Fractures of the tibial plateau frequently require surgical intervention. Open approaches are increasingly being replaced by minimally invasive techniques. Plate fixation may be uni- or bicondylar, and surgical incisions are traditionally orientated in the longitudinal plane. We describe osteoporotic fragility tibial plateau fractures managed with plate fixation applied through minimally invasive transverse incisions. All cases achieved acceptable fracture reduction, restoration of alignment, and timely bone union without infection or wound complications. This technique reduces the risk of wound complications at later arthroplasty, along with the established benefits of current minimally invasive techniques. This is the first report in the literature of the use of transverse incisions for minimally invasive plate fixation of the tibial plateau

Biggi F

Bucholz RW

Dirschl DR

Kankate RK

Langer K.

Miller MD

Schatzker J

English

Saini, AK

Desai, A

Trompeter, AJ

Newman, KJ

Elliott, DS

St George's Online Research Archive

le at ScienceDirectJournal of Orthopaedics, Trauma and Rehabilitation 22 (2017) 52e56Contents lists availabJournal of Orthopaedics, Trauma and RehabilitationJournal homepages: www.e- jotr .com & www.ejotr .orgCase ReportTransverse Incision for Minimally Invasive Plate Osteosynthesis ofOsteoporotic Tibial Plateau Fractures使用橫向切口來進行微創鋼板固定以治療骨質疏鬆性脛骨平台骨折Saini Aaron K.*, Desai Ankit, Trompeter Alex J., Newman Kevin J., Elliott David S.Rowley Bristow Orthopaedic Unit, Department of Trauma and Orthopaedics, St. Peter's Hospital, Chertsey, Surrey KT16 0PZ, UKa r t i c l e i n f oArticle history:Received 11 March 2015Received in revised form18 July 2016Accepted 21 October 2016Keywords:internal fixationlocking plateMIPOtibial plateautransverse incision* Corresponding author. E-mail: aaronsaini@nhs.nehttp://dx.doi.org/10.1016/j.jotr.2016.10.0022210-4917/Copyright©2016,HongKongOrthopaedicAssociaCC BY-NC-ND license (http://creativecommons.org/licenses/bya b s t r a c tFractures of the tibial plateau frequently require surgical intervention. Open approaches are increasinglybeing replaced by minimally invasive techniques. Plate fixation may be uni- or bicondylar, and surgicalincisions are traditionally orientated in the longitudinal plane. We describe osteoporotic fragility tibialplateau fractures managed with plate fixation applied through minimally invasive transverse incisions.All cases achieved acceptable fracture reduction, restoration of alignment, and timely bone unionwithout infection or wound complications. This technique reduces the risk of wound complications atlater arthroplasty, along with the established benefits of current minimally invasive techniques. This isthe first report in the literature of the use of transverse incisions for minimally invasive plate fixation ofthe tibial plateau.中 文 摘 要脛骨平台的骨折通常需要外科手術。開放式手術越來越多地被微創技術所取代。鋼板固定可以是單髁或雙髁,並且手術切口通常是縱向平面的。我們描述了新方法,使用橫向的切口,來進行微創鋼板固定以治療骨質疏鬆性脛骨平台骨折。我們描述了在我們中心的兩個骨質疏鬆脆性脛骨平台骨折的病例,成功地通過微創橫向切口,來進行鋼板固定手術。兩個病例都達到可接受復位,下肢調準恢復和按時骨折愈合,並沒有出現感染或傷口併發症。這是第一次在文獻中,關於把橫向切口應用於骨質疏鬆性脛骨平台骨折微創鋼板固定的報導。該技術一方面達到微創技術的好處,另一方面降低了出現傷口併發症和長遠需要接受關節置換術的風險。IntroductionTibial plateau fractures account for 1% of all fractures and a re-ported 8% of fractures in elderly people.1 Relative indications forsurgical intervention include > 5mm step of the articular surface, >5 mm displacement between fracture fragments, varus or valgusinstability, and open injuries.2 Open reduction and internal fixationis considered the gold standard of treatment, aiming for anatomicalreduction with absolute stability given the intra-articular person-ality of fractures. Soft tissue considerations are paramount, andmay be an indication for temporising measures and delay oft.tionand theHongKong College ofOrthop-nc-nd/4.0/).definitive fixation.3 Intraoperatively, care is required to minimisedisruption of the soft tissue envelope as this has direct implicationsfor fracture and wound healing, as well as postoperative rehabili-tation and recovery.Minimally invasive plate osteosynthesis (MIPO) techniqueshave been shown to allow adequate reduction, stable fixation,bone healing, early rehabilitation, and appropriate restoration