Posterior Approaches to the Tibial Plateau

Natalie Rollick, MD FRCS(C) and David Wellman, MD

Modern concepts regarding the fixation of tibial plateau fractures increasingly recognized the
importance of reduction and stable fixation of posterior fragments. As such, there have been
a multitude of approaches described to access the posterior cortical surface. Due to the prox-
imity of the popliteal neurovascular bundle and common peroneal nerve, all approaches bal-
ance dissection of neurovascular structures with achievable surgical exposure, and thus
when selecting an approach, the surgeon must assess the risk of the desired exposure with
the potential benefit. Although there are many variations in position and incision placement,
five anatomical intervals are used for treatment of posterior tibial plateau fractures:
Oper Tech Orthop 28:152-156 © 2018 Elsevier Inc. All rights reserved.

KEYWORDS tibial plateau fracture, approach, knee

Positioning fracture fragments. Unfortunately, posterior exposure, and in

particular hardware placement, is more challenging. Knee

T he majority of approaches presented here, with the

exception of the direct posterior interval, can be posi-
tioned either prone or supine. Positioning should be carefully
considered in the context of the patient's overall condition,
ease of approach, fracture reduction, and hardware place-
ment and imaging.
Prone positioning allows for easier exposure in many cases
by allowing the surgeon to have direct, unimpeded visualiza-
tion of the tissues being dissected and through the ease of
knee flexion to de-tension of the hamstrings and gastrocne-
mius. The trajectory of ideal hardware placement is frequently
posterior to anterior, which is simpler with this position.
Prone positioning is, however, more time consuming, more
challenging from an anesthetic perspective and may also be
suboptimal in a polytraumatized patient. In addition, if an
anterior approach is needed an intraoperative position change
may be required, complicating the surgical plan as posterior
fixation may impede anterior reduction and fixation.
Supine positioning is preferred in the polytrauma setting
and allows for simultaneous access to anterior and posterior
Orthopaedic Trauma Service, Hospital for Special Surgery New York
Presbyterian Hospital Weil Cornell College of Medicine, New York City, NY.
Financial Disclosure: The authors declare that they have no relevant
financial interests.
Address reprint requests to Natalie Rollick, MD FRCS(C), Orthopaedic Trauma
Service, Hospital for Special Surgery New York Presbyterian Hospital Weil
Cornell College of Medicine, 535 East 70th Street, New York City,
NY10021. E-mail: natalierollick@gmail.com WellmanD@hss.edu
flexion required for retraction of posterior structures can be
obtained through popliteal bumps, which compress struc-
tures against the bony surfaces and impede hardware trajec-
tories, or through figure of four placement, which in turn
places a varus force through the fracture and can make
reduction challenging.
Lateral positioning can be used for the posterolateral,
transfibular and extended anterolateral intervals. It allows for
improved access to the posterior aspects of the tibia while
maintaining access to the anterolateral tibia at the expense of
posteromedial access. Careful positioning of bolsters can
allow gravity to aid in fracture reduction. Imaging of the pla-
teau, although certainly still possible, is more challenging to
obtain than supine positioning.
Luo et al.1 have attempted to mitigate the limitations of
patient positioning through the “floating position” in which
the patient is positioned in lateral decubitus but the down
leg is rotated to a prone positioning. This sloppy prone posi-
tioning allows for improved access to the posterior tibia
while maintaining the potential for posterolateral, postero-
medial and anterolateral access. Lateral approaches are possi-
ble with knee flexion into a reverse figure of four position.
Posteromedial Interval
A variety of incisions including straight, oblique, curvilinear
and L-shaped, have been described for the use of the postero-
medial interval.2-7 The distal limb of the approach shoulder

152 https://doi.org/10.1053/j.oto.2018.07.005
1048-6666/© 2018 Elsevier Inc. All rights reserved.
Posterior Approaches to the Plateau 153

Figure 1 Posteromedial approach to the knee is shown. (A) After skin incision is performed and saphenous bundle protected, the pes anserine is
encountered (black arrow) and the medial head of the gastrocnemius is exposed (white arrow). (B) With the pes retracted superiorly (black
arrow) and the deep compartment retracted posteriorly (white asterisk), the posteromedial surface of the tibia is seen easily in the floor of the
incision (white arrow). (C) Further exposure of the posteromedial corner is achieved with a release of the pes for later repair (black arrow). The
deep compartment is retracted (white asterisk) to expose the posteromedial corner of the tibia (white arrow).

