Systematic Review
Arthroscopy-Assisted Surgery for Tibial Plateau Fractures Xing-zuo Chen, M.D., Cheng-gang Liu, M.D., Ying Chen, M.D., Li-qiang Wang, M.D., Qian-zheng Zhu, M.D., and Peng Lin, M.D.
Purpose: This study aimed to summarize the recent clinical outcomes of patients undergoing arthroscopy-assisted reduction and internal fixation (ARIF) for tibial plateau fractures. Methods: A systematic electronic search of the PubMed and Cochrane databases was performed in January 2014. All English-language clinical studies on tibial plateau fractures treated with ARIF that were published after January 1, 2000 were eligible for inclusion. Basic information related to the surgery was collected. Results: The search criteria initially identified 141 articles, and 19 studies were included in this systematic review. There were 2 retrospective comparative studies, 16 case series studies, and one clinical series based on a technique note. There were a total of 609 patients in this systematic review, with a mean follow-up time of 52.5 months. The most common fracture types were Schatzker types II and III. Concomitant injuries were common: 42.2% of the patients had meniscal injuries, and 21.3% had anterior cruciate ligament (ACL) injuries. In addition, the status of 90.5% of the patients was classified as good or excellent according to the clinical Rasmussen scoring system, and 90.9% of the patients were satisfied with the treatment. Only 6 severe complications were reported, including one case of compartment syndrome. Conclusions: ARIF is a reliable, effective, and safe method for the treatment of tibial plateau fractures, especially when they present with concomitant injuries. Level of Evidence: Level IV, systematic review of Level III and Level IV studies.
T
ibial plateau fractures represent approximately 1% of all fractures.1-10 Management of these fractures can be challenging for orthopaedic surgeons. If not treated properly, these fractures may lead to malfunctioning of the injured knee. Successful results depend on anatomic reduction, restoration of ligamentous stability, treatment of concomitant injures, and preservation of the soft tissue envelope.2-4,8,10-13 Traditional open reduction and internal fixation (ORIF) requires extensive soft tissue dissection, which may lead to numerous complications and risks such as wound healing, infection, and arthritis2,10,12,14 Additionally, intra-articular lesions such as meniscus or anterior cruciate ligament (ACL) injuries cannot be diagnosed and treated properly because of limited exposure. Arthroscopy-assisted reduction and internal fixation (ARIF) in the treatment of tibial plateau fractures was first
From Orthopaedic Trauma Department, China-Japan Friendship Hospital, Beijing, China. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received March 11, 2014; accepted June 2, 2014. Address correspondence to Peng Lin, M.D., Orthopaedic Trauma Department, China-Japan Friendship Hospital, No. 2, Ying Hua East Street, Chao Yang District, 10029 Beijing, China. E-mail: [email protected] Ó 2015 by the Arthroscopy Association of North America 0749-8063/14200/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.06.005
introduced by Caspari et al.15 and Jennings16 in the 1980s. Currently, ARIF is being widely used in the treatment of tibial plateau fractures.6-12,14,17-28 ARIF has shown various advantages over traditional ORIF regarding accurate reduction monitoring by direct visualization, lower morbidity because it is a minimally invasive procedure, and simplified diagnosis and treatment of intra-articular lesions. Recent literature6-12,14,17-28 has reported good short- to medium-term functional and radiologic results. However, whether ARIF will achieve better clinical results than ORIF is still under debate. ARIF has also been suggested as a potential risk factor for compartment syndrome during arthroscopic examination or treatment.1,2,8,10-12,18 The purpose of this systematic review was to summarize the recent clinical outcomes of patients undergoing ARIF for tibial plateau fractures. Our hypothesis was that ARIF is an effective method for the treatment of tibial plateau fractures.
Methods Literature Search A systematic electronic search of the PubMed and Cochrane databases was performed on January 10, 2014 for all published literature. The following key phrases were used in the title or abstract fields: [(tibial plateau) OR (proximal tibia*)] AND fracture* AND
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[(arthroscop*) OR (ARIF)]. In addition, we also searched major American and European orthopaedic journals for relevant articles. The inclusion criteria included the following: tibial plateau fractures treated with ARIF, clinical research, a mean follow-up time of no less than 24 months or a minimum follow-up of no less than 12 months, articles written in English, and articles published after January 1, 2000. The exclusion criteria included the following: tibial plateau fractures treated without arthroscopy and internal fixation; study focused only on ACL avulsion; biomechanical studies or radiologic studies; a mean follow-up time of less than 24 months and a minimal follow-up time of less than 12 months; case reports, reviews, meta-analyses, letters to editors, and technique notes; noneEnglish-language articles; and articles published before January 1, 2000. All articles generally were independently reviewed by 2 reviewers (X-Z.C., Q-Z.Z.) according to the inclusion and exclusion criteria. The full text of all the relevant studies was obtained and reviewed. Reference lists of all full-text articles were checked manually to identify additional potential articles for inclusion. Any disagreement between the 2 reviewers was settled by another senior reviewer (P.L.). The level of evidence was also determined according to the Oxford Levels of Evidence produced by the Oxford Centre for EvidenceBased Medicine.
included in this systematic review. Specifically, there were 2 Level III retrospective comparative studies,11,24 16 Level IV case series studies,6-10,12,14,18-21,23,25-28 and one clinical series based on a technique note.22 No prospective studies were identified. The mean modified CMS value was 68 (range, 59 to 79). The features and modified CMS values of each study are shown in Table 1.
Quality Assessment In a manner similar to that of Song et al.,29 we assessed the methodological quality of the articles by using the modified Coleman Methodology Score (CMS).30 Ten criteria are used to score a study, and a perfect score of 100 represents a study design that largely avoids the influences of chance, various biases, and confounding factors.
Surgical Information Among the 19 studies, only screws were used in 8 studies,6,7,9,18,22,23,25,28 only buttress plates were used in 3 studies,8,10,12 and both screws and buttress plates were used in 8 studies.11,14,19-21,24,26,27 A total of 346 patients were treated with screws only, 207 patients were treated with buttress plates or screws (or both), 11 patients obtained no internal fixation, and an additional 6 patients underwent external fixation (Table 3). A total of 241 patients (40.0%) underwent bone grafting to maintain reduction of the tibial plateau, including autografts7,8,10-12,19-21,24,27 (mostly iliac bone graft), allografts,10,18,22,28 and bone substitutes.7,19,23,26
Data Extraction The following data were extracted from the eligible articles: basic information about the article; number, sex, and mean age of the patients; mean and minimal followup times; classification of fractures and the numbers of each type; internal fixation methods; whether bone grafting was used; clinical scoring system and subjective satisfaction; range of motion of the joints; radiologic evaluations, including degree of articular depression; concomitant injuries; and complications.
Results Literature Search and Quality Assessment The search initially identified 141 articles for potential inclusion according to the criteria. After detailed assessment of all references, subsequent screening, and quality assessment (Fig 1), a total of 19 studies6-12,14,18-28 were
Patient Characteristics A total of 609 patients (610 knees) completed the last follow-up, 323 of whom were male patients and 286 of whom were female patients (Table 2). The mean age was 46.0 years old (range, 13 to 92 years); there was one study19 that focused only on patients older than 55 years. The mean follow-up time was 52.5 months (range, 12 to 138 months). All the studies except one21 used the Schatzker classification system. Based on the Schatzker classification system, the numbers of patients in each category were as follows: 62 patients with Schatzker type I fractures (lateral split), 195 patients with Schatzker type II fractures (lateral split with depression), 156 patients with Schatzker type III fractures (pure depression of the lateral plateau), 69 patients with Schatzker type IV fractures (medial plateau fracture), 46 patients with Schatzker type V fractures (bicondylar fracture), and 54 patients with type VI fractures (plateau fracture with separated metaphysis).
Clinical Evaluation Different types of rating systems were used to evaluate the clinical results of ARIF for tibial plateau fractures; 14 of the 19 studies6-8,12,14,18-20,22-25,27,28 used the clinical Rasmussen scoring system, which is widely used in studies focused on tibial plateau fractures. In addition, 90.5% (range, 80.0 to 100.0%) of the patients had classifications of good or excellent according to the clinical Rasmussen score, and 90.9% (range, 77.8 to 100%) of the patients were satisfied with the treatment. The range of motion of the injured knee was reported in 11 studies,7,8,10-12,14,18,22,23,25,26 and at least 32 patients did not regain a full range of motion (Table 4).
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Fig 1. Flowchart of study selection. (ACL, anterior cruciate ligament; ORIF, open reduction and internal fixation).
Table 1. Summary of Study Features and Quality Assessment Author Asik et al.20 Chan et al.12 Chan et al.8 Chiu et al.14 Dall’Oca et al.24
Year 2002 2003 2008 2013 2012
Di Caprio et al.9 Duan et al.25 Gill et al.23 Glabbeek et al.28 Hung et al.10 Horstmann et al.26 Kayali et al.18 Kiefer et al.21 Levy et al.22 Ohdera et al.11
2010 2008 2001 2002 2003 2003 2008 2001 2008 2003
Pogliacomi et al.27 Roerdink et al.19 Rossi et al.6 Siegler et al.7
2005 2001 2008 2011
Type of Study Case series Case series Case series Case series Retrospective comparative study Case series Case series Case series Case series Case series Case series Case series Case series Case series Retrospective comparative study Case series Case series Case series Case series
CMS, Coleman Methodology Score.
