Arthroscopically-Assisted Reduction and Internal Fixation of Intra-Articular Fractures of the Lateral Tibial Plateau

Kim Juhan; Hwi Kim Dong; Lim Jae-Hwan; Jang Hyunwoong; Wook Kim Young

doi:10.4055/jkoa.2019.54.3.227

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Juhan, Dong, Jae-Hwan, Hyunwoong, and Young: Arthroscopically-Assisted Reduction and Internal Fixation of Intra-Articular Fractures of the Lateral Tibial Plateau

Original Article

J Korean Orthop Assoc 2019;54(3):227-236.

DOI: https://doi.org/10.4055/jkoa.2019.54.3.227

Arthroscopically-Assisted Reduction and Internal Fixation of Intra-Articular Fractures of the Lateral Tibial Plateau

Kim Juhan, M.D., Hwi Kim Dong, M.D., Lim Jae-Hwan, M.D., Jang Hyunwoong, M.D., Wook Kim Young, M.D.

Department of Orthopaedic Surgery, Chosun University College of Medicine, Gwangju, Korea

Correspondence to: Dong Hwi Kim, M.D. Department of Orthopaedic Surgery, Chosun University Hospital, 365 Pilmundae-ro, Dong-gu, Gwangju 61453, Korea TEL: +82-62-220-3147 FAX: +82-62-226-3379 E-mail: oskdh@chosun.ac.kr ORCID: https://orcid.org/0000-0001-7011-8504

∗This study was supported by research fund from Chosun University, 2016

Received 22 November 201718 February 2018 Accepted 6 September 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose:

To evaluate the results of tibial lateral plateau fractures using arthroscopic-assisted reduction and internal fixation without cortical window or bone grafts.

Materials and Methods:

From March 2009 to March 2017, 27 patients with Schatzker type II tibial plateau fractures with articular depression and displacement over 5 mm on a computed tomography (CT) scan, who were treated with arthroscopic reduction and internal fixation and followed-up for at least 18 months, were enrolled in this study. Under arthroscopic guidance, the depressed fracture fragment was reduced using a freer and fixed with 5.0 or 6.5 mm cannulated screws through the inframeniscal portal without a cortical window or bone graft. The clinical and radiological results were evaluated using a Rasmussen system. Second look arthroscopy was performed in thirteen patients during the implant removal operation.

Results:

All fractures healed completely with a mean union time of 8.7 weeks (range from 8 to 12 weeks). Twenty four patients had good to excellent clinical results and 25 patients had good to excellent radiological results according to the Rasmussen classification. A well-healed articular surface with fibrocartilage was also found in 13 cases with second look arthroscopy. The 8 cases on CT scan at outpatient department follow-up showed bone union without bone grafting.

Conclusion:

Arthroscopic-assisted fixation of tibial lateral plateau fractures is a useful method without a cortical window or bone graft that produces good clinical results.

Keywords: tibial lateral plateau fracture, arthroscopy, inframeniscal portal, freer elevator, bone graft

References

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Figure 1.

Fragment interfering with the reduction is called a key fragment (thick and short arrows). The landmark of the screw insertion site was the fibular head and Gerdy’s tubercle. The thin and long arrows indicate the direction of screw insertion.

Figure 2.

Arthroscopic findings showed the depressed fracture fragment (A) and depressed fragment reduced using the freer (B). Three arthroscopic portals were used. The anteromedial portal was used for the viewing portal and 2 working (conventional anterolateral, anterolateral infra-meniscal portal) portals were used as the conventional anterolateral portal for inserting the skin hook to retract the anterior horn of lateral meniscus and anterolateral infra-meniscal portal was used to reduce the depressed fragment by the freer and small osteotome.

Figure 3.

(A) Intraoperative fluoroscopic photograph shows a reduction of a tibia plateau fracture using a freer. (B) A guide wire was inserted for fixation of a 5.0 cannulated screw. (C, D) The 5.0 mm cannulated screw with a washer is fixed.

Figure 4.

