Posterior Tibial Plateau Fractures: Surgical Anatomy, Biomechanics, and Operative Management

Introduction & Epidemiology

Tibial plateau fractures (TPFs) represent a significant proportion of intra-articular fractures, accounting for approximately 1% of all fractures and 8% of all fractures in the elderly. These complex injuries often result from high-energy trauma in younger patients (e.g., motor vehicle accidents, falls from height) and low-energy mechanisms in older, osteoporotic individuals. While anterior and lateral column fractures are more prevalent, posterior column involvement, either in isolation or as part of a bicondylar or complex injury, presents unique challenges. Fractures involving the posterior aspect of the tibial plateau are often characterized by posterior displacement of articular fragments, disruption of the posterior joint capsule, and potential damage to the posterior cruciate ligament (PCL) or posteromedial/posterolateral corner structures.

The biomechanical consequences of unaddressed posterior displacement include persistent posterior subluxation of the tibia relative to the femur, leading to chronic knee instability, altered kinematics, and accelerated post-traumatic osteoarthritis. Accurate reduction and stable fixation are paramount for restoring articular congruity and mechanical axis. Traditional anterior or anterolateral approaches often provide suboptimal visualization and reduction capabilities for posterior fragments, necessitating alternative surgical strategies. The posterior approach, particularly the posteromedial variant utilizing the semitendinosus tendon plane, offers direct access to the posterior aspect of the proximal tibia, enabling precise anatomical reduction and robust buttress plating while minimizing injury to critical neurovascular structures.

Surgical Anatomy & Biomechanics

A thorough understanding of the regional anatomy and biomechanics is critical for successful posterior tibial plateau fracture management.

Bony Anatomy

The proximal tibia consists of medial and lateral condyles, separated by the intercondylar eminence. The articular surface, covered by hyaline cartilage, exhibits a slight posterior slope (typically 7-10 degrees) that contributes to knee kinematics. Posterior column fractures primarily involve the posterior aspect of either the medial or lateral condyle, or both in bicondylar patterns. The posteromedial corner of the tibia is a crucial load-bearing region, and its disruption can lead to significant instability.

Ligamentous and Capsular Anatomy

The posterior knee capsule is reinforced by several structures. Key among these are the PCL, which originates from the medial femoral condyle and inserts into the posterior intercondylar area of the tibia, providing primary restraint to posterior tibial translation. The posteromedial corner (PMC) includes the superficial medial collateral ligament (sMCL), deep MCL, posterior oblique ligament (POL), and the semimembranosus tendon insertion complex. The posterolateral corner (PLC) comprises the fibular collateral ligament (FCL), popliteus tendon, and biceps femoris tendon. Injuries to these structures are common concomitants of complex tibial plateau fractures and must be assessed preoperatively and addressed intraoperatively if unstable.

Muscular Anatomy

The posterior aspect of the knee is enveloped by several muscles. Superficially, the gastrocnemius (medial and lateral heads) originates from the femoral condyles. Deep to the gastrocnemius, the popliteus muscle originates from the lateral femoral condyle and inserts onto the posterior aspect of the tibia, contributing to knee stability and internal rotation. The hamstring tendons (semimembranosus, semitendinosus, biceps femoris) cross the posterior knee. The semitendinosus and semimembranosus run medially, inserting onto the pes anserinus and posteromedial tibia, respectively. The biceps femoris runs laterally, inserting onto the fibular head. The plane utilized in the posteromedial approach typically lies between the medial head of the gastrocnemius and the semitendinosus/semimembranosus complex.

Neurovascular Anatomy

The popliteal fossa houses the critical neurovascular bundle. From superficial to deep (posterior to anterior), the order is the tibial nerve, popliteal vein, and popliteal artery. These structures are situated centrally within the fossa and are at risk during posterior approaches, particularly if dissection extends too far laterally or anteriorly without adequate retraction. The common peroneal nerve courses laterally around the fibular neck. Meticulous dissection and careful retraction are paramount to prevent iatrogenic injury.

Biomechanics of Posterior Tibial Plateau Fractures

Posterior column fractures often result from axial loading combined with hyperflexion or direct posterior impact, driving the femoral condyle into the posterior tibia. This can lead to impaction, depression, or shear fractures of the posterior articular surface. The posterior buttress effect is crucial for resisting posterior tibial translation and maintaining stability. Loss of this buttress due to fracture, especially with articular depression, leads to knee instability and can compromise healing. Operative fixation aims to restore the posterior buttress and articular congruence, often requiring anatomically contoured plates.

