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Name:
Posterior Column Fractures of the Tibial Plateau
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Posterior Column Fractures of the Tibial Plateau
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T00H12M09S
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https://cadmoreoriginalmedia.blob.core.windows.net/9fc136a8-cc9c-42a0-bef5-946b6f9a8abf/Posterior column fractures of the tibial plateau.mp4?sv=2019-02-02&sr=c&sig=tsufglYMjqCpHlHqJD%2FrdzvKi2Q1D5w7jWEgUCclv0w%3D&st=2024-11-21T16%3A21%3A08Z&se=2024-11-21T18%3A26%3A08Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
ASHOK GAVASKAR: Good morning, everyone. My talk would be on posterior column fractures of the tibial plateau. How to decide and formulate your surgical strategy will kind of form the focus of my talk. So when you say posterior column fractures, by definition, you are using the three column classification proposed by Luo and friend way back in 2010. And as per this classification, the area sharing would constitute the posterior column of the tibial plateau.
ASHOK GAVASKAR: To get fractures in this column is quite rare compared to other parts of the proximal tibia, but you can see posterior column fractures occurring as part of a multi-column injury very commonly. If you look at the injury mechanism of these fractures, they are typically shear injuries caused in compression failure of the posterior part of the proximal tibia with the knee in flexion. This will typically result in coronal fracture lines on the proximal tibia with fragments having posterior apexes and depressions, which tend to present on the lateral side, predominantly in the posterior aspect.
ASHOK GAVASKAR: And how do we treat these fractures? If you have an isolated depression on the posterioral lateral aspect, which is more common than the posterioral medial aspect. These fractures can be accessed from the anterior based approach indirectly. It may not be always possible, but this is one strategy that can be employed most of the time. But if you have a fracture that has resulted in disruption of the posterior cortical margins, then you need direct manipulation to achieve your reduction and also buttress that fragment from the posterior side in order to stabilize it as you would desire.
ASHOK GAVASKAR: If you look at the fracture patterns that can occur on the posterior column, you can have isolated posterolateral fragments, postero medial fragments, with or without dislocation patterns and sometimes you can have the entire posterior column fracture. If you look at posteromedial fractures, these are simple posteromedial fracture pattern. And if you have such a fracture, how would you treat surgically?
ASHOK GAVASKAR: Would you go supine or would you go prone? I would agree most of us would tend to go supine on this one. But why? What are the advantages of going through a supine and what are the limitations? If you look at the prone Lobenhoffer approach this was described to treat isolated posteromedial condyle fractures and you can also use it for certain types of fracture dislocation patterns.
ASHOK GAVASKAR: This is done prone. It offers you a direct posterior access to your fracture area. Reduction is quite easy because this is done in extension, so these fractures typically reduce an extension so you can get a good reduction on that and you achieve or you assess your reduction based on the apex and also rely on fluoro to make sure you have reduced to articular segment anatomically. But what are the caveats here?
ASHOK GAVASKAR: If you're doing a prone Lobenhoffer approach, you have to remember that there is no direct articular access on this part. So if you need an articular access, you are kind of lost. And also, if you have a comminuted apex, sometimes you cannot rely on apical production and you have to make sure you have got your articular surface produced anatomically. Also, clamp options are limited, especially if you have not positioned your patient correctly.
ASHOK GAVASKAR: Postero central depressions can be dealt with through this approach. I'm not saying no, but I believe it is much more easy to do this one in a supine position. So there are positional limitations as well. So if you look at the patient that I showed in the previous slide, of course, this patient underwent fracture fixation through a prone Lobenhoffer approach because this is kind of like amenable to that.
ASHOK GAVASKAR: And we fixed this fracture by using a swan buttress plate from the posterior aspect and you can see the reduction is anatomical and she went on to heal well. So when should we avoid going prone? So since most of these fractures are done in supine positions, so you need to know when you should avoid going prone. So these are my indications for not going prone on this practice.
