Arthroscopic treatment of tibial plateau fractures can improve the outcome

The goals of surgery include restoring articular anatomy and limb alignment.

Issue: October 2006

ByRamon Cugat, MD

Ramon Cugat, MD [photo]
Ramon Cugat

Historically, poor results were obtained in complex tibial plateau fractures with both conservative treatment and the first osteosynthesis techniques. The treatment has been changed with new technologies, leading to an improvement in osteosynthesis, early mobility of the joint, better physiotherapy etc.

Injury mechanism, diagnosis

A stress valgus is one of these in sports injuries, but this kind of injury is more frequent in automobile accident and work-related traumas. The patient’s clinical history, radiological exams, CT-scans, MRI, angiography and electromyography are used in carrying out the diagnosis.

This X-ray shows osteosynthesis of an external fracture treated with screws.

An arthroscopic intra-articular image of a tibial plateau fracture associated with a partial meniscectomy.

Cugat treats the meniscal repair using Caspari’s Punch.

Images: Cugat R

Various grading systems can be used to evaluate the fractures, such as: Schatzker; Rasmussen; AO; Hohl etc. The Hohl system is broken down as follows:

Hohl-1 = a non-displaced marginal fracture
Hohl-2 = local compression
Hohl-3 = shearing — compression
Hohl-4 = a total chondyle depression
Hohl-5 = shearing
Hohl-6 = polyfractures.

The orthopedist’s goals with these types of injuries are to restore the anatomy of the articular surface and the limb alignment. In Hohl-1, the treatment is conservative. Higher grades will require surgery. In Hohl-2, Hohl-3 and Hohl-4 this surgery could be carried out arthroscopically.

For the arthroscopic technique, the patient is placed on the operating table in decubitus supinus with the injured lower extremity positioned in a way that it can be maneuvered.

Here, Cugat relies on fluoroscopy to insert a Kirschner wire in treating an external tibial plateau fracture.	He applies arthroscopic control of a Kirschner wire used for reduction.
Fluoroscopic control of a Kirschner wire before inserting a cannulated screw offers stability.	An arthroscopic intra-articular image of a tibial plateau fracture.

The surgery begins with an articular exam to gain an accurate diagnosis of the injury. The fracture is then treated with a Kirschner wire placed centrally in the sunk area to create a tunnel and reduce it. Afterwards, the synthesis is carried out with cannulated screws. If any gap is left, this is filled in with bone graft, which can either be autograft or allograft.

If there is a meniscal injury, it is treated with suturing, which can be by the in-in method, using Fast-Fix, hooks or arrows; the in-out, using knots; or the out-in, using ArthroPierce or Caspari’s Punch, techniques. However, if suturing is not possible, it is necessary to carry out as limited a meniscectomy as possible.

When there are chondral or osteochondral lesions, treat these by anchoring them with cannulated screws, adding cancellous bone graft and, if these are not possible, removing the affected tissue.

If it is not possible to raise the tibial plateau arthroscopically, an osteotomy is necessary.

At the end of the surgery, plasma rich in growth factors (PRGF) is applied.

The benefits

The approach:

helps the diagnosis of the intra-articular injuries;
together with fluoroscopy, it is essential in carrying out treatment of tibial plateau fractures;
helps in treatment of meniscal and chondral injuries as well as some tibial spine avulsions; and
provides good reduction for fractures with separation when combined with with fluoroscopy.

Fluoroscopy, used in conjunction with the arthroscopic approach, helps to better visualize the fracture line and helps to carry out the perpendicular synthesis to this line.

I find that polyfractures with sinking have worse reduction and worse results as a consequence, and I recommend using bone graft in these cases.

For more information:
Ramon Cugat, MD, is an orthopedic surgeon at the Clinica Del Pilar, in Barcelona, Spain. He is also: Head of Surgical Team, Catalan Football Federation; a member of the education and communications committees for the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine; and an editor for Orthopaedics Today International.