offunction while minimising soft tissue disruption.4e6 This hastraditionally been performed using medial, lateral, or bilaterallongitudinal incisions to accommodate L- or T-plates in buttressmode with or without compression and supplementary lockingscrews.5,6 We describe a novel technique utilising small trans-verse incisions for plate placement and believe this further min-imises soft tissue disruption compared with the traditionallongitudinal MIPO technique, aiding early mobilisation and re-covery. This technique is aimed at low energy osteoporoticaedic Surgeons. Publishedby Elsevier (Singapore) Pte Ltd. This is an openaccess articleunder theA.K. Saini et al. / Journal of Orthopaedics, Trauma and Rehabilitation 22 (2017) 52e56 53fractures in elderly people, where restoration of axial alignment isthe primary goal over articular surface reconstruction, given thelikely need for expedited arthroplasty despite the adequacy offixation in this patient group. The resulting minimal transversescars have the added benefit of being at a tangent to, and awayfrom, the likely incision sites for future arthroplasty, reducing therisk of poorly vascularised skin bridges and their associatedcomplications.Surgical technique and case seriesWe report two cases of low energy osteoporotic fragility frac-tures managed utilising transverse incisions for bicondylar MIPOfixation. Although tibial plateau fractures are typically described bythe Schatzker classification,7 these osteoporotic fragility fracturesshow high energy patterns with low energy mechanisms and donot always fit the classic description.Patient 1A 74-year-old female presented having tripped while walking inwoodland. She had a background of asthma, hypertension, andpolymyalgia rheumatica for which she was taking long-term oralsteroids (10 mg prednisolone daily). She lived alone and mobilisedwithout aids. Computed tomography (Figure 1) showed a bicon-dylar fracture including a transverse component (OrthopaedicTrauma Association (OTA) Classification8: 41-C3). This was a closedinjury and the limb had no clinical neurological or vascular deficit.Patient 2A 66-year-old female presented having fallen from standingheight while walking. She had a background of asthma, herpessimplex, and a previously perforated gastric ulcer. She consumesFigure 1. Coronal CT scan of right knee of Patient 1 showing OTA Classification 41-C3tibial plateau fracture. CT ¼ computed tomography; OTA ¼ Orthopaedic TraumaAssociation.approximately 80 units of alcohol per week and smokes five to sixcigarettes per day. Although living in sheltered accommodation,she mobilises independently. This was a closed injury with noclinical evidence of neurological or vascular compromise. Initialradiographs showed a fracture of the right tibial plateau and thiswas confirmed with computed tomography (Figure 2), whichshowed a bicondylar injury with a transverse component (OTAClassification8: 41-C3).Surgical techniqueOnce adequately prepared for theatre and anaesthetised, thepatient is positioned supine on a radiolucent table. A smallradiolucent bolster is used under the knee. A pneumatic tourni-quet is used. Elevation of depressed articular fragments is ach-ieved using a small punch through a metaphyseal cortical windowvia a percutaneous stab incision. As the fractures have a bicondylarelement, a medial plate is used first. A 3-cm transverse incision ismade at approximately the level of the apex of the fractureposteromedially, allowing the plate to be slid down and then upagain under the skin into the appropriate position to work as abuttress. A locking guide is applied to the required periarticularplate and utilised as a handle to aid plate orientation andmanoeuvring. Once the buttress screw is applied, and the medialcondyle reduced, a second transverse incision is made on thelateral side at the level of the joint. A lateral plate is then appliedin a similar fashion, although the incision at the level of the jointon this side allows direct visualisation of all three to four proximalhorizontal screw holes. Compression of the articular block isachieved with a pelvic reduction clamp and then maintained withsubchondral locking screws