Indications & Contraindications

The decision to proceed with surgical intervention for tibial plateau fractures, particularly those involving the posterior column, is based on a comprehensive evaluation of fracture morphology, articular involvement, stability, patient factors, and soft tissue status.

Operative Indications

• Displaced Posterior Column Fractures: Articular step-off greater than 2-3 mm, condylar widening greater than 5 mm, or significant posterior depression/translation. These often correspond to complex Schatzker types (e.g., V, VI with posterior component) or AO/OTA classifications (e.g., 41-B3, C3).
• Posterior Instability: Evidence of posterior subluxation or instability on stress radiographs, clinical examination, or imaging, particularly with involvement of the posteromedial or posterolateral corner.
• Irreducible Fractures: Fractures that cannot be adequately reduced by closed means or via arthroscopy.
• Associated PCL Avulsion Fractures: Displaced avulsion fractures of the PCL from its tibial insertion that contribute to instability.
• Open Fractures: Following emergent debridement and stabilization, often requiring definitive internal fixation once soft tissue conditions permit.
• Compartment Syndrome: Requires emergent fasciotomy, with subsequent fracture fixation.

Contraindications

• Severe Soft Tissue Compromise: Extensive blistering, devitalized skin, or severe degloving that increases the risk of wound complications and infection. Staged management (external fixation followed by definitive internal fixation) may be indicated.
• Medical Instability: Patients with severe comorbidities precluding safe anesthesia and surgery.
• Active Local or Systemic Infection: Requires resolution prior to elective internal fixation.
• Non-Displaced or Minimally Displaced Fractures: If articular congruity is maintained and the knee is stable, non-operative management with protected weight-bearing and early range of motion may be appropriate.
• Severe Comminution: In some rare cases, severe comminution that precludes stable internal fixation may lead to consideration of arthroplasty, especially in elderly patients with low demands, or external fixation.

The following table summarizes common indications for operative versus non-operative management:

Pre-Operative Planning & Patient Positioning

Meticulous pre-operative planning is paramount to anticipate fracture morphology, identify associated injuries, and optimize the surgical approach.

Pre-Operative Imaging

• Plain Radiographs: Anteroposterior (AP), lateral, and oblique views (45° internal and external) are initial requisites. The lateral view is crucial for assessing posterior displacement and the overall posterior slope of the tibial plateau.
• Computed Tomography (CT) Scan: A CT scan with fine cuts and 3D reconstructions is indispensable. It provides detailed information regarding articular depression, comminution, fragment size, and orientation, which is often not fully appreciated on plain radiographs. It allows for accurate identification of posterior column involvement (posteromedial, posterolateral, or both), aids in plate templating, and identifies associated fibular head fractures or posterolateral corner avulsions.
• Magnetic Resonance Imaging (MRI): While not routinely required for bony injuries, MRI can be valuable in identifying significant soft tissue injuries, such as meniscal tears, PCL rupture, or other ligamentous disruptions that may influence surgical strategy or require concomitant repair.

Surgical Planning and Templating

Based on CT imaging, the surgeon should plan the incision, determine the extent of exposure needed, select appropriate implants (e.g., anatomically contoured posterior tibial plates, locking versus non-locking screws, varying lengths), and pre-bend plates if necessary. Consideration should be given to the number and trajectory of screws to ensure adequate purchase in potentially osteoporotic bone and to avoid joint penetration.

Patient Positioning

The posterior approach to the tibial plateau typically necessitates a prone position. This provides optimal access and allows for gravity-assisted reduction maneuvers.

• Anesthesia: General anesthesia is standard, often supplemented with a regional nerve block (e.g., sciatic nerve block) for post-operative pain management.
• Positioning:
  • Place the patient prone on the operating table.
  • A bolster or gel roll should be positioned beneath the distal thigh, extending from the midthigh to just proximal to the knee joint. This allows the knee to flex and extend freely and facilitates hyperextension.
  • Another bolster or padding may be placed under the ankle to elevate the foot slightly, ensuring the foot is not in equinus and allowing free manipulation of the ankle.
  • This setup permits hyperextension of the knee , a useful maneuver for reducing posterior column tibial plateau fractures by allowing the femoral condyle to push anteriorly on displaced posterior fragments. It also significantly facilitates C-arm imaging when using the posterior approach.
    
