Assom, M.

Blonna, D

Castoldi, Filippo

Marmotti, A

Rossi, Roberto

English

Institutional Research Information System University of Turin

TStatcaUHMrAt[Technical NoteArthroscopic Treatment of Lateral Tibial Plateau Fractures: ASimple TechniqueRoberto Rossi, M.D., Filippo Castoldi, M.D., Davide Blonna, M.D.,Antongiulio Marmotti, M.D., and Marco Assom, M.D.Abstract: We present a new technique for arthroscopic-assisted fluoroscopic treatment of externaltibial plateau fractures (Schatzker type I, II, III), using custom-made instrumentation. The instrumentincludes 4 basic elements: 2 cutting guides, a hollow trephine cutter with a saw-toothed tip, and abone plunger. The lateral plateau is restored from the opposite side. An anteromedial rectangularcortical window in the proximal diaphysis of the tibia is created using the cutting guides. To achievethe reduction, the hollow trephine cutter is introduced into the opening created. The bone plunger isinserted into the hollow trephine cutter until resistance is felt. At this point the cancellous bone iscompacted by applying force onto the plunger with the hammer so as to obtain a strong compact bonecarrot. The plunger then pushes it under the depressed area, filling it out and pushing it upward,creating an indirect reduction. The arthroscopy comes into play estimating the precise anatomicreduction of the articular surface of the tibia. No graft is necessary and cannulated lag screws fix andstrengthen the reduction. This new technique is reproducible, easy, less invasive than others, andensures a stable cartilage and subchondral support without the need for grafts. Key Words: Tibialplateau fracture—Arthroscopy—Fluoroscopy—Technique—Surgical instrumentation.fdmttdwrgtTcseibial plateau fractures represent a complex injuryinvolving the weight-bearing surface of the tibia.everal surgical techniques have been described withhe goal of anatomic reduction, rigid internal fixation,nd soft-tissue stability.1-4 As does ours, most surgicalechniques use arthroscopy, which guarantees an ac-urate diagnosis, provides an assessment of the joint,nd follows the reduction, step by step.From the Third Department of Orthopaedics and Traumatology,niversity of Turin Medical School, Mauriziano “Umberto I”ospital, Turin, Italy.Address correspondence and reprint requests to Roberto Rossi,.D., Corso Duca degli Abruzzi 15, 10129 Turin, Italy. E-mail:ossir@fastwebnet.it© 2006 by the Arthroscopy Association of North AmericaCite this article as: Rossi R, Castoldi F, Blonna D, Marmotti A,ssom M. Arthroscopic treatment of lateral tibial plateau frac-ures: a simple technique. Arthroscopy 2006;22:678.e1-678.e6doi:10.1016/j.arthro.2005.09.028].r0749-8063/06/2206-5164$32.00/0doi:10.1016/j.arthro.2005.09.028Arthroscopy: The Journal of Arthroscopic and Related SurHerein, a new, less-invasive surgical technique toacilitate the reduction of the external tibial plateauepression/fractures is proposed. As our experienceade apparent the need to resolve several questions inhis kind of fracture, such as the filling of the defect,he weakening of the lateral pillar, avoiding furtheramage to the vascular supply of the lateral plateau,e created a new technique. This procedure has beenoutinely used in our department since 1998.SURGICAL INSTRUMENTATIONThe instrument includes 4 basic elements: 2 cuttinguides (CGs), a hollow trephine cutter with a saw-oothed tip (HTC), and a bone plunger (BP) (Fig 1).he 2 CGs (10  20 mm), for right and left tibia,reate the window. The CGs have a trapezoid-likehape with 2 small slanting sides, 1 sharp guidingdge, and 1 flat edge. They are used to create aectangular cortical window with 2 small parallel678.e1gery, Vol 22, No 6 (June), 2006: pp 678.e1-678.e6s(cldcHciTrtmsafiohgacispTAaspic elemFtt678.e2 R. ROSSI ET AL.lanting sides for easy refit. The HTC is cylindrical10 mm diameter) with a saw-toothed cutting tip. Itollects cancellous bone along its pathway that will beater compressed into a carrot and plunged under theepressed area. The BP is a solid impactor with aoncave tip, 9 mm in diameter. It glides through theTC and its tip holds, compresses, and drives theancellous bone carrot under the depressed area.SURGICAL TECHNIQUEFirst, operative arthroscopy with 2 anterior portalss performed to address any intra-articular pathology.he hematoma and osteochondral fragments are thenemoved, so the lesion may be assessed and the frac-ure evaluated. The next step is to create an antero-edial rectangular cortical window with slantingFIGURE 1. The custom-made instruments include 4 basiIGURE 2. The anteromedial rectangular