Dual-Incision Approach to the Bicondylar Tibial Plateau

What it exposes. The dual-incision approach exposes both columns of a bicondylar tibial plateau through two separate, limited incisions: an anterolateral incision for the lateral split-depression and a posteromedial incision for the medial or posteromedial shear wedge. Both are performed with the patient supine, the leg rotated and the knee flexed to reach each wound, with no repositioning. Why two incisions are used. A bicondylar fracture combines a lateral split-depression (a comminuted joint surface that needs elevation and a lateral locked plate) with a posteromedial or medial shear fragment (a cortically intact wedge that displaces posteriorly and medially under axial load). The posteromedial fragment sits behind the medial collateral ligament and cannot be reduced or buttressed from the anterolateral side. A single lateral locked plate, however strong, allows that fragment to toggle and redisplace because its screws cannot gain purchase behind the medial cortex. A dedicated posteromedial buttress plate is therefore required, and that demands a second incision. A single extensile anterior incision with large subcutaneous flaps carries an unacceptable wound-complication rate, so two separate incisions with a healthy skin bridge is the safe way to expose both columns. Indications. Bicondylar tibial plateau fractures (Schatzker V) with a lateral split-depression plus a separate posteromedial or medial split fragment; Schatzker VI fractures (bicondylar with metaphyseal-diaphyseal dissociation) involving both columns; three-column injuries (lateral, medial and posterior columns) on CT; and any bicondylar fracture where a posteromedial shear fragment cannot be captured by a lateral locked plate alone. Fracture morphology that demands a second incision. A posteromedial fragment displaced greater than 2 mm and not reduced by ligamentotaxis; a fragment that extends posterior to the midpoint of the plateau on axial CT; and any posterior shear pattern in which the fragment translates posteriorly under load. Contraindications and cautions. A compromised soft-tissue envelope, in which case definitive fixation is deferred, a knee-spanning external fixator is applied, and surgery waits for the wrinkle test to become positive; an active infection or open contaminated wound over the planned incisions, when external fixation may become definitive; severe fracture blisters, which must re-epithelialise before incising; and a posteromedial fragment too small to accept a plate, which prompts reconsideration of whether a medial column is needed at all. Alternative approaches. A single lateral locked plate is acceptable when the medial column is cortically continuous and stable, but not for a true posteromedial shear fragment; a single extensile anterior approach is avoided in modern practice because of its high wound-breakdown rate; a posterolateral approach is added when a posterolateral column fragment is present; and circular or spanning external fixation is definitive when soft tissues or comorbidity preclude plating. Position and landmarks. Supine on a radiolucent table, with the C-arm brought in from the contralateral side, an ipsilateral hip bump to level the limb, and the knee flexed over a well-padded bolster to relax the posterior neurovascular bundle and improve posterior access. Anterolateral landmarks are Gerdy's tubercle (the iliotibial band insertion and the key landmark for the lateral incision), the patellar tendon and tibial tubercle (medial border of the incision), the lateral joint line and lateral femoral condyle (proximal extent), and the fibular head (posterior reference, with the common peroneal nerve wrapping its neck). Posteromedial landmarks are the palpable posteromedial border of the proximal tibia (the principal landmark), the medial femoral condyle and medial joint line (proximal extent), the pes anserinus (the conjoined sartorius, gracilis and semitendinosus), and the great saphenous vein running in the superficial fascia just posterior to the tibia. The anterolateral incision runs from just lateral to the patellar tendon over Gerdy's tubercle and distally along the anterior tibial crest, avoiding the old hockey-stick curve across the tubercle; the posteromedial incision is longitudinal, 1 to 2 cm posterior to the posteromedial border, centred over the fragment; and the skin bridge between them is measured directly and kept greater than about 7 cm. Timing and staging. These are high-energy injuries with a threatened envelope, so management is staged. In the acute stage (0 to 48 hours) a knee-spanning external fixator from the femur to the ankle provides length, alignment and ligamentotaxis, the blisters are dressed, the limb is elevated, and serial neurovascular and compartment checks are made, with a CT taken once the limb is stable. Definitive fixation (typically 7 to 14 days) follows only once the wrinkle test is positive and the blisters have re-epithelialised.

The exposure is the heart of the operation: plan and mark both incisions first, then work the posteromedial limb to reduce and buttress the shear fragment, before rebuilding the lateral split-depression against the now-stable medial column. Strict subperiosteal dissection on bone and an intact medial head of gastrocnemius are what keep the deep neurovascular structures safe throughout.

