Surgical technique: Tscherne-Johnson extensile approach for tibial plateau fractures.

BACKGROUND: The standard approach to lateral tibial plateau fractures involves elevation of the iliotibial band (IT) and anterior tibialis origin in continuity from Gerdy's tubercle and metaphyseal flare. We describe an alternative approach to increase lateral plateau joint exposure and maintain iliotibial band insertion to Gerdy's tubercle. DESCRIPTION OF TECHNIQUE: The approach entails a partial tenotomy of the anterior half of the IT band leaving the posterior IT band insertion attached to Gerdy's tubercle. Fracture lines around Gerdy's tubercle are completed or the tubercle was osteotomized and externally rotated and the joint overdistracted, allowing direct visualization of the joint depression. Joint elevation, grafting, and internal fixation are performed through this window. METHODS: We retrospectively reviewed 76 patients (two groups), Schatzker Types I to II and IV to VI fractures (66 patients), between 1989 and 2005, and 10 patients, with 10 bicondylar posterior plateau fractures, from 2002 to 2010. All patients were followed a minimum of 12 months (average, 3.9 years; range, 12 months to 10 years). Ten patients, with posterior plateau fractures, received anterolateral plateau intraarticular osteotomy for exposure of centroposterior and posterolateral articular depression. RESULTS: Average knee ROM was 2° of flexion (range, -3° to 5°) to greater than 120° of flexion (range, 100°-145°). In 66 patients, average articular depression improved from 7.4 mm to 1 mm (range, 0-5 mm) and, in 10 posterior fractures, from 18 mm to 1 mm (range, 0-4.5 mm). Infection occurred in one of the 76 patients; acute débridement and intravenous antibiotics resulted in control of the infection. CONCLUSIONS: This approach reliably increases direct visualization of the lateral plateau articular fractures and maintains IT band insertion. Articular osteotomy of the anterolateral plateau provides access to extensive posterior plateau fractures.

Unilateral proximal bifurcation of the femur.

We present a case report of a boy with a unilateral bifurcation of the proximal femur with a bifid femoral neck and 2 femoral heads. The patient had no other musculoskeletal or neurovascular abnormalities. One femoral head articulated with the acetabulum but the nonarticulating, larger head was better developed. The articulating head and neck were resected and the nonarticulating head was reduced. This hip then continued to develop well. This is the first report of such a phenomenon in the scientific literature.