Bicolumnar (Dual) Plating of the Tibial Plateau - Surgical Steps

Concept and Rationale

• Lateral column - lateral tibial plateau, addressed via anterolateral approach
• Medial column - posteromedial plateau, addressed via posteromedial approach

Preoperative Planning Checklist

Step-by-Step Technique

Step 1 - Patient Positioning

• Supine on a radiolucent table
• Hip bumped to neutral extremity rotation
• Leg elevated on a radiolucent platform
• Leg brought toward a figure-of-four position to access the posteromedial side first (external rotation)
• Pneumatic tourniquet applied (optional)
• Fluoroscopic C-arm confirmed functional before draping

Step 2 - Plan Incisions Before External Fixator Pin Placement

Step 3 - Posteromedial (Medial Column) Approach - Done First

• Subcutaneous plane - protect the saphenous nerve and vein
• Blunt dissection through the deep fascia
• Deep interval lies between the posterior border of the pes anserine tendons (retracted anteriorly) and the medial head of the gastrocnemius (retracted posteriorly)
• A retractor under the gastrocnemius medial head protects popliteal fossa neurovascular structures
• The popliteus origin is lifted and retracted laterally to directly expose the posteromedial fracture apex

• Use large and small reduction forceps, awls, and elevators
• Intraoperative distraction (manual or with femoral distractor)
• Assess articular reduction fluoroscopically (joint visualization through posteromedial approach is limited)

• Apply a 3.5-mm (or small-fragment LCP/locking) buttress/antiglide plate along the posterior cortex of the medial tibia
• Interfragmentary screws may be placed through the proximal portion of the plate
• Target medial screws anteriorly initially to avoid traversing the articular fracture until the entire joint is reduced
• Limit the number of medial screws initially - excessive medial fixation can interfere with subsequent lateral reduction

Step 4 - Anterolateral (Lateral Column) Approach - Done Second

• Incise the anterior compartment fascia (preserve a cuff of tissue for closure)
• Elevate the tibialis anterior off the lateral tibial surface subperiosteally if needed
• Lateral meniscus elevated if articular visualization is needed
• Exposure from just below the joint to the mid-shaft

• Restore articular congruity of the lateral plateau
• Reduce depressed fragments by elevating through a cortical window (if present) or through the fracture line
• Use bone void filler (allograft, synthetic, or autograft) to fill subchondral defects
• Place rafting screws close to the articular surface (within 5 mm) before adding void filler - these prevent re-depression

• Apply an anatomic proximal tibial locking plate along the lateral cortex
• Position the plate tip just below the joint line
• In the sagittal plane, the plate is slightly anterior to the fibular head
• Fix proximally with locking screws in the plate head - multiple divergent screws raft the articular surface
• Extend distally with locking screws spanning the metaphyseal injury zone using a no-touch / bridge plating technique across the comminuted metaphysis

Step 5 - Confirm Reduction of Both Columns

• Fluoroscopic confirmation of joint congruity in AP and lateral views
• Check mechanical axis alignment: use a Bowie cord (from femoral head to ankle) to verify coronal alignment
• Compare with contralateral limb on fluoroscopy
• Articular step-off should be < 2 mm
• Confirm hardware positioning - no intra-articular screw penetration

Step 6 - Bone Void Filler

• If subchondral defect present after reduction, fill with bone void filler (autograft, allograft, calcium phosphate, or other synthetic substitute)
• Place rafting screws before void filler if possible

Step 7 - Wound Closure

• Irrigate wounds copiously
• Deep fascia closed in layers
• Skin closed over a suction drain (particularly the lateral wound)
• Avoid closing under tension - if skin is compromised, consider leaving open or using VAC

Step 8 - Postoperative Management

• Posterior above-knee splint or back-slab applied immediately
• Non-weight bearing for minimum 8 weeks
• Early range of motion exercises in a hinged brace (once wounds stable) - CPM machine may be used
• Weight bearing progressed guided by clinical and radiographic healing

Key Pitfalls and How to Avoid Them

Summary of Order of Steps

1. Staged soft tissue management (temporary ex-fix)
2. Preoperative CT planning; draw incisions before pins
3. Positioning (supine, figure-of-four for medial first)
4. Posteromedial approach - reduce and fix medial column with antiglide/buttress plate (initial limited medial screws)
5. Anterolateral approach - reduce lateral plateau, rafting screws, void fill, apply lateral locking plate
6. Fluoroscopic confirmation of joint congruity and limb alignment
7. Final medial screw placement as needed
8. Wound irrigation and layered closure with drains
9. Splint application; early ROM, non-weight bearing x 8 weeks