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rthopaedics & Traumatology: Surgery & Research (2013) 99S, S208—S218

Available online at

www.sciencedirect.com

EVIEW ARTICLE

rthroscopic management of tibial plateau fractures:urgical technique

. Burdin ∗

HU de Caen, avenue Cote-de-Nâcre, 14000 Caen, France

Accepted: 27 November 2012

KEYWORDSFracture;Tibial plateau;Arthroscopy;Technique

Summary Tibial plateau fractures are serious articular fractures that are challenging to treat.Arthroscopy-assisted percutaneous fixation is the treatment of choice in Schatzker types 1, 2,3, and 4 fractures, as it ensures optimal reduction and stable fixation consistent with earlymobilisation. The most reliable fixation method seems to be percutaneous cannulated screwfixation, which is less invasive than open plate fixation. In complex proximal tibial fractures,arthroscopy may allow an evaluation of articular fracture reduction, thereby obviating the

need for extensive arthrotomy. Complementary stable fixation is crucial and should allow earlymobilisation to reap the benefits of the arthroscopic assistance. This article aims to review thetechnical points that are useful to the successful video-assisted management of tibial plateaufractures.© 2013 Published by Elsevier Masson SAS.

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ibial plateau fractures are articular lesions that threatenhort- and long-term knee function. Their surgical manage-ent is often challenging. As with all articular fractures,

he treatment goals consist of anatomic reduction, stablexation consistent with early mobilisation, and minimisa-ion of surgical trauma. Arthroscopy-assisted percutaneousxation was first described in the 1980s by Caspari and

ennings [1,2] and was subsequently proven effective inchatzker type 1, 2, and 3 fractures. Compared to openeduction and internal fixation, the decreased invasiveness

∗ 15, chemin du Clos-Joli, 14740 Rosel, France.E-mail address: burdin-g@chu-caen.fr

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877-0568/$ – see front matter © 2013 Published by Elsevier Masson SASttp://dx.doi.org/10.1016/j.otsr.2012.11.011

f arthroscopy-assisted percutaneous fixation translatesnto decreased morbidity rates. Combining arthroscopynd percutaneous fixation improves the diagnosis, evalua-ion of the reduction, and management of accompanyingesions.

Although a consensus exists regarding the general sur-ical technique, a number of points remain controversial.rthopaedic surgeons who want to use arthroscopy-assistedercutaneous fixation to treat tibial plateau fracturesust be aware of the various technical options and

tratagems described below. The use of arthroscopy inomplex proximal tibial fractures (Schatzker types 5nd 6) has been suggested, to improve the quality of

he reduction and to obviate the need for an exten-ive arthrotomy. In these fractures, arthroscopy muste combined with rigid fixation via a plate or externalevice.

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Arthroscopy for tibial plateau fractures

Background

Epidemiology

Tibial plateau fractures account for 1% of all fractures inadults. They may be related to high-energy trauma or,in elderly individuals with osteoporosis, to milder trau-matic injury. Unicondylar fractures contribute 60% of casesand usually involve the lateral plateau (90%). The inter-condylar eminence is fractured in 10% of cases. Tibialplateau fractures are bicondylar in 30% to 35% of cases[3].

Bone lesions and classification systems

Many classification systems have been developed for proxi-mal tibial fractures. In 1934, Cubin and Conley distinguishedfive radiographic types. In 1939, Marchant [4] described aclassification system that separated 23 fractures into ninetypes and established the basis for current classificationsystems by defining three elementary lesions: cleavage,depression, and the combination of both. The classificationsystem developed by Duparc and Ficat in 1960 [3] distin-guishes unicondylar and bicondylar tibial plateau fractures.Unicondylar fractures are classified according to whether

they involve cleavage, depression, or both (mixed frac-tures). Bicondylar fractures are either simple or complexwith, in this last situation, the addition of a mixed fractureof the lateral plateau (and, in the most serious forms, a

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Figure 1 The classification syst

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oronal fracture of the medial plateau). The AO classifica-ion system for long-bone fractures [5] is too complex to beuitable for everyday practice.