  • Ensure the patient's chest and hips are well-padded.
  • Tourniquet: Exsanguinate the limb by elevating it for 3 to 5 minutes and apply a high thigh pneumatic tourniquet.
• C-arm Setup: The C-arm should be positioned to allow for clear AP, lateral, and oblique fluoroscopic views of the proximal tibia and knee joint without repositioning the patient or the limb. This usually involves positioning the C-arm on the contralateral side of the table or approaching from the head/foot of the table.
• Draping: The entire limb, from mid-thigh to the foot, should be sterilely prepped and draped to allow full range of motion of the knee and ankle during the procedure.

Detailed Surgical Approach / Technique

The posteromedial approach to the tibial plateau, utilizing the semitendinosus tendon plane, provides direct access to the posterior and posteromedial aspects of the proximal tibia while safeguarding vital neurovascular structures.

Landmarks and Incision

Before making the incision, carefully palpate the posterior knee landmarks.
* Flex and extend the knee to identify the joint line.
* Palpate the knee joint from behind , identifying the fibular head and the biceps femoris tendon laterally.
* Medially , identify the pes anserinus tendons (sartorius, gracilis, semitendinosus) and the posteromedial border of the proximal tibia.
* The semimembranosus tendon is typically palpable deeper and more posterior than the semitendinosus.

The incision for a posteromedial approach is typically a straight or slightly curved longitudinal incision, approximately 10-15 cm in length, centered over the posteromedial corner of the proximal tibia. It begins approximately 2 cm proximal to the joint line and extends distally along the posteromedial aspect of the tibia.

Superficial Dissection

1. Skin Incision: Incise the skin and subcutaneous tissue. Achieve meticulous hemostasis.
2. Deep Fascia: Incise the deep fascia (crural fascia) in line with the skin incision. This exposes the underlying musculature.

Identifying the Semitendinosus Tendon Plane

This is the critical step for a safe and effective approach.
1. Identify the Medial Head of the Gastrocnemius: This muscle belly will be prominent and lies superficially.
2. Locate the Semitendinosus and Semimembranosus Tendons: These are part of the medial hamstring complex. The semitendinosus tendon is usually more superficial and anterior within the pes anserinus group, while the semimembranosus is deeper and more posterior, inserting directly onto the posterior aspect of the medial tibial condyle.
3. Develop the Plane: The internervous plane is typically between the medial head of the gastrocnemius (retracted laterally) and the semitendinosus/semimembranosus complex (retracted medially) .

Here, a longitudinal incision is made over the posteromedial aspect of the knee. The medial head of the gastrocnemius is identified and carefully retracted laterally.

The semitendinosus tendon, often part of the pes anserinus, is identified and can be retracted to expose the deeper plane.

Deep Dissection and Exposure

1. Retract Medial Gastrocnemius: The medial head of the gastrocnemius is carefully retracted laterally, exposing the posterior aspect of the joint capsule and the popliteus muscle. This retraction should be gentle but firm, using broad Hohmann retractors or similar instruments.
2. Identify Neurovascular Structures: As the dissection deepens, especially when retracting the gastrocnemius laterally, maintain constant awareness of the popliteal neurovascular bundle. These structures (tibial nerve, popliteal vein, popliteal artery) lie anterior to the gastrocnemius belly and must be protected. The tibial nerve is the most superficial of the neurovascular structures.
3. Address Semimembranosus Insertion: The direct insertion of the semimembranosus tendon onto the posterior aspect of the medial tibial condyle may need to be carefully elevated or partially released to gain adequate exposure to the posteromedial tibial plateau. If released, a suture should be placed for later repair.
4. Capsulotomy: Incise the posterior joint capsule in line with the planned plate application. This allows direct visualization of the articular surface and depressed fragments. The posterior oblique ligament (POL) is often encountered and may be incised or elevated with the capsule.
5. Expose the Fracture: Subperiosteal dissection exposes the posterior aspect of the proximal tibia and the fracture fragments. Be mindful of the posteromedial corner structures and their integrity.

Deep dissection revealing the posterior aspect of the tibial condyle. The neurovascular bundle (not shown in this specific frame but always kept in mind) lies deeper and laterally relative to this approach.

