Accepted Manuscript

Title: The anterolateral supra-fibular-head approach for plating

posterolateral tibial plateau fractures: a novel surgical
technique

Author: Sun-Jun Hu Shi-Min Chang Ying-Qi Zhang Zhuo Ma

Shou-Chao Du Kai Zhang

PII: S0020-1383(15)00732-9
DOI: http://dx.doi.org/doi:10.1016/j.injury.2015.11.010
Reference: JINJ 6497

To appear in: Injury, Int. J. Care Injured

Received date: 16-9-2015

Revised date: 5-11-2015
Accepted date: 10-11-2015

Please cite this article as: Hu S-J, Chang S-M, Zhang Y-Q, Ma Z,
Du S-C, Zhang K, The anterolateral supra-fibular-head approach for plating
posterolateral tibial plateau fractures: a novel surgical technique, Injury (2015),
http://dx.doi.org/10.1016/j.injury.2015.11.010

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The anterolateral supra-fibular-head approach for plating posterolateral

tibial plateau fractures: a novel surgical technique

Sun-Jun Hu, Shi-Min Chang, Ying-Qi Zhang, Zhuo Ma, Shou-Chao Du, Kai Zhang

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Sun-Jun Hu, Shi-Min Chang, Ying-Qi Zhang, Zhuo Ma, Shou-Chao Du

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Department of Orthopaedic Surgery, Yangpu Hospital, Tongji University School of Medicine,

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450 Tengyue Road, Shanghai 200090, People’s Republic of China

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Kai Zhang

Department of Human Anatomy, Tongji University School of Medicine, 1239 Siping Road,
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Shanghai 200090, People’s Republic of China
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Corresponding Author: Shi-Min Chang, M.D., Ph.D.

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Department of Orthopaedic Surgery, Yangpu Hospital, Tongji University School of Medicine,

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450 Tengyue Road, Shanghai 200090, P.R. China

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e-mail: shiminchang11@aliyun.com

Tel.: +86 02165690520

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Running title: Supra-fibular-head approach

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The anterolateral supra-fibular-head approach for plating posterolateral

tibial plateau fractures: a novel surgical technique

ABSTRACT

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Objective: The posterolateral (PL) tibial plateau quadrant is laterally covered by the fibular

head and posteriorly covered by a mass of muscle ligament and important neurovascular

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structures. There are several limitations in exposing and fixing the PL tibial plateau fractures

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using a posterior approach. The aim of this study is to present a novel anterolateral

supra-fibular-head approach for plating PL tibial plateau fractures.

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Methods: Five fresh and ten preserved knee specimens were dissected to measure the

following parameters:1) the vertical distance from the apex of the fibular head to the lateral
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plateau surface, 2) the transverse distance between the PL platform and fibula collateral

ligament (FCL), and 3) the tension of the FCL in different knee flexion positions. Clinically,
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isolated PL quadrant tibial plateau fractures were treated via an anterolateral

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supra-fibular-head approach and lateral rafting plate fixation. The outcome of the patients was
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assessed after a short to medium follow-up period.

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Results: The distance from the apex of the fibular head to the lateral condylar surface was

12.2±1.6 mm on average. With the knee extended and the FCL tensioned, the transverse
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distance between the PL platform and the FCL was 6.7±1.1 mm. With the knee flexed to 60º

and the FCL was in the most relaxed position, the distance increased to 21.1±3.0 mm.

Clinically, a series of 7 cases of PL tibial plateau fractures were treated via this anterolateral

supra-fibular-head approach. The patient was placed in a lateral decubitus position with the

knee flexed to approximately 60 degrees. After the posterior retraction of the FCL, the plate

was placed more posteriorly to provide a raft or horizontal belt fixation of the PL tibial

plateau fragment. After an average of 14.3 months of follow up, the knee range of

Page 2 of 46
motion(ROM) was 121.4°±8.8° (range: 105°-135°), the HSS score was 96.7±2.6 (range:

90-100), and the SMFA dysfunction score was 22.4±3.8 (range: 16-28) points.

