Anterolateral Approach to the Proximal Tibia (Lateral Tibial Plateau)

What it exposes. The anterolateral approach gives direct access to the lateral tibial plateau and the anterolateral proximal tibial metaphysis. It is the workhorse exposure for the majority of lateral column tibial plateau fractures (Schatzker I, II and III), allowing placement of a buttress plate on the anterolateral surface and a submeniscal arthrotomy for direct visualisation of the articular surface. Why this approach (and not another). Lateral split and split-depression fragments displace with valgus and axial load, and a buttress plate on the anterolateral cortex counters exactly those forces. Submeniscal arthrotomy confirms anatomic reduction (goal less than 2 mm step-off). This approach cannot address posterolateral or medial column fragments, which need their own approaches. Indications. - Schatzker Type I (pure lateral split), Type II (lateral split-depression, the commonest indication) and Type III (pure lateral depression)

• Lateral buttress plating for valgus instability
• Elevation of depressed articular segments with bone grafting
• Revision surgery for malreduced lateral plateau fractures Contraindications. - Isolated medial or posteromedial fractures (use an anteromedial or posteromedial approach)
• Severe soft-tissue compromise over the lateral knee (delayed surgery or an alternative approach)
• Medical unfitness for supine positioning with knee flexion
• Active infection Alternative approaches and the three-column concept. The proximal tibia is planned by the three-column concept (lateral, medial and posterior columns): the anterolateral approach addresses the lateral column, while the medial column needs an anteromedial approach and the posterior column (posteromedial or posterolateral fragments) needs posteromedial or posterolateral approaches. An extended lateral approach with fibular neck osteotomy is reserved for complex bicondylar fractures requiring combined access. Position & landmarks. Supine on a radiolucent table with a small bump under the ipsilateral hip to internally rotate the limb, and the knee flexed 30-40 degrees over a radiolucent triangle to relax the posterior capsule. The C-arm comes from the contralateral side. Palpate and mark Gerdy's tubercle (the anterolateral ITB insertion), the fibular head (the key landmark for the common peroneal nerve), the lateral joint line, the tibial crest, and the patella and patellar tendon (the medial boundary of the incision).

Work down through the layers over Gerdy's tubercle: incise the iliotibial band, elevate the anterior compartment subperiosteally off the lateral metaphysis (stopping short of the anterior tibial vessels), then open a submeniscal arthrotomy to see the joint.

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Structures at risk, by layer

Internervous plane. The theoretical internervous plane is between the anterior compartment (tibialis anterior, deep peroneal nerve) and the lateral compartment (peroneus longus, superficial peroneal nerve). In practice, no true intermuscular plane is developed — instead the entire anterior compartment is elevated subperiosteally as a unit off the lateral metaphysis, staying anterior to the fibular head and the lateral collateral ligament. The recurrent genicular vessels are usually ligated, and the ITB insertion at Gerdy's tubercle may be partially released for exposure. Muscular layers crossed

Extensile options. Extend proximally along the lateral border of the patella into a lateral parapatellar arthrotomy for intra-articular access (or with a tibial tubercle osteotomy). Extend distally along the anterior compartment fascia for more distal metaphyseal or diaphyseal work, stopping short of the anterior tibial artery unless the vessels are identified and protected. For bicondylar fractures, combine with an anteromedial approach (same supine position) or a posteromedial or posterolateral approach (staged, repositioning to prone or lateral decubitus). A fibular neck osteotomy is reserved for the rare case needing posterolateral access through a single extended lateral incision. Closure. Layered: repair the coronary ligament with absorbable suture (2-0 or 3-0 Vicryl), repair any ITB release or retinaculum, close the anterior compartment fascia loosely (some surgeons leave it open proximally), close subcutaneous tissue in layers to eliminate dead space, and close skin with staples, nylon or absorbable subcuticular suture. Document CPN function before leaving theatre; check compartment pressures if there is concern (especially after prolonged surgery or tourniquet use). A drain is rarely required but, if used, is removed within 24-48 hours. Complications - Intraoperative: common peroneal nerve injury (3-5 percent), anterior tibial artery injury, inadequate reduction (greater than 2 mm step-off), intra-articular hardware placement.