Fracture Reduction

1. Visualization: Direct visualization of the articular surface through the capsulotomy is crucial.
2. Fragment Manipulation: Use periosteal elevators, bone hooks, or small osteotomes to elevate depressed articular fragments.
3. Hyperextension Maneuver: The prone position with the bolster allows the surgeon to hyperextend the knee. This maneuver uses the femoral condyle as a "bumper" to push displaced posterior fragments anteriorly and restore the articular surface.
4. Temporary Fixation: Once reduced, stabilize the fragments with K-wires. Ensure the K-wires do not impede plate placement or cross the joint line.
5. Fluoroscopic Confirmation: Utilize the C-arm to confirm anatomical reduction in AP, lateral, and oblique views. The lateral view is especially important to confirm restoration of the posterior slope and articular step-off.

Articular depression is addressed by elevating the depressed fragments. This often requires careful manipulation and impaction grafting if there is significant metaphyseal bone void.

Illustration of a reduced fracture segment with temporary K-wire fixation, preparing for definitive plating.

Internal Fixation

1. Plate Selection: Anatomically contoured posterior tibial plates are preferred. Options include posteromedial specific plates, L-plates, or T-plates, often with locking screw technology for enhanced stability in comminuted or osteoporotic bone. The plate acts as a buttress to prevent recurrent posterior displacement.
2. Plate Application: Position the plate along the posteromedial aspect of the tibia. Ensure it is flush with the bone and does not impinge on soft tissues. The most proximal screws should capture the elevated articular fragments.
3. Screw Placement:
   • Articular Fragments: Use lag screws through the plate to compress articular fragments. Ensure careful measurement to avoid joint penetration.
   • Metaphyseal/Diaphyseal Fixation: Place locking and/or non-locking screws through the plate to engage the tibial shaft, providing stable fixation. Bi-cortical fixation is generally preferred where feasible and safe.
   • Fluoroscopic Guidance: Confirm screw lengths and positions fluoroscopically to prevent intra-articular penetration.

Anatomically contoured posterior buttress plate applied to the posteromedial tibia, providing stable fixation for the reduced fracture.

Multiple screws are strategically placed to capture fragments and provide robust fixation, confirming length with fluoroscopy.

This image likely depicts an intraoperative fluoroscopic view after plate and screw placement, confirming satisfactory reduction and hardware position.

Considerations for Bicondylar Fractures

For complex bicondylar fractures (e.g., Schatzker VI, AO/OTA 41-C3) with significant lateral column involvement, a combined approach may be necessary. This typically involves the posterior approach for the posteromedial column and a separate anterolateral approach for the lateral column. Staging procedures or a simultaneous "dual-incision" technique might be employed based on fracture complexity and surgeon preference.

Closure

1. Irrigation: Copious irrigation of the wound to remove debris and reduce infection risk.
2. Hardware Check: Final check of screw heads and plate position.
3. Repair Semimembranosus: If the semimembranosus insertion was elevated, repair it back to its anatomical site.
4. Capsule and Fascia Closure: Close the posterior joint capsule (if incised sufficiently to allow repair) and the deep fascia.
5. Subcutaneous and Skin Closure: Close the subcutaneous layers and skin in a standard fashion.
6. Drainage: A suction drain may be placed beneath the fascia, particularly if there has been extensive soft tissue dissection or significant bleeding.

Illustrative image of the incision closed after the procedure, ensuring appropriate skin tension and wound care.

Complications & Management

Despite meticulous surgical technique, complications can arise following posterior approaches to the tibial plateau. Early recognition and appropriate management are crucial for optimal patient outcomes.

Common Complications

| Complication | Incidence | Management / Salvage Strategy 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------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Understanding the Posterior Approach to the Tibial Plateau: The Semitendinosus Tendon Plane

Introduction & Epidemiology

Tibial plateau fractures (TPFs) represent a diverse spectrum of intra-articular injuries to the proximal tibia. While less common than their anterior or lateral counterparts, posterior column fractures are encountered in approximately 10-25% of all TPFs and are frequently associated with high-energy trauma. These fractures are distinct in their mechanism, morphology, and treatment considerations. They often result from axial loading with simultaneous knee hyperflexion or direct posterior impact, leading to posterior articular displacement, depression, or shear fractures.

The consequences of unaddressed posterior instability in TPFs include persistent posterior tibial subluxation, compromised knee biomechanics, altered joint kinematics, and increased risk of post-traumatic osteoarthritis and chronic pain. Anatomical reduction and stable internal fixation are paramount to restore joint congruity, stabilize the posterior weight-bearing dome, and facilitate early rehabilitation. Traditional anterior or anterolateral approaches often provide limited visualization and indirect reduction of posterior fragments, necessitating specific posterior surgical approaches. The posteromedial approach, leveraging the internervous plane adjacent to the semitendinosus tendon, is a well-established and highly effective technique for directly addressing posteromedial tibial plateau fractures and posterior cruciate ligament (PCL) avulsions.

