Posteromedial Intergastrocnemius Approach to the Tibial Plateau. Description of the Surgical Technique
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Published:
Apr 18, 2022
Keywords:
Tibial plateau fractures, intergastrocnemius approach, posteromedial tibial plateau approach, posterior tibial plateau approach, tibial plateau osteosynthesis
Main Article Content
Abstract
Introduction: There are multiple approaches described in the literature for the treatment of fractures that involve the posterior columns of the tibial plateau. We present an anatomical intergastrocnemius approach for the treatment of all fractures involving the posterior component. It allows access with complete visualization of the entire posterior region, facilitating the reduction and placement of the osteosynthesis material necessary to achieve the most stable configuration.
Surgical technique: We describe the posteromedial intergastrocnemius approach to access the tibial plateau performed by our team.
Conclusion: We consider that this approach represents an option to consider when treating fractures that affect both posterior columns, some of them in isolation, or the tibial insertion of the PCL. Although the neurovascular structures require constant attention during the surgical procedure, their direct vision and their meticulous protection, performed by experienced surgeons, minimizes the risk of injury, and their manipulation is not a contraindication for using this approach.
Surgical technique: We describe the posteromedial intergastrocnemius approach to access the tibial plateau performed by our team.
Conclusion: We consider that this approach represents an option to consider when treating fractures that affect both posterior columns, some of them in isolation, or the tibial insertion of the PCL. Although the neurovascular structures require constant attention during the surgical procedure, their direct vision and their meticulous protection, performed by experienced surgeons, minimizes the risk of injury, and their manipulation is not a contraindication for using this approach.
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How to Cite
Beatti, M. A., Zublin Guerra , C. M., Guichet, D. M., & Pellecchia , T. S. (2022). Posteromedial Intergastrocnemius Approach to the Tibial Plateau. Description of the Surgical Technique. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 87(2), 273-284. https://doi.org/10.15417/issn.1852-7434.2022.87.2.1437
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References
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of 525 fractures by using a CT-based classification system. Arch Orthop Trauma Surg 2013;133(07):929-34.
https://doi.org/10.1007/s00402-013-1735-4
2. Scheu Gonçalves M, Carredano González X, Colmenares Sandoval O, Yáñez Lagos C, Donoso Martínez R, et
al. Principios quirúrgicos en fracturas de platillos tibiales con compromiso de columna posterior. Rev Chil Ortop
Traumatol 2018;59(01):22-34. https://doi.org/10.1055/s-0038-1641563
3. Berihu BA, Debeb YG. Anatomical variation in bifurcation and trifurcations of sciatic nerve and its clinical
implications: in selected university in Ethiopia. BMC Res Notes 2015;8(01):633. https://doi.org/ 10.1186/s13104-015-1626-6
4. Kim D, Orron DE, Skillman JJ. Surgical significance of popliteal arterial variants. A unified angiographic
classification. Ann Surg 1989;210(06):776-81. https://doi.org/10.1097/00000658-198912000-00014
5. Tomaszewski KA, Popelsuzko P, Graves M, Pekala P, Henry B, Roy J, et al. The evidence-based surgical anatomy
of the popliteal artery and the variations in its branching patterns. J Vasc Surg 2017;65(2):521-529.e6.
https://doi.org/10.1016/j.jvs.2016.01.043
6. Hackl W, Riedl J, Reichkendler M, Benedetto KP, Freund M, Bale R. Preoperative computerized tomography
diagnosis of fractures of the tibial plateau. Unfallchirurg 2001;104(6):519-23. https://doi.org/10.1007/s001130170115
7. Brunner A, Horisberger M, Ulmar B, Hoffmann A, Babst R. Classification systems for tibial plateau fractures; does computed tomography scanning improve their reliability? Injury 2010;41(2):173-8. https://doi.org/ 10.1016/j.injury.2009.08.016
8. Doornberg JN, Rademakers MV, van den Bekerom MP, Kerkhoffs GM, Ahn J, Steller EP, et al. Two-dimensional
and three-dimensional computed tomography for the classification and characterization of tibial plateau fractures. Injury 2011;42(12):1416-25. https://doi.org/10.1016/j.injury.2011.03.025
9. Castiglia MT, Nogueira-Barbosa MH, Messias AMV, Salim R, Fogagnolo F, Schatzker J, et al. The impact of
computed tomography on decision making in tibial plateau fractures. J Knee Surg 2018;31(10):1007-14.
https//doi.org/10.1055/s-0038-1627464
10. Lobenhoffer P, Gerich T, Bertram T, Lattermann C, Pohlemann T, Tscherne H, et al. Treatment of posterior tibial plateau fractures via posteromedial and posterolateral exposures. Unfallchirurg 1997;100(12):957-67.