Level of Evidence IV IV IV IV III
Journal Knee Surgery, Sports Traumatology, Arthroscopy Arthroscopy Arthroscopy Arthroscopy Strategies in Trauma and Limb Reconstruction
CMS 71 67 79 71 77
IV IV IV IV IV IV IV IV IV III
The Journal of Bone & Joint Surgery, American Edition Chinese Journal of Traumatology Clinical Orthopaedics and Related Research Acta Orthopadica Belgica The Journal of Trauma Injury Canadian Journal of Surgery Knee Surgery, Sports Traumatology, Arthroscopy The Journal of Orthopaedic Trauma Archives of Orthopaedic and Trauma Surgery
68 65 65 68 71 59 71 63 67 63
IV IV IV IV
Acta Bio Medica Arthroscopy The Knee Orthopaedics & Traumatology: Surgery & Research
64 65 71 68
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Table 2. Patient Characteristics Involved in the Systematic Review Author Asik et al.20 Chan et al.12 Chan et al.8 Chiu et al.14 Dall’Oca et al.24
Pogliacomi et al.27 Roerdink et al.19 Rossi et al.6 Siegler et al.7
Fracture Classification Schatzker I Schatzker II Schatzker III Schatzker IV Schatzker V Schatzker VI Schatzker 5 18 12 6 3 2 Schatzker 0 0 0 0 11 7 Schatzker 1 21 4 10 8 10 Schatzker 0 0 0 5 2 18 Schatzker ARIF: 4 ARIF: 7 ARIF: 26 ARIF: 5 ARIF: 4 ARIF: 4 ORIF: 10 ORIF: 5 ORIF: 18 ORIF: 3 ORIF: 8 ORIF: 6 Schatzker 5 9 0 7 0 0 Schatzker 4 12 9 12 2 0 Schatzker 2 5 16 2 0 0 Schatzker 7 10 0 2 1 0 Schatzker 1 9 7 9 3 2 Schatzker 0 7 4 0 0 3 Schatzker 7 10 4 0 0 0 AO NA NA NA NA NA NA Schatzker 0 16 0 0 0 0 Schatzker 0 ARIF: 10 ARIF: 9 0 0 0 ORIF: 5 ORIF: 4 Schatzker 4 6 6 2 0 0 Schatzker 6 13 5 3 2 1 Schatzker 0 19 27 0 0 0 Schatzker NA NA NA 0 0 0
AO, Association for the Study of Internal Fixation; ARIF, arthroscopy-assisted reduction and internal fixation; NA, not available; ORIF, open reduction and internal fixation.
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Di Caprio et al.9 Duan et al.25 Gill et al.23 Glabbeek et al.28 Hung et al.10 Horstmann et al.26 Kayali et al.18 Kiefer et al.21 Levy et al.22 Ohdera et al.11
Number of Mean Mean Minimum Patients Sex (M/F) Age (y) Follow-up (mo) Follow-up (mo) 45 (46 knees) 34/11 39.0 36 12 18 12/6 35.0 48 39 54 25/29 48.0 87 22 25 15/10 46.0 86 60 ARIF: 50 ARIF: 23/27 51.0 73 12 ORIF: 50 ORIF: 31/19 21 9/12 20.8 80 60 39 28/11 35.9 34 12 25 10/15 45.2 24 12 20 12/8 49.0 39 27 31 19/12 46.9 36 24 14 4/10 53.0 28 18 21 14/7 41.0 38 12 31 17/14 47.4 25.1 15 16 7/9 44.8 41 12 ARIF: 19 ARIF: 5/14 ARIF: 47.5 ARIF: 22 ARIF: 12 ORIF: 9 ORIF: 4/5 ORIF: 51.5 ORIF: 51.7 ORIF: 32 18 13/5 36.0 NA 12 30 3/27 72.0 36 24 46 21/25 48.0 60 NA 27 (21 finished 17/10 45 59.5 24 follow-up)
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ARTHROSCOPY ASSISTED TIBIAL PLATEAU FRACTURES Table 3. Surgical Information Involved in the Systematic Review Author Asik et al.20
Type of Internal Fixation Plate or screw, or both
Chan et al.12 Chan et al.8 Chiu et al.14 Dall’Oca et al.24
Plate Plate Plate and screw Plate or screw (or both) external fixation
Di Caprio et al.9 Duan et al.25 Gill et al.23 Glabbeek et al.28 Hung et al.10 Horstmann et al.26
Screw Screw Screw Screw Plate Plate or screw, or both
Kayali et al.18 Kiefer et al.21
Screw Plate or screw, or both
Levy et al.22 Ohdera et al.11
Screw Plate or screw, or both
Pogliacomi et al.27
Plate or screw, or both
Roerdink et al.19 Rossi et al.6 Siegler et al.7
Plate or screw, or both Screw Screw
Number of Internal Fixations SO: 36 Combined: 10 18 54 25 SO: 38 Combined: 56 External fixation: 6 21 39 25 20 31 No fixation: 2 SO: 8 Combined: 4 21 No fixation: 2 SO: 28 Combined: 1 16 No fixation: 7 SO: 15 Combined: 6 SO: 16 Combined: 2 NA 46 27
Bone Graft Auto
Number of Bone Grafts 27
Percentage 58.7
Auto Auto NA Auto
18 53 NA 3
100.0 98.2 NA 3.0
Not used NA BS Allo Auto or Allo, or both BS
Not used NA 17 NA 25 14
Not used NA 68.0 NA 80.7 100.0
Allo Auto
14 9
66.7 29.0
Allo Auto
16 25
100.0 89.3
Auto
2
11.1
Auto or BS Not used Auto and BS
12 Not used 6
40.0 Not used 22.2
Allo, allograft; Auto, autograft; BS, bone substitute; NA, not available; SO, screw only.
Radiologic Evaluation Postoperative radiologic evaluation included 2 parts: depression of the articular surface and osteoarthritic degeneration. The evaluating systems used were the radiologic Rasmussen scoring system (10 of 19 studies6-8,12,14,18,19,22,24,27) and the Ahlbäck scale, which was used for osteoarthritic changes only (6 of 19 studies8,10,12,14,18,27). Depression of the fracture of no less than 2 mm was considered a displacement postoperatively and occurred in at least 30 patients. At least 9 patients exhibited an articular surface depression of more than 4 mm, and 25.9% (range, 3.2% to 63.0%) of the patients presented with osteoarthritis postoperatively (Table 5). Concomitant Injury and Complications Meniscus and ACL injuries were the most common combined soft tissue injuries reported in 18 of 19 studies.6-12,14,18-25,27,28 A total of 236 patients (42.2%) also had meniscal injuries and 119 patients (21.3%) also had ACL injuries. For meniscal injuries, 104 (44.1%) were repaired during the first operation. Most ACL midsubstance injuries were not operated on in the same procedure; however, ACL bony avulsions were treated with arthroscopy-assisted fixation during the same operation6,8,9,12,14,22 (Table 6).
There were a total of 41 patients with complications that did not include knee stiffness and articular surface depression (mentioned earlier). There were 6 cases of severe complications, which were reported in 3 studies20,21,24 and included one case of compartment syndrome, 3 cases of deep infection and 2 cases of deep venous thrombosis. No amputations or life-threatening diseases were reported.
Discussion Clinical Findings Previous studies3,4,10-13 have shown that restoration of articular congruity and residual laxity of the knee after treatment of tibial plateau fractures were 2 of the most important predictors of future knee function. Long-term consequences have relied more on anatomic reduction of the articular surface.7 Traditional ORIF for tibial plateau fractures has several disadvantages. Arthrotomy and transection of the meniscus have to be performed during ORIF to achieve better visualization of the displaced articular surface, which may lead to stiffness, proprioception disorders, severe postoperative pain, and wound complications.11,18,19 Moreover, a higher complication rate was reported because of extensive dissection of the soft
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Table 4. Clinical Evaluation Involved in the Systematic Review Author Asik et al.20 Chan et al.12 Chan et al.8 Chiu et al.14 Dall’Oca et al.24
Clinical Rating System Rasmussen score Rasmussen score Rasmussen score Rasmussen score Rasmussen score HSS
Di Caprio et al.9 Duan et al.25 Gill et al.23 Glabbeek et al.28 Hung et al.10 Horstmann et al.26 Kayali et al.18 Kiefer et al.21
IKDC Rasmussen score Rasmussen score Rasmussen score HSS Lysholm score Rasmussen score Lysholm score
Levy et al.22 Ohdera et al.11
Rasmussen score Hohl and Delamarter score Hohl score Rasmussen score Rasmussen score Rasmussen score HSS KSS Rasmussen score Lysholm score KSS
Pogliacomi et al.27 Roerdink et al.19 Rossi et al.6
Siegler et al.7
Objective Satisfaction* 89.0% 88.9% 96.3% 92.0% ARIF: 27.6 of 30 76.4 of 100 ORIF: 26.8 of 30 73.1 of 100 86.0% 92.3% 27.5 of 30 90.0% 93.5% 57.1% 90.0% NA
100.0% ARIF: 94.3 of 100 ORIF: 89.7 of 100 83.3% 83.3% 80.0% 28.2/30 93.0% 100.0% 25.5 of 30 86.0 of 100 85.2 of 100
Subjective Satisfaction NA 88.9% 96.3% 92.0% NA
NA 84.6% 92.0% 90.0% 93.5% 85.7% 100.0% 90.3%
NA NA 77.8%
ROM (Extension-flexion) NA 2 -130 ; 2 patients had extension lag > 10 1 -130 ; 2 patients had extension lag > 10 1 -125 ; 2 patients had extension lag > 10 NA
1 patient had extension deficit 1.6 -130 1.5 -95.2 ; 2 patients had extension lag > 10 NA 1.5 -135 0 -140 ; 1 patient had extension lag > 15 Extension 131 3 patients had isolated extension deficit; 5 patients had isolated flexion deficit; 4 patients had combined deficit 0.3 -142 ARIF: 0.7 -151.3 ; 3 patients had extension deficit ORIF: 0.5 -148.9 ; 4 patients had extension deficit 1 patient did not have full ROM
NA NA
NA NA
NA
1.4 -131.3 ; 2 patients had knee stiffness
ARIF, arthroscopy-assisted reduction and internal fixation; HSS, Hospital for Special Surgery score; IKDC, International Knee Documentation Committee form; KSS, Knee Society Score; NA, not available; ORIF, open reduction and internal fixation; ROM, range of motion. *Some studies offered only the mean score of the rating system; for those, the table describes it as mean score of full score.