Surgical Anatomy & Biomechanics

A detailed appreciation of the intricate anatomy of the posterior knee and the biomechanical implications of posterior tibial plateau fractures is foundational for a safe and successful surgical outcome.

Bony Anatomy

The proximal tibia consists of the medial and lateral tibial condyles, separated by the intercondylar eminences. The articular surface typically exhibits a posterior slope of 7-10 degrees. Posterior column fractures involve the posterior aspect of the medial or lateral condyle, or both, often extending into the posteromedial or posterolateral corners. The posteromedial corner is a critical load-bearing region, and its disruption can significantly compromise knee stability. Characteristically, posterior articular fragments are driven posteriorly and inferiorly, creating a "trapdoor" effect with the posterior cortex.

Ligamentous and Capsular Anatomy

The posterior knee capsule is a complex structure reinforced by several ligaments.
* Posterior Cruciate Ligament (PCL): The primary restraint to posterior tibial translation, originating from the medial femoral condyle and inserting into the posterior intercondylar area of the tibia. Avulsion fractures of its tibial insertion are a common association with posterior TPFs.
* Posteromedial Corner (PMC): Comprises the superficial medial collateral ligament (sMCL), deep medial collateral ligament (dMCL), and the posterior oblique ligament (POL). The insertion of the semimembranosus tendon also contributes significantly to PMC stability.
* Posterolateral Corner (PLC): Includes the fibular collateral ligament (FCL), popliteus tendon, and the arcuate ligament complex. While less commonly addressed through a purely posteromedial approach, concomitant PLC injuries can occur.

Muscular Anatomy

The musculature of the posterior knee defines the surgical planes and landmarks.
* Gastrocnemius: The medial and lateral heads are superficial, originating from the femoral condyles. The medial head of the gastrocnemius serves as a key landmark and is typically retracted laterally during the posteromedial approach.
* Hamstrings: The semimembranosus, semitendinosus, and biceps femoris tendons cross the posterior aspect of the knee.
* Semitendinosus and Gracilis: Form part of the pes anserinus insertion on the anteromedial tibia. The semitendinosus tendon is a crucial reference point for the posteromedial approach.
* Semimembranosus: Inserts onto the posteromedial aspect of the medial tibial condyle, deep to the semitendinosus. Its fibers blend with the posterior capsule and POL.
* Popliteus: Originates from the lateral femoral condyle and inserts on the posterior aspect of the proximal tibia, deep to the gastrocnemius.

Neurovascular Anatomy

The popliteal fossa houses critical neurovascular structures that are vulnerable during posterior approaches.
* Popliteal Artery and Vein: The popliteal artery is the deepest structure, lying directly on the posterior surface of the femur and knee capsule. The popliteal vein is superficial to the artery, and the tibial nerve is the most superficial of the three. These structures are centrally located within the popliteal fossa and are retracted laterally during a posteromedial approach.
* Tibial Nerve: Runs vertically through the popliteal fossa, posterior to the popliteal vessels. It is susceptible to traction injury or direct damage if not properly identified and protected.
* Common Peroneal Nerve: Courses laterally, superficial to the lateral head of the gastrocnemius, around the fibular neck. It is generally not directly within the field of a posteromedial approach but can be at risk with extensive lateral dissection or combined posterolateral approaches.

Biomechanics of Posterior Tibial Plateau Fractures

Posterior column fractures compromise the posterior buttress of the tibia, which is essential for resisting posterior translation and maintaining joint stability. Displaced or depressed fragments can lead to dynamic instability, characterized by posterior subluxation of the femur on the tibia during weight-bearing or knee flexion. This altered joint mechanics can accelerate articular cartilage wear and lead to early degenerative changes. Operative fixation aims to reconstruct this posterior buttress, restore the anatomical posterior slope, and achieve stable fixation that allows for early, protected range of motion.

Indications & Contraindications

The decision to operate on a posterior tibial plateau fracture involves careful consideration of fracture characteristics, patient status, and soft tissue integrity.