ASHOK GAVASKAR: So when you have a comminuted apex, when you are posterocentral depressions as part of fracture dislocation patterns and also in fractures where you need articular access, for example, if you have the medial column fracture as well, then you do not have a great read or a reference to base your posteromedial fragment upon. So these are the indications for me to definitely go supine on the posteromedial side.
ASHOK GAVASKAR: And that is what was done for all these three cases, as you can see, as most of us would have probably done. And if you look at cases 1 and 3 required articular access to get a reduction for us: case one because there was an intervening osteoporotic fragment that was not allowing us to get an articular reduction and case 3 because the actual medial rib was broken. So supine exposure gives you the liberty to go and do an arthrotomy anterior to the MCL and get you a cortical sorry articular reads that matched and then you can achieve your reduction.
ASHOK GAVASKAR: So how would I do a posteromedial fragment fixation? So the first step is to address any posterocentral depressions if we have as part of the fracture pattern and then get your articular reduction either based on apex, if you require an articular access, go and get exposure directly and reduce it and then clamp your fracture patterns and then anterior posterior lag screws at the sub-condral level to achieve and secure with articular reduction.
ASHOK GAVASKAR: And once you have done that, all these things are done in extension. So then now you can bring your leg into flexion and complete your fixation. So what about posterolateral fractures? There are different patterns ranging from dual depressions to split and split depressions, and these might have a high or a low apex. I will come back to that what I mean by that.
ASHOK GAVASKAR: You can also have the entire posterocolumn fracture, or you can have the posterolateral fragment as part of a multi-column fracture. And depending on the fracture pattern, you will plan your surgical approach and operative strategy. So if you look at this middle aged male, he's got a kind of posterolateral split depression injury and if you look at the rim, it is quite un-displaced and the apex is also quite high above the tibia head.
ASHOK GAVASKAR: So in this case, we chose to treat him as a kind of a pure depression coming from the anterior side, neglecting the posterior cortical rim injury. So this is intraoperatively, as you can see, he's got significant instability on the lateral side, and you can see that our operative images, the spike is around the posterolateral column. And if you look at the sutures, the blue sutures are tagging the meniscus.
ASHOK GAVASKAR: And my vital purple one is tagging the lateral collateral ligament. And once you have secured these structures, you can go again around the posterolateral corner, elevate your depression. It gives you a reasonable amount of exposure into the articular surface, which I won't say it's great, but most often enough to do your approach, do your fixator reduction and fixation. So once you go to a reduction and this is what was done - fixation by using an u plate, this is called an extended anterolateral acromial Lobenhoffer approach as is described by the Korean colleagues and this is how we ended up fixing it, restoring the articular congruity and stability to that knee.
ASHOK GAVASKAR: So if you look at this example, you can see the posterolateral depression as well as the posterior or the lateral rim broken. You can also see the fracture extending into the lateral column as well, and it's got a medial break as well. So if you look at this fracture with the posterolateral rim broken, this patient requires a direct buttress of the posterolateral rim.
ASHOK GAVASKAR: So you need direct exposure of that. If you have fracture only on the posterolateral side, then you can access it by a direct posterolateral approach. But in this case, you require to access both columns. So we did a Frasch, and the first step is to reduce and secure your posterolateral fragment with a small T buttress plate and then come back through the lateral window and complete your anterolateral fixation by using a stronger buttress plate.
ASHOK GAVASKAR: And this is what it looks like immediately post-op. And he went on to heal well, in spite of us not addressing the medial side. So it is important to remember that not all posterolateral fragments can be accessed from the lateral side. So in certain fracture patterns, when you have the apex that is running low or too medial, then you need a different approach to treat this once, because whatever you can see in the blue zone is what you can access to the posterolateral side, because anything lower than that is quite difficult because you have the anterior tibial artery crossing your field and you cannot make this approach more extent side.
ASHOK GAVASKAR: So in this patterns and also in patterns, when you have the entire posterior column broken where you are posteromedial and posterolateral fragments, then the approach of choice here would be the reverse L approach as described by confirming this landmark paper in 2010. So if you look at this case, this is a typical example of an entire posterior column fracture.