cortical window with slanhe first cut in the bone into which the sharp guiding edge of the CG is inhe bone is cut around the guide.ides, using the CG. First a small skin incision is madend the bone exposed. A small saw is used to make therst cut in the bone, into which the sharp guiding edgef the CG is inserted. At this point, the instrument iseld firmly in place and the bone is cut around theuide (Fig 2). The rectangular cortex is then removednd put aside. The HTC is introduced into the openingreated under fluoroscopic guidance (2 views), mov-ng in a distal-proximal direction from the oppositeide of the depression to about 2 cm under the de-ressed area: a cancellous bone carrot is thus obtained.he BP is inserted into the HTC until resistance is felt.t this point, the cancellous bone is compacted bypplying force onto the plunger with a small hammero as to obtain a strong compact bone carrot. Thelunger then pushes it under the depressed area, fillingt out and pushing it upward, creating an indirectents: (A) 2 (right and left) CGs, (B) an HTC, and a BP.es, made using the CG, is created. (A) A small saw is used to maketing sidserted. (B) At this point the instrument is held firmly in place andrpdpaF(T with as e HTC678.e3LATERAL TIBIAL PLATEAU FRACTURESeduction (Fig 3). The whole procedure may be re-eated in a different direction through the same win-IGURE 3. The HTC is introduced into the opening created under fluB) The plunger then pushes it under the depressed area, filling it out ahe cancellous bone is compacted by applying force onto the plungerpecimen). (D) A diagram showing the reduction performed (using thow, if needed. Once again, arthroscopy comes intolay, estimating the precise anatomic reduction of therticular surface of the tibia.pic guidance, obtaining a cancellous bone carrot (cadaver specimen).ing it upward, creating an indirect reduction (fluoroscopic view). (C)small hammer so as to obtain a strong compact bone carrot (cadaverand the BP) indirectly with the bone carrot.oroscond pushLast, once the depression has been adequately re-Fvp678.e4 R. ROSSI ET AL.IGURE 4. Preoperative radiographic findings showing a depressed area of the lateral tibial plateau (A: antero-posterior view; B: lateraliew). (C,D) Postoperative views showing the anatomical reduction of the depressed area fixed with two cannulated screws (C: antero-osterior view; D: lateral view).dra4hrbbtffitscttopstattslBhouotitbfnbmatfbwttaciaacIfopoeapcpdeirmotaftcvsdseetStprC678.e5LATERAL TIBIAL PLATEAU FRACTURESuced, 2 cannulated lag screws are placed to fix theeduction by passing in a lateral to medial direction,pproximately 1 cm below the articular surface (Fig). Postoperative management includes the use of ainged knee brace, allowing for free motion with aange of 0° to 90°. After check-up, partial weightearing is allowed after 8 weeks and a full weightearing after 3 months.DISCUSSIONCurrently, arthroscopic reduction and internal fixa-ion is the gold standard for treatment of tibial plateauracture types I, II, III according to Schatzker classi-cation.2,3,5,6 Several clinical studies have shown thathe use of the arthroscope gives good results, offeringuch advantages as the evacuation of hemarthrosis andhondral debris, visualization of the anatomic reduc-ion, a decreased morbidity, reducing hospitalizationime, and postoperative care as well as the treatmentf associated intra-articular injuries.2-4,6,7 Standardractice for the management of the depression andplit fractures (types I, II, III of Schatzker classifica-ion) of the external tibial plateau use grafts (allograft-utograft-substitute-cement) and fixation to maintainhe reduction. As a rule, the defect is filled with grafts,o improve articular reduction and decrease the risk ofecondary relapse.8 Several studies have been pub-ished describing reductions with or without grafts.9-12eaufils et al.8 state that, although filling the defectas no statistically significant effect on the results, theutcomes are better when filling is performed, partic-larly in Schatzker type II fractures. Indeed, any typef graft is able to fill the defect. However, we are ofhe opinion that autograft should be the first choice.In the technique herein described, although the grafts taken from the tibia itself, it is far from and con-ralateral (medial) to the fracture side. A cancellousone carrot large enough to fill the defect and raise theracture is obtained by repeating the procedure ifecessary, through 1 anteromedial window 10 cmelow the articular surface of the tibia (Fig 3D). Inost of the surgical techniques described in the liter-ture, the