Fractures of the tibial plateau represent 1% of all fractures and 8% of fractures in the elderly population1. These fractures represent a surgical challenge because of the variety of fracture patterns and the associated soft-tissue injuries. If not adequately treated, these fractures often cause persistent knee pain, arthritis, and angular deformity. In one study, posttraumatic knee arthritis following a tibial plateau fracture was reported, after a seven-year follow-up, in 74% of patients with an associated meniscal tear and in 34% of patients with intact menisci2.
Intercondylar eminence avulsion fractures are relatively uncommon. First described by Poncet in 1875, this injury usually has been considered to be the childhood equivalent of anterior cruciate ligament rupture in adults3. As an isolated injury, these fractures are most frequent in pediatric patients between the ages of eight and fourteen years4-9. These lesions also can occur in adults in association with another periarticular injury or a tibial plateau fracture3,5. In our experience, 19.4% of tibial plateau fractures have been associated with an intercondylar eminence fracture whereas 84.3% of tibial spine fractures in adults have been associated with a tibial plateau fracture (unpublished data). Associated tibial plateau and intercondylar eminence avulsion fractures are complex articular lesions that vary widely from one patient to another, and therefore treatment requires personalized solutions. When determining the best treatment, anatomic joint reconstruction with minimally invasive techniques should be considered. Arthroscopic reduction and internal fixation have demonstrated various advantages over open reduction and internal fixation in terms of surgical morbidity, time of hospital stay, recovery, and complications such as infection and loss of knee motion10-12. The high prevalence of associated intra-articular lesions justifies the use of arthroscopy to evaluate and treat all of the injuries. Arthroscopic techniques also are useful for fracture reduction in cases of soft-tissue entrapment and for direct visualization of the articular surface to assess the adequacy of the fracture reduction.
The purposes of the present study are to describe an arthroscopic technique for the treatment of combined tibial plateau and intercondylar eminence avulsion fractures and to analyze the results for twenty-one patients. Surgical tips to obtain the best results with treatment of a variety of fracture patterns are presented.
From January 2000 to May 2004, twenty-one patients (nine males and twelve females) with a mean age of 20.8 years and with combined tibial plateau and intercondylar eminence fractures underwent arthroscopic surgery for fracture reduction. The tibial plateau fractures were classified as Schatzker13 types I, II, and IV, and the intercondylar eminence avulsion fractures were classified as Meyers and McKeever7 types II and III (Table I). Schatzker type-III tibial plateau fractures were not associated with intercondylar eminence avulsion fractures in our experience.
Patients were evaluated preoperatively on the basis of clinical examination, standard anteroposterior and lateral knee radiographs, and computed tomography scans; patients who were managed later in the series also were evaluated with oblique knee radiographs and computed tomography scans with three-dimensional reconstruction.
Surgical Technique
Combined arthroscopic and fluoroscopic-assisted fracture reduction was performed in all cases.
The patient was placed in the supine position with a C-shaped lateral leg holder and with a thigh tourniquet. Care was taken to ensure that fluid extravasation from the knee-irrigation system did not lead to a compartment syndrome.
A two-portal arthroscopic procedure was performed first, with knee lavage and debris removal, examination of the tibial plateau and spine fractures (Figs. 1 and 2), and evaluation and treatment of the associated intra-articular lesions (Table II).
Next, the tibial plateau fracture was treated. The lateral meniscus was retracted arthroscopically if it was entrapped in the fracture site. In all cases, closed reduction of the fracture was achieved by means of ligamentotaxis and with the aid of reduction forceps. Elevation of depressed fragments was achieved with use of a curved impactor that was inserted from a small incision at the anteromedial aspect of the proximal tibial metaphysis. The impactor was then driven through the cancellous bone, under fluoroscopic control, to the center of the depressed tibial plateau fragment (Figs. 3-A and 3-B). After the fragment elevation, the articular surface was arthroscopically evaluated. No bone grafts or substitutes were used to fill the bone defects. Finally, percutaneous stabilization of the tibial plateau fracture was achieved with use of cancellous screws. If the bone quality was impaired, washers were used with the cancellous screws (Fig. 4).
For treatment of the intercondylar eminence avulsion fracture, the fracture bed was initially debrided (Fig. 5). A standard probe was used to retract the anterior horn of the medial (or lateral) meniscus or the transverse meniscal ligament, which was frequently trapped within the fracture site (Fig. 6). In some cases, the soft-tissue entrapment may recur during the fracture reduction; in such cases, definitive removal of the entrapped ligament is done until full reduction of the tibial spine is feasible. With the aid of a Caspari punch that was inserted through the anteromedial portal, four Maxilene #1 sutures were passed through the fibers of the anterior cruciate ligament as closely as possible to the distal bone fragment. The amount of anterior cruciate ligament tensioning depends on the distance of the sutures from the bone insertion. The sutures were left out of the anteromedial portal, with the right and left ends kept separate (Figs. 7, 8-A, and 8-B).
The intercondylar eminence fixation was achieved with one of two techniques, as described below.
The first technique (involving two drill holes) was used for nine patients. Through a small incision on the medial aspect of the proximal tibial metaphysis, two drill holes were placed in the knee joint, emerging in the medial and lateral aspects of the posterior part of the fracture bed (Fig. 9). With a suture passer, two messenger wires were pushed into the knee joint to pull down the right and then the left ends of the sutures out of the two tibial drill holes. The ends of the sutures were then tensioned while the reduction was checked with arthroscopy and then were tightened together over the cortical bone, with the knee in full extension (Fig. 10). This technique avoids the use of staples and is indicated for young patients with good bone quality.