Operative Indications

• Displaced Posterior Column Fractures:
  • Articular step-off greater than 2-3 mm on CT imaging.
  • Condylar widening greater than 5 mm.
  • Significant posterior articular depression compromising joint congruity or leading to instability.
  • Fractures classified as Schatzker Type V, VI with posterior involvement, or AO/OTA 41-B3 (posterior segment) and complex 41-C3.
• Posterior Knee Instability: Documented instability (e.g., increased posterior sag or drawer on stress radiographs or clinical examination) due to the fracture or associated ligamentous injuries (e.g., PCL avulsion).
• Irreducible Fractures: Fractures that cannot be anatomically reduced by closed manipulation or arthroscopic techniques.
• Associated PCL Avulsion Fractures: Displaced avulsion fractures from the tibial insertion of the PCL causing significant instability.
• Open Fractures: Following initial urgent debridement and stabilization, definitive internal fixation is often indicated once soft tissue conditions allow.
• Vascular Injury: If a concomitant popliteal artery injury is present, immediate surgical exploration and repair are warranted, often combined with fracture stabilization.

Contraindications

• Severe Soft Tissue Compromise: Extensive blistering, degloving injuries, severe edema, or other compromised soft tissue conditions that preclude safe immediate open reduction and internal fixation (ORIF). Staged management with temporary external fixation is often indicated in these scenarios.
• Significant Medical Comorbidities: Patients with severe medical instability (e.g., uncontrolled cardiac disease, respiratory failure) where the risks of general anesthesia and prolonged surgery outweigh the benefits.
• Active Local or Systemic Infection: Surgical intervention for the fracture should be deferred until the infection is controlled.
• Non-Displaced or Minimally Displaced Fractures: If articular congruity is maintained, the knee is stable, and the fracture pattern does not compromise future joint function, non-operative management with protected weight-bearing and early range of motion may be appropriate.
• Severe Comminution with Bone Loss: In cases of extreme comminution and bone loss, particularly in elderly patients with low functional demands, primary arthroplasty or prolonged external fixation might be considered, though challenging.

Pre-Operative Planning & Patient Positioning

Thorough pre-operative planning and precise patient positioning are crucial for facilitating optimal exposure, safe dissection, and accurate fracture reduction and fixation.

Pre-Operative Planning

1. Imaging Review: A detailed review of plain radiographs (AP, lateral, oblique) and, most importantly, a fine-cut CT scan with 3D reconstructions is essential. The CT scan helps delineate the precise fracture morphology, the extent of articular depression, the number and size of fragments, and the involvement of the posteromedial and/or posterolateral columns. Identify the exact location of the main posterior fragment(s), any impaction zones, and the degree of posterior slope alteration.
2. Implant Selection and Templating: Based on the CT findings, select appropriate implants. Anatomically contoured posterior tibial plates are specifically designed to buttress the posterior fragments. Pre-contouring or selecting specific plates (e.g., posteromedial plates, L-plates, T-plates) and determining screw lengths and trajectories based on templating on 3D reconstructions can save significant intraoperative time and improve fixation quality. Consider the use of cortical screws for lag fixation and locking screws for metaphyseal comminution or osteoporotic bone.
3. Blood Management: Assess the patient's hemoglobin and consider cross-matching blood if significant blood loss is anticipated.

Anesthesia and Positioning

1. Anesthesia: General endotracheal anesthesia is typically employed. A regional nerve block (e.g., sciatic nerve block or popliteal block) can be administered preoperatively to aid in postoperative pain control.

2. Patient Positioning: The standard position for a posterior approach to the tibial plateau is prone . This offers several advantages:

   • Direct Access: Provides direct and unimpeded access to the posterior aspect of the knee.
   • Gravity-Assisted Reduction: Placing a bolster beneath the thigh allows the knee to drop into hyperextension, facilitating reduction of posteriorly displaced fragments. This maneuver allows the distal femur to push the proximal tibia anteriorly, aiding in the restoration of the articular surface.
   • C-arm Accessibility: The prone position typically allows for easy and unobstructed positioning of the C-arm for intraoperative fluoroscopic imaging in AP, lateral, and oblique planes without requiring significant limb manipulation.