tissue around the knee.2,10,12,14 Conversely, satisfactory short- to medium-term clinical and radiologic results of ARIF have been reported based on some recent studies.6-12,14,18-28 ARIF has shown various advantages over traditional ORIF regarding accurate monitoring of the reduction by direct visualization, lower morbidity resulting from the minimal invasiveness of the procedure, and simplified diagnosis and treatment of intraarticular lesions. According to this systematic review, 90.5% of the patients had classifications of good or excellent according to the clinical Rasmussen score, and 90.9% of the patients were satisfied with the treatment. Schatzker types II and III were the most common types of tibial plateau fractures (Table 2). With depression of the articular surface, it is important to restore and maintain the anatomic structure of the knee, which could be held up with or without bone grafting. Roerdink et al.19 reported on 30 patients who were older than 55 years and were treated with ARIF for tibial plateau fractures; 12 of these patients underwent additional bone grafting, whereas in the others, neither bone cement nor a bone graft was used. Secondary displacement occurred postoperatively in 9 patients, within an
average time of 9 weeks. This occurred in only one patient (8%) who was treated with bone substitution and in 8 patients (44%) who were not. The difference is statistically significant. Burdin1 suggested that bone grafting should be performed in patients older than 55 years of age and in those with marked osteoporosis, who were at increased risk for secondary depression. In addition, bone grafting appeared to be preferable when the depression was greater than 6 mm. However, a different surgical technique was introduced by Rossi et al.6,31 and Levy et al.22 Instead of a common anterolateral cortical window, a lower anteromedial cortical window was created. This surgical technique allowed these fractures to be approached from a medial window, which provided a longer tunnel for subchondral support and did not cause more injury to the lateral column, which was already broken (for Schatzker types II and III). Rossi et al.6 reported that 46 patients with Schatzker type II and type III fractures underwent ARIF in which a compacted “cancellous bone graft” that was obtained from the medial metaphyseal side of the tibia was used without bone grafting. With a mean follow-up of 5 years, depression of the articular surface decreased
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Table 5. Radiologic Evaluation Involved in the Systematic Review Author Asik et al.20 Chan et al.12
Reduction Evaluation NA Rasmussen score
Excellent and Good* NA 89.0%
Chan et al.8
Rasmussen score
96.3%
Chiu et al.14 Dall’Oca et al.24
Rasmussen score Rasmussen score
Di Caprio et al.9
NA
96.0% ARIF: 16.6 of 18 ORIF: 15.9 of 18 NA
Duan et al.25
NA
NA
Gill et al.23
NA
NA
Glabbeek et al.28 Hung et al.10
NA NA
NA NA
Horstmann et al.26
NA
NA
Kayali et al.18 Kiefer et al.21 Levy et al.22
Rasmussen score NA Rasmussen score
Ohdera et al.11
NA
Pogliacomi et al.27 Roerdink et al.19
Rasmussen score Rasmussen score
66.6% 46.7%
Rossi et al.6 Siegler et al.7
Rasmussen score Rasmussen score
96.0% 8 of 18
86.0% NA 100.0%
NA
Articular Depression (Preoperatively/Postoperatively) 11 knees; 0-2 mm depression 14.2 mm/0.2 mm; 2 cases, 2 mm depression; 1 case, 3 mm depression 13.7 mm/0.3 mm; 1 case, 4-mm depression 16.8 mm/0.5 mm; 3 cases NA
Osteoarthritis Evaluation Resnick and Niwoyama criteria Ahlbäck scale for osteoarthritis
Percentage 63.0% 16.7%
Ahlbäck scale for osteoarthritis
19.0%
Ahlbäck scale for osteoarthritis NA
24.0% NA
8.0 mm/0.7 mm, 1 case, 4-mm depression NA
NA
NA
NA
7.7 mm/0.8 mm; 1 case, 4 mm depression; 1 case, 5-mm depression NA 9.2 mm/0.2 mm; 1 case, 4-mm depression 1 case, 10 mm depression; 1 case, 12-mm depression 2 cases 4 cases Postoperative depression, 0.6 mm; 3 cases, 2 mm depression; 1 case, 4 mm depression NA
NA
No severe osteoarthritis NA
1 case, 5-mm depression 9 cases; secondary displacement 8.3 mm/1.1 mm 4 cases; secondary compression
NA Ahlbäck scale for osteoarthritis
NA 3.2%
NA
NA
Ahlbäck scale for osteoarthritis NA NA
NA Ahlbäck scale for osteoarthritis Resnick and Niwoyama criteria NA NA
24.0% 12.9% 12.5%
ARIF: 15.8% ORIF: 77.8% 27.8% 53.3% 8.6% 47.6%
ARIF, arthroscopy-assisted reduction and internal fixation; NA, not available; ORIF, open reduction and internal fixation. *Some studies offered only the mean score of the rating system; for those, the table described it as mean score of full score.
from 8.3 mm (preoperatively) to 1.1 mm. The authors suggested that when the bone quality was good and there was no metaphyseal comminution, this technique is a reliable treatment option for Schatzker types II and III lateral plateau fractures. Postoperative osteoarthritis can be affected by several factors, including degree of articular step-off, alignment of the lower limb, integrity of the meniscus, and age of the patient.11,12,19 It also negatively influences clinical results whether it occurs preoperatively or postoperatively. Siegler et al.7 noted those patients with pre-existing osteoarthritis who undergo surgery after 60 years of age presented less favorable results. In the Roerdink et al.19 study, 53.3% of the patients had preexisting osteoarthritis. In only 80% of the patients was the clinical Rasmussen score rated as excellent or good, which was lower than in other studies. Cetik et al.3 applied second-look arthroscopy in 12 patients who had already been treated with ARIF for tibial plateau fractures. Hyaline cartilage in 9 patients who did not
have step-off was clearly observed on the fracture line. However, 3 patients who had a depression of 3 mm, 3 mm, and 2 mm, respectively, all had chondral defects on the tibial plateau or the femoral condyle, or both. Concomitant Injuries One of the greatest strengths of ARIF for tibial plateau fractures is that it facilitates a thorough evaluation of the associated soft tissue injuries inside the knee and treatment of these injuries during the same surgical procedure. Inappropriate treatment of the soft tissue injuries would have a negative influence on long-term clinical results.2-4,8,10-14,32 According to our systematic review, meniscal tears could be noted in 42.2% of all tibial plateau fractures (Table 6). The most common types of meniscal tears were peripheral tears and radial tears. Unstable meniscal tears can lead to pain and locking of the knee.33 In addition, patients may benefit from the chondroprotective effect of an intact meniscus. It is important to make a better
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Table 6. Soft Tissue Injury and Complications Involved in the Systematic Review Author Asik et al.20
Soft Tissue Injury (%) NA
Meniscal Injury (%) 51.0
Chan et al.12
72.0
61.0
Chan et al.8
65.0
38.8
Chiu et al.14
92.0
64.0
Dall’Oca et al.24
69.0
57.0
Di Caprio et al.9 Duan et al.25
100.0 NA
19.1 48.7
Gill et al.23
64.0
32.0
Glabbeek et al.28
50.0
35.0
Hung et al.10
52.0
44.0
Horstmann et al.26 Kayali et al.18
NA 67.0
NA 47.6
Kiefer et al.21
NA
13.0
56.3 ARIF: 57.9
56.3 ARIF: 57.9
Pogliacomi et al.27 Roerdink et al.19 Rossi et al.6
33.3 46.0 NA
22.2 40.0 28.0
Siegler et al.7
33.3
NA
Levy et al.22 Ohdera et al.11
Meniscus Management Repair: 7 Resection: 16 Repair: 11 Resection: 2 Repair: 15 Resection: 7
ACL Injury (%) 6.0
Repair: 13 Resection: 3 Repair: 32 Resection: 25
68.0
Resection: 4 Repair: 5 Resection: 14 Repair: 3 Resection: 1 Not treated: 4 Repair: 1 Resection: 6 Repair: 5 Resection: 2 NA Repair: 1 Resection: 8 Repair: 2 Resection: 2 Resection: 9 Repair: 4 Resection: 2 Not treated: 5 Resection: 4 NA Repair: 5 Resection: 8 Resection: 2
100.0 28.0
22.0 30.0
17.0
Complication (Except Knee Stiffness and Articular Surface Depression) 1 case of deep infection 1 case of wound dehiscence; 2 cases of paresthesia over the lateral calf 4 cases of wound dehiscence; 5 cases of paresthesia over the lateral calf; 1 case of loose body 1 case of wound dehiscence; 5 cases of paresthesia over the lateral calf ARIF: 1 case DVT; 1 case severe OA ORIF: 1 case of DVT; 2 cases of severe OA; 2 cases of deep infection; 2 cases of superficial infection; 1 case of CPN neurapraxia 1 case of severe OA No complication
32.0
1 case of secondary meniscal tear
15.0
1 case of CPN neurapraxia
38.0
1 case of severe OA 1 case of loose body NA NA
NA 5.0 10.0 6.0 ARIF: 0.0
1 case of compartment syndrome 1 case of hemarthrosis No complication No complication
11.1 7.0 11.0
1 case of inadequate fixation 1 case of wound infection 2 cases of wound dehiscence
NA
No complication
ACL, anterior cruciate ligament; ARIF, arthroscopy-assisted reduction and internal fixation; CPN, common peroneal nerve; DVT, deep venous thrombosis; NA, not available; OA, osteoarthritis; ORIF, open reduction and internal fixation.
decision regarding the treatment of meniscal injuries. Meniscal repair should be performed whenever possible. At a mean follow-up of 7.6 years after ORIF for tibial plateau fractures, Honkonen34 found that 44% of the patients had secondary osteoarthritis, and 74% of these patients had undergone meniscectomy. Ruiz-Ibán et al.17 reported a cohort of 15 tibial plateau fractures associated with meniscal tears that were treated with ARIF and meniscal repair. In that study, 13 of the patients underwent a second-look arthroscopy at a mean time of 14 months; 12 longitudinal peripheral tears had healed completely, and one complete radial tear had healed peripherally with a tear of the central third, which is known as the white zone. The high healing rate of meniscal repair is pretty encouraging, and it may be attributed to several causes,17 such as acute repair, a conservative postoperative protocol, and the local environment with easy access to the bone marrow.
