• Mellany Galla, Carsten Riemer, and Philipp Lobenhoffer.
• Klinik für Unfall- und Wiederherstellungschirurgie, Henriettenstiftung Hannover, Marienstrasse 72-90, 30171, Hannover. melgalla@web.de
• Oper Orthop Traumatol. 2009 Mar 1;21(1):51-64.

ObjectiveDirect posterior approach requiring minimal soft-tissue dissection for the treatment of posteromedial tibial head fractures.IndicationsPosteromedial fractures of the proximal tibia. Bicondylar tibial plateau fractures involving the posteromedial aspect of the tibial plateau. The approach can be extended for exposure of the posterolateral plateau.ContraindicationsLocal soft-tissue problems.Surgical TechniqueDirect posterior approach, mobilization and retraction of the medial head of gastrocnemius muscle. The fracture can be visualized by partial subperiosteal detachment of the popliteal muscle, whereas the medial head of gastrocnemius muscle and the semimembranosus muscle are preserved. Simplified reduction of the posteromedial fragment by extension of the knee and axial traction. Stabilization with lag screws and placement of a buttress plate (i.e., radial LCP T-plate or 3.5-mm LC plate).Postoperative ManagementPartial weight bearing with 15-20 kg for 6 weeks, unlimited range of motion.ResultsFrom 2001 to 2007, twelve patients (nine female, three male) with "medial split fractures" were treated via the direct posterior approach. Four patients had isolated "medial split fractures", seven patients bicondylar fractures of the tibial plateau, and one patient a four-part fracture. Six of our patients had acute injuries which were primarily treated at the authors' institution. The other six patients presented with malunited fractures or insufficient internal fixation (average 8.4 weeks, 3.5-24 weeks old). In all cases the fracture could be addressed by the described posterior approach. Sufficient reposition and restoration of anatomy could be achieved in all patients.

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