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Percutaneous Repair of a Schatzker III Tibial Plateau Fracture Assisted by Arthroscopy

Egol, Kenneth A. MD; Cantlon, Matthew MD; Fisher, Nina BS; Broder, Kari BA; Reisgo, Aldo MD

Journal of Orthopaedic Trauma: August 2017 - Volume 31 - Issue - p S12–S13
doi: 10.1097/BOT.0000000000000892
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Purpose: Tibial plateau fractures are articular fractures that sometimes prove difficult to effectively manage and treat. Although fluoroscopy is frequently used to assess the articular reduction in the surgical repair of tibial plateau fractures, this video demonstrates the additional benefit of arthroscopy in assisting with the articular reconstruction of a Schatzker III tibial plateau fracture.

Methods: The goal of operative treatment of tibial plateau is reconstruction of the articular surface followed by reestablishment of tibial alignment. Arthroscopy has been advocated as a possible supplement to the operative treatment of tibial plateau fractures. Arthroscopy-assisted fracture reduction has been shown to provide a significantly improved visualization of fracture fragment displacement when compared with traditional fluoroscopy use in select cases.

Results: This video demonstrates the use of arthroscopy to visualize the articular surface and aid in reduction during fixation of a tibial plateau fracture. Initially, arthroscopic visualization confirms depression of lateral tibial plateau and the elevation of the fractured segment. After fixation with 2 partially threaded cancellous screws, arthroscopy confirms articular reduction and normal relation of lateral meniscus to the articular surface.

Conclusions: Arthroscopic visualization is a reliable technique for assessing articular reduction during surgical repair of a tibial plateau fracture. In addition, this technique enables the surgeon to assess for soft tissue injuries that could potentially go undiagnosed.

Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY.

Reprints: Kenneth A. Egol, MD, 301 East 17th St, New York, NY 10003 (e-mail: Kenneth.Egol@nyumc.org).

None of the authors have financial or institutional disclosures to report related to this video. K. A. Egol is a consultant to, and receives royalties from, Exactech. He receives royalties from Slack Inc & Lippincott. He receives grant support form Orthopaedic Research and Education Foundation. There was no source of funding for this video.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jorthotrauma.com).

Video available at:http://links.lww.com/JOT/A31.

Accepted May 09, 2017

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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REFERENCES

1. Yoon RS, Liporace FA, Egol KA. Definitive fixation of tibial plateau fractures. Orthop Clin North Am. 2015;46:363–375.
2. Chen X, Liu C, Chen Y, et al. Arthroscopy-assisted surgery for tibial plateau fractures. Arthrosc J Arthrosc Relat Surg. 2015;31:143–153.
3. Chen HW, Liu GD, Wu LJ. Clinical and radiological outcomes following arthroscopic-assisted management of tibial plateau fractures: a systematic review. Knee Surgery. Sport Traumatol Arthrosc. 2015;23:3464–3472.
4. Yin X, Li J, Xu J, et al. Clinical assessment of calcium phosphate cement to treat tibial plateau fractures. J Biomater Appl. 2013;28:199–206.
5. Oztürkmen Y, Caniklioğlu M, Karamehmetoğlu M, et al. Calcium phosphate cement augmentation in the treatment of depressed tibial plateau fractures with open reduction and internal fixation. Acta Orthop Traumatol Turc. 2010;44:262–269.
6. McDonald E, Chu T, Tufaga M, et al. Tibial plateau fracture repairs augmented with calcium phosphate cement have higher in situ fatigue strength than those with autograft. J Orthop Trauma. 2011;25:90–95.
7. Urruela A, Davidovitch R, Karia R, et al. Results following operative treatment of tibial plateau fractures. J Knee Surg. 2012;26:161–166.
8. Duan X, Yang L, Guo L, et al. Arthroscopically assisted treatment for Schatzker type I-V tibial plateau fractures. Chin J Traumatol. 2008;11:288–292.
Keywords:

trauma; arthroscopy; tibial plateau

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