ASHOK GAVASKAR: You can see two fragments postero medial, posterolateral as well as opposed to a lateral central depression. And this is how we push in. The patient, though, comfortingly describe it in a sloppy lateral position. We prefer to do it in prone. So the patient is portioned prone with posts just under the thighsso that the tibia is floating, so that if I need access to the medial column or I need to clamp my fractures, I find this easier to do.
ASHOK GAVASKAR: So the first thing is to get your postero-central depression correct and then stabilize it and then go ahead and reduce the cortical rims and fix it, as we have shown here. So what are the caveats of this approach? Two, I would say like because if you go from the postero medial side, you do not have four lateral axis. So if you have axis in the blue zone, best would be to approach it from the lateral side and whatever approach nailing to the posterolateral or the postero medial or the reverse, L to me does not offer a great articular axis.
ASHOK GAVASKAR: So most often these approaches are used for stabilizing the cortical rim fragments, and then articular work is done predominantly from the anterior side. What do you need to do if you want to do one, one, two, want to look into the articular surface. So if you really want to look into the articular surface for whatever reasons, then you need to do an osteotomy, either osteotomy of the lateral femoral epicondyle or the fibular head.
ASHOK GAVASKAR: So we used to do a lot of tibial osteotomy but we kind of gave it up over a period of time in favor of the Frasch but whenever we need to do an osteotomy, yes, we can go over and do either of these, they offer a great exposure. If you look at Frasch's paper and most of the subsequent papers, he looks like he uses the posterolateral window to fix the fracture.
ASHOK GAVASKAR: He doesn't visualize the articlular segment to that. He uses an osteotomy to visualize the articular surface. So how to choose your surgical approach when you deal with the postero fragment? So these are my kind of criteria. So if you have a fracture that is located five laterally, they have an apex that is within 3 centimeters of the joint line. If we have an associated posterolateral depression, then probably posterolateral approach is better to do than the reverse L approach.
ASHOK GAVASKAR: For other fracture patterns, it would be the reverse L approach. So in summary, postero-column fractures in isolation are easy to do. Multi-column fractures require careful planning. Read your CT carefully and plan your surgical approaches so that you don't need more than two approaches. We have definitely got better at dealing with this practice right now.
ASHOK GAVASKAR: We have reproducible and extent, less extensile approaches which can be combined safely without major problems. Thank you.
Segment:0 .
ASHOK GAVASKAR: Good morning, everyone. My talk would be on posterior column fractures of the tibial plateau. How to decide and formulate your surgical strategy will kind of form the focus of my talk. So when you say posterior column fractures, by definition, you are using the three column classification proposed by Luo and friend way back in 2010. And as per this classification, the area sharing would constitute the posterior column of the tibial plateau.
ASHOK GAVASKAR: To get fractures in this column is quite rare compared to other parts of the proximal tibia, but you can see posterior column fractures occurring as part of a multi-column injury very commonly. If you look at the injury mechanism of these fractures, they are typically shear injuries caused in compression failure of the posterior part of the proximal tibia with the knee in flexion. This will typically result in coronal fracture lines on the proximal tibia with fragments having posterior apexes and depressions, which tend to present on the lateral side, predominantly in the posterior aspect.
ASHOK GAVASKAR: And how do we treat these fractures? If you have an isolated depression on the posterioral lateral aspect, which is more common than the posterioral medial aspect. These fractures can be accessed from the anterior based approach indirectly. It may not be always possible, but this is one strategy that can be employed most of the time. But if you have a fracture that has resulted in disruption of the posterior cortical margins, then you need direct manipulation to achieve your reduction and also buttress that fragment from the posterior side in order to stabilize it as you would desire.
ASHOK GAVASKAR: If you look at the fracture patterns that can occur on the posterior column, you can have isolated posterolateral fragments, postero medial fragments, with or without dislocation patterns and sometimes you can have the entire posterior column fracture. If you look at posteromedial fractures, these are simple posteromedial fracture pattern. And if you have such a fracture, how would you treat surgically?