Conclusion: The anterolateral supra-fibular-head approach can provide direct visualization

of the posterolateral tibial plateau quadrant and put the plate more posteriorly to provide a raft

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for the fragments such that good clinical outcomes can be anticipated.

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Keywords: Tibial plateau fracture, Posterolateral fracture, Surgical approach,

Supra-fibular-head approach, Lateral raft plate, Horizontal belt plate

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Introduction

A posterolateral(PL) tibial plateau fracture, either isolated or combined with another tibial

plateau quadrant, is not as uncommon as previously believed[1–4]. According to a

morphological study, the PL articular fragment has an average depression depth of 10.5 mm;

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inadequate reduction and fixation of these fractures may result in knee flexion instability and

significant morbidity[5,6].

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Conventionally, it is difficult to reduce PL tibial plateau fractures through the usual

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anterolateral approach because of the inadequate visualization of the typically posterior

displaced fragment and anatomic barriers of the fibular head and the fibular collateral

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ligament(FCL). However, direct posterior approaches require dissection of the common

peroneal nerve, have deep and limited exposure, are vulnerable anterior tibial vessel or
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popliteal vessel injury, and require the dissection of the ligamentous PL corner structure; some

approaches even require a proximal fibular osteotomy, which may cause iatrogenic
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injury[7–12].
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We present a novel technique to reduce and fix PL tibial plateau articular fractures
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through an anterolateral supra-fibular-head approach, which can provide simple and effective
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exposure with rigid raft support for the depressed articular surface.
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Anatomic considerations

Five fresh and ten preserved knee specimens were used. None of these knee joints had signs

of previous injury, abnormality, or disease. The mean age of the donors was 61 years (range:

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44-78 years).Five fresh knee specimens were from thigh amputations at the time of operation,

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while the preserved knee specimens were from the Department of Human Anatomy, Tongji

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University School of Medicine.

Each lower limb was dissected using the anterolateral supra-fibular-head approach.

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Along the incision, the distal fibre bundles of the iliotibial band were released from Gerdy’s

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tubercle to expose the deeper structure. The coronary ligament of the meniscus was cut open

to visualize the posterolateral tibial plateau. The fibular collateral ligament(FCL) was then
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mobilized, and the tension of the FCL in different knee flexion angles was manually tested.

The FCL was most relaxed when the knee was flexed to 60º. With retraction of the FCL, the
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max and mini transverse distance between the posterolateral platform rim and the FCL were
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measured. The soft tissue structure was removed to measure the distance from the apex of the

fibular head to the lateral condylar surface(Fig.1).

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The anatomic results are summarized in Table 1.

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Surgical technique

The patients were placed in a lateral decubitus position with the injured limb maintained in a

slightly flexed position (Fig.2). A thick pad was applied under the distal femur; thus, the

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weight of the lower leg can be used to open the lateral compartment of the knee.

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After sterilization, preparation and draping, the tourniquet was inflated. A 10-cm-long

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oblique skin incision was made, starting from Gerdy’s tubercle and extending

posterosuperiorly to cross over the fibular head to the joint line(Fig.3 a).The superficial

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dissection was performed as usual. Then, the space between the FCL and the lateral condylar

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was developed, and the FCL was mobilized to retract posteriorly with knee flexion to

approximately 60 degrees. The inferior border of the coronary ligament and joint capsule
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were opened, and the lateral meniscus was proximally retracted using sutures (Fig.3 b). After

clearing the hematoma in the articular cavity, the posterolateral tibial plateau fracture can be
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fully visualized, with supplementary manoeuvres of slight internal rotation and inversion of
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the lower leg.

A cortical window was developed on the anterolateral metaphysis approximately 2 cm

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below the articular surface. The depressed articular fragment was elevated using an osteotome
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to restore the congruence of the tibial plateau. Fine K-wire was used to maintain the reduction.

