|Year : 2022 | Volume
| Issue : 1 | Page : 33-41
Comparative study between arthroscopic reduction and internal fixation versus open-reduction internal fixation for tibial-plateau fractures
Ahmed H.T Waly1, Hesham M Gawish2
1 Department of Orthopaedic Surgery and Traumatology, Arthroscopy and Sports Injury Unit, Alexandria University, Alexandria, Egypt
2 Department of Orthopaedic Surgery and Traumatology, Kafr El Sheikh University, Kafr El Sheikh, Egypt
|Date of Submission||13-Nov-2021|
|Date of Decision||01-Dec-2021|
|Date of Acceptance||14-Jan-2021|
|Date of Web Publication||31-May-2022|
MD Ahmed H.T Waly
Zezenia, Alexandria, Postal Code: 21532
Source of Support: None, Conflict of Interest: None
Background Tibial-plateau fractures are challenging for orthopedic surgeons. The gold-standard treatment for most tibial-plateau fractures is open-reduction internal fixation using either screws only or plates and screws. Recently, arthroscopy has invaded the field of trauma as a useful aid in the management of intra-articular fractures. The main advantages of arthroscopic reduction and internal fixation for tibial-plateau fractures are direct visualization of intra-articular fractures, accurate fracture reduction, and diagnosis and treatment of meniscal and ligamentous injuries. This study was done to compare the results of open-reduction internal fixation versus arthroscopic reduction and internal fixation for tibial-plateau fractures.
Patients and methods A prospective comparative study was held in EL Hadra University Hospital between January 2017 and December 2019 over 56 patients. In all patients, the fracture was fixed using two to three cannulated screws. In the first group, the fixation was done using arthroscopy, while in the second group, the fixation was done using arthrotomy. All cases were assessed using Rasmussen clinical and radiological forms, Lysholm, and International Knee Documentation Committee (IKDC) scores. The minimum follow-up was 24 months since index surgery.
Results There was no statistically significant difference between the two groups regarding the clinical and radiological Rasmussen scores. Moreover, the results of the Lysholm and IKDC were comparable. However, the arthroscopic group had longer operative time than the arthrotomy group.
Conclusion Arthroscopic fixation technique was not inferior to open technique for management of Schatzker I–III fracture types with excellent comparable clinical and radiological outcomes while avoiding the drawbacks of the open approach.
Keywords: arthroscopic reduction and internal fixation, arthroscopic-assisted fixation, Schatzker classification, tibial-plateau fractures
|How to cite this article:|
Waly AH, Gawish HM. Comparative study between arthroscopic reduction and internal fixation versus open-reduction internal fixation for tibial-plateau fractures. Egypt Orthop J 2022;57:33-41
|How to cite this URL:|
Waly AH, Gawish HM. Comparative study between arthroscopic reduction and internal fixation versus open-reduction internal fixation for tibial-plateau fractures. Egypt Orthop J [serial online] 2022 [cited 2022 Sep 25];57:33-41. Available from: http://www.eoj.eg.net/text.asp?2022/57/1/33/346387
| Introduction|| |
Tibial-plateau fractures represent 1–2% of fractures of adults . The main principles of treatment of those fractures are restoring the articular anatomy, and the mechanical axis of the lower limb and faster healing ,.
Different surgical approaches have been developed and used for the treatment of these fractures . Internal osteosynthesis with plates and screws after open reduction is the method of choice for the treatment of complex fractures (types V–VI by Schatzker). For Schatzker type I–III fractures, surgical options include internal fixation with arthroscopic control (arthroscopic reduction and internal fixation, ARIF) and internal fixation with open reduction (open reduction and internal fixation, ORIF) .