through the plate. Stab incisions <5 mm are used for the insertion of distal screws. Plate position andreduction are confirmed using fluoroscopy (Figures 3 and 4).Closure is performed using staples.Both patients were allowed full free range of motion immedi-ately postoperatively. Toe-touch weight bearing was permittedfrom the 1st day, with increase to partial weight bearing at 4 weeks,and full weight bearing by 6e8 weeks.Figure 2. Coronal CT scan of right knee of Patient 2 showing OTA Classification: 41-C3tibial plateau fracture. CT ¼ computed tomography; OTA ¼ Orthopaedic TraumaAssociation.Figure 3. Patient 1 Anterior-posterior (AP) and lateral image intensifier intraoperative projections.Figure 4. Patient 2 Anterior-posterior (AP) and lateral image intensifier intraoperative projections.A.K. Saini et al. / Journal of Orthopaedics, Trauma and Rehabilitation 22 (2017) 52e5654Both patients achieved clinical and radiological union by 3months follow-up. There were no infections in either patient andall wounds healed well with minimal scar formation (Figure 5). At2-year follow-up Patient 1 continues to mobilise pain-free withoutthe use of mobility aids. There is minimal residual scarring(Figure 6). The patient is able to flex her knee to over 110 (Figure 7).Weight-bearing radiographs at 2 years show good preservation ofthe femorotibial joint space (Figure 8).Patient 2 moved from the local area and was therefore unable toattend for subsequent follow-up.DiscussionRespect of soft tissues continues to play a significant role in thesuccess of surgical fracture stabilisation. Minimising periostealstripping reduces the risk of vascular embarrassment of fracturefragments. Minimally invasive techniques compared with openprocedures have been associated with reduced soft tissue trauma,and a possible reduction in wound and infective complications.9Detractors of minimally invasive surgery may argue that smallerincisions may result in inadequate exposure and more difficultfracture reduction, which takes longer to achieve. We have shownhow adequate fracture reduction, and a favourable outcome can beachieved utilising a MIPO technique with small transverseincisions.It is important to note that the technique described here is notnecessarily appropriate for all patients. The patients reported sus-tained low energy osteoporotic fragility fractures. As these patientsare older than 60 years, chasing perfect articular reduction was notdeemed appropriate. More important was to correct the mechan-ical alignment of the limb and utilise a technique to allow the pa-tient to mobilise and move the knee immediately postoperatively.Both our patients had significant risk factors for postsurgicalcomplications such as surgical site infection and delayed woundhealing. These included smoking, alcohol excess and concomitantsteroid use. We did not observe any infections or wound compli-cations in our patients utilising small transverse incisions.Arthroplasty of the knee is typically performed through amidline skin incision, regardless of the subsequent approach uti-lised for entry into the joint, usually described in relation to thepatella. When prior surgery has been performed on a knee, anysurgeon hoping to perform subsequent arthroplasty is faced witheither trying to incorporate any previous scars, or leaving a viableskin bridge between the new and old incisions. This is particularlyprecarious around the knee given the circumferential blood supplycoursing from posterior to anterior. Any skin bridge formed,Figure 5. Healed wounds at 3-month follow-up with minimal scar formation.Figure 7. Patient 1 with active flexion to over 110 at 2-year follow-up.A.K. Saini et al. / Journal of Orthopaedics, Trauma and Rehabilitation 22 (2017) 52e56 55particularly between long longitudinal incisions is at risk of avas-cular necrosis and its sequelae. Our technique utilises short trans-verse incisions relatively far from the midline. This should reducethe risk of wound complications when subsequent arthroplasty isperformed through a longitudinal midline incision.We acknowledge the small number of patients and the relativelyshort follow-up period. A larger sample size, recruited