   

   • Specifics:
     • Place the patient prone on a radiolucent operating table.
     • A well-padded bolster is placed transversely under the distal thigh, just proximal to the knee joint. This elevates the thigh and allows the leg and foot to hang freely, enabling full knee extension and hyperextension.
     • Ensure adequate padding to all pressure points, especially the anterior superior iliac spines, knees, and ankles.
     • The ipsilateral arm can be tucked or placed on an arm board, ensuring no undue pressure on the brachial plexus.
     • Tourniquet: A pneumatic tourniquet is applied high on the thigh. The limb is exsanguinated by elevation for 3-5 minutes, and the tourniquet is inflated to a pressure sufficient to occlude arterial flow (e.g., 250-300 mmHg or 50-100 mmHg above systolic blood pressure).
   • Surgical Prep and Drape:
   • The limb is prepped circumferentially from the hip to the foot using an antiseptic solution.
   • Sterile draping should allow for full, unhindered range of motion of the knee and ankle joint throughout the procedure, crucial for reduction maneuvers and fluoroscopic imaging.

Figure 11-17: Illustrative setup demonstrating the prone patient position with a bolster beneath the distal thigh. This facilitates hyperextension of the knee, which is beneficial for fracture reduction and intraoperative fluoroscopic imaging with a C-arm.

Detailed Surgical Approach / Technique

The posteromedial approach to the tibial plateau offers direct visualization and access to the posterior and posteromedial articular surface. The key is to safely navigate the popliteal fossa structures.

Incision and Superficial Dissection

1. Landmarks: Re-palpate the joint line, the medial femoral condyle, the posteromedial border of the proximal tibia, and the hamstring tendons (semimembranosus and semitendinosus).
2. Incision: A longitudinal, slightly curved incision approximately 10-15 cm in length is made over the posteromedial aspect of the knee. It typically starts just proximal to the joint line, curving around the medial femoral condyle posteriorly, and extends distally along the posteromedial border of the tibia. This curvature helps with skin retraction and avoids tension.

The planned skin incision for a posteromedial approach, highlighting its curved nature to optimize exposure and skin laxity for closure.

1. Subcutaneous Dissection: Incise the skin and subcutaneous fat. Meticulous hemostasis is maintained.
2. Deep Fascia: Incise the deep crural fascia in line with the skin incision, exposing the underlying muscles.

Identifying the Semitendinosus Tendon Plane

This is the critical step for accessing the fracture site while protecting neurovascular structures.
1. Medial Head of Gastrocnemius: Identify the large, prominent medial head of the gastrocnemius muscle. This muscle belly forms the primary posteromedial boundary of the popliteal fossa.
2. Semitendinosus and Semimembranosus Tendons: Medially, identify the semitendinosus tendon (often with the gracilis, forming the pes anserinus) and the semimembranosus tendon. The semitendinosus is typically more superficial and anterior, while the semimembranosus is deeper, inserting more directly onto the posterior medial tibial condyle.
3. Internervous Plane Development: The primary plane for the posteromedial approach is developed between the medial head of the gastrocnemius laterally and the semitendinosus/semimembranosus complex medially.
* Carefully mobilize the medial head of the gastrocnemius and retract it laterally . This brings the popliteal neurovascular bundle into safer territory laterally, away from the direct surgical field.
* The semitendinosus and semimembranosus tendons are retracted medially .

Initial deep dissection. The medial head of the gastrocnemius is identified and gently retracted laterally to expose the deeper structures of the posterior knee.

The semitendinosus tendon, a key landmark, is identified. The surgical plane is developed between the medial gastrocnemius (retracted laterally) and the hamstring tendons (retracted medially).

Deep Dissection and Exposure of the Fracture

1. Popliteus Muscle: Deep to the gastrocnemius, the popliteus muscle may be encountered. Its fibers run obliquely from the lateral femoral condyle to the posteromedial tibia. It may need to be carefully elevated or incised along its tibial insertion for complete exposure.
2. Semimembranosus Insertion: The direct fibers of the semimembranosus tendon insert onto the posterior aspect of the medial tibial condyle and blend with the posterior capsule and POL. To expose the articular surface and facilitate reduction, these fibers, along with the posterior capsule and POL, are often carefully elevated subperiosteally off the posterior tibia as a single soft tissue sleeve. This elevation should be done carefully to allow for later repair.
3. Neurovascular Protection: Throughout the deep dissection, constant vigilance is required to protect the popliteal neurovascular bundle. These structures are always located immediately anterior and lateral to the medial head of the gastrocnemius. Broad, smooth retractors (e.g., Hohmann retractors) should be used against the bone and positioned carefully to shield the neurovascular bundle. Never use sharp instruments blindly.
4. Capsulotomy: Once the posterior aspect of the medial tibial condyle is exposed, a longitudinal capsulotomy is performed to visualize the articular surface. The incision should be made carefully to minimize damage to meniscal attachments.
5. Fracture Exposure: Subperiosteal dissection exposes the fracture fragments, often revealing a "trapdoor" effect where a posterior fragment is displaced inferiorly and posteriorly.