Alternative bone void fillers can be used to fill metaphyseal defects and add stability to
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articular surface reductions, iliac crest autografts or allogeneic bone grafts. A 3.5-mm lower

profile lateral proximal tibia locking compression plate (3.5 mm LCP, Synthes Inc., Oberderf,

Switzerland) was used. The transverse arm of the L-shaped plate, 4 holes in length and 10 mm

in width (Fig.3 c), was placed as posteriorly as possible, through the superior fibular head

space (Fig. 3 d). Typically at least 2 screws can cross the posterolateral fragment, and the

posterior-most screw should be no more than 40 mm in length, i.e., long enough to cross the

Page 6 of 46
lateral condyle. As the articular surface was reduced and fixed, the broken posterolateral

cortex did not require further reduction or fixation. The opened coronary ligament and the

released iliotibial band fibre were sutured back before incision closure.

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Patient series

From Feb 2012 to Dec 2013, a consecutive series of seven patients who sustained isolated

posterolateral tibial plateau fractures were treated by open reduction and plate fixation using

the anterolateral supra-fibular-head approach. There were five men and two women, with an

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average age of 53 years (range: 29-76). Five cases were fixed using a 3.5 mm locking raft

plate (Fig. 4), and two cases were fixed with a horizontal belt plate by using a 3.5 mm distal

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radial volar plate (Fig. 5).

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The average operation time was 78±9 min (range: 60-98). All incisions healed with no

cases of deep infection or osteomyelitis. None of the patients developed vascular injury,

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peroneal nerve paresthesia or compartment syndrome. The fractures were healed at 3 months

post-operation, as manifested by painless weight-bearing without supportive devices and

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radiographic fracture healing.

After a mean of 14.3 months (range: 12-18)of follow up, all patients had normal knee
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extension and returned to their pre-injury jobs. No patient manifested knee inflexion
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instability or abnormal weight-bearing alignment. One patient complained of a bit of stiffness

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in the injured joint that did not affect the patient’s daily work. According to the final
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assessment, the average knee range of motion(ROM) was 121.4°±8.8° (range: 105-135), the

average HSS score was 96.7±2.6 (range: 90-100), and the average SMFA dysfunction score
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was 22.4±3.8 (range: 16-28) points.

Page 8 of 46
Discussion

According to a morphological study of tibial plateau fractures, 15% of all injuries

demonstrated a posterolateral fracture fragment, with an average depth of approximately 10

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mm [13]. Although isolated posterolateral fractures consist of a small proportion

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(approximately 7 %) of all tibial plateau fractures, the treatment of choice is controversial.

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Traditional anterolateral approach is simple and familiar to orthopaedic surgeons.

However, the AL approach cannot provide full visualization of the posterior articular surface

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(can be added with arthroscopy), cannot utilize the buttress plate, and has the risk of

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iatrogenic injury of the popliteal vessels by K-wire or screw placement [14]. Lateral femoral

epicondylar osteotomy and a submeniscal approach were introduced for increased

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intraoperative exposure [15].

The posterior approach, using various types of skin incisions, was favoured by many
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authors for direct visualization of the fragment and rigid fixation with a buttress plate
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[7–10,16–19] but also has limitations [11, 20]. The posterior approach can be classified as

posterolateral with/without osteotomy (fibular neck, fibular head, and lateral femur condyle),
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posteromedial, or posterocentral. The typical anterolateral approach has also been modified by
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several authors [20–22].

We summarize these approaches, including their advantages and disadvantages, in Table

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2.

According to our study, a certain amount of space between the apex of the fibular head

and the lateral condylar surface exists and is approximately 12 mm in height on average,

which allows the possibility of placing the plate more posteriorly. Typically, two holes scan

be used to capture the posterior part of the articular fragments. With the knee flexed to 60º-70º,

the PL articular surface could be easily visualized by the internal rotation of the tibia and

Page 9 of 46
posterior retraction of the FCL. The reduction and plating of the PL fragment can be

manipulated through this interspace. Direct visualization of the articular surface can guarantee

the reduction quality.

