Review Of Surgical Approach And Complications Of Tibial Plateau Fracture

Background: Tibial plateau fractures are common yet complex injuries, and include a wide variety of fracture patterns. They are also potentially associated with significant soft tissue injury. They can occur in any age group but have a bimodal distribution with high-energy injuries usually occurring in young adults with good bone quality and low-energy fractures that typically occur in elderly patients with poor bone quality. They are mainly associated with axial, bending, and rotational forces or combination of these. Surgical treatment is increasingly common for fractures with displacement and instability. The Schatzker and AO/OTA classifications are commonly used to describe these fractures. Understanding the degree of soft tissue injury around the knee is of utmost importance regarding the timing of surgical intervention unless a purely percutaneous approach will be utilized. Although the reduction is technically easier when performed earlier, surgical delay may be necessary to decrease the risk of wound complications. The ideal surgical approach should provide exposure of the fracture site that is sufficient to facilitate both reduction of the fracture and application of the fixation implants, with minimal risk of complications such as wound healing or infection. Careful dissection and atraumatic soft tissue handling is necessary to avoid neurovascular injury or further iatrogenic insult to soft tissues. Thus, the surgeon preparing to operate on one of these fractures must choose from a variety of surgical approaches that have been described. The choice of approach is dictated principally by the fracture pattern, with consideration of the soft tissue envelope, patient factors, and associated injuries(e.g., need for vascular repair or fasciotomies) occasionally altering the surgical plan. Successful management of the soft tissues about the knee following a high-energy knee injury or tibial plateau fracture is paramount to a good outcome. The paucity of subcutaneous tissue about the knee in most patients increases the susceptibility of the soft tissues of the proximal tibia to injury by both external trauma and from within(due to displacement of bone fragments.) This increases the risk of complications following the treatment of high-energy proximal tibia fractures. The use of computed tomography(CT) has greatly improved our ability to understand the pattern of injury. CT scan with sagittal and coronal reconstructions is obtained in all proximal tibia fractures. If temporizing external fixation is necessary, CT scan is deferred until after closed reduction and external fixation has been performed. A detailed analysis of the fracture pattern, especially with respect to fracture plane(s), displacement of the joint surface, and comminution is necessary to develop a surgical tactic for fracture reduction and application of fixation implants, which in turn is critical in deciding the surgical approach(es) to be used. Early techniques for the treatment of proximal tibial fractures relied on a direct anterior midline approach, which required large soft tissue flaps to access the corresponding fracture. To address associated collateral ligament and meniscal injuries, a modification using an inverted “L”-type incision over the joint line was described. Over time, the importance of soft tissue management and the correlation of outcomes with anatomic reduction have led to fracturespecific approaches. The diminishing use of peripatellar incisions, descriptions of the posteromedial and posterolateral approaches, and common use of a dual-approach technique are the principle evolutions since Tscherne and Lobenhoffer published their overview 20 years ago. Given the subcutaneous position of the knee and upper tibia, without much intervening soft tissue, any such injury can be associated with significant soft tissue damage. Successful management of the soft tissues about the knee following a high-energy knee injury or tibial plateau fracture is paramount to a good outcome. The paucity of subcutaneous tissue about the knee in most patients increases the susceptibility of the soft tissues of the proximal tibia to injury by both external trauma and from within(due to displacement of bone fragments.) This increases the risk of complications following the treatment of high-energy proximal tibia fractures. The management of tibial plateau fractures is challenging, and patients are at risk for adverse outcomes including infection, malunion, nonunion, and stiffness. Accurate diagnosis and early management can mitigate the impact of these complications. We dichotomize tibial plateau fractures as unicondylar versus bicondylar to summarize the postoperative risk profile and complication management strategies for this family of injuries. When compared with unicondylar tibial plateau fractures, bicondylar injuries are associated with a significantly higher incidence of complications following operative management. They are typically caused by high energy trauma, leading to severe comminution, open fracture, vascular injury, and a risk of compartmental syndrome. Furthermore, bicondylar fractures may require extensive surgical dissection and soft tissue manipulation intraoperatively, leading to additional damage to an already tenuous soft tissue envelope. Thus, tibial plateau fractures, and bicondylar fractures in particular, present a unique set of challenges. Optimizing outcomes requires careful preoperative planning, reduction, and stabilization with meticulous attention to soft tissue preservation, and early recognition and treatment of acute complications in the postoperative period.Methods: By searching for a large number of relevant foreign literature, this article summarizes commonly used approaches of tibial plateau fracture, management of soft tissue injuries associated with tibial plateau fracture and postoperative complications after repair of tibial plateau fractures.