Structures at risk, by incision and layer. The deep lateral danger is the anterior tibial artery with the deep peroneal nerve; the deep medial danger is the popliteal bundle, shielded only by an intact medial gastrocnemius. The named superficial medial risk is the saphenous nerve with the great saphenous vein.

Complications. Soft-tissue failure dominates. Intra-operative risks are anterior tibial artery injury, saphenous nerve injury, articular malreduction and an inadequate skin bridge; the principal post-operative problems are wound dehiscence or necrosis, deep infection, post-traumatic arthritis, malalignment and compartment syndrome.

Extensile options. The anterolateral incision extends proximally along the lateral femoral condyle to reach the lateral knee or a distal femoral component, and distally along the anterior tibial crest to bridge a shaft extension in a Schatzker VI (accepting that the superficial peroneal nerve is encountered distally). The posteromedial incision extends proximally behind the medial femoral condyle toward the posterior knee, releasing the medial gastrocnemius from the medial femoral condyle if a true posterior approach is needed, and distally along the posteromedial border of the tibia for a shaft extension while protecting the saphenous nerve and vein throughout. A third, posterolateral incision is added when a posterolateral column fragment is present, which usually requires a lateral or prone repositioning and a separate skin bridge. Post-operative care. Immediate neurovascular checks including ankle and toe dorsiflexion, a bulky dressing with elevation above heart level, and a knee immobiliser or hinged brace for comfort. Weight bearing is non-weight-bearing or touch weight-bearing for 6 to 12 weeks, progressing guided by radiographic healing. Range of motion begins early as pain allows once wounds are sealed, with a goal of 0 to 90 degrees by 6 weeks. Follow-up is at 2 weeks for a wound check, 6 and 12 weeks for radiographs and weight-bearing progression, and 6 and 12 months for alignment and arthritis surveillance, with pharmacological thromboprophylaxis until mobile.

• Tibial plateau ORIF (Schatzker V and VI) — the principal operation performed through this exposure.
• Posteromedial approach to the tibial plateau — the medial limb of this dual approach, used in isolation for a pure posteromedial shear fragment.
• Posteromedial buttress or anti-glide plating of a posterior shear wedge.
• Lateral periarticular locked plating with subchondral rafting screws for a lateral split-depression.
• Metaphyseal bone grafting (autograft, allograft or a calcium-phosphate substitute) after articular elevation.
• Staged knee-spanning external fixation as temporisation for a high-energy soft-tissue envelope.

Guidelines, registries and global practice. The dual-incision approach is applied at trauma centres worldwide, and the principles that frame it — CT-based column analysis, staged soft-tissue management and column-specific fixation — converge across the contemporary practice, DNB and MS, MRCS and SICOT examination systems. | Body | Position on bicondylar plateau fractures | |------|------------------------------------------| | AO Foundation | CT mandatory for articular fractures; column-specific fixation with a posteromedial buttress plus a lateral locked plate; staged management with spanning external fixation for high-energy soft-tissue compromise | | BOA and BOAST | Early soft-tissue assessment, photographic documentation, joint orthoplastic care for open injuries; definitive fixation only once soft tissues permit | | OTA and AAOS | Anatomic articular reduction and restoration of the mechanical axis as primary goals; CT-based planning is the standard of care | Registry and population evidence. The population-based incidence of tibial plateau fractures is approximately 10 per 100,000 per year, with a bimodal distribution (high-energy in younger men and a fragility pattern in older women). Long-term ORIF cohorts show that residual malalignment is the strongest predictor of post-traumatic arthritis, reinforcing restoration of the mechanical axis as the operative goal. Global practice variation. In high-resource settings, precontoured lateral periarticular locked plates and routine CT are standard, and staged external fixation is widely used. In resource-limited settings, the same biomechanical principle (a posteromedial buttress plus a lateral plate) is achieved with small-fragment T, reconstruction or one-third tubular plates, and external fixation plays a larger role in both temporisation and definitive treatment. Consent (globally applicable). Discuss wound breakdown and the small risk of deep infection (the dominant complications), injury to the anterior tibial vessels and the common peroneal and saphenous nerves, post-traumatic arthritis, stiffness, and the possibility of later total knee arthroplasty if articular damage is severe.