reduction is performed through the pillar athe same side of the fracture.1,2,13However, this lateral approach may well not onlyurther weaken the fractured meta-epiphysis plateauut also compromise its vascular supply.11 That ishy we asked ourselves: “why should we compromisehe wall just to raise the ceiling?” So we chose to leavehe lateral pillar intact by using a medial approach toccess the lateral plateau. Research was carried out onadaver specimens to determine the best access pointnto the lateral tibial plateau. It was seen that a medialpproach offered easy access for the reduction andllowed for the collection of a large quantity of can-ellous bone without harming the lateral structures.ndeed, after the tibia had been divided along therontal plane, it was possible to see the exact amountf impacted cancellous bone relocated under the de-ression. The site of the cortical window allowed us tobtain a long cancellous bone carrot of about 10 cm atach procedure. The BP collects the cancellous bonelong its path, reducing it into 2 cm of strong com-acted bone carrot, which because of its biomechani-al properties is able to support and reduce the de-ressed area well (Fig 3C).The HTC device comes in only 1 size (10-mmiameter) to fit into the cortical window without weak-ning the proximal anteromedial diaphysis of the tibia,.e., a larger diameter might well compromise andeduce the maneuverability of the plunger inside theeta-diaphyseal portion of the tibia. With the aim tobtain an indirect reduction, the BP is stopped beforehe articular surface so to fill and raise the depressedrea with the bone carrot. Therefore, there is no needor a precise positioning of the BP under the fracture,hus eliminating the need for any kind of anteriorruciate ligament guide. The fluoroscopic guidance (2iews) makes visibility of the maneuver easy andecure. The cortical window is created directly on theiaphysis of the tibia only to be repositioned afterurgery with a press-fit procedure, thanks to its geom-try (Fig 4B). Therefore, on the basis of our personalxperience and to the best of our knowledge, this ishe first time a safe and reproducible reduction ofchatzker type I, II, and III fractures has been ob-ained with this technique.Acknowledgment: The authors thank the following peo-le for the critical and specialist support: for editing andeviewing, Barbara Wade, and for the line drawing, Annaasalone.REFERENCES1. Whittle AP. Fractures of lower extremity. In: Canale T, ed.Operative Orthopaedics. Philadelphia: Mosby, 1998;2094-2111.2. Buchko GM, Johnson DH. Arthroscopy assisted operativemanagement of tibial plateau fractures. Clin Orthop Rel Res1996;332:29-36.3. Jennings JE. Arthroscopic management of tibial plateau frac-tures. Arthroscopy 1985;1:160-168.4. Lubowitz JH, Elson WS, Guttmann D. Part I: Arthroscopicmanagement of tibial plateau fractures. Arthroscopy 2004;20:1063-1070.1111678.e6 R. ROSSI ET AL.5. Caspari RB, Hutton PM, Whipple TL, Meyers JF. The role ofarthroscopy in the management of tibial plateau fractures.Arthroscopy 1985;1:76-82.6. Gill TJ, Moezzi DM, Oates KM, Sterett WI. Arthroscopicreduction and internal fixation of tibial plateau fractures inskiing. Clin Orthop Rel Res 2001;383:243-249.7. McClellan RT, Comstock CP. Evaluation and treatment oftibial plateau fractures. Curr Opin Orthop 1999;10:10-21.8. Beaufils P, Hardy P, Cassard X, et al. Arthroscopic treatmentof intra-articular fractures of the knee. Eur Instr Course Lect2001;5:46-53.9. Fowble CD, Zimmer JW, Schepsis AS. The role of arthros-copy in the assessment and treatment of tibial plateau frac-tures. Arthroscopy 1993;9:584-590.0. Cassard X, Beaufils P, Blin JL, Hardy P. Osteosynthesis underarthroscopic control of separated tibial plateau fracture: 26case reports. Rev Chir Orthop 1999;85:257-266.1. Beaufils P, Hardy P, Cassard X. Arthroscopic treatment ofintra-articular fractures of the knee. In: Thorngren KG, Sou-cacos PN, Horan F, Scott J, eds. European InstructionalCourse Lectures Vol 5. London: The British Editorial Societyof Bone and Joint Surgery;2001:46-53.2. Itokazu M, Matsunaga T. Arthroscopic restoration of de-pressed tibial plateau using bone and hydroxyapatite grafts.Arthroscopy 1993;9:103-108.3. Suganumma J, Akutsu S. Arthroscopically assisted treat-ment of tibial plateau fractures. Arthroscopy 2004;10:1084-1089.

Arthroscopic Treatment of Lateral Tibial Plateau Fractures: A Simple Technique

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Arthroscopic Treatment of Lateral Tibial Plateau Fractures: A Simple Technique

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