Anatomical and Clinical Rationale for Posterolateral Transfibular Approach for Internal Fixation of the Posterolateral Column of the Tibial Plateau

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Purpose of the study — to provide an anatomical rationale and evaluate the clinical application of posterolateral surgical approach with osteotomy of the fibular head for internal fixation of the posterior aspect of the lateral tibial condyle. Material and Methods. Anatomical topography research was performed on 14 lower limbs of 8 fresh cadavers. In the first series of research L-shaped plate was fixed on the posterolateral surface of lateral tibial condyle from the examined approach, then preparation was performed and measuring of distances from various parts of the plates to the common peroneal nerve and anterior tibial artery. In the second series the authors prepared histological topograms by transverse sectioning of plastinated specimens from the knee joint area after implantation of L-shaped buttress plates. Prospective observation clinical study included 20 patients who underwent internal fixation with L-shaped buttress plate from the examined approach for fracture of the posterolateral column of the tibial plateau, type 41В by AO classification. KSS and Lysholm scales were used to evaluate treatment outcomes at days 7–10 and in 1, 3, 6 and 9 months postoperatively. Data of the anatomical and clinical research was compared. Results. Compliance with the technique of posterolateral transfibular surgical approach allows to avoid risk of injury to the common peroneal nerve and anterior tibial arthery which on the specimen were always located safely away from implanted plates. All 20 clinical cases demonstrated good visualization of bone fragments and articular surface of the tibial plateau which ensured reliable reduction and fixation by L-shaped buttress plate. KSS excellent and good outcome scores amounted to 50% and 45%, respectively, while satisfactory score was reported in 5% of cases; Lysholm scale demonstrated 55% of excellent outcomes, 45% of good outcomes, and 5% of satisfactory outcomes. Safety of the approach was verified: no injuries to large blood vessels or iatrogenic neuropathies were reported as well as no large hematomas or infectious complications of the surgical wound in early postoperative period. Conclusion. Results of the present study proved the feasibility and safety of the posterolateral transfibular surgical approach for internal fixation procedures in patients with intraarticular fractures of posterolateral column of the tibial plateau.

About the authors

A. Yu. Kochish

Russian Vreden Scientific Research Institute of Traumatology and Orthopaedics,
Kirov Military Medical Academy

Author for correspondence.

Dr. Sci. (Med.), Professor, Deputy Director for Science and Education; Professor, Department of Operative Surgery and Topographic Anatomy

St. Petersburg

Russian Federation

M. A. Kislitsyn

Semashko City Hospital No. 38


Orthopedic Surgeon

St. Petersburg

Russian Federation

I. G. Belen’kii

Pavlov First St. Petersburg State Medical University


Dr. Sci. (Med.), Associate Professor Department of Traumatology and Orthopedics


Russian Federation

B. A. Mayorov

Vsevolozhsk Clinical Interdistrict Hospital,
Pavlov First St. Petersburg State Medical University


Cand. Sci. (Med.), Head of Department of Traumatology and Orthopaedics; Assistant, Department of Traumatology and Orthopedics

St. Petersburg

Russian Federation

D. A. Starchik

Mechnikov North-West State Medical University,
Pavlov First St. Petersburg State Medical University


Dr. Sci. (Med), Professor, Head of Human Morphology Department; Professor, Department of Clinical Anatomy and Operative Surgery

