Can tibial plateau fractures be reduced and stabilised through an angiosome-sparing antero-lateral approach? Lucian B. Solomon a,b, *, P.R.J.V.C. Boopalan b,c , Adhiraj Chakrabarty b , Stuart A. Callary a,b a Centre for Orthopaedic and Trauma Research, The University of Adelaide, Adelaide, SA 5000, Australia b Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA 5000, Australia c Christian Medical College, Vellore 632004, Tamil Nadu, India Tibial plateau fractures (TPFs) and tibial shaft fractures have been shown to have a higher rate of surgical site infection (SSI) compared to all other fracture types. 1 Historically, SSIs after TPFs have been reported to be as high as 40–50%. 2,3 SSI prolongs treatment, negatively influences postoperative outcomes, reduces the patient’s quality of life and can increase health-care costs by >300%. 4 Therefore, clinical-practice changes that can reduce the rate and severity of SSIs are important for both the patient and the health-care systems. Improved surgical techniques, 5 intra-operative respect for soft tissues 6 and delayed definitive fixation 7,8 have all contributed to reducing SSIs in TPFs. However, despite recent improvements, the rates of deep SSIs after TPFs, especially after complex TPFs, continue to be reported as being between 8% 1,9 and 18%. 10 In addition, TPFs have been recently identified as an independent, non-modifiable risk factor for SSIs. 1 An angiosome is a composite tissue block of bone, muscle, fascia and skin which are linked three dimensionally by anastomotic arteries from one source vessel. 11 Dissection through any angiosome is known to devascularise the angiosome in part or entirely. 12 Current antero-lateral approaches for the treatment of TPFs are performed through curvilinear incisions over the lateral aspect of the knee and elevation of the proximal origin of the tibialis anterior (TA) muscle 13–15 and therefore through the anterior tibial angiosome (ATA). 12 An antero-lateral approach performed between the knee angiosomes without elevation of the TA muscle has the potential to decrease the rate of SSIs after TPFs. Injury, Int. J. Care Injured 45 (2014) 766–774 A R T I C L E I N F O Article history: Accepted 29 November 2013 Keywords: Tibial plateau fracture Angiosome Surgical site infection Internal fixation RSA A B S T R A C T Introduction and aim: Tibial plateau fractures (TPFs) are an independent, non-modifiable risk factor for surgical site infections (SSIs). Current antero-lateral approaches to the knee dissect through the anterior tibial angiosome (ATA), which may contribute to a higher rate of SSIs. The aim of this study was to develop an angiosome-sparing antero-lateral approach to allow reduction and fixation of lateral TPFs and to investigate its feasibility in a consecutive cohort. Methods: Twenty cadaveric knees were dissected to define the position of the vessels supplying the ATA from the lateral tibial condyle to the skin perforators. Based on these results, an angiosome-sparing surgical approach to treat lateral TPFs was developed. Fifteen consecutive patients were subsequently treated through this approach. Clinical outcomes included assessment of SSI and Lysholm score. Fracture healing and stability were assessed using the Rasmussen score and radiostereometric analysis (RSA). Results: At the latest follow-up between 1 and 4 years, there was no report of SSI. Nine patients (60%) had good or excellent Lysholm scores. The mean Rasmussen score at final follow-up was 17 (median 18, range 14–18) with 10 patients (66%) graded as excellent. Fracture fragment migration measured using RSA was below 2 mm in all cases. Discussion: This study has demonstrated that an angiosome-sparing antero-lateral approach to the lateral tibial plateau is feasible. Adequate stability of these fracture types was achieved by positioning a buttress plate away from the bone and superficial to the regional fascial layer as an ‘internal–external fixator’. Conclusion: The angiosome-sparing approach developed was able to be used in a prospective cohort and the clinical results to date are encouraging. Future clinical studies need to investigate the potential benefits of this surgical approach when compared with the previously described antero-lateral approaches. Crown Copyright ß 2013 Published by Elsevier Ltd. All rights reserved. * Corresponding author at: Level 4 Bice Building, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000, Australia. Tel.: +61 8 82222665. E-mail addresses: bogdansolomon@mac.com, Bogdan.Solomon@health.sa.gov.au (L.B. Solomon). Contents lists available at ScienceDirect Injury jo ur n al ho m epag e: ww w.els evier .c om /lo cat e/inju r y 0020–1383/$ – see front matter . Crown Copyright ß 2013 Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2013.11.035