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Versatile Extended Anterolateral (EAL) Approach with a progressive four-window strategy for posterolateral column
Juan Boluda-Mengod1, Beatriz Olías-López1, Pau Forcada-Calvet2
1Orthopaedic Trauma Unit, Department of Orthopaedics, Hospital Universitario Canarias (HUC), Carretera Ofra s/n, 38320 La Laguna, Tenerife, Spain; Faculty of Medicine, Universidad de La Laguna (ULL), Campus de Ofra, s/n, 38071 La Laguna, Tenerife, Spain.
Background:
The posterolateral (PL) column is often the most difficult one to access and manage in tibial plateau fractures. Although multiple approaches have been described, many provide limited flexibility to address diverse fracture patterns. The Versatile Extended Anterolateral (EAL) Approach with four progressive windows has been previously introduced within the Main Deformity Direction (MDD) framework. In this cadaveric study, we provide a detailed anatomical and technical description of this modified approach, characterized by an optimized skin incision and four stepwise deep windows for PL column management. The primary aim was to assess the technical feasibility of this approach. Potential reduction and fixation options associated with each window were also explored descriptively.
Materials And Methods:
Four fresh-frozen cadaveric specimens were used to evaluate surgical exposure and relationships with relevant anatomical structures. Based on the anatomical exposure achieved with each window, potential reduction and fixation strategies were explored descriptively. Representative clinical cases were included to illustrate fixation techniques.
Results:
The skin incision allowed access to all windows, achieving safe progressive PL column exposure. The four windows (pre-fibular, supra-fibular, retro-fibular, trans-fibular) expanded reduction and fixation possibilities stepwise. The trans-fibular window enabled complete articular and metaphyseal exposure. The anterior tibial artery crossing, located at a mean of 3.5cm from the tip of the fibular head, represented the distal anatomical limit of posterior exposure.
Conclusion:
The versatile EAL Approach is a feasible option for managing lateral and PL columns in tibial plateau fractures. Its progressive four-window strategy may allow tailored exposure and fixation according to fracture-specific requirements.
