The Role Of Arthroscopy In Mini-Invasive Treatment Of Tibial Plateau Fractures

Professor ŞT.CRISTEA M.D.,Ph.D., A.PRUNDEANU M.D., FL.GROSEANU M.D., D. GÂRTONEA M.D.
Clinic of Orthopaedic and Trauma Surgery, St. Pantelimon Hospital, Bucharest, Romania

1. Introduction
The treatment of tibial plateau fractures represents a challenge in current activity of an orthopedic surgeon, because these kind of fractures have an intraarticular trajectory. It is important in this kind of fractures to have a good mobility after treatment (Mills & Nork SE, 2002). Instead of the standard treatment with one or two plates and screws, we used the reduction of the fracture’s fragment with Kirschner wires under Rx control and we fixed the fragments with K wires, screw and external fixation (Marsh et al., 1995; Morandi & Pearse, 1996). Open reduction and internal fixation has a significant complication rate and this has encouraged interest in percutaneous techniques, most of which associate arthroscopy and fluoroscopy. Arthroscopy is useful to provide a good view of the articular surface and allows assessment of associated intra-articular lesions.
The objectives of this treatment are to obtain a good articular congruity, axial alignment, joint stability and functional motion.

2. Method
We used the Schatzker’s classification, minim invasive treatment and arthroscopic postreduction control (Buchko & Johnson, 1996; Cristea et al., 2010; Kenneth A.E.& Kenneth J. K., 2006).

Fig 1 Schatzker’s Classification


3. Diagnostic
We put the clinical diagnostic on the clinical signs:
-swelling of the knee;
-hemarthrosis;
-pain;
-tibia could be deviated in varus or valgus;
-weight bearing impossible;
-restriction for active movements of the knee joint.

3.1. Radiological Diagnostic
We used different kind of Rx:
-antero-posterior;
-lateral;
-oblique internal or external;
-in tension-evaluate the reduction (ligamentotaxis)


Fig 2 Schatzker’s V CT and X Ray aspects

3.2. CT Diagnostic
Using the reconstruction in sagital and coronal plane of the imagines we obtain more information about the type and localization of the fracture (Rafii et al., 1987). CT exam is mandatory for the surgical treatment planning in type 4,5 and 6 Schatzer. By all experience of using CT and Xray exams, after several different cases, the surgeon will understand the fracture aspect only by Xray exams.

4. Surgical Treatment
Most surgeons use different kind of plates with screws with open reduction of the fracture:
-’’L’’ plate;
-LC DCP plate;
-two plates;
-plate and external fixation.
In our department we agree the minimal invasive surgical treatment of these kind of fractures under fluoroscopic and arthroscopic control.
We applied this technique particularly adapted to each Schatzker type. Inspite of that , others (Casteleyn & Handelberg, 2001) consider a limited role of arthroscopy only in relative simple split, depression and split-depression fracures.
The patient is under spinal anesthesia, then with Xray control we find the fragments of the fracture. Then we try to make the reduction of the fracture by flexion, extension, traction (ligamentotaxis) (Sirkin et al., 2000).
Standard arthroscopic portals can be used, joint irrigation is mandatory with a low pressure gravity feed, and a tourniquet is always necessary to reduce bleeding. Some arthrocopic surgical experience is necessary. The scope must be left few seconds in the same position in order to flush the blood and visualise the lessions. Prolonged operation time may lead to increased fluid effusion with compartimental syndrome or deep venous thrombosis.
We will describe the technique particularly adapted to each Schatzker type.
In case of the fractures with pure cleavage, split fractures, we put K wires rectangular on the fracture’s line, subchondral, under Xray and arthroscopic guidance. Eventually we apply compression forces by putting cannulated cancellous screws in paralel planes.
In the case of fractures with depression, we introduce in the depressed bone fragment a K wire. Then we lift this bone fragment under Xray and arthroscopic control and then we put another K wire thru these reduced bone fragments, subchondral. Eventually we apply compression forces by putting cancellous screws in paralel planes.
In the case of combinated fractures, cleavage and depression we put a K wire thru the fracture’s cleavage directly in the depressed bone fragment, we lift this depressed bone fragment using strong forces till the K wire is bend, under Xray and arthroscopic control. Then we introduce another K wire thru these reduced bone fragments, perpendiculary to the cleavage fracture, then we apply compression forces by putting paralel cancellous screws. After we obtained the alignment of the articular surface we fixed these fragments with cancellous screws or another K wire. In case of cominuted fractures first we align the depression and then we reduced the cleavage. We mention that the forces applied on the K wire for the alignment of the fracture are very strong ( Cristea et al., 2010).
In case of Schatzker type V-VI we use external fixation after we obtained the alignment of the articular surface ( Cristea et al., 2010).

