According to the international literature, many orthopedic surgeons use the “straight” incision for the anterolateral approaches of tibial plateau fractures . This is the second method most often used for the anterolateral approach. It consists of an incision that begins proximal to the lateral femoral epicondyle and continues distally behind Gerdy’s tubercle. Depending on the fracture pattern, the skin incision can be either more posterior or anterior. Regarding superficial dissection, extensive subcutaneous soft tissue must be mobilized in order to expose the fascia of the tibialis anterior. The deep dissection that follows is the same as we describe above in “s-shaped” incision, using iliotibial band and fibula head as landmarks.
Typically, the patient is positioned in either supine or lateral decubitus position. Moreover, the patient’s leg can be placed in leg-holter position for better fracture reduction due to permanent ligamentotaxis.
Structures in danger
Short saphenous vein
Superficial peroneal nerve
Anterior tibial artery and deep peroneal nerve
Posterolateral plateau fractures can neither be viewed nor adequately supported with these types of procedures. Posterolateral areas cannot be visualized via the classic anterolateral approach; consequently, other techniques are needed . Several osteotomies have been described for improving exposure via a standard anterolateral approach. These osteotomies help to better visualize the posterolateral part of tibial plateau and manipulate the fragments; however, it is difficult to place the adequate posterior fixation. First, the femoral epicondyle osteotomy has been used for several orthopedic surgeries, such as total knee arthroplasty or meniscal transplantation . In 2015, a case report was described in which the lateral femoral epicondyle was osteotomized for better access to the posterolateral tibial plateau fracture . Second, the fibula resection osteotomy has been described in 2010 and includes resection of the medial and proximal fibula. Third, the digastric fibular osteotomy has been recently described in the literature improving both the visualization of the posterolateral articular surface and the ability to manipulate posterolateral fracture fragments.
2.2 Posterolateral approach
The posterolateral approach is ideal for the lateral tibial plateau fractures which have posterior displacement. This approach was initially described by Lobenhoffer et al.  in 1997 and was then modified by many surgeons such as Frosch  and Solomon  either with or without fibular osteotomy.
As Lobenhoffer  first described, the head of the fibula and the tibial tuberosity can be used for the orientation of the skin incision. The longitudinal cut runs laterally exactly in the middle of the distance between the tibial tuberosity and the fibula tip and has approximately 10 cm length. The peroneal nerve is identified proximal to the head of the fibula and is looped. The origin of the extensor muscle is then cut away, and the incision is continued tongue-shaped over the fibular neck. If there is a subcapital fibula fracture, this fracture is carefully mobilized. If this is not the case, a fibula osteotomy is performed after careful circumvention of the fibular neck. The origin of the extensor muscles is pushed about 1 cm distally. The meniscotibial ligament is incised, and the lateral meniscus is pulled proximally using holding threads. The fixed ligament of the tibiofibular joint is released, so that the head of the fibula can be pulled upward and back. As a result, the lateral collateral ligament relaxes and enables the lateral joint gap to be opened wide. The posterolateral tibial plateau is brought into the field of the surgeon’s vision in flexion and varus as well as internal rotation. If necessary, the posterolateral tibia shaft is exposed. If extensive exposure is required, the iliotibial tract on Gerdy’s tubercle can also be detached in one layer with the meniscotibial ligament.
Structures in danger
Common peroneal nerve
Lateral superior genicular artery
Lateral inferior genicular artery
Nowadays, a modification of the posterolateral approach is used that was described by Frosch et al. . A straight incision, about 8–10 cm, is made from the medial border of the biceps femoris tendon proximally to the posteromedial part of fibula distally. Subsequently, through the skin and subcutaneous tissues, the interval between the biceps femoris tendon and the lateral gastrocnemius muscle is found. In this area, the common peroneal nerve (CPN) can be identified. In particular, it is located medial to the biceps tendon, which gives off the lateral sural cutaneous nerve (LSCN) at this level. The superficial dissection ends at the plane between lateral gastrocnemius muscle with LSCN in the lateral side and biceps femoris tendon with CPN medial. It is important to know that lateral gastrocnemius is the most medial structure in this approach. Distally, the soleus is encountered at its origin on the posterolateral tibia and fibula. Blunt elevation of the soleus will provide exposure of the proximal tibia. Moreover, the anterior tibial artery should be protected in this area, because it travels to the anterior compartment, and the common peroneal nerve. The popliteus tendon is carefully mobilized, protecting the inferolateral genicular artery from injury. Finally, submeniscus arthrotomy can be performed for better visualization of the articular surface. If more exposure is needed, transverse osteotomy of the fibular neck can be performed.
A modification of this approach was described by Solomon, with an incision along the anterior border of biceps femoris and an osteotomy of the fibula . This provides the opportunity to retract the fibular head, the lateral collateral ligament, and the biceps femoris upward.
The patient may be placed in the prone, supine, or lateral decubitus position based on the patient’s other injuries and the surgeon’s preference.
2.3 Medial approach
The medial approach is used when an anteromedial fracture pattern of tibial plateau occurs . It is difficult with this approach to obtain a good access of the articular surface without injuring the medial collateral ligament. The adductor tubercle and the medial border of the tibial crest are very important landmarks for this procedure .