ASHOK GAVASKAR: Would you go supine or would you go prone? I would agree most of us would tend to go supine on this one. But why? What are the advantages of going through a supine and what are the limitations? If you look at the prone Lobenhoffer approach this was described to treat isolated posteromedial condyle fractures and you can also use it for certain types of fracture dislocation patterns.
ASHOK GAVASKAR: This is done prone. It offers you a direct posterior access to your fracture area. Reduction is quite easy because this is done in extension, so these fractures typically reduce an extension so you can get a good reduction on that and you achieve or you assess your reduction based on the apex and also rely on fluoro to make sure you have reduced to articular segment anatomically. But what are the caveats here?
ASHOK GAVASKAR: If you're doing a prone Lobenhoffer approach, you have to remember that there is no direct articular access on this part. So if you need an articular access, you are kind of lost. And also, if you have a comminuted apex, sometimes you cannot rely on apical production and you have to make sure you have got your articular surface produced anatomically. Also, clamp options are limited, especially if you have not positioned your patient correctly.
ASHOK GAVASKAR: Postero central depressions can be dealt with through this approach. I'm not saying no, but I believe it is much more easy to do this one in a supine position. So there are positional limitations as well. So if you look at the patient that I showed in the previous slide, of course, this patient underwent fracture fixation through a prone Lobenhoffer approach because this is kind of like amenable to that.
ASHOK GAVASKAR: And we fixed this fracture by using a swan buttress plate from the posterior aspect and you can see the reduction is anatomical and she went on to heal well. So when should we avoid going prone? So since most of these fractures are done in supine positions, so you need to know when you should avoid going prone. So these are my indications for not going prone on this practice.
ASHOK GAVASKAR: So when you have a comminuted apex, when you are posterocentral depressions as part of fracture dislocation patterns and also in fractures where you need articular access, for example, if you have the medial column fracture as well, then you do not have a great read or a reference to base your posteromedial fragment upon. So these are the indications for me to definitely go supine on the posteromedial side.
ASHOK GAVASKAR: And that is what was done for all these three cases, as you can see, as most of us would have probably done. And if you look at cases 1 and 3 required articular access to get a reduction for us: case one because there was an intervening osteoporotic fragment that was not allowing us to get an articular reduction and case 3 because the actual medial rib was broken. So supine exposure gives you the liberty to go and do an arthrotomy anterior to the MCL and get you a cortical sorry articular reads that matched and then you can achieve your reduction.
ASHOK GAVASKAR: So how would I do a posteromedial fragment fixation? So the first step is to address any posterocentral depressions if we have as part of the fracture pattern and then get your articular reduction either based on apex, if you require an articular access, go and get exposure directly and reduce it and then clamp your fracture patterns and then anterior posterior lag screws at the sub-condral level to achieve and secure with articular reduction.
ASHOK GAVASKAR: And once you have done that, all these things are done in extension. So then now you can bring your leg into flexion and complete your fixation. So what about posterolateral fractures? There are different patterns ranging from dual depressions to split and split depressions, and these might have a high or a low apex. I will come back to that what I mean by that.
ASHOK GAVASKAR: You can also have the entire posterocolumn fracture, or you can have the posterolateral fragment as part of a multi-column fracture. And depending on the fracture pattern, you will plan your surgical approach and operative strategy. So if you look at this middle aged male, he's got a kind of posterolateral split depression injury and if you look at the rim, it is quite un-displaced and the apex is also quite high above the tibia head.
ASHOK GAVASKAR: So in this case, we chose to treat him as a kind of a pure depression coming from the anterior side, neglecting the posterior cortical rim injury. So this is intraoperatively, as you can see, he's got significant instability on the lateral side, and you can see that our operative images, the spike is around the posterolateral column. And if you look at the sutures, the blue sutures are tagging the meniscus.
ASHOK GAVASKAR: And my vital purple one is tagging the lateral collateral ligament. And once you have secured these structures, you can go again around the posterolateral corner, elevate your depression. It gives you a reasonable amount of exposure into the articular surface, which I won't say it's great, but most often enough to do your approach, do your fixator reduction and fixation. So once you go to a reduction and this is what was done - fixation by using an u plate, this is called an extended anterolateral acromial Lobenhoffer approach as is described by the Korean colleagues and this is how we ended up fixing it, restoring the articular congruity and stability to that knee.
