Staged Prone/Supine Fixation of High-Energy Multicolumnar Tibial Plateau Fractures: A Multicenter Analysis

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Purpose:We present a surgical strategy to manage multicolumnar tibial plateau fracture variants by addressing the predominant posterior fragment employing a Lobenhoffer approach in the prone position followed by supine patient repositioning for anterolateral column access.Design:Multicenter retrospective analysis.Setting:Three academic Level 1 trauma centers.Patients/Methods:Twenty-eight cases (28 patients/28 knees) met inclusion criteria between 2003 and 2014. Patient demographic information was retrospectively reviewed with a mean follow-up time of 16.6 months (range 12–34 months). Postoperative radiographic analysis, physical examination findings, and patient outcome scores from the Knee Injury and Osteoarthritis Outcome Score questionnaire were recorded.Results:The average time to union was 3.6 months (range 3–9 months). Eighty-two percent of patients had satisfactory articular reduction (less than 2 mm articular step off). All patients demonstrated satisfactory coronal (medial proximal tibia angle 87 ± 5 degrees) and sagittal alignment (posterior proximal tibia angle 9 ± 4 degrees). Condylar width averaged 2.2 mm. Twenty percent of cases required posterior lateral columnar plating (in addition to posterior medial columnar plating), with none of these cases requiring an extensile exposure modification (medial gastrocnemius origin detachment) to expose posterior laterally. In 12 cases, the posterior approach was staged to allow for anterior soft tissue recovery before subsequent staged supine positioning and lateral column fixation. The knee range of motion averaged 123 degrees (ranged from 2 degrees of extension to 125 degrees flexion). The average Knee Injury and Osteoarthritis Outcome Score was 78/100 (range 29–95). Eleven percent of the patients in the series developed a surgical site infection (n = 3) with 2 requiring formal irrigation and debridement. The most common aseptic complication was radiographic posttraumatic arthrosis (18%). Clinically, 1 patient eventually required a total knee arthroplasty.Conclusions:High-energy multicolumnar tibial plateau fractures with significant posterior articular surface involvement may be predictably addressed with prone positioning, exposure, and fixation followed by supine repositioning and the inclusion of an anterior approach. This study demonstrates excellent postoperative radiographic results and acceptable clinical outcomes resulting from the described staged protocol.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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