Second look arthroscopy by the anteromedial portal shows a healed articular surface with fibrocartilage.

Figure 5.

A 47-year-old male with lateral plateau fracture. (A, B) Anteroposterior and lateral radiographs show a lateral tibial plateau fracture. (C, D) Preoperative computed tomography (CT) shows a Schatzker type II plateau fracture. (E, F) Arthroscopy by the anteromedial portal shows a depressed fracture fragment. (G) Arthroscopy-assisted reduction was done. (H) Lateral meniscal injury was found and repaired with absorbable sutures. (I, J) Internal fixation with 5.0 cannulated screws was done. (K, L) Postoperative CT shows an anatomically reduced articular surface.

Table 1.

Patients’ Demographics (n=27)

Case No.	Age (yr)/Sex	Injury mechanism	Schatzker classification	Associated injury	Length of followup (mo)	2nd look arthroscopy	Postoperative follow-up CT
1	53/M	Fall down	II	LM	32		○
2	23/M	MVA	II	-	18
3	60/M	MVA	II	ACL	28
4	55/M	MVA	II	PCL, LM	24
5	53/F	MVA	II	LM	25	○
6	29/M	MVA	II	LM	19
7	56/F	MVA	II	-	19
8	41/M	Sports injury	II	MCL	18
9	47/M	MVA	II	ACL	19
10	45/M	MVA	II	LM	18
11	30/M	MVA	II	LCL	33	○	○
12	53/M	MVA	II	-	25	○	○
13	48/M	MVA	II	LM	37	○
14	56/F	MVA	II	MM	25	○
15	56/F	MVA	II	MCL	29	○
16	58/M	MVA	II	MCL	28	○
17	58/F	MVA	II	MM	28	○	○
18	47/M	MVA	II	MM	21		○
19	40/M	MVA	II	LM	22	○
20	83/F	MVA	II	-	19
21	51/M	Blunt injury	II	LM	24	○
22	46/M	MVA	II	-	22
23	46/M	Blunt injury	II	MM, MCL	23	○	○
24	48/M	Fall down	II	MCL	19
25	54/F	Fall down	II	LM	26	○	○
26	19/M	MVA	II	LM	24	○
27	22/F	MVA	II	LM, MCL	19		○

CT, computed tomography; M, male; F, female; MVA, motor vehicle accident; LM, lateral meniscus; ACL, anterior cruciate ligament; PCL, posterior cruciate ligament; MCL, medial collateral ligament; LCL, lateral collateral ligament; MM, medial meniscus.

Table 2.

Clinical and Radiological Results

Case No.	Time to union (wk)	Postoperative joint step off	Radiographic result	Clinical result	Range of motion (°)	Posttraumatic osteoarthritis change	Complication
1	12		Excellent	Excellent	0–140	×
2	8		Excellent	Excellent	0–140	×
3	8		Excellent	Excellent	0–135	×
4	12		Fair	Fair	25–75	×	Ankyloses Wound infection
5	12	○	Fair	Good	0–135	×
6	10		Excellent	Excellent	0–135	×
7	12		Excellent	Fair	0–140	×
8	9		Excellent	Good	0–140	×
9	8		Excellent	Excellent	0–140	×
10	10		Excellent	Excellent	0–130	×
11	12		Excellent	Excellent	0–135	×
12	12		Excellent	Excellent	0–140	×
13	12		Good	Excellent	0–140	×
14	10		Excellent	Excellent	0–140	×
15	10		Excellent	Good	0–135	×
16	10	○	Good	Good	0–140	×
17	8		Excellent	Excellent	0–140	×
18	10		Excellent	Excellent	0–120	×
19	10		Excellent	Excellent	0–140	×
20	12		Good	Excellent	0–130	×
21	12		Excellent	Fair	0–130	×
22	10		Good	Excellent	0–130	×
23	10		Good	Good	0–140	×
24	10		Excellent	Good	0–135	×
25	8		Excellent	Excellent	0–135	×
26	10		Excellent	Good	0–135	×
27	10		Good	Good	0–135	×

M, male; F, female.

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