Accepted Manuscript

Title: Complications and outcomes of the transfibular

approach for posterolateral fractures of the tibial plateau

Author: Robinson Esteves Santos Pires Vincenzo Giordano

André Wajnsztejn Egidio Oliveira Santana Junior Rodrigo
Pesantez Mark Lee Marco Antônio Percope de Andrade

PII: S0020-1383(16)30288-1
DOI: http://dx.doi.org/doi:10.1016/j.injury.2016.07.010
Reference: JINJ 6806

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

Accepted date: 6-7-2016

Please cite this article as: Pires Robinson Esteves Santos, Giordano Vincenzo,
Wajnsztejn André, Oliveira Santana Egidio, Pesantez Rodrigo, Lee Mark,
de Andrade Marco Antônio Percope.Complications and outcomes of the
transfibular approach for posterolateral fractures of the tibial plateau.Injury
http://dx.doi.org/10.1016/j.injury.2016.07.010

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Complications and outcomes of the transfibular approach for posterolateral fractures of
the tibial plateau

Robinson Esteves Santos Pires1,2, Vincenzo Giordano2, André Wajnsztejn3, Egidio Oliveira
Santana Junior2, Rodrigo Pesantez4, Mark Lee5, Marco Antônio Percope de Andrade1.

1. Department of the Locomotive Apparatus. Federal University of Minas Gerais, Belo

Horizonte (MG), Brazil
2. Department of Orthopedics and Traumatology. Miguel Couto Hospital, Rio de Janeiro
(RJ), Brazil.
3. Department of Orthopedics and Traumatology. Federal University of São Paulo, São
Paulo (SP), Brazil
4. Department of Orthopedics and Traumatology. Fundación Santa Fe de Bogotá, Bogotá
(CU), Colombia
5. Department of Orthopedics and Traumatology. University of California, Davis Medical
Center, Sacramento (CA), United States
Corresponding author:

Robinson Esteves Santos Pires

[email protected]

Department of the Locomotive Apparatus, Federal University of Minas Gerais, Belo Horizonte
(MG), Brazil.

Avenida Professor Alfredo Balena, 190. Sala 193. Belo Horizonte (MG). CEP: 30130-100.

Phone: +55 31 3409-9757.

Conflict of interest:
The authors declare absence of conflict of interest related to this article.

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Complications and outcomes of the transfibular approach for posterolateral fractures of
the tibial plateau

Objective: Evaluate complication rates and functional outcomes of fibular neck osteotomy for
posterolateral tibial plateau fractures
Design: Retrospective case series

Setting: University hospital

Patients: From January, 2013 to October 2014, 11 patients underwent transfibular

approach for posterolateral fractures of the tibial plateau and were enrolled in the study. All
patients who underwent transfibular approach were invited the return to the hospital for another
clinical and imaging evaluation.

Intervention: Transfibular approach (fibular neck osteotomy) with open reduction and internal
fixation for posterolateral fractures of the tibial plateau.

Main outcome measurements: Complications exclusively related to the transfibular

approach: peroneal nerve palsy; knee instability; loss of reduction; nonunion and malunion of
fibular osteotomy; and functional outcomes related to knee function.

Results: Two patients failed to follow-up and were excluded from the study. Of the 9 patients
included in the study, no patients demonstrated evidence of a peroneal nerve palsy. One
patient presented loss of fracture reduction and fixation of the fibular neck osteotomy,
requiring revision screw fixation. There were no malunions of the fibular osteotomy. None
of the patients demonstrated clinically detectable posterolateral instability of the knee
following surgery. American Knee Society Score was good in 7 patients (77.8%), fair in 1
(11.1%), and poor in 1 (11.1%). American Knee Society Score/Function showed 80 points
average (60-100, S.D:11).

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Conclusion: The transfibular approach for posterolateral fractures is safe and useful for
visualizing posterolateral articular injury. The surgeon must gently protect the peroneal nerve
during the entire procedure and fix the osteotomy with long screws to prevent loss of reduction.

