[Combined surgical approaches in the treatment of complex tibial plateau fractures].

OBJECTIVE: To explore the early clinical efficacy of a posteromedial inverted "L" shape approach combined an assisted antero lateral assisted approach for the treatment of complex fractures of tibial plateau.

METHODS: From March 2011 to June 2014, the posteromedial inverted "L" shape approach combined with the antero lateral assisted approach in the treatment of Schatzker type IV, V, VI tibial plateau fracture were performed in 34 cases. There were 23 males and 11 females, ranging in age from18 to 67 years old, averaged 34.9 years old; 19 patients had fractures on the left and 15 patients had fractures on the right. According to Schatzker classification, 11 cases of type IV, 15 cases of type V and 8 cases of type VI. According to the three column classification, 23 cases of double column fractures, 11 cases of three column fractures. The X-ray healing time and knee joint mobility were recorded. The mean tibial plateau angle(TPA) and the mean posterior slope angle (PA) were measured and recorded immediately after operation, 6 and 12 months after operation. The knee function was evaluated using the Hospital for Special Surgery Score(HSS) 3, 6 and 12 months after operation.

RESULTS: Among all the patients, 28 patients were followed up, and the duration time ranged from 8 to 39 months with a mean of(21.6±8.7) months. All the fractures were healed. The healing time in terms of X-ray ranged from 12 to 24 weeks, with a mean of (14.5±3.6) weeks. The range of knee activity ranged from 105° to 135°, with a mean of (121.5±5.5)°. Immediately after operation, 6 and 12 months after operation, the mean tibial plateau angle (TPA) was (84.3±1.8)°, (85.1±1.3)°, (85.6±1.6)°, and the mean posterior slope angle (PA) was (7.8±1.6)°, (7.8±1.3)°, (7.7±2.3)°, respectively, showing no significant difference between the 3 time points. The mean HSS score at 3, 6 and 12 months after operation was 71.4±1.4, 76.7±1.7, 81.6±1.2 respectively, showing no significant differences between the 3 time points. One patient with early knee joint stiffness had 6° of the restricted straight range after the active functional exercise, 1 year after operation. Anterolateral wound dehiscence occurred in 1 cases but was cured by dressing without deep wound infection occurred. The pain occurred in 4 cases when the weather changed. At the end of follow-up, no case of knee joint instability, knee valgus, loosening or breakage occurred.

CONCLUSIONS: The posteromedial inverted "L" shape approach combined assisted anterior lateral approach for the treatment of complex fractures of tibial plateau can expose the operation area, repair the fracture under the direct vision, and implant a full amount of bone graft for the collapse of the platform.Thus, the smoothness of the articular surface is restored, and the fixation is firm, which is beneficial to the early functional exercise, less complications, and satisfactory clinical curative effects.