n tips & techniques

Section Editor: Steven F. Harwin, MD

Posterior Coronal Plating of Bicondylar Tibial

Plateau Fractures Through Posteromedial
and Anterolateral Approaches in a Healthy
Floating Supine Position
Shi-Min Chang, MD, PhD; Xin Wang, MD; Jia-Qian Zhou, MD; Yi-Gang Huang, MD, PhD; Xiao-Zhong Zhu, MD

Abstract: Bicondylar tibial plateau fractures pose a significant challenge for treating surgeons. If the articular surface of
the medial plateau has a second split component in the posterior coronal plane, it is difficult to get direct visualization and
ensure plate fixation when the patient is in the supine position.
Using a technique in which a single preparation and draping of
both legs is needed, patients were operated on using a healthy
floating supine position maneuver through dual posteromedial
and anterolateral incisions and triple plate fixations. By flexing
and adducting the contralateral healthy hip over the injured
leg, more lateral rotation of the fractured knee can be achieved,
providing better access and visualization of the posterior medial plateau using a posteromedial gastrocnemius approach.

icondylar tibial plateau

fractures (Schatzker type
V and VI and AO/OTA type
41C) are caused by highenergy trauma and are currently treated operatively using dual-incision approaches
with plate and screw fixation.1

The patient is usually placed

in the supine position intraoperatively. Generally, a posteromedial incision is used for the
medial condyle split fragment
manipulation and fixation,
and an anterolateral incision
is used for the comminuted

Drs Chang, Wang, Zhou, Huang, and Zhu are from the Department of
Orthopaedic Surgery, Tongji Hospital, Tongji University, Shanghai, Peoples
Republic of China.
Drs Chang, Wang, Zhou, Huang, and Zhu have no relevant financial relationships to disclose.
Drs Chang and Wang contributed equally to this article.
Correspondence should be addressed to: Shi-Min Chang, MD, PhD,
Department of Orthopedic Surgery, Tongji Hospital, Tongji University, 389
Xincun Rd, Shanghai 200065, Peoples Republic of China (shiminchang@
yahoo.com.cn).
doi: 10.3928/01477447-20120621-03

lateral condyle fractures, leaving a skin bridge at least 7 to

8 cm in width.2 Slight knee
flexion of approximately 30
and external rotation of the
ipsilateral hip make access to
the posteromedial edge of the
proximal tibial easier.3
However, if the articular
surface of the medial plateau
has a second split component
in the posterior coronal plane,
it is difficult to get direct visualization and achieve plate
fixation because ipsilateral hip
external rotation is restricted
while patients are in the supine
position. Usually, patients need
to be in the prone position for
the posteromedial plateau operation4-10 and then be maneuvered into the supine position
for the anterolateral plateau operation. This article describes a
modified positioning approach
that provides access to the posteromedial and anterolateral
aspects of the knee in a single
supine preparation and drape.

Preoperative Planning
Bicondylar tibial plateau
fractures are initially stabilized
with a spanning external fix-

ator or calcaneal traction in a

Brown brace (Shanghai Medical Equipment Factory, Shanghai, China) for 1 to 3 weeks to
allow soft tissue injuries to
heal and swelling to subside.
If a spanning fixator is used
and future surgery is planned,
physicians should avoid inserting pins in the areas where incisions will be made. Surgery
is undertaken when adequate
soft tissue healing is achieved.
Plain radiographs and computed tomography scans with
3-dimensional reconstruction
of the knee should be obtained
for preoperative planning.
The tibial plateau can be
classified into 4 quadrants: anteromedial, anterolateral, posteromedial, and posterolateral.
Optimal skin incisions can be
selected based on the quadrants
that the fracture involves.11 If
the medial plateau was split
into a large shearing posteromedial fragment, slight knee
flexion of approximately 30
and external rotation of the ipsilateral hip usually afford sufficient exposure for reduction
and plate fixation.3 However, if
the medial plateau was further

JULY 2012 | Volume 35 Number 7 583

n tips & techniques

1
Figure 1: Diagram showing the fixation strategies for
complex bicondylar tibial plateau fractures. The split
medial condyle fragment is repositioned anatomically.
A small plate with short screws is applied over the fracture spike in antiglide mode. The depressed lateral condyle is elevated, grafted, and fixed with a heavy buttress
plate and long screws inserted to the medial cortex to
protect the lateral plateau reduction, hold both condyles
together, and connect the reconstructed metaphysis to
the shaft.