ARIF was originally described by Caspari et al.  and Jennings  in patients with Schatzker type I–III fractures. This minimally invasive technique has been recognized as an alternative to ORIF, with lower morbidity, precise assessment of joint reduction, and the possibility of treat other intra-articular lesions. Furthermore, direct visualization of chondral surface reduction, joint lavage removal of hematoma and small loose-fracture fragment, and limited soft-tissue dissection reduced morbidity in comparison with arthrotomy, with no need to peripherally detach the meniscus to gain visualization, and improve rehabilitation and postoperative recovery, including decreased pain, shorter hospital stay, and return of knee range of motion. Moreover, ARIF avoids the complications of open approach like infections, septic arthritis, delay in postoperative return to knee range of motion, and stiffness ,,,.
The main disadvantage of the arthroscopic approach is longer operating time with the risk of extravasation of fluid-and-compartment syndrome .
Recent literature has reported good functional and radiological results in the short and medium term. However, the fact that ARIF allows better clinical and radiological results to be obtained is still debated ,,,,.
The aim of this study was to evaluate and compare the clinical and radiological results of patients treated with ARIF and ORIF. Our hypothesis was that ARIF allows obtaining clinical results similar to ORIF with satisfactory reduction and stable fixation.
| Patients and methods|| |
The study included 56 adult patients with a Schatzker  I, II, and III tibial-plateau fracture who were admitted to El Hadra University Hospital Trauma Center between January 2017 and December 2019.
The exclusion criteria were:
- Types IV, V, and VI of the Schatzker classification.
- Pathological fractures.
- Open fractures
- Associated neurovascular injury or compartment syndrome.
Patients were classified randomly into two groups. The first group (group A) was treated with ARIF. The second group (group B) was treated with classical open reduction and internal fixation.
Patients were assessed preoperatively using frontal and lateral radiograph films and computed tomography scan with 3D-reconstructive images. In all patients, the depressed fragment was elevated and supported by corticocancellous iliac filler graft and was fixed with two or three cannulated screws under fluoroscopic control.
In both groups, absolute nonweight bearing was recommended for 6 weeks with a hinged knee support allowing full ROM from day 1. Partial weight bearing was then allowed as tolerated and full support was gained at about 3 months postoperatively.
A clinical evaluation was made using clinical Rasmussen score , Lysholm , and International Knee Documentation Committee (IKDC) . Passive mobility and active (flexion and extension) were noted. Complications were identified, intraoperatively and postoperatively. In the Rasmussen score , subjective and objective parameters were identified. The results were rated as follows: excellent: 27–30 points, good: 20–26 points, fair: 10–19 points, and poor: less than 10 points.
To assess the postoperative reduction, postoperative and follow-up radiographs were used to assess the quality of the reduction, the mechanical axis of the lower limb, and the presence of osteoarthritis according to the Ahlback classification . In the last follow-up, no computed tomography scan was performed postoperatively for financial and logistic reasons. Also, Rasmussen radiological score  was used to assess postoperative reduction. The results were rated as follows: excellent: 18 points, good: 12–18 points, fair: 6–11 points, and poor: less than 6 points.
Statistical evaluation was done using SPSS, version 25 (IBM SPSS Statistics for Windows, Version 25, Armonk, NY: IBM Corp). The P value was set at 0.05. Independent t test was used to compare between the two groups as the data were parametric and normally distributed. χ2 test was used for qualitative data.
The study was approved by local ethical committee of Alexandria University Faculty of Medicine. An informed consent was taken from every patient submitted to the study. Patients were followed up for 2 years.
All patients were examined for the soft-tissue envelope of the limb before the operation. Findings like severe swelling, ecchymosis, visible contusions, and blisters were indicative for the severity of soft-tissue injury. Adequate preoperative neurovascular examination and exclusion of compartment syndrome was done. All cases were operated under spinal anesthesia with a high-thigh tourniquet and adequate draping of the graft area. In the ORIF group, the conventional techniques were used with the patient flat on the operative table.
In the ARIF group, the arthroscope requires varying degrees of knee flexion and varus/valgus stress to adequately view the joint and concomitant fluoroscopic viewing is generally with the knee extended. For this purpose, this group of patients was operated with knee flexed and leg freely hanging from the operative table to give best exposure of all compartments of the knee joint and figure-of-4 position during lateral compartment work ([Figure 1]).
|Figure 1 The ideal position for ARIF with operating leg hanging freely and flexed more than 90°. ARIF, arthroscopic reduction and internal fixation.|
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First, hematoma evacuation for good visualization and quiet examination of the knee joint. Any intra-articular pathology was dealt with before fixation. A figure-4 position allowed good access to the lateral compartment with adequate visualization of the fracture depression ([Figure 2]).