St. Petersburg

Russian Federation


  1. Шаповалов В.М., Хоминец В.В., Рикун О.В., Гладков Р.В. Хирургическое лечение переломов мыщелков большеберцовой кости. Травматология и ортопедия России. 2011;(1):53-60.
  2. Беленький И.Г., Кочиш А.Ю., Кислицын М.А. Переломы мыщелков большеберцовой кости: современные подходы к лечению и хирургические доступы (обзор литературы). Гений ортопедии. 2016;4:114-122.
  3. Yang G., 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;133(7):929-934. doi: 10.1007/s00402-013-1735-4.
  4. Zhu Y., Yang G., Luo C.F., Smith W.R., Hu C.F., Gao H., Zhong B., Zeng B.F. Computed tomography-based Three-Column Classification in tibial plateau fractures: introduction of its utility and assessment of its reproducibility. J Trauma Acute Care Surg. 2012;73(3):731-737. doi: 10.1097/TA.0b013e31825c17e7.
  5. Sohn H.S., Yoon Y.C., Cho J.W., Cho W.T., Oh C.W., Oh J.K. Incidence and fracture morphology of posterolateral fragments in lateral and bicondylar tibial plateau fractures. J Orthop Trauma. 2015;29(2): 91-97. doi: 10.1097/BOT.0000000000000170.
  6. Schatzker J. The rationale of operative fracture care. Berlin ; New York : Springer-Verlag; 1987. pp. 279-295.
  7. Chang S.M., Hu S.J., Zhang Y.Q., Yao M.W., Ma Z., Wang X. et al. A surgical protocol for bicondylar four-quadrant tibial plateau fractures. Int Orthop. 2014;38(12):2559-2564. doi: 10.1007/s00264-014-2487-7.
  8. Luo C.F., Sun H., Zhang B., Zeng B.F. Threecolumn fixation for complex tibial plateau fractures. J Orthop Trauma. 2010;24(11):683-692. doi: 10.1097/BOT.0b013e3181d436f3.
  9. Kfuri M., Schatzker J. Revisiting the Schatzker classification of tibial plateau fractures. Injury. 2018;49(12): 2252-2263. doi: 10.1016/j.injury.2018.11.010.
  10. Zhu Y., Hu C.F., Yang G., Cheng D., Luo C.F. Interobserver reliability assessment of the Schatzker, AO / OTA and three-column classification of tibial plateau fractures. J Trauma Manag Outcomes. 2013;7(1):7. doi: 10.1186/1752-2897-7-7.
  11. Yao X., Xu Y., Yuan J., Lv B., Fu X., Wang L. et al. Classification of tibia plateau fracture according to the “fourcolumn and nine-segment”. Injury. 2018;49(12): 2275-2283. doi: 10.1016/j.injury.2018.09.031.
  12. Lin K.C., Y.W. Tarng, G.Y. Lin, S.W. Yang, C.J. Hsu, RennJ.H. Prone and direct posterior approach for management of posterior column tibial plateau fractures. Orthop Traumatol Surg Res. 2015;101(4):477-482. doi: 10.1016/j.otsr.2014.12.021.
  13. Gavaskar A.S., Gopalan H., Tummala N.C., Srinivasan P. The extended posterolateral approach for split depression lateral tibial plateau fractures extending into the posterior column: 2 years follow up results of a prospective study. Injury. 2016;47(7):1497-1500. doi: 10.1016/j.injury.2016.04.021.
  14. Lobenhoffer P. Posterolateral transfibular approach to tibial plateau fractures. J Orthop Trauma. 2011;25(3):e31. author reply e31. doi: 10.1097/BOT.0b013e31820b809a.
  15. Sun H., Zhai Q.L., Xu Y.F., Wang Y.K., Luo C.F., Zhang C.Q. Combined approaches for fixation of Schatzker type II tibial plateau fractures involving the posterolateral column: a prospective observational cohort study. Arch Orthop Trauma Surg. 2015;135(2): 209-221. doi: 10.1007/s00402-014-2131-4.
  16. Sun H., Luo C.F., Yang G., Shi H.P., Zeng B.F. Anatomical evaluation of the modified posterolateral approach for posterolateral tibial plateau fracture. Eur J Orthop Surg Traumatol. 2013;23(7):809-818. doi: 10.1007/s00590-012-1067-z.
  17. Kettelkamp D.B., Chao E.Y. A method for quantitative analysis of medial and lateral compression forces at the knee during standing. Clin Orthop Relat Res. 1972;83: 202-213. doi: 10.1097/00003086-197203000-00037.
  18. Tegner Y., Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res. 1985;(198): 43-49.
  19. Старчик Д.А. Методические основы пластинации распилов тела. Морфология. 2015;(4):56-61.
  20. Heidari N., Lidder S., Grechenig W., Tesch N.P., Weinberg A.M. The risk of injury to the anterior tibial artery in the posterolateral approach to the tibia plateau: a cadaver study. J Orthop Trauma. 2013;27(4):221-225. doi: 10.1097/BOT.0b013e318271f8f0.
  21. Chu X., Liu X., Chen W., Gao J., Luo Y., Zhu J. et al. [Clinical study on treatment of posterolateral fracture of tibial plateau via superior fibular head approach]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2013;27(2):155-159. (In Chinese).
  22. Solomon L.B., Stevenson A.W., Baird R.P., Pohl A.P. Posterolateral transfibular approach to tibial plateau fractures. J Orthop Trauma. 2010;24:505-514. doi: 10.1097/BOT.0b013e3181ccba4b.
  23. Pires R.E., Giordano V., Wajnsztejn A., Oliveira Santana E.J., Pesantez R., Lee M.A., de Andrade M.A. Complications and outcomes of the transfibular approach for posterolateral fractures of the tibial plateau. Injury. 2016;47(10):2320-2325. doi: 10.1016/j.injury.2016.07.010.
  24. Кутепов С.М., Волокитина Е.А., Гилев М.В., Антониади Ю.В. Хирургическое лечение двухмыщелковых переломов большеберцовой кости. Травматология и ортопедия России. 2017;23(1):81-88.
  25. Frosch K.H., Balcarek P., Walde T., Stürmer K.M. A new posterolateral approach without fibula osteotomy for the treatment of tibial plateau fractures. J Orthop Trauma. 2010;24(8):515-520. doi: 10.1097/BOT.0b013e3181e5e17d.
  26. Solomon L.B., Stevenson A.W., Lee Y.C., Baird R.P., Howie D.W. Posterolateral and anterolateral approaches to unicondylar posterolateral tibial plateau fractures: a comparative study. Injury. 2013;44:1561-1568. doi: 10.1016/j.injury.2013.04.024.



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