The skin incision begins from the medial femoral epicondyle, about 2–3 cm over the joint line, and ends 2 cm posterior to the tibial crest, depending on fracture extension. The knee must be flexed about 15°–20° before proceeding with this skin incision (Figure 3). The superficial dissection includes the sartorius fascia, which is incised in a straight line similar to the skin. Next, the gracilis and semitendinosus tendons are identified, which arise posteriorly creating together with the sartorius the pes anserinus in the anteromedial tibia. In regard to the deep dissection, three layers exist in this area . The first is the pes anserinus tendons posterior and proximal, the second is the superficial medial collateral ligament, and the third is the deep medial collateral ligament. The first and second layers can be cut off during this procedure and should be repaired after fracture fixation. The deep medial collateral can be incised by making an arthrotomy for articular surface visualization. In most cases, fracture reduction is carried out without an arthrotomy because it can be subsequently confirmed by fluoroscopic imaging.Structures in danger
Infrapatellar branch of saphenous nerve
Medial inferior genicular artery
The patient’s position is either supine with the knee flexed (~50°–60°), the ipsilateral hip external rotated and abducted or in a “leg-holter” position.
2.4 Posteromedial approach
The posteromedial approach is mainly used for shear or coronal fractures of the medial tibial plateau . It is an ideal approach because it gives the opportunity to place an antiglide plate for better fixation of this type of fractures. Moreover, it can be done in either the supine or prone position. The prone position has the main advantage of being more comfortable for the surgeon. This is not recommended in dual approach strategies such as performed for concurrent lateral and medial plateau fractures, because of the need for the patient’s repositioning.
In posteromedial approach in supine position , the surgeon should stand on the opposite side of the injured leg. The important landmarks for the incision are the medial femoral epicondyle proximal and the posterior tibial border distally. For this approach, it is important to obtain a 30° knee flexion and external rotation of the ipsilateral hip for better access of the posteromedial area. Regarding superficial dissection, the skin incision is about 8 cm, and the sartorius fascia is incised between the medial gastrocnemius posteriorly and the pes anserinus anteriorly (Figure 4). The saphenous nerve runs just anterior to the great saphenous vein. The medial collateral ligament lies deeper than the pes anserinus and therefore cannot be injured during this approach. The semimembranosus and the popliteus muscle insertion in the posterior tibia can be released off the bone using subperiosteal dissection for better access of the fracture area. Moreover, submeniscal arthrotomy can be done to visualize the joint directly, and sutures may be placed into the meniscus for retraction. Finally, fluoroscopic imaging is necessary to confirm the appropriate reduction of the articular surface .
On the other hand, the posteromedial approach in prone position was initially described in 2003 . For this procedure, it is important to place a folded blanket under the ipsilateral femur allowing leg hyperextension for easier fracture reduction as mentioned by Moore. The skin incision is about 2 cm posterior and lateral than in the supine position. Its length is 8–10 cm running along the medial border of the medial gastrocnemius. The medial gastrocnemius is then retracted laterally developing the interval between the medial gastrocnemius and the semimembranosus. The pes tendons are placed intact anteriorly. The deep dissection continues with the subperiosteal elevation of the popliteus muscle off its insertion in the posterolateral area of tibia. Finally, modifications of this approach exist that provide additional lateral exposure such as the “S-type” procedure .
Structures in danger
Short saphenous vein
Peroneal artery and branches
Posterior tibial artery and nerve
2.5 Direct posterior approach
The direct posterior approach is rarely used for tibial plateau fractures. The fracture pattern treated with this approach is a shear posterior bicondylar plateau’s fracture with the main fracture line in coronal plane. This method has an important disadvantage when compared to other surgical incisions, and there is a higher risk for iatrogenic injury of neurovascular structures in the popliteal fossa.
Structures in danger
Sural nerve and short saphenous vein
Posterior approach was first announced in 1945 as a midline incision through popliteal fossa by Abbott and Carpenter. Many variations have been published over the years of the classic technique as “S – shape” , “L – type” incision , and lastly the “FCR”’ approach to the knee .
An “S-shape” skin incision is made from proximal-lateral to distal-medial. In this incision, the important landmarks are the Biceps Femoris proximal, the popliteal fossa at the joint line, and the medial head of the gastrocnemius distally (Figure 5). We should be attentive in the superficial dissection because underneath the skin lies the lesser saphenous vein and the sural nerve, which rests immediately lateral to the vein (Figure 6). The deep facia is incised, and the sural nerve may be followed proximally helping the surgeon to identify the tibial nerve. The tibial nerve lies superficial and slightly lateral to the popliteal vein and artery. The popliteal fossa is recognized proximally between the medial and lateral heads of the gastrocnemius and distally between the medial border of biceps femoris and the lateral border of semimembranosus. Underneath the biceps femoris is the common peroneal nerve, which is separated from the sciatic nerve just proximal to the joint line. Depending on the fracture pattern, the deep dissection may be continued either posteromedial or posterolateral as we described above (Figure 7). The landmarks are Biceps femoris, the lateral and the medial gastrocnemius, and the semimembranosus tendon.