Keywords: Tibial plateau; Transfibular osteotomy; Fibular neck osteotomy; Fractures of the
tibial plateau; Peroneal nerve palsy; Knee fractures; Tibial plateau fractures; Plate fixation;
Fractures; Nonunion.

Level of evidence: Therapeutic level IV

Introduction:

Posterior fractures of the tibial plateau are increasingly common, and the orthopaedic
surgeon is becoming familiar with this demanding treatment. The injury mechanism is an
axial force with the knee in flexion. The knee position (varus, valgus, or neutral) determines the
fracture location in the posterior column of the tibial plateau (medial, lateral, or both,
respectively)1.

Treatment for posterior column fractures has changed significantly during the last decade. Since
the first posterior approach descriptions by Galla2, Lobenhoffer and Tscherne3, and more
recently with the application of the three column concept4, surgeons have become more
confident performing exposures and treatment of posterior fracture variants.

Many surgeons are cautious about using the transfibular approach due to the concerns about
iatrogenic injury to the peroneal nerve and complications related to the fibular neck osteotomy.

However, in some fracture patterns with posterolateral articular displacement, the transfibular
approach can be the best option to achieve joint surface visualization and accurate fracture
reduction, thereby diminishing posttraumatic arthritis risk.

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The present study aims to evaluate complication rates related to the transfibular approach for
posterolateral fractures of the tibial plateau. We evaluated peroneal nerve palsy, knee
instability, nonunion, and malunion of the fibular osteotomy site.

Ethical approval was granted by the local ethics committee.

Patients and Methods

From January, 2013 to October 2014, 11 patients underwent transfibular approach for
posterolateral fractures. All surgeries were performed in one university hospital by
experienced fracture surgeons. Two patients did not return for regular follow-up and were
excluded from the study.

All fractures were classified using both Schatzker and the three-column classification systems4.

Age average, gender, injury mechanism, Schatzker and Luo classifications are shown in table 1.

All patients treated with transfibular approach were followed in outpatient clinic with
regular clinical and x-ray evaluation.

American Knee Society Score and American Knee Society Score/Function were used to verify
treatment outcomes.

Follow-up average was 16 months (12-21 months, SD:3).

All patients had standard anteroposterior and lateral radiographs.

Fracture and osteotomy union were defined as bridged cortices on two radiographic
planes and full weight bearing without pain.

Statistical analysis was conducted using SPSS with a confidence interval at 95%.

Surgical Technique

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Depending on concomitant anteromedial, anterolateral, or posteromedial
fractures, the patient was placed either in a prone or a lateral decubitus position. Either a
general or spinal anesthesia was utilized, and prophylactic antiobiotics were administered.
A tourniquet was used routinely. A ten centimeter posterolateral approach was performed using
the fibular head as a landmark. The incision starts approximately 3 cm proximal to the fibular
head and extended approximately 5-7 cm distally. The peroneal nerve was carefully identified
and gently protected with a number 2 Penrose drain during the entire procedure.

After identifying and protecting the nerve, the fibular head was drilled with a 2.5mm
intramedullary drill, starting at the proximal tip of the fibular head and directed distally into the
intramedullary canal, facilitating later screw fixation of the osteotomy. A 1.5mm Kirschner wire
was placed lateral at least 2 cm distal to the proximal tip of the fibula to mark the apex of the
chevron osteotomy and protect the peroneal nerve crossing below. A small oscillating saw was
used to cut the chevron osteotomy. Copious irrigation was utilized to avoid excessive heat
generation. Small, thin osteotomes are used to complete the osteotomy without increasing bone
removal at the level of the bone cut. The osteotomized fibular head is then retracted proximally.

A standard lateral arthrotomy was performed with submeniscal arthrotomy to allow articular
surface visualization and reduction. Standard reduction techniques including bone grafting were
used.

