Do Percutaneously Applied Medial Proximal Tibia Plates Need To Go Beneath the Pes Tendons?

Background: Bicondylar tibial plateau fractures are often associated with significant soft tissue compromise making operative treatment challenging. Dual plating through a two-incision approach following temporary external fixation has been shown to improve complication rates although deep infection rates remain high.The objective was to evaluate early outcomes following a novel technique of percutaneous application of the medial plate superficial to the pes anserinus tendons. Indications for a percutaneous medial plate included local soft tissue conditions, lack of or minimal involvement of medial articular surface with no displaced fragment requiring a posteromedial plate.

Methods: A retrospective chart review at a Level 1 Trauma Center identified twenty-four bicondylar tibial plateaus that were treated from 2015-2017 with standard lateral plate fixation and a medial plate that was percutaneously applied. Fractures were classified according to the AO/OTA classification. Demographic, injury characteristics, and co-morbidities were collected. The primary outcome was presence of a deep infection postoperatively. Secondary outcomes included secondary procedures, range of motion, and maintained radiographic alignment.

Results: The pre-dominant fracture pattern was AO/OTA 41-C3 (75%). The percutaneous medial plate was applied first (71%). The average follow-up was 427 days. Ninety-five percent achieved at least 90 degrees of flexion. All had satisfactory coronal alignment (≤5 degrees) and condylar width (<5mm). Satisfactory articular reductions (≤2mm) were noted in 76% and satisfactory sagittal alignment (≤5 degrees) in 94%. One patient had persistent wound drainage and underwent hardware removal after union. Another patient is pending hardware removal with concerns for deep infection five years post-surgery.

Conclusion: Early results demonstrate that it is safe to place the medial proximal tibia plate above the pes anserinus tendons percutaneously for select fracture patterns with maintained alignment and reduction. This technique may help to minimize deep infection rates. Level of Evidence: IV.