Of all tibial plateau fractures, 21.3% were associated with ACL injuries based on this systematic review (Table 6). Abdel-Hamid et al.32 reported that Schatzker types IV and VI fractures had significantly higher ACL injury rates compared with the 4 other Schatzker types. Treatment protocols for ACL injuries were absolutely different between bony avulsion and midsubstance ligamentous injury. Most studies1,2,6,8-12,14,22 advocated one-stage surgical fixation for ACL bony avulsion. For ACL midsubstance injury, most authors did not recommend performing ACL reconstruction at the time of fracture restoration because it might induce further soft tissue damage in addition to the already existing damage around the knee. In addition, if there was anterior instability after the union of the fracture, a second-stage ACL reconstruction was necessary. Luckily, most patients with associated ACL injuries did not require secondary reconstruction, except for 9
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patients in 3 studies.6,22,24 However, none of the data that were used for evaluation of anterior instability were available, such as the Lachman test results and KT-1000 arthrometer measurements. Further study should focus on this subject. Compartment Syndrome Compartment syndrome is one of the most catastrophic complications of all arthroscopy-related surgery. There are warnings regarding the theoretical danger of compartment syndrome when performing ARIF for tibial plateau fractures.1,2,8,10-12,18 It has been suggested that extravasation fluid leaks into the calf with the presence of fractures and capsule lesions. However, only 2 cases21,35 of compartment syndrome in the leg have ever been reported after ARIF for tibial plateau fractures. Both patients were treated with a fasciotomy at the same time as the initial surgery. Ekman and Poehling36 simulated knee arthroscopy in animals to study elevated compartment pressures with the creation of 2 capsulotomies to allow extra fluid into the surrounding tissue. They found that although this approach could produce elevated compartment pressures, the pressures would quickly return to normal. These authors concluded that the risk of true compartment syndrome is low, even given transient elevation of compartment pressure and significant fluid extravasation. The consequence of compartment syndrome is catastrophic, and therefore prevention is should be optimal.2,8,10-12,34,37 First, gravity inflow was recommended by almost all surgeons instead of pump inflow to prevent high pressure in the joint and to decrease fluid leakage, which may be the largest contributor to compartment syndrome of the leg. Tourniquet time should be minimized. A formal ARIF can be performed only after the swelling around the knee has decreased, and calcaneus traction may be needed preoperatively to allow the soft tissue to stabilize. A quick bone window and adequate intraoperative fluid drainage should be performed as soon as possible to release the intraarticular pressure. Dry-field arthroscopy is recommended for as long as possible.37 The pressure of the leg during surgery should be carefully monitored and the dorsalis pedis and posterior tibial pulses should be checked after deflation of the tourniquet. Finally, the possibility of compartment syndrome during ARIF should always be considered. Bicondylar tibial plateau fractures (Schatzker types V and VI) commonly result from high-energy trauma with significant comminution, as well as severe soft tissue injuries. The use of ORIF with bilateral buttress plates is recommended; therefore, extensive soft tissue stripping around the whole knee is always necessary, which leads to higher complication rates. ARIF could be the perfect technique in this situation; however, these types of fractures are suspected to be associated
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with a potential risk of compartment syndrome resulting from fluid extravasation. Chiu et al.14 reported a series of 25 patients with posteromedial tibial plateau fractures treated with ARIF. There were 5 patients with Schatzker type IV fractures, 2 patients with type V fractures, and 18 patients with type VI fractures. With a minimal follow-up time of 5 years, 92% had excellent or good clinical and radiologic results. No complications directly associated with arthroscopy, such as compartment syndrome, were noted in any of the 25 patients. Chan et al.12 reported on 18 patients, 7 with Schatzker type V fractures and 11 with Schatzker type VI fractures who were also treated with ARIF. With a minimal follow-up time of 4 years, the status of 89% of the patients was rated as excellent or good. Still, no complications related to arthroscopy were found. Other studies8,10,19,20,24-26 that also investigated complex tibial plateau fractures also reported no compartment syndrome cases. Based on the clinical findings, ARIF should be considered a relatively safe procedure when applied to bicondylar tibial plateau fractures, and it also has fewer complications. ARIF Versus ORIF To the best of our knowledge, there has been no prospective randomized controlled studies that compared the clinical results of ARIF to ORIF in the treatment of tibial plateau fractures. Only 3 retrospective comparative studies11,24,38 (Level III) were published; 2 of them11,24 were included in this systematic review, and one38 was published in 1993. All 3 authors tended to favor ARIF, although there was insufficient clinical evidence. Dall’Oca et al.24 compared 50 patients with tibial plateau fractures who underwent ARIF with 50 patients with tibial plateau fractures who underwent ORIF. Based on their findings, these authors suggested that there were no differences between ARIF and ORIF treatment for Schatzker type I fractures. In the case of Schatzker types II, III, and IV fractures, there was a small difference in clinical outcomes in favor of ARIF, but the differences were not statistically significant. In Schatzker types V and VI, ARIF was limited to less comminuted fractures and showed a lower incidence of infection. In the studies by Ohdera et al.11 and Fowble et al.,38 there was insufficient evidence as well. Moreover, the sample size was relatively small in their studies. Potential directions for future studies should include studies with larger sample sizes, and higher levels of evidence are required, especially for prospective randomized control studies. Limitations There are several limitations to this systematic review. First of all, all the studies included in this systematic
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review were Level III or Level IV, and no prospective randomized controlled study was enrolled. Significant sources of selection bias may be presented for the included studies. Furthermore, a group of physicians from Taiwan have published several studies focused on ARIF for tibial plateau fractures, including 4 studies8,10,12,14 in this systematic review. Different types of tibial plateau fractures and patient information were found among these 4 studies. Still, there may be some selection bias for counting some patient information twice or even more. Finally, only articles published in English between January 1, 2000 and January 10, 2014 were included.
Conclusions ARIF is a reliable, effective, and safe method for the treatment of tibial plateau fractures, especially when they present with concomitant injuries.
References 1. Burdin G. Arthroscopic management of tibial plateau fractures: Surgical technique. Orthop Traumatol Surg Res 2013;99S:208-218. 2. Chan YS. Arthroscopy-assisted surgery for tibial plateau fractures. Chang Gung Med J 2011;34:239-247. 3. Cetik O, Cift H, Asik M. Second-look arthroscopy after arthroscopy-assisted treatment of tibial plateau fractures. Knee Surg Sports Traumatol Arthrosc 2007;15:747-752. 4. Rademakers MV, Kerkhoffs GMMJ, Sierevelt IN, Raaymakers ELFB, Marti RK. Operative treatment of 109 tibial plateau fractures: Five- to 27-year follow-up results. J Orthop Trauma 2007;21:5-10. 5. Lubowitz JH, Elson WS, Guttmann D. Part I: Arthroscopic management of tibial plateau fractures. Arthroscopy 2004;20:1063-1070. 6. Rossi R, Bonasia DE, Blonna D, Assom M, Castoldi F. Prospective follow-up of a simple arthroscopic-assisted technique for lateral tibial plateau fractures: Results at 5 years. Knee 2008;15:378-383. 7. Siegler J, Galissier B, Marcheix PS, Charissoux JL, Mabit C, Arnaud JP. Percutaneous fixation of tibial plateau fractures under arthroscopy: A medium term perspective. Orthop Traumatol Surg Res 2011;97:44-50. 8. Chan YS, Chiu CH, Lo YP, et al. Arthroscopy-assisted surgery for tibial plateau fractures: 2- to 10-year followup results. Arthroscopy 2008;24:760-768. 9. Di Caprio F, Buda R, Ghermandi R, et al. Combined arthroscopic treatment of tibial plateau and intercondylar eminence avulsion fractures. J Bone Joint Surg Am 2010;92S:161-169. 10. Hung SS, Chao EK, Chan YS, et al. Arthroscopically assisted osteosynthesis for tibial plateau fractures. J Trauma 2003;54:356-363. 11. Ohdera T, Tokunaga M, Hiroshima S, Yoshimoto E, Tokunaga J, Kobayashi A. Arthroscopic management of tibial plateau fracturesdcomparison with open reduction method. Arch Orthop Trauma Surg 2003;123:489-493.
