Use of arthroscope in fracture fixation still up for debate

Although the use of arthroscopic surgery has become more prominent during the past several years, whether arthroscopic techniques are beneficial for fracture fixation is still debated among arthroscopists and trauma surgeons.

“As with any new procedures or approaches, I believe the techniques and technologies will evolve, as will its eventual acceptance in some capacity by the trauma community,” Dean K. Matsuda, MD, director of hip arthroscopy at DISC Sports and Spine and Chairman of the American Academy of Orthopaedic Surgeons Sports Medicine and Arthroscopy program committee, told Orthopedics Today. “[Just] as I have witnessed an initial resistance of some open hip preservation surgeons to arthroscopic surgery for [femoroacetabular impingement] FAI, I have also experienced a more recent and rewarding collaboration with many of these same surgeons as we try to determine what makes sense in best treating our patients with less invasive approaches.”

The most advantageous aspect of arthroscopic surgery is it is less invasive than other surgical treatments, which can help reduce the risk of complications and help patients heal faster.

Image: Bray G, DISC Sports & Spine Center

“The nature of arthroscopy implies small incisions as opposed to bigger incisions typically used for some of the fractures we were treating with traditional open approaches,” Joshua S. Dines, MD, associate professor of orthopedic surgery at Hospital for Special Surgery, said. “While not for every fracture, arthroscopy is less of a blow to the body, is easier to heal, has less potential wound complications and less potential blood loss.”

With the use of cameras, he added, arthroscopic surgery also allows for the surgeon to more easily view the injured articular surface than with open surgery.

“It seems counterintuitive, but we can often see better with arthroscopy,” Dines said. “You have cameras in there that are now basically [high definition], so if you are looking inside a joint, for instance, you can see the cartilage better than if you are using standard open techniques in many cases.”

However, according to Roy W. Sanders, MD, chairman of the Department of Orthopedics at the University of South Florida and director of Orthopedic Trauma Services at the Florida Orthopaedic Institute, in the acute setting, arthroscopic surgery offers few advantages for trauma patients who usually have fractures that cannot be fixed using an arthroscope.

“Trauma patients generally have higher-energy injuries, and the higher energy causes a more comminuted fracture. These require an open reduction to reposition the fragments,” said Sanders, who is also the Trauma Section Editor for Orthopedics Today.

Arthroscopic techniques also can be time-consuming and instrument- and technique-dependent, which can be counter-productive to trauma surgeons not well-versed in the technique, Timothy J. Bray, MD, senior associate of Reno Orthopedic Clinic and director of Orthopedic Trauma at Reno Medical Center, said.

“We are often working nights and weekends with hospital staff who are not trained or comfortable with those techniques. In patients with multiple injuries, time is of the essence, so we do not have a lot of indications in the acute situations for arthroscopic fixation,” Bray, who is also a past president of the Orthopaedic Trauma Association (OTA), told Orthopedics Today.

He added the literature reports catastrophic complications with hip arthroscopy in acetabular surgery, thus trying to remove small fragments from the hip joint arthroscopically can have significant disadvantages. James H. Lubowitz, MD, of New Mexico Knee Surgery, noted fluid infused in the joint for visualization purposes can cause swelling and other complications if the fluid is not contained to the joint.

“Arthroscopy is performed under fluid medium, so you have to be mindful of controlling where that fluid goes,” Lubowitz said. “It can extravasate or leak out, and when that happens, there are risks of complications like compartment syndrome.”

To prevent fluid leakage, Sanders said arthroscopic surgery would have to be performed several weeks after the injury when the fracture is more stiff, which may make it harder to move the fracture fragments around.

“The main issue is [arthroscopic surgery] clearly does not apply to every fracture or every trauma patient,” Dines said.

“Certain fractures, typically smaller ones, are amenable to arthroscopic repair. When you start getting into bigger long bone fractures, that becomes a different issue.” Matsuda agreed. “At present, arthroscopic fracture fixation may be best indicated for osteochondral or peri-articular fracture work, not the high acuity major trauma patient with multiple long bone fractures,” he said.

Fracture types, patterns

Although trauma surgeons tend to use minimally invasive techniques, percutaneous techniques or intramedullary fixation in the treatment of trauma patients, Bray said there are few indications for the use of arthroscopic surgery acutely. However, Dines told Orthopedics Today some trauma injury fracture types and patterns are more amenable to arthroscopic surgery than others, so surgeons should use whichever technique is going to provide the best results for patients in the long run.