Fig 3 External fixator and minim invasive reduction under X ray and arthroscopic control – intraoperative aspects

Indirect reduction techniques have the advantage of minimal soft tissue striping and fragment devitalization (Kenneth A.E.& Kenneth J. K., 2006). For badly comminuted fractures we use an external fixator as femoral – tibial distractor, eventually articulated.
We prefer to use closed methods in order to elevate depressed fragments, which can be carried out under fluoroscopic or arthroscopic guidance (Buchko & Johnson, 1996; Cristea et al., 2010). Bone tamps are placed under image and the depressed segments are elevated. Accuracy of reduction may be checked with the aid of the arthroscope. In type 4-6 because there are significant forces, lag screws alone are not sufficient to stabilize these fractures and we use external fixation.

Fig 4 Minim invasive reduction under X ray and arthroscopic control – intraoperative aspects

4.1. Asociated meniscal and ligamentous lesions
Diagnosis and immediate treatment of associated meniscal lesions by partial meniscectomy and debridement can be performed during initial arthroscopy. These may account for a lower incidence of degenerative changes in arthroscopically treated fractures cases. The collateral ligaments sprains do not require surgical treatment. They can be futher protected during mobilisation with an articulated cast-brace or a rehabilitation brace when the joint immobilisation is not necessary. The ACL lesions are reevaluated after the fracture healing and late reconstruction could be necessary.
Various lessions of soft tissue associated with tibial plateau fractures were found. These are usually neglected by most traumatic surgeons. All the meniscus lessions type, capsular disruption, intraarticular haematomas, osteochondral small fragments, ACL various lessions or collateral ligaments are associated with tibial plateau fractures.
Considering what we found in OR, we propose to associate these soft tissue lessions to the most used classification (Schatzker). So we propose the following classification of soft tissue lessions :
A1-without lesions of the meniscus or ACL
A2-with tears of the meniscus – repaired by excision and debridement
B1-lesions of the meniscus - which must be sutured
B2-fracture of the tibial plateau spine - which must be repared in emergency
C1- with desinsertion of ACL from femoral insertion - which should be repared in emergency
C2-with ireparable rupture of ACL , which can be repared later in another surgical session.


Fig 5 Minim invasive reduction of complex fracture which includes the spinal plateau. X ray and Arthroscopic control – after reduction

4.2. Author’s experience
Between 2006-2010 we had 398 tibial plateau fractures and for 262 we used surgical treatment. Of those 68% were external plateau fractures; 18% were internal plateau fractures and 14% were bilateral plateau fractures. We saw a great discrepancy between radiology and CT. On the Xray and CT we follow and appreciate the deplacement degree, fracture’s type and indication of treatment (Tscherne & Lobenhoffer, 1993).
We obtained very good results in 80% of cases, but also we have one case with infection after a month which neccessitate extraction of the screws and wires; 15% we obtained a mobility of the knee around 95-105 degree of fexion; 4% of cases we were not be able to restore the entire surface of the tibial plateau.
We reduced the infection rate by:
-reduced time of surgery;
-minimal dissection;
-extraperiosteal dissection;
-minimal size of implants;
-antibiotics.
We use anticoagulant therapy for thrombembolism profilaxy.