12. Chan YS, Yuan LJ, Hung SS, et al. Arthroscopic-assisted reduction with bilateral buttress plate fixation of complex tibial plateau fractures. Arthroscopy 2003;19:974-984. 13. Papagelopoulos PJ, Partsinevelos AA, Themistocleous GS, Mavrogenis AF, Korres DS, Soucacos PN. Complications after tibial plateau fracture surgery. Injury 2006;37: 475-484. 14. Chiu CH, Cheng CY, Tsai MC, et al. Arthroscopy-assisted reduction of posteromedial tibial plateau fractures with buttress plate and cannulated screw construct. Arthroscopy 2013;29:1346-1354. 15. Caspari RB, Hutton PM, Whipple TL, Meyers JF. The role of arthroscopy in the management of tibial plateau fractures. Arthroscopy 1985;1:76-82. 16. Jennings JE. Arthroscopic management of tibial plateau fractures. Arthroscopy 1985;1:160-168. 17. Ruiz-Ibán MÁ, Diaz-Heredia J, Elías-Martín E, MorosMarco S, del Val ICM. Repair of meniscal tears associated with tibial plateau fractures: A review of 15 cases. Am J Sports Med 2012;40:2289-2295. 18. Kayali C, ÖztÜrk H, Altay T, Reisoglu A, Agus H. Arthroscopically assisted percutaneous osteosynthesis of lateral tibial plateau fractures. Can J Surg 2008;51:378-382. 19. Roerdink WH, Oskam J, Vierhout PAM. Arthroscopically assisted osteosynthesis of tibial plateau fractures in patients older than 77 years. Arthroscopy 2001;17:826-831. 20. Asik M, Cetik O, Talu U, Sozen YV. Arthtoscopy-assisted operative management of tibial plateau fractures. Knee Surg Sports Traumatol Arthrosc 2002;10:364-370. 21. Kiefer H, Zivaljevic N, Imbirgilia JE. Arthroscopic reduction and internal fixation of lateral tibial plateau fractures. Knee Surg Sports Traumatol Arthrosc 2001;9:167-172. 22. Levy BA, Herrera DA, MacDonald P, Cole PA. The “medial approach” for arthroscopic-assisted fixation of lateral tibial plateau fractures: Patient selection and mid- to long-term results. J Orthop Trauma 2008;22:201-205. 23. Gill TJ, Moezzi DM, Oates KM, Sterett WI. Arthroscopic reduction and internal fixation of tibial plateau fractures in skiing. Clin Orthop Relat Res 2001;383:243-249. 24. Dall’Oca C, Maluta T, Lavini F, Bondi M, Micheloni GM, Bartolozzi P. Tibial plateau fractures: Compared outcomes between ARIF and ORIF. Strategies Trauma Limb Reconstr 2012;7:163-175. 25. Duan XJ, Yang L, Guo L, Chen GX, Dai G. Arthroscopically assisted treatment for Schatzker type I-IV tibial plateau fractures. Chin J Traumatol 2008;11:288-292. 26. Horstmann WG, Verheyen CCPM, Leemans R. An injectable calcium phosphate cement as a bone-graft substitute in the treatment of displaced lateral tibial plateau fractures. Injury 2003;34:141-144. 27. Pogliacomi F, Verdamo MA, Frattini M, Costantino C, Vaienti E, Soncini G. Combined arthroscopic and radioscopic management of tibial plateau fractures: Report of 18 clinical cases. Acta Biomed 2005;76:107-114. 28. Glabbeek FV, Riet RV, Jansen N, D’Anvers J, Nuyts R. Arthroscopically assisted reduction and internal fixation of tibial plateau fractures: Report of twenty cases. Acta Orthop Belg 2002;68:258-264. 29. Song GY, Zhang H, Zhang J, et al. The anterior cruciate ligament remnant: To leave it or not? Arthroscopy 2013;29: 1253-1262.
ARTHROSCOPY ASSISTED TIBIAL PLATEAU FRACTURES 30. Coleman BD, Khan KM, Maffulli N, Cook JL, Wark JD. Studies of surgical outcome after patellar tendinopathy: Clinical significance of methodological deficiencies and guidelines for future studies. Victorian Institute of Sports Tendon Study Group. Scand J Med Sci Sports 2000;10:2-11. 31. Rossi R, Castoldi F, Blonna D, Marmotti A, Assom M. Arthroscopic treatment of lateral tibial plateau fractures: A simple technique. Arthroscopy 2006;22:678.e1-e6. 32. Abdel-Hamid MZ, Chang CH, Chan YS, et al. Arthroscopic evaluation of soft tissue injuries in tibial plateau fractures: Retrospective analysis of 98 cases. Arthroscopy 2006;22: 669-675. 33. Mustonen AO, Koivikko MP, Lindahl J, et al. MRI of acute meniscal injury associated with tibial plateau fractures: Prevalence, type, and location. Am J Roentgenol 2008;191: 1002-1009.
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34. Honkonen SE. Degenerative arthritis after tibial plateau fractures. J Orthop Trauma 1995;9:273-277. 35. Belanger M, Fadale P. Compartment syndrome of the leg after arthroscopic examination of a tibial plateau fracture. Case report and review of the literature. Arthroscopy 1997;13:646-651. 36. Ekman E, Poehling G. An experimental assessment of the risk of compartment syndrome during knee arthroscopy. Arthroscopy 1996;12:193-199. 37. Lubowitz JH, Vance KJ, Ayala M, Guttmann D, Reid JB. Interference screw technique for arthroscopic reduction and internal fixation of compression fractures of the tibial plateau. Arthroscopy 2006;22:1359.e1-1359.e3. 38. Fowble CD, Zimmer JW, Schepsis AA. The role of arthroscopy in the assessment and treatment of tibial plateau fractures. Arthroscopy 1993;9:584-590.
Arthroscopy-Assisted Surgery for Tibial Plateau Fractures Xing-zuo Chen, M.D., Cheng-gang Liu, M.D., Ying Chen, M.D., Li-qiang Wang, M.D., Qian-zheng Zhu, M.D., and Peng Lin, M.D.
Purpose: This study aimed to summarize the recent clinical outcomes of patients undergoing arthroscopy-assisted reduction and internal fixation (ARIF) for tibial plateau fractures. Methods: A systematic electronic search of the PubMed and Cochrane databases was performed in January 2014. All English-language clinical studies on tibial plateau fractures treated with ARIF that were published after January 1, 2000 were eligible for inclusion. Basic information related to the surgery was collected. Results: The search criteria initially identified 141 articles, and 19 studies were included in this systematic review. There were 2 retrospective comparative studies, 16 case series studies, and one clinical series based on a technique note. There were a total of 609 patients in this systematic review, with a mean follow-up time of 52.5 months. The most common fracture types were Schatzker types II and III. Concomitant injuries were common: 42.2% of the patients had meniscal injuries, and 21.3% had anterior cruciate ligament (ACL) injuries. In addition, the status of 90.5% of the patients was classified as good or excellent according to the clinical Rasmussen scoring system, and 90.9% of the patients were satisfied with the treatment. Only 6 severe complications were reported, including one case of compartment syndrome. Conclusions: ARIF is a reliable, effective, and safe method for the treatment of tibial plateau fractures, especially when they present with concomitant injuries. Level of Evidence: Level IV, systematic review of Level III and Level IV studies.
T
ibial plateau fractures represent approximately 1% of all fractures.1-10 Management of these fractures can be challenging for orthopaedic surgeons. If not treated properly, these fractures may lead to malfunctioning of the injured knee. Successful results depend on anatomic reduction, restoration of ligamentous stability, treatment of concomitant injures, and preservation of the soft tissue envelope.2-4,8,10-13 Traditional open reduction and internal fixation (ORIF) requires extensive soft tissue dissection, which may lead to numerous complications and risks such as wound healing, infection, and arthritis2,10,12,14 Additionally, intra-articular lesions such as meniscus or anterior cruciate ligament (ACL) injuries cannot be diagnosed and treated properly because of limited exposure. Arthroscopy-assisted reduction and internal fixation (ARIF) in the treatment of tibial plateau fractures was first
From Orthopaedic Trauma Department, China-Japan Friendship Hospital, Beijing, China. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received March 11, 2014; accepted June 2, 2014. Address correspondence to Peng Lin, M.D., Orthopaedic Trauma Department, China-Japan Friendship Hospital, No. 2, Ying Hua East Street, Chao Yang District, 10029 Beijing, China. E-mail: [email protected] Ó 2015 by the Arthroscopy Association of North America 0749-8063/14200/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.06.005
introduced by Caspari et al.15 and Jennings16 in the 1980s. Currently, ARIF is being widely used in the treatment of tibial plateau fractures.6-12,14,17-28 ARIF has shown various advantages over traditional ORIF regarding accurate reduction monitoring by direct visualization, lower morbidity because it is a minimally invasive procedure, and simplified diagnosis and treatment of intra-articular lesions. Recent literature6-12,14,17-28 has reported good short- to medium-term functional and radiologic results. However, whether ARIF will achieve better clinical results than ORIF is still under debate. ARIF has also been suggested as a potential risk factor for compartment syndrome during arthroscopic examination or treatment.1,2,8,10-12,18 The purpose of this systematic review was to summarize the recent clinical outcomes of patients undergoing ARIF for tibial plateau fractures. Our hypothesis was that ARIF is an effective method for the treatment of tibial plateau fractures.
Methods Literature Search A systematic electronic search of the PubMed and Cochrane databases was performed on January 10, 2014 for all published literature. The following key phrases were used in the title or abstract fields: [(tibial plateau) OR (proximal tibia*)] AND fracture* AND
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[(arthroscop*) OR (ARIF)]. In addition, we also searched major American and European orthopaedic journals for relevant articles. The inclusion criteria included the following: tibial plateau fractures treated with ARIF, clinical research, a mean follow-up time of no less than 24 months or a minimum follow-up of no less than 12 months, articles written in English, and articles published after January 1, 2000. The exclusion criteria included the following: tibial plateau fractures treated without arthroscopy and internal fixation; study focused only on ACL avulsion; biomechanical studies or radiologic studies; a mean follow-up time of less than 24 months and a minimal follow-up time of less than 12 months; case reports, reviews, meta-analyses, letters to editors, and technique notes; noneEnglish-language articles; and articles published before January 1, 2000. All articles generally were independently reviewed by 2 reviewers (X-Z.C., Q-Z.Z.) according to the inclusion and exclusion criteria. The full text of all the relevant studies was obtained and reviewed. Reference lists of all full-text articles were checked manually to identify additional potential articles for inclusion. Any disagreement between the 2 reviewers was settled by another senior reviewer (P.L.). The level of evidence was also determined according to the Oxford Levels of Evidence produced by the Oxford Centre for EvidenceBased Medicine.
included in this systematic review. Specifically, there were 2 Level III retrospective comparative studies,11,24 16 Level IV case series studies,6-10,12,14,18-21,23,25-28 and one clinical series based on a technique note.22 No prospective studies were identified. The mean modified CMS value was 68 (range, 59 to 79). The features and modified CMS values of each study are shown in Table 1.
Quality Assessment In a manner similar to that of Song et al.,29 we assessed the methodological quality of the articles by using the modified Coleman Methodology Score (CMS).30 Ten criteria are used to score a study, and a perfect score of 100 represents a study design that largely avoids the influences of chance, various biases, and confounding factors.