The classification system developed by Schatzker is theost widely used today [6]. There are six different types:

ype 1 or lateral split, consisting in pure cleavage ofhe lateral plateau; type 2, lateral split with depression;ype 3, pure depression of the lateral plateau; type 4,edial plateau fracture with or without an intercondy-

ar fracture; type 5, bicondylar fracture; and type 6,nicondylar or bicondylar tibial plateau fracture with anxtension that separates the metaphysis from the diaph-sis (Fig. 1). The simplicity of the Schatzker system hasade it extremely popular, although it is less detailed that

he system described by Duparc and Ficat. We refer to thechatzker system in this review.

oft-tissue lesions

he periosteumhe proximal tibia receives its blood supply from an

ntramedullary network and a periosteal network (Fig. 2).ibial plateau fractures compromise the blood supply fromhe intramedullary network but leave the periosteal net-ork intact [7]. Percutaneous fixation techniques preserve

he periosteal network, whereas extensive open fixa-ion damages the proximal tibial vessels, inducing a riskf severe complications such as infection, necrosis, andon-union.

em developed by Schatzker.

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Figure 2 The periosteal blood supply to the proximal tibia iscn

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ompromised by extensive surgery, thereby inducing a risk ofecrosis, non-union, and infection.

esions to the menisci and ligamentshe frequency of meniscal lesions varies widely across stud-

es, from 2% according to Holzach et al. to nearly 47% in atudy by Vangsness et al. [8,9] (Fig. 3).

Lesions of the collateral ligaments should be sought rou-inely, as they may jeopardise knee stability and sometimesequire surgical repair during the fracture fixation proce-ure.

Damage to the anterior cruciate ligament (ACL) is com-on. Rupture of this ligament was reported in 4% of casesy Cassard et al. and 32% by Gill et al. [10,11].

Posterior cruciate ligament (PCL) lesions are less common

nd usually well tolerated.

The popliteal vessels and nerves may be damagedn the event of a high-energy trauma, major fracture

igure 3 Detachment of the meniscal rim in a patient with depression tibial plateau fracture. Meniscal suturing is indi-ated.

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isplacement, or severe ligament lesions. The blood vesselsust therefore be explored in these situations [12].

adiographic evaluation

he classification systems for tibial plateau fractures arell based on an analysis of anteroposterior, lateral, andblique radiographs, which often underestimate the sever-ty of depression [13]. It has been established that computedomography (CT) with 2- and 3-dimensional reconstructionss valuable for understanding tibial plateau fractures andlanning the surgical procedure [14]. Magnetic resonancemaging (MRI) can help to evaluate the overall lesions byetecting damage to the menisci and ligaments that can beepaired during arthroscopy-assisted percutaneous fixation.RI can document bone and cartilage lesions of considerablerognostic significance. CT-angiography is the investigationf choice when the blood vessels must be evaluated; CTs performed almost routinely as part of the preoperativeorkup.

urgical technique

asic equipment

o specific equipment is needed for the fixation of a tib-al plateau fracture. The instruments used for conventionalnee arthroscopy should be available, as well as a ligamento-lasty aiming system, a set of trephines similar to those usedor arthroscopic ACL reconstruction, and an image amplifier.

A few instruments are more specific and may be useful,epending on the fracture type and technical option chosen,s detailed below.

chatzker types 1, 2, and 3 fractures (lateral tibiallateau)

nstallation, clinical examination, and evaluation of theesionshe patient is in the supine position with a support or stirrupt the root of the limb so that limb mobility is unrestrictednd the knee can be positioned in varus or valgus duringhe procedure (Fig. 4). The leg can be placed on the oper-ting table in flexion or allowed to drop according to theurgeon’s preference. A tourniquet is placed at the root ofhe limb. A sterile tourniquet and U-shaped sterile drapesre often chosen to facilitate access to the iliac crest forone graft collection if required (Fig. 5). An image amplifiers placed on the side of the operated knee to allow antero-osterior and lateral imaging. The optimal position of themage amplifier is determined before draping.