The ideal indication of this approach is a pure PL articular depression fracture (Schatzker

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type III) or an articular depression with a minimal posterior cortex displacement that does not

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need reduction. For a significant posterior cortex rupture and a PL cortical wall requiring

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reconstruction, a direct PL approach[7]or Frosch approach[16] of one skin incision with two

deep dissection intervals for PL and AL plate fixation is indicated.

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The advantages of the supra-fibula-head approach include the following: (1) the patient

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in a lateral position rather than a prone position, (2)a simple and easy anterolateral approach,

(3) no vital neurovascular structure or PL corner structures are encountered, (4)direct

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visualization of the PL articular surface can be acquired, enabling the confirmation of fracture

reduction, and (5) can be used for isolated PL quadrant fractures or combined PL and AL
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fractures or dual condylar fractures involving the PL quadrant [23,24].

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In conclusion, using an anterolateral supra-fibular-head approach can provide direct

visualization of the posterolateral tibial plateau quadrant, place the plate more posteriorly to
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provide a raft for the fragments such that good clinical outcomes can be anticipated.
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Conflict of interest and source of funding

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No funding was received in support of this study. None of the other authors have any

conflicts of interest to declare.

Page 10 of 46
References

[1] Lobenhoffer P, Gerich T, Bertram T, Lattermann C, Pohlemann T, Tscheme H. Particular

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[2] Stallenberg B, Gevenois PA, Sintzoff SA Jr, Matos C, Andrianne Y, Struyven J. Fracture

of the posterior aspect of the lateral tibial plateau: radiographic sign of anterior cruciate

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[3] Luo CF, Sun H, Zhang B, Zeng BF. Three-column fixation for complex tibial plateau

fractures. J Orthop Trauma 2010;24(11):683–92.

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[4] Johnson EE, Timon S, Osuji C. Surgical technique: Tscherne-Johnson extensile approach

for tibial plateau fractures. Clin Orthop Relat Res 2013;471(9):2760–7.

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[5] Zhai Q, Luo C, Zhu Y, Yao L, Hu C, Zeng B, et al. Morphological characteristics of

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computer-tomography-based study. Int Orthop 2013;37(5):911–7.

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[6] Li Q, Zhang YQ, Chang SM. Posterolateral fragment characteristics

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in tibial plateau fractures. Int Orthop 2014;38(3):681–2.

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[7] Carlson DA. Posterior bicondylar tibial plateau fractures. J Orthop Trauma

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[8] Solomon LB, Stevenson AW, Baird RP, Pohl AP. Posterolateral transfibular approach to

tibial plateau fractures: technique, results, and rationale. J Orthop Trauma

2010;24(8):505–14.

[9] Chang SM, Zheng HP, Li HF, Jia YW, Huang YG, Wang X, et al. Treatment of isolated

posterior coronal fracture of the lateral tibial plateau through posterolateral approach for

direct exposure and buttress plate fixation. Arch Orthop Trauma Surg

2009;129(7):955–62.

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[10]Yu GR, Xia J, Zhou JQ, Yang YF. Low-energy fracture of posterolateral tibial plateau:

treatment by a posterolateral prone approach. J Trauma Acute Care Surg 2012;72(5):

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[11]Huang YG, Chang SM. The posterolateral approach for plating tibial plateau fractures:

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problems in secondary hardware removal. Arch Orthop Trauma Surg 2012;132(5):733–4.

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[12]Solomon LB, Stevenson AW, Lee YC, Baird RP, Howie DW. Posterolateral and

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anterolateral approaches to unicondylar posterolateral tibial plateau fractures: a

comparative study. Injury 2013;44(11):1561–8.

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[13]Xiang G, Zhi-Jun P, Qiang Z, Hang L. Morphological characteristics of posterolateral

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articular fragments in tibial plateau fractures. Orthopedics 2013;36(10):e1256–61.