For posterolateral fixation, we routinely utlilize a horizontal rafting technique, previously

described by Bermudes and Ziran5 (Figures 1 and 2). This treatment method is even
particularly helpful for associated posterolateral and anterolateral fracture patterns6.

If necessary, standard buttress plates in antiglide position can be added to achieve stable
fixation. The fibular osteotomy is typically stabilized using an intramedullary 3.5mm or
4.5mm extra long screw with a washer. If necessary, suture of the tibiofibular proximal
ligaments is performed.

The standard postoperative regimen included early range of motion and muscle strengthening
immediately after surgical wound healing. Patients are not allowed to bear body weight for 10-

5
12 weeks. Following this time, partial weight bearing is allowed and rapidly advanced to full
weight bearing as tolerated by the patients.

Results

All fractures were healed at the final imaging. No patients at final follow up developed
symptomatic nonunion or malunion of the fibular osteotomy. One patient lost reduction at the
fibular ostetotomy and required revision surgery (Figures 3 and 4)

No leg-length discrepancies were noted. One patient presented knee with varus
malalignment of 10 degrees in the operated limb and had poor functional outcome. The
American Knee Society Score was good in 7 patients (77.8%), fair in 1 (11.1%), and poor in 1
(11.1%; the varus malalignment patient). Average AKSS/Function was 80 points (60-100;
SD:11).

No patients had symptomatic knee instability, and there were no peroneal nerve palsies. No
patients developed superficial or deep infections.

There was no association between Schatzker Classification and AKSS (P=0.480) and Schatzker
Classification and AKSS/Function (P=0.076).

In addition, there was no association between Luo Classification with AKSS and with
AKSS/Function. (P= 0.323 and P= 0.526, respectively).

Finally, there was no association neither between age with AKSS nor with
AKSS/Function (P= 0.200 and P= 0.312, respectively). However, in light of the small sample
size, these statistical findings must be interpreted with caution.

Discussion

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Approaches to the surgical exposure of tibial plateau fractures have evolved from anterior
extensile exposure to more soft tissue friendly fragment specific approaches. These approaches
provide more direct visualization of fracture reduction and more precise buttress application.
Posterior approaches have become an important part of complex plateau fracture management
involving the posterior column of the articular surface4. Lobenhoffer7 developed a
posteromedial approach for posteromedial condylar fracture dislocations. This approach is
simple and safe and allows direct fracture reduction and simple application of a precise buttress
plate.

Similarly, Carlso8 described posterolateral and posteromedial approaches with the patient in
prone position for posterior column fractures. For posterior bicondylar patterns,
Bhattacharyya et al9 described a single posterior approach.

Although some authors have proposed assessing the posteromedial and posterolateral
elements through a single posteromedial approach9, this procedure is technically demanding and
carries risk of iatrogenic vascular injury due to necessary traction for visualization.

While these posterior approaches have significantly simplified exposure for specific
posteromedial and posterolateral fracture patterns, some posterior patterns, particularly in
the posterolateral part of the joint, are still challenging.

Addressing the complicated posterolateral patterns, Frosch et al10 described the anterolateral
and posterolateral arthrotomy approach without fibular osteotomy.

With the patient laterally positioned, a single laterally based incision allows for fracture
reduction and fixation.

In contrast, Solomon et al11 presented their lateral exposure using fibular osteotomy.
This approach enables treating complex anterolateral and posterolateral fractures using double
anti-glide plates. Potential complications related to this technique include peroneal nerve palsy
and fibular nonunion which were not reported in their series.

7
An additional and potentially less morbid method for posterolateral exposure was described by
Yu et al12 and requires partial fibular head ostectomy, preserving lateral collateral ligament to
prevent knee instability. The resected fibular head bone can subsequently be used as bone
graft to support depressed articular fragments.

Despite the variety of options available for posterolateral exposure, there are still fracture
patterns, particularly fracture patterns involving the posterolateral articular surface adjacent to
the proximal fibular articulation that are best visualized using a transfibular osteotomy. Still,
surgeons remain wary of transfibular approaches and the possibility for problematic
complications like peroneal nerve injury or osteotomy healing.

