History and Physical Examination

Classic patient history is trauma as a result of a fall or motor vehicle versus a pedestrian accident.^1,2 Tibial plateau fractures are common in sports, particularly in skiers. Avulsion fractures commonly occur in children and adolescents, with 50% caused by a fall from a bicycle. However, it is sometimes misunderstood that this condition occurs only in the young. Although less common, ACL avulsion also occurs in adults.

On physical examination, patients present with painful swollen knees and generally are unable to bear weight. Careful history differentiates high- or low-energy injuries and a careful examination notes any evidence of a fracture blister, compartment syndrome, meniscal or ligamentous disruption, or neurovascular injury. To re-emphasize this key point, attention must be paid to peripheral pulses, neurologic function, and the status of the compartments of the injured extremity. Any open wounds must also be evaluated to ascertain a relationship to the fracture site or joint space.

Diagnostic Imaging

Standard radiologic knee trauma views usually reveal plateau fractures, but displaced fractures and compression fractures can be missed. X-rays are not accurate for determining the amount of depression when a compression fracture component is visible. Computed tomography (CT) with three-dimensional reconstruction provides precise information regarding the extent and pattern of articular and extra-articular components of the fracture. In addition to CT scanning to assess bony pathology, magnetic resonance imaging (MRI) is also recommended. MRI is the examination of choice for soft tissue injuries associated with tibial plateau fractures.

Arteriography should be considered when any suspicion for knee dislocation or arterial injury exists. High-energy injuries are associated with higher risks of compartment syndrome and arterial injury.

Indications and Contraindications

The goal of tibial plateau fracture treatment is joint stability, with articular congruity and normal alignment. Preservation of full range of motion is also vital. Surgery is indicated for unstable or malaligned knees or articular incongruity. Surgery should also be considered to allow early range of motion for active patients, particularly athletes. The key point is articular compression or fracture displacement is the indication for surgery. Historically, 4 to 10 mm of fracture displacement or compression was considered acceptable, but today a 3- or 4-mm displacement should be considered as a relative indication for ARIF, particularly in active patients.

Contraindications to surgical intervention, when indicated, are rare. In older adult, debilitated, sedentary, and/or osteoporotic patients, the risks of surgery may outweigh the benefits. Surgical timing depends on associated soft tissue injury mechanism, including level of energy, neurovascular status, and open fracture. External fixation is usually temporizing.

The key point is that surgery is generally indicated based on fracture classification. The Schatzker classification of tibial plateau fractures is illustrated in Figure 3-1. I recommend ARIF for all type III fractures, and ARIF should be considered for types I, II, and IV fractures. Arthroscopy-assisted surgery for Schatzker type V and VI fractures (skin incision and plating, with arthroscopy but no arthrotomy), can also be considered. Chen and associates³ have reported 85.1% and 90% satisfactory results for types V and VI fractures, respectively (Table 3-1).

FIGURE 3-1 Schatzker classification of tibial plateau fractures.

(Adapted from Lubowitz J, Elson W, Guttmann D. Part I: arthroscopic management of tibial plateau fractures. Arthroscopy. 2004;20:1063-1070.)

The Meyers and McKeever classification of tibial intercondylar eminence fractures is illustrated in Figure 3-2. Surgery is indicated for type I fractures if they are associated with meniscus tears or other concomitant pathology that requires arthroscopy. Otherwise, these may be immobilized at or near full extension. Aspiration of hemarthrosis may result in substantial pain relief. There is sufficient evidence that surgery should be strongly considered for type II bird’s beak pattern fractures because of the high association of anterior horn of the medial (or occasionally the lateral) meniscus lodged within the fracture site.^2,4–7 Closed reduction may be attempted for large type IIIB fractures because associated condylar contact may allow bony reduction after aspiration and hyperextension. For displaced type III fractures, ARIF is the state of the art procedure.²

FIGURE 3-2 Meyers and McKeever classification of tibial plateau fractures.

(Adapted from Lubowitz, J, Elson, W, Guttmann, D. Part II: arthroscopic treatment of tibial plateau fractures: intercondylar eminence avulsion fracture. Arthroscopy. 2005;21:86-92).

An impressively large series by Chan and coworkers³ is summarized in Table 3-1. The key point is that fracture types I, II, III, and IV had 100% satisfactory results. Fracture type V had 87.5% satisfactory results and Schatzker type VI had 90% satisfactory results.

Hunter and Willis⁸ have described the outcome of suture or screw fixation of Myers and McKeever types II and III tibial intercondylar eminence fractures. At 32.6-month follow-up, the mean Tegner score was 6.35 and mean Lysholm score was 94.2. The best outcomes were seen in younger patients. No significant differences were seen in outcome with regard to type of fixation.