Figure 2 Posterolateral approach to the knee is shown. (A) After skin incision, the biceps tendon (black arrow) and gastrocnemius complex
(white arrow) are visualized. (B) The common peroneal nerve (black arrow) is visualized running with the biceps tendon. (C) The limits of
exposure of the posterolateral tibia (black arrow) are shown. The trifurcation of the popliteal artery limits distal exposure where the anterior tib-
ial artery (white arrow) crosses the field. The posterior compartment musculature (white asterisk) can be released off the fibular head for
increased exposure.

be localized 1-2 cm posterior to the palpable posterior border
of the tibia. Anterior incision placement will increase skin
tensioning during the procedure and can impair fracture
reduction and hardware placement. To avoid this fluoros-
copy can be used to localize the incision over the posterior
aspect of the tibia on a perfect lateral image of the knee. Prox-
imally, the incision can continue medially or turn up to 90°
to cross transversely across the popliteal crease. This “L-
shaped” incision can reduce skin tension if the surgeon plans
to access the posterolateral tibia and provides the additional
advantage of being convertible to a full direct posterior
approach if the patient is positioned prone.
The posteromedial approach utilizes the interval between
the medial head of the gastrocnemius and the posterior
aspect of the pes anserine tendons. After incision of the skin
the dissection is carried down to the fascial layer. Care
should be taken to identify and protect the saphenous vein
and nerve which often run through the approach and
are generally retracted anteriorly. Posterior incision place-
ment may place the medial sural cutaneous nerve, which
supplies posterior leg sensation, within the surgical field.
The fascia is divided over the bulk of the medial head of the
gastrocnemius.
After retraction of the pes anserine tendons anteriorly, the
shiny white fibers of the Medial Collateral Ligament (MCL)
are visible and should not be damaged. Dissection is carried
posterior to the tibia by bluntly elevating the popliteus from
medial to lateral in a cranial to caudal fashion. Staying deep
to the popliteus adds further protection to the popliteal neu-
rovascular bundle. Dissection at the distal aspect of the popli-
teus should be undertaken with care as the inferomedial
geniculate often runs here.
154
Figure 3 The extended anterolateral interval exposure is shown.
After the division of the soft tissue connections between the tibia
and fibula, the fibula is retracted posterolaterally. The white asterisk
shows the proximal tibiofibular articular surface with the fibular
head retracted. The black arrow is on the bone surface of the pos-
terolateral tibia and the white arrow highlights the submeniscal
arthrotomy.
Increased posterolateral exposure can be added through
partial or total tenotomy of the medial head of the gastrocs.
However, this technique should be avoided if possible as it
is generally not necessary and risks weakening the gastro-
csoleus complex. The middle geniculate artery may be visu-
alized penetrating the posterior joint if dissection is
carried to the midline of the posterior tibia and should
be protected.
The posteromedial approach is a commonly used
approach which is familiar to most trauma surgeons and is
distally extensile. It minimizes risks to major neurovascular
structures, although the saphenous nerve is consistently
within the field and can be damaged. While the posterome-
dial approach allows for excellent access to the posteromedial
aspect of the tibia, it becomes increasingly difficult to visual-
ize and manipulate fragments as they become more lateral.
Care should be taken while performing fixation of posterolat-
eral fractures as excessive retraction on the skin and soft tis-
sues may be required to obtain the appropriate trajectory for