The anterolateral and anteromedial portals were used to insert the arthroscope as well as working instruments. High pump pressure was avoided and only gravity inflow was allowed. When intra-articular visibility becomes sufficient, a shaver can be introduced to assist in removing the clots and small bone fragments within the joint cavity. Once joint lavage is complete, a comprehensive evaluation is performed to identify the bone and cartilage lesions, as well as any damage to other structures such as the menisci and ligaments by probing of the capsuloligamentous structures. When the anterior horn of the lateral meniscus overlaps the depressed area, a meniscal retractor was used to uncover the working area.
The depressed plateau is elevated arthroscopically using the basic tools of ACL reconstruction. A guide wire was initially introduced up through the metaphyseal bone to the apex of the fragment using an ACL guide (C guide). Once the position is checked arthroscopically, the cortical window was then created over a KW with a reamer reaching up to 2 cm below the depression ([Figure 3] and [Figure 4]).
|Figure 3 Use of C guide over the depressed area to insert a KW directed to the depressed fragment.|
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|Figure 4 A KW is inserted into the depressed area with the help of C guide.|
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The fragment was then elevated using bone tamps or bone-graft impactor. Elevation was performed very gently, under fluoroscopic and arthroscopic guidance. Once the reduction was obtained, temporary stabilization was achieved using one or two pins introduced few millimeters below the joint surface. Pin position was then evaluated on anteroposterior and lateral fluoroscopy views ([Figure 5] and [Figure 6]).
After impaction of autologous iliac crest bone grafting from the iliac bone, two cannulated screws were inserted to prevent collapse of the elevated fragment. No plates were used in this series. Meniscal sutures were done in some cases of the arthroscopic group ([Figure 7],[Figure 8],[Figure 9]).
|Figure 7 Impaction of bone chips inside the tunnel created under the defect to support the elevated fragment.|
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|Figure 8 Insertion of two subchondral KW for the fixation of bone chips under the elevated fragment.|
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|Figure 9 Fixation with cannulated subchondral screws to avoid fragment collapse.|
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| Results|| |
The study included 56 adult patients who were admitted to El Hadra University Hospital. Group A was managed arthroscopically and there were 25 patients. Their mean age was 30.4±6.9 years. Group B was managed conventionally using ORIF and there were 31 cases with mean age 30.3±6.4 years. The difference between the two groups was statistically insignificant denoting adequate matching of the groups. Patients’ demographic data are included in [Table 1]. There was a significant difference between operative time of both groups ([Figure 10]). The ARIF group had significantly longer time (P<0.05).
|Figure 10 An error bar showing the difference in the operative time between both groups.|
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Regarding the improvement of the clinical patient scores, there was no statistically significant difference in both groups regarding Rasmussen, Lysholm, or IKDC. This confirms our hypothesis, the ARIF can reach nearly the same results of ORIF. However, there were more cases with stiffness, postoperative flexion deformity, and superficial infection with open-approach group. However, the overall difference was statistically not significant ([Table 2]).
Regarding radiological evaluation, there was no statistically significant difference between the final Rasmussen score nor the incidence of arthritis in both groups. This again confirmed noninferiority of ARIF ([Table 2] and [Table 3]) ([Figure 11]).
|Figure 11 Chart showing no statistical difference between the groups in all scores tested.|
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Regarding the fracture type, there was no difference in the postoperative radiological outcomes between the three types included in the study. However, clinically, type III had the best clinical outcomes with about 21 (46%) cases out of 45 that had excellent clinical scores. Type II has the most fair results in the series. About 57% of type II had fair results ([Table 4]) ([Figure 12]).
|Figure 12 Chart showing the difference in the clinical outcomes between the three types of tibial-plateau fractures.|
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| Discussion|| |
As with any other intra-articular fracture, the tibial-plateau fracture is always challenging for orthopedic surgeons, because of its widely varying trauma, and associated soft-tissue injuries. The major treatment objectives should be reconstructing articular surfaces, obtaining stable fixation for early motion, and repairing all concomitant lesions. Joint congruity and stability should be the main treatment consideration .