“You do not want it to be [technology] over reason where you are using the camera in arthroscopy, but you are sacrificing the results we are able to get with open surgery,” Dines said. “But if I can do the same thing or better with arthroscopic surgery, then that is what I am going to do.”

He continued, “As long as surgeons are being reasonable with their own assessment of their skills and what they are able to do, I think [arthroscopy] is only an added benefit.”

Lubowitz also said results of arthroscopic surgery depend on the indication of the traumatic injury, with low-energy tibial plateau fractures, which may only be a few pieces, easier to fix arthroscopically than more severe fractures. Having said that, he pointed out several studies from Korea reported good results when an arthroscope for highly comminuted tibial plateau fractures was used. He added use of an arthroscope can be beneficial in “the upper tibia of the knee where the anterior cruciate ligament might have an avulsion fracture” or in the posterior cruciate ligament on the tibia or the femur.

According to Dines, improvements in arthroscopic techniques, instrumentation and implants during the last decade have allowed a transition in shoulder arthroscopy, allowing for more arthroscopic treatment of glenoid fractures, some greater tuberosity fractures and acromioclavicular joint separations.

Compared with elective hip arthroscopy, trauma surgery for acute fractures typically has a limited window of opportunity for optimal fracture osteosynthesis, Matsuda said. He added arthroscopic reduction and internal fixation within 1 week to 2 weeks of injury has shown promising results despite the risk of adverse events, such as intra-abdominal extravasation. He emphasized being comfortable with arthroscopy using low pump pressures or even dry arthroscopy and high vigilance. According to Lubowitz, use of an arthroscope is helpful for removing loose bodies in the hip.

When specifically looking at ankle fractures, Ned Amendola, MD, professor of orthopedic surgery and chief of the Division of Sports Medicine at Duke University, observed there is a high incidence of intra-articular injury that may not be identifiable with radiographs alone. He said an arthroscope could be used as an adjunct to identify these types of cartilage injuries.

“Treating the fracture and leaving the intra-articular pathology alone may lead to chronic discomfort after an ankle fracture,” Amendola said. “If you do an ankle arthroscopy at the time, you can see the ankle joint and make sure it is normal or, if there is something wrong, address it and fix the fracture at the same time. Then you are more likely assured there will not be any chronic pain after the fracture is healed.”

He also noted when intra-articular fractures require intra-articular reduction, an arthroscope can help the surgeon visualize the surface of the joint to help push the fragment back into place.

“The use of arthroscopy in all joints is increasing because it reduces morbidity and has a proven ability to treat certain conditions,” Amendola said. “Arthroscopy can be a useful adjunct to treat many of the fractures and minimize the problems associated with an intra-articular injury in ankle fractures.”

Future

Bray said there will not be a huge short-term indication for arthroscopic surgery for fractures in the acute patient despite the surge of arthroscopic surgery performed among trauma patients for a more accurate fixation during the last 10 years to 20 years. Conversely, Amendola said arthroscopic surgery may be put more frequently into use as surgeons become more adept and comfortable with arthroscopic-assisted surgery. Use of arthroscopic surgery for treatment of trauma patients also may be increased by the improvement of implants and instrumentation, according to Dines.

“We will come up with better, stronger materials that can be used [in a minimally invasive manner], and I think that will allow us to do a lot of things arthroscopically we have previously done through open incisions,” Dines said.

Lubowitz said arthroscopic surgery has already become the gold standard for certain types of tibia plateau fractures of the knee and he believes it will be used more for ankle fractures and distal radius fractures in the hip. Matsuda also said with the successful treatment of displaced femoral head fractures, acetabular fractures and femoral head malunions with arthroscopic osteosynthesis, the achievement of the arthroscopic equivalent of open reduction and internal fixation will help expand arthroscopy in the field of trauma.

“Patients are demanding more, which is good because it has pushed us to be better. Using arthroscopy will give us a better appreciation for some of the associated soft tissue injuries or even cartilage injuries that may need to be addressed at the same time as the fracture fixation,” Dines said.

As research methods improve and randomized controlled trials comparing fracture surgery with and without arthroscopy are performed, there will be a wider indication for the application of arthroscopic surgery, according to Lubowitz.

Recommendations

Dines and Amendola agree surgeons interested in performing arthroscopic surgery should become comfortable with the technique, know their limitations and start using it in simple cases until they become fully familiar with the nuances of arthroscopy.

