Limited Added Value of the Posterolateral Approach

Posterolateral tibial plateau fractures (AO/OTA 41-B or 41-C) represent a minority of proximal tibia fractures. Numerous surgical approaches have been described, each with unique variations and limitations. The purpose of this study is to quantitatively and qualitatively compare the surface area and structures exposed by four surgical approaches to the posterolateral proximal tibia.

Four published surgical approaches-direct posterolateral (DPL), transfibular (TF), posteromedial (PM), and anterolateral (AL)-were performed on 10 fresh-frozen cadavers. Once each exposure was obtained, a ruler was placed in the surgical field and calibrated digital images obtained. Overall, 10 bony and soft tissue landmarks were identified and the surgeon's ability to see or touch each landmark was recorded sequentially for each exposure.

An average of 3.9 ± 2.7 cm(2) of posterolateral proximal tibial cortex was exposed by the DPL approach with significantly more surface area exposed by the TF, PM, and AL approaches (p < 0.01). The AL and PM approaches revealed a significantly larger area of tibial metaphysis and, when used together, consistently exposed posterior metaphyseal and intra-articular structures.

A combination of the AL and PM approaches allows comparable surgical exposure to the proximal tibial when compared with two posterolateral approaches. These approaches can be employed together for reduction and fixation of injuries to the posterolateral tibial plateau and allow direct evaluation of the articular surface. Dedicated posterolateral approaches should be reserved for certain clinical situations, including proximal tibiofibular joint fracture or dislocation.