INTRODUCTION: Fractures of the proximal tibia requiring treatment from dorsal approaches are uncommon. Nevertheless, they must be anatomically reduced and fixed in a stable manner. We use 3 surgical approaches to treat these fractures: posterolateral, posteromedial and posterior (direct posterocentral or modified posterocentral, as applicable). Individual approaches exist in various modifications. OBJECTIVE: Description of anatomical approaches to the dorsal portion of proximal tibia. To evaluate a cohort of patients treated with these surgical approaches with respect to CT findings of each fracture, choice of surgical approach, timing of surgery, type of fracture stabilization, peri- and postoperative complications, joint surface reduction and stabilization, and functional outcomes following each surgical approach and Lansinger score. METHODOLOGY: A total of 26 patients (19 men and 7 women) who suffered proximal tibia fracture(s) requiring treatment from any of the dorsal approaches alone or in combination with any of the ventral approaches between January 2010 and December 2020 were included in the study. The average age of patients at the time of injury was 45.2 years (33-65 years) for men and 55.5 years (48-63 years) for women. Preoperative CT scan was performed in all patients. In 14 cases there were avulsion fractures of the posterior cruciate ligament (PCL), in 12 cases dislocated fractures of the posterior column of the proximal tibia (these are further divided into isolated posterolateral (PL) fractures, isolated posteromedial (PM) fractures, and combined posterolateral/posteromedial fractures). Posterolateral approach was used in 4 patients, posterior – direct posterocentral – approach in 14 patients, posterior – modified posterocentral – approach in 4 patients and posteromedial approach in 4 patients. PCL avulsion injury was treated in all cases with 1-2 screws, supplemented with washers, if necessary. Isolated posteromedial fractures were treated with plate synthesis or with an individual screw. Isolated posterolateral fractures were treated with single screws. Combined fractures (posterolateral/posteromedial) required a combination of plate osteosynthesis and single screws. RESULTS: The mean range of motion at 48 months was 0/0/130° in patients with isolated dorsal fractures, whereas in patients with combined fractures it was 0/5/120°. The average Lansinger score was 27 for avulsion PCL fractures, 26 for isolated PM fractures, 24 for isolated PL fractures and 22 for combined PM and PL fractures. Anatomical reduction of the articular surface was achieved in all (14) avulsion PCL injuries. Anatomical reduction was achieved in 3 cases (75%) of PM fractures and good reposition was achieved in 1 case (25 %). In the case of PL fractures, good reduction was achieved in 3 cases (75 %) and satisfactory reduction was achieved in 1 case (25 %). In all 4 cases of combined PM/PL fractures, anatomical reduction of PM fragment and good or satisfactory reduction of PL fragment were achieved (1 and 3 cases, respectively). Injuries to neurovascular structures, failure of osteosynthesis or deep infection after dorsal approaches were not reported. CONCLUSION: Dorsal fractures of the proximal tibia need to be treated with one of the dorsal approaches. Each approach has its advantages and disadvantages, which every surgeon dealing with this issue should be informed about. In the case of avulsion PCL fractures, the posterior approach in a form of direct posterocentral approach around the neurovascular bundle has proven reliable. In the case of isolated posteromedial fractures, the posteromedial approach is used. In case of isolated posterolateral fractures, the posterolateral approach is used. In the case of combined dorsal fractures (posteromedial/ posterolateral), on the other hand, a modified posterocentral approach completely outside the neurovascular bundle is recommended.

Ortopedicko traumatologické oddělení Nemocnice Znojmo

Úrazová nemocnice v Brně Klinika traumatologie LF MU Brno

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