Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
Arch Orthop Trauma Surg. 2019 Oct;139(10):1369-1377. doi: 10.1007/s00402-019-03200-z. Epub 2019 May 17.
The correct choice of a fracture-specific surgical approach with an articular accessibility in complex tibial plateau fractures to facilitate durable fracture fixation of the anatomic articular reconstruction is under debate, as the most important risk factor for malreduction in complex tibial plateau fractures is an impaired visualization of the articular surface.
Six established surgical approaches were simulated on 12 cadaver knees. The visible articular surface was labeled with an electrocautery device for each approach and subsequently analyzed with ImageJ. Areas of each hemiplateau were compared using the Student's t test.
In the lateral tibial plateau, the dorsal 19.0 ± 5.8% of the articular surface could be exposed via the postero-lateral approach. Via the antero-lateral arthrotomy, 36.6 ± 9.4% of the anterior articular surface was visible. The additional osteotomy of the lateral femoral epicondyle significantly increased the exposure to 65.6 ± 7.7% (p < 0.001). In the medial tibial plateau, the osteotomy of the medial femoral epicondyle significantly improved visualization of the medial articular surface (62.3 ± 8.6%) compared to the postero-medial approach (14.0 ± 7.3%) and the antero-medial approach (36.9 ± 9.2%) of the articular (p < 0.001).
Visualization of the tibial articular surface is limited through specific surgical approaches. Extension by osteotomy of the femoral epicondyle led to a significant improvement in the articular exposure without, however, obtaining sufficient visibility of the posterior joint segments, which should be included in the preoperative strategy. The proposed surgical approach-specific map of the tibial plateau may constitute an important instrument in the toolbox of an experienced surgeon to treat complex tibial plateau fractures at the highest level.
Level IV.
在复杂胫骨平台骨折中，正确选择一种具有关节可达性的骨折特异性手术入路，以促进解剖关节重建的持久骨折固定，这是有争议的，因为复杂胫骨平台骨折复位不良的最重要危险因素是关节面的可视性受损。
在 12 个尸体膝关节上模拟了 6 种已确立的手术入路。对每种入路的关节表面进行电灼标记，然后用 ImageJ 进行分析。使用 Student's t 检验比较每个半板的面积。
在外侧胫骨平台，后外侧入路可暴露关节表面的背侧 19.0±5.8%。通过前外侧关节切开术，可观察到前关节面的 36.6±9.4%。外侧股骨髁的附加截骨术显著增加了暴露面积，达到 65.6±7.7%（p<0.001）。在内侧胫骨平台，内侧股骨髁截骨术显著改善了内侧关节面的可视化（62.3±8.6%），与后内侧入路（14.0±7.3%）和前内侧入路（36.9±9.2%）相比（p<0.001）。
通过特定的手术入路，胫骨关节面的可视化受到限制。通过股骨髁截骨术的扩展，关节暴露得到了显著改善，但并未获得后关节段的充分可见性，这应包含在术前策略中。提出的胫骨平台特定手术入路图可能成为经验丰富的外科医生工具箱中的一个重要工具，以最高水平治疗复杂胫骨平台骨折。
IV 级。