Conservative Management

As noted,¹ not all fractures of the tibial plateau require surgery. Fractures that are stable and minimally displaced may be amenable to cast immobilization, or bracing may allow early motion (but with delayed weight bearing). Other indications for nonoperative treatment may include injuries to the peripheral (submeniscal) rim of the plateau, a unique fracture pattern, and fractures in older adult, low-demand, or osteoporotic patients. Meyers and McKeever type I tibial intercondylar eminence fractures may be immobilized near full extension. Aspiration may relieve pain in patient with intense hemarthrosis.

Arthroscopic Technique

My recommended ARIF technique was inspired by Caspari and colleagues,⁹ Jennings,¹⁰ and Buchko and Johnson.¹¹ Operative treatment must be specifically determined for each fracture type.

A circumferential leg holder and tourniquet are used, with the leg off the end of the table. The fluoroscope (C-arm) is turned upside down, so the flat (image acquiring) plate may be used as an operating table under the proximal tibia. Blunt double-hooked retractors may be used in a self-retaining mode with a spring-loaded suction cup designed to prevent fluid extravasation from accessory portals.

Arthroscopic lavage removes hemarthrosis. Dry arthroscopy decreases fluid extravasation and the risk of increased compartment pressure. A key point is to monitor compartment pressure, particularly in split fractures, in which extravasation occurs directly through the fracture line, to avoid fluid extravasation into the compartments. If an incision and plating is planned (ARIF without capsulotomy), these incisions should be made before arthroscopy in a location where the plate is planned; thus, fluid leak will occur via the incision rather than into the muscle compartments. To summarize, compartment pressure is monitored, measured if indicated, and thoughtful consideration given to fasciotomy if pressure is elevated.

Note that split fractures should be reduced first. For type I fractures, percutaneous, cannulated lag screws may be placed over a guide wire. In types II, III, and IV patterns, compression is first elevated using an angled tamp placed over a guide wire (Fig. 3-3). An ACL guide with a modified spoon-shaped tip to mimic the curve of the femoral condyle is used to place the guide pin in the center of the compressed fragments through a small incision in the proximal anteromedial tibial metaphysis. A coring reamer circumferentially penetrates the tibia cortex while removing as little bone as possible. A cannulated tamp is used to elevate the fracture site under arthroscopic visualization (Fig. 3-4). The underlying metaphyseal bone and cortical disk serve as autograft. A calcium- or hydroxyapatite-impregnated bioabsorbable cannulated interference screw of large diameter is then advanced through the cortical window to elevate the fracture further under direct arthroscopic visualization (Fig. 3-5). The screw first provides elevation. Next, the screw provides rigid internal fixation of the compressed fracture.¹² Moreover, for type III patterns, the screw obviates the need for percutaneous placement of subchondral, metal, cannulated buttress screws, which radically reduces morbidity. For type III fractures, using this new technique, fluoroscopy is not required. Locked buttress plating (ARIF with arthroscopy without arthrotomy) has been reported for types V and VI fractures (Figs. 3-6 to 3-8).

FIGURE 3-3 Cannulated angled tamps reduce compression fracture elements via transtibial guide wires placed with an ACL guide and a modified, spoon-shaped marking hook.

(Adapted from Lubowitz J, Elson W, Guttmann D. Part I: arthroscopic management of tibial plateau fractures. Arthroscopy. 2004;20:1063-1070.)

FIGURE 3-4 Prereduction (A) and postreduction (B) views of Shatzker type III (lateral central compression) fracture. A cannulated tamp is used to elevate the fracture site under arthroscopic visualization (arthroscopic anterolateral portal view, right knee, lateral compartment).

(From Lubowitz J, Vance K, Ayala M, et al. Interference screw technique for arthroscopic reduction and internal fixation of compression fractures of the tibial plateau. Arthroscopy. 2006;22:1359e1-1359e3.)

FIGURE 3-5 A cannulated, bioabsorbable interference screw reduces and then buttresses the tibial plateau compression fracture via the metaphyseal window.

(From Lubowitz J, Vance K, Ayala M, et al. Interference screw technique for arthroscopic reduction and internal fixation of compression fractures of the tibial plateau. Arthroscopy. 2006;22:1359e1-1359e3.)

FIGURE 3-6 Schatzker type VI tibial plateau fracture in a 35-year-old man involved in a motorcycle accident. A, B, Plain radiographs showing bicondylar fractures with diaphyseal extension(anteroposterior and lateral views). C, Anterior view of three-dimensional CT reformation showing comminuted articular surface. D, Lateral view of three-dimensional CT scan showing severe depression of bicondylar articular surface.

(From Chan Y, Chiu, C, Lo Y, et al. Arthroscopy-assisted surgery for tibial plateau fractures: 2- to 10-year follow-up results. Arthroscopy. 2008;24:760-768.