Surgical Information Among the 19 studies, only screws were used in 8 studies,6,7,9,18,22,23,25,28 only buttress plates were used in 3 studies,8,10,12 and both screws and buttress plates were used in 8 studies.11,14,19-21,24,26,27 A total of 346 patients were treated with screws only, 207 patients were treated with buttress plates or screws (or both), 11 patients obtained no internal fixation, and an additional 6 patients underwent external fixation (Table 3). A total of 241 patients (40.0%) underwent bone grafting to maintain reduction of the tibial plateau, including autografts7,8,10-12,19-21,24,27 (mostly iliac bone graft), allografts,10,18,22,28 and bone substitutes.7,19,23,26
Data Extraction The following data were extracted from the eligible articles: basic information about the article; number, sex, and mean age of the patients; mean and minimal followup times; classification of fractures and the numbers of each type; internal fixation methods; whether bone grafting was used; clinical scoring system and subjective satisfaction; range of motion of the joints; radiologic evaluations, including degree of articular depression; concomitant injuries; and complications.
Results Literature Search and Quality Assessment The search initially identified 141 articles for potential inclusion according to the criteria. After detailed assessment of all references, subsequent screening, and quality assessment (Fig 1), a total of 19 studies6-12,14,18-28 were
Patient Characteristics A total of 609 patients (610 knees) completed the last follow-up, 323 of whom were male patients and 286 of whom were female patients (Table 2). The mean age was 46.0 years old (range, 13 to 92 years); there was one study19 that focused only on patients older than 55 years. The mean follow-up time was 52.5 months (range, 12 to 138 months). All the studies except one21 used the Schatzker classification system. Based on the Schatzker classification system, the numbers of patients in each category were as follows: 62 patients with Schatzker type I fractures (lateral split), 195 patients with Schatzker type II fractures (lateral split with depression), 156 patients with Schatzker type III fractures (pure depression of the lateral plateau), 69 patients with Schatzker type IV fractures (medial plateau fracture), 46 patients with Schatzker type V fractures (bicondylar fracture), and 54 patients with type VI fractures (plateau fracture with separated metaphysis).
Clinical Evaluation Different types of rating systems were used to evaluate the clinical results of ARIF for tibial plateau fractures; 14 of the 19 studies6-8,12,14,18-20,22-25,27,28 used the clinical Rasmussen scoring system, which is widely used in studies focused on tibial plateau fractures. In addition, 90.5% (range, 80.0 to 100.0%) of the patients had classifications of good or excellent according to the clinical Rasmussen score, and 90.9% (range, 77.8 to 100%) of the patients were satisfied with the treatment. The range of motion of the injured knee was reported in 11 studies,7,8,10-12,14,18,22,23,25,26 and at least 32 patients did not regain a full range of motion (Table 4).
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Fig 1. Flowchart of study selection. (ACL, anterior cruciate ligament; ORIF, open reduction and internal fixation).
Table 1. Summary of Study Features and Quality Assessment Author Asik et al.20 Chan et al.12 Chan et al.8 Chiu et al.14 Dall’Oca et al.24
Year 2002 2003 2008 2013 2012
Di Caprio et al.9 Duan et al.25 Gill et al.23 Glabbeek et al.28 Hung et al.10 Horstmann et al.26 Kayali et al.18 Kiefer et al.21 Levy et al.22 Ohdera et al.11
2010 2008 2001 2002 2003 2003 2008 2001 2008 2003
Pogliacomi et al.27 Roerdink et al.19 Rossi et al.6 Siegler et al.7
2005 2001 2008 2011
Type of Study Case series Case series Case series Case series Retrospective comparative study Case series Case series Case series Case series Case series Case series Case series Case series Case series Retrospective comparative study Case series Case series Case series Case series
CMS, Coleman Methodology Score.
Level of Evidence IV IV IV IV III
Journal Knee Surgery, Sports Traumatology, Arthroscopy Arthroscopy Arthroscopy Arthroscopy Strategies in Trauma and Limb Reconstruction
CMS 71 67 79 71 77
IV IV IV IV IV IV IV IV IV III
The Journal of Bone & Joint Surgery, American Edition Chinese Journal of Traumatology Clinical Orthopaedics and Related Research Acta Orthopadica Belgica The Journal of Trauma Injury Canadian Journal of Surgery Knee Surgery, Sports Traumatology, Arthroscopy The Journal of Orthopaedic Trauma Archives of Orthopaedic and Trauma Surgery
68 65 65 68 71 59 71 63 67 63
IV IV IV IV
Acta Bio Medica Arthroscopy The Knee Orthopaedics & Traumatology: Surgery & Research
64 65 71 68
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Table 2. Patient Characteristics Involved in the Systematic Review Author Asik et al.20 Chan et al.12 Chan et al.8 Chiu et al.14 Dall’Oca et al.24
Pogliacomi et al.27 Roerdink et al.19 Rossi et al.6 Siegler et al.7
Fracture Classification Schatzker I Schatzker II Schatzker III Schatzker IV Schatzker V Schatzker VI Schatzker 5 18 12 6 3 2 Schatzker 0 0 0 0 11 7 Schatzker 1 21 4 10 8 10 Schatzker 0 0 0 5 2 18 Schatzker ARIF: 4 ARIF: 7 ARIF: 26 ARIF: 5 ARIF: 4 ARIF: 4 ORIF: 10 ORIF: 5 ORIF: 18 ORIF: 3 ORIF: 8 ORIF: 6 Schatzker 5 9 0 7 0 0 Schatzker 4 12 9 12 2 0 Schatzker 2 5 16 2 0 0 Schatzker 7 10 0 2 1 0 Schatzker 1 9 7 9 3 2 Schatzker 0 7 4 0 0 3 Schatzker 7 10 4 0 0 0 AO NA NA NA NA NA NA Schatzker 0 16 0 0 0 0 Schatzker 0 ARIF: 10 ARIF: 9 0 0 0 ORIF: 5 ORIF: 4 Schatzker 4 6 6 2 0 0 Schatzker 6 13 5 3 2 1 Schatzker 0 19 27 0 0 0 Schatzker NA NA NA 0 0 0
AO, Association for the Study of Internal Fixation; ARIF, arthroscopy-assisted reduction and internal fixation; NA, not available; ORIF, open reduction and internal fixation.
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Di Caprio et al.9 Duan et al.25 Gill et al.23 Glabbeek et al.28 Hung et al.10 Horstmann et al.26 Kayali et al.18 Kiefer et al.21 Levy et al.22 Ohdera et al.11
Number of Mean Mean Minimum Patients Sex (M/F) Age (y) Follow-up (mo) Follow-up (mo) 45 (46 knees) 34/11 39.0 36 12 18 12/6 35.0 48 39 54 25/29 48.0 87 22 25 15/10 46.0 86 60 ARIF: 50 ARIF: 23/27 51.0 73 12 ORIF: 50 ORIF: 31/19 21 9/12 20.8 80 60 39 28/11 35.9 34 12 25 10/15 45.2 24 12 20 12/8 49.0 39 27 31 19/12 46.9 36 24 14 4/10 53.0 28 18 21 14/7 41.0 38 12 31 17/14 47.4 25.1 15 16 7/9 44.8 41 12 ARIF: 19 ARIF: 5/14 ARIF: 47.5 ARIF: 22 ARIF: 12 ORIF: 9 ORIF: 4/5 ORIF: 51.5 ORIF: 51.7 ORIF: 32 18 13/5 36.0 NA 12 30 3/27 72.0 36 24 46 21/25 48.0 60 NA 27 (21 finished 17/10 45 59.5 24 follow-up)
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ARTHROSCOPY ASSISTED TIBIAL PLATEAU FRACTURES Table 3. Surgical Information Involved in the Systematic Review Author Asik et al.20
Type of Internal Fixation Plate or screw, or both
Chan et al.12 Chan et al.8 Chiu et al.14 Dall’Oca et al.24
Plate Plate Plate and screw Plate or screw (or both) external fixation
Di Caprio et al.9 Duan et al.25 Gill et al.23 Glabbeek et al.28 Hung et al.10 Horstmann et al.26
Screw Screw Screw Screw Plate Plate or screw, or both
Kayali et al.18 Kiefer et al.21
Screw Plate or screw, or both
Levy et al.22 Ohdera et al.11
Screw Plate or screw, or both
Pogliacomi et al.27
Plate or screw, or both
Roerdink et al.19 Rossi et al.6 Siegler et al.7
Plate or screw, or both Screw Screw
Number of Internal Fixations SO: 36 Combined: 10 18 54 25 SO: 38 Combined: 56 External fixation: 6 21 39 25 20 31 No fixation: 2 SO: 8 Combined: 4 21 No fixation: 2 SO: 28 Combined: 1 16 No fixation: 7 SO: 15 Combined: 6 SO: 16 Combined: 2 NA 46 27
Bone Graft Auto
Number of Bone Grafts 27
Percentage 58.7
Auto Auto NA Auto
18 53 NA 3
100.0 98.2 NA 3.0
Not used NA BS Allo Auto or Allo, or both BS
Not used NA 17 NA 25 14
Not used NA 68.0 NA 80.7 100.0
Allo Auto
14 9
66.7 29.0
Allo Auto
16 25
100.0 89.3
Auto
2
11.1
Auto or BS Not used Auto and BS
12 Not used 6
40.0 Not used 22.2
Allo, allograft; Auto, autograft; BS, bone substitute; NA, not available; SO, screw only.
Radiologic Evaluation Postoperative radiologic evaluation included 2 parts: depression of the articular surface and osteoarthritic degeneration. The evaluating systems used were the radiologic Rasmussen scoring system (10 of 19 studies6-8,12,14,18,19,22,24,27) and the Ahlbäck scale, which was used for osteoarthritic changes only (6 of 19 studies8,10,12,14,18,27). Depression of the fracture of no less than 2 mm was considered a displacement postoperatively and occurred in at least 30 patients. At least 9 patients exhibited an articular surface depression of more than 4 mm, and 25.9% (range, 3.2% to 63.0%) of the patients presented with osteoarthritis postoperatively (Table 5). Concomitant Injury and Complications Meniscus and ACL injuries were the most common combined soft tissue injuries reported in 18 of 19 studies.6-12,14,18-25,27,28 A total of 236 patients (42.2%) also had meniscal injuries and 119 patients (21.3%) also had ACL injuries. For meniscal injuries, 104 (44.1%) were repaired during the first operation. Most ACL midsubstance injuries were not operated on in the same procedure; however, ACL bony avulsions were treated with arthroscopy-assisted fixation during the same operation6,8,9,12,14,22 (Table 6).