The knee ligaments are tested cautiously to look for lax-ty in the coronal plane. Gentleness is crucial, to avoidncreasing the displacement of the bone fragments. Liga-ent testing is performed under fluoroscopic guidance.An anterolateral port is created for the arthroscope,

hich is gently introduced into the joint. A conventionalntero-medial port is used for the instruments. Irrigation ofhe knee with saline is achieved with gravity or a pump. These of a pump is not indispensable and has been criticised

Arthroscopy for tibial plateau fractures

Figure 4 Installation in the supine position with a support atthe root of the thigh allows arthroscopy-assisted fixation whileleaving the limb freely mobile and providing easy access to theiliac crest.

Figure 5 Installation of the surgical drapes. A useful precau-tion consists in draping the iliac crest to allow collection of anautologous bone graft.

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Figure 6 By pulling on a loop passed around the meniscus, t

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s possibly increasing the risk of compartment syndrome.evertheless, pump irrigation may facilitate joint lavage,rovided the pressure is no higher than 50 mmHg.

The surgical procedure starts with evacuation of theematoma, which is a lengthy and tedious step. A third portn a supero-lateral position can be useful for introducing aannula that helps to evacuate the hematoma and decreaseshe risk of excessive joint pressure. When intra-articular vis-bility becomes sufficient, a shaver can be introduced tossist in removing the clots and small bone fragments withinhe joint cavity. The position of the instruments in the portsan be switched as needed.

Once joint lavage is complete, a comprehensive evalua-ion is performed to identify the bone and cartilage lesions,s well as any damage to other structures such as the meniscind ligaments. All findings must be scrupulously recordedn the operative report, as the extent of the lesions is ofajor prognostic significance and can require additional sur-

ical procedures later on. Fractures that are very near theeriphery of the plateau and partly located under the menis-us may be difficult to visualise. In this case, a loop can bentroduced from lateral to medial to retract the meniscus, asuggested by Carro [15] (Fig. 6). Meniscal retraction hooks,hich are designed for this purpose, can be used also, but

heir size is often problematic.

eduction of the fractureractures characterised by pure cleavage (Schatzker type). Reduction is fairly easy to achieve. External reduc-ion may be successful: the traction exerted by the capsulend ligaments when the knee is placed in varus elevateshe lateral fragment. This manoeuvre is first performednder fluoroscopic guidance (Fig. 7). Temporary fixation ischieved using one or two K-wires, which should ideally belaced about 1 cm under the joint surface and can be usedor subsequent fixation. A fragment that is not elevated tohe level of the joint surface can be pushed gently using

square driver or a spatula resting on its cortex. Alterna-

ively, a pin can be inserted percutaneously into the fractureite and used as a lever, similar to the Kapandji tech-ique for reducing a Colles’ fracture. Fracture reduction cane facilitated and stabilised until pinning is completed by

he meniscus can be retracted to expose the depression.

S212 G. Burdin

Figure 7 Principal of fracture reduction via ligament trac-tf

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ion: the traction exerted on the bone structures elevates theragment.

sing a ball-joint forceps (Fig. 8). When fracture reductionemains impossible, a slender spatula or palpation hook cane slipped into the fracture site within the joint cavity andsed to disimpact the bone fragments [15]. This manoeuvreust be performed gently and under fluoroscopic guidance

o avoid worsening the bone lesions (Fig. 9). Finally, reduc-ion can be obtained by inserting one or two K-wires into theractured plateau and using them as a joystick to elevatehe fragment and to correct any rotational displacement.hen the fragment is in the ideal position, pins are inserted

arallel to the joint surface to ensure temporary fixation.eduction quality is assessed by fluoroscopy and arthroscopy.n fractures with isolated depression (Schatzkertype 3).

he subchondral bone (and therefore the joint surface) islevated using a tool inserted through the metaphysis, underuoroscopic and arthroscopic guidance. Direct elevation

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Figure 8 Use of a large forceps for

igure 9 Use of a palpation hook to disimpact the fracture.

sing a spatula or curved osteotome has been advocated.he instrument can be introduced through an anterolateralortical window or even through the fracture site and is usedo tamp the cancellous bone under the depressed fragment.aultless technique is required to avoid worsening the dis-lacement or penetrating into the joint cavity through theoint surface [1,2,15] (Fig. 10).