ASHOK GAVASKAR: So if you look at this example, you can see the posterolateral depression as well as the posterior or the lateral rim broken. You can also see the fracture extending into the lateral column as well, and it's got a medial break as well. So if you look at this fracture with the posterolateral rim broken, this patient requires a direct buttress of the posterolateral rim.
ASHOK GAVASKAR: So you need direct exposure of that. If you have fracture only on the posterolateral side, then you can access it by a direct posterolateral approach. But in this case, you require to access both columns. So we did a Frasch, and the first step is to reduce and secure your posterolateral fragment with a small T buttress plate and then come back through the lateral window and complete your anterolateral fixation by using a stronger buttress plate.
ASHOK GAVASKAR: And this is what it looks like immediately post-op. And he went on to heal well, in spite of us not addressing the medial side. So it is important to remember that not all posterolateral fragments can be accessed from the lateral side. So in certain fracture patterns, when you have the apex that is running low or too medial, then you need a different approach to treat this once, because whatever you can see in the blue zone is what you can access to the posterolateral side, because anything lower than that is quite difficult because you have the anterior tibial artery crossing your field and you cannot make this approach more extent side.
ASHOK GAVASKAR: So in this patterns and also in patterns, when you have the entire posterior column broken where you are posteromedial and posterolateral fragments, then the approach of choice here would be the reverse L approach as described by confirming this landmark paper in 2010. So if you look at this case, this is a typical example of an entire posterior column fracture.
ASHOK GAVASKAR: You can see two fragments postero medial, posterolateral as well as opposed to a lateral central depression. And this is how we push in. The patient, though, comfortingly describe it in a sloppy lateral position. We prefer to do it in prone. So the patient is portioned prone with posts just under the thighsso that the tibia is floating, so that if I need access to the medial column or I need to clamp my fractures, I find this easier to do.
ASHOK GAVASKAR: So the first thing is to get your postero-central depression correct and then stabilize it and then go ahead and reduce the cortical rims and fix it, as we have shown here. So what are the caveats of this approach? Two, I would say like because if you go from the postero medial side, you do not have four lateral axis. So if you have axis in the blue zone, best would be to approach it from the lateral side and whatever approach nailing to the posterolateral or the postero medial or the reverse, L to me does not offer a great articular axis.
ASHOK GAVASKAR: So most often these approaches are used for stabilizing the cortical rim fragments, and then articular work is done predominantly from the anterior side. What do you need to do if you want to do one, one, two, want to look into the articular surface. So if you really want to look into the articular surface for whatever reasons, then you need to do an osteotomy, either osteotomy of the lateral femoral epicondyle or the fibular head.
ASHOK GAVASKAR: So we used to do a lot of tibial osteotomy but we kind of gave it up over a period of time in favor of the Frasch but whenever we need to do an osteotomy, yes, we can go over and do either of these, they offer a great exposure. If you look at Frasch's paper and most of the subsequent papers, he looks like he uses the posterolateral window to fix the fracture.
ASHOK GAVASKAR: He doesn't visualize the articlular segment to that. He uses an osteotomy to visualize the articular surface. So how to choose your surgical approach when you deal with the postero fragment? So these are my kind of criteria. So if you have a fracture that is located five laterally, they have an apex that is within 3 centimeters of the joint line. If we have an associated posterolateral depression, then probably posterolateral approach is better to do than the reverse L approach.
ASHOK GAVASKAR: For other fracture patterns, it would be the reverse L approach. So in summary, postero-column fractures in isolation are easy to do. Multi-column fractures require careful planning. Read your CT carefully and plan your surgical approaches so that you don't need more than two approaches. We have definitely got better at dealing with this practice right now.
ASHOK GAVASKAR: We have reproducible and extent, less extensile approaches which can be combined safely without major problems. Thank you.
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