to use the submeniscal approach by cutting the coronary ligament, but the exposure is limited. Other extensile approaches are also developed; however, we use the extensile intra-articular approach for complex, comminuted tibial plateau fractures. This involves anterior detachment and retraction of the meniscus to improve visualization of the tibial articular surface. This approach can be utilized for lateral or medial tibial plateau fractures and it is especially helpful in diagnosing and repairing the torn meniscus. This allows for inspection of the meniscus pathology in fractures of the articular surface. This improves reduction of the fracture and the torn meniscus is repaired and reattached to the coronary ligament. Incision and reflection of the meniscus allows great exposure and inspection of the joint which is followed by reattachment and suturing of the anterior horn of the meniscus to its normal position which is followed by reattachment of the meniscotibial (coronary) ligament. The sutures are tied to the sides of the patellar tendon on the opposite side of the meniscus.