Abstract
Hypothesis
This study demonstrates the utility of a modified postero-medial surgical approach to the knee in treating a series of patients with complex tibial plateau injuries with associated postero-medial shear fractures.
Postero-medial shear fractures are under-appreciated and their clinical relevance have recently been characterised. Less invasive surgery and indirect reduction techniques are inadequate for treating these postero-medial coronal plane fractures.
Methods
The approach includes an inverted ‘L’ shaped incision and reflection of the medial head of gastrocnemius, while protecting the neurovascular structures. This is a more extensile exposure than described by Trickey (1968). Our case series includes 8 females and 8 males. The average age is 53.1 years. The mechanism of injury included 7 RTAs, 5 fall from height, 1 industrial accident and 3 valgus injuries. All patients' schatzker grade 4, or above, fractures with a posteromedial split depression. Two were open, two had vascular compromise and one had neurological injury.
Results
Average time to surgery was 6.4 days (range 0–12), operative time 142 mins (range 76–300), and length of stay 17.3 days (range 7–46). 11 patients were treated using the posrtero-medial approach alone and 5 were combined with an anterior approach. 2 patients suffered reduced range of movement requiring manipulation and physiotherapy, and 3 patients had a 5 degree fixed flexion deformity. 2 patients developed superficial wound infections treated with antibiotics alone. Anatomical reduction and fracture union was achieved in 13 patients; of the remaining 3 patients, 2 had unavoidable articular surface comminution, and 1 suffered antero-medial collapse and varus deformity.
Conclusions
These are complex fractures to treat and this posterior surgical approach allows direct reduction and optimal positioning of plates to act as buttress devices. It can be extended across the midline to the postero-lateral corner and also allows excellent exposure of the popliteal vessels should concurrent vascular repair be required.