[14]Hsieh CH. Treatment of the Posterolateral Tibial Plateau Fractures using the Anterior
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Surgical Approach. Int J Biomed Sci 2010;6(4):316–20.

[15]Yoon YC, Sim JA, Kim DH, Lee BK. Combined lateral femoral epicondylar osteotomy
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and a submeniscal approach for the treatment of a tibial plateau fracture involving the
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posterolateral quadrant. Injury 2015;46(2):422–6.

[16]Frosch KH, Balcarek P, Walde T, Stürmer KM. A new posterolateral approach without
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fibula osteotomy for the treatment of tibial plateau fractures. J Orthop Trauma
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2010;24(8):515–20.

[17]He X, Ye P, Hu Y, Huang L, Zhang F, Liu G, et al. A posterior inverted L-shaped approach

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for the treatment of posterior bicondylar tibial plateau fractures. Arch Orthop Trauma

Surg 2013;133(1):23–8.

[18]Muhm M, Schneider P, Ruffing T, Winkler H. Posterocentral approach to the posterior

tibial plateau: Reconstruction of tibial plateau fractures and avulsions of the posterior

cruciate ligament. Unfallchirurg 2013;117(9):813–21.

[19]Chen WT, Zhang YQ, Chang SM. Posterolateral approach for plating of tibial plateau

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 fractures and the risk of injury to the anterior tibial vessels. J Orthop Trauma 2013;27(9):

e228–9.

[20]Yu B, Han K, Zhan C, Zhang C, Ma H, Su J. Fibular head osteotomy: a new approach for

the treatment of lateral or posterolateral tibial plateau fractures. Knee 2010;17(5):313–8.

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[21]Sassoon AA, Torchia ME, Cross WW, Cass JR, Sems SA. Fibular shaft allograft support

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of posterior joint depression in tibial plateau fractures. J Orthop Trauma

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2013;28(7):e169–75.

[22]Chen HW, Zhou SH, Liu GD, Zhao X, Pan J, Ou S, et al. An extended anterolateral

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approach for posterolateral tibial plateau fractures. Knee Surg Sports Traumatol Arthrosc

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2014[Epub ahead of print].

[23]Chang SM, Hu SJ, Zhang YQ, Yao MW, Ma Z, Wang X, et al. A surgical protocol for
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bicondylar four-quadrant tibial plateau fractures. Int Orthop 2014;38(12):2559–64.

[24]Chang SM. Selection of surgical approaches to the posterolateral tibial plateau fracture by
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its combination patterns. J Orthop Trauma 2011;25(3): e32–3.

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 Table 1

Anatomic data.

Items Mean±SD Mini-Max

Vertical distance from the apex of the fibular head

12.2±1.6 mm 9-15 mm

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to the lateral plateau surface

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Maximum transverse distance between the
posterolateral platform and the FCL with knee 21.1±3.0 mm 16-28 mm

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flexion in 60 degrees
Minimum transverse distance between the
posterolateral platform and the FCL with knee 6.7±1.1 mm 5-9 mm

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extension

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1 Table 2

2 Comparison of different approaches to the posterolateral tibial plateau quadrant.

Approaches Merits Limitations

1 Tscherne-Johnson Increased lateral exposure and Need osteotomy
extensile [4] maintenance of iliotibial band insertion Difficulty in PL fragment fixation
to Gerdy’s tubercle Screw fixation

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2 Trans-fibular [8] Good visualization Need osteotomy and dissection of

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Posterior buttress plate fixation CPM
3 Modified anterolateral No dissection of neurovascular structures Difficulty in exposure and
Cortical window [14] insurance of fracture reduction

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Screw fixation
4 Lateral femoral Direct visualization Need osteotomy and fixation
epicondylar osteotomy No injury to FCL Screw fixation

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[15 ]
5 Direct posterolateral Direct visualization Limit visualization and space for
[7,9,10] Posterior buttress plate fixation manipulation
Need osteotomy and dissection of