There are no reports in the literature specifically focused on complications of the transfibular
approach. In the present case series, only one patient lost osteotomy fixation. In this case, simple
revision was successfully performed by placement of a longer screw. No peroneal nerve
palsies, malunions, nounions at the osteotomy site, or symptomatic posterolateral instability
were seen in this series.

Based on our experience with the transfibular approach, we recommend:

1- Making a long incision with low threshold for proximal extension to facilitate
location and dissection of the peroneal nerve proximally and to limit excessive traction.

2- Pre-drilling the fibula prior to osteotomy, facilitating screw placement for osteotomy
fixation.

3- Placing Kirschner wire marking the inferior limit of the fibular osteotomy to prevent nerve
damage during the osteotomy and serve as a reference

point for the chevron osteotomy.

4- Utilizing a chevron osteotomy technique for better bone contact, compression, and stability.

5- Stabilizing the fibular osteotomy with an extra long 3.5mm or 4.5mm cortex screw
(based on intramedullary canal diameter) with a washer. Screws shorter than 80mm must be

8
avoided due to risk of reduction loss. Larger diameter screw designs can cause iatrogenic
fracture.

6- Maintaining reduction of the tibiofibular joint with a periarticular clamp during repair of
tibiofibular ligaments.

Conclusion

This series demonstrates that the transfibular approach can be an effective and safe
procedure for the treatment of posterolateral fractures of the tibial plateau. Despite the potential
complications associated with the transfibular approach, such as peroneal nerve palsy and
fibular osteotomy nonunion, simple techniques can prevent them. Westrongly recommend
careful dissection and visualization of the peroneal nerve and fixation of the fibular osteotomy
with a 3.5mm or 4.5mm extra long cortex screw to prevent nerve injury and osteotomy
nonunion.

The primary benefit of this technique is optimal joint visualization allowing for anatomical
reduction. A larger prospective study would likely help determine the true complication rates
of this procedure and verify its safety and utility.

References

1. Yang G1, Zhai Q, Zhu Y, Sun H, Putnis S, Luo C. The incidence of posterior
tibial plateau fracture: an investigation of 525 fractures by using a CT-based classification
system. Arch Orthop Trauma Surg. 2013 Jul;133(7):929–34.

2. Galla M, Lobenhoffer P. Der direkte dorsale Zugangsweg zur Versorgung

posteromedialer Luxationsfrakturen des Tibiakopfes. Der Unfallchirurg. 2003 Mar
1;106(3):241–7.

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3. Tscherne H, Lobenhoffer P. Tibial Plateau Fractures: Management and Expected
Results. Clin Orthop Relat Res. 1993 Jul 1;292:87.

4. Luo C-F, Sun H, Zhang B, Zeng B-F. Three-column fixation for complex

tibial plateau fractures. Journal of Orthopaedic Trauma. 2010

Nov;24(11):683–92.

5. Bermúdez CA, Ziran BH, Barrette-Grischow M-K. Use of Horizontal Rafting Plates for
Posterior Elements of Complex Tibial Plateau Fractures: Description and Case Reports.
The Journal of Trauma: Injury, Infection, and Critical Care. 2008 Nov;65(5):1162–7.

6. Pires RES, Giordano V, Santos Dos JK, Labronici PJ, de Andrade MAP, de Toledo
Lourenço PRB. Expanding indications of the horizontal belt plate: A technical note. Injury.
Elsevier; 2015 Oct;46(10):2059–63.

7. Fakler JKM, Ryzewicz M, Hartshorn C, Morgan SJ, Stahel PF, Smith WR. Optimizing
the management of Moore type I postero-medial split fracture dislocations of the tibial head:
description of the Lobenhoffer approach. Journal of Orthopaedic Trauma. 2007May;21(5):330–
6.