The second technique (involving only one drill hole) was used for twelve patients. Through a small incision on the medial aspect of the proximal tibial metaphysis, the drill hole was placed, emerging in the posterior aspect of the bed of the fracture (Fig. 11). One end of the sutures was fixed to bone with a staple, after which the two ends of the sutures were bound together over the staple, with the knee in a position of full extension (Fig. 12).
At the end of the procedure, arthroscopy was used to evaluate the quality of fracture reduction (Fig. 13). Finally, one notch impingement was trimmed as needed with a shaver to allow free full knee extension.
Postoperative Treatment
On the first postoperative day, walking was begun with crutches but with no weight-bearing on the injured leg. The knee brace was locked in full extension and was removed temporarily for continuous passive motion, with a gradual increase in knee flexion, starting ten to fifteen days after surgery. Formal physical therapy was used to achieve 90° of knee flexion at three weeks and full knee motion at six weeks after surgery. Progressive weight-bearing was allowed eight weeks after surgery, with the brace and crutches discontinued after twelve weeks.
Patients were evaluated after a mean duration of follow-up of eighty months (range, sixty to 112 months). Clinical evaluation was performed with use of the International Knee Documentation Committee (IKDC) form, and functional evaluation was performed with KT-1000 arthrometer testing. In cases of tibial plateau fractures with a depressed fragment (Schatzker type-II fractures), the amount of fragment depression was measured on the preoperative radiographs and at the time of the latest follow-up on the basis of the point of maximum depression with respect to a line drawn parallel to the femoral condyles and passing through the healthy tibial plateau (Fig. 14).
Source of Funding
There was no external funding source for the present study.
No significant associations were noted between the fracture patterns of the tibial plateau and intercondylar eminence fractures.
No postoperative complications occurred. None of the patients had functional knee instability at the time of follow-up. The mean KT-1000 side-to-side difference was 1.07 mm. The mean IKDC subjective score was 84.1 points. On the IKDC objective evaluation, ten patients (48%) were classified as grade A, eight (38%) were classified as grade B, two (10%) were classified as grade C, and one (5%) was classified as grade D. One of the two patients who were rated as grade C had mild lateral compartment arthritis with pain and effusion. The second patient who was rated as grade C had a lack of full knee flexion. The patient who was rated as grade D had residual depression of 4 mm of the lateral tibial plateau, with mild genu valgum.
The nine patients with a Schatzker type-II tibial plateau fracture had a mean preoperative joint depression of 8 mm. The residual depression at the time of the latest follow-up was 0.7 mm (range, 0 to 4 mm).
No outcome differences were found between the two techniques described for fixation of the intercondylar eminence fractures.
Combined arthroscopic treatment of tibial plateau and intercondylar eminence avulsion fractures provided satisfactory results. This technique is easy to perform and provides stable fixation of the fractures and satisfactory stability of the knee in the long term.
Percutaneous screw fixation of the tibial plateau fracture was always performed in our series. This was possible in consideration of the simple fracture patterns (Schatzker types I, II, and IV). Schatzker type-III fractures were not represented in our series. Intercondylar eminence avulsion fractures usually result from high-energy trauma, often in young patients, whereas Schatzker type-III tibial plateau fractures occur as a result of low-energy trauma in older patients.
The advantages of closed reduction and percutaneous fixation for the treatment of a tibial plateau fracture include reduced postoperative pain and swelling, early recovery of knee motion, reduced risk of infection, minimal fragment devascularization, and less postoperative knee stiffness. Arthroscopy is an indispensable aid when performing percutaneous techniques, allowing direct visualization of the articular surface and other structures within the joint. The arthroscopic technique allowed for the diagnosis and treatment of associated intra-articular lesions, which were particularly frequent in our series, such as meniscal lesions (noted in 19% of the patients) and osteochondral detachments (noted in 24% of the patients). Arthroscopy may be also useful for allowing reduction in cases of entrapment of the menisci in the tibial plateau fracture site. Disadvantages of percutaneous fixation include the lack of rigid fixation and the need for delayed weight-bearing.
The intercondylar eminence avulsion fracture was reduced and stabilized during the same surgical procedure. We preferred the pull-out suture technique because of its simplicity, the avoidance of difficulties associated with the positioning of an antegrade screw with respect to the screws used for tibial plateau fracture stabilization, and the low rate of intraoperative complications, such as tibial spine fragmentation12,14. Another advantage of this technique is the ability to tension the anterior cruciate ligament appropriately. Some authors believe that intersubstance stretching of the anterior cruciate ligament occurs in association with the tibial spine fracture15 and that, as a result, overreduction may be considered. In contrast, excessive anterior cruciate ligament tightening has not been observed to result in poor outcomes15. In further support of slight over-reduction, long-term evaluation of well-reduced tibial eminence fractures has revealed subtle increases in anteroposterior knee laxity, albeit without functional deficit16-20.
Associated tibial plateau and intercondylar eminence avulsion fractures are complex intra-articular lesions, with fracture patterns that may vary widely. Treatment requires personalized solutions. In the case of a Meyers and McKeever type-I intercondylar eminence avulsion fracture, tibial plateau fracture fixation usually stabilizes the intercondylar eminence avulsion fracture. In the case of a complex tibial plateau fracture pattern, a type-I intercondylar eminence avulsion fracture may not be sufficiently secured after tibial plateau fracture fixation, requiring additional fixation. In the case of a Meyers and McKeever type-II or III intercondylar eminence avulsion fracture, pull-out suture fixation represents the ideal technique that provides stable fixation without interfering with the screws used for tibial plateau fracture fixation. Figures 15-A through 16-D illustrate the treatment techniques used for two patients with various fracture associations.
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