2
Figure 2: Photograph showing the patient placed in the supine
position, with both legs prepared and draped.

Surgical Technique

3
Figure 3: Photograph showing the contralateral healthy hip flexed
4
and adducted over the injured leg by an assistant. This results
in lateral rotation of the injured limb, and a better access to the Figure 4: Schematic drawing showing the posteromeposteromedial incision to expose the posterior coronal fragment. dial skin incision.

split into 2 or 3 components,

usually with 1 large posterior
coronal fragment, the authors

584

medial condylar fractures are

reduced and fixed separately,
with a posterior plate (coronal
fragment) and a medial plate
(sagittal fragment) in antiglide
mode, usually by small undercontoured reconstruction
plates with short screws that
grip only the proximal cortices. The lateral condyle is a
comminuted split depression
that needs articular elevation,
a bone substitute graft, and a
heavy buttress plate with long
screws inserted to the medial
cortex to protect the lateral
plateau reduction, hold both
condyles together, and connect
the reconstructed metaphysis
to the tibial shaft.

chose to prepare and drape both

legs for intraoperative manipulation to add exposure.

The operative strategy includes dual incisions and triple

plate fixation (Figure 1). Split

Under intratracheal general anesthesia, the patient

is placed in the supine position. A high-thigh pneumatic
tourniquet is applied to the
injured extremity. The authors
prepared and draped both
legs (Figure 2) and prefer to
start with the posteromedial
approach to provide a stable
medial column to which the
lateral plateau can be reduced
and stabilized. The contralateral hip is flexed and adducted
and the pelvis rotated toward
the injured side. This results in
the patients pelvis and lower
trunk in a semilateral position,
and the injured leg is rotated
laterally, allowing access to
the posterior aspect of the
knee (Figure 3). A scrubbed
assistant holds the leg in position. General anesthesia and
sufficient padding and supporting from the back allow
the patient to easily remain in
this position.

ORTHOPEDICS | Healio.com/Orthopedics

n tips & techniques

The surgeon stands on the

opposite side of the operated
limb. An inverted L-shaped
incision is made, centering the
horizontal limb at the popliteal
crease. The medial arm of the
incision is made just posterior to the medial edge of the
tibia (Figure 4). The medial
condyle is exposed through a
posteromedial gastrocnemius
approach, which is similar to
those described by Lobenhoffer et al,5 Galla and Lobenhoffer,7 and Carlson.12,13 Sharp
dissection is carried deep, and
the posterior fascia is incised
between the medial gastrocnemius (posterior border of
the dissection) and the pes anserinus anteriorly. The medial
collateral ligament remains intact anteriorly and deep to the
pes anserinus. The pes tendons
are mobilized posteriorly and
proximally, keeping their insertion intact. A Penrose drain
can be used for their retraction.
The medial gastrocnemius is then elevated posteriorly and laterally, exposing
the posterior tibia (Figure 5).
No gastrocnemius tendon release is attempted. The popliteal neurovascular structures
are safely protected deep to
the gastrocnemius muscle,
but overzealous retraction is
avoided to prevent traction injury to the tibial nerve. The soleus and popliteus muscles are
then elevated from the medial
edge of the tibia by sharp dissection, exposing the fracture
site.
The joint is then entered
posteriorly while carefully
protecting the capsular and ligament insertions. The coronal
split posterior fragment is re-

duced anatomically under direct visualization, and a small

undercontoured reconstructive
plate is placed onto the spike
and fixed in antiglide fashion,
usually with four 3.5-mm cortical screws, 2 on each side of
the spike.
The contralateral leg is put
back to its normal position, and
the fracture is checked by fluoroscopy. The sagittal split medial fragment is then reduced
and fixed with another reconstructive plate, and the entire
medial condyle is put onto the
tibia shaft. Short screws only
grasping the proximal cortices
are used to avoid interfering
lateral plateau reduction later.
The healthy leg is put back,
and the support on the patients
back is removed; this returns
the patient to a true supine position for a lateral plateau operation. A bump added under
the ipsilateral hip further internally rotates the lower limb.
The lateral tibial plateau is exposed through a conventional
anterolateral approach. After
submeniscus arthrotomy, the
comminuted lateral plateau is
visualized. The depressed articular fragments are elevated
with a large amount of cancellous and subchondral bone.
A bone grafting substitute is
placed to support the elevated
fragments. Another T- or Lshaped heavy plate with long
screws is used to buttress the
reduced lateral plateau fracture, hold the tibial condyles
together, and connect them to
the tibial shaft. Locking plates
are preferred in lateral fixation. Both incisions are closed
using absorbable sutures in
routine fashion over suction

5
Figure 5: Schematic drawing showing the posteromedial gastrocnemius
soleus approach.

drains. No external splints are

used.
After the incision has
stopped bleeding and swelling, usually 3 to 4 days postoperatively, continuous passive motion using a machine
is allowed to less than 45 of
flexion in the first week, and
increased gradually to 90
in the second week. Patients
are encouraged to regain full
range of motion in 4 weeks.
Weight bearing is restricted to
toe-touch (5-10 kg) during the
first 2 months and increased
progressively in the third
month. Full weight bearing is
not permitted before 3 months.