The key to good-quality reduction of the depressed jointurface is application of the elevating force at the cen-re of the depression. To this end, a guide-pin should benserted in the middle of the depression using a ligamento-lasty aiming system [16,17] (Fig. 11). The pin can be madeo penetrate the bone through the anterior cortex of theractured condyle to avoid damaging the normal condyle ando apply a fragment-elevating force that is nearly perpen-

icular to the joint surface. Alternatively, the pin can benserted through the other condyle to obtain a larger volumef cancellous bone for elevating the fragment. However, this

fracture reduction and fixation.

Arthroscopy for tibial plateau fractures S213

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Figure 10 Direct elevation of a pure depression frac

alternative technique causes damage to the intact condyleand elevates the joint surface in a more tangential direc-tion, which may require a few manoeuvres to adjust thereduction. Using a cross-sighting technique, we have had noinstances of fracture of the condyle penetrated by the pin.

To create the anterior cortical window for access to thecancellous bone, a ligamentoplasty auger guided over thepin previously inserted into the depression can be used.A trephine 10 mm in diameter is introduced, manually orusing a power tool, to 2 cm below the depression (Fig. 12)to cut out a cancellous bone core, which is then gentlypacked subchondrally using a bone tamp 8 mm in diame-ter. If a cannulated bone tamp or impactor is available, the

fragment can be elevated with the guide-pin in place. Oth-erwise, the guide-pin must be removed, which decreases thereliability of the manoeuvre (Fig. 13). Elevation should beperformed very gently, under fluoroscopic and arthroscopic

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Figure 11 Use of a ligamentoplasty aiming sys

using a spatula introduced through a cortical window.

uidance. Manoeuvres to adjust the reduction of the rim ofhe depressed fragment may be needed and can be achievedsing a spatula.

Rossi suggested the creation of a cortical flap using anncillary to lift a cortical rectangle measuring 10 by 20 mm.

hollow trephinein which a bone tamp can be introduceds used [18]. Venkatesh advocated the use of cannulatedmpactors featuring an oblique impaction surface to allowlevation in a direction perpendicular to the joint surface19].

Slight overcorrection of the joint surface depression fol-owed by flexion of the knee is desirable to allow the femoralondyle to shape the joint surface. Temporary stabilisation

s achieved using one or two pins introduced 1 cm below theoint surface. Pin position should be evaluated on antero-osterior and lateral fluoroscopy views (Fig. 14). Suganumand Akutsu developed an automatic pinning system with

tem to target the centre of the depression.

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Figure 12 Creation of a bone core under the depression.

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igure 13 Elevation of the joint surface by packing of theraft under the depression.

targeting frame that slides over the pin implanted intohe centre of the elevated fragment to guide the fixationires just under the previously elevated joint surface [20]

Fig. 15).n mixed fractures with both cleavage and depressionSchatzker type 2). The previously described technicaltratagems should be used in combination. The depressedragment is elevated first and the separation is then reducedsing a large bone-grasping forceps. In some cases of major

eparation, a preliminary reduction step can be performedsing the forceps to close the tibial epiphysis and restoreelative cortical continuity, thereby facilitating elevation

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ins positioned 1 cm under the joint surface through the boneore.

f the depressed fragment. When elevation is satisfactory,eduction of the separation is completed by increasing theressure by the forceps.

ixation methodlthough the best fixation method is controversial, there is

consensus that lateral tibial plateau fractures should be

ulated screws inserted percutaneously, in combination with washer (Fig. 16). The screws are tightened under arthro-copic guidance. Care should be taken to avoid excessive

Arthroscopy for tibial plateau fractures

Figure 15 Automatic elevation and fixation as describedby Suganuma and Akutsu. A targeting frame placed over the

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impactor allows positioning of the fixation wire into the bonecore.

tightening, which can adversely affect reduction quality.Screw length and position are checked fluoroscopically.

In clinical practice, this screw fixation method has beenproven reliable in isolated split fractures by several authorsincluding Schatzker et al., Denny et al., and Koval et al.[6,21,22]. However, biomechanical studies are scarce andtheir results conflicting. Denny et al. [21] found that plate

fixation was superior over screw fixation in split fractures,but this result was contradicted by Koval et al. [22]. Insplit-depression fractures, a cadaver study by Boisrenoult

Figure 16 Percutaneous fixation of a lateral tibial plateausplit fracture using 6.5-mm cannulated screws.