Deep exposure of the posteromedial tibial plateau fracture. Note the direct visualization of the articular depression, which is critical for anatomical reduction.

Fracture Reduction

1. Elevation of Depressed Fragments: Using a periosteal elevator, ball-tipped probe, or specialized bone tamps, carefully elevate the depressed articular fragments. This often requires filling the metaphyseal void created by the elevation with bone graft (autograft from the iliac crest or local cancellous bone, or allograft/synthetic bone substitutes).
2. Hyperextension Maneuver: As described in the positioning section, extending the knee (and even hyperextending it slightly) can be invaluable. The intact femoral condyle acts as a "jig" to push the posteriorly displaced tibial fragments anteriorly, aiding in reduction and restoring the posterior slope.
3. Direct Manipulation: Use reduction clamps, pointed reduction forceps, or bone hooks to manipulate and reduce larger fragments.
4. Temporary Fixation: Once anatomical reduction is achieved, secure the fragments temporarily with K-wires placed strategically to avoid planned screw trajectories.
5. Fluoroscopic Confirmation: Obtain AP, lateral, and oblique fluoroscopic images to confirm anatomical reduction, restoration of the articular surface, and proper posterior slope. The lateral view is particularly informative for assessing posterior step-off and slope.

A depiction of a bone tamp being used to elevate a depressed articular fragment, often requiring underlying bone graft to maintain the reduction.

Temporary stabilization with K-wires, indicating successful reduction of the main fragments prior to definitive fixation.

Internal Fixation

1. Plate Selection: Use an anatomically contoured posterior tibial buttress plate (e.g., L-plate, T-plate, or specialized posteromedial tibial plate). These plates are designed to provide robust support to the posterior column and resist shear forces.
2. Plate Application: Position the plate along the posteromedial aspect of the tibia, ensuring it follows the bone contour and acts as a buttress to the reduced fragments. The proximal end of the plate should buttress the most posterior and proximal fragment(s).
3. Screw Placement:
   • Lag Screws: Utilize lag screws through the plate to compress large articular fragments. Ensure careful measurement and fluoroscopic guidance to avoid intra-articular penetration.
   • Locking Screws: Deploy locking screws in the metaphysis and epiphysis, particularly in comminuted zones or osteoporotic bone, for angular stability.
   • Cortical Screws: Cortical screws are used for diaphyseal fixation. Bi-cortical purchase is preferred when safe and feasible.
   • Fluoroscopic Control: Each screw insertion should be guided and confirmed by fluoroscopy in multiple planes (AP, lateral, oblique) to confirm correct trajectory and length and to prevent joint penetration.

A contoured posterior tibial plate secured with screws. This image demonstrates how the plate provides crucial buttressing to the posterior aspect of the condyle.

Close-up view of screw placement, emphasizing the need for varied trajectories to capture multiple fragments and achieve strong bicortical fixation where appropriate.

Post-fixation fluoroscopic image, confirming satisfactory reduction, plate position, and screw lengths, ensuring no intra-articular intrusion.

Closure

1. Irrigation: Copiously irrigate the wound with sterile saline.
2. Soft Tissue Repair:
   • If the semimembranosus insertion and/or posterior capsule/POL complex were elevated, carefully repair them back to their anatomical attachments using strong, non-absorbable sutures through drill holes or soft tissue anchors. This helps restore posteromedial stability.
   • Ensure the gastrocnemius is returned to its anatomical position without tension.
3. Fascial Closure: Close the deep fascia.
4. Subcutaneous and Skin: Close the subcutaneous tissue and skin in layers.
5. Drainage: A suction drain may be placed subfascially, especially if there was extensive dissection or persistent oozing, to prevent hematoma formation.
6. Dressing: Apply a sterile dressing and a well-padded knee immobilizer or hinged knee brace.

The final closed incision, demonstrating careful attention to soft tissue handling and skin approximation.

Complications & Management

Despite meticulous surgical technique, complications can occur following posterior approaches to the tibial plateau. A proactive approach to prevention and early recognition is essential for effective management.

| Complication | Incidence (approx.) | Management / Salvage Strategy 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Clinical & Radiographic Imaging