“Orthopedic surgeons who have arthroscopy as part of their armamentarium and feel comfortable doing an arthroscopic evaluation or using the arthroscope to help with reducing the fracture, I think it would be prudent for those surgeons to use the arthroscope,” Amendola said. “I do not think the evidence is solid to say you should always use the arthroscope as part of the surgery, but [surgeons] should use it if [they are] facile and happy doing so. In that case, I do not think it would add a lot more to the surgery.”

If a trauma surgeon is unfamiliar with performing arthroscopic surgery, Lubowitz said fellowship-trained orthopedic sports medicine specialists with experience in arthroscopy can help guide in both surgery and making treatment decisions. Sanders noted if an orthopedic surgeon is not comfortable working on a patient with a lot of trauma, they should ask for an orthopedic trauma surgeon to assist with surgery.

“[Hospitals] have a general orthopedic call for an ankle fracture or wrist fracture and hand injuries and hip fractures, but when a patient comes in from a car wreck with limbs severed [and] hips dislocated, then they feel uncomfortable doing that,” said Sanders, who is also a past president of the OTA. “What they should do is they should ask for an orthopedic trauma surgeon to manage those patients.”

However, Bray said arthroscopic surgery should be used on a more limited basis if the desired outcomes are not being achieved.

“If you are interested in arthroscopic surgery, spend time with somebody who has experience in managing fractures arthroscopically and find the instrumentation to make the technique safe and time-efficient and critically review the outcomes,” Bray said. “If you are not getting the [desired] outcomes from your arthroscopic techniques, the traditional open surgery offers predictable enough outcomes that you should consider using the arthroscopic surgery on a more limited basis.”

To help keep patients safe, surgeons should be aware of the risks of compartment syndrome and control for fluid extravasation, according to both Lubowitz and Sanders. Lubowitz added surgeons should be familiar with the equipment being used ahead of time, while Matsuda stated pre-visualization of the entire procedure is important, from access to fracture reduction to fracture fixation.

“Arthroscopic washout or loose body removal is one potentially beneficial thing, but arthroscopic osteosynthesis is more challenging. One owes it to his or her patient to have a proficiency in arthroscopic surgery in that particular anatomic region,” Matsuda said. “Moreover, one must be able and willing to convert to an open procedure if initial arthroscopic attempts are unsuccessful or inadequate.” – by Casey Tingle

Editor’s note: On Sept. 28, we corrected the financial disclosures of this article to include Sanders’ financial disclosures. The Editors regret this error.

• For more information:
• Ned Amendola, MD, can be reached at Duke Sports Science Institute, Center for Living Campus, Wallace Clinic, 3475 Erwin Rd., Durham, NC 27705; email: ned.amendola@duke.edu.
• Timothy J. Bray, MD, can be reached at Reno Orthopedic Clinic, 555 N. Arlington Ave., Reno, NV 89503; email: drtimbray@sbcglobal.net.
• Joshua S. Dines, MD, can be reached at Hospital for Special Surgery, 541 E. 71st St., New York, NY 10021; email: jdinesmd@gmail.com.
• James H. Lubowitz, MD, can be reached at 1219 Gusdorf Rd., Toas, NM 87571; email: jlubowitz@icloud.com.
• Dean K. Matsuda, MD, can be reached at DISC Sports and Spine, 13160 Mindanao Way, Suite 300, Marina del Rey, CA 90292; email: saltandlight777@hotmail.com.
• Roy W. Sanders, MD, can be reached at the Florida Orthopaedic Institute, 13020 North Telecom Pkwy., Temple Terrace, FL 33637; email: ots1@aol.com.

Disclosures: Bray reports he is on the board of the Orthopedic Implant Company. Matsuda reports he receives royalties for intellectual property from Zimmer Biomet and Smith & Nephew. Dines reports he is a consultant for Arthrex. Amendola and Lubowitz report no relevant financial disclosures. Sanders reports he is a paid presenter or speaker for Zimmer Biomet and Smith & Nephew; is a paid consultant for Smith & Nephew, Stryker and Zimmer Biomet; receives research support from HHS, Medtronic, NIH (NIAMS & NICHD), Smith & Nephew, Stryker, Orthopaedic Trauma Association and the Major Extremity Trauma Research Consortium (Department of Defense); receives IP royalties from CONMED Linvatec, Smith & Nephew and Stryker; receives publishing royalties, financial or material support from the Journal of Orthopaedic Trauma; and is an editorial board member or committee member for the Journal of Orthopaedic Trauma, Orthopaedic Trauma Association and Orthopedics Today.