FIGURE 3-7 A, Preoperative arthroscopic view. A depressed medial tibial plateau is evident with a large bony gap. B, The depressed portion of the tibial articular cartilage is elevated by the technique of arthroscopy-assisted reduction with bilateral buttress plate fixation. C, The depressed portion of subchondral bone and the lateral tibial articular surface is elevated and reduced. D, Final management of ACL avulsion fracture with displacement. E, Arthroscopically assisted fixation by pullout suture. F, Four no. 5 Ethibond sutures (Ethicon, Somerville, NJ) were tied firmly at the proximal tibial site, and well reduction of ACL avulsion fracture could be visualized by arthroscopy. LFC, lateral femoral condyle; LM, lateral meniscus; MFC, medial femoral condyle.

(From Chan Y, Chiu, C, Lo Y, et al. Arthroscopy-assisted surgery for tibial plateau fractures: 2- to 10-year follow-up results. Arthroscopy. 2008;24:760-768.

FIGURE 3-8 A, Only two longitudinal wounds appear on either side of the leg postoperatively. No knee arthrotomy or extensive soft tissue dissection was performed in the patient. B, C, Plain radiographs showed solid bone union with normal alignment (anteroposterior and lateral views). The knee joint was very stable. D, After more than 7 years’ follow-up, no joint surface depression or post-traumatic osteoarthritis. Satisfaction with treatment (arthroscopy-assisted reduction with bilateral buttress plate fixation) was high.

(From Chan Y, Chiu, C, Lo Y, et al. Arthroscopy-assisted surgery for tibial plateau fractures: 2- to 10-year follow-up results. Arthroscopy. 2008;24:760-768.

Surgical Management: Tibial Intercondylar Eminence Avulsion Fractures

ARIF of ACL avulsions with screws was first described in 1993 by Lubowitz and Grauer,^13,14 but I now acknowledge disadvantages, including risks of comminution of the fracture fragment, posterior neurovascular injury, and the need for hardware removal. Because of these risks, ARIF using nonabsorbable sutures passed through drill holes and tied over the tibial tubercle is now my preferred technique.

The patient is placed in a circumferential leg holder, with the knee off the end of the table. A tourniquet facilitates visualization, and the most recently published technique concludes that no fluoroscopy is needed for this procedure.¹² Calf compartments must be continually palpated to ensure that fluid extravasation does not result in compartment syndrome. Although intercondylar eminence avulsion fractures are contained injuries, they may be associated with capsular disruption.²

Standard anterolateral and anteromedial portals are used. A central transpatellar tendon vertical portal can be used as an accessory portal when indicated. Cannulas are recommended during suture passage to prevent soft tissue interposition.

Thorough lavage removes hemarthrosis. The fracture is reduced. Fibrous tissue or clot must be removed from the fracture bed. Entrapped meniscal tissue is retracted and dislodged.

A 90-degree suture lasso may be placed percutaneously (or via an accessory portal) through the fibers of the ACL in its midcoronal plane and as close to the bony fragment (distally) as possible. The wire loop within the lasso is secured with an arthroscopic grasper (Fig. 3-9) and pulled via a cannula through either of the portals and loaded with a no. 2 high-strength suture. The high-strength suture is pulled back through the ligament fibers and out through the skin and accessory portal.

FIGURE 3-9 A 90-degree suture lasso is placed through the fibers of the ACL. The wire loop within the lasso is secured with an arthroscopic grasper.

(Adapted from Lubowitz, J, Elson, W, Guttmann, D. Part II: Arthroscopic treatment of tibial plateau fractures: intercondylar eminence avulsion fracture. Arthroscopy. 2005;21:86-92).

An ACL guide is used to placed medial and lateral drill holes to pull the ends of the suture and fragment down into the fracture bed. A longitudinal incision is centered over the tibial tubercle. The medial pin enters the tibia just medial to the tubercle, and the lateral pin just lateral. The guide places two 3-mm cannulated retropins at the medial and lateral edges of the fracture bed in the midcoronal plane under direct arthroscopic visualization.

A Nitinol wire loop is passed up through the cannulated retro pins, medially and laterally, respectively. Routine suture passage brings the suture ends out through the medial and lateral drill holes. Distal traction reduces the fracture. The sutures are tied under tension while an assistant performs a reverse Lachman maneuver. With the use of supersutures, only one suture is usually required (Fig. 3-10).

FIGURE 3-10 The fracture is reduced by pulling down on the suture ends, which are tied over the tibial tubercle.

(Adapted from Lubowitz, J, Elson, W, Guttmann, D. Part II: arthroscopic treatment of tibial plateau fractures: intercondylar eminence avulsion fracture. Arthroscopy. 2005;21:86-92).

Postoperative radiographs may suggest a few millimeters of superior displacement of the fracture fragment. This is usually not seen on the arthroscopic view, and as long as the surgeon is certain that the meniscus is not entrapped, this should not be considered a failure of surgical treatment. Despite this radiographic finding, which is often subtle, excellent functional outcome and knee stability are the rule.²