The main findings of this study are there is no significant difference between the two groups ARIF and ORIF in terms of clinical results, ROM, radiological scores, and complication rate. There is no difference in terms of the quality of the reduction. Furthermore, the complication rate is comparable. This confirms the null hypothesis according to which ARIF, for the treatment of Schatzker I–III fractures, with clinical results, is comparable to ORIF in addition to satisfactory reduction.
Open fixation of tibial-plateau fractures has a lot of drawbacks. The arthrotomy, and the submeniscal section of the meniscus, should be performed to allow the best visualization of the articular surface. This approach can cause stiffness, proprioception disturbances, severe postoperative pain, and scar complications .
Arthroscopy has been suggested to avoid these drawbacks. In our study, the rate of stiffness and PO flexion deformity was more with the ORIF group than ARIF. However, the difference in the overall complication rate was not significant.
There are many advantages of ARIF approach, including better visualization of the articular surfaces, better reduction of the fracture, better anatomical restoration of the joint surface, the possibility to assess and treat the associated intra-articular ligamentous and meniscal injuries, the possibility, through joint lavage, to remove loose fragments, the possibility to achieve stable fixation with the least amount of soft-tissue dissection, low risk of complications and low morbidity, the possibility of converting to arthrotomy if necessary, and shorter hospital stay with faster recovery of joint motion .
Ohdera et al.  confirmed no difference in operative duration, postoperative flexion, or clinical results, even though faster postoperative recovery had been noted in the ARIF group. Fowble et al.  obtained a 100% reduction that deemed satisfactory by ARIF, whereas this rate was only 55% for the ORIFs.
Kiefer et al.  found satisfactory reduction in only 80% of the ARIF series. Van Glabbeek et al.  reported only one arthroscopic-reduction failure out of a total of 20 fractures. Ohdera et al.  found satisfactory reduction in 85% of arthroscopic patients compared with only 55% of open surgical patients.
Le Baron et al.  found no statistical difference demonstrated between the two groups ARIF and ORIF in all Schatzker types tested (I–III) in terms of passive or active extension, active flexion, Lysholm and IKDC scores, the quality of the reduction, the hip–knee angle, or the presence of radiological signs of osteoarthritis. However, a significant difference existed for the HSS score, but these differences were not clinically relevant.
The mechanical stability of the fracture obtained by isolated screwing for Schatzker type I–III fractures is confirmed by the literature . This minimally invasive osteosynthesis is therefore perfectly suited to arthroscopic-assisted surgery. The use of arthroscopy makes it possible, thanks to an ACL-aiming device and without the use of an image intensifier, to reduce the sinking by acting directly on it, while obtaining an optimal placement of the cannulated screws under the joint depression ,.
ARIF exposes to technical difficulties, and in particular, the bleeding of the fracture, which can interfere with the arthroscopic procedure. This difficulty can be minimized by use of a pump, but increases the risk of fluid extravasation and the incidence of compartment syndrome. No compartment syndrome was found in our cases. However, Herbort et al.  clearly identified complex tibial-plateau fractures as a contraindication to ARIF due to the high risk of iatrogenic compartment syndrome secondary to extravasation of arthroscopic fluid, despite an extreme rarity in the literature .
This study has several limitations: small number of cases, lack of a long film to calculate limb alignment postoperatively, the selection bias as the series was not randomized (lack of randomization), and the difference in the prognosis noted between Schatzker fracture types (treatment bias).
| Conclusion|| |
ARIF technique was not inferior to ORIF for management of Schatzker I–III fracture types with excellent comparable clinical and radiological outcomes while avoiding the drawbacks of the open approach.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]
[Table 1], [Table 2], [Table 3], [Table 4]