Patient Series
Between January 2006 and
December 2008, twelve patients with bycondylar tibial
plateau fractures were prospectively treated using this
maneuver through dual posteromedial and anterolateral

incisions with triple plate fixations. Eight men and 4 women

with a mean age of 48 years
(range, 39-60 years) were included. Seven patients were
injured in traffic accidents,
and 5 were injured in falls
from a height. All fractures
were Schatzker type VI (AO/
OTA types 41C2 and 41C3).
Ten cases involved 4 plateau
quadrants and 2 cases involved
3 quadrants. Mean time from
injury to operation was 9.5
days (range, 7-12 days).
No cases of infection were
observed. One patient had a
superficial dehiscence postoperatively that healed without
further treatment. The time of
bony consolidation and full
weight bearing averaged 21.7
weeks (range, 16-26 weeks).
Patients were followed up for
at least 24 months (range, 2448 months). At 1 year postoperatively, no loss in reduction or
alignment was observed. Mean

JULY 2012 | Volume 35 Number 7 585

n tips & techniques

6C

6A

6B

6C

6F

6I

6D

6E

6H

6G

6J

6K

6L

6M

Figure 6: Anteroposterior (A) and lateral (B) radiographs of a Schatzker type VI, AO/OTA type 41C3.3 bicondylar, high-energy, tbial plateau fracture in a 55-yearold man who was in a traffic accident. Three-dimensional computed tomography scans showing a medial plateau shearing fracture (C) with a second posterior
coronal split fragment (D) and a lateral plateau comminuted depression fracture with metaphysealdiaphyseal dissociation (E). Transverse computed tomography scan showing a 4-quadrant tibial plateau comminuted fracture (F). Intraoperative photograph of the posterior coronal split fragment of the medial condyle
(G). The posterior coronal fragment is reduced and fixed with undercontoured reconstruction plate with antiglide fashion (H). Postoperative anteroposterior (I)
and lateral (J) radiographs showing a double antiglide plate with short screws for the medial condyle fixation and 1 buttress plate with long screws for lateral
condyle fixation. Photograph of posteromedial and anterolateral incisions (K). Radiographs obtained 1.5 years postoperatively showing the healed fracture (L)
with no reduction loss (M). Abbreviations: AL, anterolateral; AM, anteromedial; PL, posterolateral; PM, posteromedial.

Hospital for Special Surgery

knee score was 87.3 (range, 7895). Patients were satisfied with
their treatment outcomes.

586

An illustrative case of comminuted biconcylar tibial plateau fracture, operated on with

posteromedial and anterolat-

eral approaches in the healthy

floating supine position and
triple plate fixation, is presented in Figure 6.

Discussion
Bicondylar tibial plateau
fractures result from highenergy injuries and are often

ORTHOPEDICS | Healio.com/Orthopedics

n tips & techniques

combined with marked trauma

to the surrounding soft tissues.
Management is challenging,
requiring a combination of accurate bone reduction and fixation and minimal soft tissue
invasion. Currently, the treatment protocols can be classified into 3 categories: open
reduction and internal fixation,
limited open reduction with
percutaneous screw fixation
and hybrid fixator stabilization, and indirect reduction
and application of fine-wire
circular external fixator. Each
method has advantages and
disadvantages.14 The authors
reserve the use of external fixation devices in the treatment
of complex bicondylar tibial
plateau fractures to span the
fracture site until the patient
is amenable to definitive fixation with open reduction and
plate fixation. This treatment
principle is in accordance with
those of Krupp et al.15
The characteristics of the
most complex bicondylar
fractures follow a regular pattern.16-18 The concave medial
plateau is split in a mediolateral direction with a major posteromedial fragment,
whereas the convex lateral plateau is depressed into various
amounts of multifragments
with broadening of the lateral
compartment. In the authors
practice, bicondylar tibial plateau fractures are usually treated through posteromedial and
anterolateral incisions with 2
plate fixations. The main purpose of the posteromedial approach is to achieve an exact
anatomic fracture reduction
and fix the split fragment over
the spike in antiglide fashion

