Arthroscopic Technique for Treatment of Schatzker Type III Tibia Plateau Fractures Without Fluoroscopy

Abstract

Accurate reduction and maintenance of the stability with correct implant positioning is critical for surgical treatment of tibial plateau fractures. Our technique includes an arthroscopic reduction and fixation of Schatzker type III tibial plateau fractures with a bulls-eye screw placement without fluoroscopy control. With the arthroscopic guidance, an anterior cruciate ligament drill guide is placed and a K-wire sent to the midpoint of the depressed fragment through the guide at a 40° angle to the coronal axis of the tibia. A tunnel is created with the drill over the K-wire. The depressed fragment is further augmented with gentle impacts over the K-wire. After arthroscopic reduction control, an appropriate-sized iliac graft is pushed until it is below the depressed fragment. The targeting device is adjusted at 130° so that it is parallel to the joint line and a K-wire sent through the device so that it would pass just below the graft. The graft is then supported with cannulated screws sent over the K-wire. This technique provides an arthroscopic reduction of the chondral surface and precise placement of the rafting screws without fluoroscopy.

Fig 1

Axial computerized tomography image of a patient's right knee with Schatzker type III tibial plate fracture. The blue line represents the continuity of the bony envelope.

Fig 2

Photograph of the operation representing the patient's position. The patient is positioned supine on the operating table. The injured right knee is bent to 90° and is freely movable during the procedure; the other extremity is secured in a leg holder.

Fig 3

(A) Drawing of a type III tibial plateau fracture. The anterior cruciate ligament Drill Guide, Adapteur C-Ring with an arc of 130° is placed; the tip of the guide is at the center of the depressed fragment. A K-wire is sent through the guide until it is 1 mm past the joint. (B) Arthroscopic view of a type III tibial plateau fracture; the meniscus is elevated with a probe from the anteriolateral portal and the anteriomedial portal is used for visualization of the fracture. The K-wire tip is at the middle of the depressed fracture.

Fig 4

(A) Drawing of a type III tibial plateau fracture. Cannulated headed drill is sent through a K-wire until it is 1 cm below the cartilage. (B) Photograph of the surgical step; the surgeon is drilling over the K-wire while the assistant is holding the injured extremity still.

Fig 5

Drawing of a type III tibial plateau fracture representing the reduction of the fracture. The arthroscope is at the anteriolateral portal and a probe is used from the anteriomedial portal to apply counter force during augmentation of the depressed fracture with a tunnel dilator.

Fig 6

(A) Drawing representing maintaining the reduction with the graft. The graft is driven gently until it is below the depressed fragment. The Drill Guide, Adapteur C-Ring is adjusted so that the 2 arms are at 130° to each other. The mobile arm with the adjustable knob is pushed in the tunnel until it touches the graft. A K-wire is placed through the graduated guide pin sleeve just under the graft. (B) Arthroscopic view of the graft and K-wire. The arthroscope is in the tunnel and confirms the correct position of the K-wire.

Fig 7

(A) Drawing representing the position of the cannulated screw and graft after fixation. The graft is supported from below with a cannulated cancellous screw that is positioned over the K-wire. (B) Arthroscopic view of the fracture after reduction and fixation of the fracture. The arthroscope is at the anteriomedial portal and the lateral meniscus is elevated with a probe from the anteriolateral portal.