Can an arthroscopic fixation procedure be beneficial for patients with severe fractures?

Beneficial for severe fractures

Arthroscopic fracture fixation techniques have been used successfully for the treatment of various fractures, including tibial plateau, tibial eminence, malleoli, pilon, calcaneus, femoral head, glenoid, greater tuberosity, distal clavicle, radial head, coronoid, distal radius and scaphoid. Although literature support for use of arthroscopic techniques in the more severe fracture types at the above-mentioned anatomic locations is limited, arthroscopic fracture fixation vs. open methods can still be beneficial in terms of decreasing the invasiveness and allowing for the possibility of repairing the soft tissues and the cartilage, along with osteosynthesis.

For example, the use of arthroscopically assisted techniques in fixation of Schatzker types 5 and 6 tibial plateau fractures, Pipkin type 2 fractures, comminuted pilon fractures and distal radius AO type C3 fractures has been shown to be feasible with good to excellent results. Despite such encouraging reports, the number of arthroscopic fixation procedures in severe fracture types is considerably lower compared with less severe intra-articular fracture types. However, this does not necessarily mean the use of arthroscopy may not be as beneficial in more severe fracture fixation.

The main reason for decreased use might be hidden behind various other facts. It is common practice for severe intra-articular fracture types to be handled by trauma surgeons. However, arthroscopic fracture fixation requires extensive skills and experience that could be acquired during sports medicine and arthroscopy fellowship training. As a result, there is a conceptual separation within the specialty of orthopedic surgery with regard to which subspecialty’s umbrella the severe fracture treatment falls under. It is highly plausible that an orthopedic surgeon trained in both trauma and sports medicine, and with broad expertise in arthroscopic procedures, would be more amenable to using arthroscopic techniques in fixation of severe fracture types.

Severe fractures usually result from severe trauma associated with other fractures or injuries related to other organ systems that need emergency surgical procedures. On the other hand, arthroscopy is mainly used in elective operations and requires extra space and patient positioning in the OR. Hence, most severe fractures that could benefit from arthroscopic fixation techniques may not be practically considered for surgical procedures involving arthroscopy.

Arthroscopic fixation procedures can be beneficial for surgical treatment of severe fractures as well. Arthroscopy is not yet achieving its potential in fracture fixation. We have the wings: the arthroscope. We just need to learn how to use them and fly.

• Reference:
• Atesok K et al. Knee Surg Sports Traumatol Arthrosc. 2011;doi:10.1007/s00167-010-1298-7.

Kivanc Atesok, MD, MSc, is from the Department of Surgery, Section of Orthopaedic Surgery at the University of Manitoba and Pan Am Clinic Sports Medicine and Upper Extremity Reconstruction Fellowship Program, Winnipeg, Manitoba, Canada.
Disclosure: Atesok report no relevant financial disclosures.

Risks with arthroscopy

Operative treatment of tibial plateau fractures aims to restore congruity of the articular surface, restore alignment of the extremity and allow for early range of motion of the knee joint. Intraoperative fluoroscopy alone is not adequate to properly assess the articular reduction. Options include arthroscopic evaluation or direct visualization via an arthrotomy. Severe tibial plateau fractures are often bicondylar fractures with extensive soft tissue damage.

Most bicondylar fractures have a posteromedial shear fragment and variable amounts of multifragmented lateral comminution and depression. The posteromedial fragment shear fracture is typically not comminuted, and the fracture reduction can be visualized during the open approach. An arthrotomy is generally not needed as the articular surface is thereby indirectly reduced. If visualization of the medial joint is needed, a submeniscal arthrotomy is performed.

Arthroscopy has a risk of fluid extravasation through disrupted tissue planes leading to compartment syndrome. To minimize this risk, another option to assess the articular reduction is an arthroscopic dry-look. The lateral articular reduction is usually achieved by creating metaphyseal bone windows and using a tamp to elevate the articular surface. This is usually confirmed with a lateral submeniscal arthrotomy, again due to increased risk of compartment syndrome.

In addition, these fractures are challenging to treat. The use of arthroscopy adds to room set-up time and surgical time. In addition, the arthroscopy is technically more difficult due to extensive hematoma formation during the 2 weeks to 3 weeks it takes for the soft tissues swelling to subside and be amenable to operative fixation.

Alexandra K. Schwartz, MD, is a professor of clinical orthopedic surgery, chief of orthopedic trauma and residency director in the Department of Orthopedic Surgery at the University of California, San Diego.
Disclosure: Schwartz reports no relevant financial disclosures.