Tibial plateau fractures represent a wide range of injury patterns and usually have a bimodal distribution with high-energy injuries occurring in younger populations and low-energy injuries occurring in elderly populations.1 Although fluoroscopy is traditionally used in surgical management of tibial plateau fractures, arthroscopy-assisted reduction and internal fixation has been demonstrated to be a reliable, effective, and safe treatment option in the management of tibial plateau fractures.2,3 This technique is used most commonly in the treatment of Schatzker type I–III tibial plateau fractures, and previous studies have demonstrated that most patients experience good radiologic and clinical outcomes after arthroscopic-assisted management of tibial plateau fractures.3 This Supplemental Digital Content 1 (see Video, http://links.lww.com/JOT/A31) demonstrates the use of arthroscopy in assisting with the articular reconstruction of a Schatzker III tibial plateau fracture.
The patient is a 58-year-old female with a past medical history of end-stage renal disease, diabetes mellitus, and hypertension—who sustained a Schatzker III tibial plateau fracture after a mechanical fall. Radiographs and a computed tomography scan revealed a displaced, depressed right tibial plateau fracture.
The patient is placed supine on the operating room table with a bump under the affected extremity. Arthroscopic portals for the arc were made using an 11 blade. A cannula is then inserted through the lateral knee portal, and the arthroscope is placed to visualize fracture. Using the figure of 4 positioning, the lateral compartment is opened for visualization which demonstrates depression of entire lateral tibial plateau with cartilage fraying, no meniscal tear, and hypertrophic synovium in the notch. Inspection of medial compartment demonstrates a normal relationship between the articular surface and the medial meniscus. An arthroscopic shaver is introduced through medial portal to improve visualization. The ACL is observed to be intact and confirmed with probing. Several liters of fluid are run through knee for thorough irrigation.
A 2-cm incision is made anteromedially along the tibial crest with a 15 blade. A cortical window is made first by drilling and then by using osteotome to remove a window of medial cortical bone. This provides access for the curved tamp to elevate the depressed lateral plateau. The lateral plateau is elevated “en mass” under visualization by fluoroscopy using a large bone tamp. Two Kirschner wires from a cannulated screw set are drilled to support the elevated articular segment, which allows removal of the bone tamp. Next the void created by elevation of the joint is filled using calcium phosphate cement, which has been demonstrated to be excellent in compression and resistant to further depression.4–6 Previous studies have shown that tibial plateau fractures that are augmented with calcium phosphate demonstrate higher fatigue strength compared with autograft.6 Kirschner wires are then overdrilled to accept partially threaded cancellous screws. After measurement, two 4.0-mm partially threaded cannulated screws are placed over the wire to further enhance fixation of the tibial plateau fracture. Under radiographic guidance, placement of screws is confirmed.
Next, the arthroscope is replaced in the joint to assess articular reduction and demonstrates that the lateral plateau has been elevated to a more anatomic position. Final x-rays confirm hardware placement and restoration of the articular surface. Postoperatively, the patient is kept in extension for 1 week, then placed in a hinged knee brace and allowed free range of motion. The patient is made nonweightbearing for the first 10 weeks postoperatively, during which time they will begin physical therapy for quadriceps stretching and strengthening.
Although tibial plateau fractures represent a wide spectrum of injury patterns with varying degrees of severity, most patients who are managed surgically for a displaced tibial plateau fracture will experience good clinical and functional results.7 Simple, low-energy tibial plateau fractures are amenable to this technique. Assistance by arthroscopy in the surgical repair of tibial plateau fractures has the added benefit of being able to assess and treat soft tissue injuries and visualize the chondral surface reduction, which may improve functional outcomes.8
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