There were a total of 41 patients with complications that did not include knee stiffness and articular surface depression (mentioned earlier). There were 6 cases of severe complications, which were reported in 3 studies20,21,24 and included one case of compartment syndrome, 3 cases of deep infection and 2 cases of deep venous thrombosis. No amputations or life-threatening diseases were reported.
Discussion Clinical Findings Previous studies3,4,10-13 have shown that restoration of articular congruity and residual laxity of the knee after treatment of tibial plateau fractures were 2 of the most important predictors of future knee function. Long-term consequences have relied more on anatomic reduction of the articular surface.7 Traditional ORIF for tibial plateau fractures has several disadvantages. Arthrotomy and transection of the meniscus have to be performed during ORIF to achieve better visualization of the displaced articular surface, which may lead to stiffness, proprioception disorders, severe postoperative pain, and wound complications.11,18,19 Moreover, a higher complication rate was reported because of extensive dissection of the soft
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Table 4. Clinical Evaluation Involved in the Systematic Review Author Asik et al.20 Chan et al.12 Chan et al.8 Chiu et al.14 Dall’Oca et al.24
Clinical Rating System Rasmussen score Rasmussen score Rasmussen score Rasmussen score Rasmussen score HSS
Di Caprio et al.9 Duan et al.25 Gill et al.23 Glabbeek et al.28 Hung et al.10 Horstmann et al.26 Kayali et al.18 Kiefer et al.21
IKDC Rasmussen score Rasmussen score Rasmussen score HSS Lysholm score Rasmussen score Lysholm score
Levy et al.22 Ohdera et al.11
Rasmussen score Hohl and Delamarter score Hohl score Rasmussen score Rasmussen score Rasmussen score HSS KSS Rasmussen score Lysholm score KSS
Pogliacomi et al.27 Roerdink et al.19 Rossi et al.6
Siegler et al.7
Objective Satisfaction* 89.0% 88.9% 96.3% 92.0% ARIF: 27.6 of 30 76.4 of 100 ORIF: 26.8 of 30 73.1 of 100 86.0% 92.3% 27.5 of 30 90.0% 93.5% 57.1% 90.0% NA
100.0% ARIF: 94.3 of 100 ORIF: 89.7 of 100 83.3% 83.3% 80.0% 28.2/30 93.0% 100.0% 25.5 of 30 86.0 of 100 85.2 of 100
Subjective Satisfaction NA 88.9% 96.3% 92.0% NA
NA 84.6% 92.0% 90.0% 93.5% 85.7% 100.0% 90.3%
NA NA 77.8%
ROM (Extension-flexion) NA 2 -130 ; 2 patients had extension lag > 10 1 -130 ; 2 patients had extension lag > 10 1 -125 ; 2 patients had extension lag > 10 NA
1 patient had extension deficit 1.6 -130 1.5 -95.2 ; 2 patients had extension lag > 10 NA 1.5 -135 0 -140 ; 1 patient had extension lag > 15 Extension 131 3 patients had isolated extension deficit; 5 patients had isolated flexion deficit; 4 patients had combined deficit 0.3 -142 ARIF: 0.7 -151.3 ; 3 patients had extension deficit ORIF: 0.5 -148.9 ; 4 patients had extension deficit 1 patient did not have full ROM
NA NA
NA NA
NA
1.4 -131.3 ; 2 patients had knee stiffness
ARIF, arthroscopy-assisted reduction and internal fixation; HSS, Hospital for Special Surgery score; IKDC, International Knee Documentation Committee form; KSS, Knee Society Score; NA, not available; ORIF, open reduction and internal fixation; ROM, range of motion. *Some studies offered only the mean score of the rating system; for those, the table describes it as mean score of full score.
tissue around the knee.2,10,12,14 Conversely, satisfactory short- to medium-term clinical and radiologic results of ARIF have been reported based on some recent studies.6-12,14,18-28 ARIF has shown various advantages over traditional ORIF regarding accurate monitoring of the reduction by direct visualization, lower morbidity resulting from the minimal invasiveness of the procedure, and simplified diagnosis and treatment of intraarticular lesions. According to this systematic review, 90.5% of the patients had classifications of good or excellent according to the clinical Rasmussen score, and 90.9% of the patients were satisfied with the treatment. Schatzker types II and III were the most common types of tibial plateau fractures (Table 2). With depression of the articular surface, it is important to restore and maintain the anatomic structure of the knee, which could be held up with or without bone grafting. Roerdink et al.19 reported on 30 patients who were older than 55 years and were treated with ARIF for tibial plateau fractures; 12 of these patients underwent additional bone grafting, whereas in the others, neither bone cement nor a bone graft was used. Secondary displacement occurred postoperatively in 9 patients, within an
average time of 9 weeks. This occurred in only one patient (8%) who was treated with bone substitution and in 8 patients (44%) who were not. The difference is statistically significant. Burdin1 suggested that bone grafting should be performed in patients older than 55 years of age and in those with marked osteoporosis, who were at increased risk for secondary depression. In addition, bone grafting appeared to be preferable when the depression was greater than 6 mm. However, a different surgical technique was introduced by Rossi et al.6,31 and Levy et al.22 Instead of a common anterolateral cortical window, a lower anteromedial cortical window was created. This surgical technique allowed these fractures to be approached from a medial window, which provided a longer tunnel for subchondral support and did not cause more injury to the lateral column, which was already broken (for Schatzker types II and III). Rossi et al.6 reported that 46 patients with Schatzker type II and type III fractures underwent ARIF in which a compacted “cancellous bone graft” that was obtained from the medial metaphyseal side of the tibia was used without bone grafting. With a mean follow-up of 5 years, depression of the articular surface decreased
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Table 5. Radiologic Evaluation Involved in the Systematic Review Author Asik et al.20 Chan et al.12
Reduction Evaluation NA Rasmussen score
Excellent and Good* NA 89.0%
Chan et al.8
Rasmussen score
96.3%
Chiu et al.14 Dall’Oca et al.24
Rasmussen score Rasmussen score
Di Caprio et al.9
NA
96.0% ARIF: 16.6 of 18 ORIF: 15.9 of 18 NA
Duan et al.25
NA
NA
Gill et al.23
NA
NA
Glabbeek et al.28 Hung et al.10
NA NA
NA NA
Horstmann et al.26
NA
NA
Kayali et al.18 Kiefer et al.21 Levy et al.22
Rasmussen score NA Rasmussen score
Ohdera et al.11
NA
Pogliacomi et al.27 Roerdink et al.19
Rasmussen score Rasmussen score
66.6% 46.7%
Rossi et al.6 Siegler et al.7
Rasmussen score Rasmussen score
96.0% 8 of 18
86.0% NA 100.0%
NA
Articular Depression (Preoperatively/Postoperatively) 11 knees; 0-2 mm depression 14.2 mm/0.2 mm; 2 cases, 2 mm depression; 1 case, 3 mm depression 13.7 mm/0.3 mm; 1 case, 4-mm depression 16.8 mm/0.5 mm; 3 cases NA
Osteoarthritis Evaluation Resnick and Niwoyama criteria Ahlbäck scale for osteoarthritis
Percentage 63.0% 16.7%
Ahlbäck scale for osteoarthritis
19.0%
Ahlbäck scale for osteoarthritis NA
24.0% NA
8.0 mm/0.7 mm, 1 case, 4-mm depression NA
NA
NA
NA
7.7 mm/0.8 mm; 1 case, 4 mm depression; 1 case, 5-mm depression NA 9.2 mm/0.2 mm; 1 case, 4-mm depression 1 case, 10 mm depression; 1 case, 12-mm depression 2 cases 4 cases Postoperative depression, 0.6 mm; 3 cases, 2 mm depression; 1 case, 4 mm depression NA
NA
No severe osteoarthritis NA
1 case, 5-mm depression 9 cases; secondary displacement 8.3 mm/1.1 mm 4 cases; secondary compression
NA Ahlbäck scale for osteoarthritis
NA 3.2%
NA
NA
Ahlbäck scale for osteoarthritis NA NA
NA Ahlbäck scale for osteoarthritis Resnick and Niwoyama criteria NA NA
24.0% 12.9% 12.5%
ARIF: 15.8% ORIF: 77.8% 27.8% 53.3% 8.6% 47.6%
ARIF, arthroscopy-assisted reduction and internal fixation; NA, not available; ORIF, open reduction and internal fixation. *Some studies offered only the mean score of the rating system; for those, the table described it as mean score of full score.