screw placement which can lead to skin necrosis.
Direct Posterior Interval8
A curvilinear incision is created to avoid crossing the popli-
teal crease at perpendicular angles. Dissection is then carried
down to the level of the fascia which is sharply divided. The
short saphenous vein and medial sural cutaneous nerve are
carefully identified superficially between the two heads of
gastrocnemius and traced proximally to identify the tibial
nerve and popliteal artery. The tibial nerve is dissected proxi-
mally to the bifurcation of the sciatic nerve to identify the
common peroneal nerve. Damage to the sural nerve branches
N. Rollick and D. Wellman
to either head of the gastrocs should be minimized to avoid
denervation of the muscle fibers. Care should be taken in the
lateral margin of the wound as the bifurcation shows a high
degree of variability and the peroneal nerve will be visible at
the posterior aspect of the biceps femoris. The popliteal neu-
rovascular bundle is then mobilized to allow exposure to the
underlying plateau. Anterior-based branches should be iden-
tified and ligated to aid in mobilization, however the middle
geniculate artery should be preserved. The knee is flexed to
relax the hamstrings and gastrocs in order to enable retrac-
tion of both muscular and neurovascular tissues to expose
the popliteus, which is then dissected off the posterior cortex
of the tibia.
The direct posterior exposure provides unparalleled
access for visualization and hardware placement on the pos-
terior tibial cortex. However, this access requires a lengthy
dissection of important neurovascular structures which is
time consuming and potentially dangerous. In addition, the
direct posterior approach requires challenging prone posi-
tioning and limits the ability to access the anterior aspect of
the tibia. It is also difficult to visualize the articular surface
of the posterior tibial plateau through a submeniscal
arthrotomy.
Posterolateral Interval9,10
Initially described by Frosch et al.9 as an alternative to the
transfibular approaches, the posterolateral interval utilizes
the interval between the lateral head of the gastrocnemius
and the deeper soleus. Frosch described a straight posterolat-
eral skin incision with lateral positioning but more recent lit-
erature have described a reverse L-shaped incision with
prone positioning, sacrificing anterolateral access in order to
improve the posteromedial exposure.
The posterolateral approach begins with identification
and protection of the common peroneal nerve at the poste-
rior aspect of the biceps femoris. A Penrose drain is placed
around the nerve, which is then gently retracted anteriorly.
The interval between the lateral head of gastrocs and soleus
is identified and opened, allowing the lateral head to be
retracted medially to protect the popliteal neurovascular
bundle and the soleus to be retracted laterally. The infero-
lateral geniculate artery may lie at the base of this interval
and should be identified and ligated if it impedes access.
The popliteus is elevated off the posterior cortex in a lateral
to medial, caudal to cranial direction revealing fracture frag-
ments beneath. Denuding the fracture fragments of perios-
teum and capsular attachments should be avoided. Many
authors recommend use of a simultaneous anterolateral
approach to allow for anterior-based reduction maneuvers,
either through the fracture or a cortical window, to aid in
this goal. Exposure can be expanded by releasing the soleus
musculature off the posterior fibula. The peroneal nerve
should be dissected distally to where is wraps around the
fibular neck but dissection distal to this point should be
minimized as multiple fragile motor branches are present
and can be damaged. Distal extension of the interval is
limited to 5-7 cm from the joint line by the trifurcation of
Posterior Approaches to the Plateau 155