Fig 6 X ray Pre and postoperative aspects

Fig 7 X ray Pre and postoperative aspects

Fig 8 X ray Pre and postoperative aspects

5. Postoperative care
5.1. Deep venous thrombosis (DVT) prevention
As tibial plateau fractures are associated with considerable soft tissue trauma and sometimes with prolonged operation times using a tourniquet, DVT is not a rare complication (Williams et al., 1995).
The use of one of the low-molecular-weight heparins is advisable. We prolong their use for more than 3 weeks until the complete mobilisation of the knee and the pacient. Foot and calf mechanical compression devices can also be used with success. Compressive so-called antithromboembolic stockings are always mandatory. In some cases we used the new oral antithrombotic drugs (Dabigatran, Rivaroxaban), but still they are not officialy yet approved in trauma prevention care. There were no DVT or pulmonary embolism (PE) complications in our series.

5.2. Mobilisation
Once a satisfactory fracture reduction and stabilisation have been obtained, the immediate mobilisation is done. The soft tissue and skin coverage lesions are limited. Immediate continuous passive motion (CPM) can be beneficial for the restoration of the articular homeostasis and the remodelling of the small articular fragments. When the external fixator locks the knee, we try to achieve a stable construct to early mobilisation of the pacient. In generaly at 3-6 weeks the articular mobility is achieved, depending of the fracture type and stability of the fixation.

5.3. Weight-bearing
In general, walking with crutches with minimal load bearing is possible after a few days. In simple fractures, or stable construct fixation full bearing is allowed at 10-12 weeks. The articulated cast braces or rehabilitation braces can be usefull in early rehabilitation. Secondary, progressive impaction of the depressed zone can occur due to weight bearing, even 4 to 5 months postoperatively, especially in obese patients or those with ostheoporotic bone.

6. Complications
The risk of infection is reduce due to: reduced time of surgery, minimal dissection, extraperiosteal dissection, minimal size of implants, antibiotics. The implants ablation and antibiotics resolve that rare complication, while in classical open surgery the rate of infections and stiffness is 10 %.
Posttraumatic arthritis in a single patient with bicondylar fracture could be a good indication for total knee replacement. In total, in only 4% of cases the restore of the entire surface of the tibial plateau was not achieved. The varum deviation was finally observed in 3% of patients, with maximum value of 50.
There was no compartmental syndrome in our series due to low pressure during joint irrigation in arthroscopy, no pump was used.
We used anticoagulant therapy for thrombembolism profilaxy, and there was no DVT or PE cases in our series.

7. Conclusion
This kind of articular fractures requires perfect alignment of fracture’s fragments. It is difficult to treat these fracture especially type 5 and type 6 Schatzker.
Beside the standard treatment with one or two plates and screws, we used the reduction of the fracture’s fragment with K wire under Xray and arthroscopic control, and then we fixed the fragments with K wire and screws. First of all it is important to establish the fracture’s type. We used Schatzker classification for their identification. The preoperative planning is necessary and also the X-ray and CT scan. For this technique we used different kind of material: K wire, screws, external fixation, fluoroscope, and arthroscopy.
The role of arthroscopy in these fractures is twofold: 1. To confirm the quality of a good reduction, 2. To accurately asses and treat the associated lesions of the soft tissue – menisci, cruciate ligaments, capsular disruption.
We consider this technique minimal invasive is useful for the treatment of this kind of fracture and in most cases we have good outcome.
We obtained good results by using this method ( Cristea et al., 2010) in the surgical treatment of tibial plateau fractures. Our experience is adapted to resolve all tibial fractures type, not only Schatzker I – III, like some authors ( Siegler et al., 2011 ).
The advantages of this method are: minimal blood lost, small infection rate, good mobilization of the knee without pain, cheaper implants, reproductibility of the technique, it can be made in emergency, cost - efficient.
We used a single dose of antibiotics during surgery and anticoagulant for thrombembolism prophylaxis.

8. Bibliographs
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