https://doi.org/10.1007/s001130050218
11. Luo CF, Sun H, Zhang B, Zeng BF. Three-column fixation for complex tibial plateau fractures. J Orthop Trauma
2010;24(11):683-92. https://doi.org/10.1097/BOT.0b013e3181d436f3
12. Chang SM, Hu SJ, Zhang YQ, Yao MW, Ma Z, Wang X, et al. A surgical protocol for bicondylar four-quadrant tibial plateau fractures. Int Orthop 2014;38(12):2559-64. https://doi.org/10.1007/s00264-014-2487-7
13. Kfuri M, Schatzker J. Revisiting the Schatzker classification of tibial plateau fractures. Injury 2018;49(12):2252-63. https://doi.org/10.1016/j.injury.2018.11.010
14. Müller M, Algöwer M, Schneider R, Willeneger H. Manual of internal fixation. Techniques recommended by the AO-ASIF group. Springer-Verlag Science & Business Media; 1991.
15. Zeng ZM, Luo CF, Putnis S, Zeng BF. Biomechanical analysis of posteromedial tibial plateau split fracture fixation. Knee 2011;18(1):51-4. https://doi.org/10.1016/j.knee.2010.01.006
16. Purnell ML, Larson AI, Schnetzler KA, Harris NL, Pevny T, Diagnosis and surgical treatment of Schatzker type
IV variant biplanar medial tibial plateau fractures in alpine skiers. Tech Knee Surg 2007;6(1):17-28. Disponible en:
http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.622.1809&rep=rep1&type=pdf
17. Bose E, Ramanathan V. Anatomical variations and morphometric analysis of popliteal artery and its terminal
branches in south indian population. Int J Anat Res 2017;5(3.3):4388-93. https://doi.org/10.16965/ijar.2017.346
18. Van den Berg J, Reul M, Nunes Cardozo M, Starvoyt A, Geusens E, et al. Functional outcome of intra-articular
tibial plateau fractures: the impact of posterior column fractures. Int Orthop 2017;41(09):1865-73.
https://doi.org/10.1007/s00264-017-3566-3
19. Trickey EL. Rupture of the posterior cruciate ligament of the knee. J Bone Joint Surg Br 1967;50(2):334-41.
PMID: 5651340
20. Hoppenfeld S, DeBoer P. Surgical exposures in Orthopaedics. 2nd ed. Philadelphia, PA: Lippincott Williams
Wilkins; 1994.
21. De Boeck H, Opdecam P. Posteromedial tibial plateau fractures. Operative treatment by posterior approach. Clin Orthop Relat Res 1995;320:125-8. PMID: 7586815
22. Georgiadis G. Combined anterior and posterior approaches for complex tibial plateau fractures. J Bone Joint Surg Br 1994;76(2):285-9. PMID: 8113294
23. Minkoff J, Jaffe L, Menendez L. Limited posterolateral surgical approach to the knee for excision of osteoid
osteoma. Clin Orthop Relat Res 1987;(223):237-46. PMID: 3652582
24. Frosch KH, Balcarek P, Walde T, Stürmer KM. A new posterolateral approach without fibula osteotomy for the
treatment of tibial plateau fractures. J Orthop Trauma 2010;24(8):515-20. https://doi.org/10.1097/BOT.0b013e3181e5e17d
of 525 fractures by using a CT-based classification system. Arch Orthop Trauma Surg 2013;133(07):929-34.
https://doi.org/10.1007/s00402-013-1735-4
2. Scheu Gonçalves M, Carredano González X, Colmenares Sandoval O, Yáñez Lagos C, Donoso Martínez R, et
al. Principios quirúrgicos en fracturas de platillos tibiales con compromiso de columna posterior. Rev Chil Ortop
Traumatol 2018;59(01):22-34. https://doi.org/10.1055/s-0038-1641563
3. Berihu BA, Debeb YG. Anatomical variation in bifurcation and trifurcations of sciatic nerve and its clinical
implications: in selected university in Ethiopia. BMC Res Notes 2015;8(01):633. https://doi.org/ 10.1186/s13104-015-1626-6
4. Kim D, Orron DE, Skillman JJ. Surgical significance of popliteal arterial variants. A unified angiographic
classification. Ann Surg 1989;210(06):776-81. https://doi.org/10.1097/00000658-198912000-00014
5. Tomaszewski KA, Popelsuzko P, Graves M, Pekala P, Henry B, Roy J, et al. The evidence-based surgical anatomy
of the popliteal artery and the variations in its branching patterns. J Vasc Surg 2017;65(2):521-529.e6.