with small implants to create a

stable strut that facilitates lateral fixation. The main purposes of an anterolateral approach
are (1) to elevate the comminuted articular depression with
bone substitute grafting to fill
the gap and (2) to fix the medial cortex with a heavy buttress plate and long screws,
thus protecting the lateral
plateau reduction and holding
both condyles together, securing their contact with the tibial
shaft (Figure 1). Recently, lateral locking plates have become more popular.19,20
Generally speaking, the
surgical approach and patient
position depend on fracture
location and displacement.
Weil et al3 reported that, with
the ipsilateral knee in slight
flexion and the hip in external
rotation, the medial plateau
is accessed easily in a posteromedial supine approach.
However, when the articular
surface of the medial plateau
has a second posterior split
component in the coronal
plane, it is recommended that
management is performed
through a posterior approach
for direct visualization and
manipulation with the patient
in the prone position4-10 and,
preferably, with 2 antiglide
buttress plates.21 However, in
some clinical instances it may
be desirable place the patient
in a supine instead of a prone
position.
The position of a patient
on the operating table should
afford maximum safety to the
patient and convenience for
the surgeon. However, prone
positions are limited in some
instances, such as in patients

with associated chest trauma.

Furthermore, intraoperative
repositioning of the patient
means a second skin preparation and draping, which is
time consuming. In patients
with bicondylar fractures, it
also means that the first operation, usually to the medial plateau, is finished and the skin is
closed. It leaves no opportunity for secondary adjustment or
revision of the first procedure.
Compared with changing
patients positions intraoperatively, the advantages of the
current maneuver are a single
skin preparation and draping,
reduction in operative time,
and the opportunity for technical adjustment through the
first incision, if needed. The
main disadvantage is that an
additional scrubbed assistant
is needed to keep the healthy
leg in position.
The indications for this
healthy floating supine position are bicondylar tibial plateau fractures with a posterior
coronal fragment that requires
a separate plate fixation. It is
possible to operate on 3 (anteromedial and posteromedial) or 3 (plus posterolateral)
quadrants of bicondylar tibial
plateau fractures from the posteromedial gastrocnemius approach while the patient is in
the supine position. However,
this maneuver is not allowed
for patients with associated
spine fractures, contralateral
leg fractures, and pelvic fractures and for patients who are
obese. For those contraindications, spine and pelvic fractures should be treated first.
It is the authors practice to
change the patients position

during traditional open reduction and plate fixation or to

use a limited open reduction
technique with external fixator
protection.
In 2010, Luo et al22 introduced a floating position using
1 preparation and drape for
posteromedial and anterolateral approaches. The patient
was placed in the lateral decubitus position with the injured leg up. The lower leg and
pelvis were first rotated to a
prone position to perform posteromedial approach to fix the
posterior and medial tibial plateau fractures with an inverted
L-shaped incision. Then, the
lower leg and pelvis were rotated back to the lateral position to perform an anterolateral approach to fix the lateral
tibial plateau.
In contrast with the injuredside rotation method presented
by Luo et al,22 the current approach used rotation of the
healthy lower leg and pelvis.
By preparing and draping both
legs, the contralateral healthy
hip is flexed and adducted over
the injured leg. This maneuver makes the patients lower
trunk rotate and results in the
injured limb rotated laterally,
providing better access and
visualization of the posterior
coronal fragment in the medial
plateau. This floating supine
position allows for a healthyside maneuver, which is safer
than the injured-side manipulation.
Furthermore, in the authors opinion, intraoperative
fluoroscopic examinations of
the knee in standard anteroposterior and lateral views are
easier to achieve in the supine

JULY 2012 | Volume 35 Number 7 587

n tips & techniques

position. This positioning maneuver also can be used with

interoperative fixators or large
distractors that are applied to
facilitate tibial fracture reduction. The potential pitfalls lie
in the extensive soft tissue dissection, which is dangerous
for infection and wound healing.23

Conclusion
With single preparation and
draping of both legs in the supine position and the contralateral healthy hip flexed and
adducted over the injured leg,
more lateral rotation of the
fractured knee can be achieved,
providing better access and visualization of the posterior
medial plateau.

References
1. Barei DP, Nork SE, Mills WJ,
Coles CP, Henley MB, Benirschke SK. Functional outcomes of severe bicondylar tibial plateau fractures treated with
dual incisions and medial and
lateral plates. J Bone Joint Surg
Am. 2006; 88(8):1713-1721.
2. Endayan J, Noblin JD, Freeland
AE. Posteromedial second incision to reduce and stabilize
a displaced posterior fragment
that can occur in Schatzker
type V bicondylar tibial plateau
fractures. Orthopedics. 1996;
19(10):903-904.