prospec-tively, in a controlled study would be required to further validateour technique.Figure 6. Minimal residual scar for Patient 1 at 2-year follow-up.Traditional approaches to the medial or lateral tibial plateau,whether open or minimally invasive, are orientated in the longitu-dinal plane. This contrasts against the basic surgical principle oforientating incisions where possible along the direction and orien-tation of collagen fibres in the dermis of the skin, originally describedin German by Langer10 in 1861, and translated to English in 1978. Ourtransverse incision technique is given further credence by the wordsofHoppenfeld11whenhereports that “The linesofcleavageof theskinrun roughly transversely across the knee joint. Therefore, the morethe transverse the incision, the more cosmetic the resulting scar.”We believe our approach to these fragility fractures to be safe,reliable, and reproducible, and ideal when alignment restorationwith early patient mobilisation and rehabilitation is the goal. This ishugely significant in the context of providing a bone and soft tissue“canvas” for future arthroplasty.Figure 8. Patient 1 Anterior-posterior (AP) and lateral radiographs at 2-year follow-up.A.K. Saini et al. / Journal of Orthopaedics, Trauma and Rehabilitation 22 (2017) 52e5656Conflicts of interestThere are no conflicts of interest for any of the authors.Funding/supportNo funding was received for the work described in this article.References1. Bucholz RW, Heckman JD, Court-Brown CM, et al. Rockwood and Green's frac-tures in adults. 7th ed. Philadelphia: Lippincott Williams and Wilkins; 2009.2. Miller MD, Thompson SR, Hart R. Review of orthopaedics. 6th ed. Philadelphia:Saunders; 2012.3. Dirschl DR, Del Gaizo D. Staged management of tibial plateau fractures. Am JOrthop 2007;36:12e7.4. Kankate RK, Singh P, Elliott DS. Percutaneous plating of the low energy un-stable tibial plateau fractures: a new technique. Injury 2001;32:229e32.5. Raza H, Hashmi P, Abbas K, et al. Minimally invasive plate osteosynthesis fortibial plateau fractures. J Orthop Surg (Hong Kong) 2012;20:42e7.6. Biggi F, Di Fabio S, D'Antimo C, et al. Tibial plateau fractures: internal fixationwith locking plates and the MIPO technique. Injury 2010;41:1178e82.7. Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Torontoexperience 1968e1975. Clin Orthop Relat Res 1979;138:94e104.8. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification com-pendium d 2007: orthopaedic trauma association classification, database andoutcomes committee. J Orthop Trauma 2007;21(Suppl. 10):S1e163.9. Barei DP, Nork SE, Mills WJ, et al. Complications associated with internal fix-ation of high-energy bicondylar tibial plateau fractures utilizing a two-incisiontechnique. J Orthop Trauma 2004;18:649e57.10. Langer K. On the anatomy and physiology of the skin. I. The cleavability of thecutis. Br J Plast Surg 1978;31:3e8.11. HoppenfeldS,DeBoerP,BuckleyR.Surgical exposures inorthopaedics: theanatomicapproach. 4th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins;2001. p. 543.

Transverse Incision for Minimally Invasive Plate Osteosynthesis of Osteoporotic Tibial Plateau Fractures

 Fractures of the tibial plateau frequently require surgical intervention. Open approaches are increasingly being replaced by minimally invasive techniques. Plate fixation may be uni- or bicondylar, and surgical incisions are traditionally orientated in the longitudinal plane. We describe osteoporotic fragility tibial plateau fractures managed with plate fixation applied through minimally invasive transverse incisions. All cases achieved acceptable fracture reduction, restoration of alignment, and timely bone union without infection or wound complications. This technique reduces the risk of wound complications at later arthroplasty, along with the established benefits of current minimally invasive techniques. This is the first report in the literature of the use of transverse incisions for minimally invasive plate fixation of the tibial plateau. </jats:p

Transverse Incision for Minimally Invasive Plate Osteosynthesis of Osteoporotic Tibial Plateau Fractures

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