https://doi.org/10.1016/j.jvs.2016.01.043
6. Hackl W, Riedl J, Reichkendler M, Benedetto KP, Freund M, Bale R. Preoperative computerized tomography
diagnosis of fractures of the tibial plateau. Unfallchirurg 2001;104(6):519-23. https://doi.org/10.1007/s001130170115
7. Brunner A, Horisberger M, Ulmar B, Hoffmann A, Babst R. Classification systems for tibial plateau fractures; does computed tomography scanning improve their reliability? Injury 2010;41(2):173-8. https://doi.org/ 10.1016/j.injury.2009.08.016
8. Doornberg JN, Rademakers MV, van den Bekerom MP, Kerkhoffs GM, Ahn J, Steller EP, et al. Two-dimensional
and three-dimensional computed tomography for the classification and characterization of tibial plateau fractures. Injury 2011;42(12):1416-25. https://doi.org/10.1016/j.injury.2011.03.025
9. Castiglia MT, Nogueira-Barbosa MH, Messias AMV, Salim R, Fogagnolo F, Schatzker J, et al. The impact of
computed tomography on decision making in tibial plateau fractures. J Knee Surg 2018;31(10):1007-14.
https//doi.org/10.1055/s-0038-1627464
10. Lobenhoffer P, Gerich T, Bertram T, Lattermann C, Pohlemann T, Tscherne H, et al. Treatment of posterior tibial plateau fractures via posteromedial and posterolateral exposures. Unfallchirurg 1997;100(12):957-67.
https://doi.org/10.1007/s001130050218
11. Luo CF, Sun H, Zhang B, Zeng BF. Three-column fixation for complex tibial plateau fractures. J Orthop Trauma
2010;24(11):683-92. https://doi.org/10.1097/BOT.0b013e3181d436f3
12. Chang SM, Hu SJ, Zhang YQ, Yao MW, Ma Z, Wang X, et al. A surgical protocol for bicondylar four-quadrant tibial plateau fractures. Int Orthop 2014;38(12):2559-64. https://doi.org/10.1007/s00264-014-2487-7
13. Kfuri M, Schatzker J. Revisiting the Schatzker classification of tibial plateau fractures. Injury 2018;49(12):2252-63. https://doi.org/10.1016/j.injury.2018.11.010
14. Müller M, Algöwer M, Schneider R, Willeneger H. Manual of internal fixation. Techniques recommended by the AO-ASIF group. Springer-Verlag Science & Business Media; 1991.
15. Zeng ZM, Luo CF, Putnis S, Zeng BF. Biomechanical analysis of posteromedial tibial plateau split fracture fixation. Knee 2011;18(1):51-4. https://doi.org/10.1016/j.knee.2010.01.006
16. Purnell ML, Larson AI, Schnetzler KA, Harris NL, Pevny T, Diagnosis and surgical treatment of Schatzker type
IV variant biplanar medial tibial plateau fractures in alpine skiers. Tech Knee Surg 2007;6(1):17-28. Disponible en:
http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.622.1809&rep=rep1&type=pdf
17. Bose E, Ramanathan V. Anatomical variations and morphometric analysis of popliteal artery and its terminal
branches in south indian population. Int J Anat Res 2017;5(3.3):4388-93. https://doi.org/10.16965/ijar.2017.346
18. Van den Berg J, Reul M, Nunes Cardozo M, Starvoyt A, Geusens E, et al. Functional outcome of intra-articular
tibial plateau fractures: the impact of posterior column fractures. Int Orthop 2017;41(09):1865-73.
https://doi.org/10.1007/s00264-017-3566-3
19. Trickey EL. Rupture of the posterior cruciate ligament of the knee. J Bone Joint Surg Br 1967;50(2):334-41.
PMID: 5651340
20. Hoppenfeld S, DeBoer P. Surgical exposures in Orthopaedics. 2nd ed. Philadelphia, PA: Lippincott Williams
Wilkins; 1994.
21. De Boeck H, Opdecam P. Posteromedial tibial plateau fractures. Operative treatment by posterior approach. Clin Orthop Relat Res 1995;320:125-8. PMID: 7586815
22. Georgiadis G. Combined anterior and posterior approaches for complex tibial plateau fractures. J Bone Joint Surg Br 1994;76(2):285-9. PMID: 8113294
23. Minkoff J, Jaffe L, Menendez L. Limited posterolateral surgical approach to the knee for excision of osteoid
osteoma. Clin Orthop Relat Res 1987;(223):237-46. PMID: 3652582
24. Frosch KH, Balcarek P, Walde T, Stürmer KM. A new posterolateral approach without fibula osteotomy for the
treatment of tibial plateau fractures. J Orthop Trauma 2010;24(8):515-20. https://doi.org/10.1097/BOT.0b013e3181e5e17d