Session I - Tibia Fractures

*Closed Reduction /Percutaneous Fixation of Tibial Plateau Fractures - Arthroscopic versus Fluoroscopic Control of Reduction

Philipp Lobenhoffer, MD, M. Schulze, MD, T. Gerich, MD, C. Lattermann, MD, H. Tscherne, MD

Unfallchirurgische Klinik-Hannover Medical School, Hannover, Germany

Purpose of Study: Percutaneous reduction and fixation techniques gain importance in cases of tibial plateau fractures. Two techniques can be used to guide and control intraarticular reduction: arthroscopy and fluoroscopy. Arthroscopy may cause significant fluid extravasation in acute fractures and is difficult to perform. Fluoroscopic control has been critisized to be less precise than other techniques. This study compares the quality of reduction and the mid-term results of two patient groups with monocondylar tibial plateau fracture treated by percutaneous screw fixation after either arthroscopic reduction or reduction under fluoroscopic control.

Material and Methods: Thirty-three consecutive patients entered a prospective study. Inclusion criteria was a monocondylar tibial plateau fracture (41-B1 and B2) requiring operative reduction and suitable for closed reduction/fixation technique. Exclusion criteria were polytrauma and open fracture reduction. The first 10 patients had arthroscopy of the joint using standard videoarthroscopic techniques, a flow/pressure controlled fluid pump and a motorized shaver system. The fracture was reduced by a percutaneous clamp or an elevator inserted under the depression zone via a bone tunnel. An ACL drill guide system and cannulated reamers were used to create this tunnel. Homologous bone graft was pushed into this tunnel if necessary and 7.0 mm. cannulated screws were used for fixation. Their position was controlled by fluoroscopy at the end of the procedure. The following 23 patients were operated on a standard table using a high-resolution image intensifier to control fracture reduction. Percutaneous clamps or an elevator were used for reduction and screws were placed analogous to the first group. The rehabilitation protocol was similar for both groups with early passive and active motion and partial weight-bearing. Full weight-bearing was allowed 6 to 9 weeks after the operation depending on radiographic healing. All patients had pre- and postoperative radiographs and tomographies or CT-scans. Follow-up evaluations included Lysholm and Courvoisier scores, radiographs and clinical evaluations. The mean age of the group was 49 years (15 - 66), 19 female and 14 male patients were studied. Intra-and postoperative data were achieved from all 33 patients, follow-up data are presented from all 21 patients who have a follow-up time of more than 1 year. Age, sex and fracture pattern did not differ in the two groups.

Results: Arthroscopic reduction: No significant technical problems or complications were recorded. Intraoperative reduction was graded anatomically in 9 of 10 patients. No additional intraarticular lesions were addressed by arthroscopy. Mean follow-up time was 40 months in the 9 patients followed more than one year. Results were excellent in 8 of 9 patients (Courvoisier >40 points of 44 possible points, Lysholm > 90 of 100 poss. points). Range-of-motion was free in all these patients, only minor signs of osteoarthritis were recorded. One patient had an unreduced depression zone laterally on postoperative radiographs, developed osteoarthritis and had revision surgery with a total knee.

Flouroscopic reduction: Reduction was possible in all 23 patients and was graded anatomically in all cases. 12 cases were followed more than one year (mean follow-up 30 months). Eleven of 12 cases had an excellent clinical and radiological result (Courvoisier > 40, Lysholm > 90). No meniscus lesion and no ligamentous instability was found during the follow-up period, no revision surgery was performed in these patients. One case with a B1 fracture laterally graded as anatomical healing claimed chronic lateral pain and had arthroscopy which failed to reveal any pathological finding.

Discussion: Reduction under fluoroscopic control achieved the same quality of result as arthroscopically guided reduction, but was easier and faster to perform. Follow-up examinations of this patient group for 30 months did not reveal any overlooked pathology, clinical and radiological results were comparable to the group operated arthroscopically. The benefit of the additional joint inspection by arthroscopy in monocondylar tibial plateau fracture thus is debatable.

Conclusion: The role of arthroscopy in the treatment of certain types of tibial plateau fractures must be questioned. Reduction of monocondylar tibial plateau fractures under fluoroscopic control with percutaneous fixation is an attractive alternative to arthroscopically guided reduction especially in the multiple injured patient and in cases with serial fractures of the lower extremity.