588

3. Weil YA, Gardner MJ, Boraiah

S, Helfet DL, Lorich DG. Posteromedial supine approach for
reduction and fixation of medial
and bicondylar tibial plateau
fractures. J Orthop Trauma.
2008; 22(5):357-362.
4. Georgiadis GM. Combined anterior and posterior approaches
for complex tibial plateau fractures. J Bone Joint Surg Br.
1994; 76(2):285-289.
5. Lobenhoffer P, Gerich T, Bertram T, Lattermann C, Pohlemann T, Tscheme H. Particular
posteromedial and posterolateral approaches for the treatment of tibial head fractures [in
German]. Unfallchirurg. 1997;
100(12):957-967.
6. De Boeck H, Opdecam P.
Posteromedial tibial plateau
fractures. Operative treatment by posterior approach.
Clin Orthop Relat Res. 1995;
(320):125-128.
7. Galla M, Lobenhoffer P. The
direct, dorsal approach to the
treatment of unstable tibial
posteromedial
fracture-dislocations [in German]. Unfallchirurg. 2003; 106(3):241247.
8. Bhattacharyya T, McCarty LP
III, Harris MB, et al. The posterior shearing tibial plateau fracture: treatment and results via
a posterior approach. J Orthop
Trauma. 2005; 19(5):305-310.
9. 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):1728.

10. Fakler JK, Ryzewicz M, Hartshorn C, Morgan SJ, Stahel PF,

Smith WR. Optimizing the
management of Moore type I
postero-medial split fracture
dislocations of the tibial head:
description of the Lobenhoffer
approach. J Orthop Trauma.
2007; 21(5):330-336.
11. Chang SM. Selection of surgical approaches to the posterolateral tibial plateau fracture by
its combination patterns. J Orthop Trauma. 2011; 25(3):e32e33.
12. Carlson DA. Bicondylar frac
ture of the posterior aspect of
the tibial plateau. A case report
and a modified operative approach. J Bone Joint Surg Am.
1998; 80(7):1049-1052.
13. Carlson DA. Posterior bicondylar tibial plateau fractures. J Orthop Trauma. 2005; 19(1):7378.
14. Canadian Orthopaedic Trauma
Society. Open reduction and
internal fixation compared with
circular fixator application for
bicondylar tibial plateau fractures. Results of a multicenter,
prospective, randomized clinical trial. J Bone Joint Surg Am.
2006; 88(12):2613-2623.
15. Krupp RJ, Malkani AL, Roberts
CS, Seligson D, Crawford CH
III, Smith L. Treatment of bicondylar tibia plateau fractures
using locked plating versus
external fixation. Orthopedics.
2009; 32(8):559
16. Barei DP, OMara TJ, Taitsman LA, Dunbar RP, Nork
SE. Frequency and fracture
morphology of the posteromedial fragment in bicondylar
tibial plateau fracture pat-

terns. J Orthop Trauma. 2008;

22(3):176-182.
17. Eggli S, Hartel MJ, Kohl S,

Haupt U, Exadaktylos AK,
Rder C. Unstable bicondylar tibial plateau fractures: a
clinical investigation. J Orthop
Trauma. 2008; 22(10):673679.
18. Higgins TF, Kemper D, Klatt J.
Incidence and morphology of
the posteromedial fragment in
bicondylar tibial plateau fractures. J Orthop Trauma. 2009;
23(1):45-51.
19. Higgins TF, Klatt J, Bachus

KN. Biomechanical analysis
of bicondylar tibial plateau
fixation: how does lateral
locking plate fixation compare to dual plate fixation?
J Orthop Trauma. 2007;
21(5):301-306
20. Uhl RL, Gainor J, Horning J.
Treatment of bicondylar tibial
plateau fractures with lateral
locking plates. Orthopedics.
2008; 31(5):473-477.
21. Luo CF, Jiang R, Hu CF, Zeng
BF. Medial double-plating for
fracture dislocations involving
the proximal tibia. Knee. 2006;
13(5):389-394.
22. Luo CF, Sun H, Zhang B, Zeng
BF. Three-column fixation for
complex tibial plateau fractures. J Orthop Trauma. 2010;
24(11):683-692
23. Barei DP, Nork SE, Mills WJ,
Henley MB, Benirschke SK.
Complications associated with
internal fixation of high-energy
bicondylar tibial plateau fractures utilizing a two-incision
technique. J Orthop Trauma.
2004; 18(10):649-657.

ORTHOPEDICS | Healio.com/Orthopedics