• Early postoperative: wound dehiscence or infection (2-5 percent, higher with soft-tissue compromise), compartment syndrome (rare but possible after anterior compartment elevation), deep vein thrombosis, loss of reduction if fixation is inadequate.
• Late: post-traumatic osteoarthritis (20-40 percent long-term), knee stiffness (early ROM is essential), nonunion or malunion (less than 5 percent with proper technique), hardware prominence requiring removal.
• Failure management: early loss of reduction is managed with revision ORIF and bone grafting; infection with debridement, antibiotics and possible staged revision; established post-traumatic OA with arthroplasty in older patients or osteotomy in younger patients.

• Tibial plateau ORIF — open reduction and internal fixation of lateral plateau fractures (Schatzker I-III) is the principal operation through this exposure.
• Lateral buttress plating for split and split-depression patterns, and elevation of depressed articular segments with bone grafting of the metaphyseal void.
• Submeniscal arthrotomy with direct articular inspection, plus lateral meniscal repair or partial meniscectomy if indicated. Fixation options. A contoured 3.5 mm buttress plate (T-plate, L-plate or anatomic proximal tibia plate) is applied to the anterolateral surface just distal to the joint line, with non-locking screws placed first to achieve the buttress effect and locking screws added for osteoporotic bone or comminution. Independent lag screws fix the split component, and bone graft or a bone graft substitute fills the metaphyseal void. Screws are directed medially and posteriorly. Reduction technique. Reduce the lateral split component with pointed or large pelvic reduction clamps; elevate depressed fragments with a bone tamp or elevator through a metaphyseal window or via the fracture line; support the elevated fragment with graft; and confirm reduction through the arthrotomy and on fluoroscopy (AP, lateral and oblique views). The goal is less than 2 mm articular step-off and restoration of tibial plateau width. Postoperative protocol and outcomes. A hinged knee brace locked in extension is applied; the patient is non-weight-bearing or toe-touch for the first weeks, with gentle ROM (0-90 degrees) once the wound is stable, progressing toward 0-120 degrees by 6 weeks, and progressive weight-bearing to full by 10-12 weeks. Radiographs are taken at 2, 6 and 12 weeks, then at 6 and 12 months (CT if reduction or hardware position is in question). Good-to-excellent results occur in 70-85 percent of patients with anatomic reduction (less than 2 mm step-off), which is the strongest predictor of long-term outcome; articular step-off greater than 2 mm and condylar widening greater than 5 mm predict poorer results. Post-traumatic OA leads to arthroplasty in about 5-8 percent within 10 years; the reoperation rate is 10-15 percent (hardware removal, revision, arthroplasty).

Guidelines, registries & global practice. - Epidemiology: lateral tibial plateau fractures account for about 55-65 percent of all tibial plateau fractures worldwide; high-energy mechanisms predominate in younger patients and low-energy falls in the elderly osteoporotic population. The anterolateral approach is the most commonly performed surgical approach for tibial plateau fractures globally.

• AO Foundation / OTA: CT-based three-column analysis for all tibial plateau fractures; anterolateral approach indicated for lateral column involvement with step-off greater than 2 mm or condylar widening greater than 5 mm.
• BOAST (British Orthopaedic Association): soft-tissue assessment (wrinkle test) before definitive fixation; staged management with an external fixator if the soft tissues are compromised.
• AAOS Appropriate Use Criteria: operative fixation for displaced lateral plateau fractures in active patients; non-operative management acceptable for non-displaced fractures or low-demand patients.
• EFORT / European consensus: anatomic reduction (less than 2 mm step-off) and stable fixation to prevent post-traumatic arthritis; buttress plating for split-depression patterns.
• Registry evidence: the NJR (UK), AJRR (US) and AOANJRR (Australia) each show that malreduction increases later arthroplasty risk, with post-traumatic OA after tibial plateau fracture leading to arthroplasty in about 5-8 percent of patients within 10 years; anatomic reduction at index surgery reduces that risk.