How can the articular surface of the tibial plateau be best exposed? A comparison of specific surgical approaches.

INTRODUCTION: The correct choice of a fracture-specific surgical approach with an articular accessibility in complex tibial plateau fractures to facilitate durable fracture fixation of the anatomic articular reconstruction is under debate, as the most important risk factor for malreduction in complex tibial plateau fractures is an impaired visualization of the articular surface.

MATERIALS AND METHODS: Six established surgical approaches were simulated on 12 cadaver knees. The visible articular surface was labeled with an electrocautery device for each approach and subsequently analyzed with ImageJ. Areas of each hemiplateau were compared using the Student's t test.

RESULTS: In the lateral tibial plateau, the dorsal 19.0 ± 5.8% of the articular surface could be exposed via the postero-lateral approach. Via the antero-lateral arthrotomy, 36.6 ± 9.4% of the anterior articular surface was visible. The additional osteotomy of the lateral femoral epicondyle significantly increased the exposure to 65.6 ± 7.7% (p < 0.001). In the medial tibial plateau, the osteotomy of the medial femoral epicondyle significantly improved visualization of the medial articular surface (62.3 ± 8.6%) compared to the postero-medial approach (14.0 ± 7.3%) and the antero-medial approach (36.9 ± 9.2%) of the articular (p < 0.001).

CONCLUSIONS: Visualization of the tibial articular surface is limited through specific surgical approaches. Extension by osteotomy of the femoral epicondyle led to a significant improvement in the articular exposure without, however, obtaining sufficient visibility of the posterior joint segments, which should be included in the preoperative strategy. The proposed surgical approach-specific map of the tibial plateau may constitute an important instrument in the toolbox of an experienced surgeon to treat complex tibial plateau fractures at the highest level.

LEVEL OF EVIDENCE: Level IV.