from 8.3 mm (preoperatively) to 1.1 mm. The authors suggested that when the bone quality was good and there was no metaphyseal comminution, this technique is a reliable treatment option for Schatzker types II and III lateral plateau fractures. Postoperative osteoarthritis can be affected by several factors, including degree of articular step-off, alignment of the lower limb, integrity of the meniscus, and age of the patient.11,12,19 It also negatively influences clinical results whether it occurs preoperatively or postoperatively. Siegler et al.7 noted those patients with pre-existing osteoarthritis who undergo surgery after 60 years of age presented less favorable results. In the Roerdink et al.19 study, 53.3% of the patients had preexisting osteoarthritis. In only 80% of the patients was the clinical Rasmussen score rated as excellent or good, which was lower than in other studies. Cetik et al.3 applied second-look arthroscopy in 12 patients who had already been treated with ARIF for tibial plateau fractures. Hyaline cartilage in 9 patients who did not
have step-off was clearly observed on the fracture line. However, 3 patients who had a depression of 3 mm, 3 mm, and 2 mm, respectively, all had chondral defects on the tibial plateau or the femoral condyle, or both. Concomitant Injuries One of the greatest strengths of ARIF for tibial plateau fractures is that it facilitates a thorough evaluation of the associated soft tissue injuries inside the knee and treatment of these injuries during the same surgical procedure. Inappropriate treatment of the soft tissue injuries would have a negative influence on long-term clinical results.2-4,8,10-14,32 According to our systematic review, meniscal tears could be noted in 42.2% of all tibial plateau fractures (Table 6). The most common types of meniscal tears were peripheral tears and radial tears. Unstable meniscal tears can lead to pain and locking of the knee.33 In addition, patients may benefit from the chondroprotective effect of an intact meniscus. It is important to make a better
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Table 6. Soft Tissue Injury and Complications Involved in the Systematic Review Author Asik et al.20
Soft Tissue Injury (%) NA
Meniscal Injury (%) 51.0
Chan et al.12
72.0
61.0
Chan et al.8
65.0
38.8
Chiu et al.14
92.0
64.0
Dall’Oca et al.24
69.0
57.0
Di Caprio et al.9 Duan et al.25
100.0 NA
19.1 48.7
Gill et al.23
64.0
32.0
Glabbeek et al.28
50.0
35.0
Hung et al.10
52.0
44.0
Horstmann et al.26 Kayali et al.18
NA 67.0
NA 47.6
Kiefer et al.21
NA
13.0
56.3 ARIF: 57.9
56.3 ARIF: 57.9
Pogliacomi et al.27 Roerdink et al.19 Rossi et al.6
33.3 46.0 NA
22.2 40.0 28.0
Siegler et al.7
33.3
NA
Levy et al.22 Ohdera et al.11
Meniscus Management Repair: 7 Resection: 16 Repair: 11 Resection: 2 Repair: 15 Resection: 7
ACL Injury (%) 6.0
Repair: 13 Resection: 3 Repair: 32 Resection: 25
68.0
Resection: 4 Repair: 5 Resection: 14 Repair: 3 Resection: 1 Not treated: 4 Repair: 1 Resection: 6 Repair: 5 Resection: 2 NA Repair: 1 Resection: 8 Repair: 2 Resection: 2 Resection: 9 Repair: 4 Resection: 2 Not treated: 5 Resection: 4 NA Repair: 5 Resection: 8 Resection: 2
100.0 28.0
22.0 30.0
17.0
Complication (Except Knee Stiffness and Articular Surface Depression) 1 case of deep infection 1 case of wound dehiscence; 2 cases of paresthesia over the lateral calf 4 cases of wound dehiscence; 5 cases of paresthesia over the lateral calf; 1 case of loose body 1 case of wound dehiscence; 5 cases of paresthesia over the lateral calf ARIF: 1 case DVT; 1 case severe OA ORIF: 1 case of DVT; 2 cases of severe OA; 2 cases of deep infection; 2 cases of superficial infection; 1 case of CPN neurapraxia 1 case of severe OA No complication
32.0
1 case of secondary meniscal tear
15.0
1 case of CPN neurapraxia
38.0
1 case of severe OA 1 case of loose body NA NA
NA 5.0 10.0 6.0 ARIF: 0.0
1 case of compartment syndrome 1 case of hemarthrosis No complication No complication
11.1 7.0 11.0
1 case of inadequate fixation 1 case of wound infection 2 cases of wound dehiscence
NA
No complication
ACL, anterior cruciate ligament; ARIF, arthroscopy-assisted reduction and internal fixation; CPN, common peroneal nerve; DVT, deep venous thrombosis; NA, not available; OA, osteoarthritis; ORIF, open reduction and internal fixation.
decision regarding the treatment of meniscal injuries. Meniscal repair should be performed whenever possible. At a mean follow-up of 7.6 years after ORIF for tibial plateau fractures, Honkonen34 found that 44% of the patients had secondary osteoarthritis, and 74% of these patients had undergone meniscectomy. Ruiz-Ibán et al.17 reported a cohort of 15 tibial plateau fractures associated with meniscal tears that were treated with ARIF and meniscal repair. In that study, 13 of the patients underwent a second-look arthroscopy at a mean time of 14 months; 12 longitudinal peripheral tears had healed completely, and one complete radial tear had healed peripherally with a tear of the central third, which is known as the white zone. The high healing rate of meniscal repair is pretty encouraging, and it may be attributed to several causes,17 such as acute repair, a conservative postoperative protocol, and the local environment with easy access to the bone marrow.
Of all tibial plateau fractures, 21.3% were associated with ACL injuries based on this systematic review (Table 6). Abdel-Hamid et al.32 reported that Schatzker types IV and VI fractures had significantly higher ACL injury rates compared with the 4 other Schatzker types. Treatment protocols for ACL injuries were absolutely different between bony avulsion and midsubstance ligamentous injury. Most studies1,2,6,8-12,14,22 advocated one-stage surgical fixation for ACL bony avulsion. For ACL midsubstance injury, most authors did not recommend performing ACL reconstruction at the time of fracture restoration because it might induce further soft tissue damage in addition to the already existing damage around the knee. In addition, if there was anterior instability after the union of the fracture, a second-stage ACL reconstruction was necessary. Luckily, most patients with associated ACL injuries did not require secondary reconstruction, except for 9
ARTHROSCOPY ASSISTED TIBIAL PLATEAU FRACTURES
patients in 3 studies.6,22,24 However, none of the data that were used for evaluation of anterior instability were available, such as the Lachman test results and KT-1000 arthrometer measurements. Further study should focus on this subject. Compartment Syndrome Compartment syndrome is one of the most catastrophic complications of all arthroscopy-related surgery. There are warnings regarding the theoretical danger of compartment syndrome when performing ARIF for tibial plateau fractures.1,2,8,10-12,18 It has been suggested that extravasation fluid leaks into the calf with the presence of fractures and capsule lesions. However, only 2 cases21,35 of compartment syndrome in the leg have ever been reported after ARIF for tibial plateau fractures. Both patients were treated with a fasciotomy at the same time as the initial surgery. Ekman and Poehling36 simulated knee arthroscopy in animals to study elevated compartment pressures with the creation of 2 capsulotomies to allow extra fluid into the surrounding tissue. They found that although this approach could produce elevated compartment pressures, the pressures would quickly return to normal. These authors concluded that the risk of true compartment syndrome is low, even given transient elevation of compartment pressure and significant fluid extravasation. The consequence of compartment syndrome is catastrophic, and therefore prevention is should be optimal.2,8,10-12,34,37 First, gravity inflow was recommended by almost all surgeons instead of pump inflow to prevent high pressure in the joint and to decrease fluid leakage, which may be the largest contributor to compartment syndrome of the leg. Tourniquet time should be minimized. A formal ARIF can be performed only after the swelling around the knee has decreased, and calcaneus traction may be needed preoperatively to allow the soft tissue to stabilize. A quick bone window and adequate intraoperative fluid drainage should be performed as soon as possible to release the intraarticular pressure. Dry-field arthroscopy is recommended for as long as possible.37 The pressure of the leg during surgery should be carefully monitored and the dorsalis pedis and posterior tibial pulses should be checked after deflation of the tourniquet. Finally, the possibility of compartment syndrome during ARIF should always be considered. Bicondylar tibial plateau fractures (Schatzker types V and VI) commonly result from high-energy trauma with significant comminution, as well as severe soft tissue injuries. The use of ORIF with bilateral buttress plates is recommended; therefore, extensive soft tissue stripping around the whole knee is always necessary, which leads to higher complication rates. ARIF could be the perfect technique in this situation; however, these types of fractures are suspected to be associated
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with a potential risk of compartment syndrome resulting from fluid extravasation. Chiu et al.14 reported a series of 25 patients with posteromedial tibial plateau fractures treated with ARIF. There were 5 patients with Schatzker type IV fractures, 2 patients with type V fractures, and 18 patients with type VI fractures. With a minimal follow-up time of 5 years, 92% had excellent or good clinical and radiologic results. No complications directly associated with arthroscopy, such as compartment syndrome, were noted in any of the 25 patients. Chan et al.12 reported on 18 patients, 7 with Schatzker type V fractures and 11 with Schatzker type VI fractures who were also treated with ARIF. With a minimal follow-up time of 4 years, the status of 89% of the patients was rated as excellent or good. Still, no complications related to arthroscopy were found. Other studies8,10,19,20,24-26 that also investigated complex tibial plateau fractures also reported no compartment syndrome cases. Based on the clinical findings, ARIF should be considered a relatively safe procedure when applied to bicondylar tibial plateau fractures, and it also has fewer complications. ARIF Versus ORIF To the best of our knowledge, there has been no prospective randomized controlled studies that compared the clinical results of ARIF to ORIF in the treatment of tibial plateau fractures. Only 3 retrospective comparative studies11,24,38 (Level III) were published; 2 of them11,24 were included in this systematic review, and one38 was published in 1993. All 3 authors tended to favor ARIF, although there was insufficient clinical evidence. Dall’Oca et al.24 compared 50 patients with tibial plateau fractures who underwent ARIF with 50 patients with tibial plateau fractures who underwent ORIF. Based on their findings, these authors suggested that there were no differences between ARIF and ORIF treatment for Schatzker type I fractures. In the case of Schatzker types II, III, and IV fractures, there was a small difference in clinical outcomes in favor of ARIF, but the differences were not statistically significant. In Schatzker types V and VI, ARIF was limited to less comminuted fractures and showed a lower incidence of infection. In the studies by Ohdera et al.11 and Fowble et al.,38 there was insufficient evidence as well. Moreover, the sample size was relatively small in their studies. Potential directions for future studies should include studies with larger sample sizes, and higher levels of evidence are required, especially for prospective randomized control studies. Limitations There are several limitations to this systematic review. First of all, all the studies included in this systematic
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review were Level III or Level IV, and no prospective randomized controlled study was enrolled. Significant sources of selection bias may be presented for the included studies. Furthermore, a group of physicians from Taiwan have published several studies focused on ARIF for tibial plateau fractures, including 4 studies8,10,12,14 in this systematic review. Different types of tibial plateau fractures and patient information were found among these 4 studies. Still, there may be some selection bias for counting some patient information twice or even more. Finally, only articles published in English between January 1, 2000 and January 10, 2014 were included.
Conclusions ARIF is a reliable, effective, and safe method for the treatment of tibial plateau fractures, especially when they present with concomitant injuries.
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