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t al. found no evidence that plate fixation was superior overcrew fixation [23]. A biomechanical study by Patil et al. in

synthetic bone model supports the use of multiple 3.5-mmcrews [24].

pecific features of medial tibial plateau fracturesSchatzker type 4)

ift et al. showed in an experimental model that loads werereater through the medial than through the lateral kneeompartment and that percutaneous screw fixation was lesstable than plate-screw fixation [25]. Nevertheless, no reli-ble clinical studies have established the need for invasivexation in these patients who will not bear weight on theffected limb for 2 months. Invasive internal fixation cancelsut some of the benefits from arthroscopic treatment, mak-ng percutaneous fixation a reasonable choice in this typef fracture. However, extensive fixation may be warrantedn the event of a comminuted fracture and in patients withsteoporosis.

eplacing lost bone

he main risk factor for secondary displacement is thexistence of a large bony defect under the depression.herefore, consideration must be given to filling this defect.he 1999 SOFCOT symposium found no significant differenceetween patients managed with and without bone grafting26]. However, filling seems preferable when the depres-ion is greater than 6 mm. Filling is undoubtedly in ordern patients older than 55 years of age and in those witharked osteoporosis, who are at increased risk for secondaryepression [12,27,28].

Several materials are available for filling the bone defect:

autologous iliac crest bone grafting results in goodosteointegration and is inexpensive. However, the graft iscomposed of cancellous bone, whose immediate mechani-cal strength is limited. In addition, graft collection resultsin non-negligible morbidity [29];

frozen allogeneic bone grafts are not very convenientfor traumatology, given their high cost and limited avail-ability. In addition, their use is associated with a risk ofinfection [30];freeze-dried allogeneic bone or synthetic bone substitutesavailable as granules are safe but expensive and lack thebone-induction properties of autologous bone.

All these materials are implanted by impaction. Theirlimited initial mechanical strength has led to the sug-gestion that an interference screw be used to close theelevation orifice, thereby improving stability [31]. Tight-ening of the screw can serve to gradually elevate thedepressed fragment (Fig. 17):

the bone defect can be filled with orthopaedic cement(PMMA), which provides a useful degree of immediatemechanical strength. However, cement is an inert foreignbody that can cause problems in the event of infection

or revision surgery (Fig. 18). Thus, cement should bereserved for very elderly patients. An appealing alterna-tive consists in the use of hydroxyapatite, which providesthe same immediate mechanical strength as cement but

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igure 17 Fixation of the graft using an absorbable inter-erence screw. Tightening of the screw can serve to graduallylevate the joint surface.

allows osteo-induction to occur, thus restoring bone stock.Disadvantages of hydroxyapatite are its high cost and riskof leakage into the joint cavity. The injection must be cau-tious, slow, and performed under arthroscopic guidance[32].

reatment of other lesions

eniscal lesions

ound evidence indicates that meniscal preservation dur-ng the management of tibial plateau fractures governshe medium- and long-term outcomes [6,33,34]. Meniscalears are sutured under arthroscopic guidance after frac-ure stabilisation whenever possible. Conventional methodsor arthroscopic meniscal suturing are used. Meniscectomys performed only when suturing is not feasible.

eripheral ligament lesions

evere damage to the collateral ligaments compromisesnee stability in the coronal plane. The knee should bexamined before and after fracture fixation and stress radio-raphs should be obtained at the slightest doubt. Mostollateral ligament lesions are managed conservatively, par-icularly when the medial collateral ligament is involved.n some cases, lateral laxity may require immediate surgi-al treatment in patients with the genu varum morphotype9,33].

esions of the central pivot

CL lesions are particularly common and should be describedn the operative report. Ligamentoplasty during the frac-ure fixation procedure has been advocated but considerably

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igure 18 Use of cement to fill the bone defect followed byercutaneous screw fixation.

ncreases the complexity and length of the operation [2].any ACL tears are asymptomatic, and a frequently rec-mmended approach therefore consists in performing ACLeconstruction secondarily in those patients who develophronic knee instability [1,9,10,33,35].