the popliteal artery which is tethered by the interosseous adds the potential complication of fibular non-union and
membrane. subsequent persistent lateral knee pain. In the unusual case
The posterolateral interval allows access to the posterolat- of a posterolateral shearing tibial plateau fracture in a patient
eral plateau while avoiding a fibular osteotomy. Unfortunately, with knee osteoarthritis the transfibular approach may be a
it remains a technically challenging, unfamiliar approach poor option as removal of hardware for future total knee
which results in a deep surgical field. The depth of the surgical arthroplasty would be extremely challenging.
field is further complicated by the need for knee flexion to
visualize the posterior tibia, while knee extension is often
required for fracture reduction. In addition, the close proxim- Extended Anterolateral
ity of the common peroneal nerve and posterolateral corner Interval13,14
puts these structures at risk for iatrogenic injury. Finally, if the
Recently multiple authors have described extension of com-
patient might be a candidate for a total knee arthroplasty in
monly used anterolateral approach to improve access to the
the future the posterolateral approach makes hardware
posterolateral aspect of the tibia. Most recommend a lateral
removal challenging.
position with a bolster under the knee with the knee flexed
to 60° in order to relax posterior structures and allow grav-
Transfibular Interval11,12 ity to apply an opening varus directed force to improve
visualization.
A lateral longitudinal incision is created centered over
A curvilinear incision is made starting 1 cm lateral to the
the fibular head, just anterior to the biceps tendon.
tibial crest, curving to cross proximally over Gerdy's Tubercle
The common peroneal nerve is identified posterior to the
and the fibular head before extending superiorly. The IT band
biceps tendon and is dissected distally towards the fibular
is split in line with its fibers over Gerdy's tubercle without pene-
neck. The sural nerve branches medially in the popliteal
trating the joint capsule and then is reflected off the tubercle
fossa to innervate the gastrocnemius and should be pro-
both anteriorly and posteriorly. Distally the fascia of the anterior
tected. The peroneal nerve should be mobilized from soft
compartment is divided in line with the incision. The fascia is
tissue attachments as it passes around the fibular neck and
elevated off the tibialis anterior muscle anteriorly, then the mus-
should be released from the anterior and posterior septum
cle is elevated off the anterolateral aspect of the tibia.
to avoid tension during fibular head retraction. Branches to
To gain access to the posterolateral corner of the tibia the
the proximal tibiofibular joint will need to be identified and
dissection continues posteriorly at the rim of the tibial plateau
ligated in preparation for reflection of the fibular head. Fol-
to develop the space deep to the lateral collateral ligament and
lowing dissection of the nerve, the peroneus longus is
posterolateral corner complex. During this dissection the
removed subperiosteally from the fibular neck.
proximal tibiofibular ligaments and joint capsule are divided
Prior to fibular osteotomy, the fibular head is predrilled
allowing some posterior translation of the fibular head. An
with a 3.2-mm drill to facilitate later intramedullary fixation.
angled retractor is used to retract the fibular head posteriorly
The start point for the drill is just lateral to the insertion of
allowing visualization of the cortical surfaces and the popliteal
the biceps tendon in line with the intramedullary canal. The
tendon which runs inferomedial to superolateral to attach to
fibular osteotomy is completed through the fibular neck at
the lateral femoral condyle. A submeniscal arthrotomy is cre-
least 2-3 mm proximal to the peroneal nerve, but distal to
ated parallel to the articular surface and the meniscus is
the ligamentous and muscular attachments on the fibular
located and elevated through the use of traction sutures.
head. The fibular osteotomy can be completed with either an
The extended anterolateral approach provides access to
osteotome or an oscillating saw but attention should be on
the posterolateral aspect of the tibial plateau through a
the peroneal nerve and copious irrigations should be used to
familiar interval. Use of this approach involves limited
protect the nerve from thermal injury if a saw is selected.
dissection and risk to neurovascular structures and mini-
The fibular head is reflected proximally after release of the
mizes soft tissue dissection of the posterior knee. It also
proximal tibiofibular joint capsule exposing the entire lateral
allows posterolateral exposure while in a supine position.
joint line.
Unfortunately, while the fracture fragments can be visual-
The popliteus is dissected off the posterior aspect of the
ized and manipulated for reduction, this approach does
tibial from inferolateral to superomedial as needed, avoiding
not allow sufficient angle for the placement of buttress-
damage to the nearby inferolateral geniculate artery. A sub-
type fixation. Dissection through the proximal tibiofibular
meniscal arthrotomy is performed, fracture hematoma evacu-
joint also provides a theoretical risk of postoperative
ated, and meniscal retraction sutures placed to complete
proximal tibiofibular instability or damage to the postero-
visualization of the lateral articular surface.
lateral corner structures.
The transfibular approach is technically demanding but
provides excellent access to the entire lateral tibial plateau
facilitating simultaneous anterolateral and posterolateral
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