6 Extensile lateral [16]
7 Posteromedial [17]
8 Postero-central [18]
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CPM
Injury to PLC
Direct visualization Massive dissection
Posterior buttress plate fixation Need dissection of CPM
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Can fix the AL fragment Injury to PLC
No dissection of neurovascular structures Difficulty in exposure and
Posterior buttress plate fixation insurance of fracture reduction
Good visualization Need dissection of popliteal
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Posterior buttress plate fixation neurovascular structures

9 Partial fibular resection No dissection of neurovascular structures Need osteotomy
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[20] Direct visualization of articular surface Screw fixation

10 Supra-fibular head Direct visualization Suitable for selected cases with PL
Raft screw fixation through locking plate cortex intact or minimal
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No dissection of neurovascular and PL displacement

corner structures
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3
4 PL: posterolateral, PLC: posterolateral corner, CPN: common peroneal nerve
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 8 Figure Legends

10 Fig. 1. Anatomic measurement of the specimens.

11 a Schematic drawing to show the measurement. AB: The vertical distance from the apex

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12 of fibular head to the lateral condylar surface rim. AC: The transverse distance between

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13 the posterolateral plateau rim and the FCL.

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14 b Fresh specimen.

15

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16 Fig. 2. A lateral decubitus position with the injured limb maintained in a slightly flexed

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17 position was used during the operation.

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19 Fig. 3. Intra-operative illustration of the supra-fibula-head approach.

20 a Skin incision, starting from Gerdy’s tubercle, extending posterosuperiorly to cross over
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21 the fibular head to the joint line.

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22 b The coronary ligament and lateral meniscus was retracted proximally by sutures, and

23 the PL fragment has been elevated. Note the opened anterolateral cortical window.
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24 c An L-shaped 3.5 mm LCP for the proximal tibiacan beput more posteriorly to raft the
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25 elevated articular fragment.

26 d Schematic diagram showing the raft fixation of the PL fragments by a more posteriorly
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27 placed lateral plate over the fibular head.

28

29

30 Fig.4. Case 1 Anterolateral supra-fibula-head fixation with a 3.5-mm lower profile lateral

31 proximal tibia locking compression plate.

32 a,b AP and lateral pre-operative views showed a typical posterolateral tibial plateau

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33 fracture.

34 c–e Pre-operative CT scan showed the fragment on the posterolateral quadrant of the

35 tibial plateau.

36 f,g AP and lateral view post-operation showed that the fracture was anatomically reduced.

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37 h–j CT scan post-operation. Note that the posterolateral fragment was fully elevated and

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38 rafted by screws.

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39 k Three-dimensional reconstruction images post-operation showed that the plate was

40 placed supra to the fibularhead.

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41

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42 Fig. 5. Case 2 Anterolateral supra-fibula-head fixation with a 3.5 mm horizontal belt plate.

43 a, b AP and lateral view before operation showed a typical posterolateral tibial plateau
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44 fracture.

45 c, d Images of CT scan and reconstruction before the operation showed that the fragment
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46 was on the posterolateral quadrant of the tibial plateau.

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47 e Intraoperative photograph showed that the fracture was reduced and fixed by a

48 horizontal belt plate.

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49 f,g AP and lateral intraoperative fluoroscopy images showedthat the fracture was
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50 anatomically reduced.

51 h–j Images of CT scan and reconstruction after operation. The fragment was elevated and
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52 fixed by a horizontal belt plate.

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54
55

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55 Conflicts of interest
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57 We declare that there were no financial or personal relationships with other people or

58 organisations that could inappropriately influence our work.

59

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60

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61 Shi-Min Chang, M.D., Ph.D.
62 Department of Orthopaedic Surgery

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63 Yangpu Hospital, Tongji University School of Medicine
64 450 Tengyue Road

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65 Shanghai 200090, P.R. China
66 Email: shiminchang11@aliyun.com
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