Intercondylar fractures should be treated during theame arthroscopic procedure. Fixation can be achieved usingon-absorbable suture or a 0.5-mm steel wire. The suturesre threaded through the bone via a wire with an eye andre positioned on either side of the intercondylar eminence.lternatively, a 15 wire can be placed in the centre of the

ateral tibial spine and bent into the joint cavity. Tractionn this wire with the knee in extension ensures reduction ofhe fracture. Definitive fixation is achieved by bending theistal tip of the wire on the anterior cortex.

PCL lesions are less common (0% to 15%) and are usuallyreated conservatively [2,33,35].

ther bone lesions

one and cartilage lesions of the femoral condyle are com-on. Fixation should be performed whenever possible,

deally by arthroscopy. Osteochondral fragments that are toomall for fixation may have to be removed. Cartilage damagean cause persistent pain and early osteoarthritis and mustherefore be described in the operative report (location,ize, and treatment). In patients with a rapidly unfavourableourse, the presence of cartilage lesions may warrant therompt performance of a secondary intervention such as aealignment osteotomy.

ostoperative care

rainage is unnecessary. Hospital stay length ranges from 4o 7 days. Mobilisation is started on the day after surgery,ut weight-bearing is resumed only 8 to 10 weeks later.

Arthroscopy for tibial plateau fractures

Thromboembolism prophylaxis is given until the resumptionof weight-bearing.

Compartment syndrome is the most dreaded complica-tion but is also exceedingly rare. We are aware of a singlecase, described in 1997 by Belanger and Fadale [36]. If anirrigation pump is used, the pressure should not exceed50 mmHg [33] and the calf should be monitored during theprocedure. Thromboembolism and infection are exceedinglyrare [37].

Results

In most studies, the short- and medium-term outcomeswere good. However, few studies had follow-ups longer than3 years. Cassard et al. [10] reported knee and function scoresabove 90% and Scheerlinck et al. [33] obtained excellentHSS knee scores in 79% of patients after more than 5 yearsof follow-up. A return to the previous level of sportingactivities was obtained in 63% of the patients studied byScheerlinck et al. [33] and in 87% in a study by Holzach et al.[8]. It should be pointed out that significant joint space nar-rowing was found in 10% to 30% of patients followed-up formore than 3 years [8,10,33].

Complex fractures of the proximal tibia

The management of complex proximal tibial fractures(Schatzker 5 and 6) usually relies on reduction via an exten-sive arthrotomy followed by fixation with one or moreplates. This procedure results in considerable trauma to thesoft-tissues and compromises the blood supply to the bone(Fig. 19). Complications include stiffness, non-union, anddeep infection and occur in up to 50% of cases. Consequently,the use of arthroscopy-assisted fixation has been suggested.The objective is the restoration of joint surface congruity toobviate the need for a large arthrotomy incision. Additional

Figure 19 Example of screw-plate fixation of a fractureinvolving the tibial tubercle.

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table fixation appropriate for the extent of the fractureines is crucial to allow early mobilisation.

It has been suggested that fixation requires the use oflates (and most notably of locking plates) [38,39]. Hybrid orlizarov external fixation has also been advocated [40—43].rthroscopic fixation is complex in these rare fractures butelies on the same reduction modalities as in ‘‘simple’’ractures. Installation on an orthopaedic table has beendvocated as contributing to joint fracture reduction andacilitating restoration of the mechanical limb axis.

onclusion

rthroscopy now has a key role in the management of tib-al plateau fractures. Extensive experience with arthroscopys crucial. Arthroscopy allows an evaluation of fractureeduction without an extensive arthrotomy incision and alsonables optimal treatment of concomitant lesions. How-ver, arthroscopy is merely an evaluation tool that providesomplementary information to that obtained by fluoroscopy.onsequently, ‘‘arthroscopic fixation’’ may be a less appro-riate term than ‘‘arthroscopy-assisted management’’.

The benefits of arthroscopy are greatest when stable per-utaneous fixation consistent with immediate mobilisations performed. Therefore, the best indications are pure split,ure depression, and split-depression fractures of the lateralibial plateau.

In patients with complex proximal tibial fractures, these of arthroscopy by an experienced surgeon can minimisehe surgical trauma, provided stable fixation consistent witharly mobilisation is performed.

isclosure of interest

he author declares that he has no conflicts of interest con-erning this article.

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