8. Carlson DA. Bicondylar Fracture of the Posterior Aspect of the Tibial Plateau. A
Case Report and a Modified Operative Approach. J Bone Joint Surg Am. 1998 Jul;80(7):1049-
52.

9. Bhattacharyya T, McCarty LP, Harris MB, Morrison SM, Wixted JJ, Vrahas MS, et al.
The posterior shearing tibial plateau fracture: treatment and results via a posterior approach.
Journal of Orthopaedic Trauma. 2005 May;19(5):305–10.

10. Frosch K-H, Balcarek P, Walde T, Stürmer KM. A new posterolateral approach
without fibula osteotomy for the treatment of tibial plateau fractures. Journal of
Orthopaedic Trauma. 2010 Aug;24(8):515–20.

11. Solomon LB, Stevenson AW, Lee YC, Baird RPV, Howie DW.

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Posterolateral and anterolateral approaches to unicondylar posterolateral tibial plateau
fractures: A comparative study. Injury. Elsevier Ltd; 2013 Jun 15;:1–8.

12. 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. The Knee. 2010
Oct;17(5):313–8.

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Table 1: Age average, gender, injury mechanism, Schatzker and Luo classifications

Figure 1: Illustration of the posterolateral corner of the tibial plateau showing the
horizontal rafting plate. Observe the peroneal nerve crossing the fibular neck. Dashed
line shows the chevron osteotomy. An extra long screw was used to fix the fibular
osteotomy.

Figure 2: Posterolateral fracture of the tibial plateau. A and B: 3D CT-scan showing the
posterolateral fracture of the tibial plateau. C: CT-scan in sagittal view showing the
posterolateral shearing tibial plateau fracture. D and E: Anteroposterior and lateral
views of the postoperative images showing fracture fixation with the horizontal rafting
plate and intramedullary fixation of the fibular osteotomy with a 3.5mm cortical extra
long screw. F: Preoperative image showing: LM (lateral meniscus); FH (fibular head);
PN (peroneal nerve); KW (Kirschner wire). H: Preoperative image showing fracture
reduction and internal fixation with the 2.7mm horizontal rafting plate (LM: lateral
meniscus; FH: fibular head; PN: peroneal nerve).

Figure 3: A 42-year-old patient sustained a split depression fracture of the lateral tibial
plateau. A and B: X-ray in anteroposterior and lateral views showing the Type 2
fracture. C and D: CT-scan with 3D reconstruction showing fracture of the anterolateral
and posterolateral elements of the tibial plateau. E: CT-scan in coronal view showing
important sinking. F and G: Postoperative images in anteroposterior and lateral views
showing fracture reduction and internal fixation with horizontal rafting plate. Observe the
fibular neck osteotomy fixed with a short 3.5mm cortical screw.

Figure 4: A and B: X-ray in anteroposterior and lateral views showing loss of the initial
reduction at the fibular osteotomy. C and D: X-ray in anteroposterior and lateral views
showing surgery revision replacing the screw with a longer one. E and F: Postoperative
images after 2 months showing complete range of motion of the fractured knee.

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Table 1

Patients Gender Age Injury mechanism Schatzker Luo Classification

Classification

1 Male 35 Motorcycle II Posterior + anterolateral

columns (Flexion/Valgus)
accident

2 Female 53 Fall II Posterior + anterolateral

columns (Flexion/Valgus)

3 Female 22 Fall V Posterior + anterolateral +

anteromedial columns
(Flexion/Neutral)

4 Female 49 Fall II Posterior + anterolateral

columns (Flexion/Valgus)

14 +
Posterior + anterolateral
5 Male 24 Motorcycle V anteromedial columns
accident (Flexion/Neutral)
6 Male 19 Fall II Posterior column
(Flexion/Valgus)

7 Male 42 Fall II Posterior column

(Flexion/Valgus)

8 Male 55 Fall V Posterior + anterolateral +

anteromedial columns
(Flexion/Neutral)

9 Male 45 Fall I Posterior column

(Flexion/Valgus)

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